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On Saturday, we hosted our latest Type 1 in the City event which covered one of the almost-taboo topics of diabetes – complications. As a diabetes organisation, we seem to at times be scared of speaking about this issue and when we do it’s in hushed tones. Despite being one of the most requested topics on our event feedback forms, we’re reluctant to put it on our ever-growing calendar of events.
As a person living with diabetes, I don’t like talking complications. In a stupidly superstitious way, I feel that if I do I’ll make them come true. (Yep – me and logic. Best friends!) But after 15 years of living with diabetes, I am, for the first time, having to face complications head on. The cataracts that have been threatening to cause vision problems are now at the point where I can no longer ignore them. At my six-monthly ophthalmologist check-up last week, I decided it was time to bite the bullet and schedule the surgery to have them removed.
I’m not okay with this and it’s more than just being a complete and utter wuss when it comes to eye things. Although it’s likely that I was going to develop cataracts, my diabetes is probably the reason why they first appeared when I was 28 year old and that I will be having surgery for them at 40.
I believe that at Diabetes Australia – Vic (where I manage Community Programs) we have a responsibility to put discussions about diabetes-related complications on the table. We should be talking about them. As soon as a topic becomes taboo, there is shame and stigma associated with it. And that shouldn’t be the case. For many living with diabetes, complications are a reality. We should be providing not only information about how to reduce the risk of developing complications, but also information about continuing to live well if complications do eventuate. And we should be doing this in a safe way that doesn’t cause shame or feelings of failure.
Maybe we need to start to rethink the way we speak about complications. Time and time again we hear that if we ‘take care of ourselves’ we won’t get complications. But we know that is not the case. It suggests failure on our part if we do get complications. Sometimes people do their very best with what they have access to, and complications still happen. If we reframe the discussion and make sure we consider the role luck or genetics may play, will that mean that people are less inclined to ‘do the right things’ because they think the result is pre-determined? Or will people actually feel better knowing that, if they do develop complications, they feel confident they’ve done the best they can with the tools available to them and the capacity they have.
My dear friend who does live with some diabetes complications is my go-to person when I want to ask questions about living with such challenges. She has some really strong and valid views about how we should be discussing diabetes complications. She says, ‘Discussions about complications shouldn’t be used as a threat. We don’t need to be showing the horror stories, but we do need to have available real, factual information about complications for those who would like to find it.
‘Also we need to make people aware that complications are not the end of the world. There are lots of people walking around with complications, living their lives. I work with others with diabetes and I don’t want to be the constant, visual reminder of what ‘can happen’. But I hope that they see that even with complications life can go on.’
One of the things that my friend mentions is that at times she doesn’t feel connected to the diabetes blogs she reads.
‘Sometimes when I read blogs like yours I think that you are doing it easy. It seems like you are doing really well with it. I don’t mean that with any disrespect, but my experiences are really different to yours. I’ve never read any blogs about people with diabetes who have had the same experiences as me.’
So what do we need when we are talking to people who have complications?
‘We need peer support – whether in a group situation or one on one or on the phone or online. While having treatment for complications, I was not given any offer of support like this and I think perhaps it would have been good for me.’
I feel incredibly lucky to have this particular friend in my life. I know that she worries that hearing about her diabetes life may scare me, it does the exact opposite. I know diabetes complications may occur – they were shown to me in all their gory detail the very day I was told I had type 1 diabetes and I was terrified. But speaking to her, watching her live a rich, full life (despite being a Collingwood supporter) doesn’t terrify me. It reassures me. It helps me understand that if complications are part of my diabetes future, they don’t signal the end. And that has given me hope. She’s pretty damn amazing!
It’s a gorgeous day in Melbourne today; my BGLs are sitting pretty and there is a nice straight line on my CGM. Sometimes, it feels easier to live in hope…..
A couple of weeks ago at the ADS ADEA conference, I spoke at one of the Symposia about how healthcare professionals can get involved with diabetes social media. Today, social media has the ability to connect people like never before and is something about which I am passionate. I speak and write regularly about the power of the diabetes online community (DOC) as a way to bring together peers; my presentation at the Doctors 2.0 and You conference in Paris back in June discussed how social media can be used to connect four of the players in healthcare – patients, healthcare professionals, healthcare organisations and industry.
I was a little nervous about discussing this topic because I know how reticent a lot of HCPs are when it comes to social media and its value to people living with diabetes. Because of its very nature, social media is unregulated. There is just so much out there; how is anyone meant to know where to direct people? And equally, what should be given a very wide berth? (For the record – anything claiming that cinnamon cures diabetes is a crock and should be ignored!)
With thanks to the clever people at Diabetes.Daily.com
But actually, that wasn’t what my talk was about. My talk was about why people with diabetes turn to social media; what (and who) we look for and what we get from an online community of peers that we can’t necessarily get from our HCPs. I then moved to discuss how HCPs can engage with the very same things we are using.
My presentation was gentle – a lot of the people in the room had never considered using Facebook as a tool to provide support and connect with others living with diabetes. Whilst there is a general understanding about the value of peer support, that view is often out-dated and focuses on a more traditional picture – face-to-face support groups.
I discussed how health professionals around the world use social media as a mechanism to connect with other health professionals and how crowdsourcing diagnoses works. I suggested the audience look up Bertalan (Berci) Meskó and consider enrolling in his online Social MEDia course.
I explained how Twitter is about far more than finding out what Kim Kardashian ate for breakfast and discussed weekly diabetes tweetchats, urging the HCPs to check in, lurk for a week or two and then take part.
Social media works for people with diabetes because it feels like a safe place. I know that idea is completely contrary to what many HCPs believe – they see it as anything but safe! But I know that I can log on to Twitter or Facebook at any time of the day or night and there will be someone there who can say to me ‘I know how you feel’. There will never be judgement; there will never be accusations of not trying hard enough. But there will be support.
And I guess that’s the crux of this. We know our community and we feel safe there. In his TED talk, Berci Meskó discusses how crowdsourcing works when you know your audience and your social media networks.
The final thing I discussed was diabetes blogs. There are two ways HCPs can use blogs. The first is for themselves; they can read them; they can take in what people are saying. Because it’s by reading the blogs of people living with diabetes that the real-life stuff comes through. It’s a way for them to get a good understanding of the things that we don’t talk about in our appointments with them, but the things that are important and impact on how we manage not only our diabetes, but our every day lives.
Also, they can use them for their patients. If ever a patient says ‘I feel so alone’, I suggested that they direct them to a well-known diabetes blog. There will probably be a post somewhere in the diabetes blogosphere that will address the same issues the PWD are experiencing.
The diabetes social media world does not need to be scary and regarded with suspicion. The role of HCPs is not under threat because PWD are using social media – that’s not what it’s for. It is just the 2.0 version of peer support.
Don’t forget – weekly #OzDOC Twitter chats are on Tuesday at 8.30pm (eastern time).
DISCLAIMER
The Can Technology Cure Healthcare’s Future symposium was sponsored by Sanofi. My travel costs were covered by Sanofi, however I did not receive any payment from them. Sanofi had no input into my presentation. Good on them for supporting such an important topic!
There are times that I am dismayed at what I read on Facebook about people navigating diabetes care for themselves or their child. Today, I was asked for my comment on a situation where a child with type 1 was being threatened with the removal of her pump because her HbA1c was higher than target.
This really gets my blood boiling for a number of reasons. Let me count the ways!
- A pump is not a luxury. It is a way of delivering insulin. Let’s be clear about that. It is a tool that we use in the management of our diabetes.
- The only person who has the right to determine how their diabetes will be managed is the person with the faulty pancreas (or their parents in the case of young children).
- HCPs are there to work with us and be guided by what we need and what we are asking for. Equally, we look to them for support, education, advice and information about our diabetes management. We do not look to them to be told off or judged.
- Punishing a PWD by removing a management tool is just plain stupid. Like it or not, I need to give myself insulin and I choose to use a pump to do that. If I’m feeling a little unmotivated and don’t have the capacity to be checking my BGLs, taking away my pump is not suddenly going to give me an injection (bad, bad pun) of motivation.
- Scare tactics DO NOT WORK. I’m going to say that again. Scare tactics DO NOT WORK. Also, scare tactics DO NOT WORK.
- The person in charge at all times is the person with diabetes. Let’s be clear about that too. The PWD is up front, directing traffic. HCPs, diabetes organisations, friends and family are there to support the person in charge.
- This is going to sound crass, and I don’t mean it to, but HCPs need to remember that they are being paid to do our bidding. They are providing us with a service. And that means, if we don’t like the service, they get sacked and we find someone who will give us the service we need.
- Threatening to remove a pump is bullying behaviour and it absolves the HCP of any responsibility in the management of their patient. I will never blame my HCP if my A1c is out of range or I am not checking my BGL. I would ask that they don’t blame me and threaten me.
- Deciding to take away a pump because HbA1c is too high is placing far too much importance on the value of the HbA1c! It’s just a number that gives an average. But not much more.
- Also, by using results of an HbA1c check as a reason to threaten to remove someone’s pump is forgetting about the considerable emotional impact of diabetes. Just as an out of target A1c is not a reason to rap someone over he knuckles, an in-target A1c is not necessarily an indication that everything is A-okay.
I know that it is not always easy to be your own advocate, but it’s times like this that you really need to be able to stand up for yourself (or your child), or bring along someone who can. Being clear about what you want and need is important – and that includes being clear about what you won’t accept.
The other day , I sat in a horseshoe shaped room and on a curved screen that wrapped around the room watched a video of a house and garden. The room was dark and as I concentrated on the moving images, I forgot about the other people in the room. The people sitting on the stools around me ceased to exist as did my companion who was sitting next to me unless he shuffled in his seat or leaned over to murmur something.
I was alone, focused and unable to be distracted by anything around me. The pictures were vibrant, stunning, bright. I was swallowed into the screen and felt myself wandering the gardens and peering into the rooms. I wasn’t a visitor or a viewer, I was in there; an active participant.
At the moment, I don’t really feel like I am an active participant in my diabetes management. I feel like I am on the outside looking in and am very easily distracted to think about anything but.
Right now, diabetes is taking a back seat as I deal with other far more emotionally encompassing issues. I am still coming to terms with the pregnancy loss I experienced almost four weeks ago and some subsequent concerns. I’m angry at diabetes right now, which is irrational given that it had nothing to do with the miscarriage. But I need something to blame, and I can grab onto diabetes; hold it up as the culprit. My faulty pancreas is taking a bashing at the moment as the scapegoat I need to try to make sense of what has happened.
But I know that this can’t go on forever and sooner or later I need to start to deal with my diabetes again. I am writing about it a lot, but I suspect that is a way for me to give it prominence and know that I am at least thinking about it.
It is times like this that having loved ones around who care about me and my diabetes can be a double-edged sword. While I am fiercely independent and can’t stand the thought of someone peering over my shoulder asking about my latest BGL , I probably do appreciate some concern and perhaps a little extra gentle involvement. I know that they are reluctant to step in, fearing my further withdrawal as I stupidly try to prove my independence. The truth is, right now, I need them to step in.
It’s a balancing act, because if your loved one with diabetes doesn’t usually welcome your help, how do you step up a little without attracting their anger? Testing the waters to see what level of involvement would be welcomed is probably the first step. If you’ve noticed that your loved one isn’t checking their BGLs very much – or at all, maybe asking if you can retrieve their meter from the depths of a handbag is a first step. Or if you see that the last spent CGM sensor has not been replaced, asking if there is a reason that they have not replaced it may have them talking about why they need a bit of a break from all the data. But at least they will be thinking about the rationale behind their actions.
Perhaps offering to take care of keeping hypo stores stocked or making sure that there is enough insulin in the fridge would be welcome. And inquiring about any upcoming medical appointments and offering to accompany them – with a promise of lunch or coffee – is a lovely idea.
Everyone is different and what works for some would not be appreciated by others. Often, when we are going through tough times – whatever they may be about – we are not looking for others to provide solutions. We don’t really want advice. We just want to know that people care, are standing by us and, if necessary, will help if asked. Hopefully, the period will pass and soon enough they will be once again an active participant in their diabetes management. But until then, be gentle, be involved and let them know that you are there. They will appreciate it. They really will.
‘Why do you use a pump?’ someone asked me the other day. I’ve been pumping for so long now that I’m not sure I can really answer that anymore. I use a pump because I have type 1 diabetes and I need insulin. I know that there are other ways to administer insulin, but at this stage of the game, I’m not even willing to contemplate them. Been there; done that. So I suppose the answer is I use a pump because I need insulin and this is the way I choose to administer it.
It got me thinking about the other tools I use for my diabetes management. I use a CGM because it gives me information about changes to my blood sugar and (frequently, but certainly not always) allows me to act before I end up really high or really low. It’s how I choose to try to keep myself in range.
And I use a BGL meter because I like the ability to know my real-time blood sugar. I also use it as a way to confirm what my CGM is telling me. I check my BGL a certain number of times a day – a number that changes and a number upon which I decide – because that number of times gives me a good snapshot into what’s going on. I choose to check with this regularity because it gives me the information I need.
Together, these things work for me and for my diabetes. Would these things work for you? Maybe. But I’m not the person to say. I’m not you and I don’t know your life and I don’t know what you expect from your diabetes management devices and tools. I’m pretty clear about my expectations – I want things that are as simple to use as possible; give me the information I need when I want it and allow me to react in as-close-to-real-time as possible so as to prevent high and/or low blood sugars.
There is no one size fits all when it comes to diabetes and anyone who has any idea of life with this condition knows that. We don’t need people telling us what the best thing to do is because that ‘best thing’ may, quite possibly, be the ‘worst thing’ for you.
Also what works today may certainly not be right tomorrow. There will be times in our lives that we need more from our diabetes tools. There will be times that we want to keep an especially close eye on what’s going on and other times that we can take a small step back and just get the basic information. There will be times in our life that we really can’t deal with any more than simple, uncomplicated, straightforward data because we are too overwhelmed or just plain over it.
Working out what’s right for you may take time and effort. There could be trial and error and starting on one thing and finding it’s terrific or deciding it’s not right and ending up exactly where you started. And that’s okay. Take the time; think about what you want and what you need; see how you can go about getting it. And then choose. Choose what’s right for you.
There are some days that I just wish I didn’t open the newspaper. This is one of them. On the front page of one of the sections of today’s The Age in Melbourne I was greeted with The Diabetes Time Bomb. Making sure that I wasn’t in fact ticking, or that I didn’t need to call in the Bomb Squad to evacuate the building as they worked out whether to cut the red or blue wire, I continued reading the article.
So glad I did. ‘Going blind. Getting your leg cut off. Kidneys packing up. Dying of a heart attack. The implications of being diagnosed with diabetes are shocking.’
They were the first words in this article. I nearly stopped right there. But, I kept reading, lured by the topic of diabetes. The thing is, the remainder of the article is really well written. It draws readers’ attention to the fact that there are increasing numbers of people being diagnosed with type 2 diabetes and it is being diagnosed in younger and younger people. It’s factual; it includes quotes from several experts using evidence-based information and there is an excellent case study.
But starting an article about diabetes with a shopping list of scary complications is alarmist and pointless. There is no context offered, no explanation of what they mean, no statistics and no concern shown for those of us living with diabetes every day. It’s damaging, inconsiderate and irresponsible reporting.
The Diabetes MILES study showed that 33 per cent of people with diabetes worry about the future and the possibility of serious complications. The authors tell me it is consistently the foremost concern of people with diabetes. Reading an article like this does nothing to reduce that distress and everything to accentuate it. Nor does it provide truthful and balanced information about diabetes complications. They are not inevitable. A 30 year old with type 1 diabetes has an 88% chance of still having good vision at age 60, and with newer treatments, chances are even better.
And for people without diabetes, why would they want to keep reading? There is nothing positive in a list that includes threats of blindness, amputation, dialysis and death. Head. Sand. La la la, not listening!
I am not saying sugar-coat it (pardon the pun!), I’m really not. Diabetes is serious, the statistics are scary, the costs are prohibitive – and we do need to address these problems now. We need strategies in place to prevent type 2 diabetes in those at high risk and, for people already diagnosed with all types of diabetes, to reduce the risk of developing diabetes complications. We need the Government (whoever that might be in 6 weeks’ time!) to adopt a coordinated national diabetes strategy and fund programs to address the issues.
And we need the media to highlight these issues. We need their reach.
But can it be done by focusing on the facts and what needs to be done? Keep interviewing the professional experts and the real-life case studies. Use evidence and talk about strategies that can help. And please, leave out the melodrama and the scare tactics.
Thank you to Professor Jane Speight, Director of The Australian Centre for Behavioural Research in Diabetes (Diabetes Australia – Vic and Deakin University) for her assistance with this post. As is often the case, I speak with Jane for a balanced, thoughtful and sensible response to my ranty, unbalanced, often ridiculous thoughts.
There was an interesting post in the diabetes blogosphere this week by a paediatric endocrinologist in the US. She tells the story of a young woman whose A1c didn’t match the numbers in her meter download. It turned out that she had found a way to manipulate the meter into giving false readings that, as it turns out, were all in target. I love that this blog is incredibly sensitive in dealing with these issues and there is no judgement directed towards the young woman in the story.
One of my biggest frustrations as a – often the only – consumer representative attending scientific conferences is the constant remarks about ‘non-compliant’ patients or snide remarks about false numbers in log books. Or the complete absence of logbooks.*
I have often wondered if the questions shouldn’t be about why the patient isn’t telling the truth but rather why they feel they can’t tell the truth.
I also don’t think that we should be pointing fingers and saying people who do this deserve everything they have coming to them and if they wind up with complications it’s their own fault. Really? Let’s dissect that for a moment.
I am pretty certain that no PWD who is not being completely truthful about their numbers is ever thinking ‘I am doing this because I want to get diabetes complications’. I am sure that as each day goes by without a consideration to diabetes – no BGL checks, limited boluses, food they are told not to eat etc – the PWD is not thinking ‘Goody – I’m a day closer to diabetes complications’. I am also sure that they are dealing with guilt, confusion, feeling physically below par and incredible frustration. They probably also feel isolated and don’t know where to turn. (Well done to Shara, the endo who wrote the blog, for referring her patient to a counsellor and actually spoke about the burden of diabetes. And thanked her for being honest.)
Let’s also for a moment just remember that blaming people for developing complications is really unfair. Yes, we know that by keeping our A1c under 7% we reduce the chances of developing diabetes complications. But keeping that A1c under that magic number all the time is incredibly difficult. So many things can throw off even the finest of efforts – stress, a virus, faulty insulin, a personally or professionally difficult time are just a few reason why.
And there are people for whom complications still develop despite doing all the things they’ve been told would help reduce the risk. Sometimes, it still happens.
I have an endocrinologist who was either born without the judgement gene or has simply beaten it out of herself (or perhaps had patients beat it out of her). I never feel judged by her. And for that reason, I feel that I can be completely honest with her. I can tell her that I’m not doing great and not checking my sugars as much as either of us would ideally like me to be.
I contacted her after my recent miscarriage to let her know what happened and said I’d be in touch. I didn’t call, A week or so later, she sent me a message saying that she’d had a cancellation this week and could see me. I could have made up a million reasons as to why I couldn’t go – work, family, too busy, not available at the time. Instead I simply said that I needed some time to regroup and I’d call her when I was ready. That’s how I feel. That’s the truth. And when I see her I’ll tell her more of the truth, which is after 13 weeks of intense diabetes scrutiny, I’m taking a break. I’m not checking my BGLs 20 times a day as I was (even while wearing a CGM constantly) so I’m not doing a heap of micro bolus corrections throughout the day. Right now, diabetes is not something that I particularly care about because I am grieving and just trying to get through the day. I bolus for what I eat, I have a constantly full reservoir and I am changing my line every 3-4 days as usual. That’s all I can do. It’s enough.
Another huge frustration for me is judgement from other PWD. We are constantly rallying against judgement from HCPs or people who know nothing about diabetes. In my mind, that intolerance of diabetes judgement extends to PWD. Can anyone honestly say that they live a perfect diabetes life and always have done so?
No? Then how about you check your judgement at the door? How about we ask the question why people feel unable to tell the truth? How about we consider the emotional state of the person behaving this way and ask what help they need to be able to do what is required to live a healthy life with diabetes?
And how about we just support each other and admit that sometimes diabetes is so hard that showing up for a medical appointment deserves acknowledgement and a pat on the back.
*Here’s an exercise for anyone who has ever been judgemental about creative number-entering into log books. Get yourself a diary and for the next twelve months, write down every item of food or drink you put in your mouth including the quantity. No cheating, no exclusions, no forgetting. Every single thing, every day for a year. How hard do you think that would be? Now imagine that you have do to that and show it to someone. How would you feel having to show someone the day where your whole diet consisted of a bloody mary for breakfast and an ice-cream sandwich for dinner? Actually – the three days in a row that you did that. Now do it for life.
Half and Half in iced coffee. God bless America!
After an absence from writing here and an absence from Australia, I’m back! Seven weeks away which involved attending a couple of fantastic conferences, visiting favourite cities and discovering new places, hanging out with old friends from the diabetes online community and making new friends, and spending quality time with my family. I was also introduced to the horror wonder that is American Girl much to the excitement of the eight year-old kiddo and the shock of her parents. I ate lots of yummy food and am in rehab for my Half and Half addiction.
Red velvet cupcakes make these girls happy!
Now I’m back and as I try to acclimatise to the weather (it was 40°C the day we left NYC and 7°C the day after we returned to Melbourne) and dealing with stupid jet lag, I am also coming to terms with a lot of other things. While we were away I had a miscarriage.
The Great Wall of Jelly Beans at Dylan’s Candy Bar in NYC.
I left Melbourne for Paris feeling hopeful – I was in the early days of a pregnancy, and Aaron and I were quietly excited about the much-longed for addition to our family. And until four days before we were due to come home, we got ever more hopeful and confident that we would be returning home with some extra special excess baggage and exciting news to share with our friends and family. It wasn’t to be. I miscarried just over 13 weeks into the pregnancy.
Hanging out in Washington Square Park
I am recovering slowly but surely. I know that time allows for healing. I also know that sharing stories and talking about things helps the recovery process. Yesterday, a piece about my miscarriage was published at Mamamia. You can read about it here. It is raw and emotional and I wrote it to try to explain to myself and others the conflicting emotions with which I was dealing at the particular moment when I had to let go of my hopes.
I’ll be back writing at Diabetogenic next week – sharing some of the things about my holiday and the conferences and talking about real-life with diabetes. And about how making my own Half and Half turned out.
Let’s go Yankees!
Today, for the first time in my ‘diabetes-life’, I am wearing a medical-alert bracelet. After a hypo last night that resulted in paramedics, IV dextrose and at-home hourly BGLs (just so I could avoid going to A&E), I pulled out of the draw the bracelet I bought a couple of years ago and put it on.
I have resisted wearing medical-alert jewellery for 15 years and I’m not really sure why. I have never been backwards in coming forwards about the fact I have diabetes and I am certainly not in any way ashamed of living with this condition.
But for some reason, in my weird and twisted mind, the wearing of a piece of jewellery that brands me as ‘type 1 diabetes/insulin pump’ (as the inscription on the back of the tag says) was just too much for me to deal with. I have always associated it with the idea that I would not be able to deal with my diabetes myself; that I’d need someone else to help me and that there would be emergency situations. I’ve pretty much avoided these circumstances so far. Until last night.
So today, I located the bracelet and linked it around my wrist. It’s quite pretty to look at, provided all I can see is the bracelet part and not the tag . But each time I catch a glimpse of it – as I am typing at my computer; as I sat in a café drinking my morning coffee; lifting my arm to push hair out of my eyes – I feel defeated and somewhat branded.
I’ve always wondered about people who get tattoos which proudly declare they have diabetes and I’ve never understood why anyone would do that. I just don’t understand why someone would want to have their health status permanently tattooed to their skin. I’ve always thought if I was to do that, I’d need to add all the other ways I want people to think of me. And having ‘Harry Potter tragic’ or ‘Delusions of Nigella Lawson’ scrawled up and down my arms would just be silly! Again, it’s not because I’m ashamed of having diabetes. Perhaps it has more to do with the fact that I defiantly go against what everyone else is doing and I quite like being the only ‘un-inked’ person in the room. Of course, this is merely my own opinion and I absolutely don’t think any less of people who choose to have a diabetes tattoo. Maybe if braver, I’d do it too.
I’m heading overseas in a couple of weeks for a long trip and for the first few days, I’ll be alone, without my family. It’s probably a smart idea to have something on me that says I have diabetes – just in case something happens. Maybe it will give me some peace of mind, as I’m sure it will my family.
But for today, I’m feeling fragile and not particularly happy. Not happy that now I feel unsafe and feel the need to have something that (in my mind, and I’m sure my mind alone) screams ‘TYPE 1 DIABETES’. I feel that it’s a victory to diabetes. And I hate losing.
Lauren’s Hope jewellery has some gorgeous designs. My bracelet has five strands of black Swarovski crystals holding together the medical-alert tag. It’s quite beautiful, really!
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