Terms We Should Learn

These are terms often used by people with diabetes and their doctors. Often in the diets discussed that are popular with people with diabetes these terms are part of the discussion. The exception is the first term - polypharmacy

Polypharmacy =

1. The use of two or more drugs together, usually to treat a single condition or disease. This is the simplest form of polypharmacy.

2. The use of a number of different drugs, possibly prescribed by different doctors and filled in different pharmacies, by a patient who may have one or several health problems. This can become complex and often the people can develop drug conflicts.

3. The administration of many drugs at the same time. This can be by one or more doctors and may be similar to number 2.

Ketoacidosis =

1. Acidosis accompanied by the accumulation of ketone bodies in the body tissues and fluids.

2. Acidosis accompanied by an accumulation of ketones in the body, resulting from extensive breakdown of fats because of faulty carbohydrate metabolism. It occurs primarily as a complication of diabetes mellitus and is characterized by a fruity odor of acetone on the breath, mental confusion, dyspnea, nausea, vomiting, dehydration, weight loss, and, if untreated, coma. Emergency treatment includes the administration of insulin and IV fluids and the evaluation and correction of electrolyte imbalance. Nasogastric intubation and bladder catheterization may be required if the patient is comatose. Before discharge of the patient from the hospital, the nurse carefully reviews the meal plan, activity, blood glucose and urine ketone monitoring, and insulin schedule prescribed, emphasizing to the patient that ketoacidosis may be life-threatening and is largely avoidable by strict adherence to the patient's diabetic regimen, monitoring, and appropriate action for illness or stress.

Ketones = Poisonous acidic chemicals produced by the body when fat instead of glucose is burned for energy. Breakdown of fat occurs when not enough insulin is present to channel glucose into body cells.

Ketogenic Diet =

1. The production of ketone bodies in the body, as in diabetes mellitus or low-carbohydrate weight-loss diets.

2. One containing large amounts of fat, with minimal amounts of protein and carbohydrate. The object of such a diet is to produce ketosis.

Ketosis =

1. The accumulation of excessive ketones in the body, as in diabetic acidosis or occurring when fatty acids are incompletely metabolized.

2. The abnormal accumulation of ketones in the body as a result of excessive breakdown of fats caused by a deficiency or inadequate use of carbohydrates. Fatty acids are metabolized instead, and the end products, ketones, begin to accumulate. This condition is seen in starvation, occasionally in pregnancy if the intake of protein and carbohydrates is inadequate, and most frequently in diabetes mellitus. It is characterized by ketonuria, loss of potassium in the urine, and a fruity odor of acetone on the breath. Untreated, ketosis may progress to ketoacidosis, coma, and death.

Ketonuria = (ke″to-nu´re-ah) An excess of ketone bodies in the urine.

I am working on more terms and these are often misunderstood by most patients. Another article by Laura Dolson may also help in clarifying use of some of the above terms.

Food Plan Tips

First, I must state that I am not an expert on food and food plans. These tips are for your consideration and hopefully will give you ideas. For those that have been reading my blogs for some time now, you know I do not follow the ADA and their food plans. I can only say that in their recent guidelines they are becoming more reasonable and accepting of different food plans.

This written primarily for people with type 2 diabetes, but other people can benefit as well.

#1. There is not a “one-size-fits-all” food plan. This is probably the most important consideration. You need to discover literally what works best for you. Those of us with diabetes must use our blood glucose meter with test strips, to discover how different foods affect our bodies. This is an ongoing process because as we age or our bodies find it more difficult to process some foods and our pancreas may reduce the amount of insulin.

#2. Find a nutritionist that will be of assistance. No, I did not say a registered dietitian nutritionist. It is important that you not get involved with someone promoting for big food and insisting on whole grains. This will not help you meet your goal or goals. These are the people to avoid. If the nutritionist you have chosen promotes whole grains, find another nutritionist. They are supposed to work for you in balancing your nutritional needs with the plan you choose. They are not to work against you and promote their ideas for a food plan of your choosing. This does not mean that you cannot ask them questions and they should honestly answer your questions and help balance the needs of your food plan.

#3. Select two or three different food plans and study them in as much detail as possible. No, I will not tell you what to select as this needs to be your choice and one that you are willing to follow. This can take up to several months, but don't let anyone set a time table for you. After some studying, you may find some similarities that will allow you to start while still deciding on the food plan that you wish to use. If your chosen nutritionist tries to steer you away from your chosen plan or plans, find another nutritionist. You may ask questions, but should receive support for your plan(s). The learning process may continue for the rest of your life or you may find a need to change your food plan. Never be afraid of change.

#4. Set realistic goals of nutrition therapy for your needs as a person with diabetes. This is also an important consideration. Do you need to lose weight, hold the present weight, or perhaps gain a few pounds? All of this will be a factor in the goal you set initially and reset as you lose or gain weight. I will guess that as a person with diabetes, chances are that weight loss will be a goal. This is where the nutritionist can be a great resource person. In addition, the nutritionist should work with you at your individual desires and work to balance the nutrition.

If necessary, a nutritionist will recommend supplements where some food choices cannot be in balance. This may also be necessary and dictated by some medications. Health concerns like GERD, and some metabolic disorders may make some vitamins and minerals desirable. The nutritionist should also make recommendations for some vitamin and mineral testing if she suspects problems.

The nutritionist should also make sure that your food plan is individualized to your nutritional needs and goals, and not a one-size-fits-all food plan. Your health should always be your and your nutritionist's concern.

There can be other tips, but these should work for starters. If you have other tips that are working for you, keep using them.

Registered Dietitian Nutritionists

Right now, I am thankful that I am not limited by who I need to see for nutrition advice. The Academy of Nutrition and Dietetics (AND) was lobbying very heavy in this state for exclusive rights to be the only organization legally allowed to present nutrition and dietary information. Fortunately, that effort has been stopped.

The state medical board at the request of many doctors has come down against this. The politics were rather ugly for a few weeks. The legislators were listening and prevented the two bills from making progress out of committees. Therefore, for another year, no action will be taken.

Our support group has been watching the actions of certain state legislators to see if we should support candidates in certain districts to defeat a few candidates that supported this action for AND.

Now that a full year has passed since the name change to the Academy of Nutrition and Dietetics (AND), we are beginning to see what they are promoting. Since March is National Nutrition Month, AND is heavily promoting their Registered Dietitian Nutritionists (RDNs). Even we have seen advertisements calling for their support and recognition. We could not determine who paid for the ad that ran opposite the AND ad, but it did make people more aware of their intent and how they want to criminalize people not in their organization.

The AND spokesperson Toby Smithson has been overly expressive about the accomplishments of the RDNs and how they are now recognized by Congress and the Centers for Medicare and Medicaid services.

“Numerous scientific studies over many years, including studies mandated by Congress, have shown that medical nutrition therapy provided by a registered dietitian nutritionist can lower health costs, decrease hospital stays and improve people’s health. Besides being the designated providers under federal law of medical nutrition therapy for Medicare beneficiaries, registered dietitian nutritionists are also the preferred providers of nutrition care and services in many private-sector insurance plans.”

If this is true, why has the obesity epidemic continued to increase in numbers. Could it be that the whole grains promotion is adding to the obesity numbers? They certainly are not causing a decrease. The numbers of people being diagnosed with type 2 diabetes are also increasing and the RDNs have been increasing the whole grain promotion to people with diabetes.

The RDNs are not promoting low carbohydrate/high fat diets or the Paleo Diet. Instead, they are promoting a high carbohydrate/low fat diet supported by Big Food and the processed food industry. By doing this, they are violating their own motto of being the only safe source of nutrition information.

One-Size-Fits-All

Ouch! I can't believe I wrote that. But, my anger is up and I'm tired of Doctor One-size-fits-all. This is the second doctor in as many years that I have walked out on during an appointment and told I would not be back. I walk out because he was not listening, but reading the lab results and writing prescriptions. He had not even looked at my current medications list or heard me when I said he would need to send the prescriptions to the VA clinic.

I was having a giant problem with the prescriptions. My blood pressure has been stable for more than a year at 120 over 60 to 70 and yet he was prescribing a larger or stronger dose of the same medication I am currently taking. When I complained, he asked why his nurse aid had recorded 140 over 90. I replied that after walking at a brisk pace from the waiting room, she took my blood pressure immediately instead of waiting five minutes, which is the suggested time.

I suggested that he take my blood pressure again, but he stated – not necessary. When I looked at the next prescription, I almost choked. My lipid panel was in good shape and better than normal. Yet the doctor was prescribing a dose of statin at double the strength I was currently prescribed and actually quadruple what the VA doctor had told me to use because of muscle problems and I was splitting the pills. Even the pharmacist agreed with this action as I had asked about cutting the pill because their was not a indication that the pill could be cut.

I may not understand doctors, but I was heating up under the collar and I wanted an explanation. I politely asked, and was unceremoniously told I was the patient. As I closed my briefcase and put my coat on, he looked up and asked where I was going and told me he was not through. I quickly looked at two more prescription and I knew I could not stay with this doctor. My daily aspirin dose was increased from 81 mg to 325 mg and he was writing one for Plavix, which the VA had taken away.

I dropped the completed prescriptions on the desk and said I was leaving. He said I needed the increased medications and I asked how much extra commission he was to receive and walked out. The nurse was escorting the next patient in and said I couldn't be through. I said I was permanently through and kept walking.

I have thought about this for a couple of weeks and wonder why procedures were changing so drastically. I knew the patient I met on the way out, but he wisely said nothing. We talked afterward and he had received increases in several medications. He was taken off insulin and prescribed three oral medications. He was not filling them and had already found another doctor. He did not want to be off insulin and on management of his diabetes with oral medications.

He is young enough that he could have LADA (unofficial type 1.5) and had a longer than average honeymoon. He told me he has not told the doctor he will not be coming back, but will wait and cancel his appointment the week before.

Both of us talked about the one-size-fits-all attitude of doctors and why they cannot treat us as individuals. His new doctor has called him and asked him to consider going on oral medications. He is now looking for another doctor. I suggested that he find one that would do the proper testing and determine if he was not insulin dependent and a LADA.

We had a long talk and he finally called an endocrinologist who would see him and do the tests. He decided to go to a different city and be away from his doctors of the past.

The Groups Keeping You and Your Doctor Apart

This blog author uses more rhetoric than anything to push for a single payer system. She tries to convince us that it is not the government that comes between us and our doctors.

The agencies, organizations, and others that make it difficult for patients and doctors includes the following:

#1. The government The Department of Health and Human Services (HHS), the Centers for Medicare and Medicaid Services (CMS) are just two of the government agencies that are creating problems and coming between patients and doctors. CMS is mandating, especially for seniors, what can't be spent for medical necessities when this may be the only thing that will save a life. I am not talking about those near the end of life, but those that could be treated and have quality of life for many more years. The government agencies issue new regulations that create more paperwork.  This in turn reduces the time for doctors that they have for spending with patients.

#2. State Medical Boards and Medical Associations They help limit beneficial programs and work to promote faulty medical guidelines that the doctors have to follow. They lobby state legislatures to hobble new forms of medical practice like telemedicine and practice across state lines.

#3. The insurance industry Since managed care and pre-approvals came into existence more than 20 years ago, the insurers have delayed doctor treatments. And I mean in the emergency department and for operations. The insurers move drugs in and out of their formularies to reduce expenses. They have to keep their profit margin don't they? The worst part is they follow what CMS does and almost lock-step.

If isn't one of the above, its another. There could be other agencies and medical groups involved, but these are the main cast of characters. Now we arrive at the supporting characters.

a. The medical schools The doctors will deny this, but the medical schools do not teach some of the skills needed by doctors. Communication is a missing topic, the importance of the patient is also missing. Doctors graduate thinking they are god-like and infallible and that patients should rely on them as the source of all knowledge about what ails them. They can't explain things coherently to the patient or the patient's family. The doctors can only use medical terms and wonder why the patients do not understand them.

Then when the patients desire to have some part in their treatment, the doctor gets all up-tight and won't listen to their wishes. When the doctor writes a prescription, he expects the patient to fill the prescription and take it per directions. However, the doctor does not explain what the medication is, any side effects to watch for and what to do when they happen. When the patients asks questions, the doctor becomes angry that any patient would question him. All the courtesies are not part of the education doctors receive and some would ignore this anyhow.

b. The doctors themselves And you thought I had said enough about doctors. There are a few good doctors and even fewer great doctors. If doctors did not have this big fear of patients, they would not need to practice defensive medicine. It is their complete lack of communication that makes patients wonder what they are hiding and why. The doctor-patient trust is lacking and when patients are suspicious, everything a doctor does is analyzed.

c. The patients and their families How I hate saying this, but sometimes patients can be their own worst enemy. Also, when a spouse becomes too insistent, then the best doctor/patient relationship is in jeopardy. Even the best defensive medicine won't work when a spouse thinks something is amiss.

It is really a shame the when everyone points a finger at someone, they don't realize that they have three fingers pointing at back at them. There is a lot of blame to go around and each character plays a part.

Our March Support Groups Meeting

We heard from Dr. Tom that he had a speaker that was willing to work with us to teach us some of the things we could do for interventions. First he desired those of us that had lost friends or relatives to write as clear a picture about what our friends had done and what steps may have been taken to assist them. Tim had sent out an email to everyone asking for information from anyone that had lost someone. They were to write a detailed information description including our name and phone number for him to forward on to the speaker. This did not need to be about diabetes.

The meeting was scheduled for March 22. All the support groups were invited and we expected a full room of over 65 people. When we were ready for the meeting, we needed to delay the meeting for about 15 minutes while additional copies were produced for the overflow crowd of 82 people. Allen helped with the copying and Tim, Barry, and I passed out 3 by 5 cards. Tim asked for everyone that did not have an email address with him to complete the card with name, email address and support group name with leader. Tim explained that this was for notification of meetings and receiving information on group meetings such as this after the meeting.

As Barry and I collected the cards, Dr. Tom emphasized how important this meeting could be. Allen had asked about extra chairs while making copies and they were provided. Allen and our speaker handed out copies of the sheets our speaker would be using and Tim set up to display the sheets on the screen.

When the speaker was ready, Dr. Tom introduced him. The speaker looked at the sheet Tim had on the screen and said he appreciated that so many people were interested. He then suggested that after each sheet, he would take questions and a second meeting might be necessary if desired.

The first sheet had this:

#1. Know when to do an intervention.

#2. Know when to accept that the person did not want to prolong a treatment and wanted to die with dignity.

#3. Know what questions to ask and when.

#4. Look for clues in the answers to help guide you in providing help.

#5. Never use force or threats.

#6. Learn to read body language to know when to move forward and provide additional assistance.

#7. Make suggestions to help guide the discussion.

#8. Know when to use tough love.

#9. Know when to walk away.

Then the speaker started asking questions for the people to answer. His first question was which of these was the most important and the least important. Silence, so he picked one person to answer. The person answered that they were all equally important during an intervention. The speaker said you must have been in one and that he was right. He said that it could depend on the type of intervention and the illness, disease, or addiction that could make some of the points more or less important.

The speaker went on to say that for diabetes, all were equally important, but that number 2 was the point that most people forgot and that cancer was the same. He said that when family and other loved ones were involved, this was even more difficult.

He continued that an intervention can be done at any time, but for diabetes, the sooner the better. He asked how many had heard of denial and every hand went up. He said that as an audience of people with diabetes, he expected that. He said then that you should not be surprised when I tell you that some people stay in denial and develop varying levels depression at the same time.

He asked for a show of hands of the doctors present. There were six doctors present.

The speaker asked if any have been involved in diabetes interventions. Only two said they had been, and both people had severe depression. The speaker said those are the easiest to recognize. Those with minor depression are often able to mask this at doctor appointments.

The speaker suggested that the doctor may want to work with a group or a few of their patients that they trust and that are willing to step forward to work with patients. Then he stated that the doctors are your fist line of defense and need to help you know when an intervention or other action should be successful. Then he told the doctors he would work with them as a group, or individually, to help them recognize minor depression. He would also give them other signs to look for when a patient sees them or cancels for no reason.

The speaker said the floor was open for questions and questions he got. Even the doctors were asking questions. After over an hour of questions and answers, the speaker said I thought as much and a second session would be in order. Tim asked if April 12 would work as the following date was closer to Easter and the next was Easter weekend.

He asked for a show of hands and it was agreed. The speaker said he could do that and thanked the group for their interest. The doctors agreed and wanted everyone to be present at the next meeting. The speaker said to hang on to the handouts and read them in the coming weeks to be prepared for the next meeting. Tim ended the meeting of three plus hours. Most of our local groups wanted to talk and thanked us for including them.

Study, Elderly on Insulin More Vulnerable to Hypoglycemia

A recent study (link now broken), published on March 10 in the journal JAMA Internal Medicine states that the elderly were more than twice as likely to end up in the Emergency Room (ER) and five times more likely to be hospitalized. This is more than twice as likely to happen to those over 80 years old. Of course, the researchers are talking about those on insulin.

Managing insulin can be a complex endeavor as we age. Seniors that live by themselves or independently often have problems with vision (cataracts, glaucoma, or vision loss from aging). Add to this arthritis and other symptoms of aging and injecting insulin often becomes more difficult.

Complicate the above with varying stages of dementia and communication with caregivers becomes more difficult and often impossible. Unless the caregivers are extremely knowledgeable about diabetes, hypoglycemia symptoms are often missed and blood glucose testing may not be done as often as it should.

Some of the points that need remembering include:

1. Too little insulin can cause blood glucose levels to become too high. Over time, elevated blood glucose levels put people with diabetes at risk for serious complications.
2. Too much insulin can also be dangerous, causing hypoglycemia. Mild low blood glucose (BG) levels can cause irritability, shakiness, and sweating. As BG levels continue down, people can pass out and have seizures. Severe low BG can cause death.
3. Treating low BG levels is not as easy in the elderly. If the elderly have problems in swallowing, juice and soda may not work and often taking time to chew foods takes too long to be effective. Too often people with type 2 diabetes do not have injectable glucagon, which can be used to bring BG levels back to normal rapidly.

In some nursing homes, the proper procedures are not followed. Doctors often have nurses inject a fixed amount of rapid acting insulin and then the patient does not eat a much food as they should. This can easily create hypoglycemia. I have even witnessed people with diabetes passing some of their food to others who wanted the extra food thus they had an episode of hypoglycemia.

One family was even present when their elderly mother passed food to another resident because she did not want the food to go to waste. Then they knew why their mother had hypoglycemia. Even talking to the nurses did not prevent this and they asked why carbs could not be counted after eating, and the nurses answered they did not count carbs and if the resident passed food, they were not going to sit and try to compute how many carbs has been passed to another resident.

All they were going to do was take the carbs the dietitian had said was in the meal for them and inject insulin based on that and any correction needed before the meal. This meant that residents developing hypoglycemia were sent to the emergency room for treatment.

Another problem for the elderly is often they develop hypoglycemia unawareness. When this happens, they often are asleep and the hypoglycemia is untreated and death may result.

People on two types of insulin often have problems and inject rapid acting near the long acting insulin. This in turn converts the long acting (12 or 24 hour insulin) into short or rapid acting insulin. Hypoglycemia is the result of this happening.

While excellent blood glucose management should always be practiced, Dr. Sei Lee, an associate professor in the division of geriatrics at the University of California, San Francisco, stressed in an accompanying editorial, that he recommends that most people over 80 with type 2 diabetes not be put on insulin therapy.

“It's important to note that people with type 1 diabetes must always take insulin, the researchers said. For people with type 2 diabetes, other medications may be available.”

This is an important issue and when caregivers are in the mix, they need the training to recognize what is needed and when. Most doctors do not take the time for caregiver education and this is not a good thing. There is much our doctors are doing to create harm.