September 23, 2014

The Questionable ADA

I do need to say that I do not follow the guidelines of the ADA. I did refuse for a couple of years to read what was happening on the ADA (American Diabetes Association) website, but that was a mistake. Even if a person does not follow the ADA, we still need to know what they are saying and what guidelines and research is published by them. Some of the research is behind a pay wall, but some is available to the public.

The reason I do not follow the ADA guidelines is that the blood glucose levels they promote are levels that result in the development of the complications. Knowing this is the reason doctors say that diabetes is progressive. When the ADA says they recommend an HbA1c of 7.0 percent is their guideline, this is also in the range for complications to develop. This also causes patients to only attempt to achieve this when an HbA1c below 6.0 percent is nearer normal and while complications can still develop, they will not develop as rapidly.

Having an A1c below 5.5 percent is better, but this is not achievable by everyone. I also admit I cannot attain this level without severe hypoglycemia. I would urge people to read this by David Mendosa, Normal A1c Level. He also discusses what Dr. Bernstein says about normal A1c levels.

Although the ADA has relaxed their food plans in the last two years and in October 2013 issued new guidelines for food plans that includes low-carb, the registered dietitians (RDs) still promote high-carb/low-fat diets even though many were on the committee that developed the ADA food plans.

The ADA is too lax in their guidelines for blood glucose levels two hours after first bite (they recommend not higher than 180 mg/dl) and this will promote complications. The guidelines also say at bedtime that our blood glucose level should be less than 180 mg/dl. Their one-size-fits-all standard is not a good thing and we need to realize this, as people are all different in the way we are capable of managing our diabetes.

The last time the ADA lowered the definition for diabetes was in 1997 that dropped the criteria for diabetes from fasting blood glucose of 140 mg/dl to 126 mg/dl or higher -- a change that increased the number of people with diabetes by millions. It is now 17 years later and a poorly named term of prediabetes needs to be changed. It is not an official designation by the ADA, but with research showing that damage occurs in the prediabetes range of 100 mg/dl to 125 mg/dl it is time to declare this diabetes and move on to having it treated.

Yes, this will add approximately 86 million people to the diabetes numbers, but if done properly, many should be able to stop the severity of diabetes for decades or at least years. Knowing the ADA, this is highly unlikely. The medical profession likes to have people to treat rather than practice any form of preventive medicine.

The ADA also needs to include in their guidelines the concept of moving insulin from the treatment of last resort, to prescribing insulin at the early stages. This has proven effective in allowing the pancreas to rest and partially heal, making oral medications effective for a longer duration. Read this by David Mendosa for further clarification. Many in the medical profession will not do this because of their overwhelming fear of hypoglycemia.

I hope this explains some of the more salient reasons for not following the ADA guidelines.

September 22, 2014

A Discussion on Food Plans

Lately I have been writing about low-carb/high fat eating plans (diets for those that insist). I have to laugh, as this has really brought some unexpected emails. Some are insisting I should be eating very low carb and ketogenic. Others are insisting I should be low carb and high protein. I am laughing because most are a variety of food plans and most are saying this is the plan I need to follow.

What is discouraging is some of the people will not accept other ideas. I am not one of these. That is why I felt I must say and emphasize that 'One-Size-Does-Not-Fit-All'. For those of us with diabetes, we must each find what works for us. That does not mean that you can't take ideas from others and adapt them, but you should develop you own food plan that your meter tells you works for you. If the food plan that you are trying does not make you feel healthy and your energy is dragging, then work on changing it to another food plan.

I generally consume less than 100 grams of carbohydrates per day. I attempt to have about 15 to 20 percent carbs, 30 to 45 percent fat, and 35 to 40 percent protein. Yes, I vary quite a bit, but that is my choice. I have tried other percentages, but the high fat just was not working even with trying it for about three months. Occasionally I only eat about 50 or fewer grams of carbohydrates with higher fat and less protein, but I don't dare do this for several days in a row if I want to keep the bathroom available for my wife. I suspect part of the reason is the removal of my gallbladder almost a year ago.

I respect those that can consume more carbohydrates, but if they are using low fat, or as many do – very low fat, then they tend to start adding weight. I am not impressed with the studies of late that are low-carb, low fat, and high protein. The cardiologists are still promoting low fat, but they have a lot to learn. Most studies are short in duration and meaningless. Hopefully, we will have studies in the future of up to five years or longer that will be of value.

The best suggestion I have is tried and true! Learn to eat to your meter and the goals you establish for yourself. If possible, avoid highly processed foods, and attempt to prepare your own foods.

Read these two articles for further information - article 1, and article 2. I will be blogging more on nutrition in the future.

September 21, 2014

The Groups at Our September Meeting

We knew that several support groups would be present for the final with the specialist on interventions. We had 95 people present and had room for just a few more. With that many people we were happy that the air conditioning was working.

I was not prepared for the start. Dr. Tom took over and said we have had a successful intervention in the last two weeks. He explained that he had been brought up to date by several of the group and felt there was a good reason for the intervention. At that point he introduced Jerry to the group. He asked Jerry what his last A1c had been. Jerry answered 13.2%. There were several gasps and Dr. Tom asked people to be quiet as there would be more that would shake them up as they continued.

Dr. Tom explained that until last Saturday, he lived with his wife who is a dietitian. After several of our group had tried to work with him and had his wife stop them, some rather harsh information came to light. First his wife was very happy with his A1c and would not reduce the carbohydrates, had high fructose in many of the food items he ate, and would not let him reduce the carbohydrates he was eating.

He continued that when they were able to separate him from his wife, Jerry and he had about an hour's talk and a diagnosis that had been arrived at by the group. Dr. Tom said he had never had one of these, but had talked to another doctor that had experience with Munchausen Syndrome by Proxy. He saw a few hands go up and explained, Munchausen syndrome by proxy (MSP), a type of factitious disorder, is a mental illness in which a person acts as if an individual he or she is caring for has a physical or mental illness when the person is not really sick. In the case of diabetes, this can take the form of feeding the person with diabetes with too many carbohydrates.

Next he asked Jerry if he remembered what his A1c was at diagnosis, Jerry answered 8.0%, his second was 7.5%, the last was the 13.2%, and the plasma blood glucose reading from the week before was 331 mg/dl. Dr. Tom asked what medication(s) he was taking and he said he was on metformin, 500 mg 2X, and now he is taking insulin. He said that A.J was a great help in working with him.
At that point, Dr. Tom asked the intervention specialist to talk. The specialist stated that he had been able to talk with Jerry's wife and did agree with Dr. Tom's assessment. He could not say any more, but felt that the group had come to Jerry's aid for the right reasons and this was the first case he has seen. He said that normally you see this with one parent doing this to children, but one adult can do this to another adult.

Jerry then said that the situation had gotten out of hand and he knew that his A1c was heading the wrong direction. He said that with the support group members that had worked with him, he should be able to bring his A1c back in line or at least under 7.0%. Dr. Tom said that under 7.5% would be great, but that it was possible. Jerry said this was not what he had wanted in his life, but that there was support for action when he needed it.

The specialist then spoke for another half an hour about interventions and how valuable they could be. As he concluded, he asked if James had anything to say. James stood and said no, other than to thank everyone that had helped in his intervention and the support group for forcing a few issues when he had thought to go back to denial. He even said his wife had worked to keep him away from denial. He finished by saying he felt better now that his diabetes was being managed and that his last A1c was 6.6% and hopefully would be less at the next one.

Tim then said that they doubted we could have two meetings this valuable again, but that our group was happy for the meetings and hopefully presented something of value that everyone would remember and use to manage their diabetes more effectively. The meeting ended then. Some left, but many wanted to talk to James and his wife, and to Jerry. Dr. Tom did call him away and the doctors did want to talk to him. Allen, Ben, and Barry saw to it that they were not interrupted and A.J needed to join them. It took about an hour for people to disperse.

September 20, 2014

Warning! Terminology Is Important

When a doctor or nurse asks you who is your emergency contact, do you know whom they are asking about – 1) the actual person to contact for an emergency, 2) the person who is authorized to speak for you near the end-of-life, or 3) the person authorized to make decisions for you and has a durable medical power of attorney.

WARNING! Most medical providers and hospitals use the first one mistakenly. There is a difference in how these people may do things for you. The first person generally is the person that will contact the rest of the family and can make some minor decisions. Often this person is a spouse and often can fill all three roles.

Sometimes the spouse does not want the responsibility or is incapable of acting and the person in role 2 above is correct. This person can be a trusted friend, family member (an adult son or daughter), or other relative. The third role is the most difficult and most doctors and hospitals do not want to see this one and will often do their best to side step this person. Sometimes this person can also be an advocate for the patient and the medical profession will totally ignore this person serving in dual roles.

The point I am trying to make, don't count on your wishes being followed. I have seen this violated more often than I care to remember. It is violated by everyone from nurses to doctors, to hospital employees, to hospital administrators, and family members and this makes me sick.

Then to read about this study at the Henry Ford Hospital in Detroit added to my concerns. More than 95 percent of patients treated in an Emergency Department mistake their emergency contact as the designated medical decision maker for end-of-life care, according to a new study by Henry Ford Hospital in Detroit. The study is being presented Wednesday at the 20th International Congress on Palliative Care in Montreal.

The researchers sought to determine whether there was a correlation between the role of an emergency contact and advance directive. At various entry points into the health care system, patients are repeatedly asked to provide emergency contact information even though the health care industry doesn’t universally define what that is.

For its study, researchers surveyed 308 patients who were treated in Henry Ford’s Emergency Department in Detroit between December 2012 and April 2013. Of that number, 34 patients had an advance directive but only half of them provided a copy of it to their primary care physician.

Highlights of the survey:
99 percent said their emergency contact should be able to come to the hospital if needed.
• 97 percent of patients said they wanted their emergency contact to notify important family members if they were sick and could not do so.
• 97 percent of patients said their emergency contact should know what type of care they would want if they could not voice it.
• 95 percent expected their emergency contact should be able to tell the medical team what their wishes were if they could not.
When asked why they chose their emergency contact:
• 80 percent of patients said the emergency contact was the best way to get in touch with them.
• 43 percent said they were the designated medical decision maker.”

Erin Zimny, M.D., a Henry Ford Emergency Medicine and Palliative Care physician and a study co-author, says health literacy, which is one reason cited for low advance directive completion rates, did not play a role in their study.

We’re using an antiquated vocabulary in medicine,” she says. “We should be asking and educating patients about the importance of an advance directive instead of defaulting to the emergency contact world.” “

The study was funded by Henry Ford Hospital.

This type of information puts everyone on notice that more care needs to be taken to make sure that your wishes are followed. More on this in a future blog.

September 19, 2014

Meeting on Helping Others

On Wednesday evening, eight of us were talking with Jerry and asking him questions. Jerry asked if this was something we wanted to do and the answer surprised him. We all agreed that if they needed help, then we should help them even if it meant opposing his wife.

With that Jerry gave us a list of names and phone numbers and said he would contact them first and ask them to come to a meeting but was not sure where as he had a list of twelve people that may need help. Tim said that we should hold it next week and asked Barry and Ben if they could handle that many. He was going to ask both of the women since the list included three women and nine men. Jerry said he wanted Allen there also as two others were veterans and two others may be as well.

At that point Tim said we have a meeting this Saturday evening and we should not involve them in that at this time. We will use the room for another evening next week and this would clear it and let everyone know. We discussed this to eliminate conflicts and settled on the Friday following our large groups' meeting. Jerry asked how many would be present on Saturday and Tim said he estimated over 90 people, all with type 2 diabetes. Jerry asked if they were all from our town. Barry said no, there was a group from a town east of us, a large group from a town north of us, a few from the town west of us and three groups from our town.

Jerry wanted to know how often we had these meetings. Tim said not that often. We had one on interventions in April and a second one in May and now the third this Saturday. We have had others, but we try to have our own meeting every month. We occasionally include the group that Dr. Tom leads and have had the same groups at various meetings. We try not having meetings during the summer, but sometimes there is a meeting.

At that point Max asked to show Jerry the mirrors for examining his feet and we agreed. When he had his shoes and socks off, A.J said it was time to remove the bandages and apply the medication. Jerry said this would let him see what the doctor had seen. First A.J started with the left foot and then had Max use the mirror. He then handed the mirror to Jerry and Jerry said that one does not look that bad, but he could see why the doctor was concerned.

Then A.J applied the ointment and then applied the new bandage. Then they removed the one on the right food and A.J cleaned the area. Jerry used the mirror and really looked and grimaced. He said that looking at directly like this is much different that holding the foot up and not seeing the entire ulcer. He waited until A.J had finished treating it and rebandaging. Then he asked Max how much it would cost and Max replied that it would be about $35 to $50 depending on which type he wanted. Max and A.J moved Jerry to his computer and Max had the page on the screen.

Jerry looked and decided on the one for almost $50. Jerry bookmarked the page and said he would order it later. I asked if he had a podiatrist that he saw. Jerry said he did not and asked me if Medicare and his supplemental insurance would cover this. Then he asked what they did. I said his Medicare and insurance should cover it, but to talk to his insurance supplier to check. I said that a podiatrist trims your toenails and files them to remove sharp edges, plus he will look for foot ulcers and sores you show him on your legs, if any. Max confirmed this and said this had served him well when he had his first start of a foot ulcer. It was treated immediately and he had no problems. Max said this was the reason for his mirror and he discovered his second ulcer start early and it was treated and gave no problems.

We talked for a while longer and then left with Jerry saying he would contact everyone on the list and invite him or her for September 26. Tim called after he was home and asked about my cousin taking part and I said this was something I was going to talk to her about for a second meeting and possibly a third. I said that I would be talking to her about Jerry and see what she thinks. I said if Jerry has a good experience, they may be more receptive to what Jerry says. Tim agreed and said go ahead.

The next day, I called her and she said she would be in town that afternoon and if I could set up a time at 7:15, she would have a talk with Jerry. I contacted A.J and talked to Jerry. Jerry said he could have trouble as his wife had already billed Medicare and insurance for his education for this year and probably for the others as well. I contacted my cousin and she said she would still see him and give instructions for the following year.

September 18, 2014

Take Care of the Feet and Legs

A.J asked me to stop by Wednesday and said you helped me with the sore on my leg and I want you to look at a sore on Jerry's left foot. Jerry took his shoe and sock off and I could see what A.J was seeing. I asked Jerry how long this had been there. He said about a month or longer and his wife had said not to worry about it. I said that he had better worry and get to the doctor as soon as possible. It was a foot ulcer about a quarter of an inch deep and looked bad.

I asked why he had not had it looked at before. He said that his wife had told him it wasn't serious and he should ignore it. A.J said that it is serious and he needed to see the doctor and get it treated. I said I would take him if necessary, but the quicker he got to the doctor, the better. He put in a call to Dr. Tom's office for an appointment and they told him to come immediately and they would work him in as soon as possible. A.J said he would take him then and I went home and they went to the doctor.

When they were done, A.J called and said they would stop by. When they arrived, I met them outside and that way Jerry would not need to walk. We discussed what Dr. Tom had accomplished and Jerry said he had looked at both his feet and legs and asked if he knew of any other sores. They found the start of a second ulcer on his right foot and had treated both. A.J said he is only to walk when absolutely necessary and use the crutches even to go to the bathroom. He was to use his heels as much as possible to bear the weight.

A.J said that Jerry should be able to handle applying the medication which they needed to get from the pharmacy. Then each evening A.J was to look at the areas and report the next day to the nurse. Jerry said he felt like a burden, and both A.J and I said that this is what we do for others with diabetes and that we were glad to help. A.J said he would have another appointment in a week and the doctor would reevaluate the sores.

I suggested that I would get in touch with Max and have him come by with his mirror for looking at the feet and A.J said they were stopping to see him when they finished at the pharmacy. Jerry then said, you people think of everything. A.J said that was not totally true or we would have separated you from your wife earlier. Jerry said he would not have believed everything, but having her force carbohydrates on him and telling him to ignore a foot ulcer did scare him. He said that having people to help him was really appreciated and especially ones that would see that he was treated by a doctor when necessary.

Jerry asked how many interventions has the group accomplished. A.J said that he was our first and we were hoping that with his help, we could get his friend from relying on his wife for nutrition advice. Jerry asked who as there were several with type 2 diabetes. I then asked if they could accept a few of us joining them later that evening. A.J said they should as it sounds like there is an urgent need. I would contact Tim first and let him know. A.J said he would contact Max and change it for him to come rather than showing Jerry the mirrors in the car.

With that, A.J said about 7:00 PM then and they were off to fill Jerry's prescriptions.

September 17, 2014

Eating to Your Meter

I know you have heard this or eat to your meter. Many people with diabetes refuse to do this and often wonder why their blood glucose readings are remaining elevated. Their doctor sees A1c's that are elevated also and asks what they are eating. Many just don't answer or give what they know they should be eating and the doctor has to assume that their pancreas is not producing enough insulin or that the patient is very insulin resistant.

Yes, more test strips than your insurance will often allow, but if patients are honest with their doctors, and request extra, many doctors will go the extra mile and request the insurance company to provide more for three to six months. Some insurance companies will allow this if they see the A1c's coming down, as they don't want the extra expenses involved with complications.

This is one reason I suggest food logs be maintained as well as blood glucose reading logs. This means extra work and many people with diabetes don't see the value. I say that anything that can help manage diabetes and prevent complications is worth the effort. Life should slow down and people should take the time necessary while eating or immediately after the meal. People can forget an hour later and this robs them of the information that could be of help in determining if they need to reduce the quantity or eliminate a food item from their meal plan.

If you can afford the extra test strips, use them wisely. Continue the testing as soon as your wake up (fasting blood glucose reading) to watch for trends. Then select the meal that is generally your largest meal. Always test before the meal to give you a base for the after meal readings. This is just a suggestion, but after first bite, I start testing at the one-hour mark and test every 15 minutes until the next reading is less the previous reading. I do this every day for a week and then every few months (normally three or four months) until I am comfortable that the time was staying consistent. For me this was about 90 minutes, that was until I started slowing my eating and chewing my food longer. Then the time changed to 75 minutes.

Others that I know start testing at the one-hour mark and test every 30 minutes. Most end up at or near the 85 to 100 minute mark. That is why we tell people that what works for me, may not work for you or your mileage may vary (YMMV). Some people start testing one-half an hour after last bite. The best method is being consistent with when you start testing and the testing interval.

Now, realize that you are measuring the difference between the before and the after meal tests. Most people do not want an increase of more than 40 mg/dl. There are also people that want even less of an increase. We can use this information to determine if we need to curtail the serving size of food we eat, or if this is something we need to eliminate from our food plan. Many people strive to have premeal (preprandial) levels of 80 to 90 mg/dl and post meal (postprandial) levels under 125 mg/dl.

By doing testing, you will often be surprised what can be eaten with a smaller serving size and by counting carbohydrates.

The biggest problem is balancing the nutrition to obtain the nutrients you need including vitamins and minerals. Realize that I am not referring to whole grains which we can live without as the nutrients can be found in other foods that do not spike blood glucose levels as whole grain foods do.

September 16, 2014

Before You Get a Tattoo

Now what would a woman or for that matter a man with diabetes want with a tattoo? Unless your diabetes is extremely well managed, you will run the risk of infection and poor healing. I don't care if it is for beauty, self-expression, or any other reason. If you are one that insists on having a tattoo, make sure you know the facts before and after the tattoo. Make sure you know the types of tattoos, the tattoo risks, FDA's role, and tattoo removal options.

There are at least five types of tattoos:
Permanent Tattoo: A needle inserts colored ink into your skin. Permanent tattoos last a lifetime.
Permanent Make-Up: A needle inserts colored ink into your skin to look like eyeliner, lip liner, eyebrows, or other make-up.
Henna: Plant dye called henna or mehndi is used to stain your skin.
Black Henna: Developed from henna, may contain hair dye or other dye to darken the stain and make it last longer.
'Sticker' Temporary Tattoo: A tattoo design is on a coated paper. It is put on your skin with water. Temporary tattoos may last up to 3-4 weeks. Sticker tattoos last hours to days.

When it comes to tattoo risks, these are five of the most frequent:
  1. Infections and serious illness, like HIV or hepatitis, from unclean tattoo tools, practices, or products
  2. Allergic reactions to the inks or stains can cause skin problems, such as rashes
  3. Other skin problems like increased chance of sunburn, bumps, redness, or scarring
  4. Swelling and burning of the tattoo when you get an MRI test
  5. Pain and high costs if you want to remove a permanent tattoo
Contact your state or local health department for tattoo safety information to reduce your risk. Tell your doctor about any tattoos you have before any medical procedure.

There are four points to know about FDA's role:
  • Has not approved any inks for injecting into your skin.
  • Has not approved henna or hair dye for use on your skin. Some people have reported serious skin problems after using henna or black henna.
  • Does not regulate tattoo parlors.
  • Does monitor problems from tattoos and permanent make-up.

Please report problems online to FDA or call 1-800-332-1088. The online address is -

Removing tattoos is another problem.

Permanent tattoos can be hard and painful to remove. It may take several treatments that cost a lot of money. Talk to your doctor about your options. Remember you may not be able to completely remove your tattoo, and you could get a scar when you remove your tattoo.
Laser Removal - The FDA approves certain laser devices to remove tattoos. Lighter colors such as yellow, green, and red are more difficult to remove than darker colors such as dark blue and black. It may take 6-10 treatments to remove a tattoo. Some side effects may include bleeding, redness or soreness.

Surgery - Tattoos can sometimes be removed by cutting out the tattooed skin then sewing the skin back together. Other times, the skin can be sanded down to remove the tattoo.

Ointments and Creams - The FDA does not approve tattoo removal ointments and creams or do-it-yourself tattoo removal kits. These products may cause skin rashes, burns, or scars.

As a person with diabetes, please be careful and take my suggestion to not have tattoos put on your body if you have diabetes.