January 11, 2014

Finding the Veterans Affairs Office in Your State

If you have served in the military, either on active duty or in the reserves or National Guard that were called into active duty, you should check with your Veterans Affairs office to determine if you are eligible for medical benefits. You do have to be honorably discharged and there are some active duty lengths of service to be met.

One of our group, Allen worked with me in pulling information together for this blog. We were able to find the websites for every state, but a couple was difficult to find. Most of the time by typing in the state followed by "department of veterans affairs" in a search engine, we were successful – example: iowa department of veterans affairs. For a couple of states we needed to use this site, which does list every state and territory. Find your state and by clicking on your state, or territory, it will take you to the website.

Each state seems to handle their website differently and to find a local Veterans Affairs office requires some work. We feel fortunate that our state – Iowa – makes it fairly easy to find the office of the county in which you reside. The county map can be found here.

The remainder of this blog is for veterans living in Iowa. There is not enough space in a blog to do all states or the interest for two Iowa natives. We have learned about the Veterans Affairs offices in Iowa and are comfortable with locating information for each of the 99 counties. The information for each county is different as you click on different counties and there is no consistency from one county to the next. Some also maintain county Facebook pages with minimal information on the county site. While checking out each of the 99 counties, we came across several county sites that were down.

We were able to contact one of the counties, they will be up by the middle of the month, and another county site was down for the holidays. One county even had information on their site that they were down until a new Veterans Affairs officer was hired and then the site would be back with the new information in place. This has to be expected with retirements and others being replaced when the local VA commissioners are not satisfied with the performance of a current VA officer.

If you are a reader of this blog and a former United States military veteran, Allen and I strongly urge you to become familiar with the county website where you reside. You should take time to become familiar with where the office is located in your county. Then take the time to stop by the office and check out what benefits you are eligible for and when.

January 10, 2014

Poor SMBG Studies Lead to Wrong Conclusions

When participants that know something about self-monitoring of blood glucose (SMBG) are excluded from studies, when participants are given only testing supplies and not education, and when the study is too short, it is not surprising that a meta-analysis of SMBG studies arrives at an incorrect conclusion.

What is even more shameful is that the Centers for Medicare and Medicaid Services (CMS) also believes the incorrect conclusions and is penalizing the elderly by forcing many to rely on unreliable blood glucose meters and test strips. This is on top of the limited number of test strips they will be reimbursed for in a period for testing. What this does is force many Medicare members to pay for their own testing supplies, especially among those that know the value of blood glucose testing and do not want to manage their diabetes in the blind.

The value of self-monitoring of blood glucose is established in patients with type 1 and type 2 diabetes taking insulin. Yet, discrimination is the password for type 2 people with diabetes on oral medications. A working hypothesis has been developed that self-monitoring in these patients could prompt them to adjust their diet and lifestyle based on the immediate feedback and this would improve glycemic control.

A meta-analysis published in the Cochrane Library this year has concluded that this hypothesis is false. The meta-analysis included 12 randomized controlled trials with 3259 patients with type 2 diabetes and not on insulin. The primary outcomes were HbA1c, health-related quality of life, well-being, and patient satisfaction. Secondary outcomes were fasting plasma glucose level, hypoglycemic events, morbidity, adverse effects, and costs.

The trials of self-monitoring was shown to provide a small, statistically significant improvement in HbA1c at 6 months and at 12 months, the benefit was not statistically significant and was even smaller. The authors concluded that the overall benefit of self-monitoring in these patients is minimal at 6 months and disappears at 12 months. Patients in this part of the analysis had diabetes for at least 1 year. The study authors claim the results are consistent with those published in 2010 study of 10 trials comparing self-monitoring with no self-monitoring.

The information not explained may be more important than the meta-analysis of 12 studies. How long were the studies that were used in the meta-analysis? This is carefully left out of the analysis data. Also missing was any statements of whether education was given any of the participants. Unknown is the amount of testing supplies furnished the participants or for how long. If the testing supplies were furnished for the first six months and stopped, it is reasonable that the next six months might not show any significant improvement.

This is why they can claim that the working hypothesis is false by not making information available to the reader. I don't believe the meta-analysis was correctly done because of the missing information and this is represented in late 2013 when the original was published in March 2012.

January 9, 2014

Goals for People with Type 2 Diabetes

As a subscriber to a few American Diabetes Association newsletters, I received the following information. Granted it was written about New Year's resolutions, but since I don't believe in making them once a year and breaking them in the same month, I have them as goals to do every day, every year. As you achieve a goal, redefine the goal and then work to achieve the new goal.

Now remember, if you make a mistake, and we all do, shake it off and get back to working on the goal. Once a resolution is broken, you need to wait until the beginning of a New Year to restart – not so with goals. Learn to set achievable goals at the start and then when you achieve them, set additional goals. Just don't set a goal that is too difficult, make the goal realistic.

Sometimes it is easier to start out with small steps to be able to make great strides. The following are just some of the things to consider in setting goals.

#1. A1c – This will often depend on your doctor and the medication you are taking. Many doctors only see diabetes patients twice a year if they have well managed and on oral medications. Now if you are not managing your diabetes, your doctor may be seeing you four times a year. If you are certain medications like sulfonylureas, DPP-4 inhibitors, or insulin, you may automatically be seeing your doctor four times per year. Other medications may also have an effect on how often you doctor wishes to see you, such as blood pressure medications, statins, certain antacids, and others. Your A1c approved range should be part of the results. Do not rely on the doctor to supply the appropriate range for you unless you are very elderly and in poor health. Many doctors automatically raise this the older you become. Because I am over 70, my doctor wants mine to be between 7.0 and 7.5. I am tired of being scolded for having one below 7%.

#2. Most doctors do take your blood pressure at every appointment. This is standard for all offices, clinics, and hospitals. It is also important because diabetes and high blood pressure are closely linked therefore it is important the have you blood pressure checked at every visit.

#3. Have you feet examined at every appointment. This is a little premature, but still important. If you are seeing a foot doctor or podiatrist, not every doctor you see will need to examine your feet at every appointment. A foot exam is important because diabetes may damage the nerves and blood vessels in your feet. This can mean that small cuts and blisters can be impossible to feel and slow to heal. This is why you should also check you feet on a daily basis.

#4. Annual eye exam is important to discover early any possible diabetes related damage to the retina. You should see an optometrist or ophthalmologist once a year for a dilated eye exam. If you didn't read my blog on January 4, please do, as many people can't seem to get this right.

#5. Having an annual physical exam once a year. Most people with diabetes see their physicians more than once a year. Make sure at least one of these visits includes an annual physical exam.

The following were not part of the newsletter.

#1. Have a dental exam on an annual basis. The health of your teeth is affected by diabetes and can become infected by periodontal disease (gum disease).

#2. Keep the results of your blood glucose readings recorded. This record may help solve problems when you obtain results that don't seem right. Granted if your results of your A1c are fairly consistent your doctor may not ask to see the results, but these may be handy if you are going up and down from one appointment to the next.

January 8, 2014

Diabetes, Type 1 and Type 2 an Over Simplification

Ever wonder why there is so much confusion about whether some people are first a type 2 and then later are reclassed as a type 1 person with diabetes. Even people diagnosed with type 2 later in life do not fit into the mold as true type 2 diabetes. Some persons with type 2 diabetes actually don't fit the symptoms of type 2 because of how they became people with diabetes. Back in March 2013, I became aware of the over simplification when I wrote this blog.

Then in August, September, and October of 2013, further information came to light in three more articles that I blogged about. Now, in December 2103, even more researchers and physicians are declaring that there is more involved in the diagnosis of diabetes. “The current subdivision of cases into type 1 or type 2 'is a gross simplification, and poorly describes the true range of diabetes,' wrote Leif Groop, MD, PhD, of Lund University in Sweden, and his co-authors online Dec. 4 in The Lancet.”

Yet, in the United States, doctors are becoming even more close-minded and want everything simplified so they don't have to think. They refuse to accept that diabetes can develop from several overlapping mechanisms that can be modified by both genetic and environmental factors. I will not go so far as to say this could be the reason they are abandoning support for diabetes, but their over simplification could be a large part of their treatment and greater desire to not support patient needs for education and methods of treatment to help manage the different subgroups of people with diabetes.

No one is yet positive that the growing obesity epidemic is some areas of the world is the total cause, yet doctors in the United States declare that type 2 diabetes is a lifestyle disease and that it is progressive. Most doctors still want to blame poor nutrition and sedentary lifestyles totally for obesity.

When we read books by Dr. William Davis about the effects of wheat on the body, many bloggers about low carb, high fat nutrition and the results that are positive in reducing obesity, we know that what we are being told by the U.S. Department of Agriculture (USDA), registered dietitians, and doctors is not correct.

Many patients with diabetes present with features of two or more types. While this used to be young adults between the ages of 20 and 40, recently more confusion was added by youth presenting with forms of type 2 diabetes. Previously, most youth were correctly diagnosed with type 1 diabetes. Now we have many youth presenting with type 2 diabetes and even some with a monogenic subset, maturity-onset of diabetes in the young (MODY).

Most doctors are confused by this and not even aware of the changes happening. They do not know how to test for the variances in our youth and up into the later ages of adults. Many doctors have thrown up their hands in defeat because they cannot keep up with the changing and complex research required by diabetes. This may be another reason for the medical community turning against people with diabetes as I covered in my blog here.

Obesity used to be a clue for the presence of type 2 diabetes. Now with the rise in obesity and the number of people who are not obese being classified with type 2 diabetes, this characteristic is less helpful as a diagnostic tool.

Other subtypes of diabetes in adults include ketosis-prone diabetes in adults, a hybrid form of the disease in which patients have features of both type 1 and type 2 diabetes. Then we come to latent autoimmune diabetes of adults (LADA), in with patients tend to be younger, secrete less insulin than those with type 2, have less evidence of metabolic syndrome, and have faster progression to insulin dependency than antibody-negative patients.

Don't expect the American Diabetes Association to do anything about this as their classifications have not changed in the 2014 guidelines. They will use a foreign study when it suits them, but the study has to fit their needs.

January 7, 2014

Another Impromptu Meeting Asked by Our Local Doctor

Early this afternoon, I received an email asking if I would attend an impromptu meeting to discuss what needed to be done as a doctor would not test for Vitamin B12 or any vitamin or mineral deficiencies. One additional comment was included asking a few of us to research what the American Diabetes Association (ADA) said about this in their guidelines.

Since I have been studying the new 2014 guidelines since I discovered them on December 31, 2013, I knew there was nothing to be found. I went to the American Association of Clinical Endocrinologist (AACE) site to see if there was anything that I hadn't read before, but again nothing about testing for deficiencies. I knew there would be articles in Medscape and other places, so I called on my search engine to help me find them.

Success! I even located one reference on the ADA site, but not part of the guidelines.
The percentage of people with type 2 diabetes taking metformin and developing vitamin B12 deficiency varies from 6 to 52 percent depending on the study. I quickly sent off the URLs to Tim since he would have his laptop at the meeting. Then I copied and printed several points to have at the ready from the ADA and included the following - “Several researchers have made recommendations to screen those with type 2 diabetes on metformin for serum B12 levels. However, no formal recommendations have been provided by the medical community or the U.S. Prevention Services Task Force.”

Ten of our members were present and talking before the doctor arrived. He was upset and we could tell this. He apologized to Allen and stated that this meeting should not have been necessary. He had thought that he had been convincing enough in his presentation to the doctor Allen had trouble with about vitamin B12 deficiency. The doctor then explained that at noon, he had received a call and was told that the ADA did not have anything in the new guidelines about testing for vitamin B12 deficiency and as such, he was not going to test. He did not feel the cost, though small was worth the small percent of people that would be deficient.

Tim took over and said that he had several good articles and that I had a handout from the ADA site for another article not part of the ADA guidelines. I handed out my print out and pointed out the information I have in red above. Allen was surprised at this, and asked why no one would take responsibility for testing. The doctor said he was and that some other doctors would be testing. He asked if Tim could put up the article from ADA and Tim said it would be shortly.

After Tim had the article up, he scrolled down to this. “Although classical B12 deficiency presents with clinical symptoms such as anemia, peripheral neuropathy, depression, and cognitive impairment, these symptoms are usually absent in those with biochemical B12 deficiency.” The doctor had to ask how many knew about this and 7 of those present put their hands up. He said it is no wonder you people do research. He said he was aware of anemia, depression and cognitive impairment, but not the other two symptoms. He added this is the reason he asked for the impromptu meeting as even he could learn.

Allen spoke up and said the individual he brought in was complaining about neuropathy and that is why he thought he could be B12 deficient. He said that was also the reason he had been taken to see the endocrinologist. He was also anemic at the time. Tim stated that we try to inform our members about this and make sure, if they are on metformin for any length of time, that they are tested.

After more discussion, Tim pulled up the article from WebMD and this generated even more discussion. The doctor commented that with these two articles, he wonders why the ADA will not take a position about testing for B12 deficiency. He said he now appreciates our group even more with this meeting and the information we were able to provide. He asked one final question about whether he should consider testing the elderly, above the age of 65 for B12 and vitamin D. Several of the group answered yes, but he noticed I had not answered so he turned to me.

I said that was a difficult question. I would answer yes for anyone with diabetes, but this would be a judgmental call on his part for people without diabetes. He said if he started at age 70, would I change my answer. I said that first he should asked the patient if he/she was taking separate vitamin B12 and D supplements. If they were, he would need to ask questions about neuropathy and he would probably need to explain what neuropathy or peripheral neuropathy was. He would also need to ask if any other doctor had tested for these.

I said if this was also part of the annual exam, then the tests could be done as part of this and then only annually if they were in the lower part of the accepted range. I said that if cognitive impairment or any of the other symptoms were suspected, then yes, do the tests.

The doctor then thanked everyone for attending and asked if there were any questions. Receiving none, he asked Tim to send an email with the URLs and a copy of the summary of the meeting to him. With that, the meeting ended.

January 6, 2014

Is Patient-Centered Health Care Beneficial?

It is somewhat surprising that in today's world, with our smart phones, internet savvy and media hype, when we go to the physician for a check-up many of us tend to sit back, listen and nod in response to a doctor’s advice on our conditions or treatments. This does not sound very participatory, does it? Why does this happen?

It is unfortunate that many patients do not want to be participatory and even more do not want to be empowered. On the other side, many doctors do not want empowered or participatory patients. They have gone to great lengths to confuse patients and continue their overly paternal ways. They claim they are doing what is in the best interest of their patients, but in reality, they often ignore obvious clues and misdiagnose what the patient presents. They insist on talking at the patient and not with the patient.

For a prime example of how poorly these doctors do their medicine, read this blog from Joslin Diabetes Center. Doctors can be idiots at times and as I read this blog, those were my exact thoughts.

Two laws are now stepping in and putting these doctors on notice that they need to provide more to patients. The legislation that mandated doctors to have electronic medical records (EMRs) or (EHRs) electronic health records also mandates them to provide patient portals. This forces doctors (providers) to more actively engage patients by providing them with the capability to electronically view, download and transmit relevant information from their provider’s electronic health records, including lab test results, a list of current medications, and hospital discharge instructions. The legislation also requires that physicians engage in email with patients.

Then we have the latest legislation that mandates and puts the doctors on notice that they must communicate with their patients of earn quality points that will determine their pay structure and incentives. In anticipation of this and the provisions of the first legislation, these physicians have developed new terms to muddy the waters and push back. Meaningful use and patient engagement are the terms these physicians have invented to work their way around these requirements.

If you are one of the patients that have been given access to your EMR, then you know what I say is what happens. When you receive their emails, there are statements as part of your medical appointment that are not happening. Supposedly, you have received a pamphlet or page relating to the purpose of your visit, which you have not received and probably never will receive. Mine were counseling I supposedly received about weight loss and another about concern for the purpose of the doctor visit. All the doctor needs to do is check a box and this is meaningful use when the paper is said to have been given to you.

Communication is definitely lacking, but the physicians can claim patient engagement. The theory behind this patient engagement is that when we have access to our medical information and we are assisted to the point that we understand what our care is all about, we will respond positively to our treatment options and take better care of ourselves. If this communication actually happened, I would be very happy. Instead, I have needed to go to the computer and research to find information about the problem that I saw the doctor to communicate with on the topic.

I will admit that some doctors are actually communicating and rebuilding the doctor-patient trust, but most doctors are not. I have blogged about some of this on 28 and 29 December 2013. Another good blog by Nancy Finn about what is supposed to be happening is a blog you should read and become familiar with because it does explain some items I have not covered in this blog. She does explain patient-centered better than I do and probably because I have not seen patient-centered benefits at this time.

January 5, 2014

Food Plans According to RDs

A blog on the American Association of Diabetes Educators (AADE) site caused me to read the entire blog. This blog is written by a registered dietitian (RD) and certified diabetes educator (CDE) among other titles. She is writing this for other CDEs and RDs and is very careful to do it correctly.

She starts by promoting low fat high carbohydrate food and discouraging sweetened beverages. By starting with eating more fish, she sets the tone of her blog. Then we learn that it is the Mediterranean and DASH diets are the foods we should be modeling our meal plans around. These are high carbohydrate foods, but she suggests this is a better route than focusing on quantities of carbohydrates. Next, she explains that the recommended diets help to minimize food plans rich in fatty meats and cheese. She says this (fatty meats) is often the default when patients are encouraged to reduce carbohydrate intake. Then she carefully states this elimination of carbohydrates would be horrifying and says she jokes with her patients that all carbohydrates should not all come from ice cream.

Then the author goes mandating when she says that one food plan does not fit all patients and that this is important to our message delivery. She says they can start listening to the patient, but she also says we must adjust their food plan to meet their needs, coach them through eating real food, and work with them to minimize the intake of foods that lack nutrient density.

In other words, this is the same message just reworded and it is to be fed to us, as patients, in a way that will guide us into eating more carbohydrates and less fat. When she concludes with this statement, “It is our job to help the patient find a way to incorporate nutrient rich foods into their daily lives, help to minimize blood glucose excursions and promote overall health,” she is really saying that RDs and CDEs need to work more diligently to convince us that we are eating more healthy foods. I don't know that more carbohydrates and less fat is healthier, and for many people this will maximize blood glucose excursions and continue to make us less healthy.

It is surprising how the English language can be used to mislead the people that are not familiar with the different ways of saying something. I admit that I almost thought about it differently – for a while, but in rereading the blog, I could not help but see the real meaning. I hope you will agree.