October 26, 2013

Are Elderly Patients Obtaining Quality in Outpatient Care?

There is only one answer and no is it. Education in medicine is a key most doctors are prone to ignore. They do have a reason, although not always the best and that is third party insurance places limits on the amount of time they will reimburse doctors for their time. Therefore, doctors dictate routines for the elderly and expect them to be followed.

Sometimes the doctor's orders are right, but often they forget some small part that in turn confuses the patient and none of the routine is followed. The patient suffers and becomes further confused. That is an excellent reason we need doctors that are geriatricians and can work with the elderly to clarify what should be accomplished by the patient.

Yes, occasionally the geriatrician discovers something totally missed, over looked, or the patient did not say that puts a different perspective on what the patient needs. Dr. Leslie Kernisan is a geriatrician and works to translate the information for the elderly, the caregivers, or the family.

With the numbers of seniors growing rapidly now that the baby boom generation is beginning to enter the senior category, doctors in regular practices or working for hospitals will not be able to take the time necessary to work with the seniors, their families, or caregivers. I am aware of a few doctors that will not accept caregivers and exclude them if possible even when they have the proper legal credentials. A few are also excluding family members.

One of the people I know is having memory problems and wants her daughter present to confirm what the doctor says. After her last appointment, she nearly came completely undone, as the doctor would not allow her daughter in to the exam room. This caused the daughter to talk with her doctor and ask what he would not allow. Turns out he will appreciate having family or caregivers when necessary. The daughter scheduled her mother with her doctor and they both came away happier. The mother said she has never wanted to go to her daughter's doctor, but with the actions of her doctor, she needed an alternative and will not be returning to her doctor.

After a complete review of her medications, he found what may have triggered the mother's memory loss and after talking about this, her daughter remembered that this started happening shortly after she was put on the medication. He stated that removing this may not return all the loss, but should help. The daughter produced three prescriptions her mother had received about three weeks earlier and the doctor looked at them and said no, her mother did not need any of them and two of them were for something her mother did not have while the third medication was not advisable at her mother's age and could add to her memory problems.

The mother asked if there would be any time that her daughter could not be present. The doctor answered only if her daughter was in the hospital and then he asked if there was another family member that could attend. The daughter said that her husband could if her mother approved. The mother said if it was necessary.

Because I have not covered much of the material from Dr. Kernisan's blog, you may want to take time to read her blog especially if you may be concerned about a parent or if you are a caregiver.

October 25, 2013

More Diabetes Terms People Should Know

This is a continuation of the last post about terms that people with diabetes should know. Some admittedly are more important and some are just good to know.

This continues the list:
#8. Medications This is probably the most troublesome term for many people. Some do not wish to take medications and then run to the health store and substitute medications they think will help them. Medications need to be taken as directed for oral medications. Insulin is slightly more flexible after you learn how to use it properly and count carbohydrates. Symlin, Byetta, Bydureon, and Victoza are medications that you must understand and follow directions, as there can be severe side effects otherwise, even with the normal side effects. As with all medications, be alert for hypoglycemia and do not be afraid to communicate as needed with your doctor or requested by your doctor.

#9. Key numbers Even though I warn people not to become fixated with numbers, there are some key numbers to learn. The first is 70 mg/dl (milligrams per deciliter). Any blood glucose reading below this is considered hypoglycemia or low blood glucose. Severe hypoglycemia is defined as an event requiring assistance of another person to actively administer carbohydrates, glucagon, or take other corrective actions. This varies by individual and is the reason I will not give a number.

I cannot appreciate the numbers used by the ADA as these encourage progression to complications. The ADA definition is excessive blood glucose (whatever that is). Fasting hyperglycemia is blood glucose above a desirable level after a person has fasted for at least 8 hours. Postprandial hyperglycemia is blood glucose above a desirable level 1 to 2 hours after a person has eaten. According to the AACE, generally fasting plasma glucose should be less than 110 mg/dl and the 2-hour postprandial glucose should be less than 140 mg/dl.

Since most of us are not able to use plasma glucose because those are lab tests, we are limited to what our meter tells us. I generally have fasting blood glucose readings of less than 100 mg/dl and 2-hour postprandial of less than 140 mg/dl. Do I obtain these goals? Many days I do, but there are days when I am above them and need to work to get below them quickly.

#10. Diabetes acronyms These can be found in this blog. The acronyms are not all available and if you wish to add more, please let me know, and I will add them to a future blog.

#11. Sleep Eight hours is recommended. The message is now “eight hours plus of sleep, exercise, and nutrition”. People that can regularly get 8.5 hours of restful sleep burn more fat than people getting 5.5 hours of sleep. They have concluded that sleep loss while dieting increases the ghrelin (a hormone that stimulates appetite) associated changes in hunger, glucose and fat utilization, and energy metabolism, which slows or halts weight loss.

The researchers reported that sleep-deprived participants reported feeling hungrier during the study. They agreed that sleep may be an important factor in successful weight loss and that adequate sleep may be a significant part of the lifestyle change that has normally concentrated on diet and exercise. If you have been losing weight, but now or have hit a weight loss plateau, you may want to add sleep to the other remedies to break through the plateau and get on with losing weight. This is just another part of the lifestyle change so important for people of diabetes. Good luck!

#12. Stress When stressed, almost anyone can toss aside their usual good diabetes management practices, forget to eat the proper foods, and lose control of your blood glucose. Prolonged stress may prevent insulin from working properly which also creates additional problems. Some find logging your stress level (1 to 10 scale) each time you log your blood glucose level helps them see patterns and allows you to adjust accordingly. Learn about ways to relax and find ways to reduce stress.

Even this list of terms is not comprehensive and is not intended to be.

October 24, 2013

Terms for People with Diabetes to Know

It is not often that I do this, but I feel this is important enough to call attention to and encourage people to read this blog by David Mendosa. He was restricted in the number of words he could use for discussion, which detracts a little, but does not diminish the importance of the message. It is written primarily for those new to diabetes and to help the old hands at managing diabetes.

If you wish to take time to follow the link to David's blog, go ahead and I will wait for you to return. I wish to add a few more terms to what David covered and refer you to some of my blogs and blogs of others covering them. Some of my terms are mentioned within the terms used by David.

My list of terms:
#1. Exercise Depending on whether you are medically able, exercise can be almost what you desire as long as you are moving. The intensity can vary from running like Tom Ross when he runs 4 to 9 miles depending on the day to what David Mendosa discusses in this blog. There are other forms of exercise, such as swimming, dancing, and using resistance training. If you are approved to exercise by your doctor, this is an excellent tool in your diabetes management.

#2. Food plan David used the word diet, but I prefer food plan as this can cover most any food plan from low carbohydrate, paleo, and many more diets. There is no specific food plan for diabetes and you need to use your blood glucose meter to help you find your own food plan. A great book by Dr. William Davis titled “Wheat Belly” can be helpful in reducing carbohydrates and you may agree with Dr. Davis and his blog here. The importance of food plans for people with diabetes is that they are generally reduced calories, lower carbohydrates, and sustainable in the long term.

#3. Lifestyle changes The list I work with includes the following: weight loss, exercise, food plan, sleep, medication, heart health care, illness, hormone levels, stress, alcohol, and smoking. You may read this blog for more discussion about them individually. Yes, I did leave out weight loss, as I was a little over sensitive about that. Times have changed and I have resolved my issues even if I am still overweight.

#4. Education Unless you have a doctor that pushes education or are fortunate enough to have a certified diabetes educator (CDE) that the doctor works with and is willing to work with people with type 2 diabetes , you will more than likely need to educate yourself. This blog will give you some ideas as well as the blog of the following day. If you have questions or want more reading, contact me at my email on the profile page.

#5. Positive Attitude This is one thing I did learn from my younger brother. He was able to manage his type 2 with no medications, but he maintained a tight leash on what he ate and did his exercises. He told me that a positive attitude was what kept him going and had served him well over the 35 years. It was also good that he had a supportive wife and family that helped him. In the ten years I have had diabetes, yes, a positive attitude does help and by establishing the following, the two helped me through a burnout and two minor depressions.

#6. Good habits Establish good habits early and make them a routine. This and the above will go a long way if you have minor depression and later burnout in taking care of your diabetes. Because there are no vacations with diabetes, a positive attitude and good habits can prevent you from ruining your diabetes management completely. Yes, you will make mistakes, but with a positive attitude and good habits, it is easier to pick yourself up and learn from a mistake. I know I have.

#7. Stages While this is not quite the same as the stages of grief; however, these are important to know. They are shock or anger, denial, depression, and acceptance. My blog here discusses these in more detail. Some have suggested other stages like other diseases, but I said these don't exist in diabetes because diabetes does not need to be progressive. Plus if well managed, diabetes does not have stages, as in cancer. Yes, diabetes can be progressive to the complications if the person with diabetes does not manage their diabetes.

October 23, 2013

'Obamacare' and Mental Health Promoted

We have all heard about the can of worms. Fishermen love them and most people shrink from them. This article in WebMD is another can of worms. It is time that mental health came back and became part of medicine. We even understand and appreciate the coverage of pre-existing conditions as a benefit.

One of the factors is not mentioned and this is the lack of trained doctors to treat people needing treatment. This may the reason behind the new guideline manual the Diagnostic and Statistical Manual (DSM5). In the manual they have a medication for every conceivable mental health issue and almost say to forget counseling from a positive perspective to enable their patients to take charge of a mental health problem and overcome it. Medications are now the only answer. This may have been anticipated that other doctors will need to help fill the shortage in an as needed basis.

The psychiatrists and psychologists are in short supply in most states and this is one reason many governors discouraged mental health exams for gun owners and this confirms the continuing shortage. See my blog here about the medications being encouraged for most mental conditions.

According to the WebMD article, an estimated 32 million people will gain mental health or substance use disorder benefits, or both, as a result of the Affordable Care Act (ACA). This results from the requirement that small group and individual insurance plans offer coverage for mental health issues and substance abuse services. The author claims most large insurance plans already include such coverage; however, my blog here shows how large insurance companies side step their obligations. Maybe under ACA they will not do this as much.

The author quotes Susan Lindau, a licensed clinical social worker and associate adjunct professor at the University of Southern California School of Social Work in Los Angeles, as saying, "parity has been written into the law so mental health coverage ostensibly should be much easier to access."

Andrew Sperling, director of legislative advocacy for the National Alliance on Mental Illness (NAMI), is quoted as saying, "We're still waiting for the final regulations. And, because of the Supreme Court decision, the Medicaid expansion is optional, and a large number of states are talking about not participating. There are a high percentage of people that have a diagnosable mental illness living below the poverty line."

There are two sides to this issue and for the most part, more people will have more mental health care than before, but a large number may still be unserved. This is a loophole that needs to be eliminated, but with the current congressional climate, may not be for several years.

With the current DSM5 guidelines, many other doctors may see the shortage as a way of using prescription medications recommended under DSM5 as a way to treat more patients. Mental health care will fail under this treatment and more serious mental health problems may become worse.

With the problems people with diabetes have, this may not be good for people with diabetes needing treatment for depression.

October 22, 2013

Metformin Without Vitamin B12 May Impair Cognition

I am a little surprised at this study, as I have been aware of this for some time and knew that metformin caused Vitamin B12 deficiency. I also knew that Vitamin-B12 deficiency could cause cognition problems in patients. Now a new study from Australia suggests, repeat, suggests this may be true. Yes, there have been some conflicting studies previously, but apparently, this study can only suggest this being the case. This tells me this study missed some important points or was incomplete in the data collected.

Lead author Eileen M. Moore, PhD, a medical research scientist in the department of surgery, Deakin University, Geelong Hospital, Barwon Health, Geelong, Australia, says, “Up to 30% of patients taking metformin may be deficient in B12, and this is thought to be due to an interaction between metformin and a receptor in the distal ileum, leading to some inhibition in the uptake of the vitamin.”

She continued, "Metformin remains a very effective first-line antidiabetic drug and may reduce cardiovascular risk in patients with diabetes. Clinicians and patients should not be alarmed by these findings, but the need to monitor and correct vitamin-B12 levels is highlighted."

At least she understands how important her last statement above is and that doctors with patients on metformin need to be tested for vitamin B12 deficiency. Dr. Moore recommends "Clinicians should consider monitoring cognition in [all] patients over the age of 50 years who use metformin, especially when there are other risk factors for dementia present. Because current treatments for dementia are palliative only, intervention in the early stages of cognitive decline remains the best option.”

This is important in the United States because many doctors do not and will not test for vitamin deficiencies as they believe in the medication route only and that we should obtain our vitamins and minerals from a well balanced diet only. What these doctors do not understand is that with metformin, even patients on a well-balanced diet have malabsorption of vitamin B12 and this leads to the deficiency.

Even with this problem, people with diabetes have a link to dementia without metformin, so it would be wise to test all patients for vitamin B12 deficiency and to be concerned about dementia.

October 21, 2013

Acronyms Used By People with Diabetes

The following is some of the common and not so common acronyms that are associated with and used by people with diabetes and writers of diabetes articles.

A1C: A test that shows the percentage of hemoglobin that has glucose attached. Hemoglobin is composed of several components, and the component of concern is the "c" subcomponent of the "A1" component of hemoglobin. See Glycosylated Hemoglobin and similar diabetes tests. Also referred to as the HbA1C test.

AACE: American Association of Clinical Endocrinologists

AADE: American Association of Diabetes Educators

ADA: American Diabetes Association

AND: Academy of Nutrition and Dietetics

BMI: Body Mass Index. A measure of total body fat, which takes into, account a person's weight and height.

CDC: Centers for Disease Control and Prevention. A U.S. governmental agency.

CDE: Certified Diabetes Educator. A health professional who is certified by the National Certification Board for Diabetes Educators to teach people with diabetes how to manage their condition.

CHO: Carbohydrate Also referred to as Carb(s)

CMS: Centers for Medicare and Medicaid Services

CSII: Continuous Subcutaneous Insulin Infusion (by insulin pump).

DCCT: Diabetes Control and Complications Trial, a research study.

DI: Diabetes insipidus. A different disorder from DM.

DIDMOAD: diabetes insipidus, diabetes mellitus, optic atrophy and
deafness. Also called Wolfram Syndrome.

DM: Diabetes mellitus

DPP: Diabetes Prevention Program, a research study.

DSME: Diabetes self-management education DSME and DSMT have been in use for several years and are recognized by AADE.

DSMS: Diabetes self-management support This term came into existence in late 2012. The official definition is important and can be read in this blog. Presently, the AADE has refused to officially recognize this.

DSMT: Diabetes self-management training

ER: Electronic Record(s)

EHR: Electronic Health Record(s)

EMR: Electronic Medical Record(s)

FBS: Fasting blood sugar

FBG: Fasting blood glucose

FPG: Fasting plasma glucose

FDA: U.S. Food and Drug Administration

GAD: Glutamic Acid Decarboxylase. The presence of antibodies to GAD
(called anti-GAD antibodies) in the blood is an early indication of the
start of the autoimmune process in Type 1 Diabetes.

IDF: International Diabetes Federation

IVGTT: Intravenous Glucose Tolerance Test

JDRF or JDF: Juvenile Diabetes Research Foundation Now correctly listed as JDRF

LADA: Latent autoimmune diabetes in adults

mHealth: Mobile health – generally associated with devices and apps that can track certain health conditions. Diabetes is now included with a couple of apps.

MODY: Maturity-onset diabetes of the young

NIDDK: National Institute of Diabetes and Digestive and Kidney Disease:
A U.S. government agency that deals with diabetes; part of the NIH.

NIH: National Institute of Health

OGTT: Oral glucose tolerance test

PHHI: Persistent Hyperinsulinemic Hypoglycemia of Infancy. An alternate
term for Nesidioblastosis.

PWD: Person with diabetes or people with diabetes.

RD: Registered dietitians are supposed to be trained to give us nutritional information to help us in our management of diabetes. Normally members of AND

SAD: Standard American Diet

SMBG: Self-monitoring of blood glucose

USDA: U.S. Department of Agriculture

The diabetes complications: Common for people with diabetes, but not exclusive to people with diabetes

CKD: Chronic kidney disease

CVD: Cardiovascular disease

This is not intended to be a comprehensive list. I will work on another list to post in the future. If you have a list or even a few and wish them included, please send them my way.

October 20, 2013

Another Email From the Doctor

This time the doctor that Jason knew was a lot more direct. He asked why I used made-up names for the members. In my answer, I stated that in case anyone in our local community read my blog, they would have a difficult time identifying people unless they had heard us talking. This is the one area we try to be secretive. Plus we are so used to our names, we know who is saying what.

The next question was again about CDEs and why we don't use them. I said that most CDEs do not want to spend time with patients who manage their diabetes as well as we are able. I stated that of the three doctors that are present at group meetings do not have CDEs available and just the few of us using the diabetes clinic could utilize them but have not felt the need. With the reading we do and the research, we are not willing to listen to them spout the ADA position when we know we are capable of deciding what works best for us.

His next question was why not have one speak to the group. I stated that most do not want this and they would not be paid as we do not collect dues for this and volunteer they might, but most of us would get up and leave when ADA positions were promoted. I said many CDEs would be questioned about why they haven't endorsed positions adopted by the ADA and a committee from the AADE. We would also ask why many CDEs leave patients when the topic of depression was inserted into a conversation. Most speakers would be asked question after question looking for areas where they were not knowledgeable. Not good for us and not what CDEs would want.

He said he understood why we would not have time for RD members of AND and the promotion of big food. We probably did not use many of the foods they promote, especially the whole grains. He said after reading my review of “Wheat Belly” by Dr. William Davis, he had ordered the book and has talked to other doctors at the hospital. He was surprised at the number that already had read it. Some agreed and some had reservations about the book, but had read it. He said I had used the right information in my review and even he had some reservations, but that much made good sense. He said that since two of the doctors in the cardiology department were recommending the book to some patients, he felt that it was what he should do when he finishes it. He has had one patient ask him about the book and he stated that he was reading it and felt if could be good for him. The patient mentioned that the heart doctor had recommended that he read it.

Then he said he had the book The Type 2 Diabetes Sourcebook and if his wife had not read my blog reviewing it, he would not have been aware of the statement I quoted and though he agreed with my review, he was not aware of how truly bad the book was with the statement. He wonders how they could write something like that with all the evidence to the contrary. Yes, he said very few people die from hyperglycemia, but we do not yet know how many die from hypoglycemia because death certificates are seldom correctly completed and have no place for secondary causes.

He has said that his wife has read a lot of my blogs and since she is an advance practice nurse for a local diabetes clinic, she is not agreeing with everything I blog about, but by checking my links, she has few real disagreements. I told him to have her let me know of problems or disagreements.

I answered a few more of his questions and thanked him for the correspondence.