Think Your Hospital Is Looking Out for You?

If you think when you are in the hospital that the hospital is looking out for you, you are in the minority. Day after day, we see news of people that have stories to tell that are not showing hospitals in a good light. We hear of friends or relatives of friends that have died because of medication errors, errors in medical judgment, and errors in operations performed on the wrong patient. It will soon be apparent to even the most careful of patients that they will need a patient advocate if they are to be admitted to a hospital.

Even then, patient advocates will have a difficult time. Hospitals do not like patient advocates and do their best to work around them or even conceal what is happening. Yes, several decades ago, there were accidents and errors, but not at the ratio of today. We had doctors that spent time with patients and checked in regularly. We had nurses that knew what to do and communicated with the patient’s doctor(s) and the patients. They would alert doctors of changes in a patient's condition and test results.

Then came larger hospitals and more lawsuits. To protect their profit margin, nurses were marginalized, doctors restricted in their duties by the hospitals. Patients in the hospitals are being seen less often and not by their own physician. Is it any wonder there are more errors and improper medications given? Allergies are not checked and communications are limited.

This article in a Diabetic Connect newsletter says a lot and lays out many of the problems we encounter as people with diabetes. This from the article needs to be quoted, “The problem with hospitals is that they standardize care much more than they individualize care. This is due in large part to the huge volume of patients they service, and the need for general protocols. General protocols, however, do not work all the time for patients with diabetes. If you have never used insulin and the plan is to give you insulin in the hospital, work with your health care team to understand what to expect. I would advise family members to carry blood glucose meters with them and have them available for a quick check if necessary so that you can alert the hospital of a potential problem with high or low blood sugars.”

These general protocols can make it impossible to manage blood glucose levels in the range that you are accustomed to. Most hospitals do not want you to use your pump if you use one. They even discourage continuous glucose monitors. Occasionally you will find a hospital that will allow the patient to manage their diabetes while in the hospital, but this is rare and must be decided upon before admission. I would even suggest getting it in writing.

Another issue the article raises that I can appreciate is some hospitals are giving rapid-acting insulin after a meal. This surprisingly allows the patient to not eat the food that you will be served and/or eat what you think will be sufficient for your needs. Then the amount of insulin can be adjusted for the food eaten. Most hospital food is not very enticing and is loaded with carbohydrates. This is because of the dietitian mandate that people with diabetes should have 60 grams of carbohydrates at every meal.

I do appreciate the author's comment and I quote, “I do not in any way want this to scare you, but rather to encourage you to be an active participant in your healthcare. Any and all family members and loved ones should be involved as well.”

Hospitals need to learn how to treat people with diabetes. This will mean every family member will need to be on board and maybe even a diabetes patient advocate. If the patient is going to be incapable for any period of time and a family member is unable to be present, even a medical power of attorney will get their attention as long as the persons present are listed on the document. Even then, many hospitals will try to circumvent this document.

If you are the patient, make sure that you dot all “I's” and cross all “T's” and that your wishes are known, if possible, before admission to the hospital. Remember that the hospital protocols may not be in your best interests for diabetes management. Hospitals have protocols that are in their interest to protect their profit margin and prevent lawsuits.

Nutrients – Choline

Choline

Overview

Choline is similar to the B vitamins and is made in the liver. Choline is not strictly defined as a vitamin, but it is an essential nutrient. Choline is used for liver disease, including chronic hepatitis and cirrhosis. It is also used for depression, memory loss, Alzheimer's disease and dementia, Huntington's chorea, Tourette's disease, a brain disorder called cerebellar ataxia, certain types of seizures, and a mental condition called schizophrenia.

Choline is synthesized by the human body in small amounts, but still must be consumed to have an adequate supply. Athletes use it for bodybuilding and delaying fatigue in endurance sports. Choline is taken by pregnant women to prevent neural tube defects in their babies and it is used as a supplement in infant formulas. Other uses include preventing cancer, lowering cholesterol, and controlling asthma.

Deficiency Signs and Symptoms

The most common signs of choline deficiencies are fatty liver and hemorrhagic kidney necrosis. Dietary intake of a choline full diet can reduce the severity of the deficiency. Choline deficiency may play a role in liver disease, atherosclerosis, and possibly neurological disorders. One symptom of choline deficiency is an elevated level of the liver enzyme ALT.

Tests

There are a few tests, but none that I can find that your doctor may use. The doctor may know which tests are available to use. One that is mentioned is the platinochloride test for choline in human blood; however, this is not listed when looking for choline tests that I researched.

Recommended Daily Allowance

Adequate Intake (AI) for Choline
Life stage	Age	Males (mg/day)	Females (mg/day)
Infants	0-6 months	125	125
Infants	7-12 months	150	150
Children	1-3 years	200	200
Children	4-8 years	250	250
Children	9-13 years	375	375
Adolescents	14-18 years	550	400
Adults	19 years and older	550	425
Pregnancy	All ages	-	450
Breast-feeding	All ages	-	550

Tolerable Upper Intake Level (UL) for Choline
Age group	UL (g/day)
Infants 0-12 months	Not possible to establish*
Children 1-8 years	1.0
Children 9-13 years	2.0
Adolescents 14-18 years	3.0
Adults 19 years and older	3.5

Notice that the top chart is in milligrams and the bottom chart is in grams.

Function

Choline is similar to a B vitamin. It is used in many chemical reactions in the body. Choline seems to be an important element in the nervous system. In asthma, choline might help decrease swelling and inflammation.

Food Sources

It is in foods such as liver, muscle meats, fish, nuts, beans, peas, spinach, wheat germ, and eggs. It is generally recognized that it is important to get dietary choline from these foods as well.

Animal and plant food	Choline (mg)	Calories
5 ounces (142 g) raw beef liver	473	192
Large hardboiled egg	113	78
Half a pound (227 g) cod fish	190	238
Half a pound of chicken	150	543
Quart of milk, 1% fat	173	410
A gram soy lecithin	30 approx.	8
100 grams of Soybeans dry	116	268
A pound (454 grams) of cauliflower	177	104
A pound of spinach	113	154
A cup of wheat germ	202	432
Two cups (0.47 liters) firm tofu	142	353
Two cups of cooked kidney beans	108	450
A cup of uncooked quinoa	119	626
A cup of uncooked amaranth	135	716
A grapefruit	19	103
3 cups (710 cc) cooked brown rice	54	649
A cup (146 g) of peanuts	77	828
A cup (143 g) of almonds	74	822

Precautions

There is some concern that increasing dietary choline intake might increase the risk of cancer of the colon and rectum. One study found that women eating a diet that contains a lot of choline have an increased the risk of colon cancer. However, more research is still needed to determine the effects of diet on colon cancer.

Choline is seems to be safe when taken by mouth and used appropriately. Doses up to 3 grams daily for pregnant and breast-feeding women up to 18 years of age, and 3.5 grams daily for women 19 years and older are not likely to cause unwanted side effects. There isn’t enough information available about the safety of choline used in higher doses in pregnant or lactating women. It’s best to stick to recommended doses.

Possible Interactions

High doses (10 to 16 grams/day) of choline have been associated with a fishy body odor, vomiting, salivation, and increased sweating. The fishy body odor results from excessive production and excretion of trimethylamine, a metabolite of choline. Taking large doses of choline in the form of phosphatidylcholine (lecithin) does not generally result in fishy body odor, because its metabolism results in little trimethylamine. A dose of 7.5 grams of choline/day was found to have a slight blood pressure lowering (hypotensive) effect, which could result in dizziness or fainting. Choline magnesium trisalicylate at doses of 3 grams/day has resulted in impaired liver function, generalized itching, and ringing of the ears (tinnitus). However, it is likely that these effects were a result of the salicylate, rather than the choline in the preparation.

Little is known regarding the amount of dietary choline most likely to promote optimum health or prevent chronic disease in older adults. At present, there is no evidence to support a different intake of choline from that of younger adults (550 mg/day for men and 425 mg/day for women).

Methotrexate, a medication used in the treatment of cancer, psoriasis, and rheumatoid arthritis, inhibits the enzyme dihydrofolate reductase and therefore limits the availability of methyl groups donated from folate derivatives. Rats given methotrexate have shown evidence of diminished nutritional status of choline, including fatty liver, which can be reversed by choline supplementation. Thus, individuals taking methotrexate may have an increased choline requirement.

Nutrients – Selenium

Selenium

Overview

Selenium deficiency for those of us living in the United States is generally rare. I suggest reading my blog on selenium linked here. Excess selenium can indeed cause more harm than good so please be careful with selenium. Use this US map for determining if the food you eat comes from an area that is selenium deficient.

Selenium is an essential trace mineral found in small amounts in our body. Selenium plays a part in thyroid function and our immune system needs selenium to work properly. There are many other areas where selenium is maybe playing a role, but scientists have not determined the cause-effect in these areas. Even another area that needs more investigation is the finding that people that used selenium supplements of less than 200 mcg per day for more than seven years were at a significantly higher risk for developing type 2 diabetes.

Because of this and the number of medications that may be conflicting with selenium, it is strongly urged that people only take selenium supplements under the supervision of a doctor knowledgeable in selenium.

Potential for Deficiency

If you are healthy and eat a well-balanced diet, you should get enough selenium. You may have low levels of selenium if you:

• Smoke cigarettes
• Drink alcohol
• Take birth control pills
• Have a condition that prevents your body from absorbing enough selenium such as Crohn's disease or ulcerative colitis

Tests

Trace mineral testing is usually performed on a blood sample. Sometimes a 24-hour urine collection is obtained. Special metal-free blood or acid-washed urine containers are used to minimize the potential for sample contamination by any outside sources of minerals.

Blood and urine reflect recent mineral intake. Rarely, hair may be collected or a biopsy may be performed to obtain a tissue sample to evaluate mineral deficiencies, excesses, and storage that have occurred over time.

Recommended Daily Allowance

The minimum daily recommended dietary allowances (RDA) for selenium are listed below.

Pediatric

 Children 1 - 3 years: 20 mcg

 Children 4 - 8 years: 30 mcg

 Children 9 - 13: 40 mcg

 Children 14 - 18: 55 mcg

Adult

 19 and older: 55 mcg

 Pregnant women: 60 mcg

 Breastfeeding women: 70 mcg

As a supplement: Some studies have used 200 mcg per day for some conditions, but evidence suggests that taking that amount over a long time could increase your risk of developing diabetes. Talk to your doctor before taking more than the recommended daily allowance.

Food Sources

Dietary sources include the following: brewer's yeast and wheat germ, liver, butter, fish (mackerel, tuna, halibut, flounder, herring, smelts) and shellfish (oysters, scallops, and lobster), garlic, whole grains, sunflower seeds, and Brazil nuts are all good sources of selenium.

Selenium levels in food depend on where the food was grown. Selenium is destroyed when foods are refined or processed. Eating a variety of whole, unprocessed foods is the best way to get selenium in your diet.

Available Forms:

Selenium may be taken as part of a vitamin-mineral supplement, a nutritional antioxidant formula, or as a separate supplement. Most supplements contain a form of selenium called selenomethionine.

Precautions

There is a health risk of too much selenium. This happens when high blood levels become greater than 100 mcg/dl (micrograms per deciliter). This may result in a condition called selenosis. Selenosis symptoms include hair loss, white blotchy nails, gastrointestinal upset, garlic breath, fatigue, irritability, and mild nerve damage. In the USA, selenium toxicity is rare.

The Institute of Medicine of the National Academy of Sciences has set a tolerable upper intake level (UL) for selenium. Tolerable upper intake levels for selenium for infants, children, and adults to prevent selenosis is provided in the following table:

Age	Males and Females (mcg/day)
0–6 months	45
7–12 months	60
1–3 years	90
4–8 years	150
9–13 years	280
14–18 years	400
19+ years	400

Possible Interactions

There are many interactions that are known for selenium and some will lessen the effectiveness of the medications. Therefore, it is important that if you are having any of the following that you discuss this with a doctor knowledgeable about selenium. The list of medication conflicts is extensive and I urge you to read this. The areas that you need to be aware of include – cancer, chemotherapy, cholesterol-lowering medications, birth control pills, and gold salts.

Please read this if you have arthritis. Selenium does work with and supports iodine in the thyroid function.

Metabolic Syndrome Or Syndrome X - Diabetes Related

Metabolic syndrome or syndrome X is often spoken about as part of diabetes. Many of the tests are the same and it is true that many of the symptoms of the condition need to be heeded to prevent type 2 diabetes and cardiovascular complications.

The American Diabetes Association (ADA) has opposed the views of the World Health Organization (WHO) and the American Heart Association (AHA). Not that this is all bad, but the ADA is known to drag their feet on many issues when it comes to diabetes.

The WHO issued their guidelines back in 1998 and the AHA has done much to publicize the issue and set out guidelines similar to the WHO. The discussion is important and I will quote from some of the comments in the discussion.

“Metabolic syndrome is a set of risk factors that includes: abdominal obesity, a decreased ability to process glucose (increased blood glucose and/or insulin resistance), dyslipidemia, and hypertension. Patients who have this syndrome have been shown to be at an increased risk of developing cardiovascular disease and/or type 2 diabetes. Metabolic syndrome is a common condition that goes by many names (dysmetabolic syndrome, syndrome X, insulin resistance syndrome, obesity syndrome, and Reaven’s syndrome).”

“The National Heart Lung and Blood Institute (NHLBI) estimates that in the U.S. about 47 million adults (25%) have metabolic syndrome. It can affect anyone at any age, but it is most frequently seen in those who are significantly overweight - with most of their excess fat in the abdominal area - and inactive.”

For those interested, please read this for the table about how the three sets of criteria are laid out and compared. Also read this about additional details on metabolic syndrome and the tests, both laboratory and non-laboratory.

For most cases of metabolic syndrome, the root cause can be traced back to poor eating habits and a sedentary lifestyle. Some may be linked to genetic factors that are being researched or yet unknown. Some cases may occur in people already diagnosed with hypertension and in people with poorly controlled diabetes. With metabolic syndrome, it is important to know that all factors are interrelated.

Nutrients – Iodine

Iodine

Overview

Iodine is something I have been aware of since childhood. My mother always made sure she used iodized salt, both for cooking and for table use. This is something that I have been happy about, as both my first wife and now my second wife have been conscious about having iodized salt for use. Iodine is crucial in production of the thyroid hormone. Those of us living away from the coastal areas need to use iodized salt because there are few other ways to obtain iodine unless you are a heavy consumer of seafood from the oceans.

Iodine is a trace mineral that the body needs to make thyroid hormones, which are essential for normal growth and development. In your body, about 70 - 80% of iodine is found in the thyroid gland in the neck. The rest is distributed throughout the body, particularly in the ovaries, muscles, and blood. If your body doesn't have enough iodine, you can develop hypothyroidism (low thyroid hormone levels).

Tests for iodine deficiency

A 24-hour urine iodine collection is a useful medical test, as approximately 90% of ingested iodine is excreted in the urine. If a 24-hour urine collection is not practical, a random urine iodine-to-creatinine ratio can alternatively be used. According to the World Health Organization (WHO), in 2007, nearly 2 billion individuals had insufficient iodine intake, a third being of school age. Thus iodine deficiency, as the single greatest preventable cause of mental retardation, is an important public-health problem. In the USA, it is important the women bearing a child be tested and the newborn be tested as soon as can reasonably done.

Recommended Daily Allowance

The Food and Nutrition Board at the Institute of Medicine recommends the following dietary intake for iodine:

Infants

0 - 6 months: 110 micrograms per day (mcg/day)

7 - 12 months: 130 mcg/day

Children

1 - 3 years: 90 mcg/day

4 - 8 years: 90 mcg/day

9 - 13 years: 120 mcg/day

Adolescents and Adults

Males age 14 and older: 150 mcg/day

Females age 14 and older: 150 mcg/day

Specific recommendations depend on age, gender, and other factors (such as pregnancy). Women who are pregnant or producing breast milk (lactating) need higher amounts. Ask your doctor for the amount that is best for you.

Function

Iodine is needed for the normal metabolism of cells. Metabolism is the process of converting food into energy. Humans need iodine for normal thyroid function, and for the production of thyroid hormones. Iodine is a trace mineral and an essential nutrient found naturally in the body.

Food Sources

Iodized salt -- table salt with iodine added -- is the main food source of iodine. Seafood is naturally rich in iodine. Cod, sea bass, and haddock are good sources. Kelp is the most common vegetable seafood that is a rich source of iodine. Dairy products also contain iodine. Other good sources are plants grown in iodine-rich soil.

Precautions

Lack of enough iodine (deficiency) may occur in places that have iodine-poor soil. Many months of iodine deficiency in a person's diet may cause goiter or hypothyroidism. Without enough iodine, the thyroid cells and the thyroid gland become enlarged. No area maps for locations rich in iodine are currently available; however, seacoast areas are generally the highest in iodine.

Deficiency happens more often in women than in men, and is more common in pregnant women and older children. Getting enough iodine in the diet may prevent a form of physical and mental retardation called cretinism. Cretinism is very rare in the U.S. because iodine deficiency is generally not a problem.

Iodine poisoning is rare in the U.S. Very high intake of iodine can reduce the function of the thyroid gland.

Possible Interactions

If you are currently being treated with any of the following medications, you should not take iodine until you have first talked to your health care provider:

Antithyroid Drugs -- Use of antithyroid drugs, including propylthiouracil (PTU), and iodide may increase the hypothyroid effect of iodides.

Lithium -- Use of potassium iodide and lithium (Lithobid) may cause hypothyroidism.

Warfarin -- Use of potassium iodide (for hyperthyroidism) and warfarin (Coumadin, a blood thinning drug) may make warfarin less effective.

High blood pressure medication (ACE inhibitors and ARB's (Angiotensin Receptor Blockers)) -- Many iodine supplements contain potassium. When used with ACE inhibitors and ARB's, iodine may result in an increased level of potassium in the body, which may be dangerous.

Potassium sparing diuretics -- Since many iodine supplements contain potassium, concurrent use may result in dangerously high levels of potassium.

Amiodorone -- Concurrent use with iodine supplements may result in dangerously high levels of iodine.

Most people get plenty of iodine, and because of the complex way iodine can affect the thyroid, you should not take iodine supplements unless your doctor tells you to.

Reasons Diabetes Patients Need To Be Proactive

Proactive you say? Yes, we as patients need to become more proactive in our care and learn about diabetes, diabetes medications, and the care of ourselves. This means that we should learn and review. The new medications that may be coming to market in the next few years will need to be reviewed, as there could be some side effects and some positive results. Just letting your doctor prescribe a new medication may not be in your best interest. You will also need to check with your medical insurance company to see if they are covering it. You should know that the cost will be higher than the current medications on average or even significantly higher. Those on Medicare will still have the “doughnut hole” (though smaller) for a few years and this could be a budget buster for some.

With hospitals continuing to employ more doctors, you can bet the time you will have with your doctor during appointments will continue to shrink. This means less time will be available for the doctor to dispense education and even cover the topics necessary.  The recent guidelines from the American Diabetes Association (ADA), which shows a lot of stacking of medications, may not work for many patients. See this blog by Tom Ross for the chart, or follow his link to view how ADA is stacking oral medications. This makes it even more important for patients to educate themselves to know what the side effects of medications are. It is also important that patients learn self-monitoring of blood glucose (SMBG) and other important management skills.

It is also important to understand that just because a doctor does not mention or talk about something, there are areas that are important and should not be ignored. Exercise is one of these areas and I admit that I am tired of hearing other patients with type 2 diabetes saying, “It must not have been that important as the doctor never talked about it.” This phrase just seems to roll of the lips of patients and I can understand as either they don't wish to follow some recommendation, or in fact, the doctor did not have time to talk about it. Nutrition is also a topic most doctors do not talk about, yet for people with type 2 diabetes, nutrition is very important to great diabetes management.

Another topic doctors often don't talk about unless they are prescribing insulin is hypoglycemia. They seem to overlook the fact that this can happen and does happen to patients with type 2 diabetes on oral medications, especially sulfonylureas. A recent blog should also raise this concern. Even this short article talks about hypoglycemia, but other than list the symptoms, gives no indication of what to watch for in your blood glucose readings. This is important and many of the symptoms could be indicators of other medical problems. One check of your blood glucose will resolve this issue. If your blood glucose reading is below 70 mg/dl (3.9 mmol/L), you are in the hypoglycemia area and should take action immediately by chewing on a glucose tablet.

Just to keep this in front of you as a reminder, here are many of the symptoms of hypoglycemia,

Feeling dizzy or shaking,

Sweating and having pale skin.

Developing a headache.

Feeling hungry.

Showing sudden changes in behavior.

Moving clumsily.

Having a seizure.

Feeling confused or having difficulty paying attention.

Feeling a "tingling" sensation around the mouth.

This blogger believes we will need to become e-patients, meaning empowered patients. Her book e-Patients Live Longer, helps explain her and her beliefs, but it is a good read. Whether you have diabetes or breast cancer, it helps to be an e-patient.

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.

Not A Game Plan for Type 2 Diabetes

While not really a game plan at all, there are some features that this site may bring to peoples attention. Probably the only reason I found this site is an article in Medscape. After researching on the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) websites, I did not find a link to BloodSugarBasics.com  http://bloodsugarbasics.com/. Is this intentional? Maybe. Both websites do little to promote what they hype in articles or interviews, so it is small wonder that little is accomplished in bringing visitors to their sites.

Even my own endocrinologists do not promote this during office visits or include information about it in handouts. Why am I writing about this? Someone needs to promote what the professionals are seemingly incapable of doing. I think the person that made this comment – quote - “Unfortunately, like the AAFP, the AMA and ACC have also let us down. The societies today exist for their own purposes and not for the benefit of members. The AMA owns the CPT code system and makes more money from this behemoth than from member dues. The ACC is enthusiastically offering "products" (read $$$) to "help" doctors meet their performance goals.

It is beyond time for new professional societies to emerge that actually advocate for physicians involved directly in patient care. Perhaps one big "Society for Patient Care Physicians" that could involve everyone who actually sees patients every day, rather than the academic guideline and rule-writing "doctors" who dominate societies today.” - Unquote.

I think the comment is on target and needs to be done so that doctors that care for and about patients could have a format to get information to patients in terms they understand and this could be promoted for patients. With the Internet of today, what could be of value to patients is often lost in the dogma of the medical organizations. Most could have on their home page a link to patient information and then links on the patient page for more pages of valuable information. This information could then be reliable information that can be used for the benefit of patients and used by patients.

Even the website for approved Internet websites on the AACE website no longer has a direct link to it on the home page. Plus, they are not adding anymore approved sites. They have fulfilled their promise so-to-speak, and now want to leave it alone. For the two sites of the AACE and ACE, there is so much information that could be included as part of their websites. However, at most, the information is limited for patients and not really informative for new patients that may be searching these sites for reliable information.

On the same site is a tab named “The ABCs of Diabetes Management.” This did not surprise me as they are A1c, blood pressure, and cholesterol. Surprise, no mention is made about statins. Blood pressure goals are different than recommended by the American Heart Association, but not significantly higher. From the way the material is presented, the emphasis seems very much on the HbA1c as the measurement for how well the goals are being accomplished not any individual blood glucose tests. At least the A1c goal is 6.5%, but then they say that maybe the goal will need to be higher. No mention is made about individuals that want to strive for lower A1cs or if they will even allow for this.

Then they use four topics to help in achieving the ABCs. They include healthy eating, getting more active, taking your medication, and tracking your ABC goals. I was totally surprised at the healthy eating. They rightly say to limit refined foods and eat vegetable and some fruits. Maybe a little heavy on the fruits, but no mention of whole grains. The limited discussion on getting more active was not bad, but the discussion missed a lot of physical activity. Taking your medication(s) did not discuss any particular medication(s), but the suggestion is there. The concern for hypoglycemia is present and that is a plus. Tracking your ABC goals missed more than it covered. It talks about tracking your blood glucose levels, but does not give any meaning to why track and what to be looking for in meaning. To me, it sounds more like the reason is for the doctor than looking for reasons to the daily numbers.

In the medscape interview, Farhad Zangeneh, MD, FACP, FACE did a good thing in answer to a question about why not use the more effective treatment of bariatric surgery for all obese type 2 patients than have them struggle with lifestyle changes to achieve treatment goals. I will quote his answer - “Not all patients with type 2 diabetes are candidates for bariatric or metabolic surgery, and no matter how much weight is initially lost, there is always weight rebound. There are no easy answers and no shortcuts in the management of diabetes. Even if patients are candidates for bariatric surgery, their psychology — mindset and eating behavior — has to change before their anatomy. There is also growing evidence that patients who undergo gastric bypass surgery are prone to hypoglycemia. For the majority of patients with diabetes, management still boils down to healthy eating, physical activity, and pharmacological medical management.”

As for the goals of “The Game Plan,” most of the information is on a need to be done basis and not education about diabetes and the reasons for doing what is all but demanded that patients do. Some information is there and for some patients that function in this manner, it may be of value.

What I think is that few people are going to find this site without a direct link to it from the AACE main page or even a link from the ACE page. Few patients with type 2 diabetes ever read the articles from the medscape dot com site and I have not seen any other mention of the site elsewhere. Granted I do not read every website, but I think Merck was sold an idea with no solid intention of promoting the website by AACE. Some people will find the website from search engine use, but that will be a small number. Great idea, but no support of the site by AACE.