A Gathering of a Few of Our Members

The Saturday after our January meeting, Jason, Tim, Brenda, Sue, Allen, A.J, Barry, Ben and I gathered at our favorite restaurant for a brief meeting. Allen was still feeling that we should have been able to do more to help Albert and we knew that he needed our support. After talking with him for about half an hour, he finally admitted that there probably was not much more we could have done even if we wanted to.

Tim turned the discussion to the topic Brenda and Jason had started and suggested even though he wanted to move on and have a nurse and nutritionist speak to our February meeting, maybe we needed to have more on the topics of diabetes self-management that had not been covered. Brenda spoke and said there was a lot of preparation that needed to be done and Jason agreed saying that he thought both were relatives of mine and not just the nutritionist. I said yes, and since talking to her, I have found out that her husband has type 2 diabetes also.

Tim continued that for being a chief surgery nurse, he was very surprised how much she knew about diabetes since she is not a certified diabetes educator. He continued that we should enjoy hearing her. Everyone agreed that Brenda and Jason should have more time and it was decided to have my two cousins do a presentation on February 7 or the alternate dates depending on the weather. Then Brenda and Jason could have March 7 or alternate dates for continuing their topic of diabetes self-management.

Everyone agreed and we asked A.J how he and Jerry were doing. A.J said he is very proud of Jerry and the way he has turned his life around since not living with his wife. His right foot ulcer is gone and the other is almost healed. He is very careful with it and changes the dressing twice a day and will be on once a day next week. A.J said that he has had one blood glucose reading at 66 mg/dl and was going to over-treat it, but asked me before he did. A.J asked him to carefully wash his hands and dry and retest and the second reading was 71 mg/dl. Since they were ready to eat breakfast, he had him count the carbs he would be eating and add this to his reading and he probably would not need any insulin.

A.J continued that at 90-minutes after eating, he had a reading of 102 mg/dl and said he would test at three hours. The reading then was 96 mg/dl and this was after an hour of weight lifting with his arms. At lunch time his before meal reading was 82 mg/dl and the reading after 90 minutes post meal was 112 mg/dl. He said Jerry said he was not going to inject insulin, as he would be doing more weight lifting that afternoon. Jason asked if Dr. Tom had approved his weight lifting and A.J said he had advised doing this, as the ulcer should not bother him since he was not on his feet.

Tim said he would confirm the dates with Beverly and Suzanne for February 7 and we asked Allen if he was going to be okay. When he said yes, we went our separate ways.

Learning to Manage Diabetes by Yourself

If it were not for doctors and that fact that we need them for prescriptions, many of us with type 2 diabetes could do well without them. Considering that many with type 2 diabetes only see their doctor twice a year or for about half an hour, and all they do then is check your A1c to see how you are managing your diabetes. Often they do not have certified diabetes educators or registered dietitians to refer you to, which may be to your benefit.

Why would I say something like this? Read my blog here from June 25, 2012 for some of my reasoning. Granted doctors vary in how often they see patients with diabetes. For well managed diabetes, they will only see the patient two times per year. For people not managing their diabetes, they are most often seen four times per year. Most patients using insulin, if the doctor even sees them, (most are sent to other specialists) want to see patients four times per year or more often. It is more often for patients with well managed diabetes and the doctors are very concerned about hypoglycemia. When this happens, these doctors obtain a program to download the meter and they do look at the readings or they have one of the office staff to this and red circle anything below 75 mg/dl.

I feel fortunate that the person I see at the VA feels very much like I do. While she is concerned about hypoglycemia, she does not view my heart problems, cholesterol problems, and blood pressure problems as something that cannot be managed and is very satisfied with the test results. She also thinks for my abilities I should be below 6.5% for an A1c and encourages me to stay there, until such time as my tests indicate otherwise or I have cognitive problems.

Diabetes self-management is important for people with diabetes. We are covering this in our support group meetings and I may cover some of it here after some of the meetings if there is more information I want my readers have. The other important part of this is Self-monitoring of Blood Glucose (SMBG). For more on this, please read my blog from May 25, 2011.

I had several emails saying the study did not accomplish anything and that once the study ended, glycemic management stopped and glycemic management waned. This can happen because participants are no longer supplied with testing supplies and often cannot afford the extra supplies on their own. Yet people want it known that these people do not need the extra testing supplies. They want people to be managing their diabetes in the blind without the added information testing can help them. More doctors are at least giving new patients the chance by requesting the insurance companies to reimburse for extra testing supplies during the first four to six months. A few doctors are helping patients every other year, but these are not as many.

The biggest problem with testing is that many patients believe they are testing for their doctor. It is hard to convince them that they can learn from their testing and use the information to help them manage their diabetes. I have talked to a couple of doctors about this since I knew the doctor that the person was seeing. Then I am told by the patient that whom they test for was none of my business and of course, I tell them that if they want to lie to me, I don't care, but to lie to their doctor is not a good practice.

Diabetes Self-management Education Not being Utilized

I am not surprised that diabetes self-management education is underused or not utilized at the level many educators think it is. To begin with; there are too few certified diabetes educators (CDEs). As explained in my blog here, most are located in or near large populations and in the Washington DC to Boston corridor (Northeast Corridor). Out here in the hinterland, we occasionally have a CDE, but most are not reliable.

Our diabetes support group has discussed this among ourselves and now with the new members, we are getting many questions asking if they should make use of the classes. We are trying not to be negative, but one of the new members, Rose, did attend a class this week and is scheduled for one more class next week. She called Brenda and started asking questions and wondering if she should even go to the next class.

Brenda called Tim and me to come to her place and when we were there, she had Rose explain what had happened. Rose put the business card on the table where we could look at it. Both Tim and I noticed that the title was RD (registered dietitian) and CDE. I brought this to Rose's attention and Brenda agreed this could be the reason why Rose was not pleased. Tim asked her if most of the class was on food and Rose said that was why she was unhappy as very little was taught about self-management of diabetes. Rose said that was why she had asked for the class – to learn more about managing her diabetes since she was on insulin.

Tim asked if there were others in her class and how many. Rose said there were three others and all were not happy about the amount of time spent on food and the number of carbohydrates they were told to eat and the heavy promotion of whole grains. She said that two of those present people with type 1 diabetes and could not eat gluten. Rose said the person ignored that and emphasized that they would be missing a lot of nutrients by leaving whole grains out of their meal plans.

Tim asked Rose to think about returning to the class and she said she would not stay unless the person stuck to teaching about managing diabetes. She would go, but would leave if it was all about food. Tim thanked her, and then asked if Brenda would be opposed to adding this to our meeting on the tenth of January. Brenda said that was a good idea in case the class was about food. I told Tim that I knew a nurse that was knowledgeable about diabetes and she could present something. Rose said anything would be better than the class she had. Tim said to call her and see what was possible.

Then Tim said he would talk to Allen and Jason and see if they would like to do a presentation on this topic. Brenda spoke up and said she would like to work with Jason for the topic. Tim said for her to go ahead and we would not need the nurse then. He said that the evening could be long and Rose said that with the topic of testing and self-managing of diabetes, it would be interesting for her.

Tim thanked Brenda for asking to do the presentation. Brenda said it was time she started to give back and she would like this topic. She asked Rose to be available and think about questions she had and then write them down. Tim said that once he knew Jason was willing, he would send an email to everyone for questions they might have on the topic. He would ask them to send the questions to him for forwarding to Brenda and Jason.

Tim and I left then and Tim asked how well I knew the nurse. I said she is a second cousin and on the surgery staff of a nearby hospital. Tim said we would probably have her and the cousin that is a nutritionist for the February meeting. Tim asked me to call them and find out what they thought. Then give him their phone numbers so he could talk to them. Tim said we need to avoid Valentines day so that left the seventh or the twenty-first. I said either one should be okay and would say the first one so we have a second or third available if we have bad weather. Tim said good and we wished each other happy holidays and left.

Group Education Benefits the Elderly – Part 1

Part 1 of 2 Parts

This is one of the studies I have been searching for and I now have an answer to many of the questions that have been going through my mind as to why the elderly with diabetes are not well thought of in the medical community. From the extract, we have the objective, which states, “OBJECTIVE In this secondary analysis, we examined whether older adults with diabetes (aged 60–75 years) could benefit from self-management interventions compared with younger adults. Seventy-one community-dwelling older adults and 151 younger adults were randomized to attend a structured behavioral group, an attention control group, or one-to-one education.”

When looking at the graphs as part of the study, the groups all started with A1c's above 8.5 percent and no group ended up below 8 percent. This does not speak well for the study, as a goal should have been to bring everyone below 7.5 percent. This seems to be the shortcomings of many of the studies involving people over the age of 60. The researchers seem happy with not showing the elderly how to bring their blood glucose levels down significantly.

Within the study, the authors state that there are large numbers of older adults with diabetes, but how to provide diabetes self-management support to this group remains unclear. Older adults, aged 60 years or older, are often under represented in diabetes education interventions because of subtle changes in their functional, cognitive, and psychosocial statuses. This scares researchers away and consequently, evidence-based guidelines for this age group are not well established.

It is somewhat understandable that restrictions for this study were rather strict, but in some areas, I have to wonder if this was for the researchers convenience or to prevent confounding factors entirely. I can understand having the age range of 18 to 75 to help determine if the elderly were capable of improving their overall diabetes management

One statement that seems to sum up how researchers feel about the elderly is this. “Finally, we did not recruit adults aged 76 years and greater because these individuals may present with unique clinical (e.g., comorbidity, complications) and functional (e.g., impairment, disability) challenges that require special attention. For example, older diabetes patients are at greater risk for several geriatric syndromes, including depression, cognitive impairment, injurious falls, neuropathic pain, and urinary incontinence. These syndromes can have a deleterious effect on diabetes self-care, health status, and quality of life. Thus, the value of group versus individual diabetes education needs to be evaluated in the age 76 and up population. Importantly, future diabetes behavioral interventions need to address changes in older adult functional, cognitive, and psychosocial states and how best to assess and address these factors.”

When I wrote this blog, I emphasized, “DSME for those age 60 and older requires, and I mean requires that it be on an individual basis.” Now I must change my opinion to say that group education does work and greatly helps the people over the age of 60. Then I continued my blog in part 2 here and stressed the “importance of diabetes self-management education (DSME).

In the conclusions area, the authors had some rather welcome results, “we examined whether older adults with diabetes could benefit from self-management interventions compared with middle-aged and younger adults. We also examined whether older adults benefited from group versus individual self-management interventions. The data show that compared with the younger adults in this study, the older adults received equal glycemic benefit from participating in self-management interventions, and this finding did not differ by type of diabetes. Moreover, older adults showed the greatest glycemic improvement in the two group interventions, with both groups achieving clinically significant improvements in A1C (greater than or equal to 0.5%). Of note, both older and younger adults in the group conditions maintained their A1C improvements similarly at 12 months post intervention. Finally, the diabetes self-management interventions had a positive impact on older and younger participants’ diabetes self-care and psychosocial outcomes.” Bold is my emphasis.

To me, the best statement is the most encouraging. “Thus, clinicians can safely recommend group diabetes education classes for older patients with poor glycemic control. As the U.S. population ages and develops diabetes at a rapid rate, more high-quality research is needed to understand how normal aging processes influence how older adults learn about and take care of diabetes.” The one weakness is that researchers are not interested in helping many of us in the elderly group to become even more proficient in managing our diabetes. It seems only of you have poor glycemic control and have none of the conditions that will make management more difficult.

All members of our group agree that not enough is being done for people our age in diabetes education and that most doctors are not interested because of time constraints and other limitations. Even the majority of certified diabetes educators (CDEs) could care less about educating elderly people with type 2 diabetes. That is the reason we have called ourselves an informal peer-to-peer group because we work to help each other.

Surprise, Statins Not Shoved at Us!

This is a pleasant surprise, at the least the part of not having statins shoved at us. I am surprised that this study was allowed to go forward or even be published since statins are not mentioned. It is going to be very interesting to see how long this study stays posted before people are asking that it be pulled because statins are not mentioned or recommended.

Now, to the study, which says patients have time to learn lifestyle changes before drugs may become necessary. This is for people diagnosed with diabetes and hypertension. It could have included prediabetes and should include this. The savings for cost analysis would have been greater and possibly easier for the patients to adjust their lifestyles.

While the study mentions diabetes, it on the control of high blood pressure as the key for the time allowed before medications are needed. Yes, some people are able to manage diabetes without medications and this should be the goal for all patients. Some may need medication assistance until lifestyle changes are made to prevent potential complications from developing, but the goal should be to get off medications if possible.

This study is important as it shows there is a potential window available without severe consequences for people to adopt lifestyle changes to reduce the effects of hypertension before high blood pressure medications are necessary. To quote the study statement, “The consequences of delaying effective hypertension treatment for up to a year were small - a two-day reduction in quality-adjusted life expectancy - according to a study by University of Chicago researchers published online for the Journal of General Internal Medicine. But as the delay gets longer, the damages multiply. A ten-year delay decreased life expectancy by almost five months.”

While no mention is made about cholesterol and statins, this can be a good thing as too often this is an automatic thing for doctors to prescribe especially when diabetes and hypertension exist in the same patient. If lifestyle changes can be accomplished within one year, then it should also be possible to avoid the need for statins as the cholesterol readings generally follow the blood pressure readings brought on by lifestyle changes.

The study also emphasized the importance of working with the patients to learn how to make the lifestyle changes and receive the support for making them. The American Diabetes Association (ADA) recommends only allowing a three-month trial of medication-free lifestyle therapy for patients with moderately elevated hypertension. This is a good reason for doctors to know of this study and allow the patients up to a year for making the lifestyle changes.

“This study argues that caregivers should work with patients to help them gain the knowledge and develop the necessary skills gradually rather than rushing to drug treatment, especially if their blood pressure is only mildly elevated. It suggests that patients and providers "have more time," the authors write, "at least up to one year, to focus on diabetes self-management and lifestyle modification."”

The ideas put forth from this study are needed, but I would agree that sometimes it might be necessary for medications to be used when the test results are in excess of the upper limits. Patient safety should be exercised to bring diabetes and hypertension under good management while the patient is taught how to use and manage lifestyles changes to the fullest.