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“The humor kind of escapes [him],” Mayor Bloomberg says of the “Million Big Gulp March” in protest of his proposed soda ban. This weekend New Yorkers for Beverage Choices took to the streets to urge Bloomberg to let them put what they want into their bodies.

Bloomberg referenced obesity and obesity-related deaths in the City, saying those who opt to drink that much sugar are merely killing themselves. He also pointed to an article in the Financial Times regarding whether the Olympics should be sponsored by McDonalds and Coca Cola, neither of which are exactly the image of health.

Bloomberg also cited statistics about hospitals having to accommodate larger individuals, reports Capital New York, to make a point about our nation’s obesity trajectory. The Mayor said obesity is going to be “worse than smoking ever was.”

Pictures of the protest in the Daily Mail show tons of children taking part in the demonstration, Big Gulp cups full of sugary liquid in hand. It’s what economists call “the law of unintended consequences,” or in layman’s terms: I’m going to do the exact opposite of what you tell me to do.

Bloomberg’s exasperated reaction to the protest of his downsizing campaign is a straightforward “let them kill themselves.”

—Alissa Fleck

By Dr. Cynthia Paulis

Erectile dysfunction or impotence occurs when a man can no longer get or keep an erection firm enough for sexual intercourse. If this is an ongoing problem, it can be a sign of a serious health condition that needs evaluation, such as heart disease or poorly controlled diabetes. Oftentimes treating the underlying problem can reverse erectile dysfunction, but if it still occurs there are alternative treatments.

Dr. Aaron Katz, chairman of the department of urology at Winthrop University Medical Center, said, “The goal of oral medications is to restore or enhance blood flow to the penis.”

He said Viagra, which comes in three dose levels, works for about four hours.

“It can be very helpful for men recovering from prostate cancer surgery, where the nerves and the blood supply to the penis may have been damaged during the surgical removal of the prostate,” he said. “We typically would use this medication much earlier after the surgery than we had in the past.

“In the past, we had the philosophy of just watch and wait and maybe the blood flow and the nerves will be restored. But some of the more recent studies have shown that if you use these drugs early on…the long-lasting effects can be much greater,” he said.

“Viagra can be used as a bridge and hopefully it will restart, almost like a battery, and then maybe—hopefully—Viagra will not be used for long-term use.”

One of the other well-known drugs on the market is Cialis (tadalafil), which has a much longer-acting component but works in a similar way to Viagra.

What makes this drug unique is that it can work for 36 hours. “It does give you much more spontaneity than Viagra does,” Katz said. “Cialis is known in Europe as the ‘weekender.’ You can take it on a Friday and have sex for the entire weekend.”

Cialis comes in a 20-mg dose, but the company has now come out with 2.5-, 5- and 10-mg doses that can be taken daily.
Both Viagra and Cialis take effect within an hour of taking them. Side effects of both drugs are minimal; some men can develop back pain after taking Cialis, and both medications can cause flushing and headaches. However, they are fairly safe drugs as long as you are not taking them with nitrates, drugs commonly prescribed for chest pain such as nitroglycerin, Nitro-Bid, Nitrostat, Imdur, Monoket, Dilatrate and Isordil.

Other medications that can cause problems with erectile dysfunction meds are blood thinners, alpha blockers for benign prostatic hyperplasia and high blood pressure medication.

A third oral medication is Levitra, which works similarly to Viagra and has a four-hour window.

A recent call to a pharmacist broke down the prices as following. Their best-seller was Viagra, with a six-pill pack costing roughly $135; Levitra was the least expensive, at $10 a pill; and Cialis ranged in price from $134 for the 20-mg pill to $147 for the lower dose of 5 mg, which is taken daily.

Most of these are covered by insurance but according to the pharmacist, Viagra seems to be the one favored by insurance companies.

There are two other, non-oral medications used to treat erectile dysfunction. The alprostadil penis suppository is a small suppository that goes into the opening of the penis and delivers blood flow there. Erections usually begin within 10 minutes and last 30 to 60 minutes. It is not used often because it can cause pain and bleeding in the urethra, along with the formation of fibrous tissue.

Another method is alprostadil self-injection (brand names Caverject, Edex), wherein a fine needle is used to inject alprostadil into the base or side of the penis. The injection will produce an erection that occurs within a few minutes and lasts an hour. Side effects from this method include bleeding, prolonged erection and formation of fibrous tissue at the injection site.

Katz said, “More than 50 percent of [male] diabetics have erectile dysfunction, so this may be very helpful for those patients.”

Testosterone replacement for men with low levels of testosterone have helped some men who are menopausal and experiencing erectile dysfunction.

If medications fail, the patient may have to seek alternative treatments such as a penis pump, a penile implant or blood vessel surgery.

Katz said he has patients in their eighties with very active sex lives. One thing he emphasizes is that “you need to take care of your body. It’s all about flow and cholesterol and preventing arterial plaque that builds up in the heart and the small arteries to the penis. Men who are overweight and want to have sex, they want to take the quick fix, they want to take the Viagra—well, that’s not the answer.

“The answer is to get in shape, work out, do yoga, meditate, be mindful of what we take into our bodies,” he explained. “Eat less fat, less red meat, eat more vegetables and practice more healthy living, do more aerobic exercise—running, jogging, swimming, biking—then you will have a better sex life and you won’t need the Viagra.”

Upper East Side residents have also been outspoken about the ban. Some, like Amy Cameron, praise the mayor’s fight against obesity.

“I see the younger generation walking around with these sports drinks that they don’t even know have so much sugar in them. Then they wonder why they feel sluggish, or maybe put on a few pounds,” Cameron said. “Banning these drinks forces manufacturers to be held accountable.”

Bloomberg’s proposal would amend New York City’s health code to eliminate the sale of soda and other sugary and high-calorie drinks in containers larger than 16 ounces. Vendors found not to be complying would be fined about $200 per violation. If implemented, the restrictions would apply to restaurants, mobile food carts, movie theaters, delis and other eateries; convenience stores and supermarkets would be exempt.

Sweetened drinks with more than 25 calories per eight fluid ounces would be rendered taboo, while dairy drinks comprised of more than 50 percent milk or milk substitute, beverages containing at least 70 percent juice and diet sodas would still be available for large-volume consumption.

Kathy Rivera, a barista at a Starbucks on the Upper East Side, also said she is struck by the amount of sugar and calories young people consume in beverages alone.

“We have children come in here all the time and get venti [extra-large] drinks, and I don’t think it’s healthy for kids at 8 a.m. to be getting these drinks,” Rivera said. “I don’t think [the ban] is such a terrible idea.”

Still, some Upper East Siders argued that the ban, although promoting a positive goal, will be largely ineffective in curbing obesity. One resident, Fred, who declined to give a last name, said he supports the idea behind the proposal, but called its parameters “ridiculous.”

“I could just buy three of these,” he said, pointing to a can of soda. “They’re just banning the size, not how many. It’s absurd.”

Some nutritionists, including Dr. Jamie Kane of Park Avenue Medical Weight & Wellness, agree that the restriction on large sodas will be ineffective at reducing obesity rates in the city.

“People are still going to be addicted to sugary drinks…and there’s nothing stopping people from going back for seconds,” said Kane, a weight loss specialist who focuses on obesity. “I’m skeptical that this alone will have a major impact in the short-term.”

“Even if you’re not having the large beverages, there are other ways to get the calories,” added dietician and nutritionist Amy Fleishman. “I’ve applauded [Bloomberg’s] efforts in trying to make this a healthier neighborhood, but it’s a very specific way to fix the problem and I don’t think it’s going to solve the bigger picture.”

Still, Kane and other nutrition experts noted that the ban could serve to spark conversation and perhaps increase awareness of the city’s obesity problem.

“If it can help train people to expect smaller amounts, maybe that would be helpful,” Kane said.

Although the Department of Health puts the rate of adult obesity within the city at around 22 percent, Reuters reported in 2010 that obesity rates in a few of the city’s more affluent neighborhoods—including the Upper East Side—remain significantly lower, at around eight percent.

“I don’t think it will really affect people here. You don’t really see people walking around up here with those huge drinks,” said another Upper East Side resident.

Bloomberg’s proposal was submitted Tuesday to the New York City Board of Health, which will vote on its passage after a three-month deliberation period that will include public hearings. If approved, the ban would take effect early next year.

By Joseph Alexiou

This past July, the New England Journal of Medicine released a study showing that people with Type 1 diabetes—the metabolic disease with high levels of blood sugar caused by the body’s inability to produce insulin—were able to more effectively reduce their levels of blood sugar using insulin pumps than the traditional self-injection method.

According to the report, authored by Richard M. Bergdenstal, William V. Tamborlane, Andrew Ahmann and others, the level of glycated hemoglobin—the scientific name of the blood sugar test often called the A1C by most diabetics and endocrinologists—in
485 patients aged 7 to 70 was reduced on average from 8.3 percent to 7.5, a much more acceptable level. Twenty-seven percent of pump-therapy patients were able to reduce their A1C to under 7 percent, which is essentially the Holy Grail of acceptable sugar levels for Type 1 patients. Only 10 percent of self-injecting patients could achieve this.

So why is it, with 700,000 New Yorkers affected by diabetes, we don’t hear more about the use of insulin pumps versus traditional injection methods? Are the pumps not as effective as studies claim, or are we only now starting to benefit from the efficacy of these marvels of modern medical technology? “The technology, in general for patients with diabetes, has improved dramatically in the last 10 years,” said Dr. Joel Zonszein, a director of the Clinical Diabetes Center at the Albert Einstein College of Medicine—a division of
Montefiore Medical Center in the Bronx. “But I always say that the pump will be only as good as the person who’s using it. Patients think, ‘OK I get a pump, an automatic pilot.’ But really, they are very labor intensive.”

Insulin pumps are small electronic devices made up of a syringe and a motor-driven screwdriver. The patient attaches the pump to a catheter, which he or she has inserted into his or her skin using a needle, allowing a continuous delivery of fast-acting insulin. This plastic tubing must be changed every three days, but the constant stream of insulin allows for patients to easily adjust their level of intake for meal portions, exercise and other factors that longer-term self-injection insulin make more complicated. And the amount of needle sticks, which is usually three to five injections daily by patients who use the traditional method, are much reduced.

While diabetes experts like Dr. Zonszein and Dr. Daniel Lorber, an associate professor at the Weill-Cornell Medical and an instructor at the New York Hospital in Flushing, Queens, agree that there are advantages to using the insulin pumps, “There’s no such thing
as treatment without negatives,” said Dr. Lorber in a recent phone interview. “Pumps take work, they require logic and brain power—you can be stupid and be OK on a pump, but it’s better if you’re smart.”

According to Dr. Lorber, using the pump also requires patient training, which has more of a learning curve and can take at least a full day of training from a practice educator in the most sophisticated of diabetes medical practices. Beyond the training, there are two serious negatives for pump use: the risk of infection from improperly sanitized catheters; and mechanical pump failure—a patient who stops receiving the constant stream of fast-acting insulin can quickly develop complications of diabetic ketoacidosis, an affliction of diabetics with symptoms including falling into a coma.

Other cons of pumps include the cost—an extra $10,000 a year, which is often covered by insurance, but also the emotional and psychological weight of being attached to a machine. The size of pumps has certainly been reduced since they were introduced in the early 1990s, but “there’s an emotional response and resistance on being machine dependent,” said Dr. Lorber, who, in the face of all the negatives, sees them as minimal risks. “If I had Type 1 diabetes I’d be on a pump in a hot minute.”

Dr. Zonszein is more cautious in his view of the pump, and believes that the effectiveness of the treatment is mostly a result of the patient’s efforts, and less the technology. He sees the extra cost, no small number, to be a lot to pay for what he believes is “not such a big increase in efficiency.” Unlike the findings in the study cited above, Dr. Zonszein’s patients—80 percent of whom use a pump—are rarely able to reduce their A1C below 7 percent, regardless of the method they use for insulin delivery.

Ultimately, according to Dr. Zonszein, the best way to treat diabetes is to mimic the deficient human system as best as possible: a mechanical pancreas implanted in the pelvic region, secreting insulin directly into the central venal system. This kind of technology has been under development as long as insulin pumps, but an effective version is years away from completion.

By Gavin Aronsen

For more than three decades—all of her adult life—Angela Schramm has worked in various roles at St. Luke’s-Roosevelt Hospital Center in New York City.

Schramm, a registered nurse and diabetes educator, has spent the past 20 of those years working near her Morningside Heights home in the hospital’s outpatient department on the Upper West Side, where she has lived since 2002.

Angela Schramm is a nurse and diabetes educator at St. Luke’s-Roosevelt Hospital.

Once she received her diabetes certificate, she said, she began focusing most of her work on the disease, which currently includes individual patient consultations and a monthly group education session. However, Schramm said she has always been familiar with diabetes.

“It was just part of every nurse’s job,” she said. “It’s just such an epidemic that it’s rare to find a clinic that doesn’t have a large diabetic population.”

Schramm, 58, was born in Queens and has lived in New York all her life. She studied to become a nurse first at Queensborough Community College, before entering a Bachelor’s program at Dominican College to the north in Blauvelt.

For Schramm, moving to the Upper West Side eight years ago was a no-brainer.

“I’ve always felt very comfortable here, and I’m really happy now that I actually live here,” she said.

That community feeling includes a stronger connection with her patients—sometimes almost to a fault.

“It’s not uncommon to be on the bus with one of my patients and they’ll be talking about patient-related stuff,” she said, laughing. “I have to try to get them to separate that I’m not at work.”

Schramm has known many of her patients for a very long time.

“I see them in the store, I see them walking on Broadway,” she said. “It’s nice. It’s a very nice atmosphere to know your patients.”

Of course, these relationships aren’t always easy. A large part of Schramm’s job is helping her patients cope with diabetes, which she said was hard because “nobody wants to take medication” for a disease that’s not typically visible to the naked eye.

“So it’s an uphill battle, trying to get people to take care of themselves with preventive steps,” she said. “It’s rough to live with a chronic disease.”

A big part of that difficulty, oftentimes, is poverty. At a recent monthly meeting, Schramm spoke with her group about how they could shop at farmers markets that have come into prevalence in the city, instead of opting for less healthy options. But even those foods have become pricey, she said.

Her efforts can pay big dividends. When patients keep their blood sugars lower, it drastically reduces the risk of diabetic complications such as blindness and amputated limbs.

Schramm said her line of work is rewarding. Beyond her typical day job, she helps the clinic raise awareness of the disease on the annual World Diabetes Day in November. And after 9/11, she registered with the city’s Office of Emergency Management, through which she cared for victims of the H1N1 flu last year.

Outside of work, Schramm enjoys her patient-independent community life at Morningside Heights, as well. She enjoys a ceramics hobby and volunteering at a nearby retirement home.

“There’s a real community feeling to the Upper West Side in general,” she said.

By Mariah Summers

Treatment methods for Type 2 diabetes are rapidly changing with the development of new drugs and the erosion of the stigma around insulin use.

The disease, also referred to as adult onset diabetes, is usually diagnosed in adulthood and carries a number of misconceptions, the most common being that Type 2 diabetes is the disease of people who don’t take care of themselves.

“A lot of people think it is a disease of self-neglect, and patients may feel self-conscious,” says Dr. Ronald Tamler, assistant professor in the Division of Endocrinology and clinical trials leader of the Diabetes Program at Mt. Sinai School of
Medicine, “but it has a strong familial component.”

According to Dr. Tamler, the stigma of using insulin is born in this misconception that Type 2 diabetes is somewhat of a self-inflicted disease. Still, physicians are trying to break down the stereotypes of using insulin, including that it is a treatment of last resort, as it was once thought to be.

“People are often afraid to use insulin because it makes them think they have failed in their diet,” says Dr. Stuart Weiss, clinical assistant professor in the Department of Medicine and New York University’s Langone Medical Center. “It used to be a treatment of last resort. Now if people don’t use it, that can lead to poor blood sugar control.”

In addition to patients’ reluctance to use insulin, physicians are also unwilling at times to prescribe the drug, due to the time and emotional investment such a prescription requires.

“There is a resistance among physicians to prescribe insulin when it is needed because it takes time and an emotional toll on preparing the patient for insulin use,” Dr. Tamler says. “Insulin can be very good if needed, and there are ways to overcome the stigma on both the part of the physician and the patient.”

Among these solutions, Dr. Tamler listed insulin pens, pumps, superfine needles and pills that can be taken to supplement insulin injections throughout the day.

“One device, insulin pens, can be carried around in a pocket and can be used anywhere,” Dr. Tamler says. “You can use them and no one would know you’re taking insulin.”

As patients progress through the disease, the schedule of administering insulin could become more challenging, but such alternatives to a typical shot can help ease the psychological and physical impact of the treatment.

While the stigma attached to insulin injections continues to crumble, doctors say there are currently new forms of Type 2 diabetes treatments in development.

“The big developments in the industry have not really been in the world of insulin, but rather in the world of oral medications, which are typically given earlier in the course of diabetes,” says Dr. Tamler. “A big push is currently being made in the following category of medications for T2DM: DPP4 inhibitors, like Januvia, and GLP-1 agonists, like Byetta.”

A benefit of these new treatments is that they promote weight loss, making it easier for patients to accept them, even though they are injections.

“These new products not only help the body work to improve insulin, but also help to better control glucose and weight loss,” NYU’s Dr. Weiss says of the new injection treatments. “Most medications contribute to weight gain, and this does not. These products lead to a more significant weight loss and blood sugar does not get too low.”

Other treatment developments for Type 2 diabetes include new oral medications that will be available to patients in the near future. Two of these oral medications are SGT-2 inhibitors and Glucokinase agonists, both of which are not yet on the market.

Even with these forthcoming treatments, physicians warn that diabetes patients must always consider their diet in addition to any medication they are taking.

“Another way to reduce insulin injections is to have a non-carb meal,” Dr. Tamler says. “Determining certain meal choices if possible, with limited carbohydrates, can help with treatment.”

“The bottom line is there is no treatment that can’t be overwhelmed by a bad diet,” Dr. Weiss says. “That is the cornerstone of treatment. The future is going to be based on more people eating properly. All the medications in the world will not beat that. Aside from the social issues, the science is moving ahead.”

By Louise Murray

If you’re a pet lover, chances are you know someone who’s had a diabetic cat. Diabetes is a real problem for cats in this country, but the good news is that we now have a much better understanding of this condition, and even better, we can cure it in many cases. Best of all, we are learning how to prevent it, which is the ideal strategy for a healthy, happy cat.

Cause: It’s now believed that many cases of feline diabetes are caused by excess carbohydrates in the cat’s diet. Cats are nature’s true carnivores, unlike dogs and humans, who are omnivores. Cats are also uniquely unable to manufacture an amino acid called taurine, found in animal tissue. Cats have many such nutritional differences setting them apart from humans and dogs.

Many cat foods, particularly dry foods, contain carbohydrates. Cats are not designed to properly metabolize carbohydrates, and thus cats on dry food tend to become obese. Additionally, the excess of carbs forces the pancreas, the organ that makes insulin, to overwork. Over time, the pancreas can become exhausted, and lose the ability to make enough insulin. This lack of insulin causes diabetes.

Not all cases of feline diabetes are caused by carbs in the diet. For example, in some cases, the pancreas becomes inflamed and suffers damage affecting the ability to produce sufficient insulin.

Treatment: Most diabetic cats have not permanently lost the ability to produce insulin. Their pancreas is simply worn out. In order to rest the pancreas and allow it to return to normal function, cats are treated with insulin injections.

Several studies have shown that the most effective type of insulin for treating, and hopefully curing, feline diabetes is glargine insulin (Lantus®). This insulin was developed for humans, but has been revolutionary for cats. Due to its formulation, it has a slow, steady action that is safer and less likely to cause hypoglycemia (low blood sugar). Additionally, it has a longer effect once injected, so the cat’s blood sugar does not bounce back up before the next shot is given.

For the best chance of remission, Lantus® should be given twice a day, and the cat’s diabetes closely monitored. This can be done with blood sugar levels measured at home with a drop of blood taken from the ear, using the same kinds of monitors that human diabetics use. It can also be done by measuring the urine sugar at home, using dipsticks called Ketodiastix, which are purchased at a pharmacy. It is essential to tightly regulate diabetes; only by giving sufficient insulin to truly rest the pancreas will the cat regain the ability to manufacture her own insulin.

In veterinary medicine, as in human medicine, there are many types of specialists. For diabetic cats, it may be advisable to consult with a veterinary internal medicine specialist (acvim.org). The success of initial treatment will determine whether the cat’s diabetes is cured, or whether the cat will need lifelong insulin injections.

The second essential component of treatment is the cat’s diet. For the best chance of curing diabetes, cats are fed a canned-only diet (or balanced homemade diet formulated by a veterinary nutritionist). Any dry food, even a prescription diet labeled for diabetes, may reduce the chance of getting the cat off insulin injections. Ideally, most cats should eat a canned diet formulated for diabetes, or a canned kitten food. Be sure to consult with your veterinarian regarding the best diet for your own cat.

Prevention: We all know that “an ounce of prevention is worth a pound of cure.” Clearly, we would prefer that our cats not become diabetic in the first place. The keys are to avoid obesity and excess carbohydrates.

For diabetes prevention as well as urinary tract and digestive health, I advise feeding cats canned food in meals, rather than allowing them to graze on dry food.

When attempting to make any change in a cat’s diet, such as from dry to canned food, patience and caution are essential. Never allow a cat to “hunger strike”; this can lead to serious liver disease.
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Louise Murray, DVM DACVIM, is vice-president of ASPCA Bergh Memorial Animal Hospital.

This article first appeared in Womensenews.org