More on Blood Glucose Variables

This article from the Mayo Clinic covers some of the variables that I missed in my blog here on variances in blood glucose levels. This was written by a female and covers more than I hinted at in my blog.

Most of us understand that increased carbohydrate intake or decreased physical activity will raise our blood glucose level. When these are relatively consistent, then we need to think about the other variables that will affect our blood glucose levels. And yes, hormonal fluctuations caused by illness, injury, surgery, emotional stress, puberty, menses, and menopause can affect blood glucose levels.

Physical or emotional stress – This can cause the release of hormones called catecholamines, which often cause hyperglycemia or high blood glucose. Even if you don't have diabetes, you can develop hyperglycemia during severe illness. For those of us that have diabetes, we may need more insulin or oral diabetes medications during illness or stress. This should be something you talk to your doctor about if this happens to you.

The puberty variable – For children, insulin requirements increase during growth and especially during puberty. The cause, in part, can be attributed to the growth hormone as well as the sex hormones, estrogen and testosterone.

The menstruation and menopause variable – For girls and women, these times in life present unique challenges to blood glucose management. Estrogen and progesterone can induce temporary resistance to insulin, which can last up to a few days and then drop off.

Many women report having higher blood glucose levels a few days before beginning their period. Then when menstruation begins, some women continue to have hyperglycemia while others experience a sharp drop in blood glucose levels. During menopause, women often notice their blood glucose levels are more variable or less predictable than before.

For women with type 1 diabetes, significant hyperglycemia can lead to emergency complications such as diabetic ketoacidosis or diabetic hyperosmolar syndrome. For these conditions, immediate treatment is needed. Persistent hyperglycemia puts you at increased risk for long-term complications such as cardiovascular disease, blindness, or kidney failure.

Contrary to the advice of the American Diabetes Association and the American Association of Clinical Endocrinologists, frequent testing and recording of your blood glucose values will show patterns and make it easier for you and your doctor to manage your diabetes.

Always be proactive and ask your doctor to help you establish a 'sick day plan' to help you respond in the event of illness or injury. If you experience continued hyperglycemia, don't hesitate to ask your doctor to help you adjust your diabetes treatment regimen.

Diabetes - If You Drink Alcohol – Read This

Dr. Rosalind Breslow, Ph.D., an epidemiologist in NIAAA's Division of Epidemiology and Prevention Research led a study that appears in the February 2015 issue of Alcoholism: Clinical and Experimental Research. Dr. Breslow said the results of the study does not report actual, but potential rate of drinking and medication use that overlap.

About 42 percent of U.S. Adults who drink also report using medications that are known to interact with alcohol. This is based on a study from the National Institutes of Health. In those over 65 years of age who drink alcohol, nearly 78 percent report using alcohol-interactive medications. These findings show that a substantial percentage of people, who drink regularly, particularly older adults, could be at risk of harmful alcohol and medication interactions. Dr. Breslow suggests that people talk to their doctor or pharmacist about whether they should avoid alcohol while taking their prescribed medications.

This research is among the first to estimate the proportion of adult drinkers in the United States who may be mixing alcohol-interactive medications with alcohol. Dr. Breslow emphasizes the resulting health effects can range from mild (nausea, headaches, loss of coordination) to severe (internal bleeding, heart problems, difficulty breathing).

“Combining alcohol with medications often carries the potential for serious health risks,” said Dr. George Koob, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), part of NIH. “Based on this study, many individuals may be mixing alcohol with interactive medications and they should be aware of the possible harms.”

Some of the alcohol-interactive medications reported in the survey were blood pressure medications, sleeping pills, pain medications, muscle relaxers, diabetes and cholesterol medications, antidepressants and antipsychotics. Based on recent estimates, about 71 percent of U.S. adults drink alcohol.

You have probably seen warnings on medicines you have taken. The danger is real and the warnings should be heeded. In addition to these dangers, alcohol can make a medication less effective or even useless, or it may make the medication harmful or toxic to your body.  Some medicines that you might never have suspected can react with alcohol, including many medications which can be purchased “over-the-counter,” that is, without a prescription. Surprise, even some herbal remedies can have harmful effects when combined with alcohol. Small amounts of alcohol can make it dangerous to drive, and when you mix alcohol with certain medicines, you put yourself at even greater risk. Combining alcohol with some medicines can lead to falls and serious injuries, especially among older people.

Women, in general, have a higher risk for problems than men. When a woman drinks, the alcohol in her bloodstream typically reaches a higher level than a man’s even if both are drinking the same amount. As a result, women are more susceptible to alcohol-related damage to organs such as the liver.

And remember, older people are at particularly high risk for harmful alcohol–medication interactions. Aging slows the body’s ability to break down alcohol, so alcohol remains in a person’s system longer. Older people also are more likely to take a medication that interacts with alcohol. And in fact, they often need to take more than one of these medications.

Do You Understand Depression - Part 3

The causes of depression are many and varied. Some people are genetically predisposed to have a higher chance of having episodes of depression throughout their lifetime. If you have a parent or a sibling that has experienced depression, then you are at a higher risk for depression. Once you have depression, this is a predictor of future episodes.

Your environment is another cause of depression. Stressors and triggers can come from your home, work, and even memories can negatively affect your thoughts. Negative thoughts can affect not only mood and feelings, but also behavior and daily living. Depression can lead to self-isolation, poor nutrition, and little exercise. From my reading, I have learned that the brain and its neurotransmitters change during an episode of depression and all these factors negatively affect biology.

This is why when you have mild depression, you need to take steps to stop it there. If you have someone that understands you and can be a sounding board, make use of him or her and let him or her help you. If this does not work, then seek counseling and don't let depression get the better of you.

Depression negatively affects behavior by decreasing engagement in recreational activities and making chores and hygiene more likely to be deferred. Not being able to keep up with responsibilities at work and at home can lead to additional negative thoughts. Ever-increasingly negative thoughts, biology, and behavior all then enhance the feeling of depression. This can become a vicious cycle. What starts as something minimal can quickly snowball into severe and debilitating depression that negatively affects the biological, psychological, and social aspects of your life.

The first paragraph above says a lot and there are the people with diabetes that I am concerned about. Because some people are at higher risk for depression than others, the rest of the people around this person need to be aware that depression can negatively affect all areas of a person's life. The feelings of hopelessness and distorted thoughts and judgment can lead to self-harm and suicide. As with any disease, the symptoms and causes of depression for people with diabetes can be problems with unknown magnitude.

Like most diseases that go untreated, depression negatively affects quality of life and has complications, the most serious of which is suicide. This why I blog and our support group is working to do interventions. If anyone you know is suffering from depression, please assist them in obtaining treatment immediately.

Warning, leave certified diabetes educators (CDEs) out of this, as they avoid being in the room with anyone with diabetes that talks about depression. I have blogs up over the years where CDEs have done just this and I have been able to help a few of their victims. They can't seem even to pass this information to the person's doctor for follow-up.

Some blogs that I have found helpful include this about why are your missing work, this blog about restoring happiness, and this blog about other bloggers writing about handling depression. The last link is this on about some depression drugs causing hypoglycemia and this should be known before accepting some depression drugs.

Do You Understand Depression - Part 2

Many people will not come right out and state that they are depressed or feel depressed. Normally, the doctor should know the signs as they can accompany other real problems the person goes to the doctor to resolve.

Because of how depression can affect people diagnosed with diabetes, I would propose that the following be made mandatory for all adult people with diabetes and all parents of children with diabetes. Once a diagnosis has been made, the diagnosing doctor should schedule a session with a psychiatrist. And yes, this should be mandatory with penalties for not keeping the appointment. Insurance should be required to pay for this.

This would not be the normal visit, but an educational appointment to learn about depression, the warning signs of depression, and maybe some tests as described in this blog. Many people with diabetes (about two-thirds) do develop some depression because of the daily chores with diabetes. No stigmatism should be attached to this appointment and questions should be allowed. The psychiatrist should build a file for future assistance and learn what medications you might be willing to take. This should also build a doctor patient relationship that can be used later if needed and allow for open communications in the future.

Understand that this does not lock you in with this doctor. If you don't have a rapport with the doctor, you should be able to get a referral in the future to another psychiatrist. Some even use telemedicine to chat with you later to answer questions about depression. Don't forget the problem with burnout and these doctors may be able to assist during this and help shorten the length of the burnout.

Back to the information about depression. People that are depressed can have trouble falling and staying asleep, or conversely, they will find they want to sleep all the time. Interest in things commonly enjoyed can disappear. Feelings of guilt and hopelessness can be intense and constant. Concentration is often impaired, and appetite can be minimal or, conversely, voracious. This is when a visit with a psychiatrist could be important. The American Psychiatric Association provides a screening tool for depression that could be of help.

While about 19 percent of depression can become severe, it is better to ask for help when you recognize some of the early symptoms than say I will get better and then not get better, but worse.

When the depression gets worse, this is when thoughts often happen such as I'd be better off dead, or turn to killing oneself or others. Depression is dangerous when it distorts thinking, judgment, and decision-making. The disease of depression can make it hard to remember the last time you felt "normal" and hard to believe you will ever feel "normal" again. It can be hard to believe someone we have known as a happy, well-adjusted, and successful friend, neighbor, family member, or colleague would want to kill himself or herself. However, depression is extremely powerful.

Without this information, patients can feel lost or, worse, defeated if their symptoms progress. It is very important to become educated to get help right away if their mood worsens or if they have any of these additional symptoms.

It is important to provide crisis numbers, including the national suicide hotline (1-800-273-8255), which is available 24/7. I would advise everyone that if they are feeling dangerous to themselves, they should not wait to see a psychiatrist in the community; they should go to the nearest emergency department or call 911.

Do You Understand Depression - Part 1

Although the article is written for all people and about depression, I will be limiting my discussion to people with diabetes. About two-thirds of people with diabetes develop depression and about 19 percent of these develop severe depression. We are more susceptible to depression because diabetes is a chronic disease, there is no vacation, and we must battle it 24/7/365. Then add stress and other variables and it is easy to understand why depression can affect us.

Then because of the stigma attached to depression and it is easy to understand why many people with diabetes refuse to talk about or even see a doctor for depression. Yes, I have had ignorant doctors say it's all in your head and tell me I was just too lazy to deal with it. I could not leave that doctor fast enough – never to return. Then some people write me about getting help because when the subject was mentioned in a meeting with a certified diabetes educator, the educators all seem to want to end the session and leave the room. These examples are not the way to treat depression in people with diabetes.

What is depression and what causes it? These are often the questions people with diabetes want to know and they often start with their primary care doctors. In diabetes patients with severe depression, many visit their doctor the week before committing suicide. Yet many doctors do nothing to help people with diabetes and won't deal with depression, mild or severe.

Some people with diabetes attribute their depression to personal weakness or lack of will power. This stigma often becomes a barrier to seeking help. Not seeking help can often make those who suffer from depression feel worse. Now if doctors would understand the importance of helping those with depression, both mild and severe. This may only be a dream with the numbers of doctors that either ignore the patients' pleas for help or ridicule them for being weak.

Depression can be a feeling and often a feeling that is difficult to explain or describe. Doctors that are knowledgeable about depression do try to educate, when possible, their patients and work to dispel the stigma associated with depression. Some of the better doctors will prescribe a medication to help and other doctors will refer them to people that are knowledgeable about the different levels of depression.

Most people experience a “down” or a “blue” period every so often, but these normally resolve after a few hours or days. These are a normal part of living and life and should be expected. It is when these or feelings of sadness last for more than two weeks that we should seek help. A doctor that expresses empathy, concern, and a supportive environment can lift a large part of the burden and this can be very therapeutic.

Some of the problems associated with diabetes can bring on depression. These can include hypoglycemia, diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar nonketotic coma (HHNKC). The last two require immediate medical intervention and hypoglycemia may require immediate medical intervention if the blood glucose levels become too low.

In addition, just the fact that diabetes requires attention 24/7, can lead to mild or severe depression depending on other circumstances in a person's life.

A Dilemma for a Person with Diabetes

I find myself in a real predicament. This is a very real problem for husbands and wives, but I had not envisioned this happening to me. What you ask? My dearly beloved ignored prediabetes and said very little to me except to ask a few questions as if it were someone else's problem. On January 19, she was notified she had type 2 diabetes and the problems started.

She accepted a regular metformin prescription and not a prescription for extended release. I suspect she will have the common symptom of nausea and the rest of the side effects as she is of Asian nationality.  So far, she has had few problems.  When I try to discuss diabetes with her, she ignores my questions. She knows I blog about diabetes and she clearly stated that she did not want advice from me.

Her latest A1c is 6.9% and her A1c from a month prior was 7.0%. This is what the doctor used to confirm her type 2 diabetes. When we went grocery shopping, I did notice a few improvements in the purchases. She was looking at calories and not carbohydrates though. I did get to show her a few of the higher carbohydrates counts, but she said that I why she would only eat one serving. It will be interesting if this comes to pass.

She did surprise me when she started looking at her lab results and asking good questions about them and the ranges. The lab is using the old, and I mean old, prior 1997 ranges for diabetes even though she said the doctor told her she had type 2 diabetes. This brought out questions and I had her read this blog and the link it contained.

I know I will have to be very careful in what I say and how I say things, but if she is in denial, not much will make that change until she realizes she has diabetes. I am cautiously optimistic that a few statements made in the days since her diagnosis on January 19, 2015 will lead to acceptance.

Now she is taking a class with a dietitian and I need to be extra careful. When she talks about carbs, she is using the term to mean one carb equals 15 grams of carbohydrates. A few of my readers have asked me why I use grams of carbohydrates as they also learned what my wife has learned. Well, this is because I learned on my own and in reading labels of food containers; everything was in grams of carbohydrates. I naturally followed this and learned that it was easier for me than dividing everything by 15 to come to carbs. If I eat 35 grams of carbohydrates for a meal, this is easier than calculating 2 and one-third carbs.

Veterans with Dual Coverage Under Scrutiny

Being a veteran, this article creates resentment in me. It is as always; blame the veteran for having served the country and find ways to deny medical supplies where possible. It is bad enough that the Centers for Medicare and Medicaid Services (CMS) and the Veterans Affairs severely limit testing supplies, but now the veterans that are taking advantage of both are being put under the scope.

The researchers who are reporting this are determined to put these veterans in a bad light and prevent them from gaining the upper hand in diabetes management. Their reasoning is cost must be limited. They cite the costs of self-monitoring of blood glucose in the United States as being substantial. Medicare contractors paid more than $1.2 billion for test strips and/or lancets in 2007, and the VA, where use and cost are lower, approximately $50 million per year is spent on test strips alone.

Both Medicare and the VA, however, place restrictions on the number of test strips used per a specific time period based on the patient's diagnosis and treatment regimen. The researchers are upset with the veterans using both systems for obtaining test strips, and thereby side-stepping each system's attempts to discourage overuse.

The researchers defined overuse of test strips as more than one strip per day, or more than 365 strips per year, for those taking no diabetes medications, oral diabetes medications only or long-acting insulin without short-acting insulin. For those taking short-acting insulin, overuse was defined as more than four strips per day, or more than 1,460 strips per year.

The researchers showed their bias because a few of the oral medications do cause hypoglycemia and the users need more test strips. Data from 363,996 veterans aged at least 65 years with diabetes who used the VA health care system who received strips in 2009 were included.

A total of 260,688 veterans (71.6%) with diabetes received strips from the VA only, 82,826 (22.8% from Medicare only and 20,482 (5.6%) from both the VA and Medicare, according to the data. The researchers found that those receiving strips from the VA and Medicare received more strips (median, 600), as compared with Medicare only (median, 400) and VA only (median, 200; P<.001).

The researchers could not do the work necessary to confirm information as evidenced by this statement, “Odds for overuse also appeared to be considerably greater for those receiving coverage from both the VA and Medicare versus the VA only.”

“Patterns remained similar, the researchers noted, even when more conservative thresholds of overuse were employed.”

Then the researchers make this statement, “These findings illustrate the profound importance of understanding dual health system care and are emblematic of waste and inefficiency that must be addressed.” The researchers apparently did not confirm that there was actual waste, but concluded that there was waste and blame the veterans for trying to manage diabetes more effectively.