May 16, 2015

Neuropathy Not Caused By Diabetes

This article is titled for sensationalism, but may be a breakthrough to jolt researchers out of their lethargy. I say this because I feel that another study needs to be done to prove the conclusion. If it turns out to be true, then this is a great conclusion. Yes, I know that vitamin B12 deficiency causes neuropathy, but other deficiencies also contribute to neuropathy, vitamin D being one of them.

This article also talks about other medications that can cause neuropathy. The two medications are often prescribed for treatment of GERD (gastroesophageal reflux disease). The two are histamine H2-receptor antagonists (H2RAs) or proton pump inhibitors (PPIs).

First, this is a brief discussion of the relationship of metformin and vitamin B12. People who have been on metformin have shown a malabsorption of vitamin B-12. People with diabetes being treated with metformin tend to have a lower vitamin B-12 level and worse diabetic neuropathy than patients on other oral therapies. The proposed mechanisms of metformin-induced vitamin B-12 deficiency include a decrease in bile acid secretion resulting in bacterial overgrown that decreases intestinal absorption, decreased intrinsic factor secretion, and decreased absorption due to metformin's antagonism of cell surface receptors in the ileum. Supplementation of vitamin B-12, cessation of metformin therapy, administration of doxycycline, and oral calcium supplement, have all been shown to improve vitamin B-12 levels.

Now, this is a brief discussion of the prescriptions for GERD. H2RAs and PPIs have been documented to interfere with vitamin B-12 absorption, showing a 53% drop in protein-bound vitamin B-12 absorption with H2RA. In one study with ranitidine, the decrease in absorption was shown to be 89%. It should be noted that unbound vitamin B-12 (i.e. vitamin B-12 supplements) can be absorbed with H2RAs, but protein-bound vitamin B-12 found from food sources are not fully absorbed. The mechanism of interference has been attributed to the decrease in gastric acid, pepsin, and intrinsic factor output; however, improvement in vitamin B-12 levels can be obtained with vitamin B-12 supplementation and cessation of H2RAs and PPIs therapy.

Vitamin B-12 has several important roles in the human body, and the signs and symptoms of vitamin B-12 deficiency can easily be mistaken for diabetic neuropathy. These signs and symptoms include: paresthesias (an abnormal sensation, as prickling, itching, etc.); diminished sensation, proprioception (awareness of the position of one's body) and nerve conduction; loss of cutaneous sensation; muscle weakness; abnormal reflexes; incontinence; loss of vision; and axonal degeneration. Several studies have shown that vitamin B-12 supplementation, alone or concomitant with other agents, has improve multiple aspects of diabetic neuropathy, such as cutaneous sensitivity, pain, paresthesia, nerve conduction, and autonomic symptoms.

Metformin, H2RA, and PPI are known independently to result in a B-12 deficiency. When combined together, it has an additive effect; therefore, it is important to recognize the potential of neuropathy due to the combination of these drug therapies. Patients and doctors should be aware of this polypharmacy-induced vitamin B-12 deficiency and its potential for neuropathy, especially in the type 2 diabetes patient population with GERD. Patients and healthcare providers should also be aware of the strategies to correct this deficiency.

I contacted Allen and Barry and we did a survey of the group and only two of the group were taking metformin and a PPI and outside of a few of us that were aware of metformin causing problems, no one was aware of the GERD medications also being causes of neuropathy. This eased our minds, but we know we needed more information

May 15, 2015

Asante Ceases Operations, Asks Animas To Transition Customers

I don't normally do this, but this is important for owners of Asante "Snap" insulin pumps and even if few people with type 2 diabetes might be using one, this needs to be brought to every one's attention.  The following is from an email I received 7:32 PM CDT.

On behalf of Johnson & Johnson Diabetes Solutions Companies (JJDSC), we wanted to share with you some important industry news.  Today at 5:30 PM PST, Asante Solutions announced to its customers via email that it is ceasing all business operations and will no longer sell or support the Asante Snap Insulin Pump.  This means all current Asante Snap Insulin Pump users will soon need to transition to a new insulin pump.

Just before this announcement, the leadership of Asante specifically asked Animas to assist their customers through this transition, and we’ve agreed to help.  We understand how disappointing and frustrating it can be for patients to unexpectedly have to go through the process of finding a new insulin pump and company that will meet their needs. 

Our goal is to help every Asante Snap Insulin Pump user receive a new Animas Insulin Pump as quickly and easily as possible. 

To start the process of receiving a replacement Animas Insulin Pump, we are asking all Asante Snap pump patients to call toll free 1-877-937-7867 X1562.  Our Customer Care Representatives are available to assist them MondayFriday, 8:00 AM – 8:00 PM EST.

In order to reach as many Asante Snap customers as possible, we would appreciate you sharing information about this replacement program with your readers/followers.

Because this is such a new development, we are continuing to work through the details of this replacement program while we begin to help Asante Snap customers through their transition. Please be patient if we are not able to answer all of your questions about the program at this time.  More information will be provided as soon as it is available.  In the interim, you can direct any questions to JJDSC Communications Director Dave Detmers via the contact information below.

The JJDSC Communications Team

Dave Detmers
Director, Communications
Johnson & Johnson Diabetes Solutions Companies

Or you can go to the Asante website here and read the announcement.

Which Is Best, Paternalistic or Maternalistic Care?

Be careful with this choice, as both can be good and both equally bad. The author of this is a woman doctor and she feels maternalistic care should be better. I have experience with both and there are advantages to either male or female doctors and there are some very serious disadvantages. Some doctors have advantages based on the type of medicine they practice.

Problems for both sexes:
  1. Avoid either sex when the doctor talks at you or leaves you out of the discussion.
  2. Avoid either sex when the doctor hands you a prescription without any explanation.
  3. Avoid either sex when the doctor fails to give you clear instructions about medication side effects.
  4. Avoid either sex when the doctor does not give you a copy of your lab results and does not explain them to you.
  5. Avoid either sex when the doctor does not listen to you about the problem you are trying to explain. Keep to the facts as you know them and don't add drama to the facts.
  6. Avoid either sex when they bully you or boss you around to get the results they desire. Avoid tests when they will not explain the purpose or reason for the test.
There are many more chilling effects that the doctor can have on the doctor-patient relationship that should have you seeking another doctor. There are doctors that are plainly bad doctors, yet are still practicing medicine.

Always remember that you have little time with the doctor and if they waste the time or fail with many of the above items, seriously consider finding another doctor. Make sure they are interested in your health and providing the best care. However, remember that what you may think is the best care, may not be best for you and they should explain this to you. You also have the responsibility to listen to the doctor and then ask questions if you do not understand what you are being told.

The author uses an analogy that leaves me cold and wanting to avoid her. I am a human being with wants and needs and not a baby chick in a brood of patients for her to watch over. If she were with me every day and making sure that my medical needs were provided for on a daily basis, then I might not be so opposed the her analogy.

She says she has been taught that paternalism is not good, but feels that maternalism is the softer side and it is okay. To me they are equal and often damaging to the patient. I disagree with the author when she says maternalistic physicians do not dictate the their patients, but guide them gently in what they think best. This is the same as paternalism and you cannot separate them.

If they are good doctors, they will not be maternalistic or paternalistic, but just good doctors. They will accomplish many of the following:
  1. Good doctors will give patients autonomy, never make them feel alone, or unsupported in their care.
  2. Good doctors will care for the patient as a whole and not just the illness or problem. This will be regardless of the faults or weaknesses of the patient.
  3. Good doctors will reassure the patient they will be there for what ever they decide.
  4. Good doctors will acknowledge the patient as the unique person they are and treat them as such.

The last item above separates good doctors from poor doctors, and are the most difficult to find. Many doctors attempt to put themselves on the pedestal, but it is the great doctors that patients elevate to the pedestal. Yet it is these great doctors that know how to step off the pedestal and care for their patients as the humans they are, despite their uniqueness.

May 14, 2015

A Hospital Trap to Avoid

More and more people are being lured into this trap every day and the hospitals are doing this to raise revenue. Just be careful when being admitted to a hospital. You won't know until you get the bill that you were admitted on an observation status instead of an inpatient status. What is the difference you ask?

Inpatient means that your insurance will be billed and you may have a copay. Observation status means that your insurance won't be billed and the full bill will be yours to pay since you were considered an “outpatient.” The hospitals can change your status at any time without notifying you of the change and this makes it more difficult for you to dispute the charges.

A study released by Brown University in mid-2012 showed that across the United States, hospital admissions had decreased slightly even though the population of Medicare patients had risen. It also showed that patients kept under observational status had increased 25%. Further, those who were kept under observation status, on average, were staying longer than ever before - up to 72 hours without being admitted. These statistics led experts to try to explain why so few patients were being admitted.

Hospitals make money on patients they assign to observational status and they know what they are doing. If a patient is assigned observational status, then he/she is considered an "outpatient," meaning that he/she is not admitted to the hospital. It can be very lucrative for the hospital to assign that patient outpatient status without formally admitting him/her. Here's how:
  1. Some insurance companies, including Medicare, don't consider observation status as an admission, and therefore won't cover the cost as they would if the patient was hospitalized. That means the patient can be charged cash for their visit. The cash payment for an outpatient visit is far higher than reimbursement from insurance for an admitted patient's stay because, of course, insurance companies negotiate far lower rates for the patients they pay for.
  2. Medicare does not totally reimburse hospitals for patients who are readmitted within 30 days of leaving the hospital previously. That means that if a Medicare patient was hospitalized, then sent home, and reappears in the emergency room within 30 days, the hospital will be penalized for the readmission. By putting a patient on observational status, they avoid the penalty, and they can charge the patient cash, too.
Once the hospital makes the status observational there are problems for most patients.
  1. The out-of-pocket costs are higher. Particularly for Medicare patients - if they aren't admitted to the hospital, even if they stay there, the hospital can charge them for many things Medicare doesn't cover if Part B coverage is used. The latest ruling (2014) from CMS says that Medicare patients must be formally admitted, and stay in the hospital overnight for two midnights.

  2. Medical care can be compromised. Hospital stays are so short these days because insurance reimbursements are so low once a patient gets past a certain point in his/her care. That means there are some patients who are being sent home too early. If they begin to get sick again, or find themselves in unmanageable pain, they will try to return to the hospital. But if the hospital is reluctant to admit them, those patients may not get the care they need. The "observation status" designation can compromise the care they get because they have not been fully admitted to the hospital and are therefore not fully part of the hospital process of caring for patients.

  3. Medicare patients who must be admitted to a nursing home are required to be fully hospitalized prior to nursing home admission if they expect Medicare to pay for their nursing home stay. If a patient had been put on observation status instead of fully admitted, then there will be no nursing home reimbursement - that can amount to hundreds of thousands or more. If Medicare is to cover any nursing home costs, the patient must be formally admitted to the hospital for at least three midnights (not the same rule as the two-midnight rule mentioned above.)
This addresses only Medicare patients, however, if your healthcare is covered by a private payer, or another government payer (Tricare, Medicaid) then you would be wise to check with them to find out if your observation status is covered. As time goes on, this policy of not paying for observation status may become a trick used by all payers - and hospitals - to offset lower reimbursements.

Hospitals are becoming more creative in the way they treat patients and with the bonuses they are paying the executive officers, they will continue to harm the patients. If not medical harm, the hospitals will cause financial harm.

May 13, 2015

Diabetes Diet Myths – Part 3

The last two diabetes myths are:
I find the last two myths seem to bother newly diagnosed people with diabetes. With that said, here they are.

Myth 9 No, there is not a special diabetes diet. What the person with diabetes needs to eat is also healthy for the rest of the family. This eliminates the need to prepare special meals for the person with diabetes. It is true that the person with diabetes needs to be more careful and carefully monitor what they consume. This monitoring means counting the carbs consumed, knowing the types of carbohydrates, fats, and protein consumed. Again, a nutritionist can be of great assistance in helping the person with diabetes.

I do keep meeting people that ask about why they are not told about the special diabetes diet they should be eating. First, I make it clear that there is not a special diabetes food plan for everyone. I then explain that they have to develop their own food plan based (and this is important) on what their meter tells them. Admittedly, some will never do this, but some have said they cannot afford the extra test strips. I tell them to contact the manufacturer and follow their instruction for assistance. I seldom find out if they do this.

Myth 10 No, diet foods are often not the best choice for people with diabetes. They are often more expensive and not as healthy as the foods in the regular sections of the grocery store. And they are not as nutritious as the foods you prepare yourself. Do yourself a favor and read the labels and the ingredients on the foods to find out the number of carbohydrates per serving and the other nutritional information. Also do not forget that a nutritionist can be of help.

No, I did not say a dietitian or a certified diabetes educator because generally they are influenced by a commercial food company or promote a food plan that will contain whole grains (especially wheat) and too many carbohydrates.

Other points beyond diabetes myths. Forget about the word “diet” and think food plan or meal plan that works for you and that you know from your meter will satisfy the needs of your body. Then by combining your food plan with the exercise that works or you and the medications your doctor prescribes for you, you should have an effective tool for maintaining your blood glucose levels within the range your have set for yourself. This is the best plan for you and not a “one-size-fits-all” plan from a dietitian.

If you have been reading the sections in the WebMD article, you will know that they recommend a dietitian. In my experience with dietitians, they do not work at the individual level and generally work at the “one-size-fits-all” level. The nutritionist is generally better educated and has more knowledge about nutrition and work with each individual at their level to develop the food plan that works for them. Then they will generally show you how to adapt the food plan to fit changes that your meter indicates.

In addition, they will show you how to balance your food plan to avoid the vitamin and mineral shortages that the dietitians insist you will have when eliminating wheat from your food plan. Some will find that they don't need to eliminate all whole grains while others will find this necessary.

May 12, 2015

Diabetes Diet Myths – Part 2

Continued from the prior blog.

Developing your own meal plan is important. Often your meal plan can be a family meal plan or can be modified slightly to satisfy the family without extra cooking or work. Some family members may fuss and complain, but a healthy food plan is a must. Learn for yourself what your blood glucose testing tells you about the food.

The list in this blog includes:

Myth 5 This is definitely not a plan and can lead to problems. Yes, you should learn how to count carbs and inject insulin to cover the meal, but this is not a license to eat as more than your meter says is okay or to over treat yourself and cover the excess with insulin.

If you use oral diabetes medications, matching the extra food will generally not work. Unless your doctor gives you special instructions to do this (and most will not), do not do harm by attempting to adjust them yourself. Generally, diabetes medications work best if taken consistently and as directed by your doctor.

Myth 6 This is one I hear all the time and people complain and complain about having to stop eating their favorite foods. Sometimes this is necessary, and for some people, but for those that are comfortable with food, they are able to adapt. Sometimes the change is simple and with some foods, it can take a lot of planning and experimenting.

I often suggest several of the following for foods you love. Try these tips:
  • Changing the way your favorite foods are prepared.
  • Changing the other foods you usually eat along with your favorite foods.
  • Reducing the serving sizes of your favorite foods.
  • Using your favorite foods as a reward for following your meal plans.
A nutritionist, or a great chef, can help you find ways to include your favorites in your diabetes meal plans.

Myth 7 This is one many refuse to give up and it can destroy your food plan and make diabetes more difficult to manage. If they want the desserts, then they need to take the steps necessary to make it possible.

Here are some ways that you can have your cake and eat it, too:
  • Use artificial sweeteners.
  • Practice portion control. Instead of two scoops of ice cream, have one. Or share a dessert with a friend.
  • Use desserts as an occasional reward for following your meal plan.
  • Make desserts more nutritious. Eat fresh fruit if possible when preparing desserts. Many times, you can use less sugar than a recipe calls for without sacrificing taste or consistency.
  • Expand your horizons. Instead of ice cream, pie, or cake, try fruit, or yogurt.
Myth 8 Even though I don't totally agree, the American Diabetes Association approves the use of several artificial sweeteners in diabetes diets, including:
  • Saccharin (Sweet'N Low, Sweet Twin, Sugar Twin)
  • Aspartame (NutraSweet, Equal)
  • Acesulfame potassium (Sunett, Sweet One)
  • Sucralose (Splenda)
  • Stevia/Rebaudioside ( A Sweet Leaf, Sun Crystals, Steviva, truvia, PureVia)
A nutritionist can help you determine which sweeteners are best for which uses, whether in coffee, baking, or cooking. Artificial sweeteners are much sweeter than the equivalent amount of sugar, so it takes less of them to get the same sweetness found in sugar. This can result in eating fewer calories than when you use sugar. Artificial sweeteners have received much attention from the media and researchers. The sad news is opinions about them are conflicting.

To be concluded in the next blog.

May 11, 2015

Diabetes Diet Myths – Part 1

When doctors write about diabetes myths or discuss them, I sincerely wish they would realize the problems they create. This article in WebMD is a typical example of what the doctors don't take into consideration.

They list ten diabetes diet myths and in general have some validity, but do not consider everything. The list in this blog includes:
Yes, I am leaving them active for those that want to read them as they are covered.

Myth 1 is about sugar and poorly explained. Quote: “Simply eating too much sugar is unlikely to cause diabetes. Instead, diabetes begins when something disrupts your body's ability to turn the food you eat into energy.” Unquote. This much is true, but does not account for genetics, environment, or exposure to other causes. Certain medications or chemicals can also cause diabetes and most writers totally ignore what steroids can do to people with a pancreas that is already in trouble.

The fact that the pancreas is aging and not working as efficiently as it once did, or that insulin resistance has increased is seldom mentioned. Yes, glucose is needed by the cells for fuel, but even sugar needs to be converted.

Myth 2 is totally false as there are no rules for a diabetes diet, only what your meter tells you and you need to develop your own food plan. Having diabetes simply means that you will need to plan your meals and what you consume around your activities and medications. Yes, you will probably need to make changes in the quantity of food you eat.

Your aim is to maintain your blood glucose levels near normal for the long term. Yes, you should consider making some adjustments, but your food plan may not require as many changes as you thought, just decreasing to quantity may suffice.

Myth 3 In fact, carbohydrates (or "carbs," as most of us call them) should be limited for those of us with diabetes. They form the foundation of an unhealthy diabetes diet, or of any diet. Mostly, carbohydrate-rich foods, especially wheat and whole grains are creating much of the overweight/obesity problem in the United States today. Carbs have the greatest effect on blood glucose levels, which is why a diabetes diet asks you to monitor how many of them you eat. They also contain vitamins, minerals, and fiber; however, these are found in other foods, and often at higher levels. So choose those with the most nutrients, high-fiber fruits, and vegetables. You may find it easier to select the best carbs if you meet with a nutritionist.

Myth 4 Yes, carbohydrates often cause your blood glucose levels to rise rapidly. That is why you should consider adding more protein and fat to your food plan. Many dietitians and doctors warn about too much protein and discourage red meat, as they still believe in the myth about saturated fat. Because everyone is different, you should talk to a nutritionist or a knowledgeable doctor about whether you may have problems with too much protein or adding too much fat to your meal plan. These are large variables and your meal plan needs to be tailored to your needs. Be careful of anyone using a “one-size-fits-all” approach. Remember you are unique and this will not necessarily work for you.

Continued in the next blog.

May 10, 2015

Preventing an Insulin Overdose – Part 2

If you happen to push your blood glucose level too high, be concerned, but don't panic, as if it is only for a short time, it will not cause damage. However, a very low blood glucose level can cause damage. Again, I must emphasize that it is necessary to educate family members of actions needed if you become unconscious, very confused, or have seizures. I would urge anyone on insulin or the oral medication mentioned in the last blog to give family or friends the following instructions:
  • If you lose consciousness, they should call 911 immediately.
  • They may need to inject you with glucagon, an insulin antidote. If you’re prone to low blood sugar, ask your doctor if you should have glucagon on hand at home. This is important and should not be ignored.
  • If you're alert enough to follow instructions, they should give you sweet juice to drink.
  • If your symptoms don't steadily improve over the next hour, they should call 911.
To prevent or avoid hypoglycemic episodes, for oral medications:
  1. Know when to take a medication.
  2. If you are not feeling well and will not be eating does the doctor recommend not taking the medication?
  3. Is there a blood glucose level that the doctor would have you take the medication?
If you are using insulin, consider the following:
  1. Try to keep a consistent routine or schedule.
  2. Eat something at every mealtime. Even if you are not hungry, have some bread, a glass of milk, or a small serving of fruit. Because everyone insists you eat, they also insist taking your insulin to force you to eat. If you are ill or sick, food may not stay down; not injecting fast acting insulin would be your only choice. This should be based on your blood glucose level, as sometimes your illness will increase your blood glucose levels.
  3. Be prepared for all possibilities by keeping glucose tablets or hard candies available in your bag and your partner's. Keep some in the car, at work, at home, and your travel bag.
  4. Educate friends and family how you react to hypoglycemia and how to react and take action if you are confused or show signs of hypoglycemia. Calling 911 may be the only choice.
  5. Wear a medical alert bracelet or other alert jewelry that says you use insulin and are a person with type 1 or type 2 diabetes.
Many people can learn from reading Dr. Bernstein's book, Diabetes Solutions, and this is true for all people using insulin or oral medications that can cause hypoglycemia.

One word of warning, all oral medications in combination with insulin can cause hypoglycemia. Often the dose size of oral medications needs to be reduced when insulin is in the mix. Talking to your doctor is always a good thing.