February 16, 2013

Obesity Counseling Available for People on Medicare

Are you over the age of 65 and have a lot of weight to lose? If so, the Centers for Medicare and Medicaid Services (CMS) finally has a program in place that may be of help. The program is for overweight people that fit this - defined as a body mass index (BMI) ≥ 30 kg/m2. You must be able to lose at least 1.1 pounds per month in the first six months to qualify for the second six months. The total weight that must be lost in the first six months is 3 kg or 6 pounds, 9,82 ounces. Read this information and then talk to your primary care provider about who you will need to see if it is not this provider.

If you have to compute your body mass index (BMI) you may use this BMI Calculator. Then you may use this ideal weight calculator to determine what your ideal weight range should be. Then if you want to see what the lower limits (disregarding body frame size) should be, check out this calculator.

To qualify, it is appropriate for individuals entitled to benefits under Part A or enrolled under Part B and is recommended with a grade of A or B by the U.S. Preventive Services Task Force (USPSTF). This is the first time CMS has attempted to get this right by having providers work with you for up to one year. This applies to the frequency of consultations and the length of time.

February 15, 2013

'Whole Grain' Not Always Healthy

Current standards for classifying foods as "whole grain" are inconsistent and, in some cases, misleading, according to a new study by Harvard School of Public Health (HSPH) researchers.” This is the opening paragraph of an article that hits at the problem the food industry is promoting and doing to an unsuspecting public. The Grain Foods Foundation must be behind much of this and they are the largest promoter of “whole grains.” Of course, we must not forget the USDA and HHS as they are promoting for the grain producers. Then add the American Diabetes Association and the Academy of Nutrition and Dietetics to the mix and we have reasons to be concerned about the food we eat.

The study appears in the January 4, 2013 advanced online edition of Public Health Nutrition.  This is the link to another article. The authors say a new standard is needed to help consumers and organizations choose foods rich in whole grains.

How the “Whole Grain Stamp” (WGS) became a widely used standard is still a mystery, it is not clearly defined, and different companies use it differently. In actual use, it identifies grain products that contain higher sugars and calories than products without the WGS. The researchers want the adoption of a consistent, evidence-based standard when labeling whole grain foods. This is unfortunately the first study empirically (provable or verifiable by experience or experiment) to evaluate the healthfulness of whole grain foods. They took five commonly used industry and government definitions. This is one way to make them accountable and hold their feet to the fire.

These five definitions are:

1. The Whole Grain Stamp, a packaging symbol for products containing at least 8 grams of whole grains per serving (created by the Whole Grain Council, a non-governmental organization supported by industry dues)
2. Any whole grain as the first listed ingredient (recommended by the USDA's MyPlate and the Food and Drug Administration's Consumer Health Information guide)
3. Any whole grain as the first ingredient without added sugars in the first three ingredients (also recommended by USDA's MyPlate)
4. The word "whole" before any grain anywhere in the ingredient list (recommended by USDA's Dietary Guidelines for Americans 2010)
5. The "10:1 ratio," a ratio of total carbohydrate to fiber of less than 10 to 1, which is approximately the ratio of carbohydrate to fiber in whole wheat flour (recommended by the American Heart Association's 2020 Goals)

The researchers identified 545 grain products that they applied the five definitions to analyze how they rated. When the WGS was used, the grain products were high in fiber and lower in trans fats. However, the same grain products contained higher levels of sugar and calories when compared to products without the WGS.

The three USDA criteria had mixed results for finding healthier grain products. Considering the American Heart Association's standard (a ratio of total carbohydrate to fiber of less than or equal to 10 to 1), this proved to be the best indicator of overall healthfulness. The study found that products meeting this ratio were higher in fiber and lower in trans fats, sugar, and sodium, without higher calories than products that did not meet the ratio.

The senior author stated, "Our results will help inform national discussions about product labeling, school lunch programs, and guidance for consumers and organizations in their attempts to select whole grain products." Now will the “experts” even have a discussion or will the USDA just claim bad science and continue to give the children food that is loaded with sugar. My bet is on the last statement.

February 14, 2013

Goals for a Person with Type 2 Diabetes

What are reasonable goals for a person with type 2 diabetes? This is a topic that has bothered me for the last few months. In out informal peer-to-peer group, we all have different goals and most seem satisfied with their goals. Do we always achieve our goals? Not even close to all of us achieve our goals every time we see our doctor, but for the most part, as a group we don't miss by a lot. While the average age varies every time we add to the group, the majority are now over the age of 65. However, this does not establish goals for anyone.

The first thing I want to emphasize is that there are no standard answers or rules. We all strive to maintain certain limits that we can live with or tolerate. We all agree to attempt to keep our A1c's under 6.5% and lower if possible. We have all stated that we need to keep our lipid levels in range, if possible, but we seldom discuss this part of our lives. We have also agreed that our goals are ours and not for anyone else to follow. It happens that several of us have very similar goals and we probably talk about this more than the rest. At present, none of us is limited cognitively and this is something we have agreed among ourselves to maintain a link to watch for any cognitive problems. Diabetes and cognition are two of the factors that have bound us more tightly as a group because we care about each other as individuals.

Even as individuals, it has been enlightening to how we set our goals. With the current number of ten members and nine of us being on insulin, there is quite a bit of similarity among us. Sue is still off all medications and she is happy that we support her with her goals. She wants to keep her A1c as close to 5.5% or under if possible. Even her husband is surprised at her success as her last A1c was 5.2%. She is the youngster in our group and we do tease her about this. She replies that if the old fogies would learn from her, we could be a lot healthier.

With the A1c range for people without diabetes (normal range) according the Joslin's Diabetes Deskbook being from 4.0% to 6.0%, we have to remember that prediabetes is defined from 5.7% to 6.4%. Prediabetes is another topic that many wish would be labeled as diabetes. Because A1c values do vary quarterly, some are advocating that we should check the A1c values monthly. For more information on this, please read this blog by David Mendosa.

With this in mind, here are some goals for people to look at as possible goals they should consider as their own. Therefore, select realistic goals and work toward them.  Of the nine members on insulin, our A1cs range from 5.5% to 6.5%. as of the latest A1c values. Some of us have the same A1c and don't get too concerned since this should be expected. Max and I are the only two that occasionally exceed 6.5% and then we have to work very diligently to make sure we get below 6.5% on the next A1c.

We are all careful to avoid hypoglycemia and three of the individuals have never had hypoglycemia. Since I have been on insulin the longest, by about two years, I have had the most incidents of this, but never one that I was not aware of or prepared to correct. On several occasions, I knew as soon as I put down the syringe that I was going to need to be aware of and prevent this from happening. On two occasions, I accidentally injected my short-term insulin in the same area as the long-term injection. I stayed up late both nights and fortunately had enough test strips and glucose tablets to stay out of trouble and only get to the lower 60's for blood glucose levels.

I have had eight readings below 65 mg/dl in the nine years on insulin and the next is only five readings below 65. Then the numbers go to three and two. Why do we choose 65 for our hypoglycemia? Because we can and in general we do not get below 70 mg/dl. Several of the group try to constantly remain under 125 mg/dl and above 80 mg/dl and have been very successful at it.

We are all fortunate to have the test strips we need or be able to afford more if insurance limits us. Five of us do obtain our diabetes supplies and medications from the veteran’s administration (VA) and are thankful for that. Our testing supplies are very much what we need and we make use of them.

We are now over a month into 2013 and have now added three additional members that are very happy to have us helping them. Brenda and Sue are probably the most pleased, as two of them are women and are happy to have others to talk with. All three are presently on oral medications, which is also revealing. In our first meeting, with three of the group absent for work, the ones new to the group were very curious as to why so many of us were on insulin. Brenda was happy to say “Greater ease of management.” This of course became our discussion for that meeting. The A1cs for the new members was 6.6% to 7.0% and they were surprised at our A1cs of all being 6.5% or less. Many questions were answered about multiple daily injections and testing. The three were surprised at our relaxed attitude about this and that fact that most of us did not think anything about the extra testing and multiple injections.

They were all surprised that we used our arms and different parts of our bodies for injecting insulin. They were very interested in why and Brenda was happy to answer that we needed to prevent insulin absorption and utilization problems and avoid creating scar tissue under our skin. This in turn would affect the insulin utilization and cause insulin waste if scar tissue caused the insulin not to disperse from the injection site. Some may escape, but not the full amount injected.

Then the question was asked about alternate site testing. We all stated that we used our fingers and not alternate sites because we wanted the “now” reading for accurate correction data and needed to know this. If we were going up or down was also mentioned. Then Tim said that for those on oral medications other than sulfonylureas, alternate site testing would work if their readings were fairly consistent. Brenda advised them to be careful if their readings were still fluctuating up and down since they were new to testing. Two were on metformin and one on a sulfonylurea and metformin. All three said their doctors had advised them against alternate site testing for now, but that they were happy that we were willing to talk about this.

Allen then said that they would all be wise to read about and understand insulin, but there was no hurry since so many of us were on insulin. Then he asked how long each had been on metformin. The answer was one year and the other two for only six and eight months. The two women asked if he was concerned about vitamin B12 and when Allen said yes and vitamin D, they said that the diabetes clinic had tested both of them for these and said both had been advised to add them as supplements. The fellow said he had also been tested. Then one of the women said they understood his concern after what had happened to him and he said then you have been reading Bob's blog. All three admitted they were and Allen said at least we are all on the same page.

Then we needed to call an end to the meeting and the three of them wanted to ask more questions. We allowed one question and they agreed. The fellow asked why I was the only one blogging. I could see the eyes looking at me, so I spoke up. I said most are not ready and they do not have the desire that I have. Ben then said, he agreed as he had thought about it, but even though he enjoyed the research, he was not ready to write even once a week. He said that he does send me blog ideas and I agreed and said several others do as well. Brenda said she has no desire, but enjoys most of what I write about, but not everything. She also said that they appreciated that I did not use their real names and had agreed that I could use a made up name to keep people identified.

Since people were anxious to leave, I told the three, that if they had any interest, to please contact me and I would tell them what I could. Two have and are especially looking for other resources and a few other bloggers to read. The one has been reading from the blogger list I maintain and I have sent both other bloggers from the type 1 bloggers and others.

February 13, 2013

Excess Weight Is a Weighty Issue

How long will people keep their resolution of lose the excess weight they are carrying around? This is a problem for many people. The New Year starts out with good intentions, but by the end of the month, the intentions are gone and people are back to old habits. Yes, it is the beginning of February, and in contacting the local Weight Watchers and Curves offices, the numbers in attendance has declined almost as expected.

Curves is slightly up over normal and they are working to keep people coming. What has helped this year? Mainly it is grouping people into similar weight groups so that there is not the cross comparison and put-downs from those not having to lose as much weight. There was some extreme confrontations in the first session to weed out those that had no desire in the first place. In the five new groups, the first session eliminated one group, but the remaining four only lost two of their number.

In further conversations, they have only lost five more, which is less than they normally lose. The grouping has helped as they can more easily tailor the class to fit their needs and keep everyone moving at a similar pace. They are expecting four of them back after they heal from accidents that happened away from Curves – one a severe burn, two falling on ice, and one in an auto accident. Also, they found that by using age as a common factor in the grouping has been somewhat helpful, but that has not been a great concern for many.

Weight Watchers has lost participants at the same rate as in prior years and they are now down to the dedicated few they normally have and work with for at least the coming year. Even adding some incentives has not retained attendees. They had hoped that the fall out rate would have been lower this year.

In asking questions about what diseases may have been involved, I could not get any of this information, so I don't know if anyone has diabetes. I can appreciate the confidential nature of this relating to any individual, but I had hoped to get some numbers at least. I had asked for numbers of memberships and new members, but even this was not information they would give.

Two people that I knew were joining Weight Watchers I did talk to. I did find out why they had stopped. Both said that even though they had requested staying off third party promotion lists, they were inundated with junk mail and email for this special and that special for exercise equipment and other weight loss information. This was upsetting to them and they felt if their request could be ignored, then what other expectation did they have for any privacy.

The short “letter to the editor” in Diabetes in Control is what got me interested in this. I will admit that I was surprised by what I learned from former Weight Watchers members. When I asked about this, the question was ignored and the benefits of advertising was promoted especially stating how deep the bargains were and the benefits of exercise were so beneficial that they could not be ignored.

February 12, 2013

Public Acceptance Stopped by Data Theft Fear of EHRs

Electronic health records (EHRs) are not gaining the acceptance and fear about the security of personal data is at the head of the list. This is as it should be. Most records are not as secure as claimed, contrary to information technology (IT) assurances. Yes, patients are right to worry about the theft of medical and personal information on electronic healthy records. Even though more than half of the nation's office-based physicians are using EHRs, a survey conducted by Harris Interactive for Xerox found that 63% of American patients have a fear of hackers stealing their personal medical data.

About half of the USA population says they are worried that their digitized health data may be lost, damaged, or corrupted. They also worry that a power outage or computer crash could prevent their doctor from accessing their chart during an appointment. The survey shows that the anxiety about digitized health records has increased over the years as more records are converted from paper to computers.

When it comes to people answering straight up questions, only 26 percent of Americans will say “yes” to wanting their medical records digital. In addition, when it comes to believing they will obtain better, more efficient care, the same percent – 40 percent, agreed in both 2010 and 2012. This does not speak for positives in peoples attitudes about EHRs.

Well, people need to be concerned as the number of electronic medical records being broken into keeps rising and thieves are finding it lucrative. In an article in Computerworld, the author reports that in the past three years. About 21 million patients had their medical records compromised in data security breaches that were big enough to need to be reported to the Department of Health and Human Services (HHS), the Office of Civil Rights (OCR).

The breach notification and reporting is part of new rules under the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009. The rules not only require the public reporting of breaches but also increased penalties for violations of the Health Insurance Portability and Accountability Act (HIPAA), which requires organizations to safeguard patient information.”

Much of the data could be protected by encryption and by other means, but most records are not because of the perceived cost. Eventually, physicians, hospitals, and insurance companies will learn the true cost of unprotected records.

February 11, 2013

Problems with High A1c for Type 2 Patients

Until this article in Medscape, I had not imagined all the potential problems elevated A1c's could cause for people with diabetes. Yes, we are all aware of the complications, (retinopathy, neuropathy, nephropathy, atherosclerosis, deafness, cognitive decline), and how they love people with elevated A1c's. These complications set up shop quickly in people that let their blood glucose levels stay consistently elevated and do their best to take over these people.

New problems keep emerging for people with unmanaged type 2 diabetes, so I should not have been surprised when I read this article. In reading this, I did agree because when I think of hyperbaric oxygen therapy being used for wound healing, this explains why it is necessary because the blood cannot carry sufficient oxygen to the cells around the wound to promote healing.

The oxygen saturation (SaO 2) and partial pressure of oxygen (PO 2) in this trial was measured with simultaneous monitoring of SpO 2 in 261 type 2 patients during ventilation or oxygen inhalation. Pulse oximetry is the measuring of oxygen saturation in the veins by placing a sensor on the finger or earlobe of an adult or even children. For infants, the sensor is placed across the foot.

The study showed the relationship of diabetes that was poorly managed (A1c greater that 7%) to diabetes that was managed (A1c less than 7%) and the amount of oxygen in the blood. Those that were highest in oxygen were clearly those with A1c's less than 7%. However, it was confirmed by using arterial blood gas analysis (the method used before pulse oximetry became the standard) that the amount of oxygen in the blood was less than the pulse oximetry recorded. This raises the concern about those with A1c's in excess of 7% having enough oxygen in the blood for proper cell oxygenation.

Therefore, the researchers are correct in the alerting of treating patients for hypoxemia (inadequate oxygenation of the blood) that using the pulse oximetry is misleading for type 2 patients with elevated A1c levels. They recommend using arterial blood gas analysis for patients with poor blood glucose control during the treatment of hypoxemia to receive best results.