July 23, 2011

Is There A Link Between Insulin And Weight Gain?

This blog about insulin and weight gain is one of the better blogs on the topic I have seen. And it is written by a certified diabetes educator (CDE), so I will need to be cautious. I do have a greater understanding of the difficulty of losing weight as a person on insulin. Would I go back to oral medications if I could – no way – the management of of my diabetes as a person with Type 2 diabetes is so much easier and more effective than oral medications.

Have I had hypoglycemia from taking insulin? Yes, but very rarely. In the eight years of being on insulin, I can still count the number of episodes on ten fingers and have a few to spare. Is my carb counting that exact – I doubt it, but I don't inject all the insulin at once and generally test to see if I might need more and how much more. In general this means keeping my blood glucose levels under 150 and closer to 120 two hours after eating. For the few times I get above 150, I immediately add the extra insulin to assure myself of bringing it back down to approximately 90 at four hours.

Nora Saul at the Joslin Diabetes Center, does an excellent job of explaining why people have such a large problem with weight gain and lays the blame squarely where it belongs, on both the patient and doctor. The patient for not wanting insulin and the doctor who encourages patients to stay on oral medications. It is this treatment of last resort that makes for problems of weight gain. It is also the myths about insulin and the fear of the patient and doctor about hypoglycemia that prevents using it early on when when it would be beneficial.

Both the patient and doctor need education in the use of insulin to make it an efficient treatment without the fear of hypoglycemia. Plus what many people forget, by starting insulin use early, this allows the pancreas some rest instead of complete burn out and not requiring the quantity of insulin when the pancreas is all but done and insulin is used as the treatment of last resort.

Also important is the consideration of nutrition and exercise which is often easier before the weight gain. Quoting Nora Saul, “one reason people with type 2 diabetes often see the pounds pile on after they begin taking insulin is that they've waited too long to start.” I have written about this before and do believe this to be very true.

Please read the full blog by Nora Saul for her full explanation of what happens when you as the patient and your doctor avoid the use of insulin until it is absolutely necessary. You are not doing yourself any favors and only damaging your body by letting your blood glucose get too high and thereby undermining the normal metabolism of carbohydrates and fat. I have several Type 2 friends that can agree that waiting too long to start insulin is not a good idea. They will tell you it is better to start early.

Many people are not educated in counting carbs correctly and then enter the vicious cycle of hypoglycemia and eating to correct it. They often eat too many carbs for correction and then develop hyperglycemia – too high a blood glucose level. Another problem is the injected insulin (the short acting) stays in your body about twice as long than your own insulin ever did and as a result you end up feeling hungry. This is when you need to learn that you don't need food, and must force yourself to avoid food.

Eating at regular times becomes more important to know how to gain the advantage of ignoring the hunger as too many people feed the hunger and the management of diabetes goes out the window. It does take some discipline at the start, but with time the hunger pangs will subside and become easier to manage.

She does recommend seeing a CDE for education, but I would urge you to see a good dietitian or nutritionist, specializing in diabetes, that may not push the old American Diabetes Association way (unless you are a patient at Joslin Diabetes Center), but will use the new guidelines of individual needs and desires being more important. The key here is balancing the nutritional aspects of the food you eat and learning that the old ADA way often has too many carbs which will (I mean will) help increase your weight and keep you on an upward trend. You will need to adapt to the number of carbs that works for you and does not increase your weight.

July 22, 2011

Investigation Uncovers Disturbing Doctor Discrimination

Even if this was only researched in Illinois, you can depend on this happening across the USA. I know that this happens, but I did not realize the magnitude and numbers of children affected. Can this be corrected for the benefit of the children involved – a lot of actions will be needed by all concerned to begin to make this happen.

There was to have been a survey of doctors using at technique employed by stores called mystery shoppers, but titled stealth patients. It was to have been conducted by the Department of Health and Human Services (HHS) and was published in the Federal Register.

As of June 28, 2011, this survey has been put on hold when the American Medical Association (AMA) publicly complained and got the support of Rep. Tom Price, MD (R-GA). This survey was to discover how patients on Medicaid and Medicare are treated when attempting to obtain appointments when compared to those with regular medical insurance.

For doctors, it does reveal that it is all about the money. I say that if they have a standard of living that is so high there is no room for tightening of the financial purse strings, let them go out of business and live like many people are living that can't find jobs in today's economy. Except they will end up employed by hospitals.

The first investigation shows how the medical profession treats the children that have public insurance in the state of Illinois. The second investigation with stealth patients is about adults and what the medical community is not doing for those on Medicaid and Medicare. Hopefully this can be resolved and the survey can go forward, but much of the information is already out and the survey may be a waste now.

Until many issues are resolved for children on public insurance and Medicaid and Medicare reimbursement issues are resolved, the problems will continue to exist and these patients will continue to avail themselves of the Emergency Departments of hospitals where they cannot be refused treatment, but the taxpayers are saddled with the costs.

Read about the Illinois investigation here. The first article about the HHS survey is here, and the article stating the survey is on hold.

July 21, 2011

Education Yields Improved Blood Glucose Control

A lot of the reading about diabetes lately has been about education. Too often the improvements made during the study disappear when the study is completed and support ends. This study states that even three months after, the improvements remained. While the study was indeed small and too short, this means that there could be hope.

It can be hoped that John Hopkins researchers will make the program available for others to use and on a wider basis. Will this happen – highly doubtful. Most researchers are very protective of the programs they use and wide dissemination seldom sees the light of day.

Yes, the findings were published online in the Journal of General Internal Medicine and the article says this will offer clinicians a proven tool to help those with unmanaged diabetes. But what I dispute is that this may be available for those in the know, but it is not being widely publicized so that wide distribution can take place. Often clinicians are so overworked that they do not have time to evaluate new tools like this to even consider putting something like this into practice.

Until the medical community starts sharing this with advocacy groups and giving it wider publicity, it will be another tool that languishes in a file of disuse. This is a shame for the researchers and for the broader medical community. For example, I found this back in April when it was published and because I was not ready to write about it, it sat in my files until today. In that time, I have seen no more publicity or even mention about this study, so it is already three months with no further action to take advantage of this important proven tool.

Even this could use widespread news coverage, but apparently it isn't sexy enough to make it newsworthy. Also many of the doctors (clinicians) will not make use of this as they frown on patients who are knowledgeable and proactive in their care. So you know this group in the medical community will ignore this. It is also a known fact that most medical insurance companies will hesitate to reimburse for this. They need to be convinced that it will save dollars in the long-term.

The researchers have found a way to give patients the skills needed to solve problems in their lives so that they can take diabetes out of the closet and start caring for their own health. The success of this small study comes because the group that received an intensive nine-session, problem solving course that not only covered standard diabetes self management and care, but were taught problem-solving as a skill to help manage the financial, social, resource, and interpersonal issues that can often stand in the way of managing their diabetes.

Read about the study and its results here. Please pass this on to others that might benefit in reading about this. Lets not let this die in the files of John Hopkins medicine.

July 20, 2011

Personalizing Medicine for Diabetes Patients

It is going to be interesting to see how well this works for HealthPartners clinics in the Minneapolis, St Paul, and St Cloud area in Minnesota. I hope that there will be followup articles and maybe some blogs by those in this area about how this is working.

The article states that patients with diabetes and their physicians will have access to a new decision support tool that will support a highly customized and state-of-the-art treatment plan. The electronic medical record can present personalized patient information in a single screen to the physician and patient. This “Diabetes Wizard” is believed to be the first application that uses electronic medical records to customize individual care.

Why could this be so important? As we all know, diabetes is not a one size fits all disease, even though many doctors would like it to be that way. The Diabetes Wizard helps physicians engage patients in a discussion of the best medications (oral and insulin) plus lifestyle improvements that can give them tools for excellent management of diabetes and lower their chances of diabetes complications.

The HealthPartners Diabetes Wizard will use the results of helping patients achieve management of their diabetes and tailor a treatment plan for each patient based on best medical evidence. This will include medications for better blood pressure, blood glucose, and cholesterol management.

What was pleasantly surprising is that it will take the current blood glucose, blood pressure, and cholesterol test results that are not at goal and provide a list of medications and treatments for the physician and patient to evaluate. The Wizard will provide positives and risks of the medications, recommended doses, and clinic visit intervals. It will also suggest seeing an educator, dietitian, or pharmacist the might provide help with medication counseling, nutrition, and self management.

The Wizard can identify gaps in care. This alone could be a life saver if it alerts physicians to screen for kidney disease. It will use all data available, such as patient age, current medications, smoking status, kidney function, plus history of heart disease. This will help the physician and patient through complex treatments and can become the best approach to caring for diabetes and related issues that is customized and personalized.

I sincerely hope that we can hear from patients that this is happening to and get their input on its value. Maybe there will be a followup report on this. Read the press release here.

July 19, 2011

Help From Diabetes Support for Type 2 Diabetes

When I first read this, I have some serious doubts about what WebMd was advising, but after rereading the article, there are some excellent points and some I may ignore.

When you live with a chronic illness like Type 2 diabetes, it can often be overwhelming at times. There are times when we feel that no one understands the stress that we feel from living 24/7 with diabetes. If this is prolonged, these feelings of anxiety, stress, and isolation can become a barricade to your goal of wellness.

While the last statement can be true for many people, there are alternatives not mentioned in the article that I feel need to be said. These may not work for all people with Type 2 diabetes, but if you make it a priority and part of your daily life, a positive attitude, positive thinking, and positive acting can get you past many of the feelings of anxiety, stress, and isolation. Just realizing that I must have that positive attitude about daily living has helped me get past these feelings many times. Even when I felt like I was going down the path to a depression, thinking positive and acting positive stopped it cold and I felt like moving on with life.

Another tip not mentioned is what I am doing now – writing this blog. This is therapeutic in and of itself. Then I also read other bloggers which can make me laugh, nod my head in agreement with, release my frustrations with them, and cry once in a while. Commenting on another persons blog can be helpful at times. More often you will be offering them support or encouragement, but this can feed back to you many times over.

Now back to the WebMD article. They state that whether your main support comes from your spouse, a close friend, your physician, or a diabetes support group, there are people who care and can help.

They do make some very accurate statements in the article about the need for doctors that give an accurate diagnosis and understands diabetes. This is important because Type 2 diabetes requires regular medical checkups and for this you need a doctor that will help educate you about diabetes, diabetes medications and will help you devise an effective treatment plan. Yes, there can also be ophthalmologists, pharmacists,, dietitians, and educators that can also be helpful, but unless you live in an area that has all of these available, you may need to depend on a doctors and pharmacist only.

Wisely, the article does suggest when possible to see an endocrinologist that specializes in diabetes, even for Type 2 diabetes. Another important statement is about seeing a therapist. This should be a therapist that is knowledgeable about diabetes and the types of problems people with diabetes encounter.

Yes, I know the resistance people have to therapists – they don't like this because they are all wrapped up in the myth that people that say this imply that the disease is “all in your head.” The fact that people with diabetes get depression and often suffer from stress, makes this even more important. Both can make diabetes more difficult to manage and by talking to a therapist can often help reduce stress and make depression more recognizable and easier to get past mild to moderate episodes of depression.

This can be a key for better diabetes management. The emotional toll that diabetes exerts on your everyday life with diabetes can be eased by talks with a therapist specializing in diabetes. Your better health is important.

Please take time to read the entire article here and take advantage of what it offers.

July 18, 2011

Have You Experienced Hypoglycemia Unawareness?

An article by Elizabeth Woolley at About dot com appeared on my computer on July 7 and sort of shocked me. I guess I should not be surprised any more with all the new information coming out every day on diabetes. But this one gave me a funny feeling and made me wonder why I had missed this before. Hypoglycemic unawareness is known to affect people with Type 1 diabetes, but there is significant evidence that Type 2 people also have this problem.

The evidence presently that hypoglycemia unawareness affects those Type 2 people on insulin, or on oral medications that can cause low blood glucose. Hypoglycemia is defined as a blood sugar reading of below 70 mg/dl. If a person does not experience the symptoms of hypoglycemia, they need to take action. The more common symptoms include trembling or weakness, lack of coordination, drowsiness or confusion, headache, dizziness, double vision, excessive sweating, and convulsions or unconsciousness.

If you get to the last symptom, you are in already in trouble and a glucagon kit should also be kept available, in case the person is unable to take in sugar orally. Early in the symptoms, a juice box, candy (but not chocolate because of the fat), or glucose tablets will normally bring blood glucose levels back to normal fast.

The risk of hypoglycemia unawareness increase the longer the person has had diabetes. In a study done with people with type 2 diabetes on insulin, those who had severe hypoglycemia in the prior year were at a 17-fold higher risk of having severe hypoglycemia the next year.

Hypoglycemia can make management and treatment more difficult, but the following ways may help reduce the risk. The first suggestion is difficult with the insurance restrictions on test strips they will pay for, but you still should consider frequent testing and let your doctor know if you find your blood glucose levels are low and you do not feel any of the symptoms.

Next, if possible get self management education which most insurance will cover with a doctors order. Then work with your doctor for individualized blood glucose level goals. Also ask about flexible treatment regimens. All of these can greatly assist in your management to prevent hypoglycemia.

If you develop a history of hypoglycemia unawareness, ask your doctor about hypoglycemia avoidance for a period of 2 to 3 weeks to possibly increase sensitivity. This means allowing your blood glucose levels to be higher for this period in an effort to increase your sensitivity to the symptoms of hypoglycemia.

Read the blog here by Elizabeth Woolley, and the ADA article here. The abstract for reading is here.  This last link may not work if you browser does not accept cookies.