September 27, 2014

Meeting with People Needing Help

Our meeting on September 26 involved all 17 of our members plus 13 people Jerry had contacted. In addition there were three doctors and two members from the other groups in our town. My cousin came as well, giving us a total of 38 people.

Tim asked Dr. Tom to talk to the group first. Dr. Tom thanked everyone for attending and Jerry for encouraging the 13 to attend. He explained that there were others not belonging to the group holding the meeting because if they felt a need to join a group, this would allow them to ask questions of those present. He introduced Glen and his wife from the group that had split from our group and the two members from the group he led.

He continued by asking if there were people from other communities. There was none as all were from our town or close to our town. Then he asked if there were any that did not have type 2 diabetes. Again, the answer was none. Dr. Tom asked Jerry to talk to the group.

Jerry thanked those not part of our group for attending and he wanted everyone to know that he has separated from his wife and was encouraging everyone not to stay with her for nutrition or dietary advice. He covered the reason for the separation and said that too many carbohydrates had affected his A1c by increasing it to higher level than when he was diagnosed. He said it might be because he is married to her, but felt the others should be warned. He said he would answer all questions later and turned it back to Tim.

Tim then asked my cousin to speak. She said she had worked with many from our group and they could answer questions about her if desired. She continued that she would work with each individual at the level each desired and within that work to balance the nutrition within his or her goals. She stated that she works with people at various levels of carbohydrates and has had success. She emphasized that a one-size-fits-all does not work, and that she works with people at the individual level.

She continued that she had talked with Jerry and would be working with him after the first of the year. She had, on her own, set up a meal plan based on his needs, and would adjust it, as he needed when he changed goals. Her main task is to keep his meal plan nutritionally balanced on a daily basis. She would work from whatever level of carbs he was comfortable consuming. That could be from zero carbs to 100 grams of carbs, but presently would not suggest higher than 100 grams until his A1c was lower.

She then stated what we all realize that are on insulin – we need to reduce our carbohydrate consumption when we start on insulin, as not doing this will generally cause a weight increase. The insulin utilizes the glucose more effectively and stores the excess glucose as fat. She concluded with that.

Tim then recognized and introduced a doctor that many of us were unfamiliar with and told him he had the floor. He said he would be brief, but did want to say that he was happy to hear what people said. He did agree that three of his patients should make the change away from Jerry's wife as they were having A1c problems. He admitted that he was impressed with my cousin and wished to talk with her after the meeting.

Tim then introduced Barry and Allen and said they would make a few statements about the VA for those that might be interested. Barry asked how many of those invited by Jerry were veterans. Seven hands went up and Allen said they would talk with them after the meeting.

Tim asked if anyone had any questions and there were questions for my cousin and for Jerry. Tim said the meeting is over and asked those that were introduced take up areas so that people could ask questions and move to someone else.

Brenda and Sue had the three women asking them questions. Then two of them moved over to talk with Allen and Barry. Even the doctors were getting questions about nutrition and carbohydrates and then about the support groups. Tim and Jason were also answering questions and explaining that we would take new members, but were encouraging people to talk to the other two groups as well to find the group that fit their needs.

After the meeting had started to break up, my cousin said she would probably be working with 10 of the people. She was surprised how many carbohydrates were being promoted by Jerry's wife and their A1c's reflected this. She said two individuals would not be going back, but were going with another person and the last person was still thinking about this. Jerry came over then and asked her how things were and she repeated the information for him. Jerry said this was better than he had hoped, but he would continue talking to the rest.

Tim then talked with us and said six wanted to join our group and that of the seven veterans; only one would possibly need to wait for benefits. Dr. Tom said that he was surprised and happy with the meeting and felt we had accomplished what we set out to do. He felt that his support group gained one person and Glen's group had possibly gained four members. We broke up the meeting then.

September 26, 2014

Study Says Salt's Effect on Blood Pressure Insignificant

Now if the American Heart Association would believe this we could be on to something. I do expect to see something from them and it will be a rebuttal if I am right. It turns out they don't need to as the American Diabetes Association did it for them in DiabetesPro SmartBrief. It carried an article by Reuters of people with diabetes ignoring salt uptake warnings. Both articles were dated September 8, 2014. The salt controversy just won't go away.

Previously on August 26, 2014, Eric Topol, editor of Medscape, used two studies and compares them. I will quote this from his article, “Our crackerjack cardiovascular news managing editor, Shelley Wood, published a superb article on Medscape - the, with many of the parties and leading experts weighing in. For me, the real coup de grâce was the Wall Street Journal's editorial column, "The Salt Libel," which highlighted this conclusion: "[T]he illusion that science can provide some objective answer that applies to a special danger."

I believe that adequately sums up all there is to say about sodium, at least for now. The AHA, however, isn't backing off from its 1.5 g/d sodium guideline. But I think there's a big lesson here about guidelines without adequate evidence: They can do harm. Hopefully this lesson will prove to be impactful, because that certainly has not been the case to date (as in cholesterol/LDL, BP, PSA, mammography, and a very long list of poorly conceived, nonanchored guidelines).

Isn't it about time to recognize that there shouldn't be rules for populations? Some people are exquisitely sensitive to salt intake, while others are remarkably resistant.”

New research should play a role in determining public health initiatives for reducing epidemic hypertension. It is unfortunate that hypertension is the world's most prevalent chronic disease. I was even surprised that it was so common at the younger ages. It affects more that 30 percent of adults at age 25 and above. It accounts for 9.4 million deaths every year.

With hypertension's increasing prevalence and the difficulty the global health community has in managing it, more should be done to identify casual behavioral relationships to blood pressure outcome that can lead to better strategies for preventing hypertension.

It is obvious that the salt debate will continue until the different medical groups decide to find science for their guidelines instead of what they call “expert opinion” and consensus. The science is slowly building and showing that there is more than just “expert opinion.”

September 25, 2014

Possible Help for Diabetes Apps, Devices, and Tools

When I read this Joslin blog, I had two reactions. First, I wondered why they would do this and second, I wondered if they would botch this like so many other things they have attempted.

I do have some preconceived ideas that caused the reactions. I purchased one tool several years ago now, and after two months, it went in the trash where it belonged. I have not purchased another tool, device, or app since and probably will not purchase another even if the hype looks grand.

Most tools, apps, and devices do not work well together and often require entering and reentering data multiple times. Not only that, transferring the data to the office of the doctor would require entering the data again. Not that the doctor would even look at it, but when required I would always need to gather up papers and enter the data for sending it in the required format.

I have found that using a spreadsheet and printing this out to mail to the doctor worked and did not require entering the data more than one time. Now that the doctor can receive confidential emails, I find it easy to enter the data one time and transmit it. Most doctors do not accept emails and therefore the telephone is the only way to give them the data unless I wish to drive 30 plus miles one way to his office.

I can only hope that Joslin does the right things to have more apps, tools, and devices work together seamlessly. They say they will be working with diabetes medical device and technology companies to improve development of easier to use, more widely accessible products that will help patients manage their diabetes. They claim this could include anything from providing clinical input that may impact the redesign of pumps to be faster, more accurate, and cost-effective, or to develop a mobile app that tracks your blood glucose levels.

A nationwide shortage of endocrinologists, diabetes nurse educators, and adult diabetes care centers has burdened the healthcare system and impacted timely patient care. Joslin believes the future of medicine, particularly diabetes care, must begin with self-management technologies.

What is significant is what Joslin does not say. They do not say they will work for interoperability and this is the failing of most apps, tools, and devices. The other important missing point is complying with HIPAA. This means that the companies can mine personal data and sell it to other companies. This is the problem of 99 percent of the current crops of these available. Anything using smartphones and iPhone have this weakness.

I want my personal diabetes and medical data secure and until this is the case, I will not use the defective implements now available. I feel that the Joslin Institute for Technology Translation has a lot of work to accomplish and this blog leaves many unanswered questions.

September 24, 2014

How Much Protein?

Because there are different guidelines for protein needed I will show the chart first, which is from the Institute of Medicine (IOM).

Exactly how much protein you need changes with age:
  1. Babies need about 10 grams a day.
  2. School-age kids need 19-34 grams a day.
  3. Teenage boys need up to 52 grams a day.
  4. Teenage girls need 46 grams a day.
  5. Adult men need about 56 grams a day.
  6. Adult women need about 46 grams a day (71 grams, if pregnant or breastfeeding)

You should get at least 10% of your daily calories, but not more than 35%, from protein, according to the Institute of Medicine.

The key measure is the Dietary Reference Intake (DRI), a system of nutrition recommendations from the Institute of Medicine of the U.S. National Academy of Sciences. Used by both the United States and Canada, the DRI supersedes the Recommended Dietary Allowances (RDAs), which is still used in food labeling.

Protein from animal sources such as meat, poultry, fish, eggs, milk, cheese, and yogurt provide all nine indispensable amino acids, and for this reason are referred to as ‘complete protein.'

Doctors still want you to limit saturated fat and select leaner cuts of meat. I would only agree on limiting processed meats like hot dogs and sausage. According to researchers at the Harvard School of Public Health, to help lower the chance of heart disease, it's a good idea to limit the amount of red meat, especially processed red meat, and eat more fish, poultry, and beans.

Other researchers say if you are trying to get more omega-3s, you might choose salmon, tuna, or eggs enriched with omega-3s, and if you need more fiber, look to beans, vegetables, nuts, and legumes.

Some of us with type 2 diabetes can have real problems with protein, especially if they have kidney disease and need to limit their amount of protein. Without kidney disease and following a vegan diet, then the problem becomes consuming enough protein. That is why I listed the table for protein consumption at the beginning.

Most of the studies proclaiming low-carb diets are good also have the diet as a low fat and were replacing the carbohydrates eliminated with protein. Some said this was good and others make no comments. The reason for the low fat is that many do not recognize the fallacy of Ancel Keys and that his conclusions have been debunked.

I do not agree to the low fat argument and think fat needs to be the macronutrient added as long as protein is at the level needed providing kidney disease is not a problem. A good discussion with a nutritionist may be necessary as well as the doctor if there is a kidney disease. No, I did not say a dietitian, as they generally want the carbohydrates to stay up and especially the whole grains. Gallbladder issues may also limit the amount of fat you can tolerate.

Please read this blog by David Mendosa about protein. He covers the many sides of protein that I do not.

September 23, 2014

The Questionable ADA

I do need to say that I do not follow the guidelines of the ADA. I did refuse for a couple of years to read what was happening on the ADA (American Diabetes Association) website, but that was a mistake. Even if a person does not follow the ADA, we still need to know what they are saying and what guidelines and research is published by them. Some of the research is behind a pay wall, but some is available to the public.

The reason I do not follow the ADA guidelines is that the blood glucose levels they promote are levels that result in the development of the complications. Knowing this is the reason doctors say that diabetes is progressive. When the ADA says they recommend an HbA1c of 7.0 percent is their guideline, this is also in the range for complications to develop. This also causes patients to only attempt to achieve this when an HbA1c below 6.0 percent is nearer normal and while complications can still develop, they will not develop as rapidly.

Having an A1c below 5.5 percent is better, but this is not achievable by everyone. I also admit I cannot attain this level without severe hypoglycemia. I would urge people to read this by David Mendosa, Normal A1c Level. He also discusses what Dr. Bernstein says about normal A1c levels.

Although the ADA has relaxed their food plans in the last two years and in October 2013 issued new guidelines for food plans that includes low-carb, the registered dietitians (RDs) still promote high-carb/low-fat diets even though many were on the committee that developed the ADA food plans.

The ADA is too lax in their guidelines for blood glucose levels two hours after first bite (they recommend not higher than 180 mg/dl) and this will promote complications. The guidelines also say at bedtime that our blood glucose level should be less than 180 mg/dl. Their one-size-fits-all standard is not a good thing and we need to realize this, as people are all different in the way we are capable of managing our diabetes.

The last time the ADA lowered the definition for diabetes was in 1997 that dropped the criteria for diabetes from fasting blood glucose of 140 mg/dl to 126 mg/dl or higher -- a change that increased the number of people with diabetes by millions. It is now 17 years later and a poorly named term of prediabetes needs to be changed. It is not an official designation by the ADA, but with research showing that damage occurs in the prediabetes range of 100 mg/dl to 125 mg/dl it is time to declare this diabetes and move on to having it treated.

Yes, this will add approximately 86 million people to the diabetes numbers, but if done properly, many should be able to stop the severity of diabetes for decades or at least years. Knowing the ADA, this is highly unlikely. The medical profession likes to have people to treat rather than practice any form of preventive medicine.

The ADA also needs to include in their guidelines the concept of moving insulin from the treatment of last resort, to prescribing insulin at the early stages. This has proven effective in allowing the pancreas to rest and partially heal, making oral medications effective for a longer duration. Read this by David Mendosa for further clarification. Many in the medical profession will not do this because of their overwhelming fear of hypoglycemia.

I hope this explains some of the more salient reasons for not following the ADA guidelines.

September 22, 2014

A Discussion on Food Plans

Lately I have been writing about low-carb/high fat eating plans (diets for those that insist). I have to laugh, as this has really brought some unexpected emails. Some are insisting I should be eating very low carb and ketogenic. Others are insisting I should be low carb and high protein. I am laughing because most are a variety of food plans and most are saying this is the plan I need to follow.

What is discouraging is some of the people will not accept other ideas. I am not one of these. That is why I felt I must say and emphasize that 'One-Size-Does-Not-Fit-All'. For those of us with diabetes, we must each find what works for us. That does not mean that you can't take ideas from others and adapt them, but you should develop you own food plan that your meter tells you works for you. If the food plan that you are trying does not make you feel healthy and your energy is dragging, then work on changing it to another food plan.

I generally consume less than 100 grams of carbohydrates per day. I attempt to have about 15 to 20 percent carbs, 30 to 45 percent fat, and 35 to 40 percent protein. Yes, I vary quite a bit, but that is my choice. I have tried other percentages, but the high fat just was not working even with trying it for about three months. Occasionally I only eat about 50 or fewer grams of carbohydrates with higher fat and less protein, but I don't dare do this for several days in a row if I want to keep the bathroom available for my wife. I suspect part of the reason is the removal of my gallbladder almost a year ago.

I respect those that can consume more carbohydrates, but if they are using low fat, or as many do – very low fat, then they tend to start adding weight. I am not impressed with the studies of late that are low-carb, low fat, and high protein. The cardiologists are still promoting low fat, but they have a lot to learn. Most studies are short in duration and meaningless. Hopefully, we will have studies in the future of up to five years or longer that will be of value.

The best suggestion I have is tried and true! Learn to eat to your meter and the goals you establish for yourself. If possible, avoid highly processed foods, and attempt to prepare your own foods.

Read these two articles for further information - article 1, and article 2. I will be blogging more on nutrition in the future.

September 21, 2014

The Groups at Our September Meeting

We knew that several support groups would be present for the final with the specialist on interventions. We had 95 people present and had room for just a few more. With that many people we were happy that the air conditioning was working.

I was not prepared for the start. Dr. Tom took over and said we have had a successful intervention in the last two weeks. He explained that he had been brought up to date by several of the group and felt there was a good reason for the intervention. At that point he introduced Jerry to the group. He asked Jerry what his last A1c had been. Jerry answered 13.2%. There were several gasps and Dr. Tom asked people to be quiet as there would be more that would shake them up as they continued.

Dr. Tom explained that until last Saturday, he lived with his wife who is a dietitian. After several of our group had tried to work with him and had his wife stop them, some rather harsh information came to light. First his wife was very happy with his A1c and would not reduce the carbohydrates, had high fructose in many of the food items he ate, and would not let him reduce the carbohydrates he was eating.

He continued that when they were able to separate him from his wife, Jerry and he had about an hour's talk and a diagnosis that had been arrived at by the group. Dr. Tom said he had never had one of these, but had talked to another doctor that had experience with Munchausen Syndrome by Proxy. He saw a few hands go up and explained, Munchausen syndrome by proxy (MSP), a type of factitious disorder, is a mental illness in which a person acts as if an individual he or she is caring for has a physical or mental illness when the person is not really sick. In the case of diabetes, this can take the form of feeding the person with diabetes with too many carbohydrates.

Next he asked Jerry if he remembered what his A1c was at diagnosis, Jerry answered 8.0%, his second was 7.5%, the last was the 13.2%, and the plasma blood glucose reading from the week before was 331 mg/dl. Dr. Tom asked what medication(s) he was taking and he said he was on metformin, 500 mg 2X, and now he is taking insulin. He said that A.J was a great help in working with him.
At that point, Dr. Tom asked the intervention specialist to talk. The specialist stated that he had been able to talk with Jerry's wife and did agree with Dr. Tom's assessment. He could not say any more, but felt that the group had come to Jerry's aid for the right reasons and this was the first case he has seen. He said that normally you see this with one parent doing this to children, but one adult can do this to another adult.

Jerry then said that the situation had gotten out of hand and he knew that his A1c was heading the wrong direction. He said that with the support group members that had worked with him, he should be able to bring his A1c back in line or at least under 7.0%. Dr. Tom said that under 7.5% would be great, but that it was possible. Jerry said this was not what he had wanted in his life, but that there was support for action when he needed it.

The specialist then spoke for another half an hour about interventions and how valuable they could be. As he concluded, he asked if James had anything to say. James stood and said no, other than to thank everyone that had helped in his intervention and the support group for forcing a few issues when he had thought to go back to denial. He even said his wife had worked to keep him away from denial. He finished by saying he felt better now that his diabetes was being managed and that his last A1c was 6.6% and hopefully would be less at the next one.

Tim then said that they doubted we could have two meetings this valuable again, but that our group was happy for the meetings and hopefully presented something of value that everyone would remember and use to manage their diabetes more effectively. The meeting ended then. Some left, but many wanted to talk to James and his wife, and to Jerry. Dr. Tom did call him away and the doctors did want to talk to him. Allen, Ben, and Barry saw to it that they were not interrupted and A.J needed to join them. It took about an hour for people to disperse.