October 4, 2015

Know When You Are Receiving Bad Advice

When dealing with registered dietitians (RDs) and certified diabetes educators (CDEs) you will often be given bad advice. You need to learn what some of the bad advice is and how to turn this back on them.

Yes, I can say mandates, mantras, and other platitudes because they are often what you will receive. They often don't properly assess you and try to bully you into accepting what they are telling you.

Recently, two of our members met with a RD/CDE (dual titles) for classes. Sue had not intended to go, but her doctor did ask her to go and report back to him. The other member was Jennifer and she was hoping to hear something more than she had been hearing from us.

When the class started, the emphasis was on whole grains and eating enough carbohydrates to prevent brain damage. Jennifer asked how many that meant and the answer was 45 grams to 70 grams per day. This told Sue that she had to think fast, but the instructor was on to planning meals that would see to it that they consumed enough carbohydrates.

When she finished with this and asked if they understood what they had been told, Jennifer asked if testing showed that they were too high for the blood glucose reading, should they reduce the grams for the next meal? The instructor did not miss a beat, but went right to telling them that if the reading was too high, they should talk to the doctor about increasing their medications or adding another medication.

Sue held her peace for that round as she was planning on dropping the bomb later. Jennifer asked what would be too high a reading and the instructor stated 180 mg/dl. Jennifer said that is in the range that could cause complications and the instructor said not if she was able to add another medication.

Jennifer said then she would need to reduce her carbohydrates as anytime she consumed whole grains; she would spike over 220 mg/dl. The instructor then advised her to have a talk with her doctor as she needed the nutrients found in whole grains.

At that point, Sue felt things had gone far enough, so she explained to the instructor that she was off all medications and eating low carb/high fat as was her husband. That really upset the instructor to the point she said that then she was not diabetic and why was she taking the class. Sue said that she had support from her husband and their support group and her doctor to work at getting off all medications and with the exercise and food plan has been able to stay off all medications.

Sue continued that whole grains are not the end-all and the nutrients could be found in other foods that were nutrient dense and did not have the carbohydrate content. Sue said even the ADA has partially accepted the low carb/high fat food plan which meant that the instructor was following the USDA guidelines instead. Sue concluded that by not encouraging testing and advising more medications that she was a fraud and did not have the best interests of patients in mind, only the interests of the corporate sponsors of the AADE and AND.

With that Sue and Jennifer left. Jennifer was very surprised at what the instructor had said and the way she was pushing whole grains, carbohydrates, and medications. Sue said she was glad Jennifer had asked about testing as most of the time they will not talk about testing and the readings to avoid. Sue said that her pushing medications is not good as this is what causes people to gain weight and often need more medication. The meal plan needs to be such that less medication is needed and if necessary help lose weight.

Jennifer asked how often to test. Sue told her to always test in pairs to be able to see how the meal affected her blood glucose levels. They had arrived at their cars and Sue said she was welcome to contact most of the older members and to ask her questions. They went their separate ways and Sue told her doctor what had happened. He thanked her and said this confirmed an earlier report by one of his patients.

October 3, 2015

Gretchen Becker Back on Wildly Fluctuating

The above link is to Gretchen's blog - please stop by and read.

Gretchen is back on her own blog from Health Central.   While I will miss her on Health Central, I welcome her back on Wildly Fluctuating.   Her first blog and second blog are on October 3, 2015.

AADE Is Not a Clean Organization

The Kentucky law is similar to what the Academy for Nutrition and Dietetics has passed in several states. It provides exclusive rules for whom may teach education and provides misdemeanor penalties for others providing diabetes education. I am not sure that even doctors are exempt. They are able to practice their profession, but the interpretation will be whether they can do any diabetes education.

Yes, there is a place for interpretation, but it seems that the law is clearly written to make the American Association of Diabetes Educators (AADE) the sole organization for doing diabetes education. It will be interesting to see if the Academy for Certified Diabetes Educators is included or excluded. A lot of authority is centered with the Board of Educators that is appointed by the Governor of Kentucky.

What I find surprising is the fees being charged to maintain an active license.
Pay licensing amounts as promulgated by the board through administrative regulation, with the following restrictions:
1. Initial licensing shall not exceed one hundred dollars ($100);
2. Annual renewal shall not exceed one hundred dollars ($100);
3. Biennial renewal shall not exceed two hundred dollars ($200);
4. Late renewal shall not exceed one hundred fifty dollars ($150); and
5. The reinstatement fee shall not exceed two hundred twenty-five dollars

(a) Licenses or permits shall be renewed annually or biennially if the board
requires biennial license renewal by administrative regulation.
(b) Licenses or permits not renewed within thirty (30) days after the renewal date shall pay a late penalty as promulgated by the board in administrative regulation.

These are not cheap fees for a CDE only working part-time. Unless this is a way of forcing CDEs to work full time or get out of the AADE.

Admittedly this is my opinion, but in my reading of the information, the AADE is taking actions similar to AND to become the only source of diabetes education. This is something I will oppose in my state as I feel that it is my right to obtain diabetes education where and when I choose and not from CDEs that want exclusive rights to diabetes education.

I see too many emails from people that CDEs are promoting nutrition and not diabetes education. On further investigation, many have had two titles after their names (i.e., CDE and RD). They are promoting high carb/low fat food plans and often the carbohydrate count in 45 grams or higher numbers per meal. This says that they are not allowing low carb/high fat (LCHF) food plans. All have been promoting whole grains, which those of us that do our testing know are the wrong foods for people with diabetes. The ADA is now allowing LCHF food plans, but the USDA is of course promoting whole grains and high carb/low fat (HCLF) food advice.

Most, but not all, CDEs do not promote testing of blood glucose levels other than one time per day and generally only at fasting in the morning if taking oral medications. Those of us on insulin that test more often know that it is necessary to test in pairs to discover how different food plans affect our blood glucose levels. Many of us sacrifice to purchase sufficient test strips to test at each meal, before and after exercise and before bed or about nine times per day, and sometimes we test more often if we feel that hypoglycemia may be happening.

October 2, 2015

Diabetes Is One of the Worst Chronic Diseases

Back in March 2012, I wrote this blog about the many ways that diabetes is worse than cancer. I have not changed my mind since and I feel that diabetes is one of the worst chronic diseases.

Some factors that keep rearing their ugly heads: (for type 2 diabetes)
  • Is doctors that haven't changed their attitude and blame patients for the disease.
  • Is doctors that threaten patients with insulin to get them to follow the oral drug route.
  • Is doctors that tell patients that they have failed if the want insulin.
  • Is doctors that leave insulin as the medication of last resort.
  • Is doctors that only believe that diabetes is progressive and don't support patients that want to manage diabetes.
  • Is doctors that will not screen at risk patients for diabetes.
  • Is patients that want to keep diabetes a secret.
  • Is patients that refuse to change lifestyle habits to help manage their diabetes.
  • Is patients that listen to the doctors above and believe them.
  • Is patients that feel this the twenty-first century and there has to be a cure.
  • Is patients that feel that a natural remedy is possible for managing diabetes.
Yes, both patients and doctors contribute to the problems we have today with diabetes. Many patients do end up with progressive diabetes because they refuse to properly manage their diabetes and for others, they become so discouraged by the guilt trip laid on them by doctors that they also do not manage their diabetes.

It is this unmanaged diabetes that leads to complications and often leads to an early death. This is why many of us that blog about diabetes try to convince people with diabetes that it is not their fault – not their fault.

We also tell people that they should live for today and manage their diabetes rather than living in the past and denial. Type 2 diabetes is manageable and often can be managed for many years without serious complications. Many people die of old age and natural causes before diabetes gets a strong foothold in their lives.

Most of us know that diabetes is manageable and we work to do this. The support group that I belong to works hard to show that diabetes is manageable. Yet, we are constantly meeting people that are like the patients in the list above and refuse to listen to us. This is when we become frustrated and have to wonder why people can be so set against doing what is best for their bodies, their lives, and their families.

October 1, 2015

Avandia Ups Bone Fracture Risk

Avandia is back in the news, and not in a good way. Inside our bones there is fat. Diabetes increases the amount of this marrow fat. A study from the UNC School of Medicine shows how some diabetes drugs substantially increase bone fat and thus the risk of bone fractures.

The study, published in the journal Endocrinology, also shows that exercise can decrease the volume of bone fat caused by high doses of the diabetes drug rosiglitazone, which is sold under the brand name Avandia.

These drugs aren’t first or second-line choices of treatment for type-2 diabetes, but some patients do take them,” said study first author Maya Styner, MD, assistant professor of medicine. “And we know there are drugs in development that target the same cellular pathways as rosiglitazone does. We think doctors and patients need to better understand the relationship between diabetes, certain drugs, and the often dramatic effect on bone health.”

According to Styner’s study, Avandia affects bone fat by enhancing a critical transcription factor called PPAR – peroxisome proliferator-activated receptor – which regulates the expression of specific genes in the nuclei of cells. Essentially, rosiglitazone takes glucose out of blood to lower blood sugar and treat diabetes. But that glucose is then packaged into lipid droplets – fat. Other researchers showed that some of that fat is stored in tissue, such as belly fat. Styner’s latest research showed that the drug also causes fat to be stored inside bone.”

The author did state the researchers were surprised at the large amount of bone fat caused by Avandia. They also were somewhat surprised that exercise could reduce this fat. But, that should be expected in a rodent study.

Many patients have been surprised that some diabetes drugs adversely affect bone health. However, diabetes by itself can harm bones.

Yet, other drugs under development that could be close to FDA-approval lower blood sugar by enhancing the PPAR pathway. These drugs are referred to as fibroblast growth factor-21 agonists. “Early reports show that the same bone concerns are popping up with these new drugs,” Styner said. “Doctors and patients need to be aware of this.” Bone fat, in general, isn’t nearly as well understood as other fat depots.”

Our field is just beginning to investigate bone fat and its implications for patients,” Styner said. But she said that more bone fat means less actual bone, which increases the risk of bone fractures.

Styner said her findings are not yet directly relatable to human activity. For humans, running isn’t nearly as natural. But she said she would still advise patients at risk of declining bone health to find an exercise that suits them; the default would be taking very long walks.

Then in an article in Endocrinology Advisor, the FDA is adding a warning to canagliflozin, the SGLT2-inhibitor that this drug increases the risk of bone fracture. Apparently, bone fractures are another source of concern for some of the oral diabetes drugs.

This is why I will stay with insulin and avoid oral medications.

September 30, 2015

Managing Diabetes as You Age

Managing diabetes as we age creates many special problems. These include:
  • Cognitive ability.
  • Other illnesses (comorbid conditions).
  • Physical decline.
  • No one to assist you.
To this, we can also have doctors that like to bully us because we are elderly. These same doctors often do not properly assess us or have our best interests in mind when they decide to change our medications or change our goals.

Since there are very few studies on the elderly and diabetes, there is little that even we can rely on to counter the directions of some aggressive doctors. Most doctors look to the American Diabetes Association (ADA) for some guidance, but this is often not the case. Even some of the “experts” cannot agree among themselves.

The ADA call for hemoglobin A1C levels below 7%, blood pressure less than 140/90 mmHg and LDL cholesterol under 100 mg/dl. When the target levels were raised to a less stringent level – hemoglobin A1C under 8%, blood pressure under 150/90 mmHg and LDL cholesterol under 130 mg/dl – many seniors had better results, but many still did not meet the targets.

There is tremendous debate about appropriate clinical targets for diabetes in older adults, particularly for glucose control. Are some older adults being over-treated? Are some being under-treated? These are questions for which we don't have answers, because most studies exclude people over the age of 65. The other problem that surfaces is significant racial disparities, particularly in women, in how well diabetes is managed.

I know that the Centers for Medicare and Medicaid Services (CMS) will not pay for more patient education for diabetes. The CMS is fairly generous as it is, but our problem is finding qualified educators that are willing to work for the reimbursement CMS pays. Often there are not educators available because many people live in rural areas where CDEs are few and far between if they exist at all.

In a recent study of people aged 65 and older, in Maryland, Minnesota, Mississippi and North Carolina the participants almost had to be clustered around large cities.

Another problem is most educators do not want to work with groups of people or use telemedicine to work with groups. They prefer working one on one to be able to promote mantras and not have interruptions from people that might have some knowledge of self-monitoring of blood glucose (SMBG) or diabetes self-managing education (DSME). One diabetes support group I have spoken at refuses to have an educator talk to them, as the educator always talks to the lowest common level and presents no challenges for any level.

The other problematic aspect of working with educators and often supported by many doctors is that many of the complications associated with poor diabetes management take a long time to develop, possibly longer than the life expectancy of a patient with other illnesses. Failure to keep diabetes under control increases the risk of long-term health problems such as nerve damage, blindness and kidney disease.

The final problem is many doctors leave insulin as the medication of last resort and often the patient has received damage to their health that insulin cannot repair or manage.

September 29, 2015

Doctors Create Risk from ER to Inpatient at Hospitals

You would think that doctor-to-doctor communication would be ideal and not create problems for patients. Not so, as this study points out. Apparently, when doctors are on duty, their communication skills are absence – big time. It is somewhat surprising that both the emergency and inpatient physicians say patient safety is at risk during hand-off from the emergency department to the hospital.

The problem during hand-off is ineffective communication. The findings were published online July 22 in the Journal of Hospital Medicine. Christopher J. Smith, M.D., from the University of Nebraska Medical Center College of Medicine in Omaha, and colleagues surveyed resident, fellow, and faculty physicians directly involved in admission hand-offs from emergency medicine and five medical admitting services at a 627-bed tertiary care academic medical center.

I think the key here is self-evident – academic medical center.

The study is based on responses from 94 admitting and 32 emergency medicine physicians. The researchers found that admitting physicians reported that vital clinical information was communicated less frequently for all content areas compared to emergency medicine physicians. Nearly all (94 percent) of emergency medicine physicians felt defensive at least "sometimes." Just under one-third of all respondents (29 percent) reported hand-off-related adverse events, most frequently related to ineffective communication. Sequential hand-offs were commonly reported for both emergency medicine and admitting services and 78 percent of physicians reported that these hand-offs negatively impact patient care.

"We identified several perceived barriers to safe inter-unit hand-off from the emergency department to the inpatient setting. Hand off-related adverse events, a pattern of conflicting physician perceptions, and frequent sequential hand-offs were of particular concern," the authors write. "Our findings support the need for collaborative efforts to improve interdisciplinary communication."

Apparently, one medical discipline uses a different language than another discipline and this is the cause of inefficient communication. When the administration does not recognize these problems, little attention is paid to communication problems and they don't improve. This happens often in academic centers and other hospitals with poor administrators.

September 28, 2015

Preventing Hypoglycemia

My patience with the American Association of Diabetes Educators (AADE) is wearing very thin. It appears they are totally abandoning diabetes education for patients and concentrating on hospitals, outpatient and long-term care settings like nursing homes and group homes. I am happy that they are concerned for the elderly, but this emphasis seems a little over the top because many patients in these facilities in rural areas will not see any of this education or benefit from any of this education.

With the joint statement that was issued in conjunction with the ADA and AACE, at the ADA meeting, it appears the AADE is redirecting their efforts away from individual patients and to institutions serving patients. This could be great for the elderly, and the people in these institutions that are served by the AADE, but does not sound that great for those in rural areas and those not served by the educators.  With my blog from Sept 19, I need to change my mind and think those people living in rural areas and being cared for in rural hospitals and nursing home may have the advantage and they may not have carbohydrates shoved at them.

Often preventing hypoglycemia becomes a cognitive challenge for the elderly and many times, it is managed by others. This includes nurses and caregivers. Will caregivers receive any of this education – highly doubtful?

During a presentation at AADE 2015, the annual meeting of the American Association of Diabetes Educators, Linda Gottfredson, PhD, professor emeritus at the University of Delaware in Newark, and Kathy Stroh, MS, RD, LDN, CDE, of Westside Family Healthcare in Wilmington, Delaware, said that emergency department (ED) visits and hospitalizations due to hypoglycemia are on the rise, and clinicians have an essential role in educating patients about the risk factors.”

Severe hypoglycemia is preventable in many cases. Insulin and sulfonylureas are essential drugs in the fight against diabetes. Some patients require these medications, but some are at risk for hypoglycemia by not using these medication properly, including when and how much insulin to inject or failing to recognize when they are at risk for hypoglycemia. In addition, many diabetes patients using the various sulfonylureas take their medication when they do not eat or are not feeling like eating.

It is this improper use of insulin or sulfonylureas that are causing the increase in emergency department (ED) use and hospitalizations. Why doctors will not educate these people about the dangers of insulin or sulfonylureas is a real puzzle to me. I have been fortunate to learn on my own and have been able to prevent the need for ED use.

Many cases of hypoglycemia occur during transitions of care. These include transfers for a hospital to a nursing home, or when there are changes in health care providers. It is not uncommon for doctors to provide ineffective communication between providers.

When it comes to individual risk factors, these include some of the comorbid factors, such as depression, cognitive impairment, epilepsy, cardiovascular disease, and advanced diabetes complications.

Age is also an added risk factor, pointing out that older adults are two to three times more likely than younger patients to have an adverse drug event requiring a physician office visit or an ED visit. Older adults are also seven times more likely to have an adverse drug event requiring hospital admission.

Diabetes self-care is a complex, cognitively demanding job for patients. It requires continual vigilance, learning, reasoning, judgment, planning, anticipating, and spotting problems. Then solving them in a timely and appropriate manner under constantly changing or frequently ambiguous circumstances that are unique to the individual.