October 18, 2014

Finding Financial Help for People with Diabetes

When I did this blog on January 10,2013, I knew it was only a start, but I did not realize what would result in more questions. Then with a newsletter from “DiabetesConnect” and a blog on DiabetesMine dot com, I have received several more emails from people asking for more information. This is telling me that there is a greater need for information about finding financial assistance for diabetes supplies and medications.

It is with some trepidation that I tackle it at this time with all the changes that are expected in January 2015 under the Affordable Care Act (ACA), a.k.a., Obamacare. Will any of us be able to afford medical insurance the way it is expected to increase in cost – in come cases? At the same time, we need to be aware of what is presently available to assist people with poor medical insurance or no medical insurance.

I am very happy to give credit for the work others have done to enlighten us, but we need the information put together to prevent people from looking at too many sources and becoming discouraged. One of my questions came from a person that was using a computer in a library, and because of the lines waiting for computers he asked that I send him an email when it was complete so that he could print it off and come back to it when he can get computer time. Because of this, I was able to get the library URL and email them asking for extra time for him. I am very happy for him, as the library has gone beyond the extra step, did a lot of research for him, and help provide him with many local resources. They have put him in touch with several agencies that are helping him. He has written me many thanks and is very thankful for the help the library has given him. He says this is the first time in over two years that he has been able to test his blood glucose and have a dependable supply of insulin. Yes, he was without work, but now has a part-time job and a roof over his head even if it is at a shelter. He is also a veteran of the war in Iraq and having a very difficult time.

Based on this, I will start with the Veterans Administration and their benefits for veterans. First, let me be very specific as veteran's services vary from state to state and each state has their own setup for the location of veteran service offices. The state that you currently reside in determines where the offices are located. In the examples I am using, Iowa is the place that this applies to and I think we are fortunate in that each county has a veteran's assistance office. Normally they are located in the county seat and are generally in the telephone book under Veterans Affairs.

For the state of Iowa, it is part of the Iowa law and required to have an office in each county. Each office is staffed by at least one certified county veterans service officer (CVSO). This means that they have taken an examination and passed it on the state and federal level to be certified at the state and federal level. I know that they help a lot of veterans and in addition, they answer to a three or five member board of veterans that can dismiss CVSOs for cause.

Current service personnel being discharged from active duty are automatically eligible for veteran's benefits for five years from date of discharge. Other prior military service veterans must file an application for benefits and include all copies of DD Form 214 for each period of service. This application can be obtained from the county Veterans Affairs Office.

All VA offices and most VA clinics in Iowa have a booklet titled Iowa Department of Veterans Affairs – State and Federal Benefits for Veterans and Dependents. It is spiral bound at the top, but I haven't counted the pages. It is 3.5 inches wide by 4.5 inches high.

I highly recommend that all veterans find their local VA office and find out what you are eligible for and when.

October 17, 2014

Another Article to Put Down High Fat Diets

The advocates against high fat diets are at it again. Only this time they may have crossed to the danger side. This time they are talking about grapefruit juice being able to curb the effects of a high fat diet. While more studies are being promoted, there are a few items that need consideration before adopting grapefruit juice.

I must emphasize that many of today's medications can become toxic when taken with grapefruit or grapefruit juice. The grapefruit family can cause very serious problems when taken with about 100 medications, at latest count.

The list includes some statins that lower cholesterol (such as atorvastatin, lovastatin, and simvastatin), some antibiotics, cancer drugs, and heart drugs. Most at risk are older people who use more prescriptions and buy more grapefruit. The gist of the situation is the grapefruit, which contains furanocoumarins, which block an enzyme that normally breaks down certain medications in the body. When this happens, medication levels in the body can become toxic. This is still not on the FDA's list of things to watch for, but should be. Read my blog here from December 10, 2012.

Some doctors are aware of this, but many just are not. This is one side effect of many medications that grapefruit and grapefruit juice that can be extremely dangerous to your health. Doctors were saying it was not new news. I wish this would get more publicity, but the media does not think it is important enough or will generate enough interest.

A new study by researchers at the University of California-Berkeley claims it did for mice fed a high-fat diet, and it even lowered blood glucose levels and improved insulin tolerance. This could lead readers to believe that the diet could have been low carb, but that is not stated in the study.

The researchers say, “It is common knowledge that a diet high in fat can lead to weight gain.” This adds to the confusion and indicates a high carb diet. This is also not stated in the study.

The study was actually using rodents, which indicates nothing as the dietary habits seldom translate to humans.

The researchers stated that the research was funded by the California Grapefruit Growers Cooperative.

October 16, 2014

Frequency Important in HbA1c Testing

I must state that after reading this short piece in Diabetes in Control, I started this blog and then I tried to follow the link at the bottom. This led to more confusion and much doubt. It turns out that the link was not to the correct article in Diabetes Care, but to a Pub Med article titled “The relationship between alcohol consumption and vascular complications and mortality in individuals with type 2 diabetes.” I had expected the article to be behind a pay wall, but not this.

The short article made no mention of where the study happened, but the article alluded to the ADA. False, the study was done in the United Kingdom and in my reading of the full study, kindly provided to me by David Mendosa, I have more questions than answers, to the point of actually thinking junk research.

Some of the points that raise questions include:
#1. Data collected after the fact from laboratory reports.
#2. Data not from a randomized-controlled trail, although this is made as a suggestion by the researchers. Of course, they want more funds for this type of a trial.
#3. Dosage adjustments and other interventions are not documented.
#4. Data for too short a time frame.
#5. Data too general and not specific – example for those receiving quarterly A1c tests and had initial A1c greater than 7% had an A1c reduction of 3.8 percent. If the average were 8%, this would be greater than 7.1%.

I would agree with the research just in the fact that among our support group members, those that test quarterly have a lower overall A1c average than the two individuals that are tested on a six-month schedule.

Then there are those that use the home A1c test on a monthly basis, two members, and they have in general the best A1c levels. One is on insulin and one is on no medications. For more information on home testing read this blog by David Mendosa.

The practice pearls offered by the Diabetes in Control author are reasonable and I will quote them.
  1. While clinical guidelines are in place for HbA1c monitoring frequency, the recommended intervals are often not followed appropriately in practice.
  2. This study showed that following the recommended testing interval recommendation was associated with a lowered HbA1c, particularly in those patients with HbA1c's of >7%.
  3. Patients with testing intervals of 6 months or more were associated with increases in their HbA1c values.

The testing of A1c should not replace the testing done by individuals, but as a way of informing patients that their testing is either showing them that they are doing it right, or that they are not testing often enough or at the right time.

The recommendations by the ADA and AACE of relying only on the A1c by patients should never be followed, as this leaves the patient managing his or her diabetes in the dark and makes it more difficult to understand what is being done right or wrong.

If you have made it this far, you should read David's blog from yesterday.  He is able to put a positive light on the study.  I was upset by the false link provided by a fairly reputable service and let my negative side take over.  For this I make no apologies, as we need to be aware of weaknesses in studies and when studies are not telling us the whole story.

October 15, 2014

The Damage Being Done by the Sec of Health and Human Services

In another blog recently, a couple of doctors and I were lamenting about the state of affairs for the National Diabetes Information Clearinghouse (NDIC). It seems that the secretary for the Department of Health and Human Services (DHS) is not concerned about the accuracy or completeness of the website and may have ordered some of the information removed.

I am not saying that the current secretary is involved, but it sure seems as if the former secretary, Kathleen Sebelius may have done much of the damage. In November 2013, and earlier for other blogs, the information about Victoza (liraglutide) was still on the website and I used the information in several blogs. Then during the Spring of 2014, all the information disappeared about Victoza. Other information that was labeled black box information about two other injectable diabetes drugs also disappeared although the remaining information has remained for the drugs Symlin and Byetta or Bydureon.

The information is fortunately available on the FDA site as a PDF file, this is the link. Victoza is still available by prescription; people need to have a source for the dangers of taking the drug.

Now, the other rub about the NDIC. There have been two additional combo drugs added, but they have not been included on the website. The newest diabetes drug class, SGLT2, Invokana and two others in the class approved by the FDA are still absent from the website.

We have to wonder why the website has fallen into such bad times, or if it is the victim of the funds that were directed elsewhere by an overly ambitious department head trying to please her boss.

Either way, the NDIC is no longer a dependable source for the discussion of diabetes medications, insulin or oral pills.

October 14, 2014

Managing Diabetes When Pills Aren't Working

Sometimes, articles are published just when you need them. When wrote my blog on May 8, 2013, about helping a veteran get assistance and get on insulin, I was feeling great. She is happy to be on insulin and says her last A1c was 5.8%. Since then I have corresponded via email with two doctors that are against insulin use for type 2 diabetes until it becomes necessary. They have their reasons and it is not what I usually hear – the fear of hypoglycemia. They have told me that as long as a person with type 2 diabetes is producing insulin, they need oral medication to help in the utilization of that insulin and not additional insulin.

We have agreed to disagree because they are not afraid of insulin and do not wait until it is too late to prescribe insulin. They also agree that insulin should never be the medication of last resort, but they do agree that the tests of A1c and insulin produced do need to be done when the A1c gets above a certain point. They claim this should also be age dependent, but agree that there are individual variances.

We have discussed using insulin at diagnosis to help the pancreas recover, but they say that is not proven. I also say that the side effects of many oral medications are unacceptable and still questionable. Claim and counter-claim is the reason we have agreed to disagree. All three of us were in agreement that much information has been deleted from the National Diabetes Information Clearinghouse and even they are suspicious about what has been deleted and not added. All of the warnings required in the product packages have been removed and several products that had warnings, but are still on the market like Victoza that is no longer on the site.

The correspondence has been open and they appreciated that I was giving URLs for information on my side. We had some good discussions about a few studies and when they referenced one study, I asked why they would rely on junk science. I sent the URL to my blog on the study and another blog by someone else calling this junk science. Just testing was the response and then the discussions got serious. When I did not have access to a study, but only the abstract, I told them this. Occasionally, I was able to provide other blogs on the topic.

Rather than make this a very long blog, read this article in WebMD about overcoming objections to injections.

October 13, 2014

Doctors Whine about Non-compliant Patients

The way doctors whine about non-compliant patients is sickening! Every time they point a finger at a patient, they should remember there are probably three fingers pointing back at them. Yes, I said this and hopefully I can provide some insight. Admittedly, there are some patients that no doctor can help, but many more are just plain tired to their doctor's attitude. Because this Medscape article used the example of A1cs, I will use patients with type 2 diabetes.

Some reasons that good patients are non-compliant:
#1. The doctor is too paternalistic. These doctors have all the answers and will tell you they do not have time for education, no time for talking with the patient, and no time to instruct patients. For these doctors, it is a revolving door and they make more money this way. They will deny missed diagnoses and unhappy patients, but they insist that they have overhead to cover. Do some observations and you will notice too many employees sitting and gossiping, doing nothing and in general, not working. Efficient offices are the exception to this and they are few and far between.

#2. Too often referrals are made to dietitians that promote food plans of whole grains, high carbohydrates, and low fat. Most people with type 2 diabetes on oral medications cannot tolerate these food plans. Even patients with type 2 diabetes on insulin cannot or should not tolerate these food plans. Plus, many are not prescribed a high enough dose of the medication or combination of medications to handle the high level of carbohydrates. Then it is small wonder that the A1c levels show non-compliance. Patients then become discouraged and the A1cs tend to climb.

#3. The doctor does not compliment or encourage small successes. Too often the doctor is the one setting the goals and these are often unattainable because they are too high and could take most patients six to 12 months. If they were reasonable three month goals and reasonably attainable, then if the patient has input into setting the goals and is complimented when they achieve the goals, they are more likely to work harder for the next goal. Positive reinforcement is generally not forthcoming from many doctors.

#4. Very few doctors provide informative websites for reliable information. This is their shame and could be very informative and helpful to many patients. Yes, this would require some effort, but often the people working for them could gather much of the information for them to review and put together lists of URLs for each disease or illness. However, the cheapskates won't do this because it will not bring in money. What they may be missing out on is patient satisfaction which may influence the monies they receive in the future.

#5. Many doctors are beginning not to serve non-compliant patients. Yes, some doctors are so worried about losing money that they are refusing to be a doctor to patients they deem as non-compliant. They are only interested in passive patients that will follow their orders and not patients that are proactive and desire to have an input into their treatment. Am I being too harsh? I don't think so, as I am seeing this with many people that I am talking with that are receiving notices from their now former doctors asking them not to come back.

There are a few doctors that are realizing that the landscape is changing and are changing the way they are working with patients. One doctor recently started carefully diagnosing patients at risk for diabetes and is catching more patients with prediabetes and working with them to help them delay or possibly avoid the progression to type 2 diabetes. He is researching and working to help his patients. He is encouraging them to make lifestyle changes and has hired a nutritionist to assist his office and two other offices to help with food changes.

How do I know, because the support groups in our town are all feeling the pressures as he is encouraging his pre- and diabetes patients to join a support group. Even a couple of other supports groups are getting requests in towns around us. We are surprised because all the doctors are cooperating and even encouraging us to make room for his patients. The other doctors have also asked him to start a support group for prediabetes patients. More on this as we become aware of events.

October 12, 2014

Our Meeting with Jerry's Son

We were happy to meet Jerry's son. We were surprised by his questions, as he seemed more knowledgeable about diabetes than we had expected. He let us be surprised until he told us that his wife had type 2 diabetes and that both of her parents had type 2 diabetes.

He said that he was eating better on the food plan that his wife was eating and he described it as low carb. He said they have about 5 to 10 percent carbs, 50 to 75 percent fat, and approximately 20 to 50 percent protein. He and his wife vary the food plan on a daily basis but try to maintain less that 60 grams of carbohydrates every day. He said they also have a food scale and use it all the time. He admitted that on days they when they can exercise together, they do allow up to 80 grams of carbohydrates for treats, especially some fruits.

He added that her parents use a similar food plan and that both of them are using insulin. Her dad is a retired veteran, her mother is a retired nurse, and they have a house on one level and use an electric chair lift to use the basement. He said that his wife had diabetes before either of her parents and her dad was the last to develop diabetes.

We then asked him who had developed the food plan and he said her mother was the one that had encouraged the food plan as the hospital she worked for was having success with the food plan. She knew that the nutritionist they had was promoting it, even with a dietitian on staff who was promoting high carb with whole grains. When the food plan by the nutritionist worked so well for those with diabetes, they let the dietitian go.

Jerry said that was why his son wanted to talk to him about the food plan until he found out that he was already on a similar food plan and was so far along with learning to cook. Jerry's son asked who had supplied the cookbooks with the nutritional information. Jerry said I had and he wondered where he could find them and his son would get them for him.

I told them that it might be difficult as I have been looking for them and have not seen any after the edition I have. I added that I have not contacted the publisher and it might be wise to photocopy the address and phone number, if any. We looked, but found nothing of use and I asked what bookstores were available to them. He rattled off three of which I knew about two and I suggested that he look in the stores for the loose-leaf cookbooks. Because they would be cellophane sealed and he would need to tell them why he wanted the seal broken. If they break the seal, then they will reseal it if it does not contain the information you are looking for.

I then asked for the email address for Jerry's son and Jerry said he would send it to me later. I said I have one or two more cookbooks with nutritional information and would send his son the titles. Jerry asked if he could look at them first. I took my leave, went home to get them, and brought them back. Jerry and his son looked both over and Jerry said not one of them, but definitely the other one. His son continued looking at the one Jerry had rejected and said he wanted to have his wife look at it in the bookstore. They went to Jerry's printer, made copies of several pages, and gave me back the two books. Jerry asked to keep the two cookbooks he had been using until he knew they were or were not available. I agreed and we went back to other discussions.

Jerry's son thanked all of us for supporting his father when he needed it. He said his mother had talked to his wife and said she knew people were working to separate them, but she had foiled them to that point, but she could not know when they might succeed. Jerry said that when A.J approached him, he was finally convinced he needed help and cooperated with him.

Jerry said his talk with Dr. Tom was hard to swallow, but he knew Dr. Tom was telling him the truth and like it or not, he needed to make some changes if he wanted to manage his diabetes and not die from the complications if his A1c continued upward.
At that point, Barry asked why he had not believed him. Jerry said he had created some doubts and until A.J approached him and knew he should leave then. Jerry told Barry it was his creating doubt that meant they were successful, and for the right reason.

At that point, Tim and I said good night and left.