Diabetes, What Ignorance Does for You

Ignorance tends to be the rule when it comes to diabetes. This applies to the doctors and to the patients. Many doctors order the patients to test their blood glucose and then stop their explanation. Instead of explaining the why, when, and how to test, their ignorance shows because the patients often have no idea what they were told.

Many patients then seek out their pharmacists and receive the information needed. However, these same patients only think they are testing for their doctor because he ordered them to do it. Ignorance is king among these patients. A small group will attempt to find out why they should test and spend some time trying to learn. Then when they don't find anything that “applies” to them, they give up and test for the doctor. Others just test because the doctor told them to do this.

Some find the American Diabetes Association (ADA) website and become baffled by the mountains of information available. They soon realize that most of it is aimed at doctors and become discouraged. They do not find the information for patients, the forum, and other patient information.

Some find the American Association of Clinical Endocrinologists (AACE) website, but because they have dropped the list of approved diabetes websites and have no links to other sites they have, people do not often stumble across this site. Some do not like this site because there is not a lot of good patient information contained in it. This tells me that the AACE does not really care about patients either.

All diabetes organizations work harder for people with type 1 diabetes, as they should.  When it involves people with type 2 diabetes, we are stepped on or ignored, they won't support testing requirements and want limits on our testing supplies. The leaders of the ADA and AACE think we can survive by only knowing our A1c results. This is further discouragement for people with type 2 diabetes and many let this lead to further ignorance about the importance of managing their diabetes.

Many people refuse to learn about diabetes and how to manage their diabetes. They trust their doctor to do what is best for them and as a result, they forget to manage their diabetes, remain ignorant about diabetes, and let their blood glucose levels do damage to their bodies and progress to the complications. Most doctors fully believe this and treat their patients with diabetes accordingly with no education, or encouragement to manage their diabetes to delay or prevent the complications from developing.

If people with type 2 diabetes would learn about diabetes and how to manage it, they could do a lot to prevent or delay the progression to the complications. A few of the complications may develop, but with good diabetes management, many of the more serious ones can be delayed for many years. Most people with type 2 diabetes develop neuropathy, but with good management, even this may not develop as fully as it can.

It is still a shame that people have to let ignorance govern their life with diabetes, when it possible with self-education to manage diabetes and die of old age before many of the complications rear their ugly heads. It is also a crime that our doctors care so little for their patients and will not even help with education. If they could work with peer workers or peer mentors this could really boost the education level. Doctors could also provide a page with good diabetes sites to help with education, but doctors can't seem to do something this helpful because they won't be paid for their time.

If you think that this article is on track about whom people turn to for diabetes information, you would have to question how the questions were asked and the source of the survey. They make it sound good for the doctors, but by doing some intensive research, certain words lead to doubts. “Eight-in-10 indicate their doctor is very or somewhat involved in their own or their household member's diabetes management; half report their doctor is their primary source for condition info.” 'Somewhat involved' is a key two words and leaves a lot to be desired.  "Primary source for condition info" is very confusing and means that as diabetes progresses, the patients can only rely on receiving condition information and nothing about prevention of the progression to the complications.

The fact that AccentHealth is a source of information that they put in the waiting rooms and doctors exam rooms may mean that they have a right to claim what they do. This does not mean that the doctors are the 'go-to' source of information, just that they have some of the information that may help patients. Most doctors do not have the time for education and maybe have their nurses handing out the information provided by AccentHealth. Either way, patients must still read these handouts, many of which end up in the waste containers in the doctors' offices.

Most of the pamphlets are advertising for diabetes drugs or drugs for the disease that you are seeing the doctor for help. Very little in the pamphlets is about managing the disease and self-education. I know that the pamphlets for diabetes have very little to help the people with diabetes other than make them familiar with the drugs they want the doctor to prescribe. In my opinion, they cannot be relied on for good diabetes management information.

Dawn Phenomenon Affects Up to Half T2DM

This was a bit of a shock for me when I read that approximately half of type 2 diabetes patients are affected by the dawn phenomenon. I knew that there had to be a large number by what I read on many of the diabetes forums, but half was even larger that I had guessed. No wonder this is such a problem and concern for type 2 patients.

The study by Louis Monnier, MD, from University Montpellier, France, and colleagues reveals that the dawn phenomenon has a significant impact and is present in some patients treated by diet alone. This effect is not prevented by oral diabetes medications. The dawn phenomenon refers to a spontaneous rise in blood glucose that occurs at the end of the night in patients with type 2 diabetes. This does not occur in individuals without diabetes, because endogenously produced insulin prevents this.

The one medication that does prevent this is insulin (Lantus or Levemir) when given at bedtime. In patients whose HbA1c is approaching 7% that are demonstrating evidence of the dawn phenomenon, insulin use should be considered earlier than it is traditionally, because insulin can eliminate this effect.

"We have defined the frequency of the dawn phenomenon in type 2 diabetes, which in the present paper occurs in around 50% of patients, and this definition is more accurate than previous ones due to our use of continuous glucose monitoring [CGM] systems," Dr. Monnier told Medscape Medical News.

Dr. Monnier agrees with Geremia B Bolli, MD, from the University of Perugia, Italy, that the new findings indicate that insulin use should be considered earlier for type 2 diabetes patients showing evidence of the dawn phenomenon. Presently doctors are unable to control the dawn phenomenon with the current array of oral hypoglycemic agents, even though metformin is probably the one that has the highest potency for reducing it. Currently insulin should be considered for the treatment of type 2 diabetes as soon as the HbA1c becomes greater than 7% when patients are already treated with maximal tolerated doses of oral agents.

Dr. Bolli states, “This new research confirms that the dawn phenomenon is a common occurrence among type 2 diabetes patients, independent of oral therapy and in a real-world setting. The work also reaffirms what should be a primary objective of type 2 diabetes therapy, he says, that is, treatment of the dawn phenomenon — the normalizing of blood sugar around breakfast time. I think if A1c is greater than 7.0% and the postprandial blood glucose is okay, one has to work on the fasting blood glucose, and the best approach is basal insulin in the evening."

My advice to patients is to talk to your doctor if you are having problems with the dawn phenomenon to prevent problems of hyperglycemia in the morning. Be careful, but don't let your doctor put you off, as this is important in your management of diabetes.

David Mendosa has posted an excellent blog here about the dreaded dawn phenomenon. He covers the same study, but has more background for your reading.

Problems with Test Strip Accuracy

I hate to say this, but a large percentage of people with diabetes do not read or are afraid of reading. Why do I make this statement? I am constantly surprised what people do with their test strips. A few days ago, I was invited to a get together for several people that I knew were people with diabetes. The person being surprised was a type 1 (Lilly) and her parents had planned this.

I knew most of the people present, but I was in for a few surprises myself. We had been in the game room when we were asked to come to the dining room for some treats. I was not planning on food and let the hostess know this. I had thought to wash my hands and used paper towels to dry them. I had not seen Max and Allen arrive, but I was not surprised to see them as we came through the kitchen.

After we were all seated, the food was explained to us and we could tell that the mother had done the preparation as each was labeled with the grams of carbohydrates. For those that had doubts, the recipe was listed and the servings for each and the nutrition data. The mother said that the serving size was accurate to the gram so they knew that the carbohydrates were also correct. Max said he could vouch for them, as living across the alley; they often compared notes on recipes. He added that they had borrowed his gram scale for this as well.

At that point, we were given permission to test and go to different areas if we wanted privacy for injecting insulin. Out came the testing supplies. Allen and I both looked at each other as we watched some of the testing. We were done before most and Allen asked me if we should comment. I agreed and said to wait until we had finished at the table.

When everyone was finished, one fellow that had heard Allen and me talking asked what we had to say. I said that we had noticed habits that we felt should be educated for, if they had no objections. No one objected and Allen asked if anyone had read the instructions that came with their test strip box. No answers and Allen asked me to explain part of what we had noticed. I commented that I had not witnessed anyone washing their hands. Several said they had not seen me wash mine. I said that I had used the washroom on the lower level and Allen said he had washed his before arriving. The daughter said she had seen me use the washroom before coming upstairs to the kitchen.

Allen commented that several had test strips in unapproved containers or in paper towels. Others had dumped several test strips onto the table before testing. I continued that several had been eating fruit before being called up for the food and before testing. If they had cleaned their finger with alcohol pads as we had seen several do, we would bet that they would have hypoglycemia shortly. One of the people with type 1 diabetes laughed and said listen to the type 2's talk.

Allen said he knew that he had an insulin pump and a continuous glucose monitor (CGM) on as his equipment. I asked him to look at his CGM for about 20 minutes earlier and compare this to his meter reading. The other person with type 1 diabetes did look at his CGM and commented that he would probably have a low, as his meter was higher by quite a bit than his CGM. This caused the second person to look and he admitted that was the case for him as well.

I said that the alcohol pads did not remove the fruit sugar from their fingers and that was why they should have washed their hands with soap and water and dried their hands carefully. Allen has the same meter as I have and had just opened a new box, took his instructions out, and asked the daughter to read some of the instructions. She read the part about washing the hands with soap and water.

Next, Allen asked her to read the instructions for keeping the test strips in the container they came in and she read this. She knew to continue reading about using the test strip removed from the container as soon as possible, keeping it out of direct sunlight, and not handling it with wet hands. It also said to close the lid after removing a test strip.

Allen commented about those that were used from other containers and paper towels could not be relied on as being accurate and people were wasting money when they dumped three or four test strips on the table and did not return them to the container as soon as possible, but did after they were done with testing. The daughter continued reading about this and carefully read the part about not damaging test strips by removing too many and putting them back in the container or transferring them between containers.

One of the people with type 2 diabetes had his instructions for his test strips and read them to himself while we were discussing our instructions. He commented that his instructions were almost the same, but said to only remove one test strip and close the lid immediately, carefully insert the strip in the meter, and then prick the finger.

The one person with type 1 diabetes said he had never read about washing with soap and water and had been taught to clean his fingers with an alcohol pad. I asked him if he had trouble with his fingers cracking and having pain in testing. He said he always wears gloves when outside and used a lotion to keep his fingers from cracking. Allen suggested that he take time to read the instructions that come with his test strips and the instructions with his meter if he still had them.

The rest of the party was rather somber, but when I said something to the mother, she said that was why she enjoyed having people with type 2 around. Her daughter always learned more from people with type 2 diabetes than from the people with type 1 diabetes. Her husband said we always seemed more concerned and caring than the few with type 1 diabetes. He realized that there was a difference between the two types, but the members of the type 2 group were always willing to advise her to talk with the endocrinologist for most things instead to saying his daughter must do this or do that. He said he and his wife always appreciated that.

Allen stated this is always best and their daughter needs to trust the endocrinologist. Then Allen added that we may know some things, but if we speak out against something the endocrinologist says we are undermining the endocrinologist. The mother said that is why when we have parties, we make sure that several of you are present. She said that her daughter learned quite a lot today and said that with her being the one reading the instructions, and having the same meter, she knows that you are right. Today was a good lesson for her and she will remember that you were not putting the rest down, just correcting their poor examples. With her about ready to have a pump, she said I am happy you took the time to point her in the right direction.

With that I needed to go home and Allen was ready to leave.

How Hiking Is Good for Mind, Body, and Soul

Many people write about how hiking or being out in nature is good for the body and the mind, but everyone shies away from mentioning your soul. I think this is important to help feed the soul and let it absorb the wonders of nature and refresh itself in the beauty around you.

This article in WebMD emphasizes the body and mind being helped by hiking and this is true. Hiking does have its perks. You can take advantage of the scenery, fresh air, sounds, and smells of nature. This is true if you are not downwind of certain animals and some landfills.

Hiking in nature is a great cardio workout that equals or exceeds the benefits of walking. These benefits include less risk of heart disease, diabetes, breast cancer, and colon cancer. Then you can add help with blood pressure and blood glucose levels. Many people forget about the benefit of boosting bone density, and helping prevent osteoporosis.

Besides the above, hiking can help in weight management, muscle strength in most of the muscle groups. Gregory A. Miller, PhD, president of the American Hiking Society says, "Research shows that hiking has a positive impact on combating the symptoms of stress and anxiety."

Safety should always come first. Always consult your doctor if you are starting a hiking regimen to make sure there are no health problems that could end this. These hiking tips should be kept in mind:

#1. Start slow. Short local hikes are best for beginners and keep them on fairly level terrain at the start.

#2. Bring a buddy. Starting slowly means, you should not be on unfamiliar or remote trails, but if everything looks good, it is wise to take a buddy or be part of a group. As your skill improves, you may be more comfortable going solo.

#3. Know before you go. Always familiarize yourself with the trail map, check the weather and pack for the day. If storms are predicted, it may be wise to rethink your plan for the day.

#4. Use common sense. Until you know the hiking area, follow marked paths and trails. Avoid contact with questionable plants, give certain animals a wide area, and be careful of the pungent animals.

#5. Get into a groove. On days when it is wise to avoid nature trails, try to power-walk on hilly terrain in familiar areas. Try to carry various amount of weight in a backpack (water is always good). This will help keep your hiking skills and fitness level up.

Are you past the beginner level? Now it is time to get more out of your hiking and boost your fitness level. The following are suggestions:

#1. Use poles. Use poles to dig into the ground and push yourself forward for increasing upper body strength and to give you a stronger cardio workout.

#2. Head for the hills. Even a short hill may intensify your heart rate and burn extra calories.

#3. Bump it up. If you have the stamina and no problems, try some uneven terrain, which will work muscles and improve balance and stability.

#4. Weigh yourself down. Add extra weight to your pack (see #5 above). This can boost your calorie burn while strengthening your lower back muscles.

#5. Keep safety first. I cannot emphasize this enough. Always be alert for animals in some areas of the country, such as bears, and even coyotes. Most of the time they will avoid you, but if they are hungry, then be wary. Listen to news reports for animal problems near when you are planning to hike. Animals can vary by the area of the country in which you live. In some of the southern areas of the USA, snakes and other reptiles may be of concern.

Above all, enjoy yourself and consider taking a camera with you. David Mendosa has a blog you should read about his exploits with his cameras.

Always take your blood glucose meter and testing supplies with you, in addition to glucose tablets or glucose gel, and if needed, your medication.

Lay People Teaching People with Diabetes

I have said this before and I will probably repeat this until I die. Lay people (people with type 2 diabetes and not possessing titles behind their names) often do more good in working with other people with type 2 diabetes than certified diabetes educators (CDEs) or nurses will ever be able to do.

In a conversation recently with one of our local doctors and amongst our own group, we have found out that the level of education, but not the specialization in diabetes education, is the greatest asset we have. Not all the members of our support group have completed college, but many have. Another asset we have is experience with type 2 diabetes and desire to help people. This often pays dividends.

The doctor felt much of our success has come from our desire to help others. He added that our level of research is important and probably the fact that we are not tied to the dogma of any organization has served us well. Allen said yes to the last and added that we don't believe in secrecy and hiding our diabetes from those that we talk to and attempt to help. Jason said that our willingness to share and bring other members into the conversation has also helped and made people we are trying to help know that where one person may not have all the answers, another person may be able to compliment another member of the group.

Sue made the statement that having come from the side of being one of the 'diabetes police' has been a great advantage. She knows what could have happened and did not happen to her, and feels that she has a better awareness of the stereotyping that exists because she had been guilty of doing this. Being one of only two women in our group and receiving the support of the group has taught her many things she would probably not have learned in a largely female group.

Brenda agreed saying that the men in the support group do most of the research and share the information. While she felt that many women would do more research, our group was unique because she and Sue did not have a lot of time for research, but were not excluded because of that. Brenda commented that the day Sue was welcomed into group, made her realize she was part of a group she wanted to remain active in and participate when she could.

The doctor was not aware of this and asked Sue to explain what had happened. Sue knew her husband; Bob wanted to tell the story, so she let him. Bob said that often Sue would be the diabetes police and be pestering those with diabetes about their food choices and telling them, they should not be eating that. Two days after her diagnosis, many of the group were together at a function and several had noticed that she was not loading her plate with deserts and were inquiring the reason.

Bob said he took the opportunity to out her as now having type 2 diabetes. He admitted that he was thinking that she was going to be paid back for her activities, but instead questions were asked about her diabetes and support offered to help her accept her diagnosis. He said she was angry with him for having said anything, but he was excluded from the conversation and all questions were directed to her. After she had tried not to answer a few of the questions, the group had explained the process (similar to grief) she would be going through. They said that when she was with the group, secrecy was out and questions she had would be answered.

Bob then said they told her not to be angry with me as she had enough anger about her diabetes. They said that his telling us about your diabetes was the best thing for her as now she could not keep it a secret and this would allow them to provide help and answer her questions. Bob concluded that the group had lived up to this and had helped her get off her medication and provided ongoing support to help her stay off medications. He continued that then they directed their attention to me and what I needed to do to support her in managing her diabetes.

Sue said they even taught her about the myths she had believed and how wrong they were. She said that the biggest lesson she learned was that being on insulin did not mean they were near the end of life, but living better because of insulin. Sue felt that because her husband was learning about diabetes and supporting her, when he was diagnosed with pre-diabetes, he was just accepted as part of the group.

Tim said that we welcome family members, but will not let them be like some people that run down the group and always have something to say that is against people with diabetes. He stated one support group that Jason, I and he had attended, one family member stood up and berated the people for not telling his wife to get over her diabetes and start doing the things she should. Tim stated that as a group, we will not allow this and will ask the people to leave saying that the person with diabetes is welcome, but that they are not. We believe that support for each other is everything and we won't tolerate this behavior.

The doctor said that must be the reason his group likes meetings with this group and feel welcomed. He said that the emails sent out after the meeting is greatly appreciated by those that were not able to attend. Brenda said this is done for all members when we have an email address. The doctor said he needed to leave and he now understood more about the group and our desire to remain independent from people in the medical profession. Tim said he was always welcome because he was not pushing the ADA or other dogma at us.

Do We Need a New Word for Patient?

It seems that this is becoming a regular occurrence. Someone, somewhere is calling for new terms to describe people or persons. If it isn't for a disease like the different types of diabetes, it is the medical profession trying to obfuscate what they are talking about. Now it is a person wanting a different term for patient. While I admire her approach and her reasoning, we don't need to muddy the waters just to please a few people.

Anytime you present yourself to a doctor in the exam room, you are there as a patient, unless you are a representative of a drug company and pushing the latest drug(s) manufactured by the company you represent. If you are not in a hospital for treatment, or in a doctor's exam room, then you are who you are – Bob, Pat, John, Jane, - well you know who you are.

I admit I am tired of people being supposedly politically correct. This is bordering on the ridiculous. I see no need for a new word for patient. Think of the confusion this could provide. Many well understood words could be affected, such as doctor-patient relationship and this would become meaningless. How would you describe this relationship then? We as people do have some choice words for doctors that are not doing their job or do it very poorly. Similarly, doctors have many choice words they use to describe some patients.

Just as there are different types of patients, there are different types of doctors. Now I will take you to another blog. Dr. Jordan Grumet comes across another meaning for patient although he does not describe it that way. He used the term colleague when talking about a patient in this blog. And, in the way this is discussed, I can appreciate his use more than what others want for the term patient. Dr. Grumet does treat his patients as colleagues in discussions and treatment plans. While he does try to guide them in the decision, but he will listen to them and seriously consider their wishes.

This is one time I am happy that I did not post a blog when I thought I had it complete. Janet Byron Anderson, PhD wrote a great blog for Kevin Pho, MD about four linguistic reasons to leave the term patient remain as it is.

#1. Patient signifies a role we play, not the whole of who we are.

#2. Objections to patient target its unfavorable meanings and ignore favorable meanings that are no longer significant in modern Western culture.

#3. Unplanned semantic change can yield meanings that we’re comfortable with, while leaving the term intact.

#4. Patient has friends we’d have to deal with if we banished the term.

I enjoyed reading her blog and realized that there are people that agree with my position for leaving the term patient stand as is. I hope that you will agree.

Medicare Again Aims to Harm Medicare Patients

How can I make this less painful? I think the best way is to just say it. The Centers for Medicare and Medicaid Services (CMS) is in the process of telling patients to bend over and prepare to be screwed. I don't mean just literally, but factually as well.

If you wonder why doctors will be cutting Medicare patients and moving many out the door, just read this blog by Dr. Jordan Grumet. Then read the press coverage of what the CMS has planned for 2014. The CMS intends to pay flat rates for Medicare visits to outpatient clinics instead of payments that vary with the severity of the patient's condition.

That's right, with the CMS proposed change, a healthy sixty five year old with a cold will lead to physician charges that are the same for a ninety five year old with congestive heart failure, emphysema, and out of control diabetes. What does this mean? Physicians, fatigued and overwhelmed with patient care, will be much more likely to avoid sickly seniors. It pays the same, why not select for the most healthy of the Medicare population? Yes, doctors will be forced into this and seniors with many comorbid conditions will be forced to use emergency rooms instead of seeing their doctor.

What upsets me even more is this is what CMS is doing to doctors, this parallels what the Affordable Care Act is doing to many doctors, and this will likely force many doctors out of the practice of medicine, as we know it today. This will cause many doctors to open contract medicine offices and not serve Medicare and Medicaid patients. Contract medicine encompasses “boutique”, “concierge”, “retainer”, and “direct care.”

For the present, hospital emergency rooms have been left untouched, but when CMS moves into this area, look out Medicare patients. Patients that have multiple medical conditions may be facing euthanasia because no doctor will be able to afford to treat people with multiple medical conditions.

This is serious enough that writing your members of Congress should be your goal in the month of December. It would not hurt to write letters to the editor of your local newspaper.

Discharges Against Medical Advice

This is a delicate issue for some people. Until you have been in this situation and had to deal with the threats from doctors and nurses, this is not always a situation with clear answers. I am talking about patients who do their own discharging from a hospital. Hospitals call this “discharges against medical advice.”

Even the figures are estimated because hospitals do not want this public and is why doctors and nurses threaten patients who attempt to do this. Patients are told that their insurance will not pay the bills and all will fall to them. The estimates are that as many as two percent of all US hospital discharges or approximately 500,000 per year are designated as against medical advice. Most insurance will cover costs, but to be safe, always check with your insurance.

Yes, patients need to be careful when doing this as it can be detrimental to their health and well-being. Compared to patients that are discharged by order of the doctor, patients discharging themselves have an estimated 20% to 40% higher readmission rate. Also, their mortality rate is estimated to be 10% higher. Physicians and health care staff report feeling distressed and powerless when patients choose suboptimal care.

Well, I have been there and done that and the threats against me were real and did not hold any water. Since I was already under the gun as I was admitted to the hospital for observation, the bills were mine to begin with since I was not admitted as an inpatient, but as an outpatient for observation. When all the tests for heart problems came back negative, and no further tests had been ordered, I was feeling like why should I allow my bill to escalate because they wanted to keep me for observation.

I had told the nurse to start preparing me to be discharged and all I got was the threat that my insurance company would not pay my bills. I told the nurse that since the bills were already mine, what did she care. She walked out and did not return. So I got up, disconnected my IV's and got dressed. Next, in walks my primary care doctor and asks what I am doing. I said I was leaving since I was only on observational status and was not running up the bills I would not be able to pay.

He calmly told me that he was discharging me per orders and that if I would calm down, he would get started. It took him about 30 minutes considering the interruptions by the nurse. Twice, he politely asked her to return to her station and I would be discharged. The third time the nurse interrupted to ask to see the place where my IV's had been and the doctor did look at the back of my hands to see no indication of where the IV's had been. The nurse said I should never remove them as this could cause me health problems. I just said that I have witnessed removal enough times to know how to remove them. All I had forgotten was having gauze available to prevent bleeding on the first one.

When the doctor finished, he asked if I wanted a wheel chair and I answered no because once I was taken to the hospital door I would need to walk out in the parking lot to get to my car. I also stated that I had not been sedated to cause me to be unsteady on my feet or to be concerned about driving. He agreed and called another nurse to walk with me to the door of the hospital. When we entered the elevator, I warned the nurse to hold on, as the elevator would jerk pretty good when it started to drop and when it arrived at the floor we needed to get off on. Needless to say, she took a fall because she ignored me. She regained her feet and I told her if it stopped on any other floors and when we reached the main floor, it would repeat this. She did grab the bar and when it stopped, the braking almost caused both of us to lose our balance.

The article in the Journal of the American Medical Association (JAMA) has much more information about discharges against medical advice and is very informative. It also covers several items I did not get into and why hospitals and doctors need to change policies in the way this is handled and documented.