March 9, 2013

Does Your Doctor Blame You?

Does your doctor blame you for being overweight, not following his directions (nonadherance) for managing your diabetes, and for not taking your medications? Don't be surprised if you need to answer yes to all three of the above. This is the habit that many doctors have and they believe it is your fault that you can't lose weight. They use insulin as a threat for not getting your blood glucose levels down, and then they will say you are not taking your medications when you should or every day.

This will become more of a problem in the future under the Affordable Care Act as the Centers for Medicare and Medicaid Services doles out money for those practices and hospitals that bring more people down in weight and manage their patients more efficiently. This blog by Bob Doherty makes the case. More doctors will be doing this as a matter of course or you will be out the door as they don't want their record besmirched because of what you are unable to do in their eyes. This may also mean the doctors that threaten insulin for type 2 diabetes patients having blood glucose control problems because of the lack of education they have received from these bullying doctors. An article in ScienceDaily may be part of this increased bullying tactics.

UCLA Professor Abigal Saguy, PhD, wrote a provocative essay in the Washington Post where she called this discriminatory and profiling. She correctly states, “Despite the fact that body weight is largely determined by an individual’s biology, genetics and social environment, medical providers often blame patients for their weight and blame their weight for any health problems they have." I would encourage everyone to read her article. It is well thought out and she uses studies and patient interviews to back her statements.

Bob Doherty also confirms what is happening in our Nation's Capitol because of new regulations being proposed by agencies. If this does not scare you, then remember that we now have insurance that prevents excluding prior conditions from coverage. Now the Obama administration is wholesale throwing this out in the proposed regulations and allowing employers to charge employees more for being overweight or having certain medical problems. Therefore, the “blame the patient” is back in the limelight again and many are going to pay the price. Proposed regulations will allow employers to charge higher health insurance premiums or impose other rewards and penalties to employees based on how well they achieve improvements in their own health status.

Yesterday, January 28, 2013, “House Democrats sent a letter to the Obama administration, objecting to a proposed rule that allows employers to establish "health-contingent wellness programs" that "allow differential rewards based on health status factors, including a person's cholesterol, blood pressure, weight or body mass index." The lawmakers argued that such programs would undermine the ACA's prohibition on discrimination against persons with pre-existing conditions, and would disproportionately harm "certain population groups, including racial and ethnic minorities, such as Hispanics, African-Americans, and some Asian groups [with] a higher proportion of known genetic predisposition for certain illnesses that are screened through biometric measurement such as cholesterol or blood sugar levels."”

Now it will be interesting to see if this is reversed, or the current proposed regulations will stand as they are. Even the ACP (American College of Physicians) “in a comment letter on the same proposed rule, similarly stated "that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals."

This should include the chronic diseases (like diabetes) and other medical conditions people may not have any control over.

March 8, 2013

Diabetes Care in the Hospital

This section of “Standards of Medical Care in Diabetes—2013” is often ignored until hospitalization is necessary and often there is not time to read this unless you have access to a tablet and the internet while in the hospital. Most hospitals do not have internet access available to patients. There is some good information about hospitalization and what you can expect. Much of it is not patient friendly if you are a person with diabetes that likes to manage your diabetes very tightly. If you are unable to communicate and are hospitalized, be prepared to have your blood glucose levels managed in the range for allowing complications to set in.

Understand that hospitals have the ranges set to prevent hypoglycemia, as this is a fear they have, especially if they do not have an endocrinologist specializing in diabetes available or do not have high levels of confidence in the nursing staff. The recommendations are:

1. All patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record.
2. All patients with diabetes should have an order for blood glucose monitoring, with results available to all members of the health care team.
3. Goals for blood glucose levels:
1. Critically ill patients: Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold of no greater than 180 mg/dL (10 mmol/L). Once insulin therapy is started, a glucose range of 140–180 mg/dL (7.8–10 mmol/L) is recommended for the majority of critically ill patients.
2. More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) may be appropriate for selected patients, as long as this can be achieved without significant hypoglycemia.
3. Critically ill patients require an intravenous insulin protocol that has demonstrated efficacy and safety in achieving the desired glucose range without increasing risk for severe hypoglycemia.
4. Scheduled subcutaneous insulin with basal, nutritional, and correction components is the preferred method for achieving and maintaining glucose control in non–critically ill patients.
5. Glucose monitoring should be initiated in any patient not known to be diabetic who receives therapy associated with high risk for hyperglycemia, including high-dose glucocorticoid therapy, initiation of enteral or parenteral nutrition, or other medications such as octreotide or immunosuppressive medications. If hyperglycemia is documented and persistent, consider treating such patients to the same glycemic goals as patients with known diabetes.
6. A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medial record and tracked.
7. Consider obtaining an A1C on patients with diabetes admitted to the hospital if the result of testing in the previous 2–3 months is not available.
8. Consider obtaining an A1C in patients with risk factors for undiagnosed diabetes who exhibit hyperglycemia in the hospital.
9. Patients with hyperglycemia in the hospital who do not have a prior diagnosis of diabetes should have appropriate plans for follow-up testing and care documented at discharge.”

The above are reasonable goals (not ideal) for people in the hospital that are unable to manage their diabetes. For type 1 diabetes patients these may well be ideal goals, but for people with type 2 diabetes, these goals need revision at some point or once the patient is fully capable of managing their own diabetes, this should be allowed with supervision.

One word of warning, if you are the patient, a family member, a friend, or advocate, please insist that the nurse change the lancet in your presence. Many nurses use the same lancet for many patients and have no knowledge of how dangerous this can be, or if they know, don't care.

For most staff in hospitals and even nursing homes, numbers are just that – numbers. They look at the numbers and consider them variable markers. Yes, it says treatment of persistent hyperglycemia starting at a threshold of no greater than 180 mg/dl (10 mmol/L), but this may mean any number as long as it can be fit to the schedule that fits their work pattern. They don't want to come back and check later or even more times. And, believe it when I say they will make the numbers fit. One of our group was in the hospital recently and we checked his blood glucose after the nurse left the room. The nurse told him that his reading was 160 mg/dl and both of us had meters and checked after that and my reading on him was 262 mg/dl and his own meter gave him a reading of 254 mg/dl. Another one of the group just happened to come to see him then and he set up his meter and the reading was 265 mg/dl.

At that point, we had him use his call button. A different nurse arrived and he asked her what his blood glucose reading had been. She had us step out of the room and then read his chart. When she left, we went back and he said that she had told him 160 mg/dl. He said that was wrong and that his reading was almost 100 mg/dl higher. He said she was going to get another meter and would be back. So we waited for almost an hour for her to return. This time she was accompanied by security and asked us to leave the room. While we were out, we could hear some of what was happening and as we suspected, they were searching for his meter. Then when they were done, they wanted to search us. We laughed at them and commented about how dictatorial they were and since we were only visitors, they had no right to search us. With that we were asked to leave the hospital.

When we returned to Tim's residence, he had a phone message that after we had left, they had done another search, but found nothing. Our friend had wisely sent his meter and other supplies home with us. Since he was being discharged the next day, we decided not to see him until then. The things he told us were unreal and his advice was to avoid that hospital if you valued your life. They had used the same equipment for several patients and would not change the lancet in his presence. When his daughter had arrived to take him home, she was not allowed to see him until he was wheeled out to the car.

Yes, this is unusual, but not unexpected for that hospital, about an hour distant. Our friend said that he would avoid that hospital in the future and go to one of the larger hospitals if at all possible in the future. His daughter had stopped by and picked up her father's diabetes supplies before picking up her dad and he was happy to have them. Blood glucose was over 300 mg/dl so he was able to correct with insulin and is back to managing his blood glucose very effectively.

Tim and I had a long conversation with him and his daughter about hospital diabetes care and Tim did ask why he had not gotten permission to manage his own diabetes. He said that he had asked and was told this was not allowed and since he was only going to be there for three days, he did not think too much could go wrong. He now knows better and was glad we were there to take his diabetes supplies, which he had taken in with him. He remarked that he never suspected they would search his room so thoroughly after questioning the blood glucose reading. He said the nurses would not talk to him after that and were anything but polite when they had to make their rounds. Read what I have written before about hospital diabetes care.

The ADA guidelines are much more in line with good management (I did not say great management) than that adopted by a majority of hospitals. Therefore, know your rights and if possible have your care done by yourself with agreements beforehand and have extra copies to hand out to staff that want care only their way. If necessary, get your doctor involved as well.

Number 8 in the quoted area above is the new addition that ADA wants hospitals to add to their admitting policy. To repeat #8, “8. Consider obtaining an A1C in patients with risk factors for undiagnosed diabetes who exhibit hyperglycemia in the hospital.”
This means that if you may be at risk for diabetes, hospitals are requested by the ADA to obtain the A1c. Then if this shows positive, they are to repeat this on another day to confirm diabetes.

March 7, 2013

You Have Diabetes – What to Do. - Part 4

Part 4 of 4 Parts

The doctor handed A.J. some pamphlets on injecting and where to inject. Then he pulled out a syringe and demonstrated filling it and how to read the scale. They covered the injection sites and the reasons for not injecting the short acting insulin near the long acting and the problems this could cause. I commented that was how I got two of my hypoglycemia episodes and that I make sure I have a set routine to avoid this. The doctor asked if he had figured out how to count carbohydrates and he answered not completely and he still had a lot to learn.

Then A.J. said that we would be stopping by the bookstore afterwards and if they did not have the ones on the list, he would be ordering them online. The doctor asked to see the list and said I must have had something to do with it and we both laughed. He said he would like to add Dr. Bernstein's book "Diabetes Solution" to the list, saying it was primarily for type 1 people but he should still consider it because of the insulin and some of the discussions. I said I agreed and once he had finished it, then maybe I could borrow it. The doctor quipped I should have already read it. I said I had not and that I was still rereading Joslin's Diabetes Deskbook. The doctor asked me if I would be loaning it to my friend, and I said sure, if he was into heavy reading.

Next, the discussion turned to me being a peer mentor for him, and I said that I thought I already was. The doctor laughed and said, in working with him to reset goals and work for good diabetes management. I said sure, and that he would probably be brought into our informal peer-to-peer group for more discussions. The doctor talked to him about being able to afford to lose at most 12 to 15 pounds to be at ideal weight for his frame size and height. He said that exercise would be in his best interest especially in starting out. He emphasized the insulin could cause an increase in weight to start as it would mean more effective utilization of the carbohydrates. I suggested that they discuss carbohydrate reduction at the start until he had adjusted to the insulin. A.J. asked what we were talking about, so some time was spent on carb counting. The doctor requested that I would discuss most of this and at the next appointment the lab results would be available for several vitamin and mineral tests to set a baseline and do any adjusting at that time if supplements were needed.

Next the doctor covered getting his eyes tested for a baseline for retinopathy, but not to get new glasses, if he wore them. He said no glasses yet, but that he would get the eye exam and we would talk about it on the way home. I said we would also talk about a dental check up for him to avoid periodontal problems related to diabetes. At that point we were done and the doctor took us out to the reception desk and told them to schedule him in six weeks. After this, we headed for the bookstore. They had only one of the books and it was determined that it was better to order all of them online.

He drove home and we talked some more about his eye exam and getting a dental appointment. He asked about the group I had mentioned and I said he would be invited to the next one if he wasn't working or that several of us could get together in an evening or a Saturday for a discussion. I mentioned everyone in the group and he said he knew three of them, but had not realized they had diabetes. Now he was excited to get together with the group. He said he had heard of two others, but had not met them that he could remember. He did comment when he let me out that he appreciated my having made him change doctors and he felt very good about how he was treated and included in the decisions. He was surprised about the thoroughness and that fact that lab results were the same day instead of doing it a week before. He said that made the trip worth it even though it was farther to this doctor.

We set a time to meet online for his meter testing and injection of the Novolog before the evening meal. Then we set a second time for the Lantus. We discussed the advantages of where he started and discussed several of the routines he could use. He asked good questions and I think he did very well and felt comfortable after he had completed it. I told him to call if he had questions later and he recorded his meter readings and time of injections. We have talked about food logs, daily health logs, and testing more often to learn how the foods react and raise blood glucose levels.

He is another computer geek and has set up a database for his meter readings, food log, lab test results and other information he wants to track. He says that in general it is much easier than he had envisioned and that occasionally he does feel a little pain when testing and injecting, but is nothing he can't live with. We have continued with emails and I enjoy answering his questions.

These four blogs are what I do in situations where I can help people. I have another person that is on what I believe the verge of developing diabetes and from his lab results he is very much at risk. He has asked that I not write about his experiences. A.J. has said to write about it since I am not using his real name. He feels that if relating his experience will help others, this needs to be done. Thank you, A.J.

March 6, 2013

You Have Diabetes – What to Do - Part 3

Part 3 of 4 Parts

When we arrived, he started filling out paperwork and was called for the blood draw. Then he completed the papers and we talked until he was called for his appointment. I went with him and when the doctor saw me, he commented that I needed to stop bringing him patients. He said he was only joking and that I had brought him two great patients and he would continue taking them as long has he had room. When he started looking at the paperwork and saw the sheet from the week prior, he said that was good to have and that I was right in getting him in. He then said that in looking at the test results from today, that the oral glucose tolerance test would not be necessary as he clearly had type 2 diabetes and needed to start medications immediately. They started covering the results of A.J.'s tests and then I was handed a sheet at the request of the A.J.

The A1c had stayed the same and the plasma glucose was 201 even with fasting. The doctor asked if we had talked medications and A.J. admitted that we had. The doctor asked if he had objections to insulin and he answered that he was favorable to that. The doctor asked which oral medications he would accept and he opened up his laptop and showed him the ones he did not think would be good for him. The doctor said good, but the others were not good as well at this time because of his kidney functions and then he covered what the tests were telling him and why he would not suggest metformin and the others. The doctor said he would suggest starting on insulin and then when the diabetes was well managed, his kidney functions had improved, maybe he could consider one of the sulfonylureas or if the new medication was approved by the FDA, maybe that one.

A.J. asked if that could be done and was told yes. They talked about hypoglycemia and the symptoms and A.J. said he was aware of the symptoms and that he would be careful. Next, the doctor made sure A.J. had the office phone number in his records and told him to call when he had questions regarding insulin adjustments. They talked about goals and settled on one. Then he moved on to setting the original dosage and then how to adjust it after two weeks to bring him closer to the goals of nearer normal and which insulin to start adjusting and by how many units for how many days. If it became necessary to adjust the Novolog by 10 units total, then he needed next to adjust the Lantus by 2 units up to 6 units total, and then talk to him before making more adjustments. A.J. asked if patients were allowed to do this and the doctor repeated that for the first two weeks, no changes and then two units change every three days, if needed to a max of 10 units for the Novolog. If he reached that limit and he was still not at the goals, then adjust the Lantus by two units every three days until he reached his goals in blood glucose levels, but only up to six units. For more changes, A.J. was to call him. The doctor then emphasized that if the original doses were too high, he was to call immediately. He also told A.J. to pick up some glucose tablets when he picked up his prescriptions.

The doctor next brought out three different meters and asked which he might prefer. A.J. looked at me and I pulled mine out and pointed to the one like it. I asked if his insurance would cover this and the doctor said that it would cover any of the three he had shown us. He chose the Nano and I said good choice. Next, we talked about requesting extra testing supplies. The doctor said they had a standard request to cover the first four to six months and this would be sent via email as soon as the appointment was over and the pharmacy should hear within approximately 48 hours, or more over the weekend. He stated two business days was normal and he had not been turned down yet. The doctor then recorded the pharmacy he would be using.

Since I had my meter out, the doctor asked if I would show him where to test. I said I would, but first I wanted him to know it was wise to ignore the TV ads about not testing on his fingers. The doctor said thanks and went on to explain why we needed to test on our fingers or palms and not the alternate sites. I said that on insulin, we needed the “now” reading and not the delayed results from alternate sites. I told A.J. to open his kit and we would check the lancing device. First I showed him how to uncover where the lancet would go and to take a lancet out of the case and insert it and arm it. When that was complete, I asked to see his hands and looked at his fingers. I suggested that he start on the third setting and had him dial this in the dial. Then I showed him on my fingers where the area was best to start testing. I did it, showed him the blood, and carefully inserted the test strip into the blood. I told him to take out a test strip and insert it in the meter with the correct side up as he started to put it in wrong side up. Then I had him set the meter on the table and prick his finger. He had more blood than I expected and commented that it did not hurt at all. I had him pick up the meter with his other hand and carefully move it into the blood and watch the blood wick into the strip. He commented that was not difficult. I suggested that for now, he record the reading and time and then dial the depth back to two for the next time he tested. Concluded in tomorrow's blog.

March 5, 2013

You Have Diabetes – What to Do. - Part 2

Part 2 of 4 Parts

At that point, I asked, “and you think I am blowing smoke about you having diabetes?” I did not stop there and asked if he had health insurance – he did. I said I am getting the phone number for the diabetes clinic I go to and we are setting up an appointment for you as soon as possible.

I was able to schedule an appointment for a week later and I told the person on the phone that she was to record the following on a sheet for his file. He had an open sore on his left leg, had what sounded like neuropathy, frequent urination, constant tiredness, occasional blurred vision, always thirsty, and to check for any other diabetes symptoms, including all tests. Then she wanted to talk with him and I could hear him answer yes to everything she was asking. Then he asked 'no food for how long' and I knew he was being told to fast for at least 8 to 12 hours. He then turned to me and asked if I would accompany him. Of course, I said. He closed my phone and sat down in his car.

I took the phone from him and he said, “I've never been more scared.” I said that was natural and that if he did have diabetes, he would probably go through the stages of anger, denial, then acceptance and possibly some depression. He was quick to say that he would not take anything for depression. I said yes, he would, and be thankful if it was prescribed. I said that diabetes requires attention 24/7/365 with no vacations and he could have burnout and possibly mild depression. He said he had no depression that he was aware of, but maybe some when his wife died three years ago.

He asked what to do to be better prepared for the appointment. I said there was nothing he could do as the A1c was already determined and the oral glucose tolerance test would be what it was. I stated that he could cheat for the plasma glucose reading, but since he would be in the fasting mode, he could not cheat on that anyhow. I said that in seven days, there was not much he could really do to improve the results.

I noticed he had a laptop in the car and I asked him to open it up and I would send myself an email. I said then when I arrived home, I could send him one so that we could correspond by email and when I sent him URLs, he could open them directly. He thanked me for that and said he was sure he would have all kinds of questions.

The week before the appointment was filled with emails, he was reading, and I was answering questions. The day of his appointment, he asked if I would drive. He said he was too nervous and I asked if this was possibly a low just from fasting and he said he just wanted to be able to talk and not concentrate on driving. I said okay and we headed off.

He had many questions, had his laptop open, and was looking at this site for diabetes medications. He said that he had ruled three of the oral medications out already and I agreed that was probably wise, but that he should wait until in the appointment. He then moved to the insulin table and was asking me which insulins I was taking and why. We talked the rest of the way about insulins and that fact that he was thinking very favorably about them. He could see less side effects and quicker management if he had diabetes. We also talked insurance and which company he had. It was the same as I had before Medicare and I said that he probably would be using the same meter and test strips as I was then. To be continued in the next blog.

March 4, 2013

You Have Diabetes – What to Do. - Part 1

Part 1 of 4 Parts

Have you had a doctor say “watch what you eat, your blood sugar is a little high,” or something like this, “try to get more exercise and watch your food intake, your sugar levels are running on the high side.” These are warning signals from a doctor that is not up-to-date with the healthcare guidelines from the American Diabetes Association (ADA). It is time to get copies of all lab reports and look for the A1C% and Glucose results. If your A1c value is above 6.4% and your glucose reading is above 126, then it is time to have a serious talk and find out what the doctor is planning. If the doctor only repeats the above statements, then it says he knows little or nothing about diabetes. For your health and future healthcare, you have a decision to make and it may not be easy if you have been with this doctor for many years.

Under the above scenario, I would urge you to make some telephone calls and find a doctor that knows the ADA guidelines and is willing to do the necessary tests to determine if you have diabetes. This was driven home recently when an acquaintance was talking about his doctor appointment earlier that day. A.J. made a statement very similar to the second one above. I asked him if he had any paperwork for the lab results and he said they were in the waste container in his car. I had him dig them out and when I saw them, I surprised him when I said, OMG, almost under my breath. His A1c was 7.9% and the plasma glucose was 192. I asked him “did your doctor say you had diabetes?” “No,” he said, “just that my sugar levels were higher than normal.” I said that the readings on the paperwork were in the definite area for diabetes and that he had better get to another doctor. He just asked, “you've got to be kidding?”

At that point, I said that since I have type 2 diabetes, I knew what I was talking about and the document he had discarded in the wastebasket clearly showed that he had diabetes. He then said that the doctor would have told him. I said that he could believe his doctor, but I could bet that he was having blurred vision at times, was using the bathroom rather frequently during the night as well as during the day, that he felt tired much of the time, was thirsty all the time, and probably had several other symptoms. He asked how I knew this. I said because I know the symptoms and write about diabetes. A.J. admitted that the answer was yes to the things I had rattled off and asked why the doctor had not asked about them. I said because you did not say anything about them and all he saw was the A1c and plasma glucose reading. I emphasized that the doctor was probably one of the doctors that was afraid of saying anything and just said his sugar level was above normal.

I asked him if he wanted to get a determination done and he said not really. I then asked him if he had problems with pain in his feet, or neuropathy. He asked if I meant a burning sensation and that pain tingling feeling that made it difficult to go to sleep at night. I said, you more than likely have diabetes and I will not go into the other problems that you are looking at if you don't get medication started and get you blood glucose levels under good management. At that point, he lifted his left pant leg and showed me a sore that did not look good. I asked how long this had been going on and he said about six weeks. He said normally something like this would have been healed in about a week. The conversation will be continued in the next blog.