More on Importance of Vitamins B12 and D3

This topic is still being debated and I have had several of our new members on metformin say they don't believe they have a vitamin B12 problem. Of the seven new members that are using the VA, only two are on metformin and the rest are using insulin. On Thursday of last week, two members, Julie and Earl received their lab results and both were prescribed vitamin B12. Both have been on metformin for almost seven years. This was the reason for a few of us meeting at the restaurant to discuss what they had learned. Brenda, Allen, and I were there plus the two mentioned above.

When asked, Julie said her results were severe and she had received a shot and needed to see her primary care doctor for a second shot. Earl said he was low and the VA doctor had advised him to start on vitamin B12 immediately. Allen asked Julie if she was experiencing pain in her in her feet. She would not answer and Brenda told her that she could not hide this as Allen had been through this and we know what happens with severe vitamin B12 deficiency. She finally admitted that she was having pain in her feet and Allen said it was diabetic neuropathy. Earl said he was beginning to have minor pain in a couple of toes. Allen said that the quicker he worked to maximize his blood glucose management, the quicker the pain would possibly go away, and taking vitamin B12 is part of his diabetes management.

Brenda said this would be added to the program for January 10. Allen said good, as too many have been saying that they are having pain and will not let the doctor test them for vitamin B12 deficiency. Brenda said she has been hearing the same and she has been wondering why people will not do what is right.

Brenda then asked Allen and me if it would be correct to ask for a show of hands on how many had been tested for vitamin B12. I said the question needs to be asked and the other question that should be asked first is if anyone has a burning sensation in their feet or something that feels like a thousand pins sticking them. Allen agreed and said to ask the second question first and many will not associate their neuropathy with vitamin B12 deficiency. Then we will know who needs to be tested.

I then asked both Julie and Earl what their vitamin D results were. Both answered within the range, but at the low end of the range and that their doctor had advised taking a vitamin D3 supplement. I turned to Brenda and said this is another problem area everyone needs to be aware of and consider taking vitamin D3, not vitamin D2. Brenda said I remember you blogging about this and if you would send me the URL, I will review it and decide if we should use a slide.

Allen said that he was planning to present this to Brenda, but now that we had another experience with a member and she was in on it, she knew what needed to be included. Brenda said it would be nice to have Dr. Tom available, but she understood his needing to spend less time with our group. Allen said this may be a good thing and cause us to think more for ourselves as we did before.

We agreed and said things were right for the interventions and a few other things when we needed Dr. Tom, but now we needed to be on our own and work to help our members.

Updated Insulin Information and List

This will be a short blog, but important for anyone with type 2 diabetes considering insulin or already using insulin. It is important for people with type 1 diabetes.

A 27-page printable PDF includes Ultra Rapid-Acting, Rapid-Acting, Short-Acting, Intermediate-Acting, Long-Acting, and Pre-Mixed or Combination Insulins. Detailed information on these insulins includes: Indications, Pharmacology, Dosage and Administration, Adverse Effects, and Precautions and Contraindications. These discussions are near complete with many precautions and contraindications which many lists do not have.

The listing for Humulin 50/50 which has not been available since 2010 has been deleted.

Since insulin should not be considered the medication of last resort, please take time to download the PDF file and keep it for handy reference.

I recently had a contentious discussion with a doctor that insisted that since I was on insulin that I should change from Novolog (a rapid-acting insulin) to Afrezza (an ultra rapid-acting insulin). I asked how I would know how much insulin I would inhale for the carbohydrates I would be consuming. When he stated through trial and error, I said my health was too important and with my insulin resistance, there was no way I would be a guinea pig for him. I concluded that I liked the diabetes management that I had and would not change. That ended the discussion, but he asked me to consider it as I left.

Use the above link or a two-step link from this link.

Diabetes Self-management Education Not being Utilized

I am not surprised that diabetes self-management education is underused or not utilized at the level many educators think it is. To begin with; there are too few certified diabetes educators (CDEs). As explained in my blog here, most are located in or near large populations and in the Washington DC to Boston corridor (Northeast Corridor). Out here in the hinterland, we occasionally have a CDE, but most are not reliable.

Our diabetes support group has discussed this among ourselves and now with the new members, we are getting many questions asking if they should make use of the classes. We are trying not to be negative, but one of the new members, Rose, did attend a class this week and is scheduled for one more class next week. She called Brenda and started asking questions and wondering if she should even go to the next class.

Brenda called Tim and me to come to her place and when we were there, she had Rose explain what had happened. Rose put the business card on the table where we could look at it. Both Tim and I noticed that the title was RD (registered dietitian) and CDE. I brought this to Rose's attention and Brenda agreed this could be the reason why Rose was not pleased. Tim asked her if most of the class was on food and Rose said that was why she was unhappy as very little was taught about self-management of diabetes. Rose said that was why she had asked for the class – to learn more about managing her diabetes since she was on insulin.

Tim asked if there were others in her class and how many. Rose said there were three others and all were not happy about the amount of time spent on food and the number of carbohydrates they were told to eat and the heavy promotion of whole grains. She said that two of those present people with type 1 diabetes and could not eat gluten. Rose said the person ignored that and emphasized that they would be missing a lot of nutrients by leaving whole grains out of their meal plans.

Tim asked Rose to think about returning to the class and she said she would not stay unless the person stuck to teaching about managing diabetes. She would go, but would leave if it was all about food. Tim thanked her, and then asked if Brenda would be opposed to adding this to our meeting on the tenth of January. Brenda said that was a good idea in case the class was about food. I told Tim that I knew a nurse that was knowledgeable about diabetes and she could present something. Rose said anything would be better than the class she had. Tim said to call her and see what was possible.

Then Tim said he would talk to Allen and Jason and see if they would like to do a presentation on this topic. Brenda spoke up and said she would like to work with Jason for the topic. Tim said for her to go ahead and we would not need the nurse then. He said that the evening could be long and Rose said that with the topic of testing and self-managing of diabetes, it would be interesting for her.

Tim thanked Brenda for asking to do the presentation. Brenda said it was time she started to give back and she would like this topic. She asked Rose to be available and think about questions she had and then write them down. Tim said that once he knew Jason was willing, he would send an email to everyone for questions they might have on the topic. He would ask them to send the questions to him for forwarding to Brenda and Jason.

Tim and I left then and Tim asked how well I knew the nurse. I said she is a second cousin and on the surgery staff of a nearby hospital. Tim said we would probably have her and the cousin that is a nutritionist for the February meeting. Tim asked me to call them and find out what they thought. Then give him their phone numbers so he could talk to them. Tim said we need to avoid Valentines day so that left the seventh or the twenty-first. I said either one should be okay and would say the first one so we have a second or third available if we have bad weather. Tim said good and we wished each other happy holidays and left.

Summary of Revisions – ADA 2015 Guidelines

The new 2015 American Diabetes Association Guidelines are posted. I have been checking daily for the last week and this morning (Dec 23, 2104), they were up. There are few significant changes and most are minor updates. This is not a complete list.

The “Standards of Medical Care in Diabetes—2015” should still be viewed as a single document, but it has been divided into 14 sections, each individually referenced, to highlight important topic areas and to facilitate navigation. The supplement now includes an index to help readers find information on particular topics.

The BMI (body mass index) cut point for screening overweight or obese Asian Americans for prediabetes and type 2 diabetes was changed to 23 kg/m2 (vs. 25 kg/m2) to reflect the evidence that this population is at an increased risk for diabetes at lower BMI levels relative to the general population.

The physical activity section was revised to reflect evidence that all individuals, including those with diabetes, should be encouraged to limit the amount of time they spend being sedentary by breaking up extended amounts of time (>90 minutes) spent sitting.

Due to the increasing use of e-cigarettes, the Standards were updated to make clear that e-cigarettes are not supported as an alternative to smoking or to facilitate smoking cessation.

Immunization recommendations were revised to reflect recent Centers for Disease Control and Prevention guidelines regarding PCV13 and PPSV23 vaccinations in older adults.

The next item I do not agree with, but it says - The ADA now recommends a premeal blood glucose target of 80–130 mg/dl, rather than 70–130 mg/dl, to better reflect new data comparing actual average glucose levels with A1C targets.

To provide additional guidance on the successful implementation of continuous glucose monitoring (CGM), the Standards include new recommendations on assessing a patient’s readiness for CGM and on providing ongoing CGM support. Here the ADA missed a golden opportunity to insist that the Centers for Medicare and Medicaid Services (CMS) allow and pay for continuous glucose monitors for those over the age of 65.

ADA did a good thing when they said, to better target those at high risk for foot complications, the Standards emphasize that all patients with insensate feet, foot deformities, or a history of foot ulcers have their feet examined at every visit.

This does not include all the changes and you may read the entire sections here. The 2015 ADA Guidelines Table of Contents can be accessed at this link.

Choosing and Using a Blood Glucose Meter

How would you choose a blood glucose meter? Most of us have very little choice that have insurance. If you don't have insurance, then it will depend on what you can afford. I am glad that some organizations are publishing information about choosing a blood glucose meters, but very disappointed in the lack of solid information. This information from the Mayo Clinic lacks information.

“If you have diabetes, you'll likely need a blood glucose meter to measure and display the amount of sugar (glucose) in your blood. Exercise, food, medications, stress, and other factors affect your blood glucose level. Using a blood glucose meter can help you better manage your diabetes by tracking any fluctuations in your blood glucose level.”

The above quote makes me wonder why people with diabetes get discouraged and don't test. When the Mayo Clinic staff can say, “you'll likely need” this is about the same at saying you may not need to test. They should say, “you will need.”

“Many types of blood glucose meters are available, from basic models to more-advanced meters with multiple features and options. The cost of blood glucose meters and test strips varies, as can insurance coverage. Study your options before deciding which model to buy.”

I've said this before, but it is worth repeating, knowing what your insurance will cover, may help you avoid problems. The test strips are the real cost and many forget this. If your insurance will not cover the meters with all the bells and whistles, you could be ahead of the game. Some of the considerations are:

1. If you are having eyesight problems, a meter with vocal reading of the number may be for you. If you want secrecy and not having everyone near you hearing the reading, then vocal reading of the blood glucose number is not for you.
2. If you have hearing problems, then a good screen with few distractions and proper size numbers and properly backlit may serve you well.
3. The more complicated the meter is, the less likely you will use it.
4. The more costly the test strips are, the less likely you will test.

This is one time when a doctor may be of help if he/she has the time. If the doctor doesn't take the time, a pharmacist may be the answer. Most will, but sometimes you will need to wait a few minutes for them to complete the task they are doing. 

This by the Mayo Clinic writer makes me wonder if they really know anything about testing and using the equipment. “When selecting a blood glucose meter, it can help to know the basics of how they work. To use most blood glucose meters, you first insert a test strip into the device. Then you prick a clean fingertip with a special needle (lancet) to get a drop of blood. You carefully touch the test strip to the blood and wait for a blood glucose reading to appear on the screen.”

The lancing device holds the lancet. Then the lancing device is cocked and the end with the lancet is pressed against the side of the finger near the tip and the release is pressed. This is how the lancet brings blood to the surface for the meter with the test strip to be slid up to and into the edge of the blood. The blood is wicked into the test strip and then about five seconds later, a reading appears on the meter screen.

For other information about choosing a meter, read this article by the Mayo Clinic.

Support for More Bloggers

One never knows when what a blogger writes about will give you the clue or missing piece that will help you with better management of your diabetes. That is why I am writing about other type 2 bloggers that presently write for Health Central. I generally enjoy reading their blogs even when I may disagree with a statement they make. I hope that I can enlighten you a bit about finding them and their past blogs.

I have spent time looking for other type 2 bloggers writing for Health Central, but the only three I have found and followed for several years include – David Mendosa, Gretchen Becker, and Dr. Bill Quick. I have given you information on David Mendosa so this blog will be about the other two. I have met both David and Gretchen and enjoyed my conversation with them. Dr. Bill Quick Is not one I have met, and I am not sure I ever will.

First, I would suggest joining the site and then you may select those that you wish to follow and when they post a new sharepost (as the site calls it); you will receive an email that will allow you to go directly to the post. I admit that I follow a couple of other bloggers that post fairly regular, but not many.

I admit that I often disagree with Dr. Quick and I know the reason. He is very solidly a person that believes in clinical evidence and scientific evidence from random controlled trials. Not being a person with medical training allows me to make my own observations and decisions based on my experiences. His latest blog can be found here. By clicking on his name (in blue or light blue – depending on your browser), you will be taken to his profile page. On the right side (for all posters) will be a listing of posted shareposts. Or you may use this link and then you will have a listing of shareposts and a brief description.

Gretchen's latest sharepost is here. Follow the same information above or this link for the shareposts and brief description. Enjoy reading any of the blogs and enjoy some of the humor Gretchen sprinkles in from time to time. I like the humor as some of us get too serious in our battle with diabetes and writing about it to help other people.

Gretchen's last sharepost is titled “Low-Carb Diets and Type 2 Diabetes.” It is very much appreciated by me and I have read it a couple of times just to let it sink in.

Dr. Quick's last sharepost is titled “There's Always a First Shot for People with Diabetes.” I will understand if it is something you do not want to read about as I was not happy having to do multiple daily injections of insulin, but after the first one, I was surprised that there was no pain. Yes, I occasionally hit a nerve or a small blood vessel and have some pain, but rest assured it is not that bad.

The latest on Dr. Quick says he is a type 1, but he still writes for all types.  His latest as of today Dec 22 can be found here.  It is titled "Diabetes Q&A, A day in the Life, Numbers, What to Eat."

Diabetes Q&A: A Day in the Life, Numbers, What to Eat - See more at: http://www.healthcentral.com/diabetes/c/110/173679/diabetes-normal-target-values#sthash.I5XeIkR2.dpuf

Diabetes Q&A: A Day in the Life, Numbers, What to Eat - See more at: http://www.healthcentral.com/diabetes/c/110/173679/diabetes-normal-target-values#sthash.I5XeIkR2.dpuf

Diabetes Q&A: A Day in the Life, Numbers, What to Eat - See more at: http://www.healthcentral.com/diabetes/c/110/173679/diabetes-normal-target-values#sthash.I5XeIkR2.dpuf

Holiday Greetings

To all my readers

May you have a happy holiday season

Have a Merry Christmas!

and

A Happy New Year!

The blog will continue during the holidays. I wanted to take this opportunity to greet everyone and wish you happy holidays!