The Next Meeting with the New Member

James was happy to see us on Thursday and had lots of questions. His concern was the reduced amount of carbohydrates. Allen explained that he would use his meter to determine if the amount was too low or too high. Allen asked James when he had started his evening meal. James said about an hour earlier and Allen asked Jill if that was about right. Jill gave the time and Allen suggested that he test then. Allen recorded the time and meter reading. Allen said he would test 15 minutes later.

James was a little anxious, but I told him that by testing, he would have a better idea. Allen confirmed that and asked Jill if she had recorded the carbs James has consumed. Jill said that she had not, but could figure it out. I told her that would be good and would help us in matching the testing. I continued that we would show both of them how to maintain a food log which would help James in determining the insulin that he would need.

I started on the food log for them and Allen kept track of the time and had James test in 15 minutes. Again, he recorded the time and reading and said he would test again in 15 minutes since the last reading was higher than the one-hour postprandial reading. Allen explained what we were looking for and why. He told James that the recording and time was important because we were looking for the downturn in his blood glucose levels.

Jill and I continued working on the food log and in about 30 minutes had it complete for the day. James added a couple of items from lunch that Jill did not know about. At that time, Allen asked James to test again. Allen recorded the time and meter reading and said it is the same as the last reading, so we would do one more test and that could possibly be the last for the evening meal.

I asked Jill if she had an idea of the food for the next day. She wrote out the breakfast menu and what she would prepare for lunch. We calculated the carbs and James stated that was too low. Allen said we are only suggesting, but if you want to manage diabetes, you would be wise to consider our suggestions. Allen said you can lie to us, your wife, and even Dr. Tom, but the A1c will still give Dr. Tom an idea if you are telling the truth. Even trying to lie to yourself will not help in managing your diabetes.

Allen said it is time to test again. He recorded the time and reading and pointed out the changes to James. This reading was down sharply from the previous reading. Allen said this suggests that the high reading probably occurred between one-hour and 15 minutes and one-hour and 30 minutes. It is unusual for the two readings to be the same and that is the reason for testing at one-hour and 45 minutes. If the reading at one-hour 30 minutes had been lower, the last test would not have been needed.

Now, Allen asked what his before meal reading was. James said he did not remember. Allen asked if he would download his meter and print out today's readings. James hesitated and Allen said it is necessary when you won't record your readings on a pad of paper. While they were doing this, I talked with Jill and checked how many carbs he had for the day. He had just in excess of 130 carbs and this was more than the suggested range. Jill had her laptop and I asked her to read the email I had sent. She said she had and the links were interesting. I asked if she had a recipe that they liked and did not have the nutritional data from an old cookbook.

She reached for the cookbook and opened it. I had her join this site and then go to this page. She entered the ingredients and had the nutrition information. Jill said that was easy and I commented that it was not an accurate list of nutrients, but close enough to help in carb counting and with the blood glucose readings, they would know how close they were. I took time to go into some of the variables and said I would send her an email of where to read about more.

I told Jill that if they kept up the food log and carb count for the next few months, they would start to see patterns and this would help encourage her husband better to manage his blood glucose.

Allen and James came in then and Allen said James needs to work on recording his blood glucose readings and keeping them for the day instead of downloading his meter so often. Allen said his readings from before eating to about the highest post prandial was over 70 mg/dl. I asked James if he understood what this told him. He said Allen had said that this was too high based on the number of carbs his wife had calculated for his food. I said this should indicate that you did not inject the correct dose of insulin and needed to increase it by the formula Dr. Tom had given him. I then told James that being new to insulin and needing to lose 15 pounds, reducing the number of carbohydrates was important to prevent weight gain. If he followed our suggestions he would not gain weight and would lose weight slowly. In a couple of weeks he would be adjusted to lower carbs and would not even notice the reduced number.

Jill said that tonight was valuable for her and she was beginning to understand more of what was involved and hopefully between the two of them they could together work at improving his diabetes management. Allen said James is still being lazy in the tasks he needs to record and wanting technology to do all his work. Jill said she would work at encouraging him and I told Jill she needed to learn at the same time, but the responsibility still was his, as it was his diabetes, and not her diabetes.

With that, Allen and I said goodbye and stated we were available if they had questions. When we were outside, Allen said he would talk to Tim.

Another Meeting with the New Member

On April 22, Jill called Tim to see if he could bring Allen and me the next evening. Tim said he would check and get back to her. Jill said they both had received the equipment and were ready for more learning. After Tim had talked to each of us, we agreed if he would alert Dr. Tom. He said he had already done this and had specific instructions from Dr. Tom.

Tim sent an email to Allen and I with these instructions and what we needed to cover and not cover at this meeting. We had to pay attention to their questions and make sure we answered each one. We were to be careful not to overload them with information, but let them absorb what we were telling them. The first thing we were to cover was the downloading of the meter to the computer and what had been set for the different parameters. Then Dr. Tom wanted a print out to-date.

The next evening, Tim picked us up and we talked briefly until we arrived at their place. James and Jill met us at the door and invited us in. James wanted to go over the program for downloading his meter and Tim went with him. Allen and I followed Jill to the kitchen where she had laid out two cookbooks which she identified as new for them. She proudly brought out the scale and hesitantly asked what tare meant.

Allen turned to me and I said there is one easy way to remember. I asked for a bowl that was often used for serving food. Jill reached into a cupboard and set one on the table. I turned the scale on and waited until it processed. Then I set the bowl on the scale. Jill said that is tare. I laughed and said sort of, but watch what happens when I push the tare button. Jill said the scale just went to zero. I said right, the bowl will not be recorded as weight when you put something in the bowl. Jill reached into the refrigerator and placed a packaged salad in the bowl. The scale now read 12.5 ounces. Jill said the salad is only 12 ounces. I said and the packaging weighs supposedly 0.5 ounces. That means that the contents of the pack of salad is very close to 12 ounces. Tare means the zeroing of the container weight to obtain an accurate weight of the food in the bowl.

I asked her to get a plate they used for a meal. Then I had her reset the scale and once it was reset, to set the plate on the scale. The scale showed the plate weighed 18 ounces. Jill pushed the tare button and put the salad package on the plate. The package of salad weighed 12.5 ounces again. Jill said now I understand why you wanted this in a scale. I said if you clear this again it will weight the pan or pot you use to cook in if you also put a pad under the pan for tare weight. Then when the pan is hot, you can weigh the contents in the pan. If the recipe serves four, then you can take the pan off the scale, after recording the weight.  Then clear it again because you know the weight and put a plate on and tare the plate. By putting food on the plate or in a bowl, you can know what weight is one fourth of the total.

If you have a cookbook with nutrients listed, then you will know what the carbohydrates are for your husband. By the same procedure and a handy calculator, you can determine the size of serving your husband needs. With that, Jill asked Allen to hand her one of her cookbooks. She opened it to the page she had paper-clipped and said this is one of the recipes she and her family liked, but it has 78 grams of carbohydrates.

Allen said what else do you have with the meal. Jill said normally James has one or two slices of bread and a glass of milk at the evening meal. Allen asked if she had the bread package to look at. Jill reached into the cupboard and brought out the bread. I looked at the label and it was 18 carbs per slice. Next, she brought out the milk and Allen read the label and asked what size of glass he used. Jill reached for a glass and Allen asked how full it was normally filled. She indicated about two-thirds of a glass and rarely more. Allen said that 10 carbs will very close. He did say that if they changed to another milk or whole milk to refigure.

Tim and James came into the kitchen then and Jill said the scale did more than they had thought and that I had showed her how to use the tare button. Tim put the printout of the meter readings in front of Allen. Allen asked if he had discussed this with James and James said he has to make some improvements. Then he added - some drastic changes. His readings were in the upper 200's and he was not testing after every meal and at bedtime. Allen asked if Dr. Tom had him approved for more test strips and James answered yes and he would be testing more often. His insurance would allow the extra testing for four months before cutting him to four test strips per day.

James said Dr. Tom had told him to lose at least 15 pounds to be at ideal weight. Tim said he had brought up the Health Central weight calculator and for his frame size and Dr. Tom had used the same chart. Allen asked if he was ready to learn about food or leave this for later this week. Jill asked if Allen and I could come the next evening, as she wanted to go over what she had learned with her husband and to start teaching him how to count carbs. Tim said that he would come the following week to see how he was doing with testing and insulin. James said on Tuesday if possible as he had a meeting Wednesday evening for work he needed to attend. Everyone agreed and Tim, Allen, and I left.

Tim said he is making progress, but is somewhat intimidated by insulin and is slowly gaining confidence. Tim said he had given him a range to work toward for carbs now and to see where testing was telling him to go. He said the amount of insulin he is taking indicates with the numbers he is getting that the carbs are too many and he is not insulin resistant. I said that they got the right scale and she was learning about carbohydrates and how to calculate. I said she even has a calculator and I would show her additional help tomorrow.

Tim said to call him after our meeting was done.

Sleep Apnea Makes Diabetes Harder to Manage

This study conducted in Europe supposedly, is not news to me because I have sleep apnea. It just confirms what I am already aware of and can't get one person I know to wear his CPAP mask. He has type 2 diabetes and it is poorly managed. He now refuses to tell me his A1c results because he knows that I will tell him that his sleep apnea is making his diabetes more difficult to manage.

I am not sure why he will not use his CPAP, but I know he is constantly overtired. Recently, he lost his job because of falling asleep at work and this endangered other workers. This of course has made him more upset and I have been very careful about what I say to him. However, I still ask him why he will not use his CPAP. I have informed him that he would be able to manage his diabetes more effectively.

I do tell him that with sleep apnea, he could die in his sleep when he can't recover from an apnea. He just laughs at me and all I can do is shake my head. I finally had a talk with his doctor and urged him to consider an intervention. His doctor would not say anything because of HIPAA and I just said I was informing him of a problem with this patient.

The study is not really useful as it was done with non-diabetic people. I could not confirm this, but I could not find that it had random controls as part of it. At least it was not U.S. taxpayer money wasted on a useless study.

I doubt that sleep doctors will consider this warrants attention and screening for diabetes as the lead author tries to point out.

Since I have type 2 diabetes and sleep apnea, I can confirm how important it is to use my CPAP equipment – actually a BiPAP machine. I use my equipment every night and my sleep apnea is a non-factor in the management of my diabetes as a result.

Some of the reasons people refuse to use their sleep apnea equipment include:

1. Vanity – they don't feel sexy or manly wearing the mask
2. Some feel wearing the mask is claustrophobic
3. Some do not like the lines that the mask straps cause in their skin because they have the straps too tight
4. Many complain about the noise the machine makes
5. Many have a problem with the air leaks around the mask because they aren't properly fitted or having a mask that fits properly

I have several blogs about these problems, but feel that number 3 and 5 above can be solved if people would consider nasal mask liners as discussed in my blog here. Noise can be a problem for some, but the noise has been decreased in recent years, especially in the newer machines, and should not be the problem of older CPAP machines.

Another factor is having the mask properly fitted by a sleep specialist. Many people do not do this and blame the manufacturer for their bad decision or they just won't ask the right questions.

If you have sleep apnea and type 2 diabetes, please do yourself a favor and use your equipment as you will feel better and manage you diabetes more easily.

An Interview That Did Not Happen

It is with great reluctance that I am doing this blog. I have been attempting contact with the Academy of Certified Diabetes Educators and I trust one of the current board members that on March 26 stated that my request for an email interview was being forwarded to the Academy Board President. It is now April 23, and I have had no contact with the current board president.

This does concern me as a person with type 2 diabetes. Then I opened the ACDE website and this I quote,

“An Important Legislative Update!

Indiana Diabetes Educator Licensure

The ACDE Board of Directors (BOD) was disappointed to learn that Indiana Governor Pence signed Bill SEA 233 into law. This bill allows for a person who has NO healthcare licensure or registration to obtain a “diabetes educator license” in Indiana. The ACDE BOD recognizes that only qualified licensed/registered health care professionals who have passed a validated examination are qualified to provide diabetes self-management education. We will work closely with NCBDE and the Indiana Medical Board regarding implementation of state regulations. Our goal is to educate legislators and the general public about the validity of the CDE® credential to ensure quality diabetes education services that meet national standards are provided to those with diabetes.”

Obviously, the Indiana state legislature and the Governor of Indiana saw a clear purpose for passing this bill and making it law. Could it be that the people of Indiana are not being served by the CDE profession? Could it also be that the medical community asked for this because of problems and lack of education being given by the CDEs in Indiana?

This should bring caution to both CDE organizations and cause for investigation before making the above statement. If either of my questions is answered yes, then the CDE profession needs to investigate the reasons the law was passed and find out what the members of their profession have done to cause the law in the first place.

I have been blogging about the lack of education for people with type 2 diabetes, whether on oral medications or insulin. Many of the doctors in the state of Iowa are also upset about the lack of and poor education provided people with type 2 diabetes. Even many people with type 2 diabetes do not like the education provided by CDEs when it amounts to mandates, mantras, and worn out cliches.

Several of our local doctors are working with people in the local diabetes support groups for education and spending some time educating groups of us to help their patients. It would be great if we could be reimbursed for some of our time, but currently we do this on a volunteer basis as we feel the urgent need to help the other people with type 2 diabetes.

The above notice from the ACDE website concerns me, as it appears that the organization wants to be in charge of limiting who can pass on knowledge about diabetes to other people with diabetes. This sentence from the above quote does make one question the motives and how exclusive they intend to become. “Our goal is to educate legislators and the general public about the validity of the CDE® credential to ensure quality diabetes education services that meet national standards are provided to those with diabetes.” Bold is my emphasis and whether the national standards will be for the benefit of people with type 2 diabetes.  Quality diabetes education requires more than mandates and without educators that have diabetes themselves, often we receive little education of value when they approach education in a one-size-fits-all mode.

Exclusivity is the motto of the Academy of Nutrition and Dietetics (AND) and we don't really need another organization that promotes they are the only organization to legally serve people with diabetes education. The AND organization also tried to limit freedom of speech about nutrition and criminalize people not in their membership writing about nutrition and teaching nutrition in North Carolina and Ohio.

Polypharmacy – How I Dislike You

You just can't make some doctors happy. Even though the doctor was smiling when he said I was a drug addict, I still took offense to the statement. Having had a doctor attempt to increase my dosage for several medications to bring me in line with the guidelines for recommendations for blood pressure medications and statins has left me with a sour taste in doctors. Add to this a great discussion with a VA doctor about eliminating one medication and reducing the dosage on another medication, I really can't understand why doctors are pushing to increase some medications so enthusiastically.

Admittedly, I would like to be off a few medications, but because of the lab reports and other tests, I know that I am where I should be for the results I am obtaining. I am lower than the guidelines for blood pressure readings, yet I have had to refuse to let the nurses take my blood pressure readings immediately after entering the exam room. Not only have they increased the pace from the waiting room to the exam room, but also taking the BP with the incorrect BP cuff is another trick they have used to bring my BP readings up.

Even my wife, who is a certified nurse aide, has the right cuff for me and my BP readings are consistently 115 to 125 over 60 to 75. Yet the doctors' nurses work to get my BP up to 140 (or higher) over 90 (or higher) so that the doctor will prescribe a higher dose of BP medication.

Now the cholesterol (lipid) panel seems to be all over the range. The latest test done at the VA showed everything within the normal range, but with a three day difference in blood draw, all my results done by the hospital lab were beyond the high limit of the range. I therefore have to wonder if the hospital lab reports are inflated for the doctors to enable them to increase the statin dosage. To check the hospital lab reports, on the same day, I went to the local hospital and paid out of my own pocket to have them do a blood draw and do a lipid panel. All the results were within the ranges and the ranges were the same as the VA and the regular hospital lab. All three blood draws were fasting and that is the reason I say that the results for the doctor were inflated.

I am beginning to think I need seriously to consider changing doctors and hospital labs. Not only would I save on distance traveled, but I may also save on frustrations. When it comes to my diabetes, I don't like the idea of leaving the endocrinologist I have, but I am tired of having the suggestion of letting my A1c get above 7.0 at every appointment.

Yes, they tell me that is because of my age that they make this suggestion. I tell them that until I am unable to prevent hypoglycemia, except for the rare episode, I will continue to manage my diabetes to the best of my abilities. Only three readings below 60 mg/dl in the last year and two were at times I suspected I would go low because of injecting the Novolog too close to the Lantus injection site and testing proved I was going low and the glucose tablets did their work. The lowest reading each time was 56 mg/dl and 58 mg/dl. I consider these low, but not severe lows. The third time I injected Novolog when I should have injected Lantus.

Now am concerned because I do not have the symptoms when I get below 70 mg/dl of sweating, being shaky, or the other symptoms. I seem to have become hypoglycemia unaware in the last year and that does concern me. As a person with type 2 diabetes on insulin, I always believed that only people with type 1 diabetes had this problem. This confirms that the analogue insulins can cause this condition in both types.

Participants Wanted for New Diabetes Trial

Normally I will not promote studies, but this is one that may deserve your consideration if your are taking metformin and should consider adding another medication.  I will be quoting from much of the press release.

“Researchers at Washington University School of Medicine in St. Louis are seeking volunteers for a study that compares the long-term benefits and risks of four widely used diabetes drugs. The drugs will be given in combination with metformin (Gulcophage®), the most commonly prescribed medication for treating type 2 diabetes.” 

The trial will run for a period of five years. The researchers will evaluate how the drugs affect blood sugar levels, diabetes complications and quality of life, as well as the medications’ side effects.

“In addition to determining which medications control sugar most effectively over time, we will examine individual factors associated with better or worse response to different drugs,” said Janet B. McGill, MD, professor of medicine and principal investigator at the Washington University study site. “This is a long-term study that will provide targeted diabetes care at no cost to participants.”

“Although short-term studies have shown that drugs to lower blood sugar can be effective when used with metformin, no long-term studies have been conducted to determine which combinations work best to keep diabetes under control.”

“The nationwide study is called the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness (GRADE) study. It is expected to involve 5,000 patients across the country and 300 locally who have been diagnosed with type 2 diabetes within the past 10 years.” Bold is my emphasis.

“To be eligible for the study, people with diabetes may be taking metformin, but they cannot be on any other diabetes medication. During the study, all participants will take metformin along with a second medication randomly assigned from among four classes of medications that are approved for use with metformin by the Food and Drug Administration.”

“Three of the study drugs increase insulin levels. They are: sulfonylurea, DPP-4 inhibitor, and GLP-1 agonist. The fourth option is a long-acting form of insulin.”

“Participants will receive free clinical evaluations and management of their diabetes medications throughout the course of the study, including at least four clinic visits a year.”

“For more information or to volunteer, call study coordinator Lori Buechler at 314-362-8285, e-mail GRADESTUDY@wustl.edu or visit the study’s website,” http://endo.wustl.edu/current-clinical-studies/.

The last paragraph is the important contact information. To be eligible for the study, people with diabetes may be taking metformin, but they cannot be on any other diabetes medication.

Increasing Doctor–Patient Communications

Continued from yesterday's blog

I admit I don't have much faith in doctors and many patients being able to improve communications under the current circumstances and health care laws. Many patients have lost access to their doctors and have been placed by their insurers with new doctors. This not only make communications more difficult because both are starting over with new beginnings. Others that have retained their doctors are wondering if they have a good thing and why so many others have had to move doctors. A lot of nervousness currently exists and this affects communications.

Nancy Finn thinks technology will help in communications. While she may be seeing some improvements and changes, I have some reservations about what I am seeing in the lack of technology advances and refusal by doctors to accept technology, except what is useful in practice or will earn them money. Some doctors to satisfy the stage 2 “meaningful use” requirements are making use of patient portals on a very limited basis and most are not allowing corrections to records. Believe me, I have tried as I have found some serious errors in my medical record.

Nancy thinks that if patients and providers use tools such as the internet and mobile phones to track medical conditions, everyone can benefit. She also lists tools such as patient portals to engage in e-visits, and email to discuss non-emergency issues between visits.

After doing some research, Nancy may be on to something. This article, published on April 7 in the Star Tribune describes something I was not aware of until I read it. Doctor on Demand started about four months ago and is now in 40 states, with 1000 doctors on staff. A 15-minute video session costs $40. Minnesota Blue Cross and Blue Shield is behind this and telemedicine is being used for home visits and people going to a kiosk which has some instruments available to take vitals. Some even have an autoscope tool with a camera attached to look into ears.

This doc-in-the-box is quite satisfying for many patients. Other doctors are raising the issue of the quality of care, but patient satisfaction is running high. Even advocates for virtual exams say they work best for routine cases, but when it comes to complicated diagnosis and treatment, there is no substitute for an office visit. Even I am going to investigate what may be happening in my state of Iowa and whether this might be available here. I do doubt that Medicare is involved in this, as the only telemedicine they have become involved in to-date is when providers are on both ends.

Nancy Finn also covers wearable devices, phones and the internet to monitor chronic conditions. She lists mobile phones to text instant messaging and to deploy apps to track heart rate, blood pressure, blood glucose, weight, and fitness.

Rather that list the suggestions that Nancy has for patients and doctors, I suggest that you take time to read her blog. One item she did not mention in constructing a personal health record is to make use of Microsoft HealthVault. Read about this here and with any choice you make, please use a secure choice.

I will quote her last paragraph as it expressed my thoughts as well. “When all the parties in the health process understand the need for communication and work at providing the pathways to make it happen there will be less frustration and dissatisfaction, and the safer practice of medicine for all concerned.”