Because of all the blogs appearing about exercise, I felt it was time to discuss some problems people tend to ignore when they exercise. Yes, too many people ignore their blood glucose levels, especially the people with type 2 diabetes. Most people with type 2 diabetes don't even tell their doctors they are starting to exercise or even that they are exercising. Many are just plain lucky they have not developed hypoglycemia or had problems of having their blood glucose levels too high when they started their daily exercise.
Although most sources seldom discuss the problems involved, it is time to bring them to the front. Most people with type 1 diabetes know what happens if the blood glucose levels are too low or too high before they start their daily exercising. For some reason, many doctors just do not cover this with type 2 patients. Does this mean that we will not have problems. Just continue to push your luck and you may end up in the hospital.
In my research, it has been difficult to find conclusive answers for type 2 diabetes. Everyone agrees that a blood glucose level of 250 mg/dl (13.9 mmol/L) or higher means that you must not exercise until your levels have come down below this.
Read the American Diabetes Association Diabetes Care for guidelines and concerns before beginning a regimen of exercise. Type 2 diabetes people on insulin or sulfonylurea treatments need to be concerned at the same degree as people with type 1 diabetes. It is just that people with type 2 are less likely to have severe hypoglycemia. Exercise for people with type 2 generally improves insulin sensitivity and assists in bringing elevated blood glucose levels into the normal range.
I have said this before and it needs repeating – before beginning a regimen of exercise, please discuss this with your doctor. He may want to do some tests before allowing you to do any strenuous exercise regimens and may have other advice to assist in preventing problems. Many of these are also covered in the ADA Diabetes Care link above.
Generally the blood glucose guidelines for exercising for all types of diabetes are 100 to 250 mg/dl (5.6 to 13.9 mmol/L). For most people, this is a safe pre-exercise blood glucose range. If you are not on insulin or sulfonylurea treatments, then it is still necessary to discuss this with your doctor if you are about to start an exercise regimen after a long period of being sedentary. This applies to people controlling their blood glucose levels with diet and exercise as well to prevent possible cardiovascular problems.
There are those individuals with type 2 diabetes that do not follow the norm and their blood glucose increases with exercise. This should be discussed with the doctor and use the doctors guidance. Normally after a period of time, possibly a month or longer, depending on the type of exercise you should see your blood glucose levels dropping with exercise.
If you are a type 2 on insulin or sulfonylurea treatments, be sure to read this article from the Mayo Clinic as well. Another blog for your reading is this one.
Even this does not cover people with type 2 diabetes and prediabetes that maintain near normal levels. My advice would be to talk this over with your doctor and once you have established a pattern of safe exercise at lower levels than recommended, keep a close watch on your blood glucose levels.
Enjoy exercising for good health!
October 7, 2011
October 6, 2011
More questions for AADE
This continues the discussion of AADE and how they are going to continue to improve when they leave so many issues unanswered and seem to ignore many of them as if they were hot potatoes. Maybe the AADE needs to encourage their CDEs to get back to some basics and treat people with more respect, more empathy, and do more education.
Continuing with questions for the AADE - how are they going to work with e-patients, empowered patients, and proactive patients, then add patient advocates? One group of people most CDEs seem to avoid are patients that is proactive and empowered patients. Patients that have education about diabetes seem to bring out the worst in CDEs. Twice I have had CDEs bristle and say that they were in charge and that I was to listen and keep my mouth shut. That alone ended the appointments and any further contact.
I have not seen or heard anything about e-patients, but in talking with a patient advocate recently, he described the behavior of a CDE. He told me, she said that she did not have to deal with an intermediary and for him not to be present at the next appointment, and left the appointment.
In the blog written by Donna Tomky, the new President of the AADE on DMine, she gave the following - - DSMT = Diabetes Self-Management Training (official term for working with a CDE). This is a sore point with me and diabetes self-management training is not something most CDEs seem willing to do. From my experiences, they are more comfortable with issuing mandates, telling people what they need to do, than in doing any training.
When it comes to training, many patients are not satisfied with the limited “training”, if you can even call it that, people are receiving. More patients are interested in self-management blood glucose training (SMBG) which is applicable for day in, day out living. I know that the informal group I associate with will not meet with a CDE that promotes A1c's of 6.5 to 7.0 percent. Except for me, the group maintains A1c's of less than 6.0 percent. I am near this, but have only been able to achieve this twice.
Now that AADE has their Guidelines for the Practice of Diabetes Education, what are they doing with them? How will CDEs that sidestep and avoid these guidelines be handled? Will they be told to do better and that is all. I have a suspicion that is what will happen. I say that CDEs that ignore and tromp on the guidelines should be stripped of their certification. The same should go when they refuse to work with level 1 people and do everything to have them excluded and left out of patient discussions?
Another question - when will AADE realize the value of other programs like blood glucose awareness training (BGAT)? With many type 1 and type 2 people on insulin that are having problems with hypoglycemia, it seems reasonable that more CDEs would be using this to assist these people in dealing with hypoglycemia. I do not know of any type 2 presently that are hypoglycemically unaware, but this training should be ideal for anyone that is unaware they are having a low.
A last question for now – when will CDEs start talking about insulin usage early on after diagnosis for managing diabetes rather than as a treatment of last resort. A lot of people with type 2 diabetes have irreversible damage when they are put on insulin. I realize that doctors are not supposed to do any harm, but why do CDEs have to follow the doctors doing harm and use fear to encourage patients to stay on oral medications? What are you supposed to do when a CDE sees that you are insulin and makes the following crack, “you poor fellow, how much longer are they giving you?” What followed was very short and I'm afraid everyone in the office complex overheard my rant. That has been almost seven years ago and I had the neuropathy and sleep apnea before my diagnosis of diabetes.
Except for a few thousand of the certified diabetes educators that are dealing with most of the questions and issues I have mentioned, and work for places like Joslin Diabetes Center, the Behavioral Diabetes Institute, and other enlightened medical practices, something does need to be done to retrain most CDEs. Oh, and the CDEs that stand up for what is right in the face of being hounded out of practice by uncaring colleagues, they need our support. Those that are doing an exemplary job should not be punished for the errors and intransigence of the many.
Continuing with questions for the AADE - how are they going to work with e-patients, empowered patients, and proactive patients, then add patient advocates? One group of people most CDEs seem to avoid are patients that is proactive and empowered patients. Patients that have education about diabetes seem to bring out the worst in CDEs. Twice I have had CDEs bristle and say that they were in charge and that I was to listen and keep my mouth shut. That alone ended the appointments and any further contact.
I have not seen or heard anything about e-patients, but in talking with a patient advocate recently, he described the behavior of a CDE. He told me, she said that she did not have to deal with an intermediary and for him not to be present at the next appointment, and left the appointment.
In the blog written by Donna Tomky, the new President of the AADE on DMine, she gave the following - - DSMT = Diabetes Self-Management Training (official term for working with a CDE). This is a sore point with me and diabetes self-management training is not something most CDEs seem willing to do. From my experiences, they are more comfortable with issuing mandates, telling people what they need to do, than in doing any training.
When it comes to training, many patients are not satisfied with the limited “training”, if you can even call it that, people are receiving. More patients are interested in self-management blood glucose training (SMBG) which is applicable for day in, day out living. I know that the informal group I associate with will not meet with a CDE that promotes A1c's of 6.5 to 7.0 percent. Except for me, the group maintains A1c's of less than 6.0 percent. I am near this, but have only been able to achieve this twice.
Now that AADE has their Guidelines for the Practice of Diabetes Education, what are they doing with them? How will CDEs that sidestep and avoid these guidelines be handled? Will they be told to do better and that is all. I have a suspicion that is what will happen. I say that CDEs that ignore and tromp on the guidelines should be stripped of their certification. The same should go when they refuse to work with level 1 people and do everything to have them excluded and left out of patient discussions?
Another question - when will AADE realize the value of other programs like blood glucose awareness training (BGAT)? With many type 1 and type 2 people on insulin that are having problems with hypoglycemia, it seems reasonable that more CDEs would be using this to assist these people in dealing with hypoglycemia. I do not know of any type 2 presently that are hypoglycemically unaware, but this training should be ideal for anyone that is unaware they are having a low.
A last question for now – when will CDEs start talking about insulin usage early on after diagnosis for managing diabetes rather than as a treatment of last resort. A lot of people with type 2 diabetes have irreversible damage when they are put on insulin. I realize that doctors are not supposed to do any harm, but why do CDEs have to follow the doctors doing harm and use fear to encourage patients to stay on oral medications? What are you supposed to do when a CDE sees that you are insulin and makes the following crack, “you poor fellow, how much longer are they giving you?” What followed was very short and I'm afraid everyone in the office complex overheard my rant. That has been almost seven years ago and I had the neuropathy and sleep apnea before my diagnosis of diabetes.
Except for a few thousand of the certified diabetes educators that are dealing with most of the questions and issues I have mentioned, and work for places like Joslin Diabetes Center, the Behavioral Diabetes Institute, and other enlightened medical practices, something does need to be done to retrain most CDEs. Oh, and the CDEs that stand up for what is right in the face of being hounded out of practice by uncaring colleagues, they need our support. Those that are doing an exemplary job should not be punished for the errors and intransigence of the many.
October 5, 2011
Is the AADE Actually Making Improvements?
Amy Tenderich had a guest blogger on September 29 that answered some of questions about the American Association of Diabetes Educators (AADE). Yes, this is the certified diabetes educators (CDEs) we are discussing. They have made some improvements over the last year, but there is a lot more that needs to be done. These are a few of the ideas I want to cover.
First, there needs to be better continuing education. Their formal education is good. They stay up-to-date about equipment and some studies, but many CDEs are still lacking key pieces of information. Many do stay current with the latest changes in the American Diabetes Association guidance, but others seem to be stuck in the past and therefore make recommendations and mandates that are not always in the best interest of the patients.
So my first question is – does the AADE have a procedure for filing complaints about CDEs that give outdated advice or that do not work with patients? Then what do we do about those CDEs that cannot be civil when you ask a question that they do not like?
My second question is - what are they doing to help people with depression? Many CDEs seem very lost when this topic is brought up. Their eyes glaze over; they attempt to change the subject or do their best to divert the conversation away from the topic.
My third question is - are they going to allow people to use lower carb diets? Many, but not all are stuck on having people eat 60 carbs per meal and telling us that we are harming ourselves if we eat less that their mandated amount. Even the ADA has moved away from the mandate of 60 carbs per meal. For most of the CDEs I have met, this seems to be a mantra.
At this point it is important to note that ADA has (hard to believe, but true) changed their position about carbohydrates. Check out Standards of Care section of the 2010 ADA Clinical Practice Recommendations. The updated carbohydrate recommendation starts on page S25 and I quote it - “Although numerous studies have attempted to identify the optimal mix of macronutrients for meal plans of people with diabetes, it is unlikely that one such combination of macronutrients exists. The best mix of carbohydrate, protein, and fat appears to vary depending on individual circumstances. For those individuals seeking guidance as to macronutrient distribution in healthy adults, DRIs may be helpful (106). It must be clearly recognized that regardless of the macronutrient mix, the total caloric intake must be appropriate to the weight management goal. Further, individualization of the macronutrient composition will depend on the metabolic status of the patient (e.g., lipid profile and renal function) and/or food preferences. Plantbased diets (vegan or vegetarian) that are well planned and nutritionally adequate have also been shown to improve metabolic control (107,108). The primary goal with respect to dietary fat in individuals with diabetes is to limit saturated fatty acids, trans fatty acids, and cholesterol intake so as to reduce risk for CVD. Saturated and trans fatty acids are the principal dietary determinants of plasma LDL cholesterol. There is a lack of evidence on the effects of specific fatty acids on people with diabetes; therefore, the recommended goals are consistent with those for individuals with CVD (92,109).” (Emphasis is mine)
This will now allow variation of carbohydrate consumption to fit the individual and not forcing a certain number of carbohydrates. The low fat regimen is still advocated, but even this can change. In a discussion with a CDE, I was told in no uncertain terms that this was not accurate and I was to eat the 60 carbs per meal. This inflexible position is not acceptable and my discussion with this CDE ended.
There are many more questions that I have, but I need to get my thoughts organized and collect more information. The AADE still has more to correct and improve upon.
First, there needs to be better continuing education. Their formal education is good. They stay up-to-date about equipment and some studies, but many CDEs are still lacking key pieces of information. Many do stay current with the latest changes in the American Diabetes Association guidance, but others seem to be stuck in the past and therefore make recommendations and mandates that are not always in the best interest of the patients.
So my first question is – does the AADE have a procedure for filing complaints about CDEs that give outdated advice or that do not work with patients? Then what do we do about those CDEs that cannot be civil when you ask a question that they do not like?
My second question is - what are they doing to help people with depression? Many CDEs seem very lost when this topic is brought up. Their eyes glaze over; they attempt to change the subject or do their best to divert the conversation away from the topic.
My third question is - are they going to allow people to use lower carb diets? Many, but not all are stuck on having people eat 60 carbs per meal and telling us that we are harming ourselves if we eat less that their mandated amount. Even the ADA has moved away from the mandate of 60 carbs per meal. For most of the CDEs I have met, this seems to be a mantra.
At this point it is important to note that ADA has (hard to believe, but true) changed their position about carbohydrates. Check out Standards of Care section of the 2010 ADA Clinical Practice Recommendations. The updated carbohydrate recommendation starts on page S25 and I quote it - “Although numerous studies have attempted to identify the optimal mix of macronutrients for meal plans of people with diabetes, it is unlikely that one such combination of macronutrients exists. The best mix of carbohydrate, protein, and fat appears to vary depending on individual circumstances. For those individuals seeking guidance as to macronutrient distribution in healthy adults, DRIs may be helpful (106). It must be clearly recognized that regardless of the macronutrient mix, the total caloric intake must be appropriate to the weight management goal. Further, individualization of the macronutrient composition will depend on the metabolic status of the patient (e.g., lipid profile and renal function) and/or food preferences. Plantbased diets (vegan or vegetarian) that are well planned and nutritionally adequate have also been shown to improve metabolic control (107,108). The primary goal with respect to dietary fat in individuals with diabetes is to limit saturated fatty acids, trans fatty acids, and cholesterol intake so as to reduce risk for CVD. Saturated and trans fatty acids are the principal dietary determinants of plasma LDL cholesterol. There is a lack of evidence on the effects of specific fatty acids on people with diabetes; therefore, the recommended goals are consistent with those for individuals with CVD (92,109).” (Emphasis is mine)
This will now allow variation of carbohydrate consumption to fit the individual and not forcing a certain number of carbohydrates. The low fat regimen is still advocated, but even this can change. In a discussion with a CDE, I was told in no uncertain terms that this was not accurate and I was to eat the 60 carbs per meal. This inflexible position is not acceptable and my discussion with this CDE ended.
There are many more questions that I have, but I need to get my thoughts organized and collect more information. The AADE still has more to correct and improve upon.
October 4, 2011
Old Problems in Diabetes Education
An examination of an article and the progress being made is in order. Amy Tenderich made some convincing arguments in her article of November 15, 2007 in Diabetes Health. Then in the reply to these problems by Donna Tomky on Amy Tenderich's blog of September 29, 2011 was a pleasant surprise, but still left many questions needing discussion, if not still needing complete answers. We can accept that an organization like the American Association of Diabetes Educators (AADE) that may be slowly coming out of the doldrums of past ineffectiveness to take some time in getting things set to the right tone and accomplishing many of its new goals.
In reading some of AADE's position papers, they are being aggressive, but the membership is slow to give support. Too many have become engrained in bad habits of the past and are not ready to support the new positions. CDEs that have turned to writing books and making speeches are not supportive of the changes. Many of these CDEs have created their ladder to success and are resisting change.
In addition, many of the problems still exist because of a healthcare system mired in more ineffectiveness and concern for profits then preventive care. Our outdated medical insurance industry is even fighting harder to further increase profits at patient expense than in looking for new ways to battle the increase in medical costs. Tests are over used in many cases and insurance just continues to pay for them and pass the costs onto patients with ever-increasing premiums.
Amy found several excellent problems in 2007 worth repeating. The first was “Create a sensible career path for new recruits, including some type of mentorship”. Has this been established? AADE would like us to think so. In Donna Tom Tomky's statement, she says: “One of the most significant ways that the discipline has been strengthened since 2007 is by the development of documents that support and clarify the roles and scope of practice for diabetes educators. In 2009, AADE released The Guidelines for the Practice of Diabetes Education and the Competencies for Diabetes Educators.”
Translation – they have made it more difficult for entry into the certified diabetes educator position and made it restrictive in who they accept. This does nothing to create a career path making it easier to attain a position as a CDE. There is still nothing in the works for college courses to aid in the study for the exam and further restricts people that are eligible to become CDEs.
The second point of change put forth by Amy is “Streamline patient access to educational services”. This was not even covered by Donna Tomky other than to restate that people need a doctor referral so that they are eligible to bill their time to insurance companies. What are patients to do when they see a doctor that will not refer them or that the doctor has no one available in the small rural community? This is not a promising answer for a solution.
The third point Amy put forth is “Garner consistent support from both physicians and insurance providers for diabetes programs”. This is partially covered along with the above point in Donna's point: “We are particularly pleased to begin work on a new demonstration project focusing on mobile health. With the Office of Minority Health, Baylor Diabetes Health and Wellness Institute and AT&T, we are facilitating a project that will connect diabetes educators with patients via mobile technology and video platforms. We believe these mobile technologies have huge potential to revolutionize the way educators can interact with their patients and increase access to diabetes education services, particularly in rural and under served areas”.
Granted this is still in the development stage and we do not know how far this will go. Will the program be for minorities only? Will the program be nationwide? These are just a few of the yet unanswered questions.
Amy's fourth point is “Establish accepted best practices for diabetes treatment that are clearly communicated throughout the field”. And, the last point in Amy's list of needed changes is “Drive more proactive participation from the patient community”.
Unless I missed something on Donna's reply, these two points were completely unanswered. In place of answering the above, we were told about “Establishing State Licensure for Diabetes Educators”. Read this for more information and if interested there are some valuable links. This could open a can of wiggly worms but may well be worth the fishing.
I will continue the discussion about more questions for the AADE and maybe a few challenges, in my next several blogs.
In reading some of AADE's position papers, they are being aggressive, but the membership is slow to give support. Too many have become engrained in bad habits of the past and are not ready to support the new positions. CDEs that have turned to writing books and making speeches are not supportive of the changes. Many of these CDEs have created their ladder to success and are resisting change.
In addition, many of the problems still exist because of a healthcare system mired in more ineffectiveness and concern for profits then preventive care. Our outdated medical insurance industry is even fighting harder to further increase profits at patient expense than in looking for new ways to battle the increase in medical costs. Tests are over used in many cases and insurance just continues to pay for them and pass the costs onto patients with ever-increasing premiums.
Amy found several excellent problems in 2007 worth repeating. The first was “Create a sensible career path for new recruits, including some type of mentorship”. Has this been established? AADE would like us to think so. In Donna Tom Tomky's statement, she says: “One of the most significant ways that the discipline has been strengthened since 2007 is by the development of documents that support and clarify the roles and scope of practice for diabetes educators. In 2009, AADE released The Guidelines for the Practice of Diabetes Education and the Competencies for Diabetes Educators.”
Translation – they have made it more difficult for entry into the certified diabetes educator position and made it restrictive in who they accept. This does nothing to create a career path making it easier to attain a position as a CDE. There is still nothing in the works for college courses to aid in the study for the exam and further restricts people that are eligible to become CDEs.
The second point of change put forth by Amy is “Streamline patient access to educational services”. This was not even covered by Donna Tomky other than to restate that people need a doctor referral so that they are eligible to bill their time to insurance companies. What are patients to do when they see a doctor that will not refer them or that the doctor has no one available in the small rural community? This is not a promising answer for a solution.
The third point Amy put forth is “Garner consistent support from both physicians and insurance providers for diabetes programs”. This is partially covered along with the above point in Donna's point: “We are particularly pleased to begin work on a new demonstration project focusing on mobile health. With the Office of Minority Health, Baylor Diabetes Health and Wellness Institute and AT&T, we are facilitating a project that will connect diabetes educators with patients via mobile technology and video platforms. We believe these mobile technologies have huge potential to revolutionize the way educators can interact with their patients and increase access to diabetes education services, particularly in rural and under served areas”.
Granted this is still in the development stage and we do not know how far this will go. Will the program be for minorities only? Will the program be nationwide? These are just a few of the yet unanswered questions.
Amy's fourth point is “Establish accepted best practices for diabetes treatment that are clearly communicated throughout the field”. And, the last point in Amy's list of needed changes is “Drive more proactive participation from the patient community”.
Unless I missed something on Donna's reply, these two points were completely unanswered. In place of answering the above, we were told about “Establishing State Licensure for Diabetes Educators”. Read this for more information and if interested there are some valuable links. This could open a can of wiggly worms but may well be worth the fishing.
I will continue the discussion about more questions for the AADE and maybe a few challenges, in my next several blogs.
October 3, 2011
Maggots May Help Diabetic Wounds
I have to be amused every time I see another article on the use of maggots. No, there is nothing wrong with using them and since their use has been around for centuries, why all the fuss. Just use them and quit making a big deal about it. Yes, I know that our MRSA infected hospitals and newly trained doctors have a revulsion to their use, but be realistic. We need this type of maggots for some wounds, especially on people that refuse to manage their diabetes. If physicians can be open-minded and catch these wounds early, maggot treatment will often prevent the dreaded amputation.
The writers of this press release just do not get it. Maggots will not heal a wound. Even the researchers should know this, but apparently, they want to have people think this. What the maggots do is clean the wound of damaged tissue, which then will allow for faster healing. This is how it may help, but maggots healing a wound – never.
This small study is just another attempt to gain funding and have more studies. I say let them have the funding if it will finally convince our physicians of the value of the treatments. I know, I know, the physicians have to have the approval of the FDA – oh really. Some of these physicians ought to have to travel in some of the remote parts of Africa where medical people have not been and see people treat wounds with maggots there. It is amazing what these little creatures can accomplish. And believe me, conditions there are not sterile and the rags used to bind the wounds do not compare to the MRSA sterility of our hospitals.
Before I get totally carried away, please read this article, my blog, this bit of history, and this article. I have to have a little tongue-in-cheek fun once in a while.
The writers of this press release just do not get it. Maggots will not heal a wound. Even the researchers should know this, but apparently, they want to have people think this. What the maggots do is clean the wound of damaged tissue, which then will allow for faster healing. This is how it may help, but maggots healing a wound – never.
This small study is just another attempt to gain funding and have more studies. I say let them have the funding if it will finally convince our physicians of the value of the treatments. I know, I know, the physicians have to have the approval of the FDA – oh really. Some of these physicians ought to have to travel in some of the remote parts of Africa where medical people have not been and see people treat wounds with maggots there. It is amazing what these little creatures can accomplish. And believe me, conditions there are not sterile and the rags used to bind the wounds do not compare to the MRSA sterility of our hospitals.
Before I get totally carried away, please read this article, my blog, this bit of history, and this article. I have to have a little tongue-in-cheek fun once in a while.
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