July 10, 2015

Is a Superfoods List to Be Trusted?

Please be careful of articles that are claiming superfoods. This article in WebMD is a prime example and it is aimed at people with people with type 2 diabetes. The list includes, Berries, Eggs, Extra virgin olive oil, Kale, Low-fat milk, Nuts, Salmon, Sweet potatoes, Tea, and Whole-grain cereal.

I am positive that some of you have seen lists like this and most are developed by members of the Academy of Nutrition and Dietetics which means they are promoted by Big Food and the USDA. This should raise red flags for the validity of the list. That said, I can see several items that don't belong on the list. These are not superfoods for people with type 2 diabetes, kale, low-fat milk, and whole grain cereals. Others that should be limited include some of the berries, nuts, and tea.

Now for the reasons:
Kale. This is a farce if I ever heard of one. In the food world, it is hyped to the extreme, but in a report published by the Centers for Disease Control that ranked 47 “powerhouse fruits and vegetables, kale ranked fifteenth (with 49.07 points out of 100 for nutrient density). Here’s a roundup ofthe 10 leafy green cousins that researchers say pack a greater nutritional wallop.

Whole-grain cereal. Recently, the World Health Organization announced we should reduce our intake to a tiny 5 percent of daily calories—half of what the organization previously recommended. For someone on a 2000-calorie diet, new guidelines mean a sugar limit of about 100 calories, or 6 sugar packets. They listed this as “Health” Food Imposter #1 - Whole Grain Cereal. Most whole grain cereals serve up more sugar you’ll find in half a dozen donuts.

Low-fat milk. I don't know about you, but I need the fat in whole milk. It helps with my total daily fat intake. Yes, I have a few more carbohydrates, but I like the extra nutrients in whole milk as well.

As for limiting these foods, I would advise you read about them and use you meter to find out how your body handles them.

Berries. Many think berries are great and then overeat. Others think that just because the fruit is dried it is safe – not even. The sugar is just more concentrated and people then eat too large a serving of dried fruit.

Nuts. Be careful and don't get caught here. I no longer eat nuts, so it is hard to advise people on these, but many nuts need to be limited in the quantity you eat. I know almonds are good, but cashews can make blood glucose spike upwards. Do your research before consuming some nuts.

Tea. There are a lot of pitfalls in tea. If you can stay away from tea that has caffeine this is a good place to start. Others teas have hidden sugars. While minute in quantity, it is sugar to say the least and some areas of our country like sweet tea and this makes me sick personally and I refuse tea in many areas unless I can be assured that it is not sweet tea.

Eggs. Eggs are back in favor and I never stopped eating them even against doctor's orders. I eat eggs prepared almost any way, but I like hard-boiled, scrambled, poached, and fried. I know some people cringe at fried, but I use butter to fry them in and even olive oil.

Extra virgin olive oil. I will use this, but I prefer regular olive oil and even better, butter for cooking. Butter I may use to excess, but I do limit olive oil and extra virgin olive oil.

Salmon. I like wild salmon, and I do avoid farmed salmon or salmon that does not come from Canada or the USA catch.

Sweet potatoes. This should have been on the avoid list as the starch does convert to glucose and I wasn't paying attention. This is one that you need to check and then test afterwards to see how your body reacts to the quantity you consumed. They are high in carbohydrates and a medium at 130 grams (4.6 ounces) will have 23 grams of carbohydrates. Compared to potatoes, sweet potatoes are nutrient dense and more nutritious than the potato.

I would suggest reading the WebMD article, and the links above to give yourself some grounding in what people call superfoods and for most people with diabetes, superfoods they are not!

July 9, 2015

Doctors Often Not Knowledgeable about Zinc

When I went to the pharmacy for a prescription, I saw the pharmacist trying to make sense of a prescription. She reached for the telephone and I could see her dialing. She asked for the doctor and then she asked why the prescription. I don't know what was said from there, but I could see the pharmacist discussing this with the person on the phone.

When she was done, she came back to the person that the prescription was for and asked if she really needed it. The person said she was low and that the doctor had tested her and wrote the prescription. I could hear the pharmacist tell the person that the prescription was for too large a dosage of zinc. I had just read this article and the pharmacist could see me cringe.

When she had finished giving the person the prescription and accepting the copay, I was next. I asked the pharmacist if she had the internet on the computers. She said she did and I asked her to open Eureka Alert and when she said it was up, I asked her to type zinc in the search box. She did and said there were many selections. I asked her if they had a search by date at the bottom and when she said yes, I said to click on that. Next, I asked her what the top article was. It was this article and I had her open it and suggested that she read it.

The pharmacist said she did not need to as she was aware of the problem and it was described quite well. I said that is why you saw me cringe. I said that the person would probably be back with a copper deficiency as well as anemia. The pharmacist agreed and since I had my prescription, I said yet doctors insist on over prescribing trace minerals because they don't know better. The pharmacist would not say any more, so I left.

A small audit of clinical practice, published online in the Journal of Clinical Pathology says, too much zinc, taken in the form of dietary supplements, may disrupt copper uptake, leading to neurological problems and anemia. While this happened in Great Britain, my discussion above indicates many doctors here make the same mistakes.

Zinc is an essential trace element that is required in daily quantities of 5.5 to 9.5 mg for men and 4 to 7 mg for women. But zinc supplements are usually only available in formulations of 45 or 50 mg. The US recommended tolerable limit is 40 mg/day. While there is no evidence to suggest that taking zinc supplements in the short term is harmful, this may not be the case for longer-term use, say the researchers.

These findings by the researchers underline the lack of awareness of zinc induced copper deficiency,' who caution, 'zinc is an essential trace element, and so clinicians may consider it a safe nutrient rather than a drug carrying potential risk.

July 8, 2015

Patient Engagement Needs a Definition

This is another great blog about patient engagement! The author is correct that there is no standard definition for patient engagement. I can offer a one-word definition that anyone can understand - “Communication.” This does need to be a two-way communication. I will also quote from Dr. Rob Lamberts - Communication isn’t important to health care, communication is health care.” I like to use this because too many doctors forget this! That is why they have come up with the term “patient engagement” to muddy the waters.

In the exam room, too many doctors talk at us and not with us, go on autopilot as if we aren't there, and too often come up with the incorrect cause of why we are there. I am upset because now doctors will use this term as a way to convince others that they have meaningful use of their medical health records (MHR) or electronic health records (EHR) when in reality, it is only the records they are interested in for billing efficiency.

It is true that our health care system cannot afford another process that allows competing commercial interests to derail and hold hostage physicians and patients in the delivery of affordable patient care designed to improve outcomes, enhance patient experiences and reduce costs.

Starting in the 1990's, patient engagement has meant different things to different people and is no clearer today than it was then.

Last year I was in a doctor's office and this was on the wall - Patient Engagement is what the Patient Activation Measure score dictates. I knew that the terms could be used differently, but this did surprise me. The doctor did see me looking at it and took it down. Had I known then that I would not be seeing him again, I would have made some remarks, but I did not.

This reminds me of an earlier blog from December 16, 2014 titled Patient Engagement Is Backwards. This blog shows that the way doctors and hospitals see patient engagement is the reverse of what it needs to be. Our healthcare system discourages patient engagement by discouraging honest, straightforward communication. Many doctors patronize us and feel they are the only source of information we, as patients need. They talk at us instead of with us and many belittle us because they don't receive the information from us that is already in their records and they are too lazy to look up, or are not accessible because one electronic record will not communicate with another electronic record. HIPAA is often blamed, when it is the proprietary electronic systems that are to blame.

In reality, patients have no choice but to be engaged. They are provided these details in an inefficient way that causes a lot of frustration, worry and fear on top of already stressful medical concerns. Physicians need to think less about the patient being more engaged, and focus on how they can simplify, encourage, and automate engagement tools on behalf of the patient. People are accustomed to integrated, automated, 24-hour customer service in almost every other industry, but the healthcare system is backward.

July 7, 2015

Is Citizen (Patient) Medicine Really Here?

I need to thank Gretchen Becker for giving me this topic. While I doubt that I will see a lot of this citizen medicine happen in my lifetime, I expect that my son and daughter will experience this on a broad basis. Even though this is being played up and a very few doctors are working to make this happen, the mainstream medical community is still bickering about allowing patient centered medicine and coming up with “less is more” campaigns to confuse issues. State medical boards are also attempting to prevent much of the forward progress of medicine by opposing telemedicine and other innovative trends in medicine.

Diseases once thought to be monolithic are now being broken into subgroups, sometimes even into entirely new classes. While such novel classifications might be challenging to physicians, increased access to data is enabling patients to play a greater role in managing their care, often in ways that circumvent traditional health care protocols. The recent $215 million Precision Medicine Initiative established by the Obama administration marks a clear recognition of this changing reality.

Harvard Medicine News (HMN) recently spoke with Isaac Kohane, inaugural chair of the new HMS Department of Biomedical Informatics. Kohane has long been at the forefront of innovation in this area. HMN wanted to discuss the conference themes, in particular the disruptive—and ultimately transformative—role that patients have to play.

Kohane says what excites him most about the emerging field of precision medicine is 'that it is precise.' What that means to him is that it is going to be data-driven, both by our individual characteristics, but also by the accumulation of such characteristics across all the other patients who are like us. Rather than an anecdotal personalization, through precision medicine we have at least the promise of data-driven medicine, in the same sense that Netflix and Amazon give data-driven recommendations. In current medical practice, such data-driven behavior is largely an aspiration only.

In speaking about patients as “leaders” in precision medicine Kohane said, “In the end, no one is going to care more about our loved ones than we do. That's as it should be.” Furthermore, the rarer (and therefore the more precise) someone's diagnosis, the more likely that that patient is going to be more expert about their own condition, and current diagnostic and therapeutic approaches, than the traditional care providers are. That combination of passion and expertise allows patients to influence the direction of research, influence how data is shared among researchers and how data is shared among health care providers, influence how legislation enabling precision medicine is written, and influence the economics around the delivery of precision medicine.

Kohane continued that the medical establishment has a lot on its plate. Most of what does not get done is attributable to inertia, and only occasionally, to parochial motivations. Regardless, patients are the ultimate customers of these establishments, and the more vocal and the more clear they are in their preferences; the more likely they are to overcome this inertia. Moreover, forward-looking health care systems will figure out how to enlist and empower these patients, to improve the overall care process.

When asked how can we ensure that patients’ private data remains private? Will this require exorbitant costs, both in legal costs as well as in cyber-security infrastructure?
Kohane answered, “First, we have to acknowledge that what is currently private with respect to research activity is often not private with regard to commercial activity. In plain English, your data is already being routinely shared and sold for commercial purposes. It's much more challenging to obtain patient data for research. There's a longer story there about distorted incentives, but suffice it to say that with a patient's explicit consent and control, maintaining privacy and control is not necessarily expensive or difficult—with correct governance and correct large-scale implementation.”

I did not quote all of the information as I feel that from what Kohane says is farsighted
and opens the dialogue for further discussion.

July 6, 2015

SGLT2 Dangerous for Causing Diabetic Ketoacidosis

Allen and I were talking to a person with type 1 diabetes this last weekend and he was bragging about being on an oral medication for type 2 people with diabetes. I said that the doctor was prescribing it “off label” and there were some serious side effects to the SGLT2 medication. He asked what the side effects could be. Allen said that DKA (diabetic ketoacidosis) was the side effect and that it was not the same as that experienced generally by people with type 1 diabetes.

The person laughed and said he was not aware of any problems. Fortunately, I had just read this and had my wife's laptop with me. I pulled up the article and the definition for euglycemic, which is a condition or state in which the blood glucose level is within the normal range. See also glycemia. As reported…the presence of euglycemia appeared to delay correct diagnosis in some of the patients in their series.
  • Euglycemic DKA may be associated with the use of a SGLT2-inhibitor in type 1's.
  • Volume depletion associated with SGLT2-inhibitor use could exacerbate the problem by further increasing glucagon, cortisol, and epinephrine.
  • If insulin levels are low and glucagon and other counterregulatory hormones are high, a perfect storm exists.
Now we had his attention and he asked to read the article. When he finished, he said that then he could be in trouble as he was scheduled to a surgery on Monday, June 29. He said that it is recommended that he be off the medication for three days before any surgery.

Then I opened the Medscape article and had him read that article. His first question was how he could get access to either article, as he was not aware of either source. I said he would have to join both sites to have access to them and that they were free. Allen said it would be good to be a journalist when applying, but that there was good information, he would email him some of the links for diabetes and other information, and then he could explore for his favorite topics.

He called his doctor at his home and informed the doctor of what he had read and that he needed to postpone this surgery at least two days if possible. He asked the doctor for his email address and sent the doctor the two links and his phone number and then the doctor called him and said he would see that the surgery was set back for at least two days. He went back to talking with us.

Next, he thanked both of us and said he was sorry he had acted so badly when we started the conversation. He explained that he had always felt that people type 2 diabetes had no interest in helping people with type 1 diabetes. I said that type 1 takes enough grief from people ignorant of the difference and accused them of many of the problems that type 2 people face on a regular basis. I said we need to work together to end the ignorance and help each other at every opportunity. He agreed and thanked us again.

I said that I had sent him the links for the two articles and would send him any more that I found. I said I was aware of at least one more, but I would need to get on my home computer to find it.

Then he asked to read the first article again. He said that he had not been counseled by his doctor when he started the medication as was recommended and was happy we could show him information. He was going to have a long discussion with his doctor and consider not taking the medication. He said that it was helping in the management of his daily blood glucose levels so the decision would be difficult without the doctor understanding what could happen.

He asked if anyone we knew was using the SGLT2 medication. Allen said no, as the members of our support group only used metformin or insulin. I added that we have a few members that have been able to stop all medications after lifestyle changes. They continue the monitor their blood glucose levels and have been successful so far.

He said he needed to head home and repeated his thanks and said he would stay in touch.