Are Physicians Correct in Not Following ADA Guidelines?

This is one article that gave me a different message than I was expecting. When I read the headline “Many Physicians Do Not Follow ADA-recommended Prescribing Guidelines,”  I actually thought this may be a good thing. However, the article did not give me any of what I was thinking.

I had hoped that the discussion may have been about starting newly diagnosed patients with type 2 on insulin to gain maximum management quickly. No, the article was about prescribing oral medications only and not the use of cheaper, generic medications, but the more expensive oral medications. When doctors force patients to use oral medications that are more expensive by $1,120 (or more) per year, this is the wrong way to proceed.

These doctors do need to be called on the carpet and asked to explain their reasons.  There is one very effective generic that these doctors were not prescribing. It is the drug metformin that is recommended as the first line of treatment by the American Diabetes Association (ADA) and another Professional Group for persons newly diagnosed with type 2 diabetes.

This study was the work of researchers from CVS Caremark, Harvard University, and Brigham and Women's Hospital. It looked at data from pharmacy claims for 254,000 patients started on diabetes medications between January 1, 2006, and December 31, 2008. You know that insurance companies will review their records to see what the doctors are prescribing and whether they should revise their formulary.

After reading this blog and the linked article, you may wish to review your medications with your doctor to determine if you are using the correct medication and not one that is overly expensive. If your doctor has you on one of the brand medications and refuses to change to a generic, you may want to have a pointed discussion with the doctor or consider a second opinion.

Many Ways That Diabetes Is Worse Than Cancer

Every so often, another blogger writes a blog that sets off light bulbs for you. Tom Ross wrote a blog on February 24, 2012 that did that for me. He called the blog he was reading and writing about a rather inflammatory blog. That may be true for some people and the way they see the world, but the title was spot on for me. I am not sure how many ways I can come up with reasons diabetes is worse in some ways than cancer, but I have to agree with the “Well Done Chef” and what he wrote over a year ago.

I agree with the six reasons Jason Sandeman used in his blog (sorry link no longer exists) and I would like to add some of my own to his. Therefore, you may wish to read his blog before finishing mine. In addition, you may like to read Tom Ross's blog while you are at it. All have the right things to say. I will wait for you to return.

Some of my additions are:

1. In the USA a diagnosis of prediabetes, or for that matter diabetes, gets little attention from the doctors. You are told to watch you diet, eat low fat, and eat carbohydrates per the American Diabetes Association (ADA). This for many is poor advice. At least the American Cancer Society (ACS) is saner in their advice. I do not say the ACS is perfect, but compared to the ADA, the ACS has their act together.
2. Most medical insurance companies in the USA do nothing to assist anyone with a diagnosis of prediabetes. No supplies or medications are covered. Cancer is cancer, and the medical insurance companies are there to pay the bills although they may not fully reimburse some of the newer procedures.
3. Most doctors will insist on oral medications for diabetes, but give no sound dietary advice. Many will not prescribe testing supplies because they do not wish to make their patients become depressed by high blood glucose readings. Most do not even mention the complications that may develop if diabetes is not managed properly. If the diagnosis is cancer – all stops are pulled out to rid you of the cancer or at least put it into remission.
4. The ACS is united in their support of all types of cancer and united in their fund raising efforts. Whether it is breast cancer or prostate cancer, the support is there along with a unity of symbols and support. Not so, with the ADA, JDRF, AACE, and IDF as they each have their own agenda and guard it zealously. No cooperation there and they scream bloody murder if another organization tries to usurp any credit for their work.
5. It seems that physicians today do not know what to do with a patient diagnosed with prediabetes any better than in the past. They look to the ADA for guidance, which is not available. Unlike the ACS, the ADA has their heads where they cannot see the light, refuse to recognize that prevention could be a huge benefit, and possibly delay the onset of full diabetes for many years or possibly decades. Occasionally some medication may be needed initially while exercise and diet changes are made. The goal should be to get off the medications as soon as reasonable. The doctors do not project the importance of doing anything and the patient wrongly assumes that there is nothing to be worried about, and does nothing that could help manage the prediabetes.

The following points may have comparisons to other diseases, but for my purpose, I want to list them standing on their own. The purpose is to highlight the problems we as type 2 diabetes patients have to put up with in finding things that help us manage our diabetes.

1. If the ADA would position their heads where they could see the light and issue guidelines for medication and treatment, the medical insurance companies would follow suit and prevention could begin. This would probably mean that the patient could delay diabetes and therefore not have the costs, which puts money in the coffers of Big Pharma. Therefore, if you think the doctors at ADA are influenced by Big Pharma, you may be right. This means that the less said about prediabetes and prevention, the better for Big Pharma, as diabetes will happen sooner and require medication.
2. If the ADA could issue more up to date guidelines that fit the real world, maybe more people with type 2 would benefit. They have made some allowances recently, but the other medical professions that are required to follow them have not followed them and as a result, certified diabetes educators (CDEs) continue to follow out-dated guidelines and make life more difficult for type 2 patients. Many people do wish to determine for themselves whether a low-carb diet works for them. This normally means more protein and higher fat in the diet. The CDEs just will not accept this and use the mantra of whole grain, low fat and will not move from this stance.
3. Even many dietitians follow the guidelines of the ADA and American Medical Association. This also creates problems for those wishing to adapt their diet to low carbohydrate diets. Many need guidance for nutrition about keeping their daily diet reasonably balanced. This is often difficult to obtain good advice from dietitians that are afraid of losing their certification.
4. Education about the different aspects of managing diabetes is almost non-existent and most doctors will not spend the time necessary and most CDEs do not care enough to spend the time necessary to emphasize the importance of testing and teaching the patients how to interpret the test results and watch for trends. Because they want us to eat a set number of carbohydrates, they will not tell us to use our meter to determine how the different foods will affect our blood glucose numbers.
5. Most doctors do not understand the management of diabetes. If they have their choice, they will push oral medications on top of oral medications. If this does not work, they think that by threatening insulin they will get the patients to do better. How, the CDEs and dietitians are inept and have their mantras they follow which does not help the patients with type 2. It is up to the patient to make the changes necessary and do trial and error to arrive at what works for them.
6. Because the ADA will not issue guidelines for prediabetes, patients are unable to get testing supplies unless they pay for them. The same applies to adequate testing supplies for type 2 patients as well. In order to learn how different foods affect their blood glucose, they must purchase the additional testing supplies on their own.
7. The odds are stacked against people with type 2 diabetes, first by the ADA, next by the doctors, CDEs, and dietitians. Then add the insurance companies to keep costs down and prevent patients for learning how to manage diabetes for maximum benefits and prevention of the complications.

The only areas diabetes and cancer have in common, but are not exactly the same is dealing with big pharmaceutical companies. Cancer drugs are placed in short supply to up the price of drugs that become generic while diabetes drugs that become generic generally just ceased to be produced, forcing everyone to the more expensive drugs.

The second common area is that most medical insurance companies put cancer and diabetes patients in managed care programs to clamp down on excessive costs where possible and control the treatments. You may be well treated if the need is there, but if the insurance company feels something is excessive, they will force the doctors and hospitals to limit the services.

At least with a cancer diagnosis, you know there is a plan of real action, not the namby-pamby crap handed out with a diagnosis of prediabetes or even type 2 diabetes – if you are lucky to get any assistance. Blame must fall on the medical profession for not learning about diabetes. Then treating it properly, and educating the patients to do their due diligence with self-monitoring of blood glucose. The patients must also be trained to understand what the readings mean and when to test.

Patients should learn that they are their own laboratory experiment and act accordingly as the lab rat. Learn what the different foods do to your blood glucose levels and why you must eliminate certain foods from your menu and greatly reduce the consumption of other foods. Why can I not give you a list to remove, because each person is different, you must determine for yourself what you can eat and not eat.

Yes, I can say eat more protein, but not a lot more. Learn not to follow past mantras of the medical profession. These include, whole grains, low fat, and low cholesterol foods. You must now learn that carbohydrates are very likely your enemy, moderate to high fat meals may be your friend, and some (but not all) cholesterol-laden foods may actually help reduce your overall cholesterol levels. Generally, you will want to avoid the highly processed packaged foods.

When Is AACE Going to Update Type 2 Sources?

The AACE has removed the AACE/Takeda Link

On September 27, 2011 I blogged about AACE/Takeda web site being operational. This was a good thing because it would provide us with reliable sources for diabetes information. Now we are about five months later and no additional sites have been added to the original list. This makes me wonder what is happening at the American Association of Clinical Endocrinologists.

I had thought that this could be an excellent site to give people much good information about diabetes and give people comparisons for many of the snake oil web sites full of false information. Apparently, the AACE does not agree. Why else would it take so long to post sources that are reliable? Even the addition of a few sites per month or even every other month should not be asking too much. Unless they have to completely approve a site beyond the committee of experts.

If they are not going to approve any more web sites, why will they not say so? First, I would doubt that they have exhausted the reliable sites. There are many sites that I seriously doubt will able to satisfy their stringent guidelines, but this still leaves many that can meet their requirements.

If there are no more sites that meet their requirements, certainly they have a host of web sites that could fit under some category that lists the weakness of the sites. To have waited five months from the announcement of the site to its debut and now another five months without any additions to the original list of approved sites is very disheartening.

If you are looking for good sources, I suggest joining Google+ and adding Dr. Bill Quick (Bill Quick) to your circle. He is listing a “D” site at least five days a week and they should be reliable. He does cover the types of diabetes in the sites he lists, so it is not a listing for one type of diabetes only.

Another good source of information on Google+ is Scott Strumello. He posts links to much good information and especially for type 1 readers. He covers a variety of topics and does include the occasional tidbit for type 2.

Therefore, if you are like me and tired of the pace of the AACE in posting approved web sites, explore and read carefully. There are many good sites available that AACE and their snail's pace may get around to listing sometime in the distant future.

Is Fructose Off the Hook for Overweight and Obesity?

According to the online site WebMD, more controversy is coming. In my reading lately, fructose and gluten-free are the latest to enter the controversy. We have seen sodium and fat at the head of the line, but the latest two entries are interesting. I feel that research agendas are driving all the controversies and not pure scientific research.

As a person with diabetes, high-fructose corn syrup is on the list of “do not eat items.” Therefore, it is with more than a passing interest that I read these articlse. I do have to wonder why there is no listing of the people who are quoted in the WebMD article and who they work for. Yes, in the WebMD article they are all associated with Canadian or US universities, but are they truly independent from the grain industry?

I have in the past, not been too kind to the corn industry and have had several nonproductive conversations with people in the industry. They always spouted the mantra of “sugar is sugar” and quoted industry experts that proclaimed there was no difference. They have well rehearsed answers.  This is most unsatisfying and leaves the discussion without any conclusion.

Most studies are too small and thus not very reliable. Quite possibly, they were done to obtain the results of the agenda of the researchers. This is disturbing at best. Plus, most studies or done using healthy people and not people with diabetes.

By reading a blog by Tom Ross here, and following his link, you may read about a study on fructose reported in the Annals of Internal Medicine (page down to find the abstract). Their review states that most trials had methodological limitations and were of poor quality. They do conclude that fructose does seem to cause weight gain when substituted on the same caloric level as the carbohydrate replaced.

Therefore, with the caloric intake being equal, fructose does not automatically mean weight gain. Now I have to question whether most people can reduce the caloric intake when they are unaware of the number of calories that have been added to their soft drinks and other processed foods. This is where better labeling requirements need to be placed on foods with added fructose, regardless of the type of fructose. The control group did have weight increase when the fructose calories were in addition to the carbohydrate calories already present.

These studies do make some sense of the fructose issue, but there are still many unanswered questions about the effect of fructose on the body, especially the lipid levels produced by fructose.

Now we have another study saying the opposite of these studies. “These studies may provide important insights into the cause of the prediabetic condition known as "metabolic syndrome," which currently affects more than one-quarter of adults in the United States.” Whether this is true, or is just another agenda driven study remains to be seen. Obviously there will be more studies.

Mayo Clinic Study – Prediabetes Does Not Mean Neuropathy

Every once in a while we all need to rethink what we have learned or come to expect. So it is with prediabetes and neuropathy. A recent study conducted by Mayo Clinic researchers states that people with prediabetes are no more likely to have nerve damage termed small fiber polyneuropathy than people in good health. The point being made is that this goes against two decades of medical reports. This is interesting!

According to the lead author, "It is highly unlikely that impaired glucose or associated metabolic derangements cause polyneuropathy, at least not to the high frequency previously reported."

FDA Issues New Warning On Statin Drugs

Now we will all be wondering about our statin pills. The Food and Drug Administration has issued new warnings for all statin drugs. In addition to muscle damage, memory loss, confusion, and diabetes are listed as possible statin side effects. This much has been reported by WebMD.

Medscape also has reported the warnings are for the entire drug class. “Brand name and generic versions of statin drugs must carry these warnings on their labels, the FDA today announced.” This is good news for some people that have been resisting their doctors, but do not stop until your doctor knows about this.

This was not intended for tonight, but I felt this should be publicized.

Gluten-Free Foods – Watch Nutritional Value

This was not what I had expected from WebMD. I do feel the writer may have it right. “Move over fat, salt, and sugar. There’s a new dietary villain in town and its name is gluten.” This is not to belittle those with celiac disease, as they do need to avoid any gluten. What the food industry is doing to gluten-free foods is not a good thing and is harming people more than helping them or serving peoples' best interests.

Best estimates say that approximately 18 million Americans have some degree of gluten sensitivity. About 3 million people are estimated to have celiac disease. Gluten-free foods are the latest food industry crime. They have little concern for the health and welfare of these consumers. Yes, the foods are gluten free, but it is all the junk that is added to these foods that creates additional problems for people trying to loose weight or even maintain a balanced nutritional diet.

According to Dr. William Davis, “Eliminating all things wheat from the diet is one of the most powerful health strategies I have ever witnessed. But replacing lost wheat with manufactured gluten-free foods is little better than replacing your poppy seed muffin with a bowl of jelly beans.” Dr. Davis is a strong advocate for a wheat free life.

Reading the Nutrient Facts panels and Ingredients panels on packaged foods is a good idea to help prevent nutritional vacuum in your daily food intake on a gluten-free diet. Consider purchasing gluten free products that have added vitamins and minerals.

Refined carbohydrates dominate most commercial gluten-free foods and it takes more gluten-free ingredients to produce a tasty product. Therefore, produced baked gluten-free foods are much higher in calories and total carbohydrates than the regular foods containing gluten.

Are there dangers from a gluten-free diet? Yes, even doctors that specialize in Celiac Disease are concerned about the nutritional dangers involved in eating gluten-free diets. They urge people to get nutritional counseling and follow the advice of a dietitian specializing in Celiac Disease. These doctors are also concerned about the levels (too high) of fat and too little of fiber. They state that people that need to be gluten-free and are closely monitored can receive tremendous benefits. Until you know that you have actual gluten sensitivity, be very careful about doing this on your own. There are many pitfalls that can damage your health unless you are under doctors orders and have assistance from people specializing in gluten-free diets.

Gluten-free should not be a fad because of the dangers. This is the concern of the medical community and rightly so as this is a dangerous fad. More can be read about gluten-free here. A gluten-free diet is not a plan for weight loss and can make weight management problematic for many.   Read this on WebMd as well and this article about gluten-free.

Tackling Diabetes Care Challenges

Another “Expert Group” for diabetes is not something that gives me a lot of hope. Again, they do not include any people from the patient side. Granted there are not a lot of experts these professionals would classify as patient experts.

The name of the program is called “Improving Quality in Type 2 Diabetes: A national Initiative to Assess Guideline Adherence and Physician/Pharmacist Coordination.” This is part of a U.S. multiphase initiative that is setting out to assess the effects of current in-practice behavior across multidisciplinary professions in caring for patients with type 2 diabetes. Sounds impressive, but will this really assist patients?

I always get a sickening feeling when I read things like this as I wonder what other limits are going to be imposed on those of us with type 2 diabetes. Is this another program to declare that type 2 patients on oral medications do not need to spend time testing? Or, will someone finally realize that the physicians are not doing their duty of educating patients on the value and meaning of self-monitoring of blood glucose (SMBG).

This is always a possibility and should be high on the priorities for any expert group, but will it? “The aims of the program are:

• To reveal practice-specific obstacles of appropriate glycemic control in primary care and endocrinology in multiple locations and practice environments across the U.S.
• To assess current pharmacist practices in terms of medication education and patient monitoring of those with type 2 diabetes, and
• To determine the critical factors of successful interdisciplinary diabetes care by considering the behaviors and attitudes of physicians, staff, pharmacists and patients.”

Notice that the only mention of patients is in the last point above. Everything else is dedicated to practice level discussion. How will they determine the behaviors and attitudes of patients? Will this be just another adhering or non-adhering discussion about the patients? Or, will they actually consider the feelings and problems patients encounter in lack of diabetes education, continuing support and updated education, and the benefits of continuing education to assist the patients?

As a patient, I can only suspect that it will be more of the same lack of concern for the welfare of the patient and no thought about the lack of education provided. This will leave patients out in the cold and the “medical professionals” patting themselves of the back for again claiming to have improved life for the patient.

Until the professionals change their thought process and include patients with type 2 diabetes in any discussion, nothing will change from a patient perspective. No education will be provided to the patient, SMBG will continue to be downgraded, and patients will continue to wonder where to get reliable information and help in their management of diabetes.