Why Will Doctors Not Diagnose Diabetes?

I have heard of this, but I was not looking forward to the day I received an email with these circumstances. I answered the email, but felt I had to force the issue. The person felt he had diabetes because of his symptoms, especially his blurry vision, but his doctor would not diagnose him. All he was told was to watch what he ate as his blood sugar was becoming elevated.

I asked if he had copies of his lab reports and he answered no. He said that he had asked the doctor for a copy, but the doctor had just ignored him. I then advised him to put the request in writing with a date of request and the dates of the lab reports if possible. I told him that he might be required to wait 30 days, and if he did not receive them, there would be more work on his part.

He had said that his doctor was about 35 miles away and the next doctor was about 135 miles away from him. I had asked if he had a good relationship with a pharmacist and he said he had and in the same town as his doctor. I suggested that he talk to the pharmacist and see if he could get diabetes testing supplies, a lancet, lances, test strips, and a meter. Andy (not his real name) does not have access to other sources within 135 miles. I suggested checking Amazon and he said that would be a second choice for him.

An hour later, I received an email with a telephone number and a request to call him at the pharmacy. The pharmacist had told him he was out of supplies and would not have any for about a week. He asked what my position was and I said a type 2 diabetes patient. The pharmacist said that he had been shown my blog and wondered if there was anything more. I assured him that I had other problems, high cholesterol, high blood pressure, and sleep apnea. He asked if I knew about the A1c testing kit that used to be manufactured by Bayer and I said yes. He said he had two remaining that he would gladly sell as the expiration date was coming in 40 days.

I asked if he would use one to show Andy how to use the second one. The pharmacist agreed and asked if I could remain on the line. I agreed and I could hear them talking. Then the pharmacist came back on the phone and said he was shocked and would be recommending that he travel the extra distance to another doctor, as he firmly believed he had diabetes. I could hear Andy tell him to tell me and the pharmacist said the A1c showed 11.8. The pharmacist said he would call the doctor in a town 100 miles distant from there and get him an appointment as soon as possible. Then he would have my friend go to Amazon and look over the meters and supplies available and have him order for quicker delivery.

When the Andy arrived home he sent me another email saying that he would be seeing the new doctor the next day and would pick up testing supplies there as the pharmacist had called another pharmacist to see if he had the supplies and had set back some for him to purchase the next day. Then Andy was asking all types of questions about foods and testing. I had been pulling together blogs of mine and blogs by others for him to read and I sent them to him; telling him that we could communicate after he returned from the doctor. I did ask for his phone number and gave him mine. He said he would have his wife email me when they arrived home, as he would be busy with chores that could not wait. He said his wife is aware of what has happened and will be with him the next day.

This will be continued when I have more information.

Use Insulins – Don't Make This Mistake!

I have make mistakes with insulin and I am not proud of the way I made them. As a result, I have set up checks to make sure they don't happen again. This mistake reported in Diabetes in Control is not one I have made, but I can understand this happening. At least the pharmacist gave the pharmacy intern credit for discovering how the mistake was made. This makes this more meaningful and shows that the pharmacist takes pride in her staff and wants them to succeed.

Four days after the prescription was filled (actually refilled as the patient had been on the insulin for several years), the patient called. She complained that she was having unexplained lows at bedtime and highs during the morning and during the day. She had been questioned about food activity and how she was drawing the insulin into the

syringe and injecting the dose and nothing seemed to have changed.

All seemed to have been covered until the intern suggested that the patient might have let the insulin get too warm or too cold. It was suggested that she bring the bottles into the pharmacy to let them be examined.

After she brought them in, everything seemed okay, but the intern noticed that the bottles were in the wrong boxes. When the patient was asked about this, she said it was easier for her to hold onto the bottles for dosing if she left them in the box. She said that she must have switched them when she had taken them out to pop off the safety tops. She was instructed to place the bottles in the correct box. She was advised to make sure they were always in the proper box. There have not been any more problems for the patient.

Yes, there are a lot of things to remember with insulin, but it can be managed. Two of the three times I have had hypoglycemia, I knew that I had injected too close to the other insulin when I took the syringe out after the injection. Easy fix – just wait 30 minutes and test, going down, but still not below 90 mg/dl. Wait 15 minutes and test again. Time to chew on a glucose tablet. Wait another 15 minutes, and eat another glucose tablet. Repeat three more times and then I was back over 70 mg/dl. Wait a final 15 minutes and test for hopefully the last time and at 81 mg/dl.

The last low I am not certain what happened, the only thing I can guess, it that my finger that I used for the test was not clean and I injected too much insulin as a result. This has taught me to be extra careful and always wash my hands before testing and dry carefully. I don't use paper towels, but I use regular towels and if I need to, I change them two or three times per week.

AACE Urges Congress to Act

When I first read about this a couple of weeks ago, I was not happy with the American Association of Clinical Endocrinologists. My first thoughts were that the AACE would undo some of the good that the group Strip Safety had accomplished. But the more I thought about it, I soon realized that Alan J. Garber, M.D. of nefarious fame of the AACE was not calling the shots. I also realized that the more help for diabetes and the tools for diabetes, the better off we all could be.

The letter, signed by AACE president Mack Harrell, MD, and president-elect George Grunberger, MD, called for the passage of two bills: the Medicare CGM Access Act (HR5644/S2689), and the National Diabetes Clinical Care Commission Act (HR1074/S539). The latter would establish a public/private commission to coordinate activities that currently span 35 federal departments, agencies, and offices, according to the statement.

The letter also asks Congress to conduct follow-up hearings to examine FDA's pre- and postmarketing surveillance and enforcement activities for medical devices, along with a call for a review of Medicare's competitive bidding practices. With regard to the FDA, the AACE is asking for more rigorous pre- and postmarket surveillance of glucose testing supplies and the prohibition of devices that don't meet current quality standards.

The above are all needed and if accomplished, could be a big help for all people with diabetes. The Medicare CGM Access Act promotes Medicare coverage of continuous glucose monitors. Currently, Medicare does not reimburse for CGM, which means that well-controlled patients with type 1 diabetes lose an important means of monitoring once they hit the eligibility age of 65. Grunburger said it is unclear why Medicare does not cover the devices, despite the evidence of benefit and cost savings. The device has been associated with a reduction in hospitalizations for hypoglycemia.

Many Recalled Dietary Supplements Remain Unchanged

From recent studies, it appears that many dietary supplement manufacturers that have recalls made because of contaminated products, thumb their nose at the FDA and continue to sell the product. How bad is it? A study published in the October 22/29 issue of JAMA found that about two-thirds of FDA recalled dietary supplements analyzed, still contained banned drugs 6 months after being recalled. It is sad that this study has to be behind a pay wall.

The U.S. Food and Drug Administration (FDA) initiates class I drug recalls when products have the possibility of causing serious adverse health consequences or death. The FDA has used class I drug recalls in an effort to remove dietary supplements adulterated with pharmaceutical ingredients from U.S. markets. Research has found that even after FDA recalls, dietary supplements remain available on store shelves. However, it has not been known if the supplements on sale after FDA recalls are free of the adulterants, according to background information in the article.

Pieter A. Cohen, M.D., of Harvard Medical School, Boston, and colleagues conducted a study to determine if banned drugs were still present in dietary supplements purchased at least six months after a recall. Twenty-seven of the 274 FDA recalled supplements (9.9 percent) met inclusion criteria for the study. These supplements were analyzed using the same methods at the FDA’s laboratories (e.g., gas chromatography/mass spectrometry). Supplements were purchased an average of 34.3 months (range 8-52 months) after the FDA recall. Seventy-four percent of supplements (20 of the 27) were produced by U.S. manufacturers.

The researchers found that one or more pharmaceutical adulterant was identified in 66.7 percent of recalled supplements still available for purchase (18 of the 27). Supplements remained adulterated in 85 percent (11 of 13) of those for sports enhancement, 67 percent (6 of 9) for weight loss, and 20 percent (1 of 5) for sexual enhancement. Of the subset of supplements produced by U.S. manufacturers, 65 percent (13 of the 20) remained adulterated with banned ingredients.

Sixty-three percent of analyzed supplements contained the same adulterant identified by the FDA. Six (22.2 percent) supplements contained 1 or more additional banned ingredients not identified by the FDA. Some supplements contained both the previously identified adulterant as well as additional pharmaceutical ingredients.

“To our knowledge, this is the first study to determine if adulterants remain in supplements sold after FDA recalls,” the authors write. “Action by the FDA has not been completely effective in eliminating all potentially dangerous adulterated supplements from the U.S. marketplace. More aggressive enforcement of the law, changes to the law to increase the FDA's enforcement powers, or both will be required if sales of these products are to be prevented in the future.”

Are You Staying within Your Calorie Budget?

I know some people with type 2 diabetes are, but many are not because they are totally immersed in counting carbohydrates and they ignore calories. How many calories have you eaten today, how many should you eat? Many can guess how many calories do you need? The 2000-calorie-a-day standard is just a ballpark figure, used by FDA to calculate daily values on food labels. The following table will give you more of a range. The weakness of the table is no information is listed for active adults and for children and adolescents.

Here are the typical calorie needs of inactive adults, according to the U.S. Department of Agriculture:

WOMEN

• Ages 19-30: 2,000 calories

• Ages 31-50: 1,800 calories

• Ages 51-plus: 1,600 calories

MEN

• Ages 19-30: 2,400 calories
• Ages 31-50: 2,200 calories
• Ages 51-plus: 2,000 calories

These age ranges are for people in good health and not for people with chronic diseases like type 2 diabetes. In addition, I would question the age ranges above 51, as there could be other ranges that need clarification for people over 70. Since I am not an expert in counting calories, my guess would be that for people with type 2 diabetes should probably be less that the calories above.

Again, get out the blood glucose meter and use this before and after consuming a meal. This will also tell you if you are eating too many calories. People that are very active can probably consume more calories. There are calorie calculators like this at the Mayo Clinic website. Just be aware that all calorie calculators are based on a one-size-fits-all basis.

Just like carb counting, there are variables to consider. Metabolism is a big variable – do you have an unusually slow or fast burning metabolism. Fortunately, a doctor can give you a breath test to check that. This knowledge will help the doctor and you set an individualized calorie goal.

A majority of adults need or want to lose weight. For this, there is a one-size-fits-all calorie formula. This will work for some people, but many will not have success. If you change your level of exercise, you may lose more weight and faster than anticipated.

For people with type 2 diabetes, stick with the carbohydrate count and start learning the calorie count. This is because some foods are higher in calories than the carbohydrate count and a few foods are higher in carbohydrate count than calorie count.

We Need Self-Monitoring of Blood Glucose Taught

Many government agencies don't want this to happen. Chief among them is the US Dept of Agriculture (USDA) and the National Institute of Health (NIH). Other federal agencies also follow suit. This means that the Academy of Nutrition and Dietetics (AND), Certified Diabetes Educators, the American Diabetes Association (ADA), and the American Association of Clinical Endocrinologists (AACE) follow in lock step.

Naturally, the medical insurance industry follow the recommendations of the ADA and AACE. This means that we as patients have to work harder to obtain the test strips to know what our blood glucose levels are for us to manage our diabetes more effectively. Not knowing and operating in the dark is not the way effectively to manage diabetes.

Most blogs by CDEs and RDs never mention using our blood glucose meters with test strips because they don't want us to know how the different foods affect our blood glucose levels. This is part of the reason many people get discouraged and seldom test their blood glucose levels. This almost guarantees that diabetes will become progressive and that the complications will affect the quality of life. Self-Monitoring of Blood Glucose (SMBG) is shunned by CDEs and not talked about by RDs.

If it wasn't the leadership of the USDA and the blind following by AND, we might have reason to listen to a few that do teach SMBG. A few CDEs that do not have to worry about other CDEs looking over their shoulders, do teach Diabetes Self-Management Education (DSME) of which SMBG is a part. Many will not even teach DSME because they only believe in mandates and dogma and expect people blindly to follow. With the internet of today, this will only get worse as people learn what following these people will do to damage their health.

At least some people from the Duke University of Nursing at Durham, NC are doing something about what the CDEs are unwilling to accomplish. Read about this in a recent blog here. They are at least reviewing various methods of delivering diabetes self-management education (DSME) via the internet.

Then people with type 2 diabetes and those with prediabetes will have resources to learn about managing their diabetes. Then if the certified diabetes educators want to be exclusive and continue to make it more difficult to become a CDE and for their numbers to grow, we can ignore them and learn on the internet.

The unfortunate part of this is that it is just a study and there is no sources of DSME as such on the internet for easy access. This in one time I sincerely wish that people would put information on the Internet and then do a study instead of studying other studies. Yes, I was honestly thinking that there was a source of DSME on the Internet and that it could be available to all people with type 2 diabetes. While the study details were interesting, that is as far as it was taken.

Have Diabetes, Stop Worrying About Eggs

I know some people with or without diabetes that cannot stomach eggs. For the rest of you, eggs are a great source of protein and cholesterol will not be a problem – much to your disbelief.

According to Nicholas Fuller, PhD, from the Boden Institute Clinical Trials Unit, University of Sydney, Australia, the findings of a study suggest that eating two eggs per day, 6 days a week can be a safe part of a healthy diet for people with type 2 diabetes. The study lasted for 3 months, a time-span in which a change in cholesterol levels can become clear. It was supported by a research grant from the Australian Egg Corporation.

Yes, I know, this suggests a study that may not be without bias. A study for three months can also hide some trends and give results desired. At least Fuller said there is a lack of research into the effects of eating high amounts of eggs in people with type 2 diabetes. National guidelines on eating eggs and total cholesterol limits are inconclusive, though, and guidelines vary between different countries.

Researchers also found that eating an egg-rich diet for 3 months was linked to better appetite control, and may provide a greater sense of satiety (feeling full). Fuller said the study was motivated by the negative perception widely held toward eggs in the diets of people with type 2 diabetes.

I was a little surprised when I looked into the study and discovered that it was also a weight-control study. The study participants were required to report to the clinic each month. During the visit, they were given advice that had to follow about the types of foods and amount they could eat. Saturated fats were not allowed, but certain unsaturated fats were.

The number of participants was 140 overweight people with type 2 diabetes and they were divided into two groups – one group that would eat less than two eggs per week and the second group that would eat two eggs per day at breakfast for six days per week. Too small a study to begin with, but the results is now questionable, even the low-egg group consuming matching protein with the high-egg group. As expected, both groups were tested for cholesterol levels.

The other expected statement was the lead author calling for more research to confirm whether a high-egg diet in people with type 2 diabetes does raise HDL (good) cholesterol. Fuller commented that despite both groups being equalized for protein consumed, the high-egg group reported less hunger and greater fullness after meals.

Eggs may also help with greater weight loss, less weight regain than a conventional diet, due to the greater fullness, and less hunger reported with a high-egg diet. The high-egg group also reported more enjoyment of foods, less boredom, and more satisfaction with the diet.

I can speak to the latter quite easily now that I can eat eggs again after having my gallbladder removed. Prior to that, every time I ate hard-boiled eggs or egg salad, I would have a severe gallbladder attack. I like my eggs cooked in a wide variety of ways and can eat four to seven per day without thinking about it. I like scrambled, poached, hard & soft-boiled, fried, egg salad, and several other methods. Since my cholesterol levels are remaining where they should, I will continue to enjoy my eggs.

Type 2 Best Diet Plans – Oh Really?

First, diets fail and are considered for the short term. People with type 2 diabetes do not need something for the short term, but the long term – for the rest of our lives. As with any article written by doctors or professional writers, they forget about one crucial fact. People with type 2 diabetes should use their blood glucose meter with test strips to determine how the food affects their blood glucose levels.

Now I may be wrong, but I generally ignore writers that don't mention the above and write as if they have all the answers for food that people with type 2 diabetes should be eating. I did take time to talk with my cousin and she looked up the WebMD article and read it. She commented that they were some powerful diets and most were not suited to good weight loss. She said if they were careful about the number of calories consumed they could lose weight, but otherwise with many of the diets, they would maintain weight and maybe lose a few pounds before they gave up the diet.

She continued that many are not into lifestyle changes and thus a diet is the way possibly for short-term weight loss, but not keeping the weight off. I agree with this and said this was my thinking as well. Both of us were upset by the slides referred to in the article. We agreed that everything had to be high carb, low fat and that the recommended number of carbohydrates in slide 2 of 21, of 45-75 grams for every meal is totally unreasonable for everyone. With this recommendation, most people will gain weight, and we have to wonder whom the experts were to make this statement.

While we both agree that, “No food is off-limits with diabetes,” and without using our meters with test strips, we will never understand or be able to manage diabetes. Our meters tell us if the number of carbohydrates we consumed is too large. Then we have to decide whether to reduce the number of carbohydrates or eliminate that food from our food plan.

The DASH Diet, The Mediterranean Diet, Mark Bittman's VB6 Diet, The Volumetrics Diet, The Biggest Loser Diet, American Diabetes Association Carbohydrate Counting, Ornish Diet/The Spectrum, Weight Watchers are the diets listed in the WebMD article.  I will let you read the article, but none of these diets will work for the long term.

While many people praise these diets, I will not, primarily because they contain too many carbohydrates, too little fat, and too little protein. I also am concerned about the amount of whole grains many of the diets promote. If you use your meter, and if you are meeting your blood glucose goals, then okay. If your blood glucose levels spike above 140 mg/dl, then by all means consider reducing the serving size or eliminating the food from your food plan.