August 11, 2012

Nutrients – Iodine


Iodine is something I have been aware of since childhood. My mother always made sure she used iodized salt, both for cooking and for table use. This is something that I have been happy about, as both my first wife and now my second wife have been conscious about having iodized salt for use. Iodine is crucial in production of the thyroid hormone. Those of us living away from the coastal areas need to use iodized salt because there are few other ways to obtain iodine unless you are a heavy consumer of seafood from the oceans.

Iodine is a trace mineral that the body needs to make thyroid hormones, which are essential for normal growth and development. In your body, about 70 - 80% of iodine is found in the thyroid gland in the neck. The rest is distributed throughout the body, particularly in the ovaries, muscles, and blood. If your body doesn't have enough iodine, you can develop hypothyroidism (low thyroid hormone levels).

Tests for iodine deficiency
A 24-hour urine iodine collection is a useful medical test, as approximately 90% of ingested iodine is excreted in the urine. If a 24-hour urine collection is not practical, a random urine iodine-to-creatinine ratio can alternatively be used. According to the World Health Organization (WHO), in 2007, nearly 2 billion individuals had insufficient iodine intake, a third being of school age. Thus iodine deficiency, as the single greatest preventable cause of mental retardation, is an important public-health problem. In the USA, it is important the women bearing a child be tested and the newborn be tested as soon as can reasonably done.

Recommended Daily Allowance
The Food and Nutrition Board at the Institute of Medicine recommends the following dietary intake for iodine:
0 - 6 months: 110 micrograms per day (mcg/day)
7 - 12 months: 130 mcg/day
1 - 3 years: 90 mcg/day
4 - 8 years: 90 mcg/day
9 - 13 years: 120 mcg/day
Adolescents and Adults
Males age 14 and older: 150 mcg/day
Females age 14 and older: 150 mcg/day

Specific recommendations depend on age, gender, and other factors (such as pregnancy). Women who are pregnant or producing breast milk (lactating) need higher amounts. Ask your doctor for the amount that is best for you.

Iodine is needed for the normal metabolism of cells. Metabolism is the process of converting food into energy. Humans need iodine for normal thyroid function, and for the production of thyroid hormones. Iodine is a trace mineral and an essential nutrient found naturally in the body.

Food Sources
Iodized salt -- table salt with iodine added -- is the main food source of iodine. Seafood is naturally rich in iodine. Cod, sea bass, and haddock are good sources. Kelp is the most common vegetable seafood that is a rich source of iodine. Dairy products also contain iodine. Other good sources are plants grown in iodine-rich soil.

Lack of enough iodine (deficiency) may occur in places that have iodine-poor soil. Many months of iodine deficiency in a person's diet may cause goiter or hypothyroidism. Without enough iodine, the thyroid cells and the thyroid gland become enlarged. No area maps for locations rich in iodine are currently available; however, seacoast areas are generally the highest in iodine.

Deficiency happens more often in women than in men, and is more common in pregnant women and older children. Getting enough iodine in the diet may prevent a form of physical and mental retardation called cretinism. Cretinism is very rare in the U.S. because iodine deficiency is generally not a problem.

Iodine poisoning is rare in the U.S. Very high intake of iodine can reduce the function of the thyroid gland.

Possible Interactions
If you are currently being treated with any of the following medications, you should not take iodine until you have first talked to your health care provider:

Antithyroid Drugs -- Use of antithyroid drugs, including propylthiouracil (PTU), and iodide may increase the hypothyroid effect of iodides.
Lithium -- Use of potassium iodide and lithium (Lithobid) may cause hypothyroidism.
Warfarin -- Use of potassium iodide (for hyperthyroidism) and warfarin (Coumadin, a blood thinning drug) may make warfarin less effective.
High blood pressure medication (ACE inhibitors and ARB's (Angiotensin Receptor Blockers)) -- Many iodine supplements contain potassium. When used with ACE inhibitors and ARB's, iodine may result in an increased level of potassium in the body, which may be dangerous.
Potassium sparing diuretics -- Since many iodine supplements contain potassium, concurrent use may result in dangerously high levels of potassium.
Amiodorone -- Concurrent use with iodine supplements may result in dangerously high levels of iodine.

Most people get plenty of iodine, and because of the complex way iodine can affect the thyroid, you should not take iodine supplements unless your doctor tells you to.

August 10, 2012

Reasons Diabetes Patients Need To Be Proactive

Proactive you say? Yes, we as patients need to become more proactive in our care and learn about diabetes, diabetes medications, and the care of ourselves. This means that we should learn and review. The new medications that may be coming to market in the next few years will need to be reviewed, as there could be some side effects and some positive results. Just letting your doctor prescribe a new medication may not be in your best interest. You will also need to check with your medical insurance company to see if they are covering it. You should know that the cost will be higher than the current medications on average or even significantly higher. Those on Medicare will still have the “doughnut hole” (though smaller) for a few years and this could be a budget buster for some.

With hospitals continuing to employ more doctors, you can bet the time you will have with your doctor during appointments will continue to shrink. This means less time will be available for the doctor to dispense education and even cover the topics necessary.  The recent guidelines from the American Diabetes Association (ADA), which shows a lot of stacking of medications, may not work for many patients. See this blog by Tom Ross for the chart, or follow his link to view how ADA is stacking oral medications. This makes it even more important for patients to educate themselves to know what the side effects of medications are. It is also important that patients learn self-monitoring of blood glucose (SMBG) and other important management skills.

It is also important to understand that just because a doctor does not mention or talk about something, there are areas that are important and should not be ignored. Exercise is one of these areas and I admit that I am tired of hearing other patients with type 2 diabetes saying, “It must not have been that important as the doctor never talked about it.” This phrase just seems to roll of the lips of patients and I can understand as either they don't wish to follow some recommendation, or in fact, the doctor did not have time to talk about it. Nutrition is also a topic most doctors do not talk about, yet for people with type 2 diabetes, nutrition is very important to great diabetes management.

Another topic doctors often don't talk about unless they are prescribing insulin is hypoglycemia. They seem to overlook the fact that this can happen and does happen to patients with type 2 diabetes on oral medications, especially sulfonylureas. A recent blog should also raise this concern. Even this short article talks about hypoglycemia, but other than list the symptoms, gives no indication of what to watch for in your blood glucose readings. This is important and many of the symptoms could be indicators of other medical problems. One check of your blood glucose will resolve this issue. If your blood glucose reading is below 70 mg/dl (3.9 mmol/L), you are in the hypoglycemia area and should take action immediately by chewing on a glucose tablet.

Just to keep this in front of you as a reminder, here are many of the symptoms of hypoglycemia,
Feeling dizzy or shaking,
Sweating and having pale skin.
Developing a headache.
Feeling hungry.
Showing sudden changes in behavior.
Moving clumsily.
Having a seizure.
Feeling confused or having difficulty paying attention.
Feeling a "tingling" sensation around the mouth.

This blogger believes we will need to become e-patients, meaning empowered patients. Her book e-Patients Live Longer, helps explain her and her beliefs, but it is a good read. Whether you have diabetes or breast cancer, it helps to be an e-patient.

August 9, 2012

Meeting and Working with a Dietitian

Under the present conditions, I would suggest reconsidering any appointment with a registered dietitian (with RD in the title). While I have some friends that are RDs, they know that currently, I still want them for friends, but do not bring up the subject of nutrition when we are together. One of my cousins who is a nutritionist, not a RD,and a member of another organization, does take particular pleasure in confronting me about the situation within the Academy of Nutrition and Dietetics (AND) and how they will lose in the long run. I do think she is doing this to see how I react, but presently I just let her yammering go in one ear and out the other.

Yes, when we do get to the facts and what is in the news and other publications, we do have a spirited discussion. She has met some of our informal group, and she understands what we are doing. She did help one of the group (Allen) get a more balanced meal plan. Even he was surprised about how far out of balance he had been. She asked him to get a scale that he would use and for a week weigh his food and record what he was eating. Since he already had a scale that would work, he asked what we thought and we agreed that this could be an immense help for him.

The following week, she took the information, showed where he was weak nutritionally, and made suggestions to create meals that are more balanced or more balanced for the day. Not only did she give him suggestions, but showed him what the different suggestions could do for him per meal, but as well on a daily basis. He was in awe with the results and commented that he understood why the doctor had run so many tests. Then they both sat and went over the sheet she had prepared. A few adjustments were made and he said he was going to have to go to the grocery store. He also asked how to prepare some of the new vegetables that he generally did not eat. She actually listed different ways to cook some of foods and how to prepare some of them for eating raw. She then surprised even me and gave him her phone number to call when he had questions.

Yes, all of us present made some suggestions, but she kidded us that everyone likes a woman's touch – ooohhhh – ouch. We started kidding Allen about maybe not needing his supplements that the doctor had him taking. She stopped us immediately and asked which supplements. I said we needed to start at the beginning and she agreed.  Allen said he had been on Metformin for many years and one day had been asked by us if he was taking a vitamin B12 supplement or had been tested for the deficiency. He explained that his doctor would not do the test and Tim and I had gotten him to a doctor that I see where they did the tests and several others. Allen explained that he had a vitamin D shot and vitamin B12 shot that day. He explained what the progression had been to the current day.

Allen gave her the supplements he was taking per the doctor’s instructions and the dosage of each. She looked each over and said he had better ignore her suggestions for nutrition change until Allen and she had a chance to talk to his doctor. Then she asked how many of each supplement he had left and Allen stated that on some of them were just about out and he didn't know on a couple. She said that if possible, he should call the doctor's office and get an appointment as soon as possible. Allen called and received an appointment for the following Tuesday, and told the receptionist the reason. About half an hour later, the Doctor called and wanted to review the reason. Allen put the nutritionist on the phone and she explained the reason and what was transpiring. He asked if they could be in his office yet that afternoon. They decided they could, and they were off.

The following day, several more of us got together with the nutritionist and Allen was all smiles. My cousin said that was one of the best meetings with a doctor she had ever been involved in. She had grabbed a couple of books from her car before they had left and the doctor had the same books out when they were in his office. She said she had done some calculations on the way and that was what the doctor had wanted to see. Allen said the doctor was impressed that she had followed Allen's wishes and adapted a meal plan for each meal in the day and if one meal was short, the next meal compensated so that the day was balanced. Since Allen was still adjusting to insulin, the doctor was very happy that she had kept the number of carbohydrates down while still balancing the nutrition.

The doctor did agree with my cousin on holding some of the vegetables until Allen had exhausted the supplements and for them to go ahead if Allen was happy with what she had proposed. The doctor did want Allen to continue the vitamin D and vitamin B12 until the second appointment from now. Allen said his next appointment was in August and that would make the second in November and the doctor said he would order the tests for then and see where his levels were and make any adjustments then. The doctor, according to Allen, had said if he could work with the nutritionist, he should be good with the food supplying sufficient nutrients. The doctor said the tests would either confirm this or lead to more tests to determine if Allen's body was not making use of them in which case there would be a medical mystery to be solved.

Allen said the doctor had quizzed my cousin about her education and affiliation before going over the sheets that she had prepared. Allen was a little surprised that he had checked some of her calculations, but realized that the doctor had relaxed when he saw that his calculations agreed with hers. The doctor asked if she would be pushing the number of carbohydrates up later, and Allen said that he had been told only if that was his desire. My cousin said she told the doctor that she makes suggestions, but works at the ratio the patient desires and said that it would probably be five or six months in making, the transition to the ratio Allen wanted. She said that this would minimize the level of endotoxins.

Brenda, who did make this gathering, spoke up and said this sounded like what her daughter would say. Quick comparison of backgrounds revealed the same university, but members of different organizations. Neither is a member of AND and happy where they are members.

August 8, 2012

Not A Game Plan for Type 2 Diabetes

While not really a game plan at all, there are some features that this site may bring to peoples attention. Probably the only reason I found this site is an article in Medscape. After researching on the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) websites, I did not find a link to Is this intentional? Maybe. Both websites do little to promote what they hype in articles or interviews, so it is small wonder that little is accomplished in bringing visitors to their sites.

Even my own endocrinologists do not promote this during office visits or include information about it in handouts. Why am I writing about this? Someone needs to promote what the professionals are seemingly incapable of doing. I think the person that made this commentquote - “Unfortunately, like the AAFP, the AMA and ACC have also let us down. The societies today exist for their own purposes and not for the benefit of members. The AMA owns the CPT code system and makes more money from this behemoth than from member dues. The ACC is enthusiastically offering "products" (read $$$) to "help" doctors meet their performance goals.

It is beyond time for new professional societies to emerge that actually advocate for physicians involved directly in patient care. Perhaps one big "Society for Patient Care Physicians" that could involve everyone who actually sees patients every day, rather than the academic guideline and rule-writing "doctors" who dominate societies today.” - Unquote.

I think the comment is on target and needs to be done so that doctors that care for and about patients could have a format to get information to patients in terms they understand and this could be promoted for patients. With the Internet of today, what could be of value to patients is often lost in the dogma of the medical organizations. Most could have on their home page a link to patient information and then links on the patient page for more pages of valuable information. This information could then be reliable information that can be used for the benefit of patients and used by patients.

Even the website for approved Internet websites on the AACE website no longer has a direct link to it on the home page. Plus, they are not adding anymore approved sites. They have fulfilled their promise so-to-speak, and now want to leave it alone. For the two sites of the AACE and ACE, there is so much information that could be included as part of their websites. However, at most, the information is limited for patients and not really informative for new patients that may be searching these sites for reliable information.

On the same site is a tab named “The ABCs of Diabetes Management.” This did not surprise me as they are A1c, blood pressure, and cholesterol. Surprise, no mention is made about statins. Blood pressure goals are different than recommended by the American Heart Association, but not significantly higher. From the way the material is presented, the emphasis seems very much on the HbA1c as the measurement for how well the goals are being accomplished not any individual blood glucose tests. At least the A1c goal is 6.5%, but then they say that maybe the goal will need to be higher. No mention is made about individuals that want to strive for lower A1cs or if they will even allow for this.

Then they use four topics to help in achieving the ABCs. They include healthy eating, getting more active, taking your medication, and tracking your ABC goals. I was totally surprised at the healthy eating. They rightly say to limit refined foods and eat vegetable and some fruits. Maybe a little heavy on the fruits, but no mention of whole grains. The limited discussion on getting more active was not bad, but the discussion missed a lot of physical activity. Taking your medication(s) did not discuss any particular medication(s), but the suggestion is there. The concern for hypoglycemia is present and that is a plus. Tracking your ABC goals missed more than it covered. It talks about tracking your blood glucose levels, but does not give any meaning to why track and what to be looking for in meaning. To me, it sounds more like the reason is for the doctor than looking for reasons to the daily numbers.

In the medscape interview, Farhad Zangeneh, MD, FACP, FACE did a good thing in answer to a question about why not use the more effective treatment of bariatric surgery for all obese type 2 patients than have them struggle with lifestyle changes to achieve treatment goals. I will quote his answer - “Not all patients with type 2 diabetes are candidates for bariatric or metabolic surgery, and no matter how much weight is initially lost, there is always weight rebound. There are no easy answers and no shortcuts in the management of diabetes. Even if patients are candidates for bariatric surgery, their psychology — mindset and eating behavior — has to change before their anatomy. There is also growing evidence that patients who undergo gastric bypass surgery are prone to hypoglycemia. For the majority of patients with diabetes, management still boils down to healthy eating, physical activity, and pharmacological medical management.”

As for the goals of “The Game Plan,” most of the information is on a need to be done basis and not education about diabetes and the reasons for doing what is all but demanded that patients do. Some information is there and for some patients that function in this manner, it may be of value.

What I think is that few people are going to find this site without a direct link to it from the AACE main page or even a link from the ACE page. Few patients with type 2 diabetes ever read the articles from the medscape dot com site and I have not seen any other mention of the site elsewhere. Granted I do not read every website, but I think Merck was sold an idea with no solid intention of promoting the website by AACE. Some people will find the website from search engine use, but that will be a small number. Great idea, but no support of the site by AACE.

August 7, 2012

Why Do CDEs Not Have Sleep Apnea Training?

After asking several certified diabetes educators (CDEs) whether they have training for sleep apnea, I have to ask why they are so secretive about their training. Even my CDE relative would only answer that her practice has sent them to some training. Of five others I asked this question of, only one would say that she has some training because the practice she worked for sent her to a couple of classes.

Why are CDEs so secretive about their training? It would seem to be something they should be proud to discuss for people to understand why they display the acronym behind their names; and limit the profession by making it difficult for people to gain access to the title. Registered nurses, physician assistants, doctors, and pharmacists are not that secretive and will generally answer questions about their continuing education and even their education.

This begs another question, is the training so poor that they do not want to acknowledge what they do know and that they take classes and webinars solely to be able to check the boxes for recertification? Are they getting anything from these classes or webinars that is useful? I have tried on more than one occasion to ask questions of CDEs, but I seldom get a straight answer. Is this part of their training not to answer questions about their training? Or, is it that they are ashamed of their continuing education.

Those that are willing to talk divert the questions to their core training. Nurses will talk about their education; pharmacists will talk about their education; but try to get information about the CDE training is like talking to the proverbial brick wall. Even my relative will not answer certain questions although she will for some after she is sure I will not use her response in a blog. I asked her if I am asking the wrong questions, and she did say I was asking the right questions and that I was being polite in the way I asked most questions.

She did comment that sometimes my writing was a little blunt, but occasionally she could understand the reason behind it and the need for showing my frustration. I did tell her to read this blog, as I am very frustrated that the current AADE head is apparently alone in her ivory tower and those that answer to her are painting a picture that is not representative of what is going on in the trenches.

It is difficult to make changes when you are not given the truth or a true picture of what is happening at the lower levels. The blog I wrote back on October 6, 2011 is still as applicable today, if not more important. In the last paragraph, I made mention of a few thousand CDEs that needed our support, but in what has happened recently, maybe I should change that to a few hundreds.

Now do not misunderstand, I do not see the need for CDEs to be experts in sleep medicine. They should learn to ask the right questions about sleep and recognize the symptoms of sleep apnea. Then they should recommend to the doctor that he/she investigate further and possibly refer the patient to a sleep specialist. Because many of the people with type 2 diabetes (above 40 percent for combined men and women) have sleep apnea, this should be necessary in CDE training.

Since I am not able to say with any certainty that they have training about sleep apnea or are required to have training, this is the reason for wording the title the way I did.

Now that I have had my say, I will turn this around and say I was pleasantly surprised when I sent an email to the AACE education division. I received a prompt reply with a lot of information to research and get my head around. I was supplied with information about a sleep apnea resource for CDEs. Since I do not have a copy of the book, I will copy the description from the AADE site.

Many resources address major complications of diabetes, such as heart disease, stroke, blindness, and kidney disease. Managing Diabetes: Complications and Comorbidities focuses on the number of conditions and comorbidities that affect an individual's activities of daily living. Help your patients learn to recognize the early signs of changes that can lead to these conditions so together you can work to prevent or delay their onset.”

Learn and Earn
Free continuing education (CE) for nurses, dietitians, and pharmacists included with book purchase. When you purchase the book, the post-test will be uploaded to your online learning portal. You have two opportunities to pass the post-test and receive 4.5 CEs. One post-test is allowed per book purchase.”

Your Price: $ 24.95, Member Price: $ 19.95” This was published in January 2012 by the AADE, therefore do not look for this in your bookstore or favorite online bookseller.

I will take the word from the person corresponding with me that the topic of sleep apnea is included since the topic is not included in the description.  The site has been totally revamped and the URL that I had is not longer valid. I am just happy I have as much information as I did get.

August 6, 2012

What Can Be Done for Prediabetes?

Until now, I admit I have gone along with the term prediabetes although I have not liked the term and have called for a change in terms. I feel because of the lack of concern by the medical community and the American Diabetes Association and other organizations, it is time for action and declaring this a condition that needs treatment just like diabetes. Because it has some of the complications of diabetes and risks for others, it is time to just call it diabetes and let medications work to bring it under management.

What brought me to this. Visiting a friend that had a doctors appointment recently. He said that the doctor had said his A1c was 7.2 and that he should watch his food consumption as his sugar was a little high. I had to ask if he would see another doctor? My friend asked why? I told him that I was sorry as I was going to be very blunt, but that the information was telling me that something was wrong. I explained that an A1c reading should have gotten another test – oral glucose tolerance test (OGTT), and if it produced what I thought it would, he had diabetes. My friend said that his family had a history of diabetes on both sides of the family.

We discussed the signs and symptoms and they were there, thirst, frequent urination, and tired feeling. My friend is about 15 pounds above the weight he should be for age, height, and body build. I called my endocrinologist office and asked if they had room for a new patient. After a brief discussion, I put my friend on the phone and they had a longer discussion. He did obtain an appointment for this coming Wednesday, August 8, 2012.

Now he was full of questions. We discussed the OGTT and what he could expect. I said he would have a blood draw, and then he would drink a 75 gram container of glucose and have blood drawn at one and two hours. He would have an A1c done and if his readings were over 200 mg/dl (11.1 mmol/l) at one hour, and his A1c was over 7.0 he would be diagnosed as having diabetes. I said that they would also run a kidney test and maybe several other tests to establish a baseline for the future.

My friend followed me back to my apartment and I loaned him my spare blood glucose meter, a lancing device, lancets, and enough test strips to get him to his appointment.
I then demonstrated how to use the lancet and then load the test strip into the meter and place the test strip to wick up the blood. Since this was about a half hour before he would eat his evening meal, I was surprised by the reading of 247 mg/dl (13.7 mmol/l). I asked him if he had eaten any food since lunch and he said no, he had just finished a coke before seeing me.

I asked him how long his doctor had been telling him his sugar was a little high? He responded about two years. I then asked if he had copies of his lab reports? He said no, he had never been offered them. I explained that he would need to go to the doctors office, make his request in writing for the five years of lab tests, and probably sign a paper and show his driver's license and social security card. Then he would probably wait several weeks to receive them. I explained the reasons for this and that this would help him track his own health. I also explained that they may refer him to the laboratory itself although the doctors office should release them. My friend also said his younger brother and sister should be told. I said when he had results of this tests Wednesday. I said they should also do what you are doing.

About two hours later, he called me and said his sister had just called him that she had been diagnosed with prediabetes, and that he should be tested along with their brother. He asked permission to send his brother and sister my blog site URL and email address and I agreed. I asked if his sister had been started on any medication? He said she told him metformin, and since it was generic it did not cost that much, since her insurance would not cover it for prediabetes.

Too many doctors and far too many patients hear the word prediabetes and think nothing about it. Since the diagnosis is not full-blown diabetes, many doctors and patients just ignore the term and the possible future outcome. Yes, a small percentage of doctors and patients do take this serious, but then cannot find the education to manage the diagnosis and make the right decisions to prevent the onset of diabetes. Then the doctors have no medications other than off-label use which insurance will not cover and thus seldom is a prescription issued.

Current prediabetes range is 100 mg/dl (5.6 mmol/l) to125 mg/dl (6.9 mmol/l). This converts to an A1c reading of 5.7% to 6.4%. Yes, we would all like to have A1c's in this range. This is not the point of this blog. It to galvanize people to insist that the medical community wake up and start treating anyone with a reading in this range as having diabetes. This may be the only way to prevent or lessen the current type 2 diabetes epidemic. Actions by the medical community speak louder than words, and when they start pushing actions, then we will see actions by those with diabetes.

This study demonstrates that actions taken do yield results. By treating early and aggressively, interventions with intensive lifestyle changes or medications (including insulin) do significantly reduce the chances of developing type 2 diabetes in the future. Okay, I can understand you saying this was for prediabetes patients. The fact remains that no medical insurance company will cover medications for prevention, including Medicare. While the study has value, once it ended, no more medications were available until a diagnosis of type 2 diabetes is made. That is the reason for calling for a diagnosis of diabetes at the prediabetes levels.

With the Centers for Disease Control and Prevention (CDC) estimating that about 79 million people having prediabetes, the need for action is here now, and not in the future.

In addition to education for these people, many in the medical community will need education to make them aware of the testing that is needed and that they must diagnose diabetes to get people started on medication. The study needs more dissemination and maybe needs to be repeated, but still should not be ignored as the message is there in black and white and needs action.

Will the American Diabetes Association (ADA) take any action – highly doubtful. Will the American Association of Clinical Endocrinologists (AACE) do anything – more likely, as I have seen actions by some of them already; however, many will still not do what they should. We know that we cannot count on support from the American Medical Association. They have their heads positioned like the ADA where no light can be seen.

More bloggers need to write about this travesty being put on the people with prediabetes (actually I should say diabetes) by the ADA and others.