Dr. Kendrick Declares Scientific Debate Essential

If you have been reading my blogs of late, you have seen me criticize some of the researchers. Some have deserved it, but others are openly not thinking and applying their knowledge for research to benefit clinical research which will be needed for the fight against disease. Dr. Kendrick makes a discussion on valuable points necessary.

I will quote some of what Dr. Kendrick says. “Debate in science is essential. You would hope it were the very lifeblood of progress. One would also hope that researchers could disagree with each other in frank and open debate. But it has become increasingly obvious to me that if you criticise the experts in medical research you can expect a very rough ride indeed. You certainly risk being stomped into silence.”

“I have witnessed this quite a lot recently, and have found that the ‘stomping’ game is very simple. If a critic of an area of mainstream medicine seems to be gaining some traction with the public, they are very rapidly accused of ‘killing patients’ by various professors a.k.a. ‘experts.’”

“Sadly, it has become an article of faith that ‘experts’ cannot be argued with. For they have attained the status of demi-gods.”

“Canadian-based researcher, David Sackett, said that he would “never again lecture, write, or referee anything to do with evidence based clinical practice.” Sackett is not doing this because he has ceased to believe in evidence based clinical practice but, as the BMJ comments, because he is worried about the power of experts in stifling new ideas and wants the retirement of experts to be made compulsory.”

I find the last part of the last paragraph to be in line with my thinking as a patient of type 2 diabetes – (Sackett) “is worried about the power of experts in stifling new ideas and wants the retirement of experts to be made compulsory.” How true this is and many of the 'experts' abuse their position to prevent evidence based scientific research. We find this in nutrition research, especially with the fat argument of Ancel Keys, who started the demonization of saturated fat. This study was, however, fatally flawed. This last information on Ancel Keys is from David Mendosa's blog here.

“Sackett claims that the prestige of experts (including himself) gives their opinions far greater persuasive power than they deserve on scientific grounds alone.” Whether through deference, fear, or respect, others tend not to challenge them, and progress towards the truth is impaired in the presence of an expert,” he writes.”

Rather than quote more from Dr. Kendrick, I would urge you to read his blog and follow his explanations. Then you will be able to understand why 'experts' are not always to be followed when they prevent open and honest scientific debate.

One more disclosure needs to be discussed. The media of today, science writers, journalists, are all afraid of the experts and quote them as being “the expert.” Instead of asking hard questions about why the person is considered an expert, they worship the experts. All sorts of apologies happen the media uses something that the expert does not approve.

Insulin Type 2 Patients Over 80 Have More Hypoglycemia

You will have to excuse me if I seem to be on a rant. Headlines lately have been so misleading and down right sensationalized that I have thought to bypass the articles. In reading the articles further, I felt that rather than pass them by, maybe there were some lessons to be learned.

The headline for this one is rather tame, but still somewhat misleading - Hypoglycemia in Insulin-Treated Patients. The summary to get your attention says the following - “The elderly with diabetes now experience episodes of hypoglycemia more frequently than hyperglycemia.” Oh really! Since this is Dr. Andrew Geller, a medical officer at the Centers for Disease Control and Prevention (CDC), I had hoped to get some facts and perspective. Instead, it is mainly misinformation and highly misleading.

I admit that when I am told that this is an expert commentary, I become skeptical about the accuracy of what I am being told. Most of the time information to inform readers and explain what they are talking about is missing. General terms of severe hypoglycemia bother me. Does this mean anything below 50 mg/dl or a number below that? I will also think when they are talking hyperglycemia they are talking blood glucose levels above 180 mg/dl. Yet we are not informed and cannot therefore draw any accurate comparisons.

The only statement of substance comes in the fourth paragraph when Dr. Geller states, “Insulin-treated patients who are 80 years of age or older are more than twice as likely to go to the emergency department as patients between 45 and 64 years old. They were also 5 times more likely to be hospitalized. These findings underscore the importance of taking the risks for hypoglycemia into account when making decisions to prescribe or intensify insulin, especially among older adults.”

The expert missed an opportunity, in my opinion, to alert other doctors about checking for memory problems. Instead he just regurgitated what was supposedly reported about meal planning saying, “Meal planning is a well-recognized component of diabetes education. However, among the emergency department visits involving medication errors, a meal-related issue was the most common problem that brought patients to the emergency department.”

In the example he used of the patient injecting the short or rapid acting insulin and then forgetting to eat the meal timely, hypoglycemia caused them to go the emergency department. To me this means that memory problems should be investigated, but there is no mention of people over 80 often having these problems. Even distractions could be a problem, but instead meal planning is the only culprit.

This is what the expert says, “It's essential for diabetes patient education to continue emphasizing the importance of meal planning, and encourage patients to pay close attention to the insulin product that they administer.” Even I have made that mistake, but not often and normally (only three times in ten years) I inject the rapid acting too close to the injection site for the long acting. This causes the long acting to be converted to short acting and hypoglycemia did result. Fortunately, I recognized the problem as soon as I took the syringe out. Therefore, I had glucose tablets at the ready and started testing in 30 minutes. I tested about every 15 minutes and took glucose tablets accordingly until my glucose levels were at the proper level.

Granted the Medscape article was written for doctors, but as a patient, I feel that the information given was fair, but missed several points and alerts that should have been covered.

Type 2 Diabetes Turmoil in Treatments

Yes, there is a lot of turmoil in the type 2 medications treatment arena because of poor science like this article. The headline of the article in Medscape is “Deaths Higher When Insulin Is Second-Line Treatment for Type 2 Diabetes.” The title for the WebMD article is “Insulin-Metformin Combo Tied to Poorer Survival” and subtitled, “Other experts dispute the study's conclusions.” This blogger, Jenny Ruhl has a better title - “Why Insulin Plus Metformin May be Associated with Higher Mortality.”

I find it very hard to believe that Medscape and WebMD are related companies because of the two varied titles. I can believe the Medscape article headline is true because too often insulin in the second or even up to the fourth line of treatment. In reality, insulin should be the first line of treatment. David Mendosa writes an excellent blog here about the benefits of insulin being a short first-line of treatment.

I am in disagreement with the lead author of the research, Christianne L. Roumie, MD, associate professor of internal medicine and pediatrics at Vanderbilt University, Nashville, Tennessee. She states it is better to use two oral medications before progressing to insulin use for people with type 2 diabetes. The preferred second drug is a sulfonylurea and her study claims that this combination causes less death than metformin and insulin combination.

What she seems to forget is that the sulfonylureas have come under investigation as causing cardiovascular deaths as well. Read my blog about this here.

Most family doctors or primary care doctors know so little about dosing insulin that they stack oral medication on top of oral medication until insulin is required. They also attempt to keep type 2 patients on oral medications until it is too late for insulin to really help the way it should have if used earlier. In addition, general practitioners are afraid of hypoglycemia and this also drives them to want to keep type 2 patients on oral medications.

Then the author all but negates the study by making the following statement. “She also cautioned that findings from work such as this can create uncertainty. The complex statistical methods needed to overcome the various sources of bias and confounding that are inherent in observational research and the fact that this is a comparative-effectiveness study make it difficult for clinicians to interpret the data, she noted. "Given these caveats, many clinicians will probably refrain from making practice changes based on this study."”

Insulin Analogs, Worth the Cost?

This is another researcher looking for publicity and her 15 minutes of fame. Kasia J. Lipska, MD, an endocrinologist from the Yale School of Medicine, New Haven, Connecticut, will be presenting this research as a poster at the meeting of the American Diabetes Association (ADA) 2014 Scientific Sessions in San Francisco.

“Dr. Lipska and colleagues conducted a retrospective analysis of figures from the Optum Labs Data Warehouse, an administrative claims database of privately insured enrollees from throughout the United States. Adults aged 18 years or older with type 2 diabetes and at least 2 years of continuous plan enrollment between January 2000 and September 2010 were included. There were 123,486 enrollees who filled at least 1 prescription for insulin, with the proportion doing so rising from 9.7% in 2000 to 15.1% in 2010.”

“Dr. Lipska cautioned these findings from private health insurance records may not reflect publicly insured populations. For example, analog-insulin use is lower in the Veterans' Administration system, which has a national formulary scheme.”

“The data also couldn't capture less severe hypoglycemia that did not result in an emergency-department visit or hospital admission, she noted.”

"We are absolutely not suggesting that people stop using insulin analogs. But we hope these findings provoke a discussion about the value of healthcare for the overall population of type 2 diabetes patients."

I am very happy that there were comments and most agreed with my feelings. This is not a study, but an observational analysis of very diverse data and many missing pieces of information. And with funds from the Centers for Medicare & Medicaid Services and the National Institutes of Health, I suspect some false motives in the method of research.

Is the CMS trying to find ways to deny people on Medicare and Medicaid the use of certain insulins? I suspect this!  I just hope I am wrong.

Do You Get Caught in the Food Label Trap?

Don't lie, I used to think I was not, but now that I know what Big Food is doing, I seldom get caught anymore. When I do, my meter lets me know that I need to go back and carefully reread the label. That is no longer fun and it is easy to get angry when this happens. Also, don't get caught in the measuring differences between a dry measure and a liquid measure. My daughter and I had a good demonstration early on in my diabetes and I was right more than wrong, but it was still embarrassing to get fooled by the measuring cup.

Even more exasperating was emptying a few containers and discovering that the 10 servings listed on the label of a box was really closer to 18 servings by dry measure. Then we opened a couple of cans of vegetables and found out that the two and a half servings were closer to two servings for both vegetables. It is bad enough that the food industry is allowed to have up to a 20% discrepancy from actual, but we never could figure out the box and why that was so far off. I won't go into the ridiculous letter from the manufacturer.

If the recently proposed changes to the food label actually are more helpful, they are supposed to reflect what people actually eat. But how are they supposed to know what I eat, when I often don't know until I am ready to eat and have counted the carbohydrates. I attempt to stay under 100 grams of carbohydrates per day and generally about 80. This allows me to vary what I eat but to stay in what I term medium carb range.

I have long ago learned that measuring serves best for carb counting. Having a digital food scale with the tare feature also helps. There are a few occasions when guessing becomes a necessity, but I don't like it. My wife insists on eating out on occasion. That is when I make sure that most of the carby foods don't reach my plate.

Most of my friends guess more often than I do, but many are not overweight. Even James is only about five pounds over ideal weight and is slowly losing that. Some of them use their meters to determine the amount of insulin to inject and they are getting away with this and not adding weight.

I don't advise guesstimating as a habit as this can make it easier to overeat and help diabetes gain the upper hand.

Activity Trackers Needed for Older Adults

Activity-monitoring apps, Web sites, and wearable devices are available, but for older adults are not well designed for usability. This is because product designers do not consider those over 65 to be a viable user group. The medical profession also is extremely slow to promote activity monitoring for any age group even though this may be helpful in finding out how patients are activity-motivated.

This technology could be helpful for older adults to improve their cognitive function through proper nutrition and exercise. New human factors/ergonomics research indicates that the current technology presents usability challenges for this population.

Using technology could allow for easy self-management of health and wellness. This would also allow many older adults who have chronic conditions such as diabetes and hypertension to self-manage their health more effectively. “Research has shown that they want to track their diet and exercise, but most don’t use activity-monitoring technologies to do so.”

“In research presented at the 2014 International Symposium on Human Factors and Ergonomics in Health Care in April, authors Preusse, Tracy Mitzner, Cara Fausset, and Wendy Rogers designed a study assessing the usability of two popular Web-based and wearable activity trackers.”

The study asked older adults to track their nutrition and exercise over two weeks (too short) and report on usability issues they experienced. They were also asked about their attitudes toward to technology. The authors did a separate analysis of both trackers to uncover any design issues that could be problematic for older adults.

Usability problems the researchers found included low color contrast between icons and the screen background, small fonts, and inconsistent navigation bars among the Web sites. Study participants saw the technology as inaccurate when tracking step counts and sleep patterns. Many also reported difficulty remembering to log their information and use the device. This problem could be mitigated by nagware or more prominent reminders.

Activity-monitoring technologies can make tracking nutrition and exercise easier because they gather some data automatically and display trends over time. More studies in this nature should be encouraged and promoted by geriatricians in colleges and universities across the country. This might get the attention of product designers and manufacturers and prove how the technology could be advantageous to older adults in managing their health.

Be Careful of Incorrect Online Health Information

This blog is about incorrect health information and the internet, but I will discuss both health and diabetes information. The author of the blog is correct; there is too much information on the internet for all phases of illness and chronic illnesses that is not or even close to being correct.

I even strike out at the American Diabetes Association (ADA) because they have a one-size-fits-all philosophy for people with diabetes. The last couple of years have improved slightly, but when an organization accepts funds from Big Pharma and other related sources, you know that the advice is questionable at best. In addition the ADA is for doctors and does very little to help patients. Until recently, even the nutrition therapy/advice was only one-size-fits-all.

Even the American Association of Clinical Endocrinologists (AACE) is for doctors and does little for patients. They are also a one-size-fits-all group and don't like to vary from this. They also advocate for Big Pharma and even go so far as to train the reps of Big Pharma that see the doctors around the country and promote all kinds of drugs and even promote larger doses and “off label” uses.

Yes, the quality of the information we find online depends on what we are searching for, as presented by a study published in January by Decision Support Systems. You can find high-quality information on the diagnosis and treatment of physical diseases or injuries online. However, search results related to nutrition, fitness, and preventive health varies tremendously in quality. What we do with the information we find can be hazardous to our health.

The Pew Research Internet Project gives much to think about and I will list some of the statistics used:

1. More than 60 percent of American adults look for health information online.
2. Of these people, 60 percent report that their most recent search influenced their health-related decisions.
3. 77 percent of people seeking health information start with a general search engine like Google, Bing, or Yahoo, as opposed to going the a health-specific website.
4. Searchers are most likely to view only the results listed on the first page.
5. 13% say they began at a site that specializes in health information, like WebMD.
   
6. The most commonly researched topics are specific diseases or conditions; treatments or procedures; and doctors or other health professionals.
7. Half of online health information research is on behalf of someone else – information access by proxy.
8. 26% of online health seekers say they have been asked to pay for access to something they wanted to see online (just 2% say they did so).

“Given the direction that mobile and online health information appears to be heading – in the more, not less, direction – people need guidance from unbiased sources. Rather than recommending patients avoid Internet searches for health information, [health care] providers may consider helping patients develop good strategies for recognizing high-quality information over questionable information."

While the last paragraph above is directed at health care professionals, doctors are not inclined to help patients unfortunately. They are more inclined to consider themselves as the only source their patients need. Therefore, they are falling further behind in creating an atmosphere conducive to good doctor-patient relationships.