ADA Medical Nutrition Therapy by RDs

With eight of the eleven people being registered dietitians on the committee developing the ADA nutrition therapy recommendations for the management of adults with diabetes, is it any surprise that much of the information on page 4 conforms to the Academy of Nutrition and Dietetics (AND) policies. I feel that since the American Diabetes Association (ADA) was behind this and they were under the scrutiny of the ADA, we were spared much of the rhetoric of the AND.

Yet they did get in many policies and pronouncements of the AND. Take for example this statement, “Ideally, the individual with diabetes should be referred to a registered dietitian (RD) (or a similarly credentialed nutrition professional if outside of the U.S.) for nutrition therapy at or soon after diagnosis and for ongoing follow-up.” No, I don't like this statement as this is monopolistic in nature and I prefer someone that will work with us for the meal plan we are using and not some organization's meal plan. Nutritionists that will work with us and are not necessarily members of AND seem more interested in balanced nutrition than many RDs.

The above is from page 4 (PDF file) as is the following promoting RDs as being the only professionals that should be allowed to teach nutrition. The RDs also make a statement that should not set well with nutritionists in other countries when they state, “Health care professionals administering nutrition interventions in studies conducted outside the U.S. did not provide MNT as it is legally defined.” Legally defined here means only as defined by AND. Then they continue promoting RDs with this statement, “However, the unique academic preparation, training, skills, and expertise of the RD make him/her the preferred member of the health care team to provide diabetes MNT.” Bold is my emphasis.

Then at the top of the third column page 4, the RDs promote Table 2, Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guidelines and list them. Remember that the national organization promotes Big Food and this determines what will be promoted. Even though many declared no conflict of interests, I feel that it should be pointed out that if the person is a RD and a member of AND, they automatically have a conflict of interest because of their ties to Big Food.

Once the authors moved past page four, the promotion of food plans did become possible and not the direct claims to how RDs should be the only ones teaching medical nutrition therapy (MNT).

For an article that is more balanced than mine, read this by Laura Dolson on about dot com. She likes this new version on medical nutrition therapy and can look past the points I find troublesome. After reading her summary of the ADA food guidelines, I need to revisit the PDF file.

ADA Ditches Diet, Now Has Food Plans

The American Diabetes Association (ADA) has done something right. They have dropped the word “diet” from their medical nutrition therapy prescription. Instead, they are focusing on overall eating patterns and patient preference. They are using “eating plans” or “eating patterns” in place of diet. This is according to Alison B. Evert, MS, RD, CDE, coordinator of diabetes education programs at the University of Washington Medical Center, Seattle.

Now it will be interesting to see if the American Association of Diabetes Educators (AADE) and the Academy of Nutrition and Dietetics (AND) follows. Because AND is supported heavily by Big Food, I sincerely doubt that there will be any change in their modus operandi.

I can understand why Ms. Evert would recommend a patient being referred to a registered dietitian (RD) as soon as possible following a diabetes diagnosis. This is the way they get people set up on a high carbohydrate/low fat (HCLF) diet when the new person with diabetes has not learned about other food plans. Once they learn about other food plans, they will be less likely to follow the mandates of the RD. At least she does recognize that the referral is often delayed.

From the number of registered dietitians and certified diabetes educators on the committee that wrote the 2013 Nutrition Therapy Recommendations (this is a PDF file), it is understandable why some policies are deemphasized and others are promoted. Several statements in the published recommendations are reflective of the monopolistic attitude of the AND and their attempt to become the only recognized source of nutrition information.

One idea not mentioned in any previous guidelines is a guide for coordinating food with different types of oral glucose-lowering agents and both fixed-dose and basal-bolus insulin regimens. These were included so that clinicians would have some talking points that are evidence based.

Because RDs and CDEs do not like low carbohydrate food plans it is not a surprise that this statement was included, "A lot of the studies on low-carb didn't meet our criteria for inclusion due to factors such as high dropout rates."

Then the following was stated, “As for other macronutrients, the document advises that foods containing unsaturated fats (liquid oils) be substituted for those higher in trans- or saturated fat and that leaner protein sources and meat alternatives are preferred. Often, nutrition therapy isn't given the priority that it should have… It's a lot easier to write a prescription than to have a dialog with the patient about eating behaviors."

Some of the points are good sense and there is some good information when it is carefully analyzed.

Our Group's November Meeting

We have had several meetings in September and October, but we felt this was important because of what the endocrinologists had to say about their choices in “Choosing Wisely.” At least they did not outright cut us off from testing. They did not do us any favors in discouraging people with type 2 diabetes from testing and in the process maybe discouraging education for their patients. We included the local doctor and his group in our early November meeting.

I was surprised at the amount of discussion we had on the topic and one of the members, Rob, had written the primary spokesperson for further clarification and received a very lengthy reply (a five-page email). It appears that the American Association of Clinical Endocrinologists (AACE) and the educational arm (ACE) are even more supportive of patients than the Medscape article might lead you to believe. They firmly believe that if you are on an oral medication that can cause hypoglycemia, which the sulfonylureas are, that you should have the necessary testing supplies on hand to test if you suspect a low and to be able to test until you are back within the normal range.

This it what I felt and I thought I had written this in my blog here, but it was still good to have him address this directly. The other point he made was that with the American Diabetes Association change away from the word diet to food plans and food preferences, the AACE will need to assess patients more closely and take into account the carbohydrates generally consumed by patients before and after education. This will necessitate making sure that medications are prescribed in a manner that will not over/under medicate diabetes patients and cause hypoglycemia or hyperglycemia. The members of the AACE will need to monitor what patients are taught for food consumption to be able to tailor the dosage of medication.

Plus, another point he was kind enough to include was pointers on when not to take a medication if the patient is ill or will not be able to eat as normal. The doctor asked all of his patients to be sure to keep the copy of the letter, as this could be very valuable to those on oral medications. He would make sure to cover this in their next appointment to make sure everyone was on board and understood what he had advised people to consider. Even the doctor admitted that occasionally this was something he could forget to cover and with this letter, he now had a reminder to cover this.

At that point, the doctor thanked us for including his group and suggested we might wish to present this to the other two groups. Tim said this was on his mind as well and wanted to talk to the group about this after the meeting. Sue asked to speak then and discussed the need she was feeling to repay our group by speaking to other groups about how she had been able to get off medications. A.J. said he would like to do the same and the two of them could cover the topic because Sue had only been on oral medications and he had started on insulin, which should help people know that it might be possible.

Tim asked for a show of hands for any that might be interested from the doctor's group and there were three. The doctor said they had approached him about this and it would be good to hear this now. Tim asked Sue if she was ready and Sue said she was and A.J. felt that he could follow Sue's lead. Sue took the lead and said it was good to know that those interested had talked to the doctor as this was an important first step and without the doctor's consent, she felt that people would not be prepared to stop all medications.

Sue then stated that anyone interested should attempt to get extra testing supplies as they could greatly benefit from the extra testing for up to three months. Next, she said that an exercise regimen was necessary that they could adhere to. She felt this also should be discussed with their doctor. She and her husband used jogging and walking, swimming, and dancing. Now that the weather is changing, they have two exercise machines available for them to use when the weather is too cold or snow would be difficult to run or walk in outside.

A.J. continued that he was running about 4 miles during the evening and up to 10 on the weekends. He said that he occasionally sees Sue and Bob swimming when he uses the pool as well. He said also has a machine for when the weather is such that he will not be able to run. He said his doctor had approved of his regimen and felt this was important. He said some would need to reduce the amount of food consumed until they build up their routine and become used to the amount of exercise.

Sue confirmed this and said it was good that her husband was participating with her and admitted this may be necessary for some people to become committed to a routine. She said A.J. has been able to do this alone, but they do see each other from time to time and she said this is good even if a group wants to exercise together. She said that some are able to get off of all medications and in her correspondence, she has found that some are not able to develop the regimen strong enough to be successful in staying off medications. This is part of the reason for the additional testing and to make sure that if you need medications, you do not let your diabetes get out of hand before getting back on medications. Her husband, Bob confirmed this and said he almost went back on medications until the period of travel for him ended this fall as his readings were starting on an upward trend until he was able to stop traveling and spend the time needed to exercise with his wife.

At that point, Sue said it takes dedication and work and for some people that don't have support from family, friends, or a support group like she has, it may not be for everyone. There were a few questions and the doctor said that he agreed with what had been said and felt that for some it would be possible, but not to consider themselves as failures if they could not stay off of medications. A.J. agreed and the meeting ended.

The doctor asked to talk to Tim, Rob, and I about going with us to any meetings we were able to schedule. I stated that I already had one scheduled for the third Friday in November and wanted Rob to go with me. I said I would be back in contact with them now about Sue and A.J. presenting as well. The doctor said he would like to go with us as he had not known about this group and felt it could be good to meet their doctors and exchange ideas. I asked Sue and A.J. if they could go if the group approved their presenting and both felt they could. Tim said he would drive and the doctor volunteered if there was approval for Sue and A.J. Then we left it at that point.

In the following week I could not get approval for Sue and A.J. for this meeting, but they said this would be considered for their March meeting. The rest of us were approved, so Tim will drive then.

Importance of Medical Alert Jewelry

Warning – if you are taking insulin or oral diabetes medications that may cause hypoglycemia, you need to be wearing medical alert jewelry. Yes, I think it is that important. Everyday, an officer of law enforcement, somewhere in the United States encounters people that are driving as if they were drunk, but in reality, are suffering from low blood glucose (hypoglycemia) and they have no indication that the person has diabetes.

One highway patrol officer of my state says he has no sympathy for people with diabetes that do not wear medical alert jewelry. Because he has a younger brother that has type 1 diabetes, he knows how quickly a low can happen and the dangers it can cause when driving. He likes to tell the story of how one afternoon near the end of his duty for the day, he came upon a vehicle partially in the ditch and a female driver slumped over the wheel. Upon going up to the vehicle and looking in, he could see a medical alert bracelet. Rather than investigate then, he returned to his vehicle and called for an ambulance saying he would return with information when he could read the bracelet information.

He returned to the vehicle with a tool to open the door if needed and it was needed. Upon opening the door, he could not smell any alcohol and went to the medical alert bracelet. He could read that the young woman had type 1 diabetes and recorded the telephone number and the number on the bracelet. Then he checked to see if there was a pulse and finding one, went back to his car and called the number to his headquarters.  This was then passed to the hospital and the ambulance crew. Then the hospital checked the information and suspected hypoglycemia.

When the ambulance arrived, the first thing they did was check the blood glucose level and because of the low number, immediately started a glucose IV and then removed the woman from the vehicle and put her in the ambulance. Within 20 minutes, she regained consciousness and shortly was able to answer questions. She had the officer search her car and find her glucose log book. She had him find the page for the current day and a reading for the time she had started to drive. He knew that the reading should have been okay and asked how long she had been driving. She indicated about an hour and one half. Actual time from blood glucose reading to when the officer read this was almost two hours.

She said that she had all of a sudden felt dizzy and had started to pull off the highway. She stated that she had apparently not been able to stop the car completely before passing out. She could only remember shutting off the car, but nothing else until coming to in the ambulance. The officer had put this much together because her car was not completely in the ditch and not completely off the gravel side of the road. The officer told the woman he was glad she was wearing a medical alert bracelet. She admitted that she did not like them, but her mother had insisted on her wearing one that day.

The officer asked her permission to see if he could get the car back completely back on the gravel and she asked him to do this please. The ambulance crew continued to monitor her blood glucose level and removed the IV when she attained a certain level. They then tested her a half an hour later to see if she was holding this and the officer said that since she was and could walk, that they could return and he would check her once more before letting her drive since she had her testing supplies located. When she tested herself about 15 minutes later, she was still okay and the officer asked her to stop in 15 minutes and check herself again. She said she would and he suggested that she continue to wear her medical alert bracelet. She said that she had to now as this had given her a good scare and without it, the officer may not have had a clue as to why she was slumped over the wheel.

He said in the next year he had seen her five more times and she always held up her arm to show him she was still wearing the bracelet. He said the one time that they were able to talk, she said that she has continued wearing it and had thanked her mother for insisting on her wearing it that day.

Read this blog about the pros and cons of the different types of medical alert jewelry.

Diabetes Medications, Insulin

The medically correct terms listed here are from many sources and the most often used. I have added other terms I have been taught or that I have learned over the years.

• Onset refers to when the insulin starts to work. I was taught Begins or Activates.
• Peak refers to when the insulin works hardest. I was taught Effective Period and Period of Maximum Effectiveness.
• Duration refers to how long the insulin works. I was taught Length of Usefulness.
• Official sources list nothing about when insulin ends and I was taught End.
  

Next, we need to consider the types of insulin:

• Rapid-acting - I learned fast-acting insulin.
• Short-acting - This was never explained to me and I lumped it with fast-acting,
• Intermediate-acting - I learned this as 12-hour insulin.
• Long-acting - I learned this as 24-hour insulin.
• Pre-mixed - I learned was mixed insulin.
  

Now that you have an idea of the different terms used, understand that this applies to the average person with diabetes. All the directions and times used are for the average person. I take Lantus, which is a 24-hour insulin. I cannot count on this as through experience and my body chemistry, I have learned that I have an 18 to 20 hour effective period of insulin use. Others have no problem of Lantus lasting for 22 to 24 hours. I believe your own body chemistry has some effect on the effective period insulin will last.

For Novolog, the average times are onset of 15 minutes; peak 30 to 90 minutes, and duration of 3 to 5 hours. For me the duration is about 3.5 hours and I have no further benefit. Again your body chemistry may allow for different times. I have a friend that has to be ready to eat very quickly after injecting insulin because the onset for him is about 10 minutes and peak is about 20 to 50 minutes and duration is only 2.75 hours. Unusual, yes, but this is just his body chemistry in action.

Insulin acronyms:


L: Lente. An insulin product. It has an onset of action 2-4 hours after injection, a peak activity 6-12 hours after injection, and a duration of action of 18 to 26 hours. Lente insulins are of human make and have been discontinued in the USA, but are legal to import for people allergic to analogue insulins.


NPH: Neutral Protamine Hagedorn It has an onset of action starting about 2 hours following injection. It has a peak effect 4-12 hours after injection, and a duration of action of 18-26 hours. A nickname has been attached to this insulin and it is “not particularly helpful.”


R: Regular. An insulin that has an onset of action within 30 minutes of injection, reaches a peak effect at 1-3 hours, and has effects that last 6-8 hours


Please refer to these charts for insulin. Chart 1 (most complete), Chart 2, and Chart 3. There are other charts and you may wish to bookmark the chart that gives you the information you desire.

Endocrinologists and “Choosing Wisely”

When comparing the “Choosing Wisely” pronouncements of the Society of General Internal Medicine (SGIM) with the American Association of Clinical Endocrinologists (AACE) and their educational arm, the American College of Endocrinology (ACE) both are out of line to my way of thinking, but the AACE/ACE is more reasonable.

To review, the SGIM stated, “Don't recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin.” The AACE/ACE states, “Avoid routine multiple daily self–glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia.” If for no other reason than many oral diabetes cause hypoglycemia, this is less threatening to people with type 2 diabetes. Plus they left themselves some wiggle room with the words multiple daily. The members of SGIM clearly stated no daily home finger glucose testing unless on insulin.

Obviously, Dr. Alan Garber was not made part of the selection committee or we would be relying on only the A1C results and be completely in the dark. The ACE president, Daniel Einhorn, MD, medical director of the Scripps-Whittier Diabetes Institute, La Jolla, California is a lot more thoughtful and maybe more patient oriented. He said of “Choosing Wisely”, “The whole Choosing Wisely campaign is to alert physicians to be thoughtful and for patients to also question when something is ordered or suggested."

Dr. Einhorn explained how the endocrine societies came up with their recommendations. "The list reflects the observation of a group of experts who've seen people order certain tests that are just not necessary. Other items could have been chosen, but these were felt to be perhaps the most common mistakes made. The recommendations are likely to evolve over time as more is learned." I do not appreciate being termed a common mistake just because I have diabetes.

Dr. Einhorn is right about vitamin D. Many doctors do use the incorrect test for vitamin D deficiency. Many doctors use the 1,25-dihydroxyvitamin D when they should use the 25-hydroxyvitamin D test. This test is less expensive and valuable for vitamin D deficiency. The 1,25-dihydroxyvitamin D is correct for use in patients with hypercalcemia or end stage kidney disease.

The GLP-1 Agonists

Victoza (liraglutide [rDNA origin] injection)

I dislike starting this with a warning, but it is important and valid for this medication. Just because a celebrity chef (Paula Deen) promotes this medication does not make it safe and I suspect there will be more warnings in the future.

Warning Liraglutide injection may increase the risk that you will develop tumors of the thyroid gland, including medullary thyroid carcinoma (MTC; a type of thyroid cancer), which may cause death if it is not treated at an early stage. If you develop thyroid cancer, your thyroid gland may need to be surgically removed. Tell your doctor if you or anyone in your family has or has ever had thyroid cancer, medullary thyroid carcinoma, or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2; condition that causes tumors in more than one gland in the body). If so, your doctor will probably tell you not to use Liraglutide injection. If you experience any of the following symptoms, call your doctor immediately: lump or swelling in the neck; hoarseness; difficulty swallowing; or shortness of breath.

Keep all appointments with your doctor and the laboratory. Your doctor may order certain tests to check your body's response to Liraglutide injection.

Your doctor or pharmacist will give you the manufacturer's patient information sheet (Medication Guide) when you begin treatment with Liraglutide injection and each time you refill your prescription. Read the information carefully and ask your doctor or pharmacist if you have any questions. You can also visit the Food and Drug Administration (FDA) website (http://www.fda.gov/Drugs/DrugSafety/ucm085729.htm) or the manufacturer's website to obtain the Medication Guide.

Talk to your doctor about the risks of using Liraglutide injection.

I strongly urge you to read this link (a PDF file) or the suggested links above in the warning so that you can familiarize yourself about Victoza. There are many special instructions that need to followed for proper use and avoiding problems with Victoza. Victoza is manufactured by Novo Nordisk.

Amylin Mimetic (Symlin) (pramlintide acetate)

This medication is not for people with type 2 diabetes taking oral medications. It is only for people already taking insulin. There are several warnings you must take seriously. Symlin cannot be used in place of insulin. You must use a separate syringe to inject Symlin. Symlin may reduce the amount of insulin you need to use. Non-compliance is a problem for those taking Symlin.

Symlin does help keep your blood glucose at lower levels after you eat by helping your liver not put glucose into your blood stream. It may also prevent hunger, causing you to eat less and has the potential to assist in losing weight.

You should not take Symlin and need to talk with your doctor if you can't tell when you are having low blood glucose, a condition called hypoglycemia unawareness, you have recently had severe low blood glucose, you have stomach problems caused by diabetes-related nerve damage, and the standard if you are pregnant, planning to get pregnant, or breastfeeding. Symlin has not been studied for use in children. There may be times when you should not take your usual dose of Symlin and this includes if you're having surgery and you’re sick and can’t eat. Also, discuss with your doctor about other times not to take Symlin.

Symlin can cause the following side effects and you should be prepared for them. They include - nausea and vomiting-most often when you first start taking Symlin, swelling, redness, or itching of the skin where Symlin is injected, headache, decreased appetite, stomach pain and indigestion, tiredness, and dizziness. Symlin does not cause low blood glucose by itself; however, your risk of having low blood glucose is higher because Symlin is always taken along with insulin.

Symlin is manufactured by Amylin Pharmaceuticals, Inc.

Incretin Mimetic Byetta and Bydureon (extended-release for injectable suspension) (exenatide)

Byetta and Bydureon are very much like Symlin, but you need to add that both help slow digestion by moving the food slowly through your stomach. Both are not to be used in place of insulin; however, people on oral medications or not on any medications may use it if appropriate.

You should not take Byetta or Bydureon and need to talk with your doctor if you have severe stomach or digestive problems, you have any symptoms of kidney disease or are on dialysis, you are pregnant, planning to get pregnant, or breastfeeding, and you have type 1 diabetes. Both have not been studied for use in children.

The possible side effects Byetta and Bydureon can cause are - nausea and vomiting-most often when you first start taking them, headache, diarrhea, and dizziness. Byetta and Bydureon also can cause an acid stomach or make you feel nervous.

If you are planning to take either, you need to know about problems with your kidneys

and talk with your doctor right away if you notice any of the following - changes in the color of your urine, how often you urinate, or the amount you urinate. swelling of your hands or feet, tiredness, changes in your appetite or digestion, and a dull ache in your mid to lower back. Byetta and Bydureon do not cause low blood glucose by itself, but your risk of having low blood glucose goes up if you also take diabetes pills that cause low blood glucose, or insulin. Your doctor may advise you to take a lower dose of your other diabetes medicines while you are taking Byetta or Bydureon.

Byetta and Bydureon are manufactured by Amylin Pharmaceuticals, LLC and AstraZeneca Pharmaceuticals LP.

These GLP-1 agonists are all under suspicion of causing pancreatitis and pancreatic cancer, but presently the FDA is not convinced and seems to be waiting for additional adverse events.