What a Doctor Doesn't Say Could Be Important

This is a topic of some consternation among several of our members. We have two potential new members that are saying that the doctor told them they were 'normal.' However, when looking at the lab reports, which they did receive, we can see that their health is in jeopardy.

The fasting blood glucose reading for one individual was 146, but the A1c was 6.0 percent. This indicates to us that the pancreas is already in trouble when the fasting blood glucose level is 146 mg/dl. The total lipid panel was listed as over 300, but the HDL (good cholesterol) was 64. The triglyceride reading was 162 and the LDL reading was 95. Several other tests were just listed as high and gave no other information. Ranges were not listed for any of the tests. The second individual did not want to show us his lab reports, but said they were near the same.

When Allen compared the lab report of the first individual to his last VA readings, he was very concerned. Then he took his lab report and went to see the second individual. He had to cajole the person into letting him see his lab report. Allen would only say that his A1c was 6.4 percent and all the other readings were not good.

When we heard that, we asked if we needed to have them see another doctor. We all agreed that should be our goal and Barry said he would work with the first individual and Allen said he would work with the second person. Tim said he would talk to Dr. Tom and find out if he would see them.

Everything happens for a reason and both individuals agreed and Dr. Tom saw them the next day. Tim reported that both individuals were shocked when they had the lab reports explained to them and what each area meant. Dr. Tom explained that the lab reports were tailored to what their doctor wanted them to see and were not the lab reports they should receive. He had the correct format with what should be shown and he explained what they were missing. When asked if what the doctor told them was correct, Tim said Dr. Tom told them they were okay, but facing potentially serious health conditions. He said they were healthy, but not where they should be and urged them to change some lifestyle habits.

Since neither was seriously overweight, they should increase their exercise if possible, reduce the amount of carbohydrates they consumed, and unless they objected, he would like to see them in about two months and have lab tests done the week before. Barry and Allen said they would and in conversations with them after their appointment, they were asking why their doctor would not tell them how serious things actually were.

Tim, Barry, and Allen explained that many doctors would not until they had something they could treat. Tim explained that is one reason we suggest and took you to a doctor we trust that will explain what is happening with your health and in this case prescribe testing supplies and off-label metformin XR to help prevent type 2 diabetes.

Several of us were invited for this discussion and the two individuals had more questions, which we said was normal even after Dr. Tom explained several things. Plus, we also knew that after getting away from the doctor office, we knew they would relax and start having many more questions. Both were asking about the side effects of metformin. At that point Sue started explaining the side effects and why they had the version they were prescribed which would have the less aggressive effects. Sue explained that if they wanted an upset stomach and diarrhea, then crush the pills. The extended release meant the medicine was time released and they would not have the effects all at once. Sue continued that the full effects of the medication would not be happening for two or three weeks and by then any side effects would be in the past.

At that point we assigned names to them. Jon was the first and Jolly was the second. A.J explained that the reason for increased exercise as to lose the few pounds needed to bring them to ideal weight and to lessen the fat around the middle, or mostly adipose fat. He continued that most doctors do nothing to prevent diabetes and when you are diagnosed, will put you on oral medications first and then keep stacking oral medication after oral medications. They will use insulin as a threat to keep you on oral medications until insulin becomes a necessity.

Because of the cost, Dr. Tom will not prescribe insulin to those in pre-diabetes, but will consider it as soon as you are diagnosed with diabetes. This will help your pancreas heal and can prevent further damage. In addition, if insulin helps, then you may be able with exercise and nutrition, be able to get off all medications for several years to several decades. Both Jon and Jolly asked for resources and wanted to talk further on another day. Barry and Allen said they would get their email addresses and send them information.

George Found Some Time to Talk with Me

Before I left the Sunday gathering, George indicated he would like to talk with me even if by telephone. I said I would be available Monday and Wednesday evenings and from 3:20 PM to 11:00 PM and he said even at your apartment. I said yes and indicated that with my wife working second shift she did not get off work until 11:20 or later, but that I picked he up so that was the reason for the earlier time. He said he would call when he found the time, as he did want to ask some questions.

Now I am curious and have to wonder what George is going to want to talk about. Therefore, until he calls, I will stop this for now.

Monday evening about 9:20, George called. He said that he had some questions for me about getting married again. He knew that I had remarried a few years after my first wife passed and he was wondering how we were doing. I told him there were pros and cons and it would depend on him and his new spouse.

He admitted that he had not given it much thought until he had met my wife when he was here before and had done some searching on the internet and found several websites for corresponding with women overseas and had used one to get the names of three women and had been corresponding with two for about two years. He had been to the country, met one, and was thinking about returning to meet the other woman.

My first question was how much older he was to each woman and he answered 9 years for one and 12 for the second. I said that is better and there were many things he needed to think about and the age difference was definitely one of them. I asked him if either knew how to drive and he said they both knew how to drive. George said that was one reason he wanted to get away from the large city and to a smaller town. I said that the cost of operating and insuring a second car needed to be considered. I added that a large city could be an advantage as most women will what to go shopping and there is more selection in a larger city.

I said that getting her naturalized was not cheap and they would need to travel further here. We discussed this for some time and then I asked what they did in their country. One was a nurse and the other a doctor. I said that there would be additional schooling needed here for being either in this country. George said that the doctor had obtained her degree here and had worked for several years in a hospital before returning to her country when her parents became sick.

We discussed several other potential problems and possible solutions and George asked if this could be why both were pushing him to bring them to the United States. I said this sounded very possible and I would suggest investigating whether they could already be married and would request a divorce as soon as they became naturalized and then request that their husbands be brought to the U.S. George was shocked by this, but we talked some more and he said he would do some checking and I agreed that I could do some checking also and see what we could find out. We agreed to stay in contact and compare findings.

Insulin and Weight Gain

This blog about insulin and weight gain is one of the better blogs on the topic I have read. It is written by a certified diabetes educator (CDE), so I will need to be cautious. I do have a greater understanding of the difficulty of losing weight as a person on insulin. Would I go back to oral medications if I could – no way – the management of my diabetes as a person with type 2 diabetes is so much easier and more effective than any oral medications.

Have I had hypoglycemia from taking insulin? Yes, but very rarely. In the almost 13 full years of being on insulin, I can still count the number of episodes on ten fingers and have a couple to spare. Is my carb counting that exact – I doubt it, but I don't inject all the insulin at once and generally test to see if I might need more and how much more. In general this means keeping my blood glucose levels under 150 and closer to 120 two hours after eating. For the few times I get above 150, I immediately add the extra insulin to assure myself of bringing it back down to approximately 90 at four hours.

In a few of the author identified blogs, Nora Saul at the Joslin Diabetes Center, does an excellent job of explaining why people have such a large problem with weight gain and lays the blame squarely where it belongs, on both the patient and doctor. The patient for not wanting insulin and the doctor who encourages patients to stay on oral medications. It is this treatment of last resort that makes for problems of weight gain. It is also the myths about insulin and the fear of the patient and doctor about hypoglycemia that prevents using it early on when it would be more beneficial.

Both the patient and doctor need education in the use of insulin to make it an efficient treatment without the fear of hypoglycemia. Plus what many people forget, by starting insulin use early, this allows the pancreas some rest instead of complete burn out and not requiring the quantity of insulin when the pancreas is all but done and insulin is used as the treatment of last resort.

Also important is the consideration of nutrition and exercise, which is often easier before the weight gain. Quoting Nora Saul, “one reason people with type 2 diabetes often see the pounds pile on after they begin taking insulin is that they've waited too long to start.” I have written about this before and do believe this to be very true.

Please read the full blog by Nora Saul for her full explanation of what happens when you as the patient and your doctor avoid the use of insulin until it is absolutely necessary. You are not doing yourself any favors and only damaging your body by letting your blood glucose get too high and thereby undermining the normal metabolism of carbohydrates and fat. I have several Type 2 friends that can agree that waiting too long to start insulin is not a good idea. They will tell you it is better to start early.

Many people are not educated in counting carbs correctly and then enter the vicious cycle of hypoglycemia and eating to correct it. They often eat too many carbs for correction and then develop hyperglycemia – too high a blood glucose level. Another problem is the injected insulin (the short acting) stays in your body about twice as long than your own insulin ever did and as a result, you end up feeling hungry. This is when you need to learn that you don't need food, and must force yourself to avoid food.

Eating at regular times becomes more important to know how to gain the advantage of ignoring the hunger as too many people feed the hunger and the management of diabetes goes out the window. It does take some discipline at the start, but with time the hunger pangs will subside and become easier to manage.

She does recommend seeing a CDE for education, but I would urge you to see a good dietitian or nutritionist, specializing in diabetes, that may not push the old American Diabetes Association way (unless you are a patient at Joslin Diabetes Center), but will use the new guidelines of individual needs and desires being more important. The key here is balancing the nutritional aspects of the food you eat and learning that the old ADA way often has too many carbs which will (I mean will) help increase your weight and keep you on an upward trend. You will need to adapt to the number of carbs that works for you and does not increase your weight.

When you take insulin, glucose is able to enter your cells, and glucose levels in your blood drop. This is the desired therapeutic goal. But, if you take in more carbohydrates than you need to maintain a healthy weight — given your level of activity — your cells will get more glucose than they need. Glucose that your cells don't use accumulates as fat, hence the weight gain. Therefore to prevent weight gain, be prepared to reduce the number of carbohydrates you consume on a daily basis.

Find Help and Support That Works for You

I normally don't look for ways to disagree with doctors, but recently I could not avoid disagreeing with a doctor. I don't like being backed into a corner and I came out more aggressive than I like, but this doctor was pushing all the wrong buttons and seems determined to create a hostile confrontation.

He was telling me that I should pay more attention to some websites than I do and pay less attention to others. He was pushing WebMD harder than I would ever consider, but I did agree that sometimes there is learning you can do on many websites, even this website.

He selected this topic from WebMD and I said I have already used it for a blog. He agreed and wondered why I had passed on discussing this section.

You need a medical team that knows diabetes inside and out. They could include:

1. An endocrinologist, who has a lot of experience working with people who have diabetes
2. An ophthalmologist for your eyes
3. A pharmacist, who's familiar with all your medicines
4. A registered dietitian, who can give you pointers on what to eat
5. A diabetes educator

Now I said that was done for a reason and he wanted to know why. I tried to evade the question and he was having none of it. I said that the first three could be excellent choices, but the last two could be horrible choices. I said I have had less than pleasant experiences always with number four, and too many relatives that are number five. I do not work well with those in number five that have dual titles or more titles.

Now the doctor wanted to know which dual titles and I said #4 and #5. I then added how inadequate the list was. Where were other professions that a person might need? Now the doctor had to agree and he asked which professions. I said the list could include any of the following:

1. A podiatrist for foot care
2. A cardiologist for caring for you heart and blood system
3. A neurologist for brain and nerve care
4. An urologist for bladder and kidney care
5. A primary care physician for health care
6. Other doctors as the need is there

When I stopped, he insisted on knowing what other doctors I might need. I said possibly a surgeon, an ear, nose, and throat doctor, a hearing doctor, a sleep doctor, and I added that the list could go on. I said that every person is different and could need different doctors as no OB/GYN has been mentioned. A therapist and many other specialists are missing.

Then the doctor asked why I was so against registered dietitians. I said because they have a national organization that is trying to make them the only source for nutrition. I said that most do not have but a bachelors degree and think they know everything about nutrition. Most promote high carbohydrate consumption and low fat food plans and do not accept other meal plans.

As people with diabetes, we need to limit our carbohydrate consumption and increase our fat consumption. Some can increase protein intake, but others should not and most registered dietitians will not accept this.

Since I knew that the doctor I was talking with was a mental health therapist, I said that many people refuse to see a therapist because they often hear this - “It is only in your head.” For people with diabetes, stress and depression can be a fact of life when managing diabetes. The doctor said okay, I may have deserved that, but I also have type 2 diabetes and can understand where you are speaking about diabetes.

If you want more, read my previous blog on diabetes support.

George Here for Another Visit

Last Sunday, Barry called me and said that after three years, George was here for another visit. He asked if I was available to come over, as he would be here only through Thursday. I asked the time and he said about 4:00 PM. Barry said several other members would be there as well.

I arrived on time and yes, there were more than a few members. I counted 20 members and George was definitely enjoying having everyone there. Then Barry asked what his latest A1c was. He responded 5.4 percent and asked if anyone was lower than that. He was surprised when Allen spoke up and said 4.8 percent and A.J said 4.5 percent and Sue said 4.9 percent. Barry said A.J and Sue were not on any diabetes medications and only Allen is on insulin and uses Dr. Bernstein's “law of small numbers” to prevent hypoglycemia.

Then George said that he thought he was doing great, but he admitted compared to these, his A1c was not that great even though he was now off diabetes medications. Tim spoke up and said it still was and the rest of us were all higher than his A1c. He asked if anyone disagreed with this. The answer was an emphatic “NO”.

Next, George asked if he could talk politics, and received another no. Sue spoke then saying that that is not a topic we allow and religion is another. We agreed to this a long time ago and we have held to this. Now anything about diabetes and diabetes related is open for discussion.

George looked very disappointed and thought about this for a while and I just stated we don't go there. George asked me if I didn't include politics in my blog when talking about Obamacare. I said I have made some disparaging remarks, but I don't go further. I said many of us do not like the current healthcare plans and how patients are treated under Obamacare, but that is as far as even we carry this.

At that point George asked if we could talk about Medicare and the best plan. I asked if he had given up on his VA plan and George said no, but he was having trouble matching up to the VA with his Medicare. I said then he, Ben, Barry, Allen, and a few others could discuss later when we would not exclude the others and Barry said that was a good idea.

I asked George if he had done the reading he wanted to and George said he had and thanked me for pointing him in the right direction on the Librarys. He had joined the city library and said he was able to find the books I had and several others. He had even found Dr. Bernstein's book, “Diabetes Solutions.” He could now understand why we held the book so valuable even though we were all type 2's. He even understood why Allen was using his “law of small numbers,” and even he had used it to get off and stay off all medications with the approval of his endocrinologist.

George admitted that the endocrinologist was not in favor until he explained how he was doing this and that he would continue testing to monitor his blood glucose and go back on medications if needed. With the A1c levels that kept improving the endocrinologist said he had never had anyone have success before and he was learning with him. Sue said her husband was back on medications because of all the travel he did in the summer and lack of exercise while traveling and thanked George for sticking with his exercise.

George said he wanted to compare notes with her and with A.J if possible. Both Sue and A.J said they would find time to talk with him.

Tim asked George if he had found a support group of about 40 people and George said in a way he had, but it was too formal for him and when they told him of the dues, he decided he did not need to join. He continued that they had dues of $10 per month ($120 per year) used for paying speakers. He said this was too steep for him and eventually found a smaller group of 10 people and he was happy with that group as they met in people's homes on a monthly basis and they had no dues but a yearly fee of $20.

George said he was happy to continue receiving the news emails from our group and always appreciates them. He feels they keep him in touch with his friends here and wonders why the group he belongs to doesn't do the same, but neither group does this. Next, he said he is considering moving here, but needs to do some investigating. That is why he made the trip now.

Stress and Illness Do Cause Hyperglycemia

Have you had higher that expected blood glucose readings lately? If so, have you been ill or do you have an infection? Have you checked your feet and lower legs lately? Or, are you coming down with an illness?

If none of these is answered yes, do you have extra stress in your life – from your job, or possibly marital stress, or financial stress?

All of the above can cause higher than normal blood glucose levels or hyperglycemia. Stress or illness can trigger high blood glucose because hormones produced to combat illness or stress can also cause your blood glucose levels to rise. So, what is hyperglycemia you ask? Simply stated, hyperglycemia is any blood glucose reading above normal. Normal is a more difficult measure and varies by who you are talking about and which diabetes organization you believe.

The American Association of Clinical Endocrinologists generally says that anything over 140 mg/dl is hyperglycemia. The young people below age 21 can have a higher reading. The American Diabetes Association is much more liberal. For adults 180 mg/dl is the start of hyperglycemia. For below the age of 21, they allow 225 mg/dl for school-age children and up to 250 mg/dl for preschoolers.

People who do not have diabetes can make enough extra insulin to keep their blood sugar in a normal range during times of stress and illness. People with diabetes may need to take extra diabetes medication to keep their blood glucose near normal during times of illness or stress. If you haven't been given special instructions on how to manage your diabetes medications during illness, please contact your healthcare provider for advice.

Sometimes you may need to turn detective. Here are some possible causes of high blood glucose:

• Not enough insulin or oral diabetes medication
• Eating or drinking more carbohydrates than usual
• Less activity or exercise than usual
• Illness or infection (cold, urinary tract infection, heart attack)
• Injury or surgery
• Pain
• Positive stress (wedding or vacation) or negative stress (a death in the family or job change)
• Any change in your normal daily routine
• Certain medications
• Poor absorption of insulin at injection sites
• Insulin pump, insulin pen or meter (device issues)
• Bad insulin (outdated insulin or insulin that has been exposed to extreme temperatures)

The above are also some of the check points I use and referred to in a previous blog.

In rare incidences, stress can cause blood glucose to drop low.

Make sure you know the symptoms of high blood glucose.

Early signs/symptoms	Later signs/symptoms
Increased thirst	Fruity-smelling breath
Increased urination	Nausea and/or vomiting
Fatigue	Abdominal pain
Blurred vision	Rapid breathing
	Weakness
	Confusion
	Unconsciousness

When to contact your healthcare provider:

• You notice symptoms of high blood glucose
• Ongoing diarrhea or vomiting for more than 24 hours — or sooner if you're becoming dehydrated
• Fever that lasts more than 24 hours
• Blood glucose readings greater than 250 mg/dl (13.9 mmol/L) for more than 24 hours during illness
• If you have been instructed to check urine ketones and they are present (type 1 diabetes)

Call the emergency department if you experience any of the later signs and symptoms of high blood glucose.

Do Insulin Action Changes Confuse You?

The subject of insulin resistance and sensitivity is something I thought I had all figured out as it applies to me. However, like so many other things with diabetes, changes always happen. This last week has been one of higher levels of blood glucose levels for me than I have encountered for a long time. I checked my insulin and everything was still in date and still in date for the day I opened the vial, but still the high readings happen.

Next I checked my weight and it is down 6 pounds from the last doctor appointment, which means my insulin resistance should be less, but still the readings remain high. I am still using the same insulin to carb ratio and the same correction ratio, but the blood glucose readings are still elevated.

So a couple of days ago, I injected more fast acting insulin, 5 units more on top on what I normally inject for carbs and correction and something happened. Yes, my blood glucose rose again. Then I checked for hard areas (scar areas below my skin) in the areas I have been injecting in the stomach area and found a few more that I like, so at my last injection, I went to my leg that I haven't used for several months, now my blood glucose readings are in the range they should be and when I woke this morning, my fasting was 88 mg/dl. More reasonable and makes me feel a whole lot better.

In the research on this, I have come across several articles. I will use this article from Diabetes-in-Control. The high points include the following:

1. If you’ve had a prior hypoglycemic event
2. If your blood glucose has been running high
3. If you’ve drastically changed your normal exercise patterns
4. If you ate more calories, fat, or protein than you realized
5. If you’re stressed, mentally or physically
6. If you’re lacking on sleep
7. If you’ve had some alcohol to drink
8. If it’s a certain time of the month (women only)

Of the eight points above- #2 and #5 are points that affected me especially during the time of higher than normal blood glucose readings. The rest of the points above are not applicable as I was eating the same foods daily, I have not changed the exercise, I have slept more that eight plus hours, and I don't drink any alcohol.

Since what happened to me was the build up of scar tissue and this is not listed, It really makes me wonder what the author was thinking about and she was not the only one not considering this as a cause of higher that expected blood glucose reading.

This is why I keep my own list of check points when something like this happens. As you can see from the checks I was doing, I had more things to check on my list, but fortunately found the problem before I was in serious problems. I will explain some of the other points in a future blog, but for now I wanted to give you some of the checks I and others use.