October 1, 2014

Suggestions for ADA

I am sure all of us could all come up with favorites for the American Diabetes Association to do, but being a group by and for doctors, I doubt we will see changes that we wish would happen.

I have seen several bloggers use the term “Stage 1” to mean prediabetes and “Stage 2” for type 2 diabetes. Yet none go as far as Brenda Bell did in her Tuesday, April 20, 2010 blog. I have lifted this from her blog and thank her for this, even though I did not appreciate it at the time. While I am at it, I sincerely wish she would do more blogging, as she was often enlightening before other bloggers even thought about it.

Quote: An initial straw man chart can be derived from the American Association of Clinical Endrocrinologists' Medical Guidelines for Clinical Practice for the Management of Diabetes Mellitus (2007) examples for initial pharmacotherapy of T2DM:

Classification of Type 2 Diabetes Mellitus (based on initial therapy algorithms)
Progression Level
HbA1c (untreated)
Stage 1 (Prediabetes)
5.7 - 6.4
Stage 2
6.5 - 7.0
Stage 3
7.0 - 8.0
Stage 4
8.0 - 10.0
Stage 5
> 10.0

Other issues that play into determining the progression of T2DM include the deterioration of endogenous insulin production, the development of complications of diabetes, and the degree to which a person's blood glucose levels and HbA1c are responsive to pharmacotherapy. A more complex table of progression might include these in a manner such as this:

Classifications of Type 2 Diabetes Mellitus (proposed)
Level
HbA1c
(Goal)1
Effective Therapy
Evidence of
Complications
c-peptide
(relative)
Stage 1 (Pre-Diabetes)2
< 6.03
ILM. Oral medication optional for aggressive treatment.
none
high
Stage 2
< 6.5
Oral medication and/or insulin sensitizer required
none
high
Stage 3
< 7.0
Combination therapy and/or insulin required
possible;
possible comorbid conditions
varies
Stage 4
< 7.0
Insulin therapy required, with or without oral medications and/or pramlintide (Symlin)
probable;
possible comorbid conditions
low
Stage 5
< 8.0
Intensive insulin therapy required, possibly in conjunction with insulin sensitizers
obvious; one or more
comorbid conditions
low



1 While the HbA1c goals at the more advanced levels of diabetes progression are high enough that complications are likely to develop or intensify, those goals may not be realistically achievable with current medical and pharmaceutical technology.

2 Includes all previous diagnoses of gestational diabetes or Type 2 diabetes in which pharmacotherapy is not currently indicated

3 More aggressive practitioners may argue for an HbA1c goal of under 5.5 for Stage 1, under 6.0 for Stage 2, and under 6.5 for later stages of T2DM. The less-aggressive goals are informed in part by the (ACCORD) study, in which the tested combination therapy suggested a higher mortality risk for intensive control.

A classification scheme of this sort may remove the ambiguity of a diagnosis of "prediabetes" and its associated laissez-faire ("It's not diabetes") attitude, as well as the popular belief that once diagnosed, one can become "undiagnosed" (or perhaps "de-diagnosed"). It can also alert a medical practitioner to the need for ongoing monitoring and assessment of a person's glucose metabolism. On the other hand, classification will add to the pool of people indicated to have diabetes those who do not consider themselves to be currently affected by diabetes -- and in an environment where a positive diagnosis can mean the denial of employment, medical insurance, or healthcare, this can have worse repercussions than living with undiagnosed or untreated Stage 1 (or even Stage 2) T2DM. Unquote

The above quoted information is the most comprehensive that I have seen and I wish the ADA would give this consideration.

September 30, 2014

Change May Be Coming for Prediabetes

Yes, it may still be a few years in the future, but if researchers continue to make their voices heard, the American Diabetes Association (ADA) may feel the pressure. At present, the ADA has not given much attention to prediabetes and the term has caused most doctors to ignore prediabetes since it has no real official status. Even the medical insurance industry gives it no support.

I will quote the lead-in to the Science Daily article as it expresses what needs to be said about prediabetes.

Treating patients with prediabetes as if they had diabetes could help prevent or delay the most severe complications associated with this chronic disease, experts say. The researchers say that by not devising a treatment strategy for people with prediabetes, doctors run the risk of creating a pool of future patients with high blood sugar who then become more likely to develop serious complications, such as kidney disease, blindness, amputations, and heart disease.”

It seems that most doctors want to create a pool of future patients with high blood glucose levels. This may be the reason for the ADA not classifying prediabetes as diabetes and making it an official part of diabetes classification types. The term needs to go and be renamed, as outlined in my previous blog, Suggestions for ADA, but with more researchers recognizing the need, something may be done in the future and hopefully the near future.

According to the study authors, evidence comes from clinical trials where lifestyle change and/or glucose-lowering medications decreased the progression from prediabetes to type 2 diabetes. After leaving the interventions, the development of diabetes remained less in people who changed their lifestyle and/or took medications compared to the control group of prediabetes patients who did not have interventions.

The study authors say, “First, adults should be screened systematically to find prediabetes and early type 2 diabetes. And second, patients who are likely to benefit from treatment should have management aimed to keep their blood glucose levels as close to normal as possible.”

Lead author of the editorial, Lawrence Phillips, MD, from Emory University said, "Diabetes is generally diagnosed and first treated about ten years later than it could be. We waste this critical opportunity to slow disease progression and the development of complications. There is a strong, new argument that by combining screening to find prediabetes and early diabetes, along with management aimed to keep glucose levels as close to normal as possible, we can change the natural history of the disease and improve the lives of our patients."

Note: I will have another blog about the other side of diabetes which is not favorable for anything but more speculation. Hopefully, it will be ready next week.

September 29, 2014

Correspondence after the ADA Blog

I was expecting the harsh emails telling me that I should not be saying the points I made and that the American Diabetes Association had their guidelines for a reason. The emails are now almost 2 to 1 in favor of my points. Most are people with diabetes, but two are doctors. One doctor did chide for my saying one-size-does-not-fit-all, but explained that there does need to be a starting point on which to base a line of treatment.

Then she said that she agreed with me about assessing each individual and their desires and abilities for diabetes management. Dr. Sharon (not her real name) went on to explain that she normally has a printout of valuable websites for her patients to visit and a few pages of information that she has written for them to read. She does email this information to those that give her an email address. Then she schedules them of a second appointment within two weeks from giving them a diagnosis. Before she lets them leave from the diagnosis appointments, she has several blood samples taken to make sure that when they have the second appointment that she has the correct diagnosis, type1, type 2, or possibly LADA.

Being in a very rural area, she is happy that many of her patients do have internet access and she uses some emails and video conferencing since the insurance companies do reimburse for the video conferencing. For Medicare, she has to pay a nurse practitioner to be present, but by sharing a nurse practitioner with other doctors, this is not a problem. I was pleasantly surprised about the number of doctors that are cooperating to provide a wide range of services for patients.

What Dr. Sharon told me next was a shock. She said that the doctors cooperate by sharing offices and using their internet facilities to provide video conferencing for patients they don't serve, to prevent long trips for the patients. She said this networking has made for happier patients.

Back to the diabetes side. Dr. Sharon said that she is the only doctor among them serving patients with diabetes. The doctors in the network all provide services for each other with the responsible doctor receiving the lab results and sometimes the doctors confer among each other when a diagnosis is questionable.

She commented that she only has three patients that have A1cs over 7.5% and they are in a care facility and are frail patients. She said that even she is surprised with the number of patients that are maintaining A1cs near or below 6.0%. If and when she uses video conferencing with me, I may have more to write. Because of state line issues, I will not become a patient of her office.

September 28, 2014

Diabetes Self-Management Education Needs

I have a difficult time understanding the logic behind not educating people with diabetes the basics of Diabetes Self-Management (DSME). If the people responsible for this education are not equipped for this, then they need to teach the basics of Self-Monitoring of Blood Glucose (SMBG).

My cousin that is a nutritionist has asked my quite a few questions lately because she has been working with several other communities needing nutritional assistance. In one community, they had her there for a program with a certified diabetes educator and people were up in arms after the CDE left. She had been present for most of her program and wondered how someone with that much education could not teach, but only offer mandates and dogma.

In the question and answer part after the CDE talk, several had asked questions about sleep apnea and were told that she did not feel qualified to answer any questions about sleep apnea. The questions then turned to questions about what the different blood glucose readings were telling them about the food they were eating and my cousin said she could not believe that she evaded those questions and answered with mandates.

The last question the CDE was asked was about how to avoid depression and diabetes burnout. She started gathering her papers together while telling the people to talk about this with a psychologist. Then she promptly left.

My cousin said that many were hostile at that point, but she waited until she was introduced and said that if the group were interested, she would contact some people and ask if they would be willing to talk to the group about sleep apnea and depression and diabetes burnout. She said she would try to answer some of the questions about blood glucose testing during her presentation. She told the group that she knew of another group that could probably answer a lot of questions, but they would not be trained, as the CDE should have been.

She said her presentation should have been for 45 minutes, but lasted for about an hour and thirty minutes. They had many questions and asked some that she could not answer, but did give her a round of applause when she opened it up for questions and answers. She said nutrition was her specialty and that she was aware of diabetes only because a cousin had it and she had worked with most of our group on their daily nutrition.

The doctor advising that group had stated that he could find someone to talk about sleep apnea and depression, but the group needed more on diabetes management and equipment use. She warned me that she had given out my blog and several had pulled it up and may be sending emails with questions. I told her the doctor had already contacted me and asked for several of our group to speak at their November meeting. I said Tim had also received a call with the same request.

I asked her if she would be available to introduce us and answer more questions. Then I asked her if she was familiar with ketone meters. My cousin laughed and said she could guess why as people on low-carb/high-fat diets should use one if they are interested in maintaining a ketogenic diet. She said she has two of the three meters recommended by most of the medical insurance companies in our state. I said I would be asking for the medical insurance companies served by most of the group she had met.

I said this will be difficult, as most insurance companies will hesitate to reimburse for these, but will for some cases. She agreed and said she would talk directly to the doctor. Tim arrive then and we talked for another hour planning what we could talk about and who would be best for each part. We have more emails to send to the doctor asking questions. We agreed that as things came together for an outline that this should be sent to all the members of this group. Now the work begins.

September 27, 2014

Meeting with People Needing Help

Our meeting on September 26 involved all 17 of our members plus 13 people Jerry had contacted. In addition there were three doctors and two members from the other groups in our town. My cousin came as well, giving us a total of 38 people.

Tim asked Dr. Tom to talk to the group first. Dr. Tom thanked everyone for attending and Jerry for encouraging the 13 to attend. He explained that there were others not belonging to the group holding the meeting because if they felt a need to join a group, this would allow them to ask questions of those present. He introduced Glen and his wife from the group that had split from our group and the two members from the group he led.

He continued by asking if there were people from other communities. There was none as all were from our town or close to our town. Then he asked if there were any that did not have type 2 diabetes. Again, the answer was none. Dr. Tom asked Jerry to talk to the group.

Jerry thanked those not part of our group for attending and he wanted everyone to know that he has separated from his wife and was encouraging everyone not to stay with her for nutrition or dietary advice. He covered the reason for the separation and said that too many carbohydrates had affected his A1c by increasing it to higher level than when he was diagnosed. He said it might be because he is married to her, but felt the others should be warned. He said he would answer all questions later and turned it back to Tim.

Tim then asked my cousin to speak. She said she had worked with many from our group and they could answer questions about her if desired. She continued that she would work with each individual at the level each desired and within that work to balance the nutrition within his or her goals. She stated that she works with people at various levels of carbohydrates and has had success. She emphasized that a one-size-fits-all does not work, and that she works with people at the individual level.

She continued that she had talked with Jerry and would be working with him after the first of the year. She had, on her own, set up a meal plan based on his needs, and would adjust it, as he needed when he changed goals. Her main task is to keep his meal plan nutritionally balanced on a daily basis. She would work from whatever level of carbs he was comfortable consuming. That could be from zero carbs to 100 grams of carbs, but presently would not suggest higher than 100 grams until his A1c was lower.

She then stated what we all realize that are on insulin – we need to reduce our carbohydrate consumption when we start on insulin, as not doing this will generally cause a weight increase. The insulin utilizes the glucose more effectively and stores the excess glucose as fat. She concluded with that.

Tim then recognized and introduced a doctor that many of us were unfamiliar with and told him he had the floor. He said he would be brief, but did want to say that he was happy to hear what people said. He did agree that three of his patients should make the change away from Jerry's wife as they were having A1c problems. He admitted that he was impressed with my cousin and wished to talk with her after the meeting.

Tim then introduced Barry and Allen and said they would make a few statements about the VA for those that might be interested. Barry asked how many of those invited by Jerry were veterans. Seven hands went up and Allen said they would talk with them after the meeting.

Tim asked if anyone had any questions and there were questions for my cousin and for Jerry. Tim said the meeting is over and asked those that were introduced take up areas so that people could ask questions and move to someone else.

Brenda and Sue had the three women asking them questions. Then two of them moved over to talk with Allen and Barry. Even the doctors were getting questions about nutrition and carbohydrates and then about the support groups. Tim and Jason were also answering questions and explaining that we would take new members, but were encouraging people to talk to the other two groups as well to find the group that fit their needs.

After the meeting had started to break up, my cousin said she would probably be working with 10 of the people. She was surprised how many carbohydrates were being promoted by Jerry's wife and their A1c's reflected this. She said two individuals would not be going back, but were going with another person and the last person was still thinking about this. Jerry came over then and asked her how things were and she repeated the information for him. Jerry said this was better than he had hoped, but he would continue talking to the rest.

Tim then talked with us and said six wanted to join our group and that of the seven veterans; only one would possibly need to wait for benefits. Dr. Tom said that he was surprised and happy with the meeting and felt we had accomplished what we set out to do. He felt that his support group gained one person and Glen's group had possibly gained four members. We broke up the meeting then.

September 26, 2014

Study Says Salt's Effect on Blood Pressure Insignificant

Now if the American Heart Association would believe this we could be on to something. I do expect to see something from them and it will be a rebuttal if I am right. It turns out they don't need to as the American Diabetes Association did it for them in DiabetesPro SmartBrief. It carried an article by Reuters of people with diabetes ignoring salt uptake warnings. Both articles were dated September 8, 2014. The salt controversy just won't go away.

Previously on August 26, 2014, Eric Topol, editor of Medscape, used two studies and compares them. I will quote this from his article, “Our crackerjack cardiovascular news managing editor, Shelley Wood, published a superb article on Medscape - the heart.org, with many of the parties and leading experts weighing in. For me, the real coup de grĂ¢ce was the Wall Street Journal's editorial column, "The Salt Libel," which highlighted this conclusion: "[T]he illusion that science can provide some objective answer that applies to everyone...is a special danger."

I believe that adequately sums up all there is to say about sodium, at least for now. The AHA, however, isn't backing off from its 1.5 g/d sodium guideline. But I think there's a big lesson here about guidelines without adequate evidence: They can do harm. Hopefully this lesson will prove to be impactful, because that certainly has not been the case to date (as in cholesterol/LDL, BP, PSA, mammography, and a very long list of poorly conceived, nonanchored guidelines).

Isn't it about time to recognize that there shouldn't be rules for populations? Some people are exquisitely sensitive to salt intake, while others are remarkably resistant.”

New research should play a role in determining public health initiatives for reducing epidemic hypertension. It is unfortunate that hypertension is the world's most prevalent chronic disease. I was even surprised that it was so common at the younger ages. It affects more that 30 percent of adults at age 25 and above. It accounts for 9.4 million deaths every year.

With hypertension's increasing prevalence and the difficulty the global health community has in managing it, more should be done to identify casual behavioral relationships to blood pressure outcome that can lead to better strategies for preventing hypertension.

It is obvious that the salt debate will continue until the different medical groups decide to find science for their guidelines instead of what they call “expert opinion” and consensus. The science is slowly building and showing that there is more than just “expert opinion.”

September 25, 2014

Possible Help for Diabetes Apps, Devices, and Tools

When I read this Joslin blog, I had two reactions. First, I wondered why they would do this and second, I wondered if they would botch this like so many other things they have attempted.

I do have some preconceived ideas that caused the reactions. I purchased one tool several years ago now, and after two months, it went in the trash where it belonged. I have not purchased another tool, device, or app since and probably will not purchase another even if the hype looks grand.

Most tools, apps, and devices do not work well together and often require entering and reentering data multiple times. Not only that, transferring the data to the office of the doctor would require entering the data again. Not that the doctor would even look at it, but when required I would always need to gather up papers and enter the data for sending it in the required format.

I have found that using a spreadsheet and printing this out to mail to the doctor worked and did not require entering the data more than one time. Now that the doctor can receive confidential emails, I find it easy to enter the data one time and transmit it. Most doctors do not accept emails and therefore the telephone is the only way to give them the data unless I wish to drive 30 plus miles one way to his office.

I can only hope that Joslin does the right things to have more apps, tools, and devices work together seamlessly. They say they will be working with diabetes medical device and technology companies to improve development of easier to use, more widely accessible products that will help patients manage their diabetes. They claim this could include anything from providing clinical input that may impact the redesign of pumps to be faster, more accurate, and cost-effective, or to develop a mobile app that tracks your blood glucose levels.

A nationwide shortage of endocrinologists, diabetes nurse educators, and adult diabetes care centers has burdened the healthcare system and impacted timely patient care. Joslin believes the future of medicine, particularly diabetes care, must begin with self-management technologies.

What is significant is what Joslin does not say. They do not say they will work for interoperability and this is the failing of most apps, tools, and devices. The other important missing point is complying with HIPAA. This means that the companies can mine personal data and sell it to other companies. This is the problem of 99 percent of the current crops of these available. Anything using smartphones and iPhone have this weakness.

I want my personal diabetes and medical data secure and until this is the case, I will not use the defective implements now available. I feel that the Joslin Institute for Technology Translation has a lot of work to accomplish and this blog leaves many unanswered questions.

September 24, 2014

How Much Protein?

Because there are different guidelines for protein needed I will show the chart first, which is from the Institute of Medicine (IOM).

Exactly how much protein you need changes with age:
  1. Babies need about 10 grams a day.
  2. School-age kids need 19-34 grams a day.
  3. Teenage boys need up to 52 grams a day.
  4. Teenage girls need 46 grams a day.
  5. Adult men need about 56 grams a day.
  6. Adult women need about 46 grams a day (71 grams, if pregnant or breastfeeding)

You should get at least 10% of your daily calories, but not more than 35%, from protein, according to the Institute of Medicine.

The key measure is the Dietary Reference Intake (DRI), a system of nutrition recommendations from the Institute of Medicine of the U.S. National Academy of Sciences. Used by both the United States and Canada, the DRI supersedes the Recommended Dietary Allowances (RDAs), which is still used in food labeling.

Protein from animal sources such as meat, poultry, fish, eggs, milk, cheese, and yogurt provide all nine indispensable amino acids, and for this reason are referred to as ‘complete protein.'

Doctors still want you to limit saturated fat and select leaner cuts of meat. I would only agree on limiting processed meats like hot dogs and sausage. According to researchers at the Harvard School of Public Health, to help lower the chance of heart disease, it's a good idea to limit the amount of red meat, especially processed red meat, and eat more fish, poultry, and beans.

Other researchers say if you are trying to get more omega-3s, you might choose salmon, tuna, or eggs enriched with omega-3s, and if you need more fiber, look to beans, vegetables, nuts, and legumes.

Some of us with type 2 diabetes can have real problems with protein, especially if they have kidney disease and need to limit their amount of protein. Without kidney disease and following a vegan diet, then the problem becomes consuming enough protein. That is why I listed the table for protein consumption at the beginning.

Most of the studies proclaiming low-carb diets are good also have the diet as a low fat and were replacing the carbohydrates eliminated with protein. Some said this was good and others make no comments. The reason for the low fat is that many do not recognize the fallacy of Ancel Keys and that his conclusions have been debunked.

I do not agree to the low fat argument and think fat needs to be the macronutrient added as long as protein is at the level needed providing kidney disease is not a problem. A good discussion with a nutritionist may be necessary as well as the doctor if there is a kidney disease. No, I did not say a dietitian, as they generally want the carbohydrates to stay up and especially the whole grains. Gallbladder issues may also limit the amount of fat you can tolerate.

Please read this blog by David Mendosa about protein. He covers the many sides of protein that I do not.