Senior Health and Medicines

Medicines enter the body in several ways. They enter through an inhaler, a skin patch, a pill, an IV, or a hypodermic needle. Oh, you say I forgot an insulin syringe. Sorry folks, the needle on the syringe is a hypodermic needle. The meaning of hypodermic is under the skin and those of us injecting insulin do inject it under the skin and hopefully into a layer of fat below the skin and not in the muscle.

Medicines are also termed drugs and the terms are used interchangeably. As the drugs make their way through the body, changes happen along the path they travel. In this blog, I will focus on drugs taken by mouth, since those are the most common and many people with type 2 diabetes use them.

When you take drugs by mouth, they move through the digestive tract and are taken up by internal organs like the stomach and small intestine. Often, they are then sent to the liver, where they might be chemically altered. Finally, they are released into the bloodstream. As the bloodstream carries medicines throughout the body, the drugs can interact with many tissues and organs. Side effects can occur if a drug has unintended effects anywhere in the body.

Drugs are treated just like food, as the body attempts chemically to break them down as soon as they enter the body. Most are broken down in the stomach or small intestine and sent to the liver. The liver in turn contains protein molecules called enzymes that chemically modify drugs and other non-food substances. The chemical change of a medicine by the body is termed drug metabolism.

Often, a drug is metabolized by the body; it is processed into products called metabolites. These metabolites are often weaker than the original drug, but sometimes they have effects that are stronger than the original drug. An example of this is the codeine in the prescription painkiller Tylenol#3, which becomes fully active only after the medicine is metabolized in the liver.

Since most drugs and other 'foreign' substances are broken down in the liver, scientists often refer to the liver as the 'detoxifying' organ. This means that the liver can be damaged by too much medicine in the body. Drug metabolites usually return to the liver and are chemically altered again before they exit the body.

After a drug's metabolites have circulated in the bloodstream and done their work as medicine, the body eliminates then the same way it eliminates other wastes, in the urine or feces. Age-related changes in the kidney function can have significant effects on how fast a drug is eliminated from the body.

The above discussion helps explain in a small way, how important the liver and kidneys are to the processes that take place in the body for our drugs we take, and why many researchers refuse to test drugs on the elderly. Not only are they concerned about comorbid conditions, but also they are unsure of the liver and kidney and how well the body can handle the medicines.

Yet, our doctors prescribe these drugs and think nothing about the liver and kidney functions or the factor of aging on our liver and kidneys. Think about this the next time your doctor insists on keeping you on oral diabetes medications instead of insulin.

An Elusive Definition and a Discussion

This topic has been growing and has been presented in many other places besides the five references I will present. The topic is “patient engagement.” The term has been around since sometime in the 1990s, or maybe earlier, but really came into full use in 2012. My first exposure to the term was in Dr. Rob Lambert's blog here. In turn, I blogged about it here.

The definition is very loose and depends on who is defining it. Dr. Leslie Kernisan does a decent job of defining the phrase, but other people want to define the term as well. When the defining will arrive at one meaning remains to be seen. Back to Dr. Kernisan's definition, which says, “Supporting patient engagement means fostering a fruitful collaboration in which patients and clinicians work together to help the patient progress towards mutually agreed-upon health goals.”

“In other words, to truly foster patient engagement, it's not enough to just work together more closely on achieving a given health outcome. It is also important to work together on deciding which outcomes to pursue, why to pursue them and how to pursue them. In doing so, we engage patients in a meaningful care partnership that respects their priorities, preferences, perspective and situation. Communication with patients is, of course, essential to all of this. This is why any innovation that improves a patient's ability to access and communicate with health care providers is proudly labeled as "patient engagement."

To me, all this is fine, but I still prefer what Dr. Lamberts says. “Communication isn't important to health care, communication is health care. Care is not a static thing, it is the transaction of ideas. The patient tells me what is going on, I listen, I share my thoughts with the patient (and other providers), and the patient uses the result of this transaction for their own benefit.” Bold is my emphasis in both paragraphs.

“But our fine system doesn't embrace this definition. We indict ourselves when we talk about "patient engagement" as if it's a goal, as it reveals the current state of disengagement. Patients are not the center of care. Patients are a source of data so doctors can get "meaningful use" checks. Patients are the proof that our organizations are accountable. Patients live in our "patient-centered" medical homes.”

The Center for Advancing Health (CFAH) says, “Here is the CFAH definition of patient engagement (PE): "Actions people take to support their health and benefit from their health care."

The last definition is not that of most physicians and if you read the link above, they list six overarching themes which do not fit with the definition. Then if you read this blog by Jessie Gruman, president and founder of the Center for Advancing Health, you can understand a little more for the reason they are pushing this philosophy.

I admit that I have a very strong bias for what Dr. Lamberts has to say about patient engagement as is does not foster good communication between doctors and patients and is contrived to satisfy the “meaningful use” for receiving money for implementing medical health records. This in turn makes money for the doctors and makes billing for medical insurance reimbursement easier.

Patient Education Helps Manage Diabetes

Two points I wish to make in this blog are:

The first point = People with diabetes who receive education and training at clinical appointments had a 49 percent greater likelihood of achieving long term blood glucose management than patients not receiving any education.

The second point = Doctor training about diabetes management seemed to be ineffective in helping patients manage their glucose levels

The study outlining the above two points was published in Ethnicity and Disease. The researchers were expecting that the physician training would yield a better or an equal outcome to the education with the patient, but that did not happen. I do understand why providing intensive diabetes training to physicians did not work. Doctors do not get paid for providing diabetes education and under the current payment system, they will not provide diabetes education to patients for free.

Teaching people with diabetes how to manage their blood glucose levels helps them achieve better results. This happens because they are stakeholders and diabetes directly affects them. In addition, they spend about one hour per year with the doctor and must manage their diabetes 24/7/365.

This study happened in the Baltimore area and the findings are from 823 mostly Black patients with diabetes treated between April 2005 and July 2007. The patients, each treated by one of ten primary care physicians, were randomized into four groups.

The participants in the study were divided into four groups.

The first group received special diabetes counseling with a nurse during office visits.

The second group did not receive counseling, but was treated by five physicians who received diabetes training.

The third group received counseling and was treated by physicians who received training.

The fourth group received no training and their five physicians received no training.

The patients were seen every six months and improvement was measured by evaluating the reduction in HbA1c results. The patients receiving counseling sessions with a nurse at each office visit increased their chances of long-term blood glucose management by 49 percent after two years compared the group in which neither the patients nor the physicians received training. The physician training seemed ineffective at managing the patients' blood glucose levels.

The surprising unmentioned item is that self-monitoring of blood glucose after the completion of the study and what this may have accomplished.

Need a Magnifier to Read Your Prescription Labels?

Do you have problems reading the label on prescription vials or bottles? I admit I have a serious problem reading parts of the label. The prescription number, the dose, the number of refills, and the expiration date require using a magnifier. The instructions are easier to read and I seldom have problems with reading that. These are for prescriptions from my local pharmacy.

The prescriptions received from the VA pharmacy come with a printed sheet or sheets that are easy to read. The bottles or vials are readable for about three weeks and then the printing fades to totally unreadable. This fading is because of the oils from my hands and it does not take long to become unreadable. If I was not aware of the shape of the pill and color, it might be easy to mistake what the medication was and over use. Keeping the sheet with each bottle is not acceptable because it is too large to fit under the bottle and the bottles and vials constantly tip over and fall on the floor from the shelf.

That is why I have resorted to my own labels that are easier to read and larger in print size (font). Then I tape one side to the vial or bottle and leave the other side untaped.

Not the nicest looking, but at least I am able to read them. The paper is light enough and the vials seldom tip over until they are near empty and I have a set up to prevent this.

Now a study in Canada points to some of the problems I am having. The study published in the Canadian Pharmacists Journal, found that labels on prescription medications dispensed by pharmacies do not consistently follow recommended guidelines for legibility.

The study author, Dr. Sue Leat from Waterloo's School of Optometry and Vision Science, in Ontario, Canada, says there are few guidelines and no regulations for the print on prescription labels. She continues that what regulations there are specify only the content of prescription labels, not how they appear.

Researchers asked 45 pharmacies in three Canadian cities to print a sample prescription label with the patient's name, drug name, and use instructions. The sample label was then compared to label printing recommendations. The results showed that 44 percent of the labels met the minimum font size of 12 points. Half of

the labels were printed left justified and few of the recommendations for best use of spacing used.

All labels used capital lettering, which is difficult for patients with eye problems to read, instead of the recommended lettering. Over 90 percent of labels followed guidelines for font style, black print, and non-glossy paper. The research shows that font size and other factors can have an effect on readability of prescription labels.

The researchers plan to develop a prototype pharmaceutical label and test its readability and accuracy and use a questionnaire to survey pharmacists and patients (with and without visual impairments).

At least with my own labels, I can just make sure that the prescription number is updated and any other changes.

Are People with Diabetes Taking Too Many Supplements?

This is one of the better blogs by a CDE and deserves readership by people with diabetes even though it is written for CDEs on the AADE website. Carla Cox is right that there has been resurgence in advertising for herbal and other supplements. Late night TV has many advertisements for drugs that are supposed to help people with diabetes get off diabetes medications and others to help with weight loss.

The National Center for Complementary and Alternative Medicine says that nearly 40 percent of Americans use health care methods that are not considered mainstream medicine. The website for the National Center for Complementary and Alternative Medicine is here. Over half of the people with diabetes reportedly take nutritional supplements. Of these people, persons with type 2 are twice as likely and those with type 1 to use nutritional supplements.

In reading on diabetes forums, I often see alpha lipoic acid, cinnamon, chromium, ginkgo biloba, and a few others mentioned for various other maladies. The biggest problem for Complementary and Alternative Medicine (CAM) Supplement use that Ms. Cox is concerned about is the lack of double-blinded randomized control trails for most of the supplements.

One source is American Diabetes Association Guide to Herbs and Nutritional Supplements: What You Need to Know from Aloe to Zinc. This book is available through most bookstores and many libraries.

I do appreciate that Ms. Cox made the following statement. “It’s important to recognize that all products that change the way our body works are drugs, whether they come from “natural” or synthetic sources.” It is a problem that herbal products and supplements lack production and marketing oversight and then must be proven to cause serious health problems before they can be removed from the market.

Ms. Cox concluded her blog with a statement to ask the patients which supplements they are taking and why. Then she instructs CDEs to assess whether the supplements are healthful, harmful, or just costing patients extra money they may ill afford.

This was not available when the blog was written, but the FDA has declared one problem people with diabetes have, inflammation, a disease. This will open the door for Big Pharma to manufacture drugs for inflammation and prevent CAM from dominating in this area. I know that Big Pharma is pushing the FDA to do this in more areas as well.

We Still Can't Email Our Doctors

Technology has it good points, but many in the medical profession refuse to make use of the technology. Having been burnt by the electronic medical records and how it has damaged doctor-patient relations, I can have some sympathy, but not much. What scares me is that most doctors refuse to use emails, except for personal family correspondence.

Why is the question I keep asking? Not a doctor will answer me. The Office if the National Coordinator for Health Information Technology says that within the next decade, “all individuals, their families, and care providers should be able to send, receive, find, and use health information in a manner that is appropriate, secure, timely, and reliable.” Secure will depend on what the government wants and if they will rein in the NSA.

Forget about the lame excuses offered by government and the medical professions, email communication will soon happen as more patients start demanding this and more medical professionals start realizing the advantages. The medical professions may need a few solid and well-placed kicks where they sit to convince them, but even many of the doctors using contract medicine are already reaping the benefits of secure email and reducing the office visits.

Money is the great roadblock and is the cause of the providers' reluctance to adopt email in their practices. Nearly one million doctors rely on Medicare reimbursement and Medicare presently will not pay for emails or e visits. The American Medical Association rescinded its 1994 prohibition on rendering clinical telemedicine services and should be adequately compensated for email consultation. Privacy and security concerns are another reason providers have snubbed email. And who can blame them? Anxiety over the possibility of a HIPAA breach has escalated to a level of hysteria.

About half of Americans’ and Canadians’ 600 million annual primary care visits could be transacted online instead of face to face. Fees for e-visits range from $35 to $75 out of pocket, but can be as little as $15 with an insurance copay. Congress is considering legislation intended to shore up Medicare’s telehealth payment infrastructure. In addition, Medicaid programs cover electronic messaging in a wider variety of platforms and circumstances than Medicare does, and private payers must match that coverage in 19 states and in the District of Columbia.

There is much that needs to be improved and roadblocks removed, but don't expect this to happen anytime soon. More people are needed to write their Congressional people and encourage them to wrap Medicare into the positive column.

Please read the full article.

More on Nutrition for People with Diabetes

In the last blog, I covered eating patterns and started the macronutrients as covered in the October ADA dietary guidelines. Now I will write about protein and fat.

The macronutrient, protein. People with diabetes that don't have kidney disease might be surprised by this. There is no 'ideal' amount of protein that helps to improve blood glucose management, or even lowers the risk of heart disease. There are studies on both sides of this issue for both diseases and most are approached with a bias or what the author or funding agency is trying to prove.

The good news for those that have kidney disease do not have to follow a very low protein diet. More is the concern about malnourishment and the protein does not seem to affect the rate of progression of kidney disease. Even with all the hoop-la about red meat causing heart disease, it is more the highly processed meats that have an effect on the heart.

The macronutrient, fat. This section is more difficult and they are still trying to limit fat to a low fat diet. They of course want monounsaturated fats like olive oil and push vegetable oils. They are unanimous in eliminating trans fat as they should, but to curtail saturated fats with the evidence having been disproved still concerns me. I could agree if they had asked for moderation in the consuming of saturated fat.

The guidelines do say that there is no optimal mix of macronutrients. The statement is just made that evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.

Yet, they continue by saying it has been observed that people with diabetes eat about 45% of their calories from carbohydrate, 36–40% of calories from fat, and the remainder (16–18%) from protein. All this means is that the authors could care less about assessing people with diabetes and allowing them to have individualized eating plans. They are going to push for high carbohydrates.

They do cover omega 3 fatty acids and advise not to be taking fish oil supplements as there is no evidence that these help protect you from heart disease. The guidelines push the importance of getting your fish oils from food sources and that people eat at least two fish meals per week. This the guidelines say will help lower the risk of heart disease.

The dietary guidelines recommend that people who are 51 years of age, those who are African-American, or those that have high blood pressure, diabetes, or chronic kidney disease limit their sodium (salt) intake to 1500 milligrams (mg) per day. Restricting salt to this level is difficult and can make food unpalatable. Evidence does not support lowering salt level to this amount and the guidelines recommend capping salt intake at 2300 mg per day or the same recommendation as for the general public.

The guidelines do advise limiting alcohol as this can mask hypoglycemic symptoms and lead to problems for those on insulin. The guidelines also recommend high dietary fiber and liberal quantities of whole grains. Big Food is speaking here and for those on low-carbohydrate diets need to limit or eliminate wheat from their diets.

In rereading the guidelines for these two blogs, it has been interesting the conflicts in the advice given and how the leanings are still high-carbohydrate low-fat in nature.