April 6, 2013
Outside of one type 2 diabetes oral medication, I am happier than even to be on insulin and not oral medications. More of them are showing nasty side effects and creating other potential health problems. Sulfonylureas are suspected of causing heart problems. Avandia has been pulled from the market and Actos is a problem for bladder cancer. Thiazolidinediones (glitazones) is their class of oral medications. Now the oral class of DPP-4 inhibitors or Januvia is on the block for being a cause of irregular growth of cells in the pancreas. These may cause cancerous tumors. Even if I have thought good about Byetta, this is also now an injection to be cautious about.
This leaves only three classes of oral medication, plus a new class just approved, but with much more testing required by the FDA. Janssen Pharmaceutical’s new type 2 diabetes treatment, Invokana (canagliflozin); Invokana is the first in a new class of medications called sodium glucose co-transporter 2 (SGLT2) inhibitors to be approved in the United States. There are several types of trials required before all restrictions are lifted. From my reading, I would be very hesitant to consider the new oral medication. Others agree and have expressed this as well.
The three classes presently considered safe, but causing minimal concerns include Biguanides (Metformin), Alpha-glucosidase inhibitors (Glyset, Precose), and Glitinides (Meglitinides) (Prandin).
Never stop taking any medication you are taking; however, it would be wise to talk with your doctor and see if a change needs to be made. Do not forget to investigate insulin as there are very few side effects and what you need to be concerned about is hypoglycemia. The informal group is happy that so many of us are on insulin and the three on oral medications are asking many questions about insulin now. We have suggested that since two are on metformin and one is on a sulfonylurea that they now get too upset. We are talking to them about insulin however.
April 5, 2013
Part 3 of 3 Parts
Are you ready for you doctor appointment? The following is the rest of the questions to ask your doctor if you suspect diabetes or if you have just received a diagnosis of diabetes, type 2. The 14 questions can be read here. I am quoting the questions and adding my comments to give possible solutions. I have split the two-part questions.
Will I always need medications/insulin? It is always too early to be sure, but if possible, the goal should always be to get off medications if possible. Until you have attempted this, there is no way of knowing if you will always need medications and insulin is a medication and should not be considered the medication of last resort or as a punishment as many doctors are prone to do. If you have a doctor that does this, please do your health a favor and find a different doctor.
How will you evaluate whether these medications are the best treatment for me?
Your doctor should do a complete evaluation, noting any allergies, foods that cause problems, and several tests to determine kidney health, and heart health before prescribing medications for diabetes. Then the doctor should discuss with you what the findings recommend and then discuss the side effects with you so that together you can make a decision. A doctor that does not do any of this is not a doctor to be retained.
What are the long-term complications of diabetes, and how can I avoid them?
There are not long-term or short-term complications. They are complications and they need to be avoided if possible.
Complications don't cause themselves. Poor or no management of diabetes – meaning not testing, not losing weight, not eating balanced meals, not making other lifestyle changes, and no blood glucose management is what causes the complications. So what are the complications? Retinopathy, neuropathy, nephropathy, atherosclerosis, and deafness are the most common, and many don't include deafness. The first three and deafness are grouped together under the term microvascular complications because they result from damage to the small blood vessels. The macrovascular complication is atherosclerosis, which is caused by damage to the large blood vessels.
Retinopathy causes damage to the retina, which may lead to poorer eyesight or blindness. Neuropathy causes damage to the nerves, which cause pain and can be more than annoying pain. Nephropathy causes damage to the kidneys or increased renal problems leading to kidney failure or chronic kidney disease (CKD). Deafness or hearing loss is caused by the eardrum losing the ability to transmit sound because of short blood supply. Atherosclerosis can lead to heart attacks, stroke, or poor healing of wounds in the feet and legs. This is the cause of amputations.
Although these are not complications, there is a strong relationship with diabetes and as such, they are called comorbidities. The 2012 ADA guidelines listed the following:
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.
How do other factors such as high cholesterol and high blood pressure affect me if I have diabetes? As studies are beginning to prove, some types of cholesterol are less of a problem than thought and even the ADA has raised the blood pressure threshold for blood pressure for people with diabetes. I will not quite go to the extreme to wish statins away, but their usefulness may be in doubt, but at present are still needed. Extremely high blood pressure should be lowered with medications until changes can be made in lifestyles that make high blood pressure normal.
How often should I be seeing my doctor to optimize my diabetes management?
This will be determined by your doctor and the medication(s) you are taking. People with type 2 diabetes and not on medications may be limited to one time per year. People on most oral medications will probably be seeing a doctor only twice a year. And, people with type 2 diabetes and using insulin will probably be seeing a doctor four times per year or maybe less. The American Diabetes Association in their efforts to deny people with type 2 diabetes the treatment they need have lowered treatment expectations and some of those that are in positions of authority are making statements that some people with type 2 diabetes only need to see a doctor once a year and may not need to test at all. See my blog here for what some ADA officers are saying. You may also read this about the position of ADA and how Joslin may have affected the situation.
How often you see your doctor may also depend on how often your insurance company will reimburse the doctor for office visits.
April 4, 2013
Part 2 of 3 Parts
Are you ready for your doctor appointment? The following are more of the questions to ask your doctor if you suspect diabetes or if you have just received a diagnosis of diabetes, type 2. The 14 questions may be read here, but I have separated the two part questions to answer them more completely. I am quoting the questions and adding my comments to give possible solutions.
What are the warning signs or symptoms that my blood glucose levels are too high? The most common symptom is none at all. This is the reason many people do not know they have type 2 diabetes. The best idea is to know your family and if there is a history of diabetes. Many of the signs of diabetes can also be indicative of other problems, therefore is best to see a doctor for an accurate diagnosis. Some of the signs are tiredness, increase in urination, thirst, weight loss, change in vision, moodiness, and a few others. Some people do become irritable when they get too high, but there are no firm numbers when this happens. Read this article for more.
If you already have a diagnosis, testing is the best way to detect high BG levels. Dehydration can occur of high blood glucose levels are allowed to stay for several hours. Treatment to lower blood glucose levels is important and should be started quickly. Read these articles here and here for a better understanding of high BG or properly hyperglycemia.
What do I do if my blood glucose levels are too high? There is a multitude of possible solutions. Be honest with yourself as the only person you will be hurting is yourself. Eating food out of anger is not wise, yet this often happens the first few weeks when patients are angry about the diagnosis. Then later if you are in denial, you can also overeat or eat out of anger as well. I can say that both anger and denial are useless, but this will not prevent it from happening. Soon or later, this will happen, as they are two of the four stages people are quite likely to experience.
Yes, medication (the prescribed medication) is one way to bring down high blood glucose levels, but only take the medication when you are directed to on the medication. Walking or some exercises are another aid to bringing BG levels down. If during the first month or two you are not able to bring your blood glucose down with the medication or medications you are taking, then please investigate insulin and be prepared to talk to your doctor about this.
The most reliable method of bringing blood glucose levels down is by adapting a food plan that works for you. Because there is no exact food plan for people with diabetes, you will need to find what works for you.
What are the warning signs or symptoms that my blood glucose levels are too low? Hypoglycemia causes symptoms such as hunger, shakiness, nervousness, sweating, dizziness or light-headedness, sleepiness, confusion, difficulty speaking, anxiety, and weakness. Hypoglycemia can also happen during sleep. Some signs of hypoglycemia during sleep include crying out or having nightmares, finding pajamas or sheets damp from perspiration, and feeling tired, irritable, or confused after waking up.
The best way to determine the level of hypoglycemia is to test. If you have a diabetes diagnosis, then you should have a supply of glucose tablets on hand at all times. Don't take this lightly if you live alone. If you have a family, then make sure they know where all supplies (including the glucose tablets) are located. I lived alone for about three years and I kept my testing supplies on the nightstand when I went to bed along with the glucose tablets. One person that I know has a small refrigerator in the bedroom with other supplies that he relies on, but I have been fortunate that I have never needed to go that far.
What do I do if my blood glucose levels are too low? If you are capable, be sure to test as soon as you feel that you are low. Now if this is within the first months of your having diabetes, then you should be concerned any time you reading is below 80 mg/dl (4.4 mmol/l) and consider this a low. If you are below this but not below 70 mg/dl (3.9 mmol/l) take one glucose tablet and test 15 minutes later. If you are back above 80 mg/dl, then consider yourself okay. If you are not back above 80 mg/dl, take a second glucose tablet and test again 15 minutes later. Repeat if necessary.
A fairly simple rule to follow is to subtract the number of the reading from 80 and divide by 15 to determine the number of glucose tablets to take. This means that if the number is 45 mg/dl (2.5 mmol/l) this would be 35 or three tablets you should take and test about 15 to 20 minutes later. Yes, I am suggesting a full tablet for 5 mg/dl that would be the remainder. Repeat as necessary with one glucose tablet until you are above 80 mg/dl.
If you live alone and do not have glucose tablets, call 911 immediately if you are able. Yes, this can be a little drastic, but rather than take chances with unknown carbohydrates that are not as fast acting, I would suggest this. Some would suggest other remedies like juice. However, they may work, but are not as fast acting and the low could become severe, putting you in a coma and at risk of death. This is the reason for always having glucose tablets on hand.
How can I change my lifestyle and diet in a way that will be healthy? Or maybe not ideal, but more healthy. If you are a person that has led a sedentary life, then it is time to start some exercise that you enjoy and can maintain on a daily basis. Your goal should be at least 10,000 steps on a daily basis. Always make sure that you discuss this with your doctor before starting for medical reasons. This will give your doctor the opportunity to know what you are planning and be able to give you the go-ahead or say whoa; you will cause this or that problem. He may have suggestions that will allow for exercise in a safe manner that will not cause harm. Always start slowly and warm up to prevent injury.
For food plan (forget diet) you need to discuss this with a nutritionist that understands diabetes. Some will suggest a registered dietitian (RD), but be careful here. Many, but not all, will mandate (never a good thing) whole grains and that you consume so many carbohydrates and this may not work for you. There are so many food plans that it is difficult to know what is best for you. I would suggest maintaining a food log and blood glucose test results to see how different foods affect you. Generally, highly processed foods should be limited if not eliminated. If your budget allows, convert to fresh foods where possible and foods that have limited processing. This blog may be of help.
What are the side effects of my medications/insulin? Here is the resource you should use and become familiar with and maybe bookmark it. Find the medication or medications you are taking and look them up in the tables.
April 3, 2013
Part 1 of 3 Parts
Are you ready for your doctor appointment? The following is some of the questions to ask your doctor if you have recently received a diagnosis of diabetes, type 2. Some questions just lead to more questions and can make it difficult to follow what is and what is not important to know immediately. I have tried to stay with what is important at the start and good to learn at the beginning of your journey. Each question tells you which of my blogs contain an applicable discussion if you wish to read more or I will refer you to a blog by another writer.
I have tried to sprinkle in the acronyms that you will learn and see very often. I will also try to point out terms that you will need to learn. Why? Because you will see them used by most people that have had diabetes for several years and once you learn the language, you can learn to read without a dictionary. You may still want one handy, and there are several online. I prefer this medical dictionary, but I will also use this medical dictionary. There are others and you may search for them and see if you like them.
An example is blood sugar (BS), which I do not like, but most writers insist on using this term. Correctly, both scientifically and medically, the term should be blood glucose (BG). I would urge people new to diabetes to read this by David Mendosa. One example that I see all too often is the use of the word glucometer. This is correct only if you are referring to the meter registered to Bayer as a trademark. Correctly, your meter is just that, a meter. Also, be careful as most people refer to a meter and test strip as a unit even though you must change test strips.
The 10 questions are really 14 questions and I have divided them accordingly.
1. Should I check my blood sugar levels at home with a glucose monitor? How often should I check them?
2. What are my goals regarding blood sugar levels?
3. What are the warning signs or symptoms that my blood sugars are too high? What do I do if my blood sugars are too high?
4. What are the warning signs or symptoms that my blood sugars are too low? What do I do if my blood sugars are too low?
5. How can I change my lifestyle and diet in a way that will be healthy?
6. What are the side effects of my medications/insulin?
7. Will I always need medications/insulin? How will you evaluate whether these medications are the best treatment for me?
8. What are the long-term complications of diabetes, and how can I avoid them?
9. How do other factors such as high cholesterol and high blood pressure affect me if I have diabetes?
10. How often should I be seeing my doctor to optimize my diabetes management?
I will list each question and give my response as a patient to them. They are still questions worth considering for asking your doctor, but you will not see them answered this way.
Should I check my blood sugar levels at home with a glucose meter? Yes, you definitely should check (test) your blood glucose at home, at work, or where ever you are when testing is needed or desired. Many doctors discourage this for various reasons and this is wrong. Many doctors do not want you to know what they are or do not want you to be depressed with the high readings. If your doctor does not have a meter to give you one and a prescription for more strips, then insist (even demand) on a prescription for a meter, lancet device, lancets, and test strips before you let the doctor leave the exam room. If your doctor remains uncooperative, then you have a decision to make about possible change in doctors. For your diabetes health, the sooner you make this decision, the healthier you can be.
Testing is the only way you have for determining how different foods and food quantities affect your blood glucose (BG – is the acronym). A term you will see in blood glucose management is self-monitoring of blood glucose (SMBG – is the acronym). You will also need to test more frequently in the beginning to learn how long before you reach the high level of your BG. Many suggest one hour after first bite and for some people this can be too early. If you are a speedy eater (gobble down your food), this may work; however, studies have shown that you should eat slower for greater blood glucose management. Some writers do use the word control for the same meaning. Some will suggest testing more often until you are comfortable with when your high level of BG happens. I suggest starting at the one-hour mark and testing every half hour the first few times. When the reading is lower than the previous reading, then you may stop. Your high point has occurred between these two readings.
Having said this, I must warn you that most, if not all, insurance companies will limit the number of test strips they will reimburse for your use. Therefore, your budget may not allow for the testing you should attempt. And, these vital test strips are expensive.
How often should I check my blood glucose? This is not an easy question to answer, even for new people with type 2 diabetes. This will depend to a great extent on your medication(s), what your insurance will cover, your budget, and your comfort zone. Many people with type 2 do purchase extra test strips out of their own pocket because they can afford this. Those people with a limited budget that are on oral medications probably will need to use what the insurance will reimburse. People on sulfonylureas that have had problems with hypoglycemia should encourage their doctor to write a letter explaining this and asking for additional test strips. There are other combinations that may cause use of extra test strips and your doctor should make you aware of them and request extra test strips. Please read my blog here for some of the oral medications that can create troublesome hypoglycemia.
How often you test will depend on your desire to bring diabetes under good management and your budget. You will also need to find out how willing your doctor is to go to bat for you with the insurance company for additional testing supplies. Some companies will allow some extra test strips in the first few months, but then want to restrict you thereafter. Other insurance companies will only allow a set number of test strips per day. I recommend that you talk with your insurance company to find out what they are willing to allow. You may need to bargain with them and attempt to convince them of the need for allowing more test strips for the first three to five months. Don't be surprised if you are denied, but it is still worth the effort.
What are my goals regarding blood glucose levels? This will depend on what you are willing to tolerate. I suggest reading this for an excellent guide. Some people set lower goals and do not like being over 125 mg/dl (milligrams per deciliter) at the high point in BG. For a person just getting started, my link is a good goal. Try not to have fasting BG under 80 mg/dl, especially at first. Gain some confidence in what you are doing before letting the numbers become overly important. Yes, learn first, and then work toward them. Do not become discouraged when you cannot achieve them the first few weeks. Remember you did not develop diabetes overnight, and it can take time to set goals and achieve them. These are goals you are working to achieve and you have a lot to learn at first. I have been at this for over nine years, and there are times when I have difficulty in maintaining the range of numbers I want to achieve.
April 2, 2013
I occasionally come across something of interest in my many email newsletters, but seldom something when I am looking for it. So this was a pleasant surprise when I came across this blog about doctors using the internet. Yes, many doctors use the internet for their personal life and a few do follow some medical news and some even blog. Most physicians don't like patients using the internet to find information about what may be a problem for them. Remember, that is why doctors exist – to answer our illness questions and to take care of our medical needs.
But in this day of technology, doctors may become a thing of the past. Computers are already diagnosing some illnesses (think of IBM's "Watson") and as programmers become more proficient, computers can only get better. This is one thing most doctors do not like, and I can't blame them. This doctor knows that people are turning to the internet because doctors are not educating them and more people want to know what is possible for their problem. In other words, doctors are setting themselves up for trouble unless they overcome their aversion to patients looking up information on the internet.
This doctor, Wendy Sue Swanson, MD really speaks to what the problems are within the world of healthcare. From monitored emails and computer activity restricted and monitored in many clinics and hospitals to interference by insurance prohibiting reimbursement for providing time to patients to give them internet information. I know this, as I cannot get three of my doctors to consider using the internet. They quickly say they are restricted and move on to other topics. The one time I tried to get more information, the doctor quietly told me to use the telephone – at home.
At least this doctor is not afraid of the internet. She quotes, “For at least 1/3 of American adults, the internet is a diagnostic tool.” The doctor also says this, “In my world prevention is key. The internet is one of those keys.” She uses a Pew report to show statistics of internet use among patients. The link is here and I encourage people to read the online version. This should make you feel better about doing online searches even though your doctor may not appreciate this. For those that really get into research you will experience what many of us come across time after time – the pay wall.
Approximately one in four people looking for health information online do run into a pay wall. This is normal for many studies and research documents. I have found that sometimes these pay walls are beneficial and prevent us from seeing studies that are bad science, junk science, and unreliable science. We do have to wonder, but that is part of the excitement in research.
Numerous studies have found that what parents learn in the doctor's office needs to be relearned and according to Dr. Swanson, that is where “Dr. Google” comes in. She is a pediatrician that wants her parents to know as much about their children's health as is possible. She believes that offering online sites to parents is part of her job as a doctor. She believes that more than one third of the parents of the children she sees have at some time used the internet to learn about the health of their children.
“Contrastingly, in acute care visits for things like cough, ear infection, or colds parents rarely report that they have been online.
Tips for “online diagnosers”
1. Keep a breadcrumb trail as best you can. When we’re online we forget where we go and often don’t know who we’re listening to. Confusion comes in when families don’t remember where they have been garnering information and when they become confused by myths, personal anecdotes, and stories that lead them astray. Everything on the internet is clearly not in our best interest as parents. One solution: print things out or refer to specific links with your physician when you’re in to see them so you can look up online information together.
2. Look for advice from experts (psychologists, physicians, researchers). As parents and patients, we don’t make all of our health decisions using science but when we have the opportunity to use solid data to steer decisions, we want the correct sources. Your doctor can help vet the online voices to which you tune in. Ask your pediatrician or clinician what sites they trust the most.
3. Look for sites affiliated with academic medical centers or health care institutions. Often those sites vet and scrutinize content with their expert researchers and clinicians. I tend to encourage families to avoid sites heavily laden with advertising as I’ve learned that content on those sites can sometimes be edited to meet requirements in tone, scope, or opinion by advertisers.”
She also says, “It’s my opinion that the last thing we physicians should do is shut down our patients’ online searches. It’s a new world; we must join our patients online since nearly 1/2 of many groups are using Dr. Google to diagnose. We must guide families to trusted and valuable voices and then help confirm or redirect the results of their online learning.” You may wish to read some of her blog site as well. Dr. Swanson makes a lot of good points.
April 1, 2013
A study finally tells the truth about bariatric surgery. Even though it is not said, the only ones benefiting are the surgeons. Long-term cost savings do not happen and no evidence was found that one type of bariatric surgery produces more savings than another. This is what a 6-year analysis of private health insurance data has found.
Of course, they don't want to offend the surgeons, so Jonathan P. Weiner, DrPH, professor of health policy and management from Johns Hopkins University, Baltimore, Maryland says to assess the value of bariatric surgery, future studies need to concentrate on the benefit of improved health and well-being of patients undergoing bariatric surgery, rather than on cost savings.
JAMA deputy editor, Edward H. Livingston, MD, says that the findings call into question whether bariatric surgery is worth the cost. Then he says bariatric surgery has great short-term results, but over the population, its outcomes are less impressive.
Robin Blackstone, MD, medical director of the Scottsdale Healthcare Bariatric Center, Arizona, and immediate past president of the American Society for Metabolic and Bariatric Surgery disagrees and states the value of the life after bariatric surgery should not be measured by claims data. She claims that patients often have remission of their major medical problems, get off medications, and increase their work productivity.
It seems everyone wants a say in this article. The study, published online February 20 in JAMA Surgery, was comprised of 29,820 adult members of 7 Blue Cross/Blue Shield plans who underwent bariatric surgery during 2002 – 2008. Each patient was paired with one control patient who was obese patient. The paired patients did not undergo bariatric surgery, but did have related conditions of hypertension, type 2 diabetes, sleep apnea, metabolic syndrome, and other health conditions.
The controlled pairs were also matched to the surgery patients for age, sex, and other factors, including obesity propensity score, a measure developed by the authors for identifying obese patients from claims data. This study is interesting because the long-term costs were very close and that is the reason no one class of obese patients that underwent surgery can be said to be more cost effective than another when compared to obese patients that did not undergo surgery.
A fault of the study is the fact that no quality of life data were included and that is the reason the bariatric surgeons are calling for more studies. It can be seen that bariatric surgeons are downplaying this study to prevent it from cutting into their revenue stream. Yet they do not educate the patients about the problems or side effects of the surgery. All they do is hype to the benefits.
March 31, 2013
Part 2 of 2 parts
At first I was happy to read this, but the more I reread this, the more I had to wonder if this was for helping the patient, or assessing ways to divert the patient to the goals of the ADA, AND, USDA, and HHS. It says, “The first step in implementing a nutrition prescription is to perform a careful patient assessment. This assessment should cover the patient's current habits, issues and needs with respect to the nutritional recommendations. Identifying the patient's readiness to learn will affect the ultimate treatment plan with respect to time, course of initiation, degree of changes to be anticipated, and prospects for ultimate success. The issues and questions included in the following checklist may be included in a nutritional assessment.” The checklist is in the excerpt slightly more than half way down.
Meal planning really starts the route back to mandates, mantras, and not creating an individualized approach. Yes, individualizing is used, but only for the purpose of preparing you for the last part of the article. They lead you down the path thinking that it is being individualized for you, but in reality, it is their goals for you, as they carefully do not say what guidelines they are referring to and how variable the use of preplanned menus may not be. Then they bring in exchange or food choice lists, which are a way of saying there are limitations you will be facing. Lastly they want you to know counting – for carbohydrates and fat grams. Now we know high carbohydrates/low fat (HC/LF) is the guideline of choice.
The last part of the excerpt is where they kick individualization out the door and openly declare they are in charge. They have adapted USDA's My Plate slightly (in reality Joslin had it long before USDA) , but this does not change the intent of (HC/LF). They pushed the low fat milk to one side (though it is still displayed) and clearly state “leverage fruit, dessert, or other side dish”, hello carbohydrates and extreme low fat. They clearly state that, “New patients can be given guidance in choosing healthy foods using a picture of a plate divided into suggested servings .... It is not expected that calories would be calculated at this point in the process; this is just a starting point. The key changes targeted by healthy eating guidelines include:” Yes, new patients can more easily be led down this path, until they realize what this is doing to their health.
When David Mendosa advised me to read the Joslin's Diabetes Deskbook before finishing this, I did not realize how right he would be. I have my hands on the book now and have read the chapter the excerpt was taken from and it is just that – an excerpt. There are now several other excerpts from the chapter, all aimed at convincing patients that they need to follow the medical nutrition therapy prescription.
The hopes I had at the beginning have been dashed and this is just another attempt to make people follow a regimented nutrition plan that has proven not acceptable or workable for many of us. There are a few people that this will work for, but more that it will not.
What is it about statistics and bell curves that people at the ADA and medical institutions cannot understand. Below are two examples of bell curves and either will work to illustrate the level of carbohydrates that people may be able to consume. On either one, the left side is those that cannot eat many carbohydrates and the right side is those that are able to consume high quantities of carbohydrates. When you take the number of people with diabetes and spread them out along either bell curve, this shows why a one-size-fits-all recommendation just does not work. There are likely others that are on the curve where you may fit, but never enough to make this practical to base one recommendation on.
The following image is the USDA My Plate adopted June 2011. The book is copyrighted in 2010.
Image courtesy of chosemyplate....
No place in the excerpt (or any place in the chapter) is there any mention of blood glucose testing. This would put the individual very much back in charge and avoid a one-size-fits-all mandate. But this is not the aim of the registered dietitians. Think about this for a while if you would, if they encouraged us to test, then we would know how different foods affect us as people with diabetes. We would quickly know that certain parts of the plate need to be curtailed to prevent our blood glucose from rising to unacceptable heights. But they can't allow us to know this as this would negate the force of prescription and this would not get their high carbohydrate/low fat message across to us.