Managing Your Type 2 Diabetes - P2

Continued from yesterday's blog.

#4. Be Active: To lose weight, you should try to exercise three times a week for 30-60 minutes a day. But moving your body is good for a lot more than that.

Regular workouts can:

• Lower your blood sugar.
• Boost your heart health.
• Lower your blood pressure.
• Help insulin work better in your body.

If you find an activity you enjoy, you’ll be more likely to stick to it.

“Exercise shouldn’t feel like a punishment,” Fonseca says. If you want to go swimming, go swimming. If you want to go dancing, go dancing. That’s exercise, too.”

You can also call on a partner to help you stay the course. Whitney Bischoff, a registered nurse in Seguin, TX, was diagnosed with type 2 diabetes at age 48. Now 61, Bischoff says her disease has changed how she and her husband spend time together.

“It wasn't too long after my diagnosis that we had the opportunity to take an active vacation, and that began our more-active lifestyle,” she says. “It’s a favor, really. We treat our bodies better because of diabetes. We can live long and healthy lives through these recommended changes in our lifestyle, without missing out on life.”

#5. Focus on Food: If changing your diet seems daunting, remember: Your goal is to strike a healthy balance, not achieve "perfection."

“Generally, you need to avoid concentrated sugars,” Siminerio says. “I'm not saying don't eat the cake at your grandson's birthday -- just don't eat all the roses on the cake.”

Focus on getting plenty of fiber through plant-based foods like fruits, veggies, and whole grains. Keep track of your carbohydrates so you don’t go overboard, and stay away from sugary drinks.

Avoid trans fats, too. Instead, stock up on protein -- up to 25% of your plate at each meal should be protein from sources like fish, chicken, dairy, or vegetables.

“Vegetables really help me feel better,” Crim says. “And nuts are great. Have fruit on hand, and if you choose to eat sweets, moderate carefully, but don't deprive yourself so that you overindulge.”

The more people in your house that get on board with your meal plan, the better, Fonseca says.

“Very often, people try to diet in isolation, which is very hard to do,” he says. “You can't have a different diet from your spouse and your kids. Everybody's got to do it together.”

“Meds work differently in each person, and that affects when and what you should be eating,” she says. “A dietitian has your medical plan. It's not an off-the-shelf cookbook from someone.”

#6. Lower Your Stress: It makes your muscles get ready to fight or run away from danger. When your insulin isn’t working right, this process floods your blood with glucose (sugar).

“Stress pushes up blood glucose, raises your blood pressure, and increases your chance of heart disease,” Fonseca says.

If smoking is your stress-relief go-to, it’s time to quit. “Along with affecting your lungs, smoking narrows your blood vessels,” Siminerio says. “So if you smoke, have high blood pressure, and high lipid levels, that's like a time bomb in your body if you have diabetes.”

Here are some healthy ways to combat stress:

• Do breathing exercises.
• Tense your muscles and then release them.
• Go on a walk or jog.
• Stretch.
• Start a new hobby.
• Replace negative thoughts with positive ones.

“My advice? Have fun,” Fonseca says. “It’s a whole lifestyle change, so be sure to make it a life you enjoy.”

Managing Your Type 2 Diabetes - P1

The idea for this blog came from this article. I was not surprised at the diabetes diagnosis. I had relatives on my mother's side of the family and knew that my brother had type 2 diabetes. My brother had been able to manage his diabetes with no medications, so I was surprised that I could not. After three months, I was still in the 200's and occasionally could get into the lower 100's.

The biggest shock was after having angina surgery when a heart surgeon came to my room and called me a liar for not telling them on admission that I had type 2 diabetes. I admitted that I did not know and the surgeon called me a liar. Finally to get him our of the room, I threw the bedpan at him. I missed him because he ducked and it bounced off the wall and out onto the tiled hall floor. This brought many nurses and the heart patient in the adjoining bed asked the nurses to remove the loud mouth doctor so he could sleep.

Shortly the head of the heart department was there and was the surgeon that had operated on the individual and he asked what was happening. The fellow told him that I was being picked on for not knowing that I had diabetes by a doctor and the doctor was rude and loud and had awaken him. The surgeon apologized to me, called the head nurse to the room, and said that a sign would be placed just outside the door that anyone entering this room must get permission or trouble will happen to people ignoring the sign. The nurse was asking many questions, finally the surgeon stated everyone, and if she could not follow orders, he would find a new head nurse. After she left the room, the fellow in the other bed thanked the surgeon. The fellow then asked me if I objected and I said no. I thanked him and the surgeon for coming to our room when another surgeon could not be civil.

After I was discharged and at home, I realized I had many things to do. Remembering every thing now is a bit on the difficult side, but I will use the article as a guide,

#1. Build a Support Team: “It takes a village to manage diabetes,” says Linda Siminerio, RN, PhD, chair of the National Diabetes Education Program. Along with your doctor or nurse practitioner, you can get help from:

• Diabetes educators
• Dietitians or nutritionists
• Pharmacists
• Endocrinologists
• Podiatrists
• Dentists
• Psychologists or Therapists

Their services are often covered by insurance.

#2. Get Involved: Having a health care team is key, but you're the most important member of it. “We want you to be informed and empowered,” Siminerio says.

Take an active role in your care. Ask questions. Learn what your medications do and how to take them properly. Practice any other healthy habits your doctor recommends. And know what your A1c levels are and what they mean.

#3. Lose Weight: “Being overweight is one of the major drivers of the epidemic of diabetes,” says Vivian Fonseca, MD, a professor of medicine and pharmacology at Tulane University.

Fat can cling to muscle and important organs like your liver and pancreas, which can lead to serious complications.

The good news: You don’t have to reach a certain target weight before seeing positive results.

“Any weight loss is beneficial,” Fonseca says. “It doesn't mean you should stop after you lose a few ounces, but it’s encouraging to know that even if you lose a little bit of weight, it is helping your body. It reverses a lot of those changes.”

It's extra-important to get rid of the extra pounds around your middle. That’s why Siminerio suggests you watch your waist.

“Folks that have the classic ‘apple shape’ -- usually men in their 40s and 50s -- are at higher risk for cardiovascular disease,” she says.

Keep your goals realistic for long-lasting change. “Losing 1 pound a week is doable,” Fonseca says.

CPAP Helps Glycemic Control in OSA Patients

According to research published in the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine is a study believed to be the first randomized controlled trial of its kind. The study is titled “Effect of CPAP on glycemic control in patients with obstructive sleep apnea and type 2 diabetes: A randomized clinical trial.”

A randomized clinical trial for this is believed to be the first randomized controlled trial of its kind. Francisco Garcia-Rio, MD, PhD, professor of medicine at Autonoma University of Madrid and senior study author, said the research advanced understanding of the biological relationship between two major public health problems, which epidemiological studies have indicated are related.

"OSA is a public health problem of the first order, due to its high prevalence and marked morbidity and mortality, having been linked to traffic accidents, cardiovascular complications and, more recently, neoplastic diseases," he said. "Diabetes mellitus is a global epidemic. There are currently 382 million diabetics worldwide, a figure which is estimated to reach 592 million in 2035."

Dr. Garcia-Rio and his colleagues studied results from 50 patients with both OSA and sub-optimally controlled type 2 diabetes, who were assigned to CPAP intervention or control. Participants, who ranged in age from 18 to 80, did not change diabetes medications during the trial unless medically necessary, nor were they expected to change their diets or level of physical activity.

The researchers measured glucose control, changes in insulin sensitivity and resistance, inflammatory proteins and other biomarkers associate with type 2 diabetes glycemic control. Researchers found that those using CPAP showed a statistically significant:

1. • Decrease in glycated hemoglobin (HbA1c) levels at 6 months. (The decrease at 3 months was not statistically significant.)
2. • Improvement in insulin sensitivity at 3 and 6 months.
3. • Decrease in insulin resistance at 6 months.

The researchers found that CPAP participants experienced lower levels of the inflammatory molecules IL-1β and IL-6 and higher levels of the hormone adiponectin, an important glucose regulator.

Dr. Garcia-Rio said study findings suggest that "early identification of OSA in patients with type 2 diabetes, and assessment for metabolic abnormalities in those with OSA could reduce the cardiovascular disease risk of patients with these chronic diseases."

Researchers believe results are generalizable, given that patients included in the study were referred from diabetes units or primary care physicians, reflecting standard clinical practice. Study limitations include small sample size, lack of a placebo arm and medication changes that were necessary for some patients during the trial.

Treat Prediabetes as Type 2 Diabetes

Yes, this should be done. First, some definitions – Prediabetes = blood glucose levels of 100 mg/dl to 125 mg/dl and diabetes is considered anything above 125 mg/dl. As I stated in my previous blog, we should treat prediabetes as diabetes, no more and no less. It isn't even humorous that the majority of doctors ignore prediabetes completely.

You may hear doctors comment that, “watch what you eat as your blood sugar is creeping up,” or “your blood sugar is elevated.” Other doctors still use the older term “borderline diabetic”, or that you have a “touch of sugar.” Most times you will not even be told anything if your blood glucose levels are less than 115 to 120 mg/dl. We recently had a friend of Allen's comment that his blood glucose was 103 mg/dl and his doctor did not say anything. Allen asked him how he knew even this and his friend answered he always asks for a copy of his tests. His blood glucose test before the last one had been 98 mg/dl.

Allen said his friend had asked him if he did not have prediabetes and Allen agreed that he did. Allen said they had talked the rest of the evening about what he could do to gain control of his prediabetes. Allen covered the food plan that most of us use and developing an exercise plan. Allen said he had a substantial exercise regimen in place so they spent most of the time on a food plan. Tim suggest that he tell his friend that if he went above 115 mg/dl that he ask for a minimum dose of 500 mg (off-label) to be taken with his evening meal. Several other members that were gathered with us agreed.

I explained that it really did not matter, as any reading over 99 mg/dl meant that his pancreas was having problems and should receive assistance whether with exercise, a low carb, high fat (LCHF) food plan, or a medication. Tim agreed and added that is best for slowing the decline or healing of the pancreas. The younger a person, the best chance of healing and preventing the onset of type 2 diabetes. In an elder person, healing may not work, but often can delay the onset of type 2 diabetes.

Barry asked if his friend was testing and Allen said they had talked about this, but not made any decisions. Tim said that we should always suggest that they obtain a meter and test strips they can afford and if they have problems with this, they should consider a meter and test strips that they can obtain at Walmart. I agreed with Tim and said that once they have a meter and test strips, someone from this group should spend time explaining the best method of testing and what the test results mean, by teaching Self-Monitoring of Blood Glucose (SMBG). Then we should explain goal setting and what might be reasonable goals for them.

Brenda said that we should suggest various goals. She asked for anyone that disagreed to say something and we would discuss each point. Since we are dealing with prediabetes, fasting should be from 65 to 100 mg/dl and not higher. She said that fasting readings of higher than 100 indicates the need for meal plan concern and possible metformin. Postprandial should always be below 140 mg/dl and preferably not higher than 120 mg/dl. Readings higher that 140 mg/dl indicates meal plan problems and need for metformin possibly two times per day. She said I know this disagrees with the metformin recommended before, but until they bring the number of carbohydrates down and increase the fat consumption, metformin may be necessary.

This generated some discussion and most wanted the postprandial set at 120 or 125 mg/dl. We agreed on 140 to begin until they had a good meal plan (LCHF) and then bring it down to 120 mg/dl. Some felt that fasting should be 65 to 90 mg/dl, but most were comfortable with the 65 to 100 mg/dl. Tim also felt that anyone with fasting numbers 100 or above should ask for an HbA1c test and everyone agreed. We all agreed that even with the term prediabetes, we should consider it as the earliest stage of type 2 diabetes.

Diabetes, Seek out Information for Power

I am surprised that I have been asked to do this blog. Two of our support group, Barry and Jack had an unusual meeting with a certified diabetes educator (CDE) and were both told to go back on oral medications. Both questioned why and were told that they were managing their diabetes too well and this CDE felt they should come off insulin and return to oral medications.

In addition, they were told that they were not consuming enough carbohydrates and would have problems if they didn't start consuming more. They she had quizzed them about the amount of fat they were eating and said they should be eating low fat as fat was not good for them. Jack said they both laughed at her and said they were not going to change. The low carb/high fat food plan they were eating was making their diabetes easier to manage and the insulin was helping them manage their diabetes.

Barry asked her why they should change when they were having success and their latest A1c's were both 5.4%. She promptly asked if they recently had a hypoglycemia episode. Both had answered nothing below 65 mg/dl and both declared they realized that the upper limit was 70 mg/dl, but they were not concerned about a few readings in the 65 to 70 range.

Jack said that she chastised them for being under 90 mg/dl. She felt that for their age this should be the lower limit. Barry said she continued that they should both have A1c's near or above 7.0%. Jack said he became a little hostile and told her she was out of line and that her one-size-fits-all solution meant that she had not properly assessed them and their abilities to manage diabetes on an individual basis.

When she would not back down from her decision, both got up and left saying they were not round pegs she could fit into her square holes. They knew from testing that they were capable of managing their diabetes and would not listen to what she was mandating.

Barry said he remembered a blog I had written back June 2012 and said something about CDEs not having a proper perspective on people with type 2 diabetes. I had him look at this blog, and he said that is the one. Jack read it and said that summarized his feelings as well and that is why he was intending to ignore her advice. Jack added that her one-size-fits-all advice was not for them and he did not like the way she had come across to them.

Jack added that I had another blog back in 2011 that said something about knowledge about diabetes being power. I pulled this blog up and he said yes. He said that if I would put the URLs in an email to him, he would email our group about what had transpired and how we should avoid CDEs that could not individualize plans or do proper assessments.

Barry said that their doctor had suggested seeing her because she was new to the area and they could make use of the two hours of education allowed by Medicare. Barry said they had only used less that an hour and they were going to tell their doctor not to send other patients. People with type 2 diabetes and well managed were going to be very disappointed. I suggested that they explain her push for high carb/low fat when the were doing the opposite. Jack said he would as it was the doctor that had suggested this in the first place.

Late the next day, Barry called to say that was exactly what his doctor wanted to hear and now he would not be sending other patients. Barry said that was why he sent two of his well managed type 2 patients. Barry said he had even sent one of his type 1 patients and the CDE wanted him to consider stopping the pump. Barry asked if this was for a short vacation and the doctor had said permanently.

Barry told me the doctor had said there is a need for a CDE, but not one so far behind in her education, out of touch with doing an accurate assessment, and one that would advise a patient to abandon a pump.

Type 2 and Insulin Use

Carla Cox, PhD, RD, CSSD, CDE starts off her blog on the American Association of Diabetes Educators (AADE) website with something that truly surprises me. All I can say is thank you Carla. I have been fortunate never to have a provider (doctor) say what makes her want to scream. Believe it or not, it was a certified diabetes educator that said, “If you cannot control your diabetes better, you will have to be put on insulin.” This was in the month following my diagnosis and I was still figuring out what I could eat and my numbers were still generally above 250 mg/dl. When this was said, I got up, and said that may be necessary, but your way of stating this sounds like a threat from someone that does not understand diabetes as I went out the door. I did not understand then how correct I was, but I found out over the next few months that this person did not really understand diabetes and was terminated for her attitude.

I did call my insurance company when I got home and explained what had happened and how long I was in the room with her. I was told that I was not the first to complain and payment would reflect the short time and lack of education. October 2003 was the month of diagnosis and this was about mid-November. I did see my doctor mid-December and he was concerned that I had not reduced my blood-glucose readings more. He had me rescheduled for late January. He suggested that I do some research on insulin. No, there was not order, just a very polite suggestion.

I knew by the middle of January that I would be better on insulin and had read two books and done a lot of Internet reading. I had the blood draw and the doctor was ready to see me. I said the test results would probably be late and he said yes. I said he was welcome to look at my recorded results for blood glucose readings and that I should be using insulin. My readings were still generally over 150 mg/dl. He said he still was not sure, but that he would talk to the person and get me started with some education while waiting the test results. I said I would not meet with the person I had before and he said she is no longer part of the office and he felt that the RN would be able to gain my confidence.

I must admit he was right. The first question she asked me was what I knew about insulin. I opened my briefcase and showed her the two books and said there were many types of insulin and I wanted to stay away from any mixed insulins. I would probably need a 24-hour insulin and a fast or rapid acting insulin. At that point, the doctor entered the office and had the test results. My A1c was 7.1% and my lipid panel was within range. The doctor said I should probably stay on oral medications for a little longer. I said I am tired of being overly hungry and fighting to bring my blood glucose levels down and being even hungrier. The RN spoke up and said that with the knowledge I had already that I should be on insulin. We talked for a few minutes longer and he pulled out his prescription pad and wrote several prescriptions. He instructed the RN to give me one of the better meters and for me to stop using the one I had.

The next 45 minutes with the RN were intense and rewarding at the same time. She gave me the starting dosage for Lantus and Novolog after doing some calculations. She anticipated my questions and showed me how to calculate and refine adjustments over several weeks as needed to get me to the levels I had expressed wanting to reach. Then we covered the correction ratio for correcting readings that were higher that desired before a meal. She carefully wrote out all the calculations and what to do to adjust the dosage to get near the readings I wanted. Then she had me walk through several calculations. This was a great learning experience for me and I still have the calculations. This fit my learning style – observe and then do – and I remember how to do this today.

Then she said it was time to scare the dickens out of me and I said like hypoglycemia. She did a double take and asked where I had read this. I pulled out the book (the second in my list here) and showed her the tabs I had created on post-it paper. She looked at the area I had marked and stated, “You do know then.” I said she had not read far enough to read some of the tips to correct hypoglycemia and what not to do. She said if you know that now, I don't need to cover this. She did take time to look at many of the tabs I had marked and then she went to the copier and copied the cover of the book. I told her where I had purchased both books (including the first on the list) and she said she had not seen either of them and wanted to read both now that she knew of them.

Next, she wanted to talk about reading labels and I hauled out my third book and a cookbook. She asked what I had learned. So I showed her the labels I had put in the book from different foods and explained that I had a scale to weigh things if necessary. Next, I opened the cookbook (Betty Crocker's Cookbook, ninth edition – ring binder)) with the nutrition information with each recipe and said I look at the number of servings in the recipe and multiply the carbohydrates by the number of servings and divide by the number of servings I would be using. She said I understood better than most and I thanked her. She did suggest a carb counting book that I had not heard about and we covered a few other pointers she wanted to cover.

She commented how much she wished others would work to understand diabetes and investigate insulin like I had. I said that not everyone has an interest and many do not want to talk about diabetes. I said I had gone to several bookstores and several places on the Internet looking for books, especially after the doctor had politely asked me to learn about insulin. She made sure I had the telephone numbers for my doctor and how to contract her or her associate if I was having problems. We did exchange emails a few times and she would give me new book titles that she thought I might be interested in.

About a year later, I lost contact. I have met a few CDEs outside of an office setting and had enjoyable experiences. In an office setting, I have not had an experience I wish to repeat. I am very surprised and appreciative that I had such a pleasant experience with a registered nurse.

I have to wonder as most of the cookbooks since then no longer have the nutritional information included especially the hardbound editions. In looking through the bookstore a week ago, all of the hardbound and paperback cookbooks do not have the nutritional information included. This store does not carry any of the ring binder versions.

News from Our Informal Peer-to-peer Group

One of the members asked me why I have not blogged about our group lately. I asked what happened this summer and fall. He said many of the group traveled during the summer and some had just recently returned the first part of October. Some of us had gotten together occasionally, but not regularly, as there were not a lot of new things to occupy us as a group. Even now, we have not had the entire group present.

Some of us are excited about the new study from Sweden that identifies a new marker for determining diabetes approximately ten years before diagnosis. True this needs further study, but may be a lead in the right direction. It means nothing to those of us that already have type 2 diabetes, but if this can assist in making potential diabetes patients make lifestyle changes now and delay or even prevent diabetes - this is a good thing. We will be watching for further research on this topic.

In addition to my having to take a forced writing vacation per my doctors to let my wrist heal, two of the group has had some illness and another has a family member with an illness that put the spouse in the hospital. This has caused us to be more careful and less likely to take time to get together. Some of have been exchanging emails of late attempting to figure out a convenient time after the holidays for all to get together and possibly introduce three new members. I have the two women that I met recently and Barry and Ben have a new friend as well. There may be others that we haven't heard from yet.

Several of the members are quizzing me heavily about my peer mentoring experiences. Three of the group is asking if they could sit in on a session, see how I answer questions, and possibly consider doing something similar. We have talked extensively about how I answer questions. I first told them that I do not make suggestions in many areas unless it preface it with “you must talk to your doctor.” I make sure the question is answered with talking with your doctor and suggest two or three possibilities to help guide the questions. I warned them about making recommendations that might sound like advising people to take a certain medication. I said that we cannot do this and this type of advice can create legal liabilities we don't need. I explained about one participant that was trying to get me to do just that. I also said I would need to talk to the doctors and see if they were willing to have others sitting in. I said it could be beneficial having more than one person relating experiences. They agreed I should get permission first. We also are looking for a place to allow more than one person since my office is not the most convenient.

Allen and Max have been on my case and in my face lately about being a turncoat and helping a type 1. I know this is good-natured as Allen lives three houses away from the now 14 year-old young girl that I wrote about here. He did not realize I knew them until one day this last summer when he saw me visiting with the family. He came over and then Max who happens to live directly across the alley saw us together and joined in. They all knew each other, but not that Lily had type 1 diabetes and her family did not know that Allen and Max were people with type 2 diabetes. What was to have been a short visit from me concluded about four hours later after the evening meal. We all had an enjoyable time and Lily had a great time teasing the three of us asking questions since we are all on insulin.

Are People With Type 2 Lazy and Undisciplined?

This is the curse of having type 2 diabetes. Even people with type 1 diabetes are affected by this from people that are ignorant about type 2 diabetes. Unfortunately, even people in the medical profession seem ignorant about type 2 diabetes and insult their patients.

Of the group of people that I get together on a regular basis, only two of us have weight problems. Of the six that are on insulin, we are the two with constant battles to shed some weight. Yet even the rest of the group receives insults when people find out that that we have type 2 diabetes.

We receive comments about our inability to exercise, lack of will to leave the table, eating too much sugar, and not having the will power to prevent diabetes. Not only do we hear these insults, but also when we are together, people are constantly inspecting our table to see what we are eating. It will vary among us, but most have unsweetened tea or diet beverages, some will have a salad with vinegar and oil, and a few of us may have a meat without a bun or bread, or another protein.

Depending on the time of day, some of us may have fried eggs or even poached eggs, yet we have people that insist that we have sweetened tea and make not so pleasant comments about what we are eating. Yet there they sit with their donuts and sweetened drinks like regular colas, coffee with cream and sugar. Or they have a plate of pasta and few vegetables, and they are blaming us for our diabetes.

Oh, yes, when one of them is diagnosed with diabetes, we would like to return the favor, but our group has chosen to take the high road and not the road they have chosen. Even the member (Sue) of our group who had been a pain in our side as the diabetes police has more than once commented that if only she knew then what she knows now, she would have thought twice before making insulting remarks.

Even her husband (an informal member) is surprised we have not rubbed her face in it. We just answer, “what would we gain” - except a very negative attitude. We promote as positive an attitude as we can even in the face of most insults. We feel that this is the reason we get along so well when we are together – whether this includes three of us or all eight of us. We are a confident group that generally ignores the insulting comments directed at us.

Isn't it great to have an invisible disease? At least among the members in our group, we enjoy the company of each other and the interests we have in reading and comparing notes about what we read.

Our last addition to our group (Allen) has asked to stay in our group so that he can learn and carry information to another group of his friends that have type 2 diabetes. He stated he likes the informal nature of the group and the way in which we support each other. He stated that he likes to read, but the rest of his type 2 friends are not into computers and research or reading.

All of those that he gets together with are on oral medications and do little testing. This bothers him (Allen) and he has been asking a lot of questions about testing which we answer. Last Thursday we got into depression as he was having a downer, as was another in his group. Since there were only five of us, we told him to get the member in so we could possibly answer some of his questions.

Well, the two others from his group accompanied the friend he called as they were already there with him. Our group members knew something was indeed wrong just as soon as they arrived. Our member, Tim, asked a few questions and said we had better get him to the emergency room or if a doctor could see him, he would prefer that. Several calls were made and we were able to get him to his doctor that knows diabetes. The doctor was waiting on their arrival and took him immediately and Tim accompanied him.

Later after the appointment, Tim explained that they were admitting him to the hospital and putting a watch on him as he was suicidal and very deeply depressed. Tim said that the other two friends of his were both going to visit him when allowed and well as a couple of our group. For now, that is where we left it.

We did get together with Allen to see what his mood was, but Allen said seeing his friend in that shape had scared him deeply and he was not down now. He expressed his feelings as more of concern for his friend than worry about himself and this was the reason for his downer, as he did not know what to do for his friend. He thanked Tim for knowing what to do.

We discussed asking the doctor to speak to both groups about depression and how to recognize the symptoms he had. Tim said he would talk to the doctor and see what could be arranged.

We discovered that the person Tim had helped was the eldest brother of our member (Sue) and she had not been aware that he had been admitted to the hospital until she received the email from us about the day's events. After she had been to the hospital and seen her brother, she had her husband stop by Tim's house and thanked him. Tim told her we were not aware of their relationship or we would have let her know immediately.

Our group has decided to use this example to discuss with the members of both groups about the problems of keeping diabetes a secret.

You may enjoy reading this blog by Elizabeth Woolley.

Tackling Diabetes Care Challenges

Another “Expert Group” for diabetes is not something that gives me a lot of hope. Again, they do not include any people from the patient side. Granted there are not a lot of experts these professionals would classify as patient experts.

The name of the program is called “Improving Quality in Type 2 Diabetes: A national Initiative to Assess Guideline Adherence and Physician/Pharmacist Coordination.” This is part of a U.S. multiphase initiative that is setting out to assess the effects of current in-practice behavior across multidisciplinary professions in caring for patients with type 2 diabetes. Sounds impressive, but will this really assist patients?

I always get a sickening feeling when I read things like this as I wonder what other limits are going to be imposed on those of us with type 2 diabetes. Is this another program to declare that type 2 patients on oral medications do not need to spend time testing? Or, will someone finally realize that the physicians are not doing their duty of educating patients on the value and meaning of self-monitoring of blood glucose (SMBG).

This is always a possibility and should be high on the priorities for any expert group, but will it? “The aims of the program are:

• To reveal practice-specific obstacles of appropriate glycemic control in primary care and endocrinology in multiple locations and practice environments across the U.S.
• To assess current pharmacist practices in terms of medication education and patient monitoring of those with type 2 diabetes, and
• To determine the critical factors of successful interdisciplinary diabetes care by considering the behaviors and attitudes of physicians, staff, pharmacists and patients.”

Notice that the only mention of patients is in the last point above. Everything else is dedicated to practice level discussion. How will they determine the behaviors and attitudes of patients? Will this be just another adhering or non-adhering discussion about the patients? Or, will they actually consider the feelings and problems patients encounter in lack of diabetes education, continuing support and updated education, and the benefits of continuing education to assist the patients?

As a patient, I can only suspect that it will be more of the same lack of concern for the welfare of the patient and no thought about the lack of education provided. This will leave patients out in the cold and the “medical professionals” patting themselves of the back for again claiming to have improved life for the patient.

Until the professionals change their thought process and include patients with type 2 diabetes in any discussion, nothing will change from a patient perspective. No education will be provided to the patient, SMBG will continue to be downgraded, and patients will continue to wonder where to get reliable information and help in their management of diabetes.

Uncaring About Diabetes – Not an Easy Challenge

For several days, I have been wrestling with how to write about a potential member of our diabetes group. This person has type 2 diabetes and has been included in our discussions on two occasions. He is still not convinced that he has to do anything about his diabetes and we know that he is in denial. The first time he attended we knew he was very angry and not accepting his diagnosis.

Then Jan Chait who writes for Diabetes Self Management wrote an excellent blog February 14, 2012 about someone that was seeming uncaring about diabetes. This cleared the cobwebs and I am writing about this person. He is retired and lives alone. He said that he knows of no one in his family that has or had diabetes, but did lose his wife to what he says was diabetes about three years ago. She was diagnosed about three years prior to her death with diabetes and put on insulin at the start.

He does not know what caused her death other than he blames the diabetes and insulin. When he found out that six of our group was on insulin, he about passed out and asked how long we had been on insulin. I am the longest of our group on insulin at eight full years and another has been on insulin for about five years. The shortest time on insulin is almost three months. Others have been on insulin for more than one year.

This surprised him and he asked why we were all appearing to be healthy and able to get around on our own. His wife had been put on insulin and about nine months later had one foot amputated and was in a wheel chair.

When asked what his A1c was, he could not tell us. All he knew was that the doctor had told him he had diabetes and wanted him to start a medication. He could not tell us the medication, as he was not going to take it. We knew we had a challenge. How were we going to get him to accept his diabetes and take the steps to manage diabetes?

We did encourage him to get copies of his test results done by the doctor. We also talked some about food and made some suggestions we thought might help him. He seemed very receptive to most of our ideas. When we got to moderate to high fat, he balked and said his doctor has encouraged him to be on a low fat diet. We asked if he was having problems with weight gain to which he answered no. We then asked him if he was having cholesterol problems and how he was doing on the lipid panel. He said good as far as he knew.

Again, we strongly urged him to get copies of all tests the doctor had done. Then we asked, if he did not mind, bring them for him to read from to add a solid foundation for discussion. He said he would and we let him go with that. He said he will stay in contact with his closest neighbor who is one of us and had invited him to the meetings. I have since learned that he is out exercising every day that he is able. He jogs and walks every day – weather permitting and apparently has a treadmill in his house.

Now if we can get him past his denial and to accept his diagnosis. Then he may be more open to some serious discussions for managing his diabetes. We are hoping that we may have another potential member. We are also aware we have a challenge ahead of us.

Obesity Prevention Should Consider Day Care

This study is correct that day care needs some light shined on it to help in the fight against childhood obesity, and not mentioned is the fight against childhood type 2 diabetes. Focusing attention on one factor (day care) should not be the case although this article does bring up some excellent weaknesses and problems with our day care facilities and systems which needs to be highlighted and parents need to heed.

With 82 percent of American children under the age of six in child care centers while their parents work, parents need to be concerned about the food their children consume away from their control. Children in full-time day care can consume two-thirds of their daily calories and this is under the control of other adults and their nutritional guide.

The study disclosed that most states have minimal requirements for healthy eating and physical activity while a child is in day care. These requirements may not meet public health care recommendations.

Day care centers that quality for government financial assistance must meet guidelines that call for children to get foods high in nutrients, but low in fat, sugar, and salt. Studies have found that some day care centers fall short of meeting these standards. Other day care centers that receive no federal assistance are under no requirements to provide at the same standards and many do not.

Then the other problem is that children do not always eat what they are served and demand foods that they should not have. So day care caters to these demands rather than have the children complain that they are hungry when the parents pick them up.
Often the children do not eat enough of the recommended foods if they eat any at all.

Some day care providers provide healthy foods and eat the same foods with the children to encourage the children to eat them. Most Head Start programs follow this model. Other studies show that the providers often do not coach the children to heed their feeling of fullness or hunger. Many just make comments about how much or how little the child was eating and do nothing to reinforce good eating.

When it comes to physical activity, day care seems to have no standards or even guidelines that they follow. Studies have followed children at day care centers and in many the children were sedentary more than 80 percent of the time under observation. The studies that many children are not getting much exercise because staffers do not encourage this or they take physical activity away as a punishment.

What should parents do? Because you are giving control of your child or children to a day care center, several suggestions are offered that can help parents. For physical activity, look at the entire center, outdoor areas, and indoor areas and ask questions about how they are used and if they have scheduled activity times. Know that the larger child care centers have more specific regulations for food and physical activity while home-based child care centers may not.

Look at the eating area and ask how food is served. Are meals served family style for the children able to help themselves and are the children taught how to take responsibility for what the put on their plate. This gives them a good sense of what to eat and does not give them situations of a pile of food being place on their plate that they may not eat.

Ask to see a menu and look at the variety of foods offered. Look for duplications on certain days and especially watch for fried foods such as chicken nuggets, fish sticks, and french fries and these should raise red flags about the variety and healthfulness of the foods. Then ask the staff about how the children are doing at mealtimes and whether the children are willing to try new foods.

Carry this over to the home setting and ask the child what he had to eat. If the child says he had something that he does not eat at home, don't be afraid to ask the care center for the recipe and continue to engage the child in conversations about the day care center. Look for both positives and potential warning signs. Also check the child's weight on a regular basis and compare it to what the doctor says is normal or near normal weight for size and age.

Inactivity Linked to Risk for Type 2 Diabetes

I wish I could comprehend some items with the ability of Tom Ross. He has a sense of humor and skepticism that make reading him blog very enjoyable for me. He can rant and vent with the best of them and you will not even know it by the way he writes. That is another reason to read his blog.

Since his blog is not one that you can link to for a specific post, I will just tell you that you need to read his post from Thursday, August 25, 2011. I like the way he boiled done the relationship between obesity and diabetes and then took us to the study which is the topic of this blog – inactivity. You will need to scroll down the page to find the blog, and I think you will enjoy his presentation. He packs a lot of good sense into his discussion and at the same time makes excellent points.

Quote I doubt very much that we are ever going to narrow this down to a simple cause-and-effect relationship between a single issue and diabetes; it is far more likely to be a tangled interaction between multiple factors.

But one factor which could be as important as obesity tends to be mentioned far less often than obesity is, as a possible cause of diabetes: physical inactivity. Unquote.

That is one of the best ways to describe much of the discussion from many articles about diabetes and obesity.

So rather that cover the topic again, it is well worth your time to read Tom's blog and then read two articles covering the topic – here from Science Daily and Medical News Today here.

Making Changes in Managing Diabetes

Changes – life is full of changes and we need to know how to make them for the improvement of our health. This blog from the Mayo Clinic makes some excellent suggestions and will hopefully start you on the right path to change. I know it is helping me, but I still need to make more changes.

First they lay out three steps or fundamentals in making changes and then walk you through the steps.

The first step is the unfreezing step. In other words becoming used to the new idea or change needed and motivating yourself to make the change. In diabetes, this involves or can involve many ideas and some motivators. The diagnosis itself can be a huge motivator. Then later an increase in A1c can become a change motivator. A great motivator for me was my doctor asking me what I could do to make a change and did I want his help. It took some discussion, but after he had laid out some possible changes, I was able to select two for starters and discuss them with him.

Others can realize that changes are needed when family members ask the right questions and we realize the current path is not working and that staying the course will not make the situation get better. When you realize a change is necessary, the mind over matter mental game needs a resolution. Real or imagined anxieties can get in the way of making the change.

The second step in making the change. This step involves deciding on what changes need to occur. This is when laying out the pros and cons on paper can often show you what needs changing and sometimes can become a boost in making the change. Other activities may also help. This can include may of the following. Choosing the specific change or changes you want to work on changing. Please be realistic and avoid trying to change everything.

Write the change or changes down and post it where you will see it every day. This can be your daily reminder of what you need to accomplish. If you have others (family members or significant other) available, ask for their help and encouragement. If necessary find a support group to assist you. See you diabetes health care team on a regular basis. Track you test results and work to keep the test results where they belong or improving.

The third and last step is making this change permanent or freezing the behavioral change. While this may be the most difficult step, it does need to become a habit and something you can do automatically. Succeeding here makes you a better person, dedicated and living for better health.

Once this is accomplished, repeat the steps for the next change or changes. There is nothing better than having success to make you want to do more changes. But often it takes doing them one or two changes at a time.

Have success and live healthy!

I Do Have to Believe AACE Is Not PR Motivated

Yes, I do believe AACE is not motivated in public relations and now I am getting concerned. Back on April 29, 2011 we were told by the American Association of Clinical Endocrinologists (AACE) George Grunberger, MD, national board director through a Medscape article that AACE and Takeda Pharmaceuticals were putting up a new website to assist people with type 2 diabetes.

According to Dr. Grunberger, “The idea of the new Web site is not to provide new patient information about diabetes, but to direct patients to educational resources on the Web that provide credible information about the disease. Inaccurate or incomplete information can lead to unnecessary stress or confusion for people living with type 2 diabetes. We need to make it easier for healthcare professionals, patients, and caregivers to access reliable sources of information, which can form a foundation for treatment and care decisions." Read my blog about this here.

In this blog on July 1, I asked if it was all hype. Now it is the first of August and I still have seen no results. This time I am doing my homework as I had been wondering if the article was printed with no backup information. On that I would be wrong as on the Takeda Pharmaceuticals website they do have a news release dated March 22, 2011 to confirm at least this much. You may read this for yourself. I have been contacting people to find out what is planned and when.

So rather than just vent, I will have to say that in an answer from AACE and Takeda, I have been told that it is still coming, just that it was taking longer than anticipated. Both responders are confident in their reply. Apparently the experts can't agree and vetting is taking longer than anticipated (my thoughts).

Am I upset, somewhat, if it had been an appointment with a doctor and I missed it, I would have been sent a letter telling me how valuable their time was and to reschedule. What I get upset about is when a doctor(s) or an association misses something, they don't feel an explanation is in order. Whether I speak only for myself, or if others agree, we should have been told that there was an unforeseen delay and our patience is appreciated. Even if they would have said that it would be longer than anticipated, at least then I would not be quite so upset, and avoided venting my feelings about how doctors do more to destroy doctor/patient relationships than patients will ever do.

I am still concerned about the delay and why one hand does not know what the other hand is doing and why when something is released that it will happen in June, the public relations people did not inform us that there would be a delay. I still wonder which sites will obtain the approval of those doing the vetting of sites. With the delay, I do have to wonder again if some of the sites selected will allow for individualized selection of treatment options or whether it will be a one size fits all approach. The latter will kill it before it even gets going!

I will continue to watch for the site's appearance and what websites make the initial selection criteria. This will be an indicator of what to expect and the stand of the AACE about the approved websites.

Six Ways to Help Manage Type 2 Diabetes – P1

Much of the following has application for all types of diabetes. However, I am concentrating the discussion to Type 2 diabetes and may expand this beyond the pointers in the WebMd article. Their point is six ways to wreck your blood sugar levels or what not to do. I would like to approach this from what to do to manage you blood glucose levels.

First I would do away with the term used by many writers “blood sugar”. This term continues the misinformation about sugar being the culprit for diabetes. In fact this can have an affect, but the larger culprit is carbohydrates which is converted to blood glucose by our bodies. And we don't measure blood sugar with our meters, but blood glucose.

Type 2 diabetes is a serious chronic disease and therefore a tough adversary requiring constant vigilance to keep ahead of it as part of your individual management plan.

The article uses the following with a short discussion: Not knowing your disease, expecting too much too soon, going it alone, neglecting other problems, misunderstanding and misusing medications, and finally making poor food choices. Yes, these are six easy mistakes to make and everyone at some time in their diabetes lives will make them. It is what we learn from these falls and how fast we recover after making a mistake that determines how well we manage our diabetes.

Error 1 - Not Knowing Your Disease

The first one can be a key for assistance in managing the rest more effectively. As a person with diabetes, you need to learn about diabetes. Andrew Ahmann, MD, director of the Harold Schnitzer Diabetes Health Center at Oregon Health and Science University in Portland, Oregon, makes a statement rarely uttered by doctors. He says “You are your own doctor 99.9 percent of the time.”

He does mean that you are the one managing your diet, making sure you do exercise, and taking your medication on schedule. Dr. Ahmann also states, “classes on coping with diabetes are an excellent but underused resource. Not enough patients seek them out, and not enough doctors send their patients to them.” People need to learn how diabetes works to be able to make more informed decisions and better manage diabetes.

The only comment I make to that is that people often receive information that they will need to adapt to their lives and needs. The people presenting the information instruct from materials and fundamentals from the American Diabetes Association which is presented as a one size fits all approach. They will soon learn that one size does not fit all and that they have individual needs as well, so learning to adapt becomes essential.

Too many doctors discourage use of the internet, and for them rightfully so, because of all the misinformation that exists on the internet. Some doctors are providing short lists of good information, but not enough to make a dent for all the people needing information. So I will encourage people newly diagnosed with Type 2 diabetes to search the internet on their own and look for reliable information – discarding information that seems to or offers cures, as this just is not possible.

The one source that had promised some assistance, the Association of American Clinical Endocrinologists (AACE) has failed in their attempt to provide reliable information. See my blog here. I will provide the site link for this blog in part four of six parts.

Is There A Link Between Insulin And Weight Gain?

This blog about insulin and weight gain is one of the better blogs on the topic I have seen. And it is written by a certified diabetes educator (CDE), so I will need to be cautious. I do have a greater understanding of the difficulty of losing weight as a person on insulin. Would I go back to oral medications if I could – no way – the management of of my diabetes as a person with Type 2 diabetes is so much easier and more effective than oral medications.

Have I had hypoglycemia from taking insulin? Yes, but very rarely. In the eight years of being on insulin, I can still count the number of episodes on ten fingers and have a few to spare. Is my carb counting that exact – I doubt it, but I don't inject all the insulin at once and generally test to see if I might need more and how much more. In general this means keeping my blood glucose levels under 150 and closer to 120 two hours after eating. For the few times I get above 150, I immediately add the extra insulin to assure myself of bringing it back down to approximately 90 at four hours.

Nora Saul at the Joslin Diabetes Center, does an excellent job of explaining why people have such a large problem with weight gain and lays the blame squarely where it belongs, on both the patient and doctor. The patient for not wanting insulin and the doctor who encourages patients to stay on oral medications. It is this treatment of last resort that makes for problems of weight gain. It is also the myths about insulin and the fear of the patient and doctor about hypoglycemia that prevents using it early on when when it would be beneficial.

Both the patient and doctor need education in the use of insulin to make it an efficient treatment without the fear of hypoglycemia. Plus what many people forget, by starting insulin use early, this allows the pancreas some rest instead of complete burn out and not requiring the quantity of insulin when the pancreas is all but done and insulin is used as the treatment of last resort.

Also important is the consideration of nutrition and exercise which is often easier before the weight gain. Quoting Nora Saul, “one reason people with type 2 diabetes often see the pounds pile on after they begin taking insulin is that they've waited too long to start.” I have written about this before and do believe this to be very true.

Please read the full blog by Nora Saul for her full explanation of what happens when you as the patient and your doctor avoid the use of insulin until it is absolutely necessary. You are not doing yourself any favors and only damaging your body by letting your blood glucose get too high and thereby undermining the normal metabolism of carbohydrates and fat. I have several Type 2 friends that can agree that waiting too long to start insulin is not a good idea. They will tell you it is better to start early.

Many people are not educated in counting carbs correctly and then enter the vicious cycle of hypoglycemia and eating to correct it. They often eat too many carbs for correction and then develop hyperglycemia – too high a blood glucose level. Another problem is the injected insulin (the short acting) stays in your body about twice as long than your own insulin ever did and as a result you end up feeling hungry. This is when you need to learn that you don't need food, and must force yourself to avoid food.

Eating at regular times becomes more important to know how to gain the advantage of ignoring the hunger as too many people feed the hunger and the management of diabetes goes out the window. It does take some discipline at the start, but with time the hunger pangs will subside and become easier to manage.

She does recommend seeing a CDE for education, but I would urge you to see a good dietitian or nutritionist, specializing in diabetes, that may not push the old American Diabetes Association way (unless you are a patient at Joslin Diabetes Center), but will use the new guidelines of individual needs and desires being more important. The key here is balancing the nutritional aspects of the food you eat and learning that the old ADA way often has too many carbs which will (I mean will) help increase your weight and keep you on an upward trend. You will need to adapt to the number of carbs that works for you and does not increase your weight.

Help From Diabetes Support for Type 2 Diabetes

When I first read this, I have some serious doubts about what WebMd was advising, but after rereading the article, there are some excellent points and some I may ignore.

When you live with a chronic illness like Type 2 diabetes, it can often be overwhelming at times. There are times when we feel that no one understands the stress that we feel from living 24/7 with diabetes. If this is prolonged, these feelings of anxiety, stress, and isolation can become a barricade to your goal of wellness.

While the last statement can be true for many people, there are alternatives not mentioned in the article that I feel need to be said. These may not work for all people with Type 2 diabetes, but if you make it a priority and part of your daily life, a positive attitude, positive thinking, and positive acting can get you past many of the feelings of anxiety, stress, and isolation. Just realizing that I must have that positive attitude about daily living has helped me get past these feelings many times. Even when I felt like I was going down the path to a depression, thinking positive and acting positive stopped it cold and I felt like moving on with life.

Another tip not mentioned is what I am doing now – writing this blog. This is therapeutic in and of itself. Then I also read other bloggers which can make me laugh, nod my head in agreement with, release my frustrations with them, and cry once in a while. Commenting on another persons blog can be helpful at times. More often you will be offering them support or encouragement, but this can feed back to you many times over.

Now back to the WebMD article. They state that whether your main support comes from your spouse, a close friend, your physician, or a diabetes support group, there are people who care and can help.

They do make some very accurate statements in the article about the need for doctors that give an accurate diagnosis and understands diabetes. This is important because Type 2 diabetes requires regular medical checkups and for this you need a doctor that will help educate you about diabetes, diabetes medications and will help you devise an effective treatment plan. Yes, there can also be ophthalmologists, pharmacists,, dietitians, and educators that can also be helpful, but unless you live in an area that has all of these available, you may need to depend on a doctors and pharmacist only.

Wisely, the article does suggest when possible to see an endocrinologist that specializes in diabetes, even for Type 2 diabetes. Another important statement is about seeing a therapist. This should be a therapist that is knowledgeable about diabetes and the types of problems people with diabetes encounter.

Yes, I know the resistance people have to therapists – they don't like this because they are all wrapped up in the myth that people that say this imply that the disease is “all in your head.” The fact that people with diabetes get depression and often suffer from stress, makes this even more important. Both can make diabetes more difficult to manage and by talking to a therapist can often help reduce stress and make depression more recognizable and easier to get past mild to moderate episodes of depression.

This can be a key for better diabetes management. The emotional toll that diabetes exerts on your everyday life with diabetes can be eased by talks with a therapist specializing in diabetes. Your better health is important.

Please take time to read the entire article here and take advantage of what it offers.

Have You Experienced Hypoglycemia Unawareness?

An article by Elizabeth Woolley at About dot com appeared on my computer on July 7 and sort of shocked me. I guess I should not be surprised any more with all the new information coming out every day on diabetes. But this one gave me a funny feeling and made me wonder why I had missed this before. Hypoglycemic unawareness is known to affect people with Type 1 diabetes, but there is significant evidence that Type 2 people also have this problem.

The evidence presently that hypoglycemia unawareness affects those Type 2 people on insulin, or on oral medications that can cause low blood glucose. Hypoglycemia is defined as a blood sugar reading of below 70 mg/dl. If a person does not experience the symptoms of hypoglycemia, they need to take action. The more common symptoms include trembling or weakness, lack of coordination, drowsiness or confusion, headache, dizziness, double vision, excessive sweating, and convulsions or unconsciousness.

If you get to the last symptom, you are in already in trouble and a glucagon kit should also be kept available, in case the person is unable to take in sugar orally. Early in the symptoms, a juice box, candy (but not chocolate because of the fat), or glucose tablets will normally bring blood glucose levels back to normal fast.

The risk of hypoglycemia unawareness increase the longer the person has had diabetes. In a study done with people with type 2 diabetes on insulin, those who had severe hypoglycemia in the prior year were at a 17-fold higher risk of having severe hypoglycemia the next year.

Hypoglycemia can make management and treatment more difficult, but the following ways may help reduce the risk. The first suggestion is difficult with the insurance restrictions on test strips they will pay for, but you still should consider frequent testing and let your doctor know if you find your blood glucose levels are low and you do not feel any of the symptoms.

Next, if possible get self management education which most insurance will cover with a doctors order. Then work with your doctor for individualized blood glucose level goals. Also ask about flexible treatment regimens. All of these can greatly assist in your management to prevent hypoglycemia.

If you develop a history of hypoglycemia unawareness, ask your doctor about hypoglycemia avoidance for a period of 2 to 3 weeks to possibly increase sensitivity. This means allowing your blood glucose levels to be higher for this period in an effort to increase your sensitivity to the symptoms of hypoglycemia.

Read the blog here by Elizabeth Woolley, and the ADA article here. The abstract for reading is here.  This last link may not work if you browser does not accept cookies.

How Would You React - P1

NOTE: At request of the parents, no names are being used.

Why all the excitement about a blood glucose meter reading? Oh yes, it is just a number, but those of us with diabetes just happen to live with numbers and by the numbers it does mean something. Should we be upset when someone asks about a number when they see us testing? Many seem to get hyper about it. Yes, many get tired of the diabetes police and related reactions for good reason. Some people are just too nosy for our liking, but what the hey – we have to live too.

Granted, I will probably never be in a similar situation, but over a month ago now, I was at a local restaurant with a fellow type 2, and I had a person at another table asked me what my number happened to be. I had not even noticed them watching me. Since I am not bashful, I said what it was. Turns out that the mother was using this as a teaching moment for her daughter. She apologized for asking, but explained that her daughter of 12 had just been diagnosed that morning.

So for about the next hour, we talked about diabetes and what the meter meant to us. The daughter had been diagnosed as a Type 1, so they were thinking I had to be a Type 1 since I used insulin. After a little explanation, they were full of questions about the differences and why some people seemed so secretive and others like myself just did what I needed to do and went on living.

Granted most of the questions were about Type 1 and if there were similarities between the two types. I found out that they had just been to the endocrinologist. I asked when their next appointment was and was told they would be seeing the CDE and nutritionist the following day. So I answered the questions I could to the best of my ability and said that they should write them down so they could ask them again for the right answer just in case. The daughter reached into her school bag and got a pad and pen and started writing and I think this is key – without being asked.

It was most unfortunate or fortunate depending on how you view it that the next day we both came into the hall outside of adjacent offices at the same time. The mother said hello and the endo asked all of us to step into the room and asked what had happened. The daughter said that she had been told by the CDE to limit her sports participation and not to be talking to people with Type 2 diabetes. The endo asked what sports she was involved in. The answer was basketball, softball and soccer and she was hoping to become involved in track – cross country running.

The endo said she would like to see her after she was completed with the dietitian as she wanted to discuss the pump in light of this and she might delay putting her on the pump (and she has delayed it now). Then she asked the mother what books she was planning to purchase at the bookstore. She mentioned a couple of the books my friend and I had suggested and the endo said good, looked at me and said she was going to give her a couple of others to add to this and we left that meeting so the dietitian could start.

On the way out to get me set up for my next appointment, she commented that I had suggested the right books and she would recommend at least two more and possibly a third. As she prepared to leave, she said it sounds like you have a good grasp on most of the differences between the types and to keep it up. Well, I have a lot to learn yet, but at least I have not steered the mother and daughter wrong.

Since I thought that the mother and daughter would be delayed for at least an hour, I took time to do some shopping and then headed for the bookstore. They had finished early, and were there and had most of the books collected, but had not located two of them. Generally I don't like to loan from my library, but this time I volunteered telling them that it would help them decide which book would fit their needs on carb counting. They placed an order for the one the store did not have in stock and we left.

More in the next blog P2 of three.