Venting or Blowing off Frustration

Several things have happened the last few days affecting the new members of our support group and a few others we know. All of us were upset and wondered why the doctors cannot include some of this in their instructions. Other people wonder why the other professions seem so entrenched in their dogma that they are worthless in helping with education.

Another blogger and I had this discussion a few years ago, but I still see people that insist that they test at one hour after eating and others argue that they should be testing two hours after testing. A.J and I were talking recently and A.J said he needed to test. A friend of his said that was not good, as he should have tested an hour prior. He clearly stated that the test was worthless now. I asked why he would presume to know when it was best for A.J to test. He said that is what his doctor had told him.

I said doctors don't know everything and they figure one hour is good enough so some people will not see the actual high. A.J had finished and said that his doctor had said to test several times to determine when his high point was. He continued that he had been told to start testing as the half-hour after first bite and test every 15 minutes until the readings started to decrease. After doing this three times per week for three weeks, he has found that about 115 to 130 minutes pass before his high point. I said I have also done this and I normally have about the same range, which means I use the two-hour mark for mine.

I said we have several individuals that reach their high point at 90 minutes and a few that reach theirs at 60 minutes. I am even aware of one individual that does not reach his high until 150 minutes. A.J then asked the person if he had even done the testing to determine when he generally reaches his high. He said no, but would follow what his doctor had told him to do.

Then I asked if his A1c was always higher than expected. He thought for a while, and finally said many had been. A.J asked if he thought we were blowing smoke about testing where his high point after meals occurred. He hesitated and said that is why you do all the testing. A.J told him this is just part of the problem of not knowing the time when you blood glucose hits its high point. Next I asked if he tested before eating and he said he did. I said that was good and by knowing the approximate time to the high point he would then have a better picture of how the food he consumed was affecting his blood glucose.

A.J did say that his high point could be one hour, but without testing he could never be sure. A.J continued that he does the testing about once a year to confirm that the average is still at two hours. He then said that as we age or change the food we consume, this could easily change.

I asked what medication he was taking and he replied Lantus and Novolog. I added that I take the same medications, but I am aware of changes that can happen. This is one reason I test more often than many doctors want me to.

A.J's friend said that he probably had some things to learn, but he would do some extra testing to find out when he reached his high point after eating. A.J thanked him for opening his mind for alternate suggestions.

Helping a Spouse or Loved One with Diabetes

This is one topic where specifics are difficult and helping some spouses can be very difficult. Every good intention can result in worse behavior by the spouse with diabetes. Not a good situation to have happen.

I am a little disappointed that the Mayo Clinic is rerunning a blog post from April 24, 2013. This summer seems to be the summer for reruns. The topic of helping a spouse is still a great topic. In addition, they use information from William Polonsky, Ph.D., which makes this even more valuable.

How do you help someone who won't help himself or herself, especially when he or she is an adult? Let's face it, diabetes isn't an easy disease to have or manage. It can be frustrating and takes work. On top of that, everyone seems to have an opinion about diabetes, whether it's valid or not.

When a family member or friend of someone has diabetes, you may see your loved one struggle with diabetes management. And, some people with diabetes tend to minimize or ignore their diabetes. Burnout can occur from years of managing the condition. Ignoring something bad that is happening to you makes perfect sense only if there is really nothing you can do about it. That is why watching a family member or partner do little or nothing to keep his or her diabetes under control can be so heartbreaking.

Still, if you're a family member, friend or partner of someone with diabetes, it's important to remember whose diabetes it is and respect boundaries. Crossing these boundaries can often create additional problems. Nagging, being a watchdog, extracting promises, and manipulating someone to do what you want them to do doesn't work in most cases.

“So what should you do? Dr. Polonsky offers the following advice:

• Don't assume you know what your loved one with diabetes is thinking.
• Do try and understand how your loved one's actions make sense from their perspective.
• Don't offer advice unless you're asked.
• Do offer to help if the individual is receptive.
• Remind your loved one that he or she is loved on a regular basis.
• Take care of yourself and seek education about diabetes.”

“In addition, it may be useful to:

• Ask your partner, friend or family member to join you for a walk, bike ride or other activity (but accept "no" if that's the response).
• Offer healthy food options, but don't make demands. Ultimately, it's the other person's choice.
• Try not to nag.
• Don't let another person's diabetes take control of your life.
• Seek counseling if you feel overwhelmed.
• Try motivating yourself to make lifestyle changes if needed.
• Learn to set boundaries.”

This is important:

• Take care of yourself and find your own support system.
• Respect your loved one's wishes and show them you care.
• Hopefully your loved one will discover that he or she isn't powerless and can do something to cope with and manage his or her diabetes.

Also, please read my blogs on this topic for other ideas. The first is about supporting a loved one with diabetes and please follow the links included in that blog. The second is about helping a spouse with diabetes.

The last suggestion is to do an intervention assisted by the doctor and other people the doctor might suggest. I have seen successful interventions, but unless everyone involved knows what to do, they can also create greater barriers for the couple.

Is The Study Reliable and Truthful?

Are we heading into an era of junk science? From all indications, this seems to be the case. Patients will suffer and doctors will be blamed. Yet, it is Big Pharma that sets many of the studies that are not reliable and the leaders of the many physician organization, associations, and academies that promote the guidelines based on unreliable studies and data.

If you think otherwise, read this article in the New York Times and this blog by Dr. Malcolm Kendrick about why studies are not done to refute or confirm the previous studies. Another blog that is interesting is this one by Tom Naughton.

All confirm how poor and poorly constructed the research studies of today are and give some idea of where medicine is headed.

Normally I do not reference articles appearing in the New York Times because they are written for sensationalism, but this article actually outlines many of the problems of today's research studies. The biggest truth is some of the steps you can find out about a study.

“First, if the study examined the effects of a therapy only on animals or in a test tube, we have very limited insight into how it will actually work in humans. You should take any claims about effects on people with more than a grain of salt. Next, for studies involving humans, ask yourself: What method did the researchers use? How similar am I to the people it examined?” If you are between 21 and 50, chances are in your favor you could be similar, but if you are above the age of 50 or younger that 21, a healthy dose of skepticism is in order.

“This random assignment is powerful. If done with enough people, it causes the two groups to be statistically identical to each other except for the experience of the treatment (or not). Whatever changes are observed can usually be attributed to that treatment with a good degree of confidence.”

“Though a randomized trial makes two groups statistically identical to each other — apart from treatment received — it still doesn’t mean either group is identical to you. If the individuals selected to participate in the trial happen to be very similar to you — similar ages, income, living environment and so forth — that increases the chances that the results would apply to you. But if you’re, say, a 65-year-old, middle-class New Yorker, a study whose subjects were poor 30-somethings in rural China may not translate to your experience.”

“This is one of the chief limitations of randomized trials. They’re typically focused on narrow populations that meet strict criteria — those most likely to benefit from treatment. Many drug trials exclude older patients or children because of ethical or safety concerns. Many, particularly much earlier trials didn’t include women. We know a lot less about how drugs affect groups who weren’t studied than we might like. Harm could even come if it was assumed that findings from those who were studied applied to people who weren’t.”

Dr. Kendrick says, “It has become clear that much of medical research is flawed, and so inherently biased that much of it/most of it simply cannot be relied upon. One of the strongest critics of this current situation is a brilliant statistician, Professor John P Ionnadis. His seminal paper on the subject of medical research, which is nearly ten years old now, was entitled ‘Why Most Published Research Findings Are False ‘.”

I think if you can read all three of the links in the second paragraph above, you will understand why many studies are so poor.

Tools Needed for Blood Glucose Testing

Okay, you have been diagnosed with type 2 diabetes. Now what? You will need some testing supplies to help you learn to manage your blood glucose levels. The first set of supplies is called a blood glucose meter for holding the test strips. I will cover the test strips later, but know these are what your meter reads and translates information from a drop of blood for your meter to read in a form that you can use.

The meter (no I did not say monitor (continuous glucose monitor [CGM], which is what most people with type 1 diabetes use)) will tell you if your blood glucose is right on, too low, or too high. Realize that your doctor can assist you in suggesting goals, but should never set the goal for you. Blood glucose meters can also tell you how diet, exercise, stress, sickness, and your medications affect your blood glucose levels.

Some suggestions for the meter you use:

1. Is it and the necessary supplies covered by your medical insurance?
2. Is the screen large enough to easily read?
3. Is the amount of blood required small enough?
4. Does the meter support a download function to a computer or smart phone?
5. Does the meter contain too many bells and whistles that are not needed?

The smaller the amount of blood required means you don't need to stick yourself as deep. This means it is easier to be successful, and you are less likely to waste test strips. With a meter that can be downloaded to your computer, you can create charts to see how your blood glucose levels vary throughout the day and this can help you make better decisions of when to exercise and what to have for breakfast.

If by chance you don't have medical insurance, consider the reasonably priced meters, test strips, and other supplies from Walmart.

Before doing any testing, start by washing your hands thoroughly with hot water (as hot as you can tolerate) and soap. Once washed, dry thoroughly and then consider testing. The only time to use anything else (alcohol pad) is when you need to clean a finger for testing (and do not have access to water) and know that you have not been eating fruit and have fruit juice on your hands.

Always have the testing supplies handy and set the meter on a level surface. Next, open the container of test strips and remove one strip, close the container, and carefully slide the test strip into the opening in the meter. Hopefully if needed, you have inserted the lancet before taking the test strip out. Pick up the lancing device, arm it (by pushing the spring loaded part of the device), and prick the side of your finger near the tip by pushing the release button. Then you can gently squeeze a small amount of blood and slide the test strip into the blood.

If you are not taking insulin, your insurance will limit the number of test strips you will be able to use. This is when you will ask the doctor for extra test strips for the first three or more months to allow you to do more testing. By testing more often and especially in pairs, you will be able to determine how different foods affect your blood glucose levels.

Some doctors will not even authorize a meter and test strips and this is when it will become necessary to change doctors. Ask your doctor how you can best use your strips to learn how meals, exercise, and rest affect your blood glucose.

Before you ask, know that Medicare covers only one test strip a day for those on oral medications. This is when you must decide if you can afford extra test strips for a few months.

If your meter comes with a case, keep it and use it to hold the container of test strips, the meter, the lancing device, and a small supply of lancets. Keeping the meter in the case will help keep it clean, prevent most dirt for clogging up the opening for inserting the test strips and is just a good habit to prevent possible damage to the meter.

The last item that is important to have on hand is a sharps container or several sharps containers if you are using syringes. You can get inexpensive sharps containers at the drugstore. Or use bleach, laundry soap containers, or detergent bottles made of thick plastic that you can’t see through.

Know the disposal rules in your area and follow them. These vary by state and often differ from one city to another. It is always wise to ask.

Doctors Love to Whine about Everything

From electronic medical records, meaningful use, professional names, and now retail clinics, doctors complain and whine about almost anything of late. Maybe it is time for patients to complain about doctors. Maybe they are in the wrong profession. Yet there are doctors that have found medicine very rewarding and are not complaining, but setting examples of what works for them. They have said goodbye to dealing with the insurance companies and charge their patients a monthly fee ranging from very reasonable to utterly unreasonable.

The American College of Physicians (ACP) is trying to throttle the retail health clinics and control them out of business. They want the retail clinics to be limited in the scope of practice and all but demand that they reject patients not associated with primary care providers. The ACP is calling for research that proves the damage caused by retail health clinics and antibiotics they are likely to over prescribed.

I feel this is an arrogance that shows how doctors over rate their indispensability. Retail health clinics (RHCs) serve a valuable segment of the population and should not be regulated by other jealous doctors, but by the states if necessary. Many young people use these retail health clinics occasionally without the need for a primary care physician (PCP). They may only see a doctor once in ten years and have no need for a PCP. Yet, the PCPs see this as an opportunity to force these people to see them as well.

It often makes more sense to visit a retail health clinic than go to an emergency room at a greater cost, especially for something that is not serious. I have blogged about how state medical boards are trying to control urgent care centers (UCCs) and RHCs may face the same roadblock in many states. I am betting the job protection some medical professions are promoting may well backfire on them when people have to wait up to six months for an appointment.

Emergency rooms are now over worked and this will only become worse if some state medical boards are not limited in their powers. I cannot find the exact number, but some states have taken a positive step toward the future by joining a multi-state organization in physician licensing to support telemedicine. More of this needs to be done and supported to help blunt the coming physician shortage in the future.

Unmanaged Diabetes Equals Complications

Barry called yesterday and said he had an acquaintance with a problem. He said Allen was on the way and asked for my help also. When I arrived, Barry said that a blood glucose meter reading he had given the person said “High.” I suggested that he be taken to the hospital and the person said “No Way.”

I asked what type of diabetes he had and he said type 1. I asked when he had last taken insulin and he said he was out and had not taken a shot since the morning before. At that point I said he needed to go to the hospital as he could develop diabetic ketoacidosis and without emergency treatment he could die. What he said next shocked all three of us. He said that is the plan.

We looked at each other and I said he was going to the hospital whether he wanted to or not. When he refused, Allen called 911 and the ambulance and police were there very fast. Thank goodness for the police as he was very combative. Allen explained what was happening and when they had him restrained, he started convulsing. He was loaded into the ambulance and Allen was asked to go with the ambulance.

Barry and I followed shortly after we made sure that the police has secured his home. When we arrived at the hospital, Allen said that they had treated him and he was stable, but they were monitoring him and put him under a suicide watch. Allen said he would be transferred to another hospital that could give him the counseling necessary and make sure he had the medications needed. Then the Doctor came to talk with us. We confirmed that he had refused to come to the hospital and had not taken insulin for over 24 hours. The doctor asked us several more questions and Barry gave him what family information he knew and the doctor thanked us for calling 911.

When one sister arrived, she asked which one of us had called 911 and Allen received a big hug. She briefly said that he was having vision and kidney problems and may need a kidney transplant, but until he was evaluated, she would not know for sure. She did think that could be the reason he was avoiding taking his insulin and beyond that the family was aware that he was not taking care of himself. She stated that they had been working with him, but he was rejecting help and would not tell them what his blood glucose readings were or where his medications were located.

She asked Barry and Allen to stay until after she had talked further with the doctor and then accompany her to his house and do a search for anything that might be found. She thanked me and I left. Later that afternoon, Barry called and said they had found his medications, but it looked like he had not taken them since filling the prescriptions. They found one vial of unused insulin still within the expiration date, but no others. They had even looked through the waste baskets. They found several unpaid bills and other information that the family will need to take care of and a few other problems they will need to investigate.

Barry concluded that she had contacted the rest of the family and they were at the hospital or would be during visiting hours until he was transferred, probably the next morning.

This is scary what can happen when a person is not wanting to take care of him/her self. This is an extreme example of a patient caused complication.

Surprise Request from Tim

Tim asked for a few of us to meet with him on Saturday. We were concerned as this is unusual for him to ask a few to meet. When we were all together at his residence, Tim started by thanking us and stating that he had never planned this, as he had never had a reason to be so negative.

Tim pointed at me and said back when I had told him that I would walk out of a meeting if he ever invited a certified diabetes educator (CDE) to address the group, he thought I was not serious. He continued that now he knew why and would never invite a CDE to speak to the group. Allen asked him what had happened.

Tim stated that the medical insurance he carried had put him on a program where he needed to meet with a CDE for an hour each year and a registered dietitian (RD) for two hours each year. He had agreed to meet with a CDE, but had discouraged any contact with a RD and asked why not a nutritionist that he was meeting with for an hour each year. They finally allowed this but said it needed to be for two hours, but still felt it should be with the nutritionist they choose. This was still being negotiated, and he would keep us posted.

Barry said that the session with the CDE must not have gone well and I said it must have been with a person with dual titles (RD and CDE). Tim said dual titles and most of the hour was about carbohydrates and no diabetes education. Before you ask, I have been in contact with the insurance carrier and even they were surprised at the lack of diabetes education. Tim continued that they were not aware of the dual titles and he answered many questions about what was covered. He said that he has faxed them a copy of her business card and a formal complaint that when he is in a meeting for diabetes education, he did not consider nutrition only as education on diabetes.

I stated this is a common problem with the dual titles and I suggest you send out an email about this suggesting that people refuse diabetes education from people with dual titles unless it does not include RD or RDN (registered dietitian nutritionist). Allen said this may have been happening for many people that don't know the difference and they have been getting away with doing that. Allen asked me what I was going to do about my cousin Beverly when she became a CDE.

I said this should not be a problem as her dual titles will be RN (registered nurse) and CDE and she will be teaching diabetes education from a nurse perspective and not a dietitian. In addition, we have resolved our issues pertaining to CDE status and with her husband having type 2 diabetes, she knows how important good diabetes education is and needs to be.

Jason asked if most of Tim's session had been on how many grams of carbohydrates to eat and how important low fat was to his health. Tim grimaced and said that was the most of it and how to prepare meals to get the correct number of carbohydrates in each meal.

Barry stated that most dietitians only have a bachelor's degree, with Allison having a master's degree and Suzanne having a PhD, we are well informed, and they will work with us for good nutrition instead of promoting carbohydrates on top of carbohydrates. Jason added that they know good nutrition and teach this. They do not need to follow what the Academy of Nutrition and Dietetics promotes and are not shills for Big Food.

I said that most insurance companies do not accurately tell us what was billed and therefore we have no transparency in what was billed for us to dispute any billing. This should be done for all billings by our insurance before anything is paid and especially for diabetes education and nutrition. If this were standard, the dual titles would have to do things correctly. Plus, this would prevent double billings for both education and nutrition when it was to be for one only.