New Diabetes Legislation A Benefit for Whom?

What is this that has people going gaga and experts trying to get their names out in front to be part of a new commission? It seems a yet to be passed congressional legislation is to blame. First it will have to be passed by the House and Senate and be signed by the President. Chances seem average for this to happen, but probably not until after the election. In a letter from my congressional representative, he stated that it was highly doubtful anything would happen in the current year. Once again, patients are not called upon to serve and lend their voices.

If passed, it will establish the National Diabetes Clinical Care Commission (NDCCC). Under the Senate version, the NDCCC will include diabetes experts and other health care providers who work directly with diabetes patients. Also included will be patient advocates and representatives from the federal agencies most involved in diabetes care activities. Yet unknown is the actual number of commission members. Hopefully, non-government members will out number government members.

If passed, the NDCCC will have the responsibility of evaluating current federal quality improvement initiatives and identify redundant and ineffective policies. The NDCCC will also determine which policies are effective, if any. The commission will make recommendations to the Secretary of Health and Human Services and to the Congress on new approaches and the consolidation of existing operations. The claim is made that this will help leverage the federal investment in diabetes research. Past leverages of diabetes research has reduced the number of test strips people with diabetes are allowed to be reimbursed for so I have doubts that this will improve patient outcomes or reduce to burden of diabetes.

The act is endorsed by the major diabetes organizations, including the Pediatric Endocrine Society, the Endocrine Society, the American Academy of Ophthalmology, and the American Diabetes Association, in addition to the AACE and JDRF. You have to know that these groups want to have representatives on the commission. These groups are rule and guideline oriented and will do nothing to enhance to patients' position and lend efficiency to the government agencies. Everything will be aimed at the average patient and nothing will be done for the individual differences and providing assistance for patients that vary outside the “norm”.

Tom Ross at notmedicatedyet has an excellent blog about this topic. Even with his forewarning, I was not able to get any information from the site that he had a problem with even though I tried to get it to print. I will only add that what I was able to read was interesting.

This piece of congressional legislation will be of benefit only to those who serve and will do nothing for the patient population to prevent diabetes or assist those already having diabetes. If it is passed, it will not be of benefit for those needing help, only the rule and guideline makers who serve on the commission. Once again, the patients that are needing a voice in our government will be left wanting.

Get Your Medical Test Results

This is a topic I have advocated for with patients since shortly after diagnosis. I am not sure why, but many people are pushing back and saying they don't need copies of their laboratory results. I am guessing many that are older than I am have passively followed their doctor and do not have any idea or care what the results are. They trust their doctor to inform them if something is out of normal or prescribe a pill to correct the problem. This implicit trust may be earned, but I can't help but wonder if this is a wise course of action considering many patients only see their doctor for 10 to 15 minutes per appointment and many only see the doctor twice a year.

Even patients younger than myself put me off saying they don't need them. To this I ask if they know what the trends are in their test results. Are they holding steady, heading downward, or heading in the wrong direction. No one can answer me. Yes, people do seem to be tired of me and my talking about test results and getting copies of them.

Well, one of my acquaintances found out the hard way this last week. He was lucky his wife just happened to forget something needed for her job and came back to get it. He had collapsed on the kitchen floor and was unresponsive when she found him. She called 911 and then he was airlifted to another hospital. He will not be home for some time as his doctors say the normal stay is in excess of two weeks, and with his condition on arrival, they are estimating a longer stay.

Turns out his doctor had overlooked a key test result that would have prevented this and a supplement and medication would have corrected it without being hospitalized. What the wife found out from the hospital after they had requested a copy of the lab results was that the key note was on a page two and the doctor had thrown page two by mistake. Most lab reports are on one page unless they are noted page 1 of x pages at the bottom and this one had nothing. Even most one-page lab reports say page 1 of 1.

The doctors even talked to the wife about making sure that they get copies of all lab reports and other test reports. She asked why and was told that this was so they as patients might spot something the doctor(s) may miss. They stated that they would take the time to discuss the lab results with them, how to read them, what to look for, and how to track the results. The wife still isn't sure she wants lab reports? At least the husband now wants the test results.

My doctors know me and that I will be asking for a copy. Normally they like to cover them with me and they know I will be entering them into a spreadsheet, and even graphing them. From what I am reading, many people need to go in several days before the appointment to have the blood drawn or give a urine sample and then obtain the test results at their appointment. I seem to be different than most as I go in about 30 minutes or more ahead of my appointment and have this done and receive the results at my appointment. Yes, occasionally a test is done from the already drawn blood sample, and I am told this. I always request a mailed copy when it is given to the doctor or some will email a copy of the test results. If I don't receive either within seven working days, I call the doctor's office and ask. If I am told something like it is in the mail, I make a point of going to the office and asking for a copy.

Trisha Torrey at about dot com wrote about this back in early April and this is very important in today's medicine when doctor's do not have the time to make phone calls and do not use technology except for the records and at home for personal use. Thinking that a test was normal because you received no call can be life ending in today's medicine. Doctors today do not have the time that our doctors in the past had.

Think Your Hospital Is Looking Out for You?

If you think when you are in the hospital that the hospital is looking out for you, you are in the minority. Day after day, we see news of people that have stories to tell that are not showing hospitals in a good light. We hear of friends or relatives of friends that have died because of medication errors, errors in medical judgment, and errors in operations performed on the wrong patient. It will soon be apparent to even the most careful of patients that they will need a patient advocate if they are to be admitted to a hospital.

Even then, patient advocates will have a difficult time. Hospitals do not like patient advocates and do their best to work around them or even conceal what is happening. Yes, several decades ago, there were accidents and errors, but not at the ratio of today. We had doctors that spent time with patients and checked in regularly. We had nurses that knew what to do and communicated with the patient’s doctor(s) and the patients. They would alert doctors of changes in a patient's condition and test results.

Then came larger hospitals and more lawsuits. To protect their profit margin, nurses were marginalized, doctors restricted in their duties by the hospitals. Patients in the hospitals are being seen less often and not by their own physician. Is it any wonder there are more errors and improper medications given? Allergies are not checked and communications are limited.

This article in a Diabetic Connect newsletter says a lot and lays out many of the problems we encounter as people with diabetes. This from the article needs to be quoted, “The problem with hospitals is that they standardize care much more than they individualize care. This is due in large part to the huge volume of patients they service, and the need for general protocols. General protocols, however, do not work all the time for patients with diabetes. If you have never used insulin and the plan is to give you insulin in the hospital, work with your health care team to understand what to expect. I would advise family members to carry blood glucose meters with them and have them available for a quick check if necessary so that you can alert the hospital of a potential problem with high or low blood sugars.”

These general protocols can make it impossible to manage blood glucose levels in the range that you are accustomed to. Most hospitals do not want you to use your pump if you use one. They even discourage continuous glucose monitors. Occasionally you will find a hospital that will allow the patient to manage their diabetes while in the hospital, but this is rare and must be decided upon before admission. I would even suggest getting it in writing.

Another issue the article raises that I can appreciate is some hospitals are giving rapid-acting insulin after a meal. This surprisingly allows the patient to not eat the food that you will be served and/or eat what you think will be sufficient for your needs. Then the amount of insulin can be adjusted for the food eaten. Most hospital food is not very enticing and is loaded with carbohydrates. This is because of the dietitian mandate that people with diabetes should have 60 grams of carbohydrates at every meal.

I do appreciate the author's comment and I quote, “I do not in any way want this to scare you, but rather to encourage you to be an active participant in your healthcare. Any and all family members and loved ones should be involved as well.”

Hospitals need to learn how to treat people with diabetes. This will mean every family member will need to be on board and maybe even a diabetes patient advocate. If the patient is going to be incapable for any period of time and a family member is unable to be present, even a medical power of attorney will get their attention as long as the persons present are listed on the document. Even then, many hospitals will try to circumvent this document.

If you are the patient, make sure that you dot all “I's” and cross all “T's” and that your wishes are known, if possible, before admission to the hospital. Remember that the hospital protocols may not be in your best interests for diabetes management. Hospitals have protocols that are in their interest to protect their profit margin and prevent lawsuits.

Nutrients – Choline

Choline

Overview

Choline is similar to the B vitamins and is made in the liver. Choline is not strictly defined as a vitamin, but it is an essential nutrient. Choline is used for liver disease, including chronic hepatitis and cirrhosis. It is also used for depression, memory loss, Alzheimer's disease and dementia, Huntington's chorea, Tourette's disease, a brain disorder called cerebellar ataxia, certain types of seizures, and a mental condition called schizophrenia.

Choline is synthesized by the human body in small amounts, but still must be consumed to have an adequate supply. Athletes use it for bodybuilding and delaying fatigue in endurance sports. Choline is taken by pregnant women to prevent neural tube defects in their babies and it is used as a supplement in infant formulas. Other uses include preventing cancer, lowering cholesterol, and controlling asthma.

Deficiency Signs and Symptoms

The most common signs of choline deficiencies are fatty liver and hemorrhagic kidney necrosis. Dietary intake of a choline full diet can reduce the severity of the deficiency. Choline deficiency may play a role in liver disease, atherosclerosis, and possibly neurological disorders. One symptom of choline deficiency is an elevated level of the liver enzyme ALT.

Tests

There are a few tests, but none that I can find that your doctor may use. The doctor may know which tests are available to use. One that is mentioned is the platinochloride test for choline in human blood; however, this is not listed when looking for choline tests that I researched.

Recommended Daily Allowance

Adequate Intake (AI) for Choline
Life stage	Age	Males (mg/day)	Females (mg/day)
Infants	0-6 months	125	125
Infants	7-12 months	150	150
Children	1-3 years	200	200
Children	4-8 years	250	250
Children	9-13 years	375	375
Adolescents	14-18 years	550	400
Adults	19 years and older	550	425
Pregnancy	All ages	-	450
Breast-feeding	All ages	-	550

Tolerable Upper Intake Level (UL) for Choline
Age group	UL (g/day)
Infants 0-12 months	Not possible to establish*
Children 1-8 years	1.0
Children 9-13 years	2.0
Adolescents 14-18 years	3.0
Adults 19 years and older	3.5

Notice that the top chart is in milligrams and the bottom chart is in grams.

Function

Choline is similar to a B vitamin. It is used in many chemical reactions in the body. Choline seems to be an important element in the nervous system. In asthma, choline might help decrease swelling and inflammation.

Food Sources

It is in foods such as liver, muscle meats, fish, nuts, beans, peas, spinach, wheat germ, and eggs. It is generally recognized that it is important to get dietary choline from these foods as well.

Animal and plant food	Choline (mg)	Calories
5 ounces (142 g) raw beef liver	473	192
Large hardboiled egg	113	78
Half a pound (227 g) cod fish	190	238
Half a pound of chicken	150	543
Quart of milk, 1% fat	173	410
A gram soy lecithin	30 approx.	8
100 grams of Soybeans dry	116	268
A pound (454 grams) of cauliflower	177	104
A pound of spinach	113	154
A cup of wheat germ	202	432
Two cups (0.47 liters) firm tofu	142	353
Two cups of cooked kidney beans	108	450
A cup of uncooked quinoa	119	626
A cup of uncooked amaranth	135	716
A grapefruit	19	103
3 cups (710 cc) cooked brown rice	54	649
A cup (146 g) of peanuts	77	828
A cup (143 g) of almonds	74	822

Precautions

There is some concern that increasing dietary choline intake might increase the risk of cancer of the colon and rectum. One study found that women eating a diet that contains a lot of choline have an increased the risk of colon cancer. However, more research is still needed to determine the effects of diet on colon cancer.

Choline is seems to be safe when taken by mouth and used appropriately. Doses up to 3 grams daily for pregnant and breast-feeding women up to 18 years of age, and 3.5 grams daily for women 19 years and older are not likely to cause unwanted side effects. There isn’t enough information available about the safety of choline used in higher doses in pregnant or lactating women. It’s best to stick to recommended doses.

Possible Interactions

High doses (10 to 16 grams/day) of choline have been associated with a fishy body odor, vomiting, salivation, and increased sweating. The fishy body odor results from excessive production and excretion of trimethylamine, a metabolite of choline. Taking large doses of choline in the form of phosphatidylcholine (lecithin) does not generally result in fishy body odor, because its metabolism results in little trimethylamine. A dose of 7.5 grams of choline/day was found to have a slight blood pressure lowering (hypotensive) effect, which could result in dizziness or fainting. Choline magnesium trisalicylate at doses of 3 grams/day has resulted in impaired liver function, generalized itching, and ringing of the ears (tinnitus). However, it is likely that these effects were a result of the salicylate, rather than the choline in the preparation.

Little is known regarding the amount of dietary choline most likely to promote optimum health or prevent chronic disease in older adults. At present, there is no evidence to support a different intake of choline from that of younger adults (550 mg/day for men and 425 mg/day for women).

Methotrexate, a medication used in the treatment of cancer, psoriasis, and rheumatoid arthritis, inhibits the enzyme dihydrofolate reductase and therefore limits the availability of methyl groups donated from folate derivatives. Rats given methotrexate have shown evidence of diminished nutritional status of choline, including fatty liver, which can be reversed by choline supplementation. Thus, individuals taking methotrexate may have an increased choline requirement.

Nutrients – Selenium

Selenium

Overview

Selenium deficiency for those of us living in the United States is generally rare. I suggest reading my blog on selenium linked here. Excess selenium can indeed cause more harm than good so please be careful with selenium. Use this US map for determining if the food you eat comes from an area that is selenium deficient.

Selenium is an essential trace mineral found in small amounts in our body. Selenium plays a part in thyroid function and our immune system needs selenium to work properly. There are many other areas where selenium is maybe playing a role, but scientists have not determined the cause-effect in these areas. Even another area that needs more investigation is the finding that people that used selenium supplements of less than 200 mcg per day for more than seven years were at a significantly higher risk for developing type 2 diabetes.

Because of this and the number of medications that may be conflicting with selenium, it is strongly urged that people only take selenium supplements under the supervision of a doctor knowledgeable in selenium.

Potential for Deficiency

If you are healthy and eat a well-balanced diet, you should get enough selenium. You may have low levels of selenium if you:

• Smoke cigarettes
• Drink alcohol
• Take birth control pills
• Have a condition that prevents your body from absorbing enough selenium such as Crohn's disease or ulcerative colitis

Tests

Trace mineral testing is usually performed on a blood sample. Sometimes a 24-hour urine collection is obtained. Special metal-free blood or acid-washed urine containers are used to minimize the potential for sample contamination by any outside sources of minerals.

Blood and urine reflect recent mineral intake. Rarely, hair may be collected or a biopsy may be performed to obtain a tissue sample to evaluate mineral deficiencies, excesses, and storage that have occurred over time.

Recommended Daily Allowance

The minimum daily recommended dietary allowances (RDA) for selenium are listed below.

Pediatric

 Children 1 - 3 years: 20 mcg

 Children 4 - 8 years: 30 mcg

 Children 9 - 13: 40 mcg

 Children 14 - 18: 55 mcg

Adult

 19 and older: 55 mcg

 Pregnant women: 60 mcg

 Breastfeeding women: 70 mcg

As a supplement: Some studies have used 200 mcg per day for some conditions, but evidence suggests that taking that amount over a long time could increase your risk of developing diabetes. Talk to your doctor before taking more than the recommended daily allowance.

Food Sources

Dietary sources include the following: brewer's yeast and wheat germ, liver, butter, fish (mackerel, tuna, halibut, flounder, herring, smelts) and shellfish (oysters, scallops, and lobster), garlic, whole grains, sunflower seeds, and Brazil nuts are all good sources of selenium.

Selenium levels in food depend on where the food was grown. Selenium is destroyed when foods are refined or processed. Eating a variety of whole, unprocessed foods is the best way to get selenium in your diet.

Available Forms:

Selenium may be taken as part of a vitamin-mineral supplement, a nutritional antioxidant formula, or as a separate supplement. Most supplements contain a form of selenium called selenomethionine.

Precautions

There is a health risk of too much selenium. This happens when high blood levels become greater than 100 mcg/dl (micrograms per deciliter). This may result in a condition called selenosis. Selenosis symptoms include hair loss, white blotchy nails, gastrointestinal upset, garlic breath, fatigue, irritability, and mild nerve damage. In the USA, selenium toxicity is rare.

The Institute of Medicine of the National Academy of Sciences has set a tolerable upper intake level (UL) for selenium. Tolerable upper intake levels for selenium for infants, children, and adults to prevent selenosis is provided in the following table:

Age	Males and Females (mcg/day)
0–6 months	45
7–12 months	60
1–3 years	90
4–8 years	150
9–13 years	280
14–18 years	400
19+ years	400

Possible Interactions

There are many interactions that are known for selenium and some will lessen the effectiveness of the medications. Therefore, it is important that if you are having any of the following that you discuss this with a doctor knowledgeable about selenium. The list of medication conflicts is extensive and I urge you to read this. The areas that you need to be aware of include – cancer, chemotherapy, cholesterol-lowering medications, birth control pills, and gold salts.

Please read this if you have arthritis. Selenium does work with and supports iodine in the thyroid function.

Metabolic Syndrome Or Syndrome X - Diabetes Related

Metabolic syndrome or syndrome X is often spoken about as part of diabetes. Many of the tests are the same and it is true that many of the symptoms of the condition need to be heeded to prevent type 2 diabetes and cardiovascular complications.

The American Diabetes Association (ADA) has opposed the views of the World Health Organization (WHO) and the American Heart Association (AHA). Not that this is all bad, but the ADA is known to drag their feet on many issues when it comes to diabetes.

The WHO issued their guidelines back in 1998 and the AHA has done much to publicize the issue and set out guidelines similar to the WHO. The discussion is important and I will quote from some of the comments in the discussion.

“Metabolic syndrome is a set of risk factors that includes: abdominal obesity, a decreased ability to process glucose (increased blood glucose and/or insulin resistance), dyslipidemia, and hypertension. Patients who have this syndrome have been shown to be at an increased risk of developing cardiovascular disease and/or type 2 diabetes. Metabolic syndrome is a common condition that goes by many names (dysmetabolic syndrome, syndrome X, insulin resistance syndrome, obesity syndrome, and Reaven’s syndrome).”

“The National Heart Lung and Blood Institute (NHLBI) estimates that in the U.S. about 47 million adults (25%) have metabolic syndrome. It can affect anyone at any age, but it is most frequently seen in those who are significantly overweight - with most of their excess fat in the abdominal area - and inactive.”

For those interested, please read this for the table about how the three sets of criteria are laid out and compared. Also read this about additional details on metabolic syndrome and the tests, both laboratory and non-laboratory.

For most cases of metabolic syndrome, the root cause can be traced back to poor eating habits and a sedentary lifestyle. Some may be linked to genetic factors that are being researched or yet unknown. Some cases may occur in people already diagnosed with hypertension and in people with poorly controlled diabetes. With metabolic syndrome, it is important to know that all factors are interrelated.