More with the Diabetes Goals

In the gathering we had in the last blog, we finally got to what medication each was taking and we were shocked that only one person was on insulin because his doctor believed that he had LADA diabetes. The rest were all on Invokana or Farxiga and metformin. Ben spoke and asked how they were doing on these medications. The fellow on insulin stated that he was doing very well and that his last A1c was 5.8 percent.

The one on Invokana asked if someone would look at the bottom of one foot. When Tim said okay, he took off his shoe and sock. When Jerry looked, he said he should see a doctor immediately and even go to the emergency room that day as he had the start of a nasty foot ulcer and possibly a second one. One of the fellows on Farxiga asked if he could look and then said he had two that were worse than that. Jerry had him remove his shoe and sock and when he saw both ulcers, he said we needed to take him immediately.

Another said he had a cracked heel and Tim asked him to remove his shoe and sock. Tim said he needs to go to the hospital as well as he had an infection in his heel and gangrene may have already started. I asked all of them if the doctor had ever checked their feet and the answer from all was no. Tim then asked if all would take off their shoes and socks and let us inspect their feet. There was no hesitation and what we discovered had us very concerned.

Tim asked if he could have all of their email addresses and there was one question of why. Tim said so that we could send them emails about our experiences, articles on foot ulcers, and articles about the medications they were taking. In addition, each of us would receive their email address and our email addresses and if they would include their phone numbers, they would also receive our phone numbers. Everyone did give Tim the information and then Tim said that they would all need out support over the next few months because of the problems they were having.

Tim said that he hoped none of them would require an amputation, but in looking at a couple of them, he could not say what the doctor would want to do. This had two of the individuals very anxious and one asked not to be taken to the hospital. Jerry said he should go and if we had caught it early enough, then he could just spend several months in treatment. If he waited, an amputation would be required.

Tim said he had one of my blogs that he would send to each of them and he would need to find the article on the SGLT2 Inhibitors causing amputations, as I had not written about this.

With that, we loaded the fellows on two vans and headed for the emergency department to have the doctor on duty look at their feet and legs. Two individuals were hospitalized after being operated on and two others were admitted for further treatment the next day. Only one was treated and released with Jerry saying that for the first few days, he would change his coverings and applying the medicine.

All four were taken off their SGLT2 Inhibitors and put on insulin while in the hospital. What else happened, we don't know at this time, but we feel better in helping these individuals.

Knowing Your Diabetes Goals

A.J called several others and me last Sunday to meet with him and Jerry. When we were all gathered, Tim, Allen, Ben, Barry, Jason, and Max were in attendance. Tim asked what was happening. A.J said that Jerry and he were talking to several people new to type 2 diabetes and they were upset with the doctors they had. He continued that the doctors were setting the goals for them and demanding that they achieve them.

Jerry said the two people he was talking with were both over 70 years of age and one doctor had told the person to achieve an A1c of 7.5 percent (at diagnosis the A1c was 11.8 percent) and at the same time consume 50 grams of carbohydrates per meal and eating three meals per day. Jerry said the fellow was overweight by 50 pounds and wanted to lose the weight, but the food plan he was on was keeping him from losing any weight.

Jerry said the second person was about Allen's age and his doctor told him to achieve an A1c of 8.0 percent. His A1c at diagnosis was 12.7 percent. He was told to consume 55 grams of carbohydrates per each of three meals. Jerry said this person was almost 80 pounds overweight and had also been counseled to consider bariatric surgery.

I suggested that we invite the persons to a meeting with us and really get down to business when we could ask them questions directly. Tim said he agreed and unless A.J and Jerry had objections to this, we should do this. A.J said he agreed and he had three people he was talking to and they were all over 67 years of age. Jerry agreed and said he could call his two people and A.J said he would call his people.

Max said he was happy that the two of us were there since we were overweight and this should help them feel more at ease. I agreed and stated that we should find out what medication or medications they were taking before going too far into the discussion.

While we were waiting for them to arrive, we discussed what some of our objectives should be and how far were should promote them. All of us agreed that we should ask them what they felt like and depending what they thought should encourage all of them to consider insulin. We all agreed that a reasonable A1c for them would be between 6 percent and possibly 7 percent but preferably below 6.5 percent.

They were all present after 30 minutes and the discussion started. They surprised us by asking questions about what medications we were using. When they found out all of us except Jerry and A.J were on insulin, they were asking why and what was our latest A1c was. When Allen said his was 4.6 percent, they wanted to know how this was possible. Allen said he follows Dr. Richard Bernstein and his “law of small numbers”. Small numbers of carbs consumed require small amounts of insulin which helps prevent hyperglycemia (highs) and hypoglycemia (lows) which are both dangerous. These can still happen, but are fewer than if we eat larger numbers of carbohydrates.

They then asked why the doctors were pushing the large number of carbohydrates and Tim said because they are not comfortable with our way of eating and still believe in low fat. Tim said we all consume lower carbohydrates and most of us eat less than 50 grams of carbohydrates per day and higher amounts of fat. Most of us consume a mid-range amount of protein, but the exact percentage each person eats will vary as we test to find out what works best for each of us.

This brought a look of surprise and two asked how we test, as their doctors had not said anything about testing anything. At that point, Barry asked if they had any lab results from their diagnosis. All shook their head and one said how do we obtain these. Tim said that they needed to request in writing for the information. You should put the information on paper, then go to the doctor's office, and ask for the information. You will be given a form to complete and sign. This will mean transferring your information to their form. Then write the date your requested the information on your paper, as you may need this later. Expect most doctors to take the full 30 days to respond and you may need to remind them that the 30 days have passed and they you are filing papers with the Department of Health and Human Services, Office of Civil Rights (OCR).

We talked for another two hours and I will have another blog on this.

Many Whining about Prediabetes Initiative

I don't understand why so many professionals in the medical community and patients are whining about the prediabetes initiative promoted by the ADA, the American Medical Association (AMA), and the Centers for Disease Control and Prevention (CDC). Yet, in the July 11 issue of the Wall Street Journal, we have something laid out for us. Sensationalized? Yes! Still this reflects some of what I have heard. The biggest fallacy in the article is saying at the top that it is the government that is promoting this, when the CDC was the only government agency involved with the initiative.

The doctors quoted in the article say this screening of millions of people risks over diagnosis of the condition and could cause needless fears. Then the article starts out by explaining was a woman says, “Honestly, I wish I didn’t know. I mean for me, because I’m healthy, there’s not much I can do besides have the stress in my head. Every time I eat something now I’m worried.”

The article uses “experts” to say prediabetes, or blood-sugar levels that are higher than normal, but not high enough to qualify as diabetes, is often best left undiagnosed.

It is known that more than 1 in 3 adults in the U.S. have prediabetes, 90 percent of whom aren't aware of it. Without intervention, between 15% and 30% of these people will develop type 2 diabetes within five years.

This is probably one of the few times I will ever agree with Dr. Robert Ratner when he says, “What is the impact of telling somebody you have prediabetes and an increased risk of diabetes? Number one, you get their attention and get them to pay attention to their lifestyle. What’s the downside of a better lifestyle?”

Then the article turns to the “experts” who say the bar is set too low on what level of blood sugar should define prediabetes. Moreover, the number of people with the condition who will develop Type 2 diabetes is far lower than the 30%.

“Most people with prediabetes have blood-sugar levels at the low end of the range - between 5.7% and 6.0%, says the Mayo Clinic’s Dr. Montori. Studies show only about 5% of people with A1C levels of 5.7% or 5.8% will progress to Type 2 diabetes within five years, and very few progress after that, he says.”

Nit picking is my answer, as this says nothing about the rest between 6.0% and 6.5% that he leaves out.

“Stop worrying. Don’t worry below 6” on the A1C scale, says Dr. Richard Kahn, a professor of medicine at the University of North Carolina. He says he suggests people who are overweight or obese to lose weight, not just those with prediabetes.”

Then in the comments section, you need to exclude those that complain about the actions of the government and go ballistic about this. I will quote two comments I found that speak for many.

Quote: First - Most Doctors/patients think of Disease as an All or none phenomenon. A significant number of people already have Heart blockage by the time they are diagnosed technically with Diabetes. We do not develop High BP or Diabetes (or even cancer) overnight. Our BP/Sugar level rises in fits/starts, in most but not all instances, over several years (maybe as long as 10 years). The damage to our various organs similarly occurs over this time period long before the "Official Diagnosis". Of course, medicines are not indicated during this period. However, lifestyle changes, incl healthier eating habits/exercise/stop smoking etc., can help delay/prevent Diabetes/Hypertension and Heart disease. Personally, I would like to know if I have Prediabetes; then I have the choice of ignoring it or taking actions to prevent Diabetes.

Second - I do not understand not wanting to improve your health and preventing vs treating. 5 years ago I was approaching pre-diabetes. At advice of my Mayo MD I joined the Y, enrolled in the Diabetes Prevention Program, lost 50 lbs which I have kept off, learned a lot about nutrition. I am an advocate for that program & have urged many to enroll, & been a poster child for them with my success.. I was somewhat healthy before, now I am better than ever & often thought to be far younger than my 71 years age. Most people who are overweight are walking time bombs, why not get healthier, it takes work, but so worth it. Yes, a lifestyle change, not a diet. Unquote

The Salt Controversy Won't Go Away

Even though this article says salt intake has become a major health concern in the United States, the main concern should be the lack of clear and good science in how salt affects the body for the different age groups and with different health problems. Whenever one point is pushed, everyone has to add their point of the argument and there is some science behind their points, but very poor science.

From reading the article several times, the one part that keeps rearing its head is what is the correct amount for salt consumption. This is where everyone disagrees. Most people have their numbers picked out and will not agree to any other number for salt intake. All the following are for one day.

• American Heart Association – 1500 milligrams
• Dietary Guidelines for Americans – 2300 milligrams
• Most US adults – more than 3400 milligrams
• Food and Drug Administration – 2300 milligrams
• Institute of Medicine – 2300 milligrams
• Grocery Manufacturers Association (GMA) – want more research

Earlier this month, the FDA issued draft guidelines for the reduction of sodium in processed foods, which accounts for around 75 percent of all salt consumption.

These guidelines aim to lower salt intake for consumers to the recommended level of 2,300 milligrams daily. This is proposed to reduce the health risks associated with high salt consumption.

How much sodium is in your food?

• A single slice of bread contains anywhere from 80-230 milligrams of sodium
• Some breakfast cereals can contain up to 300 milligrams of sodium before milk is added
• One slice of frozen pizza can contain 370-730 milligrams of sodium.

It is well known that the body needs some salt; it is important for nerve and muscle function, and it helps regulate bodily fluids.

One study, published in the journal Cell Metabolism last year, even suggested that salt consumption could stave off harmful bacteria and reduce the risk of infection.

There are many studies on salt, but few are definitive. Most have an agenda or bias in the way they were done. Some of the problems discovered include:

• Numerous studies have indicated that consuming too much salt can increase the risk of serious health problems.
• Research links high salt intake to hypertension, stroke, and heart disease.
• A study earlier this year also suggested a high-salt diet may cause liver damage.
• Another study linked high salt intake to increased risk of multiple sclerosis (MS).
• A study last month suggested that even 3,000 milligrams of sodium daily may be too little and could put health at risk. It found that adults who consumed less than 3,000 milligrams of salt a day were at greater risk of heart attack, stroke, and premature death than those with an average sodium intake. The team questioned the health risks of high salt intake, finding that it was only adults who already had high blood pressure who were at greater risk of heart disease and stroke with high salt intake - defined as 6,000 milligrams daily.
• Another 2014 study found that reducing salt intake to less than 2,500 milligrams a day was not linked to reduced risk of the health conditions associated with high salt consumption.

Despite such findings, the FDA concludes there is an "overwhelming body of scientific evidence" that reducing daily sodium intake to less than 2,300 milligrams can prevent the health risks of a high-salt diet. All government agencies are in agreement that people should consume less than 2300 milligrams of salt.

While it seems many health experts are in support of government strategies to reduce salt intake among the general public, others say more research should be conducted on the long-term health effects of low-salt diets before making recommendations.

Additionally, many researchers and organizations - including the Grocery Manufacturers Association (GMA) - believe further research is required to pinpoint the exact salt intake that is most beneficial for health.

"Like others inside and outside of government, we believe additional work is needed to determine the acceptable range of sodium intake for optimal health," says Leon Bruner, chief science officer of the GMA. "This evaluation should include research that indicates health risks for people who consume too much sodium as well as health risks from consuming too little sodium."

What surprises me the most is the way everyone is entrenched in their belief and won't consider other opinions and even many studies, flawed or not. The other objection I have is most will not consider ethnic groups and their salt needs or sensitivity. A one-size-fits-all approach is even adding more folly to the entrenched positions. A mentioned need is studies by age and comorbidities. This could help in conjunction with the different ethnic groups to determine salt needs.

More about a Few Emails

Several people were asking me about the diabetes service dogs and how soon there would be a device that could do what the dog could do. I admit I told them that a device could be developed, but most people may not know to use it when they don't feel the symptoms.

I told them that a device could be great, but if a person did not recognize the symptoms, how would they know to test with a device. I stated that many people with type 1 diabetes do become hypoglycemia unaware at different times when they have had too many episodes of hypoglycemia in a short period of time. Some may opt for the device, depending on the cost, while others will remain with the dogs because of the companionship.

A properly trained dog and an owner that knows how to reinforce the training can be an unbeatable team. This also raises the question of how much the device will cost. Will they make the device as expensive as a dog? This has entered the thoughts of many people and many are questioning this.

I have received several emails asking me why people want to keep diabetes a secret. I must admit that this is a puzzle for me as well, but some people have had close family members keep health secrets from them and they just assume this is the way to live. Some may have had friends diagnosed with diabetes and see the stigma that comes with this and decide they don't want to let others know about their diabetes.

One person said he was taught a valuable lesson while at work when he collapsed from hypoglycemia and another person with type 1 diabetes went to his locker, found some insulin and testing supplies, and told the ambulance people that he has diabetes. They tested his blood glucose and after a reading of 32 mg/dl, added a container of glucose to his IV. When he came to in the hospital and the doctor told him how close to death he came, he decided after hearing the details, he needed to tell others about his diabetes.

I am surprised at the disagreements with use of Epsom salts and soaking your feet in them. One writer said she has been doing this for about a decade and has had no ill-effects from soaking her feet. The next person said he wished someone had said something sooner as he was having problems with severely dry feet. The only thing I could question was the amount of Epsom salts that had been used to the amount of water, and the length of time they soaked their feet. The woman was using a quarter cup of Epsom Salt to a gallon of water and soaking her feet for five minutes. The man was using a full cup of Epsom Salt to a gallon of water and soaking his feet for 30 minutes. I cannot say this is the cause, but this makes one curious about other causes.

There were several emails thanking me for the parent and teen guidelines for treating young people. Several complained about the lack of doctor concern for sanitation by not washing their hands between patients or wearing latex gloves and changing between patients. The second complaint was lack of communication with the patient and the parents. Many got the feeling that the less they knew, the less they could put in a lawsuit and this was the aim of the doctor.

I had a big surprise on this blog from March 17, 2013 as people that were having problems with their meal plans that they were following from the ADA and Joslin Diabetes. When they found this blog, it answered several questions, but left them wondering what to eat to lose weight and better manage their diabetes.

This has created an interesting discussion and most were opposed to increasing their fat consumption and lowering their carbohydrate consumption below certain levels. I agreed that they should work toward that goal, but they should work to lower their carbohydrate consumption below 50 grams per day. Most were hesitant to be that low, but were willing to work to be below 100 grams. I am still encouraging them to increase their fat consumption, but this will take some time and they have had the low fat dogma ingrained in them for too many years.

I Have Been Busy Answering Emails

I have lost track of the number of emails lately, but I do appreciate them as it tells me that people are reading some of my blog postings. Plus, I enjoy being able to help people. The emails covered a variety of topics and were mainly from the last two months. There were a few topics from 2012 and 2013.

My biggest concern is the response to this and this blog. Many have concerns about why they or a parent were not told about grapefruit causing toxic medication problems for statins and heart medications. One email author said he had been told not to consume grapefruit or grapefruit juice, but his mother had not found out about it until his wife needed to take her to the hospital in serious condition one Saturday morning.

The next morning she asked for a glass of grapefruit juice and the nurse looked at the medications list and asked her if she wanted to stay in the hospital or possibly be sicker to the point of death. His mother said that grapefruit was a natural fruit and she wanted it. At that point her doctor and her son arrived and she complained about not being able to have grapefruit juice with her breakfast. Her doctor told her about the interaction with her statin, simvastatin, and that was why she was fortunate her daughter in-law had rushed her to the emergency room.

He explained the dangers and when she still insisted on the grapefruit juice, he said he would stop her statin and prescribe something else. He said she could not have grapefruit for two days because the statin needs to be out of her body before she had grapefruit or grapefruit juice. He then said he would bring something for her to read so that she could understand why she should not mix grapefruit with a statin.

When she insisted on the grapefruit juice, her doctor explained that if she had the grapefruit juice and still had the statin medication in her system, it could cause her death. She laughed and the doctor said this is why she should read the article he would bring her. He called the nurse station and had them find the article and bring it to her. When she still insisted, her son said even he had been told this by his doctor, and that was the reason he had stopped eating grapefruit.

Her son stated that even after she had read the article, she still insisted on having the grapefruit juice and when she could not, called for the nurse to dial the hospital administrator and she would give him instructions to bring her some grapefruit juice. When he would not, she told her son to get her out of the hospital even against doctor's orders.

The son stated that even when he refused, she tried to get her clothes and leave. It took her son and three nurses to restrain her. Two doctors arrived then and as she collapsed, they rushed her to the ICU unit and needed to operate shortly thereafter because she had a heart attack.

Now he is talking to the heart doctor about his mother's obsession with grapefruit juice. The doctor said that he would prescribe a medication that would not interact with the grapefruit juice.

He thanked me for writing the several blogs on this problem and polypharmacy and he may have missed this otherwise, when he was prescribed a statin and in that discussion, the doctor did make this known and was happy that he would follow the instructions. He said his mother's doctor was happy that she would not be able to drink grapefruit juice for several days and the statin should be out of her body by then.

This has become longer than I thought, but the author said he appreciated my alerting him and we have exchange several emails over the last week and he says his mother should be out of the hospital sometime Monday. He says his mother still insists on grapefruit juice, but now he does not need to worry and he or his wife will accompany her to any doctor appointments in the future. The doctor has also provided him with the current list of medications that can be adversely affected by grapefruit. He said it is almost four full pages in length.

He gave me permission to use the information.

Many Veterans Not Receiving Medical Care

Why is this happening? It is happening because a few high ranking personnel within the VA system do not want to lose their bonuses of up to a million dollars. Yes, that is right. Starting with the Secretary for Veteran Affairs and down to the State offices, they have gotten so used to the bonuses, they will do anything to keep them.

This includes declaring up to 6,000 living veterans deceased in the US and ending their benefits. It also includes increasing the paperwork to prevent eligible veterans from obtaining benefits. In the last several years, the schemes have multiplied to prevent veterans from receiving benefits.

The members of our support group have generally received benefits, but many are being delayed and or rescheduled for periods up to three months. I have been postponed now for the last three times and various excuses are given me.

Other than the fact I don't like traveling when it is snowing, I will now need to take my chances and now I will be forced to travel in either January or February. I had avoided this for several years, but continued delays will now make this happen.

We know this is being directed by someone at the state level and it involves transfers of doctors, and someone in the local office providing information to that person.

Do I expect repercussions from this blog? Possibly, but I am not sure what will happen. I do know how I will react if there are problems.