AND and Their High Carb Diet

I knew this day would come and I would be asked why I was so against the Academy of Nutrition and Dietetics (AND). This question came from a Certified Diabetes Educator (CDE) and I was surprised by her sincerity. She said she was considering additional schooling to add the title RD to her list. Because of this I attempted to be reasonable and not over the top about my dislike for members of AND and still encourage her to find another profession to study.

These are the points I raised:

Members of AND, in general, are shills for big food.

Members of AND promote high carb low fat meals and set meal carb consumption too high.

Members of AND are working to become the only source of nutrition and criminalize people with more nutrition education.

Many members of AND are also CDEs and when they are to teach as a CDE, they switch to teaching nutrition.

Members of AND are intolerant of diabetes coaches, nutritionists with a Masters degree or a PhD.

Members of AND feel that all people with type 2 diabetes need to do is increase the dosage of a medication or add more medications.

The CDE said she had heard many of these things and know they switch from teaching topics for CDEs to nutrition because this is what they are directed to do.

I explained that our support group has a great relationship with our insurance companies and report this every time to prevent them from being paid for non-CDE topics. Whenever we have to deal with dual titled CDEs and RDs, we are very careful about what is taught. When they switch, we walk out and report to our insurance company to prevent them being paid for switching.

I then asked her why she did not want to become a nurse. She said that she had thought about it, but was not sure she could. I said that many hospitals have full time CDEs working for them as RNs. I told her that I had a cousin being paid to take courses for becoming a CDE at a hospital as by the end of last year, both RN, CDEs were retiring. She seemed interested for a few minutes, but decided she did not want to become a RN. I reminded her that not all RNs are required to be on the floor, because my cousin was a surgical specialist and this was why the hospital wanted her to become a CDE.

I also suggested that some hospitals may reimburse costs to become a RN. I said then you would be obligated to that hospital for several years. She commented that was not something she wanted, as she liked the idea of being able to move when she felt like it.

Because I knew she would probably become a dual title RD/CDE, I ended my conversation, excused myself, and left.

More Support Group Members Angry with CDEs

Alice sent out an email to several members asking what to do. She had a session that was to be about diabetes education and because she had converted to insulin the day before, she was looking forward to some education. However, she did not received any diabetes education because the person had a dual title RD/CDE with her.

Alice said they started out with carbohydrates immediately and she should be eating low fat and about 55 grams of carbohydrates per meal. Alice said the session was supposed to be on diabetes education and since they were not going to teach this, she was leaving and filing a complaint with the insurance company. Alice said she left with them laughing behind her and felt they would be doing this to more of our people if allowed.

Tim called a meeting for all that could attend.  Because of the extremely cold weather on the weekends we had canceled our January meeting on January 16.  It turns out that the weather for January 23 was to be warmer.

When the meeting started, Tim said we have a real problem with CDEs and they are out to create problems for our group. They have been bringing in dual title RD/CDE to avoid teaching anything about diabetes. To date, we have avoided the insurance companies paying for this lack of diabetes education when a referral happens for education. The point they are doing is switching to nutrition and trying to bill for time that belongs to Allison or Suzanne.

Tim thanked Alice for calling the insurance company to prevent them from billing for teaching nutrition and eventually they will give this up, but for now we will be sending everyone reminders to not let this happen, even accidentally. We as a group now have Allison and Suzanne approved for nutrition for all members. They work with us and do not insist on whole grains and a set number of carbohydrates. With them doing what we need, our group receives great nutrition advice and they work with the number of carbohydrates we want to consume individually.

Alan, another of the new members asked if someone wanted a registered dietitian, would we allow this. Tim said we don't demand this, but we encourage everyone to use Dr. Bernstein's “law of small numbers” to keep medications low and prevent problems. We don't follow his numbers exactly, but suggest using your meter and testing in pairs to determine what works for you. Many of us limit our carbohydrate consumption to 50 grams or lower. We have three that are using 80 grams of carbohydrates, but we know that works for them. Alan said he was checking, but he liked the lower number of carbohydrates and agreed with our suggestions.

Allen said that was okay, as we don't demand anything, but hope that everyone sees the value in what we suggest. Jason said we started out as a group of three and then doubled our number and have continued to grow. Jerry said that about 14 that were using his now ex-wife came over to this group and several went back to her, and we have two of them back after their A1c continued upward. That was a time when we had a few problems or growing pains and we learned from that.

Alice said she felt part of the group and was happy for the support she received for walking away from being taught nutrition by a dual title. She admitted that she was feeling better after asking questions about being hungry and being advised by several to increase the amount of fat in my meal plan. This solved my hungry problem in two weeks and now I am very comfortable with the food plan. Testing is a key and while many of us don't like purchasing some testing supplies on our own, it has been worth every dollar to have an A1c below 6 percent and nearer to 5 percent.

One Less Diabetes Organization

This is a follow-up of the last blog that I ended with the note that Dr. Bill Quick says the Academy of Certified Diabetes Educators is now defunct. Dr. Quick says this is one less cook in the kitchen. I can't say I'm sorry that this has happened. This is good news in several ways as this means that we will not need to deal with an organization that has been taking the exclusive route. Now we will also not need to be concerned when the AADE, AND, and ADA are issuing joint statements and wonder why ACDE is not mentioned.

On December 27, I blogged about the problems with the website and lack of activity. At least now, I have an answer, thanks to Dr. Quick.

This does not solve many problems for those of us with type 2 diabetes and for those of us in our support group, it has possibly added to our problems. We are finding that we are being sabotaged by the dual title RD/CDEs and we don't appreciate this as a support group.

The support group has gained support from the insurance companies and the quicker the CDEs realize this, the better off everyone will be. My cousin will not have her 1,000 hours in for some time and will still have her test to sit for and pass, but we now know that she can start her 1,000 hours next month which is a big plus for our group.

So shortly, we will be able to obtain some valuable diabetes education. Yes, we may need to travel 35 miles one way, but the education will definitely help. Several of the members are talking about doing some traveling together to save on travel costs, and this is another positive.

I have been in contact with my cousin and informed her that we were waiting and would like a schedule as soon as it is reasonable. She does say that the CDE that Tim has seen is available and would be involved in her training. I referred this to Tim and said that Alice should possibly consider this. Tim said he would discuss this with her and two others.

Reasons for Ignoring Diabetes Education

Riva Greenberg starts a great blog, but then ends it by asking questions of the past AADE President Deborah Greenwood, PhD, RN, BC-ADM, CDE and the 2016 President Hope Warshaw, MMSc, RD, CDE, BC-ADM. Notice the multiple titles and especially the current president of RD, CDE. The past president is an RN, CDE.

This means that the RD will be emphasized to CDEs and other dual titles. Our support group has been wondering if we would have more luck in 2016 to receive diabetes education, but with this president, we do not think this will happen.

Most of our members are tired of going to an appointment for diabetes education and not receiving education, but nutritional advice of low fat, high carbohydrate advice, which the insurance won't pay for when they only approved for diabetes education. Most of us get the standard mandate of whole grains and 45 to 70 grams of carbohydrates per meal. Yet, the RD/CDEs insist that they should be teaching nutrition. Or, they give out mandates of getting more medication to cover the carbohydrates consumed and they tell the doctors to up the dose of medication or add another medication. So typical of CDEs that do not understand the value of low carb, high fat, moderate protein food plans. This means we don't need a higher dose of medication (insulin or oral) and do not need to add another medication.

We have had discussions with our insurance company and they are happy with the cost savings that have happened of the last few years and have now accepted Suzanne and Allison as nutritional advisers for most of us and they see the nutritional benefits in the different test results and cost savings. The insurance company has also allowed splitting the two hours they require, as they know we obtain more benefits by using this method.

After several complaints about CDE/RDs only teaching nutrition, the insurance company sends a letter that they will only pay for diabetes education and not to submit if they did not teach diabetes education. All CDEs have canceled when this happens. Most know that we have our own nutritionists and that the insurance is paying them and they don't like this and want to use up the time when possible.

In addition, we are now asking the CDEs to teach Self-Monitoring of Blood Glucose (SMBG). Since they do not want to teach the importance of testing, they have told the doctors that the ADA advises that well controlled diabetes do not need to test, but rely only on the A1c. This is thanks to Dr. Robert Ratner, chief scientific and medical officer for the ADA.

This is one reason we think that CDEs need to be ignored and not allowed to give bad education in the form of mandates, mantras, and dogma.

Now I suggest you read a blog by David Mendosa that has a different approach about CDEs and DSME. It is different and more positive than mine is. My blog reflects what our support group members have experienced.

Important NOTE:  According the Dr. Bill Quick's website, the Academy of Certified Diabetes Educators is now defunct.  Dr. Quick says this is one less cook in the kitchen.  I can't say I'm sorry that this has happened.  Too many things were not being covered and this leaves the AADE back in charge of CDEs, which basically means doing nothing for people with type 2 diabetes and prediabetes. 

Surprise Request from Tim

Tim asked for a few of us to meet with him on Saturday. We were concerned as this is unusual for him to ask a few to meet. When we were all together at his residence, Tim started by thanking us and stating that he had never planned this, as he had never had a reason to be so negative.

Tim pointed at me and said back when I had told him that I would walk out of a meeting if he ever invited a certified diabetes educator (CDE) to address the group, he thought I was not serious. He continued that now he knew why and would never invite a CDE to speak to the group. Allen asked him what had happened.

Tim stated that the medical insurance he carried had put him on a program where he needed to meet with a CDE for an hour each year and a registered dietitian (RD) for two hours each year. He had agreed to meet with a CDE, but had discouraged any contact with a RD and asked why not a nutritionist that he was meeting with for an hour each year. They finally allowed this but said it needed to be for two hours, but still felt it should be with the nutritionist they choose. This was still being negotiated, and he would keep us posted.

Barry said that the session with the CDE must not have gone well and I said it must have been with a person with dual titles (RD and CDE). Tim said dual titles and most of the hour was about carbohydrates and no diabetes education. Before you ask, I have been in contact with the insurance carrier and even they were surprised at the lack of diabetes education. Tim continued that they were not aware of the dual titles and he answered many questions about what was covered. He said that he has faxed them a copy of her business card and a formal complaint that when he is in a meeting for diabetes education, he did not consider nutrition only as education on diabetes.

I stated this is a common problem with the dual titles and I suggest you send out an email about this suggesting that people refuse diabetes education from people with dual titles unless it does not include RD or RDN (registered dietitian nutritionist). Allen said this may have been happening for many people that don't know the difference and they have been getting away with doing that. Allen asked me what I was going to do about my cousin Beverly when she became a CDE.

I said this should not be a problem as her dual titles will be RN (registered nurse) and CDE and she will be teaching diabetes education from a nurse perspective and not a dietitian. In addition, we have resolved our issues pertaining to CDE status and with her husband having type 2 diabetes, she knows how important good diabetes education is and needs to be.

Jason asked if most of Tim's session had been on how many grams of carbohydrates to eat and how important low fat was to his health. Tim grimaced and said that was the most of it and how to prepare meals to get the correct number of carbohydrates in each meal.

Barry stated that most dietitians only have a bachelor's degree, with Allison having a master's degree and Suzanne having a PhD, we are well informed, and they will work with us for good nutrition instead of promoting carbohydrates on top of carbohydrates. Jason added that they know good nutrition and teach this. They do not need to follow what the Academy of Nutrition and Dietetics promotes and are not shills for Big Food.

I said that most insurance companies do not accurately tell us what was billed and therefore we have no transparency in what was billed for us to dispute any billing. This should be done for all billings by our insurance before anything is paid and especially for diabetes education and nutrition. If this were standard, the dual titles would have to do things correctly. Plus, this would prevent double billings for both education and nutrition when it was to be for one only.

Should CDEs Be Teaching Nutrition?

Yes, I have realized that many titles often are associated like RD (registered dietitian) and CDE (certified diabetes educator). To be honest I was just reading the titles and wondering which was most prominent or used to the near exclusion of the other. After the blog yesterday, I really have to wonder which organization has priority and which exerts the most influence on the actions of the person.

I have talked to two CDEs, one of them also with the title of RD. Both said at one time, the first title after the name used to be the primary practice of the individual. Then in 2006, this has had some repercussions when the American Dietetic Association (now the Academy of Nutrition and Dietetics (AND)) started enforcing strict adherence to guidelines or lose their license. They both admit there has been some relaxation in the last year, but they are still very careful.

Whether this is correct, I do not know. I just have to wonder what influence AND has on the CDE profession.

Nutrition is taught by both CDEs and RDs and both generally urge more consumption of carbohydrates than many with diabetes are willing to consume. This is a great turn-off for people with diabetes that understand the value of consuming fewer carbohydrates.

I am thankful I have a cousin that is a nutritionist and has now completed her PhD in nutrition. She is my go to person for nutrition questions. Recently I discovered that another second cousin has moved into the area and she is a registered nurse with almost 20 years experience in surgical nursing. We have only had one conversation about what she does, but I expect that I will learn more in the months ahead as her husband is planning to retire in the job he currently has.

They have three children and one has type 1 diabetes. That was to topic of most of our conversation and a lot of questions were directed my way. I have connected their daughter with Lilly that is an honorary member of our support group and they are learning from each other.

I Have to Wonder about the ACDE

Yes, I do need to wonder about the Academy of Certified Diabetes Educators. They are being very secretive and not really telling people about their activities. When I did this blog on April 23, 2014, the An Important Legislative Update about the new law in Indiana was already posted. It is now August 14 and the information is now down sometime during the day on August 11.

Attempts to contact two Indiana Legislators failed, but I was able to communicate with two Indiana CDEs on the condition I would not reveal their names. One is working with a brother-in-law and a couple of his friends and the other is working with two female friends to qualify them to work with type 2 people as peer-to-peer diabetes coaches or peer diabetes mentors. All five have type 2 diabetes and have many other type 2 friends they want to help.

As of 1/22/2014, Indiana has 367 CDEs according to the National Certification Board for Diabetes Educators (NCBDE) of 18,401 that are certified as diabetes educators and hold a certificate. This does not tell us anything, as they don't answer these questions:

What the numbers don't tell us:

How many are retired and not working as CDEs.

How many have taken up research work and not working as CDEs.

How many are its officers in ivory towers and not working as CDEs.

How many are on book promotion tours and not working as CDEs.

How many are only working part-time as CDEs.

How many are actually working full-time as CDEs.

There are also others that work as CDEs and RDs and therefore not full-time as CDEs. With all this missing information, it is small wonder that many of us with type 2 diabetes are not seeing or receiving any education from CDEs.  The numbers only tell us how many have passed the CDE examination and hold a certificate.

With the hidden numbers, both CDE organizations can tell us what they want and make it difficult to prove them wrong. When you get to know a few of them, they can be very forthcoming and properly assess us and individualize recommendations. Others make you want to run away and never see them again when they spout mandates and expect us to follow them. Education seldom crosses their lips and they become very agitated when questioned.

Then we come to the dual occupations (CDE and RD) and they follow the USDA and orders of Big Food. They elevate mandates to ridiculous heights and use some slick word trickery to keep patients off guard. They have answers for everything and promote high carbohydrate, low fat with mandates that we must eat a set number of carbohydrates at each meal if we want to be healthy and supply our brain with energy. Then when we learn how wrong they are, we won't listen to them again.

The Academy of Certified Diabetes Educators is already developing a reputation of being exclusive and while they will allow anyone that has taken and passed the NCBDE examination, they are fighting to discredit anyone that can help others learn how to better manage diabetes. We do not have enough educators to educate people with type 2 diabetes and we do not need this 'only certified diabetes educators can teach about diabetes' crap. We don't need the mandates, mantras, and one-size-fits-all that many of the CDEs use.

I wish that the two CDEs I communicated with were not so far away, I think I could learn a lot from them.

Are CDEs the Correct Support for You?

Are certified diabetes educators the correct people to go to for support? Before I answer, there are some facts that need to be stated. The American Association of Diabetes Educators (AADE) claims 13,000 members. The Academy of Certified Diabetes Educators (ACDE) makes no claims, but declares that 18,000 have passed the National Certification Board for Diabetes Educators (NCBDE) examination.

What all organizations avoid telling us or stating includes:

Not telling us how many are retired and not working as CDEs.

How many have taken up research work and not working as CDEs.

How many are its officers in ivory towers and not working as CDEs.

How many are on book promotion tours and not working as CDEs.

How many are only working part-time as CDEs.

How many are working full-time as CDEs.

There are also others that work as CDEs and RDs and therefore not full-time as CDEs. With all this missing information it is small wonder that many of us with type 2 diabetes are not seeing or receiving any education from CDEs. This also explains why many in rural areas of the United States do not have access to CDEs as most live in highly dense population areas where they have plenty of patients.

I do not begrudge the many type 1 people as they often have greater need for CDEs than many type 2 people do. And from experience, I know that most CDEs do not want to work with type 2 people. That is not to say that type 2 people refuse to see CDEs. We do mainly because we are older and understand when we are fed mandates and mantras and are just expected to follow them. A new member in our community had classes and decided to attend, but after the first class, refused to attend the next two classes. When asked why, she said the CDE was teaching to the lowest common denominator and handing out mandates. She refused to answer the simplest of questions and only answered two questions the entire class.

When she started mandating the number of carbohydrates we should eat at every meal, one of the class members told her that a dietitian would be having a class following her class and she should stick to diabetes education and not what we should eat. Only two of the class were on insulin and those were the questions she answered. When one of the class asked about burnout and depression, she quickly pickup up her materials and said she had a patient appointment to go to and left.

The dietitian followed and would not discuss any questions and stuck to her prepared material. She was also mandating that everyone should eat a minimum number of carbohydrates per meal (55 grams minimum) and to make sure that they stayed on a low fat meal plan (no more than 10% of total calories). When a class member asked why everyone had to eat the same one-size-fits-all meal plan and could not adapt their meal plan to what worked for them, the RD said she was the instructor, had the needed education, and they were to follow her instructions. At that point most of the class got up and left.

When the person showed us the schedule and who the CDE and RD were, a few of our support group could see that they both had the titles of CDE and RD. So when many of us type 2 people see this, we understand the conflict of interest (COI) because of the support of the AADE by Big Pharma and the Academy of Nutrition and Dietetics (AND) by Big Food and Big Agriculture.

The person started asking questions of those present and we took the time to explain and answer all of his questions. Tim got his email address and said he would be sent email addresses for the rest of the members and we would try to answer most of his questions. Allen told him that a one-size-fits-all solution did not work for type 2 diabetes and that if CDEs and RDs would not properly assess his as an individual, then he was right not to attend classes.

Joslin Bloggers Hide Behind Anonymity

Very seldom does a blogger on Joslin Communications identify him/her self as the author of a blog. This raises all types of questions about the integrity of the message of the blog and of Joslin itself. This allows authors to take pot shots at various people in complete anonymity. Since doctor William Davis published the book in 2011, I did not write a review about it until December of 2012. I have to question why Joslin decided to try to discredit the book in February 2014.

Did Joslin succeed, not to my way of thinking? They only succeeded in discrediting Joslin. The author has to be a registered dietitian or certified diabetes educator. One common thread promoted by registered dietitians is, “... some of the restricted foods, such as fruit and oats, eliminate sources of vitamins, minerals and phytoestrogens.”  I have never understood why this line of defense is so often used when other foods will provide the vitamins and minerals. Anyone working with a nutritionist or knowing nutrition can always find many foods rich in the vitamins and mineral dietitians claim we are missing by not consuming whole grains.

Then we also need to remember that dietitians that are members of the Academy of Nutrition and Dietetics are strongly influenced by the grain and food industry. I would think that the employees of Joslin would rise above the conflict of interest. I guess this is wishful thinking on my part considering that other Joslin employees are operating with conflicts of interest from the pharmaceutical industry and medical device industry.

The Joslin blog reads very much like reading the information put out by the Grain Foods Foundation. It contains much misleading information and focuses on half-truths and citing information to mislead the reader. If you want to understand the issue, read this blog by David Mendosa who questions why Dr. Davis did not go farther and eliminate all grains. Then read this by Peter Bronski, who objectively points out the shortcomings of Dr. Davis's book.

The Joslin blog, in my opinion, rehashes old information and adds little to the discussion that has not been said before by the 'experts' of the Grain Foods Foundation.

ADA Medical Nutrition Therapy by RDs

With eight of the eleven people being registered dietitians on the committee developing the ADA nutrition therapy recommendations for the management of adults with diabetes, is it any surprise that much of the information on page 4 conforms to the Academy of Nutrition and Dietetics (AND) policies. I feel that since the American Diabetes Association (ADA) was behind this and they were under the scrutiny of the ADA, we were spared much of the rhetoric of the AND.

Yet they did get in many policies and pronouncements of the AND. Take for example this statement, “Ideally, the individual with diabetes should be referred to a registered dietitian (RD) (or a similarly credentialed nutrition professional if outside of the U.S.) for nutrition therapy at or soon after diagnosis and for ongoing follow-up.” No, I don't like this statement as this is monopolistic in nature and I prefer someone that will work with us for the meal plan we are using and not some organization's meal plan. Nutritionists that will work with us and are not necessarily members of AND seem more interested in balanced nutrition than many RDs.

The above is from page 4 (PDF file) as is the following promoting RDs as being the only professionals that should be allowed to teach nutrition. The RDs also make a statement that should not set well with nutritionists in other countries when they state, “Health care professionals administering nutrition interventions in studies conducted outside the U.S. did not provide MNT as it is legally defined.” Legally defined here means only as defined by AND. Then they continue promoting RDs with this statement, “However, the unique academic preparation, training, skills, and expertise of the RD make him/her the preferred member of the health care team to provide diabetes MNT.” Bold is my emphasis.

Then at the top of the third column page 4, the RDs promote Table 2, Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guidelines and list them. Remember that the national organization promotes Big Food and this determines what will be promoted. Even though many declared no conflict of interests, I feel that it should be pointed out that if the person is a RD and a member of AND, they automatically have a conflict of interest because of their ties to Big Food.

Once the authors moved past page four, the promotion of food plans did become possible and not the direct claims to how RDs should be the only ones teaching medical nutrition therapy (MNT).

For an article that is more balanced than mine, read this by Laura Dolson on about dot com. She likes this new version on medical nutrition therapy and can look past the points I find troublesome. After reading her summary of the ADA food guidelines, I need to revisit the PDF file.

ADA Ditches Diet, Now Has Food Plans

The American Diabetes Association (ADA) has done something right. They have dropped the word “diet” from their medical nutrition therapy prescription. Instead, they are focusing on overall eating patterns and patient preference. They are using “eating plans” or “eating patterns” in place of diet. This is according to Alison B. Evert, MS, RD, CDE, coordinator of diabetes education programs at the University of Washington Medical Center, Seattle.

Now it will be interesting to see if the American Association of Diabetes Educators (AADE) and the Academy of Nutrition and Dietetics (AND) follows. Because AND is supported heavily by Big Food, I sincerely doubt that there will be any change in their modus operandi.

I can understand why Ms. Evert would recommend a patient being referred to a registered dietitian (RD) as soon as possible following a diabetes diagnosis. This is the way they get people set up on a high carbohydrate/low fat (HCLF) diet when the new person with diabetes has not learned about other food plans. Once they learn about other food plans, they will be less likely to follow the mandates of the RD. At least she does recognize that the referral is often delayed.

From the number of registered dietitians and certified diabetes educators on the committee that wrote the 2013 Nutrition Therapy Recommendations (this is a PDF file), it is understandable why some policies are deemphasized and others are promoted. Several statements in the published recommendations are reflective of the monopolistic attitude of the AND and their attempt to become the only recognized source of nutrition information.

One idea not mentioned in any previous guidelines is a guide for coordinating food with different types of oral glucose-lowering agents and both fixed-dose and basal-bolus insulin regimens. These were included so that clinicians would have some talking points that are evidence based.

Because RDs and CDEs do not like low carbohydrate food plans it is not a surprise that this statement was included, "A lot of the studies on low-carb didn't meet our criteria for inclusion due to factors such as high dropout rates."

Then the following was stated, “As for other macronutrients, the document advises that foods containing unsaturated fats (liquid oils) be substituted for those higher in trans- or saturated fat and that leaner protein sources and meat alternatives are preferred. Often, nutrition therapy isn't given the priority that it should have… It's a lot easier to write a prescription than to have a dialog with the patient about eating behaviors."

Some of the points are good sense and there is some good information when it is carefully analyzed.

Another Email From the Doctor

This time the doctor that Jason knew was a lot more direct. He asked why I used made-up names for the members. In my answer, I stated that in case anyone in our local community read my blog, they would have a difficult time identifying people unless they had heard us talking. This is the one area we try to be secretive. Plus we are so used to our names, we know who is saying what.

The next question was again about CDEs and why we don't use them. I said that most CDEs do not want to spend time with patients who manage their diabetes as well as we are able. I stated that of the three doctors that are present at group meetings do not have CDEs available and just the few of us using the diabetes clinic could utilize them but have not felt the need. With the reading we do and the research, we are not willing to listen to them spout the ADA position when we know we are capable of deciding what works best for us.

His next question was why not have one speak to the group. I stated that most do not want this and they would not be paid as we do not collect dues for this and volunteer they might, but most of us would get up and leave when ADA positions were promoted. I said many CDEs would be questioned about why they haven't endorsed positions adopted by the ADA and a committee from the AADE. We would also ask why many CDEs leave patients when the topic of depression was inserted into a conversation. Most speakers would be asked question after question looking for areas where they were not knowledgeable. Not good for us and not what CDEs would want.

He said he understood why we would not have time for RD members of AND and the promotion of big food. We probably did not use many of the foods they promote, especially the whole grains. He said after reading my review of “Wheat Belly” by Dr. William Davis, he had ordered the book and has talked to other doctors at the hospital. He was surprised at the number that already had read it. Some agreed and some had reservations about the book, but had read it. He said I had used the right information in my review and even he had some reservations, but that much made good sense. He said that since two of the doctors in the cardiology department were recommending the book to some patients, he felt that it was what he should do when he finishes it. He has had one patient ask him about the book and he stated that he was reading it and felt if could be good for him. The patient mentioned that the heart doctor had recommended that he read it.

Then he said he had the book The Type 2 Diabetes Sourcebook and if his wife had not read my blog reviewing it, he would not have been aware of the statement I quoted and though he agreed with my review, he was not aware of how truly bad the book was with the statement. He wonders how they could write something like that with all the evidence to the contrary. Yes, he said very few people die from hyperglycemia, but we do not yet know how many die from hypoglycemia because death certificates are seldom correctly completed and have no place for secondary causes.

He has said that his wife has read a lot of my blogs and since she is an advance practice nurse for a local diabetes clinic, she is not agreeing with everything I blog about, but by checking my links, she has few real disagreements. I told him to have her let me know of problems or disagreements.

I answered a few more of his questions and thanked him for the correspondence.

Diabetes Tips and Applications

The previous month, I received an email asking questions that are quite common and important for people recently diagnosed with type 2 diabetes. First, this person wanted to know why he was having such a difficult time managing his diabetes. This reminded me of my blog here. Then he wanted to know if there were any applications that he could use to upload the readings from his blood glucose meter to his doctor. There were several other questions which I have answered in my emails with him and I may do another blog on reasons for using insulin and for avoiding some foods.

In exchanging emails, I discovered he was following the directions of a registered dietitian (RD) and eating the high carbohydrate – low fat meal plan. He also was still attempting to determine what I was talking about in self-monitoring of blood glucose (SMBG). He stated that the certified diabetes educator (CDE) had covered testing and how to do it and then just told him to test one hour after finish eating and moved on to confirm what the dietitian had told him about eating a set number of carbohydrates at each meal and snacks. Sounds like a mandate to do something without really educating him about the why, where, when, and how to use the results.

Is it any wonder I get upset with these “professionals” that cannot do education and live by mandates and mantras. I will not go any further with this, but get back to SMBG. I explained why we test our blood glucose so often at the beginning. This is done to determine how our bodies react to the foods or combination of foods and testing is the only way to determine this. His return email asked why the RD or CDE had not explained this to him. I explained to him that the CDE must tell him about testing and where to test, but generally this is where they stop, as they do not want you to realize the benefits of testing and finding out how the foods affect your blood glucose levels.

Of course, the RD will not explain this, as they want you to just follow their instructions without question. It is using the knowledge you gain from SMBG that tells you how the different foods affect your blood glucose levels and this in turn will let you know that what the RD and CDE issue in their mandates is not the whole truth. Some of the foods will spike your blood glucose readings to a high level. This tells you that you must limit the number of carbohydrates by reducing the quantity of these foods or removing them from your food plan. In addition, you will be looking for different results from different food combinations and also for determining if you are on the correct path to achieving your goals. If you are not moving in the right direction, as was the case for this person, you need to reevaluate the food plan and see what needs to be changed.

For this person, I suggested removing most whole grains and all highly processed foods. He reported back about a week later that his blood glucose levels were greatly improved and he had also reduced the quantity of potatoes he was eating. His fasting blood glucose levels were generally under 100 mg/dl and most of his after meal (post prandial) blood glucose levels were under 140 mg/dl. He was still having some problems with his evening and bedtime testing, but felt that with some additional reductions in food quantities and changing foods this was improving. His final comment was how much better he was feeling and that he was not gaining more weight and actually dropping a few pounds.

He commented that he felt he was gaining more benefits from his exercise and felt this was also translating into better blood glucose readings. Next we covered applications for transferring information from his blood glucose meter to an app and then on to the doctor. I discovered that he travels within a block of his doctor's office to and from work and asked if his doctor could read his meter. He checked and found out that his doctor could and had the software program to download his meter. They talked about how often the doctor wanted to do this and over the six weeks we have been corresponding, the doctor is happy with his readings and now has him doing it only at his appointments.

I had suggested that he purchase the software program and download the meter readings to his computer on a monthly basis. After comparing the two apps he had discovered, plus the cost of a new cell phone to handle the application and needing to manually log his readings to the application, he feels very good about not having purchased any and that the software cost was much cheaper, he wonders why he had not thought of that in the beginning. He now has the software download his meter daily and he is able to compare readings for the preceding week and any period of time.

He admits that he still has trouble maintaining his food log and health log, but as he solves more problems, he says that is getting easier as well. He is comfortable with his daily carbohydrates being in the 120g to 160 gram range and very happy that his weight is nearing the goal he and his doctor wanted. We have discussed his activity (exercise) level and carbohydrate level and he says that he may increase the carbohydrate level to avoid losing excess weight below the goal. He does not want to reduce his exercise level, as he feels good about this now.

He has a job that keeps him fairly active and is not a desk jockey. This helps him and he now feels much better with how he is managing his diabetes. His last A1c was 6.5 which is down from the 8.9 at diagnosis. He is now gaining confidence that he will get to 6.0 or lower in the months ahead. He is asking many good questions now and gaining confidence that he will be able to learn more on his own. He has canceled the next appointments with the RD and CDE, because he feels they would not be a help to him. I said that was up to him, but that maybe he should have kept the CDE appointment to see what was said, but he was determined not to waste any more time with them.

Occupations That Can Assist People with Diabetes

For this blog, I will start with the people that may have the least training. This is not to say that many do not have college degrees or have not learned from experience or the college of hard knocks. Some will do excellent work and be able to translate information into understandable meaning for people new to diabetes or people still learning about diabetes. Most will not be afraid to tell patients that now is the time to learn when they hear someone say, “It could not have been important as my doctor did not mention this,” or “I did not hear anything about this.”

Yes, many doctors do not cover everything because of time constraints. This is where peer-to-peer workers and peer mentors will become a valuable asset in working with other diabetes patients. They can use experiences to excellent advantage and gently challenge other patients to learn.

Peer-to-peer workers will generally be working on a one on one basis and will report to a doctor at some point. Some patients will do better in a peer-to-peer setting and this should be taken full advantage of, as education is so important. The informal setting is often more relaxing and makes the giving and receiving of information easier. If the person giving the information is given proper training, she/he can become a powerful tool in getting information to other patients.

Peer mentors may or may not work with groups of people. They can work in either an informal setting or a formal setting. When working in a group setting, they need to be open to taking the discussion in a direction that will teach the most people. Having just had my first session as a volunteer peer mentor by video conferencing (telemedicine if you will permit), there are many areas to be concerned about. With no formal training or certification to point to, a peer mentor must not make medical recommendations about medications or when to take medications. This is the function of doctors and other medically qualified individuals. This does not mean that you are prohibited from talking about different medications as long as you make comparisons and discuss all sides of any issues. There are areas where you have experiences that you may share, and many subjects that may be presented for discussion.

If you are working with patients of a particular doctor(s) like I am, you must set the ground rules before hand to not conflict with a doctor's instructions. I am fortunate that wife of this husband-wife team earned a degree in nutrition before her medical degree, so I don't need to answer most nutrition questions. I have been given permission to discuss pros and cons of different diets, suggesting what works best for one individual may not be the best for another, and then passing them to her for further discussion. Since I am a blogger, the two doctors knew my position on many issues and only asked me to tone down my position on a few issues. Because they have no certified diabetes educators that will work with them, they were looking for other means to cover many areas. We had discussed many issues in the weeks leading up to the shared medical appointment (SMA) and they had one SMA before this where they discussed doing this, but this still did not prevent a couple of the questions.

They knew areas where I could be aggressive in nature and that I normally would not tell readers to use a particular medication. We had a long discussion about the many times I would suggest to patients that they may need to consider finding another doctor. They explained their position on many of these issues and were surprised when I stated that their position was what I was looking for and expressed agreement. The wife did ask that I not get too expressive about some areas of nutrition, but that I was welcome to encourage people to find their own level for carbohydrates, protein, and fat. She felt this could be an area of concern for many patients as they only had one person on a low carb diet. She as a dietitian was not concerned about fat levels other than avoiding anything over 60%. She would prefer people stayed under 50%, but would allow people to experiment. She also stated she would prefer working with people at their dietary preference and if needed encourage them to eat certain foods the help balance their nutrients. This did not come up in the first session, but they will be doing more testing to determine certain deficiencies and suggesting supplements for those who cannot or will not eat certain foods. They both said my blogs had alerted them to the vitamin B12 deficiency for patients who had been on metformin for extended periods and they had one patient with a deficiency.

Nutritionists need to step forward and be recognized. I am talking about those that have a four-year degree or an advanced degree in nutrition. The field of diabetes is in need of people that are more concerned with the nutritional value of food consumed by people with diabetes that how many carbohydrates are in each meal. Nutrition for people with diabetes is not a one-size-fits-all proposition and we need guidance on an individual basis. We have had enough of the mandates, mantras, and dogma. This may work for some, but not the many.

One group that I have also had conflicts with is people that call themselves diabetes coaches. These people seldom have diabetes and come from a variety of professional pursuits. Of the four I have dealt with, all have come from the nursing profession. I know a few that have a dietitian background, and another that was a certified diabetes educator. I am not saying that there are not possibly good diabetes coaches, but I personally disagree with many of their positions and visions of how people with diabetes must eat, live, and sleep. I have only seen one that recognized the value of exercise. Most diabetes coaches promote the same mantras, mandates, and dogma as certified diabetes educators and dietitians that are members of the Academy of Nutrition and Dietetics (AND). This means whole grains and low fat and no compromises. Disagree with them or question them, and they will not keep you as a customer or client. Unfortunately, my experience has been – it is their way, or the highway. Considering the following paragraph, I may have had experiences with the bad apples in diabetes coaching.

On July 30, 2012, Allison B has an excellent blog on the Diabetes Coaches. This presented in a different light than I have encountered. Apparently, this category has some people that know what they are doing and can be an excellent addition to your healthcare team. They have an international  professional organization and do work across many chronic illnesses and diseases. Some of these coaches do have diabetes and speaks well for what they are accomplishing. Take time to read the blog as this may help you decide that this is a group you need. Many use the telemedicine type of communication, which means that can be successful to wide geographical locations.

Until the lawsuit is settled and there will be more, I will attempt to leave the registered dietitians and AND out of discussions. If there is more news that surfaces about them, yes, I will write about it.

Like any profession, the certified diabetes educators (CDEs) have their bad apples. Their numbers are not keeping pace with the need and increase of people diagnosed with diabetes. It would be interesting to know what the actual numbers of CDEs are and whether they are in practice as CDEs, whether they work full-time or only part-time, or whether they are writing books and doing speaking tours, and not actually serving patients.

If these people would do the education that their title says, we might not have the epidemic we are facing today. Lack of diabetes education is just that, little is actually being taught.

Problems in Personalizing Diabetes Education for Type 2's

So, this is what they want to call it when those of us with type 2 diabetes don’t allow ourselves to be where certified diabetes educators (CDEs) want to pigeon hole us. They think we are round pegs and they want to put us in square holes. The author does admit that they don't take people's style or personality into account when recommending treatments. Maybe it is time to take the glaze off the eyes of CDEs and others, and let them know who we are.

Yes, those of us with type 2 diabetes do know this and this is one reason we avoid sessions with CDEs. We are individuals and want to be treated and respected as such. We do not like the one-size-fits-all category you try to put us in. You say the treatment for diabetes is not very flexible. Is this because of the professional organizations that wield unbending power and you don't dare vary from the mantras they promote? Yes, for a great majority of type 2 diabetes patients, it requires taking medications, testing our blood glucose, and often eating on a schedule. The need to have a consistent amount of carbohydrates at each meal is where we come to a parting of ways.

I don't understand why it is that CDEs and for that matter registered dietitians (RDs) need to be so set on doing more harm than good when dealing with type 2 diabetes. Yes, I said more harm than good. Some diabetes patients are able to consume the awful number of carbohydrates with low fat you recommend, but there are others of us that do better on much less carbohydrates and more fat. That is because all of us are different and have different needs where foods are concerned. Then when you happen to have someone that is successful in controlling diabetes with exercise and diet, you go ballistic and say they can't be in compliance because they are not on medication. The truth is these people know how to manage diabetes without medications and have the A1c's to prove it. They are not the aberrations you want to tag them as.

We know that those with type 1 diabetes are helped by you and you do good work for them. When it comes to those of us with type 2 diabetes, you are an anathema for us, promoting whole grains at times when they are not appropriate for some, low fat when many of us need moderate to high fat foods. The one-size-fits-all approach is not what works for many of us. This is why you are disliked by many. You come at us with your mantras and expect us to follow them. You do not teach us self-monitoring of blood glucose (SMBG) because you feel we might actually learn what your low fat, high carbohydrate mantra is doing to us. Because you are also convinced that oral medications has to be our medication and not insulin, you will not teach people with type 2 diabetes how to count carbohydrates.

Those of us that have learned to eat by what our meter tells us and how to use SMBG are a thorn in your side because we understand that we may be able to consume more carbohydrates in the morning and not in the evening while others have the opposite problem. We do not believe the pronouncements of the USDA that are trumpeted by the American Diabetes Association and followed by the American Association of Diabetes Educators (AADE) and the Academy of Nutrition and Dietetics (AND).

When you complain that breakfasts are not carbohydrate equivalents, maybe you should stop and realize that this is what this person needs and they just might have learned how to adjust their medication to prevent having to eat the carbohydrates you try to mandate that we must eat.

When you ask “how do we help the round pegs?”, please know we are not asking you to change your personalities, just leave us alone since you refuse to give us the tools needed and shove mantras, mandates, and platitudes at us. I have learned more from other patients in an informal peer-to-peer setting than any CDE or RD has been able to teach me. We are also fortunate to have some honest to goodness nutritionists still available to help us that are more concerned about nutrition than the number of carbohydrates we must eat for each meal. Yes, they do suggest ideas, but in general try to balance our nutrition for what we have found out via our meter works for us.

Thank goodness, we have some free spirit type 2's that have learned how to count carbohydrates and calories. They have learned to ignore some of your recommendations from your blog here. They know that the fixed dose of insulin forces us to eat a set number of carbohydrates so they know to ignore this. Even the sliding scale is ignored by many as unworkable although some of us use a type of sliding scale in our correction dose of insulin. Most are quietly learning how to adjust their insulin dosage to carbohydrates they will consume.

Another reason we can be free spirits is that for many of us, our pancreas hasn't completely crapped out on us and by avoiding the oral medications that force our pancreas to work overtime, we often can have the hope of some functionality for many years. More people are slowly waking up to the idea of using insulin earlier on to preserve some pancreas functionality. Granted, this may make our computations of carbohydrates to insulin ratio vary, but we will learn to adjust.

I will continue to support other round pegs and free spirits that have found the tools we need and are advocating to others to learn what they need is available from other sources. We have no organization looking over our shoulder or licensure contentions to prevent us from saying what works for me, may not work for you, your mileage may vary, and we are not locked into mantras and unworkable mandates. We can honestly look people in the eye and tell them about SMBG and how important this is to learn how different foods affect our blood glucose levels.

We are not afraid to tell people that the doctor is there for guidance, but we have to become our own lab rat in our own science experiment to discover what works best for us. Once we have this knowledge, no CDE or RD will again be in a position to bully us into following them down the path to destruction.

I am enthusiastic about working with the round pegs and free spirits that reject the advice you hand out to square holes and want people with type 2 diabetes to follow blindly. Even some doctors and endocrinologists are discovering that your advice does not work, especially for people that have found the paleolithic lifestyle or the low carbohydrate lifestyle. There are other types of living lifestyles that are working for other people with type 2 diabetes and doctors are learning that good nutritional information is more important than mandates and mantras.

Some of these same doctors and endocrinologists are also beginning to understand the importance of many of the tools CDEs and RDs continue to ignore and do not teach to people with type 2 diabetes. Fortunately we are a very diverse group and don't fit the square holes you insist we should fit into. Maybe it is this diversity that puzzles you so much because we don't fit nicely the patterns and established rules that you work with for people with type 1 diabetes. We know that you don't like us becoming our own science experiment because then you know we will not adhere to what you preach. Viva La Difference!