Holiday Greetings

To all my readers

May you have a happy holiday season

Have a Merry Christmas!

and

A Happy New Year!

The blog will continue during the holidays. I wanted to take this opportunity to greet everyone and wish you happy holidays!

Diabetes Management Relying on Pharmacists

Pharmacists are being relied on more and more to play a key role in diabetes management, especially for type 2 patients. With certified diabetes educators not adding membership at a pace to keep up with the increase in numbers of new type 2 patients, this is a welcome help for type 2 patients.

I will not include a single case study from Washington, but will use the national program Project IMPACT: Diabetes, a program launched in 25 communities across the United States with disproportionately high numbers of cases of diabetes.  This study found that many participants saw improved levels of A1c levels, cholesterol, blood pressure, and body mass index. The data was compiled by the American Pharmacists Association Foundation.

This data found that because patients had one-on-one consultations with their pharmacists, medications could be adjusted to better meet patients' needs, allowing for improved results. The study also had the pharmacists provide counseling on exercise, nutrition, and lifestyle changes while collaborating with physicians, diabetes educators, and other healthcare providers to ensure that patients receive comprehensive care.

"Working together with pharmacists empowers all types of patients, rich and poor, insured and uninsured, anywhere in America, to take the steps they need to understand and manage their diabetes while living healthier lives."

"Everyone with diabetes faces challenges such as adhering to prescribed medications, monitoring blood glucose levels, staying current with vaccines and foot and eye exams, and maintaining a healthy diet and lifestyle," Lindsay Watson, RPh, director of applied innovation for the American Pharmacists Association Foundation, said in a press release.

I don't expect that all pharmacists are participating or anticipate being this involved in the needs of people with diabetes, but many are working to improve the lives of people with diabetes. Much of this is possible because people are more willing to talk to pharmacists than they are to doctors on a time schedule. Then think about the doctors belittling their patients and using threats to keep patients on oral medications and it is easy to understand why many patients are more willing to discuss medical problems with a non-judgmental pharmacist.

Another factor in favor of the pharmacists is across the United States in the smaller rural communities; the pharmacists are part of this community and receive the respect of the community. Helping their pharmacy customers is part of a natural outreach to their community.

If you haven't read my previous blog about a five state pharmacy group and how they are helping patients with diabetes, please do so as this could be what is needed to stop the diabetes epidemic.

User Errors in Blood Glucose Testing

User errors are very common for people with diabetes. The equipment that helps us measure our blood glucose and manage our diabetes is delicate and deserves our care to function as intended. Yet, I see people doing the wrong things and wonder why the readings they receive from their meters are unreliable.

This is not a comprehensive list, because when I think it might be, I always discover another error or watch people abuse their testing equipment in a new way. I do wish people would read the instructions that are contained in the box with the container of test strips and read the instruction manual that comes with their meter.

The list of user errors that I have seen to-date:

#1. Not keeping the test strips in the container they came in. I have seen people take them out of purses, wallets, zip-lock bags, and other containers. Some even have them in tea bags holders or folded paper towels to protect them from the light, but this is not the correct way to carry them. The container you receive them in is the only proper container to carry them in as this container is manufactured to protect them from light and moisture. If you will be spending the day on the water, then you may wish to put the container and your testing equipment in a zip-lock bag.

#2. Not carrying the meter in its case. Using the case that came with the meter is best, but will not prevent lint and dust from getting in the meter if the case is left open when not using the meter. Lint and dust are often the culprits that cause a meter to not read the test strip properly. I have seen people carry the meter in purses, pockets, and backpacks or fanny packs and not in the intended carrying case. I have even watched people search through their purses, backpacks, and other places for the different parts to the lancet device while dust was blowing onto their meter. One of our support group members commented about people handling their test strips and meters with wet hands after getting out of the swimming pool to test their blood glucose levels. If you want accuracy in testing, this is not a good practice.

#3. Keeping the container of test strips and meters on the car dashboard, in the car glove box, or even the seat of the car in the summer or winter. This delicate equipment has temperature guidelines for storage and use. Baking them in the car or freezing them will not produce accurate test results. Yet this seems to be a favorite place for people to carry them.

#4. Using test strips in direct sunlight. This is a big no no, but I see people do this quite frequently. Not too many days ago, my wife and I were in a restaurant, and a couple was sitting in the sunlight. I watched the wife take her meter out of the purse and sit it in direct sunlight, then dump out a few test strips, pick one up, and insert in her meter. Then she needed to hunt up the parts of the lancing device from her handbag, assemble it, and then prick her finger and wick the blood into the test strip. I could see her pull out the test strip, insert another from the pile on the table, and repeat the process. This happened two more times before she gave up. The first error was not having the lancet device ready for use. Then she should have only taken one strip from the container and kept the meter and inserted test strip behind something to prevent the direct sun from shining on it while pricking her finger.

#5. Most people do not take time to read the instructions that come in the box with the test strip container. I admit I did this for a few years until instructions started to change. Until about four years ago, instructions seldom changed. Now they change at least once a year if not more often. Maybe not much of a change, but changes nonetheless. Some have been important, such as the change from using alcohol pads to wipe the finger to using warm water and soap to clean your fingers and then drying your hands thoroughly.

#6. Many people are not aware of using the second drop of blood or when this should be used. Read my blog here for when to use the second drop of blood.

We as patients can make many more errors in testing our blood glucose levels. For the errors David Mendosa covers, read his blog here. David has a better grasp of some of the mistakes we can make when we don't respect the delicate equipment we have to use.

I have also written other blogs about errors we make. The first is about the importance in hand washing that is here and the second is about the needless ways we find to waste test strips and this blog is here.

For those that have problems getting a single test strip out of the container, my suggestion is obtaining a plastic tweezers for use. I have two that I use when I open a new container. I have taken both and glued a quarter of an inch length of a three eighth inch wide rubber band on the outside of the tip of one side of the tweezers and then wrap it slightly around the tip.  The second tip as a quarter in of a thin rubber band glued to the inside of the tip.  To pull out a test strip, I insert outside of the first part into the container very carefully and once I have it far enough in to pull out a test strip. I have the container tilted enough to pull one strip out and then when it is far enough out to rotate the tweezers to grasp with both tips, I lightly squeeze and extract the test strip. Still holding the test strip with the tweezers, I set the container down and close the lid. Then I grasp the test strip with my fingers and set the tweezers down. I then pick up the meter and carefully insert the test strip in the slot in the meter.

Granted, this did take some practice to do this without damaging a test strip. It is better than dumping a few test strips out and then risk damaging them when putting them back into the container. I don't know that the manufacturers of the test strips would approve of this, but it works for me. Never, I repeat, never use a metal tweezers. The metal will damage the test strip and some have been magnetized and this will damage the test strip.

And with many of the errors I witness, I ask myself why these people are even testing. They create a climate that wastes test strips and do not receive readings that are reliable. It is bad enough that there is a built in margin of error, but to needlessly add more error margin with the mistakes many people add to the built in error margin really is a waste of money for the results they receive.  If you are using insulin, these errors can create hypoglycemia that you don't want.

Diabetes, What Ignorance Does for You

Ignorance tends to be the rule when it comes to diabetes. This applies to the doctors and to the patients. Many doctors order the patients to test their blood glucose and then stop their explanation. Instead of explaining the why, when, and how to test, their ignorance shows because the patients often have no idea what they were told.

Many patients then seek out their pharmacists and receive the information needed. However, these same patients only think they are testing for their doctor because he ordered them to do it. Ignorance is king among these patients. A small group will attempt to find out why they should test and spend some time trying to learn. Then when they don't find anything that “applies” to them, they give up and test for the doctor. Others just test because the doctor told them to do this.

Some find the American Diabetes Association (ADA) website and become baffled by the mountains of information available. They soon realize that most of it is aimed at doctors and become discouraged. They do not find the information for patients, the forum, and other patient information.

Some find the American Association of Clinical Endocrinologists (AACE) website, but because they have dropped the list of approved diabetes websites and have no links to other sites they have, people do not often stumble across this site. Some do not like this site because there is not a lot of good patient information contained in it. This tells me that the AACE does not really care about patients either.

All diabetes organizations work harder for people with type 1 diabetes, as they should.  When it involves people with type 2 diabetes, we are stepped on or ignored, they won't support testing requirements and want limits on our testing supplies. The leaders of the ADA and AACE think we can survive by only knowing our A1c results. This is further discouragement for people with type 2 diabetes and many let this lead to further ignorance about the importance of managing their diabetes.

Many people refuse to learn about diabetes and how to manage their diabetes. They trust their doctor to do what is best for them and as a result, they forget to manage their diabetes, remain ignorant about diabetes, and let their blood glucose levels do damage to their bodies and progress to the complications. Most doctors fully believe this and treat their patients with diabetes accordingly with no education, or encouragement to manage their diabetes to delay or prevent the complications from developing.

If people with type 2 diabetes would learn about diabetes and how to manage it, they could do a lot to prevent or delay the progression to the complications. A few of the complications may develop, but with good diabetes management, many of the more serious ones can be delayed for many years. Most people with type 2 diabetes develop neuropathy, but with good management, even this may not develop as fully as it can.

It is still a shame that people have to let ignorance govern their life with diabetes, when it possible with self-education to manage diabetes and die of old age before many of the complications rear their ugly heads. It is also a crime that our doctors care so little for their patients and will not even help with education. If they could work with peer workers or peer mentors this could really boost the education level. Doctors could also provide a page with good diabetes sites to help with education, but doctors can't seem to do something this helpful because they won't be paid for their time.

If you think that this article is on track about whom people turn to for diabetes information, you would have to question how the questions were asked and the source of the survey. They make it sound good for the doctors, but by doing some intensive research, certain words lead to doubts. “Eight-in-10 indicate their doctor is very or somewhat involved in their own or their household member's diabetes management; half report their doctor is their primary source for condition info.” 'Somewhat involved' is a key two words and leaves a lot to be desired.  "Primary source for condition info" is very confusing and means that as diabetes progresses, the patients can only rely on receiving condition information and nothing about prevention of the progression to the complications.

The fact that AccentHealth is a source of information that they put in the waiting rooms and doctors exam rooms may mean that they have a right to claim what they do. This does not mean that the doctors are the 'go-to' source of information, just that they have some of the information that may help patients. Most doctors do not have the time for education and maybe have their nurses handing out the information provided by AccentHealth. Either way, patients must still read these handouts, many of which end up in the waste containers in the doctors' offices.

Most of the pamphlets are advertising for diabetes drugs or drugs for the disease that you are seeing the doctor for help. Very little in the pamphlets is about managing the disease and self-education. I know that the pamphlets for diabetes have very little to help the people with diabetes other than make them familiar with the drugs they want the doctor to prescribe. In my opinion, they cannot be relied on for good diabetes management information.

Dawn Phenomenon Affects Up to Half T2DM

This was a bit of a shock for me when I read that approximately half of type 2 diabetes patients are affected by the dawn phenomenon. I knew that there had to be a large number by what I read on many of the diabetes forums, but half was even larger that I had guessed. No wonder this is such a problem and concern for type 2 patients.

The study by Louis Monnier, MD, from University Montpellier, France, and colleagues reveals that the dawn phenomenon has a significant impact and is present in some patients treated by diet alone. This effect is not prevented by oral diabetes medications. The dawn phenomenon refers to a spontaneous rise in blood glucose that occurs at the end of the night in patients with type 2 diabetes. This does not occur in individuals without diabetes, because endogenously produced insulin prevents this.

The one medication that does prevent this is insulin (Lantus or Levemir) when given at bedtime. In patients whose HbA1c is approaching 7% that are demonstrating evidence of the dawn phenomenon, insulin use should be considered earlier than it is traditionally, because insulin can eliminate this effect.

"We have defined the frequency of the dawn phenomenon in type 2 diabetes, which in the present paper occurs in around 50% of patients, and this definition is more accurate than previous ones due to our use of continuous glucose monitoring [CGM] systems," Dr. Monnier told Medscape Medical News.

Dr. Monnier agrees with Geremia B Bolli, MD, from the University of Perugia, Italy, that the new findings indicate that insulin use should be considered earlier for type 2 diabetes patients showing evidence of the dawn phenomenon. Presently doctors are unable to control the dawn phenomenon with the current array of oral hypoglycemic agents, even though metformin is probably the one that has the highest potency for reducing it. Currently insulin should be considered for the treatment of type 2 diabetes as soon as the HbA1c becomes greater than 7% when patients are already treated with maximal tolerated doses of oral agents.

Dr. Bolli states, “This new research confirms that the dawn phenomenon is a common occurrence among type 2 diabetes patients, independent of oral therapy and in a real-world setting. The work also reaffirms what should be a primary objective of type 2 diabetes therapy, he says, that is, treatment of the dawn phenomenon — the normalizing of blood sugar around breakfast time. I think if A1c is greater than 7.0% and the postprandial blood glucose is okay, one has to work on the fasting blood glucose, and the best approach is basal insulin in the evening."

My advice to patients is to talk to your doctor if you are having problems with the dawn phenomenon to prevent problems of hyperglycemia in the morning. Be careful, but don't let your doctor put you off, as this is important in your management of diabetes.

David Mendosa has posted an excellent blog here about the dreaded dawn phenomenon. He covers the same study, but has more background for your reading.

Problems with Test Strip Accuracy

I hate to say this, but a large percentage of people with diabetes do not read or are afraid of reading. Why do I make this statement? I am constantly surprised what people do with their test strips. A few days ago, I was invited to a get together for several people that I knew were people with diabetes. The person being surprised was a type 1 (Lilly) and her parents had planned this.

I knew most of the people present, but I was in for a few surprises myself. We had been in the game room when we were asked to come to the dining room for some treats. I was not planning on food and let the hostess know this. I had thought to wash my hands and used paper towels to dry them. I had not seen Max and Allen arrive, but I was not surprised to see them as we came through the kitchen.

After we were all seated, the food was explained to us and we could tell that the mother had done the preparation as each was labeled with the grams of carbohydrates. For those that had doubts, the recipe was listed and the servings for each and the nutrition data. The mother said that the serving size was accurate to the gram so they knew that the carbohydrates were also correct. Max said he could vouch for them, as living across the alley; they often compared notes on recipes. He added that they had borrowed his gram scale for this as well.

At that point, we were given permission to test and go to different areas if we wanted privacy for injecting insulin. Out came the testing supplies. Allen and I both looked at each other as we watched some of the testing. We were done before most and Allen asked me if we should comment. I agreed and said to wait until we had finished at the table.

When everyone was finished, one fellow that had heard Allen and me talking asked what we had to say. I said that we had noticed habits that we felt should be educated for, if they had no objections. No one objected and Allen asked if anyone had read the instructions that came with their test strip box. No answers and Allen asked me to explain part of what we had noticed. I commented that I had not witnessed anyone washing their hands. Several said they had not seen me wash mine. I said that I had used the washroom on the lower level and Allen said he had washed his before arriving. The daughter said she had seen me use the washroom before coming upstairs to the kitchen.

Allen commented that several had test strips in unapproved containers or in paper towels. Others had dumped several test strips onto the table before testing. I continued that several had been eating fruit before being called up for the food and before testing. If they had cleaned their finger with alcohol pads as we had seen several do, we would bet that they would have hypoglycemia shortly. One of the people with type 1 diabetes laughed and said listen to the type 2's talk.

Allen said he knew that he had an insulin pump and a continuous glucose monitor (CGM) on as his equipment. I asked him to look at his CGM for about 20 minutes earlier and compare this to his meter reading. The other person with type 1 diabetes did look at his CGM and commented that he would probably have a low, as his meter was higher by quite a bit than his CGM. This caused the second person to look and he admitted that was the case for him as well.

I said that the alcohol pads did not remove the fruit sugar from their fingers and that was why they should have washed their hands with soap and water and dried their hands carefully. Allen has the same meter as I have and had just opened a new box, took his instructions out, and asked the daughter to read some of the instructions. She read the part about washing the hands with soap and water.

Next, Allen asked her to read the instructions for keeping the test strips in the container they came in and she read this. She knew to continue reading about using the test strip removed from the container as soon as possible, keeping it out of direct sunlight, and not handling it with wet hands. It also said to close the lid after removing a test strip.

Allen commented about those that were used from other containers and paper towels could not be relied on as being accurate and people were wasting money when they dumped three or four test strips on the table and did not return them to the container as soon as possible, but did after they were done with testing. The daughter continued reading about this and carefully read the part about not damaging test strips by removing too many and putting them back in the container or transferring them between containers.

One of the people with type 2 diabetes had his instructions for his test strips and read them to himself while we were discussing our instructions. He commented that his instructions were almost the same, but said to only remove one test strip and close the lid immediately, carefully insert the strip in the meter, and then prick the finger.

The one person with type 1 diabetes said he had never read about washing with soap and water and had been taught to clean his fingers with an alcohol pad. I asked him if he had trouble with his fingers cracking and having pain in testing. He said he always wears gloves when outside and used a lotion to keep his fingers from cracking. Allen suggested that he take time to read the instructions that come with his test strips and the instructions with his meter if he still had them.

The rest of the party was rather somber, but when I said something to the mother, she said that was why she enjoyed having people with type 2 around. Her daughter always learned more from people with type 2 diabetes than from the people with type 1 diabetes. Her husband said we always seemed more concerned and caring than the few with type 1 diabetes. He realized that there was a difference between the two types, but the members of the type 2 group were always willing to advise her to talk with the endocrinologist for most things instead to saying his daughter must do this or do that. He said he and his wife always appreciated that.

Allen stated this is always best and their daughter needs to trust the endocrinologist. Then Allen added that we may know some things, but if we speak out against something the endocrinologist says we are undermining the endocrinologist. The mother said that is why when we have parties, we make sure that several of you are present. She said that her daughter learned quite a lot today and said that with her being the one reading the instructions, and having the same meter, she knows that you are right. Today was a good lesson for her and she will remember that you were not putting the rest down, just correcting their poor examples. With her about ready to have a pump, she said I am happy you took the time to point her in the right direction.

With that I needed to go home and Allen was ready to leave.

How Hiking Is Good for Mind, Body, and Soul

Many people write about how hiking or being out in nature is good for the body and the mind, but everyone shies away from mentioning your soul. I think this is important to help feed the soul and let it absorb the wonders of nature and refresh itself in the beauty around you.

This article in WebMD emphasizes the body and mind being helped by hiking and this is true. Hiking does have its perks. You can take advantage of the scenery, fresh air, sounds, and smells of nature. This is true if you are not downwind of certain animals and some landfills.

Hiking in nature is a great cardio workout that equals or exceeds the benefits of walking. These benefits include less risk of heart disease, diabetes, breast cancer, and colon cancer. Then you can add help with blood pressure and blood glucose levels. Many people forget about the benefit of boosting bone density, and helping prevent osteoporosis.

Besides the above, hiking can help in weight management, muscle strength in most of the muscle groups. Gregory A. Miller, PhD, president of the American Hiking Society says, "Research shows that hiking has a positive impact on combating the symptoms of stress and anxiety."

Safety should always come first. Always consult your doctor if you are starting a hiking regimen to make sure there are no health problems that could end this. These hiking tips should be kept in mind:

#1. Start slow. Short local hikes are best for beginners and keep them on fairly level terrain at the start.

#2. Bring a buddy. Starting slowly means, you should not be on unfamiliar or remote trails, but if everything looks good, it is wise to take a buddy or be part of a group. As your skill improves, you may be more comfortable going solo.

#3. Know before you go. Always familiarize yourself with the trail map, check the weather and pack for the day. If storms are predicted, it may be wise to rethink your plan for the day.

#4. Use common sense. Until you know the hiking area, follow marked paths and trails. Avoid contact with questionable plants, give certain animals a wide area, and be careful of the pungent animals.

#5. Get into a groove. On days when it is wise to avoid nature trails, try to power-walk on hilly terrain in familiar areas. Try to carry various amount of weight in a backpack (water is always good). This will help keep your hiking skills and fitness level up.

Are you past the beginner level? Now it is time to get more out of your hiking and boost your fitness level. The following are suggestions:

#1. Use poles. Use poles to dig into the ground and push yourself forward for increasing upper body strength and to give you a stronger cardio workout.

#2. Head for the hills. Even a short hill may intensify your heart rate and burn extra calories.

#3. Bump it up. If you have the stamina and no problems, try some uneven terrain, which will work muscles and improve balance and stability.

#4. Weigh yourself down. Add extra weight to your pack (see #5 above). This can boost your calorie burn while strengthening your lower back muscles.

#5. Keep safety first. I cannot emphasize this enough. Always be alert for animals in some areas of the country, such as bears, and even coyotes. Most of the time they will avoid you, but if they are hungry, then be wary. Listen to news reports for animal problems near when you are planning to hike. Animals can vary by the area of the country in which you live. In some of the southern areas of the USA, snakes and other reptiles may be of concern.

Above all, enjoy yourself and consider taking a camera with you. David Mendosa has a blog you should read about his exploits with his cameras.

Always take your blood glucose meter and testing supplies with you, in addition to glucose tablets or glucose gel, and if needed, your medication.