Tag: Diabetes Education

Nutrition

Why pair carbohydrates with protein or fat?

Posted on by mghdiabeteseducation

By Lindsay Boland, dietetic intern

Blood sugar spikes
Changes in blood sugar levels over time 

Carbohydrates are the body’s primary source of fuel. When we eat carbohydrates, they are broken down into glucose (sugar) which gets absorbed through the small intestine into the bloodstream. Normally when sugar enters the bloodstream, insulin moves the sugar into our cells to where it is either used for immediate energy or stored for energy to be used later.

When you have diabetes, this process may take a little bit longer either because the body doesn’t make enough insulin or can’t use the insulin it makes properly. This leaves sugar hanging out in the blood stream for longer than it should. Therefore, when carbohydrates are consumed in large quantities, it often causes a spike in blood sugar.  Sometimes it may be necessary to take medications or insulin to help move the sugar out of the blood and into the cells.

The good news is we can help prevent these spikes in blood sugar by pairing certain foods together. Protein, fat and fiber require a little more work to be broken down than carbohydrates. This means these foods stay in our stomachs longer and take more time to enter the bloodstream. Pairing carbohydrate foods with a source of protein or fat and some fiber helps slow the absorption of the sugars into the bloodstream. This helps us maintain more steady blood sugar levels throughout the day, which allows our body to use these sugars appropriately for energy.

Snack examples:

CARBOHYDRATE PROTEIN/FAT
1 Medium Apple 1 Tbsp Peanut Butter
5 Whole Grain Crackers 1-2 Hardboiled Eggs
1 Cup Grapes 1oz Cheese
¾ Cup Berries 6-8oz Plain Greek Yogurt
2 Tbsp Dried Fruit 12-15 Almonds
Post content reviewed by Melanie Pearsall, RD, CDE

 

 

 

0
recipes

Pasta with Beet Greens, Goat Cheese and Raisins

Posted on by mghdiabeteseducation

The addition of greens, raisins and almonds to pasta is a healthy new spin on a quick dinner.  Beets are in season in Massachusetts from June to October. Beet greens are often thrown away after beets are removed.  Instead, save the greens: they are a good source of many nutrients, including vitamin A, vitamin C and vitamin K.  If beet greens aren’t available, you can substitute any dark green like Swiss chard or spinach.

Ingredients:
8 ounces (1/2 of a 1-pound box) whole wheat penne pasta
¼ cup sliced almonds
1½ tbsp olive oil
1 clove garlic, minced
2 cups chopped beet greens
¼ cup raisins
3 oz goat cheese (soft variety, such as Chevre)
½ tsp salt
Black pepper to taste

Instructions:
Prepare pasta according to the directions on the package. While pasta is cooking, toast the almonds in a large, dry sauté pan over medium heat until they turn golden brown (about 3 minutes). Remove almonds from pan and place in a small bowl. Add olive oil to the pan and add garlic, greens and raisins.  Sauté for about 3 minutes, until greens are tender and wilted. (If necessary, once greens are fully cooked, remove sauté pan from heat until pasta is cooked.)

Once pasta is cooked, reserve ½ cup of the pasta water and add it to the sauté pan with the greens.  Let mixture cook for about 1-2 minutes until slightly thickened.  Meanwhile, drain pasta from remaining water. Add pasta, toasted almonds, goat cheese, salt and pepper to the greens and toss to combine.

Yield: 4 servings (about 1 cup each)

Nutrition Information per Serving:
Calories: 375 • Protein: 15 g • Sodium: 380 mg • Carbohydrate: 53 g • Fiber: 7 g • Fat: 14 g Sat Fat: 4 g

Recipe adapted from Cooking Light
0
My Story, Nutrition, Uncategorized

My Story: Gaining Confidence in the Kitchen

Posted on by mghdiabeteseducation

By Kait

I never used to cook at home. In fact I HATED cooking. I had no confidence in the kitchen and burned everything, even toast. Time was another reason I didn’t cook often. I always thought cooking a meal had to take a ton of time; I really just wanted my food to appear in front of me. At the same time, I wanted to eat healthier but had no idea where to start or what to do with things like vegetables and spices. Then a coworker mentioned she had signed up for Plated [a subscription meal service] and suggested I give it a try. It sounded like an interesting concept, so I went for it.

What I like most is that it saves time and effort. Everything you need to make the dish is included and portioned out for you. Some recipes use ingredients I never would have bought on my own because I didn’t know how to use them, so it’s a great way to try new things. I also discovered that cooking doesn’t take up as much time as I thought. We typically cook at home 3-4 times a week (usually dinner). We’re definitely eating as a family more often, and I enjoy getting to spend time with loved ones while preparing meals.

We’ve been using Plated for about a year now and I feel much better about my cooking skills. I know if I made a recipe once I can do it again. You get to keep the recipe cards, so we’ll usually do a little experimenting the next time we make the dish. I’m eating healthier now, too. Before, I never really ate vegetables (or if I did they were just raw). I’d go into the grocery store and see all these wonderful looking vegetables but feel intimidated not knowing what to do with them. Now that I have a better idea how to cook them, I include vegetables with my meals often.

I recommend signing up for something like Plated if you don’t have much confidence with cooking. The recipes are easy and they tell you about how much time it takes to make. You’ll learn how to cook new things and different types of vegetables. My parents actually signed up for another meal delivery service, Blue Apron, because of my experience with Plated.

 

 

0
Health

Group Visits: Best Practices in Team-Based Care at MGH Back Bay

Posted on by mghdiabeteseducation

In April of this year, MGH Back Bay began trying out a new model for delivering care and education for their diabetes community: shared group medical visits. Led by a nurse practitioner, a diabetes nurse educator and a registered dietitian, these shared visits are offered to people with prediabetes or Type 2 Diabetes (newly diagnosed or anyone needing a little extra help bringing blood sugars under control). Visits are divided into two sessions, two weeks apart. The first session focuses on diabetes basics and nutrition; the second covers nutrition in more detail and reviews complications.

At the beginning of each session, the nurse practitioner meets with each participant for a short individual visit. A larger group discussion takes place afterwards. Although there is a curriculum with prepared material about A1C, blood pressure and cholesterol (LDL), the discussion is allowed to grow organically. Questions are encouraged and participants are welcome to share personal stories if they wish. Opportunities for hands-on learning are woven into the session, such as exercises on reading food labels or using rice in a shoe to illustrate symptoms of neuropathy. At the end of the second session, participants are asked to identify and write down one or two goals to work on. The diabetes nurse educator mails these goals two months after the group as a reminder of what was motivating them during the visit.

Response to the shared group visits has been very positive. The opportunity to talk about living with diabetes and learn tips from peers for overcoming every day challenges is a highlight for many. Much of the success of this visit model is the emphasis on team-based care. One of the reasons for offering shared visits was providing better access to nutrition education. Since a registered dietitian is there for the visit, participants do not need to schedule a separate appointment. The group setting also helps reduce anxiety some feel about seeing a dietitian. In addition to clinical outcomes (improved A1C, reduced weight), scheduling a follow up visit with a dietitian is considered a mark of success for this visit model.

More shared group medical visits have been planned for the fall. Given how well visits have gone so far, the practice is considering offering shared group visits for other chronic conditions such as hypertension

0
Nutrition, Uncategorized

Trans Fat: What is it and Why Should I Avoid it?

Posted on by mghdiabeteseducation

Alison Bliven, Dietetic Intern

What is it?

Trans fat has been used since the 1950’s in order to add certain tastes and textures to packaged and prepared foods while also increasing their shelf life. These fats naturally occur in small amounts in some animal products and oils, but the product used in processed foods is man-made and differs slightly from the naturally found substance. Hydrogen ions are forced into oil in a process called ‘hydrogenation’ which turns the oil into a solid. This product is called partially hydrogenated oil (PHO for short) and is filled with trans fats. This PHO is what is used in place of butter or oil in a variety of processed foods in order to keep them fresher longer.

Why is it bad for me?

For half a decade trans fats were included on the Food and Drug Administration’s (FDA) Generally Regarded as Safe list. However, more recent studies have linked the consumption of trans fats to increased risk of coronary heart disease: by raising ‘bad’ cholesterol (LDL) and lowering ‘good’ cholesterol (HDL), trans fat contributes to the buildup of plaque in arteries which can lead to heart attack. Insulin resistance, a sign of Type 2 Diabetes, has also been shown to have strong connections with trans fat intake.

What foods contain trans fat?

Trans fats naturally occur in meat, dairy, and some oils. The amount of trans fats found in these sources make up an insignificant part of the American diet and are not considered a health concern. The majority of trans fats come from processed foods.  For example:  crackers, cookies, cakes, frozen pies, microwave popcorn, stick margarine, coffee creamer, biscuits, cinnamon rolls and ready to use frosting. Luckily, the number of foods containing trans fats is decreasing, and should soon be nonexistent.

What is being done to protect us?

As mentioned above, studies have overwhelmingly shown a direct connection between trans fats and certain negative health outcomes. This evidence has led to the FDA passing laws that will phase trans fats out of food manufacturing completely. The first step in this process is including the content of trans fats on the nutrition label. This allows the consumer (you) to know what the product contains, to an extent. Food companies are allowed to put ‘0 grams trans fat’ on their labels if the product contains less than 0.5 grams per serving. There are two problems with this: 1) foods with small amounts can add up to a significant intake when more than one serving is eaten and 2) the Institute of Medicine has concluded that there are no safe levels of artificial trans fats in the diet. Even though the FDA is attempting to preserve Americans’ health, there is only so much it can do during the lag time before trans fats are outlawed completely.

What can I do?

Read the label! Look for products that include the phrase ‘trans fat free’ – by law these products can contain no trans fats. Also, scan the list of ingredients for words such as ‘hydrogenated oils’, ‘partially hydrogenated oil’, ‘PHO’, and ‘vegetable shortening’. If the food contains any of these ingredients, there is sure to be some amount of trans fat in it. Other tips include choosing liquid oils or soft tub margarine over stick margarine, and avoiding or limiting commercially baked foods and packaged snacks. Filling up on foods naturally high in fiber (whole grains, beans, peas, fruits, vegetables) means there will be less room for foods containing trans fats and will help promote general health as well.

Remember, Trans Fat Free ≠ Healthy!

One very important takeaway from this article is that just because a food is trans fat free or has very low trans fat, it doesn’t automatically make the food well-balanced or healthy! Limiting trans fats is just one component of a healthful diet that includes lots of fruits and veggies, a focus on whole grains, and limited intake of higher fat meats and dairy products.

(Post content reviewed by MGH Department of Nutrition and Food Services)

 

 

0
Fitness, Uncategorized

Use the Force (for Fitness)

Posted on by mghdiabeteseducation

By Chrisanne Sikora, Sr. Project Specialist
Diabetes Self-Management Education Program

Chrisanne headshot

Chances are “okay grab your lightsaber, get ready to move” is not something you’d expect to hear in a group fitness class. Gyms and health clubs often run special promotions after the holidays when many people begin setting up new fitness routines. Last week when I read an article about one of the nearby gyms offering a free class inspired by the new Star Wars movie, I thought it sounded a little silly but also like it could be a lot of fun. I figured why not? and called to sign up.

After we’d picked out a lightsaber and chosen our spots the instructor, Cassie, explained the class was designed around the idea of circuit training. We’d learn a sequence (or “circuit”) of about four exercises that we would do for a minute each. After we’d done each sequence three times, we’d start over with a new sequence. Cassie showed us the first sequence while a dance remix of the Star Wars theme played over the speakers, and we were off.

I couldn’t help but giggle along with the woman next to me as we swung our lightsabers side to side while doing lunges. Aside from thin disks used to slide our feet along the floor (and of course a toy lightsaber), there was no equipment used in the class. Most of the exercises were versions of basic moves like squats and push-ups that use bodyweight as resistance. Even so, the class was more challenging than you’d think! By the time we started our second sequence you could see several people were already getting tired – and we still had another whole sequence to go!

The second and third sequences were more challenging than the first, but Cassie always gave us the option of going back to an easier move if anything became too difficult. By the end of the class everyone was tired, sweaty, probably a little sore, but smiling. On the way out, I chatted with a couple of classmates about what we’d expected going in and how much fun the whole experience was. Maybe if we take the class again we’ll be able to float rocks with our thoughts.

The two key things I took away from the class were:

  • You can get a really good, challenging workout with using just your bodyweight. No equipment (or even a gym!) required.
  • The most important part of any routine is making it FUN. If you’re not enjoying yourself, it will be hard to stick with it.
0
Nutrition, recipes

Beans, beans, the magical fruit…

Posted on by mghdiabeteseducation

By Kelsey Baumgarten
Dietetic Intern

What comes to mind when you hear the word “beans?” Maybe you think of chili, baked beans, minestrone soup, gallo pinto, burritos. Whatever you think about beans, you may not know how they are related to your health and blood sugar control.

While the old rhyme calls beans a magical “fruit,” they are, in fact, a vegetable! They’re part of a larger group of vegetables called legumes, which includes foods like black beans, chickpeas, lentils, and split peas. When counting carbohydrates, legumes should be counted as a starchy vegetable. However, if you can think of the rhyme, it may help you remember that a ⅓-cup serving of beans has a similar number of carbohydrates as a piece of fruit.

The more you eat, the more you toot…

Many people avoid beans because of their reputation for causing gastrointestinal discomfort. The gas related to eating beans is caused by the fiber and starches your body can’t break down. These are digested by the bacteria in your intestines.

The more you toot, the better you feel…

The fiber is part of what makes beans so good for you! Fiber can help lower your cholesterol and prevent constipation. Over time, your body will get used to it and you will notice less discomfort.

So let’s have beans at every meal!

You don’t need to have beans at every meal like the song suggests, but beans do make a great choice for balanced meals and snacks. Try swapping beans for some of your usual servings of pasta, potato, squash, and bread. You can even replace half of your starch with a half serving of legumes:

  • Eat a smaller portion of pasta, and add beans into the pasta sauce.
  • Mash black beans into a half serving of mashed potatoes.
  • Sprinkle beans on top of a thin-crust pizza
  • Add roasted chickpeas to your salad instead of croutons (just toss dry chickpeas in olive oil and salt, and broil until crispy— about 10 minutes)

Snacking on beans (15-30 g carbs)

  • 2 tablespoons of hummus or edamame dip + 6 whole grain crackers
  • ½ cup of lentil soup
  • ½ cup kidney beans, sprinkled with olive oil and Italian seasoning
  • ⅓ cup soy nuts + 1 piece fresh fruit

Don’t forget:
While legumes are a great source of plant protein, their carbohydrates will still raise your blood sugar. Legumes generally supply 15-20 grams of carbohydrates per serving. Be sure to check the nutrition label of whichever kind you are eating.

Beans can be a great addition to your diet. For increased fiber intake and heart-health benefits, aim to eat 3 or more servings every week. With so many nutrients per serving, they really are a “magical fruit”!

Did you know? You can use beans to make healthier baked goods and desserts!

Cannellini Carrot Muffins

  • BeanCarrotMuffin1 can* cannellini or kidney beans, drained and rinsed
  • 2 eggs
  • 2 tbsp canola oil
  • 2 tbsp molasses
  • ½ tsp salt
  • 1 ½ tsp cinnamon
  • 1 ½ cups grated carrots
  • ½ cup walnuts
  • ¾ cup whole wheat flour
  • ¼ cup oats
  • ¾ cup granulated sugar
  • 2 tsp baking powder

Preheat oven to 325° F. Grease a 12-cup muffin tin and set aside.

In a food processor, puree beans, eggs, oil, molasses, salt, and cinnamon until very smooth. Add carrots and nuts and blend on low speed until nuts and carrots are in small chunks. In a separate bowl, mix flour, oats, sugar, and baking powder. Add the bean mixture to the flour mixture and stir until just combined. Pour into the muffin tins and bake for 35-40 minutes.

*You can also use beans cooked from dry. 1 can = 1½ cups cooked beans.

Per muffin: 190 calories • 40g carb • 5g protein • 4g fiber • 7g fat

Black bean Chocolate Hummus
(who knew hummus could taste like dessert?)

BeanChocolateHummus
  • 1 can* black beans, drained and rinsed
  • 3 tbsp canola oil
  • 6 tbsp cocoa powder
  • 3 tbsp honey
  • ¼ tsp vanilla extract
  • ¼ tsp almond extract
  • 1 tbsp decaf coffee (or water)

Blend all ingredients in a food processor until smooth. Serves 8.

For a snack with 30g carbs, spread hummus over 2 graham cracker squares (1 full sheet), or use as dip for 1 serving of apple slices or strawberries.

Per serving (about 2 tbsp): 150 calories • 20g carb • 5g protein • 5g fiber • 7g fat

*You can also use beans cooked from dry. 1 can = 1½ cups cooked beans.

 (Post content reviewed by MGH Department of Nutrition and Food Services)
0
Uncategorized

Prediabetes

Posted on by mghdiabeteseducation

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

What is prediabetes? Does it become diabetes? How is it diagnosed? How can it be treated? Do medications work? I feel like I have more and more patients asking me these questions and with recent statistics stating that over 54 million people in the US have prediabetes, I’m probably right. Prediabetes is a condition where the blood sugar is elevated but not so elevated that it’s diabetes. It typically does not have any symptoms, but there are instances where people might have symptoms of problems commonly associated with diabetes, such as retina changes or neuropathy. Some people may have a change in their skin called acanthosis nigricans. This means that the skin is darker in color in places like the armpit, behind the neck, or on the elbows, knees or knuckles.

Prediabetes is diagnosed with the same blood tests as those used to diagnose diabetes but the result parameters are different. Prediabetes is diagnosed when the A1C is between 5.7% and 6.4%; fasting glucose is between 100mg/dl and 125mg/dl; or when the 2 hour oral glucose tolerance test is between 140mg/dl and 199mg/dl. People that have a positive test are advised to have the test rechecked every 1 to 2 years to monitor for type 2 diabetes.

The cause of prediabetes is not known but it is thought that genetics may play a part and that there is increased insulin resistance. Much like with diabetes, there are established risk factors for the development of prediabetes. These risk factors include: age; positive family history; being of African American, Asian, Pacific Indian, and Hispanic ethnicity; overweight (especially with an increased abdominal girth); being sedentary; and PCOS (polycystic ovarian syndrome). A diagnosis of prediabetes does not mean an automatic progression to type 2 diabetes, but many people will progress to diabetes within 10 years of initial diagnosis.

There are many things that can be done to improve your health and possibly help the blood sugar values revert to normal range. There are some instances where metformin (Glucophage), a medication commonly used to treat type 2 diabetes, may be started, but that is an individual decision between the patient and their health care provider. The mainstay of treatment consists of lifestyle changes. For example: eating smaller portions, avoiding sugary beverages and fried foods, and walking most days of the week for 30 minutes at a moderate pace. I always tell my patients that they don’t have to join a gym or run a marathon, but they do have to move a little bit more each day. Remember, walking is the least costly form of exercise and will yield great benefits for your physical and mental health. I hope I have provided answers to your questions and some healthful tips to try and incorporate into your daily life. Now, I think I’ll take my own advice and leave the laptop behind so I can go take a walk in this gorgeous sunshine.

0
Health

Hydration, Hydration, Hydration!

Posted on by mghdiabeteseducation

By Marjorie Clapp, MGH Dietetic Intern

The human body is comprised of roughly 60-70% water. For this reason, maintaining proper fluid balance can dramatically influence how well our bodily systems work, including nerves and muscles, cognition, and immune function. Unfortunately, staying hydrated isn’t always easy. In fact, about 70% of Americans are chronically dehydrated. Here are some tips and tricks to help keep you hydrated this summer.

How do I know if I’m dehydrated? Feeling thirsty is the most obvious indicator that you need to drink more. The color of your urine can also help determine your hydration status. Your urine should be pale yellow or clear. If it’s darker than that, it’s time to drink! Other common signs of dehydration include headache, dizziness, fatigue, confusion, and irritability.

Hydration Tip: Keep a tall glass of water on your bedside table and drink before getting ready for your day.

How much fluid do I need? Although fluid needs depend on many factors, including size, activity level, and climate, a good goal is to consume no less than 64oz each day, although some research estimates needs to be much higher (~90oz/day for women, ~125oz/day for men).

Hydration Tip: Exercisers require additional fluids to replenish water lost through sweat and respiration. Weigh yourself before and after working out and aim to consume 3 cups of water for every pound lost during exercise.

When is the best time to hydrate? Anytime! Aim to sip fluids throughout the day to prevent dehydration. Although it’s recommended to consume the majority of your fluid from water; milk, juice, soda, and caffeinated beverages count towards your fluid goal. Just remember to read labels. Calories from sweetened beverages can add up quickly! Food can also help you reach your fluid goals. Water-rich foods include lettuce (96% water), watermelon (92% water), grapefruit (91% water), broccoli (91% water) and yogurt (89% water).

Hydration Tip: Keep a water bottle on hand in your bag or purse to encourage hydration throughout the day.

What about sports drinks? Most sports drinks contain electrolytes (sodium, potassium, chloride, phosphorus) and added sugars to help your body refuel after strenuous exercise. If you’re sweating heavily or exercising for more than 60 minutes, a sports drink may be appropriate. However, most people can rehydrate appropriately with water and a balanced post-workout snack such as an apple with string cheese, hummus and whole grain crackers, or a banana with 1-2 Tablespoons of nut butter.

Hydration Tip: Try diluting/cutting your sports drink with water to provide some electrolytes but reducing the sugar and calories.

(Post content reviewed by MGH Department of Nutrition and Food Services)
0
Health

Driving and Diabetes

Posted on by mghdiabeteseducation

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NPPossessing a driver’s license is a rite of passage in our society.
A driver’s license is seen as a gateway to independence and is a necessity for survival in many instances since many places in the US don’t have adequate public transportation. Driving is such a huge part of our lives, but there are instances when the ability to drive competently is also at issue. The American Diabetes Association (ADA) published a Position Statement on Diabetes and Driving in the 2014 Clinical Practice Recommendations. I would like to summarize the key points of this Position to provide an overview to help both people with diabetes and their health care providers have the best information about driving with diabetes.

The process for identifying drivers with diabetes varies from state to state, depending on what type of vehicle the driver needs to be licensed for. In some states, questions such as “Do you have any medical condition that may interfere with the safe operation of a motor vehicle?” are asked at the initial application for license. These questions may then prompt the need for further medical evaluation. There is no need for a medical examination just because the driver has diabetes. Most often a medical evaluation would be requested when there has been a documented episode of hypoglycemia while driving. Visit the ADA Website for more information on specific rules for each state.

Drivers with diabetes that are commercial drivers in interstate commerce have different rules and follow a set of uniform federal regulations. ALL drivers are subject to an examination every 2 years to update the driver’s ongoing general fitness. Drivers with diabetes managed with diet, exercise, and oral medications do not have any further requirements. Drivers who use insulin often require a more detailed medical evaluation so an exemption to drive and medical certification can be granted. Drivers for commercial motor vehicles, such as school bus drivers and vehicles that transport passengers or hazardous materials are subjected to more strict evaluations that differ state to state.

There are many factors to consider when caring for the driver with diabetes. I want to be clear: a diagnosis of diabetes or the use of oral medications or insulin does not mean that driving ability is compromised. The ADA has determined that the single most significant factor associated with collisions for drivers with diabetes appears to be a recent history of severe hypoglycemia regardless of diabetes type or treatment. The ADA Workgroup on Hypoglycemia defines severe hypoglycemia as an event that disrupts cognitive motor function and requires the assistance of another person to treat the hypoglycemic event.

The plan of assessment and care of the driver with diabetes needs to be individualized. It is important to not only review hypoglycemia awareness, but to also review the other conditions that could interfere with safe driving. These conditions may include decreased visual acuity due to retinopathy or cataracts, neuropathy that diminishes the sensation of the right foot, or sleep apnea which can result in daytime sleepiness. Drivers that have had a hypoglycemic event will need much closer evaluation and education. The driver may need re-education to address issues with mealtimes and dosing of medications (or medications may need to be adjusted altogether), further education about hypoglycemia awareness, and the best methods of treating low blood sugars. Drivers who have had episodes with severe hypoglycemia may also need to perform additional glucometer testing.

People driving for long distances should have a good supply of glucose tablets easily available in the glove compartment or in the console. A supply of snacks such as packages of cheese and peanut butter crackers or nuts should also be stored in the front of the car with the driver and checked before each trip. Drivers who feel hypoglycemia occurring while driving should pull off the road immediately, put on their blinkers, and treat with a fast acting carbohydrate. Do not resume driving until blood sugar values are normalized.

Finally, I advise that all of my patients with diabetes have a medical ID with them at all times. Symptoms of hypoglycemia may appear as if driving under the influence of alcohol or drugs, which can lead to losing precious treatment time if there is an incident where you are unable to identify yourself as having diabetes.  First responders are trained to look for things like a bracelet or necklace, or a card in the wallet.

0