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.

Under Treatment of Pre-diabetes Has Future Costs

This is another great topic presented at the AACE 2015 meeting. Pre-diabetes is an underserved segment of the diabetes population and gets no respect. Even the ADA who called the expert gathering for this in 2003 has taken no action to promote treatment of people with pre-diabetes.

At least the AADE says it may be time to rethink management of pre-diabetes, according to some experts and clinicians may need to do more to address pre-diabetes. Unfortunately, there are no agents approved by the Food and Drug Administration (FDA) for treating pre-diabetes. Yet, an estimated 79 million people in the USA have pre-diabetes and 40% to 50% of those will progress to type 2 diabetes.

Consequently, endocrinologists and other health care providers may want to be more aggressive in managing pre-diabetes once it is diagnosed, researchers said at AADE 2015, the annual meeting of the American Association of Diabetes Educators.

This attitude of managing pre-diabetes once it is diagnosed is the crux of the problem. Many doctors and clinicians don't take pre-diabetes seriously and refuse to diagnose it especially in light of no FDA approved medications for pre-diabetes.

“We have interacted with many providers in the past who did not see management of prediabetes as a patient-care priority. They felt that there wasn't much to do until the formal diagnosis of diabetes was made. It is important to appreciate the continuum of diabetes,” clinical pharmacist Jeremy Johnson, PharmD, MBA, of the Southwestern Oklahoma State University College of Pharmacy in Waterford, said during a presentation.

Once a patient has pre-diabetes, the pathophysiologic process that builds to what we have defined as ‘diabetes' has begun. Prevention or the delay of disease progression is the goal.”

“With prediabetes, many of the pathophysiologic abnormalities already exist,” clinical pharmacist Katherine O'Neal, PharmD, MBA, BCACP, CDE, BC-ADM, AE-C, of the University of Oklahoma College of Pharmacy and School of Community Medicine in Tulsa said, “and upon diagnosis, approximately 10% to 15% of patients show signs of microvascular complications.”

Currently, the American Diabetes Association (ADA) recommends lifestyle changes as first-line therapy for pre-diabetes.

“While lifestyle modifications are extremely important, at times, drug therapy may be of benefit or necessary,” Johnson told Endocrinology Advisor. “While many providers may be familiar with lifestyle recommendations and use of metformin as recommended by the American Diabetes Association, other options are often needed.”

Johnson and O'Neal presented a review of the current literature on the effectiveness of non-traditional agents in the management of pre-diabetes. They said it is now the responsibility of health care providers to share with patients who have pre-diabetes all available options to help delay the progression to diabetes.

“Under diagnosing and under treating pre-diabetes is having an enormous economic, clinical and humanistic impact,” Johnson said.

There was more to the report, but the concern needs to be education of doctors to the importance of treating patients with pre-diabetes to slow or prevent the progression to full diabetes. The following is important to the discussion:

Eventually, the beta cells can no longer compensate and hyperglycemia is the result.

Johnson said pre-diabetes is often not diagnosed until complications present and approximately one-fourth are undiagnosed. Therefore, he suggests that clinicians should consider screening asymptomatic adults if they are overweight (BMI of at least 25) or have one or more risk factors.

He also recommends women be screened if they delivered a baby weighing more than 9 lb, had gestational diabetes or have polycystic ovary syndrome (PCOS).

At present, the ADA recommends weight loss if necessary, increasing physical activity to at least 150 minutes per week of moderate physical activity and the addition of metformin if the patient:

• Has impaired glucose tolerance or impaired fasting glucose
• Has an HbA1c between 5.7% and 6.4%
• Has a BMI greater than 35
• Is younger than 60 years old
• Is a woman over the age of 60
• Has had gestational diabetes

In some aspects of the discussion, I have to wonder the purpose of the medications promoted and would question possible conflicts of interest. The two speakers were promoting some heavy-duty oral medications. You can read the article here.

Researchers Say Pre-diabetes Label Unnecessary

Researchers from University College London and the Mayo Clinic have raised a few valid concerns, if, they had done their research properly. Too often, other factors drive research and not the true nature of research. In this case, financial considerations seem to be front and center and studies were hand picked to fit the researcher's agenda.

While people may not agree with me, this article should be read and people making their own determinations. At least the World Health Organization (WHO) has stated that the use of 'pre-diabetes' is discouraged to avoid any stigma associated with the word diabetes and the fact that many people do not progress to diabetes as the term implies. Bold is my emphasis.

I do agree that the term pre-diabetes is a poor term and causes most people that do not understand diabetes to ignore what they could do to prevent the full onset of type 2 diabetes. The following statement bothers me and is what raised red flags for me. “The authors (of the study) showed that treatments to reduce blood sugar only delayed the onset of type 2 diabetes by a few years, and found no evidence of long-term health benefits.”

With the total absence of education by the medical profession and researchers world wide, it is small wonder that people that develop type 2 diabetes are not aware that full onset of diabetes could be delayed or prevented. These same doctors even laugh about how they will have patients to treat until they retire because people will progress to diabetes and then to the complications. This is a typical reaction by doctors that do not understand diabetes.

"Pre-diabetes is an artificial category with virtually zero clinical relevance," says lead author John S Yudkin, Emeritus Professor of Medicine at UCL. "There is no proven benefit of giving diabetes treatment drugs to people in this category before they develop diabetes, particularly since many of them would not go on to develop diabetes anyway. Sensibly, the WHO and NICE and the International Diabetes Federation do not recognize pre-diabetes at present but I am concerned about the rising influence of the term.”

While I doubt this study will do anything to cause action by the American Diabetes Association (ADA), we can hope that the ADA will make the readings above 99 mg/dl,

part of the diabetes spectrum. There can be serious complications developing in this area called pre-diabetes. These complications vary by individual and with most doctors ignoring pre-diabetes and declaring that nothing happens, more people will continue to develop complications.