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.