June 15, 2012

What is Your Diabetes Diet?

At times I wish I was an expert, then I realize this is not something you can be educated for nor to be desired. I enjoy being able to write about many topics and not be chained to an organization or profession. As a patient, I am able to advocate and write about topics from a patient's perspective, applying what I experience and learn from others. When people that want us to believe they are experts, I sometimes need to stop and question if they are truly what they want us to believe.

Hence, when I saw this article with the title “Diabetes Diet” I had to read it to see what they were saying. True the title is a misnomer as there is not a diet specific to diabetes. There may be people that think this or want to believe this, but there can only be suggestions that fit us as individuals, that we have found work for us, and what our blood glucose meter says works for us. The experts don't want us to use our meters.

This article starts with the proper lead-in and is understandable. Let me back up and clarify that. Diet is the word used and we all understand that diets fail. Food plan is a more appropriate description for what people with diabetes need. The author starts the second paragraph right and I quote the first four sentences. “There is no prescribed diet plan for those with diabetes. Rather, eating plans are tailored to fit an individual's needs, schedules, and eating habits. A diabetes diet plan must also be balanced with the intake of insulin and oral diabetes medications. In general, the principles of a healthy diabetes diet are the same for everyone.”

I may be reading something into the “plan must also be balanced with the intake of insulin and oral medications;” however, I will try not to think this means that the insulin or dosage of oral medications determines the amount of food to be eaten. The last sentence in the paragraph above is what disturbs me, and the sentence that follows just confirmed my thoughts.

Consumption of a variety of foods including whole grains, fruits, non-fat dairy products, beans, and lean meats or vegetarian substitutes, poultry and fish is recommended to achieve a healthy diet.” Yes, the high carbohydrate, low fat mantra is again the saying of choice. The individualization idea is thrown out and it is the same one-size-fits-all mantra they have been preaching for years. This makes this author no different from others.

They all want us to think they are promoting the individual (platitudes) but they eventually fall back to the same approach. The article is downhill after that and I will come back for another point later. While reading and thinking about this article, I have wondered why in discussing food plans, nothing is ever mentioned about blood glucose testing. This would give meaning to the individualization as everyone would be different and food plans would take on a more individual flair.

Yes, but I keep forgetting about the obvious collusion between government agencies and medical organizations and related groups of “experts” and the fraudulent intent of misleading diabetes patients. This lengthy list includes three (no four) government agencies and four organizations. On one side is the USDA, which sets the food policy and this, is promoted by the American Diabetes Association, the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. On the other side are the Centers for Medicare and Medicaid Services and the National Institutes of Health and the Centers for Disease Control and Prevention funding studies to prove that patients do not need to test that often and derive no benefits from testing. The goal is preventing patients from knowing how foods affect their blood glucose levels and finding out how bad the advice is, being promoted by our “experts.” This is probably the reason that self-monitoring of blood glucose is discouraged by the four organizations.

The point that the author makes next really makes me vent and rant. It also gives me cause to never be considered an expert. I have to quote, “Many experts, including the American Diabetes Association, recommend that 50% to 60% of daily calories come from carbohydrates, 12% to 20% from protein, and no more than 30% from fat. People with diabetes may also benefit from eating small meals throughout the day instead of eating one or two heavy meals. No foods are absolutely forbidden for people with diabetes, and attention to portion control and advance meal planning can help people with diabetes enjoy the same meals as others in the family.”

The only good advice in the above quote is about people with diabetes possibly benefiting from eating small meals throughout the day. Some of us call this grazing and this does benefit many people with type 2 diabetes. I am currently using a food plan of 10% to 20% carbohydrates, 20% to 35% protein, and 45% to 60% fat. I am feeling better and all indications show positive effects in better diabetes management and lipid panel results.

June 14, 2012

Why Doctors Fear Starting Patients on Insulin

This is a Canadian study, but is applicable to the U.S. physicians as well. The opening statement is a little surprising when the myths about insulin are considered.  For many U.S. patients, the myths are out in full force and both doctors and patients seem to believe many of them. But, I digress.

The statement that doctors are more reluctant to start their patients on insulin than the patients are themselves says volumes and must be explored. Dr. Catherine Yu, a researcher at the hospital's Keenan Research Centre and senior author of the paper states, "There are no clear recommendations on the safest and most effective way to start patients on it, and so physicians are often hesitant to do so."

Dr. Yu and colleagues analyzed past studies to find out what barriers existed to starting patients on insulin, and how insulin compared to other blood sugar lowering medications in terms of its effect on blood sugars and weight. They then made recommendations for physicians and other health care providers based on evidence from the past studies.”

Their findings were published in the online edition of the Canadian Medical Association Journal.

What they found is that doctor's fears of common side effects such as weight gain and low blood sugar were amplified compared to their patient's fears, and that doctors were more concerned than their patients about the possibility of injection-related pain and anxiety. They also discovered that many doctors where only familiar with the insulins of past usage and older delivery systems. They needed to be reeducated about the newer insulins and methods of delivery.

Like many of us now using insulin, we find it much easier to use and if we use care and learn to use it properly. Instead of eating to a certain amount of insulin, we need to learn to count our carbohydrates and adjust our fast acting insulin accordingly. This will prevent most of the risk of low blood glucose and by limiting our carbohydrates, we can prevent the weight gain many fear. Exercise if medically able is another way of assisting the prevention of weight gain.

Although Dr. Yu's suggestion of starting patients on a once a day injection of long acting or 24 hour insulin while reducing the oral medications is good, those of us in our group all went from oral medications one day to insulin injections the next day. Granted this worked well for us and we were comfortable with this transition, some doctors are not. This is why we like our endocrinologists and the assistance they were able to give us.

When insulin myths are taken out of the equation, adapting to insulin use for most people can be efficiently accomplished. Education is required for using the best injection sites and matching rapid acting insulin to carbohydrates to be consumed. It is also wise to eat at regular times and is a person is ill and does not feel like eating, then do not inject the rapid acting insulin. More frequent testing is required and this must become a habit so that adjustments may be made for higher or lower blood glucose readings preprandial (before meals).

June 13, 2012

Three Quarters of Sunscreens Not Safe

Even with the FDA regulations and research on sunscreens, can we trust the products? Studies for the market of sunscreens for 2012 indicate that only one quarter of the products on the market is safe. Another area will also be scrutinized over the next year. Some are already making their accusations but at this time, there seems to be only speculations and no scientific proof. If proven, then everyone will know for sure.

This speculation has to do with nano-sized particles of zinc oxide in sunscreens. This will be researched over this summer and hopefully we will have an answer before next summer. So for now everyone is promoting their headlines, but when you get to the reading, they do say “may” cause cancer. There also is concern about titanium dioxide.

Yes, there are people on both sides of any issue and here we have the Environmental Working Group on one side, and some, but not all dermatologists on the other side. Both sides do agree that people should use sunscreens. The disagreement is about which works best, how often to apply, and safety of chemicals used in the product. The FDA has now come forward to eliminate some of the ambiguous terms manufacturers have been using. The words waterproof, sweatproof, and sunblock are now not allowed, but you may see "water-resistant," "sweat-resistant," and just plain "sunscreen". I wish this would be enforced, as there is still much of this on local shelves. I have looked and reported this to store managers, but it is not taken off the shelves. The FDA does need to enforce what they mandate.

The good outcome of FDA finally issuing some rules is that now they can be revised to make sunscreens more effective. EWG has been a leader in getting manufacturers to improve products and for the last three years there has been improvements; however, there is more to be accomplished when three quarters of the sunscreens on the market still are of poor quality and do not meet the needs of people or often are not even meeting standards. Until some heavy fines are levied against manufacturers for mislabeling and false advertising, we will probably continue to see inferior products on store shelves. Some heavy fines should also be levied against store chains and other outlets that bring out what remains from prior years inventory for sale.

Read about sunscreens here is this Medscape article and here for the WebMD discussion. Although I can't recommend it, for those that need to be positive about what they are purchasing, check out EWG's website here.

June 12, 2012

Making the Most Out of Your Doctor Appointments

Okay, I do miss some of my doctor appointments. Why does this happen? To be honest, I am not sure if it is my subconscious kicking in and telling me to ignore it or whether I am having memory problems. I do know that when the weather is bad, I will not travel the thirty plus miles one way, and I know that one got canceled (I actually called) because of the price of gas and trying to stretch the budget.

My appointments have become too routine and my lab results have been very consistent (boring comes to mind). What puzzles me even more is how difficult it is to schedule several doctor appointments in one day. In nine years of trying to do this, I have only succeeded getting two doctor's appointments in one day once – repeat one time. I thought I had done it three other times, but one doctor always had to reschedule for some legitimate reason. I do not like this, but things do mess with doctors schedules that cannot be prevented.

I am discussing this because of a blog in diabetesselfmanagement.com that brings up some excellent pointers that we should follow to get the most out of our doctor appointments. It is written for diabetes appointments, but I am covering all doctor appointments. Read the blog and see how you compare and if you are planning for a successful healthcare visit. I will cover each point as well to show how I compare. First, I must state that I have no problems with keeping my diabetes appointments. It is my other doctors I have my problems in forgetting my appointments.

1. Make time for it (the appointment). As a retired person, I seldom have any conflicts for my time – unless it is during the winter months and the weather is bad. As suggested I do turn off my cell phone and if I forget, most offices have reminders to do just that. I have heard people talking on their cell phones during office visits and I can understand doctors becoming very annoyed by this.
2. Plan ahead. Since we cannot remember everything to ask the doctor, I do make a list of questions that I need covered. Then a day or two before the appointment I try to prioritize them in order of their importance to me. I print them out so that if time runs out, I can hand it to the doctor and most of the time I will receive something in the mail with answers, or some doctors will call and give me the answer. Always record any activity out of the usual, like job changes, travel, or other changes. For me this is not a problem, but I do make mention of applicable health problems that concern me. I have them written down and also have blank paper to record instructions. I do repeat what I have written to make sure I have understood what the doctor has said.
3. Bring your meter and logbook. Although many people will not let their doctor have access to their meter, I think I get much more out of my appointments as the doctor does download my meter and reviews the readings and a couple of graphs with me. I always have my logbook for food and insulin injections if it is needed.
4. Facing the scale. Get over it, the number is what it is and you can only remove heavy clothing like a heavy winter coat. I know this is the procedure for most of my office visits, so I have an interest, but I do not obsess about it. I do get a few wry comments, but I just say it is what it is and the topic usually is dropped. I did have one doctor ask if I would consider bariatric procedure. My instantaneous no response stopped him cold. He did ask why and I carefully told him why explaining several of the things I would not be told and the problems this could cause for me. He commented I must have researched this and I hauled out a printout and he looked at it and when he saw the source, handed it back. He said that he had read it and agreed with it, but that the hospital was pushing all doctors to try to see what could be done. He did say he would not bring it up again with me, if I could hold my current weight or reduce it, as he was looking at my weight chart and said I have been up and down but that I was under what my highest had been. I told him to look for possible alternatives, but to forget people that insisted on the ADA way. He agreed and said I did not need the calories or carbohydrates.
5. Discuss your medicines. This is important and is something doctors are mostly requiring. Although the blog suggests a list or the bottles, I normally use the list method, but I do have two doctors that are now demanding the bottles before giving out any new prescriptions or renewals. They are not requiring this at every appointment, only when something is to be renewed. Some use e-prescribing and a few still are not. This blog does what should be done but few blogs do. It tells you to list all over-the-counter or herbal products

Many people insist they do not have to tell their doctor what supplements or other non-prescription medications they are taking. I will say I record everything, even prescriptions that are for short periods and I have not taken for some time since the last appointment. I do list the period that they were taken.

6. Take off your shoes and socks. For appointments with your diabetes doctor and your podiatrist this is a must. You may not have both, but you should consider this. Yes, it is a requirement for your podiatrist, but may not be for your diabetes doctor or endocrinologist if they know you see a podiatrist regularly. Either way, you should consider this as being important for the health of your feet. Even my neurologist surprises me once in a while when checking my neuropathy.

Especially for your podiatrist be prepared to discuss any foot-related concerns you may have. If you have problems with trimming your toenails or finding shoes that fit, and you don't have a podiatrist, ask for a referral to one.

7. Discuss your goals. Always be prepared for this, especially for your diabetes and have questions at the ready for your doctor as to how best achieve these. Be prepared as some doctors are only interesting in the A1c readings and you may need to ask some specific questions to convince the doctor you are serious. With all candor, if your doctor is unwilling to listen and discuss your goals, consider the need to find another doctor that will work with you to achieve goals for both of you.
8. Bring your calendar. Always bring your appointment book, or calendar (digital or paper) with you to schedule future visits. Make sure that you allow sufficient time between lab tests and your appointment to prevent conflicts or obtaining lab results. Always ask for a copy of lab results to assist you in tracking your own health.
9. Get the most from your minutes. This may seem difficult as the 10 to 15 minutes go by fast. Accept that the doctor may feel as rushed as you and you may have more questions than he has time to answer. I admit this is often the case for me. So I prioritize my questions to get the most important ones answered first. I am fortunate that a few of my doctors realize that I have a list and they do ask that I put my name, address, and telephone number on it. I always do this and they generally take the list of questions and answer them after hours or mail me the answers. One doctor does use email to answer them. I have had one doctor then call if he has a no-show to answer questions. Another doctor does answer the questions and gives me my sheet with his answers at the next appointment. This has let me know that I should be detailed in my questions and a couple of the doctors have thanked me for doing this.

Not every appointment will go as planned, so the better you have prepared yourself, the easier it can be for both of you. Although this seldom happens, I did have one appointment terminated as the doctor was called away on an emergency. I did hear him instruct his nurse to get my list of questions and give me my copy of the lab report as he hustled off. The nurse did say that it way one of his family in the emergency room, but that was all she said. Two days later, he called to ask if I understood the lab reports and if I had paper and pen available. He answered my questions after saying it was his wife that had been in a vehicle accident.

This was totally appreciated and explained why he had rushed off and I was very appreciative of his time in answering my questions. In the appointments since, no further mention was made of what happened and things were normal for the appointments. This is just one more reason to have a list of questions ready with your information included. I have found out over time that most doctors will appreciate the questions printed out in case they are short of time and the good ones will evaluate the questions and respond to the important ones. Depending on the number of questions, some do mail back the answers.

June 11, 2012

New Hyperglycemia Management Guidelines

After doing much reading and trying to follow what is said in the document released April 19, 2012 as the new hyperglycemia management guidelines, I am beginning to understand what is being said. The guidelines were published in DiabetesCare by the American Diabetes Association (ADA) and in Diabetologia by the European Association for the Study of Diabetes (EASD).

The last guidelines on management of hyperglycemia were published about five years ago and recent developments have now been incorporated into the new guidelines. The claim is made that there is growing complexity and some controversy in contemporary glycemic management for persons with type 2 diabetes – you think? What I do not understand is the thinking that oral medication is the route to follow by adding medication after medication to solve the problem.

According the experts, the answer has to follow the ACCORD rules and this is what pulled the study down. Medication on top of medication just does not work, but our diabetes experts think this is the only way and Big Pharma has them convinced that this is the route to go. This violates other statements and basically means things will be business as usual.

Oh, yes, the guidelines are full of platitudes to make us think that the new guidelines are patient oriented, but when the president of ADA's medicine and science states that the ADA set the HbA1c goal at 7% in general, but with some individualization, this means little or no change. At least other bloggers are thinking that little will change and that doctors will continue to push oral medication after oral medication until it is too late for insulin to prevent complications.

When the president for medicine and science of the American Diabetes Association, Vivian Fonseca, MD, of Tulane University in New Orleans criticizes a study, you know that the ADA has something to protect in the new guidelines. This is one of medication combinations – in fact the medication combination promoted in the chart so highly prized by the ADA.

I agree with Tom Ross when he states. “ What's new in these guidelines, apparently, is the emphasis on figuring out which drug combination is right for different kinds of patients, on the basis of many different factors which can limit the efficacy or safety of particular drugs in particular individuals. I don't think this is the revolution in thinking about diabetes care that I would have liked to see.”

Everything about the new guidelines seems prefaced on getting patients on medications and as soon as possible. There seems no room for patients that want to manage diabetes with diet and exercise; and there are many doing just that and succeeding.

The other point that really upsets me – if they are really advocating individuals and allowing individual choices, why is insulin listed last? This is just a continuation of the mantra of making this the medication of last resort when complications have already made themselves known. I really need to wonder if people that desire to move to insulin will be allowed the choice, or will the doctors want to keep piling oral medications on and generating more and more severe side effects. The side effects of insulin are minor in comparison to some of the oral diabetes medications. What are these so-called experts thinking? They must be followers of the insulin myths.