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1. Dont OFTEN SEE N You AND SPARKY OVT HERE FEELING EXTRA ENERGETICE ILLUSTRATION JOSEPH SHIVERS www dia Iribe us DIATRIBE 47 e RESEARCH AND PRODUCT NEWS FOR PEOPLE WITH DIABETES Qsymia O Qsymia 7 3 Capses 30 Capsules Row Key ia a Qsymia is now available from select mail order pharmacies The low 3 75 mg dose above left costs about 120 per month The recommended 7 5 mg dose above right costs around 135 per month tirs The US Capitol Building www diaTribe us new now next On September 17 Vivus announced that its obesity medication Qsymia formerly Qnexa is now available on the US market this happened at least several weeks earlier than expected Qsymia is a once daily pill extended release combination intended to be used with diet and exercise by adults with a body mass index BMI greater than 30 kg m2 or a BMI greater than 27 kg m2 and a weight related condition such as type 2 diabetes high blood pressure or high cholesterol see new now next in diaTribe 45 As a reminder the drug is available in four different doses to give users more flexibility and to ease the transition to the higher doses The recommended mid dose of Qsymia will cost approximately 135 per month about 5 per day the lower dose will cost 120 per month the three quarter dose will be about 163 per month and the high dose will be about 184 per month about 6 per day although thes2. Water Resistance Unlike the Animas pumps and Insulet s OmniPod the t slim is not completely water proof According to the company the t slim has been tested in three feet of water for 30 minutes what s known as an IPX7 rating similar to Medtronic pumps essentially it s water resistant However I must confess that I ve broken multiple pumps due to water damage so this is a concern for me The pump worked fine after I submerged it in a cup of water for ten minutes though I will need to wear it for a longer period to fully test its durability and water resilience Cost and Insurance And of course the very very important question is cost Insurance companies typically pay for a new insulin pump once every four years though this can vary Tandem has already signed contracts with some major insurers and is currently working with custom ers on a case by case basis to obtain insurance coverage We understand that the t slim has a higher list price about 6 995 than the Medtronic Paradigm Revel about 6 500 Animas OneTouch Ping about 6 300 and Insulet OmniPod only around 600 for the starter kit although pods are more expensive than sets on an ongoing basis so that is an important consideration for those who must pay co insurance However Tandem has a large staff dedicated to reimbursement so if you are interested in getting the t slim pump the best way to figure out your situation is to contact Tandem
3. d In this issue from the editor 1 Kelly share some very posi tive news and highlights the latest new cool technology to manage diabetes and obesity quotable quotes 2 S he said what fingersticks ccceeeeee 2 The chase is on new now NeXt 3 Vivus obesity medication Qsymia launches a major diabetes medication goes ge neric anew drug approved for painful diabetic neuropa thy and more test dive Snakes 7 Touchscreen meets insu lin pump in Tandem s new t slim diaTribe dialogue 12 Retrofit CEO Jeff Hyman explains what makes data driven weight loss using Skype sessions Wifi scales and wireless pedometers so different thinking like a pancreas 16 Gary Scheiner searches for the happy medium between neglecting your diabetes care and being completely over whelmed trial watch ieena 18 Can a new version of Lantus improve glucose control Can an insulin GLP 1 combo lower A1c To get your free subscription to dia Tribe visit www diaTribe us a ISSUE 47 e SEPTEMBER 2012 research and product news for people with diabetes from the editor few days ago I received the most amazing news As you may recall from Jim Hirsch s extraordinary logbook in diaTribe 45 Jay Ward is a prisoner at Leavenworth s medium security penitentiary who has been receiving dangerously substandard care for his type
4. either the consumer or their employer or the insurance company or the government RETROFIT AND DIABETES Adam What about people with diabetes Can you talk about that aspect Mr Hyman We have a number of people with diabetes on the program and quite a few people with prediabetes where their physician has told them they re on the wrong path And we paired them up with dietitians who have expertise in diabetes and with behav ior coaches that have expertise in diabetes So while it s not a diabetes focused program we leverage that expertise We re always evaluating if we should have a diabetes specific program and maybe we will one day 14 DIATRIBE 47 e RESEARCH AND PRODUCT NEWS FOR PEOPLE WITH DIABETES Dr Holly Wyatt in her research has found that there s a trade off Initially you do it with food But to keep the weight off over time its got to be through increasing activity and more importantly strength training That s really the engine that burns calories throughout the day We actually think weight maintenance is the harder part because now we created that deficit www dia Iribe us Adam From an insurer perspective it would be very compelling to show that Retrofit slows or halts the progression from prediabetes to diabetes Mr Hyman So many of our clients track their blood glucose numbers before the pro gram and then during the program they send us a copy of the report We ll actually
5. Alasdair Wilkins Last November high tech entrepreneur Jeff Hyman and a team of leading weight loss experts launched Retrofit which offers one year programs designed to help people lose 10 to 15 of their body weight The company provides each Retrofit client with his or her own dietitian exercise physiologist and behavior coach all of whom offer their guidance over weekly Skype sessions meaning they re available anywhere and any time Weve written before about how impressed we are by Retrofit s approach see from the editor in diaTribe 41 and as the company approaches its first anniversary we decided to check in with Mr Hyman He visited our San Francisco headquarters to provide an in depth explanation of how the Retrofit program works Acknowledging the program is a significant investment for many who might be interested the one year Retrofit membership costs between 3 000 and 4 000 he discussed how employers insurance companies and eventual ly the government could work to make it more affordable While Retrofit doesn t feature a diabetes specific program Mr Hyman said tt has helped people with diabetes and prediabetes lower their weight and glucose levels He closed by explaining why exercise is vital not only to short term weight loss but keeping weight off long term For more about Retrofit check out the company s website at Retrofitme com As an exlusive offer to diaTribe readers Retrofit is offering a
6. Medium For most of us the goal is to keep diabetes from interfering with our quality of life There are several ways diabetes can and does interfere 1 We can put so much effort into it that it gets in the way of enjoying our daily activities In the example above William s all out emphasis on tight blood sugar control keeps him from taking his wife out to dinner affects his moods and creates a financial burden 2 We neglect it to the point that the blood sugars are causing immediate problems For Jess poor control is affecting her sleep her studies and her friendships She may have been trying to conceal her diabetes from others but after the incident at the party it is apparent that she doesn t just have diabetes she has a problem dealing with it 3 We put ourselves at risk for serious health problems by running our blood sugar too high or too low Jess is setting herself up for eye kidney nerve and circulatory problems by letting her blood sugar run high so often But William is also setting himself up for problems His obsession with tight control has caused so many lows that he s lost the abil ity to sense when hypoglycemia is developing It may just be a matter of time before he has a serious accident due to undetected hypoglycemia 17 DIATRIBE 47 e RESEARCH AND PRODUCT NEWS FOR PEOPLE WITH DIABETES By taking care of these few key survival responsibilities you can keep yourself out of Immediate ha
7. Mr Hyman Ninety five percent of our customers are losing weight on the program The majority of our customers are on track to lose at least ten percent of their weight Experts have told me this has never been seen before in the industry It s transformative But it s not rocket science We re just keeping people on the straight and narrow for a year We ve got many many hundreds of people who are slowly but surely succeeding on the pro gram Time will tell if they keep the weight off over time But what gives us confidence is that based on our advisory board s experience most people fall off the wagon after two to three months So the fact that we ve now kept these people on for six nine coming up on 12 months next month is in and of itself remarkable because most people will have failed 13 DIATRIBE 47 e RESEARCH AND PRODUCT NEWS FOR PEOPLE WITH DIABETES A recent study found that 59 of employers are now contributing or giving employees some money to apply to wellness and weight loss It s my premise that eventually the US government will have to do something about It can t say when But if you look at the numbers If we keep going at this rate in 25 years our healthcare system Is in trouble Their blood glucose numbers are transformed In six months And they didn t lose a ton of weight but they lose enough to make a difference www diaTribe us Adam You mentioned that the behavioral side
8. a box at the top of the screen and inputting your own number of units Options allows you to suspend insulin set up profiles load a new reservoir what Tandem calls a cartridge set a temp basal and view history The bolus screen is a perfect example of how the t slim s user interface is simple and convenient The side by side large block design makes it very clear what can be entered while a running tally at the top totals the insulin dose A tab at the bottom allows you to click and view the full delivery calculation in a nice vertical arithmetic layout Entering a blood glucose value or number of carbs pulls up a touchscreen numeric keypad like dial ing a phone number and cleverly Tandem has included an addition sign that will tally the carbs from multiple foods This struck me as a great addition considering how tiring diabetes math can sometimes be Extending and Quick Bolusing After entering the information for a bolus the final screen before delivery gives you the option of extending the bolus this was just a toggle switch and was available for every bolus unlike on other pumps where you must preselect an extended bolus before entering anything into the bolus calculator The t slim also has a great quick bolus feature that uses only the screen lock button on top of the pump Increments can be in units of insulin or carbs making the t slim the only pump that offers either option for a quick bolus I used this fe
9. and the internet Gary is also Dean of Type 1 University uww typeiuniversity com an online school of higher learning for insulin users See our Test Drive in diaTribe 29 for more information on this resource Gary can be reached at gary integrateddiabetes com or toll free at 877 735 3648 18 DIATRIBE 47 e RESEARCH AND PRODUCT NEWS FOR PEOPLE WITH DIABETES Can a new version of Lantus improve glucose control Can an insulin GLP 1 combo lower Alc trial watch Comparison of a New Formulation of Insulin Glargine With Lantus in Patients With Type 1 Diabetes Mellitus on Basal Plus Mealtime Insulin ClinicalTrials gov Identifier NCT01658579 http clinicaltrials gov ct2 show NCT01658579 While Sanofi s Lantus insulin glargine has emerged as the standard for basal insulin companies such as Novo Nordisk Eli Lilly and Sanofi itself are still working on new long acting insulins that offer more flexible dosing options less risk of hypoglycemia and other novel features that distinguish them from Lantus Sanofi previously announced its own new clinically different formulation of Lantus was in phase 3 trials and it is now undertaking an additional phase 2 study comparing the effectiveness of the current FDA approved version of Lantus with this new formulation The trial is primarily focusing on the percentage of time participants spend in their target glucose range on either version of insulin glargine Partici
10. even deadlier NCDs such as cardiovas cular disease cancer and coronary heart disease Indeed elevated blood glucose physical inactivity and being overweight or obese are risk factors that combined account for an estimated 17 of global deaths About 12 of the global population is obese although there s extreme variance between regions in the Americas 36 of people are overweight and a further 26 are obese while only 11 are overweight and a further 3 are obese in Southeast Asia Obesity currently accounts for about 2 8 million deaths every year worldwide primarily due to its links with type 2 diabetes high blood pressure and cholesterol The WHO hopes to act on this alarming new data by setting targets to prevent and control NCDs including the development of a global monitoring system to pinpoint the regions most at risk It is still early days for these efforts but hopefully this latest confirmation of these disturbing trends will spur governments to action We are not however holding our breath waiting for the US government to act in the near future AW D Chinese Teenagers than American Teens A new study from the University of North Carolina and the Chinese Center for Disease Control CCDC has found that diabetes is four times more common among Chinese teenagers 1 9 than it is among their American counterparts 0 5 This is despite the fact that according to the researchers type 1 diabetes is virtually unknown among E
11. find we don t need to be perfect We try to lose one pound a week very slow steady progress Adam Many would call this just a high tech diet What would you say to those individuals Mr Hyman It s not a diet and we don t use the word diet We don t believe in starva tion We don t believe in restricting people from all their favorite foods That s not sus tainable right We can teach balance and portion control Why am I eating a gallon of ice cream at night if I m not hungry That s not a food issue That s a behavioral issue Is that stress eating emotional eating binge eating eating out of boredom eating out of depres sion We have all these reasons that we all turn to food what we believe is almost an addiction So we do this little by little over 365 days and that s the program We were lucky to recruit Dr Robert Kushner who runs the obesity program at North western and Dr Jim Hill who runs the program at the University of Colorado With Doc tors Kushner and Hill we have developed a protocol that 500 clients are on If you do it in a sustainable way for enough time changes take hold The average diet is going to last nine weeks This is not a diet It s true commitment It s a one year program After you have joined we lock the door behind you And so that alone I think weeds out people that aren t serious Adam How successful are people at losing weight while on Retrofit
12. go off And they start to lose weight and then they gain weight and they live within this very tight range And that s what we teach our clients how to do It s an energy balance and all about bal ancing your calories in and out You can t give an exact range and it s a little bit different for everybody based on your metabolism your starting weight your gender your age and your percent muscle versus fat So we can t just give people a number We have to iterate to get there But that s what the second phase of the program is all about 15 DIATRIBE 47 e RESEARCH AND PRODUCT NEWS FOR PEOPLE WITH DIABETES We have to teach people you cant out exercise a poor diet Most people don t understand that very basic concept When a customer first JOINS US ON average they take 2 000 steps a day Dr Hill has found that if you take 10 000 steps a day It s really hard not to lose weight www dia Iribe us Adam What I ve heard at obesity conferences and reading the literature is that if people try to lose weight by just burning off calories with exercise and not changing their eating habits they end up eating those calories back again But at the same time anybody who s sustained weight loss over a pe riod of time has a very active exercise component Could you talk a little bit about that Mr Hyman What your average person does is they go to the gym and exercise for an hour and a half and kill them
13. liaise with their physician if they want with no additional fee Their blood glucose numbers are transformed in six months And they didn t lose a ton of weight but they lose enough to make a difference So what I ve learned from the experts on our team is that an over weight person losing 10 of their weight reduces their risk of many diseases by 50 to 80 That s where you get the biggest bang for your buck We get customers who lose 25 pounds or 30 pounds but they re not going to become a cover model anytime soon However it s enough to make the difference such that their blood glucose numbers are transformed They go off medications or they reduce them That s why we focus on losing at least 10 of body weight THE ROLE OF EXERCISE Adam We spoke with Dr Arya Sharma who s a weight loss guru See our diaTribe dialogue with Dr Sharma in diaTribe 45 It is his opinion that if you go on a calorie restriction diet you will lose a certain amount of weight But in order to maintain that weight loss over a long period of time you have to maintain the diet Is that realistic for anybody Mr Hyman Just so I m very clear to lose one pound per week you need to create a net calorie deficit of 500 calories per day i e 3500 calories a week equals one pound of fat That is roughly what we work with our clients to do Some of them lose two pounds de pending on their story Over time you start seeing the curves plateau a
14. obvious difference between the t slim and other pumps is the touchscreen I found this to be the most compelling feature of the pump and a major departure from the button driven devices I ve used since I began pumping in 2002 The Touchscreen Most important the touchscreen is easy to use intuitive to navigate through and re sponsive I appreciated the screen s very bright high contrast full color design which also incorporates highly readable bold font and large icons that make selection easy and mis taps rare Unlike some other medical device touchscreens I also appreciated that the t slim screen did not require a lot of finger pressure to use it s right on par with using an iPhone or Android smartphone The one minor shortcoming of the t slim touchscreen is it doesn t have the smartphone swiping i e to navigate up down left and right that I m so used to Instead you must hit a down or up arrow key though this was a fairly minor inconvenience because few of the menus take up more than one screen length The Battery Another departure from other pumps is the t slim s rechargeable battery which lasts seven days on a full charge A dead battery would take about 90 minutes to completely 7 The t slim battery recharging BACK Timed Settings 12 00 AM The t slim offers an improved streamlined approach to setting the user s personal profile www dia Iribe us charge and on average it takes ab
15. of Retrofit is one aspect that makes it unique Can you talk about that approach Mr Hyman The protocol that we use is really interesting Dr Kushner who has over 30 years of experience identified 21 distinct personality types that prevent you from losing weight He calls them lifestyle patterns which he summarized in a very good book called Dr Kushner s Personality Type Diet Couch potato meal skipper constant muncher midnight snacker all these are different eating patterns And sure enough you ll read it and say Yeah that s me Dr Kushner developed a 50 question quiz that identifies your lifestyle patterns It s on our home page and nearly 15 000 people have taken it We email results to people totally free And then if you choose to join Retrofit that becomes the basis of your protocol It s a very very personalized service which is why you get better results than a group meeting where you often must dumb it down to the lowest common denominator It s not possible to personalize because you have twenty people in the room We have clients who have diabetes or are vegetarians or travel all the time For the latter as an example you d have to figure out how to exercise in their hotel room PAYING FOR RETROFIT Adam Is it possible you could obtain reimbursement either in the United States or in the UK or other countries Mr Hyman Yes Right now half of our business is direct to consumers They come to th
16. well Finding the right balance that happy medium is what it s all about Extreme approaches to diabetes management are clearly unhealthy and unwise However there is still a spectrum of effort that can produce desired results Not everyone has to be right in the middle www dia Iribe us her pump when it runs out of insulin rather than on a fixed schedule and her usual work outs at the gym have been replaced by the walking she does between classes Jess has also discovered the joys of long college weekends featuring parties that run from Thursday afternoons through Sunday complete with drinking and dancing Uncontrolled blood sugars are causing some unexpected problems for Jess She s not sleeping well at night due to frequent trips to the bathroom and she keeps getting yeast infections She s having a hard time concentrating and her once first rate memorization skills have been failing her come exam time The weekend fun came to an abrupt end last weekend when Jess had seriously low blood sugar at a party Paramedics had to be called and Jess said some things under the influence of low blood sugar that bothered many of her friends and classmates William by contrast has it all under control A 33 year old software engineer and new father William weighs and measures everything he eats and avoids eating out out of fear that he ll get the carb count wrong His wife isn t thrilled with the idea of ne
17. 1 diabetes Jay was receiving NPH and regular insulin hours after his meals instead of the recommended 15 30 minutes before meals causing his glucose levels to spike to 300 or 400 mg dl and putting him at a significantly increased risk for diabetes complications But now thanks to the inspiring tireless advocacy of Jay s father of diaTribe contributor Jim Hirsch and all of you who so wonderfully declared your support by signing our petition Jay is now receiving a combination of Lantus and rapid acting insulin This is unquestionably a huge step forward especially because he is now getting these newer insulins before lunch and dinner While his care still isn t perfect Jay still gets his morning insulin shot after breakfast and Leavenworth doctors are still refusing to treat the hepatitis C he previously contracted during his incarceration it s moments like these that give me hope that if we work together we can help those who need it most Thank you again Indeed Jay s story is a dramatic illustration of a more basic point in the daily management of diabetes we all face challenges and roadblocks Encouragingly technology is making our efforts easier in both obvious and less noticeable ways For instance look no further than this month s diaTribe dialogue with Jeff Hyman founder and CEO of Retrofit a data driven weight loss start up Retrofit is all about aggressively helping people lose weight either 10 or 15 ove
18. ast Asian youth Although prediabetes remains much more common in Ameri can children 20 than it does for Chinese children 8 4 and the overall prevalence of diabetes in China 6 9 is actually lower than that of the United States 9 3 Hong Kong 9 8 and South Korea 8 1 the relatively high incidence of diabetes among China s youth may point to a serious national health problem down the road for the world s most populous nation Worse yet obesity and prediabetes appear to be signifi cantly more common among Chinese children ages 7 11 than for adolescents ages 12 18 suggesting the country s youth diabetes crisis is skewed quite young and getting worse AW New Study Suggests Diabetes is Four Times More Common Among Pa pese October 27 2012 1s 9 00 am 5 00 pm San Diego Convention Center San Diego CA Taking Control 4 Your Dioba ia o SOT ef achlorprotit educational orgenizaiicn Tandem s new t slim insulin pump BATTERY 10 20 AM June 11 2012 INSULIN ining 1 09 hrs The t slim home screen www dia Iribe us test drive Touchscreen Meets Insulin Pump in Tandem s New t slim by Adam Brown Design is a funny word Some people think design means how it looks But of course if you dig deeper it s really how it works To design something really well you have to get it You have to really grok what it s all about It takes a passionate commitment to really t
19. ature to program and deliver a bolus without looking at the pump and to very quickly take a bolus without unlocking the pump screen and using the carb calculator Part Three Safety Adam s Favorites e 10 seconds to cancel a bolus e A plethora of confirmation screens alerts and warning messages It s great to make a cool looking sleekly designed insulin pump but it s also a medical device infusing insulin As such I was glad to see a vast array of built in safety features confirmation screens galore alerts when you have not completed an action for 90 seconds e g you were in the middle of calculating a bolus and forgot to deliver it red bold text to draw attention to important items an automatic screen lock following a bolus or when the screen is tapped three times in quick succession e g to prevent accidental touch screen taps while in your pocket and a user interface feature called dynamic error han dling that prevents the user from selecting illogical items in real time e g you can enter 100 grams of carbs but the pump prevents you from adding another zero for 1 000 My favorite safety feature of the pump was the cancel stop bolus button After program ming and confirming a bolus the t slim gives you approximately 10 seconds to cancel the bolus before it ever starts delivering it On other pumps programming and confirming a bolus initiates delivery immediately so unless you have lightning fast fingers ca
20. ay tennis using the USTA s specially designed kid friendly rackets ball and miniature court www diaIribe us forms of this condition Improved blood glucose control can slow down and sometimes even reverse the damage to nerves but medications and devices are often still needed to treat the pain and numbness of neuropathy Nucynta ER is the third drug to gain FDA approval to treat DPN following Eli Lilly s antidepressant Cymbalta duloxetine and Pfizer s anticonvulsant Lyrica pregabalin Last month also saw the approval of Neu roMetrix s pain management device Sensus for DPN see new now next in diaTribe 46 We recently had a chance to talk with Dr Keith Candiotti a professor at the University of Miami School of Medicine and consultant to J amp J for Nucynta ER Notably he suggested that Nucynta ER could be particularly useful for people who are experiencing especially intense pain from DPN or an exacerbation of their existing pain Nucynta ER works by increasing the activity of the brain s opioid receptors which are linked to pain relief This means Nucynta ER treats DPN in a fundamentally different way than Cymbalta and Lyrica This is great news because DPN affects so many different aspects of the brain and body which makes it notoriously complicated to treat and there s no guarantee a drug therapy that is successful for one person will work for others Nucynta ER is specifi cally approved to treat the painful sy
21. commend its use Actos belongs to a class of medications called TZDs short for thiazolidinediones which potently lower blood glucose levels by making the body more sensitive to insulin First approved in 1999 Actos is currently the only drug in this medication class to be widely available in the US and Europe The first drug in this class Warner Lambert s Rezulin was pulled from the market in 2000 because of liver toxicity GlaxoSmithKline s Avandia was also approved at almost the same time as Actos but became restricted in 2010 due to concerns about an association with heart attacks see new now next in diaTribe 24 Actos also has a number of side effects including weight gain and bone fractures and clinical studies have more recently revealed an increased risk of bladder cancer in people taking Actos see new now next in diaTribe 34 An NIH backed study found people taking Actos for more than five years were two to three times more likely to develop blad der cancer than those taking other diabetes medications As a result the use of Actos as a type 2 diabetes treatment has declined by about 40 in the past year Despite these con cerns use of Actos at low doses is still endorsed by many leading diabetologists because of the drug s unique benefits on insulin resistance Also the link with bladder cancer is based on the five year analysis of a Takeda backed study the more recent eight year analysis suggests the link between Acto
22. d is on track to build an impressive 8 600 child friendly courts by the end of the year The As sociation is complementing that major achievement by providing child specific training to 12 000 new and current tennis coaches teachers and volunteers as well as 150 000 worth of new tennis equipment to programs for children ten and younger Considering 30 million Americans played tennis in the past year we hope this partnership can make a dent in the childhood obesity epidemic We also very much hope to soon see an agree ment with Partnership for a Healthier America and a life sclences company we urge them to rally AW AB Latest WHO Statistics Reveal One in Ten People Have Elevated Blood Glucose Worldwide The World Health Organization WHO recently released its World Health Statistics 2012 report compiling data from 194 countries The report estimates that about 9 of women and 10 of men worldwide have elevated levels of fasting blood glucose notably this is the first major report to our knowledge that includes data on blood glucose levels The report also offers a long term outlook on the spread of noncommunicable DIATRIBE 47 e RESEARCH AND PRODUCT NEWS FOR PEOPLE WITH DIABETES www dia Iribe us diseases NCD which includes diabetes and obesity Diabetes is only directly responsible for about 3 5 of NCD deaths although it bears pointing out that diabetes elevated glucose levels and obesity all increase the risk of
23. directly Closing Thoughts I was impressed and plan to keep the t slim assuming my insurance will help cover some of the cost fingers crossed though the devil will be in the details since I changed to my current pump fairly recently That said I m definitely still interested in trying the upcom ing Animas Vibe integrated with the Dexcom Gen 4 CGM Insulet s smaller second gen eration pod and Medtronic s MiniMed 530G with low glucose suspend as a reminder all these devices are currently under FDA review or will be submitted to the FDA soon Indeed this is a great time for patients with so many innovations coming and I had a great week trying out something so new For more information on Tandem s t slim see new now next in diaTribe 38 and Tandem s website at www tandemdiabetes com products t slim 11 DIATRIBE 47 e RESEARCH AND PRODUCT NEWS FOR PEOPLE WITH DIABETES Jeff Hyman founder and CEO of Retrofit The average diet iS going to last nine weeks This is not a diet It s true commitment It s a one year program It s not a diet and we dont use the word diet We don t believe in starvation We don t believe in restricting people trom all their favorite foods That s not sustainable right www dia Iribe us dia lribe dialogue Jeff Hyman Discusses How Retrotit s Data Driven High Tech Approach Offers an Aggressive Solution to Losing Weight Long Term by Adam Brown and
24. e website and just put it on their credit card The other half is through employers and most of that is subsidized A recent study found that 59 of employers are now contributing or giving employees some money to apply to wellness and weight loss They understand that that s way less expensive than treating diabetes later especially self insured employers Now that we ve got some outcome data we are starting to get calls from insurance com panies That is the next level and we re still having those discussions Insurance companies spend hundreds of millions of dollars treating all the diseases that are caused by obesity Medications gastric bypass the list is endless We re starting to en gage in those discussions with insurers It s my premise that eventually the US Govern ment will have to do something about it I can t say when But if you look at the numbers if we keep going at this rate in 25 years our healthcare system is in trouble So it strikes me that at some point the government will get involved And in addition to starting to curtail this food advertisement to kids and a bunch of other things I believe that the government will start to offer some kind of support financial support for ef fective programs The programs will have to work which is again why I m maniacally focused on outcomes I m not trying to be the cheapest program I just want to have the best outcomes because ultimately someone will pay for it
25. e Recognizing and treating hypoglycemia properly By taking care of these few key items you can keep yourself out of immediate harm s way and lay the foundation for more advanced management techniques when you Tre ready willing and able Examples of these glucose management responsibilities include e Counting carbs e Matching insulin to carb intake e Timing insulin doses properly e Exercising regularly e Adjusting insulin based on physical activity e Keeping records e Proper management of injection or pump infusion sites e Seeing healthcare providers on a regular basis A list like this could fill up the next 10 pages but you get the idea These are the types of things that let us do more than just survive with diabetes They allow us to thrive as well Nobody can or should be expected to do everything right all the time Pick and choose the activities that are most pertinent to you and don t overdo it Diabetes management may be necessary for life but there is a lot more to life than managing diabetes Gary Scheiner MS CDE is Owner and Clinical Director of Integrated Diabetes Services a private consult ing practice located near Philadelphia for people with diabetes who utilize intensive insulin therapy He is the author of several books including Think Like A Pancreas A Practical Guide to Managing Diabetes With Insulin He and his team of Certified Diabetes Educators work with people throughout the world via phone
26. e prices may be somewhat higher depending on where the drug is purchased Since only around 30 of prescriptions for weight management drugs are paid for by private insurers and Medicare Part D does not cover weight management medications as yet it is likely that people who want to use Qsymia will have to pay these costs out of pocket initially However Vivus is optimistic that some employers will soon take on at least some of the cost of the drug The company is also working with private insurers and the government to get Qsymia covered in the future Initially Qsymia will be available through certified mail order pharmacies from Walgreens CVS and Kaiser Permanente for members only though expansion to other pharmacies is expected soon Vivus ability to get Kaiser on board so early is particularly notable in our view as it likely signals future potential for coverage by the very influential and cost focused insurer And indeed we believe the Kaiser coverage speaks volumes about what may be available going forward we suspect large employers over time who really want to help their employees will be covering it For more information on Qsymia speak with your healthcare provider or visit www qsymia com and if you work at a com pany you would like to see cover it speak with your benefits manager AW D Vivus Obesity Drug Qsymia Launches Alert Seniors on Medicare Look For Access to the Diabetes Preven tion Program Exercise and w
27. eight loss have been shown to significantly reduce a person s risk of moving from prediabetes to type 2 diabetes However insurance coverage for these lifestyle based prevention programs is relatively rare which often makes them too ex pensive for many who are at the greatest risk To that end Senators Al Franken D MN Richard Lugar R IN and Jay Rockefeller D WV recently introduced the Medicare Diabetes Prevention Act of 2012 which if enacted would provide seniors access to the Diabetes Prevention Program DPP through their Medicare benefits read full details of the bill here A landmark clinical trial found that the DPP reduced the risk of diabetes by 71 in people over 60 The program is currently offered at over 300 YMCA branches in 30 states see new now next in diaTribe 23 Over 16 weeks the DPP sets two main goals for its participants to reduce body weight by 7 and to participate in at least 150 minutes of physical activity each week The ADA has strongly endorsed both the DPP and the Medicare Diabetes Prevention Act The bill suggests that extending access to the DPP to all Medicare beneficiaries could prevent as many as three million people with prediabetes progressing to diabetes between now and 2020 Because medical expenses for people with diabetes are more than double those without the condition the total savings are estimated at over 190 billion over the next decade The bill could also pave the way for further expans
28. enstal MD Jennifer Block RN CDE Only a quarter of doctors are self employed an extraordinary turnabout Dr Zachary Bloomgarden MD E 5 Dr Bruce Bode MD from a decade ago when a majority were independent They ve decided to Dr Nancy Bohannon MD become employees and health systems have become chains a e ae Aa d ia Dr Atul Gawande e aii and Women s Hospital Boston MA from his New Dr Wendell Cheatham MD Yorker article Big Med Dr Edward Damiano PhD Dr Michael Dougan PhD Dr Steven Edelman MD i Dr Satish Garg MD fingersticks Dr Barry Ginsberg MD PhD Jeff Halpern Dr Karin Hehenberger MD PhD Dr Lutz Heinemann PhD Debbie Hinnen CDE Dr Irl Hirsch MD Jeff Hitchcock Dr Lois Jovanovic MD Dr David Kendall MD Dr Aaron Kowalski PhD Davida Kruger BC ADM Dr Harold Lebovitz MD PhD Dr William H Polonsky PhD Michael Robinton Dr Francesco Rubino MD Dr Steven Russell MD PhD Gary Scheiner MS CDE Dr Jane Jeffrie Seley DNP CDE Dr Jay Skyler MD Dr William Tamborlane MD Virginia Valentine CDE Dr Kenneth Ward MD Hope Warshaw RD CDE Dr Stuart Weinzimer MD Dr Darrell Wilson MD l Dr Howard Wolpert MD MarkYarchoan Y Gloria Yee RN CDE o Dr Paul Zimmet MD PhD The chase is on Dr Bernard Zinman MD Dr Howard C Zisser MD My EWCATOR SAID IF 1 WANTED TO STOP CHASING MY BLOOD SUGAR 1 SHOULD START CHASING MY DOG
29. gLira and metformin compared to taking metformin and either just insulin degludec or just Victoza Participants must have type 2 diabetes an Aic between 7 0 and 9 0 a BMI no greater than 40 kg m2 and be using a daily GLP 1 agonist as part of their treatment for at least 90 days before beginning the study The study is recruiting 429 participants at 55 locations in 24 states AL AZ CA FL GA IL IN KY MD MI MO NE NV NH NJ NY NC OH PA TN TX UT VA WA as well as additional locations in Australia France and Slovakia For more information call the Novo Nordisk Clinical Trial Call Center at 866 867 7178 AW Why not subscribe for free to diaTribe Receive the latest information from the cutting edge of diabetes research and a T e 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 Close Concerns the publisher of diaTribe has ongoing business relationships with companies in the field Please see diatribe us sponsor policy php for a current list www diaTribe us
30. horoughly understand something chew it up not Just quickly swallow it Most people dont take the time to do that Those were the words of the late Steve Jobs in an interview with Wired in February 1996 More than a decade later Tandem Diabetes Care took this idea to heart with its new t slim touchscreen insulin pump which it designed after conducting a remarkable 4 000 in depth interviews with patients healthcare providers and caregivers Tandem really wanted to get inside the minds of people who take insulin pumpers and non pumpers alike The new pump was approved by the FDA in November 2011 see new now next in diaTribe 38 and launched just last month I was able to get trained on the t slim at Tan dem s San Diego headquarters soon after it launched and what follows is my experience wearing the device over the past week Three themes have emerged some clear differenc es from other pumps a focus on simplicity and convenience and an attention to safety Part One Differences from Other Pumps Adam s Favorites e iPhone like touchscreen e Rechargeable battery e Highly customizable personal profiles for insulin delivery From the minute I opened the shipping box it was clear that the t slim pump was some what different from other pumps I ve used included with the pump were a USB charg ing cable and adapters for both the wall and car Even the included user manual comes on a credit card like thumb drive But the most
31. ibe us Changing an Infusion Set and Cartridge The one area where the t slim was different from other pumps but in a way that cre ated more hassle was when it came time to change a reservoir and pump set the t slim works with any luer lock infusion set The process took me an average of around nine minutes with the t slim more than double the average of four minutes it took me on the Medtronic Paradigm and Animas OneTouch Ping The process is slow for a few reasons 1 the pump takes a bit of time to automatically clear air out of the new cartridge I ap preciated this since air bubbles can cause some unexplained and frustrating highs 2 because of the micro delivery technology it takes the pump a couple minutes to prime and fill the tubing with insulin and 3 you are guided via step by step on screen pictures and prompts which take extra time to clear relative to the Animas and Medtronic pumps As we understand it the cartridge change process is a leading cause of calls into manufac turers support lines and one of the reasons Tandem included this extra guidance In the future I think Tandem could improve the process by prefilling the cartridges with insulin similar to the Asante Pearl or perhaps speeding the priming process by allowing users to turn off the pictures once they have the process down On the plus side the cartridge does hold 300 units of insulin a notable feat considering the t slim is about 25 slimmer tha
32. ion of coverage so that even more of the estimated 67 million Americans with prediabetes can gain affordable DIATRIBE 47 e RESEARCH AND PRODUCT NEWS FOR PEOPLE WITH DIABETES access to the DPP Unfortunately the congressional monitoring site GovTrack gives the bill a relatively low probability of being passed though our fingers are crossed and we will continue to keep tabs on its progress over the coming months If you re looking for ways to advocate for the bill s passage check out Kerri Morrone Sparling s sum musings in diaTribe 46 AW m as Takeda s Oral Medication Actos Goes Generic Making it Significantly Cheaper actos E On August 17 the FDA approved Mylan s new generic versions of Actos pio glitazone a once daily oral tablet for the treatment of type 2 diabetes originally sold by Takeda Mylan Teva and Ranbaxy all plan to sell generic versions of the drug The introduction of generic Actos should substantially reduce the price of the drug One esti mate suggests the current price of 270 for 30 mg Actos could drop to 153 this time next 1 as hydrochloride A Takeda s TZD medication Actos will now be sold in generic year and by 2015 the price could be as low as just 15 and no more than about 90 This form by Mylan Teva and means Actos now has significant potential as a low cost treatment for type 2 diabetes Ranbaxy which could mean healthcare providers will become more likely to re
33. ist and a behavior change expert The customer meets with their team of experts via Skype video conference They ar range the day and time from 6 AM until midnight seven days a week Each person gets their own registered dietitian a behavior coach with ten years experience and a Master s degree and an exercise physiologist with ten years experience and Master s degree You work with those three people for a full year It s not a random rotation call center type 12 DIATRIBE 47 e RESEARCH AND PRODUCT NEWS FOR PEOPLE WITH DIABETES People need to sleep at least six and a halt hours a night in order to really be able to lose weight Ninety five percent of our customers are losing weight on the program The majority of our customers are on track to lose at least ten percent of their weight Experts have told me this has never been seen before in the industry Dr Robert Kushner who has over 30 years of experience identified 21 distinct personality types that prevent you from losing weight www dia Iribe us It s literally three people They re on your speed dial And each week you meet with one of them on a rotating basis for a half hour session e g my dietitian this week my thera pist next week etc Between Skype sessions you have unlimited access to your team for questions comments and concerns So if you re going to this restaurant in New York your dietitian will download the men
34. mptons of DPN when a continuous round the clock opioid analgesic is required Adding more treatment options for DPN is always needed and we re hopeful Nucynta ER can provide some relief for those who have not had success with Cymbalta or Lyrica AW Partnership for a Healthier America and the US Tennis Association Join Forces against Childhood Obesity During the US Open tennis tournament earlier this month Larry Soler of the Partnership for a Healthier America PHA announced a pair of new initiatives to pro mote fitness and combat obesity in children see the diaTribe dialogue with Mr Soler in diaTribe 35 Children should be getting at least 60 minutes of physical activity every day but past estimates suggest just 42 of elementary school students and only 29 of high school students are at this benchmark and those figures are likely overly generous estimates in our view To help children be more active Mr Soler announced a major commitment from the United States Tennis Association USTA building 3 200 kid sized tennis courts in 2012 in addition to the 3 000 it previously built in 2011 all of which improves both the availability and child friendliness of the sport These courts are a little over half the size of a regular court and the USTA advises children to use specially designed kid sized rackets and balls which are significantly slower than those used by adults Encouragingly the USTA has already exceeded the 3 200 court goal an
35. n the Animas OneTouch Ping and Medtronic Paradigm insulin pumps As a reminder only the Medtronic Paradigm 723 holds 300 units Part Two Focus on Simplicity and Convenience Adam s Favorites e Very simple menu layout intuitive user interface and fast navigation e Bolus menu design e Quick bolus feature The marketing tagline for the t slim is touch simplicity which is most evident in the device s user interface The pump is very similar to the user interface concept and button design pioneered by the iPhone 1 a touchscreen to use it 2 a button on top that blacks out the screen and locks it and 3 a button on the face of the device that immediately takes you back to the home screen at any time Since the home screen is really the hub of the pump s software and the starting point to perform any action on the device I really liked having a single button take me there immediately It was much faster than on other pumps I ve used where you keep hitting a back button to exit a menu The Menu Design I did not need to open the instruction manual to figure out the t slim s menu layout and the overall design made navigating through the pump quite fast Taking a combination meal and correction bolus for 30 grams of carbs and a blood glucose of 165 mg dl took me an average of nine seconds on the t slim compared to double the time 18 seconds with the Medtronic Paradigm and nearly triple the time 26 seconds with the Animas OneT
36. ncelling the full amount of the bolus is very challenging I found this feature of the t slim valuable when I had second thoughts about the bolus I just gave The cancel bolus button also ap pears right on the home screen as a red X during the 10 second grace period so there is no need to dig into a menu and hunt around for this feature 10 DIATRIBE 47 e RESEARCH AND PRODUCT NEWS FOR PEOPLE WITH DIABETES We field tested the t slim s water resistance www dia Iribe us Part Four The t slim s Durability and Cost Durability As an outdoorsy and active person I was initially concerned about the t slim s durabil ity Tandem has told me that if a user accidentally cracks the screen the pump will be replaced under warranty While I can t say I did my own extensive crash tests I know that many young attendees at the recent Children with Diabetes Friends for Life conference had contests to try and break the trial t slim pumps and it was pretty challenging for them to do so I think in the end it took one t slim pump thrown at another one to crack it and it was still fully functional The starter kit comes with a hard plastic case that wraps around the pump for additional protection and the t slim touchscreen also has a pre applied protective film I have not worn the pump long enough to have too many ac cidental drops but the durability will be on the top of my mind as I get more experience with the device
37. ng that balance Adam Jeff thanks so much for taking the time to speak with us Mr Hyman I enjoyed it very much Thank you thinking like a pancreas Nii Happy Medium Finding Balance Between Diabetes Neglectus and Diabetes Overwhelmus by Gary Scheiner MS CDE From what I can tell there are two ways diabetes can ruin your life You can ignore it let it run amok and have blood sugars that are all over the place Or you can obsess over it and let it take over your every waking minute Take these two examples Jess is a 19 year old college freshman who has had type 1 diabe tes since she was in third grade As is the case for many students living on their own for the first time diabetes takes a pretty low priority in her life somewhere between calling her parents and putting away her laundry She checks her blood sugar each morn ing but doesn t pay much attention to it the rest of the day At mealtimes she takes rapid acting insulin basing the dose more on gut instinct than on the actual carbs in her meal And there are lots of late night snacks that just don t get covered at all She changes out 16 DIATRIBE 47 e RESEARCH AND PRODUCT NEWS FOR PEOPLE WITH DIABETES One question we all face in living with diabetes is how much work should we put into It It s similar to preparing for an exam in school study too little and your chances of success are low But overpreparation can be a problem as
38. oing to bed later and waking up later It s very easy to toggle between these profiles and it s all located in one centralized menu You can have up to six different personal profiles and up to 16 time segments within each A New Delivery Mechanism Instead of a conventional piston driven delivery where a mechanical screw drives a syringe built into a reservoir the way a Medtronic Animas Roche or Insulet pump works the t slim uses a micro delivery technology This means that very small amounts of insulin are shuttled from the reservoir to the infusion set and the full insulin supply is never directly exposed to the user s body as it is with other pumps Notably the pump can deliver in increments of as little as 0 001 units compared to 0 025 for the Animas OneTouch Ping and Medtronic Paradigm and 0 05 units per hour for the Insulet Omni Pod While I cannot say that I noticed a difference from these novel accuracy and safety features in my blood glucose numbers over the last week I can say it was comforting to know that the pump has these innovations Perhaps Tandem will eventually conduct studies to examine whether these are indeed beneficial for glycemic control O 7 Remove the cartridge and install an unused cartridge Press the UNLOCK button when completed Instructions for changing the t slim s infusion set and cartridge Options The t slim Options menu DONE The t slim carb calculator www diaTr
39. onally a pumper sets up basal rates by time of day in one menu an insulin to carb ratio by time of day in another menu a cor rection factor by time of day in a third menu and a target blood glucose or range by time of day in a fourth menu The separate menus do not interact meaning that a change in one parameter e g the time a basal rate changes is not reflected in the other menus On past pumps at least for me this process has sometimes resulted in a disjointed insulin profile with parameters that do not match up Tandem has improved and streamlined this process which is good news in our view because we worry a lot about optimizing glycemic management In a recent dQ amp A survey fewer than 60 of patients and 50 of educators thought that their insulin pumps were configured optimally very disappoint ing from a patient perspective In the t slim s personal profile menu all four parameters basal rate correction fac tor insulin to carb ratio and target glucose are set for a particular time of day These appear in a single menu and are saved together The entire day s worth of settings is then saved within a particular profile which you give a custom name and can easily and quick ly duplicate I have one profile called Home that is based on my level of activity at home and my normal diet and wake up time But I also have a Travel profile with different set tings as well as a Sleeping in profile for g
40. ouch Ping I know a matter of seconds may not sound like a lot but when you re bolusing multiple times a day I take an average of six boluses per day every day that adds up The t slim s home screen displays the most critical pump information two large buttons called Bolus and Options a battery life indicator in both percent and an icon an in sulin reservoir indicator in both units and an icon the time and the date and insulin on board IOB in both units and time remaining IOB is my favorite part of the home screen because I use it so religiously and it s such a meaningful improvement for me over other pumps that only display IOB in units remaining and hide this in a status menu J The t slim bolus calculator 10 20 AM The quick bolus function Confirm Request 180 mg dL The t slim confirms each bolus above and provides ten seconds to cancel below 10 20AM June 11 2012 Reques tng 10 u Bolus www diaTribe us The Bolus Calculator Since bolusing is the most common interaction a user has with a pump I appreciated that this was front and center on the home screen Clicking the Bolus button immediately takes you into the bolus menu where you can enter carbs and or a blood glucose level if the carb calculator is turned on or just insulin units and a blood glucose if the carb calculator is turned off You can quickly override the calculator s dose by clicking
41. out a minute of charge time for every percentage point of battery life i e if the pump is at 80 battery life that s about 20 minutes to fully charge it Tandem recommends plugging in the t slim for 10 15 minutes every day to top it off I did this while I showered see water resistant information below or when sitting next to my computer and the t slim would always return to 100 battery life The pump can be charged whether or not you are connected to it Although a rechargeable battery is new to insulin pumps I found it refreshing and fairly easy to remember to plug it in I m used to doing it for my Dexcom Seven Plus CGM my LifeScan OneTouch Verio IQ blood glucose meter my cell phone my laptop my iPod and pretty much everything else these days The included charger cable is the very com mon micro USB computer cable used for many consumer electronics and I was happy to see Tandem include a wall adapter and car adapter There are also a variety of battery packs solar chargers and the like for those who will not have access to electricity Tan dem is not currently selling these but they are easy to find online I was glad to hear this is an option since I know many pumpers that are into outdoor camping and backpacking where charging would be a challenge Personal Profiles The third biggest difference between the t slim and other pumps is setting up the pump s insulin profiles and bolus calculator settings Traditi
42. pants must have type 1 diabetes and an Aic no greater than 9 0 The study is currently recruiting 56 participants at Sanofi s investigation sites in Minneapolis MN site 840001 and Temecula CA site 840002 For more informa tion please send an email with the number of your preferred site to contact us sanofi aventis com AW The Efficacy of Insulin Degludec Liraglutide in Controlling Glycemia in Adults With Type 2 Diabetes Inadequately Controlled on GLP 1 Receptor Agonist and Metformin Therapy DUAL III ClinicalTrials gov Identifier NCT01676116 http clinicaltrials gov ct2 show study NCT01676116 IDegLira is Novo Nordisk s combination of its GLP 1 agonist Victoza and its ultra long acting insulin degludec which is still pending approval from the FDA and other global regulatory agencies By combining the two therapies in a fixed ratio which means any increase in the amount of insulin would also require a proportional increase in Victoza IDegLira has so far demonstrated improved glycemic control potential for weight loss and less risk of hypoglycemia than insulin alone Last month Novo Nordisk announced updates on its phase 3 IDegLira trials See new now next in diaTribe 46 with the DUAL I trial producing favorable results and the DUAL II trial on track to complete by the end of the year The company is now beginning work on the DUAL III trial which will com pare the change in participant Aic levels when taking IDe
43. r the course of a year Retrofit provides a team of experts a dietitian an exercise physiologist and a behavior coach whose job via personalized live appointments on Skype is to keep people on that path to weight loss and ultimately to weight management As Jeff told us the secret to success is his team just won t allow Retrofit users to quit Speaking of technology some big news this month for people with type 1 and type 2 on insulin albeit those with good insurance is the launch of Tandem s new touchscreen insulin pump the t slim which is the first insulin pump with a touchscreen See Adam Brown s test drive for our take on what makes the pump s features different from others on the market Still for all the amazing resources available and all the loved ones and experts there to offer their help it s easy to feel overwhelmed by the personal responsibilities and burdens of your own daily diabetes care That can mean either going overboard in your self management or letting things slide and forgetting critical parts of your care Diabetes educator Gary Scheiner devotes his latest think like a pancreas column to how best to work through and ultimately avoid these issues Anyone who has ever struggled with how best to manage their insulin will benefit immensely from Gary s common sense tips We know diabetes requires optimum resources to help ease the stress and that s why we re always working to make diaTribe one of the be
44. rm s way and lay the foundation for more advanced management techniques when you re ready willing and able www dia Iribe us Extreme approaches to diabetes management are clearly unhealthy and unwise However there is still a spectrum of effort that can produce desired results Not everyone has to be right in the middle It s okay to gravitate toward the Jess or William approach but with some common sense modifications Jess for example doesn t have to check her blood sugar hourly the way William does But checking before she goes to bed and taking appropriate action such as snacking or taking insulin could go a long way toward keeping her safe And William might raise his target blood sugar slightly and expand what he considers his acceptable range This would al low him more dietary flexibility and may keep him in a better mood The Outer Limits Whichever side of the spectrum you prefer it s important to distinguish between essen tial non negotiable responsibilities of living with diabetes and secondary behaviors that are not necessary for survival but are important for controlling blood sugar effectively For most people with type 1 diabetes as well as those with type 2 who are on an intensive insulin program essential survival responsibilities include e Taking basal insulin daily e Taking rapid insulin with all meals and snacks e Checking blood glucose before eating and at bedtime
45. s and bladder cancer was weaker than previously thought and did not appear to be statistically significant for any of the groups tested Of the three companies selling generic versions of Actos Teva and Mylan also plan to launch generic versions of Actoplus Met a combination therapy that incorporates both Actos and metformin in a single pill The FDA applies the same stringent safety require ments to generic drugs as it does to their brand name counterparts meaning that the risk of bladder cancer is no different in the generic tablets than it currently is in Takeda s Actos With these safety concerns in mind we suspect many doctors and nurses will shy away from use that said the lower price is certainly attractive and some believe that much lower doses confer much lower risk for side effects AW Chronic Pain Drug Nucynta ER Granted FDA Approval for Manage D ment Of Diabetic Peripheral Neuropathy On August 29 J amp J s chronic pain drug Nucynta ER tapentadol was granted FDA approval for the management of the pain associated with diabetic peripheral neu ropathy DPN Diabetic neuropathy is one of the most common complications of diabe tes affecting about half of all people with diabetes at some point in their lifetimes Pe Nucynta ER is available in five ripheral neuropathy which primarily affects the legs and feet is one of the most common doses including 100 mg 150 mg and 200 mg 4 www diaTribe us Children pl
46. s it becomes harder and harder to lose weight To continue to lose weight you have then to begin to increase the exercise There s no question about it Dr Holly Wyatt in her research has found that there s a trade off Initially you do it with food But to keep the weight off over time it s got to be through increasing activity and more importantly strength training That s really the engine that burns calories throughout the day Most Americans have no idea they think you just go onto the treadmill While that s great you ve got to do strength training twice a week We teach clients how to do all that Once our customer gets to the goal weight we re just working with them to maintain That is in and of itself another process So of the one year product roughly half of it is weight loss and half is weight maintenance And we actually think weight maintenance is the harder part because now we created that deficit Now we need to teach you how to live within a band You re not going to be perfect but it s almost like a stock price chart that s kind of going sideways You know you ve got some fluctuations And what the National Weight Loss Control Registry which Dr Hill developed shows is that people that keep the weight off over time learn how to live within this span They weigh themselves regularly a couple of times a week at least And they notice that they ve gained a little bit and then the alarm bells
47. selves They think they burned a thousand calories they ve actually burned 300 And they go and have a bagel and a latte at Starbucks right We have to teach people you can t out exercise a poor diet Most people don t understand that very basic concept With that said there comes a point in time where you just can t eat any less where you don t want to eat any less And so the only other option is starting to increase the exer cise The benefit you get from strength training is that it s powering your engine muscle burns more calories than fat So you get this lasting burn of calories throughout the day as opposed to just during a cardio session But they re both important We generally tell people that exercise is necessary to keep the weight off When a customer first joins us on average they take 2 000 steps a day Dr Hill has found that if you take 10 000 steps a day it s really hard not to lose weight You ve got to be eating a ton to outdo that So we notch them up from 2 000 to 2 500 a day to 3 000 a day and kind of go from there Just over the course of a few months very gradual and we re not trying to drop them in a gym and kill them But then by month four and six they ve lost some weight We re down this part of the curve And now we start to really introduce the exercise They ve got some self confidence They feel more energy And then that becomes a huge part of the focus and you re just findi
48. special discount of 500 off its weight loss program When purchasing a plan on the website simply enter the exclusive discount code OCTOBER into the box marked Referrer to get this great savings This code will expire on October 31 2012 and cannot be combined with any other offers WHAT IS RETROFIT Adam Brown To start could you give us a quick background on how you came to Retrofit and started the company Jeff Hyman I put on two pounds a year like a typical American I m 44 And I got toa point where I just was fed up with that I tried everything I would lose weight gain it back lose weight gain it back My wife eventually dragged me to a destination wellness resort which changed my life I worked with therapists dietitians and exercise physiolo gists For me it was a transformative experience But the problem is that it s 1 000 a day So last year I started thinking about how to make it scalable using technology Retrofit is a one year behavior change program deliv ered entirely online There s nothing magical or mystical about it other than it works be cause it s a very intensive robust and multi dimensional program It includes of course nutrition and exercise And we believe most uniquely behavior change In our view this aspect is responsible for about 50 of weight loss between the ears The last important thing Retrofit includes is third party accountability to a dietitian exercise physiolog
49. st resources available very best DIATRIBE 47 e RESEARCH AND PRODUCT NEWS FOR PEOPLE WITH DIABETES dia lribe staff quotable quotes Editor in Chief The First Lady and I have met with four star generals who say obesity may Kelly L Close i 5 i be our greatest national security threat we hear stories of new recruits Managing Editors breaking bones and having joint problems because they have not grown up Adam Brown r E Alasdair R Wilkins with all of the various cross fitness activities that have made us strong and Vincent Wu healthy A ae Mr Sam Kass White House Assistant Chef and Senior Policy Advisor for Healthy Food Initiatives Washington D C on the urgency of increasing physical activity and Contributors combatting childhood obesity at the US Open September 1 Flushing Meadows NY Hannah Deming Gary Scheiner Joseph P Shivers If people work in an environment where they believe there is meaning they SN Foi AME will put up with a lot It goes beyond the significant personal consequences for an individual physician It affects whom patients can see when they are sick the quality of care they receive and their safety Doctors are losing dia Iribe their inspiration and that is a very frightening thing advisory bo ard Dr Tait D Shanafelt The Mayo Clinic Rochester MN from Dr Pauline W Chen s New York Times article The Widespread Problem of Doctor Burnout Dr Richard Berg
50. u and tell you what to order It s a very high level of personal service with a lot of technology behind it We have 65 of these experts now across the country that cover all states and all time zones And our clients are across the country even though we re based in Chicago In addition to your team you ll receive two wireless devices The first is the Withings Wi Fi scale You connect this to your Wi Fi network at home you step on the scale and it instantly sends your data to your team We require customers to weigh in once a week Our average customer weighs in five times a week They get very addicted to the data and the progress and half our clients are men You also get a wireless pedometer Fitbit that tracks the steps you take miles per day and calories per day At night it tracks how long you sleep and how well you sleep which is a huge issue for a lot of customers People need to sleep at least six and a half hours a night in order to really be able to lose weight A lot of our customers will only sleep three hours a night so with the pedometer we can find it out and begin behavior coaching work to figure out what s going on All this data is wirelessly uploaded to us You get your own private dashboard that your team is looking at every single day and it s a very high accountability program in a very supportive way They re not looking to catch you doing something wrong and we don t expect perfection The truth is we
51. ver eating out but she deals with it for William s benefit He wears a continuous glucose monitor and also checks his blood sugar just about every hour in order to keep from going above or below target His insurance company doesn t cover all the strips so he pays out of pocket for about half of them something that is a bit of a drain on the family budget A perfectionist by trade William takes it personally when his blood sugar is above nor mal He aggressively covers above target readings with either insulin or a quick run on the treadmill This has caused William to experience more than his share of lows but he s more comfortable and in a much better mood when he s low than when he s high William also keeps detailed records and analyzes them often resulting in therapy changes several times each week Despite his doctor s warnings about making changes too often William feels that he knows his body better than anyone and lets his tight A1c speak for itself There you have Jess and William Two people with extreme approaches to diabetes man agement and each with their own set of issues One question we all face in living with diabetes is how much work should we put into it It s similar to preparing for an exam in school study too little and your chances of success are low But over preparation can be a problem as well Finding the right balance that happy medium is what it s all about The Search For The Happy
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