July 24, 2014

Researchers Say Pre-diabetes Label Unnecessary

Researchers from University College London and the Mayo Clinic have raised a few valid concerns, if, they had done their research properly. Too often, other factors drive research and not the true nature of research. In this case, financial considerations seem to be front and center and studies were hand picked to fit the researcher's agenda.

While people may not agree with me, this article should be read and people making their own determinations. At least the World Health Organization (WHO) has stated that the use of 'pre-diabetes' is discouraged to avoid any stigma associated with the word diabetes and the fact that many people do not progress to diabetes as the term implies. Bold is my emphasis.

I do agree that the term pre-diabetes is a poor term and causes most people that do not understand diabetes to ignore what they could do to prevent the full onset of type 2 diabetes. The following statement bothers me and is what raised red flags for me. “The authors (of the study) showed that treatments to reduce blood sugar only delayed the onset of type 2 diabetes by a few years, and found no evidence of long-term health benefits.”

With the total absence of education by the medical profession and researchers world wide, it is small wonder that people that develop type 2 diabetes are not aware that full onset of diabetes could be delayed or prevented. These same doctors even laugh about how they will have patients to treat until they retire because people will progress to diabetes and then to the complications. This is a typical reaction by doctors that do not understand diabetes.

"Pre-diabetes is an artificial category with virtually zero clinical relevance," says lead author John S Yudkin, Emeritus Professor of Medicine at UCL. "There is no proven benefit of giving diabetes treatment drugs to people in this category before they develop diabetes, particularly since many of them would not go on to develop diabetes anyway. Sensibly, the WHO and NICE and the International Diabetes Federation do not recognize pre-diabetes at present but I am concerned about the rising influence of the term.”

While I doubt this study will do anything to cause action by the American Diabetes Association (ADA), we can hope that the ADA will make the readings above 99 mg/dl,
part of the diabetes spectrum. There can be serious complications developing in this area called pre-diabetes. These complications vary by individual and with most doctors ignoring pre-diabetes and declaring that nothing happens, more people will continue to develop complications.

July 23, 2014

More Diabetes Management Tips Part 2

This is a continuation of the previous blog with five tips.

#6. Fight Everyday Stress With Activity. Living with diabetes can make you sad or unhappy at times. Stress not only affects your mood, but it can raise your blood glucose levels. Stress may cause you to make poor food choices and drink more alcohol. An easy way to feel better from everyday stress is to become active. Being active raises the levels of chemicals in your brain that make you feel good. If you don't want to exercise in a gym, join a sports team or take dance lessons to keep moving. Swimming is also another way to stay active.

#7. Exercise in Short Sessions, If Needed. Finding the time to exercise may be hard for some people. It can also be hard to keep going if you're not used to exercising for 30 minutes straight. The good news is you can spread your 30 minutes throughout the day. Three 10-minute walks are as good as 30 minutes at once. So don't hold out to exercise when you have a lot of time. Moderate physical activity (both strength building and cardio) will help you control your blood glucose, lower your blood pressure and cholesterol, and reduce stress.

#8. Try Strength Workouts If You Are Able. All types of exercise can benefit people with diabetes. But training with weights or other resistance equipment may help you prevent muscle loss (lost muscle often leads to more fat). Several studies suggest strength training. Lifting weights, for example, improves your reaction to insulin and your glucose tolerance. Of course, regular strength training can also improve your muscle mass and help you lose weight, too.

#9. Check Your Feet Every Night. Use a hand mirror or ask someone to help you look for cuts, swelling, or color changes on your feet. Don't forget to look between your toes, too. If you see unhealed cuts or broken skin, call your doctor right away. Make foot care part of your daily routine. Wash and moisturize your feet and trim your toenails as needed. Talk to your doctor about treating corns or calluses. Have your doctor examine your feet during every appointment.

#10. Choose a Date to Quit Smoking. If you smoke, picking a date to quit gives you the chance to prepare for it. You may need help beating the mental and physical parts of nicotine addiction. Stop-smoking programs, support groups, and wellness centers can offer professional help. Whether you quit cold turkey or use other treatments to help you quit, having time to prepare for it may improve your chances of success. Choose what works for you and quit as soon as possible.

#11. Drink Alcohol Only With Food. Your doctor may say it's OK for you to have an occasional drink. Drink alcohol only when you can eat something along with it, because alcohol can cause low blood sugar. Also have some water handy in case you get thirsty. Even so, mixed drinks can raise your blood sugar if you use juice or a regular soda as your mixer. Women should drink no more than one alcoholic drink per day, and men no more than two a day. Or I would suggest stop alcohol consumption completely.

I have said this before, but it is worth repeating. Keep a positive attitude. This will serve you well.

If you have other things that help you manage diabetes, make use of them and don't forget them. Every person varies in their management and abilities to manage diabetes, but this should not deter you from managing your diabetes to the best of your abilities and seeking help from others, if needed. Your doctor may be one of these persons as well as your pharmacist.

July 22, 2014

More Diabetes Management Tips Part 1

I am using WebMD for the ideas, but not the rhetoric and the pushing of carbohydrates and high carb low fat that the articles promote. Again, like so many other sources, they do not encourage using your meter with test strips to tell you how different foods affect your body. This seems to be how they encourage people to ignore diabetes and overeat. Yet they write about decreasing obesity, but don't really support it when it comes to diabetes.

I have written about other tips for managing diabetes in this blog, and WebMD had some items that need to be discussed.

#1. Eat the Foods You Like Within Reason. Having diabetes doesn't mean you can't eat your favorite foods. However, you need to know how your food choices will affect your blood glucose. By using your meter, this will help you learn skills and reinforce diabetes skills. Learn how to count carbs, read food labels, and size up portions that will let you keep your diabetes in check while still enjoying your favorite meals. Learn which of your favorite foods spike your blood glucose more that 40 mg/dl. Then limit the quantity you consume or eliminate that food.

#2. Define Your Plate and the Plate Size. Use a rule of three to build a healthy, satisfying meal. This rule may help you lose weight and manage your diabetes by increasing your intake of non-starchy foods. Divide your plate in half. Fill one-half with non-starchy vegetables like spinach or broccoli. Next, divide the empty side into two halves. Use one for starchy foods like bread or pasta. In the last section, add meat or another protein. You can also add an 8-ounce glass of low-fat milk and a ½-cup of fruit. This may not be the best and for some will not help them lose weight. This is only a suggestion and each person needs to find what works for them. Low fat milk does not work for me as I like whole milk, but not in large glasses.

#3. Write It Down and I Mean Everything. Develop the habit of writing down your critical information. Record your daily blood sugar levels and track how food, activity, and medicines affect your blood sugar and A1c test results. A written record can show you and your doctor whether your diabetes treatment is working over the long term. Writing down your goals and feelings in a journal may also help you stay on track and better communicate with your health care providers. I admit I may over do this, but I like records that help remind me of the past and especially the mistakes I make. This reminds me not to make the mistake again.

#4. Have a Sick-Day Plan in Place. This is something missing for many people with diabetes. This should be one of the first things you do. Common illnesses like colds, flu, and diarrhea can make your blood sugar rise. Having diabetes, in turn may make it harder to fight off infections. Have a plan in case you get sick. Store snacks that are easy on the stomach but can still give you enough fluids and carbs, if necessary. Check your blood sugar more often and know when to check for ketones and when to call your doctor. Get a flu shot every year. A flu shot may not prevent the flu, but you should have a milder case and recover quicker.

#5. Manage Your Medicines and Where They Are Stored. You may take pills or injections to manage your diabetes. Try to keep, at a minimum, 3 days' worth of your diabetes medicines and supplies on hand in case of an emergency, as well as a list of all your medicines. I would suggest 7 to 10 days of your medications. Your drugs may interact with other medicines, even ones that can be bought without a prescription. Make sure to tell your doctor before you take any new medicine. And always take your list to your regular doctor and dental appointments. Do not store medicines in the kitchen or bathroom as moisture or heat is often bad for some medications and testing supplies.

I will continue with 6 more tips in the next blog.

July 21, 2014

It Seems Everyone Now Worried About Elderly Medication

For decades, no one has expressed concern for the elderly or that they were often over medicated. Since the NY Times column and several other articles, the popular theme now is flooding the internet with articles and stories about the elderly being over medicated. I am proposing another purpose for these articles. Under the Affordable Care Act, aka Obamacare, many medical procedures and medications are being withheld from the elderly. These articles are for the purpose of showing cause for the medications being withheld, as if they have been overtreated.

However, this is also a cover by the media because they also want the elderly to die from the treatments withheld from the elderly. They are backing the current administration and their objectives of euthanasia.

What I am surprised is that the Diabetes in Control (DiC) people were suckered in by the NY Times article. Dr. Bill Quick in his blog here points out the shortcoming of the study which he says did not determine many essential points.

The DiC does state that the older diabetes patients are often switched to insulin and sulfonylureas to provide intensive therapy to manage blood glucose levels. This is too often done by doctors that are not knowledgeable about diabetes and their patients are kept on oral medications until it is too late and they have to be moved to insulin as the medication of last resort.

What is not stated in the study is how many had other conditions (comorbid) that could have caused worry for over treatment. Memory problems and conditions of dementia are not made known. It could even be that many of the veterans had no other conditions and had no memory problems. Then to say that they were overtreated could be in error when the patients were knowledgeable and wanted tight management their blood glucose levels.

The worry of hypoglycemia is often overstated because doctors do not know how to treat patients with diabetes. They could be over treating their patients with oral medications and causing serious side effects because they do not have the knowledge or information needed.

I admit that I am becoming irritated at doctors that keep ordering me to let my blood glucose levels rise above 7.0%. I am 72 years of age and on insulins, Lantus and Novolog, and while I have had levels that occasionally scare me, I have only had one level requiring my wife to assist me in recovering. Unless I develop memory problems, I will not let my blood glucose levels rise to the 8% to 9% that the people at DiC and other doctors want for the age of 75 or older.

I do have other comorbid conditions, high blood pressure, cholesterol problems, heart disease, and weight problems. The blood pressure and cholesterol are well managed by medications. I need to have a discussion with the doctor about my blood pressure levels that are constantly creeping lower. So far, I have not had any dizziness or other problems when getting up quickly, but today's BP readings have been 102 over 54 on rising and three hours later 110 over 60. I would think that I should be nearer 120 over 70, but I am afraid that the guidelines of 140 over 80 are not what I want.

July 20, 2014

Managing Your Medicines

Of course, for many seniors with memory problems or those with different forms of dementia, managing medications can be extremely difficult and often requires family assistance or caregiver assistance. Don't look the other direction or ignore these people, as they deserve to be cared for and have quality of life until the end.

Their problems with memory issues can often lead to not taking medications or taking them only when remembered. This can mean doubling up of medications sometimes as well. Making sure that medications are stored properly, have not expired, and are taken as directed requires time and attention. Many of the elderly take many medications at the same time and remembering what each if for, when to take each, and how to take each can be difficult.

There are some strategies that can be used to help manage medicines wisely.
#1. Maintain a checklist. For all prescriptions and over-the-counter medications you take, keep and update a checklist. The suggested format here may work for some people. It can be printed out or modified to a spreadsheet. Try to have at least two copies of your checklist. Put one on the refrigerator door or where your medications are stored and have one copy for your wallet or purse.

#2. Review your medicine record or list often. Do this before every visit to your doctor and when every your doctor prescribes a new medicine. Also do this whenever you stop or start a new over-the-counter medication or dietary supplement. Whenever your doctor discontinues a medication, adds a new medication, or changes the dosage of a medication, ask the doctor to write this information out with instructions for each medication. Keep this information handy.

#3. Ask your pharmacist to provide your medications in large, easy to open containers with large-print labels, if needed. Never put more than one medicine in the same container unless it is a multi-day dispenser. Always keep medicines in their original containers – again unless they have been organized in a multi-day dispenser. You may want to have multi-day dispensers that organize your medicines by the day and time you should take them.

#4. Determine how each medication should be stored. Ask your doctor or pharmacist how best to store each medicine. Insulin and some medicines must be stored in the refrigerator. Your kitchen cabinet near the stove and the bathroom medicine cabinet is not a good place to store most medicines because of the moist warm conditions that can exist and cause the drugs to break down more quickly. Many medicines have temperature range requirements for storage.

#5. Do not taking a prescription drug unless your doctors orders it or says it is okay. It is not okay just because you are feeling better. Some medicines are for a specific length of time and are not fully effective until the full amount it taken.

#6. Get prescriptions refilled early to avoid running out. Check with your insurance to find out how early they authorize refills. Also, running out of a medicine can cause problems. Check expiration dates and ask your doctor for a refill prescription if needed.

#7. Keep all medicines out of sight and reach of children. Store all medicines securely and away from pets. If children do visit your house, be extra cautious and have the phone number of the nearest poison control center handy.

Always remember that your pharmacist is an excellent resource for information about your medicines. Your pharmacist will answer questions and help you select non-prescription medications. It is wise to have your prescriptions filled by one pharmacist because this provides a backup for stopping medication conflicts

Be prepared in case of accidental poisoning involving medications or other substances. Call Poison Help at 1-800-222-1222 to speak with a poison expert at the poison center serving your area. The service is free and available 24 hours a day, 7 days a week, and calls are always free and confidential. Interpreter services are also available in 160 languages. Keep the number programmed in your home phone and mobile device.”

For more information, visit the Poison Help website at www.poisonhelp.hrsa.gov

July 19, 2014

Senior Health and Medicines

Medicines enter the body in several ways. They enter through an inhaler, a skin patch, a pill, an IV, or a hypodermic needle. Oh, you say I forgot an insulin syringe. Sorry folks, the needle on the syringe is a hypodermic needle. The meaning of hypodermic is under the skin and those of us injecting insulin do inject it under the skin and hopefully into a layer of fat below the skin and not in the muscle.

Medicines are also termed drugs and the terms are used interchangeably. As the drugs make their way through the body, changes happen along the path they travel. In this blog, I will focus on drugs taken by mouth, since those are the most common and many people with type 2 diabetes use them.

When you take drugs by mouth, they move through the digestive tract and are taken up by internal organs like the stomach and small intestine. Often, they are then sent to the liver, where they might be chemically altered. Finally, they are released into the bloodstream. As the bloodstream carries medicines throughout the body, the drugs can interact with many tissues and organs. Side effects can occur if a drug has unintended effects anywhere in the body.

Drugs are treated just like food, as the body attempts chemically to break them down as soon as they enter the body. Most are broken down in the stomach or small intestine and sent to the liver. The liver in turn contains protein molecules called enzymes that chemically modify drugs and other non-food substances. The chemical change of a medicine by the body is termed drug metabolism.

Often, a drug is metabolized by the body; it is processed into products called metabolites. These metabolites are often weaker than the original drug, but sometimes they have effects that are stronger than the original drug. An example of this is the codeine in the prescription painkiller Tylenol#3, which becomes fully active only after the medicine is metabolized in the liver.

Since most drugs and other 'foreign' substances are broken down in the liver, scientists often refer to the liver as the 'detoxifying' organ. This means that the liver can be damaged by too much medicine in the body. Drug metabolites usually return to the liver and are chemically altered again before they exit the body.

After a drug's metabolites have circulated in the bloodstream and done their work as medicine, the body eliminates then the same way it eliminates other wastes, in the urine or feces. Age-related changes in the kidney function can have significant effects on how fast a drug is eliminated from the body.

The above discussion helps explain in a small way, how important the liver and kidneys are to the processes that take place in the body for our drugs we take, and why many researchers refuse to test drugs on the elderly. Not only are they concerned about comorbid conditions, but also they are unsure of the liver and kidney and how well the body can handle the medicines.

Yet, our doctors prescribe these drugs and think nothing about the liver and kidney functions or the factor of aging on our liver and kidneys. Think about this the next time your doctor insists on keeping you on oral diabetes medications instead of insulin.

July 18, 2014

An Elusive Definition and a Discussion

This topic has been growing and has been presented in many other places besides the five references I will present. The topic is “patient engagement.” The term has been around since sometime in the 1990s, or maybe earlier, but really came into full use in 2012. My first exposure to the term was in Dr. Rob Lambert's blog here. In turn, I blogged about it here.

The definition is very loose and depends on who is defining it. Dr. Leslie Kernisan does a decent job of defining the phrase, but other people want to define the term as well. When the defining will arrive at one meaning remains to be seen. Back to Dr. Kernisan's definition, which says, “Supporting patient engagement means fostering a fruitful collaboration in which patients and clinicians work together to help the patient progress towards mutually agreed-upon health goals.”

In other words, to truly foster patient engagement, it's not enough to just work together more closely on achieving a given health outcome. It is also important to work together on deciding which outcomes to pursue, why to pursue them and how to pursue them. In doing so, we engage patients in a meaningful care partnership that respects their priorities, preferences, perspective and situation. Communication with patients is, of course, essential to all of this. This is why any innovation that improves a patient's ability to access and communicate with health care providers is proudly labeled as "patient engagement."

To me, all this is fine, but I still prefer what Dr. Lamberts says. “Communication isn't important to health care, communication is health care. Care is not a static thing, it is the transaction of ideas. The patient tells me what is going on, I listen, I share my thoughts with the patient (and other providers), and the patient uses the result of this transaction for their own benefit.” Bold is my emphasis in both paragraphs.

But our fine system doesn't embrace this definition. We indict ourselves when we talk about "patient engagement" as if it's a goal, as it reveals the current state of disengagement. Patients are not the center of care. Patients are a source of data so doctors can get "meaningful use" checks. Patients are the proof that our organizations are accountable. Patients live in our "patient-centered" medical homes.”

The Center for Advancing Health (CFAH) says, “Here is the CFAH definition of patient engagement (PE): "Actions people take to support their health and benefit from their health care."

The last definition is not that of most physicians and if you read the link above, they list six overarching themes which do not fit with the definition. Then if you read this blog by Jessie Gruman, president and founder of the Center for Advancing Health, you can understand a little more for the reason they are pushing this philosophy.

I admit that I have a very strong bias for what Dr. Lamberts has to say about patient engagement as is does not foster good communication between doctors and patients and is contrived to satisfy the “meaningful use” for receiving money for implementing medical health records. This in turn makes money for the doctors and makes billing for medical insurance reimbursement easier.


July 17, 2014

Patient Education Helps Manage Diabetes

Two points I wish to make in this blog are:
The first point = People with diabetes who receive education and training at clinical appointments had a 49 percent greater likelihood of achieving long term blood glucose management than patients not receiving any education.

The second point = Doctor training about diabetes management seemed to be ineffective in helping patients manage their glucose levels

The study outlining the above two points was published in Ethnicity and Disease. The researchers were expecting that the physician training would yield a better or an equal outcome to the education with the patient, but that did not happen. I do understand why providing intensive diabetes training to physicians did not work. Doctors do not get paid for providing diabetes education and under the current payment system, they will not provide diabetes education to patients for free.

Teaching people with diabetes how to manage their blood glucose levels helps them achieve better results. This happens because they are stakeholders and diabetes directly affects them. In addition, they spend about one hour per year with the doctor and must manage their diabetes 24/7/365.

This study happened in the Baltimore area and the findings are from 823 mostly Black patients with diabetes treated between April 2005 and July 2007. The patients, each treated by one of ten primary care physicians, were randomized into four groups.

The participants in the study were divided into four groups.
The first group received special diabetes counseling with a nurse during office visits.
The second group did not receive counseling, but was treated by five physicians who received diabetes training.
The third group received counseling and was treated by physicians who received training.
The fourth group received no training and their five physicians received no training.

The patients were seen every six months and improvement was measured by evaluating the reduction in HbA1c results. The patients receiving counseling sessions with a nurse at each office visit increased their chances of long-term blood glucose management by 49 percent after two years compared the group in which neither the patients nor the physicians received training. The physician training seemed ineffective at managing the patients' blood glucose levels.

The surprising unmentioned item is that self-monitoring of blood glucose after the completion of the study and what this may have accomplished.