Sleep Apnea May Be Tied to Diabetes

Prior to this study, most studies included few patients and were too short in length. Now we have a larger study and a suggested link between sleep apnea and diabetes.  Unfortunately, the study had some critical limitations. The limitations included lack of family history of diabetes, the race of the participants, and the possible misclassification of some subjects due to the limitations of the administrative health data used.

This is a severe fault of the study and that is the reason I only used the words 'may be tied' in the title. I don't care that they used the word “tied” in their title with claims of a link between obstructive sleep apnea and diabetes. Yes, there are some similarities between the two and being overweight is very common. As to one causing the other, this is still unproven. I will continue so that you can make up your own mind.

Lead author, Tetyana Kendzerska, MD, PhD, of the University of Toronto says, "Our study, with a larger sample size and a median follow-up of 67 months was able to address some of the limitations of earlier studies on the connection between OSA and diabetes. We found that among patients with OSA, the initial severity of the disease predicted the subsequent risk for incident diabetes."

The study included 8,678 adults with suspected OSA without diabetes at baseline who underwent a diagnostic sleep study between 1994 and 2010 and were followed through May 2011 using provincial health administrative data to examine the occurrence of diabetes. The apnea-hypopnea index (AHI) was used to assess sleep apnea severity. The AHI indicates severity based on the number of apneas per hour of sleep. Patients were classified as not having OSA (AHI < 5), or having mild (AHI 5-14.9), moderate (AHI 15-30) or severe (AHI>30) OSA.

During the follow-up, 1017 (11.7%) patients developed diabetes. In analyses, adjusting for known risk factors for diabetes, including age, sex, body mass index, neck circumference, smoking, income status and comorbidities at baseline, patients with an AHI>30 had a 30% higher risk of developing diabetes than those with an AHI <5 .="" 23="" a="" developing="" diabetes.="" had="" increased="" mild="" moderate="" of="" or="" osa="" p="" patients="" risk="" with="">

"After adjusting for other potential causes, we were able to demonstrate a significant association between OSA severity and the risk of developing diabetes, said Dr. Kendzerska. Our findings that prolonged oxygen desaturation, shorter sleep time, and higher heart rate were associated with diabetes are consistent with the pathophysiological mechanisms thought to underlie the relationship between OSA and diabetes."

Can We Afford 40% of Our Citizens to Have Diabetes?

This two out of every five projection of diabetes for adults is gloomy and at the same time should alert us to other problems we are facing. Then add to this that the rates for black women and Hispanics will be at 50 percent. And these projections do not include children and adolescents. What are the other problems we are facing?

This is just a partial list, but a very serious situation.

#1. There will be longer waits for doctor appointments. This is because of a projected doctor shortage.

#2. A serious lack of diabetes education is about to take place. It is serious enough at present, but with the activities of one certified diabetes educator group and their activities in opposing anyone being able to assist in education, it will become worse. This group is declaring that only CDEs are capable (not) of giving this education and others are not capable is the height of being conceited. With both CDE organizations unwilling to use telemedicine or group education, education will become a short commodity.

I will give credit where credit is due and that is many doctors in rural areas are taking diabetes patients that are willing and giving them education about diabetes to work for them as peer mentors or peer-to-peer workers. I have even been pleasantly surprised by the response I have received from the two doctors in Kansas that I have volunteered for as a peer mentor. They are having many of their patients ask me questions via email because they are not getting many questions answered by the telemedicine operation in Kansas. Time seems to be a constraint.

#3. Endocrinologists are even more overwhelmed because doctors are pushing many diabetes patients to them. This long article in Medscape helps explain the problem.

#4. No figures are being given for the numbers of new diabetes patients that have developed diabetes because of statins. At least we know that it may be near ten percent based on this study in Italy. See my blog from yesterday.

#5. No help is being provided by our government to encourage diet change. The USDA keeps promoting whole grains and other high carbohydrate foods instead of low carbohydrate, high fat nutrition. We also have the corn and wheat organizations influencing the registered dietitians to promote this as well.

Doctors, in their jaded wisdom, have coined the term "diabesity" to reflect the combined effects of the diabetes and obesity epidemics. They claim they go hand-in-hand, but give no reason for those obese patients without diabetes. And why should those people that are thin and diagnosed with type 2 diabetes need to put up with these prejudiced doctors. Plus these same doctors are not doing anything to educate patients or applying pressure to our government to change the nutrition of the population.

Not all the news from the study was bad -- the researchers found that people with type 2 diabetes are living longer than in the past. The CDC researchers estimated that the number of years lost to a diabetes patient diagnosed at age 40 decreased from nearly 8 years in the 1990s to about 6 years in the 2000s for men, and from almost 9 years to just under 7 years for women.

There is still a mountain of work that needs to be accomplished to help our population learn about proper nutrition – from the government level to the individual level.

Statin Adherence Increases Diabetes Cases

I admit I don't understand doctors that feel the risk of type 2 diabetes is secondary to the benefits of statin use. Since they do not take statins they have no concern about developing diabetes and therefore they make these statements with no thought about the costs or problems of diabetes.

Yet these doctors still insist the benefits of statins in reducing cardiovascular events clearly overwhelm the diabetes risk. The critical error in the study is that they do not report on cardiovascular events so the study is weighed for the results they wanted to report.

The risk of new-onset diabetes increases with increasing adherence to statin therapy, according to a study published online June 26 in Diabetes Care.

Giovanni Corrao, Ph.D., from the University of Milano-Bicocca in Italy, and colleagues examined the correlation between adherence to statin therapy and the risk of developing diabetes in a study involving 115,709 residents of the Italian Lombardy region. Participants were newly treated with statins during 2003 to 2004 and were followed from the index prescription until 2010. Patients who began treatment with an antidiabetic agent or were hospitalized for a main diagnosis of type 2 diabetes (outcome) were identified during this period. The proportion of days covered with statins was measured to determine adherence (exposure).

“The researchers found that 11,154 cohort members experienced the outcome during follow-up. The hazard ratios for the exposure-outcome association varied with adherence, with hazard ratios of 1.12 for those with low statin adherence (26 to 50 percent); 1.22 for intermediate adherence (51 to 75 percent); and 1.32 for high adherence (≥75 percent), versus very-low adherence (<25 i="" percent="">

About a tenth of the participants developed type 2 diabetes and this does not seem insignificant to me. This leads me to understand why the rate of diabetes is increasing worldwide at such an alarming rate.

Using CPAP During a Cold

Okay, you are using a CPAP machine and waking up rested. You have overcome your resistance to using the machine on a daily basis and are happy using it. Now, you are coming down with a head cold and are wondering what to do and think you should possibly take a break from using it until you are over the cold.

It is okay to take a break from using CPAP, if you have a cold. You may find that you have a residual benefit from the treatment, even several days into the break. This is because the inflammation and swelling of the tissues in the upper airway will take time to become affected again. See my blog from yesterday for possible breathing help using a CPAP.

When you have an upper respiratory infection, such as the common cold may make it more difficult to use CPAP. Similar to what occurs with allergies, the nose may become congested and runny. A stuffy nose may make it hard to breathe with the machine. The discharge of mucus may dirty the CPAP mask, especially if you use nasal pillows. The flow of air may also cause irritation if you have a sore throat. Each time you cough, opening the mouth may make the pressure uncomfortable.

If you do decide to continue using your CPAP during your cold, you may find it helpful to use a medication to alleviate a stuffy nose. Over-the-counter saline spray is inexpensive and effective. It can be used as often as you need it and will moisten the lining of the nose. Afrin spray may also provide relief, but it should not be used long term due to the risk for rebound congestion of the nose.

Other prescription medications may relieve chronic congestion related to allergies, including topical nasal steroids sprays such as Flonase, Nasonex, Patanase, and Astelin. It may also be helpful to rinse the nasal sinuses with a neti pot. If you have diabetes, be careful and only use prescription medications under the direction of a doctor, as many can raise blood glucose more than you want.

Some people actually like to use CPAP during a cold, especially if there is not a lot of nasal discharge. The heated and humidified air may add comfort and relief. This pressurized air may also move mucus along the nasal passage and decrease congestion. My CPAP has a heated humidifier and does help during a cold.

During and after your cold, it is important to be diligent about cleaning the CPAP mask, tubing, and humidifier tank. Give everything a thorough rinse with a mild soap and water.

Even if you want to take a break from CPAP when you have a cold, you don’t have to. If you find that you can tolerate the treatment during illness, it will help you to sleep better and wake feeling more rested. Except for one particularly bad cold, I have been quite comfortable using my CPAP machine and it has actually helped lessen the symptoms of my colds. You may need to experiment to find if this works for you.

Sleep Tips to Help You Breathe Easier with a Cold

How often do you suffer from a cold? Whether you have a head cold, a chest cold, or a combination sinus and head cold, there are ways to make it more bearable and help with breathing. Most of the time using one or more of these suggestions allows me to continue using my CPAP machine during a cold.

#1. Use a Nasal Strip. Applied externally to the middle of the nose, nasal strips have an adhesive on one side. Choose the appropriate size (small, medium, or large), wash, and dry your face before applying.

#2. Take a Hot Shower Before Bed. The steam and humidity of a shower cause sinuses to drain and the lining of the nasal passages to constrict, relieving some of the stuffiness of a cold. You can achieve the same effect by sipping a cup of hot tea or having a bowl of hot soup.

Chicken soup, the age-old cold remedy, may indeed have special benefits. When researchers at Mount Sinai Medical Center tested the venerable cold prescription in 15 cold sufferers, chicken soup proved more effective than plain hot water in clearing out sinuses.

Avoid drinking cold beverages near bedtime, however. I know from experience that even drinking cold water increases congestion. Other cold beverages have the same effect when done within a few hours of bedtime.

#3. Use a Saline Rinse. One of the safest ways to unblock congested sinuses and get a good night’s sleep is to use a saline rinse, in either a spray bottle or a neti pot. A neti pot is a small container with a narrow spout that’s used to pour small amounts of saline rinse into the nostrils. The saltwater washes mucus and irritants from your nose and helps the cells that move the mucus.

It's important, according to the CDC, that if you irrigate, flush, or rinse your sinuses, you use distilled, sterile, or previously boiled water to make up the irrigation solution. It’s also important to rinse the irrigation device after each use and leave it open to air-dry. Saline is a safer bet than over-the-counter or prescription spray nasal decongestants. Although topical decongestants effectively reduce congestion, versions that contain pseudoephedrine may cause sleeplessness and agitation. You may be able to breathe easier but not be able to fall asleep.

If you have to use a nasal decongestant, stop after 3 days and throw the bottle away.

Prescription sleeping pills may also be a bad idea when you have a cold. Sleeping pills can exacerbate upper respiratory obstruction in people with sleep apnea, which is a common problem for people who are overweight or obese. If a cold is the reason, you’re having trouble sleeping, it’s far better to treat the symptoms of the cold than take a sleeping pill.

#4. Elevate the Head of the Bed. One common recommendation is to prop your head up on pillows to help sinuses drain more easily. This is bad advice, as by bending your neck at an unnatural position, you can actually make it harder to breathe. Instead, use a large, wedge-shaped pillow that raises the upper body from the waist up. Or raise the head of the bed by placing bricks, books, or a telephone directory under the legs. Don’t raise it more than 6 inches, however, or the tilt will make you slide out of bed. The slight incline causes blood to flow away from the head and thus reduces inflammation of the air passages.

#5. Apply a Mentholated Gel. This is another venerable treatment that remains popular. And it may help, although not the way many people once thought. Studies have shown that menthol doesn’t actually open up the airways. Instead, the cooling sensation it causes makes people feel as if they’re breathing more freely. And let’s face it, that’s what’s important when you’re trying to treat the symptoms of a cold.

This does not often help those using a CPAP machine with nasal pillows or a nasal mask. If you do try this, do not be surprised if it does not help.

#6. Sleep on Schedule. When cold symptoms make it tough to sleep, paying attention to the basic rules of good sleep hygiene is more important than ever.

By now most of us know the basics:

• Go to bed and wake up on a regular schedule. (That way, when bedtime rolls around, you’re in the habit of going to sleep.)
• Avoid stimulating beverages like caffeinated coffee or alcohol in the hours before going to sleep.
• Reserve your bed for sleep, not a place to work, read, or watch TV.
• And if you do find yourself tossing and turning, get out of bed (and the bedroom, if possible) so you don’t associate bed with insomnia. Do something that you find relaxing until you feel tired enough to go to sleep.

Good sleep hygiene can be as effective as prescription drugs in helping some people sleep.

“Getting enough shut-eye may be especially critical during cold and flu season, according to a 2009 study by researchers at Carnegie Mellon University in Pittsburgh. The researchers enlisted 153 volunteers who agreed to be quarantined and then exposed to the viruses that cause most colds. Those who slept less than 7 hours were almost three times more likely to develop colds than those who got 8 hours of sleep or more.”

What Is the Future of the AADE?

Is there a future for the American Association of Diabetes Educators (AADE)? Not if the Academy of Certified Diabetes Educators (ACDE) has anything to say about it. At present they both have members that have taken the test given by the National Certification Board for Diabetes Educators (NCBDE) and passed it. The ACDE is taking the exclusive route and not allowing honorary membership and is lobbying hard in some states to prohibit anyone with knowledge of diabetes from passing this on to other people with diabetes. This includes peer-to-peer diabetes workers, peer diabetes mentors, diabetes coaches, and others.

The AADE does have honorary members and does unofficially work with a few of the groups in the last sentence above. And the AADE does not list all that have passed the NCBDE examination as members. The about 13,000 members does become more realistic when you consider those that have retired or are not doing certified diabetes education work. Although neither organization is particularly transparent in their actions, from my observations the AADE is the more transparent of the two.

Now I will take a blog by one of theAADE members posted on the AADE website and discuss the points made in the blog. You may read the points here.

“•We should keep moving forward with our public awareness campaign to increase media exposure highlighting what we do for people with diabetes (PWD). Rather than relying on a healthcare provider to recommend diabetes self-management education and support (DSME/S), let PWD know about what we do so they can ask for a referral (similar to what patients do regarding medications after they read or hear about something new).”

False advertising is not what they should be doing. This is the aim of Big Pharma in their advertising and the hypochondriacs answer the call. There has to be some reason that healthcare providers stop referring diabetes patients to CDEs. I know some doctors do not like the conflicts created by CDEs and this is why many will no longer refer diabetes patients. In other more rural areas, CDEs are just not available. When CDEs teach to the lowest level, make mandates the rule and do little actual education, then we must wonder if they have a purpose. Even many studies find that peer-to-peer education produces better A1cs.

“•When considering the value of diabetes education/educators, recognition should be given to what we prevent including the onset of diabetes, complications from diabetes, and costs (i.e., to prevent hospital admissions).”

Oh, if only this last could be true! The CDEs generally do not work with people with pre-diabetes or counsel them. Very few ever work with type 2 diabetes patients; therefore, I have to wonder with so few CDEs, how can we depend on these people to really fulfill the needs of so many. Most CDEs do not properly assess persons with diabetes (PWD). For many it is a one-size-fits-all or nothing. Many will not work with a PWD that talks about depression and most avoid dealing with depression or burnout. How can patients trust CDEs that avoid something like mild depression.

“•Diabetes education should be at the beginning of the algorithm for care of a person with diabetes; not at the middle or end when problems could have already occurred.”

The above is true, but there are not enough CDEs to take this on. Most will not work with telemedicine or groups of patients.

“•Diabetes educators are key providers in chronic care; we should brand our profession to be included in the chronic care model.”

Diabetes is a chronic illness, but with the few CDEs, how can we depend on CDEs to fill this role. Mandates do not work for people with diabetes and we need individual treatment, not the one-size-fits-all treatment they dish out.

“•Diabetes educators need to be armed with more knowledge on the business of diabetes to help us in the current medical care environment (i.e., Patient-Centered Medical Homes, Accountable Care Organizations, etc.).”

Many CDEs are learning that doctors are excluding them from the new medical care environment because of their attitudes.

“•We need to get legislators on our side to push through legislation that will help us in our work with PWD.”

This statement can be taken several ways and is open for interpretation. We have one organization doing this now and we don't need another organization trying to criminalize people for helping others with diabetes.

“•Diabetes educators can collaborate with more money-generating pieces of medical care so we can give quality care to PWD in a team approach (rather than struggling financially on our own and being considered a money-losing part of care).”

They do have a lot to learn.

“•We should clarify the levels of the diabetes educator so it is understood by us, healthcare providers, and the public.”

What levels are they talking about? The levels of mandates, maybe. Or those that run from people with depression? Now if they have different levels of education and training, maybe we should know this.

“•Many people with prediabetes may not appreciate the importance of behavior change to prevent the onset of type 2 diabetes. Perhaps prediabetes should be renamed Stage 1 diabetes to increase the importance of the condition and changes that can be made to prevent progression to DM (Stage 2 diabetes).”

This is one point I could support.

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“•We should look for ways to influence the prevention of type 2 diabetes, from children to adults, with methods that can be accessed by all in need (including those with socio-economic challenges).”

No comments.

“•Electronic medical records give challenge and benefit. Diabetes educators should be at the table during the creation of EMRs to improve ease of use and beneficial data output.”

They are a way behind on this one. EMRs have already been created and are being updated all the time.

“•There are not enough diabetes educators to meet the needs of all PWD that could benefit from DSME/S. We need to get the word out about diabetes education in academic programs and to current healthcare providers that might be interested in becoming diabetes educators. At the same time, we need to increase the public’s knowledge of how we can help, increasing referrals to prevent closing of programs (and back to the knowledge about the business of DSME/S).”

The first sentence is correct, and the rest is a pipe dream as some are interested until they find out about the test and the qualifications needed.

Hydration Myths – Part 2

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. This is a continuation of the previous blog.

Myth #4: There’s No Such Thing As Too Much Water.
Celebrities and laypeople alike have claimed that consuming extra water can improve your skin, help you sleep, and boost overall health by "detoxing" your body. But, it’s not necessary. There is no evidence that excess water makes your body more clean. That being said, hopefully you have heard of water poisoning. If you haven't, you have now and the medical term is hyponatremia (a.k.a. low sodium levels), which can result from drinking too much water. Hyponatremia is a rare, but dangerous condition that can develop when athletes and others dilute their bodies' natural sodium content by drinking too much water, causing their water levels to rise and their cells to swell.

Prolonged-endurance athletes, like the folks you see at marathons and triathlons, tend to encounter this ailment most frequently; it’s generally not something you need to stress about during exercise class or a power-walk around your neighborhood. There is no need to go overboard and try over drinking water.

Myth #5: Clear Pee Is The Healthiest Pee.
You’ve probably heard that proper hydration leads to completely-clear pee. That’s true for the most part, but you can cut yourself a bit of slack; a healthy urinary hue can range from fully clear to a light, lemonade-ish yellow. Dark urine does indicate dehydration, though, so pay attention to what’s in your toilet bowl or urinal, especially during the summer. Drink more water if your urine is more deep-gold than pale-yellow. You should be drinking enough to make you go to the bathroom every two to four hours, during the summer.

Myth #6: Severe Dehydration Is An “Old-People’s Problem.”
Although dehydration is a bigger risk for children, older folks, and people with chronic illnesses, it can and does happen to healthy adults, too, especially those who live in high altitudes or who exercise vigorously in hot, humid weather, or the hottest part of the day. Other than thirst, signs to watch for are heightened temperature, a flushed complexion, rapid pulse, fast breathing, dizziness, and overall weakness. If you notice any of those symptoms, stop what you’re doing and replenish your fluid levels, as soon as possible.

You’ll want to seek out immediate medical care, though, if you notice signs of extreme dehydration, such as: super-dry mouth, skin, or mucus membranes; sunken eyes; little to zero urine output; pinched-looking skin; low blood pressure; and confusion, delirium, or unconsciousness. Complications of this kind of dehydration can be frightening and severe: seizures, brain swelling, kidney failure, coma, and even death, to name a few.

Sounds Scary - Here's How To Deal
The best way to deal with dehydration is to drink enough liquids to prevent it from happening in the first place. Other ways to stay hydrated this summer are to eat water-rich fruits and veggies such as celery, pineapple, watermelon, kiwi, citrus fruits, and carrots; they won’t meet your hydration needs on their own, but they can help give a boost. Coconut water is great, as are some forms of dairy, such as yogurt and kefir. Soup, oatmeal, and smoothies are also good choices. For those of us with diabetes, we need to find other foods and those with lower numbers of carbohydrates.

No matter how you opt to keep your body hydrated the remainder of this summer, make hydration a priority. The summer months may be all about fun in the sun, but there’s nothing more fun-squashing than having to hide out in your apartment (or beach house, or hotel room, or cabin in the woods) with a bad case of the dehydration blues. Even worse, spending time in the hospital while being treated for dehydration.

Some events are held during the hottest part of the day and if you are having problems with dehydration, it might be wise to avoid these. Do your exercising during the cool part of the day or most often in the early morning. Occasionally the evening will be cool enough to do your exercising. If it is very hot, find an air-conditioned building for your exercising.