Internists Blow It in Choosing Wisely

I will attempt to stay away from ranting, but this Medscape article did get me going and I will never understand why the Society of General Internal Medicine (SGIM) chose to make this choice. I can only guess they want to keep the diabetes epidemic in full out advancement.


I know from David Mendosa and his blog here that most doctors believe that diabetes is progressive. This is their shame then and they deserve being told this. I know that diabetes can be halted and kept at bay for many years. Each person is different in their abilities, but for the SGIM to take this stance, means that I no longer have faith in their side of the practice. I will say that having a diabetes clinic for my diabetes and being on insulin does make a difference for me.


I just feel very sad for the other diabetes patients on oral medications because of what they will face in the days and months ahead by being kept in the dark about their blood glucose levels. They will not be taught about self-monitoring of their blood glucose and what the readings mean. They will not be able to obtain testing supplies to have any guidance for managing their diabetes.


This means that diabetes will become progressive for them and they will have no knowledge of how they are doing to even manage diabetes. The complications will develop more quickly and become worse quicker. They will probably spend more time in the hospital and help elevate the medical costs everyone is trying to reduce. This is a sad day for people with diabetes.


We in the diabetes online community can only hope and pray that many will come to the internet to learn about diabetes and see some of these blogs and wonder why they are not being told to test. I know that I will continue to promote testing, encourage veterans to apply for assistance from the Veteran Affairs, and be able to learn about testing and test.


Several of my fellow type 2's in our peer-to-peer support group are now emailing me to find out what is going on and they have scheduled a meeting for this Saturday. As of the last email, we now have four support groups that are planning to attend plus two doctors. The room has been reserved to accommodate everyone and this may be quite a discussion. Makes me happy that my blog here got everyone alerted to what is happening.


Tim and I have been in conversation about this and the otherMedscape article here that I have not finished my blog on.

Urgent - Internists Blow It in Choosing Wisely Points

Dr. Robert Ratner, chief scientific and medical officer for the ADA that says, “Many people with type 2 diabetes who are on medications don't need to do home glucose monitoring at all," in talking about oral medications must be celebrating big time now. The Society of General Internal Medicine (SGIM) released their list of not always necessary, tests or procedures.


Topping their list is, "Don't recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin.” This means that patients will not receive any education and will be operating in the dark to manage their diabetes. This also means that insurance will not pay for any testing supplies.


We think the diabetes epidemic is bad now, but wait until the full effect of this takes place. Diabetes complications will cost our healthcare system dearly. We complain about Medicare only covering one test strip per day now. Just wait until test strips become more expensive and patients on oral medications are operating in the blind and not able to know what their blood glucose levels are.


Think of the deaths caused by hypoglycemia, the trips to the emergency department because the patient cannot test or goes into a coma from hypoglycemia. Angry, HELL YES, I am angry. This is one of the most idiotic things to do to patients with type 2 diabetes. We don't need less, in this case no testing supplies, but should be receiving more test strips.


Now I wonder if doctors or endocrinologists will even go to bat for their patients to receive more test strips to learn what foods are doing to their blood glucose. This is a horrible blow to the diabetes epidemic and confirms that doctors don't care about diabetes. They just want patients to develop the complications so they have something to treat and don't want patients that become knowledgeable to stop the progression to the complications.


More on this when I have more time to think and get my anger under some semblance of control.

Is There a Best Way, Part 5

This is almost a repeat of a blog I did back on November 9, 2011, but I hope that I have a few new thoughts of benefit to my readers. For those with type 2 diabetes and on oral medications, affording the extra test strips may be a hindrance, but if you are able to afford them you will be better off if you are having problems managing your diabetes. Therefore, most of this is aimed for people newly diagnosed or recently diagnosed with type 2 diabetes whether you are on oral medications or on insulin.


Eating to your meter shortly after diagnosis is very important. We have all read this, but have you really tested this? Eating to your meter can be very beneficial in helping you manage your blood glucose. For those with type 2 diabetes and on oral medications, this is a philosophy you almost must adopt to manage diabetes effectively. Counting carbohydrates is even more important so that you learn how to manage the food intake to get the greatest efficiency from your diabetes medications.


Even being on insulin this is important to make your diabetes management more effective and hopefully reduce the amount of insulin you will need to inject. The medications you are taking will only manage so many carbohydrates effectively and then you start to lose control. This then becomes more important to know what your blood glucose meter is telling you about the quantity of food you consumed. Using your meter also can indicate which foods you need to severely limit and which you can consume or may need to eliminate altogether from your menu.


Most of you will probably need to have a good discussion with your doctor about the number of test strips your medical insurance will over. Most doctors are able to write a letter that will get coverage for extra test strips for up to six months before the insurance will stop covering them, but not Medicare. The important discussion with your doctor is the reason and length of time you want the extra test strips. Extra test strips may not be available if your doctor will not write a letter to your insurance company. Occasionally, you as the patient will need to make a call to your insurance to negotiate for extra test strips. It would be in your best interest of diabetes health to make the plea to your insurance company.


On limited test strips, eating to your meter may be very discouraging because you do not have a lot of information to guide you. That is one reason, I suggest that if you can afford it for a few months, buy extra test trips. The extra testing supplies will give you confidence in your carb counting and portion of food intake. It will also make it easier to determine what foods are best left off the menu.


There are various plans discussed for those on limited test strips so you will need to work with what works best for you. A food log after diagnosis is also an aid that many people just do not understand the need to keep. I can attest to how many times this has told me why my postprandial blood glucose levels were higher than they should have been and what I did not do. The important part is not lying to yourself, but keeping accurate logs. I record my log at the end of each meal and record the carbohydrate count before starting the meal.


Knowledge is power, and therefore knowing what each test is telling you, watch for trends in fasting blood glucose levels and use your meter to learn more from pre-meal testing to tell you about your prior meal. If you can afford extra test strips for a month or two, learn that you do not want your pre-prandial and postprandial readings to increase more than 40 mg/dl if possible. You should also develop an exercise regimen with your doctor's approval to help get your blood glucose numbers to become the best for you.


If you do have trouble with managing your blood glucose levels, give insulin a consideration and study about it before the need arises.


Read a couple of other articles about eating to you meter here and here. Before reading the second article, please locate this conversion chart and page down to glucose. For many of the readings you will need to divide by the conversion factor.

How Did You Handle Your Diabetes Diagnosis?

This is a question I receive in emails almost every month and I have my answer that I copy and paste in a return email. I will share it now.


First, I let people know that I was in the hospital when I received my diagnosis. I had been operated on to balloon out several arteries and had a stent implanted in one artery. As such, I had no room to become angry about the diagnosis. All I could do was let the nurses do their injections of insulin and follow their instructions if I was not able to eat enough, which was quite often.


When I was awake the first day, the hospital diabetes educator came around and introduced me to the testing supplies and how to test. She only had the equipment that my insurance would cover and of course told me that I would be given prescriptions for everything when I was discharged from the hospital. Since all the pharmacies would be closed when I was to be discharged, I was able to have her obtain my test strips and oral medications that the doctor had prescribed. She was very polite and took time to explain what the two medications were and how they would work for me.


What she all but ordered me to eat was whole grain foods and very lean meats (low fat of course). Little did I know then what problems this would cause. My son was able to come home to be able to transport me from the hospital. The next day I was able to fill the rest of my prescriptions. I was very fortunate that my pharmacist was watching my prescriptions and even then told me not to use the alcohol pads for cleaning my fingers. She said I should keep some around for times when I could not wash my hands, but that would always be the best to prevent cracked skin and very painful blood glucose testing. Since this was late October, I followed her directions.


Since I was still working, I did take the extra test strips at my expense. The pharmacist also showed me where to test on the sides of my fingers and explained that there was less nerves so I would have less pain. The pharmacist also suggested that I set up a log to track my blood glucose readings and the time. She also asked if a food log had been explained to me and I said no. She asked if I had a scale. I told her about my scale which could weigh in grams and ounces, could be zeroed for the container (called tare weight) and she commented that with that I was ahead of the game. She was becoming busy then and told me to write down questions and come back another day. She concluded that if she had time she would answer them for me then, or take them and answer them for me and I could pick them up another day.


Since my son had to get back to his work and schooling, he left the following day leaving me to my own devices. A couple of days later, I drove to the health food store and I needed a refill of my daily multivitamin. Since I knew the owner and knew that she had diabetes, I felt she would be able to answer a few questions. She did ask which medications I was taking and wondered why I had not been given one of the sulfonylureas. I said I was allergic to them so she moved on to research them. I told her I was not looking for a natural medication.


She said that she did not know of any that would help diabetes as she had tried several after her diagnosis and had only received short time help. She explained that once her body replenished what she was short of, the effects stopped. She did write down what to research myself and the tests to ask the doctor to do, to see if I was in the normal or low range. Then we talked about nutrition and the fact that I should reduce the number of carbohydrates and whole grains to get better results with the medications I was taking.


Her advice brought me out of the upper 200's to the upper 100's for blood glucose readings even though I kept reducing the number of grams of carbohydrates. So the next appointment in January the doctor and I had a good discussion about insulin. Since I had been researching it, he set me up with another doctor to establish the starting dosage for each insulin and she told me how to adjust (titrate) the amount of insulin based on my blood glucose readings for a correction and the number of carbohydrates I would be eating for that meal. She covered the readings I should be trying for and that it could take some time to get there.


She also covered hypoglycemia and having glucose tablets available for use. Then she started handing me sheet upon sheet covering the symptoms of hypoglycemia, hyperglycemia, and getting my baseline eye examination, dental examination, and set me up for a follow-up appointment with her and my primary doctor for making further corrections. With this I was off and running and managing my diabetes. Instead of A1c's in the upper 7's, my next was just above 6.0%.


I soon discovered that all the goals were what the American Diabetes Association recommended and further discussions with the owner of the health food store and my pharmacist taught me that it was better to set goals less that the ADA recommendations. I was reading Gretchen Becker's book The First Year - Type 2 Diabetes by then and I had found the website for David Mendosa.


Over the next few years, I did a lot of reading and researching on the internet. I had my first denial about three years after diagnosis and a bout of minor depression about the same time. Like most people, I have made bad mistakes, but I am happy to say that I have learned by making these mistakes.

Is There a Best Way, Part 4

I admit that I do not understand why people continue to insist that their doctors are not telling them about the cure for diabetes. All I can say to this is good luck folks! There presently is no cure. I do tell them that if they maximize their lifestyle changes, they may be able to get off medications and stay off if they develop good nutrition and a good exercise regimen.


The second thing I get asked is what are the rules that will make diabetes manageable. All that I can answer to these is there are no rules, only guides and what works for certain segments of those with diabetes. Yet, they insist there has to be at least one rule. It is unfortunate for these people that there is one rule; if they refuse to manage their diabetes, complications will develop.


Below are some tips that may help, but many people will refuse to follow them.

Tip 1. Relax, you did not develop diabetes overnight. It may take some time to get your diabetes under the management level you want. As you become more comfortable with living with diabetes and how it affects your body, you will develop a routine. While diabetes will be in your thoughts daily, it will not necessarily limit you. Some people are able to radically change their lifestyle overnight, while others do not find the comfort zone for a few months.

Tip 2. What works for me may not work for you.  Type 2 diabetes is a very individual disease. We can do a lot of adjusting to try to get the numbers where we want them. No one can say - "do what I do", and you will have the same results. We can only tell you what works for us, but you will have to experiment to find what works for you.

Tip 3. Let you meter tell you what to eat - it should become your best friend. Experiment with different foods and test one or two hours later to see what your blood glucose reading is. Test a lot the first couple of months and try different foods and combinations of food. Determine the amount fat in your foods to know whether you need to test at one hour and three hours. Eating a meal with more carbohydrates than normal should make you check your blood glucose reading to determine how the foods affect your blood glucose levels. When you have established some good routines and habits, then you may reduce your testing frequency. Be prepared to test more often and make it a habit to do intensive testing when things change or to check for possible changes.

Tip 4. It is all about carbohydrates (carbs). Everyone has to develop his or her own daily carb budget or menu. Then you need to follow it to help keep your diabetes under good management. You will eventually develop a plan and possibly some variations. There are some other factors such as lactose intolerance or gluten allergies that can interfere with a person's daily nutrition. Learn how to keep experimenting to develop what works for you. Many people with type 2 diabetes find that a medium to low carbohydrate regimen works well for them. Others find that the Paleo food plan works. Others find other food plans, but each must find the food plan that works for them.

Tip 5. Diabetes requires a lifestyle change - not a diet - diets fail. It is also not a day or two thing, it is a 24/7 lifestyle change, and we are in for the rest of our lives. The process involves learning everything you can about your diabetes, and everything you can about yourself and your body. Then apply it to your life on a daily basis.

Tip 6. You will make mistakes. We all do, and if you make one, it is important what you decide to do about it, but it is more important what you learn from the mistake. Pick up the pieces, reassemble them, and move on. It is not healthy to become stuck in depression or feel like a failure. We do not fail, we do not blame ourselves, and we learn to experiment.

Tip 7. Be flexible, being rigid will break you. Do not become obsessed with numbers - they should become part of routines and goals, but not an obsession. Diabetes can change at a moments notice. What works well today may not work tomorrow. There may be no rhyme or reason to the change, it may change for a reason you can comprehend, or it may simply leave you guessing. Sometimes, you just have to blame the phase of the moon for messing with your numbers and let the stress melt away.

Tip 8. Keep moving! Otherwise, they will be throwing dirt on you. Exercise as much as you are medically able. Park as far from the store as you are able, use stairs when possible, and not the elevator. You need to find the level of exercise that suits you. Some people exercise after every meal, some are not able, and it is all part of being flexible.

Tip 9. If you feel like screaming, kicking, maybe saying something under your breath, well, do it! There are times that diabetes can seem overwhelming and nothing is what it should be. As long as you are not screaming at your spouse, the kids, others, and kicking the animals - let it happen. There are times you must get it out of your system.

Tip 10. Do not let denial and small failures derail your diabetes management. This will defeat you and allow complications to get a foothold in your life. We are not perfect; however, there is a lot we can do to minimize complications, delay complications, or possibly prevent complications.

Tip 11. Keep a positive attitude. This will serve you well.

Tip 12. Remember the eleven tips and use them!

If you find other tips that work for you and apply to your circumstances, write them down and use them. This is not meant to be all-inclusive. Always be prepared to change your approach and goals as your situation changes.


Any guideline, from the ADA or any other source, probably works for somebody, but if you ever met that person, you might find that you have nothing in common with him/her. Therefore, the important question is not whether that person can get away with eating rice. The important question is whether you can get away with eating rice.

This is important - guidelines are theory-based. Good diabetes management has to be reality-based. In practical terms, what that means is that you don't ask the ADA whether or not you will get away with eating a cookie. You eat the cookie, you ask your meter if in fact you did get away with it. If the answer is "no", you make a note of that and you learn from your mistake.

Don't focus on theory -- focus on experimentation. Find out what works for you, and what doesn't work for you. Let your meter be your final authority. If one way of eating doesn't get you good results, find another food plan.

Changing Doctors, Now May Not Be the Best Time

Normally I would not be afraid to suggest changing doctors if you are not receiving correct care for your diabetes. But, as we draw closer to the implementation of the Affordable Care Act (ACA), this may not be the best time for changing doctors. I say this with caution because some doctors are cleaning house by dismissing patients they no longer wish to have as patients. Why? Because if you are a patient that is not following their orders, have complex medical problems, or are what they deem as obese, they do not want you to be a drag on their practice. You could be the patient that prevents them from receiving the incentives they feel entitled to under the new guidelines from the Centers for Medicare and Medicaid Services (CMS).


For the rest of you that are satisfied with your doctor or have a great doctor-patient relationship, work on keeping it that way or strengthening it, even if the relationship might not be that great. Once January 1, 2014 arrives, there will be an influx of new patients to take the place of dismissed patients and they will pick and chose from among them. If you live in a rural area of the US, the doctors may become even fewer and farther between.


Also, living in a rural area, it may be more difficult to find an endocrinologist if you are needing insulin to replace oral medications. Don't count on having certified diabetes educators (CDEs) available or registered dietitians (RDs) in the rural areas. Until we get a few years of corrections in the ACA, and incentives are again revised to encourage doctors to move out to the rural areas, finding doctors may become a very real problem.


In all of this, I can only hope that telemedicine is not hamstrung to prevent medical assistance for the people in rural areas. I just know that several state legislatures failed to enact laws because of lobbying efforts of the state medical boards and several medical professional groups.


There is hope as some doctors and endocrinologists are changing and working to change. They are seeing the handwriting on the wall. They are beginning to see a small decline in the “pill cure” generation and a giant increase in internet savvy patients. These primary care providers will not be able to dictate and prevent their patients from finding evidence that the doctors are out of touch and not doing the patients' right. This has been a pleasant revelation.


Also, with the publishing of doctor information by the CMS on the Physician Compare website for people to have access for researching which doctors are taking how much money from representatives of big pharma and other incentives, doctors will no longer be able to hide their biases.