August 20, 2011

Is Your Bologna Named Diabetes?

This may not be fair, but when I read the title of this article, all I could think of was Tom Naughton and his funny picture with his mouth stuffed with what looks like eight pieces of rolled bologna. His motto is what keeps me coming back. Enjoy yourself here reading Tom.

The article is not as funny and is written with a clear agenda to stop people from eating red meat. The first statement which I find valid is that processed products such as bologna and hot dogs can increase your risk of type 2 diabetes. It also says that the risk is increased by almost half. Then it takes off on getting your protein from other sources such as nuts, whole grains, and low fat dairy and that this will have the reverse effect.

All of this may have some scientific basis, but I prefer to get much of my protein from unprocessed meats, whether beef, pork, or poultry. This article is clearly not written for me, but is written for anyone that will not eat red meat and may or may not be vegan.

So while I thought the title was something I could relate to, the agenda is definitely biased against all red meats – processed or unprocessed. My guess is that this is definitely a bad science study and the conclusions are engineered to put the message out that they were looking for and wanted to promote.

Another study finds that processed meats are still on the hot seat and increase the risk for stroke or death, but the evidence for unprocessed red meat is not as strong. You may read this study here.

August 19, 2011

Exercise, Exercise, Exercise

Endorphins are released as a result of exercise and these cause good feelings and relaxation for your body. The amount of exercise needed to release these endorphins has not been measured and very little attempt has been made to do this.

Even with this knowledge, many people just do not see the benefits of exercising and do nothing about exercise. And people that have had diabetes for a long time and have developed any complications take this as a sign they should not exercise.

Not so, according to Jacqueline Shahar, MEd, RCEP, CDE, a clinical exercise physiologist and manager of Exercise Services in the Joslin Clinic at Joslin Diabetes Center. Patients with diabetes complications should definitely continue to find appropriate opportunities for physical activity. In the Joslin’s Easy Start program many patients have significant diabetes complications and are able to exercise regularly and safely as part of their diabetes self-management plan.

She also explains that there is always some type of exercise people with complications can do. Not remaining active can lead to developing additional complications. Without some exercise people with diabetes can lose functional capacity (the ability to do the activities of daily living).

Take time to read the blog here where the different exercises for different complications is discussed. She covers the main complications and what can be done in spite of the complications.

After you have read that blog, another blog by Victoria Kron may also help make you want to exercise. She does have a brief discussion about why it is so hard for people to start an exercise routine or regimen. “It’s the execution of the intention that loses something in the translation” is her explanation.

The one factor that both authors and often myself tend to forget is the necessity to mention talking to your doctor for approval. The doctor may have suggestions or objections to how you exercise. Start out slowly, make sure it is something that fits within the guidelines of the first blog above if you have complications. What are you waiting for?

Depending on the level of exercise you are capable of, be sure to know the blood glucose levels that are safe for exercising and test to be sure you abide by these guidelines. Again your doctor should provide you with the guidelines.

Now that I have covered the more difficult parts, this article should also encourage you to take what you have learned and give you even more reasons to exercise. We are all used to being told that adults should do at least 150 minutes (five days at 30 minutes per day) of exercise per week and this has been a good thing.

Now a study done in Taiwan shows that 15 minutes per day can reduce the risk of death by 14 percent and increase life expectancy by three years. While the study is based on self reported results over an eight year period, it included more than 400,000 people. Fifteen minutes per day equates to 105 minutes per week.

This study should help convince people about the need for exercise. Also read this blog about the same study.

August 18, 2011

Shared Medical Appointments

This is one idea I do keep seeing more and more about. Now that I have discussed concierge medical practices in my last blog, I also feel this needs another look. The primary care physicians (PCPs) are under more and more pressure as their numbers decrease and few are entering the profession. When it comes to diabetes, there are also not enough endocrinologists specializing in diabetes to make it possible for everyone not having a good PCP to find an endocrinologist.

This is where shared medical appointments may become a necessity for many PCPs and endocrinologists specializing in diabetes. Studies have shown that they do work and work well. Often one of the benefits for patients is that they can see they are not alone and this builds bonds within the group participating in SMAs. It is the healing power of group interaction that has been well documented. Groups are inherently therapeutic and the interactions can often do wonders for the entire group.

I have mentioned this in my previous blogs on SMAs that this may not be for all doctors and even some patients, but it needs to be considered. Three general models for the shared medical appointment exist: 1) the cooperative health care clinic (CHCC), created for older patients requiring frequent, broad-spectrum care; 2) the disease-specific CHCC, a diagnostically exclusive group that aids patients with chronic-disease management; and 3) the drop-in group medical appointment (DIGMA), intended for established patients needing a more comprehensive approach to their follow-up care.

There are, however, an almost infinite number of variations of shared medical appointments that a care team may choose to incorporate into their practice, depending on the patient population they serve.

SMAs typically involve a medical provider, a facilitator (a nurse, behaviorist or health educator) a documenter (optional but cost-effective), an educator as needed, and one or two medical assistants (MAs) to check in patients. Administrative support is essential to ensure access, document and code patients’ visits, obtain confidentiality waivers, check in patients and prepare the room.

SMAs may be continuous, occurring at regular days and times and encouraging patients to form a cohesive group. A continuity group comprises the same people with the same physician and the same or similar conditions, or people who share a demographic characteristic, such as postmenopausal women. Membership changes occasionally through attrition or additions, but ongoing attendance is assumed.

Read these two articles about SMAs and the benefits, here, and here. For a rather lengthy description of one for diabetes, read the article in ADA Spectrum. There are many more sources and if you want to read more, use your search engine and enter “shared medical appointments”.

August 17, 2011

Concierge Practice Is a Doctor's Right

Web activity about concierge medical practice is getting heated and more is being said almost every week. A few months ago, there was a blog now and then and some exploratory articles, but in the last week, there had been a flurry of blogs and articles. Some have been very condemning and others very open and forward thinking. Not being a doctor, I can only express my thoughts of how I view them as a potential patient.

First, is it really a doctor's right to have a concierge-type practice? What is to prevent this from becoming a bigger fact of life than it already is? I think that a doctor has every right to have a medical practice in any form the doctor desires. As long as the doctor maintains his/her license to practice, why does he/she need to be locked into one form of medical practice – even one that is flawed like our current system?

I can see advantages for certain doctors to have the concierge medical practice. This allows them the freedom outside the restrictions of a standard practice as we have become accustom to using. The cost of overhead can be cut dramatically as employees may or many not be needed. Time spent doing paperwork for insurance is non-existent, and a lot of other expenses just don't happen. In some areas the doctor can own the building and only pay taxes and utilities plus maintenance. Otherwise, the office can be rented and pay utilities.

The doctor in the this article lays out a good case for concierge practice. It is an interview and the doctor does and excellent job of ignoring obvious attempts to agitate him and stays on topic. He spells out the advantages to doctors and patients who desire wellness and not treating an illness or disease after the fact. Yes, there will be some of that, but prevention and wellness will now receive the value it should.

Someone really felt that they had been stepped on in this article and wrote about it as if people did not understand what was happening. I don't agree with the author and the understanding felt was directed at the profession. At least the author of the original article was allowed to respond. I do think his attack on the concierge practice is misplaced and a little over the top.

There will definitely be some problems left behind in the aftermath of primary care physicians moving to concierge practices, but people will start demanding to see doctors and some of the specialists may end up doing some of the primary care whether they wish to or not.

A patient describes a visit to a doctor in concierge practice and describes his satisfaction with the visit. Enjoy reading his blog.

I do have one concern – that being the new medical organizations being established under the Affordable Care Act. How will the concierge practices fit within the Accountable Care Organizations (ACOs), or will they be completely exempt. Once this is established, I can see many benefits for concierge medical practices.

August 16, 2011

CPAP Is Effective Treatment For Sleep Apnea

With the Federal budget under the stress it is, why do we need more reports verifying what we already know. This has to be one of the more wasteful reports funded by HHS' Agency for Healthcare Research and Quality (AHRQ). They told us that the continuous positive airway pressure (CPAP) machine is the effective way to treat obstructive sleep apnea (OSA).

The report also cited another treatment with a mouthpiece called a mandibular advancement device (MAD) as being very effective. Both the CPAP and MUD have been known to be effective for several years and I have known this and have seen several studies reporting this, so my question is why the need to reinforce this and spend money to do it. The report also failed to mention the other oral equipment that is available.

Then the report goes on to state that weight loss and surgery may also be effective, but the evidence is not as strong. What the report fails to mention is that surgery can not be undone and if done improperly more damage can be done. The report does note that all treatments have possible side effects, but I have had very few minor side effects with the CPAP machine. These are all things that the American Sleep Apnea Association has had on their web site. If you have sleep apnea, take time to familiarize yourself with the site, and investigate the sleep apnea forum. The web site has been revamped so some of the blog links below may only take you to the site.

Apparently the current administration feels the necessity to duplicate the findings of others so that the Centers for Medicare and Medicaid have a government report to use in their decisions for approving or disapproving reimbursements.

What all sources fail to recognize is that the majority of doctors prescribe the CPAP machine and leave the dental profession to prescribe the mouthpiece. The patient seldom is even told about the other equipment. Both doctors and dentists use sleep studies and current practice prohibits referrals when something does not work. If I had not done my homework I might not have become aware of this.

I have written several blogs on sleep apnea and you may read more from these. The most recent on sleep apnea surgery is on February 9, 2011, and another more detailed on urgery is on October 4, 2010. For a blog on oral appliances read this blog. For two parts on identifying sleep apnea read here and here. Then I have another two part blog on sleep apnea and hospitalization here and here. I have several other blogs about the importance of sleep in managing diabetes which I will leave and if someone desires them please make a comment.

The article that started this blog is here and a copy with added detail is here.