February 25, 2017

Early Insulin, Less Weight Gain for Type 2

We have seen that basal insulin causes less weight gain than other insulin regimes. In this prospective, multicenter analysis, we see data that suggests initiation of basal insulin therapy earlier on in disease duration may be beneficial for therapy on the grounds of concern over weight gain appears to be counter-productive. This is especially true given the potentially superior glycemic control also associated with early insulin initiation, further limiting weight gain. As such, prolonging the start of insulin.

Peter Bramlage, MD, of the Institute for Pharmacology and Preventive Medicine in Mahlow, Germany, and colleagues analyzed data from two groups of patients with type 2 diabetes diagnosed on or after Jan. 1, 2011, identified through the Diabetes Versorgungs-Evaluation (DIVE) registry, a German multicenter registry involving 200 physician offices specializing in type 2 diabetes. The first group included insulin-naive patients receiving basal insulin for the first time (n = 113; concomitant oral antidiabetic use was permitted); the second group included patients receiving their first oral antidiabetic therapy without simultaneous basal or short-acting insulin (n = 408).

Researchers found that, relative to baseline body weight, patients in the basal insulin group gained an average of 0.98 kg at 1 year vs. a loss of 1.52 kg for those not using insulin (P less than .001); results persisted when expressed as a proportional change from baseline (P less than .001).

In multivariable analysis, researchers observed that baseline weight (regression coefficient = 0.89; 95% CI, 0.81-0.97) and diabetes duration (regression coefficient = 2.52; 95% CI, 0.53-4.52) were the only factors that were predictors of weight gain between baseline and 1 year in the basal insulin group.

The researchers noted that the duration of diabetes before basal insulin therapy as an independent predictor of weight gain was “logical,” as early initiation would minimize HbA1c escalation and avoid the creation of a “BMI deficit.”

The researchers wrote that, “Despite disagreement over the direction of weight change, findings from prior and present studies suggest that shorter diabetes duration is associated with more favorable weight outcomes, and early initiation of basal insulin therapy may be advantageous

Many of these clinical case studies exemplify the diversity of patients who may benefit from early insulin initiation. Ultimately, it is hoped that early initiation of therapy will not only prevent weight gain and short-term complications, but also reduce long-term morbidity and mortality by getting to goal earlier and potentially alter the natural history of the disease. This latter concept is currently of intense interest. Although optimal disease management is patient-specific, achieving and maintaining tight glycemic control are the primary goals of therapy.

Because many type 2 diabetes patients will eventually require insulin therapy, overcoming fears and therapeutic barriers to initiating therapy early as needed are essential for reducing the vascular comorbidities of this highly prevalent disease in patients of all ages. Fortunately, a number of new clinical tools are available, including both prandial and basal insulin analogs, new insulin-delivery devices, and an ever-improving knowledge of the pathophysiology and natural history of diabetes.

February 24, 2017

Newly Diagnosed Type 2, Start Using Insulin

I have written about being on insulin and probably will again. It is a shame that more people do not use insulin and even more shameful that many doctors will not encourage their patients to use insulin. Probably the most disturbing is that fact that many physicians actually use insulin as a threat to keep their patients on oral medications and to get them to work harder at controlling their diabetes.

This failure as these professionals call it is of their own making and is making more patients wonder where these doctors got their medical license. When the current “pill cure” generation passes, these doctors are going to face an Internet savvy group of patients that will call them out on their threats and stop using these deadbeat doctors.

A few doctors and some endocrinologists are starting to use insulin when some patients are first diagnosed. Though not enough are doing this, this will allow the pancreas to recover or rest, and bring a greater degree of control immediately. Doing this allows stopping the progression toward complications faster and this is a valid concern. Being on insulin at the start does not mean that you have failed or that you will need to be on insulin for the rest of you life. That will depend on the stage of your diabetes when diagnosed and the lifestyle changes you make. Please read the thoughts of David Mendosa on this topic.

Many patients started on insulin are able to get off and on to oral medications. Most are encouraged to change their lifestyle and be serious from the beginning about exercise and nutrition. A number of the patients have successfully gotten off all medications and are controlling with nutrition and exercise. In talking to a few individuals, they were very concerned when started on insulin, but with the faster lowering of their A1c and stricter control of their diabetes, they are satisfied that this was a way they would not have thought about, but did work well for them. Of the three persons I have talked with, only one was still on oral medications. The other two are off all diabetes medications.

One of the individuals I was able to talk with admitted that he had to overcome his extreme dislike for needles, but since he was always going to need to test, the needles were just another hurdle he had to overcome. He also felt that since the doctor was not threatening him, but encouraging him, that maybe he should listen and learn.

They did emphasize that it was important to receive from the start, the meetings with the nutritionist or diabetes dietitian to get the lifestyle change underway. This more than anything, they felt created the success they were experiencing. They admitted that it was difficult at the start, but as more of the changes were introduced with the reasons for the change also instilled with the change, they learned how to adapt and that they did feel better and wanted to continue what they were learning.

They were also happy that they had been allowed to experiment with lower carbs and different foods. I then asked if they were they told they must eat a minimum number of carbs? All three agreed that they had been told that a number of carbs was suggested. Then all three felt that this was the last time the number of carbs was pushed. They felt that the nutritional value was more important than a set number of carbohydrates in all discussions. A balanced diet was the main topic and when a couple of them wanted to experiment with a lower carb restriction, only the nutritional values of what they wanted to eat was the topic.

Yes, the number of carbs was taken into account, but they felt that then the dietitian was more interested in teaching them the way to determine the nutritional values of the foods and where to substitute to not harm the overall nutritional value and still stay at the carbohydrate value they had chosen. This was a big eye opener for me and restores a little of my respect for some dietitians.

Just don't let a dietitian say I need a minimum number of carbohydrates, as at that point, I admit, I tune them out and forget the rest of the class. I am happy for the success these individuals were having and that they will remember what to do and the reasons for doing it. This is the place of the support people and this example should be more widespread than it is today.

February 23, 2017

Diabetes Is Not Your Fault

It does not matter what type of diabetes that is diagnosed, it still comes with a jolt, a shock, or a big dread. Once the pronouncement has been made, then the anger, guilt, denial, depression, anxiety, loneliness, helplessness, and fear can set in. Hopefully they don't all arrive at once, but much of this can happen.

If it is type 2 diabetes, then many people develop a lot of self-blame, or the feeling that the diabetes is their fault. This means that stigma is attached to them and people keep reminding them of this. It is unfortunate that good diabetes management generally involves losing or maintaining weight. This is where people want to lay a guilt trip on the person with diabetes.

Why is it acceptable in America for people to blame others for getting diabetes? This is very hurtful and generally inaccurate. Lifestyle can be the cause, but generally, it is the people who are genetically disposed that get type 2 diabetes. Genetics will affect when two people can both live a sedentary and unhealthy eating lifestyle, only one gets diabetes and the other does not.

The problem is that you did not cause the diabetes you have. It does not mean that you are a bad person. It is just that your body has decided that it wants to behave differently than we would like. At present, there is no way of knowing what triggered your body to develop diabetes, just that you were capable of getting diabetes.

The good news is that there is an upside, yes, I said upside, and I did not stutter. Since type 2 diabetes is generally a lifestyle disease, exercise and way of life will have an effect on diabetes. You have the opportunity to change your lifestyle and delay or even prevent any complications. It is up to you!

The other advantage of having diabetes it that it is manageable. All it requires is an effort on your part to turn your life around. And no, I did not say cure, but diabetes is manageable and you can manage it.

For those that wonder why them when no one else in their family has diabetes, I will not tell them that someone in their past may have been predisposed to diabetes, but never was diagnosed. I will not tell them that they just don't know. Many people from past generations were very secretive about their health. I know, my father's family was that way. You just did not talk about health issues with them. My mother's family was a little more open, but they still were not a fountain of information.

February 22, 2017

Talking with Family about Diabetes

Talking with family or friends about diabetes is not always easy. With the myths that exist about diabetes, it can be difficult to avoid snide remarks and nagging from family or friends that feel that they are helping you manage your diabetes.

You may get comments like - "Should you be eating that?" "I found this article online, and it says that people with diabetes need to ..." "Have you tested your blood sugar today?"

If you have diabetes, you've probably heard questions and comments like these at least once from some friends and family members. How can you teach these well-meaning folks to offer the kind of help you need, instead of what they think you need?

#1. Erase myths with education. "There's a lot of misinformation about diabetes, and it's important that people understand what's true and what isn't," says Dawn Sherr, RD, a practice manager at the American Association of Diabetes Educators. "For people who are close to you -- spouses, family members, or close friends -- encourage them to attend a diabetes education class, or ask them to accompany you to an office visit to get a better understanding of how diabetes is going to affect you."

#2. Figure out what support means to you. For example, some people see reminders about what to eat or what to buy at the store as helpful -- others don't. "If someone asks me if I've tested my blood sugar today, I see it as showing that they care about me," says Elizabeth Mwanga, owner of a health care tech company. "But for other people, that can feel like nagging." Sit loved ones down and explain the kind of help that works best for you.

#3. Make family and friends part of the solution. "If you're newly diagnosed with diabetes and trying to become more physically fit or eat better, encourage your friends and family to be supportive and participate themselves," Sherr says. If you make lifestyle changes a group effort, it allows them to feel like they're contributing and lets them see just how hard you're working.

#4. Stress small steps. "Just because someone has been diagnosed with diabetes doesn't mean they will change everything about their life overnight," Sherr says. "Let the people in your life know that."

#5. Be honest with yourself. It can't hurt to take a quick look in the mirror. Are the comments bothering you because they might be a little bit on target?

#6. Let others know you appreciate their concern. Most of the time, when people "nag" you about your diabetes, they do it out of concern and love, not to be a pain. Tell your husband or mom or best friend, "It means a lot that you care so much about me and want me to be healthy. Trust me -- I've got this under control."

#7. Other tips and questions for your doctor.
Can you help me with the skills to handle diabetes?

How well do you think I'm managing my condition? What's the one thing I should focus on most?

How do I talk to my partner and family about diabetes?

What do I need to know to still enjoy going out to dinner with family and friends?

How can diabetes affect my sex life?

February 21, 2017

Talk to Your Doctor and Pharmacist

I firmly believe in this. I see too many people avoiding this and causing themselves health problems. Yes, there is a growing epidemic in this country and it is on two fronts. Many people are not talking to their doctors. And, at the same time, doctors are not talking to their patients. These are not what I am referring to, but both are part of the epidemic.

Medical situations arise every day and people think they can handle them without talking to their doctor. A brief article the other day made an excellent point about the need to talk to your doctor. Some people will disagree with what I am going to say, but they are the ones that will end up in the emergency room and the hospital or even the local mortuary. Yes, it is that serious.

When people come down with the common cold or also develop problems with mucus plugging their nose, they head for the nearest store or pharmacy to get a decongestant. If you are healthy and have no known medical problems, chances are that no damage will be done.

But if you have any of the following health conditions, doing this is not advisable. These health conditions are heart problems or high blood pressure, glaucoma, thyroid problems, diabetes, or prostrate problems. With these conditions, it is wise to consult with your doctor. Most over-the-counter products like decongestants are clearly labeled with a warning for high blood pressure but little else. Some do say they will raise blood glucose levels.

Most people will demand privacy and other grounds for avoiding what I am proposing, but after seeing a friend in the hospital recently for just the above situation, I think for the sake of safety, all over-the-counter drugs that require a warning, should only be available through a pharmacy and be kept behind the counter requiring a prescription if they have health problems listed above.

This may be an unnecessary burden on doctors and pharmacists, but in this day with computers, this should be workable. Some patients will go to extreme measures to avoid this happening and shop pharmacies to avoid the need for a prescription. They will do anything to step around the system. The dangers of doing this are there and people still want to ignore them.

This is the reason that I only have two pharmacies and all my doctors know which ones to deal with. If I am looking for an over-the-counter medicine, I talk with the pharmacist after I have read the label. Often the pharmacist suggests another product that does not have the dangers. Occasionally I am told to not take any and go to the doctor. I respect the pharmacist for this and this is one reason for not wanting many pharmacists to deal with for my prescriptions.

I find that these relationships work for my better health care and as a result, the doctors are more confident in what I do. Plus the pharmacist is more willing to answer questions and even supplies me with additional information when it is felt that it will be of value.

February 20, 2017

Teach Children Emergency Basics

This can be controversial, but I think one that should seriously be considered. Often I read or hear of a child being a hero because they had been taught how to dial 911, or had heard about it from adult conversations and just did it, or they just do something to help save a life.

On one of the diabetes discussion groups about seven years ago, a person was asking how to get a judge to stop visitation and joint custody rights to prevent her two children from being exposed to their father (a type1) when he has hypoglycemic episodes. She was very adamant in preventing them from witnessing their father at these times. I was proud of the people in the group who asked how often this happened, was he known for the episodes, and had she ever witnessed him have a hypoglycemic episode?

She was only aware of one time when he was at work and he was rushed to the hospital. Then she was asked if the children knew how to dial 911? She did not know and said that was not the issue. Because of the one hypoglycemic incident, she wanted to be sure that he would not expose the children to any. Many felt she was doing this for her own selfish motives and asked if she had even talked to the children (ages 9 and 12) about their feelings. She never answered so I think the people were correct.

The idea of teaching our children to dial 911 is an excellent idea. At what age should they be taught? This may well depend on the children, the family circumstances, and the general health of the parent(s) or family members. Of course, they must understand that this is for emergencies only.

As to teaching the children about handling chronic diseases and the possible effects like hypoglycemia or seizures, this is will depend on the child or children and their willingness to help and be part of the support structure within the family. If an episode happens and the children or child goes running to hide, then they may not be ready.

If the children or child stays and observes, then afterward asks questions, this is the time to start the conversation. Find out what they remember and if they feel that they could help. Do answer all their questions as completely as possible, or take them to the hospital or fire station (or where ever the emergency people are stationed) so that they can see where they are located and if possible, let them ask questions of the emergency personnel.

If the children balk at anything, do not force an issue. They often understand things better than we realize and are more resilient than we give them credit. It is best to let things progress at their (the child's) pace. Just be there for them, answer their questions honestly to the best of your ability and ask them if they would like to hear an explanation from a person knowledgeable about the question they asked. Do not forget if they answer yes. It may take time to develop resources to ask questions to, but this will show the children that you care and will follow through.

Teach them at their pace and as much as they want to learn. Then ask them some questions to see how much they retain. You may be pleasantly surprised. Never force them into areas where they do not want to go, but encourage them at every opportunity.

I am not a professional and not trained in this. These are my opinions and feelings from observations of some families with chronic illnesses/diseases and how they handled sensitive or emergency situations. These children are now very knowledgeable and are assisting in many ways in our society today, and I think this because of the circumstances they were exposed to as children.

February 19, 2017

Gluten-Free May Mean Arsenic or Mercury Poisoning

Allison called Wednesday and asked if I had read this about gluten-free foods. I told her that I had and would have a blog about it in the coming week. She said she had several other articles and would be asking Brenda to have a program if we were having a meeting this or next weekend. She said she is aware of the flu among the members and that three were in the hospital. I said that only two were still in the hospital and that now I may be coming down with it.

To my blog – a new study suggests that a gluten-free diet may pose serious health risks, after finding that the eating pattern may raise the risk of exposure to arsenic and mercury.

Study co-author Maria Argos, assistant professor of epidemiology at the University of Illinois at Chicago (UIC), and colleagues recently reported their findings in the journal Epidemiology.

A gluten-free diet excludes foods that contain gluten - a protein found in wheat, barley, and rye, as well as the byproducts of these grains.

For people with celiac disease - an autoimmune condition whereby gluten intake leads to intestinal damage - a gluten-free diet is the only treatment for the condition.

However, according to a 2012 survey, around 28-30 percent of us restrict our gluten intake or avoid consuming the protein completely, even in the absence of gluten sensitivities.

Rice flour is a common substitute for gluten in many gluten-free products. Argos and colleagues point out that rice can bioaccumulate arsenic, mercury, and other potentially harmful toxic metals from water, soil, or fertilizers. Exposure to these metals has been associated with increased risk of cardiovascular disease, cancer, and other diseases.

"Despite such a dramatic shift in the diet of many Americans, little is known about how gluten-free diets might affect exposure to toxic metals found in certain foods," note the authors.

With the aim of investigating the link between gluten-free diets and toxic metal exposure, Argos and team analyzed the data of 7,471 individuals who were a part of the National Health and Nutrition Examination Survey between 2009 and 2014.

The researchers identified 73 participants aged between 6 and 80 who reported following a gluten-free diet. Blood and urine samples were taken from all participants and assessed for levels of arsenic and mercury.

The researchers found that levels of each toxic metal were much higher among subjects who followed a gluten-free diet than those who did not eat gluten-free products; mercury levels were 70 percent higher in the blood of gluten-free subjects, while arsenic levels in urine were almost twice as high.

According to Argos, these findings suggest that there may be "unintended consequences of eating a gluten-free diet," though further studies are needed to confirm whether this is the case.

The researchers add that:
  1. "With the increasing popularity of gluten-free diets, these findings may have important health implications since the health effects of low-level arsenic and mercury exposure from food sources are uncertain but may increase the risk for cancer and other chronic diseases.
  2. Although we can only speculate, rice may be contributing to the observed higher concentrations of metal biomarkers among those on a gluten-free diet as the primary substitute grain in gluten-free products."

Argos points out that there are regulations in Europe that limit arsenic levels in food products, and he suggests that the United States might benefit from similar regulations.

"We regulate levels of arsenic in water, but if rice flour consumption increases the risk for exposure to arsenic, it would make sense to regulate the metal in foods as well," he adds.