DiaTribe - Research and Product News For People With Diabetes - Issue #7

VO L U M E 1 • I S S U E 7
�� research and product news for people with diabetes

��
in this issue Beautiful Landmarks for an
®
World Diabetes Day ...... 1 Unrecognized Epidemic (B.L.U.E)
ILLUSTRATION: DANIEL BELKIN

B.L.U.E.
The first UN-sponsored World Diabetes
Letter from the Editor .. 2
Day (WDD) took place on November
Quotable Quotes ........... 6 14, 2007, signaling real progress for the
(S)he said what?!? diabetes world. We spent three eventful
FingerSticks ................... 6
days in New York and came away feeling
Flying with diabetes rather positive about our community’s
ability to effect change. Diabetes is
diaTribe Dialogue ........... 7 slowly being recognized as much more
Dr. Francine Kaufman on
the global diabetes epidemic than just a healthcare problem – it’s an
economic problem, a social problem,
Logbook.......................... 10 and a development problem. Much of
In search of reimbursement: the focus during WDD was on early
A CGM odyssey
intervention and improved treatments to reduce both the human and financial costs of
Conference Pearls .......... 12 diabetic complications. Virtually all speakers discussed the great need to raise awareness
ISPAD news – children, and increase education, especially in developing countries. The International Diabetes
the DAWN study and pain
Federation (IDF) did a tremendous job managing the global efforts that made WDD a
perception
success. We encourage you to join the awareness campaign by teaching somebody one
SUM Musings ............... 14 helpful fact about diabetes – just one fact to anyone! – once you finish reading diaTribe
Pumping, after a fashion of course!
Learning Curve .............. 15
Inhaled inslin: Into thin air? The premier of the revealing documentary, Diabetes – A Global Epidemic, kicked off the
week’s celebrations. To anybody who was not in the know, one could easily mistake the
Test Drive ........................ 17 elegant gathering at New York’s Museum of Natural History on Monday, November 12, as
Measured strides away from
pre-prediabetes
just another night at the museum. It would have been difficult to tell that the lady in the
fabulous red dress had just circumnavigated
What We’re Reading ...... 19 the globe with a film crew from Discovery
The Diabetes Barometer and Health, chasing down eye-opening diabetes
a troubled letter to the New
York Times stories. This lady is Dr. Francine Kaufman,
whom we interviewed in this issue’s diaTribe
PHOTO: MARK YARCHOAN
NewNowNext ................ 20 dialogue.

aDorn and accessorize
Trial Watch ...................... 20 The fabulous evening was a prelude to

Getting to the bottom of the the more solemn event at the United Nations,
incretin debate with Dr. Martin Silink, President of the
IDF. Every time we hear the measured diaTribe ensured that our very own Coit
tones of Dr. Silink, we experience a sense Tower, here in San Francisco was lit blue.
To subscribe to diaTribe,
visit www.diaTribe.us.
continued on page 3 1
D I AT R I B E • R E S E A R C H A N D P R O D U C T N E W S F O R P E O P L E W I T H D I A B E T E S
from the editor
A
ll diabetes is personal: “How does it affect that one individual”
is something we ask ourselves a lot. A solemn truth is that
diabetes has become more and more global - an epidemic of our
time that is reaching further into every country on every continent in
the world. The task is channeling the specific human experiences into a
diaTribe staff lasting movement for improved care.
Editor in Chief
This issue of diaTribe spotlights global initiatives that we hope will be catalysts
Kelly L. Close
for change. The first United Nations World Diabetes Day was on Nov. 14. It was a genuine
Managing Editor celebration of our unity, spirit, and perseverance – as well as a clear call for more resources,
James S. Hirsch
awareness, and education. From the blue lights that illumined iconic buildings across the
Contributers globe, to the 246-step march in New York that represented how many millions of people
Kaku Armah worldwide have the disease, to the inspiring words of Dr. Martin Silink, President of the
Daniel Belkin International Diabetes Federation, we hope this day did indeed represent a “tipping point”
Michael Chen
for our cause. There are an estimated 246 million people with diabetes globally - that
Jenny Jin
Sierra Walton compared to 33 million with AIDS and 25 million with cancer. All conditions should have
Mark Yachoan advocates, but the speed at which diabetes is increasing makes us feel that ours needs even
more attention from policymakers and insurers in particular.
Design
Gina Wilson
In this issue, we have an inspiring interview with Dr. Francine Kaufman,
who traveled to six continents over the past year for a documentary titled,
“Diabetes- A Global Epidemic” – this premiered during the World Diabetes Day
commemorations. Dr. Kaufman is widely known for her work with children and obesity.
diaTribe But in the hour-long documentary, which was narrated by Glenn Close and generously
supported by Novo Nordisk, she shares with us stories both inspirational and heartbreaking
advisory board from other countries and other cultures, and she reminds us of our daunting challenge.
“No matter what,” she said, “you would be hard-pressed to be on this planet without having
Jennifer Block, RN, CDE diabetes affect your life.” You can next see the documentary on December 18 at 8 am EST or
Dr. Zachary Bloomgarden, MD you can watch it anytime at http://discoveryhealthcme.discovery.com/beyond/miniPlayer.
Dr. Bruce Bode, MD html?playerId=1312399220. A preview of the documentary is on our diaTribe video news
Dr. Nancy Bohannon, MD site at http://www.youtube.com/watch?v=mu2tEE0w5nw.
Dr. Bruce Buckingham, MD
Dr. Wendell Cheatham, MD diaTribe celebrates a fantastic first year anniversary. Please help us commemorate
Dr. Steven Edelman this milestone by filling out a short diaTribe survey at http://www.surveymonkey.com/s.as
Dr. Barry Ginsberg, MD, PhD px?sm=64MtTn9UeDen7Sh2IPsnSQ_3d_3d. We hope to continue growing from strength
Debbie Hinnen, CDE to strength with your valuable input and hopefully, your willingness to join our Patient
Dr. Irl Hirsch, MD Advisory Board.
Jeff Hitchcock
Dr. Lois Jovanovic, MD It is no longer news that there is diabetes news every day; we always try to focus
Dr. Francine Kaufman, MD on how any given trial, experiment, or product will affect an individual patient. That’s how
Dr. Aaron Kowalski, PhD
we live it and breathe it. All diabetes is personal, and we are the main characters in our own
Mirasol Panlilio
little dramas . . . but our stage is truly worldwide. On this note, happy holidays to our global
Dr. William H. Polonsky, PhD
community.
Michael Robinton
Jane Jeffrie Seley, NP, CDE
Peace,
Dr. Paul Strumph, MD
Virginia Valentine, CDE
Dr. Howard Wolpert, MD
Gloria Yee, RN, CDE
Kelly L. Close
2
www.diaTribe.us
Currently, 80 percent of continued from page 1

of comfort akin to having a great cut man in our corner of the ring. Dr. Silink delivered
diabetes medical care multiple presentations over four days and would inevitably touch on three things: his take
expenditures are from on the concept of the “tipping point,” the creation of a global fund for diabetes, and blue-
lit buildings around the world. The “tipping point,” popularized by Malcolm Gladwell,
developed countries characterizes the domino effect for an idea once a critical mass of support has been
while, paradoxically, attained. This was how the UN Resolution on diabetes gained traction last year, and this
is how Dr. Silink believes governmental actions, implementing the ideas laid out in the
80 percent of diabetic Resolution, will occur.
patients will soon live in Currently, 80 percent of diabetes medical care expenditures are from developed countries
low-to-middle-income while, paradoxically, 80 percent of diabetic patients will soon live in low-to-middle-income
countries. Bangladesh, a low-income country, took the initiative and spearheaded the UN
countries. Resolution on diabetes after the idea was brought to the UN by two determined spirits (see
below). diaTribe must point out that at the European Association for the Study of Diabetes
conference in 2006, Bangladesh was the sole country calling for a UN Resolution – there
was a tiny press conference with fewer than five of us present – huge kudos to the country
for making the impossible happen.
Naturally, we were happy that Dr. Silink mentioned Coit Tower in San Francisco, our
hometown, whenever he noted buildings lit in blue to raise awareness of diabetes. Check
out the diaTribe video on http://www.youtube.com/watch?v=bVI_BuOkPNk to see how
this happened and write to us at comments@diatribe.us and let us know if you saw a
building in your city light up blue on November 14 and tell us what it meant to you! We’ll
have a quotable quotes page about WDD next issue! We were so glad to see locally, that the
hard work with the International Diabetes Federation (IDF) and the mayor’s office came to
fruition – we hope San Francisco will continue to wake up, along with other cities around
the globe, and fight even harder to raise awareness about diabetes. With diaTribe, the Coit
Tower lighting was co-sponsored by the Diabetes Care Coalition (DCC), the American
Diabetes Association (ADA), Diabetes Mine, and Johnson & Johnson. We note that here
in the Bay Area, our esteemed mayor, Gavin Newsom, who signed the proclamation for
the lighting of Coit Tower began an impressive Shape Up! Program in 2006 to get people
moving – long may this continue!
Globally, icons were lit up to commemorate the day, including the Leaning Tower of Pisa,
the Sydney Opera House, the Sears Tower, the Taipei 100 Tower (the tallest building in the
world since 2004 no less), Niagara Falls, the London Eye, Seoul Tower, Moshe Aviv tower
in Tel-Aviv, Catedral de Lima in Peru, and of course the Empire State Building in New York
(see our photomontage at the end of this article).
The amazing Changing Diabetes Bus that we’ve now seen in South Africa (IDF ‘06), Chicago
Write to us at (ADA ‘07) and Berlin (ISPAD ‘07 – see this issue’s Conference Pearls) spent two days as the
center of a very hip diabetes village set up in the heart of Union Square in Manhattan. This
comments@diatribe. 56-foot mobile testament to Novo Nordisk’s commitment to diabetes education received
us and let us know if ~5,500 visitors and performed 439 diabetes screenings in a single day. In a day! Without
a doubt, diabetes awareness at its best. Once the highly regarded Dr. Alan Moses, Chief
you saw a building in Medical Officer for Novo Nordisk, had officially opened New York’s leg of the bus tour, we
were struck by the swiftness with which the visits occurred. New York was originally slated
your city light up blue on
as the final destination for the bus tour; however, true to Novo Nordisk’s commitment, diaTribe
November 14 and tell us learned that the tour would continue into 2008 – starting in France! Indeed, at the Changing
Diabetes bus, New Yorkers came, New Yorkers saw, and New Yorkers departed – equipped with
what it meant to you!
a pedometer to undertake healthy lifestyle changes – learning how to work practically toward
www.diaTribe.us
the American Heart Association’s goal of 10,000 steps a day.
The World Diabetes Day circular blue logo, featured on the lapels of many, underscores
that the global diabetes community must unify to combat the epidemic. This could not have
been more evident during the formation of the Human Blue Circle – hundreds of people
with blue umbrellas gathered in the UN’s Rose Garden, to listen to words from Dr. Silink
and Her Excellency Ismat Jahan, Permanent Representative of Bangladesh to the UN.
It was a powerful moment when about 700 umbrellas were hoisted up over about 1,000
people standing shoulder to shoulder with one goal in mind – get the word out about the
epidemic. Each step of the ensuing 246-step march – up First Avenue to the 59th St. Bridge
– represented a million people with diabetes worldwide, a statement that attests to the
power of community action.
In closing, we salute a very important and most unassuming group, the incredible
IDF’s Youth Ambassadors – the official advocates for the United Nations Resolution on
diabetes. Our enormous appreciation goes out again to Clare Rosenfeld and her mother,
Kari Rosenfeld – two exceptional and now very well known diabetes advocates. At age
17, Clare came up with the idea for the Resolution, which ultimately came into being in
2006. With the help of the IDF, she founded the International Diabetes Youth Advocates
– a dedicated group of 25 young people with diabetes striving to better the lives of people
with diabetes in their communities and worldwide. The Youth Ambassadors were out in
full force during the WDD events, and we look forward to chronicling more great work
from them over the coming years. diaTribe thanks you, for your perseverance and your
acumen in getting WDD off the ground. What an inspired and inspiring week and what a
way to get us ready for 2008.
A WDD diaTribe photomontage
ALL IMAGES COURTESY OF HTTP://WWW.WORLDDIABETESDAY.ORG/WDDGALLERY

Leaning Tower of Pisa – Italy
Niagara Falls – Canada

San Francisco Proclamation on
World Diabetes Day
The Human Blue Circle Great Buddha of Kotokuin –Japan Sydney Opera House – Australia
4
www.diaTribe.us continued on page 5
A WDD diaTribe photomontage
Kuwait Towers – Kuwait

The London Eye –UK
Taipei 101 – Taipei
Christ the Redeemer – Brazil Astana Baiterek – Kazakhstan Ponte Vecchio Florence – Italy
ALL IMAGES COURTESY OF HTTP://WWW.WORLDDIABETESDAY.ORG/WDDGALLERY

Fountain in Craiova – Romania Antwerp City Hall – Belgium
Spinnaker Tower – UK
Azrieli Center – Tel-Aviv Malgrate Castle – Italy

Tokyo Tower – Tokyo
5
www.diaTribe.us
quotable quotes
“No matter what, you would be hard-pressed to be on this planet without having diabetes
affect your life.”
—Dr. Fran Kaufman, explaining that everybody is the target audience of her World
Diabetes Day documentary, because everybody is affected, directly or indirectly, by
diabetes. See our complete interview with Dr. Kaufman in this issue’s diaTribe dialogue.
“In Sub-Saharan Africa, [in] a country like Mali, you live less than a year if you’re a child
and you’re diagnosed with diabetes.”
—Dr. Fran Kaufman discussing her recent multi-continent trip, which was covered by
Discovery Health.
“World Diabetes Day in New York and at the UN was phenomenal. What an experience to
see the world come together in blue and to recognize the effect that diabetes has on people
across the globe.”
—Dr. Fran Kaufman, when asked to describe her overall reaction to World Diabetes
Day.
“I want to see you bouncing in your seat.”

—Dr. Richard Atkinson, pointing out that people can burn up to 850 calories per day by
fidgeting.
finger sticks
6
www.diaTribe.us
diaTribe dialogue
Diabetes Warriors:
T1/2
The Stories Behind the Statistics
Dr. Francine Kaufman is a highly respected and well known pediatric endocrinologist.
She is the director of the Comprehensive Childhood Diabetes Center, and head of
the Center for Endocrinology, Diabetes and Metabolism at Children’s Hospital Los
Angeles. Dr. Kaufman recently completed a six-continent tour with a film crew from
Discovery Health – a collaborative effort led by Dr. Kaufman to draw attention to the
plight of children and adults living with diabetes around the world. The premier of her
documentary, Diabetes – A Global Epidemic, at the New York City Museum of Natural
History, was the first in a series of events leading up to World Diabetes Day celebrations
in New York on November 14th 2007. We believe the title of this piece speaks for itself. In
this interview, Dr. Kaufman discusses the making of the documentary and compares the
treatment of diabetes in America and abroad.
You can view Diabetes: A Global Epidemic online at http://discoveryhealthcme.
discovery.com/diabetes-global/diabetes-global.html
Kelly Close: Thank you so much Dr. Kaufman for taking time to speak with diaTribe.
Dr. Francine Kaufman Could you talk broadly about your recent multi-continent trip? What were the goals of the
program, how did it unfold, and who approached you to do this program?
Dr. Fran Kaufman: I actually approached them. I had the great opportunity to know Dr.
John Whyte when I was ADA president. We came up with the concept that diabetes, as a
worldwide epidemic, should really be shown in its entirety, including the entire globe. We
“
then asked for and received from Novo Nordisk, an unrestricted educational grant to move
We then asked for and ahead. And we pretty much chased the diabetes epidemic across the globe. So, we went to
every continent, save Antarctica! We really went in search of the stories of diabetes, the
received from Novo stories of the people affected and the stories of what we now call our Warriors – the health
Nordisk, an unrestricted care providers, the politicians, the people out there going into battle against diabetes every
day, on every continent. We featured a residential home in Cape Town in the townships, a
educational grant to place where children are sent when they’re diagnosed. Most of them have type 1 and can’t
go to live in their own homes because of lack of resources or lack of education.
move ahead. We pretty
much chased the Kaku Armah: Can you tell us more about those who were running the homes?
diabetes epidemic
“
Dr. Kaufman: This home was run by nuns – a German order that has been there for a
across the globe. long time, taking care of children with diabetes and with other health care needs as well. So,
there, the children do have access to insulin. They have meters, they have good nutrition,
and good opportunities for physical activities, but of course, they’re without their families.
And we captured this one child who was just incredible, who talked to us about [how] he
knows he’s healthier in the home and he’s actually crying as he’s telling us, he’s so genuine.
And he knows it’s good for his health, but he doesn’t really want to be there. He wants to be
with his family.
Kelly: Of course.
Dr. Kaufman: Any child would want to be. This is the effect of diabetes in countries and
in areas of countries in which there aren’t the resources to keep these children healthy and
www.diaTribe.us
well. So they age out at some point and then what happens? They just go back out into an
PHOTO COURTESY OF DR. KAUFMAN
environment in which there is little access and little opportunity to be able to survive. This
is particularly true in Sub-Saharan Africa, where in a country like Mali, a child lives less
than a year after he or she is diagnosed with diabetes.
Kelly: Wow. Just because they don’t have access to insulin?
Dr. Kaufman: They don’t have access to insulin or health care providers. If they have
insulin they don’t have enough strips and I can go on and on. The whole health care
Dr. Kaufman with children at paradigm is really not there. That is why programs like Life for a Child and Insulin for Life
the Tehuis St Joseph’s Home for are so important. These programs provide insulin at a markedly reduced rate and certainly,
Chronic Invalid Children in Cape Insulin for Life is getting a lot of donated insulin from around the world. But insulin
Town, South Africa. without strips, without meters, without education, without access to health care or some
kind of provider doesn’t get you anywhere. It’s not just, “We’ll send insulin down there.”
That’s what everybody thinks at the beginning, including me. Obviously, that doesn’t solve
“
the problem.
It’s not just, “We’ll send
Kaku: So, do they have the same problems there, as we have here, with physicians not
insulin down there.”
wanting to go into diabetes?
That’s what everybody
Dr. Kaufman: In Africa, certainly, type 1 [prevalence] is much less. It’s also much less
thinks at the beginning, common in Asia. But there are so many people in India and Asia. And actually, there are
including me. Obviously, a fair number of children who develop type 1 diabetes in these areas of the world. To care
for children with type 1 diabetes takes a lot training and in many areas care is not given by
that doesn’t solve the
“
physicians. It’s done more by nurses. So there has to be that capacity, and I think many
problem. areas of the world are overwhelmed with taking care of people with type 2.
Kelly: That’s interesting. What was your next stop?
Dr. Kaufman: We went to India where we visited the clinics of two very, very well-known
diabetologists – Dr. Ramachandran and Dr. Mohan – in Chennai. Each of their clinics
followed 100,000 people. But they’re very, very comprehensive… it’s pretty amazing. You
walk in, they’ve got dental care, and they’ve got a pharmacy that supplies medications and
devices. They actually have food that you can buy. [And they have] shoes… shoes are a huge
issue in India, going barefoot can lead to problems that put people at risk for amputation.
The clinics were truly comprehensive. You get all your diabetes education, medication, and
everything else that you need. So, they really end up giving you everything.
Kelly: Is this government funded?
Dr. Kaufman: No, it’s private. So, obviously it’s not accessible to everyone, which is
incredibly unfortunate. But they are committed to going out into rural regions, so we
followed them to rural India. We were in the outskirts of Chennai, hours away – you get to
the village and there is almost no electricity, no running water, people are living in huts,
the animals are all over. Dr. Mohan brings a mobile van out there with a satellite dish, so
Dr. Mohan’s mobile van with they’re doing retinal photos and sending it back to the main medical centers. They’re doing
oral glucose tolerance tests (OGTTs) – with a number of positive screens – and they’re out
satellite linkup to transfer retinal
just greeting everybody.
images from rural areas in
Chennai, India to urban medical Dr. Kaufman: Right after India, we went to Australia.
centers.
www.diaTribe.us
Kaku: Diabetes management in Australia seems to win a lot of praise – can you talk a bit
more about that?
Dr. Kaufman: Yes, they’re really aware of their epidemiology. Dr. Paul Zimmet and his
group have really led a huge effort. They’re teaching people weight training and healthy
lifestyles. Plus, I think they’re a bit more globally supported and promoted by their
government. There’s a big contrast because they’ve got a national health policy. I say this
all the time: every kid I take care of is going to lose their insurance. And so, they have
to scramble. They have to figure out some way to get coverage, and it’s just insane. It’s
completely insane that they can have diabetes and not have access to health care, supplies,
medications, and secondary preventive services.
“
I say this all the time:
every kid I take care of
is going to lose their
Kelly: How did you think about government support in the US compared to government
support in some of the other places that you visited?
Dr. Kaufman: Well the next place we went to was Finland. There, the cities have been
redesigned. They’ve been trying to work on reducing both their diabetes and cardiovascular
insurance. And so, they rates for a decade– it’s the North Karelian Project. The environment is a lot more health-
have to scramble. They promoting there. Everybody’s got access to health care. Prevention is a real aspect of the
health care business. So, they’re really set up to be able to do it. You go to a place like
have to figure out some Finland and you have envy. To me, the starkest contrast between the US and Finland
is that Finland has universal health care. The United States is behind the eight ball and
way to get coverage,
comparable, in some ways, to the developing world – South Africa – because of our lack of
and it’s just insane that access to health care for everyone.
they can have diabetes

Kelly: Who is the target audience for the documentary?
and not have access to
Dr. Kaufman: Anybody and everybody. Hopefully, those who live with diabetes will
health care, supplies, find something that resonates with them. Those who don’t know much about diabetes will
medications, and hopefully gain knowledge, at least, as to the scope of the problem and realize that it affects
each and every one of us in some way. No matter what, you would be hard-pressed to be on
secondary preventive
“
this planet without having diabetes affect your life.
services. — Please visit www.diaTribe.us/issues/7/diabetes-dialogue.php for the full version of
this fascinating interview. diaTribe was fortunate enough to be invited to the premier of
the film, Diabetes – A Global Epidemic at the Museum of Natural History in New York to
kick off World Diabetes Day celebrations. Remarked Dr. Kaufman, “World Diabetes Day
in New York and at the United Nations was phenomenal. What an experience to see the
world come together in blue and to recognize the effect that diabetes has on people across
the globe.” We wholeheartedly agree.
Dr. Kaufman with some of

PHOTO COURTESY OF DR. KAUFMAN
the International Diabetes

Federation Youth Ambassadors
in Cape Town, South Africa.
9
www.diaTribe.us
logbook
In Search of Reimbursement: A CGM Odyssey
T1 By James S. Hirsch
W
ill continuous glucose monitoring (CGM) revolutionize diabetes
care? Companies are investing hundreds of millions of dollars.
The Juvenile Diabetes Research Foundation (JDRF) has made
a significant commitment; and at least one top diabetes expert, Jay Skyler,
believes CGM will replace finger-stick tests in five years.
But the ultimate But the ultimate acceptance of CGM may hinge less on the
technologists, the health care providers, or even the patients but on
acceptance of CGM another group entirely – the insurers.
may hinge less on the If insurers were principally interested in the health of its customers, it would gladly
support a medical device that, when properly used, offers clear benefits. But private
technologists, the health insurers are in business to make money; and public insurers, Medicare and Medicaid,
already face spiraling health care costs.
care providers, or even
So convincing payers that a medical device like continuous sensors – new, expensive,
the patients but on unproven over the long run – should be reimbursed will be difficult.
I speak from experience.
another group entirely
This past summer, I was asked to use the DexCom SEVEN for a six-week trial. As
– the insurers. I’ve previously written (diaTribe issue 5 Test Drive), I’m not a technology expert and did
not particularly covet CGM, but my experience with this device was quite favorable. The
system still has its glitches, but knowing in real-time what your blood sugar is – and which
direction it’s heading – could have life-saving advantages. The sensors’ real power, in my
judgment, is less physiological than psychological, forcing patients to be more engaged with
their diabetes.
In my case, the DexCom SEVEN allowed me to fine-tune my overnight basal rates on
my insulin pump, caught several lows before I did, and improved my control. Over the past
20 years or so, my A1c’s have consistently been in the mid to high 6’s. My A1c, using the
sensors for only six weeks, was 6.1 (A1c’s measure average blood sugars over three months).
Put me on the SEVEN for three months, and I would easily post an A1c in the 5’s, with little
fear of hypoglycemia.
So when my trial with the SEVEN ended, I wanted to continue. If I were beginning
from scratch, the start-up kit costs $800, which includes the receiver (which displays
your glucose readings) and the transmitter (which attaches to your body and relays the
numbers). I already had the equipment; I just needed to pay for the disposable sensors:
each one costs $60 and lasts for seven days. If you wear one constantly, the cost is $240 a
month, or $2,880 a year. Throw in extra glucose strips for calibrating the device, and you’re
looking at $3,000 a year.
I wouldn’t say $3,000 would bankrupt our family, but it’s enough to seek
reimbursement – and certainly enough to deter many patients, perhaps myself included,
from using CGM.
So I asked my insurer, Harvard Pilgrim HealthCare of New England, to cover the
DexCom STS SEVEN continuous sensors. DexCom actually filed the paperwork, which is apparently standard among medical
glucose monitoring system
device companies – I’ve used three different insulin pumps, and each company had its
own staff to deal with the insurers. As part of the application, my physician wrote a letter
explaining why I needed a continuous sensor.
As it happens, my need was more than an amorphous appeal to “better control.” Three
years ago, I had passed out from hypoglycemia while driving on the highway. My son, then
www.diaTribe.us
age 3, was in the backseat. The car veered off the highway and flipped over like a 4,400-
pound pancake. Miraculously, no one was hurt or even scraped. My son vaguely remembers
it like he would a roller coaster ride.
My doctor cited the incident in his letter, noting that I am “vulnerable to severe episodes
characterized by confusion and loss of consciousness . . . [and] this device is necessary for
Mr. Hirsch’s well-being and safe care.”
On September 12, Harvard Pilgrim sent me a letter rejecting my application. There was no
information on why it was rejected, except that the service is not covered under my benefit plan.
The result wasn’t surprising – we simply don’t have enough clinical evidence to
persuade payers of CGM’s benefits. The technology is too new, and clinical trials are time-
consuming and expensive. Some studies are taking place, with the JDRF’s 10-site trial
As it happens, my need being the most ambitious. But until CGM’s benefits – improved glycemic control and less
hypoglycemia – are clearly documented in peer-reviewed journals, insurers will balk at
was more than an
reimbursement. (One positive note: The Centers for Medicare and Medicaid Services have
amorphous appeal to issued billing codes for CGM, beginning January 1, which will ease the processing of claims;
details can be found at www.jdrf.org/artificialpancreas.)
“better control.” Three Some patients have received coverage for CGM, but those decisions are made case by
years ago, I had passed case. Policies vary by insurer and region. The best advice to any patient, once rejected, is to
appeal, appeal, and – when all else fails – appeal again.
out from hypoglycemia So after I was rejected, I appealed, writing a letter to Harvard Pilgrim on September 19.
while driving on the “You didn’t indicate why [CGM] is a ‘benefit exclusion,’” I wrote, “but I would like to share
why I believe the product is a necessary benefit.”
highway. My son, I noted that the cost of maintaining tight glycemic control for type 1 diabetes (insulin,
glucose meters, etc.) is relatively small compared to the cost of treating complications
then age 3, was in
(kidney failure, heart disease, etc.), which is why most insurers cover these basic supplies.
the backseat. The car But even with improved pharmaceuticals and devices, achieving near-normal blood sugars
is difficult because so many variables change glucose levels, the most obvious being food,
veered off the highway
exercise, and insulin. “Moreover, blood sugar levels vacillate wildly because of stress,
and flipped over like a anxiety, or mood changes. They fluctuate when your mother-in-law visits or when the Red
Sox are playing the Yankees, when you’re on a job interview or a date or a bumpy plane
4,400-pound pancake. ride, when your favorite department store has a huge sale or when you’re drawing to an
Miraculously, no one was inside straight. In other words, life changes your blood sugar.”
I explained why CGM’s “trend lines” are so important – patients not only know what
hurt or even scraped. My their blood sugar is but where it’s heading, and why that information can pre-empt a severe
son vaguely remembers low or curtail an impending high. I also described my car accident, in which my son and I
were required to visit an emergency room. “My son got a peanut butter and jelly sandwich;
it like he would a roller I got a Band-Aid. Our combined bill: $1,397, which our insurer covered.”
I also discussed my experiences wearing the DexCom SEVEN, concluding, “If I had [the
coaster ride.
device] three years ago, I’m confident I would not have had the accident.”
I acknowledged that the sensors are not cheap but wrote that I believed “they will
ultimately save insurers money through fewer Emergency-Room visits, better glycemic
control, and fewer complications . . . common sense should dictate that any product that
reduces hypoglycemia and improves glycemic control is worth covering in full.”
On October 17, Harvard Pilgrim rejected my appeal. The bizarre part was why.
Harvard Pilgrim said it “does not cover glucose monitoring systems that are not linked
directly to an external ambulatory insulin infusion pump,” and that a “Physician Advisor”
had reviewed “the product information available on the Dexcom web site [and] determined
that [the SEVEN] is not directly connected to an insulin infusion pump.”
My first thought was: I hope Harvard Pilgrim did not pay this Physician Advisor a lot of
money to learn something – that the SEVEN is not connected to a pump – that I could have
www.diaTribe.us
“
[Blood sugar levels]
fluctuate when your
mother-in-law visits or
told Harvard Pilgrim for free.
My second thought was: What possible rationale does Harvard Pilgrim have for covering
continuous sensors linked to an insulin pump, but not the sensors by themselves?
Harvard Pilgrim did acknowledge that “there is no question that the system would be
very helpful in monitoring your insulin levels,” which led to my third thought: the system
when the Red Sox are doesn’t measure insulin levels (it measures blood sugars), so how in the hell can Harvard
Pilgrim pass judgment on something that it doesn’t even understand?
playing the Yankees,
I called my “Appeals Analyst,” Kay Frye, who said Harvard Pilgrim would only
when you’re on a job reimburse such a product if coverage were mandated by state law or if the product was
included in the existing benefits negotiated by my wife’s employer.
interview or a date or
So I now had several options. I could move to another state, if any exists, that mandates
a bumpy ride. In other CGM coverage. My wife can quit her job and find an employer who might include CGM
in its benefits. I can sue Harvard Pilgrim. Or I can seek an external review by writing the
words, life changes your
“
Massachusetts Department of Public Health.
blood sugar. I am seeking the latter, and a DexCom manager is helping me prepare my appeal.
Presumably, if the state health department deems that CGM is necessary for me, Harvard
Pilgrim will relent.
I’ll let you know my results. Until then, if you want some tips on how to win CGM
coverage, check out JDRF’s helpful Web site, www.jdrf.org/cgmcoverage.
Good luck.
conference pearls
International Society For Pediatric And Adolescent
T1 Diabetes (ISPAD)
ISPAD is the only international society specifically for all types of childhood diabetes
– most commonly, type 1. This year’s ISPAD meeting took place at the stylish Berlin
Convention Center in Alexanderplatz, Germany. It was billed as the biggest ISPAD
meeting yet, with 1,300 people from 66 countries; the theme was Diabetes in Motion,
which highlights the remarkable momentum in our field. Witness the declaration by the
International Diabetes Federation (IDF) and the World Health Organization (WHO) that
2007-2008 is the Year of the Child and the Adolescent with Diabetes
• The Diabetes Attitudes, Wishes & Needs (DAWN) Youth global program
was a highlight of the meeting. This initiative, sponsored by Novo Nordisk, aims to
raise awareness of the psychological, social and educational support needed for children
and adolescents with type 1 diabetes – most notably centered around depression.
Hopefully, the study will provide insights to physicians and policymakers alike, both
nationally and globally.
The study includes surveys such as the DAWN Youth WebTalk, which is taking place in
nine countries. The effort is designed to be a conversation among youth, their families, and
the medical community to help patients play a more central role in their care. Early results
from this survey indicate that 40-50 percent of parents report that their child’s academic
performance is affected by diabetes. Some recommendations so far include:
• The need healthcare providers to recognize and treat the psycho-social aspect of
the disease as well as the physical aspect as part of routine care.
• Development of age-appropriate support programs.
• Better education of school personnel about diabetes.
www.diaTribe.us
The conference panel that discussed the DAWN study pushed for regulation to allow school
staff to help children with diabetes. In most European countries, children have to rely on friends
or school staff. In most other countries, including the U.S., staff and school nurses are often
not permitted to help students with diabetes treatments like their testing blood sugar or giving
insulin injections. Furthermore, a large percentage of school staff and nurses are not trained to
deal with hypoglycemia or other diabetes emergencies. This is disheartening, and we hope that
this study corrects these shortcomings – there’s a long way to go.
You can be a part of this survey by visiting www.dawnsurvey.com/webtalk and
completing the online questionnaire with the survey code NWS1.
• While at ISPAD, diaTribe also learned that the incidence of type 2
diabetes in children is increasing dramatically in almost all countries. In the
U.S. there was a 10-fold increase in incidence from 1990-2000. In Australia there’s been
a 5-20 percent increase per year since 2001. In Japan, the incidence of type 2 increased
dramatically in the 1980’s, remained high until the early 2000’s, and now incidence has
fallen, probably due to improved public healthcare measures. This marks the first country
in which the trend has been reversed.
A panel discussing this issue suggested that in rich countries, the challenge is making
the system work for children. “The U.S. has so many systems (that) we really have no
system, said Dr. Stuart Brink, a pediatric endocrinologist. In poorer countries, children
die because of poor access to care. Lack of insulin, for example, is still the leading cause
of death of children with diabetes. In these countries, multiple daily injections (MDI) are
the best way to reduce diabetic complications, but the majority of people with diabetes are
not on MDI, even if they can get insulin. The panel also noted their surprise that after 30
years, the cost of self-monitoring of blood glucose is still so high. A child could be supplied
with insulin for $225, but it costs $700 a year for blood glucose monitoring. While these
numbers may not be the most daunting, they often represent entire annual salaries in
developing countries. What would you do if you had to pay your entire annual salary to buy
the drugs to keep yourself or your child alive?
• Also at ISPAD, there was a fascinating session on the perception of pain,
sponsored by Terumo, a Japanese medical products company. Pain is not felt in
the same way by different people, and this is particularly true with needles and lancets. In
the 1920’s, people with diabetes were given a glass syringe, two (huge) needles and a file (to
sharpen the needles). Ouch! Do needles still hurt – or is the pain psychological?
In studies by Dr. Ragnar Hanas of Uddevalla, Sweden, some 28 percent of children
reported a fear of needles (and 35 percent of their parents!). Eight percent of kids said they
couldn’t concentrate because they feared their next injection. It also turns out that there is a
pain memory – early childhood pain means a greater sensitivity to pain in later life. To deal
with injection pain, Dr Hanas was a big proponent of using ‘injection ports’ – in-dwelling
catheters – such as the Insuflon or the I-Port.
Meanwhile, Dr. Thomas Danne presented a trial he performed on the Terumo Finetouch
lancet. It turned out that the absolute “pain perception” with Terumo was much lower
than with conventional lancets. This may be because the Terumo lancet has a hollow-bore
needle, and its entry into the skin is very shallow.
The investigators lanced 164 children with their hand inside a ‘black box’. At random,
they used the Finetouch lancet, a conventional lancet and a placebo (a click only, without
a needle inside the lancing device). The Finetouch was only painful 46 percent of the time,
versus 69 percent for conventional and 8 percent for the placebo.
This study showed a real difference with the Terumo lancet, but sadly this product is not
available in the USA, and the company tells us that it has no immediate plans to market it
here. Let’s hope another company can find a way to innovate on pain reduction.
13
www.diaTribe.us
SUM Musings
Pumping, After a Fashion
T1 By Kerri Morrone
Kerri Morrone has been living with type 1 diabetes for almost twenty
years. She writes a much-trafficked diabetes blog, Six Until Me (SUM),
and is an active member of the diabetes community. She is known for
her tagline, “Diabetes doesn’t define me, but it helps explain me.”
The frustration of feeling
F
or so many years, I had avoided making the switch to an insulin
like a human pincushion
pump because I didn’t feel ready for any external signage
all came to a head one advertising my diabetes. For over 17 years, I had lived with
quiet injections and subtle finger pricks, which made switching to a pump the oddest
night, when I was taking
combination of pride and fear. And people only knew I had diabetes if I chose to tell them.
my fifth injection of the The frustration of feeling like a human pincushion all came to a head one night, when I was
taking my fifth injection of the day; something inside of me broke in two pieces and my fear
day; something inside of mixed with strength like socks in the laundry. I called my doctor that night and left a long
me broke in two pieces message on her machine, asking her to write me a prescription. Within a few weeks, I was
sitting at the Joslin Diabetes Center in Boston, attending my first pump training class.
and my fear mixed with When I first started pumping, I felt so strange with this machine clipped to the
strength like socks in the waistband of my pants. Unsure of how ready I was and worried about the perceptions of
other people, I chose to wear the pump completely exposed, with the tubing loose and the
laundry. device completely visible. The novelty of the pump and my inexperience had me constantly
pushing the buttons and touching my hip to make sure it was still there. To be perfectly
honest, I was terribly proud of myself for taking the pumping plunge. I wanted people to
see it… I wanted people to ask. Their questions gave me an opportunity to educate and
helped me gain a definite level of comfort.
However, as I became more at ease with the insulin pump and its novelty wore off a bit,
I wanted to be in control I started making it less of an accessory to my outfits and more of a concealed instrument. I
wasn’t ashamed of being diabetic or wearing an insulin pump, but I wanted to be in control
of who knew I had of who knew. I am very proud of my decision to pump and elated with the profoundly
positive effects it has on my diabetes management. Keeping the pump under literal wraps
diabetes. But I also
had nothing to do with shame but was more about being seen as “Kerri” before I was “Kerri
wanted to be in control of the diabetic.” I wanted to be in control of who knew I had diabetes. But I also wanted to be
in control of the diabetes itself.
the diabetes itself. At first, I wore my pump clipped into the pocket of my jeans. This was an acceptable
place when I was dressed casually, but moving forward as a woman in my twenties brought
me into a more professional environment, where I left my jeans at home and instead
introduced skirts, suits, and dresses into my wardrobe. When I was interviewing for
different jobs, I wore my best black suit, a crisp button-down, and my insulin pump clipped
discreetly into the waistband of my pants, undetected by everyone. When I go out with my
friends, my pump ends up tucked into the back pocket of my pants. And a few weeks ago,
when I ordered my wedding gown, the seamstress and I talked about the pocket she was
going to create so my pump would not be the focal point on my wedding day.
Hiding an insulin pump can be done, but sometimes it takes a bit of trickery. Since I
am using a Medtronic MiniMed 512 these days, I have both the pump itself and the tubing.
I’ve done just about everything to keep my pump out of sight. When I don a fancy dress, I
tuck the pump discreetly into the front of my bra. Depending on the neckline of a dress,
sometimes the pump ends up secured in the side of my bra, underneath my arm. I’ve used
www.diaTribe.us
I once rigged up a little the “thigh thing” favored by so many people with diabetes. It is a garter-esque piece of
fabric with a sleeve attached, allowing for the pump to stay wrapped around my leg. And
contraption using the clip in a moment of desperation, I once rigged up a little contraption using the clip on straps to
on straps to a convertible a convertible bra, the case from the thigh holster, and a slip of duct tape. MacGyver’s got
nothing on me!
bra, the case from the My favorite spot is to hide the pump in my sock, which is a move I wish I had figured out
years ago. With the infusion set on my thigh and the tubing snaking down my leg, a tight
thigh holster, and a slip of
trouser sock keeps the pump resting neatly against the side of my shin.
duct tape. MacGyver’s The biggest problems I’ve experienced concealing the pump have centered on bolusing.
Hiding it in my bra is one thing, but reaching in and digging around for the pump before
got nothing on me!
meals makes for an interesting ice-breaker. However, my options range from foraging to
using a pump remote to excusing myself to the bathroom. I’d never sacrifice my health for
fashion, so even these frustrating moments of pump-wrangling come second to controlling
my diabetes.
Admittedly, insulin pumping and all of its maintenance can be a bit of a burden. But
when I’m looking at my blood sugars and how much tighter they have become, wearing an
insulin pump has given me a stronger sense of control. Within three months of starting on
my insulin pump, my rattled A1C dropped from a frustrating 8.3 percent to 6.4 percent, my
dawn phenomenon had met its match, and my lows became less frequent.
It’s fashionable to be healthy.
learning curve
Inhaled Insulin: Into Thin Air?
T1/2
By Mark Yarchoan
E
xubera never caught on, but several powerhouse companies are still betting on
inhaled insulin. Does inhaled insulin have a future, or are other efforts bound to
vaporize as well?
At this point, all we know is that Exubera’s was one of the costliest flops in the history
of the pharmaceutical industry. Exubera had been in development for over 10 years,
and its manufacturer (Pfizer) believed that it would be a very successful drug that would
revolutionize the treatment of diabetes. However, in spite of high expectations and heavy
promotion, Exubera failed to gain market traction – its sales amounted to less than one
third of one percent of the insulin market. Pfizer pulled Exubera from the market in
Lack of simplicity wasn’t October, less than two years after the drug was first approved, citing poor sales and little
faith in the products’ future. The episode cost Pfizer $2.8 billion. What went wrong with
Exubera’s only problem. Exubera?
We also believe Pfizer
Exubera’s Exuberance
underestimated the The bottom line, in our view, is that Pfizer was trying to introduce a consumer product
that wasn’t friendly to the consumer at all. It was just too complicated. We can point to
challenge of getting type
the simplicity of Lantus, Januvia, and the OmniPod insulin pump as major advantages
2 patients on insulin. for these therapies/ technologies that are enjoying great levels of success Exubera didn’t
have this. Lack of simplicity wasn’t Exubera’s only problem. We also believe Pfizer
“Insulin initiation,” as they underestimated the challenge of getting type 2 patients on insulin. “Insulin initiation,”
say in the business world, as they say in the business world, is just plain hard. National statistics show that over 60
percent of type 2 patients are not at A1c goal but only 29 percent of type 2 patients are on
is just plain hard. insulin. Ironically, insulin carries a stigma that deters many type 2 patients from its use,
www.diaTribe.us
and many physicians are also not eager to introduce the therapy either because they are
poorly reimbursed for their time and training or because they are pooly trained themselves
and don’t understand it well enough to help patients. A number of other factors contributed
to Exubera’s quick demise as well, in our view.
• The inhaler was first-generation and imperfect – like many “first”
generation medical devices. We don’t think Pfizer should have advertised Exubera
as “simple and trouble-free as an asthma inhaler” because the reality was far different.
If a company isn’t straightforward with patients, that’s the first mistake! The inhaler
resembled a bulky stapler, making it troublesome to carry around – perhaps if Pfizer had
acknowledged this and discussed how it was working to make improvements, that would
have helped (the next version would definitely have been better!). Pfizer also seems to have
underestimated other elements, like difficulty in cleaning.
• Long-term safety wasn’t yet established. Exubera caused a decrease in
lung size and breathing ability in some patients. Although Exubera’s short-term
IMAGE COURTESY OF ALKERMES
safety was well documented (we had seen some eight-year data at EASD in Amsterdam last
fall), and in most cases breathing difficulty could be reversed when discontinued, long-
term safety concerns about Exubera lingered. Moreover, patients were required to undergo
lung-function testing both before using Exubera and after six months of use – this was also
seen as “high hassle factor.” Sad to say, lung function testing presented an inconvenience
to patients as well as to overworked physicians who sometimes didn’t even know where to
The Alkermes/Eli Lilly inhaled advise patients to go for the tests.
• Dosing was generally burdensome. Whereas injected insulin is traditionally
insulin device, AIR Insulin
prescribed in international units – no complicated conversion required – Exubera was
placed next to an IPod Nano
prescribed in milligrams. A single milligram of Exubera was equivalent to about three units
for size comparison. of insulin, but this relationship was not linear. For example, three milligrams of Exubera
were equal to eight units of insulin rather than nine. That’s confusing – and we think we’re
good at math!
• Exubera was more expensive than injected insulin, and provided no
benefits in efficacy. As a result, many insurance companies balked at paying for it.
Almost every state’s Medicare program as well as many private insurers placed Exubera
in their most expensive tier. Exubera cost about $5 per day, compared to about $2-3 for
insulin taken using a syringe and vial or a pen. Similarly, the National Health Service in the
UK recommended against the use of Exubera because it had not been proven to be more
effective than existing treatments. Germany also wouldn’t pay for it.
• The actual benefits were outweighed by drawbacks and were not broadly
characterized as “breakthrough.” For patients with “needle-phobia,” Exubera did
provide some relief from needles in administering rapid-acting insulins. Nevertheless,
certain patients still needed to inject insulin in addition to taking Exubera. There really
wasn’t precedence for people to go on mealtime insulin before long-acting analogs
– perhaps more studies should have been done on this front. Additionally, the needles
for insulin have shrunk so significantly over the last decade that the burden of injections
has decreased – as has the perception of the burden of diabetes! To most patients, the
advantages of inhaled insulin did not outweigh the disadvantages. Furthermore, physicians
felt encumbered in prescribing Exubera due to its complex dosing and lung function tests.
• Pfizer didn’t do a standout job marketing or selling Exubera. Although
Pfizer developed Exubera with another company, Nektar Pharmaceuticals, we didn’t have
the impression that Pfizer took full advantage of this collaboration – Nektar likely could
have advised Pfizer better than anyone. In fact, Nektar, which received royalties from
Exubera sales, was not even warned by Pfizer that the drug was going to be pulled from the
market. Optimal communication between two parties is always difficult but here, it seemed
particularly absent. We believe this would have helped Exubera succeed in the marketplace.
www.diaTribe.us
Lessons learned and future directions

Pfizer was actually co-developing a second generation of inhaled insulin with Nektar called
Next Generation Inhaled (NGI) insulin, but announced it would discontinue that effort
as well. The inhaled insulin market is now completely open, and some manufacturers
– MannKind, Novo Nordisk, and Eli Lilly (partnering with Alkermes) – continue to pursue
their own inhaled insulins.
MannKind is developing a product called Technosphere Insulin (TI). So far, over 3,000
patients have been treated with TI, and MannKind plans to launch this by late 2009 or
2010. Since Exubera’s demise, MannKind has made notable attempts to differentiate TI,
arguing that it will offer clinical advantages over vial insulin. Whereas Exubera peaked
about an hour after administration and was therefore no more rapid than other available
rapid-acting insulins, MannKind claims that TI will be absorbed in the blood stream almost
instantaneously and will peak in only 12-14 minutes – much faster than other available
rapid-acting insulins. This, the company says, will help to normalize post-prandial glucose
We cannot stress
levels and will lower the risk of hypoglycemia. We could all use less hypoglycemia, that’s for
enough that insulin sure. If MannKind can deliver on the promise, this should be positive for patients.
TI should also be simpler for patients to use than Exubera. MannKind has previously
initiation is hard
announced that TI insulin will be dosed in units (not in milligrams) – this should be easier!
enough with the fear of – and will be administered by a device that is “small, simple, low maintenance, and easy
to use.” Also importantly, the existing four clinical trials of TI have shown no decline in
hypoglycemia, weight lung function. Long may that last! Although lung-function testing will most likely still
gain and healthcare be mandated for TI users, the lung “sparing” of TI may help to convince patients and
physicians of its long-term safety.
provider reimbursement. Alkermes and Eli Lilly and have teamed up to create an inhaled product called AIR
We praise all efforts Insulin. From what we’ve seen, their device is less than half the size of the Exubera unit. We
believe size and portability are very important.
to develop new, more Novo Nordisk’s inhaled insulin product, AERx IDMS is currently undergoing phase 3
studies. This device will use a single unit increment dosing system to deliver insulin. It is
convenient, and safer
expected to come to market within the next few years.
insulin-delivery methods. These drug manufacturers know that many diabetes patients say that, all things being
equal, they would rather receive insulin by inhalation than injection. Pfizer proved that
inhaled insulin is possible and safe. Now, it’s somebody else’s turn to give us an inhaled
insulin product that a good number of patients want to use. We cannot stress enough that
insulin initiation is hard enough with the fear of hypoglycemia, weight gain and healthcare
provider reimbursement. We praise all efforts to develop new, more convenient, and safer
insulin-delivery methods.
Test Drive
Measured Strides Away from Pre-Prediabetes
T2 By Kaku Armah
U
nder normal circumstances, I would not even dream of owning
a pedometer. However, things changed for me during the World
Diabetes Day celebrations in New York. At one event, I had my
A1c checked, and it was 5.9 percent. Good? Bad? On one hand, I have not
been diagnosed with diabetes, but on the other hand, that number is higher
than I’d like. I had tested at 5.2 percent and 5.9 percent on two different
machines on the same day so I keep convincing myself that these values
www.diaTribe.us
are more a reflection of imprecise A1c measurements – and not because of my routine
ice-cream comfort scoops before bed. After three days of celebrating diabetes awareness in
New York, I decided to take a more proactive stance, concluding that I was teetering on the
edge of what I like to call “pre-prediabetes”. I picked up one of many free pedometers from
the Novo Nordisk booth (thank you!) and became a step-counter. Armed with the ipod–
shuffle sized device strapped to my belt, I now can keep track of how much I move.
How does a bottom-dollar pedometer work? It has a tiny mechanical sensor that
“counts” steps by taking into account how much the body shakes when walking. The shock
from feet hitting the ground or a hip movement is sufficient to move the step counter
forward by one unit. More advanced pedometers allow you to set body weight and step size.
Mine is a more bare-bones model, featuring a single button marked “R” for reset. I think
that’s pretty much all I need.
In my frustration, I gave I have to tell you, the first few days of owning a pedometer were eye-opening. I thought
I was hitting the American Heart Association (AHA) target of 10,000 steps a day without
the pedometer more even trying – but my pedometer showed only a measly 450 steps. In my frustration, I gave
than a few “accidental” the pedometer more than a few “accidental” shuffles while I sat watching television at
the end of the day. It wasn’t entirely my fault. I stayed just a few blocks from the United
shuffles while I sat Nations building, where a lot of the events were taking place; hence my low mileage.
The next day, I decided that circumnavigation was going to be the only way to put up a
watching television at
good score – I was already becoming competitive. In a day, I became the most inefficient
the end of the day. walker in the city. I actually contemplated going up all the down escalators instead of
taking the stairs in the UN building, but the surly security guard – with his surly baton
– convinced me otherwise. Needless to say, I posted numbers in the high 3,000s at the end
of the day. Still not at the AHA target, but I figured I was on the right track.
Fast forward three weeks and I’m back in San Francisco, pedaling my bike up from
Fulton Street to Divisadero Street. This goes without saying, but I will say it anyway: When
San Franciscans say up, they mean UP! There are some days when the only thing that keeps
me from simply walking my bike is the little pinch under my belly button from my Peddie
(yes, that’s what I named him), and I don’t care if he does rhyme with Teddy. Since there
is less shock registered from riding, I usually don’t get very accurate results; so I devised
In a day, I became the
a simple formula where I just multiply the value on the pedometer screen by a “fatigue
most inefficient walker factor” when I get home, and that seems to be pretty “accurate.” Not the most scientific
procedure but it makes me feel better about the hills I have to conquer everyday.
in the city. I actually
I have saved the best news for last. The most steps in a day that I have recorded so far
contemplated going up is 7,452! And this was the day after Black Friday when I went to engage in a bit of retail
therapy while taking a break from studying for the GREs. Having a pedometer is a great
all the down escalators excuse to shop, if you want my opinion. That said, I did return home for an amazing shrimp
instead of taking the salad, so you can forget about grabbing a quick bite at some fast food chain just because you
are out shopping.
stairs in the UN building, Do we really need to have constant reminders to do basic things like walking, drinking
but the surly security enough water, flossing, and checking traffic before crossing the road? It almost seems inane
that I need some element of competition in order to actively engage in healthy living. But
guard - with his surly hey, this seems to be working for me so I’ll roll with it – or should I say stroll with it.
baton - convinced me
— Kaku will be back in a future issue of diaTribe doing a head to head test of two
otherwise. pedometers. If you have a particular device you have been eyeing and would like to see in
test drive, please contact us at comments@diatribe.us. As always, we’d love to have your
input.
18
www.diaTribe.us
what we’re reading

The Diabetes Barometer
T1/2
Barometers have never quite conjured up the image of ~80 pages of hard hitting
truths and revealing statistics on diabetes. At least not until a week before World Diabetes
Day 2007 when Novo Nordisk published the first report of its Changing Diabetes
Barometer. It has taken us a fair amount of time to understand the important role this vast
“global pressure gauge” will play in diabetes as this epidemic unfolds.
PHOTO COURTESY OF NOVO NORDISK
The The Novo Nordisk Changing Diabetes Barometer is an annual collection of facts,
figures, ideas, and innovations based on data collected nationally and internationally.
Lise Kingo, Executive Vice President at Novo Nordisk, best explained the concept of the
barometer when she said, “We have been driving the fight against diabetes in the dark
for far too long. We need to put the lights on. We need to keep score of our shared efforts
against diabetes to drive sustainable change.” While patients, families, physicians, and
industry attack diabetes from multiple angles, it is important to keep a record of all
approaches, progress ,and results. This record will help thought-leaders to better map out
new research directions since we cannot know where we’re going if we do not know where
we have been.
In this first volume of the Barometer, Novo Nordisk covered 21 pilot countries. They
highlighted the achievements of a subset of these countries that have had national diabetes
associations for long enough to have faced substantial challenges and overcome them. The
report discusses trends key to diabetes prevention and management globally. One finding,
for example, was that only a third of the countries studied regularly track key measures
like blood glucose, blood pressure, and cholesterol levels. To boot, the report found that
very few of the countries have the right systems in place to accurately measure diabetes
statistics.
We look forward to the second volume, which will provide further examples of best
practices in diabetes worldwide and include information on the Changing Diabetes
Barometer Scholarship.
A letter of concern to the New York Times

T1 Dr. Lawrence Soler of the Juvenile Diabetes Research Foundation (JDRF) wrote
a letter to the New York Times on November 27 regarding what we would agree was a
substantial oversight in a November 20 piece entitled “Twins on a Medical Odyssey After a
“
Diagnosis of Diabetes” (http://www.nytimes.com/2007/11/20/health/20diab.html). The
The program that is touching story describes how Ali Newman’s diagnosis of type 1 diabetes may have been
enough of a forewarning to prevent a similar diagnosis in her twin sibling, Marissa.
paying for this [type 1 Marissa is the first enrollee for an oral insulin study run by the Type 1 Diabetes TrialNet
– a network of diabetes research centers funded by multiple organizations including the
diabetes] research may
NIH/NIDDK, JDRF and the American Diabetes Association.
well be closed down What Dr. Soler points out in his abridged letter is that, despite the promising work being
done on diabetes, “the program that is paying for this (type 1 diabetes) research may well
unless Congress takes
be closed down unless Congress takes action by year’s end [2007].” In a conversation with
action by year’s end diaTribe, he mentioned that 35 percent of federal type 1 funding will be lost if the NIH’s
“
Type 1 Special Diabetes Statutory Funding Program is not renewed. This could potentially
[2007]. affect 60,000 clinical research participants.
He called on diaTribe to help get the message out about the JDRF’s Promise to
Remember Me Campaign, where ordinary families affected by diabetes contact their
Congressional representatives. This is the JDRF’s top legislative priority and you can
help this effort by visiting http://promise.jdrf.org/. Check out diaTribe Editor Kelly
www.diaTribe.us
Close’s blog on this campaign at http://www.revolutionhealth.com/blogs/kellyclose/jdrf-

promise-to-remem-7776. Let’s go out and get some promises! What else can you do?
Think about reimbursement, another big priority, and sign our petition that we’re going
to send to governments around the globe to show them we really care! Visit http://www.
surveymonkey.com/s.aspx?sm=CeG1e2pg7dS0ajPv26na9g_3d_3d.
NewNowNext
aDorn and accessorize
T1/2
There are times when we would rather just leave our ungainly diabetes equipment
(and our diabetes for that matter) at home. While the latter isn’t practical, aDorn designs
PHOTO BY JENNIFER DORN
has developed a way to transform the bulky into the elegant. Each style of bag has a pouch
– which is detachable from the main bag – where diabetes supplies can be stowed. Founder
Jennifer Dorn told diaTribe that her signature detachable pouch – tagged the aDorn
clutch – gets tucked away “magnetically, securely and stylishly” behind the bag forming
the hallmark of the brand. Our favorite is the aDorn Messenger bag that can fit up to a 17”
laptop as well as a watertight ice pocket to keep insulin cool, if the intensity is high enough
The aDorn messenger bag in your life that you think you need it! Visit http://www.adorndesigns.com/index.html to
– hideaway pouch elegantly check out all the styles. Enter diaTribe exclusive promotional code ADORNDIATRIBE to
stores diabetes supplies receive a $15 discount on your first purchase.
trial watch
Getting to the bottom of the incretin debate
T2 http://www.clinicaltrials.gov/ct2/show/NCT00469833?term=byetta&recr
=Open&rank=18
This study seeks to understand the defects of insulin secretion that lead to abnormal
breakdown of glucose in diabetes patients. It will focus on the incretin effect, which you can
read more about in issue 5 What We’re Reading (http://www.diatribe.us/issues/5/what-
were-reading.php ). In short, an incretin is a gut hormone that promotes insulin release
from the beta cells of the pancreas after eating. They also reduce the rate at which digested
food is absorbed into the blood and prevent the body from releasing glucagon – a hormone
released to increase blood glucose levels. This study is looking to conclusively determine
the effect of two incretins, GLP-1 and GIP, on post-meal insulin secretion by comparing
their effects both in diabetic patients and in non-diabetics. Requirements for the diabetic
patients include: A1c between 6.5 and 9.5 percent, treatment with metformin, sulfonylurea
or a combination of the two, and a BMI between 28 and 40. Participants without diabetes
must be between 30 and 65 without a history of the disease. The study will be located in
Ohio and will start recruiting early next year. Please contact Dr. D’Alessio at 513-558-6899
or email him at David. D’Alessio@uc.edu for more information.
��
Why not subscribe to diaTribe? Then you can receive the latest
information from the cutting edge of diabetes research and
product innovation. For more information, visit www.diaTribe.us
��
diaTribe publishes information about diabetes products and research. This information is not a substitute for medical advice and should not be used to
change treatment or therapy. diaTribe urges readers to consult with professional care providers in all matters relating to their health.
www.diaTribe.us

DiaTribe - Research and Product News For People With Diabetes - Issue #7

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

DiaTribe - Research and Product News For People With Diabetes - Issue #7

Uploaded by

Copyright:

Available Formats

VO L U M E 1 • I S S U E 7

�������� research and product news for people with diabetes

World Diabetes Day ...... 1 Unrecognized Epidemic (B.L.U.E)

ILLUSTRATION: DANIEL BELKIN

NewNowNext ................ 20 dialogue.

Trial Watch ...................... 20 The fabulous evening was a prelude to

from the editor

Currently, 80 percent of continued from page 1

the American Heart Association’s goal of 10,000 steps a day.

A WDD diaTribe photomontage

ALL IMAGES COURTESY OF HTTP://WWW.WORLDDIABETESDAY.ORG/WDDGALLERY

Niagara Falls – Canada

A WDD diaTribe photomontage

Kuwait Towers – Kuwait

Taipei 101 – Taipei

ALL IMAGES COURTESY OF HTTP://WWW.WORLDDIABETESDAY.ORG/WDDGALLERY

Azrieli Center – Tel-Aviv Malgrate Castle – Italy

“I want to see you bouncing in your seat.”

Kelly: Wow. Just because they don’t have access to insulin?

Kelly: That’s interesting. What was your next stop?

Kelly: Is this government funded?

they can have diabetes

Dr. Kaufman with some of

the International Diabetes

Lessons learned and future directions

what we’re reading

A letter of concern to the New York Times

Close’s blog on this campaign at http://www.revolutionhealth.com/blogs/kellyclose/jdrf-

You might also like

�� research and product news for people with diabetes