May 22, 2015

Are Large Breakfasts Better?

I know that many people with diabetes pass on breakfast. Even some of my friends just have a snack. Now these two articles don't give me hope. The first article is from Medscape and says a large breakfast and small dinner are tied to better diabetes control. The second article appeared in ScienceDaily (reported from the Missouri Education research press release) and says prevent type 2 diabetes blood-sugar spikes by eating more protein for breakfast. Both studies appear to be junk science at best.

It is sad that the first study is so small, only 18 people, eight men and ten women, ages 30 to 70. The 18 people were being treated with either metformin and dietary advice or diet advice alone. This also begs the question if some might not have diabetes. The study period was also only six days and then two weeks later another six days on a different diet. At least the study leader wants longer studies to see if the benefits would continue over time. This means that the study has little value.

The second study says even less. It does not discuss the length of the study or give the number of people involved in the study. This leaves only one thing in common, the promotion of protein for breakfast and the statement that this helps blood glucose management later in the day.

The only reason I am writing about this is because I eat a high protein breakfast and have since I was a child. My mother saw to that. She always prepared two or three eggs of various preparations and homemade sausage or other pork product. Add to that hash browns, or fried potatoes (American). There were never a large quantity of potatoes except when I was a teenager and doing lots of chores on the farm before going to school.

Yet, this does not affect my blood glucose level after evening meal. The fewer carbs I eat for the evening meal is the only factor that I can say helps my blood glucose level. Granted, I use insulin and this may be why I have not had the results claimed in either of these two studies.

This is why each person must find their own food plan and make it their own. Studies like this should be considered, but they should never become an end-all. Your blood glucose meter should be your guide and eating to your meter to maintain your blood glucose levels is my suggestion.

May 21, 2015

Hospitals Are At It Again

If hospitals could get worse, I don't know how they would do it. When I read this blog, I had to laugh at what they do in the name of progress. I also thank the doctor that wrote the blog and is standing up for nurses. Too often, the reverse is true.

I must admit that the Nurses Week of May 6 to May 12 seems strange and but the dates are picked to honor certain nurses and that is their choice. But that is not the reason for this blog. Hospitals are pulling out the wallet to pay for some rather absurd customer relations. Hospitals are hiring "customer relations" experts to train hospital staff, and nurses in particular, in how to become more Disney. They think this will solve their problems.

A recent article in Atlantic, titled “The Problem with Satisfied Patients," describes the economic incentives hospitals face to improve patient satisfaction scores. Granted, hospitals have a financial stake in this, and the Centers for Medicare and Medicaid Services (CMS) controls some of the money they feel they are entitled to receive. The amount of this money is linked to patient satisfaction scores. The majority of the 32-question survey, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) addresses nursing care. For example, in a section about nurses, the survey asks, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”

This sounds reasonable on the surface, but then look deeper to see what sorts of issues patients were concerned about when they rated nursing care poorly on this section. Again, from the Atlantic:
  • “My roommate was dying all night and his breathing was very noisy”
  • “The hospital doesn’t have Splenda.” A nurse at the New Jersey hospital lacking Splenda said, “This somehow became the fault of the nurse and ended up being placed in her personnel file.”
  • An Oregon critical-care nurse had to argue with a patient who believed he was being mistreated because he didn’t get enough pastrami on his sandwich (he had recently had quadruple-bypass surgery).

Now hospitals are using misguided attempts to improve healthcare and this has led some hospitals to focus on making people happy, rather than making them well. When healthcare is at its best, hospitals are four-star hotels, and nurses, personal butlers at the ready, at least, that’s how many hospitals seem to interpret a government mandate.

When Department of Health and Human Services (HHS) administrators decided to base 30 percent of hospitals’ Medicare reimbursement on patient satisfaction survey scores, they likely figured that transparency and accountability would improve healthcare. The CMS officials wrote, rather reasonably, “Delivery of high-quality, patient-centered care requires us to carefully consider the patient’s experience in the hospital inpatient setting.” They probably had no idea that their methods could end up indirectly harming patients.

The doctor then wrote, “Now think of the terrific nurses in your lives. Are they terrific because they act like Disney concierge services to patients? Now certainly that wouldn't exclude them from being terrific, but those are not the qualities that come to my mind when I think of terrific nurses. Think of: strong, compassionate, "real," able to confront challenging patients in a way that I could never do as a physician, resourceful, creative, and watchful for errors or early signs of distress. Note that "finds Splenda and extra pastrami" do not appear on this list.”

This patient satisfaction thing has gotten out of control. It's a tremendous amount of money being spent on the wrong thing. Of course, treating patients with respect and dignity is important. That's not the same thing as satisfaction, though. The patient satisfaction thing places the emphasis on making patients happy, not healthy, feeling pampered, not prepared for the worst.

An example that really makes the point is this:
A hospital that switched its meal service to microwaved meals, food-service administrators openly attributed low patient scores to nurses’ failure to present and describe the food adequately. It is both noteworthy and unsurprising that the hospital’s response was to tell the nurses to “make the food sound better” rather than actually to make the food better.
This is the wrong way to enhance patient satisfaction. This may come back to haunt the hospitals. I feel the effort is misplaced and will result if less patient satisfaction.

May 20, 2015

Testing for Diabetes Diagnosis

Why are doctors misdiagnosing the type of diabetes? I find it shameful the number of people I have met in the last year that have been given the incorrect diagnosis. Granted most have been diagnosed with type 2 diabetes when, in fact they had LADA. I have also seen one that was considered type 2 and upon testing by an endocrinologist was found to have MODY #3.

It seems that many doctors still use age as the determinate for the type of diabetes. What makes me feel this way? I was contacted on Saturday by the parents of a teenager that had been diagnosed as type 1 and the parents were asking me if the doctor could be wrong. I did say possibly and asked why they thought this. The mother said he is about 30 pounds overweight and since he had not lost weight, they were wondering if their son might be a type 2. I advised them to have an endocrinologist retest him and then they would know for sure. They were able to get into the endocrinologist on Tuesday, May 12, and after the tests; they did find out that their son had type 2 diabetes.

When they called Tuesday evening, May 19, the mother thanked me for suggesting the endocrinologist. She said the endo did suggest that he stay on insulin for a few years and then see how the diabetes was affecting him. She added that the guidelines were insulin as the first line of treatment until he reached an older age. I said this is something that is still in study, but this should make it easier for their son to manage his diabetes. I did ask their son's age and she answered that he had just turned 13. I answered that then things were being done correctly and she and her husband should work with it and be thankful they had the correct diagnosis.

The mother then asked about pumps and a continuous glucose monitor. I said that would need to be talked about with the endocrinologist. I said I am not aware of any insurance that covers this for type 2 people, but I could not say for sure or how the endocrinologist would answer. I suggested to the mother that until she had her questions about equipment answered by an endocrinologist that she continue with the current treatment. She said that his glucose level was still too high and she did not know what to do about it.

I said she needed to call the endocrinologist and have the readings available for them and ask her questions. Then I asked if their son was rebelling and not testing as often as he should. She said that was possible and she would carefully watch when he was at home. I asked if he was eating more than he should eat and had food stashed for between meals or other times. She was uncertain, but would investigate. I suggested that she do this carefully and not to confront her son. She said the endocrinologist had cautioned her about doing this as well. I concluded by suggesting she ask the endocrinologist how often she should call with questions and if she could write the questions down to prevent calling every time they had questions. She said she had started this and was leaving room for answers. I assured that I would answer non-medical questions and give suggestions between doctor visits and possible calls. With that, she thanked me as they were learning and the URLs I had supplied were helping also.

May 19, 2015

Something I Could Not Believe

What is it about our doctors that do not tell newly diagnosed people about what diabetes is and leave patients uninformed? Allen and I were talking to a newly diagnosed person with diabetes and he asked us how soon he would be able to return to his normal life. We both looked at each other and rolled our eyes in disbelief. He saw this and asked what we were thinking.

Allen responded that we were wondering what the doctor had told him and what he understood about diabetes. He stated that the doctor had told him he had type 2 diabetes and prescribed metformin for the three meals. I asked if he had been prescribed testing supplies and he said, no, that the doctor did not want him testing. Allen asked if he could afford testing supplies and he answered yes.

Allen called Dr. Tom's office and asked if he would prescribe testing supplies if he brought the fellow in. Allen asked the fellow if he had time to see another doctor. When he answered yes, Allen said we were closer to his car and we should go now. When we arrive, Allen asked if he could accompany him to see the doctor. He answered yes and went with him when he was called for the doctor visit.

Later, I was called also and Dr. Tom said he wanted both of us to hear what he told him and to be able to reinforce what he said later. He already had a prescription for the testing supplies. Dr. Tom said he would answer the question about diabetes and he turned to the fellow and said diabetes was for life. With the proper lifestyle changes, food plan, and exercise, he might be able to get off of his medication for several to many years.

Dr. Tom explained that this varies with each individual, the damage already done, and how well they manage their diabetes. Returning to prior bad habits and diabetes would be back. We could see the fellow's jaw drop and he stated that he thought that after taking a round of the medications he could return to the way things had been. Dr. Tom looked at me and said tell him what he has after you leave. I said we would and thanked him.

With that, we were told to take him to check out. The three of us walked to check out and the person paid the fee. Then we left the office and returned to where Allen had parked his car originally. Then we sat and talked with him about diabetes. I told him that presently diabetes had no cure. He had the disease presently on a permanent basis and would need his abilities to manage it on a daily basis. He was a person with diabetes 24/7/365 and there are no vacations.

The fellow was very upset after that and asked if we had rules we had to follow. Allen said no, as what worked for one person may not be the same as what worked for another person. I asked if he had a personal computer and he said yes. I asked how far his residence was and he said across the street. Allen said he had time and would show him some of the websites to use and the email addresses for the two of us and for A.J. Then he could also chat with him as A.J and a few others had been successful in eliminating the need for medications at present, but are still testing and will return to medications, if and when needed.

I added that as we age, our pancreas often becomes less capable of producing the insulin needed and an oral medication may be needed or insulin of different types may be required to prevent elevation of our blood glucose. I reminded Allen that the fellow needed to fill the prescriptions and needed to be taught how to test. Allen said he would and that he would be back the next day to continue the teaching and would have A.J over as well if it was agreed. The fellow agreed and I walked to my car and went home.

Later, I answered several questions for him about using the search on my website and how to look for different topics. He is learning fast and is determined to get off medications.

May 18, 2015

Our May Support Group Meeting

Our second meeting for the month of May was better than the first and we came away feeling much better. My nurse cousin, Beverly did the presentation about neuropathy and the various causes.

She started off with a few questions. She asked how many had neuropathy. When there were only a few hands, she asked everyone to please be honest as she would move on to another topic if so few of us had neuropathy. At that, Tim asked everyone to consider being honest. This topic was important and he said there was some new information that might be worth considering. Slowly people started raising a hand until at least those that we knew had neuropathy had their hand up.

Tim turned to Beverly and said that everyone that we knew had neuropathy did have his or her hand up. Finally, one more hand was raised. At that point, Allen asked if there was anyone else. He then said that some things were good to keep secret, but when it came to diabetes, Allen said this is not good and we saw what happened with foot problems. We had too many people just begging for amputations. Neuropathy can prevent people from feeling some injuries that can lead to amputations.

Beverly said she would stay on this topic, and she agreed Allen had the right idea and understanding neuropathy was important. She then started by saying we are learning more almost every day about this, but there is still a lot we don't know. She then said both of us have read the same articles and she was happy that I had blogged about it on May 16 and 17, and while it is needed, more testing should be done to determine how accurate the numbers were, the three drugs may only be the tip if the iceberg.

Beverly said I know what Allen went through as Bob has told me and a deficiency of vitamin B12 and Vitamin D were both severe and caused Allen to have two shots of each and to take supplements. Bob has told me he has always tested in range for both, but he is taking supplements. Beverly continued that even her husband Tom takes supplements and is tested two times a year to see what the results are. That is why this new study is important.

Next, Beverly asked how many had gastroesophageal reflux disease (GERD). The numbers were less and this was expected. So Beverly explained what GERD is and that an esophageal scope inserted down the throat into the stomach is used to make that determination. The scope has a light and viewing screen that allows the operator to view the tissue in the esophagus and stomach and take samples if needed. The surgeon is looking for inflammation and potential cancerous cells. Tim did put up the slides of the scope and its operation that she had provided and this drew a lot of discussion.

Then she ask Tim to start the slides on the medications that cause neuropathy by creating vitamin B12 deficiency. This brought up a lot of questions and discussion. She had Tim bring up the other slides from other blogs she had prepared. Because of the time, Tim said we would continue for a little time longer and then we would need to call a halt.

Barry asked what the other topic she would have covered. She said that would have been about colon cancer. This brought questions of the age to start checking. Beverly said this varies by family history and other factors. She said that often she sees the need for many women to start at age 45 and every one else at age 50. Some men also need to start at the age of 45. Siblings of people with colon cancer should possibly start earlier.

Beverly asked how many have had a colonoscopy. All but three hands went up. Her next question asked how many had diverticulitis or more properly pockets or small out pockets in their colon. Six hands were raised and as Tim presented the slide, three more were raised.

Beverly said in talking with Tim, she understood we normally do not have meetings in June through the end of August. Tim asked how many would like this meeting earlier. Every hand was raised. Tim asked how many would be able to attend if a meeting was held on June 6. All but two of the members were in favor. Next, he asked about May 30 and six did not raise their hand. When he asked about June 13, all hands were raised. Beverly said that would work for her and Tim said we will have a meeting on June 13. With that, Tim ended the meeting. It took another 30 minutes for everyone to leave, as there were a lot of questions.

May 17, 2015

Diabetic Neuropathy May Be Caused By Low Vitamin D

Diabetic peripheral neuropathy (DPN) is a type of diabetic neuropathy that occurs in the arms and legs, and can result in symptoms such as numbness, tingling, burning, sensitivity to touch, and loss of balance. Now, in a new meta-analysis, researchers out of China have found that vitamin D deficiency may contribute to diabetic peripheral neuropathy.

Researchers have yet to determine the cause of DPN. However, it is thought that oxidative stress from hyperglycemia and inflammation plays a role. Studies looking specifically at vitamin D and DPN are scarce. Because vitamin D has been shown to help maintain beta cell function and reduce inflammation, some researchers speculate that low levels of vitamin D may be a risk factor for DPN.

In late 2014, a research team from China analyzed all available research on vitamin D and DPN to determine if vitamin D is related to risk of DPN in patients with diabetes.
They searched the available literature for studies that looked at vitamin D levels and DPN in type 2 diabetes or compared vitamin D levels in DPN patients to those without DPN. Six observational studies equaling a total of 1,484 patients with type 2 diabetes were included in the analysis.

Did a combined analysis of these studies reveal a relationship between vitamin D and DPN? The researchers found:
  • Compared to those without DPN, patients with DPN had a significantly lower average vitamin D level of 7.69 ng/ml.
  • After looking at the studies that adjusted for confounding variables, patients with a vitamin D level lower than 20 ng/ml had a 2.68 times increased risk for DPN compared to those with a higher level.
The researchers stated,
“In conclusion, this meta-analysis suggests that vitamin D is involved in the development of DPN in type 2 diabetic patients, and vitamin D deficiency is very likely to be associated with increased risk of DPN.”

They went on to add,
“The identification of the associations of DPN with modifiable risk factors can provide us some implications for the development of new therapies for DPN. Since vitamin D deficiency is a modifiable risk factor for DPN, vitamin D supplements may be an effective treatment for type 2 diabetics with DPN and vitamin D deficiency.”

The researchers note that the small number of studies and study population may limit their results. They also acknowledge that the inclusion of cross-sectional and case-control studies limits their analysis, whereas the inclusion of prospective studies could improve understanding of vitamin D’s role in DPN. Presently there are no published trials looking at vitamin D supplementation and DPN.

While systematic reviews and meta-analyses come with a few notable flaws, such as study differences, this research provides a comprehensive first-look at vitamin D’s role in DPN. At least, the release says prospective studies should be conducted next, and followed by clinical trials, before firm conclusions can be made.

I would appreciate you reading my blog from May 16 for other information on causes of neuropathy. With the many causes of neuropathy, those of us with neuropathy should be aware of the tests and medications that may help us or harm us.

May 16, 2015

Neuropathy Not Caused By Diabetes

This article is titled for sensationalism, but may be a breakthrough to jolt researchers out of their lethargy. I say this because I feel that another study needs to be done to prove the conclusion. If it turns out to be true, then this is a great conclusion. Yes, I know that vitamin B12 deficiency causes neuropathy, but other deficiencies also contribute to neuropathy, vitamin D being one of them.

This article also talks about other medications that can cause neuropathy. The two medications are often prescribed for treatment of GERD (gastroesophageal reflux disease). The two are histamine H2-receptor antagonists (H2RAs) or proton pump inhibitors (PPIs).

First, this is a brief discussion of the relationship of metformin and vitamin B12. People who have been on metformin have shown a malabsorption of vitamin B-12. People with diabetes being treated with metformin tend to have a lower vitamin B-12 level and worse diabetic neuropathy than patients on other oral therapies. The proposed mechanisms of metformin-induced vitamin B-12 deficiency include a decrease in bile acid secretion resulting in bacterial overgrown that decreases intestinal absorption, decreased intrinsic factor secretion, and decreased absorption due to metformin's antagonism of cell surface receptors in the ileum. Supplementation of vitamin B-12, cessation of metformin therapy, administration of doxycycline, and oral calcium supplement, have all been shown to improve vitamin B-12 levels.

Now, this is a brief discussion of the prescriptions for GERD. H2RAs and PPIs have been documented to interfere with vitamin B-12 absorption, showing a 53% drop in protein-bound vitamin B-12 absorption with H2RA. In one study with ranitidine, the decrease in absorption was shown to be 89%. It should be noted that unbound vitamin B-12 (i.e. vitamin B-12 supplements) can be absorbed with H2RAs, but protein-bound vitamin B-12 found from food sources are not fully absorbed. The mechanism of interference has been attributed to the decrease in gastric acid, pepsin, and intrinsic factor output; however, improvement in vitamin B-12 levels can be obtained with vitamin B-12 supplementation and cessation of H2RAs and PPIs therapy.

Vitamin B-12 has several important roles in the human body, and the signs and symptoms of vitamin B-12 deficiency can easily be mistaken for diabetic neuropathy. These signs and symptoms include: paresthesias (an abnormal sensation, as prickling, itching, etc.); diminished sensation, proprioception (awareness of the position of one's body) and nerve conduction; loss of cutaneous sensation; muscle weakness; abnormal reflexes; incontinence; loss of vision; and axonal degeneration. Several studies have shown that vitamin B-12 supplementation, alone or concomitant with other agents, has improve multiple aspects of diabetic neuropathy, such as cutaneous sensitivity, pain, paresthesia, nerve conduction, and autonomic symptoms.

Metformin, H2RA, and PPI are known independently to result in a B-12 deficiency. When combined together, it has an additive effect; therefore, it is important to recognize the potential of neuropathy due to the combination of these drug therapies. Patients and doctors should be aware of this polypharmacy-induced vitamin B-12 deficiency and its potential for neuropathy, especially in the type 2 diabetes patient population with GERD. Patients and healthcare providers should also be aware of the strategies to correct this deficiency.

I contacted Allen and Barry and we did a survey of the group and only two of the group were taking metformin and a PPI and outside of a few of us that were aware of metformin causing problems, no one was aware of the GERD medications also being causes of neuropathy. This eased our minds, but we know we needed more information

May 15, 2015

Asante Ceases Operations, Asks Animas To Transition Customers

I don't normally do this, but this is important for owners of Asante "Snap" insulin pumps and even if few people with type 2 diabetes might be using one, this needs to be brought to every one's attention.  The following is from an email I received 7:32 PM CDT.

On behalf of Johnson & Johnson Diabetes Solutions Companies (JJDSC), we wanted to share with you some important industry news.  Today at 5:30 PM PST, Asante Solutions announced to its customers via email that it is ceasing all business operations and will no longer sell or support the Asante Snap Insulin Pump.  This means all current Asante Snap Insulin Pump users will soon need to transition to a new insulin pump.

Just before this announcement, the leadership of Asante specifically asked Animas to assist their customers through this transition, and we’ve agreed to help.  We understand how disappointing and frustrating it can be for patients to unexpectedly have to go through the process of finding a new insulin pump and company that will meet their needs. 

Our goal is to help every Asante Snap Insulin Pump user receive a new Animas Insulin Pump as quickly and easily as possible. 

To start the process of receiving a replacement Animas Insulin Pump, we are asking all Asante Snap pump patients to call toll free 1-877-937-7867 X1562.  Our Customer Care Representatives are available to assist them MondayFriday, 8:00 AM – 8:00 PM EST.

In order to reach as many Asante Snap customers as possible, we would appreciate you sharing information about this replacement program with your readers/followers.

Because this is such a new development, we are continuing to work through the details of this replacement program while we begin to help Asante Snap customers through their transition. Please be patient if we are not able to answer all of your questions about the program at this time.  More information will be provided as soon as it is available.  In the interim, you can direct any questions to JJDSC Communications Director Dave Detmers via the contact information below.

Regards,
The JJDSC Communications Team


Dave Detmers
Director, Communications
Johnson & Johnson Diabetes Solutions Companies

Or you can go to the Asante website here and read the announcement.