Diabetes Caused Cognitive Decline Affects All Ages

With type 2 diabetes on the rise, it can actually be regarded as an epidemic propagating as a consequence of poor lifestyle choices, bad feeding habits and a sedentary life. The International Diabetes Federation (IDF) estimates that there are over 380 million cases of diabetes throughout the world and predict that it may rise to around 600 million in the next 20 years.

One of the consequences or complications of diabetes is cognitive decline. There are several studies showing that diabetes causes an acceleration of age-related cognitive decline. But it’s not just age-related cognitive decline, patients with diabetes also have a higher risk of developing cognitive decline associated with different brain pathologies. Diabetes increases the likelihood of developing vascular diseases, Alzheimer’s disease, mild cognitive impairment and dementia. Although these diseases have different onset mechanisms, they can all be intensified by diabetes.

Hyperglycemia is known to increase neuronal cell death through oxidation processes and generation of free radicals, thereby having neurodegenerative effects. Hyperglycemia can also cause damage to blood vessels through inflammatory mechanisms, leading to reduced blood flow to the brain and, consequently, reduced oxygen delivery, which results in the development of brain injuries.

If we add hypertension to the equation, which is commonly observed in patients with diabetes, vascular deficits become even worse, increasing the risk of stroke, for example, which is indeed more common in diabetic patients.

This effect of diabetes is not only observed in the elderly. Although type 2 diabetes accelerates age-related cognitive decline, younger patients also show signs of cognitive impairment. In a study that followed dementia-free diabetic patients with a mean age of 40 years at the start of the study it was shown that, seven years later, diabetes had led to a degradation of memory, visual perception, and attention performance, as well as to a loss of brain integrity. Diabetes and higher fasting blood glucose levels were correlated with gray matter loss in the brain. This shows that cognitive decline is clearly anticipated in diabetes patients.

Another study, which followed patients with an average initial age of 54 throughout 10 years, showed that, compared with healthy participants, those with diabetes had a 45% faster decline in memory (10 year difference in decline), a 29% faster decline in reasoning, and a 24% faster decline in the global cognitive score. Furthermore, diabetes patients who had a poorer glycemic control had a faster decline in memory and reasoning, while participants with pre-diabetes or newly diagnosed diabetes had similar rates of decline to those with normal glycemia.

It seems that the earlier the onset of diabetes, the higher the risk of accelerated cognitive decline. And even teenagers can be affected by the neurological consequences of type 2 diabetes. A pilot study following adolescents with type 2 diabetes showed that there are significant volume losses in a number of areas of the brain, as well as reduced white matter integrity. Given the fast increase in the incidence of type 2 diabetes (and other metabolic diseases) that is being observed in teenagers, this is clearly a reason for concern.

Therapeutic strategies designed to control glycemia will most likely help reduce the effects of diabetes on the brain. Many of the mechanisms of diabetes-associated dementia and cognitive impairment can be counterbalanced by a good diet and by exercise. Early intervention is fundamental. Yet our doctors are not knowledgeable in how to do this and don't understand nutrition.

Just to show how important diet and exercise are to diabetes care: there is scientific evidence showing that lifestyle changes are actually more effective than antidiabetic drugs. But instead of using diet and exercise as a way to control all the detrimental effects of diabetes, it would actually be better to use them to prevent it. Diet needs to be thought of as a way of eating and lifestyle of eating and not as a diet.

Education Can Make a Difference

Kate Cornell really hit one out of the park in her “importance of education” blog.

Her statement, “education in relation to type 2 diabetes has been my passion, for lack of a better word. It is something which I feel is sorely lacking and desperately needed,” says a lot.

Why doctors don't do any diabetes education is a mystery to me. I can understand why most doctors avoid referring patients to certified diabetes educators (CDEs). With the numbers of people with type 2 diabetes, and the small numbers of CDEs, in this area and many other rural areas there are many reasons diabetes education is lacking. Medicare does not reimburse doctors for education and does a poor job of reimbursing CDEs.

Can these be solved? More than likely not, but time will tell. With Medicare's bidding process taking front page, maybe Congress will also take a look at the way Medicare is paying doctors and others.

While Paula Deen was a flop in her attempt to promote a diabetes product, was not knowledgeable about type 2 diabetes when she made her announcement, and could not carry on a coherent discussion without making mistakes.

The latest two celebrities have more experience with type 2 diabetes, but I can't say they aren't above making money; they at least made their decisions after doing some research.

Dr. Phil is promoting Bydureon® (exenatide extended-release) the once a week injectable. He doesn't claim to use the product, but does promote the following rules:

At the core of the ON IT Movement is Dr. Phil’s “6 Rules to Get ON IT.” At OnItMovement.com, Dr. Phil McGraw explains these six rules in a series of motivational videos:

1. Move forward. Tackle your type 2 diabetes head on – no more guilt, no more being overwhelmed.
2. Get educated. Understand more about type 2 diabetes so you’ll be armed with the know-how to fight back more effectively.
3. Build a team. Pull together a team – your doctor, your spouse, your kids, a trainer at a gym or your buddies at work – and lead it.
4. Replace bad habits. Think about which aspects of your lifestyle need to change, and one by one, replace the bad habits with good habits.
5. Make a plan. Have goals and create a plan to get you to those goals.
6. Stick to it. Join the ON IT Movement to learn more about tools that can help you stick to your plan – whether it’s finding healthy recipes, getting ideas for exercising or learning how to change your everyday habits.

James Earl Jones says he is using Invokana® (canagliflozin) and that it is helping him with his blood glucose levels. He has done interviews and this is one to read.

At least both celebrities agree that one-size-does-not-fit-all and that each person needs to find their own path and what works for them.

Manage Depression and Manage Diabetes

Among people with diabetes, depression is a fact of life. Some have severe depression, but for most, it is mild depression. It is also a fact that many people with diabetes do not seek the help they need because of the stigma that is attached to depression.

Depression has been linked to increased hyperglycemia, morbidity, and mortality. The treatments for the symptoms as well as for depression can lead to improvement in quality of life. Depression is feeling blue or sad, which can interfere with daily life and be a burden on the patient and those around them.

There are many symptoms of depression. This list is just a few:

• feeling of depressed or sad mood
• diminished interest in activities, which used to be pleasurable
• weight gain or loss
• psychomotor agitation or retardation
• feeling of guilt
• difficulty concentrating
• recurrent suicidal thoughts

There are many causes of depression such as genetics, environmental factor, or psychological factors. This is also a reason that the stigma should not be put on people with depression as often it is not something that they can control. Progress is being made in finding other causes for depression and I have a blog about five of these.

It my understanding, about 67 percent of people with diabetes do suffer from some type of depression; however, most of the time you will see this listed as just depression with no definitive definition. Then about 19 percent of people with diabetes suffer from serious depression and again no accurate definition accompanies this statement.

Some depression tends to run in families and scientists are investigating certain genes that make an individual more prone to depression. However, while genetics do play a big part in depression, many would agree that it is the combination with environmental or other factors that would bring on depression. The loss of a loved one, trauma, difficult relationship, or any stressful situation may trigger a depressive episode in a patient. These are debilitating symptoms for a patient and can prevent them from taking proper care of themselves.

A retrospective cohort study looked at 1,399 patients diagnosed with both depression and type 2 diabetes, and compared their glycemic control using their A1c levels. The study found that 50.9% of depressed patients who are on antidepressants have good glycemic control as compared to only 34.6% of depressed patients without antidepressants. After adjusting for covariates, the study found that those on antidepressants are twice as likely to attain their glycemic goals as compared to those not receiving antidepressants.

A Diabetes Website Still Getting Its Feet Wet

This website information came to me in an email from Craig Idlebrook. He is the Editor for both Type 2 Nation and Insulin Nation (I will leave this for you to explore on your own). The founder of the two sites, Chris Leach, passed away in 2013. The group in charge of the two sites (eps) currently does not have any other sites or publications. Insulin Nation started in 2012 and Type 2 Nation started in 2013.

Other people involved in the Type 2 Nation can be found here (scroll down for the entire list of the Team).  Several are well recognized in the diabetes community and the diabetes online community (DOC). This and other information about the website can be found in the pull down tabs near the top of the page.

The Home Tab features two of the other tabs – First Person and Recipes. Going to those tabs will get you more stories and recipes. I currently have problems with the sound system, so I am unable to explore Speech Enabled box in the near top right column below the search box.

The Treatment tab covers some of the problems of diabetes and while the blogs are short, they are very informative. Currently the Technology tab has two articles and needs more. The Weight Loss tab is articles about weight and covers a wide variety of weight loss topics.

On a scale of 1 to 5, with 5 being top rated, I could only give this site a 4+ as this site has only a couple of weaknesses and overall is strong.

Attitudes with Type 2 Diabetes

What causes the attitudes of some people after receiving a diagnosis of type 2 diabetes? This topic came up a week ago when a few of the support group were talking about what to do for a fellow that had just been diagnosed and refused to discuss this with a couple of the group. He was even angry that we knew that he had diabetes.

This day as we were talking, he came in and noticed us and almost left, but after looking at us, went up to the counter and ordered an ice cream sundae plus a regular coke. Then he went to the opposite end of the seating area and started eating his sundae.

We were ready to leave and quietly left. After we were out of the door, he opened the door and shouted at us saying he could eat anything he chose. Allen turned and told him that he could, and when his eyesight failed, not to complain to us.

We felt this required some thought and arrived at the following:

• Often the newly diagnosed get into denial
• The newly diagnosed decide to keep their diabetes a secret for their own reason.
• Type 2 as a general thing seems to start out much more slowly than type 1. Type 2 diabetes is ambiguous and how acute it is, varies all over the map.
• People with type 2 often refuse to change their eating habits and often do not change lifestyle habits.
• Doctors of type 2 patients do not explain the seriousness of type 2 and that while a good A1c may look good, having an episode of hyperglycemia and then an episode of hypoglycemia is not to be desired.
• Many people with type 2 have guilt that they caused their diabetes and the doctors often reinforce this guilt.
• Finally, too many people with type 2 diabetes try to live in the past instead of the present.

We came up with many other possibilities and finally said enough. When it is possible to do an intervention, we will consider doing this. The rest of the time we need to keep educating people and letting them read materials that might convince them to accept their diabetes and start actively managing their diabetes.

A.J agreed and Jerry wanted to do more. We told Jerry that he could attempt more, but not to be surprised if he was ignored. Since this fellow lived alone, there was not someone else that we could appeal to for help. Jason said he is very likely in denial and it will be difficult to convince him to change. I told Jerry that it took some time to convince him and he was uncooperative for some time until he realized that he needed to change something.

A.J said that even Jack was very hard to get through to and it took a specialist and a doctor to bring him around. In that case, we had a wife to help and keep him on the right path. Jerry said he still wanted to help the fellow, but would keep what we had said in mind and be more patient in his approach. We thanked him and we went to our homes.

Learn Prediabetes Is Not Diabetes

Since 2003, when the American Diabetes Association (ADA) convened a group of “experts” to declare the blood glucose levels between 100 and 125 mg/dl (3.9 to 6.9 mmol/L) as prediabetes, all people were aware of was that diabetes started at 126 mg/dl (7.0 mmol/L).  This classification applies only to type 2 diabetes.

Since then the ADA has done little to encourage doctors to screen for prediabetes.  A few doctors have been screening for prediabetes and doing an excellent job at this, but the bulk of people with prediabetes are still unaware they even have this.  The ADA, for all their “expert” knowledge, has done little in the way of education or helping the people that might have prediabetes become aware of what might happen if they do nothing to prevent the onset of full type 2 diabetes.  

Receiving a diagnosis of prediabetes is a serious wake-up event.  It does not necessarily mean that type 2 diabetes is a foregone conclusion.  There are changes that you can make to slow the progression to diabetes and for some people to prevent diabetes.  The following are some suggestions to consider:

Develop an exercise regimen you enjoy.  Doing this is one of the best things you can do to make diabetes less likely.  If it has been a while since you exercised or you are medically able, start by building more activity into your routine by taking the stairs or doing some stretching during TV commercials.  Physical activity is an essential part of the treatment plan for prediabetes, because it lowers blood glucose levels and decreases body fat.  Check with your doctor to see if you have limitations.

Lower your weight if this is needed.  If you're overweight, you might not have to lose as much as you think to make a difference.  In one study, people who had prediabetes and lost 5% to 7% of their body weight (just 10-14 pounds in someone who weights 200 pounds) cut their chances of getting diabetes by 58%.

See your doctor more often if possible.  It is recommended to see your doctor every three to six months.  If you're doing well, you may get positive reinforcement from your doctor.  If it's not going so well, your doctor can help you get back on track.  If you are like me, you will appreciate words of encouragement, and even words needed to put you back on the right path.

Develop a good food plan that your meter approves.  Load up on vegetables, especially the less-starchy kinds such as spinach, broccoli, carrots, and green beans.  Aim for at least three servings a day.  Add more high-fiber foods into your day.  Enjoy fruits in moderation - 1 to 3 servings per day. Eliminate whole-grain foods as much as possible and do eliminate processed grains.  In general, eliminate white rice from your food plan.

Also, swap out high-calorie drinks.  Drink whole milk rather than skim milk and diet soda rather than regular soda.  Choose cheese, yogurt, and low carb salad dressings. Choose fresh fruit when it is available and not fruit juice.

Make sleep a priority and sleep the suggested hours when possible.  Not getting enough sleep regularly makes losing weight more difficult.  A sleep shortfall also makes it harder for your body to use insulin effectively and may make prediabetes and diabetes more difficult to manage.  Set good sleep habits.  Go to bed and wake up at the same time every day. Relax before you turn out the lights.  Don't watch TV or use your computer or smartphone when you're trying to fall asleep.  Avoid caffeine after lunch if you have trouble sleeping.

Get support and ask for help when needed.  Losing weight, eating a healthy diet, and exercising regularly is easier if you have people helping you out, holding you accountable, and cheering you on.  Consider joining a group where you can pursue a healthier lifestyle in the company of others with similar goals.  The right diabetes educator and nutritionist may also help you learn about what you need to do to prevent your prediabetes from becoming diabetes.  Sometimes this will be a doctor, a nurse, or just a friend.

Choose and commit to the task of managing your diabetes.  Having the right mind-set and a positive attitude can help.  Learn to accept that you won’t do things perfectly every day, but pledge to do your best most of the time.  Make a conscious choice to be consistent as possible with everyday activities that are in the best interest of your health.  Learn to tell yourself, I’m going to give it my best.  I’m going to make small changes over time that will become good habits.  These changes will add up over time and help you manage your prediabetes or diabetes if it progresses that far.

Diabetes and Sleep Apnea

I have written more than the one below on sleep apnea, but this is mainly concerning sleep apnea and management of blood glucose.

http://bobsdiabetes.blogspot.com/2014/04/sleep-apnea-makes-diabetes-harder-to.html

The sad part is many people with sleep apnea do not realize that they are at risk for diabetes and a slightly a smaller percentage of those with diabetes are at risk for sleep apnea. Even then, people will not listen when they have one condition and you warn them about the risk for the other.

Sleep apnea and understanding that it affects blood glucose management negatively is important. I am fortunate that I have no problems using my sleep apnea equipment, as I obtain the sleep I need and sleep apnea is not a factor in the management of my blood glucose levels. I have a few acquaintances and a few more friends that ignore their sleep apnea and laugh at me when I bring the following into the discussion.

Some of the reasons people refuse to use their sleep apnea equipment include:

1. Vanity – they don't feel sexy or manly wearing the mask
2. Some feel wearing the mask is claustrophobic
3. Some do not like the lines that the mask straps cause in their skin because they have the straps too tight
4. Many complain about the noise the machine makes
5. Many have a problem with the air leaks around the mask because they aren't properly fitted or having a mask that fits properly
6. Many people do not understand that not getting the sleep they need will contribute to the development of diabetes or make diabetes more difficult to manage.

Severe obstructive sleep apnea (OSA) may increase a person's risk of developing diabetes by 30% or greater. This is according to an article published online June 6, 2014 in the American Journal of Respiratory and Critical Care Medicine.

Of the 8678, patients who underwent the sleep study, 1017 (11.7%) developed diabetes during a median of 67 months of follow-up, which translates to a cumulative incidence of 9.1% at 5 years. Incidence came to 7.5% for patients with mild OSA, 9.9% for moderate OSA, and 14.9% for severe OSA. Limitations of the study include missing data on some potential confounders, such as race and family history of diabetes and the inability to categorize diabetes as type 1 or type 2.

Another author wrote, a man over age 65 with type 2 diabetes has a 67 percent chance of having sleep apnea; for older women, the chance is almost 50 percent. Besides making it difficult to get a good night’s sleep, sleep apnea increases stress on the body, causing blood sugar levels to rise. So it is especially important for people with type 2 diabetes to recognize sleep apnea and have it treated.

People with type 2 diabetes are often obese and insulin resistant, and have large amounts of visceral fat, fat deep inside the body that is covering and surrounding their organs. What causes sleep apnea isn’t entirely known, but there appears to be a connection between insulin resistance, obesity, especially with visceral fat and a big waistline, and sleep apnea. This makes obese people with visceral fat and type 2 diabetes more likely also to have sleep apnea.

The most common symptom of obstructive sleep apnea is loud, persistent snoring, which may include pauses followed by gasping or choking. (Keep in mind that not all snorers have sleep apnea.) Other symptoms include:

• Chronic fatigue (for example, you may fall asleep while driving or during inactive times throughout the day)
• Problems concentrating (inability to complete simple tasks)
• Mood swings (happy one minute and unhappy the next)
• Difficulty controlling blood pressure and blood sugar levels

Please, I Need Help

Yes, this last year was a great year for me, but I am asking my readers for assistance in locating other type 2 bloggers. I have found several new and some not so new type 2 diabetes bloggers. I have some more bloggers being posted on January 2, 2105. If you know a type 2 blogger, please send me an email with the internet address (URL) so that I can check them out and post them on a quarterly basis to those that are already posted. My email address is on my profile page, or you may post the information in a comment to this blog.

I have several bloggers from other countries, but I know there are more. The only qualification I am asking is that they have type 2 diabetes and are blogging about type 2 diabetes. I will include other writers, especially doctors that write about diabetes, but do not have diabetes themselves. I am cautious about some that are only advertising services for type 2 diabetes and I refuse to promote consulting and other businesses aimed at people with diabetes.

Forget about those promoting snake oil and a diabetes cure, as I will not list them. Likewise, I have an objection to those writers' that are promoting promises of a reversal of type 2 diabetes or prediabetes. It is possible for people with type 2 diabetes to avoid medication or start with medication and by changing lifestyles have been able to get off of all diabetes medications. Some are able to stay off for several years and others for a few decades.

I will not list people that have not blogged or more than 12 months. If they have restarted and have blogged for two or more months, then they are eligible to be listed.

I will be listing several blog sources that include both type 1 and type 2 bloggers, but both types are worth reading and it is easier to list the site and not pull out the type 2 only bloggers.

Food Plan Study Of Interest

In a short 24-week study, HbA1c levels improved and cholesterol levels were reduced to the point of reduced need for statins. Type 2 diabetes patients are normally advised by dietitians to make dietary decisions that are high in carbohydrates and low in fat and protein. This increase in carbohydrates leads to high postprandial blood glucose levels. Because of this, there is more interest in food plans low in carbohydrates with higher amounts of fat and protein for type 2 diabetes management. Past studies have been done with food plans that are low in both carbohydrates and fat. Both have proved successful in lowering body weight, blood pressure, and insulin concentrations. Most of these prior studies have ignored the role of physical activity and glycemic variability.

This new study was designed to compare the use of a high carbohydrate, low fat diet (53% carbohydrate, 17% protein, and 30% fat) to a very low carbohydrate, high unsaturated fat diet (14% carbohydrate, 28% protein, and 58% fat). This would be used with measurements taken at baseline and end of trail to see what their impact was on glycemic control and risk factors associated with cardiovascular disease in type 2 diabetes patients.

A total of 115 obese type diabetes patients were randomly assigned to one of the two diet groups. In addition, they both participated in a supervised exercise program. The primary outcome was a change in HbA1c. Secondary outcomes included effects on glycemic variability, and changes in anti-glycemic medications, lipid profile, and blood pressure readings.

Those in the low carbohydrate diet group showed a larger decrease in HbA1c when compared to the high carbohydrate diet group and changes in anti-glycemic medications were also more likely in this group as seen by the changes in the medication effects score. Differences in the diets were not seen in weight loss, and no diet effect was observed in the fasting blood glucose, LDL reduction, or blood pressure.

The results of this study show the impact that diet selection can have on managing type 2 diabetes. While both of the diets studied in this trial showed some positive results, the very low carbohydrate diet was more effective in lowering HbA1c, reducing anti-glycemic medication requirements, and improving HDL cholesterol. And of course, they made the statement that larger trials with a similar design can be used to determine if a low carbohydrate, high unsaturated fat diet continues to have an impact on managing diabetes beyond a 24-week timeframe.

For this short of a trial or study, the few conclusions show that people with type 2 diabetes need to make lifestyle changes in both diet and exercise. While both diets showed improvements in weight, a very low carbohydrate, high unsaturated fat diet showed more beneficial in lowering HbA1c, anti-glycemic medication requirements and increasing HDL cholesterol.

Diabetes Does Not Have To Be Progressive

This blog by Nancy Klobassa Davidson, R.N. on April 4, 2014 represents a blog by a large medical organization (the Mayo Clinic) that identifies their blog author. No anonymity here like the blogs on Joslin Communications, a part of the Joslin Diabetes Center.

The topic is a controversial topic about diabetes being progressive. While I have to swallow hard to agree with parts of this, it is presented rationally and it is easy to understand. It is true that many people refuse to manage their diabetes in a manner strong enough to prevent diabetes from becoming progressive. The author does not account for the people that die of old age or other causes and not diabetes.

I would not argue that for many people, dying from diabetes or diabetes related causes (i.e., heart disease, kidney failure) is more common than we would like to have happen. We may be debating medical semantics, as some people have heart disease before developing diabetes and the same for kidney disease.

This statement by the blog author is important enough to quote. “Recently, I met a woman who was upset that no health care provider or diabetes educator had explained to her, at the time her diabetes was diagnosed, that diabetes is a progressive disease. She thought that if she "behaved herself," her diabetes could be cured, or at least stay in holding pattern.”

Yes, there are people with diabetes that mistakenly believe they can be cured. All I have to do is talk to the owner of a health food store and she will confirm this. She knows this is not true as she has type 2 diabetes, but says that about twice a month, someone will come to her store seeking a cure for diabetes. She tells me that people say the darnest things and her favorite is, “this is the twenty-first century, there has to be a cure.”

The author's logic presents both sides of the disagreement better than most. She does not state many of the obvious conclusions, but sidesteps many issues by saying, “this varies per individual, and everyone is different.” I can agree with this, because we all age and manage our diabetes differently. It is the definition of progressive that needs clarification. Progressive means aging or becoming older. With aging, our organs all lose their efficiency and the pancreas is no different.

For me, progression of diabetes would mean that it progresses to the complications and on to death. Some people are able to manage diabetes for many years (and even for decades) with nutrition (diet) and exercise. As the pancreas ages, oral medication may become necessary. As we continue to age, other injectables or insulin may become necessary.

As long as retinopathy, kidney disease, and heart disease caused by diabetes are not becoming worse with age, then diabetes has not become progressive. But you did not mention neuropathy you say. Correct, because about two-thirds of people with diabetes develop neuropathy and there is some conflict here as many, like myself, that develop neuropathy many years prior to being diagnosed with diabetes. My neurologist and I have an ongoing discussion about this as he says that with the development of diabetes, that the neuropathy is now classified as diabetic neuropathy.  Sort of the chicken and egg version of which came first.

Many people, without their doctor's threat, often feel that they have failed when it comes time to transition to insulin. Often they wait too long to do this. They haven't failed, it is just their normal thing as they age and the pancreas not functioning very well that causes the need for insulin. Insulin can be very helpful and a necessary tool in the management of type 2 diabetes.

Delaying to use of insulin too long causes high blood glucose levels and prolonged periods of high blood glucose is what causes the onset of complications. Insulin does not cause complications and in most cases if started early enough can prevent the complications and heal those that are just beginning.

Even though the blog used for reference above says diabetes is progressive, it is still worth reading.

Is Polypharmacy In Your Future?

What is polypharmacy? There are several definitions so this is not always the best term to use.

1. The use of two or more drugs together, usually to treat a single condition or disease.

2. The use of a number of different drugs, possibly prescribed by different doctors and filled in different pharmacies, by a patient who may have one or several health problems.

3. The administration of many drugs at the same time.

Don't forget that the term drugs also includes herbal remedies, vitamins, minerals, and other supplements. Often they are referred to as dietary supplements, but they are still drugs. 

 

Normally this is a concern of the elderly. However, last Friday, I was in the house of a friend as he was sitting down for the evening meal. His wife was at the side table with her back to us. I could not be sure what she was doing until she seated herself at the table. She had one container for herself and a slightly larger one for her husband, each containing many pills.

Both are in their early 40's and I thought to myself, they are too young to be taking this many medications. Sure, I take 9 pills at breakfast and the same at bedtime and then insulin injections of two types. However, I am about 30 years their senior.

After they had finished eating, he and I headed for his workshop. Once there, I asked how many pills he took in a day. He said they were not all medications and that only eight were prescription. He said the rest are dietary supplements. I asked if any of them were prescribed and he said only one – vitamin D.

I helped him figure out the woodworking project he was making and gave him alternatives for making it stronger. We continued talking until he was satisfied and drawing different diagrams for the needed joinery. Then we went inside to his computer where I showed him where I had gotten my ideas and he looked at the explanations for several and bookmarked the page.

Next, I asked if he would read something that I had written about vitamin D. He moved over so I could access the keyboard and mouse. First, I brought up this blog and after he had read it, he called his wife and asked her to read it. Her first question was why the doctor needed to prescribe it if there was something less expensive. She went to the cabinet and brought the bottle over. She said this is definitely D2.

Now she wanted more information and went to her computer. I brought up the blog for her and when she went to the bottom and clicked on the University of Oregon link, she asked where to go. I told her to click on vitamins and she said they have something on all of these. More of a question, but she went to one other and was reading that. She bookmarked that and went to back to find the minerals. Then she asked her husband if he has been tested for selenium and he said no.

Now she said they had better do some reading and check out the rest that they were taking. I suggested that they also read the problems or cautions for use with prescriptions. She said that was what she was concerned about. She asked if I had any other suggestions and I gave her this blog, which she quickly bookmarked.

Then she asked for my email address saying she would probably have more questions. She sent me an email with her and her husband's email so that I would have them. Then she took time to read some of the other information on my blog page and asked if that was why I blogged. I admitted that because of diabetes and felt that it was important to pass on information to others.

Then I was shocked when she said she had just been diagnosed with type 2 diabetes the day before. I asked her if she had gestational diabetes with their two children and she said only the second one. She continued that the doctor had not believed her plasma blood glucose level and did an A1c and even then would not say she had diabetes. Next, she went through the oral glucose tolerance test. After two hours of that, the doctor finally said she had type 2 diabetes.

The husband said it was getting late and his wife had some errands to take care of the next day. He asked if I could come back after I took my wife to work. He said they needed to learn more about using the computer. As it was, they mostly used it for video and chatting with family and the children at college. I agreed and said goodbye.