June 26, 2015

Mild Compression Socks Safe for Diabetic Limb Edema

I don't know what it is lately, but the last few days have brought me topics that I had not expected. This topic is very much something I deal with on a daily basis. I found mild compression socks about six years ago and decided to buy a dozen pair. I have never regretted this decision, even with a few that lose their hold at the top, and work their way down my leg during the day. About two years ago, I added another dozen pair.

And yes, I have the edema in my legs which can make my shoes become very snug late in the day. I was very happy to read this article in Medscape and I read it several times.

Yes, I have been concerned about wearing them, but I fortunately I have had no problems. Since I have neuropathy in my feet plus the edema, I do fit the area of concerns by the researchers. They were concerned before the study about the compression being harmful. They did discover in the study that that there was a significant decrease in calf and ankle circumference, without vascularity being compromised. Great news!

In addition, skin-perfusion pressure significantly increased in the group treated with the compression socks, indicating that microvascular circulation may have improved with mild compression.

James Wrobel, DPM, from the University of Michigan Medical School, Ann Arbor, Michigan says, “This is an interesting study that adds more clarity in this area.” He said the results would encourage him to use mild compression socks more frequently in patients with diabetes with clinically significant peripheral arterial disease.

"Using compression stockings can help with fatigue and cramping associated with edema in the lower extremities and may also help with long-term venous health," he added.

Edema is a risk factor for venous and diabetes-related foot ulcers among patients with diabetes, as well as being implicated in reducing healing for existing diabetes-related foot ulcers,” said Dr. Wrobel.

But although the standard treatment for lower-extremity edema is compression therapy, at a graded pressure of 35 to 45 mm Hg, this has traditionally been avoided in people with diabetes, Ms Branigan told meeting attendees. Instead, noncompression stockings have been advocated for such patients. Michelle Branigan, from Scholl College of Podiatric Medicine at Rosalind Franklin University, Chicago, Illinois, said, “A
prior pilot study of mild compression diabetic stockings (18 to 25 mm Hg) used in 20 subjects with diabetes and lower-extremity edema, published in 2012, indicated that this approach significantly reduced calf and foot circumference and significantly improved the ankle-brachial index, Ms Branigan explained. In addition, cutaneous edema was significantly decreased and overall lower extremity edema was reduced without compromising vascularity.”

Dr Branigan concluded, "Mild compression diabetic socks may be safely used in diabetes patients with mild to moderate lower-extremity edema."

This Medscape article says more and I really enjoyed reading it.

June 25, 2015

The Diabetes Education Follies – Part 4

Dr. Robert Ratner, chief scientific and medical officer for the ADA says, “Many people with type 2 diabetes who are on medications don't need to do home glucose monitoring at all," in talking about oral medications. Dr. Ratner must be muttering to himself now that the joint statement by the American Diabetes Association (ADA), The American Association of Diabetes Educators (AADE), and The Academy of Nutrition and Dietetics (AND) focuses primarily on type 2 diabetes.

Dr. Ratner is the person many doctors quote when they won't recommend testing supplies and has enjoyed a position of high esteem among these physicians. Unfortunately, he will maintain this position because very few CDEs will be doing education for people with type 2 diabetes. The few that may receive education will be among the 20 to 25 percent of type 2 people using insulin in the larger metropolitan areas.

In the conversation with my cousin Beverly, she asked why CDEs do not teach DSME to type 2 people on oral medication. I explained about Dr. Ratner and his statement and that CDEs will generally not teach even self-monitoring of blood glucose (SMBG) which is part of diabetes self-management education. Her husband Tom asked how the support group knew so much about it. I said because we have done our research and learned this by working with each other. I took time to show him Alan Shanley's blogs on the same topic and he bookmarked his blog for reading later.

Beverly said there is a lot of need for CDEs is this area, and I agreed. I said with three community colleges and four colleges in about an hour's drive, there is a great need even among type 1 people. I said that there are several type 2 diabetes support groups, but I am not aware of any type 1 diabetes support groups. Tom admitted that he felt most comfortable with our group even with most being older them him. He said it is probably because you accept people as they are and are not afraid to take on any topic. I thanked him and said we have had some growing pains and the last three weeks have been nail-biting, but we survived and now the summer is here and we will not have any meetings until September.

I told Tom that depending on his schedule, we could get together a few times and discuss different issues, or we could do most of it via email. Beverly then dropped a bomb on both of us. She said that the hospital had asked her to earn her CDE certificate because the two nurses that had certificates were retiring later this fall and they would be without a CDE. She said one of them really hadn't done much CDE work for the last two years. She concluded that the hospital would pay for her additional education and testing.

I told Beverly that as long as she could put up with my bias and not be upset with the comments I might make, that she should go for it if she had interest in doing it. Beverly said she had talked with the other CDE cousin that was not talking to me and felt that it could be interesting. We talked about the second CDE organization and I had her read a few of my blogs about it. She said that the seemingly exclusive attitude was a problem for her as she would be teaching a lot to Tom and she liked the peer mentor or peer-to-peer worker ideas I had promoted. At that point, Tom suggested that they needed to leave and they did.

June 24, 2015

The Diabetes Education Follies – Part 3

When it comes to certified diabetes educators (CDEs), there has been much controversy over the last several years. A few of the things I have noticed may have changed a little, but there are continuing problems. First, there needs to be better continuing education. Most CDEs have good formal education. They stay up-to-date about most of the equipment and some studies, but many CDEs are still lacking key pieces of information. Many do stay current with the latest changes in the American Diabetes Association guidance, but others seem to be stuck in the past and therefore make recommendations and mandates that are not always in the best interest of the patients.

One question I have asked that still begs an answer is - does the AADE have a procedure for filing complaints about CDEs that give outdated advice or that do not work with patients? Then what do we do about those CDEs that cannot be civil when you ask a question that they do not like?

My next unanswered question is - what are they doing to help people with depression? Many CDEs seem very lost when this topic is brought up. Their eyes glaze over; they attempt to change the subject or do their best to divert the conversation away from the topic. Some even leave the appointment.

My last question is - are they going to allow people to use lower carb diets? Many, but not all are stuck on having people eat 60 carbs per meal and telling us that we are harming ourselves if we eat less that their mandated amount. Even the ADA has moved away from the mandate of 60 carbs per meal. For most of the CDEs I have met, this seems to be a mantra.

I am very upset about another problem that has been happening since the formation of a new CDE organization. It is serious enough at present, but with the activities of one certified diabetes educator group and their activities in opposing anyone being able to assist in education, it will become worse. This group is declaring that only CDEs are capable of giving this education and others are not capable is the height of being conceited. With both CDE organizations unwilling to use telemedicine or group education, education will become a short commodity, especially with the recent joint statement.

I will give credit where credit is due and that is many doctors in rural areas are taking diabetes patients that are willing and giving them education about diabetes to work for them as peer mentors or peer-to-peer workers. I have even been pleasantly surprised by the response I have received from the two doctors in Kansas that I have volunteered for as a peer mentor in the past. They are having many of their patients ask me questions via email because they are not getting many questions answered by the telemedicine operation in Kansas. Time seems to be a constraint.

No help is being provided by our government to encourage diet change. The USDA keeps promoting whole grains and other high carbohydrate foods instead of low carbohydrate, medium to high fat nutrition. We also have the corn and wheat organizations influencing the registered dietitians to promote this as well.

This has really put a burr in my saddle. Doctors, in their jaded wisdom, have coined the term "diabesity" to reflect the combined effects of the diabetes and obesity epidemics. They claim that the two go hand-in-hand, but give no reason for those obese patients without diabetes. And why should those people that are thin and diagnosed with type 2 diabetes need to put up with these prejudiced doctors. Plus these same doctors are not doing anything to educate patients or applying pressure to our government to change the nutrition of the population.

Lastly, I want to question the futurefor the CDEs. Is there a future for the American Association of Diabetes Educators (AADE)? Not if the Academy of Certified Diabetes Educators (ACDE) has anything to say about it. At present, they both have members that have taken the test given by the National Certification Board for Diabetes Educators (NCBDE) and passed it. The ACDE is taking the exclusive route and not allowing honorary membership and is lobbying hard in a few states to prohibit anyone with knowledge of diabetes from passing this on to other people with diabetes. This includes peer-to-peer diabetes workers, peer diabetes mentors, diabetes coaches, and others. Fortunately, one state had defeated their bill. A second state put the bill on hold and it will be reintroduced next year.

June 23, 2015

The Diabetes Education Follies – Part 2

A phrase that Brian Cohen enlightened me with during the last week is "treat to failure" protocol of medications and many other aspects of diabetes. Thank you, Brian! Now I won't blame every doctor, as there are some that will prescribe insulin early and will actually work with patients to improve their health. It is unfortunate that most doctors do treat to failure and then belittle their patients and accuse them of failing when it is the doctors that have failed us.

Now granted, we could have been more informed and insisted that the doctors prescribe insulin, but even with this, most will not and will continue to blame us for their failure as doctors. Yes, I am on a rant and for good reason. This goes back to the recent ADA Scientific Session in Boston, which I did not attend. The joint statement issued by the American Diabetes Association (ADA), The American Association of Diabetes Educators (AADE), and The Academy of Nutrition and Dietetics (AND) is touted as the end-all, one-size-fits-all solution for our diabetes education woes. Not likely, is my response.

With approximately 30 million type 2 diabetes patients and at most about 18,000 CDEs, I will use the number of CDEs from the AADE 2015 Fact Sheet which states there is more than 14,000 CDEs. This means that for this many patients each CDE could spend one hour with all but 103 patients using 14,000. Let me explain why this will not happen. There are many retired CDEs, many are only working part-time, others are writing books and on book signing tours, and this does not even count those not working as CDEs. Many CDEs will only work with type 1 patients and this leaves those with prediabetes unserved.

From the AADE fact sheet (a PDF file) 61 percent are nurses, 11 percent are pharmacists, 25 percent are dietitians, and 3 percent are other health professionals. This means that most are required to work in their primary profession to earn a living. As such, CDEs seldom work with any diabetes patients other than those with type 1 diabetes. I have learned more on my own and from a nurse practitioner than from a CDE. Even my non-CDE pharmacist has given me good diabetes information. I have a second cousin that is a CDE, but we don't talk anymore because of my bias.

In the area of Iowa where I live, there are a few CDEs, but mostly they are working for hospitals and a couple of diabetes clinics. There are a few others, but not in the immediate area. My wife surprisingly received a good deal of her education from a nurse/registered dietitian. This did take me by surprise and the education was much better than I had expected her to receive. Carbohydrates were not pushed, but actually discouraged. Most fat was also discouraged, but not totally.

June 22, 2015

The Diabetes Education Follies – Part 1

When I wrote this blog, I did use the word 'may' instead of 'will' and the more I am seeing and hearing, I am very happy that I was cautious. My wife does not believe me, but I overheard two women talking while waiting for my wife to get a few groceries. They did not notice I was sitting in the car and how they missed me, I do not know. Or they could have just figured he is elderly and won't understand what we are talking about.

First they was talking about the joint statement (a PDF file) issued by the American Diabetes Association (ADA), The American Association of Diabetes Educators (AADE), and The Academy of Nutrition and Dietetics (AND). One mentioned that as long as she does not receive any direction from the headquarters, she will be happy. The other said she was happy not taking referrals and felt that she always received the worst patients when she was taking them. She continued that now she did not have to worry about what she said, as she probably would be in disagreement with the doctor in his promotion of low to medium carb, medium fat to high fat.

The other woman said that most do not understand how important whole grains are and said some are saying they can get the micronutrients from other foods. The other agreed and said that without referrals she does not need to teach anything about diabetes and does not like the fat people with type 2 diabetes. Other people were coming to the cars and the two ended their conversation and got into their cars and left. I guess I am fortunate not to know either person, but I would have liked to have given them a lecture.

This seems to be the attitude of many that have the title of CDEs or RDs. None of them especially like type 2 diabetes patients and for me the feeling is mutual. I have known too many CDEs that are too limited in their background and don't want to be in a room with anyone having depression. In discussing this with my nurse cousin, Beverly, she said that she has had too many CDEs not be able to counsel patients with diabetes and other conditions because they lacked the education or experience.

We had a great discussion on Saturday, 13 June after our last meeting was canceled. She said she could understand why very few of us felt like having a meeting. So she and Tom stopped by to talk with me. When I mentioned the ACDE she asked what organization that was and I told her that it is the new Academy of Certified Diabetes Educators that became official the beginning of the new year. Tom pulled it up on his laptop and he said this does create problems for fulfilling the joint statement.

I said this also makes transparency more difficult as the numbers just are hard to arrive at. No organization is willing to disclose the membership numbers, retired members, members working in corporations and not doing mainstream diabetes education, or even members working part time.