Have You Been Evaluated for Patient Adherence?

This is the first in an on going series from Joslin's Diabetes Deskbook. The book is interesting as a patient and I will write blogs about the excerpts from Diabetesin Control dot com. There is much available for good discussion.

The first two paragraphs are a key to this discussion. “The gap in meeting clinical targets is in large part due to the gap that presently exists between actual and optimal treatment goals and strategies for patients and physicians.

Even when patients have an ongoing relationship with their primary physician, they often fall short of the recommended treatment goals due to gaps between actual and ideal treatment strategies. Collaboration is the key to closing this gap. Your patients are the most underused resource in your clinical practice. If you and your patients are able to jointly establish aligned goals, they will improve their health, and you will improve the efficiency of your practice and outcomes that you can achieve.”

Often there is a difference of opinion about optimal treatment goals between patients and physicians. Sometimes this is on purpose and at other times, it is difficult to determine why they are different. In reading the deskbook, it is easy to discern some of the reasons for the differences in goals. Younger patients may want to manage their diabetes very stringently and the physician does not want the goals to be so tight.

Then when it comes to the elderly, some are still capable of tight management and the physicians are demanding that they loosen up their management. This is when the physician needs to step back and reassess the patient to determine if they are indeed capable of this maintenance and if encouragement is in order rather that changing goals.

The five steps outlined in this excerpt are enlightening, if only more physicians would see them as valuable. The patient and physician may have a long history, but this does not mean that the physician is in command. The steps include:

First Step - When you enter the room where the patient is, start with a simple open-ended question like "What brings you in today?" Other questions are also useful and the doctor needs to listen to the patient. Most patients take about 32 seconds to create the answer and finish their statement. Most physicians make the mistake of interrupting at about 23 seconds to ask another question or redirect the discussion. This may make it seem to the patient that the doctor is in autopilot and not listening to them.

Second Step – Be sure to help the patient focus on their risk factors, and to appreciate their clinical importance. Many doctors fail here by not explaining carefully the risk factors and working with the patient to help them understand them. The discussion of all the risk factors at once does not work... ”This unfocused shotgun approach often leads to inaction, or to the wrong action.”

Third Step - If you and the patient have succeeded in reaching an agreement about a general goal such as A1c, then ask the patient how they would like to get there. Letting the patient set a goal can be guided to a point, to make the patient desire to take the action to obtain a better A1c. However, the doctor cannot set the goal and expect the patient to meet it. When the patient sets a goal that is attainable and does, this is the positive reinforcement that the patient needs and will work for other goals knowing that the doctor is there with him/her to make sure the goal is attainable. If the patient falls short and the doctor has the daily data – blood glucose readings, food log, and other records the patient has maintained, the doctor should be able to offer guidance to help the patient achieve the goal by the next visit.

Fourth Step - Having chosen a goal and a treatment strategy, it is important to encourage the patient not to lose momentum. “Remember that there are different paths to achieving the same result, with different combinations of lifestyle changes and medications. If their strategy doesn't seem optimal, you can then suggest: "I have some information on what strategies have worked for other patients similar to you. Would you like to hear some of these possibilities?"” Different techniques work for different patients and doctors need to work with patients to assist them and thereby increase their value and help the patient keep the desire to do more to meet the goal.

Fifth Step - Keep Cycling - The hardest work involves the first four steps described above. Often physicians and patients come up short of reaching their goals because they lose momentum. Encouragement is important. Because the patient is the person managing their diabetes on a daily basis, knowing that the doctor is helping them set reasonable goals and assisting them in achieving these goals, makes the doctor more appreciated.

This statement from the excerpt is important, and I quote, “This is a great time to be treating people with diabetes, and those without diabetes who are at risk for cardiovascular disease. Clinical results are improving dramatically; and while clinical gaps continue to exist, they are responsive to a number of different approaches. This provides an opportunity for the physician, but an opportunity that is best addressed through collaboration with your patient. The physician's role is to evaluate the patient's disease state, listen carefully to their concerns, and then provide the needed information that will help to inform and form the patient's choices. The patient controls their disease, whether they want to or not. You need to be the best guide possible in their journey toward health.”

Wheat Belly Review

I have now finished reading Wheat Belly by William Davis MD. Yes, I am late to the reporting. Therefore, this will be a review that is different than what many write. I knew that David Mendosa and Tom Naughton had written reviews and I sought out their blogs. After recording them, I went to the search engine and typed in “wheat belly by william davis review” and pressed the enter key. I received 147,000 results. At first glance, not all entries are book reviews and of course, many items are repeated several times with some different wording.

Before going further, I will say that taking so long to read the book helped me understand many of the points Dr. Davis put forth. I have greatly reduced the amount of wheat I consume by about 90%, and the weight is declining. I have enjoyed reading many of the reviews that were written even before I purchased the book. I am happy to report that many of the reviews are positive and the one review that disputes some of the studies Dr. Davis uses is not negative either.

The Grain Foods Foundation is naturally sticking out against Dr. Davis because he is a threat to their business. Most of the time they quote the same unproven points about grains, especially whole grains, are healthy for us. They have their experts and very few studies that conclusively support this, but both sides of this issue have “experts.”  You may read several blogs on the Grain Foods Foundation blog site here (link is broken now as they removed the blog and comments). Sometimes the comments are better than the blog. There are several blogs following this in the month of September 2011.

I would urge everyone to read a blog by Peter Bronski, who with his wife, have the blog, “No Gluten, No Problem” blog site. I think he does raise some good issues. I will admit that in Chapter 7, Dr. Davis is a bit glib in his discussion of diabetes. Eliminating wheat for many people with type 2 diabetes, do have good results and some are able to eliminate medications totally – at least until they revert to old habits. Diabetes is not curable yet, but people reading chapter may think they are cured.

David Mendosa wrote his review here. Tom Naughton had a two-part interview here and here. Tom also had two very good articles about the reactions of the grain producers here and here. Tom makes valid points and I enjoy reading his blogs. Then go to BalancedBites and read the review by Diane Sanfilippo, BS, Certified Nutrition Consultant, one of four women writing for the blog site. After completing that blog, take time to read the review by Dana Carpender on “Hold the Toast” blog site, and author of “500 Low Carb Recipes.”

If you haven't read Wheat Belly by William Davis MD, it is worth the time and there is much to be said for the fact that wheat is not the wheat of biblical times or even 100 years ago. It has been so perverted with genetics engineering that is does not resemble the wheat of old. It can cause diabetes and other health problems and is a real problem similar to high fructose corn syrup. Our modern agriculture is trying to feed the world, but in doing so has created health problems that are spreading around the world. We need someone to point this out, like Dr. Davis.

Holiday Gifts for Person with Diabetes

At this time of year and before birthdays, people are always looking for gifts that people with diabetes will appreciate. Joslin Diabetes has a list and some suggestions that could be appropriate. I will say that the books listed in the blog should be considered with care as the American Diabetes Association is not known for low carbohydrate cookbooks, but some may appreciate them.

Books of any kind should be purchased with care because a book about type 1 diabetes may be very appropriate for a person with type 1 diabetes, but not appreciated by a person with type 2 diabetes. Another consideration should be about the subject matter covered in the book. Also, consider if the person is likes to read. A book that I received as a combination birthday and Christmas present is much appreciated – Joslin's Diabetes Deskbook, Updated Second Edition. Read my review here. You may read a little about it here and there are some other books as well. Yes, they are advertised for healthcare professionals, but sometimes these can benefit patients as well. I will be asking for the Educating Your Patient with Diabetes but only after I have a chance to see the book and preview the table of contents and look at a few chapters.

These books and many other excellent books may be found at Amazon and I will provide this link. There are several pages of diabetes books. Most are excellent to good, but there are a few I would not want in my library.

One suggestion from the Joslin blog is the possible purchase of an electronic food scale that calculates the carb counts of food. This may be on the expensive side for many people, but could be of value if you have the funds. One the less expensive side is items like a pedometer or resistance bands. Read the entire Joslin blog as ideas are presented to the end of the blog.

Even at this late date, do not forget that a printout of books can be given and specify the amount that you are willing to pay for the book or books. I have had people do this for me, I always enjoyed looking at the selection they were offering, and I made it a point always to choose the best book I was interested in and could stay below what they were willing to spend. One time, I did ask for one book over the amount offered, but I made sure that I paid the excess. The book had just been published and I had planned to buy it myself, but had hints about books so I had held off. He also wanted the book so I told him that we could split the cost, he would let me use it for six months until his birthday, and then he could own it.

Therapeutic Goals for Older Adults with Diabetes

When I wrote these two blogs, here and here, I did not realize I would be revisiting the topic for the elderly so quickly. However, a blog by Joslin Communications brought some good points back into the discussion and need to be considered, especially for elderly patients with diabetes. Since I have to classify myself as elderly, I have a special interest in these discussions. Wishing it was easier doesn't solve any problems and makes these articles and blogs that much more valuable. More doctors specializing in geriatrics are also learning about diabetes and diabetes management for the elderly. This can definitely be a step forward in assisting the elderly to maintain excellent management of diabetes. The Joslin blog starts with the over 70 elderly and my two blogs were for the elderly of age 60 and over.

Yes, I am concerned about the age many decide to consider elderly. This 10-year difference can mean many things to different people. I cannot tell if this is because the people doing the writing are nearing one age and want to not be classified in the elderly, or if this is done for another reason. Since I fit in either group, I have nothing to keep me from writing about the elderly as being age 60 and over. Health problems are still problems regardless of a person's age. Often many healthcare providers do not assess the elderly correctly and therefore do not prescribe the correct medication levels. Other doctors feel these people are a burden to society and will not properly treat them. Still other doctors and especially some healthcare providers believe that anyone over 80 should be euthanized and are an expense to society. This is not right as many of these people are still productive and contributors to society.

This article about the elderly just approaches the topic as a one-size-fits-all subject and degrades people that are capable of managing their diabetes. I know that for some people, the guidelines are reasonable, but not for everyone. I'll be darned if I will accept A1c targets of between 7.0 and 7.5 mg/dl, but this is what this article says and it states that this should be individualized for co-morbidities, cognitive and functional status. This means they will encourage higher A1c levels for many people. I take to mean that because we are classified as over the age of 70, they want diabetes complications to take over and end our life sooner, rather than later. Even though they say individualized, nothing is mentioned about those that are capable and able to manage their diabetes with no problems. Everything is aimed at the elderly that have problems and difficulty managing life.

“The International Association of Gerontology and Geriatrics, the European Diabetes Working Party for Older People, and the International Task Force of Experts in Diabetes combined resources to tackle the problem of addressing the needs of older adults with diabetes. The group addressed eight categories of concern: hypoglycemia, therapy, diabetes in the nursing home, influence of co morbidities, glucose targets, family/caretaker perspectives, diabetes education, and patient safety.”

These are great topics to be discussed and some of the elderly are affected by these areas and the need for concern for these people is well placed. I am happy to see that 'diabetes in the nursing home' is one of the areas for concern. Too often, people with diabetes in nursing homes are barely cared for and what little care they do receive is done by care providers that do not care and do not understand diabetes. It would be interesting to know what A1c's these people have. But forget that, most nursing homes are not even required to have these records for people incarcerated in their facilities. Even if states have regulations about safety and patient abuse, diabetes is not even mentioned and this goes unmanaged in many states.

Even though I find much to be concerned about in this blog, I will quote much of the last part of the blog as these tips are valid for anyone having these problems. “In addition to the medical establishment loosening their guidelines for acceptable control in the elderly, you can do things for yourself that can make your diabetes self-management easier.

If memory is an issue

1. Use your meter to set alarms to remind you to take your medicine or check your blood glucose. Even though I did not believe this – many meters do have alarms. Get help if necessary from someone that is tech savvy.

2. Get a pill dispenser—if you take a lot of pills this can help you keep track of which medications you need to take and which you have already taken.

If vision is a problem

1. Have a bright task light available—you will see better with direct lighting for reading such things as drug labels

2. Contrast helps! Put light objects against a dark background and vice-versa to make them stand out.

3. Ask your educator about syringe magnifiers that can help you see the markings on the insulin vial. If an educator is not available, please talk to your pharmacist.

4. Ask your educator for a meter that talks or has large print. This may be of help for some, but if privacy is an issue, the meter that talks may not be for you.

If dexterity is an issue

 Ask your educator about meters and supplies that are easy to handle. If an educator is not available, please talk to your pharmacist.

Joslin’s Geriatric Diabetes Clinic is apparently different from many diabetes clinics and worth reading about here and here. The only objection I can find is the one-size-fits-all discussion, but why should I be surprised, this is the stance of the American Diabetes Association, the American Association of Clinical Endocrinologists, and supporting groups.

Supplements – Does the Elderly Need Them?

This debate has been around for some time and just does not go away. Do elderly people need to take supplements? Some “experts” say no, other “experts” say yes. Many of these “experts” are assuming that the elderly have unlimited funds, can prepare meals that are nutritionally complete, and reside in areas that are safe and easy to move around within. Most of the “experts” have never had to spend a day in the shoes of some of the elderly.

I wish some of these “experts” would have to do a field study of the elderly and really get out and spend a few weeks seeing how they live, how safe it is for them to even walk around the neighborhood they live in, and how little money has to last for a month for food, shelter, and medications. This says nothing about transportation and some of the other necessities of life. Most of these elderly have no money left for supplements.

To ridicule the elderly like Donald B. McCormick, PhD, an Emory professor emeritus of biochemistry and the graduate program in nutrition and health sciences at Emory, takes ridicule to new levels. He says, “A lot of money is wasted in providing unnecessary supplements to millions of people who don't need them.” It is one thing to sit in the towers of academia and make statements like this, but I would have to ask if he has even seen where some of the elderly live. Then he continues, “We know too little to suggest there is a greater need in the elderly for most of these vitamins and minerals. A supplement does not cure the aging process.”

He thinks that the elderly believe they need vitamins and mineral supplements to blunt the aging process and the older they get the more supplements they need. He seems determined to take these supplements away from the elderly. One statement that McCormick makes I have to agree with and it is this - “At very high levels, some vitamins and minerals can be toxic.” This is especially true for many of the fat-soluble vitamins and minerals that the body can't readily flush.

Yes, McCormick does soften his rhetoric further into the article. He almost allows for obtaining most of them from foods, but with dietary changes. While I agree that it is best to obtain your nutrients from food, not all the elderly do well at cooking and balancing their nutritional needs. Not everyone can make use of nutrition experts and others capable of helping them.

Andrea Giancoli, RD, MPH, a spokeswoman for The Academy of Nutrition and Dietetics does carefully say that when counseling older adults, it is first necessary to determine what nutrients are lacking in the diet. I can believe it when she says it is often vitamin D, calcium, and vitamin B12. She does say she tries to fix it with food. I will give her positive marks for saying, “I don't think we should be recommending supplements blindly without assessing their food intake.”

Does the elderly need supplements? This debate will continue and probably never be resolved. I do think many of the elderly need some of the supplements because they do not eat a large variety of foods and are often short of some nutrients. Having seen some of my friends have anemia and be short of Vitamin D and Vitamin B12, I know what can happen. Another area of concern is those supplements that may cause extreme and even deadly side effects when taken with some prescriptions. Therefore, I have to urge caution for any supplements and urge all patients to make sure their physician knows what supplements are being taken.