February 15, 2014

Commercial Foods Industry Messing with Salt, Again

Because of government, public health, and professional organizations applying pressures on the food manufacturers to reduce sodium intake, the food industry is experimenting with salt alternatives and forms of salt to reduce sodium intake. How will this fare in the long-term? Even now, consumers are cautious about buying low sodium, no sodium, and reduced sodium products because they claim this sacrifices flavor.

As a result, food companies are finding less drastic ways to reduce sodium in foods without alerting consumers. This involves stopping labeling claims on packages and rebranding products to emphasize low sodium. The answer it appears is to maximize how salt in the product interacts with the tongue. Increasing the boldness of salt's flavor can be done by using different crystal sizes and shapes as found in varieties of Kosher salts, sea salts, and specialty salts. This is being tried by increasing salt's surface area and reducing its general density for products like chips, crackers, and some baked goods. Spanish researchers have found a potential use of newly developed hollow salt microspheres on commonly eaten foods could reduce sodium intake by approximately nine percent.

Several companies are also developing products with potassium chloride in combination with salt in order to reduce sodium in foods while masking the metallic taste that can sometimes go along with potassium chloride. Applications include salad dressing, mayonnaise, processed meat and poultry products, cheese and dairy products, baked goods and snacks, as well as prepared meals and entrees in restaurant chains. The next step when reducing sodium and finding substitutes is to work on savory notes to enhance salt’s flavor using glutamate-containing ingredients such as glutamate-rich yeast and mushroom extracts.” More on this below.

This is somewhat humorous, one company is adding color to the salt with the use of fruits and vegetables to show consumers how much salt they are adding to food. Innovation may be taking its toll as some are using hot sauce, soy sauce, adding smoke flavors to salts, and dairy product solids to foods. Reducing sodium to a given product clearly will depend on the functionality of salt in the product.

I think it will become wise, if not mandatory, for all consumers to read the label and ingredient's sections on food containers to avoid some of the problems the food industry will be causing. I urge everyone to be cautious with foods containing potassium chloride because of consuming an excess of potassium. Please read my blog here on the potential interactions and problems excess potassium may cause. Always talk with your doctor before this becomes a problem. Potassium is essential for life, but use caution to avoid excess.

In the italicized paragraph above, be careful of products containing glutamate ingredients. Glutamate is a salt of glutamic acid or an ester of glutamic acid. Not everyone can tolerate these, but the number of these people is generally unknown because the medical community generally does not test for these.

February 14, 2014

Is There A Best Way for Type 2 To Bolus?

Everyone seems to recommend something different when type 2 people are put on insulin. I know that everyone is afraid of insulin and doctors and others are all worried about people not injecting their insulin. This is discussed at great length in this Joslin blog, but I wonder if this is the best way. I dislike that the blog author is giving many of the insulin myths credit without giving them the recognition and doing something to disprove them.

It is as if the author believes the myths and it reads as if this is why they need to find new ways to ease patients new to insulin into injecting. I realize that some people start out with basal insulin (long acting) before bed and this is reasonable if they need help with the oral medication.

A little background here. I went from two oral medications to basal (Lantus – long acting) and bolus (Novolog – rapid acting) insulin during the day and have never looked back. I knew that I needed insulin for better diabetes health and I was ready for it. I have not regretted the decision and I have been better off as a result. I was working part-time and my boss knew that I had diabetes when I was in the hospital for a heart problem. There was never any problem with finding time for injecting and taking care of my diabetes.

I know not everyone is given the latitude by their employer to take care of their diabetes like I was, but the Americans with Disabilities Act can be used if there are problems. Yes, diabetes falls within the disabilities and provides some protection at your job. And, yes, I admit to being a trifle callous after having a great boss and other employees to protect me. At least he knew about the Americans with Disabilities Act and made sure all employees knew something about it.

As a result, I find that too many people -
  1. Want to keep diabetes a secret.
  2. Are afraid to inject insulin without complete privacy.
  3. Let their fears overcome their health needs.
  4. Cling to diabetes myths because they don't understand insulin.

The above reasons are bad enough, but then add to this the fear of what the doctor is saying about insulin being a punishment and common sense health care goes out the window. Then when bloggers on the Joslin diabetes blog have to use words like – too burdensome and overwhelming, and more cumbersome, people have to wonder if there is something wrong with insulin.

I have a fear that too many diabetes care professionals are not using positive thinking about insulin and the benefits of insulin, but are letting people with type 2 diabetes dictate the necessity of avoiding insulin. Yes, they want adherence to insulin and are therefore trying to baby step patients into insulin. This is unfortunate for many people that need insulin to better manage their diabetes.

If it seems like I am saying to push insulin all at once, yes, I am because then you adjust and should take it in stride. I know many people that have done this and most of the members of our support group started insulin in one day and are all happy they did and were able to improve their diabetes management. I can feel for those that do not have a family support structure, workplace support structure, or support group for support, but the quicker they move away from oral medications to the full insulin regimen, the better they will be.

February 13, 2014

Mixed-up Diabetes Myths – Part 2

Part 2 of 2 parts

Continuation of diabetes myths

#6. You will need to give up your favorite foods. There is some truth in this. Many of the whole-grain foods, breads, most potatoes, and white rice should be eliminated without thinking. Sometimes some people can have small servings if they have planned for these.

Some of the other food favorites will still be allowed if you do the following:
  1. Change the way your favorite foods are prepared.
  2. Making adjustments in the foods you usually eat with your favorite foods.
  3. Reducing the serving sizes of your favorite foods.
  4. Occasionally using your favorite foods as a treat when the carb count has been planned.

#7. You have to give up desserts of you have diabetes. Very false! You need to limit the amount you eat or save the dessert for special occasions when you allow for the extra carbs. Or use these suggestions:
  1. Use artificial sweeteners in desserts.
  2. Reduce the amount of the dessert, or share with a friend.
  3. Use desserts as an infrequent reward for following your diabetes food plan.
  4. Make desserts more nutritious. With most recipes, using less sugar can be done without ruining taste, or consistency.
  5. Expand your dessert horizons. Try different yogurts and fruit.

#8. Artificial sweeteners are dangerous for people with diabetes. The jury is still out on artificial sweeteners. There are some studies lately that have conflicting data. Even though the American Diabetes Association approves the use of the following sweeteners, saccharin, aspartame, acesulfame potassium, and sucralose, there are more ‘natural’ sweeteners coming on the market that may give better options.

#9. You need to eat special diabetic meals. Again, this is hype and diabetic diets do not exist. Food manufacturers and dietitians want you to believe there are diabetic diets, but these are often packed with carbohydrates. The food plans that are good for people with diabetes are also good choices for the rest of the family and no special meals need to be prepared. It is important for people with diabetes to consume less food or eat to what his/her blood glucose meter tells them in the right quantity.

#10. Diet foods are the best choices for diabetes. Don't believe this one. They are more expensive than and not as nutritious as some foods found in the regular areas of your grocery store. Often foods that you prepare yourself will be more nutritious and better for you. Learn how to read labels on the foods you choose and carefully read the ingredients section.

It is important to know that you can't learn everything overnight and some of the above pointers may need refreshing before they become second nature. By taking exercise and the medication, you can use what you eat, if you know the meaning of the meter readings, to keep your blood glucose levels close to or near normal levels.

February 12, 2014

Mixed-up Diabetes Myths – Part 1

Part 1 of 2 parts

Too many people believe these myths and do not understand what diabetes is and what is required by people with diabetes. This is then spread by the people with no understanding and knowledge of diabetes to literally make the life of people with diabetes hell to live everyday. They become accusatory to people with diabetes and will not listen to the truth. This is done to people with all types of diabetes, but I am writing this for mainly people with type 2 diabetes.

The following myths WebMD says are associated with diabetes:
#1. Eating too much sugar causes diabetes. It would be great if this was true and there would be an easy way to prevent diabetes. But this is untrue and the causes of diabetes are not totally understood. Diabetes normally starts because some function that the body does normally slows down or becomes nearly unfunctional. When you eat food, it is broken down into glucose. This means that all food is handled this way. Glucose is the food for cells and without adequate insulin, it will not enter the individual cells and they become starved for fuel that the body needs.

#2. There are too many rules in a diabetes diet. First, there is not a specific diabetes diet. The person with diabetes needs to use his/her meter to determine how foods affect the body and the blood glucose levels. This is becoming tougher all the time with the doctors, insurers, and government always wanting to limit the testing supplies. Always remember that what works for one person, may not work for you. You need to determine the food that works for you and learn to limit the quantity of food you consume based on the results of your meter. The level of your exercise, the medication(s) you are taking need to be determined to keep your blood glucose levels as close to normal as possible.

#3. Carbohydrates are bad for diabetes. This one is more true than false. Our dietitians push carbohydrates at us as being necessary and the foundation of a healthy diabetes diet. The foregoing sentence is the false part and this is because they have a conflict of interest because they are a puppet of Big Food. More people are finding that food plans that limit carbohydrates are healthier and help manage diabetes.

The dietitians always bring the same dogma to the table that people that don't consume many carbohydrates, especially whole grains, are missing many essential nutrients, meaning vitamins, minerals, and fiber. They might be believed if people hadn't learned that there are other foods lower in carbohydrates and can also balance the nutrients, in fact, can have more of the nutrients than whole grains. Yes, some fruits and many vegetables are still needed, but be careful what you believe from dietitians.

#4. Protein is better than carbohydrates for diabetes. BE CARFUL. Because carbohydrates affect blood glucose levels so quickly, you may be inclined to and should eat less carbohydrates. However, do not substitute too much protein for the carbohydrates cut from your food plan. If you do, you can possibly develop other health problems. If you can find someone well schooled in nutrition consult with them and not dietitians because they will only promote high carbohydrate/low fat food plans and you need a balanced food plan that fits your needs. Fats are not the bad boys and too little fat is also bad for your health.

#5. You can adjust your diabetes drugs to 'cover' whatever you eat. This is just false. Don't do this unless you have discussed this with your doctor and he has approved. Most doctors will not unless you are overly thin and you could gain a few pounds. Insulin is also about the only medication you will be allowed to use for this if approved. Most diabetes drugs work best when they are taken consistently and as directed by your doctor. Oral medications normally will not be able to manage diabetes if too many carbohydrates are consumed and will have even more trouble if the level of fats in your food plan is too low.

February 11, 2014

Doctors Now Asking for Email Addresses

I admit I had to think twice when I was asked for my email address. I am still concerned that it will be sold as part of a list by an unscrupulous doctor. This will not happen for some time, as I am part of a small group of patients enrolled to the patient portal to meet the meaningful use requirement.

There are still requirements for them to meet and it is great to watch them jump through the hoops. In this article, Dr. Pelzman describes some of the problems in obtaining patients' email addresses. He does cover many points and leaves out a few others.

Why people will not give out emails when they willing do the following online -
  1. Using their credit card numbers online.
  2. Banking online.
  3. Putting their home address on Facebook.
  4. Telling people on Facebook they are on vacation. where, and when.

If you have a Yahoo email account, I can understand why you would not give it to anyone. I strongly suspect that Yahoo sells the email account information with the amount of spam and junk emails I receive daily. Many are from advertisers on Yahoo and I have asked Yahoo for over a year to delete my account, but as of today, it is still there and the spam emails are increasing almost daily. I know that twice in the last two years, my email account has been hacked and the last time the contacts were removed and many of them received emails with viruses attached. In addition, Yahoo does not remove phishing attacks and other libelous attacks that other email services are great at preventing.

If the National Security Agency (NSA) can copy our telephone communications and retail stores like Target can compromise credit cards, then we know that obtaining information from our electronic health records is an easy task. Fact is hospitals and clinics are to report when their servers are hacked into and the Health and Human Services Department is maintaining this list.

The number of times our medical electronic records are accessed for information and to enter information into our records is often many times per year. Labs, hospital servers, insurance companies, and claims data flows from and to our records before and after every visit.

Dr. Pelzman is promoting bringing people into the new century and likes the savings he feels is to be had. He wants to make sure everyone is on board and he feels that he can safely bring them into a new, more efficient world. He admits that some will never be part of it, but he promotes the brave new world coming at us.

February 10, 2014

Medicare Really Harming Seniors with Diabetes

You knew this was likely to happen! Medicare's national mail-order program is ripe with problems and the Centers for Medicare and Medicaid Services (CMS) is not concerned except to defend their actions. All this started when the American Association of Diabetes Educators (AADE) did their homework and discovered that the regulations Congress specified are not being adhered to and in fact are being ignored.

Martha L. Rinker, JD, AADE's chief advocacy officer, told Medscape Medical News that despite CMS rules that forbid suppliers from pressuring patients to switch glucose-meter/test-strip brands and that allow physicians to write prescriptions for specific brands, the way the program is being conducted is leading many patients to switch anyway, with potentially negative consequences.”

Part of the problem is when a patient receives a meter they don't know how to use it will not be used. This defeats the purpose and results in waste. Ms. Rinker is also concerned about the accuracy of some of the low priced meters and test strips being foisted on Medicare beneficiaries.

Of course, some of the mail-order companies disagree and bring up the conflict of interest because some of the supporters of the AADE are also manufacturers. As expected, CMS is saying there is nothing out of order and that the agency has comprehensive monitoring in place. The CMS is not sending inspectors out, and they seem to be relying on the honesty of the suppliers.

"Although Congress clearly intended the 50% rule to ensure that beneficiaries would have access to the brands offered before the national mail-order program, CMS is failing to ensure that beneficiaries continue to have access to familiar test systems," the AADE report says.

Once the program was underway, CMS has not insured that the 50% rule has stayed in force. The AADE found in Medicare supplier directory that by the end of the first quarter of the mail-order program, only 5 suppliers were offering more than 50% of the testing systems that had been available prior to the competitive bidding program. On Medicare's website, the majority of suppliers were offering less than 50%, and in the AADE survey, no supplier offered more than 50%.

CMS said that requirement applied only at the time of bidding. Even though the legislation required that suppliers comply with the 'physician-authorization process' many are supposedly pushing beneficiary's to take substitutes. According to the CMS, failure to comply with all of these rules "constitutes a breach of contract and can result in termination of the supplier's contract." Apparently, CMS is not enforcing this requirement either.

CMS also states Medicare does not pay for convenience. It pays for medical necessity. This basically says they only care about cutting cost even if the Medicare patient is harmed. They will make their own rules, again, even if the Medicare patient is harmed.

February 9, 2014

Medicare Bill May Help in Treating Chronic Diseases

This may be controversial and Congress does not seem to care. Until more information on the bipartisan bill becomes available, I will go with my gut instincts on this one. Medscape has a decent article covering the Congressional bill now in both the Senate and House. I had hoped for more comments to the article, but I still have my ideas.

Since the Medscape article does not chose to identify the bill numbers, all I have is this to identify – “The Better Care, Lower Cost Act.” On the surface, it sounds like a great idea, but I fear there is much that needs to be digested and exposed to the general public and this is where the controversy may lie.

The article does promote the Act and says, “The Better Care, Lower Cost Act resorts to traditional managed-care tools such as risk-adjusted capitated (large – my addition) payments to clinicians, but also promotes the use of high-tech tools, including telemedicine in rural areas, remote monitoring, and smartphone apps that help patients better manage their conditions. Healthcare providers would voluntarily form multidisciplinary teams — possibly partnered with hospitals — that would enjoy important advantages over accountable care organizations (ACOs) in rendering coordinated, cost-effective care to seniors with chronic illnesses, according to the bill's sponsors.”

Senator Wyden (D-OR) then hypes the bill stating, "Medicare reform must be built around offering better quality, more affordable care for these seniors. Fortunately, there are pioneering practices and plans that are paving the way. Medicare is now dominated by cancer, diabetes, heart disease, and other chronic conditions."

The lawmakers then cite data from the Centers of Medicare and Medicaid Services showing, “that 68% of Medicare beneficiaries have more than one chronic illness, and that this group accounts for 93% of Medicare spending. They also point out that 98% of what they call costly hospitalizations involve such beneficiaries. Keeping the chronically ill healthy enough to avoid a trip to the hospital is the Holy Grail of Medicare cost-cutters. Accordingly, the bill calls quality and cost-containment 'interdependent goals.'" Bold is my emphasis.

To accomplish this, multidisciplinary clinical teams will be certified as qualified Better Care Programs (BCPs) and will receive large payments for Medicare beneficiaries with multiple chronic illnesses that are risk adjusted for health status. BCPs will be different from Accountable Care Organizations (ACOs).

The key difference between the ACO and the BCP will be that BCPs are free to target and enroll the sickest Medicare patients. This will allow them to specialize in such patients and their chronic illnesses. The Congressional bill sponsors go to great lengths to say that BCPs will outperform ACOs to the benefit of physicians and patients alike.

A BCP must develop a care plan for each patient that, when appropriate, will include the use of digital technology — telemedicine, remote patient monitoring, smartphone apps — "that promote(s) patient engagement and self-care while maintaining patient safety." The care plan itself must be easily integrated into electronic health record systems.”

All this sounds great and uses all the correct terminology possibly to confuse the general public. I admit that I am skeptical and wonder if one comment to the article might not be correct when he says, “How long will it be before these teams are designated "death panels"'?