July 26, 2016

Have You Been Checked for Diabetic Retinopathy?

Maybe I have been fortunate because at three months after diagnosis, I had an eye examination to establish a baseline for the condition of my eyes. Even though I had been diagnosed late, I had no indication of diabetic retinopathy. Because of my age, I have had an eye examination at least once a year since and when the cataracts started, it has been every six months.

I have now completed the cataract surgeries and I am still wearing glasses, but much less strong a prescription. I will be checked again in November because of other problems, which were caused by torn retina repairs in both eyes, but I still feel very fortunate with my eyesight.

The Australian study is somewhat of a disappointment as they state that general practitioners are waiting about three years before referring patients to have an eye examination done. If diabetes management is poor, a lot of damage can be done in three years. If diabetes management is good, then seldom will there be any damage, but I would not like to be in that situation.

An average delay of 3.1 years for an initial diabetes eye exam was found in a recent Australian study. The findings were published online in a letter to the editor in Clinical & Experimental Ophthalmology.

Brigitte M. Papa, MD, from the University of Melbourne in Australia, and colleagues examined current general practitioner (GP) management practices for diabetic retinopathy screening in a cross-sectional survey of 598 GPs in Victoria. The survey comprised 12 questions relating to diabetic retinopathy screening. Data were included from 198 responses to the survey, of which 175 were complete.

Overall, 53% of GPs reported that they referred newly diagnosed individuals for an eye check at the time of diagnosis; 23% referred patients at 1 year or more after initial diagnosis.

Ninety-seven percent of GPs reported referring patients with type 2 diabetes for diabetic retinopathy screening at least biennially. However, only 55% and 39% of GPs verified patient uptake of the first eye referral and confirmed receipt of a report from the eye health professional following the first eye assessment, respectively.

This study signals the need for better systems of care to support diabetic retinopathy screening and, ultimately, improve long-term visual outcomes for persons with diabetes.

The American Diabetes Association recommends an eye checkup every second year and this may be okay for some individuals, but people with diabetes should follow the directions of their eye care professional.

Several of our members are also now being considered for cataract surgery and it is surprising how many of the newer members have never followed through in having there eyes checked. A.J was really shocked as he remembers the endocrinologist telling him to have an eye checkup and a teeth checkup and the two of us talking about this on the way home.

A.J said he did not want a meeting this early, but felt that the first meeting in September should cover this topic and other things that needed to be done. We have covered taking care of our feet, but not the other points that need to be done after diagnosis. I agreed and said we needed to talk to Tim.

July 25, 2016

Suicide Risk Increases In Bariatric Surgery Patients

Using the search terms “suicide among bariatric surgery patients,” I found several articles on studies about the suicide risk increase in patients having bariatric surgery.

This study, published online October 7 in JAMA Surgery says - suicide attempts increase substantially in morbidly obese patients in the years following bariatric surgery, when the "honeymoon" period of substantial weight loss comes to an end.

Mental health has been discovered to be the main culprit during the 5 years preceding the surgery. Patients with morbid obesity are more likely to have mental health problems than the general population anyway, so we see a higher prevalence of mental illness diagnoses prior to bariatric surgery,"

Many patients do benefit from the surgery; a small proportion of patients may experience self-harm issues. We are suggesting is that they be referred back to the appropriate mental health professional after surgery so that any potential for self-harm can be dealt with.

Investigators carried out a population-based, self-matched longitudinal cohort analysis of patients living in the province of Ontario who underwent bariatric surgery. A total of 8815 patients underwent bariatric surgery during the 5-year enrollment period, almost all of whom underwent the Roux-en-Y gastric bypass procedure.

A total of 111 patients (1.3%) of the cohort had at least one self-harm emergency before or after surgery, including 11 patients who had emergencies in both periods ― 37 in the preoperative period, and 63 in the postoperative period. Most events were reported in women, in patients aged 35 years or older, and in those living in urban areas. Intentional self-poisoning by medication was the most common means of attempted suicide, accounting for 73% of all suicide attempts. Physical trauma accounted for about 21% of the events. Almost all events were considered of high triage urgency and resulted in hospitalization.

Most bariatric surgery programs do offer mental health consultations before the surgery to ensure that candidates are suited to undergo the procedure. They found in the current study, the period for mental health support may need to be considerably longer for some patients. Suicide attempt rates were distinctly accentuated in patients living in lower-income and rural areas.

The authors note "patients with a history of major depression similarly accounted for almost all events, suggesting that such patients also merit a comprehensive risk assessment."

In an accompanying editorial, Amir Ghaferi, MD, and Carol Lindsay-Westphal, PhD, Veterans Administration Healthcare System, Ann Arbor, Michigan, note, "the study has two important findings." First, the preoperative incidence of self-harm emergencies in patients undergoing bariatric surgery is twice that of the population in general and increases by an additional 50% in the postoperative period. Clearly there is significant room for improvement to identify ideal screening tools, protocols, and follow-up, they suggest.

"Secondly, most self-harm emergencies occur in the second and third postoperative years," they point out.

Most bariatric surgery programs focus on the first postoperative year, when most weight loss occurs. Given the findings of the current study, "data support the call for long-term follow-up in bariatric surgery, especially for patients with a history of major depressive disorder and/or self- harm."

Commenting on the study for Medscape Medical News, Sanjeev Sockalingam, MD, associate professor of psychiatry, University of Toronto, in Ontario, noted that most patients who come for bariatric surgery have a lifetime history of a formal psychiatric illness. Dr Sockalingam is also director of psychiatric assessment in a large-volume bariatric surgery program at the Toronto Western Hospital.

"What I think this signals is that obesity and mental health have a really close bidirectional relationship," Dr Sockalingam said. One thing the current study did not do is look at what happens to severely obese people who do not undergo bariatric surgery, which would have made for an interesting comparison, he added.

In a broader context, Dr Sockalingam believes the study clearly shows how important it is to screen patients not just before they undergo bariatric surgery but over the long term. "Having a history of psychiatric illness is not a reason not to undergo surgery," Dr Sockalingam said.

"It is really about making sure that people have appropriate support, that their mental health condition is appropriately managed and stable, and most importantly, that they have appropriate access and follow-up for their mental health as they go through their postoperative journey."

Since 2009, there has been a mandated 5-year follow-up period in bariatric centers in the province of Ontario. Dr Ghaferi reports receiving salary support from Blue Cross Blue Shield of Michigan as director of the Michigan Bariatric Surgery Collaborative. None of the other study authors nor Dr Sockalingam have disclosed any relevant financial relationships.

July 24, 2016

Quality of Life after Bariatric Surgery

Weight loss surgery is helping in the reduction of Type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, sexual dysfunction, and even the mortality rate.

Bariatric surgery is recommended by the National Institute of Health for Obese patients with a body mass index (BMI) of at least 40 or less obese patients with serious coexisting medical condition I and a BMI of at least 35. According to National Health and Nutrition Examination Survey, 34% of Americans have metabolic syndrome, with a waist circumference greater than or equal to 102cm (men) or 88cm (women); triglyceride greater than or equal to 150 mg/dl, HDL less than 40 mg/dl (men) or 50 mg/dl (women); hypertension greater than or equal to 130/85 mmHg; and fasting glucose greater than or equal to 100 mg/dl.

The purpose of this study is to determine whether surgical weight loss helps in the reduction of type 2 diabetes and decreases mortality rate. Numerous prior studies have demonstrated a connection between drastic surgical weight loss and an improvement in type 2 diabetes, as well as a decrease in mortality rate. The primary endpoint of bariatric surgery is weight loss. The overall percentage of excess weight loss (EWL) is 47-70%. A systematic review discovered EWL greater than 50 %. A meta-analysis study also concluded that adjustable gastric banding (AGB) is associated with less weight loss.

In another prospective observational study, 4,776 consecutive patients undergoing a bariatric surgery reported a low mortality rate of 0.3%. There are a number of complications associated with surgical weight loss surgery, about 70%, such as myocardial infarction and pulmonary embolism, which are the major causes of mortality. Those with higher mortality rate after bariatric surgery are patients with a higher BMI, males, older age, smokers and those with multiple comorbidities.

Observational and meta-analysis both demonstrate that bariatric surgery is effective in controlling type 2 diabetes, decreasing anti-diabetic drug usage and a high remission rates. Of the 135,246 subjects using meta-analysis, 78% had complete resolution with HbA1c less than 6.5%. However, factors like shorter duration of diabetes, greater weight loss, and former oral antidiabetic drug usage are some of the anticipating reasons of type 2 diabetes remission. For clinical outcome, a study performed by Brethauer et al performed between 2004 and 2007 had a mean estimated weight loss of 55% and a mean HbA1c, which decreased from 7.5±1.5% to 6.5±1.2%.

In another study organized at Cleveland clinic, 150 patients with T2DM were randomized to conventional medical therapy with HbA1c level of 7.5±1.8% in the medical therapy group. For the mortality rate, a meta-analysis of 44,022 subjects from eight trials demonstrated a reduced risk of global mortality with (OR =0.58, CI 0.49-0.63).

Another study was organized to determine whether bariatric surgery improves one’s sexual function. Patients undergoing this procedure fill gender relevant questionnaires, whereby their sexual performance is assessed. This is done before the surgery and 6-7 months after surgery. A statistical analysis test was done using SPSS 11.0 software. Continuous variables were compared using student t-test for independent samples. Of the 51 patients who underwent the surgery, 48 of them finished the second half after the 6-7 months post-surgery questionnaires. With a P less than 0.001, the results were statistically significant. Of the 43 women, 20 of them had a Female Sexual Function Index (FSFI) score of 24.66 before surgery, indicating a sexual dysfunction; but only 4 remained with dysfunction after post-surgery. This indicated a P less than 0.001. For the men, there was a baseline of 40.2 to 43.9, so they did not achieve statistical significance. This study shows that weight loss positively influences sexual function in the obese population. A limitation of this study included a low response by bariatric patients.

In conclusion, there have been a number of studies that have broadened our knowledge on the safety and efficacy of bariatric procedures and the effect on obesity, type 2 diabetes, and sexual dysfunction. The surgery therefore helps to improve one’s quality of life.

July 23, 2016

Type 2 Metabolic Surgery is Still Bariatric Surgery

The new bariatric surgery guidelines cite effectiveness, cost efficiency, and safety as reasons to consider the procedure. With all the problems I am finding, I have serious doubts about the long-term safety.

The International Diabetes Federation Taskforce on Epidemiology and Prevention of Diabetes convened a consensus working group of diabetologists, endocrinologists, surgeons and public health experts to review the appropriate role of surgery and other gastrointestinal interventions in the treatment and prevention of type 2 diabetes. The specific goals were: to develop practical recommendations for clinicians on patient selection; to identify barriers to surgical access and suggest interventions for health policy changes that ensure equitable access to surgery when indicated; and to identify priorities for research.

Bariatric surgery can significantly improve glycemic control in severely obese patients with type 2 diabetes. It is an effective, safe (questionable) and cost-effective therapy for these patients. Surgery can be considered an appropriate treatment for people with type 2 diabetes and obesity that have not achieved the recommended treatment targets with medical therapies, especially in the presence of other major comorbidities. The procedures must be performed within accepted guidelines and require appropriate multidisciplinary assessment, comprehensive patient education and ongoing care, as well as safe and standardized surgical procedures.

The last sentence above does describe what must be done and has not been done in the past by a lot of surgeons and primary care physicians or other doctors.

Metabolic, or weight-loss, surgery quickly and dramatically improves blood glucose control. Until now, however, it has not been included in clinical practice guidelines as a treatment option for people with diabetes. The Statement and Clinical Guidelines were published in the June 2016 issue of Diabetes Care, available in print and online on May 24, 2016.

Despite continuing advances in diabetes pharmacotherapy, fewer than half of adults with type 2 diabetes attain therapeutic goals designed to reduce long-term risks of complications, especially for glycemic control, and lifestyle interventions are disappointing in the long term. Metabolic surgery, on the other hand, has been shown to improve glucose homeostasis more effectively than any known pharmaceutical or behavioral approach. Despite such evidence, to date, metabolic surgery had not been included in clinical guidelines for diabetes care as a recommended intervention.

According to the new guidelines, metabolic surgery should be recommended to treat type 2 diabetes in patients with Class III obesity (BMI greater than or equal to 40 kg/m2), as well as in those with Class II obesity (BMI between 35 and 39.9 kg/m2) when hyperglycemia is inadequately controlled by lifestyle and medical therapy. It should also be considered for patients with type 2 diabetes who have a BMI between 30 and 34.9 kg/m2 if hyperglycemia is inadequately controlled. The Consensus Statement also recognizes that BMI thresholds in Asian patients, who develop type 2 at lower BMI than other populations, should be lowered 2.5 kg/m2 for each of these categories.

These conclusions are based on a large body of evidence, including 11 randomized clinical trials showing that in most cases surgery can either reduce blood glucose levels below diabetic thresholds (“diabetes remission”) or maintain adequate glycemic control despite major reduction in medication usage. While relapse of hyperglycemia may occur in up to 50% of patients with initial remission, most patients maintain substantial improvement of A1C long term.

Economic studies also show that metabolic surgery is cost-effective. The authors of the new guidelines recommend that healthcare regulators introduce appropriate reimbursement policies for metabolic surgery for people with type 2 diabetes.

July 22, 2016

Gastric-Bypass Creates Hypoglycemia Problems

If you are concerned about hypoglycemia, then this article should scare the dickens out of you. The title grabbed my attention - Gastric Bypass Reduces Symptoms, Hormonal Responses to Hypoglycemia. In other words, after gastric bypass surgery, you will have even fewer symptoms and other responses to hypoglycemia, i.e., you will be operating more in the blind and may not have any knowledge you are having hypoglycemia.

Gastric bypass surgery patients have lowered glucose levels and frequent asymptomatic hypoglycemic episodes, Niclas Abrahamsson, MD, PhD, from Uppsala University in Sweden, and colleagues examined symptoms and hormonal and autonomic nerve responses in patients exposed to hypoglycemia before and after gastric bypass. Twelve obese patients without diabetes underwent hyperinsulinemic hypoglycemic clamp before and after gastric bypass surgery.

The researchers found that after surgery the Edinburgh Hypoglycemia symptom delta scores during clamp were attenuated from 10.7 to 5.2. Marked reductions in glucagon, cortisol, catecholamine, and sympathetic nerve responses to hypoglycemia were seen after surgery. A delayed response was seen in growth hormones, but to a higher peak level. During hypoglycemia, glucagon-like peptide-1 and gastric inhibitory peptide increased, but to a lesser extent after surgery.

Catecholamine is any of a group of sympathomimetic amines (including dopamine, epinephrine, and norepinephrine), the aromatic portion of whose molecule is catechol.

Gastric bypass surgery causes a resetting of glucose homeostasis, which reduces symptoms and neurohormonal responses to hypoglycemia, the researchers wrote. Further studies should address the underlying mechanisms as well as their impact on the overall metabolic effects of gastric bypass surgery.

All this leads to problems for people with diabetes that do not recognize when they are having an episode of hypoglycemia and possibly means that they could go into a coma and die. Not a pleasant outlook for these people. Yet this is not something that the bariatric surgeons will pass on the prospective patients.

July 21, 2016

Life after Bariatric Surgery in Adolescents

The authors of this study say the benefits of weight loss surgery for younger patients may persist for years. Since this was only a three-year study, I think this is a lot of speculation on their part.

While adolescent obesity is becoming an epidemic, with numbers doubling from 800 to 1,600 from 2003 to 2009 or six years, the bariatric surgeons must be licking their chops for the additional income.

Bariatric surgery is one of the feasible therapies for seriously obese adolescents. It includes a variety of procedures: reducing the size of a stomach with a gastric band, or removal of a portion, or resecting or rerouting to a small stomach pouch. To date there have been limited prospective studies analyzing BMI and other outcomes of currently used procedures. The purpose of the study is to examine the efficacy and safety of bariatric surgery in adolescents, even years after treatment.

The study was a multicenter, observational study using adolescents who were less than 19 years of age. They had to be obese and were recruited for undergoing bariatric surgery. The Committee of the study was made up of a Principal Investigator, a Data Coordinator, and a project scientist; this took place from March 2007 to February 2012. Data was collected at 6 months, 1, 2 and 3 years postoperative, with most research visits taking place at clinical centers or the subjects’ homes. Outcomes measured were weight loss, quality of life, coexisting conditions and micronutrient outcomes, using linear mixed and separate models. Poisson regression was also used to calculate unadjusted rates and 95% confidence interval.

Of the 242 adolescents recruited, 161 (67%) did Roux-en-Y gastric bypass and 67 (28%) did sleeve gastrectomy. 98% of participants had a BMI of more than 40, with the majority from a low income household. 99% of the cohort participated and completed 88% of all postoperative visits through the 3-year study endpoint. 90% completed all visits at 1 year, 89% at 2 years and 85% at 3 years. The mean weight reduction at 3 years was 41 kg, with a mean percentage weight loss of 27% (95% confidence interval).

At baseline, all participants were obese with a BMI greater than 30, but by 3 years 26% were no longer obese. 96 participants had an elevated blood pressure at baseline, but normalized by 3 years after their surgery with 74% of them having 95% confidence interval. For 171 participants with dyslipidemia at baseline, 66% were at a normalized value at 3 years (95% confidence interval) without lipid-lowering therapy drugs. For participants with abnormal kidney function, 86% of them had a normalized kidney function (95% confidence interval). For diabetes, there was no improvement in patients with type 1 after 3 years, but type 2 had a confidence interval of 95%, median glycated hemoglobin of 5.3%, a median fasting glucose of 88 mg/dl and median insulin of 12 IU/ml. The mean quality of life score was 63 (95% CI) at baseline, but increased to 83 by 3 years with a P less than 0.001 after the surgery.

For nutritional measures, patients had low levels of ferritin at the end of 3 years from baseline with 57% (95% confidence interval) and P less than 0.001. For vitamin B12, only 8% had a deficiency at the end of 3 years as compared to a baseline of 35%. 16% of participants who went through this surgery had vitamin A deficiency at the end of 3 years. One participant died from complications of hypoglycemia 3 years after surgery. Of the intra-abdominal procedures related to bariatric surgery 24% were performed within the first year, 55% within the second year and 21% within third year.

In conclusion, there was a significant reduction of weight, obesity, and coexisting conditions, and increase in their quality of life. However, there were specific deficiencies in micronutrients; therefore, multivitamin and mineral supplementation is needed. Abdominal procedures show an increased risk with bariatric surgery in the adolescent population.

A study of 53 younger adolescents with a mean age of 14 years had a mean BMI decrease of 20 and an increase of 5 cm in mean height 3 years after sleeve gastrectomy. This indicates that adolescents can lose a clinically significant amount of weight after bariatric surgery, and the majority of patients were able to maintain meaningful weight loss for at least 3 years.

The weakness of this study includes the use of a small population size, especially the diabetes sample size; also, the observational nature of the study introduces heterogeneity into the data. Additionally, the lack of a control group made it difficult to place the postoperative changes in weight and health status completely into perspective since behavioral treatment can result in modest improvement in weight and cardio-metabolic health.

July 20, 2016

Adverse Topics in Bariatric Surgery

On Saturday, Max called and asked if I could come to his place. I agreed and when I arrived, Tim, and two other members of our support group were present. Max said that the three of them had been approached by the hospital and doctors to have bariatric surgery. Max said he had turned them down, but the other two had agreed to an appointment which would be the following Wednesday to see if they qualified for the surgery.

Max asked me if I had been approached and I said not this time. Max said he would not consider bariatric because of all he had read and that I had blogged about recently. I said there is a lot more that needs to be blogged about and I have five or more topics to work on writing. One of the two spoke up then and asked why we would not consider bariatric surgery.

Max and I started listing the reasons:
  • You would not be told everything you will need to know
  • You will only be able to eat a spoonful of food at any one time.
  • You will need to wait once you swallow before you can have a swallow of water
  • You cannot drink or should not drink any alcohol
  • You may have diarrhea or vomiting
  • You will have many vitamin and mineral deficiencies and may require shots for the vitamin and minerals to be of any value
  • Most oral medications may no longer work
  • Insulin may be required to manage your diabetes
  • You will need mental health counseling
  • You will possibly lose the ability to detect hypoglycemia
  • About three to five plus years later, your risk of suicide increases

I said these are the ones we can think of immediately, but there are more. Yes, your diabetes may be put in remission about 12 to 18 months after the surgery, which is a good thing.

The next thing you need to be aware of is the small amount of food you will be able to consume without stretching you stomach. This is a big problem for most people and when they do this, they will regain much of the weight and diabetes will return. Several of the people we know have needed a second surgery to repair the stomach and the cycle can repeat itself.

Several things you need to be aware of before consenting to the surgery. Always make sure that you have a meeting about the side effects several days before the surgery is scheduled. Many surgeons rush you into surgery and never cover the side effects. Others present you with a consent form just before surgery and expect you to sign it without reading it. Whenever any of these happen, you would be wise to walk away and never look back.

Many of these surgeons are only interested in the money and not your health. They will not do anything for you after your surgery and seldom cover the things that you need to do following surgery.

A minority of bariatric surgeons will do things correctly and do tests before and after surgery to make sure that your primary care doctor follows through with the care and tests necessary.

July 19, 2016

Challenges of Preventing Diabetes

Edward C. Chao, DO, is a doctor practicing in the VA San Diego Healthcare System and is an associate clinical professor of medicine at the University of California, San Diego. He is the author of the article I am using for this blog.

Preventing the potentially devastating and often irreversible complications of diabetes, or better yet, keeping the condition itself from even developing, is far less burdensome for patients, costs less to the health care system, and leads to a better quality of life for patients. So, why are increasingly alarming numbers of patients developing prediabetes or diabetes? With all the knowledge we now have, where are we coming up short? Why?

We have all heard about the proverbial frog in boiling water. If you drop it in to a pot, it will take decisive, quick action, as it sees the danger; it will jump back out immediately. But if the water is gradually heating up, the frog does not appreciate the risk as keenly. I think patients and diabetes professionals alike sometimes tend to see diabetes this way. It is human nature.

The latest estimates say that 86 million Americans are considered to meet the criteria for prediabetes. The scary part is 90% do not know it. Without delving into the debate over whether this should be considered an entity, can't we be proactive and stem the tide before someone develops type 2 diabetes and add to the 25% of individuals who revert to normoglycemia?

We have read and heard about studies such as the Diabetes Prevention Program (DPP) and several others that show the superiority of intensive lifestyle intervention over metformin for preventing diabetes. What stops our patients from succeeding like the participants in these trials? Here are 3 possible reasons.
  1. It is not in our (human) nature. We sometimes do not take the long view or consider the big picture. It is all too easy and necessary to focus on what's at hand: the daily stresses and challenges of work, taking care of our families, paying our bills, and maybe sometimes, taking just a tiny slice of vacation to relax. Who has the energy or the time to try to avoid a disease that may not be diagnosed or, if so, may show up years down the road? “I'll worry about that later. I have too many things on my plate, and I just don't have the time to deal with all of that right now” or “That won't happen to me.”

    For those with diabetes, some may approach the future with a similar attitude of avoidance. If a patient does not feel any differently when his or her glucose is 200 mg/dl or 300 mg/dl, why spend all of this time testing or performing any of the other multiple self-management tasks that are so crucial to living well with diabetes?

    Additionally, we as a society generally are used to and tend to gravitate toward the quick solution, instant messaging, same-day delivery for packages, seeing 50 “likes” on our Facebook page posts within minutes of updating our status. If we run into trouble, we sometimes think: “There's a pill for that.”
  1. These studies looking at prevention took place in a different setting, with intensive lifestyle changes complemented by close monitoring and support. But what about translating this to the real world, to the communities in which patients live? Some components of large clinical studies on preventing diabetes, such as intensive lifestyle intervention implemented in the DPP, can be challenging to apply in communities. In one study, Dr Ackermann and colleagues randomly assigned 509 low-income individuals with prediabetes who were overweight or obese. After attending several lessons of the DPP adapted to the YMCA, the mean weight loss at 12 months was 2.3 kg greater for the intervention group vs the standard care cohort. For the 40% of participants who completed 9 or more sessions, the weight loss was 5.3 kg more than those who received standard care.
  1. Health is not just the absence of disease or feeling unwell. We must change our mindset, as individuals and as society as a whole. This speaks to the idea of emphasizing the process rather than the product or end goal. Many of us tend to put our focus on the 25-lb weight loss or reaching a target HbA1c of 7.0%. But what about the steps that we have to take daily to make achieving these targets a reality? I heard an analogy once that asked, “What if I gave you a car that was brand new and in perfect condition? It looks and runs great. If anything happens to it, whether it's a scratch or a crash, that's it; you don't get to trade in for a new one. Knowing this, how would you look at it? How would you treat it?”

    We must start viewing our health in the same way. We must expand our mindset not only to stamp out diabetes, but to prevent it from even occurring. We can stem the tide and avoid heading down the road towards 1 in 3 Americans with diabetes by 2050. Individually and collectively, we need to both think and act differently. Unquote:
It is obvious from my blog here that the medical community thinks differently and are worried about over diagnosis and causing anxiety in patients. This was not available to me before my diagnosis of type 2 diabetes, but I sure wish it was. I could have done something possibly to have lessened my fight to manage my diabetes.

What is even scarier is that prediabetes is increasing among healthy weight
American adults. See this short article about the percentages as we age.