March 30, 2012

What Are Best Tests for Neuropathy?

Two articles both cite the 1996-2007 Health and Retirement Study to identify individuals with a diagnosis of peripheral neuropathy. They focused on 15 relevant tests and examined the number and patterns of tests six months before and after the initial diagnosis.

What the two articles concentrate on is holding up the expensive MRIs that many doctors order which is less than definitive for diagnosis. Then they make a leap that does upset me. They assume that most everyone with neuropathy has diabetes and declare that the oral glucose tolerance test (OGTT) be performed instead. The OGTT is cheaper and may be a solution, but it is far from the most reliable as well when done by itself.

What are they going to do next when the patient does not have diabetes? I have a hard time understanding researchers that assume neuropathy means you have diabetes. There are other causes of neuropathy and the researchers focused on 15 relevant tests. They may mention them in the full study report, but the press release just focuses on MRIs and OGTT.

I must have been fortunate as four tests were used to determine that I had neuropathy and MRI and OGTT were not among them. I was diagnosed several years prior to the diagnosis of diabetes. The neurologist also did a thorough examination of my feet, hands, and lower legs. Then he did the tests before stating that I had peripheral neuropathy.

We do need to use tests for neuropathy that are definitive and not just the expensive tests. Therefore, the researchers are pointing out a real problem we have in our medical system.

March 29, 2012

Potatoes, Rice, and Bread = Carbohydrates

When reading blogs written by people required to follow the dogma of the American Diabetes Association (ADA), I can only say that the advice needs to be scrutinized very carefully. They tend to treat topics like carbohydrates as a “one size fits all” mantra.

This means you should trust your meter and what it is telling you about the foods you are consuming. Then adjust your portion size to fit what your meter is telling you. Yes, some people can eat all three foods in the title above, and others must eliminate all three from their menu. This means that each individual must find their level and follow it. Periodically you may need to retest to see if anything has changed as this can happen.

We must understand that the ADA promotes the USDA MyPlate solution for starches. Promoting them as the source of nutrients can be misleading as many of the vitamins and minerals can be found in other foods and often in higher quantities. There are people that cannot tolerate gluten found in grains, but these people are often ignored in their advice.

The question included potatoes, rice, and bread, but bread is often the main topic of discussion and brown rice is just given a mention. Potatoes are often completely ignored and a broad statement is made about starches. While potatoes are starches, some types of potatoes create lower blood glucose problems than others. Here again, testing is the only way I know that will give you answers of what types will work for your body chemistry. I am still able eat some potatoes, but not as often or as much as before diabetes.

What I have been surprised about is the rice. One variety (white rice) that everyone has told me to avoid, I can have a decent size serving and have only a small increase in blood glucose. Now brown rice does raise my blood glucose more than 60 mg/dl with just a small serving. This is why each person needs to find out what their body tolerates and not rely on others and what works for them.

Educators will not tell you that if you have a weight problem, elimination of wheat from your diet may help the most in weight reduction. They will only say to eliminate the highly processed bread and use whole wheat bread. Both contribute to the weight problem and it is the quantity of bread consumed. If you can tolerate wheat, consider greatly limiting the quantity.

Everyone needs to be confident of what they eat in relation to the level the food will raise your blood glucose. Meters today are slowly becoming more accurate and we need to trust them. I still find changes that I need to make as I age and my body becomes more sensitive to certain types of carbohydrates.

March 28, 2012

Pharmacists Could Be Health Care Providers

This is a great article and everyone should read this. Will it work? This will depend on many factors and largest problem is the patients themselves. Why, you ask? Because many patients fill one prescription at one pharmacy and then go to another pharmacy to fill a second prescription. This is so common it is scary. I see it all the time. I asked a couple not too long ago, why they would do this. I was not surprised by the answer as I have heard it before.

They said it was not the business of the pharmacist to know all their medications. The husband goes to several doctors and goes to the three pharmacies in town to fill prescriptions from different doctors. The wife sees four different doctors and does the same. Each takes more than five different medications. I asked if they had time to talk, but they were in a hurry to get the next pharmacy.

As they walked away, I could not help but think that they are living very dangerously. They are the ones putting their health and lives in jeopardy. I wonder if they had the same attitude about keeping the supplements they take from their doctors. They were both older than me, and the wife was using a walker, but they were as unconcerned about my question and more concerned about keep information away from the pharmacist.

I am concerned about my privacy as much as the next person, but when it comes to my health, I want to make sure my doctors know and that my pharmacist knows. Granted I do business with two pharmacies, one a military pharmacy and the other a local pharmacy. You bet I make sure the local pharmacy has a list of all medications I am taking plus any supplements. I try to update the list at least quarterly with the local pharmacy.

Only once has the local pharmacy asked me to stop taking a supplement and one prescription when the two would have conflicted with the new medication I needed for ten days. I was asked several questions and the reason for the new prescription and then she told me which supplement and prescription to stop and for how long. This was most reassuring to me and let me know that I was doing the right thing by having my list of medications and supplements on file with the pharmacy.

This interview with Rear Admiral Scott F. Giberson, RPh, PhC, MPH, US Assistant Surgeon General and chief professional officer of pharmacy at the US Public Health Service in Rockville, Maryland is very interesting about moving pharmacists into the healthcare profession legislatively.

The model Dr. Giberson is proposing would compensate pharmacists (as healthcare providers) based on the level of service they provide. Much like other health professionals, as the complexity of care increases, so too would the compensation. It may include both Medicaid Part D and Medicare Part B. Currently, pharmacists receive compensation within Medicare Part D for services provided through Medication Therapy Management (MTM). However, this is limited by considerable restrictions, including the number of medications (at least seven) the patient takes and the number of chronic conditions (two or three).

This subject I am sure will continue to be put before professionals and congress.
There are even greater ramifications not mentioned here. First, most doctors are being required to submit prescriptions electronically which should help eliminate some of the pharmacy hopping done by many people. As they get closer to issuing all prescriptions electronically, it will become evident to the doctors what patients are doing and may help the doctors to avoid conflicts in medications and even supplements.

This country still has a long way to go in this arena, but progress is being made. More doctors as beginning to ask the right questions about prescriptions and supplements and some are beginning to insist on a complete list from their patients. Some even are requiring that patients bring the actual medications with them to the appointments. A few doctors are even asking to see the supplement bottles as well. Patient medication safety is on the move and will be slowly implemented. Now is the time and next the clinics in many communities will be brought into this.

March 27, 2012

Know Your Keywords for Insulin Medication

It is often difficult to know which is the official term for the different types of insulin. One author will use one set of terms and a different author uses another set of terms. Then when you get out the magnifying glass and decipher the text on the materials supplied with the insulin, you will occasionally see a third set of terms. For someone new or even experienced with using insulin, this can be a little confusing.

Since I do not have but two types of insulin that I use, I cannot find the terms best used in the materials supplied with many of the insulins so if you have other types, do not hesitate to add comments with the terms used. The best chart I have found to-date for the terminology is this in WebMD. An incomplete listing of terms can be found here and I will add other terms that I have been taught from various sources and some “off-label” terms.

The medically correct terms listed here are from many sources and the most often used. I have added other terms I have been taught or that I have learned over the years.

  • Onset refers to when the insulin starts to work. I was taught Begins or Activates.
  • Peak refers to when the insulin works hardest. I was taught Effective Period and Period of Maximum Effectiveness.
  • Duration refers to how long the insulin works. I was taught Length of Usefulness.
  • Official sources list nothing about when insulin ends and I was taught End.

Next, we need to consider the types of insulin:
  • Rapid-acting - I learned fast-acting insulin.
  • Short-acting - This was never explained to me and I lumped it with fast-acting,
  • Intermediate-acting - I learned this as 12-hour insulin.
  • Long-acting - I learned this as 24-hour insulin.
  • Pre-mixed - All I learned was mixed insulin.

Now that you have an idea of the different terms used, understand that this applies to the average person with diabetes. All the directions and times used are for the average person. I take Lantus, which is a 24-hour insulin. I cannot count on this as through experience and my body chemistry, I have learned that I have an 18 to 20 hour effective period of insulin use. Others have no problem of Lantus lasting for 22 to 24 hours. I believe your own body chemistry has some effect on the effective period insulin will last.

After discussing this with my endocrinologist after changing times for injection and always having problems at the end of the 24-hour period, we decided to split my Lantus injection and take half the dosage twelve hours apart. To many this is stacking insulin; however, this has eliminated the dawn phenomenon for me and leveled out the total day for me. For some people this does not work.

If you look at this chart, you will see that Novolog duration is 3 to 5 hours. I normally get the 3 1/2 hours and no further benefits. For every person, you will need to carefully monitor your results to determine if you are in the average group, or if you fit another area.

I never really thought that being my own lab rat would be any fun, but over the years, I have learned otherwise. More than once my own experiments have proven beneficial in managing my diabetes more effectively. This does not mean that I have not needed to repeat experiments, as I have. Sometimes, I need to make adjustments and other times they become temporary. Each person has to find his or her own level of comfort and tolerance.

Some weeks are great and sometimes days can become a nightmare trying to discover what needs to be adjusted. Keeping a positive attitude and realizing that some times an answer will not be discerned is important. Do not be taken aback when later you realize what happened. Just remember for the next time.

March 26, 2012

Are People With Type 2 Lazy and Undisciplined?

This is the curse of having type 2 diabetes. Even people with type 1 diabetes are affected by this from people that are ignorant about type 2 diabetes. Unfortunately, even people in the medical profession seem ignorant about type 2 diabetes and insult their patients.

Of the group of people that I get together on a regular basis, only two of us have weight problems. Of the six that are on insulin, we are the two with constant battles to shed some weight. Yet even the rest of the group receives insults when people find out that that we have type 2 diabetes.

We receive comments about our inability to exercise, lack of will to leave the table, eating too much sugar, and not having the will power to prevent diabetes. Not only do we hear these insults, but also when we are together, people are constantly inspecting our table to see what we are eating. It will vary among us, but most have unsweetened tea or diet beverages, some will have a salad with vinegar and oil, and a few of us may have a meat without a bun or bread, or another protein.

Depending on the time of day, some of us may have fried eggs or even poached eggs, yet we have people that insist that we have sweetened tea and make not so pleasant comments about what we are eating. Yet there they sit with their donuts and sweetened drinks like regular colas, coffee with cream and sugar. Or they have a plate of pasta and few vegetables, and they are blaming us for our diabetes.

Oh, yes, when one of them is diagnosed with diabetes, we would like to return the favor, but our group has chosen to take the high road and not the road they have chosen. Even the member (Sue) of our group who had been a pain in our side as the diabetes police has more than once commented that if only she knew then what she knows now, she would have thought twice before making insulting remarks.

Even her husband (an informal member) is surprised we have not rubbed her face in it. We just answer, “what would we gain” - except a very negative attitude. We promote as positive an attitude as we can even in the face of most insults. We feel that this is the reason we get along so well when we are together – whether this includes three of us or all eight of us. We are a confident group that generally ignores the insulting comments directed at us.

Isn't it great to have an invisible disease? At least among the members in our group, we enjoy the company of each other and the interests we have in reading and comparing notes about what we read.

Our last addition to our group (Allen) has asked to stay in our group so that he can learn and carry information to another group of his friends that have type 2 diabetes. He stated he likes the informal nature of the group and the way in which we support each other. He stated that he likes to read, but the rest of his type 2 friends are not into computers and research or reading.

All of those that he gets together with are on oral medications and do little testing. This bothers him (Allen) and he has been asking a lot of questions about testing which we answer. Last Thursday we got into depression as he was having a downer, as was another in his group. Since there were only five of us, we told him to get the member in so we could possibly answer some of his questions.

Well, the two others from his group accompanied the friend he called as they were already there with him. Our group members knew something was indeed wrong just as soon as they arrived. Our member, Tim, asked a few questions and said we had better get him to the emergency room or if a doctor could see him, he would prefer that. Several calls were made and we were able to get him to his doctor that knows diabetes. The doctor was waiting on their arrival and took him immediately and Tim accompanied him.

Later after the appointment, Tim explained that they were admitting him to the hospital and putting a watch on him as he was suicidal and very deeply depressed. Tim said that the other two friends of his were both going to visit him when allowed and well as a couple of our group. For now, that is where we left it.

We did get together with Allen to see what his mood was, but Allen said seeing his friend in that shape had scared him deeply and he was not down now. He expressed his feelings as more of concern for his friend than worry about himself and this was the reason for his downer, as he did not know what to do for his friend. He thanked Tim for knowing what to do.

We discussed asking the doctor to speak to both groups about depression and how to recognize the symptoms he had. Tim said he would talk to the doctor and see what could be arranged.

We discovered that the person Tim had helped was the eldest brother of our member (Sue) and she had not been aware that he had been admitted to the hospital until she received the email from us about the day's events. After she had been to the hospital and seen her brother, she had her husband stop by Tim's house and thanked him. Tim told her we were not aware of their relationship or we would have let her know immediately.

Our group has decided to use this example to discuss with the members of both groups about the problems of keeping diabetes a secret.

You may enjoy reading this blog by Elizabeth Woolley.