October 4, 2014

People Can Use These to Stop Diabetes Burnout

I will work on adapting these to diabetes, as they fit what we need to prevent diabetes burnout and occasionally some depression.

#1. Wait for what's right instead of acting on what you want right now. So you want that cookie now. Yes, they are fresh out of the oven and the smell is very overwhelming. I suggest waiting until after you have finished your meal and know that you have kept the carbohydrates consumed total low enough that you are able to have the carbohydrates in the cookie.

#2. Sit with discomfort. In the above tip, those who are emotionally stable are able to tolerate the wait. Remember the things you muttered under your breath or because of your hunger for the cookie. How would the response have been different if you had tolerated your desire for an hour? Tip 1 was about choosing the best action and this tip is about sitting on an emotion without taking any action.

#3. Get some perspective. We have all probably heard the saying, “Hindsight is 20/20.” With diabetes, being in the trenches often makes it difficult to see the bigger picture. Yet, sometimes things happen for you and not to you. This can be important and you often receive a gift that you could not give yourself.

#4. Practice acceptance. Acceptance is not the same as complacence. It's not about giving up and letting the stress take over — it's about experiencing your emotions and trusting that you'll bounce back.

#5. Remember the power of time. The emotionally stable or resilient remember that time heals all wounds. People who have a tendency to feel depressed often fear spiraling back into it, but feeling an emotion is not the same as getting caught in it. Think back to the last time you felt like this. You may have thought it was the end of the world, but you recovered. The same is true now. This is when a positive attitude can resolve issues.

#6. Let go of having all the answers right now. Often, when those of us with diabetes try hard to find answers to challenging diabetes puzzles, we unknowingly put our blinders on. We are so consumed with having answers on our schedule that we forget that we only receive when we are ready. The emotionally resilient remember that it's okay to not have it all figured out.

#7. Engage in self-care. Emotionally resilient people with diabetes know that self-care is a non-negotiable. The doctor is not available 24/7. It's a daily practice and commitment to self that strengthens their inner resolve. Ranging from exercise, to meditation, to a cup of tea, to the correct number of carbohydrates, the resilient have go-to stress busters that don't involve hitting the bottle.

#8. Laugh it off. Sometimes things just suck, and you simply need to laugh it off. Humor goes a long way.

#9. Choose to be happy above being right. Emotionally resilient people with diabetes know that being right is not what will make them happy. Sure, it's nice to be right, but it's better to be happy. Ask yourself if picking a fight is really worth it. Are you fighting to resolve the situation, or fighting to win it? In any moment, you can choose what's more important to you - the relationship or your pride.

#10. Instead of focusing on what's wrong, the resilient focus on what's right. Remember, where attention goes, energy flows. So why not cultivate more of what you want instead of what you don't. There is always something to be thankful for.

Ultimately, emotional stability is all about attitude. By practicing these ten responses to stress, you'll be able to spend more time living with ease and grace, spending more time in the light with fleeting moments of darkness!

October 3, 2014

An Argument Against the Prediabetes Classification

At least this is not a study, but an analysis by “experts.” They are talking about the two parts – the medicine and the politics of prediabetes. The article is part of a series in the British Medical Journal on over diagnosis. They say that the risks and harms to patients will depend in expanding disease definitions. They began their analysis by reminding the reader that prediabetes is a heterogeneous concept or a concept composed of parts of different kinds, having widely dissimilar elements or constituents:

“Concept one” - The original category of intermediate hyperglycemia was termed "impaired glucose tolerance" and was based on the oral glucose tolerance test. Only since 1997 was an intermediate category of "impaired fasting glucose" created, “concept two” with revision in 2003 to expand the range of qualifying values. “Concept three” Because A1c was not used for diagnostic testing until 2010; it is only recently that a nameless intermediate category based on A1c was designated. Unfortunately, the overlap of these three definitions is far from perfect, so the starting point for the discussion is already confused. This is the interpretation of the experts.

They declare there is a limited value of prediabetes. They said the importance was whether a diagnosis of prediabetes guarantees a future diagnosis of diabetes. They declare that no matter how prediabetes is defined, the answer is “no” - less than one-half of all such people will develop diabetes within 10 years. The two authors say that clinical trials from around the world have demonstrated that diabetes risk among high-risk individuals can indeed be reduced, but Yudkin and Montori argue that diabetes onset was merely delayed by 2-4 years, at high cost and only among a subset of the intervention groups.

“The following quote summarizes their position: "The US Diabetes Prevention Program results imply that you can give an at-risk person with pre-diabetes a 100% chance of using metformin with the goal of reducing by 31% their risk of developing a condition that might require them to use metformin." Yudkin and Montori conclude that it is critically important to address the epidemic of obesity and diabetes. However, they assert that available resources should be used to change the root causes of the epidemic rather than to medicalize otherwise healthy patients with prediabetes.”

Then they switch to a study published in Diabetes Care about the risk of cardiovascular disease (CVD) in people with prediabetes. “The Diabetes Prevention Program Outcomes Study (DPPOS) is the follow-up to a randomized clinical trial of individuals who had prediabetes. Of the 2775 participants in DPPOS, 1509 (54%) had achieved normal glucose regulation (NGR) at least once during the DPP, whereas 496 (18%) remained with prediabetes and 770 (28%) developed diabetes. The investigators also compared individual CVD risk factors, including cholesterol, smoking status, blood pressure, and diabetes status, all assessed annually.”

What bothers me is that 54 percent of people with prediabetes do have problems with high blood pressure and need medications and 34 percent used statins and these “experts” say we should not be concerned with prediabetes. Yes, this does mean that possibly some may be medicated that should not be, but if they could focus on those with the greatest risk factors then some would be missed, but many would be helped.

Maybe the new method of determining diabetes need to be put in place as this would be a great diagnostic tool and could more accurately tell which people with prediabetes were at risk. Read my blog here about the possible new test.

It is my opinion that these “experts” should support testing people for prediabetes and using every test possible to find those at risk for developing type 2 diabetes.

October 2, 2014

Having Your End of Life Wishes Followed

When a doctor or nurse asks you who is your emergency contact, do you know whom they are asking about or are they asking for an advance directive? Don't know do you? Even they are unsure, but they will make a mistake either way. Doctors, nurses, hospitals, even other health care providers ignore what is in their files, computers, and even what seems like common sense.

If a family member is present, that will be the person they listen to and they will not look at their medical files on you to see who is responsible. The family member may not be the person trusted by you and the one to carry out your wishes. Most often if the person present will agree with the proposals of the doctor (often the most expensive) this will be the course of action. They will not pay attention to “do not resuscitate” (DNR) orders or other orders that may be on file. This applies to doctors, hospitals, and especially nursing homes or long-term care facilities.

Hospitals and nursing homes want to keep the beds full and if they are and know they have people waiting for admission, they might obey DNR orders. Financial decisions are the rules applied and they are very difficult to override. Even when the person the patient has chosen to be their decision maker is available, they will often contact other family members first hoping to bypass the advance directive or the emergency contact person. Money rules and is the driving force behind the decisions made.

I am in a real quandary as my adult children have stated they will not follow my wishes and my wife will not talk about death. I have finally asked two friends if they would serve in that capacity. Both have agreed and I have arrived at a plan that may serve my wishes. The doctors are not happy with my plan and have asked for the names of my family so that they may be contacted. I have carefully not given them out and only given out the names of my two friends. It is unfortunate that my wife works for the local hospital and will possibly have influence in the final decisions. This is because Medicare requires the ambulance to take me to the local hospital first and then I can be transferred, if needed and approved, to another hospital.

The purpose of this blog is to encourage people to talk about death with their family and make sure everyone agrees with your wishes. This is often not an easy task for everyone as many family members just are not ready to talk about the future. It is better to do this while you are at your full faculties and your decisions cannot be disputed, or are less likely to be contested.

October 1, 2014

Suggestions for ADA

I am sure all of us could all come up with favorites for the American Diabetes Association to do, but being a group by and for doctors, I doubt we will see changes that we wish would happen.

I have seen several bloggers use the term “Stage 1” to mean prediabetes and “Stage 2” for type 2 diabetes. Yet none go as far as Brenda Bell did in her Tuesday, April 20, 2010 blog. I have lifted this from her blog and thank her for this, even though I did not appreciate it at the time. While I am at it, I sincerely wish she would do more blogging, as she was often enlightening before other bloggers even thought about it.

Quote: An initial straw man chart can be derived from the American Association of Clinical Endrocrinologists' Medical Guidelines for Clinical Practice for the Management of Diabetes Mellitus (2007) examples for initial pharmacotherapy of T2DM:

Classification of Type 2 Diabetes Mellitus (based on initial therapy algorithms)
Progression Level
HbA1c (untreated)
Stage 1 (Prediabetes)
5.7 - 6.4
Stage 2
6.5 - 7.0
Stage 3
7.0 - 8.0
Stage 4
8.0 - 10.0
Stage 5
> 10.0

Other issues that play into determining the progression of T2DM include the deterioration of endogenous insulin production, the development of complications of diabetes, and the degree to which a person's blood glucose levels and HbA1c are responsive to pharmacotherapy. A more complex table of progression might include these in a manner such as this:

Classifications of Type 2 Diabetes Mellitus (proposed)
Effective Therapy
Evidence of
Stage 1 (Pre-Diabetes)2
< 6.03
ILM. Oral medication optional for aggressive treatment.
Stage 2
< 6.5
Oral medication and/or insulin sensitizer required
Stage 3
< 7.0
Combination therapy and/or insulin required
possible comorbid conditions
Stage 4
< 7.0
Insulin therapy required, with or without oral medications and/or pramlintide (Symlin)
possible comorbid conditions
Stage 5
< 8.0
Intensive insulin therapy required, possibly in conjunction with insulin sensitizers
obvious; one or more
comorbid conditions

1 While the HbA1c goals at the more advanced levels of diabetes progression are high enough that complications are likely to develop or intensify, those goals may not be realistically achievable with current medical and pharmaceutical technology.

2 Includes all previous diagnoses of gestational diabetes or Type 2 diabetes in which pharmacotherapy is not currently indicated

3 More aggressive practitioners may argue for an HbA1c goal of under 5.5 for Stage 1, under 6.0 for Stage 2, and under 6.5 for later stages of T2DM. The less-aggressive goals are informed in part by the (ACCORD) study, in which the tested combination therapy suggested a higher mortality risk for intensive control.

A classification scheme of this sort may remove the ambiguity of a diagnosis of "prediabetes" and its associated laissez-faire ("It's not diabetes") attitude, as well as the popular belief that once diagnosed, one can become "undiagnosed" (or perhaps "de-diagnosed"). It can also alert a medical practitioner to the need for ongoing monitoring and assessment of a person's glucose metabolism. On the other hand, classification will add to the pool of people indicated to have diabetes those who do not consider themselves to be currently affected by diabetes -- and in an environment where a positive diagnosis can mean the denial of employment, medical insurance, or healthcare, this can have worse repercussions than living with undiagnosed or untreated Stage 1 (or even Stage 2) T2DM. Unquote

The above quoted information is the most comprehensive that I have seen and I wish the ADA would give this consideration.

September 30, 2014

Change May Be Coming for Prediabetes

Yes, it may still be a few years in the future, but if researchers continue to make their voices heard, the American Diabetes Association (ADA) may feel the pressure. At present, the ADA has not given much attention to prediabetes and the term has caused most doctors to ignore prediabetes since it has no real official status. Even the medical insurance industry gives it no support.

I will quote the lead-in to the Science Daily article as it expresses what needs to be said about prediabetes.

Treating patients with prediabetes as if they had diabetes could help prevent or delay the most severe complications associated with this chronic disease, experts say. The researchers say that by not devising a treatment strategy for people with prediabetes, doctors run the risk of creating a pool of future patients with high blood sugar who then become more likely to develop serious complications, such as kidney disease, blindness, amputations, and heart disease.”

It seems that most doctors want to create a pool of future patients with high blood glucose levels. This may be the reason for the ADA not classifying prediabetes as diabetes and making it an official part of diabetes classification types. The term needs to go and be renamed, as outlined in my previous blog, Suggestions for ADA, but with more researchers recognizing the need, something may be done in the future and hopefully the near future.

According to the study authors, evidence comes from clinical trials where lifestyle change and/or glucose-lowering medications decreased the progression from prediabetes to type 2 diabetes. After leaving the interventions, the development of diabetes remained less in people who changed their lifestyle and/or took medications compared to the control group of prediabetes patients who did not have interventions.

The study authors say, “First, adults should be screened systematically to find prediabetes and early type 2 diabetes. And second, patients who are likely to benefit from treatment should have management aimed to keep their blood glucose levels as close to normal as possible.”

Lead author of the editorial, Lawrence Phillips, MD, from Emory University said, "Diabetes is generally diagnosed and first treated about ten years later than it could be. We waste this critical opportunity to slow disease progression and the development of complications. There is a strong, new argument that by combining screening to find prediabetes and early diabetes, along with management aimed to keep glucose levels as close to normal as possible, we can change the natural history of the disease and improve the lives of our patients."

Note: I will have another blog about the other side of diabetes which is not favorable for anything but more speculation. Hopefully, it will be ready next week.

September 29, 2014

Correspondence after the ADA Blog

I was expecting the harsh emails telling me that I should not be saying the points I made and that the American Diabetes Association had their guidelines for a reason. The emails are now almost 2 to 1 in favor of my points. Most are people with diabetes, but two are doctors. One doctor did chide for my saying one-size-does-not-fit-all, but explained that there does need to be a starting point on which to base a line of treatment.

Then she said that she agreed with me about assessing each individual and their desires and abilities for diabetes management. Dr. Sharon (not her real name) went on to explain that she normally has a printout of valuable websites for her patients to visit and a few pages of information that she has written for them to read. She does email this information to those that give her an email address. Then she schedules them of a second appointment within two weeks from giving them a diagnosis. Before she lets them leave from the diagnosis appointments, she has several blood samples taken to make sure that when they have the second appointment that she has the correct diagnosis, type1, type 2, or possibly LADA.

Being in a very rural area, she is happy that many of her patients do have internet access and she uses some emails and video conferencing since the insurance companies do reimburse for the video conferencing. For Medicare, she has to pay a nurse practitioner to be present, but by sharing a nurse practitioner with other doctors, this is not a problem. I was pleasantly surprised about the number of doctors that are cooperating to provide a wide range of services for patients.

What Dr. Sharon told me next was a shock. She said that the doctors cooperate by sharing offices and using their internet facilities to provide video conferencing for patients they don't serve, to prevent long trips for the patients. She said this networking has made for happier patients.

Back to the diabetes side. Dr. Sharon said that she is the only doctor among them serving patients with diabetes. The doctors in the network all provide services for each other with the responsible doctor receiving the lab results and sometimes the doctors confer among each other when a diagnosis is questionable.

She commented that she only has three patients that have A1cs over 7.5% and they are in a care facility and are frail patients. She said that even she is surprised with the number of patients that are maintaining A1cs near or below 6.0%. If and when she uses video conferencing with me, I may have more to write. Because of state line issues, I will not become a patient of her office.

September 28, 2014

Diabetes Self-Management Education Needs

I have a difficult time understanding the logic behind not educating people with diabetes the basics of Diabetes Self-Management (DSME). If the people responsible for this education are not equipped for this, then they need to teach the basics of Self-Monitoring of Blood Glucose (SMBG).

My cousin that is a nutritionist has asked me quite a few questions lately because she has been working with several other communities needing nutritional assistance. In one community, they had her there for a program with a certified diabetes educator and people were up in arms after the CDE left. She had been present for most of her program and wondered how someone with that much education could not teach, but only offer mandates and dogma.

In the question and answer part after the CDE talk, several had asked questions about sleep apnea and were told that she did not feel qualified to answer any questions about sleep apnea. The questions then turned to questions about what the different blood glucose readings were telling them about the food they were eating and my cousin said she could not believe that she evaded those questions and answered with mandates.

The last question the CDE was asked was about how to avoid depression and diabetes burnout. She started gathering her papers together while telling the people to talk about this with a psychologist. Then she promptly left.

My cousin said that many were hostile at that point, but she waited until she was introduced and said that if the group were interested, she would contact some people and ask if they would be willing to talk to the group about sleep apnea and depression and diabetes burnout. She said she would try to answer some of the questions about blood glucose testing during her presentation. She told the group that she knew of another group that could probably answer a lot of questions, but they would not be trained, as the CDE should have been.

She said her presentation should have been for 45 minutes, but lasted for about an hour and thirty minutes. They had many questions and asked some that she could not answer, but did give her a round of applause when she opened it up for questions and answers. She said nutrition was her specialty and that she was aware of diabetes only because a cousin had it and she had worked with most of our group on their daily nutrition.

The doctor advising that group had stated that he could find someone to talk about sleep apnea and depression, but the group needed more on diabetes management and equipment use. She warned me that she had given out my blog and several had pulled it up and may be sending emails with questions. I told her the doctor had already contacted me and asked for several of our group to speak at their November meeting. I said Tim had also received a call with the same request.

I asked her if she would be available to introduce us and answer more questions. Then I asked her if she was familiar with ketone meters. My cousin laughed and said she could guess why as people on low-carb/high-fat diets should use one if they are interested in maintaining a ketogenic diet. She said she has two of the three meters recommended by most of the medical insurance companies in our state. I said I would be asking for the medical insurance companies served by most of the group she had met.

I said this will be difficult, as most insurance companies will hesitate to reimburse for these, but will for some cases. She agreed and said she would talk directly to the doctor. Tim arrive then and we talked for another hour planning what we could talk about and who would be best for each part. We have more emails to send to the doctor asking questions. We agreed that as things came together for an outline that this should be sent to all the members of this group. Now the work begins.