It's That Time Again . . .

The rows of candy in the Seasonal Aisle will be replaced with Diet Food, mostly toxic. The media will be full of diet advice, mostly wrong. The bookstores (what few are left, but that's another story) will move the newest Miracle Diet books to the front of the store, each one promising to reveal a simple secret that will make the pounds drop off like magic. The gym will be packed.

It only lasts a month. Then the shelf at the grocery store will be full of chips and dips for SuperBowl parties, at least in the USA, you won't have to wait in line for a treadmill at the gym. The Miracle Diet Books will be shelved with all the other, failed, diet books, as it becomes clear that this year's magical secret is no better than last year's.

People with diabetes, of course, don't have the luxury of dieting only for 2 weeks in January. We have to watch what we eat year-round because we can't afford to let high blood sugars ravage our bodies. But as I've explained elsewhere, people with diabetes are also normal human beings, and that means that a certain amount of the time we are going to eat things that aren't good for us, overdo it, and pack on a few pounds over holidays.

The critical thing for us to master is not that we never eat anything that is off plan, but that, when we do, we learn how to get back on track as soon as we realize things are getting out of control.

A few hours over 200 mg/dl (11.1 mmol/L) won't make you go blind, give you a heart attack, or take out your kidneys. Neither will a few weeks. Most people who develop the classic diabetic complications do so after years of exposure to blood sugars way over 140 mg/dl (7.7 mmol/L)--the level that appears to be the upward limit of safety. Details HERE.)

But as many of us have learned the hard way,those harmless hours of high blood sugars have a way of turning into weeks and months, sometimes without our noticing it, and when that happens, those damaging years aren't far behind.

So it's good practice to clean up our act every now, and this January period right after the holidays is a great time to do it.

As always, our primary focus should be first on bringing our blood sugars back to where we know they should be. Most people at this time of year diet for weight loss, but weight loss is not what preserves the health of people with diabetes, no matter how many times you may have heard this said.

What preserves our health is keeping our blood sugars as close to the normal range as possible. That means staying under 140 mg/dl (7.7 mmol/L) and, if possible, ended up under 120 mg/dl a few hours after we finish a meal. Lower is better if we can do it without experiencing hypos (defined, technically, as blood sugars under 70 mg/dl (3.9 mmol/L)).

After you've gotten your sugars into control, you might also decide to drop some weight which may happen on its own if you're new to cutting back on carbs, but which will likely require some calorie restriction if you are an old hand at it.

Modest weight goals work better than ambitious ones. Set a goal you can achieve in a month, which may be anywhere from three to ten pounds depending on your size, and then set a new goal at the end of the month rather than setting a grandiose goal ("I'm going to lose 80 lbs!") which is much harder to attain and much easier to depress you after the first enthusiasm wears off.

If your blood sugar has been running a bit high lately or your occasional snacking has turned into round the clock eating, you will run into some known problems when you cut back. For starters, you're likely to be very hungry. Fortunately, the physiological component of your hunger is entirely due to the change you are making in your blood sugar and should be gone within a day or two once you get back on track. Remind yourself that if you can get through two days of eating the way you want to eat it will become a lot easier.

The other problem you'll run into is temptation. There is something about seeing some food we have decided not to eat that makes us immediately crave it. If that food is always in our field of vision, it can become very hard to withstand the urge to eat it. Diets that rely on willpower can be very short diets. So plan ahead to eliminate as much temptation as possible. Here are some suggestions I've found helpful. Please post your own in the comments section.

1. If it's not there, you can't eat it. Rid your home of any food that you find hard to resist. A common diet disaster pattern is eating perfectly all day, only to come home and blow it all by snacking on junk as the evening progresses. So throw out, or give away the items you end up pigging out on. If they aren't there, you might think about eating them, but you won't be able to eat them. This sounds idiotically simple, but the world is still full of people who try to diet with fridges full of ice cream.

This may require taking a hard line with family members. Demand their support. If they argue that just because you are on a diet they shouldn't have to be, ask that they keep their junk food somewhere out of your sight. Even just putting snack foods in a cupboard instead of leaving them out on a counter where you see them every time you walk through the kitchen can make a big difference. Just remember, Monkey See, Monkey Eat.

2. Don't Watch TV Commercials. One major cause of diet stress turns out to be the ads on TV. Seeing food makes people hungry, and TV is full of closeups of pizzas and burgers and "endless" shrimp. One strategy that has worked for our family is to use the commercial breaks for mini exercise sessions. During the commercial breaks turn off the sound and do some pushups. Lift hand weights. Run a few laps around the house. I have a nice long, steep driveway which is just the right size for a few laps of brisk walking during my beloved Patriots games. You'll feel a bit silly, but you may be amazed at how much better you feel if you do this. Even better, turn off the TV entirely and read or do things online that don't expose you to food porn.

3. Set modest goals. I don't tell myself I'm going to eat perfectly for the rest of my life. Instead I say, "I'm going to eat perfectly for the next two weeks. Then I'll see where things are at and decide what to do next." What I usually do next is continue to eat reasonably, because two weeks of keeping things clean makes it much easier for me to continue. But for me, it's very important to maintain my feeling that I am in control, not the diabetes.

4. Eat Dull Food. Stephan Guyenet over at The Whole Health Source Blog has posted some interesting research over this past year about how the palatability of food tends to push us towards weight gain. I've found that it is often easier for me to diet when I eat the same predictable dull low carb foods for breakfast and lunch every day for a few weeks. When they become intolerable, replace them with other dull foods. Eggs and meat or cheese for breakfast, Fage yogurt and nuts for lunch, a big green salad with meat for dinner, are good examples. All too often when people start dieting they spend their time reading diet cookbooks and recipe web sites looking for ideas. This dwelling on food is the last thing you need to do. If you need to come up with recipe ideas for a new diet, do it before your diet starts. Then think about other things.

5. Do A Different Diet. If you're trying to lose weight, especially if your previous attempt hasn't worked out as well as you had hoped, rather than just reflexively reach for the newest diet doctor book with its promise of Miracle Weight Loss Secrets, take some time analyze what it was about your last diet that made it fail.

Was it that you didn't like the foods you ended up eating? If so, don't go back to eating those foods, but find other foods that you might like better to diet on. Did the diet make you hungry, even after the first week was over? If so, maybe you are past the point where diet alone can flatten your blood sugars to where you aren't hungry. Maybe it's time for metformin, or perhaps insulin.

If you haven't had your thyroid checked in a while, do, and make sure your doctor does more than a TSH test to determine if you are having thyroid problems. Diet alone is not enough to solve many metabolic problems. Hunger is a SYMPTOM. If cutting back on sugar and starch do not resolve nagging physiological hunger, it may be time to get help from an intelligent doctor.

Your issues with failed diets of the past may be different, so you need to figure out what it was that derailed you. Doing the same thing over and over again expecting a different result is the definition of futility. So figure out what didn't work for you and solve the problem it posed.

6. Hold Yourself Accountable. Post your weight or blood sugar goal and daily progress in the appropriate section of an online diet or diabetes support forum. If that is too exposed, log them into tracking software, like Fitday.com for diet or one of the diet and blood sugar tracking apps available for your smart phone.

Average your results every week and see if the trend is up or down. Weekly averaging of individual values for things like weight and post-meal sugars will give you a much better idea of how you are doing than just looking at the individual values that can be all over the place.

7.Investigate What You're Eating. One of the biggest reasons for diet failure turns out to be eating a lot more than you think you are eating. If you are trying to cut carbs, you need to learn about how much carbohydrate there is in every food you eat. Look it up online. Download diet software. Use an app.

And remember that the nutrition counts you read are always pegged to a specific weight or volume. Weigh and measure your food for a few days to see what you are really eating. If you are like most people you may find that you are eating between two and three times as much carbohydrate each day as you think you are and far more calories, too.

What are your tips? Add them in the comments section.

 

Mitochondrial Diabetes: Another Non-Insulin Resistant Adult Onset Diabetes

I've been reading up on mitochondria this month, in the writings of Nick Lane, Power, Sex, Suicide: Mitochondria and the Meaning of Life, and Oxygen: The Molecule That Made the World. There was a lot of interesting information in both books, but because at times Lane writes in a confused way about the relationship of diabetes and mitochondrial dysfunction, I became curious about what is actually known about mitochondrial failure and diabetes and started reading up on the subject.

It turns out that there is a distinct genetic form of diabetes caused by the A3243G mutation in the mitochondrial DNA-encoded tRNA(Leu,UUR) gene. It causes an adult onset form of diabetes that can be misdiagnosed as either Type 1 or Type 2 depending on how late the onset is. Some people get it in their 20s, while others only develop it in middle age. The average age of onset is 38 years. Whatever the time of onset, 100% of those who have this gene will eventually become diabetic, with a form of diabetes characterized by failure to secrete insulin, rather than insulin resistance.

Like all the genetic forms of diabetes, this is another case where the actual expression of the gene defect can range from very mild to severe. Some people who carry it won't develop diabetes until they are in their 60s, while others may get it in their teens and be misdiagnosed as Type 1 (though the person with it will not show the characteristic antibodies associated with autoimmune Type 1.) The actual percentage of mitochondria carrying the mutation in various tissues will vary from person to person diagnosed with it, and that may have something to do with the severity of the diabetes, as well as whether other damaging effects of the gene are present (discussed below.)

A very severe condition caused by this gene mutation is called MELAS syndrome and reading about its symptoms can be scary, as they include stroke, and a shortened life. But the good news is that now that gene testing is more widely available, scientists are now finding that many people with the same mutation have far less severe manifestations that go undetected until they are gene tested, though these other carriers may have various health problems that seem like the usual wear and tear that are actually byproducts of the gene.

Also, and very interestingly, people with this gene defect, who tend to be thin and at times shorter than their peers, prior to becoming diabetic will have completely normal C-peptide and glucose tolerance tests. However as the gene expresses in their beta cells it apparently causes the mitochondria in the beta cells to fail, leading to the death of the beta cells.

This gene is found in varying frequencies in different ethnic populations. It was found in almost 3% of a Japanese diabetic population, and in about 1% of a group of Dutch people with diabetes. The incidence was lower in those participating in the UKPDS, and in a French population--roughly .5%.

Because mitochondrial genes are passed only from the mother, the family pattern of this genetic form of diabetes appears strictly in the maternal line. Men can get it if their mothers have it, but they cannot pass it on to their children.

This gene defect also appears occasionally spontaneously, so it is possible to have it without a family history but this is very rare.

This gene defect also causes hearing loss in the higher frequency ranges which often becomes evident shortly before the diabetes appears. For that reason this kind of diabetes is also called MIDD (Maternally Inherited Diabetes with Deafness.)

People with this gene may also have a hard-to-detect problem with their heart muscles--asymptomatic cardiomyopathy--which makes it very important that they avoid Avandia and Actos, which have been proven to increase the risk of heart failure in people who take them. The sulfonylurea drugs except gliclazide are also problematic since they also seem to have a negative effect on the heart.

Changes in retinal pigmentation also present in many carriers of the A3243G mutation and they may be more prone than others to develop retinopathy, though it appears that controlling blood sugar will lessen the risk of this happening. Other symptoms which are related to the gene defect can include problems with the digestive tract including diarrhea, obstruction, and severe heartburn.

This gene defect can also cause problems with kidneys that will show up as protein in the urine but are not necessarily linked to high blood sugars, as is typical in diabetes, but are another outcome of the failing mitochondria.

In some people with this gene defect there are other manifestations of mitochondrial failure throughout the body including the inability to tolerate exercise and a frequent migraines. A smaller number have strokes at a young age. This is one reason why you would want to be screened for this gene if you do have the history of diabetes running down the maternal line of your family in conjunction with deafness.

Because mitochondrial failure can cause a rise in lactic acid, people with this form of diabetes should not take metformin as they are at risk for lactic acidosis.

If your family and personal history are suggestive of this kind of diabetes, demand that it be ruled out. It is very possible that your family doctor will NOT have heard of it, so you may have to educate him or her. If you encounter resistance (such as the doctor responding to your showing him one of the articles below by saying, "Where did you earn your M.D.?") find another doctor. This kind of diabetes because it may come with other organ problems requires that you find the support of a very good, up-to-date medical team.

The appropriate treatment for mitochondrial diabetes is insulin, as it brings about the progressive loss of beta cells over time, so it won't be fully controlled by diet. The better you control your blood sugars, the less stress you are putting on those beta cells that remain, so it's likely that very tight control--as close to normal as possible--will have some effect, and of course, it will help prevent the development of the classic diabetic complications.

I have heard from one person diagnosed with MELAS whose diabetes was being controlled with insulin but who was having trouble with her control. She reported that following the "Test test test" strategy this site recommends was helpful for improving her control. You can read about it HERE.

Though I read recommendations online that it is possible to treat milder versions with sulfonylurea drugs, this is probably a bad idea given the recent findings (published after these articles were written) that sulfonylurea drugs can harm the heart.

If you have the symptoms of this form of diabetes you should get your heart checked out by a talented cardiologist--ideally one who practices in a teaching hospital who might have heard of this syndrome, rather than one of the hacks who practices out of a community hospital and prescribes statins to everyone who walks through the door.

As is too often the case with oddball forms of diabetes, most of what you find in scanning the research is diagnostic, rather than information about how to treat the condition. That is probably because it is rare and no one will get rich treating it. If you do have this kind of diabetes it is likely that like everyone else with some form of diabetes your overall health will be better if you keep your blood sugar as close to normal as possible, which even with insulin usually requires keeping a close eye on carbohydrate intake and ratcheting it down until you are avoiding the blood sugar spikes over 140 mg/dl (7.7 mmol/L) that are known to cause the classic diabetic complications.

RESOURCES FOR LEARNING ABOUT MITOCHONDRIAL DIABETES

Mitochondrial Diabetes Molecular Mechanisms and Clinical Presentation.
J. Antonie Maassen et al.Diabetes .53.2007.S103 Diabetes February 2004 vol. 53 no. suppl 1 S103-S109 doi: 10.2337/

Epidemiology and Treatment of Mitochondrial Disorders. Patrick M Chinnery, et al. American Journal of Medical Genetics (Semin. Med. Genet.) 106:94±101 (2001)

Markedly different clinical features in 2 diabetes mellitus patients with extremely high tissue levels of the mitochondrial DNA A3243G mutation. Shinji Harihara. Gerontologia (2008) Volume: 54, Issue: 3, Pages: 168-172

Protean Phenotypic Features of the A3243G Mitochondrial DNA Mutation. Petra Kaufmann et al. Archive of Neurology VOL 66 (NO. 1), JAN 2009

Another Dangrously Misleading Study Promoting High A1cs as Healthy

A presentation given at the recent 44th annual meeting of the American Society of Nephrology claims that patients on dialysis have better outcomes when they have higher A1cs. As reported in Medscape, the chief researcher says, "The range from 6% to 9% seems to be the lower range of risk. There's even an impression that you could say that from 7% to 9% is the lowest risk."

You can read the report of the presentation here. It also got some play in the medical news and newsletters directed to doctors and appears summarized on quite a few diabetes sites. The Medscape article gives the best summary. Signing up is free:

Medscape:Diabetics on Dialysis Do Better With Higher Hemoglobin A1c.

It is all too likely that busy family doctors who encounter this information will add it to the rest of the bad research that has convinced them that it's dangerous for people with Type 2 Diabetes to lower their blood sugars to normal levels. (You can read about how misinterpreted studies have led this toxic recommendation HERE.)

To understand the real meaning of the paper given at American Society of Nephrology you have to know that other research looking into the blood sugars of people on dialysis has found that because of the impact of dialysis on their red blood cells, the A1cs of people on dialysis do not correlate to their blood sugars.

In a published review of the research that discovered the inapplicability of the A1c test to people on dialysis, the author writes

We expected maybe the hemoglobin A1c would be slightly impacted by the shortened red cell survival when we went into the study, but the results were shocking to us in that the hemoglobin A1c levels were significantly lower to where they would affect patient care and outcomes.

You can read this report here:

HbA1c Inaccurate in Diabetic Patients on Hemodialysis, Study Says Hogan, Michelle. Nephrology Times: April 2008 - Volume 1 - Issue 4. doi: 10.1097/01.NEP.0000334255.74897.99

The crucial findings of this study were:

Compared with patients who did not have kidney disease, patients with end-stage renal disease had higher mean serum glucose concentrations-172 mg/dL vs 146 mg/dL-and higher percent glycated albumin-18.7% vs 15.3%-but lower hemoglobin A1c-6.8% vs 7.3%.

For a glucose level of 150 mg/dL, for example, hemoglobin A1c was about 6.5% in the dialysis group but 7.5% in the normal renal function group.

There is another test that gives a better idea of blood sugar control over a longer time period, but it isn't available in the U.S.. What is available is testing with your blood sugar meter--which is more accurate in predicting health outcomes than the A1c ever was.

Test your blood sugar 1 hour after eating. If your level is under 140 mg/dl (7.7 mmol/L) you are in the range that research suggests will avoid diabetic complications. If you are staying over 140 mg/dl (7.7 mmol/L) for more than an hour or two you are raising your risk of complications. The more time spent over that level, the more likely it is that you are damaging your organs.

The damage doesn't start immediately, and most of us will see occasional readings over that level from time to time that, if they are isolated events, aren't likely to cause damage. But if we are seeing them every day, it's time to take action.

If you are on dialysis, you will want to rely on what you see when you test your blood sugar after meals, not the A1c, to ensure that you aren't worsening whatever other diabetic complications you already have by maintaining damaging high blood sugar levels.

And if you aren't on dialysis and want to keep your nerves, kidneys, eyes and heart healthy, don't let any doctor tell you that it's dangerous to lower your A1c below 6.5%. The evidence suggests that it is not only safe, but very healthy to lower your blood sugar to normal levels, as long as you aren't doing it using Avandia, Actos, Glipizide or Glimiperide all of which have been shown to damage the heart.. The one other "dangerous" way to lower blood sugar is to use insulin in such a way that you balance high blood sugars with hypos. If you are using insulin but never see hypos below 60 mg/dl (3.3 mmol/L) you have nothing to fear.

If you avoid these known dangerous drugs and use carb restriction, metformin, and/or insulin dosed correctly to lower your blood sugar, especially if you start close to diagnosis (or in the pre-diabetic stage) before long term exposure to high blood sugars have damaged your heart, nerves, and blood vessels, your long term outlook should be very good.

And if your doctor disagrees, find a new doctor. Only doctors whose knowledge of diabetes is gleaned only from dumbed down one-paragraph newsletter summaries--or from perky drug company reps who encourage doctors to keep patients at high A1cs because their expensive new drugs only achieve higher than normal A1cs--believe that lowering A1c to normal levels is dangerous.

 

For Colorectal Cancer It's the Blood Sugar NOT The Insulin Level That Counts

A recently published study based on data from the Womans Health Initiative (WHI) sheds light on a question many of us have wondered about: Is the higher incidence of cancer among people with Type 2 caused by higher insulin levels (or, perhaps injected insulin) or something else?

The study was conducted by a team at The Albert Einstein College of Medicine, which some of you may remember is where Dr. Bernstein earned his M.D.. It has through the years done several low carb studies, too.

The study is summarized here:

Science Daily: High Blood Sugar Levels in Older Women Linked to Colorectal Cancer

The actual abstract is found here:


A longitudinal study of serum insulin and glucose levels in relation to colorectal cancer risk among postmenopausal women. G C Kabat et al. British Journal of Cancer , (29 November 2011) | doi:10.1038/bjc.2011.512

From the abstract we learn that in a group of 4902 middle aged women who were tracked for 12 years, about 1.6 percent developed colorectal cancer. They had had their fasting blood sugar and fasting insulin measured at the beginning of the study and occasionally through the study. This study found that women whose fasting blood sugar was over 99.5 mg/dl (5.53 mmol/L) at the beginning of the study had a greater risk of developing colorectal cancer than those with blood sugars under 89.5 mg/dl (4.98 mmol/L). The relationship held true for subsequent blood tests too.

However--and this is what is interesting about this study--there was no relationship between these women's fasting insulin levels or the calculated HOMA values (which are believed to measure insulin resistance) and their risk of getting this cancer.

So this data would suggest that it is the high blood sugars, not the high insulin which promotes the cancer.

Before you panic because your fasting blood sugar is over 99.5 mg/dl (as is the case with many of us thanks to dawn phenomenon) remind yourself of this: from what we can see in other contexts, it isn't actually mildly elevated fasting blood sugars that damage our bodies. We see the correlation between fasting sugars and complications in studies because in people eating high carbohydrate diets, mildly elevated fasting blood sugars almost always go hand in hand with significantly elevated post meal sugars. Especially in women, who may be diabetic by glucose tolerance test for up to a decade before they would be diagnosed using a fasting glucose test. (You can see the data backing this up HERE.)

So a woman with a fasting sugar of 105 mg/dl, for example, when she eats her morning bagel with jelly, along with a sweetened latte, may easily reach a blood sugar that approaches 200 mg/dl even if it resolves fairly quickly due to a near-healthy second phase insulin release. But if diabetic you should wake up with a blood sugar of 105 mg/dl and eat an egg and bacon for your breakfast with no carbs, you may easily end up with a blood sugar of 95 an hour later, which suggests you would have a similar health outcome to a completely non-diabetic woman with a fasting blood sugar of 89 mg/dl who ends up at 95 mg/dl an hour after eating her breakfast.

It's also worth noting that the statistical measure the study calculated was "risk" not incidence--and that risk is a statistical artifact that magnifies numbers to provide a more dramatic impact. The actual increase in incididence due to elevated blood sugar was likely around 5 cases per thousand or .5%.

But on the positive side, the fact that even after using magifying statistical techniques like "risk" the researchers couldn't find the expected connection between fasting insulin levels, HOMA, and cancer gives us one more, intriguing, piece of data to answer the quesion, "Do people with diabetes get cancer because of high insulin levels (injected or natural) or because of high blood sugars?" Here at least, it looks like the answer is, as is the case with all the other diabetic complications, "It's the blood sugars, stupid!"

This is very good news because our insulin levels are very hard to control and insulin resistance may be genetic and not something we can lower. Even many devout low carbers with Type 2 continue to be insulin resistant no matter what they weigh (based on how much insulin they have to inject to lower their blood sugars.) But insulin resistant or not, we can control our blood sugars--often most effectively with insulin--and if the conclusion of this study is reinforced by findings in other studies, we may be able to relax about the potential impact on cancer of our injecting insulin to control those blood sugars.

One last note: If you have had years of exposure to higher than normal blood sugars, you might be interested in knowing that Metformin has been shown to suppress the growth of existing early colorectal growths in people without diabetes. Read about that HERE.

Though researchers often state that metformin inhibits cancer due to its effect on lowering insulin, this is just a guess. The belief that it is high insulin levels that cause a greater incidence of cancer among people with diabetes is far from proven and that theory is exactly the belief this study debunks.

In fact, there is evidence emerging that metformin's anti-cancer properties are independent of its effect on insulin and have to do with its ability to suppress TORC1, a cell growth factor. (For example, see THIS STUDY.)

NOTE: Since posting this I have reviewed the full text of the study and see nothing to change the conclusions discussed here. It looks very well conducted, involved people from various well-respected public health departments in universities and medical schools, and gives no hint of corporate meddling.

Another Book?

Now that I've discharged my obligations under my contract with the publisher of my novels, I'm considering what to do next. And that is leading me to ask what I could do that would be of use to the people who visit http://Bloodsugar101.com and this blog.

Publishing the book version of the site has taught me that most people still find books a better way to study a complex topic, even when the information in the book is also available on a web site.

This has been a pleasant surprise, as has been the steady stream of fan mail that the book generates. There's no question that people who read the book learn far more than people who visit the site, if for no other reason than that most people who visit the site only read a couple pages before leaving.

So that raises the question: Should I write another book? And if I do, what should be its subject?

I have some ideas of my own, but before I plunge in I'd love to hear some feedback from you about what topics you would like to learn more about. I'd also like to know, iIf you read my book, Blood Sugar 101, if you thought there was something important that was left out.

Keep in mind, of course, that there are many topics I'd love to be able to write about that are too poorly researched to justify a book. For example, I have spent quite a lot of time looking into the physiology of weight loss, but the more research I read, the less conviction I have that any of it can be trusted. The quality is just abysmal and unlike the publications about diabetes, my many hours of study did not turn up any overlooked gems.

On the other hand, very little has come up that is new since I wrote Blood Sugar 101. In fact, it is rather depressing just how little that would be of any use to someone trying to preserve their health.

But though I might feel that way, life has taught me that one problem with making yourself into an "expert" in some topic area is that the things that bore me after a decade of daily attention to the topic may be exciting to people who haven't soaked their head in this stuff for years.

So I welcome your feedback. What kind of book--if any--do you think would be most useful to a reader who has already read Blood Sugar 101? Click on the comment link below and share your thoughts with me. The only thing I will ask is that you keep your comments on the topic I've sketched out here.

If you want to ask questions or debate other diabetes-related issues, there's a nice community growing on the Blood Sugar 101 Facebook page, where you are welcome to post your thoughts on topics other than the subject of this post.