September 17, 2014

Eating to Your Meter

I know you have heard this or eat to your meter. Many people with diabetes refuse to do this and often wonder why their blood glucose readings are remaining elevated. Their doctor sees A1c's that are elevated also and asks what they are eating. Many just don't answer or give what they know they should be eating and the doctor has to assume that their pancreas is not producing enough insulin or that the patient is very insulin resistant.

Yes, more test strips than your insurance will often allow, but if patients are honest with their doctors, and request extra, many doctors will go the extra mile and request the insurance company to provide more for three to six months. Some insurance companies will allow this if they see the A1c's coming down, as they don't want the extra expenses involved with complications.

This is one reason I suggest food logs be maintained as well as blood glucose reading logs. This means extra work and many people with diabetes don't see the value. I say that anything that can help manage diabetes and prevent complications is worth the effort. Life should slow down and people should take the time necessary while eating or immediately after the meal. People can forget an hour later and this robs them of the information that could be of help in determining if they need to reduce the quantity or eliminate a food item from their meal plan.

If you can afford the extra test strips, use them wisely. Continue the testing as soon as your wake up (fasting blood glucose reading) to watch for trends. Then select the meal that is generally your largest meal. Always test before the meal to give you a base for the after meal readings. This is just a suggestion, but after first bite, I start testing at the one-hour mark and test every 15 minutes until the next reading is less the previous reading. I do this every day for a week and then every few months (normally three or four months) until I am comfortable that the time was staying consistent. For me this was about 90 minutes, that was until I started slowing my eating and chewing my food longer. Then the time changed to 75 minutes.

Others that I know start testing at the one-hour mark and test every 30 minutes. Most end up at or near the 85 to 100 minute mark. That is why we tell people that what works for me, may not work for you or your mileage may vary (YMMV). Some people start testing one-half an hour after last bite. The best method is being consistent with when you start testing and the testing interval.

Now, realize that you are measuring the difference between the before and the after meal tests. Most people do not want an increase of more than 40 mg/dl. There are also people that want even less of an increase. We can use this information to determine if we need to curtail the serving size of food we eat, or if this is something we need to eliminate from our food plan. Many people strive to have premeal (preprandial) levels of 80 to 90 mg/dl and post meal (postprandial) levels under 125 mg/dl.

By doing testing, you will often be surprised what can be eaten with a smaller serving size and by counting carbohydrates.

The biggest problem is balancing the nutrition to obtain the nutrients you need including vitamins and minerals. Realize that I am not referring to whole grains which we can live without as the nutrients can be found in other foods that do not spike blood glucose levels as whole grain foods do.

September 16, 2014

Before You Get a Tattoo

Now what would a woman or for that matter a man with diabetes want with a tattoo? Unless your diabetes is extremely well managed, you will run the risk of infection and poor healing. I don't care if it is for beauty, self-expression, or any other reason. If you are one that insists on having a tattoo, make sure you know the facts before and after the tattoo. Make sure you know the types of tattoos, the tattoo risks, FDA's role, and tattoo removal options.

There are at least five types of tattoos:
Permanent Tattoo: A needle inserts colored ink into your skin. Permanent tattoos last a lifetime.
Permanent Make-Up: A needle inserts colored ink into your skin to look like eyeliner, lip liner, eyebrows, or other make-up.
Henna: Plant dye called henna or mehndi is used to stain your skin.
Black Henna: Developed from henna, may contain hair dye or other dye to darken the stain and make it last longer.
'Sticker' Temporary Tattoo: A tattoo design is on a coated paper. It is put on your skin with water. Temporary tattoos may last up to 3-4 weeks. Sticker tattoos last hours to days.

When it comes to tattoo risks, these are five of the most frequent:
  1. Infections and serious illness, like HIV or hepatitis, from unclean tattoo tools, practices, or products
  2. Allergic reactions to the inks or stains can cause skin problems, such as rashes
  3. Other skin problems like increased chance of sunburn, bumps, redness, or scarring
  4. Swelling and burning of the tattoo when you get an MRI test
  5. Pain and high costs if you want to remove a permanent tattoo
Contact your state or local health department for tattoo safety information to reduce your risk. Tell your doctor about any tattoos you have before any medical procedure.

There are four points to know about FDA's role:
  • Has not approved any inks for injecting into your skin.
  • Has not approved henna or hair dye for use on your skin. Some people have reported serious skin problems after using henna or black henna.
  • Does not regulate tattoo parlors.
  • Does monitor problems from tattoos and permanent make-up.

Please report problems online to FDA or call 1-800-332-1088. The online address is -

Removing tattoos is another problem.

Permanent tattoos can be hard and painful to remove. It may take several treatments that cost a lot of money. Talk to your doctor about your options. Remember you may not be able to completely remove your tattoo, and you could get a scar when you remove your tattoo.
Laser Removal - The FDA approves certain laser devices to remove tattoos. Lighter colors such as yellow, green, and red are more difficult to remove than darker colors such as dark blue and black. It may take 6-10 treatments to remove a tattoo. Some side effects may include bleeding, redness or soreness.

Surgery - Tattoos can sometimes be removed by cutting out the tattooed skin then sewing the skin back together. Other times, the skin can be sanded down to remove the tattoo.

Ointments and Creams - The FDA does not approve tattoo removal ointments and creams or do-it-yourself tattoo removal kits. These products may cause skin rashes, burns, or scars.

As a person with diabetes, please be careful and take my suggestion to not have tattoos put on your body if you have diabetes.

September 15, 2014

Should Current Way of Diagnosing Diabetes Be Changed?

Normally I avoid this topic when it deals with women that have had gestational diabetes. The healthcare system in the United States tried and failed properly to diagnose gestational diabetes because everyone argued against increasing the number of women with gestational diabetes.

Now the United Kingdom is taking another approach and studied recently pregnant women to discover biochemical markers that would indicate type 2 diabetes earlier.  The current way of diagnosing type-2 diabetes using blood glucose levels needs to be revised, research by scientists from The University of Manchester and King’s College London suggests. The findings, published in the journal PLOS ONE (full study can be read at this link), show the current method of diagnosis - using blood glucose levels - means patients are diagnosed too late so that their blood vessels may already be damaged.

The study focused on young, previously pregnant women followed up in Greater Manchester after being identified as at increased, intermediate, and low risk of developing type-2 diabetes. Researchers examined biochemical markers in the blood before glucose became elevated – so before the patients reached the pre-diabetes stage.

Their findings show that changes in types of blood fat metabolites - naturally occurring particles that come from and make up fats in the blood - appear to be good indicators of developing type-2 diabetes. The changes in these particles were detectable well before changes in blood glucose that now define type-2 diabetes or pre-diabetes. The team’s findings could be important for future diagnosis and, in turn, treatments.

They found that several groups of fat metabolites, also linked to body fat, were changed in the blood, as were others including some amino acids and to some extent vitamin D, before glucose levels increased. Blood vessels become damaged as part of the condition, but problems in the vessels arise before high blood sugar sets in during a ‘pre-diabetes’ period.

I think this is the key - the authors argue that rather than concentrating purely on glucose-directed treatments, which do not improve blood vessel health, a new, quite different definition of type-2 diabetes is required, partly based on the distribution of fat metabolites in the blood in the pre-diabetes stage. Not only could this improve treatment before the full onset of type 2 diabetes, but possibly delay or prevent onset of type 2 diabetes for some, and with dietary changes possibly delay full onset of type 2 diabetes for years.

September 14, 2014

Helping a Fellow Person with Diabetes

This last week has been a busy one. Barry tried and lost getting his friend separated from his wife. She has become very guarded in her desire of being with her husband. Then A.J had a try and she let her guard down on Saturday. They went for a drive, picked up Allen and Barry, and drove to Dr. Tom's residence since it was Saturday.

Then they talked and gave him the nickname of Jerry. He wanted to know why and they told him so that if his wife was around they could talk about Jerry and his wife would be none the wiser.

Dr. Tom asked the members to leave and talked to Jerry for almost an hour. We are not sure what was said, but when Jerry came out, Barry said he was very quiet and just asked to be taken to Barry's home. Once there, Jerry would not talk about what he and Dr. Tom had discussed, but he asked if there was space available for him to stay for several weeks. Barry said they did not have space, but that A.J did have room and A.J confirmed this.

They talked about getting his clothes and diabetes supplies and how they would explain this to his wife. Jerry said he had a suggestion from Dr. Tom, but he was not sure he could pull it off. Barry asked if he could use some help and Jerry said yes, but he added, you do not want the rage of my wife. Allen said they could take it and with the five of them, it should not take that long. Ben said they had some boxes and A.J said he had some containers and he would get them. They decided to all drive and have places for the boxes.

A.J said things were better than expected and in 30 minutes, they had what Jerry needed and were gone. There were some words, but nothing really severe. When they had Jerry moved in at A.J's, they called me to come over. Jerry was surprised that of the six we were all veterans. A.J helped set up Jerry's computer, and when that was completed, Jerry said he knew from Barry and Allen that I had a blog. I gave him the address and he opened it. After he bookmarked it, I showed him the profile page and he said you have four blogs. I said two were closed, but the one on type 2 bloggers could be of interest for others that blog about diabetes.

I had him open that page, showed him the posts, and told him to explore, as he wanted. Then we talked about what Jerry needed to do Monday. He wanted to go to the bank, open a new account, and transfer some money to it. He would also need to instruct the bank to deposit his next check to that account, if it came before the bank account number is changed.

Jerry said then he should go to the Social Security Office, change his address, and bank information. Allen said he would take him if needed. Jerry accepted that and said it could be sometime before he would get his car because he felt it necessary to leave his wife with transportation. Jerry then stated he would need to get his supplemental insurance moved and get that settled. Barry said someone would be available when needed. Jerry thanked everyone and said he wanted to relax and complete Monday before he talked a lot more. Allen wrote his phone number on a pad for Jerry and Barry also wrote his just in case. I put mine on the pad also and took my leave.

This is not settled and the next few weeks could be very tense.

September 13, 2014

Should CDEs Be Teaching Nutrition?

Yes, I have realized that many titles often are associated like RD (registered dietitian) and CDE (certified diabetes educator). To be honest I was just reading the titles and wondering which was most prominent or used to the near exclusion of the other. After the blog yesterday, I really have to wonder which organization has priority and which exerts the most influence on the actions of the person.

I have talked to two CDEs, one of them also with the title of RD. Both said at one time, the first title after the name used to be the primary practice of the individual. Then in 2006, this has had some repercussions when the American Dietetic Association (now the Academy of Nutrition and Dietetics (AND)) started enforcing strict adherence to guidelines or lose their license. They both admit there has been some relaxation in the last year, but they are still very careful.

Whether this is correct, I do not know. I just have to wonder what influence AND has on the CDE profession.

Nutrition is taught by both CDEs and RDs and both generally urge more consumption of carbohydrates than many with diabetes are willing to consume. This is a great turn-off for people with diabetes that understand the value of consuming fewer carbohydrates.

I am thankful I have a cousin that is a nutritionist and has now completed her PhD in nutrition. She is my go to person for nutrition questions. Recently I discovered that another second cousin has moved into the area and she is a registered nurse with almost 20 years experience in surgical nursing. We have only had one conversation about what she does, but I expect that I will learn more in the months ahead as her husband is planning to retire in the job he currently has.

They have three children and one has type 1 diabetes. That was to topic of most of our conversation and a lot of questions were directed my way. I have connected their daughter with Lilly that is an honorary member of our support group and they are learning from each other.

September 12, 2014

Is There Value for Patients in the New AADE Leadership?

There will be much debate in 2015 and especially 2016 about the possible actions of the officers of the American Association of Diabetes Educators (AADE). Over at DiabetesMine on September 2, 2014 there is a discussion with the two incoming officers for the next two years.

The incoming president for January 1, 2015 is Deborah Greenwood, a longtime California educator who’s currently president-elect. I do not know much about this person, but she will face some very difficult tasks when she assumes office. Ms Greenwood does feel that providing quality education is important.

What was good to hear is the possible opening of restrictions previously held by the AADE of only accepting people who passed the examination given by the National Certification Board for Diabetes Educators (NCBDE)? Yes, they had some honorary members, but this is different.

According to information we have so far is the new group will be called Associate Diabetes Educators. This was announced at the annual meeting last month. This will be a true non-licensed health care provider category and will be a way to bring more into the profession. Peer support is now more recognized, and this is one more way to incorporate people with all skills. It’s fantastic that they’re formally recognizing this community and everyone plays a role. There’s a whole committee of people who have been working on the Associate Diabetes Educator piece, and they’re continuing to refine it.

For once, this appeals to me and shows that they are more interested in serving people with diabetes. With the expanding number of people with diabetes and even pre-diabetes, there is too few people to help now.

This flies in the face of the Academy of Certified Diabetes Educators (ACDE) that are limiting members to only those that pass the test given by the NCBDE. If this becomes reality, the AADE will gain greatly and the ACDE will become very unpopular with diabetes patients. This says their exclusive ways will hurt them. Sounds like a very productive year ahead for the AADE.

My real concern will begin in 2016 when Hope Warshaw takes over as president. She has a lot of controversy surrounding her and carries the title of Registered Dietitian (RD) and means that the Academy of Nutrition and Dietetics (AND) may exert some influence. No one has made notice of this.

In addition to being an RD, she created quite a stir about two years ago when she stated that we need too many carbohydrates per day – in excess of 200 grams of carbohydrates. Instead of saying that she could have misspoke and that some people could do with less, she would not back down and people really struck out at her. She has also created some other rumblings on other issues, but seems to avoid controversy after the carbohydrate fiasco.

She seems welcomed by many in the diabetes-on-line-community, but I will continue my reservations until she is no longer president of the AADE.

September 11, 2014

Doctor-Patient Communication for Diabetes Patients

Today this is even more important, but communication is happening even less. The main culprit is the electronic medical record and the time that doctors need to spend at the computer during the office visit. They have boxes to check and other notes to make. Even the fastest of typists has little time for communication in at 12 to 15 minute appointment.

This doctor still emphasizes the importance of communication and lists 10 points to back this up. I find this statement very valid, especially as a patient. He says, “Communication and interpersonal skills of the physician are the heart and soul of our profession as medical doctors.”

He lists the Golden Rules for effective communication by doctors in the diabetes clinic:

#1. Recognize the importance of patient empowerment as being fundamental to diabetes management. The physician's role is to provide knowledge and expertise to enable patients make informed decisions. But, it is the patients, themselves who are in charge of their destiny and the decisions and choices they make.

#2. Use appropriate words and language when talking to patients with diabetes. Avoid invoking guilt, laying blame, or using incriminating tactics. Perceived benefits are better than perceived threats. Negative or careless language can be harmful and can demotivate patients.
#3. Allow collaborative care, shared decision making, and "strike a deal" with the patient at each therapeutic juncture encountered. An informed communication style of the physician that included a participatory role for the patient in decision making resulted in significant improvement in patient self-care and glycemic control (glycated hemoglobin [HbA1c] improved by as much as 0.7%). In another study, the improvement in HbA1c was found to be even greater (1.5%) as a result of patient engagement in decision making. By contrast, a dominating and controlling style of communication by the healthcare provider resulted in poor metabolic control.

#4. Be practical and seek realistic goals. Focus on the achievable. Life is not about HbA1c level for every diabetes patient or every time for the regular patient attending the clinic.

#5. Be nonjudgmental. Obese patients were less likely to lose weight if they felt the attending physician was in some way judgmental about their weight.

#6. Consider cultural issues, religious beliefs, and personal values of the patient. With some individuals and in certain parts of the world, religious beliefs are dearly held and may even take precedence over other issues in life. This can present a delicate situation to the unwary practitioner who may need to tread carefully between respecting personal values of the patient, on the one hand, and not compromising medical care provided, on the other.

#7. Reward effort, not just outcome. Even modest encouragement can inspire patients to do more for their cause.

#8. Stay tuned to the patient's feelings and pick up the clues early. On average, a diabetes patient drops 2.6 clues per clinic visit. Subtle hints can be related to anything from loneliness at home to shortage of money. Although the physician does not have to solve every problem, an empathic response to the patient's concerns can improve clinic dynamics and change outcome. Furthermore, missed clues mean lost opportunities and, interestingly, lead to longer, not shorter, clinic visits.

#9. Use visual tools as much as possible: make a simple drawing or show the patient a relevant graph or picture to facilitate understanding and enhance motivation. The mere provision of a poster of HbA1c values marked with target goals improved metabolic control significantly in the patients tested. In another study, the Vision Study, investigators showed that graphic display of self-monitored blood glucose data significantly improved metabolic control, with an impressive 0.93% reduction in HbA1c in the type 2 diabetes patients studied. Patients are more believing in something they can see.

#10. Does your patient comprehend and remember the instructions given at the clinic? Patients have poor recall of decisions made at the clinic and tend to forget as much as 50% of what they are told by their physician. To explore the benefits of checking patient comprehension and recall, Schillinger et al. listened to audiotapes taken at outpatient settings and found a significant improvement in glycemic control in patients whose physicians applied this simple interactive strategy compared with those who were not assessed for comprehension and recall. Asking your patient to restate and summarize your instructions makes good sense and is obviously therapeutically rewarding.”

If doctors would do this, then they should also have a recording to give patients to play back at home to reinforce this as well. The doctors should also have approved printouts of reliable internet sources for the patients to read if they are interested.

It is interesting how little HbA1c level has changed over recent years despite the introduction of numerous antidiabetes agents and advanced diabetes technologies.

The doctor says, “The tips cited above are not meant to be a call for physicians to just "be nicer" to their patients or a ploy to improve customer service at the diabetes clinic. Rather, they emphasize the point that the quality of doctor–patient interaction is an important determinant of glycemic control and healthcare outcome for people with diabetes.”

The doctor continues, “Needless to say, communication is accessible to all physicians and is free of charge to all patients. Furthermore, communication has no cardiovascular risk or any other side effects to consider and so will not require regulatory body approval before release into the "markets." Communication should, in my opinion, be considered a universal first-line therapy in any future guidelines made for the treatment of diabetes. We should also train physicians on the art and craftsmanship of communication with people with diabetes.

September 10, 2014

CPAP Effective for Older People

Continuous positive airway pressure (CPAP) is effective at treating sleep apnea in older people, a new study has found. I can believe this as most older people have conquered most of their fears and vanity of wearing the equipment and realize the importance of sleep to their health.

Previous studies have established the benefits of CPAP in middle-aged people with OSA (obstructive sleep apnea), but until now there has been no research on whether the treatment is useful and cost-effective for older patients. The new research found that CPAP reduces how sleepy patients feel in the daytime and reduces healthcare costs. The researchers say CPAP should be offered routinely to older patients with OSA, and more should be done to raise awareness of the condition.

Now if the United States would accept the research. The study was published in Lancet Respiratory Medicine. It involved 278 patients aged 65 or over at 14 NHS centers in the UK. It was led by researchers at Imperial College London and the Royal Infirmary of Edinburgh in collaboration with the Medical Research Council Clinical Trials Unit at UCL, and the Universities of Oxford and York. It was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme.

Sleep apnea can be hugely damaging to patients' quality of life and increase their risk of road accidents, heart disease and other conditions. Lots of older people might benefit from this treatment. Many patients feel rejuvenated after using CPAP because they're able to sleep much better and it may even improve their brain function. Patients with sleep apnea sometimes stop breathing for 30 seconds or longer at night before they wake up and start breathing again. In these pauses, their blood oxygen levels fall.

The low oxygen levels at night might accelerate cognitive decline in old people, and studies have found that sleep apnea causes changes in the grey matter in the brain. They're currently researching whether treatment can prevent or reverse those changes.