August 16, 2014

Hydration Myths – Part 1

Hydration myths are hydration myths. But when diabetes is in the picture, the solution is not always as easy as it is for healthy adults. Dehydration can occur in any season, but most only think about this during the summer. As the temperature rises, our bodies lose more water because of perspiration. For people with diabetes, we cannot just drink anything we can get our hands on. For us it must be unsweetened beverages, unsweetened lemonade, or water.

While there is low-calorie Gatorade, this may be needed by some people for obtaining electrolytes that are needed by our bodies. Make sure that you do not over do the number of carbohydrates. Staying hydrated also helps your system flush out waste and maintain proper blood pressure / heart rate. Water can even aid your body in keeping up a healthy metabolism. This need has generated some myths that need to by understood.

Myth #1: Drink Eight 12-Ounce Glasses, Every Day.
This is different than most of us are used to seeing. Where did the 12-ounce glass come to be the standard. The Institute of Medicine recommends about 91 ounces of water per day for women and 120 ounces for men. I even have a difficult time with this because everyone is different and need more or less water, sleep, and the number is only a variable. The amount of water you actually need per day depends on climatic conditions, what type of clothing you’re wearing (yes, really), and your exercise intensity and duration.

Myth #2: Just Drink When You’re Thirsty.
I know this is false especially during the other seasons. I was shoveling snow during the winter over 20 years ago and when I finished, my clothes next to my body were soaking wet. I thought nothing of it and took a shower and put on clean clothes. Next thing I knew, I was in the emergency room and had an IV feeding me saline solution. The doctor said I was severely dehydrated. Even he was surprised that this happened during the winter and asked me what I had been doing. After explaining everything, he admitted that it was possible to be dehydrated, but was surprised it had been that severe. This last winter, I asked him if he had more cases of winter dehydration. He laughed and said I was the first of many winter dehydration patients he has treated in the years since.

Sure, thirst can be a sign of dehydration, but I found out otherwise. Exercise can actually blunt your thirst mechanism, causing you to feel un-thirsty even when your body is screaming for water. So, stay on the safe side and drink up during physical exertion.

Myth #3: A Sports Drink Is Your Best Bet.

What to drink depends on what you’re doing. Sports drinks are not always the best. It can be healthier to drink water and then have a post exercise snack that is rich in sodium or potassium. With diabetes, this puts limits on our choices. Bananas as suggested, are out for most people because of the carbohydrates they contain.

While coffee can rehydrate you, if you have diabetes, be careful of the amount of caffeine that you consume. Too much can increase your blood glucose levels rather substantially. If you insist on having your caffeine, be sure you are not doing this following exercise or before you exercise if you want to manage you blood glucose levels. And yes, water can be your best drink when it comes to hydration. Plus, research shows that water can be digestion-boosting.

August 15, 2014

Diabetes Education Better in a Group or Individually?

The Certified Diabetes Educators could learn from this study. I doubt they would see the value, as they like to work on an individual basis.

While the study was done in Ontario, Canada, it was carried out in a real-world situation and involved more than 75,000 patients. The only real flaw was they were unable to distinguish type 1 from type 2 diabetes, so the analyses could not be stratified by diabetes type. "However, the overwhelming majority of patients with diabetes in the population have type 2," they observe.

The study examining individual counseling for self-care in patients with diabetes vs. group education has found that the latter is associated with better outcomes. Senior author Baiju Shah, MD, PhD, of the Institute for Clinical Evaluative Sciences, Toronto, Ontario said, “We wanted to investigate in our population cohort what the differences were, based on individual appointments vs. the group-class approach, recognizing that the ministry of health and payers are pushing toward group programs because they're cheaper — you can treat more people with the same staff. We wanted to look at whether there was a clinical justification for that."

They were pleased to find that not only is group education more efficient in terms of resource utilization, it actually leads to better care and better patient outcomes, so it's a win-win situation: you can save money and improve care. "There's been a little bit of clinical-trial data that compare different ways of delivering diabetes education, but there really hasn't been very much literature published in this area," Dr. Shah explained.

The study did find that those patients participating in group classes were less likely to visit the emergency room, to be hospitalized for hypo- or hyperglycemia, or to develop foot ulcers. Those in group-therapy were also more likely to have adequate HbA1c and lipid testing. Unfortunately, they were more likely to use statins than those in one-on-one care.

The research is published by Jeremiah Hwee, MSc, also of the Institute for Clinical Evaluative Sciences, and colleagues in the May/June issue of the Canadian Journal of Public Health.

The researchers identified all patients in Ontario who attended diabetes education programs in 2006 and were grouped according to the type of program they attended. Individual appointment numbers = 55,761
Group appointment numbers = 12,234
Mixture of both = 9,829

The diabetes self-education was provided by nurses and dietitians. The size of the group classes was generally five to 10 patients plus family members. There were some centers in smaller towns where the group program would be run once a month and all patients in the town with diabetes would attend.

The study used secondary data and had no direct access to patients, but other studies have been published suggesting visits tend to be longer. Many of these group sessions were a full day or half a day compared to 20 to 30 minutes for individual counseling.

Previous research has shown that the information received from group classes is rated as more useful by patients than that received at individual classes. It is also known that discussing diabetes with others can be very important and peer-to-peer interaction can reinforce what is learned.

August 14, 2014

I Have to Wonder about the ACDE

Yes, I do need to wonder about the Academy of Certified Diabetes Educators. They are being very secretive and not really telling people about their activities. When I did this blog on April 23, 2014, the An Important Legislative Update about the new law in Indiana was already posted. It is now August 14 and the information is now down sometime during the day on August 11.

Attempts to contact two Indiana Legislators failed, but I was able to communicate with two Indiana CDEs on the condition I would not reveal their names. One is working with a brother-in-law and a couple of his friends and the other is working with two female friends to qualify them to work with type 2 people as peer-to-peer diabetes coaches or peer diabetes mentors. All five have type 2 diabetes and have many other type 2 friends they want to help.

As of 1/22/2014, Indiana has 367 CDEs according to the National Certification Board for Diabetes Educators (NCBDE) of 18,401 that are certified as diabetes educators and hold a certificate. This does not tell us anything, as they don't answer these questions:
What the numbers don't tell us:
How many are retired and not working as CDEs.
How many have taken up research work and not working as CDEs.
How many are its officers in ivory towers and not working as CDEs.
How many are on book promotion tours and not working as CDEs.
How many are only working part-time as CDEs.
How many are actually working full-time as CDEs.

There are also others that work as CDEs and RDs and therefore not full-time as CDEs. With all this missing information, it is small wonder that many of us with type 2 diabetes are not seeing or receiving any education from CDEs.  The numbers only tell us how many have passed the CDE examination and hold a certificate.

With the hidden numbers, both CDE organizations can tell us what they want and make it difficult to prove them wrong. When you get to know a few of them, they can be very forthcoming and properly assess us and individualize recommendations. Others make you want to run away and never see them again when they spout mandates and expect us to follow them. Education seldom crosses their lips and they become very agitated when questioned.

Then we come to the dual occupations (CDE and RD) and they follow the USDA and orders of Big Food. They elevate mandates to ridiculous heights and use some slick word trickery to keep patients off guard. They have answers for everything and promote high carbohydrate, low fat with mandates that we must eat a set number of carbohydrates at each meal if we want to be healthy and supply our brain with energy. Then when we learn how wrong they are, we won't listen to them again.

The Academy of Certified Diabetes Educators is already developing a reputation of being exclusive and while they will allow anyone that has taken and passed the NCBDE examination, they are fighting to discredit anyone that can help others learn how to better manage diabetes. We do not have enough educators to educate people with type 2 diabetes and we do not need this 'only certified diabetes educators can teach about diabetes' crap. We don't need the mandates, mantras, and one-size-fits-all that many of the CDEs use.

I wish that the two CDEs I communicated with were not so far away, I think I could learn a lot from them.

August 13, 2014

Stop Your Diabetes Self-Sabotage

This must be human nature or it wouldn't happen with such regularity. We all know what to do and do it right, but this self-defeating, self-sabotaging behavior wouldn't happen or happen so often. It’s important to recognize the early signs of self-sabotage: procrastination, self-defeating behavior, fear, and perfectionism. If you do, you can pick yourself up and put yourself on the right behavior before doing any damage, right?

Yet, about once a week, I do receive an email from someone that is in denial, has allowed themselves a holiday, and are having problems getting back on the correct management path.

Procrastination This bad behavior seems to rear its ugly head quite frequently, even for me. I catch myself wanting to put something off for another day or two when I know better. No, this does not happen with my medications, but mainly with poor eating habits.

Mine happens after days I want to treat myself for something that has been going great, but the treat is still there and I want to have it the second day and a few more days. I have eliminated the cake that I make myself from scratch, but when rhubarb is in season, I have a crustless rhubarb pie that I have loved over the years and I love the taste. I have tried making it with stevia and other sweeteners, but the taste is not the same as using sugar. Watermelon is the other treat and I am not talking the tasteless seed free variety.

Self-Defeating Behaviors If you are feeling overwhelmed by the challenges of your battles with diabetes, you may find yourself overeating or skipping you exercise. Many of us encounter mild depression and burnout from our daily diabetes duties. This is when we can fall to unhealthy behaviors and sabotaging good diabetes management.

When this happens, we need to force ourselves to make healthier choices. Since I don't drink coffee, I have no temptations there. I love my water and diet caffeine free coke, but there are times that regular coke would taste good. I don't keep that around just to eliminate that temptation.

That is why it is necessary to purchase watermelon halves instead of a full watermelon. This is one time that I do love eating and I have to be very careful and keep the quantity within reason. And with good watermelon, the temptation is there.

Fear Don't let nagging doubts build as they create more serious health problems if these doubts go unrecognized, they can get in the way of action. When we start to consistently doubt ourselves, this is not a good thing. We need to acknowledge our fears and how they hold us back from acting in a positive manner.

This is a good time for us to reach out to people we know will be supportive. A simple text, email, or phone call can distract us from our negative feelings. The person can be a member of a support group – this helps me and we all support each other. We know they will be there for us when we need the positive support.

Another tactic is positive self-talk. At the end of the day (or in a particularly bad moment) remind yourself of recent accomplishments -- then give yourself a pat on the back. All you need is to remove your focus long enough for your fear to fade.

Perfectionism This is my worst enemy and I do get very frustrated when I don't achieve my goals as fast as I want. According to the article, this can contribute very easily to self-sabotaging behaviors.

A team of experts at Joslin Diabetes Center claim the best strategy is to have long-term goals so realistic that failure is erased. Biting off bigger goals that are difficult to achieve is not realistic. Practicing patience is better than setting unachievable goals. Working with your health care team setting out small, attainable goals is desirable. After success with one goal, move to the next. This method leads to building one success on top of another.

Now for the positive side. This is not an easy task, but in general, it has served me in most situations and definitely has reduced the self-sabotage for me. This is developing a positive attitude and practicing this on a daily basis. This does not mean that there is no place for anger if it is directed properly and then when the anger is over, get back into the positive.

August 12, 2014

Insulin Myths and Problems They Cause – Part 2

This is a continuation of the previous blog.

Myth 4: “If I am placed on insulin therapy, I will gain weight.”
Some people with Type 2 diabetes may gain weight after starting insulin therapy. Yes, this is true if people going in insulin do not cut the number of carbohydrates. This is because of improved blood glucose control. Uncontrolled diabetes causes people to lose weight because glucose cannot get to the cells in the body. When insulin is introduced, glucose can be absorbed from the carbohydrates eaten, leading to some of the weight that was previously lost being regained, but only if they do not reduce carbohydrates consumed.

The good news is that weight gain tends to level out as insulin therapy continues, and the weight gain may be temporary. Ultimately, the benefits of good blood glucose control will reduce the risk of complications and should take priority. By reducing carbohydrate consumption, often weight gain is stopped before too much weight is added. Adopting a low carbohydrate, high fat, medium protein meal plan, can prevent added weight gain and allow weight lost if needed.

Myth 5: “Insulin causes complications like blindness, amputations, and kidney failure.”
Part of the reason behind the “negative image” of insulin is that physicians have historically used it as a warning to keep their patients motivated and focused on oral medication therapies. It’s no wonder that people who try their best, but inevitably need insulin therapy, often feel guilty. Another reason this is believed is that many people have known people with these complications that developed before insulin, but insulin therapy is all they can remember.

Doctors commonly delay starting insulin due to their own lack of knowledge about the treatment. Some of these include a fear of causing low blood glucose or a concern that their patients will not adhere to an insulin regimen. The result is that insulin is often added to therapy too late in the course of diabetes. The reality is that people do not develop complications from being started on insulin, but rather, they develop complications from being started on insulin too late. Insulin actually reduces your risk of getting complications. Adding insulin to your treatment can improve your control and result in fewer complications than you would have had otherwise.

Hopefully, these myths about insulin will go away as doctors begin insulin therapy sooner rather than later and people with diabetes become more educated about insulin treatment. So if your physician tells you its time to add insulin to your regimen, just remember, diabetes is a chronic illness. The longer you’ve had type 2 diabetes, the more likely you are to need insulin. Insulin can provide improved blood glucose control and slow or prevent the development of complications. The following are more insulin myths.

Myth 6: “Insulin causes sterility and sexual dysfunction.”
This happens when insulin is delayed for too long and oral medications are no longer effective. Doctors need to lose their fears and become more knowledgeable.

Myth 7: “Insulin use is the beginning of the end.”
This is because doctors use insulin as treatment of last resort. People that let their doctors get away with this can fall into this myth, making it true. I have been on insulin for about 11 years and even at age 72, I feel I have many more years to look forward to and enjoy.

Myth 8: “Insulin is toxic.”
The number of people that find this true is very small. Most are allergic to something in the manufactured insulins and some are allergic to the animal insulins. Animal insulins are no longer available in the United States, but can be legally imported by doctors for those in need.

Myth 9: “Insulin use will label me as a drug addict.”
I have been questioned by the police about my use of syringes. Fortunately, I had the insulin there and the pharmacy RX on the box and after checking, the officer was very polite.

Myth 10: “Insulin use is an inconvenience.”
This is true, but only if you let be an inconvenience. Your diabetes health is too important for you to let this be a reason for avoiding insulin. In the almost 11 full years of using insulin, I have injected when in view of others, in private, and I refuse to use unsanitary bathrooms. On airplanes, I have been allowed to use the food gallery when it was not in use.

August 11, 2014

Insulin Myths and Problems They Cause – Part 1

Insulin myths are promoted by doctors that do not understand diabetes and are afraid of patients having a hypoglycemia episode. They use threats about failing when taking oral medications and the threat of insulin if they don't succeed. This atmosphere generated by doctors can lead to the following myths.

Myth 1: “It’s my fault I am being put on insulin because I didn’t do what I was supposed to do.”
No, it is not your fault! You have not received the education necessary to better manage your diabetes, and have had a threatening attitude from your medical providers. These doctors have used threats and left insulin as the medication of last resort. It is your fault that you let them do this to you and did not ask for insulin before it became necessary. This may have prevented this myth – diabetes is progressive from becoming true.

The doctors, CDE's, and others believe that diabetes is progressive because this is what they see in their daily practice. But because of their attitude and threatening ways of leaving insulin as a medication of last resort, they cannot help but see this. Their disrespect for us and treating us as people capable of making some decisions for ourselves is a disgrace to all doctors. There are a few doctors and more endocrinologists that will start us on insulin earlier before our pancreas is worn out and allow us to manage our diabetes to prevent it from becoming progressive.

It is inevitable that the insulin-producing beta cells of the pancreas will deteriorate over time, resulting in insulin deficiency. In other words, the pancreas cannot keep up with the body’s need for insulin no matter what you’ve done to manage your diabetes. Accordingly, insulin treatment is a normal and effective way of replacing the body’s insulin. Think of it as a form of 'hormone replacement therapy.' The goal of all diabetes treatment is to find the right combination of treatments to provide the best blood glucose control while minimizing side effects and insulin is the best of those options. Then remember that there are lifestyle changes that can help and for the different lifestyle changes, read my blog here.

Myth 2: “Insulin injections hurt.”
Most people are surprised by how little an insulin injection actually hurts. With the small, fine needles available today, insulin injections are virtually painless. Insulin is injected into the layer of fat below the skin where there are no pain receptors. In fact, most people feel that the finger pricks used to measure their blood glucose levels hurt much more than their insulin injections. Still more of us have learned how to prick our fingers that greatly eliminates much of this pain.

Myth 3: “Now that I am on insulin therapy, I will have more episodes of low blood glucose.”
Although some episodes of hypoglycemia, or low blood glucose (defined as a level below 70 mg/dl) may occur in people using insulin, severe hypoglycemia is rare and has been shown to affect only about 0.5% of people with Type 2 diabetes. You can learn how to prevent, recognize, and treat hypoglycemia, therefore avoiding severe hypoglycemia episodes.

Early symptoms of hypoglycemia include shakiness, nervousness, sweating, and confusion. People with diabetes should always carry glucose tablets with them, along with a blood glucose meter to check glucose levels when any of these symptoms occur. Treatment is usually 15 grams of carbohydrate, examples of which include 3 or 4 glucose tablets, 4 ounces (1/2 cup) of fruit juice or regular (non-diet) cola, or 5 or 6 pieces of hard candy.

Blood glucose levels should be checked again in 15 minutes and, if levels are still low, the steps above should be repeated until the glucose level is 70 mg/dl or higher. Strong evidence has demonstrated that the benefits of achieving good blood glucose control outweigh minor episodes of hypoglycemia as long as these episodes are not too severe or too frequent. Never allow blood glucose levels to become hypoglycemic if at all possible. Do not over consume when experiencing a low and put yourself in a yo-yo situation of highs and lows.

August 10, 2014

You Can Reduce Prescription Errors

It is often the case that you go for a prescription refill and when you get home and take the container of pills out, you notice they are a different colored pill or even now a capsule instead of a pill. What to do? First, call the pharmacy and explain what you have seen. Most pharmacists will tell you they have changed suppliers or the doctor had changed your prescription. These should be red flags and you need to be careful now. You should have been told this when you picked up the prescription. If the doctor did change the prescription, you should have been notified about the reason for the change. Some doctors are increasing the dosage of statins without notifying their patients.

Hopefully, you did not wait until you were out to refill your prescription. First, check the information on the containers to be sure that it is the same medicine and the same dosage. Next, if the dosage has changed, contact the doctor to find out why and be prepared to encourage the doctor to return it to the former dosage. Document everything and if your doctor did change without informing you, be prepared.

So what can you do, as a patient, to be sure that your prescriptions are correct?

Keep a list of your current medications with you at all times. Include the brand or generic name, dose and frequency. Paper, online or on your phone – wherever it's easiest and most accessible. Put a paper list in your wallet to cover you in emergencies, consider that even if you use your phone routinely.

Cross-check and update your medicine list with your provider at every visit. This is called "medication reconciliation," It is one of the most important things you can do at a doctor visit. You would be shocked how many patients come to a visit without knowing the names of the drugs they are taking. When the doctor prescribes a new medicine, how can he/she be sure it doesn't interact badly with something you are already taking? If the doctor is lucky, your pharmacist will pick it up, but only if you've filled a prescription in his/her system before. Don't leave it to chance. Take charge.

Ask for an updated list of your medications and prescriptions before leaving your doctor's office. Most electronic medical records (EMRs) can create a current medicine list, so ask your doc or his/her staff for a copy. If you use it as your medicine list to carry with you, everyone will be on the same page. Alternatively, if your practice gives out an AVS (after visit summary) at checkout, that usually will have your medicine list on it.

If you're tech savvy, use the practice patient portal. Your provider's practice portal has a medicine list. Take it upon yourself to check the portal between visits to be sure your medicine list is up to date and correct. You can usually print your medicine list yourself from the patient portal.

Cross-check every medicine after you pick it up against the prescription your provider wrote. This includes refills. Use your printed medicine list, the portal or your AVS to check what your provider wants you to be taking. If you don't have that, you can ask the pharmacist for a copy of your prescription. Don't wait until side effects occur, as my patient did, to double-check. Your health is too important for that.

Don't hesitate to speak up if you think a prescription is wrong. You take it once a week, and now it says twice a week? Say something. And it's not just the pharmacist who can make a mistake. Your doctor isn't perfect either. In fact, since doctors started using the EMR to write prescriptions, mistakes can easily happen. So please, stop the doctor if you think it is wrong.

Finally, don't forget that so called "natural" supplements are medicines too. Some doctors are very adverse to 'natural' supplements. Other doctors are accepting them, but are concerned about the ones they are not told about because of the conflicts between 'natural' supplements and prescription medications. If you're taking any kind of supplement, vitamin, herb or natural product, be sure to add it to your medication list.