2016 ADA Guidelines for the Elderly

ADA terms us Older Adults and I use elderly. Maybe I am not politically correct, but I use the term(s) I am comfortable with and I don't always worry about being politically correct.

Diabetes is an important health condition for the aging population. The ADA says 26 percent of patients over the age of 65 years have diabetes and this number is expected to increase rapidly in the coming decades. Older individuals with diabetes have higher rates of premature death, functional disability, and coexisting illnesses, such as hypertension, coronary heart disease, and stroke, than those without diabetes – and the list goes on. Older adults with diabetes have more geriatric syndromes, such as polypharmacy, cognitive impairment, urinary incontinence, injurious falls, and persistent pain.

Screening for diabetes complications in older adults also should be individualized and periodically revisited, since the results of screening tests may impact therapeutic approaches and targets. Older adults are at increased risk for depression and should therefore be screened and treated accordingly. Diabetes management may require assessment of medical, functional, mental, and social domains. This may provide a framework to determine targets and therapeutic approaches. Particular attention should be paid to complications that can develop over short periods of time and/or that would significantly impair functional status, such as visual and lower-extremity complications.

Diabetes increases the incidence of all-cause dementia, Alzheimer disease, and vascular dementia when compared with rates in people with normal glucose tolerance. The effects of hyperglycemia and hyperinsulinemia on the brain are areas of intense research interest. Poor glycemic control is associated with a decline in cognitive function, and longer duration of diabetes worsens cognitive function. Older adults with diabetes should be carefully screened and monitored for cognitive impairment.

It is important to prevent hypoglycemia to reduce the risk of cognitive decline and to carefully assess and reassess patients’ risk for worsening of glycemic control and functional decline. Older adults are at higher risk of hypoglycemia for many reasons, including insulin deficiency and progressive renal insufficiency. In addition, older adults tend to have higher rates of unidentified cognitive deficits, causing difficulty in complex self-care activities - glucose monitoring, adjusting insulin doses, etc.. These deficits have been associated with increased risk of hypoglycemia and with severe hypoglycemia linked to increased dementia. Therefore, it is important to routinely screen older adults for cognitive dysfunction and discuss findings with the caregivers. Hypoglycemic events should be diligently monitored and avoided, whereas glycemic targets and pharmacological interventions may need to be adjusted to accommodate for the changing needs of the older adult.

At least they do make the following statements. For patients with advanced diabetes complications, life-limiting comorbid illness, or substantial cognitive or functional impairment, it is reasonable to set less intensive glycemic target goals. These patients are less likely to benefit from reducing the risk of microvascular complications and more likely to suffer serious adverse effects from hypoglycemia. However, patients with poorly controlled diabetes may be subject to acute complications of diabetes, including dehydration, poor wound healing, and hyperglycemic hyperosmolar coma. Glycemic goals at a minimum should avoid these consequences.

There is more that can be read at this link.

Doctors Can Help People with Diabetes

I often see people coming to the diabetes forums wondering what they can do. Most are very discouraged by their diagnosis and wondering where they can learn how to manage their diabetes. Most are not too polite in describing what their doctor said to them. Many feel that their doctor was accusing them for their diabetes and others felt their doctor was ridiculing them and a few felt that they were being bullied by their doctor.

This is often quite a bit to overcome, but most answers to their questions do their best to allay their guilt and encourage them to conquer their fears and then suggest following links to some very positive messages. Others tell them that they have experienced similar problems, but the people on the forum could help them and they would learn as well.

Varun Iyengar and Adam Brown describe in the diaTribe newsletter what Dr. Bill Polonsky said when he gave a talk on diabetes distress at the recent IDF World Diabetes Congress in Vancouver. He covered what this emotional state looks like, how and why it occurs, and simple strategies for addressing it. This reflects his research dedicated to one big question: how can we help people with diabetes feel motivated to succeed?

Dr. Polonsky stressed that doctors and other providers often communicate the wrong message, rather than hope, patients hear negatives and feel fear. The reason for vigilant management is not to live a long and healthy life, but to avoid complications. That framing makes a difference, as people with diabetes often go on to develop distress: an attitude of feeling defeated by diabetes.

Dr. Polonsky shared what “diabetes distress” sounds like in practice:

• “Diabetes is taking up too much of my mental and physical energy every day”
• “I am often failing with my diabetes regimen.”
• “Friends or family are not supportive enough of my self-care efforts.”
• “Diabetes controls my life.”
• “I will end up with serious long-term complications no matter what I do.”

How common is diabetes distress? (You are not alone!)

The rate of diabetes distress is far greater than is often appreciated; 39% of type 1 and 35% of type 2 patients experience significant levels of diabetes distress at any given time. This distress cannot be treated with depression medications because…it is not depression! Rather, it requires a greater focus on acknowledging and addressing the emotional and behavioral obstacles associated with diabetes.

This statement by Dr. Polonsky is the way he turns a negative into a positive, “Well-controlled diabetes is the leading cause of nothing!” This is how Dr. Polonsky stresses the need to adapt the messages people with diabetes hear from doctors, providers, and caregivers, moving away from “blame and shame” to a new message, positive in nature.

Varun Iyengar and Adam Brown had much more to say about Dr. Polonsky's talk and I hope that the above link works, as it is very interesting.

Statins May Increase Kidney Disease

This should make everyone take notice. Long-term statin use may increase kidney disease. While we are all familiar with statins increasing the risk of type 2 diabetes, this is somewhat of a surprise, but seems logical. Many of the drugs of today have more and more side effects and many can cause harms to patients.

Considering that statins have no proven cardiovascular disease prevention or life lengthening effects, it seems that the statins all have more harm causing properties than health improving properties.

In a December 1, 2015 issue of the American Journal of Cardiology, lead author Dr, Tushar Acharya of the University of California, San Francisco, said an 8-year retrospective study with a median 6.4 year follow-up associated long-term statin use with an increased risk of kidney disease. Statin users, compared with case-matched controls that didn't use statins, showed a 30% to 36% greater prevalence of kidney disease during follow-up.

Senior author Dr. Ishak A Mansi, University of Texas Southwestern, Dallas, said, “Patients who are taking statins should not stop taking them based on this study. Our study did not examine whether the benefits outweigh the risk, as it was not designed for that. Still, this study shows that despite the use of statins for more than a quarter of a century, there are aspects about its long-term effects in noncardiac diseases that we do not know very well. We are missing more extensive, real-world data of the effectiveness of statins on total morbidity and all-cause mortality, and we need further studies specifically focusing on long-term outcomes in primary prevention."

Dr. Mansi continued, “The new [ACC] guidelines . . . are projected to increase statin use to many more hundreds of millions of healthy people, and before we do that we better make sure that we are not causing harm. Our paper says to scientists, physicians, funding agencies, [and] policy makers: 'Watch out, [it] seems that we still do not know enough about the long-term effects of these drugs on [the] overall well-being of patients.'"

The overall cohort comprised 43,438 individuals: 13,626 statin users and 29,812 nonusers. The most commonly prescribed statin was simvastatin (73.5%), followed by atorvastatin (17.4%), pravastatin (7%), and rosuvastatin (Crestor, AstraZeneca) (1.7%); 38% of the statin users received high-intensity doses. The statin users took the drugs for a mean of 4.65 years.

The researchers matched 6342 statin users in the overall cohort with 6342 nonusers, according to baseline demographics, comorbidities, and presence of renal disease, healthcare utilization, and medication use. In this matched cohort, patients had a mean age of 56, and 45% were women.

"The findings of this study, though cautionary, suggest that short-term [randomized controlled trial] may not fully describe long-term adverse effects of statins," Acharya and colleagues conclude. Statins lower the risk of cardiovascular disease and cardiovascular death, but "on the other hand, statins increase the risk of incident diabetes and possibly kidney diseases, both of which paradoxically increase long-term morbidity and mortality," they continue.

ADA 2016 Guidelines – Summary of Revisions

The new American Diabetes Association 2016 guidelines are now posted and the ADA is apparently attempting to be politically correct. The word diabetic will no longer be used to describe patients, but will only be used as an adjective when describing something like diabetic neuropathy. OH -WOW! And, there are more examples of political correctness through out the guidelines.

Strategies for improving care has been revised – including recommendations on tailoring treatment to vulnerable populations with diabetes, including recommendations for those with food insecurity, cognitive dysfunction and/or mental illness, and HIV, and a discussion on disparities related to ethnicity, culture, sex, socioeconomic differences, and disparities.

The support for only diagnosing based on HbA1c has been diminished and includes fasting plasma glucose, 75-gram oral glucose tolerance test, and the A1c test, with no preference to one test. The screening recommendations have now been revised to test all adults beginning at age 45 years, regardless of weight.

Two sections were combined – Initial Evaluation and Diabetes Management Planning and Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care, and Immunization from the 2015 Standards were combined into one section for 2016 to reflect the importance of integrating medical evaluation, patient engagement, and ongoing care that highlight the importance of lifestyle and behavioral modification. The nutrition and vaccination recommendations were streamlined to focus on those aspects of care most important and most relevant to people with diabetes.

Many people will be happy to see this - Because of the growing number of older adults with insulin-dependent diabetes, the ADA added the recommendation that people who use continuous glucose monitoring and insulin pumps should have continued access after they turn 65 years of age. Now we will need to push out congressional representatives to pass a bill to force Medicare to do this.

“Atherosclerotic cardiovascular disease” (ASCVD) has replaced the former term “cardiovascular disease” (CVD), as ASCVD is a more specific term.

A new recommendation for pharmacological treatment of older adults was added. To reflect new evidence on ASCVD risk among women, the recommendation to consider aspirin therapy in women aged greater than 60 years has been changed to include women aged 50 years and greater. A recommendation was also added to address antiplatelet use in patients aged less than 50 years with multiple risk factors.

A recommendation was made to reflect new evidence that adding ezetimibe to moderate-intensity statin provides additional cardiovascular benefits for select individuals with diabetes and should be considered. A new table provides efficacy and dose details on high- and moderate-intensity statin therapy.

“Nephropathy” was changed to “diabetic kidney disease” to emphasize that, while nephropathy may stem from a variety of causes, attention is placed on kidney disease that is directly related to diabetes. There are several minor edits to this section. The significant ones, based on new evidence, are as follows:

Diabetic kidney disease: guidance was added on when to refer for renal replacement treatment and when to refer to physicians experienced in the care of diabetic kidney disease.

Diabetic retinopathy: guidance was added on the use of intravitreal anti-VEGF agents for the treatment of center-involved diabetic macular edema, as they were more effective than monotherapy or combination therapy with laser.

The scope of youth section is more comprehensive, capturing the nuances of diabetes care in the pediatric population. This includes new recommendations addressing diabetes self-management education and support, psychosocial issues, and treatment guidelines for type 2 diabetes in youth.

The recommendation to obtain a fasting lipid profile in children starting at age 2 years has been changed to age 10 years, based on a scientific statement on type 1 diabetes and cardiovascular disease from the American Heart Association and the ADA.

There is more and I may cover some of this separately at a later date. Find the Table of Contents here.

What Is Happening at ACDE?

I am confused and I am not sure what is happening. I used to be able to access the Academy of Certified Diabetes Educators website, but since the tenth and maybe the ninth of December, I have not been able to access it by the main page, and this is the message I get on the screen. The URL is this - http://www.academycde.org/ .

The website you are attempting to access cannot be found
There is no website configured at the address you have provided.
Please try the following: If you typed the page address in the Address bar, make sure that it is spelled correctly. Contact the organziation to see if the address is correct. Search Google for the website's correct address. ERROR - URL not found Internet Information Services Technical Information (for support personnel) YourMembership.com:Contact Us

I for one did not believe they are out of business and after several experiments, I have found another way into the website on 14 December. It is this URL - https://academycde.site-ym.com/?page=OfficersAndBoard .

In exploring the site further, I had to wonder why some places look like nothing is being done. The newsletter area only shows archived newsletters through July and I remember that normally it was three months after when it was archived. They may not have issued newsletters for August and September.

The ACDE Connection July 2015

The ACDE Connection June 2015

The ACDE Connection May 2015

The ACDE Connection April 2015

The ACDE Connection March 2015

There are past newsletters from August 2014 to February 2015.

The last area that surprises me is in the Calendar of Events. After having a meeting on June 7, 2015, I would have thought a future meeting would have been posted for ACDE. I do need to be concerned about why they are pulling the main page of the website and what they are attempting to cover up. If the company that does the web page, “Professionally Managed by Capitol Consultants, Inc.” is that inept then their must be real problems or the ACDE has not paid the fee due Capital Consultants, Inc.

Should We Let Guilt about Diabetes Ruin Our Lives?

I am not sure about this, as the idea came from this blog by Karen McChesney on A Sweet Life. The way she wrote the blog, I am sure that those with type 1 diabetes agree with her feelings.

As a person with type 2 diabetes, I admit I have many misgivings about what she describes and would never allow myself to have the blood glucose readings she describes having for several hours. Many of those in our support group are talking about this and are wondering why we don't feel this way. We know that people with type 1 diabetes are afraid of hypoglycemia and we have to wonder several things.

First, are they not taught how to use correction injections and if they over bolus too often. Allen, who had a recent A1c of 5.1 percent, said he is at a loss to understand type 1 people. He said that eating a low carb, high fat food plan should prevent the problems she described. Ben asked why anyone would let his or her blood glucose levels remain in the 200's for several hours.

Ellie (a type 1 herself and an honorary member of our support group) asked if we would listen to her. She agreed with our food plan and said too many people with type 1 diabetes eat normally and plan on covering the extra carbohydrates with insulin. While she said she does not agree with this, it explains why many people yo-yo up and down and when they have lows over correct and then need to bolus for the hyperglycemia.

Ellie is a freshman in college this year and says that her type 1 friends ridicule her for her low carb, high fat meal plan and don't understand why she does not have lows and uses so little insulin. She then tells them about the support group she belongs to at home that are all type 2 people, most follow this food plan, and many have A1c's in the low 5%'s. When asked what her A1c is, many are surprised that she is also between 5.0 and 5.5%. She has only had one person ask her about her food plan, but after a few days, rejected it saying she did not like feeling hungry all the time.

She said she advised her to increase her fat percentage and add a little more salt. She finally discovered the person was following the advice of her mother to also eat low fat and realized that it was a no win situation and her friend normally had an A1c above 7.0% and had gained 20 pounds in her first semester of College. After that she decided not to talk about her A1c and her meal plan. She just thanked us for our support and being there when she needed our help, by answering her questions directly or through her parents. She asked us to pass on a special thank you to Brenda's daughter for her nutritional help. Tim said we would and we thanked her for her input.

Barry said that explains a lot, and we need to remember that our food plans work for us and we know they do. Other people need to experiment on their own to discover whether they can use the low carb, high fat food plans.

Our support group does not believe guilt should be any reason to diminish our

our diabetes management or our level of blood glucose maintenance. We all know that other variables can make our diabetes management more difficult, such as stress, illness, lack of sleep, and many other variables, but we need to have our diabetes held in check by what we eat and how we manage our blood glucose levels.

Managing Drug Side Effects – Part 2

When you talk to your doctor, have a list of all other medications and/or supplements you're taking - both prescription and over-the-counter. Sometimes, side effects are caused by two or more drugs reacting negatively together, and you may not need both.

Keep in mind that a new symptom may actually be a drug side effect. If you don't give your doctor the whole story, he may diagnose you with another condition entirely, and prescribe another drug to treat it.

There are a lot of factors that go into side effects -- not just the medication itself," Owen says. "You may be able to prevent them by avoiding alcohol or certain foods, or by making other small changes to your diet or lifestyle."

For example, if you take an antidepressant that helps you feel better but also causes you to gain weight, you may have to pay more attention to your nutrition and exercise plan.

Some medicines, like cholesterol drugs and blood thinners, may not work as well if you eat grapefruit or foods high in Vitamin K. Grapefruit can also make the cholesterol and blood thinners become toxic to your body. Other drugs may make you sensitive to the sun, so wear sunscreen or cover up outside.

It's smart to do your own research about your medicine. Read the label and all the instructions that come with your prescription. Talk with other people who have similar health problems. Please search reliable sources on the Internet.

If you read or hear about another drug that may have fewer side effects, ask your doctor or pharmacist about it. Side effects of newer medications may not be as well known as those on the market for years, so you might ask about switching to an older, more proven drug.

Never stop a medicine or change your dosage without your doctor's approval, especially if you're being treated for a serious health condition. You need to take some medicines, like antibiotics, for a full course to avoid getting sick again. Others don't work as well if you skip a dose, cut it in half, or take it with or without food.

You may be able to tolerate some side effects, especially if they're temporary or if the pros outweigh the cons. But, if a bad drug reaction puts you at risk for more medical problems or seriously affects your health, it may be time for a change. Always notify your prescribing doctor and explain what is happening.

Medications that cause dizziness, for example, can increase your risk of death or serious injury from falling, especially if you're an older adult. And treatments that affect your ability to enjoy time with friends or romantic partners may not be your best option if alternatives are available. If you are one of the elderly, make sure that the doctor will be monitoring you until you are sure that the drug can be effective and that your body is receiving the intended benefits.

Sometimes it takes a bit of trial and error, but often you can find a medicine that works without affecting your quality of life. Also, ask the doctor about whether grapefruit is a problem with a drug and follow the instructions carefully. Some foods need to be avoided with a few drugs.

Managing Drug Side Effects – Part 1

This article has some excellent advice that many people chose to ignore. Yes,

prescription drugs heal us when we're sick, ease our pain when we ache, and prevent or control long-term conditions. But sometimes, even when they do the job they're supposed to, they have unwelcome side effects.

Many people automatically rule out a medication, even if it's an important part of managing a health condition. But you shouldn't accept unpleasant reactions without question, either.

I find this very interesting. “Side effects can happen with almost any medicine, says Jim Owen, doctor of pharmacy and vice president of practice and science affairs at the American Pharmacists Association. “They're common with everything from birth control pills to cancer-fighting chemotherapy drugs.”

Many prescription drugs, for example, cause stomach problems like nausea, diarrhea, or constipation because they pass through your digestive system. Antidepressants, muscle relaxants, blood pressure, or diabetes medications may cause dizziness. Some might make you feel drowsy, depressed, or irritable. Some may cause weight gain. Some may disrupt your sleep or your ability (or desire) for sex.

"I tell my patients that chronic symptoms are not acceptable," says Lisa Liu, MD, a family doctor at Gottleib Memorial Hospital in Melrose Park, IL. "I won't allow them to have ongoing pain or discomfort unless we have tried every alternative."

When your doctor prescribes a new medicine, ask about common side effects.

"You, your doctor, and your pharmacist should be working together so everyone has the same information," Jim Owen says. "You should know which side effects are serious, which ones will go away on their own, and which ones can be prevented."

“Once you start taking a drug, mention any unexpected symptoms to your doctor or pharmacist as soon as possible. This includes changes in your sex life,” Liu says, “Which many patients are embarrassed or afraid to talk about.”

Some side effects go away over time as your body gets used to a new drug, so your doctor may recommend you stick with your current plan for a little longer. In other cases, you may be able to lower your dose, try a different drug, or add another one, like an anti-nausea medicine, to your routine. As you age, your body may not be as efficient in using the drug and your doctor should be made aware of this.

"People often think that just because they have a bad reaction to one drug, they can't take any other drugs in the same class, but that's not always the case," Liu says. "Sometimes side effects are due to very specific ingredients that not every brand uses."

Changing the time of day you take your medicine may help, too, if your doctor gives you the okay or if your pharmacist tells you to ask the doctor. "If someone is on four blood pressure medications, for example, I tell them not to take them all at once," Liu says. "For patients whose birth control or antidepressant makes them dizzy, I have them take it right before bed."

Personal Emergency Response Devices

This is a service, which I may have missed in the past, but as I continue to age, I admit I am looking more into these products – personal emergency products. Products exist that are interesting and some that have been in existence for years, but do little. Some cover decent distances and others only short distances. Some have hidden fees, long contracts, and are expensive. Others have the equipment and only have a monthly fee. There are always some costs that aren't explained and these can turn you off to the equipment.

I understand why people are drawn to personal emergency devices, but many are not willing to wear it. Many forget or don’t want to have something around their neck or on their wrist. A personal emergency device also has to activate when an emergency occurs, either by automatically detecting a fall or problem, or because the user triggers it. Currently, most devices do not have this ability and only work if you are within operating range and the wearer pushes the button.

I am investigating only one device currently, but I have a couple others to investigate is I become serious. The equipment cost is $0.00 and the activation fee is $0.00. Monthly monitoring costs $29.95 per month or cellular monthly monitoring is $34.95 per month. This is from Medical Alert and is the basic cost.

There no long term commitment required, but – surprise - for liability purposes, they do require a Monitoring Agreement to be signed. A non-refundable deposit is required prior to a Medical Alert system being shipped. This deposit is the equivalent of three months monitoring. At the end of those 3 months, the Medical Alert service can be canceled with no penalty with 30 days notice (or you are required to have the service for 4 months). This is one of the more reasonable conditions.

I do not advise letting them have open access to your credit cards or auto draws to a checking or savings account. Unless a specific date was requested, credit card payments are processed on the 1st of the month and checking and savings account payments are processed on the 5th of the month. Invoices are mailed the first week of the month.

The cost of the unit if it’s lost or damaged is this schedule:
The PERS replacement cost is $350.
The Mobile Alert replacement cost is $350.
The Alert 911 replacement cost is $150.

The company has a Better Business Bureau rating of A+ as of 12/22/15 and has the Good Housekeeping seal of approval.

Some companies have long-term contracts and others have high activation fees and you pay for the equipment before it is shipped.

The one thing I have not found out is how close you have to be to the station for you to have access for a household monitor (PERS)(personal emergency response system). This is a weakness of several of the companies. Also before you sign anything, make sure you read the fine print, get all the facts, and addresses if you need to break the contract. For a couple of companies, you will pay dearly if you don't.

For research, type life alert or medical alert in your search engine.

Why Is Everyone Worried about A1c Overtesting?

Disclosure for me – I am a person with type 2 diabetes and am managing my diabetes with insulin. I only have two HbA1c tests per year and I do not feel this is often enough. Admittedly, I discontinued seeing an endocrinologist because I was consistently being asked to raise my A1c to level above 7.5%. When my A1c was under 6.5%, I was told rather sternly to let my A1c rise. I, of course do not believe this and believe I should manage my glucose levels to the best of my ability.

Fortunately, my VA nurse practitioner believes this also and with the other tests they run, she can determine that my meal plan is not affecting my health and the tests clearly show this. So I will continue to follow the low carb, high fat, moderate protein food plan and hopefully my next A1c test will be better and I won't have a couple of infections and another problem that will keep it as high.

It seems that certain doctors feel that for persons with well-managed diabetes, that they only need at most two HbA1c tests per year. Fortunately, some doctors disagree and feel that their patients need four tests per year. And some individuals buy their own kits to test on a monthly basis. This must drive these doctors into a tizzy.

Dr. Rozalina McCoy, a professor of medicine at the Mayo Clinic, in Rochester, Minn. is one of these doctors and a lead researcher that states - "I think part of the problem is that we often think more testing is better."

Her research showed that over 60% of adults in the United States with well-controlled type 2 diabetes receive more than the recommended number of tests for HbA1c. And excessive testing increases the risk of treatment being intensified despite a patient having normal HbA1c levels, a new retrospective analysis of an administrative claims database demonstrates.

The test, which gauges a person's average blood sugar control over the past three months, is routinely used to diagnose and monitor type 2 diabetes. But guidelines say it should be done only once or twice a year if a patient has been showing good blood sugar control, according to the study.

First, the HbA1c test reflects the prior four months and this is from David Mendosa's blog. I think this is a common mistake that the article author made, as the author of the second article did not even mention this.

"I think the most important drivers of HbA1c overtesting in the US are multifactorial," Dr McCoy told Medscape Medical News.

She and her colleague identified some factors that seem to play a role in how frequently patients are tested, including the number of different healthcare providers each patient sees and whether their endocrinologist also treats type 1 diabetes patients, who do require more frequent monitoring. Also, there was a wide geographic variation in frequency of testing.

Current guidelines recommend patients with stable glycemic control receive HbA1c tests once or twice a year. While this is true, often once a year is insufficient and because the American Diabetes Association only recommends A1c tests, patients often need to pay for their own test strips or completely operate in the dark. Dr. Robert Ratner, chief scientific and medical officer for the ADA that says, “Many people with type 2 diabetes who are on medications don't need to do home glucose monitoring at all," in talking about oral medications.

With all this stacked against diabetes patients, it is small wonder, many patients see several doctors to be HbA1c tested several times per year. Unlike the following statement, with the ADA against you, I believe that overtesting of HbA1c is over researched. This is just another way the medical community is working to harm patients with well managed type 2 diabetes.  The researchers also use a value of A1c greater that 7 percent for increased A1c testing.  When will they learn that A1c values above 6.5 percent can lead to complications.  It is no small wonder that this is why doctors consider type 2 diabetes progressive.  They want to limit testing and give no education.

“And in an accompanying editorial, Rodney Hayward, MD, University of Michigan, Ann Arbor, says the current study "probably greatly underestimates" the size of the overtreatment problem among US patients with type 2 diabetes. This common belief that there is "no harm in looking" continues to result in not just waste in the healthcare system but palpable patient harm, he stresses.”

For an HbA1c test the cost is very reasonable and a few extra tests are minimal cost and often great security for type 2 patients and generally create little harm.

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! 

I must apologize, as before my computer crashes in August and September, I had a blog written for gifts for people with diabetes, but it did not survive the crashes.  I had intended to publish it right after Thanksgiving, but I completely forgot about it since I no longer had it.

Doctors Now Advocating Statins for Children

It seems that endocrinologists, cardiologists, and several other medical groups in the medical world are promoting statins like never before. Not only are they now promoting them for children above the age of five years of age, but the also have flooded the medical journals with information that many (almost 50 percent) of eligible adults are not taking statins.

I cannot prove this, but it seems that there must be a lot of money to be made from promoting statins and many medical groups are thus promoting statins. This statement is beginning to have more significance - “Statin use has become what appears to us to be a kind of religion, an unchallengeable article of faith among some doctors.”

One in five children and adolescents had at least one abnormal cholesterol measure, according to new data from the CDC. "While the authors do not focus on this, some of the very high total cholesterol and non-HDL-cholesterol values are likely due to genetic causes such as familial hypercholesterolemia," wrote Daniels, who was not involved with the study. "The heterozygous form of familial hypercholesterolemia occurs in approximately one in 250 individuals."

Obesity is also listed as a potential risk factor, as nearly half (44.3%) of obese children and adolescents had some form of abnormal cholesterol, more than three times that of their normal weight peers (13.8%). Obese children and adolescents also saw statistically significant differences in high total cholesterol (11.6%) compared with those who were normal weight (6.3%) and overweight (6.9%).

Switching to the adults, nearly half of American adults who should be taking cholesterol-lowering drugs do not, according to research published in the U.S. Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report. The CDC study team analyzed national data from 2005 to 2014 and found that 36.7% of U.S. adults — 78.1 million people aged 21 and older — were eligible to take cholesterol-lowering medications or was already taking them.

Many of the medical groups now believe that with statins now being generic, the benefits now favor statins and are pushing them very aggressively. There are few doctors that warn about the side effects and most never even consider that most statins deplete the levels of CoQ10 or Coenzyme Q10 made by our bodies. Most doctors do not even test for this and some people will develop problems because of this.

According to the University of Maryland Medical Center (UMMC), statins lower your body’s levels of coenzyme Q10. As your levels go down, the side effects of statins increase. Taking CoQ10 supplements might help increase the levels in the body and reduce problems.

Learning to Manage Diabetes

For people that want a different source for diabetes information, I would like to refer you to the site – BD Diabetes Education Center (the link is not always dependable). While it is not the most comprehensive site, they have a great overview of certain topics and can give us topics to research.

The first area is for those injecting medications to help manage diabetes and reduce discomfort. Do take the time to view the links they put in blue. If you are injecting insulin or another medication, BD lists some things to keep in mind:

1) Consistent delivery into fat layer

• Injections should consistently enter the fat just underneath the skin and should avoid the muscle.
  Watch demonstration: how to inject with a syringe
  Watch demonstration: how to inject with a pen
• Injections into the muscle are more common with longer needles, leading to quicker insulin action and greater risk of low blood sugar.
  Learn how to recognize and treat low blood sugar
  
  
• A 4mm x 32G pen needle rarely enters the muscle as compared with longer 6mm-12mm pen needles.
  Learn which pen needles do not require a pinch up.

2) Injection site location and rotation

• Common injection sites include the stomach, thigh, buttocks and upper arm.
• Rotating among these sites may reduce the risk of lypodystrophy, lumps of fat that develop under the skin from injecting in the same spot repeatedly.
  More discussion at bottom.

• A 4mm pen needle length allows for a “straight in” no pinch injection technique at all injection sites. This allows you to inject with one hand into harder to reach areas like the upper arm or the buttocks.

3) Choices of needle type, length and gauge

• Factors to consider when choosing a needle are the thickness (gauge) and the length of the needle.
• People who have participated in studies seem to prefer the 4mm x 32G pen needle over other longer pen needle lengths.

4) Additional tips

• How to improve your injection technique
  
  
• A reused needle does not enter the skin as easily or as cleanly because it has become dulled by use and the lubricant that lets the needle enter the skin has been rubbed off. Use pen needles and syringes only once.
• All used sharps should be contained and disposed of in a sealed sharps container according to local municipality regulations.

Number is 2 above is probably the most important to me and what I have been reading about lately. Rotating among these sites may reduce the risk of lypodystrophy, lumps of fat that develop under the skin from injecting in the same spot repeatedly. I am not sure that the term lypodystrophy is correct, as I have always been told that the area that is used for injections day after day develops scar tissue in the fatty area. This traps the medication and does not allow, generally insulin, to be dispersed for use in the blood stream.

There is much more to the site and I will suggest that you explore the site.

CKD May Result from Proton Pump Inhibitors

This article caused me to ask my pharmacist some questions about the medication I was taking for acid reflux. She said that because of the gall bladder removal they were careful to give me an acid reflux medication that was not a proton pump inhibitor.

The article is this one and discusses that certain medications often used to treat heartburn and acid reflux may have damaging effects on the kidneys. The drugs, called proton pump inhibitors (PPIs), are among the top 10 class of prescribed medications in the United States.

With all the problems of chronic kidney disease (CKD) on the increase, apparently physicians are not properly assessing patients and keeping the patients on the medication for too long. Three studies indicate that PPIs may be contributing to the CKD epidemic.

In one study, Benjamin Lazarus, MBBS (Johns Hopkins University) and his colleagues followed 10,482 adults with normal kidney function from 1996 to 2011. They found that PPI users were between 20% and 50% more likely to develop CKD than non-PPI users, even after accounting for baseline differences between users and non-users. This discovery was replicated in a second study, in which over 240,000 patients were followed from 1997 to 2014. “In both studies, people who used a different class of medications to suppress stomach acid, known as H2-blockers, did not have a higher risk of developing kidney disease,” said Dr. Lazarus. “If we know the potential adverse effects of PPI medications we can design better interventions to reduce overuse.”

In the third study, Pradeep Arora, MD (SUNY, Buffalo) and his team found that among 24,149 patients who developed CKD between 2001 and 2008 (out of a total of 71,516 patients), 25.7% were treated with PPIs. Among the total group of patients, those who took PPIs were less likely to have vascular disease, cancer, diabetes, hypertension, and chronic obstructive pulmonary disease. However, PPI use was linked with a 10% increased risk of CKD and a 76% increased risk of dying prematurely.

“As a large number of patients are being treated with PPIs, health care providers need to be better educated about the potential side effects of these drugs, such as CKD,” said Dr. Arora. “PPIs are often prescribed outside of their approved uses, and it has been estimated that up to two-thirds of all people on PPIs do not have a verified indication for the drug.”

This warning was issued - Please consult your doctor or other qualified health care provider if you have any questions about a medical condition, or before taking any drug, changing your diet or commencing or discontinuing any course of treatment. Do not ignore or delay obtaining professional medical advice because of information accessed through ASN. Call 911 or your doctor for all medical emergencies.

The proton pump inhibitors include:

• Omeprazole (Prilosec), also available over-the-counter (without a prescription)
• Esomeprazole (Nexium)
• Lansoprazole (Prevacid)
• Rabeprazole (AcipHex)
• Pantoprazole (Protonix)
• Dexlansoprazole (Kapidex)
  

Bringing Everyone Up to Date

I am very surprised and yet very happy. This fall has been one of ups and downs for many of the support group. Most of us are happy that most of the dual title (RD and CDE) people have moved out of the area. We know that two CDEs are still around and one RD is still preaching high carb, but for the most part, many of the new members have been given permission to see Brenda's daughter or my cousin for nutrition advice.

Tim is very happy as he has been approved for using my cousin for nutrition and Bonnie has worked with a CDE and asked Tim to use her if his insurance will approve. Tim agreed after meeting her and asking several questions, and has told Bonnie that as soon as she can practice, she had better plan on being busy.

Allen, Barry, and Ben have found a doctor that believes them and it wasn't Dr. Tom. Even Sue has changed to the same doctor. Allen, Jerry, and I all had our VA appointments the same day and Allen and Jerry had excellent A1c's. Because of a couple of infections the prior month, and another problem, my A1c was higher than I anticipated. I have other doctor appointments now and may need to see a VA specialist next year.

Beverly is away for some classes and our December meeting could not happen. We did try and other activities seemed to conflict. So, Sue and Jason are planning a program for January. We did have a brief meeting on December 16, since most could attend that evening. There were a few questions that Allen, I needed to answer about insulin, and A.J had quite a few questions about exercise. Sue's husband, Bob said that his fall schedule had forced him to go on metformin and that presently he was taking it two times per day for a total of 1,000 mg.

A.J emphasized that a YMCA membership was not necessary, but could help for those that could afford it. A.J said that with the open fall we have had, he has not needed to use a swimming pool and has been able to exercise outside most days. He asked how many could jump rope and was surprised at the lack of response. A.J said that he is using this for some of his exercise and his incline tread mill at other times on days that it has rained enough to keep him from running.

Then A.J showed the group the jacket he wore when running. With the florescent stripes, we could appreciate why he showed us. Sue commented that she has almost hit other runners and walkers that wear dark clothing in the evenings now that it turns dark early. Several of the new members asked where they could find the florescent material. A.J listed several places and where it was the least expensive and where to find the widest stripes. Then he displayed the pants he uses with their stripes. He said that he has two sets and uses both and is happy he has them. He estimated that his total cost was about $35 and he said that he probably has more stripes than needed, but it was up to each person how visible they wanted to be in the evenings.

This generated quite a bit of discussion and then Tim said the meeting was adjourned and people could talk among themselves if needed. Half an hour later the cleanup was done and everyone left. Tim wanted to talk to me, we went to my car, and Tim said that with Bonnie and my cousin taking classes for several months, we needed to have Brenda's daughter and members of our group have programs for a few months. I agreed and said I would be looking for topics and Tim said he had several topics in mind and he would put them in an email and ask for volunteers. I thanked Tim and said I would wait for the email.

People with Diabetes and HBP May Not Donate Kidneys

Yes, you read this right! The reason is most people with diabetes and high blood pressure (HBP) may have kidney damage that would not support living on one kidney.

Researchers are saying that donors with those conditions face a high risk of developing kidney problems themselves, and may need both kidneys in the long term. The advisory is part of a set of new metrics, based on a donor’s health prior to donation, that can predict the lifetime incidence of kidney failure or end-stage renal disease (ESRD).

Dr. Hassan Ibrahim, a nephrologist at the University of Minnesota Medical Center, led the team that looked at the health impacts from diabetes and high blood pressure, or hypertension, in living kidney donors. They found that people who have diabetes or high blood pressure have a two to four times higher chance of experiencing reduced kidney function compared to those who do not.

Dr. Darla Granger, director of the St. John Transplant Specialty Center in Michigan, and a transplant surgeon, said that people with diabetes are ruled out as donors at her facility. If a person has high blood pressure and wishes to donate a kidney, they may be considered on a case-by-case basis. Both conditions are top causes of kidney failure. “You don’t want to create end-stage renal disease in someone because you took their kidney,” she said. However, both hypertension and diabetes can be reversed with lifestyle and diet changes. Donors who can reform their lifestyles may be reconsidered, she said.

Both conditions, diabetes and high blood pressure are the top causes of kidney failure. Granger said, “If a person has high blood pressure and wishes to donate a kidney, they may be considered on a case-by-case basis. Obesity is affecting the donor kidney pool and type 2 diabetes is a disease related to obesity. ”

There are so many more people waiting for kidneys than there are available donors. People with diabetes or hypertension who want to help another person by donating a kidney may not realize that they could wind up hurting themselves in the long run. “You don’t want to create end-stage renal disease in someone because you took their kidney,” she said. “But both hypertension and diabetes can be reversed with lifestyle and diet changes. Donors who can reform their lifestyles may be reconsidered,” she said.

Group or Shared Medical Appointments

Group (GMA) or shared medical appointments (SMA) seem to have taken on a life of their own in the last few years. I have been involved with two doctors that have asked me about SMAs and they both were surprised that a lay person (patient) would be promoting them. I have put both in contact with the doctors that have trained their own peer mentors to help them and received their thanks.

Now I am beginning to see some research on group medical appointments. I see little difference between them and they can vary by how a doctor wants to call them.

Medical management delivered via group medical appointments appears to be effective for glycemic control in patients with type 2 diabetes, according to research published in Diabetes Spectrum. It is a shame that this research has to be behind a pay wall, but at least I can use this to give to doctors that ask questions.

Cora A. Caballero, NP, from Loma Linda Healthcare System in California, and colleagues conducted an electronic chart review comparing group medical appointments care for 52 male patients with usual primary care for 52 male patients, all with type 2 diabetes. Demographic and health-related variables were analyzed.

The researchers found that the target HbA1c goals were reached by a greater proportion of group medical appointment patients (50%) than usual primary care patients (19.2%). The rate of decline of HbA1c over time was significantly faster for group medical appointment participants vs usual primary care participants.

"This study demonstrated that the concept of medical management delivered in a group approach had a positive effect on glycemic control in patients with type 2 diabetes," the researchers wrote. "GMAs were found to be an effective approach to achieving patient-centered goals for improving the glycemic control of patients with type 2 diabetes."

No mention is made about secrecy and any problems encountered. I think this is great and hopefully opens the door to more GMAs or SMAs.

Are Seniors Being Treated Properly?

A recent newsletter from diaTribe caught my attention, particularly an article by Kelly Close. Her article is titled, “How Should We Be Treating Seniors with Diabetes?” I must admit that it raises some valid points, but in the back of my mind, I feel that it missed some important points.

The article she used is a New York Times article about a hypothetical patient with type 2 diabetes, concocted by researchers at the University of Michigan and the Veterans Affairs Ann Arbor Healthcare System. The NY Times article is not an article we should pay a lot of attention to or be overly concerned about because this is done like most articles as a “one-size-fits-all” example.

Kelly says of the NY Times article, “The article raises important concerns about the overtreatment of people with diabetes; however, it fails to address the growing number of methods designed to minimize these very risks that are so very important as this epidemic expands beyond what anyone imagined.”

I can agree with the statement, but I need to be concerned about the next statement - “It is true that most mealtime insulins, as well as sulfonylureas, come with a meaningful risk of hypoglycemia. As a person with diabetes, I welcome the chance to mitigate this risk. However, in just the past decade, many new diabetes drug classes now exist with virtually no risk of low blood sugars (incretins, SGLT-2 inhibitors). And more importantly, at least one of these drugs, Jardiance (empagliflozin), recently showed reduced cardiovascular risk in high-risk elderly people with type 2 diabetes.

With the recent FDA warnings issued forSGLT2 inhibitors, I would be hard pressed to agree that this class of drugs should be considered as something that helps mitigate this risk of problems for people with diabetes. I may be overly conservative, but I only consider one oral medication worth considering in the treatment of diabetes and that drug is metformin. And with insulin, these are the only drugs I can say that I approve of and consider the rest unsafe for people with diabetes.

Granted some people can tolerate some of the other classes of drugs, but when it comes to the elderly (or seniors) no testing has been done on the drugs for the elderly. The drugs are just prescribed with no information available on how the elderly will react to the drugs or if they will even work as they do on younger patients.

When dealing with seniors, more care must be taken and each prescription needs to be monitored carefully to discontinue the drug quickly if certain side effects become evident.

Plus when dealing with the elderly, cognitive ability must always be a consideration and many drugs need to be off the table when cognition problems are discovered. Another factor often overlooked is the caregivers for the elderly. What are their abilities and how much knowledge are they willing to absorb to be able to care for the elderly.

One of the greatest problems facing the elderly of today is the physicians that want to bully them and not listen to their or the caregivers descriptions of what might be wrong with the patients. They often just hand out a fist full of prescriptions and expect the patient to take or be given the medications as directed. They know little about geriatrics and often don't even care.

For the reasons above and our poor medical system, the elderly are not properly cared for or treated with respect.

Communication Improves Health Outcomes

Finding this article was a pleasant surprise. Not only that, but the source was even a bigger surprise – Physicians Practice. Most doctors use other terms and seem to love them as a way of confusing true communications. This article seems to be pointing back to the importance of real communications.

Communication is the key that could improve healthcare for doctors and patients around the world. I think it is proper to use this by Dr. Rob Lamberts - “Communication isn’t important to health care, communication is health care.” as it is very appropriate to this discussion.

Research has shown that collaborative communication between clinicians and patients has multiple benefits, including increased patient satisfaction, treatment adherence, and decreased rates of 30-day readmissions. Most clinicians, who average about 250,000 patient encounters over a lifetime, know that communication can help reduce patient safety risks and insurance costs, while increasing their sense of effectiveness and job satisfaction. Yet, an overwhelming majority of physicians has never received professional development on how to manage patient communication.

Doctor-patient collaborative conversations are powerful tools to bring about a change in attitudes while building life skills, knowledge, trust, and confidence. This can ultimately result in meaningful and sustained changes in health behaviors. In a sense, this collaboration allows for clearer expectations, understanding, and knowledge that can enable the doctor to better understand and meet the patients’ needs.

It also can help them empower patients to assume responsibility and take steps, albeit sometimes small ones, to manage their own healthcare. This type of collaborative interaction engenders empathy and trust, all of which increase health outcomes, as well as patient and doctor satisfaction.

Without communication, the doctor patient relationship will not exist and patients will not view time spent at an appointment as time well spent and will feel that the doctors are there only to write prescriptions and pass out pills. Many patients will not understand the need for filling the prescriptions and won't know what the side effects of some medications will be or how to handle them. Lack of communication causes more problems and harms than many doctors realize.

Communication strategies such as Motivation Interviewing (MI), theory of the mind (or mentalizing), and emotional regulation, all constructs shown to increase patient satisfaction, collaboration, and health outcomes, are important elements of any conversation solution that physicians may consider.

I would urge people to read the link the first paragraph as there is more to this than I have covered.

More about the Egg

Cholesterol contained in eggs caused eggs to receive a bad reputation in the past. Many in the medical profession felt eggs were too high in cholesterol to be part of a healthy food plan. Now the role of dietary cholesterol as it relates to a person's total blood cholesterol count now appears to be smaller than previously thought. Family history may have more influence on your cholesterol levels than how much dietary cholesterol is in your food. The bigger threat to your cholesterol levels is food that is high in trans fats according to the "experts."

I can imagine some of you almost choked when A.J and I said we consumed 12 eggs per week and sometimes more. The “experts” still recommend that a person with diabetes should not consume more than 200 mg of cholesterol each day. People that do not have diabetes may consume about 300 mg per day. One large egg has about 186 mg of cholesterol, which does not leave much room for other dietary cholesterol once that egg is eaten.

The “experts” claim that research suggests that high levels of egg consumption may (this is the key word) raise the risk of developing type 2 diabetes and heart disease. While the connection isn’t clear, researchers believe that excessive cholesterol intake, when it comes from animal foods, may increase those risks.

Because I already have diabetes, I basically ignore the statement, “Since all of the cholesterol is in the yolk, you can eat egg whites without worrying about how they’re affecting your daily consumption of cholesterol.” Many restaurants offer egg white alternatives to whole eggs in their dishes. You can also buy cholesterol-free egg substitutes in the stores that are made with egg whites.

Keep in mind that you need to whole egg to get the advantage of a complete protein. The yolk is also the exclusive home of some key egg nutrients. Almost all the vitamin A in an egg, for instance, resides in the yolk. The same is true for most of the choline, omega-3s, and calcium in an egg

I admit that I do not agree with the ADA when they want to limit egg consumption to three eggs per week. Nor do I agree with consuming only egg whites and missing the important nutrients in the egg yolk.

I admit that I like to consume eggs in the various ways, fried, poached, scrambled, salad, and in many other dishes. The ADA claims that eggs are less healthy when fried in butter or olive oil, but I can agree that you should not use vegetable oils. I am also contrary to the ADA because I like my sausage and my high fat bacon.

A hard-boiled egg can be a handy high-protein snack if you have diabetes. The protein will help keep you full without affecting your blood sugar. Protein not only slows digestion, it also slows glucose absorption, which is very helpful if you have diabetes. Having protein at every meal and for the occasional snack is a smart step for anyone with diabetes. However, they make the last statement and also do not want you to consume more than three eggs per week. Somewhere they need to be more consistent in their recommendations.

ADA Recommends Eggs for PWD

I almost ignored this article about ADA saying that eggs were good for people with diabetes. If it had not been for A.J, I might have passed on this. When A.J asked me about my thoughts on the article, I had forgotten about it already. A.J said he had also skipped over this the first time as he had just come from an appointment with the heart doctor and had been told not to eat eggs because of the cholesterol they contained. He said he had just nodded and forgot about the advice as his levels for cholesterol were very good and he could not figure out why he was being lectured about cholesterol.

A.J said he had been eating about twelve eggs per week and occasionally a few more when he wanted more protein. I agreed that I ate about the same number of eggs and had a hard time understanding why some doctors were still pushing no eggs because of the cholesterol. A.J asked me to read the article and then blog about it.

The American Diabetes Association considers eggs an excellent choice for people with diabetes. One large egg contains about half a gram of carbohydrates and this will not cause a spike in your blood glucose level. Many people with and without diabetes are afraid of eggs because one large egg contains nearly 200 mg of cholesterol. This is what drives many doctors to discourage eggs, but much of the evidence is still in favor of the egg and while highly debatable by doctors, many in our support group have great lipid panels and have no worry about cholesterol.

Monitoring your cholesterol is important if you have diabetes because diabetes is a risk factor for cardiovascular disease. High levels of cholesterol in the bloodstream also raises the risk of developing cardiovascular disease. Therefore, it is important for anyone with diabetes to be aware of and minimize other heart disease risks.

There are many benefits that people don't know about eggs. A whole egg contains about 7 grams of protein (a complete protein). Eggs are an excellent source of potassium and we need potassium for nerve and muscle health. This also helps balance sodium levels in the body as well, which improves your cardiovascular health.

Eggs have many nutrients, such as lutein, which protects you against disease, and choline, which is thought to improve brain health. Egg yolks contain biotin, which is important for healthy hair, skin, and nails, as well as insulin production. Eggs from chickens that roam on pastures will be high in omega-3s, which are beneficial fats for diabetics.

Eggs are easy on the waistline, too. One large egg has only about 75 calories and 5 grams of fat, only 1.6 grams of which are saturated fat. Eggs are versatile and can be prepared in different ways to suit your tastes. You can make an already-healthy food even better by mixing in tomatoes, spinach, or other vegetables.

Stop Self-Sabotaging Your Health – Part 2

This is continued from the previous blog.

#6. You think the glass is half empty. Do you allow negative self-talk to sabotage your healthy behaviors? Degenerative language can keep you in a negative space about your progress and achievements. When it comes to working out, California-based personal trainer Jenny Schatzle says you may have thoughts like, “I should have run faster” or “The person next to me looks better” or “I still have much more weight to lose.” Negative thoughts demotivate people from moving forward towards health that is more positive. “It doesn’t matter how fast or slow you go, you’re still lapping the person sitting on the couch. Be present and proud that you’re doing it at all.”

#7. You don’t think you’re good enough. Low self-esteem can instill a sense of feeling unworthy, that you don’t really deserve the benefits you’ve worked for diligently. This can prevent you from trying your hardest because if you hold a little something back, you can always say, “Well, I could have succeeded, but it cost too much or I had other priorities.” While this can help you save face, recognize that it’s not a genuine effort.

#8. You succumb to your self-destructive habits. Most of us have at least one. It might be tobacco, alcohol, or even ice cream. Whatever the habit, realize that habits are resistant to change. It takes perseverance, discipline and a good plan.

#9. You stop when you start seeing results. Many people can set goals and begin to see some progress as they work towards them. But don’t think you’ve made it just because you’re losing weight or building muscle tone. You need to maintain the discipline and keep it going. The Transtheoretical Model of behavior change says to really develop a long-lasting behavior, you need to maintain it for at least 6 months. Some people start seeing results and begin slowing down, stopping the very behavior that got them there in the first place.

#10. You expect the “old you” will reappear. In a bizarre twist, expecting the worst is a form of self-preservation. Even though we might be succeeding fabulously on our new workout or weight loss plan, because we are creatures of comfort, it’s somehow easier if we revert to our old selves. It’s like an old comfortable shoe.

I have been guilty of some of these, but I am not proud of letting these happen. I do see many other people with diabetes that continue to use many of these to sabotage their diabetes management. The sad thing is that they don't even realize they are sabotaging their management. I would like to say that we are all human, but that would be a cop out.

Stop Self-Sabotaging Your Health – Part 1

Have you stopped doing what you know is the right thing to do? Have you fallen off the wagon and can't get back on track? What causes us to do these things? I have previously written about self-sabotage of maintaining our good diabetes habits and it may be time to cover this topic again. I have received several emails lately that lead me to this, even though I have answered the emails.

In my previous blog, I covered only four points, but this time I will expand to 10 points.

#1. You’re stuck on auto-pilot. Despite the best of intentions, it’s hard to break out of that comfortable routine to which we’ve become accustomed. Get home from work, eat dinner and slide right into that easy chair. We have become a product of our own conditioning.

#2. You blame your responsibilities. One of the more common ways we sabotage ourselves is by not taking responsibility for our own lives. The reasoning goes something like this. “I don’t have time for exercise because I have to take care of my children/spouse/elderly parent/grandchild.” We all have responsibilities and it’s easy to subconsciously use them as excuses not to go after our dreams, because if we do, we may fail. Remember, doing something is better than doing nothing.

#3. You procrastinate. Another common form of self-sabotage is putting things off. A popular tactic of perfectionists. “Perfectionism leads to procrastination which leads to paralysis,” says Paul Coleman, author of the book, “Finding Peace When Your Heart is in Pieces.” It’s easy to be caught up in minutia and lose time. You can also over think things and spend all your time planning and none of it doing. Please realize it’s better to be done than perfect.

#4. You set unrealistic goals. Sure, it would make a huge difference if you worked out 2 hours a day. But, that’s not likely to happen. So why set a goal that is impossible to achieve? Then you waste time and energy dealing with the guilt that follows. Instead of setting lofty, unrealistic goals, be honest with yourself and come up with a plan you can adhere to and accomplish.

#5. Your friends and family undermine your lifestyle. Who in your social circle seems to get you regularly off the healthy track? You want to eat healthy but your friend talks you into going for pizza. While all relationships are unique, it’s worth examining how you feel after spending time with people. Are you getting an equal share of the relationship? If not, is it because you’re allowing your needs to become subservient to theirs? Perhaps you need to let it be known that you’re on a quest for a healthy lifestyle and ask them if they want to come along for the ride. You might just be surprised by their answer.

I will give the last five points in the next blog.

Have You Talked to Your Doctor about Insulin?

A 'Thank You' goes out to David Mendosa for his blog on December 3, which gave me a start for my own blog about people with type 2 diabetes giving insulin a fair consideration. Too many refuse to even consider insulin and as a result do not effectively manage their diabetes.

Yes, too many people with type 2 diabetes never consider insulin as the first line of treatment, but only as the last line of diabetes treatment when all else fails. The sad part of this is that they are encouraged by doctors to only use oral medications with many unpleasant side effects.

Many people with type 2 diabetes are not willing to give up their poor eating habits and as a result, the oral medications are not able to manage diabetes. Diabetes then becomes progressive and steadily becomes worse. The doctors keep adding one oral medication after another to help manage diabetes – to no avail. It is what the doctors want because they have an unhealthy fear of insulin causing a low (hypoglycemia).

That is the reason doctors keep changing and/or stacking one oral medication on top of another. They even use the threat of insulin to get you to change your eating habits and manage your diabetes more effectively. But, you are so afraid of insulin that you will not even consider it. For some it could be the fear of needles and for others it is the desire to stay on pills. For others, the insulin myths have a huge effect in scaring them away from great diabetes management.

David has some good questions to ask your doctor about insulin and I agree with most of them. The last two may get negative responses from your insurance company, Medicare will not authorize number six in his list, and even people with type 1 are denied access when they should have CGMs.

If you are a person newly diagnosed, be aware that most endocrinologists will work with you on insulin and often will prescribe insulin to help you manage diabetes effectively to give your pancreas time to recover from the strain you have given it before diagnosis.

Know that by using a low carb/high fat meal plan is also good for you and will make diabetes easier to manage and will not require a lot of insulin. I have written about making insulin the first choice for treatment of type 2 diabetes. I have also written about what to do when first diagnosed.

SGLT2 Inhibitors Receives New FDA Warnings

The FDA said Friday December 4, that SGLT2 (sodium-glucose cotransporter-2) inhibitors such as empagliflozin (Jardiance), dapagliflozin (Farxiga), and canagliflozin (Invokana) will need new warnings on the risks of ketoacidosis, urinary tract infections, and other serious illnesses.

The FDA communication stated that there have been more than 70 cases of ketoacidosis reported to the agency. The also listed 19 “life-threatening” cases of urosepsis (septic poisoning from retained and absorbed urinary substances) and pyelonephritis (inflammation of the kidney and its pelvis, caused by a bacterial infection).

The 19 cases of serious urinary tract infections occurred only in patients treated with canagliflozin or dapagliflozin; although the FDA stopped short of saying that empagliflozin was free of such risk. Although none were fatal, four patients needed intensive care treatment and all were hospitalized. No data were available on patients’ prior history of urinary infections, and the review did not identify other factors that might predispose patients to such infections.

Review of the adverse event reports disclosed that the median time between the start of SGLT2 inhibitor therapy and onset of ketoacidosis was 43 days (range 1 day to 1 year). The drug dose did not seem to be related to the risk of ketoacidosis, the agency said.

The review did identify some other potential risk factors. These included:

• Infection
• Low carbohydrate diet or reduction in overall caloric intake
• Reduction or discontinuation of insulin therapy
• Discontinuing an oral insulin secretagogue
• Alcohol use

The FDA recommended that physicians consider these risk factors before prescribing SGLT2 inhibitors and that patients taking these agents and complaining of symptoms consistent with ketoacidosis be formally evaluated. The agency also said that the drugs should be stopped if ketoacidosis is suspected.

And, when patients on these drugs have risk factors known to increase risk of ketoacidosis, such as prolonged fasting because of surgery or acute illness, clinicians should consider monitoring the patients closely or stopping the drugs altogether.

I had wondered how long it would be before this happened and how many more events have to happen before the drugs have more limited use.