August 30, 2014

Important News about Dietitians

The Academy of Nutrition and Dietetics (AND) is finally being set back on its heels. In their drive to become the only organization authorized to dispense nutritional information, they are meeting stiff opposition that is foiling their every move and in 2014, the organization lost their stranglehold on Michigan.

Michigan passed its Dietitian/Nutritionist Licensure Act in 2006. This created a monopoly for Registered Dietitians and excluded other nutrition professionals whether equal or better educated and qualified. On July 15, 2014, the governor signed HB 4688 into law, repealing the state's monopolistic licensure law for nutrition professionals.

The effort was a combined effort of several organizations that are working to prevent or repeal other state licensure laws. Other notable successes this year:
  • In New York, ASB 4999, a bill sponsored by the AND which we fought, ultimately died in committee because of all the messages you sent to NY legislators.
  • In the last three years, ANH-USA and its allies have managed to block nineteen separate attempts to institute monopolistic dietetic laws across the nation. We also proactively and positively reshaped the anticompetitive law in Illinois, where the AND is headquartered.
  • The federal Bureau of Labor Statistics (BLS) keeps a list of professions where each is defined in detail and statistics about it are kept. Previously, “Dietitians and Nutritionists” were categorized together, and the AND was listed as the sole certifying organization for the entire profession. In a milestone victory on January 8, 2014, nutritionists managed to get “Nutrition” defined as a different profession than “Dietetics,” and importantly, the BCNS (Board for Certification of Nutrition Specialists) is now identified as the certifying organization for nutritionists. This national, federal recognition of the unique credentials of Certified Nutrition Specialists is extraordinarily important.
  • And don’t forget our recent federal victory in which nutritionists won equal recognition with dietitians for the right to prescribe patient diets in hospitals.”

Some of the organizations working in cooperation include the Board for Certification of Nutrition Specialists (BCNS), the Alliance for Natural Health (ANH-USA), and other national groups.

August 29, 2014

Low Carb Is for People with Diabetes

Since this hit the press, more sources are picking this up and trying to make headlines with it. There are some very disappointing conclusions and what they claim are points of evidence, backed up by clinical studies. Something is very wrong and I doubt will be seriously adopted as presented. And to substitute protein for carbohydrates displaced may for many create other health problems.

Yes, the problem is that the low-carbohydrate recommendation is not low-carbohydrate/high-fat (LC/HF) that many of us are used to, but a low-carbohydrate/low-fat meal plan. This also means that it is high in protein which can also cause problems for some individuals.

This new study involving researchers from the University of Alabama at Birmingham and other institutions says patients with Type 1 and Type 2 diabetes should eat a diet low in carbohydrates. “The study, accepted for publication in Nutrition and available on the journal’s website, offers 12 points of evidence showing that low-carbohydrate diets should be the first line of attack for treatment of Type 2 diabetes, and should be used in conjunction with insulin in those with Type 1 diabetes.”

It is the 12 points I wish to draw your attention to are these:
Quoting -
The 12 points of evidence, backed up by clinical studies, are:
  1. High blood sugar is the most salient feature of diabetes. Dietary carbohydrate
    restriction has the greatest effect on decreasing blood glucose levels.
  2. During the epidemics of obesity and Type 2 diabetes, caloric increases have
    been due almost entirely to increased carbohydrates.
  3. Benefits of dietary carbohydrate restriction do not require weight loss.
  4. Although weight loss is not required for benefit, no dietary intervention is
    better than carbohydrate restriction for weight loss.
  5. Adherence to low-carbohydrate diets in people with Type 2 diabetes is at
    least as good as adherence to any other dietary interventions and frequently is
    significantly better.
  6. Replacement of carbohydrates with proteins is generally beneficial.
  7. Dietary total and saturated fats do not correlate with risk of cardiovascular disease.
  8. Plasma-saturated fatty acids are controlled by dietary carbohydrates more
    than by dietary lipids.
  9. The best predictor of microvascular and, to a lesser extent, macrovascular
    complications in patients with Type 2 diabetes is glycemic control (HbA1c).
  10. Dietary carbohydrate restriction is the most effective method of reducing serum triglycerides and increasing high-density lipoprotein.
  11. Patients with Type 2 diabetes on carbohydrate-restricted diets reduce and
    frequently eliminate medication. People with Type 1 usually require less insulin.
  12. Intensive glucose-lowering by dietary carbohydrate restriction has no side
    effects comparable to the effects of intensive pharmacologic treatment.
    Unquote
The items 6 and 7 in bold are the two items I question. Replacing some of the carbohydrates with protein may work for most people, but not everyone.

By side-stepping the fat issue, they are not realizing that the lipid panel or cholesterol levels will greatly improve and statins may become unneeded. Number 8 may also be unnecessary on a medium to high fat meal plan.

August 28, 2014

Conflicts of Interest

I don't understand why some researchers seem to think that people will not check their conflicts of interest. Three recent reports have been very interesting lately. Two were about diabetes and one was about sleep apnea.

The one about sleep apnea did not mention the conflicts of interest, but further research did find the original study. Only one of the authors listed a conflict of interest as a consultant for a pharmaceutical company. By searching three other authors or researchers, two were surgeons by profession and the third was a college professor for surgery. Finding information on the remaining researchers yielded nothing.

This made sense because of the way they were heavily promoting sleep apnea surgery over other treatments. When the American Sleep Apnea Association recommends CPAP first and surgery as the last resort, for these authors pushing surgery first, this tells me that they are only interested in the money and not the health of the patient.

One of the diabetes studies was funded by a pharmaceutical company and the authors after some extensive searches were all employees of the same company. Not much confidence to be gained from that study.

The other diabetes study was also funded by the same pharmaceutical company, but the researchers were all employees or students of the same university. The lead researcher was the only one to declare a conflict of interest and that was to the study funder. And they want us to believe the studies and that the data shows legitimate information. When a study shows data that is completely contrary to other studies and what we have seen in life, how can we be expected to believe the researchers were not influenced by the funder?

No, I am not giving the names of the studies, as I see no value in spreading their messages. Three days of searches and tracing information has left me with a severely bad taste in my mouth to the point I will probably not read another study funded by this pharmaceutical company. I have had too many bad experiences with the medications this company manufactures and am fortunate that my doctors have been able to substitute other medications not from this company. I will leave it at that.

This article should be read by more people as it covers what happens when a reputable journal is sold to unknown enterprises and for $1,200 will print anything. This may be what is happening to other journals and we are not told about the sale and are therefore surprised by the junk articles we a being asked to read.

August 27, 2014

New Approach for Diabetes Patients

William H. Polonsky, PhD, CDE, has it correct when it comes to dealing with diabetes patients. Dr. Polonsky is a clinical psychologist and co-founder of the Behavioral Diabetes Institute in San Diego, CA. He said, “We've got the right medications, we have so much knowledge, and we have great tools to help people manage their diabetes effectively. Unfortunately, none of those things will work if we can't convince our patients to make use of them, and that is why we all know it comes down to behavior.”

I will be using his article in Medscape to write about this. He wrote this column based on the talk he gave when accepting the Richard R. Rubin Award at the 2014 annual meeting of the American Diabetes Association.

Dr. Polonsky says all he has done for the past 25-30 years is focus on the behavioral aspects of diabetes, both as a clinician and as a researcher. I may not be quoting him correctly, but he has said, “Diabetes causes nothing, it is the lack of diabetes management that causes complications.” I firmly believe he is correct, yet there are some that have been very vocal in their desire to have him be more politically correct and stop using this statement. Shame on them.

In some cases, Dr. Polonsky says, “The way that we use behavior-change interventions with our patients may work very, very well. But sometimes, these seemingly simple and brilliant behavior-change interventions -- such as collaborative goal setting and action planning -- just don't work at all.”

I think the reason we have so many frustrations with trying to encourage and promote behavior change with our patients is because we make 3 fundamental mistakes. I often make them myself.”

I feel that Dr. Polonsky is writing as a clinical psychologist, but I see this also in CDE's. The three mistakes he outlines are:

#1. Probably the most important mistake is that we push a little too hard. “Most of us are so concerned about our patients -- we so much want to help and we are so overtrained as problem-solvers -- that we essentially demand behavior change before our patients are ready for it. They may not be convinced that what we are encouraging them to do is really worthwhile, even if they seem to be cooperating with us. They may harbor suspicions about medications, or question whether they can really make dietary changes, or whether those changes will even make any difference.”

He says that learning to take your time and setting the right mood is important for patients.

#2. The second mistake involves what he calls the principle of the mundane. “We often "overfocus" on the obstacles that our patients face. We view these barriers to behavior change as big, dramatic complications, and that is probably the fault of researchers like me. I have made a big deal out of these things over the years: depression, eating disorders, fear of hypoglycemia.”

The one Dr. Polonsky focuses on is what he calls "meh," or apathy or indifference. Many of the patients do not view diabetes as a priority in their lives, and that may be totally justified because the patients are much like us. Life gets in the way.

So, we need to appreciate that the biggest barriers to behavior change may not be big stuff but little stuff. People may simply be overwhelmed by diabetes, just stressed and confused, and not dealing with the disease at the best problem-solving level.”

#3. The third principle is what he calls ATMs (actions that matter). “Many of my colleagues who are somewhat skilled in behavior change have fallen into this trap of diabetes empowerment: When they talk to their patients and ask where they might want to make some lifestyle changes, they imply that the particular answer doesn't matter. "Mrs. Smith, what do you want to do?" "Well, I guess I should drink more water every day. I can do that. Or maybe I should have fewer tortillas at every meal, or maybe..."

Certainly, the patient should be the decision-maker in this, but I think we must remember to get the most "bang for the buck." Instead of giving the impression that any change is admirable and will lead to even more positive behavior, we should be willing to collaborate and inform our patients about the facts. "Look, you have diabetes and there are probably 100 different things that you could do to improve your health, but they are not all equally important. We can put them in order of priority: knowing your glucose numbers is critical; smoking is a bad thing; being on the right medication and then taking it may be the most important thing. That is where you can get the biggest bang for your buck."

I quoted much of his article because it is important. There is much we as patients can learn from this. I will also be using this in my role as a peer mentor and as a peer-to-peer worker. Too often I find myself pushing and expecting because I have experiences to relay that the others should be more willing to accept my words. I have found out this does not always work and that those I am working with do not want to make changes and are looking for something easier that they can do.

One person that Allen and I had been working with kept insisting that there had to be something that he could take and reverse his diabetes. Nothing we were saying was accepted and we could tell he was not even following us. After several meetings, we had to tell him that after he wasted his money, he would be back, probably having complications, and then we would be able to help him. We did not have that chance as he passed the following week. We have learned that his blood glucose became so high that he went into a coma and died the following day.

His daughter did tell us this and asked for information on several bottles she had found on his table. We were able to find information on them and as you might have guessed, they were either for supposed cures or reversing diabetes and none were of any value. We suggested that she have a talk with his doctor and have him consider showing them to other patients and explain that they do not help. His doctor agreed and has been successful with this approach.

August 26, 2014

Leg Cramps and Possible Prevention

In order to keep the title readable, I left out muscle spasms, charley horse, and calf cramps. All may be related and are often caused by similar problems. All can be painful, wake us up during sleep, and prevent us from getting a good night's sleep. Some of us even have them during the day.

Many of us with diabetes can suffer from the pain, and not knowing the cause can be as painful when we don't know how to prevent this.

First, I want to discuss some of the probable causes.
#1. Dehydration Some people are not aware that they are dehydrated, while others when asked can admit that they could have been. If there is a chance that this is the cause, I suggest increasing fluid intake (water) during the day, unless you have a medical restriction.

#2. Potassium deficiency Are you taking a diuretic for hypertension, many people with diabetes are taking at least one. Doctors hesitate to do the necessary tests to determine deficiencies of potassium. Magnesium, calcium, and vitamin B12 and a few other minerals need to be tested.

#3. Neuropathy If the person has neuropathy, there may be hyperactivity of the nerve/muscle causing the cramps. Malfunctioning nerves, which could be caused by a problem such as a spinal cord injury or pinched nerve in the neck or back? For neuropathy, vitamin B12 is often the culprit.

#4. Overuse Have you been exercising more than usual? Muscles that are overused can cramp. This is often the least cause and generally will disappear after a few days. Be careful of exercising in the heat and not stretching correctly before exercising.

#5. Exposure to cold temperatures or cold water Take a warm shower or bath before bed to relax the muscles and make sure your body is warm before going to bed.

#6. Other medical conditions Blood flow problems in the legs (peripheral arterial disease), kidney disease, thyroid disease, and multiple sclerosis can cause cramps..

#7. Sitting for a long time This is something many people miss, as well as standing on a hard surface for a long time, or putting your legs in awkward positions while you sleep.

#8. Taking certain medicines Medicines, such as antipsychotics, birth control pills, diuretics, statins, and steroids are common causes of leg and muscle cramps and can be side effects of the medications. For a more comprehensive list, read this article in WebMD.

#9. Poor blood circulation in the legs This should be checked by your doctor as this can become serious and lead to other problems.

What if muscle cramps keep coming back?
Have a serious talk with your doctor if the muscle cramps keep coming back are severe enough to consistently interrupt you sleep. These may be symptoms of another problem, such as restless legs syndrome. If cramps keep coming back, bother you a lot, or interfere with your sleep, your doctor may prescribe medicine that relaxes your muscles. If any of the above conditions exist and the doctor will not test for the deficiencies in number 2 above, it may be necessary to consider a new doctor.

Other help for muscle cramps include calf muscle stretches done routinely before going to bed. This is a pretty low-risk intervention and should be worth a try. You may read about this in this blog.

How can you prevent muscle cramps?
These tips may help prevent muscle cramps:
  1. Drink plenty of water and other fluids, enough so that your urine is light yellow or clear like water.
  2. Limit or avoid drinks with alcohol or caffeine. These can make you dehydrated, which means your body has lost too much fluid.
  3. Make sure you are eating healthy foods that are rich in calcium, potassium, magnesium, and vitamin B12.
  4. Ride a bike or stationary bike to condition and stretch your muscles.
  5. Stretch your muscles every day, especially before and after exercise and at bedtime.
  6. Don't suddenly increase the amount of exercise you get. Increase your exercise a little each week.
  7. Take a daily multivitamin supplement.
  8. Use a heating pad on the affected muscle.

If you are taking medicines that are known to cause leg cramps, your doctor may prescribe different medicines or change to dose to provide relief.

August 25, 2014

Children and Sleep Apnea

This study found overweight kids who had surgery were more likely to become obese within seven months. Tonsillectomies are commonly done to relieve sleep apnea in children, but a new study confirms that the treatment can speed kids' weight gain -- especially if they're already overweight. This is often the problem and many surgeons will not tell the family that this happens and urge them to exercise with their children to prevent this from happening.

The researchers did say that it is a concern, because obesity is a risk factor for a range of health problems, including sleep apnea. They are not advising against tonsillectomy for the children who need it. They are saying that doctors (plus surgeons) and parents should be taught that a healthy diet and exercise become even more important after the children have surgery. The researchers state that the surgery does create a 'certainty' that weight gain is an effect of the surgery.

That's because children in the study were randomly assigned to have surgery or to "watchful waiting" -- putting off surgery and staying with other options, such as medications to better control any nasal allergies or asthma symptoms. Altogether, 204 children aged 5 to 9 were assigned to have surgery right away, while 192 stuck with watchful waiting. It was found that over seven months, children who underwent surgery showed a quicker average weight gain, versus kids in the comparison group.

It was a small difference overall. And for children who were normal weight, there was no major effect. It was not making normal-weight children obese. It was alarming that of those children that were overweight before surgery, 52 percent had become officially obese seven months after surgery. 21 percent of overweight children in the watchful-waiting group were obese.

Sleep apnea also causes metabolic changes. The growth hormone is released at night, and sleep apnea can interfere with that. The body may adapt metabolism in an effort to maintain a child's growth. Then when sleep apnea is managed, the children are set up for rapid weight gain. Now, with childhood obesity on the rise, many kids with sleep apnea are already overweight or obese. If they rapidly put on pounds, their sleep apnea might return in six months to a year.

Diet and exercise are key for children with sleep apnea. Many can do well without surgery using CPAP, proper nutrition, and exercise. This reminds me of blogs from February and March 2012 when I was sending articles to a set of parents in another state that were trying to avoid surgery on their son. Their insurance and I agreed that surgery should be the last resort and they are very happy this was possible. Their sleep doctor emphasized proper nutrition and exercise with the CPAP use and the entire family has responded very positively.

August 24, 2014

Family Support May Be Beneficial For CPAP Users

Family support for CPAP use may help in using the equipment. I know that does not matter for me because without my CPAP equipment use, I would be overtired and difficult to be around. Other people depend on family support for doing anything that their doctor may prescribe or recommend. I have seen this first hand and when I ask friends why they won't take a medication or use their CPAP machine, I normally receive this answer – 'my spouse makes fun of using it' or 'my family thinks it is funny and make a comedy out my using it.”

I now have a widow of a friend that is regretting the fun she made of her husband using a CPAP machine and full-face mask. Last week he did not wake up after suffering an apnea and even CPR could not revive him. She is a nurse and should have known better than making fun of his CPAP and its use. The autopsy revealed that he had died from a heart attack. On several occasions, I had warned him that this could happen and that he needed to use the equipment every night. I had even introduced him to the mask liners which had stopped the air leaks and noises from the mask when the seal was broken.

Yes, he was about 40 pounds overweight and had been in a sleep lab for his diagnosis, but his wife was not sympathetic and constantly made fun of the equipment and his use of it. I attended his funeral, but avoided his wife, but afterward she wanted to talk to me. I told her there was nothing to talk about and I was there for him. I left without saying anything.

This study by the American Academy of Sleep Medicine, is very clear in stating that people with obstructive sleep apnea (OSA) who are single or have unsupportive family relationships may be less likely to adhere to continuous positive airway pressure therapy.

Results show that individuals who were married or living with a partner had better CPAP adherence after the first three months of treatment than individuals who were single. Higher ratings of family relationship quality also were associated with better adherence. Results of the study were adjusted for potential confounding factors including age, gender, and body mass index.

If you are a CPAP user, a spouse of a CPAP user, or a family member of a CPAP user, do them a favor and give them your support, please. Read the article in the link above and help them use the CPAP equipment; they just might live longer and be around when you need them.

The American Academy of Sleep Medicine reports that obstructive sleep apnea is a common sleep illness affecting up to seven percent of men and five percent of women. It involves repetitive episodes of complete or partial upper airway obstruction occurring during sleep despite an ongoing effort to breathe. The most effective treatment option for OSA is CPAP therapy, which helps to keep the airway open by providing a stream of air through a mask that is worn during sleep.”

August 23, 2014

Sleep Apnea May Be Tied to Diabetes

Prior to this study, most studies included few patients and were too short in length. Now we have a larger study and a suggested link between sleep apnea and diabetes.  Unfortunately, the study had some critical limitations. The limitations included lack of family history of diabetes, the race of the participants, and the possible misclassification of some subjects due to the limitations of the administrative health data used.

This is a severe fault of the study and that is the reason I only used the words 'may be tied' in the title. I don't care that they used the word “tied” in their title with claims of a link between obstructive sleep apnea and diabetes. Yes, there are some similarities between the two and being overweight is very common. As to one causing the other, this is still unproven. I will continue so that you can make up your own mind.

Lead author, Tetyana Kendzerska, MD, PhD, of the University of Toronto says, "Our study, with a larger sample size and a median follow-up of 67 months was able to address some of the limitations of earlier studies on the connection between OSA and diabetes. We found that among patients with OSA, the initial severity of the disease predicted the subsequent risk for incident diabetes."

The study included 8,678 adults with suspected OSA without diabetes at baseline who underwent a diagnostic sleep study between 1994 and 2010 and were followed through May 2011 using provincial health administrative data to examine the occurrence of diabetes. The apnea-hypopnea index (AHI) was used to assess sleep apnea severity. The AHI indicates severity based on the number of apneas per hour of sleep. Patients were classified as not having OSA (AHI < 5), or having mild (AHI 5-14.9), moderate (AHI 15-30) or severe (AHI>30) OSA.

During the follow-up, 1017 (11.7%) patients developed diabetes. In analyses, adjusting for known risk factors for diabetes, including age, sex, body mass index, neck circumference, smoking, income status and comorbidities at baseline, patients with an AHI>30 had a 30% higher risk of developing diabetes than those with an AHI <5 .="" 23="" a="" developing="" diabetes.="" had="" increased="" mild="" moderate="" of="" or="" osa="" p="" patients="" risk="" with="">

"After adjusting for other potential causes, we were able to demonstrate a significant association between OSA severity and the risk of developing diabetes, said Dr. Kendzerska. Our findings that prolonged oxygen desaturation, shorter sleep time, and higher heart rate were associated with diabetes are consistent with the pathophysiological mechanisms thought to underlie the relationship between OSA and diabetes."