The Holidays and Alcohol for People with Diabetes

Okay call me Scrooge, but it has been a long time since I have had alcohol of any kind and I admit that even then, I never understood having alcohol during the holidays. I became the designated driver during the holidays and felt good about this as I got to see and hear some things not meant for me to see or for my ears normally.

Then when I developed diabetes, I was happy I was not drinking. I always felt that family came first and not the parties. Alcohol can torpedo even the best diet plan. There are several effects of alcohol, the first being the lowering of a person's inhibitions. This in turn makes keeping to a meal plan harder to keep and that large piece of dessert finds its way onto your plate with little resistance.

Alcohol can disrupt sleep and those of us with diabetes know we need our sleep. Yes, and the next day, we are often have a craving for more food – I remember this from my single days while overseas. And I know from what I have read that having a meal heavy in carbohydrates and then drinking a few glasses of wine, people can have blood glucose problems when they have a low from the alcohol.

Everyone and especially people with diabetes, don't have the ability to compensate for alcohol. Cocktails and mixed drinks often have 300 to 400 calories and many frozen drinks get as high as 700 calories. Most people do not add the calories of alcoholic drinks to the calories of the meal and there goes the food plan out the window.

Where the person got the information that answers the questions, I really have to doubt the correctness of some of the material. The author says a calorie is a calorie and those of us with diabetes know that one calorie can differ from another calorie. Then the author says, "Theoretically, everyone could lose weight if they lowered their calories to a certain level.”

The author says alcohol isn't really a food, but a toxin. This means that the body sends the alcohol to the liver to detoxify it, break alcohol down, and convert some of it to sugar and other things that the body can eliminate. Alcohol does not provide what the body needs – essential amino acids and fats.

Alcohol can increase our hunger. Some people do have this problem and with diabetes, this is when they lose good diabetes management. Some “experts” recommend moderation, but then allow more than some people should consume. The moderation has to vary for each person rather then the “one-size-fits-all” advice that is often given. Some men would be better served not having any alcohol, as would many women.

The holidays seem to bring out the worse in people hosting parties. Unless it is strictly a bring your own alcohol affair, most hosts want to push alcohol on their guests even when they have been told “no, thank you.” Then they insist and make platitudes about everyone else having a drink. Even a second “no, thanks” brings even more pressure. This is when I take my leave and when asked later why I left, I just say, because the person hosting the party did not understand the meaning of the word “No.”

Okay call me Scrooge, but it has been a long time since I have had alcohol of any kind and I admit that even then, I never understood having alcohol during the holidays. I became the designated driver during the holidays and felt good about this as I got to see and hear some things not meant for me to see or for my ears normally.

Then when I developed diabetes, I was happy I was not drinking. I always felt that family came first and not the parties. Alcohol can torpedo even the best diet plan. There are several effects of alcohol, the first being the lowering of a person's inhibitions. This in turn makes keeping to a meal plan harder to keep and that large piece of dessert finds its way onto your plate with little resistance.

Alcohol can disrupt sleep and those of us with diabetes know we need our sleep. Yes, and the next day, we are often have a craving for more food – I remember this from my single days while overseas. And I know from what I have read that having a meal heavy in carbohydrates and then drinking a few glasses of wine, people can have blood glucose problems when they have a low from the alcohol.

Everyone and especially people with diabetes, don't have the ability to compensate for alcohol. Cocktails and mixed drinks often have 300 to 400 calories and many frozen drinks get as high as 700 calories. Most people do not add the calories of alcoholic drinks to the calories of the meal and there goes the food plan out the window.

Where the person got the information that answers the questions, I really have to doubt the correctness of some of the material. The author says a calorie is a calorie and those of us with diabetes know that one calorie can differ from another calorie. Then the author says, "Theoretically, everyone could lose weight if they lowered their calories to a certain level.”

The author says alcohol isn't really a food, but a toxin. This means that the body sends the alcohol to the liver to detoxify it, break alcohol down, and convert some of it to sugar and other things that the body can eliminate. Alcohol does not provide what the body needs – essential amino acids and fats.

Alcohol can increase our hunger. Some people do have this problem and with diabetes, this is when they lose good diabetes management. Some “experts” recommend moderation, but then allow more than some people should consume. The moderation has to vary for each person rather then the “one-size-fits-all” advice that is often given. Some men would be better served not having any alcohol, as would many women.

The holidays seem to bring out the worse in people hosting parties. Unless it is strictly a bring your own alcohol affair, most hosts want to push alcohol on their guests even when they have been told “no, thank you.” Then they insist and make platitudes about everyone else having a drink. Even a second “no, thanks” brings even more pressure. This is when I take my leave and when asked later why I left, I just say, because the person hosting the party did not understand the meaning of the word “No.”

The Dangers of Hypoglycemia

There are 15 Effects of low blood sugar on the body, but there may be more. This article by Healthline dot com covers the 15 effects and is interesting to read. If you have experienced hypoglycemia, this article is worth your time. I cannot reproduce the image and the links to the discussions, but it would be worth your time to explore. Many go to the same paragraph so by reading the material below the image, you will have the important information.

I do wish this had been available when I wrote this blog and this blog, as it would have made an excellent reference. Since we do not have any of our members taking any of the sulfonylureas, or any of the other oral medications, except those on metformin, they are convinced that they do not have to worry about hypoglycemia. We have told them that they are less at risk, but there is no guarantee of prevention of hypoglycemia. Those of us on insulin are all aware that hypoglycemia is possible. That is one reason we voluntarily check on each other.

Having low blood glucose levels is not to be ignored as it can cause a rapid heartbeat and heart palpitations. If you do not have any of the obvious symptoms of low blood glucose, which include many or only one of the following: weakness, lightheadedness, and dizziness, feeling nervous, anxious, or irritable, hungry, have tingling or numbness of the mouth, blurred vision, headache, and confusion. You might also have some of the following: lack of coordination, chills, clammy skin, sweating, difficulty performing simple tasks, or at night having nightmares, cry out during sleep, or other unusual behaviors. Quite a list isn't it. Just be thankful that you can have some of these symptoms.

If you become one of the people that does not have any of the above symptoms, then you will have a condition called 'hypoglycemia unawareness.' This can happen if you experience low blood glucose so often that it changes your body’s response. Low blood glucose normally causes your body to release a stress hormone, such as epinephrine. Epinephrine is responsible for those early warning signs, like hunger and shakiness. Low blood glucose is defined as levels below 70 milligrams per deciliter (mg/dl) or 3.9 mmol/L.

Once it does happen, much care needs to be taken. A continuous glucose monitor should be necessary. If your insurance will not allow one, then take time to learn BGAT (blood glucose awareness training), it just may save your life. You will need to learn this on your own as the CDEs refuse to teach it.

Does the Glycemic Index Matter?

This is one study that goes against many studies, and being a small study – 163 overweight people divided into four groups – does not prove what they wanted to prove. The reason is there are too many variables that are not accounted for and they pushed conclusions that may not have been accurately accounted for in the study.

Yes, low glycemic index foods may not have resulted in greater weight loss, but even in the study details which I was able to acquire, the low glycemic index foods were not revealed.

I do not appreciate that even what they consider healthy foods are not detailed. Some low glycemic foods can be unhealthy and not telling what low glycemic foods were used is just as bad as not stating what healthy foods were used.

I could believe that may of the foods used were from the foods promoted by the USDA and this statement does call this into question, “In fact, researchers found that overweight adults placed on a low-GI diet actually showed less sensitivity to insulin than those on a high-GI diet. Insulin is the body's key blood-sugar-regulating hormone, and a decline in insulin sensitivity can eventually lead to type 2 diabetes.”

When a researcher says, "Low-GI diets are difficult to follow," I can believe this, as they are not as nutritious as the foods in a higher-GI diet. Then this statement points to possibly the reason for this research, "If you don't have to worry about foods' glycemic index, that makes it easier to follow a healthy diet." Don't get me wrong, the glycemic index isn't the end-all, but can provide some pointers that help people avoid diabetes or delay the onset of diabetes.

What annoyed me was that all of the diets were based on the DASH diet ((Dietary Approaches to Stop Hypertension) which is supposedly a heart-healthy plan that is built around fruits and vegetables, fiber-rich grains, 'good fats like olive oil, fish, and low-fat dairy products. Then they varied the number of carbohydrates to distinguish the different diets, either 58 percent or 40 percent of daily calories, and finally either high or low in glycemic index.

The variable was added after five weeks when the study volunteers were switched to a different diet of the four diets. By not saying which, the results could have been easily swayed the way the researchers desired. All of the participants were required to eat their main meal at the research center and then given their other meals and snacks to take home.

By not saying which diets and which they were switched to at the end of the first five weeks, they then claim the results showed some surprises. They claimed that the high-carb, high-GI diet had the greatest results in insulin sensitivity. In contrast, the people's insulin sensitivity barely changed when they followed the high-carb/low-GI diet, the study reported. None of the participants had diabetes according to the researchers.

Some in Medical Profession Afraid of Technology

Well, maybe not all in the medical profession, but at least the author of this Joslin blog raises issues which are upsetting. I am upset by a statement by Howard Wolpert, M.D., Director of the Joslin Institute for Technology Translation (JITT) when he says, “While the iWatch has the potential to enhance diabetes care in the digital realm, it is still lacking crucial functionalities that prevent the iWatch, and similar devices, from serving as a sufficient replacement for current technologies, such as continuous glucose monitors.”

Now I have to wonder how he arrived at this. I don't think the Apple iWatch intended to replace continuous glucose monitors. If the iWatch can read the data from the current and future versions, then I don't see the problem. Too many of the diabetes tools are too proprietary and guard their data zealously. Dr. Wolpert does say, “I think this has tremendous potential. But for patients to effectively use this information, the information collected needs to be analyzed to identify patterns and this needs to be coupled to specific guidance and feedback to patients around their diabetes self-care.”

This sounds very typical of Joslin. They seem to assume that people with diabetes are too stupid to self manage their diabetes. Most doctors do not have the time to provide specific guidance and feedback to patients around their diabetes self care. And in many areas there is definitely a lack of certified diabetes educators to provide education about self-care.

“Apple collaborated with Mayo Clinic and Epic Systems to create Health and HealthKit and while these partnerships provide new and innovative ways to improve access to care, they also pose regulatory issues. Dr. Wolpert cautions that with diabetes, companies such as Apple do not, “always recognize the challenges associated with developing individualized tools for diabetes care.””

At least Apple collaborated with the Mayo Clinic and Epic Systems and this may be why Joslin is negative about the iWatch. The Joslin blog author goes out of the way criticize Apple at every turn as if the two organizations don't know about diabetes or even HIPAA. While it can be understood that it might take some time to make the best benefit out of the data, the author is doing a great job of decrying Apple and the iWatch.

“One of the drawbacks with all the data collected with multiple sensors using wearable technology is overloading the patient and caregiver with too much information,” said Dr. Wolpert. “It can be counterproductive if the information is not processed and analyzed, and if the treatment recommendations are realistic and manageable for the patient. The benefit derived from using the technology needs to outweigh any additional burden that might go along with the use of the technology.”

The second statement above is why I have to wonder why Dr. Wolpert thinks all patients' are stupid. Many of the tech savvy people are often capable of making better use of the data than many doctors make. To begin with, most primary care doctors do not even look at the data from the blood glucose meters or even the logs kept by the patients. All they are interested in is the HbA1c test and maybe ask a few questions and you are out the door.

“This is setting the stage for a transformation for the way healthcare is delivered, particularly for people with diabetes who often need around the clock guidance,” Dr. Wolpert concluded.

Apparently Dr. Wolpert has unlimited amount of time to spend with a limited number of patients. Most doctors spend about 15 minutes per quarter or about one hour per year, so we cannot count on around the clock guidance. It is obvious that someone lives in a dream world.

More on Importance of Vitamins B12 and D3

This topic is still being debated and I have had several of our new members on metformin say they don't believe they have a vitamin B12 problem. Of the seven new members that are using the VA, only two are on metformin and the rest are using insulin. On Thursday of last week, two members, Julie and Earl received their lab results and both were prescribed vitamin B12. Both have been on metformin for almost seven years. This was the reason for a few of us meeting at the restaurant to discuss what they had learned. Brenda, Allen, and I were there plus the two mentioned above.

When asked, Julie said her results were severe and she had received a shot and needed to see her primary care doctor for a second shot. Earl said he was low and the VA doctor had advised him to start on vitamin B12 immediately. Allen asked Julie if she was experiencing pain in her in her feet. She would not answer and Brenda told her that she could not hide this as Allen had been through this and we know what happens with severe vitamin B12 deficiency. She finally admitted that she was having pain in her feet and Allen said it was diabetic neuropathy. Earl said he was beginning to have minor pain in a couple of toes. Allen said that the quicker he worked to maximize his blood glucose management, the quicker the pain would possibly go away, and taking vitamin B12 is part of his diabetes management.

Brenda said this would be added to the program for January 10. Allen said good, as too many have been saying that they are having pain and will not let the doctor test them for vitamin B12 deficiency. Brenda said she has been hearing the same and she has been wondering why people will not do what is right.

Brenda then asked Allen and me if it would be correct to ask for a show of hands on how many had been tested for vitamin B12. I said the question needs to be asked and the other question that should be asked first is if anyone has a burning sensation in their feet or something that feels like a thousand pins sticking them. Allen agreed and said to ask the second question first and many will not associate their neuropathy with vitamin B12 deficiency. Then we will know who needs to be tested.

I then asked both Julie and Earl what their vitamin D results were. Both answered within the range, but at the low end of the range and that their doctor had advised taking a vitamin D3 supplement. I turned to Brenda and said this is another problem area everyone needs to be aware of and consider taking vitamin D3, not vitamin D2. Brenda said I remember you blogging about this and if you would send me the URL, I will review it and decide if we should use a slide.

Allen said that he was planning to present this to Brenda, but now that we had another experience with a member and she was in on it, she knew what needed to be included. Brenda said it would be nice to have Dr. Tom available, but she understood his needing to spend less time with our group. Allen said this may be a good thing and cause us to think more for ourselves as we did before.

We agreed and said things were right for the interventions and a few other things when we needed Dr. Tom, but now we needed to be on our own and work to help our members.

Updated Insulin Information and List

This will be a short blog, but important for anyone with type 2 diabetes considering insulin or already using insulin. It is important for people with type 1 diabetes.

A 27-page printable PDF includes Ultra Rapid-Acting, Rapid-Acting, Short-Acting, Intermediate-Acting, Long-Acting, and Pre-Mixed or Combination Insulins. Detailed information on these insulins includes: Indications, Pharmacology, Dosage and Administration, Adverse Effects, and Precautions and Contraindications. These discussions are near complete with many precautions and contraindications which many lists do not have.

The listing for Humulin 50/50 which has not been available since 2010 has been deleted.

Since insulin should not be considered the medication of last resort, please take time to download the PDF file and keep it for handy reference.

I recently had a contentious discussion with a doctor that insisted that since I was on insulin that I should change from Novolog (a rapid-acting insulin) to Afrezza (an ultra rapid-acting insulin). I asked how I would know how much insulin I would inhale for the carbohydrates I would be consuming. When he stated through trial and error, I said my health was too important and with my insulin resistance, there was no way I would be a guinea pig for him. I concluded that I liked the diabetes management that I had and would not change. That ended the discussion, but he asked me to consider it as I left.

Use the above link or a two-step link from this link.

Diabetes Self-management Education Not being Utilized

I am not surprised that diabetes self-management education is underused or not utilized at the level many educators think it is. To begin with; there are too few certified diabetes educators (CDEs). As explained in my blog here, most are located in or near large populations and in the Washington DC to Boston corridor (Northeast Corridor). Out here in the hinterland, we occasionally have a CDE, but most are not reliable.

Our diabetes support group has discussed this among ourselves and now with the new members, we are getting many questions asking if they should make use of the classes. We are trying not to be negative, but one of the new members, Rose, did attend a class this week and is scheduled for one more class next week. She called Brenda and started asking questions and wondering if she should even go to the next class.

Brenda called Tim and me to come to her place and when we were there, she had Rose explain what had happened. Rose put the business card on the table where we could look at it. Both Tim and I noticed that the title was RD (registered dietitian) and CDE. I brought this to Rose's attention and Brenda agreed this could be the reason why Rose was not pleased. Tim asked her if most of the class was on food and Rose said that was why she was unhappy as very little was taught about self-management of diabetes. Rose said that was why she had asked for the class – to learn more about managing her diabetes since she was on insulin.

Tim asked if there were others in her class and how many. Rose said there were three others and all were not happy about the amount of time spent on food and the number of carbohydrates they were told to eat and the heavy promotion of whole grains. She said that two of those present people with type 1 diabetes and could not eat gluten. Rose said the person ignored that and emphasized that they would be missing a lot of nutrients by leaving whole grains out of their meal plans.

Tim asked Rose to think about returning to the class and she said she would not stay unless the person stuck to teaching about managing diabetes. She would go, but would leave if it was all about food. Tim thanked her, and then asked if Brenda would be opposed to adding this to our meeting on the tenth of January. Brenda said that was a good idea in case the class was about food. I told Tim that I knew a nurse that was knowledgeable about diabetes and she could present something. Rose said anything would be better than the class she had. Tim said to call her and see what was possible.

Then Tim said he would talk to Allen and Jason and see if they would like to do a presentation on this topic. Brenda spoke up and said she would like to work with Jason for the topic. Tim said for her to go ahead and we would not need the nurse then. He said that the evening could be long and Rose said that with the topic of testing and self-managing of diabetes, it would be interesting for her.

Tim thanked Brenda for asking to do the presentation. Brenda said it was time she started to give back and she would like this topic. She asked Rose to be available and think about questions she had and then write them down. Tim said that once he knew Jason was willing, he would send an email to everyone for questions they might have on the topic. He would ask them to send the questions to him for forwarding to Brenda and Jason.

Tim and I left then and Tim asked how well I knew the nurse. I said she is a second cousin and on the surgery staff of a nearby hospital. Tim said we would probably have her and the cousin that is a nutritionist for the February meeting. Tim asked me to call them and find out what they thought. Then give him their phone numbers so he could talk to them. Tim said we need to avoid Valentines day so that left the seventh or the twenty-first. I said either one should be okay and would say the first one so we have a second or third available if we have bad weather. Tim said good and we wished each other happy holidays and left.

Summary of Revisions – ADA 2015 Guidelines

The new 2015 American Diabetes Association Guidelines are posted. I have been checking daily for the last week and this morning (Dec 23, 2104), they were up. There are few significant changes and most are minor updates. This is not a complete list.

The “Standards of Medical Care in Diabetes—2015” should still be viewed as a single document, but it has been divided into 14 sections, each individually referenced, to highlight important topic areas and to facilitate navigation. The supplement now includes an index to help readers find information on particular topics.

The BMI (body mass index) cut point for screening overweight or obese Asian Americans for prediabetes and type 2 diabetes was changed to 23 kg/m2 (vs. 25 kg/m2) to reflect the evidence that this population is at an increased risk for diabetes at lower BMI levels relative to the general population.

The physical activity section was revised to reflect evidence that all individuals, including those with diabetes, should be encouraged to limit the amount of time they spend being sedentary by breaking up extended amounts of time (>90 minutes) spent sitting.

Due to the increasing use of e-cigarettes, the Standards were updated to make clear that e-cigarettes are not supported as an alternative to smoking or to facilitate smoking cessation.

Immunization recommendations were revised to reflect recent Centers for Disease Control and Prevention guidelines regarding PCV13 and PPSV23 vaccinations in older adults.

The next item I do not agree with, but it says - The ADA now recommends a premeal blood glucose target of 80–130 mg/dl, rather than 70–130 mg/dl, to better reflect new data comparing actual average glucose levels with A1C targets.

To provide additional guidance on the successful implementation of continuous glucose monitoring (CGM), the Standards include new recommendations on assessing a patient’s readiness for CGM and on providing ongoing CGM support. Here the ADA missed a golden opportunity to insist that the Centers for Medicare and Medicaid Services (CMS) allow and pay for continuous glucose monitors for those over the age of 65.

ADA did a good thing when they said, to better target those at high risk for foot complications, the Standards emphasize that all patients with insensate feet, foot deformities, or a history of foot ulcers have their feet examined at every visit.

This does not include all the changes and you may read the entire sections here. The 2015 ADA Guidelines Table of Contents can be accessed at this link.

Choosing and Using a Blood Glucose Meter

How would you choose a blood glucose meter? Most of us have very little choice that have insurance. If you don't have insurance, then it will depend on what you can afford. I am glad that some organizations are publishing information about choosing a blood glucose meters, but very disappointed in the lack of solid information. This information from the Mayo Clinic lacks information.

“If you have diabetes, you'll likely need a blood glucose meter to measure and display the amount of sugar (glucose) in your blood. Exercise, food, medications, stress, and other factors affect your blood glucose level. Using a blood glucose meter can help you better manage your diabetes by tracking any fluctuations in your blood glucose level.”

The above quote makes me wonder why people with diabetes get discouraged and don't test. When the Mayo Clinic staff can say, “you'll likely need” this is about the same at saying you may not need to test. They should say, “you will need.”

“Many types of blood glucose meters are available, from basic models to more-advanced meters with multiple features and options. The cost of blood glucose meters and test strips varies, as can insurance coverage. Study your options before deciding which model to buy.”

I've said this before, but it is worth repeating, knowing what your insurance will cover, may help you avoid problems. The test strips are the real cost and many forget this. If your insurance will not cover the meters with all the bells and whistles, you could be ahead of the game. Some of the considerations are:

1. If you are having eyesight problems, a meter with vocal reading of the number may be for you. If you want secrecy and not having everyone near you hearing the reading, then vocal reading of the blood glucose number is not for you.
2. If you have hearing problems, then a good screen with few distractions and proper size numbers and properly backlit may serve you well.
3. The more complicated the meter is, the less likely you will use it.
4. The more costly the test strips are, the less likely you will test.

This is one time when a doctor may be of help if he/she has the time. If the doctor doesn't take the time, a pharmacist may be the answer. Most will, but sometimes you will need to wait a few minutes for them to complete the task they are doing. 

This by the Mayo Clinic writer makes me wonder if they really know anything about testing and using the equipment. “When selecting a blood glucose meter, it can help to know the basics of how they work. To use most blood glucose meters, you first insert a test strip into the device. Then you prick a clean fingertip with a special needle (lancet) to get a drop of blood. You carefully touch the test strip to the blood and wait for a blood glucose reading to appear on the screen.”

The lancing device holds the lancet. Then the lancing device is cocked and the end with the lancet is pressed against the side of the finger near the tip and the release is pressed. This is how the lancet brings blood to the surface for the meter with the test strip to be slid up to and into the edge of the blood. The blood is wicked into the test strip and then about five seconds later, a reading appears on the meter screen.

For other information about choosing a meter, read this article by the Mayo Clinic.

Support for More Bloggers

One never knows when what a blogger writes about will give you the clue or missing piece that will help you with better management of your diabetes. That is why I am writing about other type 2 bloggers that presently write for Health Central. I generally enjoy reading their blogs even when I may disagree with a statement they make. I hope that I can enlighten you a bit about finding them and their past blogs.

I have spent time looking for other type 2 bloggers writing for Health Central, but the only three I have found and followed for several years include – David Mendosa, Gretchen Becker, and Dr. Bill Quick. I have given you information on David Mendosa so this blog will be about the other two. I have met both David and Gretchen and enjoyed my conversation with them. Dr. Bill Quick Is not one I have met, and I am not sure I ever will.

First, I would suggest joining the site and then you may select those that you wish to follow and when they post a new sharepost (as the site calls it); you will receive an email that will allow you to go directly to the post. I admit that I follow a couple of other bloggers that post fairly regular, but not many.

I admit that I often disagree with Dr. Quick and I know the reason. He is very solidly a person that believes in clinical evidence and scientific evidence from random controlled trials. Not being a person with medical training allows me to make my own observations and decisions based on my experiences. His latest blog can be found here. By clicking on his name (in blue or light blue – depending on your browser), you will be taken to his profile page. On the right side (for all posters) will be a listing of posted shareposts. Or you may use this link and then you will have a listing of shareposts and a brief description.

Gretchen's latest sharepost is here. Follow the same information above or this link for the shareposts and brief description. Enjoy reading any of the blogs and enjoy some of the humor Gretchen sprinkles in from time to time. I like the humor as some of us get too serious in our battle with diabetes and writing about it to help other people.

Gretchen's last sharepost is titled “Low-Carb Diets and Type 2 Diabetes.” It is very much appreciated by me and I have read it a couple of times just to let it sink in.

Dr. Quick's last sharepost is titled “There's Always a First Shot for People with Diabetes.” I will understand if it is something you do not want to read about as I was not happy having to do multiple daily injections of insulin, but after the first one, I was surprised that there was no pain. Yes, I occasionally hit a nerve or a small blood vessel and have some pain, but rest assured it is not that bad.

The latest on Dr. Quick says he is a type 1, but he still writes for all types.  His latest as of today Dec 22 can be found here.  It is titled "Diabetes Q&A, A day in the Life, Numbers, What to Eat."

Diabetes Q&A: A Day in the Life, Numbers, What to Eat - See more at: http://www.healthcentral.com/diabetes/c/110/173679/diabetes-normal-target-values#sthash.I5XeIkR2.dpuf

Diabetes Q&A: A Day in the Life, Numbers, What to Eat - See more at: http://www.healthcentral.com/diabetes/c/110/173679/diabetes-normal-target-values#sthash.I5XeIkR2.dpuf

Diabetes Q&A: A Day in the Life, Numbers, What to Eat - See more at: http://www.healthcentral.com/diabetes/c/110/173679/diabetes-normal-target-values#sthash.I5XeIkR2.dpuf

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!

Support for Other Bloggers

Every once in a while, something comes along that gets to you and gives you a swift kick in the backside. The eighteenth was one of those times, the person I respect was the bearer of the message, and he does not even know it until now. In his blog here about Dr. Bernstein’s diabetes university, David Mendosa said, “Medicine is finally coming around to recognize that carbs, not fats, are the enemy of diabetes...”

I often ignore statements like this, but recently I had a doctor ask me what type of food plan I was using. When I said low carb, medium to high fat, I did not receive the usual lecture about fats being bad, just an okay and with no gallbladder, be careful. That should have registered at the time, but I gave it no more thought until I was reading David's post.

On the nineteenth, I called the doctor and asked him why he had changed away from the lecturing about eating low fat. I about fell out of my chair at his answer. He said, “I am learning from my patients and more are going medium to low carb and medium to high fat.” He continued that if they were not afraid to tell me that, then what was I missing. He said I went on a search and found other doctors saying the same thing and then I came across several diabetes bloggers that were writing about this. The final convincing came in a blog a patient of mine wrote about an interview with Adele Hite. He said her reference to Dr. Eric Westman was the information I needed as I had been reading about some of his work and this sent me back to research his work.

I accepted this and decided that I had better listen to Dr. Bernstein’s diabetes videos or classes on YouTube. Yes, they were interesting and included some interesting American Diabetes Association history. This confirmed for me why the ADA is always behind the times and research. They are afraid of making changes and will only change when the preponderance of evidence forces the change. While I can agree that change is not always best, the ADA is way behind the times and seems to wait until many doctors have already made the change, then they claim the credit when they make the change.  He now has four videos posted.

Please take time to read David's blog as he makes some great points. I had wanted to comment on his blog, but when I thought more about it, I felt this blog would be better and I did not want to curb my thoughts.

Sleep Apnea in the US Threatens Public Health

New studies highlight the destructive nature of obstructive sleep apnea and benefits of CPAP therapy. Public health and safety are threatened by the increasing prevalence of obstructive sleep apnea, which now afflicts at least 25 million adults in the U.S., according to the National Healthy Sleep AwarenessProject. Several new studies highlight the destructive nature of obstructive sleep apnea, a chronic disease that increases the risk of high blood pressure, heart disease, Type 2 diabetes, stroke, and depression.

Public safety is only given a mention, but needs more emphasis as it is unknown how many accidents are caused by people being drowsy or asleep while driving. I have even seen drivers asleep at the when at stoplights. Sometimes other drivers sit and honk at them, but most just drive around them.

Data published previously in the American Journal of Epidemiology shows that the prevalence rates of obstructive sleep apnea have increased substantially during the last two decades, most likely because of the obesity epidemic. The latest estimates predict that 26 percent of adults between the ages of 30 and 70 years have sleep apnea.

Obstructive sleep apnea is destroying the health of millions of Americans, and the problem has only gotten worse over the last two decades. The effective treatment of sleep apnea is one of the keys to success as our nation attempts to reduce health care spending and improve chronic disease management.

Findings from new studies emphasize the negative effects of sleep apnea on brain and heart health. These health risks can be reduced through the effective treatment of sleep apnea with continuous positive airway pressure (CPAP) therapy.

1. “A neuroimaging study in the September issue of the journal Sleep found that participants with severe, untreated sleep apnea had a significant reduction in white matter fiber integrity in multiple brain areas, which was accompanied by impairments to cognition, mood, and daytime alertness. One year of CPAP therapy led to an almost complete reversal of this brain damage.
2. A study published online ahead of print Sept. 21 in the journal NeuroImage found functional and anatomical changes in brainstem regions of people with sleep apnea.
3. A study in the October issue of Anesthesiology shows that diagnosing sleep apnea and prescribing CPAP therapy prior to surgery significantly reduced postoperative cardiovascular complications - specifically cardiac arrest and shock - by more than half.
4. A study published online ahead of print Sept. 19 in the Journal of Hypertension found a favorable reduction of blood pressure with CPAP treatment in patients with resistant hypertension and sleep apnea.
5. A Brazilian population study published online ahead of print Sept. 23 found that nocturnal cardiac arrhythmias occurred in 92 percent of patients with severe sleep apnea, compared with 53 percent of people without sleep apnea. The prevalence of rhythm disturbance also increased with sleep apnea severity. “

Common warning signs for sleep apnea include snoring and choking, gasping, or silent breathing pauses during sleep. The American Academy of Sleep Medicine, Centers for Disease Control and Prevention, Sleep Research Society, and other partners in the National Healthy Sleep Awareness Project urge anyone with signs or symptoms of sleep apnea to visit this website to pledge to "Stop the Snore" and talk to a doctor about sleep apnea.

If you suspect you have sleep apnea, follow the directions above and see a doctor specializing in sleep problems. I use a CPAP machine daily and find that I have not had more problems with sleep and am generally rested when I awake in the morning.

More Activities to Help a Member

Allen called me the next evening and said he did not seem to be getting through to the new member even after our session the prior day. I suggested that Allen should talk to Tim about using this as a topic for our January meeting. Or I said that we should at least explore the idea and see how many would be in favor of this as a topic. Allen agreed that most of the old members would know the importance and maybe we should do one for the new members.

Allen said he would call Tim and to be ready for Tim to call. About 30 minutes later, Tim did call and said I must have some thoughts since Allen mentioned we had been together and talked about this. I said that we needed to do something and consider the importance since others may be operating under similar methods and these were bad habits that need to stop. I suggested that Tim send an email to the old members to explain this and ask if they would accept a meeting on this topic. I also said we needed to talk to Dr. Tom and find out what can be done to change the person from a Medicare supplier to a local pharmacy.

Tim said now we were getting somewhere and that we had something that may help more of our members when they went on Medicare. He said he would talk to Dr. Tom and get back to me the following day.

Tim called me the next evening, Thursday, and was perplexed. Dr. Tom said there was not much he could do or recommend to help the former patient. He was not listening to anything he was telling him and had his own way of doing things and he doubted he would listen to any of us. I said it sounds like an intervention is not in order, but we should keep lines of communication open. I continued that seven of the new members were obtaining VA assistance and an eighth new member would be next year. As such, I feel that we need to ask the old members first and go with what they feel. I said I would do the program, but that A.J or Barry could possibly be better received.

Tim said he would talk with Allen and send out emails. Then when he had heard back, he would talk to A.J and Barry to see whether they would want to present the program as he know they could use some of my blogs for ideas and slides. I said that would work for me. With that, Tim said he would talk to me when he heard back from them.

Allen called and thanked me for having added to his thoughts and said he hopes everyone will answer promptly. Allen got his wish, as Saturday morning, Tim called and said everyone was in favor and that A.J and Barry wanted to do it together and I would be hearing from Barry about slides. When my wife and I returned home late Saturday afternoon, I had a message from Barry asking me to call him the next afternoon.

When I called Barry on Sunday, he thanked me for not doing the program as he had talked to Allen and felt it would be good for someone else to be presenting the program. He said he was working on an outline with A.J and would send it to me when they were about done. I said okay and I would start the slides when I had the outline.

On Wednesday, December 17, Barry sent me the outline and I started the slides and when completed sent them to Barry. Then that evening, he called and thanked me and asked that I add more slides from the instructions he had obtained from Jack who was using the same meter and test strips as Albert was using. I said that was great and I would use the instructions and meter information that all of us with the VA were using. Barry said that he would be by shortly to pick the instructions and scan them into his computer as his program allowed him to size them for easier use for slides.

When he arrived, I already had the instructions from Barry on the Medicare supplied meter and test strips and commented this might get Albert's attention, but from talking to Tim, I was not high in the hope department. Barry said that Allen was not hopeful either, but we had to try. Barry said that all of us getting our testing supplies from the VA were currently using the same meter and test strips which was good and this should help both those receiving testing supplies from Medicare and the VA. Barry said he normally read the instructions he received and if no changes were evident, he and Ben normally discarded them.

Barry took time to read the meter instructions and said they were very similar to the meter instructions for the Medicare meters and the test strip instructions were almost identical. Barry commented that we should attempt to keep up to date with as many meters as the group was using and keep the instructions on slides that could be printed out for any changes made. Barry said that Jack had tried to obtain the test solution for the Medicare test strips, but had not been able to obtain it, but was informed that it would be available sometime in 2015.

Barry concluded that Jack was researching information for us and anyone else that received testing supplies from Medicare. Barry said that members not on Medicare and the VA would be receiving an email from Tim asking for copies of meter instructions and test strip instructions for meters they may be using. First, he was asking for the brand of meters to find out the different brands being used by the members. Then we will use copies of the different brands and get slides made to have them available. I said we should include our type 1 member is this and said I would send an email to Tim and Barry said Allen had already done this and she was using the same meter as those used by the VA members.

Time to Transform Rural Health Care

I need to start this with a statement that I think my definition of rural healthcare differs from the definition used in this article. The article uses 19.3 percent as the number living in a rural area, and says only about 10 percent of physicians practice in rural areas. The article also declares that 65 percent of all Health Professional Shortage Areas are in rural areas. It is small wonder that many must travel long distances to see a specialist after months waiting for an appointment.

Even in areas where rural primary care providers (PCPs) remain committed and engaged in the community, often having been raised and educated there, these providers often lack close connections to specialists who tend to be based in larger, urban academic medical centers (AMC). The result is a worsening gap in specialty care access, in turn leading to a deteriorative effect on rural provider morale and retention.

Much of this is because many local hospitals are being bought out by regional hospital groups and becoming larger and more incapable to serving rural primary care providers (PCPs). We are seeing this in our community and now the local hospital sends many patients out to other hospitals. What is disturbing is that most patients are transported by medical helicopters at added costs rather that by ambulance which still are expensive, but about a tenth of the cost of a helicopter.

Most of the efforts to improve rural care have focused on enhancing the patchwork of federally regulated safety net programs, with the goal of increasing quality of care by increasing access to primary, routine, and emergency care. Innovative communications technologies, decision support tools, and initiatives to enhance “broadband” access in rural areas are enabling some frontline rural health care professionals, and even patients and family members themselves, to implement new approaches to delivering high-quality care even with limited availability of physicians, and particularly expert physicians.

I do not understand why authors of many articles dance around the issues. Telemedicine and its use are not new technologies – just underused technologies that many third party payors (medical insurance companies and Medicare) do not want to pay for and constantly put obstacles up to stop its use.

Some states are attempting to install high-speed internet lines, but the political issue is being lobbied heavily against from many businesses and internet providers. In addition to improving quality and capacity of care within rural communities, these approaches also have the potential to generate cost savings. Receiving more specialized treatment from a PCP may reduce complications and emergency department visits, as well as the volume of costly and unnecessary referrals to tertiary centers. Provider education and electronic consultation approaches may also provide cheaper ‘junior’ specialty care as this dissemination of knowledge enables PCPs to provide more care themselves.

Yes, telemedicine can do this and more. Yet, despite this potential for improved care and cost savings, the United States health care system is not set up to recognize and reward these approaches. Because they represent a traditional health care facilities and in-person consultations and services, they are often not supported under traditional fee-for-service payment systems like Medicare.

Changes are supposed to happen under the Affordable Care Act, but many of the provisions are being postponed by the President or his Health and Human Services department. However, until our Congress decides that rural healthcare is important, very little will be accomplished. Funding of telemedicine to obtain the cost savings many know has potential will not happen until Congress does something positive to force the insurance industry to support telemedicine.

Patient Engagement Is Backwards

This was a surprise when I read this about patient engagement! Finally, someone that felt similar to what I thought about patient engagement and a doctor to boot. This is worth quoting - “This drive for patient engagement often fails to recognize one important truth: Our healthcare system inadvertently, yet potently, discourages engagement. It ignores the fact that the patient is already the most engaged person in healthcare. The patient bears the disease, the pain, the scar – and, ultimately, the bill. In our search for greater engagement, we must realize what the comic strip Pogo said years ago – “we have met the enemy, and he is us.””

Yes, our healthcare system discourages patient engagement by discouraging honest, straightforward communication. Many doctors also patronize us and feel they are the only source of information we, as patients need. They talk at us instead of with us and many belittle us because they don't receive the information from us that is already in their records and they are too lazy to look up, or are not accessible because one electronic record will not communicate with another electronic record. HIPAA is often blamed, when it is the proprietary electronic systems that are to blame.

Physicians expect patients to bring test results to an appointment – because patient information is often not shared throughout the complex and fragmented systems. Patients are expected to remember their entire health history, and repeat it ad nauseum, because the unconnected systems fail to share. Patients are expected to recount the complex names of the all the drugs they are taking, and at what doses. And it’s not uncommon for these questions to be asked many times in a single hospitalization, during outpatient visits, and again each time a patient encounters a new caregiver.

The Office of the National Coordinator for Health Information Technology reports that one in three patients experience gaps in information exchange, which we rely on the patient to solve. This number may be a significant underestimate because physicians are so used to this level of fragmentation and repetition, that they no longer see it for the system failure it is.

In reality, patients have no choice but to be engaged. They are provided these details in an inefficient way that causes a lot of frustration, worry and fear on top of already stressful medical concerns. Physicians need to think less about the patient being more engaged, and focus on how they can simplify, encourage, and automate engagement tools on behalf of the patient. People are accustomed to integrated, automated, 24-hour customer service in almost every other industry.

Yet, when it comes to the patient's most important asset – health – the consumer experience is dependent on fax machines, scribbled notes, hand-carried printouts, and the memories of those most in need of care. If our healthcare system were to implement the automation, connection and coordination that other industries have used to change the face of consumer engagement, boosting patient engagement wouldn’t be an issue. Physicians would instead be easing the burdens on the very patients they are trying to help.

I can honestly say that as a patient with diabetes the physicians in this area cannot access my records unless they are in the same practice and this is very discouraging and I have to keep banging my head against the errors in the different medical records – and believe me – each electronic medical record has errors and try as I have, none of them have been corrected. What is scary is that some of the offices have refused to correct the errors that even they know are in error.

The article used an example of how concerned parents figured out how to hack into their diabetic children’s glucose monitors so they could remotely track their blood sugar levels. I know other heart patients that have tried to obtain information from heart monitors, but could not because the data was only supposed to be accessible to doctors with the right equipment. Hacking turned out to be the only solution. Should something so essential to managing a loved ones’ health or one's own health require it to be hacked to make that data accessible? I think you know my answer.

We, as patients, need to improve how the healthcare system engages with patients by demanding the various technologies used to take care of us talking to each other. Additionally, we need to demand transparent pricing information or we won’t succeed in receiving better individual care, or lowering costs.

Diabetes Training Programs Are Underused

Study leader Rui Li, who is a researcher with the National Center for Chronic Disease Prevention and Health Promotion of the Centers for Disease Control and Prevention in Atlanta told Reuters Health in an email that diabetes training programs are underused.  For me it is easy to understand why they are underused. To begin, there are too few qualified people to teach diabetes self-management education and training (DSME/T) and some of those that could do this are more enamored with using mandates and mantras than actually teaching.

The other problem with the general delivery of the article, because no distinction is made between type 1 and type 2 diabetes. Some reference is made about those on insulin taking the classes, but here again, we are left guessing. A comment is made that those in the North Central region of the U.S. and in metropolitan areas generally have a higher participation rate in DSME/T. This is understandable as there are more certified diabetes educators in metropolitan areas and less in rural areas and often none in many rural areas.

The curriculum of DSMT often includes information about diabetes disease process and treatment options; healthy lifestyle; blood glucose monitoring; preventing, detecting and treating diabetes complications; and developing personalized strategies for decision making

When DSME/T is done correctly, it helps patients improve glycemic management which in turn reduces the risk for diabetes complications, hospitalizations, and health care costs. The study looked at claims data for almost 100,000 adults with private insurance that were diagnosed with diabetes in 2009 to 2012. They found that less than seven percent participated in diabetes self-management education training. Although many people with diabetes know about the classes, a major issue was that individuals with diabetes may not be attending DSME/T once they are referred.

Researchers said better marketing efforts, focusing on education of doctors, patients, and support persons, are needed to publicize the DSME/T programs. Promotion of the message that DSME/T is the foundation of diabetes care might be helpful in promoting the programs. In my own opinion, certified diabetes educators need to improve their method of delivery, actually do education, and stop with the mandates and mantras and then more people might attend the education classes.

The researchers stated that everyone in the study had private insurance, but Medicare and Medicaid programs cover the cost of DSME/T. They said that 40 states mandated private insurance cover DSME/T, but there are private plans that still do not cover it and others that require a co-payment. A person not involved in the study, Kate Lorig, director of the Stanford Patient Education Research Center at Stanford School of Medicine in California, stated that the system for becoming a recognized diabetes program eligible for Medicare reimbursement is difficult and restrictive, plus it is expensive for a program to apply for and receive recognition.

Lorig thinks the way to boost the use of diabetes training programs is to lower the barriers to reimbursement faced by the health care providers who do the training.

Right now reimbursement is usually based on first having a billing code and then have the right content in the education and the right person giving it, she said.

Tramadol Causes Low Blood Glucose

As painkillers go, this was a surprise! Admittedly, I have not used this painkiller, but none that I have used caused me any problems and I have taken some powerful painkillers, but not tramadol. Tramadol is a narcotic painkiller whose use has increased worldwide steadily. The new research demonstrates that the drug creates about a threefold increased risk of being hospitalized for low blood glucose.

Even though some of these low blood glucose episodes proved fatal, the association seen in the study does not prove a cause and effect relationship, and instead of issuing a cautionary warning, the researchers just call for more research. Something this problematic should be further researched and at the same time should cause a warning pending additional research. Granted the research was done in Canada, but when WebMD and then Endocrinology Advisor have articles on it, then there has to be some importance attached.

Even though the researchers emphasize that the study found serious low blood glucose even occurred in fewer than one person for every 1,000 people taking tramadol every year. The big surprise is that this is among all types of people and not just those with diabetes. The researchers said an analysis of people who have taken tramadol suggests that 40 percent of tramadol induced hypoglycemia cases did not have known risk factors.

Tramadol is considered a weak narcotic drug used for mild to moderate pain and has grown in popularity because it has been said to be less addictive. Tramadol acts differently than other narcotic drugs, as it disrupts the functioning of two chemicals in the body: serotonin and norepinephrine. This is the aspect of the drug that appears to be related to lowering blood sugar

Anyone who takes tramadol is at risk for low blood sugar, not only people with diabetes, who may already be at risk of low blood sugar due to their diabetes treatment. Prior to use, physicians and patients should consider the balance of all of the possible concerns about tramadol along with its relatively mild beneficial effect at relieving pain.

Tramadol may have a limited role in some patients, but like other narcotics, it carries risks that often outweigh the benefits. Patients should be told about the potential for all adverse effects, including hypoglycemia. Tramadol isn't the only option for pain relief, as there are other weak narcotic drugs that can be used instead of tramadol.

Assisting a New Member with Testing

On Tuesday, Allen called and asked if I had time to help the newest member to join, Albert, as he had an A1c that was much higher than he had anticipated. Allen asked me to stop by his place and we would go to Albert's apartment. When we arrived, we parked behind his car and as we passed Albert's car, we could see a meter and test strip container lying on the passenger seat. I commented that I could already see problems. Allen then looked and said he hoped not that.

When we were greeted at the apartment door, Albert invited us in and after we were in the kitchen, I could see other potential problems. A meter was lying on the counter and another meter was lying on a kitchen stool. I asked how many meters he had. He said seven that he uses and a few others he has lost. He said they were all the same meter brand and he didn't need to worry about test strips that way. None of the meters was in a case and the test strip containers were setting around the kitchen.

Allen suggested we talk about his meters and where he was storing them. After Allen explained that he had some serious concerns about the accuracy of the equipment, Albert asked why. I explained that the kitchen was not the best place to keep the containers of test strips and that applied to the bathroom as well. Albert then showed us the bathroom where there was another meter and two containers of test strips setting on the counter next to the sink.

I asked Albert to select the bathroom meter and one container of test strips and then when we were back in the kitchen, to select another set. Then we adjourned to the living room and we asked Albert to test with each meter and a test strip. Allen and I both had our meter and test strip and we took them out. We used an alcohol pad to clean the lancing device and put new lancets in the device. When Albert was ready, we asked him to test using each meter.

Before he tested, Allen and I asked when he had last eaten and he said about three hours earlier. Allen said he would use his meter and test him first. After Allen had tested him, the reading was 184 mg/dl. I then used my meter and the result was 182 mg/dl. Albert then set his up and tested with the bathroom meter and the reading was 116 mg/dl and the reading from the kitchen meter was 102 mg/dl. Albert asked to look at our meters and when he saw that they were the same, he asked why our meters were so much higher than his were.

Allen nodded at me and I said because our meters are kept in the case when not in use and not laying around catching dust and lint. Allen then said we also keep our test strip container in the case along with the lancet and lancing device. This minimizes the dust and lint from getting in the meter and keeps our test strip container protected.  I continued that with the test strip containers setting around and in high moisture areas, which was probably why he was not getting near accurate blood glucose readings. I said that I keep all of my test strip containers in a zip-lock bag in a room that is fairly dry and not receiving direct sunlight. Plus this, I cover the bag with a dark washcloth to protect them.

Allen asked where he had obtained the meters and test strips and Albert said from the supply outlet that Medicare had told him to use. I had never heard of the meter brand and Allen had not either. We told Albert to attempt to obtain a test solution to be able to check his test strips, but added that he may have no luck in obtaining the test strip solution.

Allen then stated that the test strips were probably all unreliable and his meters not being properly protected could also be adding to the problem of his blood glucose readings being low and his A1c much higher. I asked Albert if he used the meter and test strips we saw in the car. He answered yes when he feels low. I stated that both the meter and test strips had temperature ranges for storage and use and keeping them in the car during the summer and winter and in direct sunlight would make both unreliable and basically unusable.

Next, I asked if he had read the instructions that came with his meter and the instructions that were in the box with his test strip container. He said he had never read them. We asked if he had any of the instructions around and he said he always takes the test strip container out of the box and throws any papers away as soon as he receives them in the mail.

Allen and I just looked at each other and shook our heads. We knew we had some educating to perform and soon. We asked when he would receive this next order and he said after the first of the year on the day following New Year's or on Saturday. Allen emphasized to him that he should not open all the test strip boxes immediately and if he needed to open one, to keep the instructions and read it. I asked if he would be receiving a new meter then and he said no, but he would in the July order of next year.

We said we would talk after he received his new supply and cover the proper use of the meter and test strips. Allen told him that he had an extra case for the meter and test strips and he would give him one if he would use it and not leave everything lying around and exposed to the elements. Since he was on metformin, we did not understand why he would feel a low since metformin did not cause them. He may have a false low when his blood glucose dropped quickly, but with his meter and test strips being stored where they could freeze, they would not be reliable. He said if he would carry the case next to his body when outside, he would supply him with a case he could use if he would promise to use it. Allen said he would see him the next day and we left.

Please, I Need Help

Yes, this last year was a great year for me, but I am asking my readers for assistance in locating other type 2 bloggers. I have found several new and some not so new type 2 diabetes bloggers. I have some more bloggers being posted on January 2, 2105. If you know a type 2 blogger, please send me an email with the internet address (URL) so that I can check them out and post them on a quarterly basis to those that are already posted. My email address is on my profile page, or you may post the information in a comment to this blog.

I have several bloggers from other countries, but I know there are more. The only qualification I am asking is that they have type 2 diabetes and are blogging about type 2 diabetes. I will include other writers, especially doctors that write about diabetes, but do not have diabetes themselves. I am cautious about some that are only advertising services for type 2 diabetes and I refuse to promote consulting and other businesses aimed at people with diabetes.

Forget about those promoting snake oil and a diabetes cure, as I will not list them. Likewise, I have an objection to those writers' that are promoting promises of a reversal of type 2 diabetes or prediabetes. It is possible for people with type 2 diabetes to avoid medication or start with medication and by changing lifestyles have been able to get off of all diabetes medications. Some are able to stay off for several years and others for a few decades.

I will not list people that have not blogged or more than 12 months. If they have restarted and have blogged for two or more months, then they are eligible to be listed.

I will be listing several blog sources that include both type 1 and type 2 bloggers, but both types are worth reading and it is easier to list the site and not pull out the type 2 only bloggers.

Care for Elderly Still a Problem

In several articles lately, the elderly have been shown to be on the short end and not receiving the care they may need. This is not a simple problem or a problem with easy answers. Report lead author Alicia I. Arbaje, M.D., M.P.H., director of transitional care research and assistant professor of medicine at Johns Hopkins Bayview Medical Center and the Johns Hopkins University School of Medicine said that what is believed to be the first interview-style qualitative study of its kind among health care providers in the trenches, displays very real problems.

A team led by a Johns Hopkins geriatrician has further documented barriers to better care of older adults as they are transferred from hospital to rehabilitation center to home, and too often back again. They used comments and concerns drawn from in-depth interviews of 18 physicians and two home health care agency administrators to create a framework for evaluating what actions and programs might improve care.

The research says:

1. more attention should be given to preventing drug errors or missed doses of medicine
2. earlier and more frequent communications among health care providers at different sites
3. the elimination of discharge planning delays
4. and patient education.
   
   

The Affordable Care Act of 2010 established a pay-for-performance financial incentive program to motivate better coordination. The study results suggest, however, that health care providers are unclear about how these incentives will be designed and are concerned that the wrong outcomes or processes will be measured.

Currently, health care providers have concerns about pay for performance that need to be considered. They desire a voice in the design process. Yea for them, but if this is the case, then patients should also have a voice as many health care providers do not have the desires and needs of the elderly patients in mind. The evidence of the current lack of concern by health care providers provides ample reason to include patients, patient advocates, and social workers in the mix of voices. This would be one way to avoid the same mistakes being currently carried on by our providers.

“In their report on their work, “Excellence in Transitional Care of Older Adults and Pay-for-Performance: Perspectives of Health Care Professionals,” published in the December 2014 issue of The Joint Commission Journal on Quality and Patient Safety, the investigators note the persistent “mixed reviews” of the impact of tying compensation to quality of care. They also say that care transitions across health care settings remain “common, complicated, costly, and potentially hazardous for older adults.” As the ranks of older adults grow and their numerous illnesses require ever more drugs, specialists and facilities, poor transitional care frequently leads to re-hospitalizations and complications for patients.”

The research team uncovered three themes that addressed pay for performance:

1. components and markers of effective care transitions,
2. difficulties in design and implementation of pay-for-performance strategies,
3. and unmet needs in delivering optimal care during transitions.
   
   

The research findings suggest ways to better define health care providers’ roles in care transitions:

1. enhance communication,
2. determine performance measurements,
3. and improve education and training of providers.
   
   

Among the recommendations in the framework are calls for holding health care providers:

• more accountable for patient education,
• reimbursing providers for care coordination activities,
• and providing training and hands-on experience for providers to facilitate care transitions.

Report lead author Arbaje explains that, “Health care providers may need additional training to better execute care transitions and to understand their role during transitions. Without this education, it is difficult to design pay-for-performance strategies with an end result of good patient care.”

Are We Really Facing a Shortage of Doctors?

At least this is slightly a more balanced approach with both sides having realistic projections. I will only say that I agree that there will be a doctor shortage, but maybe not primary care doctors, as least as big as is being projected.

The shortage will be severe in geriatric doctors. These are the doctors that will be needed to care for the baby boomers that are increasing every day. Geriatric means, pertaining to elderly persons or the aging process. Primary care doctors are not qualified to handle geriatric medicine, especially those with multiple diseases or chronic conditions. Some will be needed for those with single conditions, but geriatric doctors should be in charge of these patients. Read this article in WebMD as they present their points.

Many medical groups, led by the Association of American Medical Colleges say they think the shortage will be close to 130,000 in the next 10 to 12 years. It is the health care economists that are less convinced. They say that concerns that the nation faces a looming physician shortage, particularly in the primary care specialties, are common. An expert panel of the Institute of Medicine (IOM) wrote in a report that the committee did not find credible supporting evidence of a severe physician shortage.

As many as 10,000 baby boomers are becoming eligible for Medicare every day. And older people tend to have more medical needs. Everyone thinks that the Affordable Care Act (ACA) is creating millions of patients, but they may soon see that the ACA is driving millions of patients away from coverage and doctors. There are more of these predictions every day and one radio program that I listen to sporadically has callers that are complaining about not being able to afford the new Obamacare insurance with the high premiums and high deductibles.

I can agree there will be a mismatch but maybe not in the doctors needed, but in the location of these doctors. New doctors seem to cluster in the northeastern part of our country and in or near the larger cities. The medical associations or doctor organizations are crying for more primary care physicians, but they are crying for the wrong doctors. Doctors of geriatrics will be needed for the aging population and not primary care doctors. Yet, the medical associations don't see it that way.

Many primary care doctors cannot take care of complex elder patients and handle the combinations of chronic conditions they are likely to have. Some of the larger medical practices may have doctors or specialists to care for them, but most in smaller and rural communities will be ill trained and equipped to handle these patients.

In some geographical locations, many services can be provided by primary care doctors, but in other locations, physician assistants, nurse practitioners, and even pharmacists and social workers will need to be included in the mix. .

Currently, physicians who are specialists make considerably more than those who practice primary care, which many experts say is a huge deterrent to doctors becoming generalists, particularly when they have large medical school loans to pay off. However, “team-based care,” where a physician oversees a group of health professionals, is considered by many to be not only more cost-effective, but also a way to lower the number of doctors the nation needs to train.

What may happen in the future is unclear with doctors and economists making their predictions. Some areas of the country will be well served and the seniors well taken care of medically. It is the rural areas that I am concerned about where there will be single practitioners serving the Medicare patients. Traveling over 150 miles to see a doctor may not be possible. Until telemedicine is authorized and the rural states have internet connections for everyone, seniors may actually be in danger of being harmed.

Thoughts for Value in Food Labels

This blog by Professor Jennie Brand-Miller talks about what we really need on food labels to help us make better choices. I will do my best to comment on her ideas as she does have some important information. Before getting to that, I would like to discuss the US food labeling system.

The current revised food labels used on foods still allows for a 20 percent error margin and the processing companies and food manufacturers do not have to test their products as often. I can almost bet that some merchandise is outside of the 20 percent error margin because of the time of harvest, the farm where grown, and how the food was raised. Food that is raised on poor soils will not be as nutritious as food from fertile farmland. Then we have the chemicals used to keep insects down and herbicides used (including GMOs). Food that includes GMOs are said to be safe, but research is not up to date and is being challenged at various levels.

For manufactured foods, scales go a long way in helping meet the 20 percent error margin. This still does not guarantee that the 20 percent error margin is met 100 percent of the time, but they are higher in accuracy than for most raised foods.

The following are just a few of the considerations that need to be made:

• The energy content (calories) of a food is not the best way to judge a food – lentils and liquorice have the same energy density.
• The fat content of food is not the best way to judge a food – nuts have more fat and are more energy dense than French fries.
• The sugar content is not the best way to judge a food – dried fruit is full of sugar.
• The sodium content is not the best way to judge a food – soft drinks are low in sodium.

These are just a few of the considerations we need to determine our individual food plan. This is one reason many of us encourage each person with diabetes to develop your own food plan.

Some people need to consider the following when developing their food plan. Yes, you need to read the labels on all foods to have some idea of the nutrients and the amount your are consuming. You also need to use your meter to help you develop your food plan. Some ideas that you need to consider include:

1. Do you need to reduce the number of carbohydrates you consume?
2. Do you need to increase the amount of fat in your food plan?
3. Do you need to increase the amount of protein in your food plan?

The next thing I have to question as a person with diabetes is most of the food plans seem to be for the healthy person and not for people with diabetes. Authors seldom suggest that people with diabetes use their blood glucose meters before and after eating to learn if what they consume is causing their blood glucose levels to spike at levels that are too high to manage.

Brand-Miller says many ignore micronutrients – vitamins, minerals and phytochemicals. She continues they ignore two important proven attributes of foods in the new nutrition – the protein content and the GI of the carbohydrates. While those of us with diabetes need to restrict our intake of carbohydrates, this is not mentioned. Brand-Miller sidesteps the fat consumption that is essential for our satiety and helps reduce our appetite. She says carbohydrates and protein are proven to help to curb appetite. Then she says appetite matters. Appetite is what drives our energy intake. I says this is what causes our weight gain.

Professor Jennie Brand-Miller concludes this way - “What would I like to see on food labels? I’d like to see a system that:

• Focuses on the positive.
• Rates foods according to their contribution to desirable macronutrient and micronutrient intakes.
• Uses Adam Drewnowski’s Nutrient Rich Foods Index, which rates individual foods based on their overall nutritional value, as an essential component.
• Encourages higher protein intake, particularly from legumes.
• Distinguishes between naturally-occurring and added sugars.

I would advocate that we make the most of something we already have available to use on our food packaging here in Australia and that is proven to work: two certified and recognizable symbols that are signposts to both healthy foods and healthy diets.”
I think in the United States, we need a slightly different system, but with the USDA dietary guidelines not being part of it.