Is It Any Surprise Patients Are Non-compliant?

I am again writing about doctors complaining about us as non-compliant patients. This time I am really concerned by what is happening in the health care we are supposed to receive, but seldom do. This time it is when patients are discharged from a hospital. Even when hospitals know that they will be penalized for readmission of the patient within 30 days, they seem to care less.

“A 2007 Institute of Medicine report accurately describes the fears and worries that accompany most life-threatening illnesses, regardless of the diagnosis. These include basics like:

• The physical pain and exhaustion of the condition and its treatment.
• Not understanding about the diagnosis, treatment options, and how to manage your illness and overall health.
• Not having family members or other people who can provide emotional support and practical day-to-day help such as performing important household tasks.
• Not having transportation to medical appointments, pharmacies or other health services.
• Financial problems, ranging from concerns about health insurance to payments for treatments, or problems paying household bills during and after treatment.
• Concern for how family members and loved ones are coping.
• The challenges of changing behaviors to minimize impact of the disease (smoking, exercise, dietary changes, etc.).”

The above is important and includes most of the psychosocial stresses accompanying a crisis as it does with the heroic medical interventions that saved us. Yet these are completely ignored by the hospital staff and physicians when patients are discharged from the hospital.

The author of this blog relates that when she was discharged from the hospital cardiology care unit, “not one of the cardiac nurses, residents or cardiologists who cared for me during my post-heart attack hospitalization had said one word to me about any of the important and commonly experienced psychosocial issues on this list.

1. Not one of them asked, if I'd be able to afford the fistful of expensive new cardiac meds I'd been prescribed after surviving what doctors call the "widowmaker" heart attack.
2. Not one asked if there was anybody at home to help take care of me there, or if there was anybody at home who needed me to take care of them.
3. Not one asked if I'd be returning to a high-stress job, or even if I had enough banked sick time or vacation days to take sufficient time off to recuperate before going back to work.

Such real-life issues are simply not the concern of most of our health care providers.”

“It's almost as if they are unaware of the considerable research that suggests ignoring the psychosocial issues of their seriously ill patients increases the risk of poor outcomes and higher hospital readmission rates down the road.”

"Those suffering from psychosocial issues can have difficulty remembering things, concentrating, and making decisions. These mental health problems can also decrease patients' motivation to complete treatment, take their medications, change unhealthy practices such as smoking, and decrease their ability to cope with the demands of a rigorous treatment process... There is also growing evidence that stress can directly interfere with the working of the body's immune system and other functions."

With this outlook on life displayed by health care providers, it is a wonder that anyone survives a trip to the hospital, especially the elderly. Still the doctors fight over who is to care for the patients once they leave the hospital, but even that doesn't happen because hospitals seldom communicate with outside doctors. We have more than just a broken health care system, when one branch of care refuses to communicate with another branch.

Watch B12 Levels If You Take Metformin or Antacids

The Joslin Diabetes Center apparently has some doubts about metformin causing vitamin B12 deficiency. Studies have shown that long-term metformin use causes about 30 percent of patients to develop B12 deficiency. Yet, Joslin believes that food is the answer and waits until the last two paragraphs to discuss to problems that vitamin B12 deficiency can cause. They even try to minimize the deficiency and go to great lengths and quote the American Diabetes Association to emphasize their point.

The unidentified blog author says, “But just because these people taking metformin had lower levels of B12 in their bloodstream doesn’t necessarily mean the B12 that’s there isn’t getting the job done. New measurements of B12 activity have indicated that although metformin does seem to reduce blood levels of B12, this may not reduce the vitamin’s effectiveness in carrying out it its functions in the body. When B12 doesn’t work the way it’s supposed to, levels of something called total plasma homocysteine (tHcy) go up. But newer studies looking at the levels of tHcy in people who take metformin have found that they have not been elevated.”

“According to an article published this year in Diabetes Care, “low serum B12 alone without disturbances in the metabolic markers has no diagnostic value.” From a practical standpoint, this means that if a B12 deficiency is suspected from a serum B12 test, further testing should be undertaken before assuming the patient is B12 deficient.”

Vitamin B12 is one of the B vitamins that are needed for the healthy development of blood cells, DNA, and the nervous system. B12 is a water soluble vitamin and can possibly be stored in the liver as long as one year. Vitamin B12 is obtained from most animal products, fish, and especially animal liver. People eating a vegan diet will need to consume a B12 supplement, B12 enriched tofu, or yeast to obtain adequate levels of vitamin B12.

This is important for people with type 2 diabetes and on metformin. B12 deficiency can lead to megaloblastic anemia, a type of anemia in which the red blood cells are significantly larger than normal. People with mild B12 deficiency may feel weak and tired, bleed easily, experience tingling in the hands and feet (neuropathy), and swelling of the tongue. People that experience severe B12 deficiency can have serious effects such as memory loss, delusions, lost of taste and smell.

In the last paragraph, the author finally admits that metformin contributes to serum B12 deficiency by preventing its transfer into the blood through a calcium dependent membrane. This leads to decreased absorption. For vitamin B12 to be absorbed into the blood stream, it needs an acid environment in the stomach.

As people get older and have the need to take acid reducing medications, such as antacids or proton pump inhibitors, they have the increase in the likelihood that they will suffer from a B12 deficiency. It is also possible for this to happen in certain gastrointestinal disorders such as atrophic gastritis, Crohns disease, and surgical reduction of the stomach.

I admit I do not understand doctors that fail to test for B12 deficiency properly and just tell people to eat more meats. Few consider the person's age or ask what medications the person is taking that might be a cause for B12 deficiency.

This article also helps justify B12 testing. Early Alzheimer's can be confused for B12 deficiency. Please read the post linked.

New Glasses for Elderly Often Equals Increase in Fall Risk

When I wrote about antidepressants possibly causing falls for the elderly, binocular vision disorders is higher than expected in the elderly, most binocular vision disorders are treatable with glasses, vision therapy, or occasionally surgery. It is recommended that people keep their glasses up-to-date with regular eye examinations. This will avoid large prescription changes and is a good way to maintain good vision, decrease risk of falls, and maintain a good quality of life as you age.

Now we have a non-scientific review in optometry and vision science that says that over-aggressive eyeglass prescription changes need to be avoided. Blurred vision contributes to the risk of falling in older adults—but getting new glasses with a big change in vision prescription may increase the risk rather than decreasing it. Falls are the major cause of accidental death and non-fatal injuries in the elderly. At least one-third of healthy adults age 65 or older fall at least once a year. For those 90 or older, the risk increases to about 60 percent.

The reviewer, David B. Elliott, PhD, says that falls in older adults aren't accidents. Most of the time, they're related to a wide range of risk factors including older age, disabilities, muscle weakness, and many different medical conditions. The more risk factors you have, the more likely you are to fall.

In the elderly, reduced vision in a large risk factor for falls. This suggests that interventions to correct vision, glasses, or cataract surgery, would reduce the risk of falling. The surprising factor, most studies have shown little or no reduction in falls among the elderly receiving a new vision correction.

Magnification from some new glasses may contribute to increased risk of falls. Receiving large changes in a glasses prescription also increases the risk of falls. This is because the frail elderly may have more difficulty adapting to these large changes and often are at increased risk of falling during the period of adapting.

I needed to smile when I read, 'If it ain't broke, don't fix it' when speaking about large or magnification changes in glasses for the elderly. The elderly take longer to adapt to changes in glasses prescriptions because they are not familiar with some changes. Dr. Elliott advises caution with changes for the elderly.

Maximizing vision corrections for the elderly is not advised and optometrists need to assess properly the risk factors, including history of falls, medical conditions, and medications used. Dr. Elliott advises taking a conservative approach to prescribing new glasses for older adults with a history of falls or risk factors for falling.

Finally, Dr. Elliott suggests keeping the same type of prescriptions, bifocals, or progressive lenses, unless there is a significant reason for change. If a patent is used to wearing single-vision glasses, they should not be moved to bifocals or progressive lenses. A change like this is going to increase the risk of falls.

If you are a caregiver for an elderly person, always be aware of what the person uses for glasses and if necessary, change optometrists if they are being radical in the changes in glasses.

The Recent Activities of AND

The Academy of Nutrition and Dietetics (AND) almost succeeded in becoming the only profession to handle the duties of a dietitian for hospitals receiving money from the Centers for Medicare and Medicaid Services (CMS). In the last week, nutritionists not members of AND were added to the list of people allowed to direct nutrition in hospitals and other institutions receiving money from CMS.

This might take the attitude out of some of the members of AND and I think this is overdue. The local hospital dietitian is still sputtering about the meals A.J. received while he was in the hospital. She finally admitted that the doctor was right for the patient receiving a liquid diet as he is now off the liquid diet and on soft food for several days before he will be allowed regular food. He did have a second operation to repair something missed during the first operation. He will be in the hospital for at least another week, as they keep watch, to see how he is healing.

A.J. has been moved to a nursing home and is getting the meals he asks for and enjoys. He will remain there until the arm casts are removed and he is capable to taking care of himself. He admits he is tired of being fed by others and wants the casts off. The doctor Tom says it will be at least another four weeks. This did not sit well with A.J.   A couple of days later, he was in a better mood as doctor Tom had part of the cast on his left arm removed so that he could bend his elbow. He still could not feed himself, but with this, he was happier.

For several years now, the AND's main lobbying efforts have been to introduce licensure laws on 'scope of practice' that prevent qualified non-AND nutrition professionals from practicing. These laws are then enforced by state health boards and state dietetics boards dominated by pro-AND dietitians.

This covers the AND's activities in four states:

Maryland – The AND sought and received authority in April 2014 to expand the state dietetic board's power to send nutrition professionals cease-and-desist letters (a right usually restricted to the state Attorney General) and to increase penalties for non-compliant professionals.

California – AND is seeking the right to provide independent medical nutrition therapy without the supervision of a physician or surgeon, and to receive insurance reimbursement for this.

New Jersey - AND has bills that would only allow licensed RDs to engage in medical nutritional therapy. This would be an exclusive right.

New York - An almost identical bill is moving through the New York legislature.

If you live in these states, you should be concerned and consider action to amend or stop the legislation.

Problems – Diabetes and Tattoos

Since I don't have tattoos, I admit I don't understand people that insist on having them. When I blogged about tattoos here and a doctor's insistence that they be standardized for those of us that have diabetes, I was a little snarky and asked the doctor to stay out of our lives. Now there is more on tattoos and one of the better articles about people with diabetes obtaining tattoos.

The article starts with a discussion about a young woman with an infection from her tattoo. What is not said is the level of diabetes management and whether proper care had been taken. People with diabetes are predisposed to staphylococcal infection.

Tattoos are popular, and teens do like them. However, the tattoo application process and aftercare can be long, painful, and stressful. This can be problematic for people with diabetes. Both blood pressure and blood glucose levels can rise while the tattoo is being applied. Add high blood glucose levels because of unmanaged diabetes, and the risk of infection increases.

Factors to consider before obtaining a tattoo:

Tattooist quality The tattoo studio should be licensed and/or accredited. The patients should also research the company's reputation, hygiene, and safety practices.

Safety and awareness The tattooist should be informed of the patient's diabetes so they can tailor both the procedure and aftercare information. Always walk away from a business that does not show the proper concern for a person with diabetes.

Placement Certain areas should be avoided including those with poor circulation, such as:

• Buttocks
• Shins
• Ankles
• Feet
• Common insulin injection sites such as arms, abdomen, and thighs.

Tattoos in these places usually take longer to heal, which can lead to complications and infection.

Other Risks

• Allergic reactions - reaction to the substances used in the inks and equipment.
• Skin infection - the tattooed area of skin may become infected if the studio and/or tattoo equipment is not clean or proper aftercare is not applied.
• Scarring - tattoo application can cause the formation of an oversized scar known as a keloid, which can be irritable and slightly painful.
• Blood-borne diseases - if the tattoo needle or ink has not been sterilized, there is a risk of blood-borne illnesses such as HIV and Hepatitis B or C.
• Wound healing - abnormally high levels of blood glucose could delay healing of the tattooed skin and increase the risk of infection.

If the patient feels unwell or sees any sign of infection after the tattoo has been completed, they should seek immediate help from their doctor or diabetes healthcare team.

If you are a person with diabetes that just has to have a tattoo, be sure you at least go prepared and follow the information above.

To Prevent Lung Infections, Use the Right Oils

This blog is not about diabetes, but may help many with diabetes and their friends. When I first read this, I had to reread it. The next step was to ask for a full copy of the study. This was furnished.

The Feinberg School of Medicine, Northwestern University, Chicago, IL has published the study. The study examined 4,526 individuals from the Coronary Artery Risk Development in Young Adults Study (CARDIA). The study shows drastically different health effects of vitamin E depending on its form. The form of Vitamin E called gamma-tocopherol in the ubiquitous soybean, corn and canola oils is associated with decreased lung function in humans. The other form of Vitamin E, alpha-tocopherol, which is found in olive and sunflower oils, is associated with better lung function.

Senior author Joan Cook-Mills, an associate professor of medicine in allergy/immunology at Northwestern University Feinberg School of Medicine presented her research in May at the Oxidants and Antioxidants in Biology World Congress. It was also published in the journal Respiratory Research.

Cook-Mills reports that at the rate of affected people in the study, there could be 4 and one-half million individuals in the U.S. with reduced lung function because of their high canola, soybean, and corn oil consumption or gamma-tocopherol consumption.

A spirometer is the instrument used to measure the capacity of the lungs and this showed that alpha-tocopherol form of Vitamin E improved lung function.

The rates of asthma in the U.S. has increased in the last 40 years, coinciding with the removal from our diets of lard and butter and replacing these with soybean, canola, and corn oils. Supposedly, according to faulty research, they were thought to be healthier for our hearts. Cook-Mills said that in looking at other countries' asthma rates, those with significantly lower asthma rates have diets high in olive and sunflower oils.

“In the U.S., the average blood plasma level of gamma-tocopherol is four or more times higher than those of European and Scandinavian countries that consume sunflower and olive oil, Cook-Mills noted.”
"People in countries that consume olive and sunflower oil have the lowest rate of asthma and those that consume soybean, corn and canola oil have the highest rate of asthma," Cook-Mills said. "When people consume alpha-tocopherol, which is rich in olive oil and sunflower oil, their lung function is better."

A Discussion about 'Noncompliant Patients'

While most doctors still label patients as non-compliant, a few doctors are speaking out against this and this doctor-to-be says even doctors are often the most non-compliant. It is called guideline non-adherence. I thought this was most appropriate and fit the discussion to a tee.

Elaine Khoong says, “What bothers me the most about this phrase, though, is how it’s often stated with such disdain. We act as if it’s incomprehensible that someone would ignore our evidence-based recommendations. If the patient would only bother to listen, he or she would get better. If we were patients, we would be compliant.

But that’s simply not true. We are no different from our patients. We practice our own form of noncompliance. Despite the fact that many guidelines are created after systematic reviews and meta-analyses – processes we would never have time to go through ourselves – we, like our own patients, are often noncompliant.”

I think she states this correctly and to the point. She does continue with more evidence about how doctors ignore guidelines and practice as they see fit. They ignore what they want to in the guidelines and use the parts they are comfortable in using. When they have not kept up with a treatment, they fall back to what is easy for them.

We see this with diabetes all the time and doctors just don't keep abreast with the treatments they are not comfortable in using. This is especially true when it comes to insulin. Why else would they stack oral medications on top of other oral medications? It is plain that they don't know enough about insulin to prescribe it.

The doctors then intimidate patients and belittle patients to stay on oral medications. Some even threaten their patients with insulin to keep them on oral medications. Then when the patients know that the oral medications are no longer helping them manage their diabetes, the doctors say they are non-compliant and say bad things to and about patients. It is clear that the doctors are non-adherent in staying current with the diabetes treatments and they will not admit it.

Fortunately, today there are more doctors and doctors-to-be that do not believe patients are non-compliant without a reason. Doctors that refuse to communicate and talk with their patients are the worst offenders. These doctors talk at or don't communicate with their patients.

The patients of today do desire more inclusion in their treatments and change doctors that exclude them in the decisions. Yet, these same doctors blame the patients for not following instructions when they don't follow the treatment guidelines.