Just a Few Notes on the AADE

I had planned to have more information about the two bills (H.R. 1726 and S. 1345), but dealing with an attorney can be time consuming. In addition, they can be overly cautious and this is probably a good idea on this topic.

After meeting with the attorney (a specialist on Social Security), he felt that I had a lot of information, but because he was traveling to Washington, DC on October 1, he asked me to hold up on my blog until he could read the official papers on file with the two chambers of Congress. If they were identical to the two copies on the AADE website, he would give me information for my blog and allow me to go ahead. If there is a difference, he will send me copies of the differences if possible, and offer suggestions.

He is concerned, but would not say about what or give me any clues. He did ask me to investigate and see if I could find out if any states currently had licensing or funding laws for CDEs on the books and to see if I could find out if they were on the Internet. We are concerned what the law passed in Kentucky says and how it is written, as this will give us an idea of what the AADE is promoting in other states.

I have my work cut out for me and will be busy for the next few days. After doing some research, the task may not be that difficult as there are only two states that have anything on the books. I am concerned about those in Kentucky as the punishment for non-CDEs doing any teaching about diabetes is only a misdemeanor.

It is not stated whether this teaching is for a fee or just writing about diabetes and teaching this way. In other words, it seems open to interpretation and may affect many people that are not CDEs. Sounds and looks like this may be written after the Academy of Nutrition and Dietetics (AND) laws. Time will tell once we see how they react to people writing and blogging about diabetes.

Now Indiana is still in the early stages and is being strongly opposed by the Academy of Certified Diabetes Educators (ACDE), which has introduced a proposed law to reverse the current law and not allow non-CDEs to be taught how to teach about diabetes.

Florida and Pennsylvania are only the two other states with pending legislation at this point. There may be other pending legislation states, but as of yet there are none.

Eating Healthy with Diabetes

This is why I am very cautious in what I follow on WebMD. To my way of eating and thinking, this is not close to healthy. The opening statement is reasonable and can be accepted.

Be picky. Choose the right foods to keep your diabetes in check. Try to cook at home instead of going out. It's easier to keep track of what you eat when you make your own meals. I will quote what WebMD says and write my thoughts.

Quote: 1. Think whole.

Use brown rice and whole wheat pasta. Look for 100% whole wheat flour and breads as well as other whole grains such as oats and barley. Make the switch simple. For instance, if you are short on time, pop a packet of pre-cooked frozen brown rice into the microwave. Unquote.

These foods, which are carbohydrate dense, will raise your blood glucose more than desired and you want to avoid whole grains.

Quote: 2. Fill up!

Aim for at least 8 grams of fiber per meal, especially when you eat carbohydrate-rich foods. It will help manage your blood sugar, keep you feeling full, and be good for your heart health. That’s extra important because diabetes makes heart disease more likely. Try peas, beans, oats, barley, and fruits like apples, pears, berries, and citrus fruit, vegetables like sweet potatoes, Brussels sprouts, broccoli, carrots, and beets. Unquote.

Yes, 8 grams of fiber per meal is ideal, but you don't need to eat carbohydrate-rich foods. Be careful of vegetables that are carbohydrate-rich. Fiber is important for bodily functions, but you don't need the high amount of carbohydrates.

Quote: 3. Replace some carbs with good fat.

Monounsaturated fats -- nuts, avocadoes, olive oil, and canola oil -- can help lower your blood sugar. Just avoid huge portions so you don’t take in too many calories. Add nuts and avocado to salads and entrees. Look for salad dressings, marinades, and sauces made with canola or olive oil. You can also cook with these two oils. Unquote.

This is correct and very important, but forget the canola oil, which is not healthy. Don't forget the saturated fats, which are important also.

Quote: 4. Eat foods that won't spike blood sugar.

Foods that aren't likely to cause a big rise in blood sugar include meat, poultry, fish, avocados, salad vegetables, eggs, and cheese. Adding these items to your plate will help balance the foods you eat that contain carbs. Unquote.

Number 4 is correct and one that deserves being adhered to and followed.

Quote: 5. Go lean.

Choose recipes with less saturated fat. Maybe skip that cream sauce and look for lean cuts of meat, skim or low-fat dairy, and vegetable sources of protein like beans, lentils, or nuts. Unquote.

Most saturated fat is good for us. The trouble exists because many doctors have little knowledge about nutrition and still believe in the knowledge put forth by Keyes back in the 1970s. Whole milk may have more carbohydrates than skim milk, but whole cream is good for us.

Quote: 6. Check the fine print.

Does your recipe spell out what the calories, carbs, fiber, and fat are? That info comes in handy. Then all you have to do is stick to the suggested serving size and you’ll know exactly what you get. Unquote.

This makes sense and if you know what your body needs; do not be afraid of a few carbs, and high fat, plus a normal serving of protein.

Quote: 7. Think plant fat.

Make canola oil or olive oil your go-to ingredients. Both are rich in monounsaturated fat. Canola oil also has heart-healthy omega-3 fatty acids. Unquote.

Olive oil is good for us, but beware of canola oil or other soybean oils. Canola and soybean oils do not have much of the heart healthy omega-3 fatty acids. They are also heavy in the omega-6, which our bodies do not need.

Quote: 8. Make salads easier.

Prep so it’s super-simple to throw together. Store a large spinach salad or vegetable-filled romaine lettuce salad in an airtight container without dressing. (You can add it later.) You can have a crisp tasty salad with your dinner or as a snack for the next several days. Unquote.

Salads are good and this suggestion is worth considering.

Quote: 9. Slice up dessert.

With a few chops of a knife, you can turn a few pieces of fruit into a beautiful fruit salad. Drizzle lemon or orange juice over the top. Then toss to coat the fruit. The vitamin C in the citrus juice helps prevent browning. Unquote.

Some fruit great, but watch using the orange juice as it will send glucose levels higher than desired. You would be wiser to eat the orange and forget about the juice.

Quote: 10. Outsmart your drink.

Watch the calories, sugar, and alcohol. If plain water doesn’t appeal, you can try a fizzy flavored (but not sweetened) water. Or sip no-calorie tea or coffee as the perfect finish to your home-made meal. Unquote.

This is worth considering and be careful about over consuming excessive amounts of caffeine. Decaff coffee is good, but water is by far the best.

One-Third of Diabetes Patients Meet Treatment Goals

This is an interesting study; however, I think it is what you are not told that could add several caveats to the study. The study looked at blood glucose, blood pressure, and cholesterol levels as defined by the American Diabetes Association.

Because the study is behind a pay wall creates problems in finding some information and we are only given what the researchers want us to know to make the points they desire. Some of the caveats that I can see:

1. How many of the participants have refused to take statins?
2. How many of the participants have taken the blood pressure medications, but are resistant to the aim of the medication?
3. What is the percentage of women to men?
4. What is the percentage of each ethnic group?
5. What is the age range and the average age?

Since only one third of the seniors with diabetes have the three aspects – diabetes, BP, and cholesterol under control as defined by the ADA guidelines, the above points could be very important and significantly affect the findings.

The study included 1,574 patients with diabetes, aged 65 years and older, in Maryland, Minnesota, Mississippi and North Carolina. The researchers looked at whether the participants met ADA guidelines for three key measures of good diabetes control: blood glucose, blood pressure and cholesterol levels.

The results indicated that only one in three of the patients had diabetes controlled as defined by the ADA guidelines.

I find the next almost amusing without the information in the above points. “Although some experts consider the ADA guidelines too demanding for seniors, even using less stringent measures, the researchers found that many of the patients did not have their diabetes under control.”

The study also found significant racial disparities, particularly in women, in how well diabetes is managed. Black women were much less likely than white women to have control of blood glucose, blood pressure and cholesterol levels.

"This research gives us a good picture of diabetes control in older adults and gets us thinking about what it means that older Americans are not meeting clinical targets and how we should address this from a public health perspective," study leader Elizabeth Selvin, PhD, a professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health in Baltimore, said in a school news release.

"There is tremendous debate about appropriate clinical targets for diabetes in older adults, particularly for glucose control. Are some older adults being over-treated? Are some being undertreated? These are questions for which we don't have answers."

I say that without more patient data, we can only speculate about the overtreatment or undertreatment. How stringent were the restrictions on exclusion from the study and did the participants need to match certain criteria? The American Diabetes Association guidelines call for hemoglobin A1C levels below seven percent, blood pressure under 140/90 mmHg and LDL cholesterol under 100 mg/dl. While 72 percent met the hemoglobin A1C level, 73 percent met blood pressure goals and 63 percent had good cholesterol levels, only 35 percent met all three targets.

When the target levels were raised to a less stringent level – hemoglobin A1C under eight percent, blood pressure under 150/90 mmHg and LDL cholesterol under 130 mg/dl – the results were better, but many still did not meet the targets. Ninety percent met the target for hemoglobin A1C, 87 percent for blood pressure and 86 percent for cholesterol. Yet only 68 percent had their diabetes well controlled by meeting all three targets.

More research is needed to determine what the best control targets are in an older population. The researchers say that each patient needs to be carefully considered individually. A 70-year-old with newly diagnosed diabetes and no other major illnesses should probably be treated differently than someone who is 70 but has long-standing diabetes and is struggling with other major health issues, yet guidelines often consider these two patients to be similar.

The researchers say more also needs to be understood about racial disparities in diabetes control, particularly with regard to women. The racial differences persisted even when the researchers accounted for factors such as income and education levels. White women were 58 percent more likely than black women to meet all three clinical targets.

Under Treatment of Pre-diabetes Has Future Costs

This is another great topic presented at the AACE 2015 meeting. Pre-diabetes is an underserved segment of the diabetes population and gets no respect. Even the ADA who called the expert gathering for this in 2003 has taken no action to promote treatment of people with pre-diabetes.

At least the AADE says it may be time to rethink management of pre-diabetes, according to some experts and clinicians may need to do more to address pre-diabetes. Unfortunately, there are no agents approved by the Food and Drug Administration (FDA) for treating pre-diabetes. Yet, an estimated 79 million people in the USA have pre-diabetes and 40% to 50% of those will progress to type 2 diabetes.

Consequently, endocrinologists and other health care providers may want to be more aggressive in managing pre-diabetes once it is diagnosed, researchers said at AADE 2015, the annual meeting of the American Association of Diabetes Educators.

This attitude of managing pre-diabetes once it is diagnosed is the crux of the problem. Many doctors and clinicians don't take pre-diabetes seriously and refuse to diagnose it especially in light of no FDA approved medications for pre-diabetes.

“We have interacted with many providers in the past who did not see management of prediabetes as a patient-care priority. They felt that there wasn't much to do until the formal diagnosis of diabetes was made. It is important to appreciate the continuum of diabetes,” clinical pharmacist Jeremy Johnson, PharmD, MBA, of the Southwestern Oklahoma State University College of Pharmacy in Waterford, said during a presentation.

Once a patient has pre-diabetes, the pathophysiologic process that builds to what we have defined as ‘diabetes' has begun. Prevention or the delay of disease progression is the goal.”

“With prediabetes, many of the pathophysiologic abnormalities already exist,” clinical pharmacist Katherine O'Neal, PharmD, MBA, BCACP, CDE, BC-ADM, AE-C, of the University of Oklahoma College of Pharmacy and School of Community Medicine in Tulsa said, “and upon diagnosis, approximately 10% to 15% of patients show signs of microvascular complications.”

Currently, the American Diabetes Association (ADA) recommends lifestyle changes as first-line therapy for pre-diabetes.

“While lifestyle modifications are extremely important, at times, drug therapy may be of benefit or necessary,” Johnson told Endocrinology Advisor. “While many providers may be familiar with lifestyle recommendations and use of metformin as recommended by the American Diabetes Association, other options are often needed.”

Johnson and O'Neal presented a review of the current literature on the effectiveness of non-traditional agents in the management of pre-diabetes. They said it is now the responsibility of health care providers to share with patients who have pre-diabetes all available options to help delay the progression to diabetes.

“Under diagnosing and under treating pre-diabetes is having an enormous economic, clinical and humanistic impact,” Johnson said.

There was more to the report, but the concern needs to be education of doctors to the importance of treating patients with pre-diabetes to slow or prevent the progression to full diabetes. The following is important to the discussion:

Eventually, the beta cells can no longer compensate and hyperglycemia is the result.

Johnson said pre-diabetes is often not diagnosed until complications present and approximately one-fourth are undiagnosed. Therefore, he suggests that clinicians should consider screening asymptomatic adults if they are overweight (BMI of at least 25) or have one or more risk factors.

He also recommends women be screened if they delivered a baby weighing more than 9 lb, had gestational diabetes or have polycystic ovary syndrome (PCOS).

At present, the ADA recommends weight loss if necessary, increasing physical activity to at least 150 minutes per week of moderate physical activity and the addition of metformin if the patient:

• Has impaired glucose tolerance or impaired fasting glucose
• Has an HbA1c between 5.7% and 6.4%
• Has a BMI greater than 35
• Is younger than 60 years old
• Is a woman over the age of 60
• Has had gestational diabetes

In some aspects of the discussion, I have to wonder the purpose of the medications promoted and would question possible conflicts of interest. The two speakers were promoting some heavy-duty oral medications. You can read the article here.

Move Insulin to the First Line of Treatment

I hope Patrick Totty of Diabetes Health is right. With all the problems being discovered with the oral medications, insulin may soon be the medication of choice. Presently the only safe oral medication seems to be metformin.

Early-use of insulin isn’t a new notion. Over the past decade, numerous studies have supported the early introduction of insulin in some type 2 cases. One example of research into the concept is available at the National Institutes of Health. Googling “early insulin treatment” brings up many similar studies. Read the Diabetes-in-Control report here.

I do like this idea, but, yes one of these, I have to wonder if doctors will accept this and knowing what some doctors say, many do not believe in insulin and only recommend oral medications on top of oral medications. I think that making insulin a first- rather than a last-resort medication should be seriously considered.

In the past, the initial treatment for type 2 diabetes has been a sulfonylurea and metformin. This means the sulfonylurea is used for increased insulin production and metformin is used for a decrease in liver-produced glucose levels. As is the case of sulfonylureas, eventually begin to lose their effectiveness. This then leads to diabetes becoming progressive.

Patrick Totty has talked to Professor John Wilding, a British endocrinologist and diabetes researcher, who said he has been recommending the early use of insulin as a routine element in the treatment of many recently diagnosed type 2s. I have heard this from a few endocrinologists in the USA and as Mr. Totty has heard, the reason for doing this is to overwhelm early type 2 diabetes and its unwanted effects on blood sugar levels. This says that the progress of diabetes may be delayed indefinitely, and occasionally permanently.

The great thing is that insulin provides a “rest period” for pancreatic beta cells that have been heavily stressed as patients move from metabolic syndrome or pre-diabetes to full-onset diabetes.

One of the good things about starting on insulin is that it’s compatible with some other type 2 drugs, such as metformin or gliflozins. Because those drugs are directed at other organs than the pancreas (metformin/liver; gliflozins/kidneys), they can join insulin in as an effective team. By separately acting to reduce blood sugar levels, those two drugs can bring down blood sugars to a point that allows insulin users to inject lower doses than if they were using insulin alone.

Nor only is it needles that cause people with newly diagnosed type 2 diabetes to

resist adding insulin out of the gate to their medicinal routines. The news that you’re diabetic is hard enough by itself to wrap your mind around, never mind committing to a treatment that involves sticking yourself several times per day. Much of people’s dread of needles comes from mental images of being on an endless treadmill of self-administered shots.

Modern needles are very short and incredibly thin, much of the public and many type 2s still perceive insulin as a last resort, a sort of final defense when all of the other available defenses have crumbled. But, for many endocrinologists and healthcare providers delaying insulin is like refusing to use the best weapon in the arsenal in the years-long struggle against diabetes.

The prospect of being able to overwhelm early onset type 2 will persuade many of the newly diagnosed to start with insulin. As patterns and evidence develop in favor of early insulin treatment, other type 2s, formerly reluctant to make the jump to insulin, may rethink the whole matter.

Once this is accomplished, the doctors will need to be convinced and the people with type 2 diabetes will need to learn how to change lifestyle habits and strongly consider low carb/high fat meal plans.

Why Are Doctors Waiting to Stop Diabetes

We have learned that preventing diabetes through lifestyle interventions is possible. This has been consistently reported in other clinical trials. While this is somewhat less effective in the real world, even translational studies of combined diet and physical activity programs have shown reduced diabetes risk. We are talking about people with pre-diabetes.

These programs are cost-effective and relatively inexpensive, especially when delivered in a group format, with a median cost per participant of less than $500. Unfortunately, no cost-benefit studies were identified, so we do not know how much of a long-term impact diabetes prevention may have on healthcare costs.

However, given that patients with diabetes incur medical expenditures that are more than twice as high as those of patients without diabetes, simple logic suggests that the impact could be substantial, even when considering that costs for people with pre-diabetes are already elevated. The biggest problem is we do not know the extent to which evidence-based diet-and-exercise diabetes prevention programs are being offered.

Although somewhat less effective than lifestyle, metformin has been shown to prevent diabetes in clinical trials. Metformin has been shown to be a cost-saving intervention and is clearly easier to deliver on a population-wide basis than diet and exercise programs. In patients with newly diagnosed diabetes, metformin is most effective when given at diagnosis and at lower A1c levels than if delayed, suggesting that beginning metformin before diabetes develops may further enhance its effectiveness.

Despite this evidence, and even though metformin is included in the American Diabetes Association guideline for diabetes prevention, only a small minority of patients at risk for diabetes are receiving metformin. If a relatively simple and inexpensive intervention is reaching less than 5% of its target population, we can imagine that a more complex and costly intervention will not fare any better. Of interest, the 5% treatment rate is actually an improvement over a previous study based on 2005-2006 National Health and Nutrition Examination Survey data, in which no patients with pre-diabetes were receiving metformin and only about one third had received advice about diet and exercise.

We know that type 2 diabetes is a major public health crisis and we know that it can be prevented. The Community Preventive Services Task Force has just issued a recommendation for promotion of combined diet and physical activity programs by healthcare systems, communities, and other implementers. For those unwilling or unable to participate, metformin offers a simple, low-cost, and effective alternative. What are doctors waiting for?

I am only guessing, but I feel that many doctors are not interested in treating pre-diabetes. I have heard doctors laugh about pre-diabetes and say they would not treat these people until they had something treatable. One doctor and I had a heated discussion about this in a hospital cafeteria until two other doctors ushered him away and one came back to ask me to leave and was none to polite about it. As I was leaving, I asked why it was that some doctors like to do harm to patients.