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.

American Society of Nutrition, Not a Good Society

I would like to thank Steve Cooksey for pointing this out, but I cannot totally agree with him. Yes, the American Society of Nutrition (ASN) has some serious conflicts of interest, but they are not trying to criminalize other nutritionists like the Academy of Nutrition and Dietetics. In my searching, I also discovered another writer that is not happy with the conflicts of interest. And this person is a member of the ASN.

The person is Marion Nestle and she has her own blog, Food Politics. She covers a wide range of political issues in writing about nutrition and I have bookmarked her blog to go back and read several years of blogs. Her articles were from November 20 and November 21, 2013. In the two blogs, she covers her concerns about the ASN and the American Journal of Clinical Nutrition (AJCN)

Now Marion Nestle is more objective in her criticism and less radical than Steve Cooksey which is to be expected, but she is more careful in laying out her concerns. I do think that the entire list of sustaining partners needs to be shown even if it makes for a long blog. I have included the hype from ASN.

ASN Sustaining Partners

The American Society for Nutrition is pleased to acknowledge the generous support from these organizations for educational programs of the Society.

• Abbott Nutrition
  

• Alliance for Potato Research & Education
  

• Almond Board of California
  

• Biofortis Clinical Research
  

• California Walnut Board
  

• Cargill, Inc.
  

• The Coca-Cola Company
  

• Council for Responsible Nutrition
  

• The Dannon Company
  

• DSM Nutritional Products, LLC
  

• DuPont Nutrition and Health
  

• Egg Nutrition Center
  

• General Mills Bell Institute of Health & Nutrition
  

• Herbalife Nutrition Institute
  

• The Hillshire Brands Company
  

• Kellogg Company
  

• Kraft Foods Group
  

• Mars Chocolate North America
  

• McCormick Science Institute
  

• McDonald's
  

• Mondelez International, Inc.
  

• Monsanto Company
  

• National Cattlemen's Beef Association
  

• National Dairy Council
  

• Nestle Nutrition Institute
  

• PepsiCo
  

• Pfizer, Inc.
  

• Pharmavite, LLC
  

• The Sugar Association
  

• Tate & Lyle
  

• Unilever North America
  

The Sustaining Partners are represented in the Society by the Sustaining Partner Roundtable. The members of this roundtable help to provide visibility within ASN to matters of interest to industry by exchanging ideas and providing corporate financial support for the society's activities in education/training, scientific programs, and professional outreach.

The one statement by Steve Cooksey that I can agree with is this - “If you turn over a rock in the nutrition industry, you’ll find the money of Big Food and smell the stench of greed that follows it.

This will mean that I will need to investigate more of the organizations involved with nutrition over the next months.

Meeting and Working with a Dietitian

Under the present conditions, I would suggest reconsidering any appointment with a registered dietitian (with RD in the title). While I have some friends that are RDs, they know that currently, I still want them for friends, but do not bring up the subject of nutrition when we are together. One of my cousins who is a nutritionist, not a RD,and a member of another organization, does take particular pleasure in confronting me about the situation within the Academy of Nutrition and Dietetics (AND) and how they will lose in the long run. I do think she is doing this to see how I react, but presently I just let her yammering go in one ear and out the other.

Yes, when we do get to the facts and what is in the news and other publications, we do have a spirited discussion. She has met some of our informal group, and she understands what we are doing. She did help one of the group (Allen) get a more balanced meal plan. Even he was surprised about how far out of balance he had been. She asked him to get a scale that he would use and for a week weigh his food and record what he was eating. Since he already had a scale that would work, he asked what we thought and we agreed that this could be an immense help for him.

The following week, she took the information, showed where he was weak nutritionally, and made suggestions to create meals that are more balanced or more balanced for the day. Not only did she give him suggestions, but showed him what the different suggestions could do for him per meal, but as well on a daily basis. He was in awe with the results and commented that he understood why the doctor had run so many tests. Then they both sat and went over the sheet she had prepared. A few adjustments were made and he said he was going to have to go to the grocery store. He also asked how to prepare some of the new vegetables that he generally did not eat. She actually listed different ways to cook some of foods and how to prepare some of them for eating raw. She then surprised even me and gave him her phone number to call when he had questions.

Yes, all of us present made some suggestions, but she kidded us that everyone likes a woman's touch – ooohhhh – ouch. We started kidding Allen about maybe not needing his supplements that the doctor had him taking. She stopped us immediately and asked which supplements. I said we needed to start at the beginning and she agreed.  Allen said he had been on Metformin for many years and one day had been asked by us if he was taking a vitamin B12 supplement or had been tested for the deficiency. He explained that his doctor would not do the test and Tim and I had gotten him to a doctor that I see where they did the tests and several others. Allen explained that he had a vitamin D shot and vitamin B12 shot that day. He explained what the progression had been to the current day.

Allen gave her the supplements he was taking per the doctor’s instructions and the dosage of each. She looked each over and said he had better ignore her suggestions for nutrition change until Allen and she had a chance to talk to his doctor. Then she asked how many of each supplement he had left and Allen stated that on some of them were just about out and he didn't know on a couple. She said that if possible, he should call the doctor's office and get an appointment as soon as possible. Allen called and received an appointment for the following Tuesday, and told the receptionist the reason. About half an hour later, the Doctor called and wanted to review the reason. Allen put the nutritionist on the phone and she explained the reason and what was transpiring. He asked if they could be in his office yet that afternoon. They decided they could, and they were off.

The following day, several more of us got together with the nutritionist and Allen was all smiles. My cousin said that was one of the best meetings with a doctor she had ever been involved in. She had grabbed a couple of books from her car before they had left and the doctor had the same books out when they were in his office. She said she had done some calculations on the way and that was what the doctor had wanted to see. Allen said the doctor was impressed that she had followed Allen's wishes and adapted a meal plan for each meal in the day and if one meal was short, the next meal compensated so that the day was balanced. Since Allen was still adjusting to insulin, the doctor was very happy that she had kept the number of carbohydrates down while still balancing the nutrition.

The doctor did agree with my cousin on holding some of the vegetables until Allen had exhausted the supplements and for them to go ahead if Allen was happy with what she had proposed. The doctor did want Allen to continue the vitamin D and vitamin B12 until the second appointment from now. Allen said his next appointment was in August and that would make the second in November and the doctor said he would order the tests for then and see where his levels were and make any adjustments then. The doctor, according to Allen, had said if he could work with the nutritionist, he should be good with the food supplying sufficient nutrients. The doctor said the tests would either confirm this or lead to more tests to determine if Allen's body was not making use of them in which case there would be a medical mystery to be solved.

Allen said the doctor had quizzed my cousin about her education and affiliation before going over the sheets that she had prepared. Allen was a little surprised that he had checked some of her calculations, but realized that the doctor had relaxed when he saw that his calculations agreed with hers. The doctor asked if she would be pushing the number of carbohydrates up later, and Allen said that he had been told only if that was his desire. My cousin said she told the doctor that she makes suggestions, but works at the ratio the patient desires and said that it would probably be five or six months in making, the transition to the ratio Allen wanted. She said that this would minimize the level of endotoxins.

Brenda, who did make this gathering, spoke up and said this sounded like what her daughter would say. Quick comparison of backgrounds revealed the same university, but members of different organizations. Neither is a member of AND and happy where they are members.

Occupations That Can Assist People with Diabetes

For this blog, I will start with the people that may have the least training. This is not to say that many do not have college degrees or have not learned from experience or the college of hard knocks. Some will do excellent work and be able to translate information into understandable meaning for people new to diabetes or people still learning about diabetes. Most will not be afraid to tell patients that now is the time to learn when they hear someone say, “It could not have been important as my doctor did not mention this,” or “I did not hear anything about this.”

Yes, many doctors do not cover everything because of time constraints. This is where peer-to-peer workers and peer mentors will become a valuable asset in working with other diabetes patients. They can use experiences to excellent advantage and gently challenge other patients to learn.

Peer-to-peer workers will generally be working on a one on one basis and will report to a doctor at some point. Some patients will do better in a peer-to-peer setting and this should be taken full advantage of, as education is so important. The informal setting is often more relaxing and makes the giving and receiving of information easier. If the person giving the information is given proper training, she/he can become a powerful tool in getting information to other patients.

Peer mentors may or may not work with groups of people. They can work in either an informal setting or a formal setting. When working in a group setting, they need to be open to taking the discussion in a direction that will teach the most people. Having just had my first session as a volunteer peer mentor by video conferencing (telemedicine if you will permit), there are many areas to be concerned about. With no formal training or certification to point to, a peer mentor must not make medical recommendations about medications or when to take medications. This is the function of doctors and other medically qualified individuals. This does not mean that you are prohibited from talking about different medications as long as you make comparisons and discuss all sides of any issues. There are areas where you have experiences that you may share, and many subjects that may be presented for discussion.

If you are working with patients of a particular doctor(s) like I am, you must set the ground rules before hand to not conflict with a doctor's instructions. I am fortunate that wife of this husband-wife team earned a degree in nutrition before her medical degree, so I don't need to answer most nutrition questions. I have been given permission to discuss pros and cons of different diets, suggesting what works best for one individual may not be the best for another, and then passing them to her for further discussion. Since I am a blogger, the two doctors knew my position on many issues and only asked me to tone down my position on a few issues. Because they have no certified diabetes educators that will work with them, they were looking for other means to cover many areas. We had discussed many issues in the weeks leading up to the shared medical appointment (SMA) and they had one SMA before this where they discussed doing this, but this still did not prevent a couple of the questions.

They knew areas where I could be aggressive in nature and that I normally would not tell readers to use a particular medication. We had a long discussion about the many times I would suggest to patients that they may need to consider finding another doctor. They explained their position on many of these issues and were surprised when I stated that their position was what I was looking for and expressed agreement. The wife did ask that I not get too expressive about some areas of nutrition, but that I was welcome to encourage people to find their own level for carbohydrates, protein, and fat. She felt this could be an area of concern for many patients as they only had one person on a low carb diet. She as a dietitian was not concerned about fat levels other than avoiding anything over 60%. She would prefer people stayed under 50%, but would allow people to experiment. She also stated she would prefer working with people at their dietary preference and if needed encourage them to eat certain foods the help balance their nutrients. This did not come up in the first session, but they will be doing more testing to determine certain deficiencies and suggesting supplements for those who cannot or will not eat certain foods. They both said my blogs had alerted them to the vitamin B12 deficiency for patients who had been on metformin for extended periods and they had one patient with a deficiency.

Nutritionists need to step forward and be recognized. I am talking about those that have a four-year degree or an advanced degree in nutrition. The field of diabetes is in need of people that are more concerned with the nutritional value of food consumed by people with diabetes that how many carbohydrates are in each meal. Nutrition for people with diabetes is not a one-size-fits-all proposition and we need guidance on an individual basis. We have had enough of the mandates, mantras, and dogma. This may work for some, but not the many.

One group that I have also had conflicts with is people that call themselves diabetes coaches. These people seldom have diabetes and come from a variety of professional pursuits. Of the four I have dealt with, all have come from the nursing profession. I know a few that have a dietitian background, and another that was a certified diabetes educator. I am not saying that there are not possibly good diabetes coaches, but I personally disagree with many of their positions and visions of how people with diabetes must eat, live, and sleep. I have only seen one that recognized the value of exercise. Most diabetes coaches promote the same mantras, mandates, and dogma as certified diabetes educators and dietitians that are members of the Academy of Nutrition and Dietetics (AND). This means whole grains and low fat and no compromises. Disagree with them or question them, and they will not keep you as a customer or client. Unfortunately, my experience has been – it is their way, or the highway. Considering the following paragraph, I may have had experiences with the bad apples in diabetes coaching.

On July 30, 2012, Allison B has an excellent blog on the Diabetes Coaches. This presented in a different light than I have encountered. Apparently, this category has some people that know what they are doing and can be an excellent addition to your healthcare team. They have an international  professional organization and do work across many chronic illnesses and diseases. Some of these coaches do have diabetes and speaks well for what they are accomplishing. Take time to read the blog as this may help you decide that this is a group you need. Many use the telemedicine type of communication, which means that can be successful to wide geographical locations.

Until the lawsuit is settled and there will be more, I will attempt to leave the registered dietitians and AND out of discussions. If there is more news that surfaces about them, yes, I will write about it.

Like any profession, the certified diabetes educators (CDEs) have their bad apples. Their numbers are not keeping pace with the need and increase of people diagnosed with diabetes. It would be interesting to know what the actual numbers of CDEs are and whether they are in practice as CDEs, whether they work full-time or only part-time, or whether they are writing books and doing speaking tours, and not actually serving patients.

If these people would do the education that their title says, we might not have the epidemic we are facing today. Lack of diabetes education is just that, little is actually being taught.