June 22, 2013

June Calendar of Monthly Events

I must apologize for the lateness of this post, this has been a busy month and a lot of new topics of interest that I pushed to get written and this kept being postponed.  

There are three monthly events for June and all of them are important for people with diabetes. National Home Safety Month may be questionable, but if you are like me and have neuropathy, then safety is of the utmost importance. This year's theme, "Safety Starts with Me." Make sure that you wear shoes or protective slippers that will protect your feet. If you drop and break something, make sure it is all picked up. A shard of glass, or Pyrex and if your feet are unprotected, a cut may not be caught until it is infected. This makes foot inspection very important and even more important is vacuuming the entire area necessary.

Also, make sure many things are secured and won't fall or cause you to trip over them. There are hundreds of accidents that are never anticipated and any one of them can cause cuts or even severe bruises. This is the reason not to be barefoot even in the house or apartment. There are other accidents and while I don't like mentioning them, many people are just not careful around most bedroom furniture and stub their feet on the bed legs. Oh, yes, I have done this myself and had the broken big toe to prove it. Fortunately, I did not have diabetes at the time, but it still was a long healing period. Think of what else could go wrong and it probably will. With diabetes, injury prevention is a strong part of home safety. Do your part every month and think what you can do during National Home Safety Month to prevent problems during the rest of the year.

Vision Research Month happens to follow Healthy Vision Month. In the last 20 years, eye health research has linked diet and nutrition with a decreased risk of age-related macular degeneration (AMD). A clinical study of older adults concluded that taking an antioxidant vitamin or mineral supplement significantly reduced the risk of advanced AMD progression in some people. Additionally, today there is significant evidence that vitamin D plays a part in preventing AMD.

This is why it is very important to have your eyes check regularly and when possible support vision research. There are too many rare eye disorders for which there is no research taking place.

The last national month event is employee wellness month. National Employee Wellness Month is an annual initiative that helps business leaders learn how companies are successfully engaging employees in healthy lifestyles. It showcases how prevention, coupled with supportive social communities like the workplace, can improve employee health and productivity, lower healthcare costs, and create a healthy workplace environment.

Employee health directly impacts healthcare costs, which is a board-level issue for every US organization and company. We can do something about this. 75% of these costs are driven by preventable and highly manageable chronic diseases, like heart disease, type 2 diabetes, and some forms of cancer. National Employee Wellness Month brings attention to the workplace’s role in helping employees make healthy choices that make a sustainable impact on costly lifestyle-related disease.

June 21, 2013

More Criticism of the AACE Diabetes Algorithms

The American Association of Clinical Endocrinologists apparently likes to pick and chose its fights. They did not attack Anne L. Peters, MD, CDE, Professor of Clinical Medicine; Director, Clinical Diabetes Programs, Keck School of Medicine, University of Southern California, Los Angeles, California. Yet, they pulled out all stops to clash with Jerry Avorn, MD, Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology and Pharmacoeconomics in the Department of Medicine at Brigham and Women’s Hospital.

Therefore, I would be inclined to believe Dr. Avorn struck a raw nerve in his criticism of AACE's business ethics and they could not let that go without a denial for posturing position. Dr. Avorn stated in his New York Times op-ed piece, “The A.A.C.E.’s latest guidelines elevate many second- or third-line drugs to more prominent positions in the prescribing hierarchy, rivaling once uncontested go-to medications like metformin, an inexpensive generic. They also emphasize the riskiness of established treatments like insulin and glipizide, which now carry yellow warning.”

This is something to consider and I missed this point in my discussion here. Dr. Avorn also states in his New York Times op-ed piece, “But there is also concern that they could have been influenced by another factor: the manufacturers of some of these new drugs financially supported the development of the guidelines, and many of the authors are paid consultants to some of those companies.” I agree, as there was too little information published with the AACE Diabetes Algorithms and nothing stating how they were developed and if others had approved them. When something is just published with little additional information except some press and quotes from a Dr. Garber, criticism should be expected.

When you know that they have many corporate-partners in the pharmaceutical ranks, the denial of what Dr. Avorn says holds no water and clearly is done to appease the corporate ranks. Review the corporate-partners list here. If you carefully read this denial on the AACE website, they only deny corporate funding of the algorithms, but make no denial of the consulting fees paid by corporate-partners. There may have been a healthy bonus in their consulting pay. How else could these “experts” have, “Donated days of time and talent to accomplish what they value as an important component of public health.”

June 20, 2013

Updated Hypoglycemia Classifications

That the American Diabetes Association (ADA) and The Endocrine Society would undertake this project says that hypoglycemia has been of greater concern by doctors lately. Five members from each organization were called together by the Chair, who is a member of both. A planning conference call was held before a two-day meeting at which staff from both organizations attended. The writing group used data from recent clinical trials and studies to update a prior work group report. Some conclusions were developed from expert opinion.

The new report reviews the impact of hypoglycemia on patients with diabetes and provides guidance about using this information in clinical practice. Because this was developed for clinical practice, I will not approach that side of it. As a patient, I have many reservations and concerns about the definitions and lack of understanding for patients to help them determine the severity of a hypoglycemic episode. This is where I feel the professionals are writing only for each other, and not to assist patients or to help educate patients. This lack of concern for education of patients is probably why I become upset. If, only if, they had taken some extra time to have expanded some areas, and include more information about hypoglycemia in the report, they could have also provided some excellent advice and guidance for patients. Believe it or not, many of us do learn.

The information is contained in PDF files and three can be found in this article. This link will take you to the Diabetes Care site as part of ADA where you can click on the Full Text (PDF) and download and read the data and background. The same link also has a slide set which you will need to click on and this will take you to a second page where again you will need to click on Slide Set which will open a window on screen to download a Microsoft PowerPoint Presentation (1.3 MB). The image below (slide 5) in about the consensus process and process of finally bringing it to publishing where we are able to read it. I felt this could be interesting. What is disappointing is that it is only nine slides in length. 

In the on PDF file Hypoglycemia Classification there are only four classifications given; however, in reading the full text file, it lists five classifications. All are determined with a measured plasma glucose concentration less than 70 mg/dl (3.9 mmol/l). Since this is for clinical use, I can understand the plasma glucose being necessary. However, most patients do not have the facilities to do this test, unless they work in a lab and take equipment home with them. So we use blood glucose meters and hypoglycemia is still for us a reading below less than 70 mg/dl (3.9 mmol/l).

The following are the five hypoglycemia classes:

#1) Severe hypoglycemia.

#2) Documented symptomatic hypoglycemia.

#3) Asymptomatic hypoglycemia.

#4) Probable symptomatic hypoglycemia.

#5) Pseudo-hypoglycemia.

Please read the PDF files if possible as the discussion contained in the “Full Text” file at the Diabetes Care site is more meaningful than the short PDF files in the like above from Diabetes-in-Control. I would suggest that many people have what is termed #5 above, except they may have heard it as false hypoglycemia. This often happens when people are newly diagnosed and because of medications (insulin and oral diabetes medications) are taking effect. Because your body has become used to high levels of blood glucose, when it starts dropping, this can cause these false symptoms of hypoglycemia. This is when testing can be important to determine the actual level.

Then the authors say some things that may be necessary, but could cause added expense to physicians. They claim that there is a need for accurate meters in the less than 75 mg/dl range for treating insulin patients. True, insulin can drive blood glucose levels down faster than oral medications, but even these patients need accurate meters. The authors then continue that those outpatients who are taking medications that rarely cause hypoglycemia don't need the more accurate meters. A lot on the judgmental side in my opinion.

The last issue that concerns me is the instructions for bringing blood glucose levels back to normal. This is included in the “Treating Hypoglycemia” PDF in this Diabetes-in-Control article. I have seen many people with type 1 diabetes blog about keeping juice boxes for treating hypoglycemia, but even they are not as fast a glucose tablets. The authors seem to prefer juice over glucose tabs as they list their preference as juice, skim milk, Life Savors candies and then glucose tabs or gel. I will give them credit for their instructions for glucose tabs or gel. They advise checking the package, because doses vary from brand to brand.

Not to dispute their “experts,” but I prefer the list at cardio smart and the order recommended.