What Is Your Risk Tolerance Level?

Emails can be interesting and have some of the most difficult questions to answer. Like Tom Ross (page down to Feb 26), I do get questions about what do I recommend for an A1c. I can only reply, what is your tolerance level? Or, the question will be something about the point on the A1c scale that prevents diabetes complications. To this, I always respond there are no A1c levels that will prevent complications, only reduce the risk level for complications to develop, unless you die first.

Most people do not understand what I mean by tolerance level. They are looking for numbers that they can remember and have as a goal. I then need to remind them that I could give them numbers upon numbers, they would not be able to achieve them, and they don't believe me. I ask them what their last three A1c readings were. I will use an example of 5.8%, 6.1%, 5.6%. In this case, it is a total of 17.5. Now divide this by 3 and the answer if 5.83%. Now if you are lucky, you might be able to obtain the next A1c of 5.8%, but most people will not. This person said she would not even try, as she wanted to go lower than the 5.6%. She actually did achieve an A1c of 5.3% for her next A1c.

This is an excellent A1c and some people are able to get this. She is following Dr. Richard Bernstein’s “Diabetes Solution” and hopes to obtain 5.0% and maintain the level within a few tenths. That is her goal and tolerance level. She does not wish to be above 5.2% after that.

My tolerance level is not to get above 6.5%. I have bounced all over the place and don't like this. Generally, I am between 5.9 and 6.6%, but have had lower and higher, but for the last two years, this has been the range. One doctor has emphatically told me to bring it up above 6.5%. I said that was not in my tolerance level and I wished to be closer to 6.0%. When he persisted, I asked if he was asking me to leave his practice. He claimed he that he was not, but for my age, this is where he felt I should be. I did tell him that I did not appreciate him pushing me to speed up the development of complications and that next time he said to bring my A1c up, I would not be back. We will see what happens.

Therefore, if you want to think of comfort zone instead of tolerance level or risk level, that will work. Everyone has their comfort zone they wish to maintain and this is good. I do encourage not being above 6.5% and the younger you are, the lower your comfort zone should be. I don't know that I will ever be comfortable above 6.5%, even as I grow older, but I will cross that bridge when I get there.

The higher the A1c level, the higher the level of risk you are willing to endure with diabetes. You are always at risk for development of any complication, but the closer you are able to maintain your A1c to the normal for healthy people, the less risk you are under. The recommended A1c of 6.5% by the American Association of Clinical Endocrinologists is not ideal and the risk level for diabetes complications is higher than an A1c of 6.0%. I do not understand why the American Diabetes Association sets their recommendation of A1c at 7.0%.

The table of the estimated average glucose (mg/dl) to A1c% is here and I suggest that you use the table to aid you in finding your comfort zone. The medication(s) you are on will also help you decide the risk, tolerance, or comfort level you wish to have as your goal.

Some Random Thoughts on ADA's Guidelines

Year after year after year, we get similar guidelines from the American Diabetes Association. Occasionally we get something of value, but most of the time people with diabetes are hard pressed to learn anything new or have the guidelines in their favor. Most of the time they make it more difficult for people with diabetes to believe they are doing things for them or that there is any attempt to make life easier.

Back in 2003, ADA made a statement in their guidelines that insurance companies took to mean that only three blood glucose tests per day were sufficient for insulin dependent people. Since then all we have heard is platitudes and we will correct this. To this, I say malarkey! Has the insurance industry raised the number of test strips they will reimburse? No! And, this year my research has indicated some concern, but no promise of increased numbers of test strips that will be covered by insurance.

Also, I notice that the ADA is doing nothing for the type 2 people on oral medications that would like to be able to test more regularly than twice a day or even those on no medications. If these people are not able to test on a consistence basis, they are operating in the blind and cannot be sure that they are doing the right things to manage their diabetes. This is criminal in the way type 2 diabetes patients are treated.

Is the ADA so in bed with Big Pharma and the USDA that they bring more harm to patients by limiting testing supplies, education, and support for people with diabetes? Is this done to put more type 2 patients on insulin and to keep patients from knowing that the USDA line of nutrition is not as healthy for people with diabetes as claimed. Without testing more than once or twice a day, all we can look for is trends and rely on an A1c two times per year, which is not sufficient to maintain good diabetes management.

Some people are fortunate they can afford the extra testing supplies and are able to keep their blood glucose levels in the near normal range. Some purchase test strips as they can afford them to use for extra checking or for times when they are having problems. Those that cannot afford extra testing supplies have to rely on their doctor for assistance if they will even go to bat for them.

Then with the shortage of certified diabetes educators for education, it is no wonder that people with type 2 diabetes get discouraged. Many of the elder generation do not have access to computers to find information online about diabetes. Others also do not have access to computers except at libraries, which limits their access. This is more reasons that doctors need to utilize patients as peer workers and help spread the education. Community organizations need to work to bring people with type 2 diabetes together to give education where possible. It is doubtful that the American Association of Diabetes Educators (AADE) will even consider working with non-trained diabetes peer mentors, peer-to-peer workers, or other lay people.

I will have more on this in another blog. It is clear that the majority of people with type 2 diabetes are not receiving the education that they should. The people with type 2 diabetes are clearly not demanding the services that should be available to them. The ADA is very much discriminating against people with type 2 diabetes, contrary to the platitudes issued yearly as guidelines.

ADA Standards of Diabetes Care in 2013

This article from Diabetes in Control is not one I expected. Then when Dr. Robert Ratner, chief scientific and medical officer for the ADA says, “Many people with type 2 diabetes who are on medications don't need to do home glucose monitoring at all," Bold is my emphasis. I must wonder if he is many bricks short of a full load. He sounds a lot like a doctor I heard of recently that does not use the A1c, but only the oral glucose tolerance tests for diagnosing patients and adjusting medications later.

With people like this in positions of responsibility in the American Diabetes Association, I am not surprised at the telemarketing scandal that was reported here last year. Why would someone make statements like this? Yes, I can rant and become angry, but with leaders like this, how can I even respect the ADA. This even removes hopes that may have been there for help, when we have leaders that open their mouth and make stupid statements like this. For what purpose? Are they trying to divert attention away from something more idiotic someone said or did? Quite possibly.

Then why do they even make statements like this, when they pull the rug out from underneath many people with type 2 diabetes (in the above bold red statement). "For patients who aren't on insulin, self-monitoring has to be linked to education on what to do. Patients need guidance on what to do when the numbers are out of line. Do they need to call their doctor? Change their diet or take medicine? They have to be taught how to utilize the information." It seems ridiculous how they can kick people when they are down and then make something sound so promising. I think this is “feel good” hype and a way to keep people off balance while they do nothing.

Maybe the statements were made to deflect the criticism for ADA partnering with Domino Foods, Inc. This cannot be a good reflection on the American Diabetes Association. However, this article appeared on January 15, 2013, and the earlier statements were written on December 27, 2012. Either way, the ADA is not living up to doing anything for the patients they are supposed to serve or even helping the physician members who need the support. This also reminds me of the activities of the Academy of Nutrition and Dietetics which is also in bed with the food industry.

Going back to the last quote in red above, I am keenly aware of the fact that many patients need to learn completely on their own how to self-monitor their blood glucose and interpret what the blood glucose readings mean. This is what I had to do before I started on insulin and this is something the members of our group do to help each other whenever needed. Sue has been very appreciative that we have been very willing to help her in determining what the different blood glucose readings may mean and how to learn to determine this for herself. The three new members on oral medications are asking questions and happy that we are willing to answer any questions they have. So, for us, the ADA can keep their “feel good” hype.

Even though none of us within the group has any of the formal training for diabetes self-management education, we seem to be doing very well at working with others and educating them about managing their diabetes. We do become upset when the leaders of the ADA make statements like the first quote as these people need the test strips to be able to determine what their blood glucose readings are to become educated. They need to understand what happens with their bodies in processing blood glucose and what different foods can do to their blood glucose levels.

Group Education Benefits the Elderly – Part 2

Part 2 of 2 Parts

I for one am very glad to see this study from the last blog. This exemplifies what I have seen in our local peer-to-peer group (ages 57 to 76). Those that have needed the companionship of the group and the learning experience have been able to obtain it. Allen has been very expressive in his thanks when a few of us recognized that he needed to be tested for vitamin deficiencies. He now says that he was not ready to leave his doctor, but that we proved to him the necessity of making the change when his doctor would not do the testing for vitamin deficiencies.

He has thanked us profusely for saving his life and making him feel so much more healthy. His A1c's had not been that high, but in the low 6's. His blood glucose levels are now almost always under 140 mg/dl and his A1c's are now below 6.0% and he has only had one episode of hypoglycemia. He is still attempting to get his two friends involved, but they are not interested yet.

Barry has also expressed his thanks for what the group did for his brother Ben when he was suffering from depression. Even their sister Sue has been very thankful for the group and what we have done for each other. Being the only one on no medications has been great for her because she says that the whole group has been so supportive. She also thanks us for not having held it against her for her diabetes police tactics before she was diagnosed.

Even other members of the group are happy that we can get together, no matter what our age is and openly discuss topics and help each other. That is why this study became the topic of our discussion at the last meeting. Even Brenda was happy to have the full copy of the study to read. She wanted to know how I had gotten it. Tim always has his laptop and A.J. had his, so this made it easier to pull up the relevant sites and I showed everyone how I had found whom to contact. I said I had written the contact person an email and had received a copy the following Monday. I had shown it to a few people and then printed copies for the meeting.

I then showed those that were interested that sometimes this becomes impossible because there are not email addresses available even using the single and batch search at this site. Barry asked if I wanted help in the future and I said I would take any help offered. Ben commented that with Barry's help and help from the rest of us that even he was enjoying searching for diabetes articles. He felt more like a contributing member of the group rather than just soaking up information from the rest of us. This got us off topic in discussing learning or contributing and everyone thought that the more that wanted to contribute, the stronger the group would become.

Tim agreed and said he would work with Barry, A.J., and myself to help people that wanted to learn best methods of research and then if someone had a particular interest in a topic, then they could do the research and present it in a group gathering. Tim said that my blog of February 8 was a good place to start as he had bookmarked most of the sites and the rest should reread it and see where it could help them. He then said that if someone had a website that was good for this, to send it to him and he would collect them and forward them to me for inclusion in another blog so that everyone could have them available.

The study for us was in many respects an eye opener and made all of us happy to be part of a group that helped each other. We all agreed that we had learning to do and several asked that my cousin be invited to the next meeting to talk about nutrition. Jessie asked what this would mean and the rest of the new people were curious as well. Tim explained that my cousin was a person with a nutrition degree and worked with different doctors around the area and did some nutrition counseling as well.

John asked if she was a registered dietitian. Allen said no, that she worked at the level the patient was at and was more interested in balancing the nutrition than in pushing carbohydrates. Brenda said that she will get your insurance information so that if you wish a one on one consultation, she will bill your Medicare account or insurance company information. She also stated that there may be a co-pay up front. Otherwise, she will just speak to the group and answer a few questions about nutrition. I stated that there is no pressure to have a consultation. Allen quietly explained how she had helped him and worked with his doctor to get him the nutrition assistance he needed. He did explain that she had urged him to take some supplements because of the foods he was not eating.

Jason said he appreciated her for making suggestions of what foods to eat, but he said she only makes suggestions and if you hesitate, she will make other suggestions looking for ideas that will help supply foods that will balance the nutrition. If something is still short, she will recommend a supplement. He said that he is eating less carbs, but has better overall nutrition and a few supplements. He continued saying that his doctor is surprised that he has no vitamin or mineral deficiencies and is well within the normal range.

Rob and Max admitted they had not had any consultations with her, but Max admitted that now that he was on Medicare, he was thinking seriously about it since Medicare did allow this and even promoted it. Elaine commented that it was good to be in the group if this was what the group promoted, yet did not apply pressure to have people do things that did cost money unless they wanted this. She said that the study had interested her and she felt that these were good to have available when the group got together. She asked if her husband could attend occasionally. Sue said sure, that her husband was unable to make this meeting, but that he was normally present.

Because we are now at 14 members, Tim suggested that it was becoming more difficult for people to meet in some homes. Both Jessie and Elaine said they could accommodate this many and a few more. Allen asked if we could converse with his two friends and convince them to come. When he mentioned their names, Jessie said both were neighbors and she would be happy to talk with them. Elaine said that if Jessie was not successful, her husband might talk to them, as he knew them.

Rob said he could accommodate possibly three or four more and Max admitted that he could only handle two more and if husbands were there, he would not have room. I suggested that we inquire around and see what might be available for our growing group. Tim suggested churches and I said I would check at the hospital and city hall. We finished on that thought.

Group Education Benefits the Elderly – Part 1

Part 1 of 2 Parts

This is one of the studies I have been searching for and I now have an answer to many of the questions that have been going through my mind as to why the elderly with diabetes are not well thought of in the medical community. From the extract, we have the objective, which states, “OBJECTIVE In this secondary analysis, we examined whether older adults with diabetes (aged 60–75 years) could benefit from self-management interventions compared with younger adults. Seventy-one community-dwelling older adults and 151 younger adults were randomized to attend a structured behavioral group, an attention control group, or one-to-one education.”

When looking at the graphs as part of the study, the groups all started with A1c's above 8.5 percent and no group ended up below 8 percent. This does not speak well for the study, as a goal should have been to bring everyone below 7.5 percent. This seems to be the shortcomings of many of the studies involving people over the age of 60. The researchers seem happy with not showing the elderly how to bring their blood glucose levels down significantly.

Within the study, the authors state that there are large numbers of older adults with diabetes, but how to provide diabetes self-management support to this group remains unclear. Older adults, aged 60 years or older, are often under represented in diabetes education interventions because of subtle changes in their functional, cognitive, and psychosocial statuses. This scares researchers away and consequently, evidence-based guidelines for this age group are not well established.

It is somewhat understandable that restrictions for this study were rather strict, but in some areas, I have to wonder if this was for the researchers convenience or to prevent confounding factors entirely. I can understand having the age range of 18 to 75 to help determine if the elderly were capable of improving their overall diabetes management

One statement that seems to sum up how researchers feel about the elderly is this. “Finally, we did not recruit adults aged 76 years and greater because these individuals may present with unique clinical (e.g., comorbidity, complications) and functional (e.g., impairment, disability) challenges that require special attention. For example, older diabetes patients are at greater risk for several geriatric syndromes, including depression, cognitive impairment, injurious falls, neuropathic pain, and urinary incontinence. These syndromes can have a deleterious effect on diabetes self-care, health status, and quality of life. Thus, the value of group versus individual diabetes education needs to be evaluated in the age 76 and up population. Importantly, future diabetes behavioral interventions need to address changes in older adult functional, cognitive, and psychosocial states and how best to assess and address these factors.”

When I wrote this blog, I emphasized, “DSME for those age 60 and older requires, and I mean requires that it be on an individual basis.” Now I must change my opinion to say that group education does work and greatly helps the people over the age of 60. Then I continued my blog in part 2 here and stressed the “importance of diabetes self-management education (DSME).

In the conclusions area, the authors had some rather welcome results, “we examined whether older adults with diabetes could benefit from self-management interventions compared with middle-aged and younger adults. We also examined whether older adults benefited from group versus individual self-management interventions. The data show that compared with the younger adults in this study, the older adults received equal glycemic benefit from participating in self-management interventions, and this finding did not differ by type of diabetes. Moreover, older adults showed the greatest glycemic improvement in the two group interventions, with both groups achieving clinically significant improvements in A1C (greater than or equal to 0.5%). Of note, both older and younger adults in the group conditions maintained their A1C improvements similarly at 12 months post intervention. Finally, the diabetes self-management interventions had a positive impact on older and younger participants’ diabetes self-care and psychosocial outcomes.” Bold is my emphasis.

To me, the best statement is the most encouraging. “Thus, clinicians can safely recommend group diabetes education classes for older patients with poor glycemic control. As the U.S. population ages and develops diabetes at a rapid rate, more high-quality research is needed to understand how normal aging processes influence how older adults learn about and take care of diabetes.” The one weakness is that researchers are not interested in helping many of us in the elderly group to become even more proficient in managing our diabetes. It seems only of you have poor glycemic control and have none of the conditions that will make management more difficult.

All members of our group agree that not enough is being done for people our age in diabetes education and that most doctors are not interested because of time constraints and other limitations. Even the majority of certified diabetes educators (CDEs) could care less about educating elderly people with type 2 diabetes. That is the reason we have called ourselves an informal peer-to-peer group because we work to help each other.

Nutrients - Potassium

Potassium

Overview

Potassium is a mineral that the body needs to work normally. It helps nerves and muscles communicate. It also helps move nutrients into cells and waste products out of cells. A diet rich in potassium helps to offset some of sodium's harmful effects on blood pressure. Most people get all the potassium they need from what they eat and drink.

Too much sodium as is common in Western diets that use a lot of salt, may increase the need for potassium. Diarrhea, vomiting, excessive sweating, malnutrition, malabsorption syndromes (such as Crohn's disease) can also cause potassium deficiency, as well as use of a kind of heart medicine called loop diuretics, mainly furosemide.

Tests

This test measures the amount of potassium in the blood. Potassium is an electrolyte that is vital to cell metabolism and muscle function. Potassium, along with other electrolytes such as sodium, chloride, and bicarbonate (total CO2), helps regulate the amount of fluid in the body, stimulates muscle contraction, and maintains a stable acid-base balance. Potassium is present in all body fluids, but most potassium is found within your cells. Only about 2% is present in fluids outside the cells and in the liquid part of the blood (called serum or plasma). Because the blood concentration of potassium is so small, minor changes can have significant consequences. If potassium levels are too low or too high, there can be serious health consequences; a person may be at risk for developing shock, respiratory failure, or heart rhythm disturbances. An abnormal potassium level can alter the function of neuromuscular tissue; for example, the heart muscle may lose its ability to contract.

Why Get Tested?

To determine whether your potassium level is within normal limits and to help evaluate an electrolyte imbalance; to monitor chronic or acute hyperkalemia or hypokalemia

When to Get Tested?

As part of a routine medical exam, when you have symptoms such as weakness and/or cardiac arrhythmia, or when an electrolyte imbalance is suspected; at regular intervals when you are taking a medication and/or have a disease or condition, such as high blood pressure (hypertension) or kidney disease, that can affect your potassium level

Recommended Daily Allowance

Pediatric

1. Infants birth - 6 months: 400 mg/day
2. Infants 7 months - 12 months: 700 mg/day
3. Children 1 -3 years: 3 grams (3,000 mg)/day
4. Children 4 - 8 years: 3.8 grams (3,800 mg)/day
5. Children 9 - 13 years: 4.5 grams (4,500 mg)/day

Adult

1. Adults 19 years and older: 4.7 grams (4,700 mg)/day
2. Pregnant women: 4.7 grams (4,700 mg)/day
3. Breastfeeding women: 5.1 grams (5,100 mg)/day

An important note – other than the small amount included in a multivitamin. Never take potassium supplements except under a doctor's guidance. Do not give potassium supplements to a child unless your doctor prescribes it.

Food Sources

Good sources of potassium include bananas, citrus juices (such as orange juice), avocados, cantaloupes, tomatoes, potatoes, lima beans, flounder, salmon, cod, chicken, and other meats. By far the most well known source of potassium is the banana.

Precautions

With potassium it is always wise to have a conversation with you doctor and only take potassium with the supervision of your doctor. This is one supplement that has more dangers than positives.

Possible Interactions

“If you are being treated with any of the following medications, you should not use potassium without first talking to your health care provider.

Angiotensin Converting Enzyme (ACE) Inhibitors: These drugs, including benazepril, captopril, enalapril, fosinopril, lisinopril, moeexipril, perdinodopril, quinapril, ramipril, trandolapril, may increase the risk of hyperkaleimia.

Angiotensin Receptor Blockers: Increased risk of hyperkalemia.

Potassium Sparing Diuretics: These drugs, including amiloride, triamterene, spironolactone, may increase the risk of hyperkalemia.

Indomethacin: May increase the risk of hyperkalemia.

The following medications may cause potassium levels to rise:

• Nonsteroidal anti-inflammatory drugs (NSAIDs): People who have poor kidney function and take NSAIDs are at higher risk.
• ACE inhibitors: These drugs treat high blood pressure, heart disease, diabetes, some chronic kidney diseases, migraines, and scleroderma. People who take ACE inhibitors and NSAIDs, potassium sparing diuretics, or salt substitutes may be particularly vulnerable to hyperkalemia (too much potassium). A rise in potassium from ACE inhibitors may also be more likely in people with poor kidney function and diabetes. ACE inhibitors include:
  • Benazepril (Lotensin)
  • Captopril (Capoten)
  • Enlapril (Vasotec)
  • Fosinopril (Monopril)
  • Lisinopril (Zestril)
  • Moexipril (Univasc)
  • Peridopril (Aceon)
  • Ramipril (Altace)
  • Trandolapril (Mavik)
• Heparin (used for blood clots)
• Cyclosporine (used to suppress the immune system)
• Trimethoprimand sulfamethoxazole, called Bactrim or Septra (an antibiotic)
• Beta-blockers: Used to treat high blood pressure, glaucoma, migraines
  • Atenolol (Tenormin)
  • Metoprolol (Lopressor, Toprol-XL)
  • Propranolol (Inderal)

The following medications may cause potassium levels to decrease:

• Thiazide diuretics
  • Hydrochlorothiazide
  • Chlorothiazide (Diuril)
  • Indapamide (Lozol)
  • Metolzaone (Zaroxolyn)
• Loop diuretics
  • Furosemide (Lasix)
  • Bumetanide (Bumex)
  • Torsemide (Demadex)
  • Ethacrynic acid (Edecrin)
• Corticosteroids
• Amphotericin B (Fungizone)
• Antacids
• Insulin
• Fluconazole (Diflucan): Used to treat fungal infections
• Theophylline (TheoDur): Used for asthma
• Laxatives”

If you are taking any of these medications, it is important for your doctor to test your potassium levels to see whether or not you need a supplement. Do not start taking a supplement on your own.

Hospital Charges and Total Bills

Some readers may wonder why I am writing about hospitals so much, but when it comes to their phobia about hypoglycemia and what they charge for doing nothing at times make them an easy target. Many hospitals deserve the target they have hung on themselves. When I wrote my blog on March 8, I did not know some additional facts that I now have and I think it deserves covering.

I had written then, “The things he told us were unreal and his advice was to avoid that hospital if you valued your life. They had used the same equipment for several patients and would not change the lancet in his presence. When his daughter had arrived to take him home, she was not allowed to see him until he was wheeled out to the car.” I was not aware that our friend had written his insurance company for a copy of the hospital bill and had gone back to the hospital for a copy of the bill from them.

Now several of us have gotten together and analyzed the two bills. We were surprised that the insurance had sent him a copy to begin with, and it was like looking at two different bills. Granted, he does not have a copy of the doctor's bill, but that will probably look much the same. The bill he had obtained from the hospital was summarized by the day and the insurance company bill was very detailed by item.

We have all heard about the $20 to $30 charge for an aspirin. Well folks, guess what diabetes supplies cost? The lancet charge was $18 each time although they used the lancet on many different patients and would not change it in from of him. The cost of the test strip was itemized at $45 for each test strip. The time for the test and recording the test result was charged out at $50 for one quarter of an hour each time. The insulin charge was truly outrageous at the cost of a vial for each injection. If we had not seen the nurse put the syringe in the sharps container, we would have wondered if they had not used the syringe on several patients. The charge for the syringe was $26.50. Like he said, he had not used any kleenex, but was charged for one box at $10 each day. The nurses were the only ones that had used any of them. He said there was a new box every day, so you have to wonder where they went.

I could go on about other costs, but this was the part that interested us. It would be interesting to see what other hospitals charge for these items. I am sure it is like aspirin and the charges do vary depending on the costs of overhead and how they are applied.