Have Prediabetes, Steps to Take Now

Receiving a diagnosis of prediabetes can be a good thing. Still many people do not use this wake-up call and let it progress to type 2 diabetes. I was not one of the lucky ones as I was diagnosed with type 2 diabetes shortly after the ADA had the “experts” declare the range of 100 to 125 mg/dl as prediabetes in 2003.

Receiving a diagnosis of prediabetes should be a serious wake-up call, but most doctors refuse to give this to patients. The doctors still use the terms “watch what you eat as your blood sugar is creeping up,” or “your blood sugar is elevated.” Other doctors still use the older term “borderline diabetic”, or that you have a “touch of sugar.” Most times you will not even be told anything if your blood glucose levels are less than 115 to 120 mg/dl.

The above is the reason to always ask for a copy of all test results. This is how you can check what your doctor tells you and you will know if you have prediabetes.

Knowing that you have prediabetes does not mean that you will definitely develop diabetes. You often still have time to prevent the development of type 2 diabetes. You and you alone have an opportunity to initiate changes and possibly prevent the progression to type 2 diabetes. Consider making these seven changes in your daily habits.

1. Move More Becoming more active is one of the best things you can do to make diabetes less likely. If it's been a while since you exercised, start by building more activity into your routine by taking the stairs or doing some stretching during TV commercials. Physical activity is an essential part of the treatment plan for prediabetes, because it lowers blood glucose levels and decreases body fat. Ideally, you should exercise at least 30 minutes a day, five days a week. Let your doctor know about your exercise plans and it is important to ask if you have any limitations.

2. Lower Your Weight If you're overweight, you might not have to lose as much as you think to make a difference. In one study, people who had prediabetes and lost 5% to 7% of their body weight (just 10-14 pounds in someone who weights 200 pounds) cut their chances of getting diabetes by 58%.

3. See Your Doctor More Often See your doctor every three to six months or find a different doctor if he has refused to recognized prediabetes. If you're doing well, you can get positive reinforcement from your doctor. If it's not going so well, your doctor can help you get back on track. Patients like some tangible evidence of success or failure.

4. Eat Better

• Load up on vegetables, especially the less-starchy kinds such as spinach, broccoli, and green beans. Aim for at least three servings a day.
• Add more high-fiber foods into your day.
• Enjoy fruits in moderation - 1 to 3 servings per day.

Also, swap out high-calorie foods. Drink whole milk, diet soda rather than regular soda. Choose fatty versions of cheese and yogurt. Choose fresh fruit and peanut butter.

5. Make Sleep a Priority

Not getting enough sleep regularly makes losing weight harder. A sleep shortfall also makes it harder for your body to use insulin effectively and may make type 2 diabetes more likely. Set good sleep habits. Attempt to go to bed and wake up at the same time every day. Relax before you turn out the lights. Don't watch TV or use your computer or smartphone when you're trying to fall asleep. Avoid caffeine after lunch if you have trouble sleeping.

6. Get Support Losing weight, eating a healthy diet, and exercising regularly is easier if you have people helping you out, holding you accountable, and cheering you on. Consider joining a group where you can pursue a healthier lifestyle in the company of others with similar goals.

7. Choose and Commit

Having the right mind-set can help. This means having a positive attitude above all else. Accept that you won’t do things perfectly every day, but pledge to do your best most of the time. Make a conscious choice to be consistent with everyday activities that are in the best interest of your health. Tell yourself, ‘I’m going to give it my best. I’m going to make small changes over time.’ These changes will add up.

A New Problem for Several of the Group

I hadn't realized how important this is until Barry called Tim and me about an individual newly diagnosed with type 2 diabetes. Because of the extreme elevated A1c, he had been prescribed insulin. Barry had been at the pharmacy when he went to pick up his prescriptions. When the pharmacist said he needed the syringes, the fellow said that there was no way he would stick himself with a needle. And, there was also no way he would stick his finger to draw blood.

When we arrived, Barry was doing his best and Allen who happened to be there for a prescription was helping. When Barry finished telling us the happenings, we shook our heads and asked the fellow if he wanted to die. I said all four of us use insulin and think nothing about pricking our fingers and injecting insulin, which we need.

The fellow said that he would not prick his finger and would not even consider injecting insulin. Tim asked why and if he was afraid of needles? His answer surprised all of us. He was not afraid and had used needles in the past when he was on illegal drugs. That was the reason he would not be caught again and go back to prison for using needles.

I said that had an easy remedy and as long as he had a copy of the prescription and a letter from the doctor, they should not bother him longer than to confirm the information. I said I had a run in with a policeman a couple of times but my boxes with the vials inside have a prescription on each and once they see that, they thank me and move on. I added that he could also go to the police station and show them the medications and prescription and that should help.

That got his attention, he asked the pharmacist for a copy of the prescriptions, and she ran copies and said that if he took the needles and insulin they would have prescription information on them as well. The meter and lancing device would not as a prescription was not required to obtain one. He paid his bill and asked who would go with him. Tim and I agreed and we followed him to the office.

The officer in charge recognized him and asked why he was there. He said I now have needles and insulin and wanted the department to know that I was not on illegal drugs. He laid the insulin and needles on the counter, they were looked at, and the prescriptions read. They made one phone call to the doctor and then handed everything back to him. They thanked him for making them aware of what had happened and this is appreciated. They stated that all would know of this and as long as he stayed clean, he would not be bothered.

With that we left and he asked Tim if he would show him how to test. He said he had been given starting amounts to inject and he would start there. Tim said he would and they got into Tim's car and he showed him where to prick his finger and receive enough blood to get a reading on his meter.

Tim emailed us that things had gone well and he was on track to bring his diabetes under management. Tim did say that the person was invited to our next meeting in February. He added that he felt that the diagnosis had been made late and insulin would be needed, but said the fellow will be working to attempt to get off all medications. Tim said he had sent him an email with the email addresses for the four of us and we now had his email.

Treat Prediabetes as Type 2 Diabetes

Yes, this should be done. First, some definitions – Prediabetes = blood glucose levels of 100 mg/dl to 125 mg/dl and diabetes is considered anything above 125 mg/dl. As I stated in my previous blog, we should treat prediabetes as diabetes, no more and no less. It isn't even humorous that the majority of doctors ignore prediabetes completely.

You may hear doctors comment that, “watch what you eat as your blood sugar is creeping up,” or “your blood sugar is elevated.” Other doctors still use the older term “borderline diabetic”, or that you have a “touch of sugar.” Most times you will not even be told anything if your blood glucose levels are less than 115 to 120 mg/dl. We recently had a friend of Allen's comment that his blood glucose was 103 mg/dl and his doctor did not say anything. Allen asked him how he knew even this and his friend answered he always asks for a copy of his tests. His blood glucose test before the last one had been 98 mg/dl.

Allen said his friend had asked him if he did not have prediabetes and Allen agreed that he did. Allen said they had talked the rest of the evening about what he could do to gain control of his prediabetes. Allen covered the food plan that most of us use and developing an exercise plan. Allen said he had a substantial exercise regimen in place so they spent most of the time on a food plan. Tim suggest that he tell his friend that if he went above 115 mg/dl that he ask for a minimum dose of 500 mg (off-label) to be taken with his evening meal. Several other members that were gathered with us agreed.

I explained that it really did not matter, as any reading over 99 mg/dl meant that his pancreas was having problems and should receive assistance whether with exercise, a low carb, high fat (LCHF) food plan, or a medication. Tim agreed and added that is best for slowing the decline or healing of the pancreas. The younger a person, the best chance of healing and preventing the onset of type 2 diabetes. In an elder person, healing may not work, but often can delay the onset of type 2 diabetes.

Barry asked if his friend was testing and Allen said they had talked about this, but not made any decisions. Tim said that we should always suggest that they obtain a meter and test strips they can afford and if they have problems with this, they should consider a meter and test strips that they can obtain at Walmart. I agreed with Tim and said that once they have a meter and test strips, someone from this group should spend time explaining the best method of testing and what the test results mean, by teaching Self-Monitoring of Blood Glucose (SMBG). Then we should explain goal setting and what might be reasonable goals for them.

Brenda said that we should suggest various goals. She asked for anyone that disagreed to say something and we would discuss each point. Since we are dealing with prediabetes, fasting should be from 65 to 100 mg/dl and not higher. She said that fasting readings of higher than 100 indicates the need for meal plan concern and possible metformin. Postprandial should always be below 140 mg/dl and preferably not higher than 120 mg/dl. Readings higher that 140 mg/dl indicates meal plan problems and need for metformin possibly two times per day. She said I know this disagrees with the metformin recommended before, but until they bring the number of carbohydrates down and increase the fat consumption, metformin may be necessary.

This generated some discussion and most wanted the postprandial set at 120 or 125 mg/dl. We agreed on 140 to begin until they had a good meal plan (LCHF) and then bring it down to 120 mg/dl. Some felt that fasting should be 65 to 90 mg/dl, but most were comfortable with the 65 to 100 mg/dl. Tim also felt that anyone with fasting numbers 100 or above should ask for an HbA1c test and everyone agreed. We all agreed that even with the term prediabetes, we should consider it as the earliest stage of type 2 diabetes.

Is Metformin Losing Its Luster?

The current black box warning may be overstating the kidney risk. Yet, we need to use some caution. Metformin has a reputation of being a real blockbuster drug and is the primary drug in the treatment of type 2 diabetes. This may be a potential problem due the FDA and the limit placed on it usage. The current label carries a contraindication against the use of metformin when serum creatinine levels exceed 1.4 mg/dl in women or 1.5 mg/dl in men.

Despite its establishment as the first-line therapy for type 2 diabetes, about one-half of the patients currently in the United States do not take it. A major proponent of this is its current labeling, which expresses, for some, unjustifiable concerns about its use for treatment in those with mild to moderate renal insufficiency.

In the last few years, clinicians in the USA have developed an overwhelming consensus that the US Food and Drug Administration (FDA) labeling for metformin could be more lenient and also that it can be expressed in more precise estimated glomerular filtration rates (eGFRs), rather than serum creatinine.

The FDA's initial rationale behind the label was due to resilient evidence that phenformin caused lactic acidosis (another biguanide which has been removed from the US market). Metformin is cleared from the body via the kidneys and for patients with significant renal failure, there were increasing concerns that metformin could potentially build up to relatively high levels that could leave patients to have lactic acidosis. There is now an overwhelming two decades’ worth of research and evidence showing no serious increased risks for lactic acidosis in patients with mild-to-moderately impaired renal function.

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have furthermore supported the removal of restrictions on metformin, propagating the notion that practitioners “would continue to prescribe metformin even when the eGFR falls to less than 45 to 60 mL/min/1.73m2, perhaps with dose adjustments to account for reduced renal clearance of the compound. One criterion for stopping the drug is an eGFR of less than 30 ml/min/1.73m2.” It is important to note that patients with chronic kidney disease would require stringent follow-up of renal function.

One of the most recent studies published on the potential impact of metformin eligibility for adults in the United States assessed 3,902 patients with diabetes who partook in the 1999-2010 National Health and Nutrition Examination Surveys. These patients were eligible if the serum creatinine levels met the eligibility markers “of less than 1.4 mg/dl for women and less than 1.5 mg/dl for men along with eGFR categories (likely safe, greater than or equal to 45 mL/min/1.73 m2; contraindicated, less than 30 mL/min/1.73 m2; and indeterminate, 30–44 mL/min/1.73 m2).” Different equations were used to measure eGFR, including: four-variable MDRD, CKD-EPI, CKD-EPI cystain C and Cockroft-Gault with diabetes itself being self-reported or for patients with an A1C greater than 6.5%.

The results of this particular study demonstrated that by replacing the serum creatinine threshold with eGFR thresholds, practitioners were able to expand metformin’s utilization for patients without any significant safety concerns. Findings noted that metformin use amongst patients with an eGFR of 90 ml/min or higher was 90% with a slight drop to 80% with an eGFR of 60 to 90 ml/min. Even with patients with an eGFR below 30 ml/min were found continuing use of metformin; based off of the collected results, an estimation could be made on how many additional people may have benefited from starting therapy (approximately 425,000 patients if the data was from the 60 to 90 ml/min group and almost 560,000 patients if expanded to the 30 to 60 ml/min group). The key main findings of the study include: metformin use has increased in the past decade or so for treatment of type 2 diabetes and implementing eGFR or CrCl rather than serum creatinine thresholds for eligibility of use could considerably expand the utilization of the drug. With greater use of metformin, there is consequently tighter glycemic control, resulting in improvement of healthcare.

Looking forward to the future, additional research is imperative, including prospective randomized trials of metformin at multiple stages of renal injury and a much closer examination of archives of CKD patients taking metformin.

A Blog Worth Reading by Everyone

This is one blog I can easily recommend that everyone read. It is a shame that we in the USA do not have doctors like this that would be helpful to people with all types of diabetes.

Again, I would urge you to read this blog to better understand what we are missing in medical care in the USA.

Bariatric Surgery Patients Often Have Mental Health Problems

When a few of the new members read this in endocrinology advisor, they were concerned about two friends that were setting up for bariatric surgery. Janet was very concerned about her friend and Millie was concerned as were several others that knew their friends. They asked Tim and me to come and talk with them about what they should know.

Both Tim and I were somewhat aware of the problems, but we reread the information. Apparently, depression and binge eating disorder are common among patients seeking and undergoing bariatric surgery. This is according to the data published in JAMA recently. Janet and Millie both said that both of their friends often suffered from depression and Janet said her friend had the habit of binge eating regularly. Millie said her friend seldom binge ate, but has a few times when she in going into depression.

Tim suggested that they should see professionals before the surgery to find out if they would talk about these two mental health problems. Janet asked why we called binge eating a mental health problem. I said because it is something that is a problem that needs to be addressed and it has mental health ramifications. Millie said she could understand this and did see the need for counseling about this. Tim suggested that they have their friends receive counseling before bariatric surgery and not have the surgery until they have the counseling.

Tim asked if they knew the weight of the two individuals. Janet said her friend was about 340 pounds and Millie said her friend was about 300 pounds. Tim said that while both of us did not favor bariatric surgery, it is one method of promoting weight loss and improving weight-related comorbidities in obese patients, but mental health has received less attention. Mental health conditions may be common in this patient population; research on the prevalence and their association with outcomes after bariatric surgery varies.

Random-effects pooled estimates revealed that 23% of patients seeking and undergoing bariatric surgery had a current mood disorder, most commonly depression and 17% were diagnosed with binge eating disorder.

Both estimates are higher than published rates for the general U.S. population, suggesting that special attention should be paid to these conditions among bariatric patients. Other mental health conditions, such as psychosis, PTSD, and personality disorders are less common but may be more prominent in select subgroups such as U.S. veterans.

Data regarding the link between preoperative mental health conditions and postoperative weight loss were conflicting. Neither depression nor binge eating disorder was consistently associated with differences in weight outcomes. However, bariatric surgery was consistently associated with an 8% to 74% decrease in prevalence of depression in 7 studies and a 40% to 70% decrease in the severity of depressive symptoms in 6 studies.

Future studies would benefit from including these characteristics as well as having clear eligibility criteria, standardized instruments, regular measurement intervals, and transparency with respect to time-specific follow-up rates. By addressing these methodological issues, future work can help to identify the optimal strategy for evaluating patients' mental health before bariatric surgery.

Problems Removing First Test Strips from a Vial

I am seeing people complain about their finger size and removing the first test strips from a vial. I believe most have this problem to a small or large degree depending on the size of your fingers. Some people are capable of using their small finger, but most of us probably are not able to use them.

What I did was to obtain a plastic tweezers that I have adapted for removing the test strips until I can comfortably remove them with my finger. No, I did not say a metal tweezers! If you wish to ruin several test strips (a dozen or so), go ahead and get a metal, but I won't recommend wasting money like this. Most pharmacies have or can order them and this is what I did.

Then I take a quarter inch wide rubber band and using glue, I attach to the inside and wrap it to the outside so that one leg of the tweezers has a rubber on three sides. Trim to remove excess on the ends of the rubber band. Then attach a short piece to the other leg on the inside only.

When the glue has dried, it is ready for use. I then use the leg with the rubber band on three side and use the outside to align with a test strip and use just enough pressure to raise one test strip above the rest and rotate the three sides to retain a grip on a test strip and bring the other leg against the other side of the test strip to fully remove the test strip. Occasionally in the process, two test strips will adhere together and you will need to start over on a different test strip. I also hold the vial of test strips at about 45 or 50 degrees to make it easier to raise a single test strip.

Often it is easier just to use the tweezers and insert it into the meter. Then set the tweezers aside, use the lancing device, and lance the finger for testing and after having enough blood, slide the meter with the test strip into the blood so that it can wick the blood into the test strip.

Note: It did take some practice to efficiently remove a single test strip and insert it into the meter, but practice was worth getting the test strip remove from the vial and into the meter.

This is neither FDA approved nor a recommendation by the test strip manufacturer, but it works for me and saves test strips being damaged and saves my fingers.

More Support Group Members Angry with CDEs

Alice sent out an email to several members asking what to do. She had a session that was to be about diabetes education and because she had converted to insulin the day before, she was looking forward to some education. However, she did not received any diabetes education because the person had a dual title RD/CDE with her.

Alice said they started out with carbohydrates immediately and she should be eating low fat and about 55 grams of carbohydrates per meal. Alice said the session was supposed to be on diabetes education and since they were not going to teach this, she was leaving and filing a complaint with the insurance company. Alice said she left with them laughing behind her and felt they would be doing this to more of our people if allowed.

Tim called a meeting for all that could attend.  Because of the extremely cold weather on the weekends we had canceled our January meeting on January 16.  It turns out that the weather for January 23 was to be warmer.

When the meeting started, Tim said we have a real problem with CDEs and they are out to create problems for our group. They have been bringing in dual title RD/CDE to avoid teaching anything about diabetes. To date, we have avoided the insurance companies paying for this lack of diabetes education when a referral happens for education. The point they are doing is switching to nutrition and trying to bill for time that belongs to Allison or Suzanne.

Tim thanked Alice for calling the insurance company to prevent them from billing for teaching nutrition and eventually they will give this up, but for now we will be sending everyone reminders to not let this happen, even accidentally. We as a group now have Allison and Suzanne approved for nutrition for all members. They work with us and do not insist on whole grains and a set number of carbohydrates. With them doing what we need, our group receives great nutrition advice and they work with the number of carbohydrates we want to consume individually.

Alan, another of the new members asked if someone wanted a registered dietitian, would we allow this. Tim said we don't demand this, but we encourage everyone to use Dr. Bernstein's “law of small numbers” to keep medications low and prevent problems. We don't follow his numbers exactly, but suggest using your meter and testing in pairs to determine what works for you. Many of us limit our carbohydrate consumption to 50 grams or lower. We have three that are using 80 grams of carbohydrates, but we know that works for them. Alan said he was checking, but he liked the lower number of carbohydrates and agreed with our suggestions.

Allen said that was okay, as we don't demand anything, but hope that everyone sees the value in what we suggest. Jason said we started out as a group of three and then doubled our number and have continued to grow. Jerry said that about 14 that were using his now ex-wife came over to this group and several went back to her, and we have two of them back after their A1c continued upward. That was a time when we had a few problems or growing pains and we learned from that.

Alice said she felt part of the group and was happy for the support she received for walking away from being taught nutrition by a dual title. She admitted that she was feeling better after asking questions about being hungry and being advised by several to increase the amount of fat in my meal plan. This solved my hungry problem in two weeks and now I am very comfortable with the food plan. Testing is a key and while many of us don't like purchasing some testing supplies on our own, it has been worth every dollar to have an A1c below 6 percent and nearer to 5 percent.