Medical Nutrition Therapy by Prescription – Part 1

Part 1 of 2 parts

From the book Joslin's Diabetes Deskbook, second edition, this excerpt is interesting and definitely more definitive than most information that I read about nutrition for people with diabetes. To be honest, this is the first time I have read diabetes nutrition being referred to as “medical nutrition therapy.” Yes, and I must apologize for this error as the American Diabetes Association has been using this term for several years – in their annual guidelines. My dislike for the ADA has colored my reading habits and I had hoped that it would not. Now I have a greater understanding of the purpose behind the use of the term “medical nutrition therapy.” This is the procedure they use to convince people to consume greater quantities of carbohydrates.

Then to include this in the diabetes treatment strategy makes this a topic of interest. I will admit that in rereading the excerpt, I have developed some serious questions about it and have some real concerns about what is not being said. Why? Because the opening is there for mandates and the one-size-fits-all mantra. I would feel a lot more at ease if some points had been made that would have precluded these from happening. I have mixed feelings about the way this topic is presented. This will cover the conflicts that are built in and some that may not be apparent on the surface.

The one statement that has me worried about what may not have been included in this excerpt is this, “The American Diabetes Association, the American Dietetic Association (now the Academy of Nutrition and Dietetics) and Joslin Diabetes Center have developed guidelines and curricula for nutrition education.” I could accept Joslin Diabetes Center, but to include the ADA and AND raises all types of red flags for me. Anytime I have read something when these two organizations are either involved or mentioned, they use the “for individuals” platitude and later opt for the one-size-fits-all mantra and preach high carbohydrate/low fat (HC/LF) which does not work for many individuals with diabetes.

Registered dietitians working for the Joslin Diabetes Center may be able to do things for the individual, but I have met the worst of the RDs in my area and they all tailor nutrition around HC/LF and insist that I eat a set number of carbohydrates per meal. This does not work for me and I have the over weight problem to prove it. Then, when you find out that the Academy of Nutrition and Dietetics is introducing legislation in most states to make them the only organization legally allowed to give out nutritional advice. I say that this monopoly position takes away my rights to get nutritional information from others that are not governed by mandates or that do not take their guidance from the USDA and HHS. Fortunately, more people are beginning to understand how wrong their guidance is and how unscientific the background is for their nutrition guidelines.

Using the nutrition prescription involves calculating caloric levels and determining appropriate levels of nutrients. It factors in the weight, clinical goals, activity levels, and health status of the patient. Yes, the excerpt said this and three of the factors are correct to be assessed, but clinical goals? Come-on people, lets be real. How can clinical goals be a valid part of patient assessment? Oh, right, this is where they throw individual treatment out and issue the mandates, mantras, and one-size-fits-all. This is where they say you are not trying hard enough to follow their directions and thus you are noncompliant, so out the door you go. This is so like the ADA and AND, but I had hopes that Joslin was bigger than they were. This does point out the use of the “by prescription” and why they are using it. Patients are wising up to the purposes behind the use of certain terms. By using prescription in combination with medical nutrition therapy, they are hoping patients will be more likely to follow their advice.

Because of my conflicts with RDs, you know this statement has to upset me, “The registered dietitian (RD) is an important part of the diabetes healthcare delivery team.”  Yes, it does, but not as badly as it has. This has been a point of contention for me. Lately, both on some diabetes forums and in some of my emails, fellow people with diabetes are saying they have figured out when the RDs are no longer working for them as individuals and are in the one-size-fits-all mode. They know that they need to cut them out of their team.

The next section cuts to the core of the problems for many people. What is “healthy” eating? I admit I have been a misuser of this term big time and I will try to break myself of this habit. The term “healthy” is a misnomer in so many of its uses that it is becoming an accepted term. This still does not mean that it is used properly. For this clarification, I must thank Adele Hite, who says, “A word about “healthy” food. I have no idea what that means. To be honest, I’d love for that term to disappear altogether. The World Health Organization describes health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” If “being healthy” is the equivalent of “being well,” then it is easy to see that the phrase “healthy food” makes little sense. It’s hard to be “well” and be “food” at the same time!”  Maybe I am stretching a little, but I think this applies equally to “healthy” eating, “healthy” lifestyles, and several other uses. Read her blog here for further explanations.

Back to the excerpt, the goals laid out are realistic, but often misused. The goals listed are - individualized calorie levels for growth/maintenance or weight loss, blood glucose control, normalization of blood lipid levels, and blood pressure control. No mention is given to blood glucose testing and a way of achieving the first two goals. What is lacking is any discussion of the standards that are reasonable ranges to be achieved. Without these, the patient has no knowledge of what to work towards. Here again I have to suppose they are omitting this because they adhere to the USDA and HHS guidelines and do not want us as patients to discover how bad these guidelines are for us.

Continued in Part 2.

Engaged Patients Vs Patient Activation

What I don't appreciate is people in the medical profession that constantly hang tags on me as a patient. I'm sure you have heard some of them – non-compliant, non-adherent, and others. We as patients are supposed to treat medical professionals with respect when they won't respect us. This blog is slightly different, the title may have been changed on them to make it sound more appealing, and this adds to the confusion and makes the issue more complex.

In this blog, the authors use several terms to describe us. They start out using the term patients, then change to call us assets. Then they go off the beam and call us “patient activation” as measured by the Patient Activation Measure. This is one of the measurements that they take of us so they can decide if we are compliant or non-compliant. The more activated we are the more compliant we become.

Then they really insult patients by saying, “Patients, like swimming students, are starting at different levels. Yet in health care, we tend to throw everyone into the deep end of the pool and assume they can swim.” Yet these medical professionals won't do anything to educate their patients or give them help in learning. This could do wonders to help the patient want to learn, if they knew the medical professional really cared enough to help.

What level of help is required? I don't think they even know, or care, as like they say, throw them in the deep end and see if they can swim. Then when patients come back with questions they have, these same medical professional get angry because they don't think the patients have used reliable sources for information. Yes, I can agree with their anger when a patient brings in reams of paper with questions on several topics that require the medical professional to do reading during the appointment.

My question is, when are these medical professionals going to learn that if you give patients information, like a list of URLs for good internet sources and a brief description of the topic, most patients will appreciate this and if they are computer literate, they will learn. Granted this would mean that the medical professionals would be required to ask some questions, but the rewards would be more activated patients. Will this happen, I sincerely doubt it as I have asked several doctors to provide some URLs, but to date, I have not seen any. I even asked them to use my email address to send them to me. Nothing. Then the third time, I took in several URLs I knew were reliable, and asked for the URLs to be checked out. Still nothing. This would require them to do something they can't bill for, therefore, this is why I doubt very seriously any medical professional will do any education or even give out a list of reliable internet sources to patients who would like to have this list to help them become better, more activated patients.

Therefore, I will not even discuss terms we as patients would find more acceptable, like proactive, empowered, or others, because the majority of medical professions don't give a damn, don't want to deal with these types of patients, and unlike these authors are advocating, it ain't gonna happen unless the medical professionals can bill for it. For them their time is too valuable now to do anything that might yield greater returns in the future.

They just don't see the tsunami coming with the Affordable Care Act and the implications for them.

Diabetes Prevention – T2DM – Part 2

Part 2 of 2 Parts

Other factors in knowing you need to work to prevent type 2 diabetes.

Gestational diabetes is a risk for developing type 2 diabetes later in life, yet this is often overlooked by doctors, and no warnings are given to these women. Generally, type 2 diabetes will occur in 40 percent of women in the 10 years following gestational diabetes. This number jumps to 50 percent in women that are obese following gestational diabetes.

Efforts are taking place to determine if women having had gestational diabetes can be treated using lifestyle changes and medications to prevent the onset of type 2 diabetes. This appears fruitful and further research is needed to identify women who will respond to this therapy.

Next, we come to the part that is surrounded in controversy. Diet as they term it, but better is food plans are a critical issue when exploring the disease processes. Is it the food itself or the age and lifestyle of those consuming the food that is the risk? Cinnamon, coffee, and fenugreek seeds are some of the food products many feel are associated with the development or prevention of diabetes; they have not been truly scientifically investigated. The foods talked about below have been studied, but even this is questionable, and the results are supposedly independent of weight, age, physical activity, and family history.

I will state that the foods are representative of the high carbohydrate – low fat way of thinking and are not necessarily healthy for everyone. They state that in a study involving more that 42,000 men, diets high in red meat, processed meat, high fat dairy products, and sweets, all were associated with an increased risk of diabetes. No definition of percentage of red meats was given to make this valid. Processed meat and sweets are quite likely culprits.

The data on dairy products varies, depending if the person is obese or not. In obese individuals, the more dairy consumed, the lower the risk for the metabolic syndrome. Those consuming more than 35 servings of dairy foods per week had a lower risk compared to those consuming less than 10 servings per week. This association is not as strong in lean individuals.

Sugar consumption alone has not been associated with the development of type 2 diabetes. Weight gain is associated with sugar consumption. However, after adjusting for weight gain and other variables, there appears to be a relationship between drinking sugar-laden beverages and the development of type 2 diabetes. Women who drink one or more of these drinks a day have almost twice the risk of developing diabetes than women who drink one a month or less.

No information was given for other meal plans or foods, just what they want us to exclude. Highly processed foods and foods high in carbohydrates with high glycemic values should be avoided.

I urge you to read all six pages of the article for more information.

Diabetes Prevention – T2DM – Part 1

Part 1 of 2 Parts

Can type 2 diabetes be prevented? This is a question I am often asked in emails and the answer does depend on many factors. Not surprisingly, the answer is both yes and no. It depends on too many variables such as: are you predisposed or genetically at risk (family history of diabetes), are you overweight to obese, do you smoke, have you been injured in the pancreas, have you been on steroids for medical reasons (hip replacement, had chronic back pain, etc.) where you have needed steroids for extended periods of time, or have you led a sedentary lifestyle. Researchers are discovering that sometimes these risks do not exist, but people still develop type 2 diabetes.

I have also been exposed to people that are morbidly obese, yet they have not developed diabetes. Thus, you can see that the question does not yield a yes or no response. Generally, the risks in the above paragraph will hold true, but don't count on it. Still if you are over weight, it will be an advantage for you to lose weight and exercise if you are medically able. Do exercise if your doctor sees no medical problems preventing this.

Even the American Diabetes Association (ADA) is strongly advising people who are at risk for diabetes to lose weight and exercise as a means of preventing type 2 diabetes. It is wise not to follow the weight loss plans from the ADA, as they are not proven to work. Until the ADA separates their organization from the USDA and the Department of Health and Human Services (HHS) and the information they dispense, losing weight will become a problem of preventing weight gain. High carbohydrate/low fat foods will generally cause most people to gain weight or make it next to impossible to lose weight.

The following are important and worth quoting. “The risk for developing diabetes increases in certain cases such as the following.

1. Genetics: People with a close relative with type 2 diabetes are at higher risk.

2. Ethnic background: For example, the actual prevalence of diabetes in the Caucasian population of the US is about 7.1% while in the African American population, it increases to about 12.6%. Approximately 8.4% of Asian Americans and 11.6% of Hispanic Americans are affected. In a well studied group of Native Americans, the Pima Indians, the prevalence increases to almost 35%.

3. Birth weight: There is a relationship between birth weight and developing diabetes, and it's the opposite of what you'd intuitively think. The lower the birth weight the higher the risk of type 2 diabetes. At the other end of the spectrum, a very high birth weight (over 8.8 pounds or 4 kg) also is associated with an increased risk. Additionally, mothers of infants who had a higher birth weight (over 9 pounds) are at increased risk for developing diabetes.

4. Metabolic syndrome: People who have the metabolic syndrome are at especially high risk for developing diabetes.

5. Obesity: Obesity is probably the most impressive risk factor and in most situations the most controllable. This is in part due to the fact that obesity increases the body's resistance to insulin. Studies have shown that reversal of obesity through weight reduction improves insulin sensitivity and regulation of blood sugar. However, the distribution of fat is important. The classic "pear" shape person (smaller waist than hips) has a lower risk of developing diabetes than the "apple" shape person (larger around the waist). The exact reason for this difference is unknown, but it is thought to have something to do with the metabolic activity of the fat tissue in different areas of the body.”

Thanks to endocrinologists that are making use of their education to routinely look for indicators of problems in blood glucose metabolism that can be seen years before the onset of diabetes, we now have hope of delaying diabetes in patients who are at high risk for developing diabetes.

Some of the red flags that may indicate risk if diabetes include irregular menses. The lengthening of menstrual cycles in obese women especially those who had cycles greater than 40 days indicates twice the risk of developing diabetes as those whose cycle was every 26 to 31 days. This is thought to be linked to polycystic ovary disease, which is known to be associated with insulin resistance. Insulin resistance is thought to be a precursor for type 2 diabetes.

Another red flag is impaired fasting glucose. This is being considered because of the expansion of the at risk definition to people with fasting glucose levels from 100 mg/dl to 125 mg/dl for developing type 2 diabetes. It is also known that these people are at an increased risk for heart disease and stroke.

Three other red flags are late to the list and are now better understood; include inflammation and endothelial dysfunction (abnormal response of the inner lining of blood vessels) and retinal artery narrowing (narrowing of the tiny blood vessels in the back of the eye). The inflammation marker known as C-reactive protein has been shown to be increased in women at risk for developing the metabolic syndrome, and in both men and women at risk for developing type 2 diabetes.

Scheduling Type 2 Medications and Meals

This is a topic I am asked about, see questions about it on forums, and hear some bad stories about when the medications are not explained to patients by their doctors or pharmacists. In most states, pharmacists are required to answer questions about prescription medications and when you are new to any medication, most are required to tell you about the medication. Just having the pharmacist fill the prescription, picking it up, and paying for it is not the proper course when a medication is new to you or a family member. Often the pharmacist will only highlight a few things like when to take it and repeat what the directions spell out on the container. Fortunately, in my state, they cannot stop there if you ask questions. Pharmacists have been penalized for not doing what the law requires.

This is one of the few blogs that I have seen on diabetes oral medications and scheduling them with your meals. The blog should be read by everyone and then if you have questions for your doctor or pharmacist, ask away. I have written about oral medications previously, but did not cover scheduling them with meals. Even this source says little about meals when they cover the different oral medications.

The above image carries a very important message. I cannot stress how important this is and how much better your diabetes management can be if you have knowledge about your medication(s). Then add to it the meal schedule and knowing when to take your medication in relation to your meal schedule can really be a boost to your diabetes management. Those of us taking insulin learn this early on and make use of this for the best diabetes management. That is the reason for encouraging you to read the blog by Joslin.

Most oral medications do suggest not taking a medication before a meal if you are not feeling well and may skip the meal. This is to prevent a low (hypoglycemia episode) from happening. Some oral medications do not need to be taken before or with food and therefore do not cause hypoglycemia by themselves or cause gastrointestinal tract problems.

Assessment of Common Comorbid Conditions

When talking about two diseases that occur together, I have some real questions about the purpose of the listing the American Diabetes Association (ADA) published in their 2013 guidelines. The first one is more linked to diabetes because of small blood vessel damage in unmanaged diabetes. I understand the researchers finding conflicting evidence when they don't separate type 2 people by age and don't do age-adjustments. If they are including hearing loss as a common disease with diabetes until there is more proof, then maybe this could be a good thing. Except that this is only the second year they have done this for any of the comorbid conditions.

Prior to 2012, this section did not exist as it is. In 2012, the following were listed:

1. Hearing impairment,

2. Obstructive sleep apnea,

3. Fatty liver disease,

4. Low testosterone in men,

5. Periodontal disease,

6. Certain cancers,

7. Fractures, and

8. Cognitive impairment.

Then for the 2013 guidelines they added depression, almost as an afterthought.

I am concerned about the fact that some of these accompanying diseases that have links to diabetes being listed as comorbid conditions. I realize the links to two of the above are disputed (#1 and #8), but I had thought that depression was a strong link. The rest I can agree need listing as accompanying diseases or comorbid conditions.

Either way, those of us with diabetes need to be aware these and take care of ourselves to prevent or treat these conditions. Many of us do have these conditions so knowing this is definitely a help. I have written about sleep apnea because I have this. At present, I don’t know of any cancers, but I do have fatty liver disease.

Diabetes Amputations Can Be Halved

Those of us with diabetes, and I am not singling out any type, have the fear of amputation. This is on the mind of everyone at some time. Yet, I continually read articles, press releases, and stories saying that many of the amputations should never have been necessary if people with diabetes would have followed foot care procedures in the early stages.

Yes, this may sound harsh, but many could have been prevented as this study shows.  Orthotic researchers at Sahlgrenska Academy, University of Gothenburg, Sweden, have studied diabetic foot complications ever since 2008. Granted, this was a specialized study with orthotic shoe inserts that protect our feet and minimize the risk of foot ulcers. Foot ulcers are one of the problems for people with diabetes and often cause the need for amputation.

Researchers completed the study that involved 114 Swedish patients with diabetes who were at risk of developing foot ulcers. The results show that shoe inserts, podiatry, information, and regular foot checkups can prevent the ulcers. This could eliminate the need of amputation by more than 50 percent.

This should shine the emphasis on foot care and the reason to see your podiatrist on a regular basis. Discuss the need for shoe inserts and talk about areas of the foot carefully to examine on a daily basis. I know that too often, I became bored with seeing my podiatrist because it was just a toenail clipping and looking at calluses. This study has renewed my desire to see my podiatrist and have a discussion about the areas to watch on a more earnest basis.

Another area of concern happened during the month of February in another press release showing that foot ulcers are more resistant to hyperbaric oxygen therapy and that this could be the reason for more amputations. I will be blogging about that study in another blog, but wanted this to be on your mind as a way to prevent foot ulcers before this need ever became a concern.

This was not part of the study and therefore is just my thoughts, but in previous conversations with my podiatrist, he would always ask what my last A1c results were.  This leads me to believe that maintaining A1c's will help minimize the effects of foot ulcers to a point if you need shoe orthotics and use them. It may not prevent all foot ulcers, but should aid in their being taken care of before they become a problem. Maintaining blood glucose management that keeps blood glucose levels, as near to normal as possible should be the goal of every person with diabetes to prevent foot ulcers from becoming a problem with diabetes.

Image courtesy of madisonpodiatrist.com

Also, read my blog here for keeping happy feet. Many of the points used in that blog apply here as well and should become part of your routine for good footwear and foot care. I will not use more images as they are not pleasant to look at, but if you wish to satisfy your curiosity, use your search engine and type in “foot ulcers” and then click on images. This is why bloggers stress foot care as being an important part of diabetes management.