Lap-Band Surgery Gets Another Black Eye

When the American Diabetes Association endorses something, look out. By that, I mean the less than honorable surgeons will find a way to fatten their wallets. From the Federal Food and Drug Administration (FDA) to the California Department of Insurance (CDI), plus other agencies are continuing their investigations into the practices of gastric banding in Southern California.

“In December, the US Food and Drug Administration (FDA) warned the marketing firm called 1-800-Get-Thin and 8 affiliated surgery centers that the ads are misleading because they fail to spell out the risks of the surgery. The agency ordered the businesses to change the ads immediately.” The FDA has this right, and the risks are not to be taken lightly. See my blog here for links to many of the risks.

What is frightening are the deaths, which has resulted from the surgery since 2009. Supposedly, there have been at least five deaths to patients after having the gastric banding operation. The 1-800-Get-Thin marketing firm and the surgery centers have been the subject of two wrongful-death suits and a whistleblower suit from ex-employees and patients. The last suit alleges the cover-up of a patient death in addition to other problems.

In addition to the CDI investigation, the Los Angeles County Board of Supervisors is investigating the ad campaign. They are seeking legislation to regulate bariatric surgery centers. Then we know when something like this hits the news, you can be assured members of Congress will want to hold hearings.

The whistleblower suit goes on to show who the real owners are and that they have been disciplined by the California Medical Board in 2008. It goes on to expose the shell companies that were designed to conceal the brothers' ownership.

At least this surgery may be rid of a couple of bad apples that is doing damage to patients and giving gastric-banding a black eye. The important aspect of this is the adverse publicity may make patients think twice and be sure they understand all the risks of this type or surgery.

Read the three articles that cover much of the same areas – article 1, article 2 and article 3. Be sure you know the risks before you submit to this surgery and do your due diligence in investigating the surgeon and surgery center doing the procedure. Gastric-banding or lap-band surgery is not for everyone.

Is Three Meals Per Day The Only Answer?

Is basic information too simplistic? Or in this case, the correct answer? This is one time I feel very strongly that a basic discussion leaves more unanswered questions than it answers. While the information given makes sense, it stops by not covering any of the real variables and leaves one statement hanging in the wind.

This statement should have been included – in all cases, be sure to talk with your doctor about your meal plan so it can be tailored to your needs and the size of your medication dose. Simple, but effective in direction for the medication the doctor may prescribe. Many people just do not eat breakfast and this can be a problem for some medications to prevent hypoglycemia (lows).

If you are on a dose of medication that can cause low blood glucose reactions, your doctor may be able to decrease the dose of medication to avoid hypoglycemia or change medications. I can agree that three meals per day is good for most people; however, there are many people with diabetes that do not eat three meals per day whether it is breakfast or another meal. If the doctor is not aware of this, problems may be created that can be avoided.

Then the blog really makes you think when they talk about insulin. Is this the only time you should talk with your doctor? I think you must communicate with your doctor whether you are on no medications, oral medications, or insulin. Even one of Joslin’s own blogs discusses the three choices for insulin injection for type 2. Why was this not linked to this blog?

Also missing was several other key points. Many people with type 2 diabetes have found that grazing (5 to 8 small meals per day) works very well with some oral medications. Others have found that low-carb is the way to go and others have settled on the medium range of carbs per day that works best for them. This is not a “one size fits all” world that medical people seem to dream exists.

Please read the blog that started this thought. I have one more thought before leaving this. Basic information may work, but do not leave gaping holes in the information.

Type 2 Blood Glucose Testing Problems

When two people you respect write about the same topic with seemingly opposing viewpoints, it really can make you scratch your head. Gretchen Becker first covered this and I was in full agreement with her. Her blog is here. Then David Mendosa covered the same study on February 3 here.

Gretchen's statement, “Here we go again! It seems that every few years another group announces that blood glucose (BG) testing strips aren't useful in patients with type 2 diabetes who don't take insulin.” This is an explanation often faced by people with type 2 diabetes not on insulin.

David's statement, “A big new review shows that people who don’t use insulin are wasting their time and money when they test their blood glucose.” This is something that got me to thinking and rereading both blogs very carefully. Both statements seem to be heading in the same direction.

After reading and rereading both blogs about this study in done in Europe, it is important to understand that the same types of studies are done in North America. The governments in Europe, Canada, and the USA, plus the medical insurance companies in the USA are all looking for ways to lower costs.

What should offend every person with type 2 about these studies is they use the term SMBG (self-monitoring of blood glucose) as if it were the culprit. They then state that blood glucose testing is a waste of time and resources. What they omit is that the medical professions in all countries are lax in giving patients the education necessary to understand how to use the blood glucose readings. They provide very little in guidance to their patients for proper decision making when looking at blood glucose readings.

Some of us around the world have been fortunate to receive some education in what to do with our blood glucose test results. Others have been able to research online and self-educate themselves. It is knowing how to adjust diet and exercise to keep blood glucose levels as close to normal as possible that gives meaning to testing. The readings are truly of no value unless you know what to do to bring high readings down and how different foods affect your blood glucose levels. This also applies to preventing lows and all extreme highs and lows.

In essence, you need to become your own science experiment with yourself as your own lab rat or mouse. This is where the challenge is and where learning how diet and exercise affect your blood glucose proves knowledge can be very powerful. There are many factors like general health, other diseases, mental or medical conditions can make this even more of a challenge.

This discussion is for those people not using insulin. So read both blogs and you will see that they are in agreement. They have stated that education is the power in knowing how to use blood glucose readings to adjust diet and exercise and possible other lifestyle adjustments for better health.

Patients Want to Read, Share Their Medical Records

This may open some controversies. According to a pair of US studies, patients want easy access to any doctor's notes recorded in their medical records and they want the right to let others view their medical records. This bothers me in so many ways. Yes, I would like easier access to my own medical records, but reserve the right to prohibit others from viewing them. There are many sides to this issue and some changes needed.

The other issue in this article is the idea that there is more evidence that some in the medical community want to see patients actively participate in their care and know what is happening and this will improve their care. This is very much needed although many patients still want the doctor to make the decision and give them the pill that will solve the problem. Wake up patients; only if you take time to learn about your condition or medical problem, chances are that your health may improve. Old habits must be removed and new knowledge replaces them.

Presently there is a long and tedious process to obtain copies of many medical records, while are some are easily accessible. When you have an appointment, be sure to ask the nurse and the doctor for copies of your lab reports if lab work was done for your appointment. These they should provide immediately and most do without hesitation. Once you leave the office, then time becomes a problem as you must sign forms and wait for copies. In addition, there may be a charge for making copies. Other records are more difficult to come by.

These studies are interesting as they talk about transparency and making medical records more available. If only this could work, instead of being as tedious as is the process is now. Most medical facilities seem to work the “wear them down” mantra in getting copies of their medical records. They will work every angle in delay and make a mistake and they legitimately delay your access.

This statement is interesting, “Increasingly, health systems are making it easier for patients to get access to prescription lists, lab results and, sometimes, doctors' notes. Delbanco said one reason is that "the whole world is becoming transparent ... The other is that computers make it easier."” I hope Dr. Tom Delbanco at Beth Israel Deaconess Medical Center and Harvard Medical School is right in his statement. This runs contrary to most information I have seen on this topic.

E-patient Dave (Dave deBronkart) is a patient advocate writer and speaker and believes that patients can become a second set of eyes to prevent things from falling through the cracks. He also feels that patients are capable of helping avoid mistakes. I agree here, but there are times when it may be best to withhold some tests results until the doctor has reviewed them and can present them with a complete explanation.

The numbers of patients wanting to share their information with other providers and family members (spouse) seems to vary depending on the study. One group had 35 percent privacy concerns while 22 percent were interested in sharing their doctor's notes with a family member, doctor, or other health professional. At the Veterans Affairs medical centers, about 80 percent would designate primarily a spouse to have access to their records.

In this article, a majority of the doctors (over two-thirds) did not like the idea of patients having access to their notes or educating the patients. These are the doctors that I am concerned about, that want their patients to follow them blindly and their directions without question.

Since this is a topic becoming more talked about, please take time to read both articles and some of e-patient Dave's blogs. Some doctors are bound to resist this trend, some doctors will resist mildly, and others will welcome the change. Which group will your doctor be a member.

Vitamins and Mortality - In Defense of Supplements

The latest controversy of many involves supplements. We have heard about salt and fats (more on this in another blog), but now researchers are coming out on both sides of the supplements issue. I have a number of blogs on supplements and many of the dangers. My suggestion, as always, is to use caution and research those that you are taking. Overdosing can be hazardous to your health and some overdoses can be fatal.

Also, consult with you doctor or your pharmacist to make sure you are not overdosing or using supplements that should not be taken with certain prescriptions. Just because they are natural does not make them always safe. Three of my blogs about taking supplements are here, here, and here.

The article that started this blog is here and the article (of Oct 10, 2011) they are disputing is here. They could also have been referring to my blog and the article it covered here but they did not. The controversy is not so much about the results of different studies, but the methodology used in the previous study. The fact that some variables that could have had value were not used and too much reliance on individual reporting led to somewhat vague reporting.

The authors of the study reported in October themselves conceded, "It is not advisable to make a causal statement of excess risk based on these observational data." Yet they proceeded to make some statements that the evidence did not confirm.

The commentary of the article on Feb 1, 2012, did do some analysis of the potential effects of following some conclusions to show that the original study may have miscalculated in making their conclusions. I found this statement rather compelling, “In addition, unlike for pharmaceutical agents, the source of vitamin supplement plays an important role. Synthetic vitamin E (dl-alpha-tocopherol) is thought to be much less potent than its natural vitamin E (d-alpha-tocopherol) counterpart and may have a varying clinical effect.”

In conclusion, the use of naturally found vitamins and minerals in our food may be more beneficial in the long term, but minus these being adequate, supplements may be necessary. If done with the knowledge of physicians that understand the importance of supplements in the proper amounts, generally people will have few problems. Not exceeding the recommended daily allowance (RDA) is important.

Are You Allowed Sweets As A Type 2?

I almost gave this blog passing marks, until I reread it and wondered when calories had replaced carbohydrates as a measure for determining the quantity of food we eat.

Then I need to ask what are they basing “consumed adequate quantities from the recommended food groups” on in their statement. We are all in trouble if it is the USDA Plate model for nutrition.

This appears to be just another “one size fits all” blog. It would be great if this was true and then we could probably agree on more issues in caring for diabetes. In the real world outside the medical community and especially the world of the American Diabetes Association, individual variances are common and must be allowed.

Yes, we need to be concerned about the number of calories we consume on a daily basis to avoid increasing our weight, but carbohydrates are the rule of consumption for people with diabetes, be they medications free, using oral medications, or using insulin.

The blog is correct when it says, “We now know that both sugar and starch can raise blood glucose. In fact, some starches can raise blood glucose more quickly than some sugary foods. For example, white bread will elevate blood glucose more quickly than a chocolate chip cookie containing equal amounts of carbohydrates.”

Calories or carbohydrates all can be measured on a bell curve. Some people with diabetes are able to eat the average and have no problems with weight gain or blood glucose levels. Other people have problems and must consume less than the average calories and carbohydrates while there are some that can consume more than the average. This has to be based on the body chemistry of the individual, the condition of their pancreas and the lifestyle of the individual.

So please keep this in mind when you read blogs that generalize like this one. If you wish to have treats, as in sweets, make sure that you have made allowances for them

Store Insulin Properly

For those of us using insulin, how we store insulin is important. Insulin should be stored in your refrigerator. Preferably you will have a shelf on which you store it and not on the compartment in the refrigerator door. If needed use a container to coral the boxes and contain them in one location. Many sources will not say where to store them in the refrigerator, but storing them in a door compartment will submit them to being jostled and shaken and for some types of insulin, this is not proper.

Once you are ready to use a vial of insulin, remove it from the refrigerator ahead of time and let it warm to room temperature. Once you open the vile, that is, remove the plastic cap, you have 28 days to use it. Generally it will not last longer than that. Therefore, even if you return it to the refrigerator, the 28 days still applies. Therefore rather than spending time to rewarm the insulin before injection to prevent the sting of cold insulin which can be very painful, keep the open insulin at room temperature for the 28 days.

If you do not use the insulin in the 28 days, talk to the pharmacist and follow their directions. Most of us use a vial of insulin in less than 28 days; therefore, storage is not a problem. Be sure to prevent storing the insulin in temperature extremes. Never freeze insulin.

My instruction sheet for Novolog states to keep in the refrigerator or at room temperature below 86 degrees Fahrenheit (30 degrees Celsius) for up to 28 days. It goes on to say keep the vials away from direct heat or light, in other words store it in the box it came in. Dispose of an opened vial after 28 days even if there is remaining insulin. Do not draw up another dose for use later. Unopened vials can be used until the expiration date on the label if it has been stored in the refrigerator. The same instructions apply to cartridges or insulin pens.

Take time to read the information that comes in the box with the insulin. If you are like me, I need a magnifying glass for the small print. This will prevent you from having future problems. Check the expiration on the box of the vial and discard any that are out of date. Always check the vial before use to make sure that it looks okay and never use any insulin that has crystals or clumps in the vial.

For a short press release of the ADA recommendations read this. Be sure to follow the directions that come with your insulin.

Are Insulin Shots Avoidable?

Even the Joslin Diabetes Center agrees that insulin probably is not avoidable. They lean heavily on the statement that diabetes is a progressive disease. I do agree with their statement that the longer you have type 2 diabetes, the more likely your pancreas will deteriorate and you will need to be on insulin.

This may happen even if you take excellent care of yourself. This is where in their discussion they drop the ball when they could have used their blog for further education on the use of insulin. Most people use insulin as the medication of last resort and they should consider using it earlier.

Even knowing this, I will promote people that are able to catch their diabetes early and use exercise and diet to avoid all medications. Even people that have diabetes are able to change their lifestyles and get off medications. Some are able to do this for a few years and others are capable of staying off medications for several decades. This is because they are able to slow or even halt the progression of diabetes for an unknown length of time. This length of time depends on their bodies and their ability to follow a strict management regimen. It will also depend on how their pancreas has been previously damaged.

Remember that diabetes and the use of insulin is not a death sentence. This is a myth promoted by physicians to have their patients adhere to the oral medications as a way of managing diabetes. In truth, insulin can be an aid for your pancreas and lengthen its useful life. Yes, you need to be more careful and if you are capable of an exercise regimen, you will need to regulate your insulin use very carefully to prevent hypoglycemia.

This is a good reason to investigate insulin early to educate yourself about using insulin, the advantages and the disadvantages. Knowing the myths and the facts about insulin is important. Being knowledgeable in listening to people promoting the myths even if you know better is more important than getting into arguments.

The second blog by Joslin is a little more complicated. It is technically correct; however, I have seen and been taught different terminology. This is often the case when talking about diabetes. One group uses one set of terms and another group uses another set of terms. Sometimes it is the difference between physicians and patients, while at other times one group of physicians use different terms not used by another group of physicians.

Rather than add terms at this point, please read the blog by Joslin and learn the terms they use with their definitions as this is the important part.