December 23, 2011

Why Do People with Diabetes Keep It a Secret?

This blog (link is now broken) from Diabetes Health really hit home for me. It reminded me of my blog of December 6 and a blog last July (link now broken) by Ronnie Gregory. Why do people insist on keeping their diabetes a secret? One question has been answered, but most of us were aware of the answer because we always have the “diabetes police” on patrol at every gathering.

And yes, we get tired of their snide remarks about how we could have prevented diabetes. I admit I was surprised when one of those that has been on my diabetes police list was looking very carefully at the food on the serving table this last weekend. I asked her why she was not selecting many items and why she had passed on the deserts. Normally she would have selected two or three pieces of different deserts.

She did not answer, but her husband did. He stated that she now has type 2 diabetes! If looks could kill, he was due for some talking to as soon as she could get him alone. I kept my peace, although I would have liked to dish out some of what she was always handing me.

I purposely selected the same table to sit with her and her husband. She wanted to move to another table, but her husband said she should stay seated and maybe take some of the medicine she was due. I admit I wanted to, but I just asked her why she wanted to keep her diabetes secret. Silence. I asked what she had learned since her diagnosis. Again, silence.

At that point, I know there were two others from our type 2 group that had joined us at the table, so I asked everyone to introduce themselves and then I started talking about diabetes. Of course, I knew the others and we started a lively discussion about diabetes and what medications we were taking. I knew all of us were on insulin, so it did not take long for her to ask if we were near the end of life.

At that point the one woman from our group that does not always get together with us was just sitting down at the next table answered, “No Sweetie, we just want better management of our diabetes.” Then another of our group asked her where she had read this? The woman answered that was what she had heard. Almost in unison the rest of said, “It’s a myth”.

From that point on, she started asking questions. We interrupted just long enough to move the two tables together so we could talk and hear better without being at two separate tables. It was not long before our former “Diabetes police person” was crying. She asked why we were being so kind when she had always rubbed it in our faces. One of the group answered very well for all of us by saying that was not the way we were and we were taking this opportunity to help her when she needed it. I then added, “That she could keep her secrecy from others, but in the presence of other people with diabetes, she should learn to talk about it and get her questions answered.

We did answer most of her questions that evening and learned that she was having troubles with her blood glucose readings being too high and that the metformin did not seem to be working. She was on only 1000 MG total of twice a day of 500 Mg, and had been on it for only three weeks. We found out that she had not seen a dietitian or been counseled about counting carbohydrates or when to test. She was not a person that was overweight and really was having a difficult time accepting the diagnosis. We also suggested that she talk to her doctor about increasing the metformin.

We talked about anger, denial, and accepting the diagnosis. We warned her about depression and to recognize some of the symptoms. We talked about doctors, and getting familiar with the provisions of her medical insurance. She had a policy like two of the group and we covered some of the things she would be able to receive coverage for at no cost other than co-pay. Then we talked to the husband about his duties and what he should and should not do to assist her. That was a very interesting discussion and he was surprised at the things he learned. We did thank him for speaking up when he should have kept his peace, and his wife thanked us again for not rubbing her face in it.

She did get a few email addresses and phone numbers plus a few web sites she should read. We spent some more time discussing diabetes myths. Several times, we had to reassure her that what she had heard was incorrect and that the facts would prove otherwise. We all said that for a while we would guard her secret, but that eventually she should let others know and become an advocate for diabetes education. The woman from our group said she could talk to her anytime, and she would direct questions to the rest of us that had the information if she did not.

We concluded our discussion by saying that she should explore her options and increase her exercise. If they could afford it to get a prescription for more test strips from the doctor even if it meant paying for the prescription. Her husband said they could afford the extra strips and asked how long she should do the extra testing. We said that would depend on her and getting an appointment with a dietitian knowledgeable about diabetes. We told her that once she learned to count carbs and used the testing to learn how the different foods affect her blood glucose levels, then she could possibly reduce her testing to what insurance covered. We said she should not rule out insulin, but to learn about it before needing to use it. She ended the discussion by stating that after the talk with us that she felt like denial was behind her, and that she needed more discussion and learning. We all promised to help where we could.

I think we made another person a member of our group. Take time to read this blog about not keeping diabetes a secret (repeat of first link). It covers other reasons for getting rid of secrecy.

December 22, 2011

Important Tests Needed By People With Diabetes - P4

There are always more tests if you have diabetes. One test that you will receive or should be given every time you visit the doctor is the blood pressure (BP) test. This non-laboratory test is an indicator of your heart activity, health, and potential artery problems.

Blood pressure (also termed hypertension) is measured as systolic (upper) and diastolic (lower) pressures. BP numbers are usually written as 120/80 mmHg (120 systolic over 80 diastolic millimeters of mercury). Systolic means the pressure when the heart beats while pumping blood and diastolic means the pressure when the heart is a rest between heartbeats.

The table below shows normal blood pressure numbers for adults. It also shows which numbers put you at greater risk for health problems.

Categories for Blood Pressure Levels in Adults (measured in millimeters of mercury, or mmHg)

Category Systolic
(top number)
(bottom number)
Less than 120
Less than 80
High blood pressure

     Stage 1
     Stage 2
160 or higher
100 or higher
The ranges in the table apply to most adults (aged 18 and older) who do not have short-term serious illnesses.

High blood pressure, is a persistent elevation in blood pressure that taxes the heart and can, over time, cause damage to organs such as the kidneys, brain, eyes, and heart. BP is the amount of force blood exerts on the walls of the arteries and veins. BP depends on the force and rate of the contraction of the heart as it pumps oxygenated blood from the left ventricle (compartment) of the heart into the arteries and the resistance to that flow. The amount of resistance depends on the elasticity and diameter of the blood vessels and how much blood is flowing through them.

Blood pressure is dynamic; it rises and falls depending on a person’s level of activity, time of day, and physical and emotional stresses. In healthy people, it is largely controlled by the autonomic nervous system but is also regulated by hormones, including:
  • Angiotensin II — produced by the kidneys, it causes increased resistance in blood vessels.
  • Aldosterone — produced by the adrenal glands in response to angiotensin II, it affects the amount of sodium, potassium, and fluids excreted by the kidneys.
  • Catecholamines — such as epinephrine, also called adrenaline, produced by the adrenal glands in response to stress and increases heart rate and resistance in blood vessels.
When one or more of the regulating factors is not able to respond appropriately to the demands of the body, then the pressure of the blood may become persistently increased.

With diabetes you should schedule yourself or an annual eye exam. Retinopathy is what the eye doctor should be monitoring. Normally your doctor will advise you to have this done. The purpose is to establish a baseline early to help determine if retinopathy is happening or progressing. Retinopathy is caused by the rupture of small blood vessels in the eye and over time causes dimming of sight and eventually blindness. This is a major reason for managing diabetes and maintaining excellent blood glucose levels. BP levels can also have an effect.

Another exam that needs to happen is a hearing test. This will also develop a baseline for future tests to determine if there is hearing loss happening. Small blood vessels in your inner ear can be damaged by high blood glucose levels and over time will rupture and cause hearing loss. It is important to maintain excellent blood glucose levels and BP readings.

Many people and even doctors forget about establishing a baseline for the thyroid gland by giving a TSH test. People with all types of diabetes may develop thyroid problems. The test is also known as Thyrotropin with the formal name of Thyroid-simulating Hormone. Related tests include T4, T3, Thyroid Panel, Thyroid Antibodies. The reason to have the test is to screen for and help diagnose thyroid disorders - to monitor treatment of hypothyroidism and hyperthyroidism. This test may be given anytime you have blood drawn and some medications can affect the results so it is important that you tell your doctor about all medications and supplements you are taking. For more information see this web site.

A person may develop hyperthyroidism when TSH levels are increased. Symptoms include rapid heart rate, weight loss, nervousness, hand tremors, irritated eyes and difficulty sleeping. If TSH levels decrease, hypothyroidism may develop. Symptoms include weight gain, dry skin, constipation, cold intolerance, and fatigue. Thyroid diseases may alter thyroid hormone levels regardless of the amount of TSH present in the blood.

If you are taking metformin, know that the B12 test is important because metformin does deplete the level of vitamin B12. If you obtain a lot of B12 from the food you are eating, B12 supplements may not be necessary. All persons that have been on metformin for any length of time should ask for the B12 test. Generally once a year is sufficient unless there are problems and then it may be done more often by your doctor.

A high coronary artery calcium (CAC) score is known to be a strong indicator of coronary heart disease. This test is becoming more important in the analysis of heart disease in everyone, but since people with diabetes are even more at risk for heart disease, this could be especially important for people with diabetes. Persons with diabetes are twice as likely to develop heart and vascular disease. About 60 percent of diabetes patients are likely to die from a vascular event. Read this article about CAC.

One last item is to obtain copies of all tests to allow you to track the results. You may see something that your doctor misses and by charting the results, this will give you a good insight into your own health and show favorable and unfavorable trends.

Part 4 of 4. This concludes the lists of tests for people with diabetes discussion. There are always others tests for other conditions.

December 21, 2011

Important Tests Needed By People With Diabetes - P3

The discussion of this blog will be about tests doctors should use to track your diabetes and related possible complications. The first test helps analyze the status of your kidneys, liver, blood proteins, electrolytes, and acid/base balance. This is a Comprehensive Metabolic Panel (CMP) and is typically a group of 14 specific tests that have been approved, named, and assigned a CPT code (a Current Procedural Terminology number) as a panel by Medicare. Read about the different tests here.

The CMP includes these tests: glucose and calcium; albumin and total protein (proteins); electrolytes – sodium, potassium, CO2 (carbon dioxide, bicarbonate), and chloride; liver tests - ALP (alkaline phosphatase), ALT (alanine amino transferase, also called SGPT), AST (aspartate amino transferase, also called SGOT), and Bilirubin; kidney tests - BUN (blood urea nitrogen) and creatinine.

Next is the Basic Metabolic Panel (BMP), a group of 8 specific tests that have been approved, named, and assigned a CPT code. Many doctors use this test instead of the CMP. Read about the different tests here and compare to the CMP. Both tests are done from a blood draw. Neither the BMP or CMP are diagnostic in nature, but can help the doctor decide if more specific tests need to be completed for diagnosis of a problem.

The BMP includes these tests: glucose and calcium; electrolytes – sodium, potassium, CO2 (carbon dioxide, bicarbonate), and chloride; kidney tests - BUN (blood urea nitrogen) and creatinine.

More of us are probably familiar with the cholesterol tests (lipid panel). This is a group of tests that should be performed on a quarterly basis, but may not be if you have had no problems in the past. This is a very important groups of tests and give the doctor good information about cardiovascular health. The lipid profile is a group of tests done to determine the risk of coronary heart disease and are good indicators if someone is likely to have a heart attack or stroke caused by blockage of blood vessels or atherosclerois (hardening of the arteries. Read about the different tests that make up the lipid panel here.

The lipid profile normally includes - total cholesterol, high-density lipoprotein cholesterol (HDL-C) — often called good cholesterol, low-density lipoprotein cholesterol (LDL-C) —often called bad cholesterol, and triglycerides. An extended profile may also include very low-density lipoprotein cholesterol (VLDL-C) and non-HDL-C. Some labs also include ratios in the test results.

The last test in this group is the microalbumin test for kidney damage. This test is preferred annually if you have diabetes or hypertension and is extremely important for those not managing their diabetes or hypertension. For those with higher A1c's that are not managing their diabetes, the tests may be done more frequently. It screens for metabolic and kidney disorders plus urinary tract infections.

You will be asked to collect either a random sample of urine while you are at the doctor's office or laboratory, a timed urine sample (such as 4 hours or overnight), or you may be requested to collect a complete 24-hour urine sample. Your doctor or the laboratory will give you a container and instructions for properly collecting a timed or 24-hour urine sample.

The National Kidney Foundation recommends that everyone with diabetes between 12 and 70 years of age have a urine test for microalbuminuria at least once a year. According to the American Diabetes Association, everyone with type 1 diabetes should be tested annually, starting 5 years after onset, and all those with type 2 diabetes should start at the time of diagnosis.

If microalbuminuria is detected, it should be confirmed by retesting and, if positive on 2 of 3 determinations over a 3-6 month period, it is considered to be present and appropriate treatment should be given. Patients with hypertension may be tested at regular intervals, with the frequency determined by their doctor.

Part 3 of 4

December 20, 2011

Important Tests Needed By People With Diabetes - P2

Back in August 2010, I wrote about five or six important lab tests for people with type 2 diabetes. I need to update this and add more tests and be a little more detailed than I was then. It is not my intention to discuss the tests for gestational diabetes, but a few are common across all diabetes types. The discussion for this blog is about monitoring diabetes, by your doctor and by you.

Once you are diagnosed with diabetes, the glucose (or blood glucose) test will become very important to you. This test has other names starting with fasting blood glucose (FBG), or fasting plasma glucose (FPG). This is done either in a lab or in the doctor's office lab. Normal fasting is required of a minimum of 8 to up to12 hours. This is done by drawing blood from you and gives two results. The first is the fasting plasma glucose reading and the second is the A1c results. Normally other tests are done at the same time, but this discussion is on glucose. An A1c test can be accomplished without fasting and is often done this way.

These tests can be performed at various intervals depending on the patient and the doctor. If the doctor is overworked and the patient is active in his/her care, some doctors only see a patient once a year. Others see their patients twice a year, but most doctors still try to see their patients with diabetes four times per year.

The blood glucose (or glucose) test will become one of your daily tests. This is not the same as the blood glucose test taken in the doctor’s office or lab. This requires a blood glucose meter and test strips and is done several times per day depending on the type of diabetes you are diagnosed with and the limits of test strips mandated by your medical insurance or Medicare. This will also depend on whether you are on oral medications, insulin, or a combination of the two.

If you can afford to purchase test strips on your own over and above what your insurance or Medicare covers, please consider doing this. If extra test strips are over your budget, pick times for study like your fasting after arising in the morning. Know what you wish to attain and look to this test for guidance. Then pick another time during the day, which will assist you in maintaining your goals. Then after a period of time switch your testing times and use them for about a month. Be prepared to return to the original testing times if the secondary times are well managed.

One of the reasons for encouraging people to purchase extra test strips over what insurance reimburses is to test what different foods do to your blood glucose levels. This requires you to test after every meal at approximately 1 to 2 hours. This will tell you if you need to reduce the portion or eliminate the food from the menu. Because everyone's body chemistry is different, it is important to become you own chemistry experiment and learn by testing how the different foods affect you.

Until you learn to count carbohydrates from a dietitian or certified diabetes educator or another professional, the testing will only give you general ideas. Get a referral by your doctor and lacking that, call your insurance company and ask them for permission or a list of registered dietitians knowledgeable in diabetes.

Yes, we can say to eliminate certain foods and often encourage people to do so because of our own history and the history of others with type 2. However, everyone being different, it is still best to test for yourself. It is almost like a symmetrical bell curve with carbohydrates. Some people can only tolerate a small number of carbohydrates and people at the other end of the curve can tolerate more than the average person. The American Diabetes Association treats everyone the same in the number of carbohydrates they can consume. This is far from the truth and is a reason for testing more shortly after diagnosis. Once you have found your level of carbohydrates, then reduce testing to what insurance or Medicare will reimburse.

I would also suggest that more testing be done again when foods are changed or blood glucose levels from your tests show an increasing trend. Maybe you can reduce the number of carbohydrates consumed without increasing testing, but for those of us that are very conscious of blood glucose levels, we like to be sure. Read my blog here for testing.

What we are looking for is trends and hopefully the levels are steady and not increasing. When blood glucose levels are trending upward, this will most likely be reflected in your next A1c test and you should be ready to discuss this with your doctor. Most endocrinologists will want to take readings from your own meter and see what readings you are getting. Not all doctors want or can deal with this information so always be prepared.

Several bloggers have also discussed this topic and I offer their discussions for your reading as they can possibly shed a different perspective on this subject of testing that will make more sense to you. Tom Ross has two blogs that may assist you in knowing how to test if on a limited supply of test strips. The first is here and the second with additional thoughts is here.

Joslin Diabetes Center has a blog here and Alan Shanley has a blog here about the importance of testing. Alan's second blog is here. The blogs by Tom and Alan are important as they also have type 2 and presently Tom is managing his with diet and exercise. 

Part 2 of 4.

December 19, 2011

Important Tests Needed By People with Diabetes - P1

Diagnosis of diabetes for type 2 is often a sticky topic in the last few years. This is very true for all types of diabetes. Too often physicians make assumptions that are not correct. They look at a person, the age, and often do one of the required tests. Often they are correct, but what a disappointment for those that are incorrectly diagnosed. Even the American Diabetes Association makes mistakes and this one could be very large.

There are tests for screening, tests for diagnosis, tests for monitoring, tests to evaluate glucose levels, and tests for the complications of diabetes. Read this blog as well by Joslin Diabetes Center about tests for diagnosis.

The tests for screening and/or to diagnose pre-diabetes and diabetes can be used as part of a regular physical, when a patient has symptoms suggesting diabetes, when a patient has a condition that is associated with diabetes, and when a patient presents to the emergency room with an acute condition.

Screening tests generally include:
  1. Fasting glucose (fasting blood glucose, FBG) – this test measures the level of glucose in the blood after an 8-12 hour fast. Also fasting plasma glucose (FPG).
  2. A1c (also called hemoglobin A1c or glycohemoglobin) – this test evaluates the average amount of glucose in the blood over the last 2 to 3 months and has been recommended more recently as another test to screen for diabetes.
  3. Sometimes a random blood glucose level is used for screening when a fasting test is not possible, such as when a person is seriously ill.
  4. Sometimes random urine samples are tested for glucose, protein, and ketones during a physical. If glucose and/or protein or ketones are present on the indicator strip dipped in the urine sample, the person has a problem that needs to be addressed. This is a screening tool, but it is not sensitive enough for diagnosis or monitoring.

If you trust the American Diabetes Association (ADA), they promote first the A1c test, then the FPG and finally the oral glucose tolerance test. You must use care with all tests and know the limitations of each.

  1. The FBG requires an 8-hour fast.
  2. The OGTT requires that the person have a fasting glucose test, followed by the person drinking a standard amount of glucose solution to "challenge" their system, followed by another glucose test 2 hours later.
  3. With the A1c, people do not have to fast for 8 hours or endure multiple blood samples being taken over several hours, but the test is not recommended for everyone. It should not be used for diabetes diagnosis in people who have had recent severe bleeding or blood transfusions, those with chronic kidney or liver disease, and people with blood disorders such as iron-deficiency anemia, vitamin B12 anemia, and hemoglobin variants. In addition, only A1c tests that have been referenced to an accepted laboratory method (standardized) should be used for diagnostic or screening purposes. Currently, point-of-care tests, such as those that may be used at a doctor’s office or a patient’s bedside, are too variable for use in diagnosis but can be used to monitor treatment (lifestyle and drug therapies). Also, the A1c is of questionable value in diagnosis of young people (read this).

If the initial result from one of the above tests is abnormal, the test should be repeated on another day to confirm a diagnosis of diabetes. Once the diagnosis had been made then it may be wise to have the diabetes autoantibodies test, which should help distinguish between type 1 and type 2 diabetes if the diagnosis is unclear. The presence of one or more of these antibodies indicates type 1 diabetes.

Now for pre-diabetes and diabetes, the guidelines are as follows: The A1c test can be used to either monitor diabetes treatment in a person that has diabetes or to screen for and diagnose diabetes and prediabetes. An A1c of less than 5.7% is not diabetes, an A1c of 5.7% to 6.4% says prediabetes, and an A1c of greater than 6.4% is diabetes.

Some doctors use the fasting plasma glucose (FPG) test and the A1c to make a diagnosis. The FPG reading of less than 100 mg/dl (5.6 mmol/L) means no diabetes, a FPG reading of 100 to 125 mg/dl (5.6 to 6.9 mmol/L) is prediabetes, and a FPG reading greater than 125 mg/dl (6.9 mmol/L) is diabetes.

Others also add the oral glucose tolerance test (OGTT). This requires the person to drink a 75-gram glucose drink. At the two-hour mark a blood sample is drawn. If the results are less than 140 mg/dl (7.8 mmol/L) then you do not have diabetes or prediabetes. If the results are from 140 to 200 mg/dl (7.8 to 11.1 mmol/L) it is considered prediabetes. If the results are over 200 mg/dl (11.1 mmol/L) then the diagnosis is diabetes.

Part 1 of 4