Should CDEs Be Teaching Nutrition?

Yes, I have realized that many titles often are associated like RD (registered dietitian) and CDE (certified diabetes educator). To be honest I was just reading the titles and wondering which was most prominent or used to the near exclusion of the other. After the blog yesterday, I really have to wonder which organization has priority and which exerts the most influence on the actions of the person.

I have talked to two CDEs, one of them also with the title of RD. Both said at one time, the first title after the name used to be the primary practice of the individual. Then in 2006, this has had some repercussions when the American Dietetic Association (now the Academy of Nutrition and Dietetics (AND)) started enforcing strict adherence to guidelines or lose their license. They both admit there has been some relaxation in the last year, but they are still very careful.

Whether this is correct, I do not know. I just have to wonder what influence AND has on the CDE profession.

Nutrition is taught by both CDEs and RDs and both generally urge more consumption of carbohydrates than many with diabetes are willing to consume. This is a great turn-off for people with diabetes that understand the value of consuming fewer carbohydrates.

I am thankful I have a cousin that is a nutritionist and has now completed her PhD in nutrition. She is my go to person for nutrition questions. Recently I discovered that another second cousin has moved into the area and she is a registered nurse with almost 20 years experience in surgical nursing. We have only had one conversation about what she does, but I expect that I will learn more in the months ahead as her husband is planning to retire in the job he currently has.

They have three children and one has type 1 diabetes. That was to topic of most of our conversation and a lot of questions were directed my way. I have connected their daughter with Lilly that is an honorary member of our support group and they are learning from each other.

Is There Value for Patients in the New AADE Leadership?

There will be much debate in 2015 and especially 2016 about the possible actions of the officers of the American Association of Diabetes Educators (AADE). Over at DiabetesMine on September 2, 2014 there is a discussion with the two incoming officers for the next two years.

The incoming president for January 1, 2015 is Deborah Greenwood, a longtime California educator who’s currently president-elect. I do not know much about this person, but she will face some very difficult tasks when she assumes office. Ms Greenwood does feel that providing quality education is important.

What was good to hear is the possible opening of restrictions previously held by the AADE of only accepting people who passed the examination given by the National Certification Board for Diabetes Educators (NCBDE)? Yes, they had some honorary members, but this is different.

According to information we have so far is the new group will be called Associate Diabetes Educators. This was announced at the annual meeting last month. This will be a true non-licensed health care provider category and will be a way to bring more into the profession. Peer support is now more recognized, and this is one more way to incorporate people with all skills. It’s fantastic that they’re formally recognizing this community and everyone plays a role. There’s a whole committee of people who have been working on the Associate Diabetes Educator piece, and they’re continuing to refine it.

For once, this appeals to me and shows that they are more interested in serving people with diabetes. With the expanding number of people with diabetes and even pre-diabetes, there is too few people to help now.

This flies in the face of the Academy of Certified Diabetes Educators (ACDE) that are limiting members to only those that pass the test given by the NCBDE. If this becomes reality, the AADE will gain greatly and the ACDE will become very unpopular with diabetes patients. This says their exclusive ways will hurt them. Sounds like a very productive year ahead for the AADE.

My real concern will begin in 2016 when Hope Warshaw takes over as president. She has a lot of controversy surrounding her and carries the title of Registered Dietitian (RD) and means that the Academy of Nutrition and Dietetics (AND) may exert some influence. No one has made notice of this.

In addition to being an RD, she created quite a stir about two years ago when she stated that we need too many carbohydrates per day – in excess of 200 grams of carbohydrates. Instead of saying that she could have misspoke and that some people could do with less, she would not back down and people really struck out at her. She has also created some other rumblings on other issues, but seems to avoid controversy after the carbohydrate fiasco.

She seems welcomed by many in the diabetes-on-line-community, but I will continue my reservations until she is no longer president of the AADE.

Doctor-Patient Communication for Diabetes Patients

Today this is even more important, but communication is happening even less. The main culprit is the electronic medical record and the time that doctors need to spend at the computer during the office visit. They have boxes to check and other notes to make. Even the fastest of typists has little time for communication in at 12 to 15 minute appointment.

This doctor still emphasizes the importance of communication and lists 10 points to back this up. I find this statement very valid, especially as a patient. He says, “Communication and interpersonal skills of the physician are the heart and soul of our profession as medical doctors.”

He lists the Golden Rules for effective communication by doctors in the diabetes clinic:

“#1. Recognize the importance of patient empowerment as being fundamental to diabetes management. The physician's role is to provide knowledge and expertise to enable patients make informed decisions. But, it is the patients, themselves who are in charge of their destiny and the decisions and choices they make.

#2. Use appropriate words and language when talking to patients with diabetes. Avoid invoking guilt, laying blame, or using incriminating tactics. Perceived benefits are better than perceived threats. Negative or careless language can be harmful and can demotivate patients.

#3. Allow collaborative care, shared decision making, and "strike a deal" with the patient at each therapeutic juncture encountered. An informed communication style of the physician that included a participatory role for the patient in decision making resulted in significant improvement in patient self-care and glycemic control (glycated hemoglobin [HbA1c] improved by as much as 0.7%). In another study, the improvement in HbA1c was found to be even greater (1.5%) as a result of patient engagement in decision making. By contrast, a dominating and controlling style of communication by the healthcare provider resulted in poor metabolic control.

#4. Be practical and seek realistic goals. Focus on the achievable. Life is not about HbA1c level for every diabetes patient or every time for the regular patient attending the clinic.

#5. Be nonjudgmental. Obese patients were less likely to lose weight if they felt the attending physician was in some way judgmental about their weight.

#6. Consider cultural issues, religious beliefs, and personal values of the patient. With some individuals and in certain parts of the world, religious beliefs are dearly held and may even take precedence over other issues in life. This can present a delicate situation to the unwary practitioner who may need to tread carefully between respecting personal values of the patient, on the one hand, and not compromising medical care provided, on the other.

#7. Reward effort, not just outcome. Even modest encouragement can inspire patients to do more for their cause.

#8. Stay tuned to the patient's feelings and pick up the clues early. On average, a diabetes patient drops 2.6 clues per clinic visit. Subtle hints can be related to anything from loneliness at home to shortage of money. Although the physician does not have to solve every problem, an empathic response to the patient's concerns can improve clinic dynamics and change outcome. Furthermore, missed clues mean lost opportunities and, interestingly, lead to longer, not shorter, clinic visits.

#9. Use visual tools as much as possible: make a simple drawing or show the patient a relevant graph or picture to facilitate understanding and enhance motivation. The mere provision of a poster of HbA1c values marked with target goals improved metabolic control significantly in the patients tested. In another study, the Vision Study, investigators showed that graphic display of self-monitored blood glucose data significantly improved metabolic control, with an impressive 0.93% reduction in HbA1c in the type 2 diabetes patients studied. Patients are more believing in something they can see.

#10. Does your patient comprehend and remember the instructions given at the clinic? Patients have poor recall of decisions made at the clinic and tend to forget as much as 50% of what they are told by their physician. To explore the benefits of checking patient comprehension and recall, Schillinger et al. listened to audiotapes taken at outpatient settings and found a significant improvement in glycemic control in patients whose physicians applied this simple interactive strategy compared with those who were not assessed for comprehension and recall. Asking your patient to restate and summarize your instructions makes good sense and is obviously therapeutically rewarding.”

If doctors would do this, then they should also have a recording to give patients to play back at home to reinforce this as well. The doctors should also have approved printouts of reliable internet sources for the patients to read if they are interested.

It is interesting how little HbA1c level has changed over recent years despite the introduction of numerous antidiabetes agents and advanced diabetes technologies.

The doctor says, “The tips cited above are not meant to be a call for physicians to just "be nicer" to their patients or a ploy to improve customer service at the diabetes clinic. Rather, they emphasize the point that the quality of doctor–patient interaction is an important determinant of glycemic control and healthcare outcome for people with diabetes.”

The doctor continues, “Needless to say, communication is accessible to all physicians and is free of charge to all patients. Furthermore, communication has no cardiovascular risk or any other side effects to consider and so will not require regulatory body approval before release into the "markets." Communication should, in my opinion, be considered a universal first-line therapy in any future guidelines made for the treatment of diabetes. We should also train physicians on the art and craftsmanship of communication with people with diabetes.

CPAP Effective for Older People

Continuous positive airway pressure (CPAP) is effective at treating sleep apnea in older people, a new study has found. I can believe this as most older people have conquered most of their fears and vanity of wearing the equipment and realize the importance of sleep to their health.

Previous studies have established the benefits of CPAP in middle-aged people with OSA (obstructive sleep apnea), but until now there has been no research on whether the treatment is useful and cost-effective for older patients. The new research found that CPAP reduces how sleepy patients feel in the daytime and reduces healthcare costs. The researchers say CPAP should be offered routinely to older patients with OSA, and more should be done to raise awareness of the condition.

Now if the United States would accept the research. The study was published in Lancet Respiratory Medicine. It involved 278 patients aged 65 or over at 14 NHS centers in the UK. It was led by researchers at Imperial College London and the Royal Infirmary of Edinburgh in collaboration with the Medical Research Council Clinical Trials Unit at UCL, and the Universities of Oxford and York. It was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme.

Sleep apnea can be hugely damaging to patients' quality of life and increase their risk of road accidents, heart disease and other conditions. Lots of older people might benefit from this treatment. Many patients feel rejuvenated after using CPAP because they're able to sleep much better and it may even improve their brain function. Patients with sleep apnea sometimes stop breathing for 30 seconds or longer at night before they wake up and start breathing again. In these pauses, their blood oxygen levels fall.

The low oxygen levels at night might accelerate cognitive decline in old people, and studies have found that sleep apnea causes changes in the grey matter in the brain. They're currently researching whether treatment can prevent or reverse those changes.

Weight Loss Drugs May Not Be the Answer

Even with the algorithm from the American Association of Clinical Endocrinologists, the use of weight loss drugs is still not the blockbuster Big Pharma had dreamed they would be.

Obesity experts blame the poor sales of weight loss drugs on:

#1. Doctors' lack of training in how to treat obesity.

#2. Concerns about the medications' safety.

#3. A lack of insurance coverage.

The following are my additions to the above:

#4. Doctors' favoritism of surgery, including bariatric surgery.

#5. The costs of weight loss drugs, often in excess of $200 per month. It is hard to keep people on the drugs as long as 1 year due to price.

#6. Doctors' have this belief that 'willpower' is going to help.

#7. Doctors' are more likely to advise obese patients to eat less and move more, but diet and exercise, by and large, is ineffective for treating obesity.

#8. There are about 50 diseases (includes diabetes) that are caused by obesity. Doctors are happy to replace your knees, but this is not addressing the root problem.

One patient says that the weight loss drugs suppresses your appetite and food that you normally eat is lost when you lose your desire to eat it. The drugs can make you irritable and angry – changing your mood. Sleep can be affected because you are not able to stay asleep and are unable to fall back to sleep quickly.

Many people that undergo weight loss surgery are not properly warned about this being a life-long commitment and many regain the weight later in life and require more surgery

Losing weight when obese is a problem for many people and it seems there is not an easy solution.

Be Careful of People Advising Against Low Carb

Before I learned that the glycemic index for foods was developed by using only healthy people, I was an advocate for using low glycemic foods. Now I only use the index as a guideline and nothing more. Several researchers have also recommended using them as guides because they have discovered that certain chronic illnesses do not yield the same results.

Now the author of the glycemic index, Professor Jennie Brand-Miller, is speaking out against very low-carbohydrate meal plans (diets). She was answering this question - If carbs increase my blood glucose levels, wouldn’t a low-carb diet (or even a very low one) make better sense for managing it? Her answer was “In theory, a low-carbohydrate diet seems a logical choice if your aim is simply to reduce blood glucose levels. But presumably your goal is long-term, optimum health with good glycemic control and reduced risk of chronic disease. If so, very low-carbohydrate diets need a little caution because you will be missing out on the micronutrients, antioxidants, phytochemicals and fibre that plant foods (fruit, starchy vegetables, legumes and grains) provide.”

She then avoids talking about fats of any kind when she continues, “In studies that tracked individuals for long periods of time, those eating the least amount of carbohydrate and very high amounts of protein had almost double the risk of dying during the follow up period, especially from cardiovascular disease. You might also find this very low carbohydrate diet so extreme that it's hard to lead a normal social life and enjoy eating because you have to exclude so many favourite foods (think potatoes, oranges and honey).” Bold is my emphasis.

Then she refers to this from Nutrition in July 2014 which the press release can be read here and my blog on it here. She says that the authors, “Call for a complete reappraisal of dietary guidelines for diabetes management and they present evidence for dietary carbohydrate restriction as the first approach in diabetes management. I do think there is some truth in the benefit of modest reductions in carbohydrate intake (to say 40–45% energy). However, I’m not in favour of further reduction because it’s just too hard for most people to comply. Conversely, I'm not recommending an increase in carbohydrate intake to 65% of calories to someone with diabetes; it strikes me as "pushing the envelope" too far.”

For people that do talk about low carb and at least medium fat, read these blogs by David Mendosa, Managing the Condition of Diabetes, Managing Diabetes with a Strange Fat, and Saturated Fat is Back for People with Diabetes. An article in Medscape talks about different fatty acids and how they affect us.

She concludes her article about low carb diets with this statement. “I believe that very low-carb diets are unnecessarily restrictive (bread, potato, rice, grains and most fruits are off the menu) and may spell trouble in the long term if poor quality food takes the place of high quality carbohydrate. Modestly higher protein/low GI diets strike me as a happy medium between low fat and low carb-diets – you can have your carbs, but choose them carefully.”

Impromptu August Meeting

We do have a scheduled September meeting, but Tim and Allen have been working on something they wanted to present. Last Saturday August 30 Tim called everyone for a meeting. Of the 16 members, only 12 were able to attend, plus Dr. Tom.

Tim said I know many of you have been working with other people with type 2 diabetes and have not been having a lot of success. The community has lost three to diabetes and related issues this summer. Allen, Barry, Bob, and A.J have been involved with two of the three, while Tim and Dr. Tom had been working with the third individual. Tim continued that Allen and Barry are working with a difficult case because the wife is a registered dietitian and preventing them from accomplishing much.

Next, he commented on the fellow A.J and I have been working with and having small success with, but not getting far at present. A.J said it is because he is also listening to the wife of the individual Allen and Barry is having problems getting to reduce his carbohydrates. Dr. Tom spoke then and said two of the three deaths involved patients of his and even he had not expected them to die. The families had stopped all investigations about cause of death and therefore we can only suppose that diabetes has something to do with the death. The third one was identified as caused by diabetes, but not the reason, but it was suspected that extreme hyperglycemia was involved.

Tim asked if this wasn't discouraging. All of us agreed and Allen said he does not understand why some people just will not manage their diabetes. Barry added that they have not been able to reason with the people, especially those getting advice from the dietitian. Allen said this might be the toughest situation that we have encountered. The person with diabetes is not happy with his A1c's, but the wife is and keeps insisting he needs his carbohydrates. Plus she is the one cooking and feeding him the high carbohydrate foods. Barry added that she does not avoid high fructose corn syrup and it is found in several of the foods she prepares.

Jason asked if the husband couldn't just eat less. Barry said he had tried that and she just insists he eat more. Barry said he had tried to convince her that low-carb and medium fat was better, but she just says she isn't convinced and that she is the one that knows nutrition.

We talked a little longer, but could not come to something agreeable, so we broke up with the idea to keeping our research going.

Then on September 1, we got the information we needed and the emails were rapid between us. Allen's comment that the wife must be trying to kill her husband by Munchausen's by proxy syndrome seemed a bit extreme, but it fits the way she is so happy with his A1c. Why else would she reject low carb and insist on the high carb and so heavy on the whole grains.

Dr. Tom asked if there was a way for us to get him to his office without the wife, and that has become our next project.

Factors in Managing Your Blood Glucose – Part 2

This is a continuation of the previous blog.

Activity:

Light activity - Light activity can have a surprising glucose-lowering effect. Walking could be considered light exercise.

High-intensity and moderate exercise - Please read my blog on safe blood glucose levels for exercising. Also talk with your doctor before beginning exercise that fits in this category.

Exercise is often described as something that always lowers blood glucose; however, high-intensity exercise, such as sprinting or weight lifting, can sometimes raise blood glucose. This stems from the adrenaline response, which tells the body to release stored glucose. But this is not a reason to avoid high intensity exercise – studies show it can improve blood glucose for one to three days post-exercise! Please note that in some cases high-intensity exercise can also drop blood glucose very rapidly (2-3 mg/dl per minute), especially if you are taking insulin. This also happens to many people on oral medications until they have been exercising for a couple of weeks or longer. The best way to see how individual exercise sessions affect your blood glucose is to test prior and after exercise.

Biological:

Dawn phenomenon - The “dawn phenomenon” normally occurs in people with type 2 diabetes. The term refers to the body’s daily production of hormones around wake up time. During this time, the body makes less insulin and produces more glucagon, which raises blood glucose. The best way to figure out how dawn phenomenon affects you is to wear a CGM or wake up and test your blood glucose early in the morning. Not everyone experiences dawn phenomenon, but it is common for about 50 percent of type 2 patients on oral medications,

Scar tissue and lipodystrophy – If you are taking oral medications only, this will not affect you. Using the same sites on the body for injections sights can lead to lipodystrophy and scar tissue buildup. These result in erratic absorption of insulin, leading to glycemic variability and making it harder to spend more time in range. To avoid these issues, rotate your injection sites and don't reuse needles.

Insufficient Sleep - In my experience, I have found that I need more insulin on days following less than seven hours of sleep. The highest blood glucose of the day is even higher on days following little sleep. These findings are consistent with many studies, which have found that not getting enough sleep leads to worse diabetes management, insulin resistance, weight gain, and increased food intake.

Stress and illness - Stress and illness can cause the body to release epinephrine (adrenaline), glucagon, growth hormone, and cortisol. As a result, more glucose is released from the liver (glucagon, adrenaline) and the body can become less sensitive to insulin (growth hormone, cortisol). In some cases, people are much more insulin sensitive right before getting sick and can tend to run low blood sugars.

Allergies – Research did not yield any results and apparently is not worthy of study. I do have one friend that suffers from ragweed allergy and has problems with his blood glucose levels during ragweed pollen season.

A higher glucose level (“glucotoxicity”) - Hyperglycemia can lead to a state known as “glucotoxicity,” which can actually cause insulin resistance. People going on insulin after being on oral medications can experience this and spend a few days up to two weeks adjusting insulin to bring this under management.

Periods (Menstruation) - There is not an easy answer to the question of how periods affect women’s blood sugars. Many women report having higher blood sugar levels a few days prior to their period starting, but some women notice a sharp drop in sugar levels. To figure out how you respond, your best bet is to test your blood glucose often during this time of month.

Smoking - Some studies suggest that smoking can increase insulin resistance, and people with diabetes who smoke are more likely than nonsmokers to have trouble with insulin dosing and managing their diabetes. Smokers also have higher risks for serious complications.

Environmental:

Medication or insulin that has gone bad – Some people stop taking oral medications and when they need to restart, use the old medications, and get little or no help. Others ruin their insulin by exposing it to direct sunlight or leaving it in the car on a hot day. The worst part is that it’s hard to know if it has actually gone bad unless you try a new vial. In addition, the insulin may work unpredictably. Unopened insulin should be stored in a refrigerator at approximately 36-46 °F. According to the FDA, insulin can be left unrefrigerated at a temperature from 59-86 °F for up to 28 days.

An accurate blood glucose reading - While this seems fairly obvious, I occasionally find myself testing multiple times in a row, since I do not believe the initial value. In some cases, the second time I get a much lower value, and it’s because I failed to wash my hands. I suggest retesting if you don’t believe the value on the meter.

Altitude – People on oral medications generally notice little difference with being at higher or even lower altitude. People using insulin need to be careful as insulin resistance can increase insulin needs. Others that are climbing or skiing may need less insulin. Testing more frequently may be a necessity.

To the above and the previous blog, I would be remiss if I did not mention attitude. A positive attitude makes diabetes management easier and helps make diabetes burnout and mild depression easier to conquer. Then add developing good habits that become part of a daily routine and burnout seldom happens.

Another blog about the reasons for variability of blood glucose levels is this one.  There are overlaps with the ideas included in the blog from yesterday and this blog of today.