Diabetes and Obstructive Sleep Apnea Relationship

As observational studies go, headlines are overstated and causation is not proved. Yet many headlines use the terms linked and tied instead of may increase the risk. The lead researcher, Dr. Tetyana Kendzerska, with the University of Toronto's Institute of Health Policy, Management, and Evaluation says, “Patients with severe sleep apnea had a 30 percent higher risk of developing diabetes than those without sleep apnea.”

The full study, a PDF file,  is garnering many headlines, from HealthDay, to Science Daily and several others. I developed severe obstructive sleep apnea which was finally diagnosed in 2001, approximately two years ahead of the diabetes diagnosis. I knew then that I had OSA for several years prior to that and my wife said that I had snored and had apneas for at least two years prior. The sad part was not getting a doctor to believe my wife until I almost wrecked our car when taking my wife to a doctor appointment.

“Kendzerska cautioned, however, that this was an observational study, and cannot prove that sleep apnea causes diabetes. "We are not able to investigate causality, just an association," she explained”

“Shelby Freedman Harris, director of the Behavioral Sleep Medicine Program and the Sleep-Wake Disorders Center at Montefiore Medical Center in New York City, said, "I definitely think that this is an important study highlighting the need for more sleep apnea awareness, screening and treatment. "Given the large sample size, it further places emphasis on sleep apnea as a predictor of diabetes, and hopefully with earlier intervention, it can greatly impact the health costs for diabetes management as well as improve the outcomes for many patients," she said.”

The most notable limitation of the study was there was no information about family history of diabetes.

Reducing Medical Errors in Diabetes Care Needed

The public believes that our medical system can and should be improved. Even I believe this, but the larger problem of diabetes care requires our attention. With the number of people diagnosed daily, even many of them are not finding out how to care for themselves adequately.

Errors in diabetes care become a common cause of complications that can result of disability and even death, according to this article in Diabetes in Control. Yet, the diabetes errors being reported are likely much lower than the actual number. At least the report from the Institute of Medicine (IOM) catapulted the issue onto the front pages of magazines and newspapers in the United States.

The challenge before us now in not documenting how bad the number of errors have been, but to focus on how best to help those who are in fact providing care to patients with diabetes. Not only is this task more difficult, but also more important. How this is done will be what we need to improve care. The following discussion may help us highlight some of the common misconceptions:

#1. It is the belief that there is always someone to be held accountable for the error and remove them from the system. However, most of the important medical errors are multifactorial and are the result of numerous small oversights, any one of which, if corrected, might have prevented or reversed the error.

#2. The "system" is providing obstacles that result in blame falling on the individual at the point of care. However, these problems often have more to do with the system of care itself. This system or “culture of safety” is defective and needs to be improved or at the minimum corrected from the top-down. A culture of safety should be defined as any situation requiring providers to work together as a cohesive unit on behalf of patients; safety.

#3. It is the belief that correcting all errors in the main objective. Wrong! Many errors do not harm anyone and often are spotted by the people who make them. These often are the result of taking shortcuts. These errors are usually corrected when the work is reviewed. It is sound strategy to set up procedures for providers to routinely check both their work and others. In this way, the vast majority of errors can be caught and corrected without harming patients.

#4. It is often believed that the nurses are the cause of many errors. Not correct! It is the hospitals that have reduced the nurse-patient ratio and added stress to the nursing staff. By employing non-nurse technicians, the error rate is increasing and the nurses and doctors cannot keep the stress at even a manageable level. Many errors are repeated again and again because they are not reported or shared with others. The Institute for Safe Medication Practices is one place to report errors anonymously. This will share the errors with hundreds of thousands of medical professionals and help them prevent these errors.

For patients with diabetes, frequent glucose monitoring, wound care, and the clinical needs of those with orthostatic hypotension, renal disease, and retinopathy can lead to increased nursing requirements. We can do a great deal to champion the need for more nurses at the bedsides of patients.

Electronic Medical Records (EMRs) can prevent errors from poor handwriting, but they also open the door for new types of errors. These errors are checking off the wrong dose, directions, or even the wrong drug. Some errors can be stopped if providers would routinely run a drug-interaction check on prescriptions before giving them to the patients. With EMRs, this can be done almost instantly.

If hospitals and doctors are to improve safety for diabetic patients, here are a few starters:

#1. Offer more education that is patient-centered, requiring the patients to demonstrate what they know.

#2. Increase awareness of the need for adequate resources, particularly sufficient time for doctors to thoroughly evaluate clinical problems.

#3. Form ad-hoc teams of doctors and nurses to work together more cohesively in the care of diabetic patients.

#4. Change the paradigm so that providers think less about who is to blame and more about how to prevent catastrophes caused by the system in which they work.

#5. Change the tort system so that hospitals and providers can focus on making the system better and not on avoiding frivolous and illogical lawsuits. And

#6. Make the system of care as focused on quality as it is on cost containment.

Each of these issues can play an important role in the improvement of the system of care and in the protection of the diabetic patients from the consequences of medical errors. To this, add patient education to help them prevent errors at home that may well prevent the need for hospitalization.

Food Industry Profits Come First

What will the food industry think up next to fool the public? The abstract for the study by a George Washington University associate professor, Ivy Ken, makes some accurate observations about the priorities of the food industry. The full study is in this PDF file.

Learn about these two organizations - the Partnership for a Healthier America (PHA) and the Alliance for a Healthier Generation (AHG). Ivy Ken says, “The analysis I present here reveals that the organizations’ positive message of “getting everybody together” to solve the problem of childhood obesity is meant to deliberately obscure corporate culpability.”

Food corporations and the related industries rarely prioritize healthy communities over healthy profit margins, but their profits depend on community acceptance. Corporations co-opt the rhetorical tactics typically associated with social movement organizations to frame their profit-maximizing practices as the solution to the problem of childhood obesity. The “work together” theme is a cover to obtain the acceptance of the public.

The extent of the companies' commitments is to create new marketing campaigns for lower-calorie products, making healthier options more prominent in stores, but still on the same shelves as their full-sugar, full fat options products. An example of the marketing campaign can be found here. Phil Ruggiero covers two different marketing campaigns and both show what can happen if people with diabetes believe the advertisements.

Food companies or Big Food work hard to divert our attention away from the problems of obesity and diabetes so that they can continue to have a healthy profit. It is fortunate that we have as much information on packaging as we do, although Big Food is attempting to corrupt the latest labeling change.

Please consider reading the full study by downloading the PDF file at the link in the first paragraph.

ADA Advocating for Poorer Food in Schools

The American Diabetes Association (ADA) is putting words in my mouth and they are very sour. In an email I received today, June 10, 2014, from Tekisha D. Everette, PhD, Managing Director, Federal Government Affairs, American Diabetes Association, I was told, “As a Diabetes Advocate, you led the fight to ensure America’s children have access to healthy school food. Because of you, Congress passed legislation in 2010 making school breakfasts and lunches healthier. Next year, snacks and drinks served in school will be as well.”

Apparently, they don't know me at all. I would never advocate for the food the USDA says must be served in school lunch menus. High carbohydrate - low fat is not my idea and for many students they are protesting as well. Limiting the total calorie count to 850 calories is not good for growing adolescents. In addition, the USDA is pushing low sodium (not salt) which a growing body needs. And the USDA is promoting whole grains to be served with every lunch.

Then the email continues - “But now, the House of Representatives is poised to roll back these important new nutrition standards. We cannot allow this to happen!”

Well, ADA, I have written my representative advising him that I will vote against him if the bill does not get passed and USDA taken out of the equation. The school lunch program has been ruined for many children and they are complaining about being hungry.

Is it any wonder that the fast food establishments are the first stop for many children when they leave school? The more meat they can get the better they feel. Most are left completely unsatisfied by the manufactured meats they receive in sandwiches they are served as part of the school lunch program.

The USDA high carb/low fat will not reduce the obesity epidemic threatening our children and this will add to the diabetes numbers ADA says we must prevent by supporting the USDA nutrition guidelines for our schools.

For those that agree with me or need more reading, three blogs by Tom Naughton should help. Blog 1, blog2, and blog 3 are just a few of his against the current USDA policy of the poor food supplied out children.

Interventions, Understanding Depression

I don't know what happened for the month of May, but with several of the members helping others and others visiting friends and members in the hospital and then the nursing home, we had no reason for a meeting, as we were busy enough. Then Dr. Tom advised us that the speaker for the June session on interventions asked to be excused until September or October.

For now, we have no plans for meetings until at least September. Allen and Tim have been working with James and report that he is finally doing much better and that his last A1c was 7.9% which is a great improvement and even Dr. Tom is pleased as he hopes to have it under 6.5% when it will be checked again in August.

A.J. asked me to do this blog and thanked me for the previous depression blog. He knew about this and admitted that he had intended to ask me earlier, but when he read the blog, he felt that he should wait so it would be later. Thank you A.J. as I had intended on having it for our May meeting, which did not happen.

The blog referred to is about depression and when you should get help. The Centers on Disease Control and Prevention reports that depression many affect as many as 1 in 10 adults. They list the following as possible symptoms:

1. Have little interest or pleasure in doing things
2. Can't work or have trouble with doing routine activities
3. Feel down, very sad, or hopeless
4. Have trouble falling asleep, staying asleep, or find you are sleeping too much
5. Feel tired or have little energy
6. Can't eat or are overeating
7. Feel bad about yourself, feel that you are a failure, or that you have let yourself or your family down
8. Have trouble concentrating on things, such as reading the newspaper or watching television
9. Find that you are moving or speaking so slowly that other people have noticed, or the opposite, you are so fidgety or restless that you can't be still

Many people fear seeking mental health care. Seeking professional help is often the best way to get well. Mental health is just like physical health, sometimes we need to get treatment and care to get better.

Depression is often associated with other chronic diseases, like arthritis, heart disease, or diabetes, and can make managing those conditions more difficult. For many people, physical conditions can contribute to problems with their mental health, problems that are often ignored and not treated.

Even though the author recommends that you start with your primary care physician, I have found that most try to laugh it off and say you are not depressed if you have enough fortitude to bring it up. At least my endocrinologist knew what I was saying and after looking at my A1c and a few other tests, asked a couple of questions and then advised me to stay in touch. My depression was minor and he felt that I could handle it, but I was to call if I could not.

Medication and talk therapies are about equally effective. Sometimes it is best to use both together and for some people it does not work. I know from experience that if you have a major depression, you need to see a therapist sooner rather than later. If you have depression multiple times, a combination of therapy and medication is the usual treatment. Talk therapy for the first few times of minor depression can often be the best, especially if the doctor helps train you in how to overcome minor depression.

Are DNR Orders Followed?

In another discussion with one of my doctors, he ordered me to have a living will and a DNR (Do Not Resuscitate) order on file. I asked why and explained that with the number of doctors ignoring them when a family member would not honor them and requested lifesaving attempts, should I even consider having them on file. Even the hospital he worked for often bypassed them to honor the wishes of the family.

What followed was an unpleasant discussion about the reasons wishes of the family came first. I said that is one reason that all I have on file is a medical power of attorney for the one family member that will follow my wishes. No other family member is authorized to speak for me. If they are allowed to bypass the designated family member, legal consequences are to be imposed on all parties, especially the family members that try to interrupt the medical power of attorney.

The doctor was not happy about this, but I explained that this was the only way I could enforce my wishes over the hospital and other family members. This would ensure that the hospital could not bypass the medical power of attorney without consequences and puts other family members on notice to step aside for the person with authorization to act for me.

This happened before this blog was published on the website Center for Advancing Health. It has a great discussion about DNR, and how it is often ignored. The author is well qualified to write about this and explains several medical terms often misused. She writes about how doctors abuse DNR and often refuse to treat younger patients for whom they have a DNR on file. The following is how bad DNR is misused and abused.

“Most recently, physicians and nurses caring for pediatric patients also told interviewers that in practice, DNR means far more than just "do not perform CPR." In this survey of 107 pediatricians and 159 pediatric nurses in a hospital setting, 67 percent believed a DNR order only applies to what to do after a cardiac arrest – but 33 percent said it implied other limitations. And 52 percent said that once a DNR order is in place, a whole host of diagnostic and therapeutic interventions should be withdrawn, over and beyond CPR, and a small but disturbing minority, six percent, said that a DNR order means that comfort measures only are to be provided.”

The above is one more reason I will not put on file a DNR order and will limit my wishes to the medical power of attorney. The blog author covers several other terms that are being used, but again doctors are not having the proper discussions with the patient.

Using the Test Strip Control Solution

I am a little surprised to see this topic, but since it is one that is seldom written about or even talked about, I am more than happy to write about this. The Mayo Clinic expert diabetes blog is the source and Nancy Klobassa Davidson, R.N. is the author.

The topic is the blood glucose control solution for use at home to check the accuracy of your test strips and meter. Most of the information even I have read about in the past has dealt only with using the test solution for checking test strips. In the ten plus years, I have used a fair number of test strips. Using the control solution, I have found only one container of test strips to be bad.

Seldom, if ever, do doctors or certified diabetes educators even talk about the control solution. The blood glucose meter kits handed out to new patients today do not include a vial of the test solution. Many pharmacies do not even carry the control solution or only have it for one brand. The control solution costs extra, uses a test strip, and has an expiration date.

The author states that this can be a confusing concept to teach and while it is another task for the person with diabetes to remember when managing his or her diabetes, some could be better off using the control solution. Yet, most educators and even those nurses that prefer to not teach this, as they are afraid more people might actually learn that there is not a program in place after the FDA approval to insure test strip quality and accuracy.

What the author recommends if the control solution returns results outside the range listed on the test strip vial seems a trifle bit overdone. The first two steps should have been done before using the control solution, not afterward. If the test strips are expired, why waste the control solution on expired test strips. If the control solution has expired, why waste a test strip to discover this. The third and fourth suggestions are valid. I have seen containers of test strips and meters on car dashes during both summer and winter.

“What should you do if a glucose control test is out of range?

• Check the expiration date on your test strips. If they've expired, this could result in false high or low blood glucose readings. Replace the test strips immediately with new, unexpired test strips.
• Check the expiration date on the blood glucose control solution. Each meter company has a different replacement time for control solution, whether that's after 3 months, 6 months or 12 months.
• Consider storage conditions. If the test strips haven't expired, consider whether the test strips might have been exposed to extreme heat, cold, light, or moisture. Did you leave the cap off the test strips, exposing them to light or moisture? For example, a steamy bathroom is probably not the best place to keep your meter and test strip supplies.
• Did you recently drop the meter? Contact the meter company if there doesn't seem to be any explanation for the glucose control test to be out of range. It could be a meter problem, and you may need to replace your meter.”

The FDA is even more extravagant in how they recommend you waste test strips. Read the blog in the link above for those wasteful tips.