March 19, 2016

Blood Pressure Measurements in Question

Another controversy has erupted around blood pressure measurement and this has been created by doctors. Doctors have done this by creating a 'one-size-fits-all' program for hypertension treatment. Most are prescribing blood pressure medications to those that really don't need the medications and others are over prescribing the medications to lower blood pressure levels to those of the guidelines.

These doctors do not care that it may lower blood pressures too low for the elderly and cause them falls that may be very serious. All they care about is the levels and issuing the prescriptions. They do not take into consideration the person's age and other comorbid conditions, in other words the patient is not properly assessed.

Blood pressure readings vary, but most people with diabetes should have a reading of no more than 140/80. The first, or top, number is the "systolic pressure," or the pressure in the arteries when your heart beats and fills the arteries with blood. The second, or bottom, number is the "diastolic pressure," or the pressure in the arteries when your heart rests between beats, filling itself with blood for the next contraction.

There is some “expert” disagreement with the above numbers and some groups feel that BP readings should be 130/75-80. When it comes to preventing diabetes complications, normal blood pressure is as important as good control of your blood sugar levels.

A small reduction as the primary composite outcome may not justify the increased adverse events and costs associated with an intervention targeting systolic blood pressure (BP) less than 120 mm Hg, according to an Ideas and Opinions piece published online Feb. 23 in the Annals of Internal Medicine.

Eduardo Ortiz, M.D., M.P.H., from Washington D.C., and Paul A. James, M.D., from the University of Iowa in Iowa City, discuss the results of the Systolic Blood Pressure Intervention Trial (SPRINT), which were promoted before publication. The results showed a risk reduction in the primary composite outcome with a lower target systolic BP.

The researchers note that based on the results, for 1,000 persons treated over 3.2 years with a systolic BP target of less than 120 mm Hg versus 140 mm Hg, 16 persons would benefit, 22 would be seriously harmed, and 962 would experience no benefits or harms. In addition to a small decrease in event rates, the aggressively treated group more frequently had serious adverse drug events, which were possibly or definitely related to the intervention.

"We do not believe that the small absolute benefit seen in SPRINT provides convincing evidence that large segments of the population should be treated with additional drugs to a systolic BP goal less than 120 mm Hg, especially when the adverse events, costs, and burden of such treatment are considered," the authors write.

March 18, 2016

Many Type 2's Eat More on Oral Medications

Tim called 11 of us together the other evening. When I arrived, Ben, Barry, Allen, Jason, Sue, and Bob were already there. Shortly Brenda, A.J, Jerry, and Max arrived. Tim asked all of us one question – What were our eating habits shortly after diagnosis?

Tim continued that most of us may have changed immediately, and the rest changed slowly. All of us reduced our carbohydrates greatly or slowly as we saw improvements in our meter readings. Others of us did a lot of reading and started reducing our carbohydrates because of our reading. Some of us learned from others, like David Mendosa and a few other writers. By the time the six of us that were original to this group met, we were all eating low carb and medium to high fat. Some of us were eating higher protein until we learned that we needed to bring this back to normal levels and increase the amount of fat we were eating.

Allen asked what had caused this analysis. Tim said we have several possible new members for our April meeting and several of our current members that are continuing to eat more carbohydrates than when diagnosed. Sue said that is a problem and you want a different program for our April meeting. Brenda said this sounds like a plan and Jason added that will help Brenda and I work on our presentation even more.

Tim said, Yes, and I will let you continue your presentation if you are ready as we have postponed it too many times. Brenda said that this problem is more pressing and deserves our attention. Allen said we would go with what is decided tonight.

Tim thanked us and said he felt we needed to be concerned for a few of our members and help educate everyone about low carb high fat way of eating. Sue asked why that terminology? I answered because this is not a diet and is a way of eating that needs to be long-term. Most diets are at best short-term and then weight is often regained and the process starts over.

Brenda said this is a conversation that she and her daughter had recently and diet was a term her daughter did not like when it came to people with diabetes. She continued that 'way of eating' sounds very good and she would change to that. Sue agreed with her and added way of eating is something we needed to change when we were diagnosed.

The rest agreed and asked Tim where he had heard this. Tim said that I was the first place he had heard it and I added that I had found it on a diabetes forum. In addition, I would suggest we use 'eating to your meter' as a way of communicating with the potential new members.

Allen said this is what we have done in the past and now don't need to worry as much because most of the foods we eat now are familiar to us and we know what the effect will be from past testing. Barry said this may be of help for the new members and some of the recent members.

Allen said we will do our standard of having questions and talking about the VA and other topics that we want them to be aware and know. Tim thanked us for reminding him of this as he had forgot the topics we needed to cover for all new members. With that, we concluded our discussion and talked a little while before heading to our homes.

March 17, 2016

An Insulin Pump Cannot Help a Bad Diet

I have had many arguments with people with type 1 diabetes with insulin pumps when they say they could eat what they wanted and bolus insulin accordingly. Does this work? I don't believe so. It doesn’t work with injections and I don't believe it works with pumps either. Matching insulin to carbs is nowhere near an exact science. This is true whether taking injections or pumping. There is huge margin for error. The error can come from inaccurate food labeling. It can come from “estimating” our carb intake. It can come from how our body is absorbing the insulin itself (what degree of resistance we have).

Not to mention that a carb is not a carb. Pumps take into consideration carb quantity, not carb quality. For instance, 30 grams of carbs from broccoli will act completely differently in the body than 30 grams of carbs from cake. However, in your pump, these will both receive the same insulin coverage.

Next, eating whatever we want and taking insulin to cover it will cause weight gain and increased insulin resistance, whether we are on injections or a pump. Also, most insulin users are unaware that a portion of the protein we eat turns into glucose as well, particularly if you are an adult and sedentary and are eating more protein than you need.

Therefore, a low carb high fat approach is really necessary to avoid complications with pump use. Eating less carbs, thereby using less insulin, will reduce the margin for errors. See Dr. Bernstein’s law of small numbers here. Choosing better quality carbohydrates like non-starchy vegetables and eliminating processed and refined carbs like sugar and all grains as well as even “real food” that is high glycemic, like starches and most fruit, will stabilize blood glucose levels.

Just remember, an insulin pump is a delivery device. While pumps are wonderfully convenient and can even decrease insulin usage, as well as reduce the number of needle sticks, they can’t work miracles. They can only do their best with what you give them to work with. Eating a healthy, whole food, low carb high fat way of eating with frequent blood glucose monitoring and adjusting as needed will help you get the most from your insulin pump.

Some blood glucose fluctuations are not caused by factors that can be prevented, like elevations during “growth spurts” in children, hormonal changes or other physiologic processes that cannot necessarily be prevented. Add to these stress, lack of sleep, infections, and other causes.

Yet with all this, most of the type 1 people I have met recently are convinced they can eat what they want and cover with insulin. They have refused to consider any other way even though several are gaining weight and a couple are way overweight.

Our honorary type 1 member knows how important this is and has been forced to keep quiet because other type 1's don't believe her and even ridicule her for the way she eats. When she was in high school and active in sports, she did eat more, but still tried to eat low carb high fat with extra protein. Now that she is in college and not active in sports, she has been more careful in her way of eating.

March 16, 2016

Despite Hurdles, Telepsychiatry Use Rising

I admit that the terms used to help people with mental health are somewhat confusing and I don't know why the authors have to muddy the information and try to confuse people, especially those looking for services being offered in underserved areas of the United States.

The first term is telemental health and it is described as a rapidly growing field. It is used in a range of settings for patients with a variety of disorders. The second term is telepsychiatry. Then they use my favorite term, telemedicine and the last term is telehealth.

According to a 2014 report by the U.S.Department of Health and Human Services there is a major shortage of psychiatrists. The report states that there are 4,000 shortage areas in which there the psychiatrist-to-resident ratio is equal to or greater than 1:30,000.

Researchers continue to find support for its use in evaluating or treating an ever-expanding list of psychiatric disorders, including some of the latest studies involving attention-deficit/hyperactivity disorder, schizophrenia, post-traumatic stress disorder, and autism. Many of these studies investigated the efficacy of treatment delivered via video as compared to in person and have found that services delivered by video are at least as effective as in-person visits.

Most people have a high-speed connection even in rural areas although some of the 4,000 shortage areas do not have this. As potential applications of telemental health have expanded, many aspects of delivering care via video have eased considerably over years. The sound quality has improved while the occurrence of glitches like freezing has decreased.

However, some of the barriers that have hampered its use remain unchanged or are changing very slowly. Though some insurance companies now cover telehealth services, many do not. Clinicians should check with any insurance companies they work with to inquire about reimbursement for telehealth services.

In 2009, the American Telemedicine Association published Practice Guidelines for Video-Conferencing-Based Telemental Health that highlights necessary clinical and technological competencies, and the American Psychological Association released guidelines in 2013.

“The practice of telepsychology involves consideration of legal requirements, ethical standards, telecommunication technologies, intra- and interagency policies, and other external constraints, as well as the demands of the particular professional context,” the authors wrote.

Therapists providing services via telehealth should receive ongoing training, and they should check with the licensing laws and policies of the insurance companies with whom they are contracted to stay up to date on inevitable changes to come.

March 15, 2016

LCHF Being Discouraged by Dietitians

Are dietitians the modern day luddites? From what we are seeing, this is apparently very true. The dietetic groups in several countries are persecuting doctors and even their own members for speaking out against low fat high carbohydrate food plans and in favor with low carbohydrate high fat food plans.

Starting with Jennifer Elliott, an Australian dietitian, who has been de-registered by her professional body: the Dietitians Association of Australia (DAA) for putting her patients health above the interests of the corrupt DAA, to Professor Tim Noakes in South Africa who is facing a hearing that is anything but fair. Some are saying it is more like the Spanish Inquisition.

If dietitians and their associations were beacons of success, I could understand their concerns. However, many of the dietetic organizations and their members have received money from junk food companies. Most of the dietetic organizations and their members have not achieved anything in the obesity battle and the linked type 2 diabetes.

David Mendosa has a blog with an image of a headstone and the words on it are Low-Fat, born 1939, died 2015 – helped the world get fatter and sicker. Unfortunately, this may only be for the United States at present as the dietetic organizations and their members in many other countries are doubling down on the value of low fat and pushing carbohydrates with the help of junk food companies.

In the United States, the low fat high carbohydrate diet recommendations may soon be going the way of the Dodo, as will many dietitians that cling to failed pseudo science. If dietitians want to be respected as true professionals, they should they should start acting like professionals. This means that they would work with all professionals for the benefit of their patients. In addition, they must free themselves from junk food companies, who have infiltrated many of the dietetic organizations and bought the approval of countless dietitians worldwide.

Fortunately the world of dietetics is not a lost cause, indeed the opposite applies. The list of Scientists, Doctors and Dietitians grows longer by the day, who have raised themselves above the parapet, of greed and the corruption of junk food. They realize the last forty years of low fat and high carbohydrate recommendations have failed totally. These enlightened professionals are recommending a whole fresh food diet, it is ludicrous for anyone to argue against a real food lifestyle. The longer the established dietetic organizations try to turn back the tide, the more irrelevant they will become.

This diet can no longer be defended by appeal to the authority of prestigious medical organizations or by rejecting clinical experience and a growing medical literature suggesting that the much-maligned low-carbohydrate, high-protein diet may have a salutary effect on the epidemics in question.

March 14, 2016

After Diagnosis, What Is Next?

After diagnosis, the questions do start. Many let the doctor set their goals and then when they cannot meet the goals, they often give up and forget to do anything to manage their diabetes. A few others ignore the goals that the doctors set for them and start reading on the Internet. Some will not find the right information and also give up.

Others keep searching and eventually discover what works for them and even if their doctor does not set them up with a blood glucose meter and test strips, they find a way to obtain them and learn how to test. They learn how to eat to their meter and find out what foods they can eat and which foods they must eliminate from the menu. The best thing they do is look for trends and test to know if the “way of eating” is working for them.

Some of the things I learned early after diagnosis was reading the website of David Mendosa and then later his blogs on Health Central. I also read the book by Gretchen Becker – The First Year, Type 2 Diabetes, which really opened my eyes to what the doctor had not told me or anyone else for that matter.

Here are some of the tips I learned:
  1. Do not be afraid to take some time to learn about diabetes. You did not get diabetes overnight and bringing under great management can take some time.
  2. Please take diabetes seriously. Unmanaged diabetes is deadly, but it doesn’t have to be. Properly managed diabetes can lead to a long and healthy life.
  3. Make lifestyle changes. Please read two of my blogs about the components of lifestyles here and here. Most people only concentrate on diet and exercise and forget about the other components. I prefer using “way of eating” instead of diet and diet is at best a temporary change and the change needs to be something we do permanently.
  4. Take your medications regularly, and as directed by your doctor. This is important; however, don't be afraid to ask about insulin and other medications. Also, if the doctor does not explain the side effect of the medication(s) prescribed, make sure to discuss this with the pharmacist.
  5. Test your blood sugar regularly. Even if you need to purchase some test strips on your own, this is very important, especially if you learn to eat to your meter. Always test before a meal and one or two hours after a meal. This will tell you how the food you ate is affecting your blood glucose levels.
  6. Meet with your doctors regularly. No, I did not say medical team and this will vary by individual and the competence of your doctors. Managing your health now means you must care for all of your health needs.
  7. Get check-ups and other testing regularly. Blood pressure, lipid profile, dilated eye exams, kidney function exams, A1C testing, all of these will be important in making sure your body is in working order.
  8. Find a Support System. This will vary by individual. Some will have a supportive spouse or even another family member. Others will rely on a good friend and some will need to be part of a support group.

Know that unmanaged diabetes is deadly and that good management of diabetes can be a blessing. Those that manage their diabetes often will die of old age before the diabetes complications can kill them. Most doctors consider diabetes as progressive, but people are proving them wrong. Keep a positive attitude.

March 13, 2016

Our March 2016 Meeting

When we gathered for our March meeting, we had five possible new members and Tim said we had two others that were unable to attend. Tim said we would be covering topics some of us have already heard, but felt with the new members, it would be good to have a repeat of many of the topics. First, he called on Allen to discuss VA benefits. Two of the new members needed to get paperwork completed for VA benefits. After Allen finished, he set up a time for the following week to accompany them to the local VA office.

Next, we had Allison cover carbohydrates and supplements. This totally surprised the potential new members as they all admitted that their doctors had recommended at least 60 grams of carbohydrates per meal. She covered that in general, the group members all consumed less than 50 grams of carbohydrates per day using a low carb high fat way of eating. Allison then asked the newer members if any of them were still eating more than 50 grams of carbohydrates. Two admitted they were, and Allison said she would want to talk to them later.

Next Allison asked how many were taking supplements and all the five admitted they were. Next, she asked Tim to put up the slides and he brought up the picture of a grapefruit. She asked the five how many were taking statins and four admitted they were. When she asked which statin, we were all shocked when they answered the same one and then Allison asked if any were eating grapefruit. Two answered that they were, but not that often. At that point Allison asked how many considered grapefruit natural. All five raised their hands and Allison continued that grapefruit could make the statin toxic in their body and be serious enough to cause death. Many, but not all statins were affected by a chemical in grapefruit that causes this toxicity and grapefruit is not to be eaten if you take certain statins, heart medications, and a few blood pressure medications.

Yes, you can claim that grapefruit is natural, but many natural foods have conflicts with some medications. Barry said that even a friend of his is now dead because he did not believe this. Even some natural supplements also can cause death when taken with some medications. Allison said this is true and when doctors ask you about supplements or medications you are taking, please do not leave any out of the list you provide. You should also be tested to determine if the vitamins, minerals, and supplements are needed. Yes, many doctors will not do the tests, but members of this support group are aware of doctors that will test, so ask when necessary.

Allison said the important point for the newer and new members would be the testing in pairs. Yes, many people will need to purchase extra test strips because insurance will not cover but one or two per day unless you are on insulin, but the information you will obtain from testing in pairs is important and will help you decide what foods should be eliminated from your menu or greatly reduced to stay within your goals. She said there is a good variance among the members and that 120 to 140 mg/dl are appropriate goals.

Always test before you eat (pre-prandial) and then test one to two hours after eating (post-prandial). Many do take the extra test strips to test starting about 30 minutes and test every 15 minutes until the readings start downward. Some do this from first bite and others do this at last bite. Allison concluded that either is acceptable, but it is important to always do this consistently.

Tim asked for a vote on the potential new members after they all agreed they still wanted to join.  The vote was unanimous for accepting them as members. 

Next, Tim opened the meeting up for questions and even a few of the newer members had many questions for Allison and some of the old-time members. After about 40 minutes, Allison asked to talk to the two eating 80 grams or more of carbohydrates, and Allen and Barry had a few questions about VA benefits. Tim and Brenda had a few questions about doctors that would do vitamin, mineral, and supplement testing. Then Tim announced that the meeting was over and the cleanup started.

Allison thanked us again and said she understood why she was asked and was appreciative for being asked.