JDRF 2013 Children's Congress

As a former middle and high school teacher, I was always well aware of how most of my students chose to spend their summers: lots of late nights, sleeping in until noon, hanging out with friends during the day, and maybe the occasional summer job. But, this is not how 150 children with diabetes are choosing to spend their time this week. These children, who are from the United States and abroad, are united together in Washington, D.C. to encourage Congress to continue funding research initiatives aimed at preventing, curing, and treating type 1 diabetes. This event, called Children's Congress,  is organized by the Juvenile Diabetes Research Foundation (JDRF) and has been an effective advocacy tool.

A past Children's Congress testifying at a U.S.
Senate committee hearing. Source: JDRF

JDRF Children's Congress will convene July 8-10 in Washington, D.C. During these three days, children will meet with their elected officials and even testify before a Senate committee. I have watched several videos of this year's delegates (The Wyoming delegate is my favorite) and am very happy to be represented by so many wonderful and ambitious children. They are very articulate, and I am confident that they will tell their stories eloquently when given the chance.

If you would like to learn more about the Children's Congress, visit the link here. You can show your support for the Children's Congress by following the JDRF on twitter @JDRF and by tweeting your support using the hashtag #JDRFcc2013.

A Bag of Gold

In five weeks, I will begin medical school at the University of Mississippi Medical Center (UMMC) in Jackson. In preparation for the semester, UMMC sent all of the soon-to-be M1 students the book Kitchen Table Wisdom by Dr. Rachel Naomi Remen. Dr. Remen began her career as a pediatrician, but eventually became a pioneer of holistic and integrative medicine. Her biography on the back cover of the book explains that she has "trained many thousands of physicians to practice medicine from the heart." The book is compilation of short stories from her career counseling a myriad of patients suffering from chronic and terminal illness.

One short story that stood out to me was titled Grace. One of Dr. Remen's patients, a physician with cancer, told Dr. Remen a parable of a miserably poor man walking down a road. Shiva and Shakti, the Divine Couple of Hinduism, were watching the man from their heavenly abode. Shakti turned to her husband and begged him to give the man gold. Shiva explained to his wife that he could not do that because the man was not ready to receive it. Shakti continued to beg her husband to help the man, so Shiva eventually dropped a bag of gold in the poor man's path. As the poor man got closer to the gold, he thought to himself, "Look there, a large rock. How fortunate that I have seen it. I might have torn these poor sandals of mine even further." He carefully stepped over the bag of gold and went on his way.

Dr. Remen explains that life often drops bags of gold in our path, but they rarely look like what they are. When she asked her patient if life had ever given him an unrecognizable bag of gold that he had used to enrich his life he smiled and said, "Cancer."

Like cancer for Dr. Remen's patient, diabetes has been a bag of gold that has enriched my life. As a teenager, I learned discipline from the disease, which translated into academic and personal success that continues today. My diagnosis also provided me the opportunity to learn from an early age how precious the gift of life really is. Our days on Earth are numbered and we do not know how many we will get. Therefore, I try to live in the present. When I hear music, I dance. When I hear a song, I sing. I try to tell the people whom I love that I love them. I smile and laugh often and don't sweat the small things. I also know that my daily struggle with diabetes will make me a compassionate and empathetic physician. I will be able to relate to patients who live with pain, fatigue, or some other ailment. Diabetes has taken things away from me -- money, a few nights of good sleep, and the ability to eat foods without thinking how it will disrupt my body -- but it has given me so much more. It has been a bag of gold that has enriched my life.

Going "Bananas" Over Exercise

A 100-gram banana and all natural
butter is my fuel for exercise

I would be lost without bananas. I eat them on oatmeal for breakfast; I eat them when I'm hypoglycemic; and I eat them with peanut butter as a snack. Needless to say, they are a staple of my diabetes management plan. But, what I really love about bananas is that they are a power food for exercise, particularly for persons with diabetes.

What is so terrific about bananas? For starters, they are a good source of vitamin C, vitamin B6, potassium, and manganese. Most important, they are packed full of energy, and relatively low on the glycemic index. This means that they will raise your blood glucose levels at a moderate pace over a
long period of time. This makes them an EXCELLENT fuel source for exercise.

I typically do an hour of running/walking or cycling daily (if possible). I have found a single 100g banana (unpeeled) with a spoonful of all-natural peanut butter to be the best combination of carbs, fats, and protein to fuel a one hour cardiovascular workout. My routine is to 1) check my blood glucose levels, 2) eat the banana and peanut butter, and 3) begin working out after 20-25 minutes. The goal is to keep my levels between 140 and 185 while exercising. Therefore, if my glucose levels are high during my pre-exercise check (>135), I only eat half a banana in order to avoid spiking my levels too much. I have had very few problems with hypoglycemia while exercising by following this routine.

It is important to note that I only exercise 3 hours after my last bolus. This ensures that I don't have any active insulin placing downward pressure on my glucose levels. If you try this routine, please check your glucose levels again before working out, while working out, and afterwards. This will give you a better sense of what happens to your body before, during, and after exercise. Good luck!

Recap of the JDRF Walk in Gulfport

Team Live-abetes before the walk.

Mary and I participated in the JDRF Walk for a Cure in Gulfport, MS last Saturday. This was the first walk for both of us and we had a great time! Our team, Live-abetes, was able to raise about $700 for the JDRF, and we are very appreciative of our generous benefactors. Overall, the event raised a little over $15,000.

In addition to raising money, the Walk provided an opportunity to meet with other persons and families affected by type 1 diabetes. A total of 17 teams participated in the walk. One team was a corporate team, and 14 of the remaining 16 teams had a newly diagnosed person with diabetes. I always read about how children are being diagnosed at younger ages, but my experience at the Walk brought this fact to light. Many of the newly diagnosed persons I met were under the age of 10-years-old. Some were diagnosed as young as 18 months! It was heartbreaking to see young children who will never remember a "normal" life without the disease. I came away from the event very grateful to have been diagnosed at the age of 14/15 (two days before my 15th birthday), which provided me the opportunity to have a normal childhood eating birthday cake and playing sports without a care in the world; but, more resolved than ever to assist the JDRF in finding a cure.

A special thank you to the gals from the JDRF Mississippi chapter in Jackson who worked hard to organize the event.

JDRF Walk Today!

Mary and I are doing the JDRF walk this morning in Gulfport. If you would like to donate to our team, cleverly called "Live-abetes," please click this link and follow the instructions. I will have a blog post about the event next week!

Thank you for the support. God bless!

Mississippi Healthcare at a Crossroads

I'm not from Mississippi, but I love Mississippi. A lot. I was brought to the state after college via a service-through-teaching program that placed me on the Mississippi Gulf Coast. I met my wife, who was born and raised in Mississippi, and we plan to live, work, and eventually retire in this state. Next Fall, I will begin medical school at the University of Mississippi Medical Center in Jackson. It is here, in the capital city, where a debate over medicaid expansion and the future of healthcare and medicine in Mississippi is currently being waged.

Mississippi is hardly a picture of perfect health. To the chagrin of most citizens, Mississippi often finds itself in the worst position of most important state rankings. A 2011 analysis of obesity in the United States conducted by The Heart Forum determined the adult obesity rate in Mississippi to be 34.9%, which earned it the distinction of being the fattest state in the union. This rate is expected to grow to 66.7% by 2030. Keep in mind that these statistics only describe the portion of the population that is obese and do not account for people who are merely "overweight." This means that it is quite possible that less than 10% of the population could be persons at a normal weight by 2030, which is absolutely frightening. Along with obesity comes a myriad of expensive health issues - metabolic syndrome, type 2 diabetes, heart disease, and cancer.

According to the Kaiser Family Foundation, an estimated 442,900 of the state's 3 million citizens are uninsured. Many uninsured persons are members of the working poor class. They hold jobs that do not offer health insurance and earn too little money to pay for health insurance on the open market. Moreover, they often do not qualify for medicaid because they make too much money.

To top it off, the Mississippi health delivery system is facing a severe doctor shortage - both primary care and specialties - particularly in rural areas of the state.

The general state of Mississippi healthcare can be easily summed up as follows: we're fat and we lack access to health insurance and healthcare. Unless something changes soon, Mississippi will face an all out health crisis within the next couple decades. The state is truly at a healthcare crossroads.

Fixing the Doctor Shortage

Governor Phil Bryant

In October 2012, Mississippi Governor Phil Bryant announced a $10 million community block grant from the Mississippi Development Authority in order to expand the school of medicine and add 1,000 physicians to the workforce. These funds will go towards expanding the medical school size (currently 135 students) and the number of residency positions. According to a report commissioned by Bryant and conducted by the Mississippi Economic Council, each doctor in a rural area has a $2 million economic impact on the community. In other words, investing in more physicians pays back dividends.

Plans to increase the number of physicians should be commended. But, should the state also find ways increase access to healthcare?

Medicaid Expansion

On March 23, 2010, President Obama signed into law the Affordable Care Act. Dubbed Obamacare, the law sought the expansion of health insurance coverage for millions of Americans, reform of the health insurance industry, and changes to many aspects of the current fee-for-service reimbursement scheme. Under the law, states have an incentive to expand medicaid coverage because the federal government will pay for 100% of the expansion from 2014-2017, and then 90% of the program costs after that. For every $1 that Mississippi spends on expansion, the federal government will pay $14. On the surface, this appears to be "free" money, but in the words of the late economist Milton Friedman, there is no such thing as a free lunch. The expansion of state medicaid programs will be financed through large increases in federal taxes and fines on individuals who do not purchase health insurance as well as businesses who do not make health insurance available to employees.

Just what are the costs of expanding medicaid? A University Research Center study estimates that the state would spend $159.1 million more on medicaid in 2025 than it spends now. Moreover, the state can reasonably expect to generate $63.3 million in revenue; thus, leading to a loss of $95.8 million.

Some experts believe that the costs are overestimated. Retired state health officer Dr. Alton Cobb believes expanding medicaid will increase visits to primary care physicians and reduce the number of costly visits to ER. Mississippi currently ranks 7th in per-capita ER visits. From my own experience, I tend to agree with Dr. Cobb. Too many people go to the ER for ailments that could have easily been treated by primary care physicians at a considerably lower cost. Most trips to the ER result in a plethora of tests - urine tests, blood tests, CT scans, and x-rays - many unnecessary but performed out of fear of litigation. Expanding medicaid could curb such visits. In addition, retired state economist Phil Pepper believes expansion would create 9,000 new jobs in the health sector. Of course, this would mean that if medicaid expansion were to be undertaken, it would be nearly impossible to reverse for fear of job loss and devastating economic consequences.

CEO Evan Dillard

Who supports medicaid expansion? Hospital administrators. Currently, hospitals that treat uninsured patients receive money from the federal government to offset costs. Mississippi hospitals will lose millions of federal dollars if the state does not choose to expand medicaid. Moreover, hospital CEOs claim they will be forced to lay off employees and reduce the supply of healthcare due to funding cuts. According to Evan Dillard, CEO of Forrest General Hospital, "It's ludicrous for the poorest state in the country ... not to do expansion." Some Democrat and Republican lawmakers support expansion as well. If the state chooses not to expand, its citizens will be paying to expand medicaid in other states through federal taxes. They claim that they do not support the Affordable Care Act, but must act in accordance with the law of the land.


Who is against medicaid expansion? Primarily Republican politicians who fear the high cost of expansion and political repercussions for appearing to support Obamacare. Governor Phil Bryant has said that he will not support medicaid expansion. His position was bolstered last week when a poll showed that 76% of registered Republicans are against expansion even though only 13% claimed to be knowledgable on the issue. Bryant's two arguments against expansion are 1) the federal government will not actually end up paying as much as it says it will because it cannot afford it and 2) the medicaid system is currently replete with waste and fraud. Both arguments are sound, but does that mean the state should do nothing at all?

The Crossroads

The choice confronting Mississippi lawmakers will have a profound impact on the health, wellness, and economy of the state. If the state chooses not to expand, there will still be individuals who lack health insurance but need healthcare. They are not going away. Expansion could potentially curb overall healthcare costs by providing access to primary health care for thousands of people who need it. Moreover, expansion could be considered an economic investment as healthy people are more productive workers, more likely to work and pay taxes. If supplying a single physician in a rural area has a $2 million economic impact, what economic impact does making healthcare more accessible ultimately have? Even if lawmakers choose not to expand, they should find ways to make the system more efficient so that the dollars can be better spent. Choosing to keep the status quo would be the most devastating outcome. It will be interesting to see which road the state chooses to travel.

Exercising with T1D

Exercising is such an integral part of maintaining good blood glucose levels. I consider it to be the second best way (insulin being the first) to keep my sugars under control. In fact, I like to do fairly rigorous 15-minute workouts if my blood glucose levels are a little high in order to bring it down. Even though exercise is so important, it can be difficult for persons with T1D to figure out how to manage blood glucose levels during exercise. For this reason, I decided to make a video that provides some helpful exercise management tips.

A few notes about the video:

• I always get my blood glucose levels into the 140-180 mg/dL range with an upward trend prior to exercising. It's not shown in this video, but my blood glucose was 145 mg/dL when I started working out.
• I use a pump and do not adjust basal rates during the work out.
• Checking blood glucose levels is the key! You have to know what's going on during before, during, and after working out.
• I do bolus entirely for the recovery drink. You might not have to!
• It has taken me a while to figure out the best exercise routine that works. What I do may or may not work best for you. Diabetes is an individual disease after all.
• I am not a doctor. Please consult a licensed physician before beginning an exercise routine!

I hope you enjoy the video!

Adding Incentives to Your Management Plan

I have been very busy over the last month and half and have neglected my duties as a blogger! In addition to teaching nursing chemistry classes at Spring Hill College, I am currently working on a local mayoral campaign. It's been difficult to find time to write for the blog, but I promise to do better!

Around the holidays, my wife likes to torture me by leaving out fun-size holiday chocolates in a variety of locations in our home. As tasty as these treats can be, eating them can be a poor management decision because, let's be honest, you can't stop with just one! It's not just a momentary elevation in blood glucose levels that a person with diabetes should be worried about, however. Studies have demonstrated that the consumption of foods with sugar and/or high fructose corn syrup can increase LDL (bad) cholesterol. This is a topic that I have previously discussed on this blog.

The Nutcracker dolls closely

guard fun-size chocolate 

pieces in our home.

So, is it ever ok to just indulge and enjoy these delicious chocolates? I say yes, but only if you have earned it through exercise. In his book Not Dead Yet, Phil Southerland explains that he began biking when he was young because he realized that if he biked long enough, he could have a snickers bar and his blood glucose levels would still stay in range. Like Mr. Southerland, I too have found that I can have a piece of chocolate (or two) without much impact on my blood glucose levels if I have engaged in 40+ minutes of cardiovascular exercise. This includes things like walking, jogging, cycling, swimming, playing tennis, shooting hoops, or raking leaves. Hopefully, for your sake, it's not raking leaves because if you're like me, you loathe that activity. More important, you can eat that piece of chocolate or few bites of cheesecake (not a fat, huge piece) because exercise helps raise HDL (good) cholesterol; thus, adding a layer of cardiovascular protection. Incentives can also prevent the occasional (or frequent) sugar binge because you can still eat the sweets you love in moderation. At the end of the day, good management is all about living a life of moderation.

I like having incentives in my management plan because it keeps me accountable. I enjoy having a few pieces of chocolate, and since it's something I want, I'm willing to do the work to earn it. Adding incentives to your management plan is easy. First, come up with a plan. My plan goes as follows: if I exercise for 30 minutes, then I can eat 1 piece of chocolate; If I exercise for 1 hour, then I get 2 pieces, and so on. Second, put your plan in writing and sign it. This makes you psychologically more likely to follow it. As long as you stick to your plan, you can enjoy the sweets you love guilt-free and still maintain good control!

Bon Appétit: Broccoli and Cauliflower Creole Pasta

I have decided to showcase some of the delicious meals my wife and I make in a new segment called Bon Appétit. In addition to sharing recipes, I will list serving sizes, number of carbohydrates, and how I bolus for the meal.

The first dish that I want to share with you is broccoli and cauliflower creole pasta. The main spice used in the dish is Tony's creole seasoning, which is very popular along the Gulf Coast where we live. Tony's gives the dish a little kick and makes it very flavorful!

Below are the ingredients and a step-by-step list of how to prepare the dish.

Ingredients

Broccoli and Cauliflower 
Creole Paste

1. Whole grain thin spaghetti (1 serving size = 56g of dry pasta)
2. Broccoli
3. Cauliflower
4. Extra Virgin Olive Oil
5. Italian cheese
6. Tony Chachere's Original Creole Seasoning

Directions

1. Chop and wash broccoli and cauliflower. Steam it for approximately 12 minutes on medium heat. 
2. While steaming the vegetables, measure out the number of servings of pasta you want to cook. Bring water to a boil and cook the pasta for 6-7 minutes until al dente. 
3. Pour extra virgin olive oil on the cooked pasta and toss. Amount depends on how much pasta was cooked.
4. Place pasta and vegetables in serving dishes. Sprinkle Italian cheese and *Tony's on the pasta.
5. Serve!

*Tony's is relatively high in sodium, so be mindful if you have high blood pressure or are at high risk of kidney disease. You can buy sodium-reduced or sodium-free Tony's.

Nutritional and Bolus Information

Each serving of the dish has ~41 carbohydrates. I usually measure out 1.5 servings (84g of dry pasta) for myself when we make this dish. Whole grain pastas are higher in fiber and digest slower than white pastas. Therefore, I always use a 30 minute square wave bolus. I have found that I actually need to give a little less insulin for this dish than the number of carbs would suggest likely because of the fiber, but this might not be the case for everyone. My CGM always shows a very small spike over a 30 minute period for this meal and then a gradual decline to normal levels within 1.5-2 hours. Whole grain pasta is low on the glycemic index, which makes it a great choice for people with diabetes.

Bon appétit!

Exercise and BG Now - January 4 @ 6:15pm

Heart-rate monitor (L) and BG

meter (R)

Just finished cycling. I was on the saddle for about 1 hour, burned 697 calories, and my blood glucose levels are currently at 157. I checked my blood sugar at 4pm and was sitting at 98. I ate half of a cliff bar and half of a banana and waited about 1 hour before hopping on the bike. 157 is a little higher than usual after an hour of cycling and the CGM shows me sitting steady, so I gave a small bolus (0.7 units) and am getting ready to eat dinner. I love cycling because once it comes back down into range, it'll be solid the rest of the night!

My 2013 New Year's Resolutions

Well, we survived the Mayan apocalypse and, for the time being, a fiscal cliff has been averted, which can only mean one thing: 2013 is here, y’all! This year is going to be full of new things as Mary and I move to Jackson, MS and I begin medical school at the University of Mississippi Medical Center. In addition, we are taking high school students to Ireland and Scotland in June. Though it may be a bit cliché, I decided to write a post listing my top 5 New Year's resolutions for 2013. Some are obviously serious and some are, well, not. Regardless, here they are (drumroll please):

5. Be a good friend. I have a tendency to get busy with numerous side projects and forget to call, email, text, etc. good friends from high school and college. Our relationships with other people define us, and I know that I need to be a better friend.

4. Determine whether or not there is a cure for Bieber Fever. If there is, then surely they will teach us about it in medical school, right?

3. Continue to maintain a good HbA1c. This next year is going to be replete with challenges – moving, traveling, medical school. All of these events will pose their own unique management challenges for controlling my diabetes along the way. I intend to use my own knowledge as well as the support of the DOC to steady the ship and stay healthy.

2. Complete an ADA Ride for the Cure. I recently fell in love with cycling. I have completed a few organized rides, though none of them have been for a cause. My brother and I have talked about doing an ADA ride together, and I want to make this happen!

1.    Be the best diabetes advocate I can be. I’m excited to move to Jackson, MS because the only JDRF and ADA offices in the state are located there. This seems a little outrageous considering the high rate of diabetes (mostly type 2) in the state. Nevertheless, I hope to volunteer at a few events and connect with other people who are affected by diabetes.

Well, there you go, my 5 resolutions for 2013. What resolutions do you have for the new year?