December 13, 2014
On Tuesday, Allen called and asked if I had time to help the newest member to join, Albert, as he had an A1c that was much higher than he had anticipated. Allen asked me to stop by his place and we would go to Albert's apartment. When we arrived, we parked behind his car and as we passed Albert's car, we could see a meter and test strip container lying on the passenger seat. I commented that I could already see problems. Allen then looked and said he hoped not that.
When we were greeted at the apartment door, Albert invited us in and after we were in the kitchen, I could see other potential problems. A meter was lying on the counter and another meter was lying on a kitchen stool. I asked how many meters he had. He said seven that he uses and a few others he has lost. He said they were all the same meter brand and he didn't need to worry about test strips that way. None of the meters was in a case and the test strip containers were setting around the kitchen.
Allen suggested we talk about his meters and where he was storing them. After Allen explained that he had some serious concerns about the accuracy of the equipment, Albert asked why. I explained that the kitchen was not the best place to keep the containers of test strips and that applied to the bathroom as well. Albert then showed us the bathroom where there was another meter and two containers of test strips setting on the counter next to the sink.
I asked Albert to select the bathroom meter and one container of test strips and then when we were back in the kitchen, to select another set. Then we adjourned to the living room and we asked Albert to test with each meter and a test strip. Allen and I both had our meter and test strip and we took them out. We used an alcohol pad to clean the lancing device and put new lancets in the device. When Albert was ready, we asked him to test using each meter.
Before he tested, Allen and I asked when he had last eaten and he said about three hours earlier. Allen said he would use his meter and test him first. After Allen had tested him, the reading was 184 mg/dl. I then used my meter and the result was 182 mg/dl. Albert then set his up and tested with the bathroom meter and the reading was 116 mg/dl and the reading from the kitchen meter was 102 mg/dl. Albert asked to look at our meters and when he saw that they were the same, he asked why our meters were so much higher than his were.
Allen nodded at me and I said because our meters are kept in the case when not in use and not laying around catching dust and lint. Allen then said we also keep our test strip container in the case along with the lancet and lancing device. This minimizes the dust and lint from getting in the meter and keeps our test strip container protected. I continued that with the test strip containers setting around and in high moisture areas, which was probably why he was not getting near accurate blood glucose readings. I said that I keep all of my test strip containers in a zip-lock bag in a room that is fairly dry and not receiving direct sunlight. Plus this, I cover the bag with a dark washcloth to protect them.
Allen asked where he had obtained the meters and test strips and Albert said from the supply outlet that Medicare had told him to use. I had never heard of the meter brand and Allen had not either. We told Albert to attempt to obtain a test solution to be able to check his test strips, but added that he may have no luck in obtaining the test strip solution.
Allen then stated that the test strips were probably all unreliable and his meters not being properly protected could also be adding to the problem of his blood glucose readings being low and his A1c much higher. I asked Albert if he used the meter and test strips we saw in the car. He answered yes when he feels low. I stated that both the meter and test strips had temperature ranges for storage and use and keeping them in the car during the summer and winter and in direct sunlight would make both unreliable and basically unusable.
Next, I asked if he had read the instructions that came with his meter and the instructions that were in the box with his test strip container. He said he had never read them. We asked if he had any of the instructions around and he said he always takes the test strip container out of the box and throws any papers away as soon as he receives them in the mail.
Allen and I just looked at each other and shook our heads. We knew we had some educating to perform and soon. We asked when he would receive this next order and he said after the first of the year on the day following New Year's or on Saturday. Allen emphasized to him that he should not open all the test strip boxes immediately and if he needed to open one, to keep the instructions and read it. I asked if he would be receiving a new meter then and he said no, but he would in the July order of next year.
We said we would talk after he received his new supply and cover the proper use of the meter and test strips. Allen told him that he had an extra case for the meter and test strips and he would give him one if he would use it and not leave everything lying around and exposed to the elements. Since he was on metformin, we did not understand why he would feel a low since metformin did not cause them. He may have a false low when his blood glucose dropped quickly, but with his meter and test strips being stored where they could freeze, they would not be reliable. He said if he would carry the case next to his body when outside, he would supply him with a case he could use if he would promise to use it. Allen said he would see him the next day and we left.
December 12, 2014
Yes, this last year was a great year for me, but I am asking my readers for assistance in locating other type 2 bloggers. I have found several new and some not so new type 2 diabetes bloggers. I have some more bloggers being posted on January 2, 2105. If you know a type 2 blogger, please send me an email with the internet address (URL) so that I can check them out and post them on a quarterly basis to those that are already posted. My email address is on my profile page, or you may post the information in a comment to this blog.
I have several bloggers from other countries, but I know there are more. The only qualification I am asking is that they have type 2 diabetes and are blogging about type 2 diabetes. I will include other writers, especially doctors that write about diabetes, but do not have diabetes themselves. I am cautious about some that are only advertising services for type 2 diabetes and I refuse to promote consulting and other businesses aimed at people with diabetes.
Forget about those promoting snake oil and a diabetes cure, as I will not list them. Likewise, I have an objection to those writers' that are promoting promises of a reversal of type 2 diabetes or prediabetes. It is possible for people with type 2 diabetes to avoid medication or start with medication and by changing lifestyles have been able to get off of all diabetes medications. Some are able to stay off for several years and others for a few decades.
I will not list people that have not blogged or more than 12 months. If they have restarted and have blogged for two or more months, then they are eligible to be listed.
I will be listing several blog sources that include both type 1 and type 2 bloggers, but both types are worth reading and it is easier to list the site and not pull out the type 2 only bloggers.
December 11, 2014
In several articles lately, the elderly have been shown to be on the short end and not receiving the care they may need. This is not a simple problem or a problem with easy answers. Report lead author Alicia I. Arbaje, M.D., M.P.H., director of transitional care research and assistant professor of medicine at Johns Hopkins Bayview Medical Center and the Johns Hopkins University School of Medicine said that what is believed to be the first interview-style qualitative study of its kind among health care providers in the trenches, displays very real problems.
A team led by a Johns Hopkins geriatrician has further documented barriers to better care of older adults as they are transferred from hospital to rehabilitation center to home, and too often back again. They used comments and concerns drawn from in-depth interviews of 18 physicians and two home health care agency administrators to create a framework for evaluating what actions and programs might improve care.
The research says:
- more attention should be given to preventing drug errors or missed doses of medicine
- earlier and more frequent communications among health care providers at different sites
- the elimination of discharge planning delays
- and patient education.
The Affordable Care Act of 2010 established a pay-for-performance financial incentive program to motivate better coordination. The study results suggest, however, that health care providers are unclear about how these incentives will be designed and are concerned that the wrong outcomes or processes will be measured.
Currently, health care providers have concerns about pay for performance that need to be considered. They desire a voice in the design process. Yea for them, but if this is the case, then patients should also have a voice as many health care providers do not have the desires and needs of the elderly patients in mind. The evidence of the current lack of concern by health care providers provides ample reason to include patients, patient advocates, and social workers in the mix of voices. This would be one way to avoid the same mistakes being currently carried on by our providers.
“In their report on their work, “Excellence in Transitional Care of Older Adults and Pay-for-Performance: Perspectives of Health Care Professionals,” published in the December 2014 issue of The Joint Commission Journal on Quality and Patient Safety, the investigators note the persistent “mixed reviews” of the impact of tying compensation to quality of care. They also say that care transitions across health care settings remain “common, complicated, costly, and potentially hazardous for older adults.” As the ranks of older adults grow and their numerous illnesses require ever more drugs, specialists and facilities, poor transitional care frequently leads to re-hospitalizations and complications for patients.”
The research team uncovered three themes that addressed pay for performance:
- components and markers of effective care transitions,
- difficulties in design and implementation of pay-for-performance strategies,
- and unmet needs in delivering optimal care during transitions.
The research findings suggest ways to better define health care providers’ roles in care transitions:
- enhance communication,
- determine performance measurements,
- and improve education and training of providers.
Among the recommendations in the framework are calls for holding health care providers:
- more accountable for patient education,
- reimbursing providers for care coordination activities,
- and providing training and hands-on experience for providers to facilitate care transitions.
Report lead author Arbaje explains that, “Health care providers may need additional training to better execute care transitions and to understand their role during transitions. Without this education, it is difficult to design pay-for-performance strategies with an end result of good patient care.”
December 10, 2014
At least this is slightly a more balanced approach with both sides having realistic projections. I will only say that I agree that there will be a doctor shortage, but maybe not primary care doctors, as least as big as is being projected.
The shortage will be severe in geriatric doctors. These are the doctors that will be needed to care for the baby boomers that are increasing every day. Geriatric means, pertaining to elderly persons or the aging process. Primary care doctors are not qualified to handle geriatric medicine, especially those with multiple diseases or chronic conditions. Some will be needed for those with single conditions, but geriatric doctors should be in charge of these patients. Read this article in WebMD as they present their points.
Many medical groups, led by the Association of American Medical Colleges say they think the shortage will be close to 130,000 in the next 10 to 12 years. It is the health care economists that are less convinced. They say that concerns that the nation faces a looming physician shortage, particularly in the primary care specialties, are common. An expert panel of the Institute of Medicine (IOM) wrote in a report that the committee did not find credible supporting evidence of a severe physician shortage.
As many as 10,000 baby boomers are becoming eligible for Medicare every day. And older people tend to have more medical needs. Everyone thinks that the Affordable Care Act (ACA) is creating millions of patients, but they may soon see that the ACA is driving millions of patients away from coverage and doctors. There are more of these predictions every day and one radio program that I listen to sporadically has callers that are complaining about not being able to afford the new Obamacare insurance with the high premiums and high deductibles.
I can agree there will be a mismatch but maybe not in the doctors needed, but in the location of these doctors. New doctors seem to cluster in the northeastern part of our country and in or near the larger cities. The medical associations or doctor organizations are crying for more primary care physicians, but they are crying for the wrong doctors. Doctors of geriatrics will be needed for the aging population and not primary care doctors. Yet, the medical associations don't see it that way.
Many primary care doctors cannot take care of complex elder patients and handle the combinations of chronic conditions they are likely to have. Some of the larger medical practices may have doctors or specialists to care for them, but most in smaller and rural communities will be ill trained and equipped to handle these patients.
In some geographical locations, many services can be provided by primary care doctors, but in other locations, physician assistants, nurse practitioners, and even pharmacists and social workers will need to be included in the mix. .
Currently, physicians who are specialists make considerably more than those who practice primary care, which many experts say is a huge deterrent to doctors becoming generalists, particularly when they have large medical school loans to pay off. However, “team-based care,” where a physician oversees a group of health professionals, is considered by many to be not only more cost-effective, but also a way to lower the number of doctors the nation needs to train.
What may happen in the future is unclear with doctors and economists making their predictions. Some areas of the country will be well served and the seniors well taken care of medically. It is the rural areas that I am concerned about where there will be single practitioners serving the Medicare patients. Traveling over 150 miles to see a doctor may not be possible. Until telemedicine is authorized and the rural states have internet connections for everyone, seniors may actually be in danger of being harmed.
December 9, 2014
This blog by Professor Jennie Brand-Miller talks about what we really need on food labels to help us make better choices. I will do my best to comment on her ideas as she does have some important information. Before getting to that, I would like to discuss the US food labeling system.
The current revised food labels used on foods still allows for a 20 percent error margin and the processing companies and food manufacturers do not have to test their products as often. I can almost bet that some merchandise is outside of the 20 percent error margin because of the time of harvest, the farm where grown, and how the food was raised. Food that is raised on poor soils will not be as nutritious as food from fertile farmland. Then we have the chemicals used to keep insects down and herbicides used (including GMOs). Food that includes GMOs are said to be safe, but research is not up to date and is being challenged at various levels.
For manufactured foods, scales go a long way in helping meet the 20 percent error margin. This still does not guarantee that the 20 percent error margin is met 100 percent of the time, but they are higher in accuracy than for most raised foods.
The following are just a few of the considerations that need to be made:
- The energy content (calories) of a food is not the best way to judge a food – lentils and liquorice have the same energy density.
- The fat content of food is not the best way to judge a food – nuts have more fat and are more energy dense than French fries.
- The sugar content is not the best way to judge a food – dried fruit is full of sugar.
- The sodium content is not the best way to judge a food – soft drinks are low in sodium.
These are just a few of the considerations we need to determine our individual food plan. This is one reason many of us encourage each person with diabetes to develop your own food plan.
Some people need to consider the following when developing their food plan. Yes, you need to read the labels on all foods to have some idea of the nutrients and the amount your are consuming. You also need to use your meter to help you develop your food plan. Some ideas that you need to consider include:
- Do you need to reduce the number of carbohydrates you consume?
- Do you need to increase the amount of fat in your food plan?
- Do you need to increase the amount of protein in your food plan?
The next thing I have to question as a person with diabetes is most of the food plans seem to be for the healthy person and not for people with diabetes. Authors seldom suggest that people with diabetes use their blood glucose meters before and after eating to learn if what they consume is causing their blood glucose levels to spike at levels that are too high to manage.
Brand-Miller says many ignore micronutrients – vitamins, minerals and phytochemicals. She continues they ignore two important proven attributes of foods in the new nutrition – the protein content and the GI of the carbohydrates. While those of us with diabetes need to restrict our intake of carbohydrates, this is not mentioned. Brand-Miller sidesteps the fat consumption that is essential for our satiety and helps reduce our appetite. She says carbohydrates and protein are proven to help to curb appetite. Then she says appetite matters. Appetite is what drives our energy intake. I says this is what causes our weight gain.
Professor Jennie Brand-Miller concludes this way - “What would I like to see on food labels? I’d like to see a system that:
Professor Jennie Brand-Miller concludes this way - “What would I like to see on food labels? I’d like to see a system that:
- Focuses on the positive.
- Rates foods according to their contribution to desirable macronutrient and micronutrient intakes.
- Uses Adam Drewnowski’s Nutrient Rich Foods Index, which rates individual foods based on their overall nutritional value, as an essential component.
- Encourages higher protein intake, particularly from legumes.
- Distinguishes between naturally-occurring and added sugars.
I would advocate that we make the most of something we already have available to use on our food packaging here in Australia and that is proven to work: two certified and recognizable symbols that are signposts to both healthy foods and healthy diets.”
I think in the United States, we need a slightly different system, but with the USDA dietary guidelines not being part of it.
I think in the United States, we need a slightly different system, but with the USDA dietary guidelines not being part of it.
December 8, 2014
I have blogged about carbohydrates (and that is natural for those of us with type 2 diabetes) because we need to reduce the number of carbohydrates we consume. I have also blogged about fat because we now know that fat is not bad for us like many doctors want us to believe that follow the teaching of Ancel Keys who has been proven wrong. Many are having better test result for cholesterol when eating more fat.
Now we are hearing about the third macronutrient, protein. Yes, most grocery stores have more foods advertised as being high protein. Although protein has, until recently, kept a low profile compared to fat and carbohydrates, it’s always been a major player in the body. Present in every cell, proteins act as building blocks for all types of tissue. Foods naturally high in protein, such as meat, poultry, fish, beans, eggs, nuts, and seeds, also tend to be high in other important nutrients.
Some writers want to label high protein a fad, and others are saying protein is needed for the building blocks in our body. While the latter is true, high quantities of protein can have adverse effects on our body, especially for those that have renal weakness. When a writer says there are a lot of perceived health benefits to consuming more protein, remember that the meaning of perceived means - to recognize, discern, envision, or understand.
Three-quarters of U.S. consumers agree that protein contributes to a healthy diet, and more than half say they want to eat more of it. The study found that nearly half of the primary grocery shoppers in a household have bought protein-enriched foods. Americans are looking for protein to aid in satiety, weight management, boost muscle recovery, and build muscle after a workout
The U.S. is by far the world’s biggest market for high-protein products. Introductions of foods and drinks making a high-protein claim in 2012 were almost triple that of any other country. And yet, according to the most recent available data, Americans aren’t exactly pigging out on protein.
They really don’t have to, according to the government’s 2010 Dietary Guidelines, to be updated late next year. The guidelines, issued jointly by the U.S. Department of Agriculture and the Department of Health and Human Services, give plenty of leeway when it comes to protein, recommending that adults over age 18 get 10% to 35% of their daily calories from the nutrient. Nobody’s anywhere near the 35%, says Trish Britten, PhD, a USDA nutritionist. As a population, we are at 15.5%. And the top 5% of protein-eaters get only 19.6% of their calories from the nutrient, Britten says.
The USDA recently began calculating Americans’ usual intake of protein, so information about trends over time isn’t yet available. But if saturated fat consumption is any indication, change occurs very slowly. The USDA has been tracking saturated fat as a percent of calories forever. So despite the growing popularity of protein-added products, it’s doubtful that Americans are eating much more than they were before it was all the rage.
Frank Hu, MD, PhD, MPH, a professor of nutrition and epidemiology at Harvard says, “The current American diet contains too much refined carbohydrates. I think it’s a good idea to replace at least some of the refined carbs and added sugars with healthy sources of proteins, such as nuts, legumes, no-fat dairy products. In other words, trading a nutty chocolate bar for a handful of nuts might not be a bad idea.”
Dr. Hu continues, “If you’re engaged in a high level of physical activity, particularly resistance training, you probably need more protein than the average individual, perhaps as much as 20% to 25% of your calories.” Dr. Hu concludes by saying, “We don’t know how high is too high, although, given the USDA data, few Americans are anywhere near the upper limit of the government’s Dietary Guidelines. If you want to increase your protein, cut back on less-nutritious foods such as simple carbs.”
Yoni Freedhoff, MD, an assistant professor of family medicine at the University of Ottawa, made this statement, "Unless you have pre-existing kidney problems I have no concerns about people eating large amounts of protein.”
The last statement is the concern you should have before jumping on the protein bandwagon. If necessary, have a talk with your doctor and find out if there are problems or if he needs to do some tests. Let the doctor know that you are interested in increasing the amount of protein in your diet. This will let the doctor know that he needs to make sure that you will not have problems with increased protein.
December 7, 2014
Our December 6 meeting was somewhat different than most meetings. We welcomed two additional members bringing our total to 33 members. The topic of goals was our discussion for the meeting and Max and I were the leaders.
What are reasonable goals for a person with type 2 diabetes? This is a topic that has bothered me for the last few months. In our support group, we all have different goals and most seem satisfied with their goals. Do we always achieve our goals? Not even all of us achieve our goals every time we see our doctor, but for the most part, as a group we don't miss by a lot. While the average age varies every time we add to the group, the majority are now over the age of 61. However, this does not establish goals for anyone.
The first thing I want to emphasize is that there are no standard answers or rules. I did remind everyone of the rules in this blog. We all strive to maintain certain limits that we can live with or tolerate. We all agree to attempt to keep our A1c's under 6.5% and lower if possible. We have all stated that we need to keep our lipid levels in range, if possible, but we seldom discuss this part of our lives. We have also agreed that our goals are ours and not for anyone else to follow. It happens that several of us have very similar goals and we probably talk about this more than the rest. At present, none of us is limited cognitively and this is something we have agreed among ourselves to maintain a link to watch for any cognitive problems. Diabetes and cognition are two of the factors that have bound us more tightly as a group because we care about each other as individuals.
Even as individuals, it has been enlightening how we set our goals. With the current number of thirty-three members and twenty-one of us being on insulin, there is quite a bit of similarity among us. Sue is still off all medications and she is happy that we support her with her goals. She wants to keep her A1c as close to 5.5% or under if possible. Even her husband is surprised at her success as her last A1c was 5.2%. She was the youngster in our group and we did tease her about this. She replies that if the old fogies would learn from her, we could be a lot healthier.
With the A1c range for people without diabetes (normal range) according the Joslin's Diabetes Deskbook being from 4.0% to 6.0%, we have to remember that prediabetes is defined from 5.7% to 6.4%. Prediabetes is another topic that many wish would be labeled as diabetes. Because A1c values do vary quarterly, some are suggesting that we should check the A1c values monthly. For more information on this, please read this blog by David Mendosa. We used David's blog for discussion about this.
With this in mind, here are some goals for people to look at as possible goals they should consider as their own. Therefore, select realistic goals and work toward them.
Of the twenty-one members on insulin, our A1cs range from 5.2% to 6.5%, as of the latest A1c values. Some of us have the same A1c and don't get too concerned since this should be expected. Max and I are the only two that occasionally exceed 6.5% and then we have to work very diligently to make sure we get below 6.5% on the next A1c. Those on oral meds had a greater variance and are still learning to manage their diabetes after learning more on management.
We are all careful to avoid hypoglycemia and three of the individuals have never had hypoglycemia. Since I have been on insulin the longest, by about two years, I have had the most incidents of this. On several occasions, I knew as soon as I put down the syringe that I was going to need to be aware of and prevent this from happening. On two occasions, I accidentally injected my short-term insulin in the same area as the long-term injection. I stayed up late both nights and fortunately had enough test strips and glucose tablets to stay out of trouble and only get to the lower 60's for blood glucose levels.
I have had eight readings below 70 mg/dl in the ten years on insulin and the next person has had only five readings below 70. Then the numbers go to three and two. Several of the group tries to constantly remain under 125 mg/dl and above 80 mg/dl and have been very successful at it.
We are all fortunate to have the test strips we need or be able to afford more if insurance limits us. Thirteen of us do obtain our diabetes supplies and medications from the veteran’s administration (VA) and are thankful for that. Our testing supplies are very much what we need, and we make use of them.
We are now close to 2015 and have now added sixteen additional members that are very happy to have us helping them. Brenda and Sue are probably the most pleased, as six of them are women and are happy to have others to talk with. Of the eight, four are on insulin and three are on oral medications, with Sue on no medications. The ones new to the group were very curious as to why so many of us were on insulin. Brenda was happy to say “Greater ease of management.” Many questions were answered about multiple daily injections and testing. They were surprised at our relaxed attitude about this and that fact that most of us did not think anything about the extra testing and multiple injections.
They were all surprised that we used our arms and different parts of our bodies for injecting insulin. They were very interested in why and Brenda was happy to answer that we needed to prevent insulin absorption and utilization problems and avoid creating scar tissue under our skin. This in turn would affect the insulin utilization and cause insulin waste if scar tissue caused the insulin not to disperse from the injection site. Some may escape, but not the full amount injected.
Then the question was asked about alternate site testing. We all stated that we used our fingers and not alternate sites because we wanted the “now” reading for accurate correction data and needed to know this. If we were going up or down was also mentioned. Then Tim said that for those on oral medications other than sulfonylureas, alternate site testing would work if their readings were fairly consistent.
The meeting ended and there was some intense discussion.