Goals for a Person with Type 2 Diabetes

What are reasonable goals for a person with type 2 diabetes? This is a topic that has bothered me for the last few months. In out informal peer-to-peer group, we all have different goals and most seem satisfied with their goals. Do we always achieve our goals? Not even close to all of us achieve our goals every time we see our doctor, but for the most part, as a group we don't miss by a lot. While the average age varies every time we add to the group, the majority are now over the age of 65. However, this does not establish goals for anyone.

The first thing I want to emphasize is that there are no standard answers or rules. We all strive to maintain certain limits that we can live with or tolerate. We all agree to attempt to keep our A1c's under 6.5% and lower if possible. We have all stated that we need to keep our lipid levels in range, if possible, but we seldom discuss this part of our lives. We have also agreed that our goals are ours and not for anyone else to follow. It happens that several of us have very similar goals and we probably talk about this more than the rest. At present, none of us is limited cognitively and this is something we have agreed among ourselves to maintain a link to watch for any cognitive problems. Diabetes and cognition are two of the factors that have bound us more tightly as a group because we care about each other as individuals.

Even as individuals, it has been enlightening to how we set our goals. With the current number of ten members and nine of us being on insulin, there is quite a bit of similarity among us. Sue is still off all medications and she is happy that we support her with her goals. She wants to keep her A1c as close to 5.5% or under if possible. Even her husband is surprised at her success as her last A1c was 5.2%. She is the youngster in our group and we do tease her about this. She replies that if the old fogies would learn from her, we could be a lot healthier.

With the A1c range for people without diabetes (normal range) according the Joslin's Diabetes Deskbook being from 4.0% to 6.0%, we have to remember that prediabetes is defined from 5.7% to 6.4%. Prediabetes is another topic that many wish would be labeled as diabetes. Because A1c values do vary quarterly, some are advocating that we should check the A1c values monthly. For more information on this, please read this blog by David Mendosa.

With this in mind, here are some goals for people to look at as possible goals they should consider as their own. Therefore, select realistic goals and work toward them.  Of the nine members on insulin, our A1cs range from 5.5% to 6.5%. as of the latest A1c values. Some of us have the same A1c and don't get too concerned since this should be expected. Max and I are the only two that occasionally exceed 6.5% and then we have to work very diligently to make sure we get below 6.5% on the next A1c.

We are all careful to avoid hypoglycemia and three of the individuals have never had hypoglycemia. Since I have been on insulin the longest, by about two years, I have had the most incidents of this, but never one that I was not aware of or prepared to correct. On several occasions, I knew as soon as I put down the syringe that I was going to need to be aware of and prevent this from happening. On two occasions, I accidentally injected my short-term insulin in the same area as the long-term injection. I stayed up late both nights and fortunately had enough test strips and glucose tablets to stay out of trouble and only get to the lower 60's for blood glucose levels.

I have had eight readings below 65 mg/dl in the nine years on insulin and the next is only five readings below 65. Then the numbers go to three and two. Why do we choose 65 for our hypoglycemia? Because we can and in general we do not get below 70 mg/dl. Several of the group try to constantly remain under 125 mg/dl and above 80 mg/dl and have been very successful at it.

We are all fortunate to have the test strips we need or be able to afford more if insurance limits us. Five of us do obtain our diabetes supplies and medications from the veteran’s administration (VA) and are thankful for that. Our testing supplies are very much what we need and we make use of them.

We are now over a month into 2013 and have now added three additional members that are very happy to have us helping them. Brenda and Sue are probably the most pleased, as two of them are women and are happy to have others to talk with. All three are presently on oral medications, which is also revealing. In our first meeting, with three of the group absent for work, the ones new to the group were very curious as to why so many of us were on insulin. Brenda was happy to say “Greater ease of management.” This of course became our discussion for that meeting. The A1cs for the new members was 6.6% to 7.0% and they were surprised at our A1cs of all being 6.5% or less. Many questions were answered about multiple daily injections and testing. The three were surprised at our relaxed attitude about this and that fact that most of us did not think anything about the extra testing and multiple injections.

They were all surprised that we used our arms and different parts of our bodies for injecting insulin. They were very interested in why and Brenda was happy to answer that we needed to prevent insulin absorption and utilization problems and avoid creating scar tissue under our skin. This in turn would affect the insulin utilization and cause insulin waste if scar tissue caused the insulin not to disperse from the injection site. Some may escape, but not the full amount injected.

Then the question was asked about alternate site testing. We all stated that we used our fingers and not alternate sites because we wanted the “now” reading for accurate correction data and needed to know this. If we were going up or down was also mentioned. Then Tim said that for those on oral medications other than sulfonylureas, alternate site testing would work if their readings were fairly consistent. Brenda advised them to be careful if their readings were still fluctuating up and down since they were new to testing. Two were on metformin and one on a sulfonylurea and metformin. All three said their doctors had advised them against alternate site testing for now, but that they were happy that we were willing to talk about this.

Allen then said that they would all be wise to read about and understand insulin, but there was no hurry since so many of us were on insulin. Then he asked how long each had been on metformin. The answer was one year and the other two for only six and eight months. The two women asked if he was concerned about vitamin B12 and when Allen said yes and vitamin D, they said that the diabetes clinic had tested both of them for these and said both had been advised to add them as supplements. The fellow said he had also been tested. Then one of the women said they understood his concern after what had happened to him and he said then you have been reading Bob's blog. All three admitted they were and Allen said at least we are all on the same page.

Then we needed to call an end to the meeting and the three of them wanted to ask more questions. We allowed one question and they agreed. The fellow asked why I was the only one blogging. I could see the eyes looking at me, so I spoke up. I said most are not ready and they do not have the desire that I have. Ben then said, he agreed as he had thought about it, but even though he enjoyed the research, he was not ready to write even once a week. He said that he does send me blog ideas and I agreed and said several others do as well. Brenda said she has no desire, but enjoys most of what I write about, but not everything. She also said that they appreciated that I did not use their real names and had agreed that I could use a made up name to keep people identified.

Since people were anxious to leave, I told the three, that if they had any interest, to please contact me and I would tell them what I could. Two have and are especially looking for other resources and a few other bloggers to read. The one has been reading from the blogger list I maintain and I have sent both other bloggers from the type 1 bloggers and others.

Just Thoughts from the Last Few Months

Having computer failure and moving to a backup computer is not fun, but it is doable. Having lost many of my favorites and bookmarks is difficult to rebuild and I still have a quite few I have not recovered. I have noticed that many of my favorites are seldom posting blogs. Yes, they post, but not as frequently as they had in the past. I have found some activity on Facebook and Google+; so much of the activity may have gone where they get more immediate response, which can be more rewarding. I say good for them, I will miss them.

I do have accounts with both, but cannot find time for participating. I admit I am tired of receiving invites to play the games on Facebook. I would much rather play one game of solitaire which will be over shortly, and not waste a lot of time I see wasted on Facebook games. I enjoy researching and reading more than playing these games. There are so many good sources of information, some very interesting, and a lot of garbage is published trying to pass itself off as something important.

Part of what irritates me is the small studies done that mean nothing more than a call for more money to do larger and even less meaningful studies. Yes, I am venting. Then I get tired of all the rodent studies that herald a breakthrough. Yet we seldom see much beyond these rodent studies. Why? Because so much just won’t translate to the human body. Then there is the type of studies blogged about very accurately by Tom Ross here. This alone has me wondering how these get by peer review and how they are funded in the first place. It also raises questions about data committees and who else passed the buck. These researchers need to have criminal penalties imposed and do some prison time for their fraudulent use of research funds.

Now back to bloggers. I know bloggers come and go. Some I do miss and wonder what I could have done to encourage them. Others, well I hope you learned something while you were here and nothing serious has caused you to leave. I know from experience that sometimes a thick skin is needed and at other times, you can get emails for help that you cannot answer. Blogging can be very rewarding and at other times, you wonder if you are reaching anyone with something informative.

Then there are times when you receive both good comments (I receive mostly emails) and negative emails. I have been very surprised by what blogs get responses. I have had several over the last couple of months. Were the blogs that good? No, I can honestly say for a couple, I missed a lot and will write more later for some of them. At the same time, I at least opened the door for further discussion and I am learning a lot from one doctor, and for that, I am very thankful. I am also thankful for some of the contacts I have been making. Being a patient does have some advantages and at other times garners some sharp criticism. If I can continue to learn from some of the criticism, then I will have gained.

Several professionals have answered emails and we have started good discussions. A couple have contacted me and their discussions have been even more productive. I have been surprised at the questions and information they have requested and the responses to the information. You never know when something you blog about can open avenues for conversation.

Another activity that has been brought to my attention in the last few months is the use of peer mentors. I was a little shocked when I learned this, but after talking with a doctor using peer mentors and two of the peer mentors, I have learned a lot. The doctor stated that the nearest certified diabetes educator was over 150 miles distant and the closest registered dietitian was over 200 miles distant. The doctor had attempted to use the computer for video conferencing, but could not work around their schedules.

The doctor said he had two patients that he knew spent time researching on the Internet about diabetes and decided to have them in for a session of questions and answers just with him. He was pleased with the interaction with both, but one was not interested in peer mentoring. Therefore, he started with just one person and the first few sessions with patients went very well. In the meantime, both he and his peer mentor looked for others that would be capable. Over the next six months, they found and interviewed six more people, ending up with four peer mentors.

How did I end up being in contact with them? One of the peer mentors had read one of my blogs about shared medical appointments (SMAs) and made the doctor aware of this. The doctor was not sure if this would work for him, but was interested in exploring the topic. Over the last four weeks, we have corresponded about this. The doctors admits he does not like my stance on the American Diabetes Association, but is pleasantly surprised about the alternatives I do present.

My opposition to a one-size-fits-all mantra also got his attention, as did the discussion he had with his mentors about this. He knows that many people do not have the ability to afford the extra test strips to eat to your meter, or to discover how the different foods affect their bodies at diagnosis or at different times afterward. After discussing programs that a few of the test strip manufacturers have, he is now on a mission to see what can be done for his patients. Two of his mentors are writing on his behalf to see what can be accomplished. The office has gathered the numbers of each different meter used by his patients so that they can use this for volume.

He has asked about having SMAs with 5 to 9 people only as this about all his office can hold in the reception area. We have talked about having them at 4:00 PM to avoid interruptions. He does feel this would be workable, and if necessary he can see them going past 5:00 PM. Since he has the computers and equipment from attempting to set up with the CDEs and RDs, he seems willing to try this. His office is now surveying his patients with type 2 diabetes to find out how many would be interested. He is aware from reading my blog that secrecy for some may be an issue. He is investigating the frequency of having the SMAs, but in the beginning will start with quarterly.

He has used the video conferencing with me and has said he hopes I am not disappointed by not being asked to mentor for him. I said no, as I was writing my blogs and would be starting with two other doctors in the coming weeks as a peer mentor for them. I did email him copies of my twelve-blog series and the dates to be published and that if parts of them were useful then I had served as well in supplying education topics. He has forwarded them to his mentors and one has thanked me for them.

I have supplied him with the names of several people with nutrition degrees in his area and he said he was not aware of them, but would be in contact with a couple to see if schedules could be worked out. I have to thank my contacts for the names I sent to him.

Even if I have no other contacts like this, the last few weeks have been very rewarding for me. Complaints aside, I have learned a lot and even one that was especially critical has given me a valuable lesson in how to approach a couple of topics.