Diabetes Amputations Can Be Halved

Those of us with diabetes, and I am not singling out any type, have the fear of amputation. This is on the mind of everyone at some time. Yet, I continually read articles, press releases, and stories saying that many of the amputations should never have been necessary if people with diabetes would have followed foot care procedures in the early stages.

Yes, this may sound harsh, but many could have been prevented as this study shows.  Orthotic researchers at Sahlgrenska Academy, University of Gothenburg, Sweden, have studied diabetic foot complications ever since 2008. Granted, this was a specialized study with orthotic shoe inserts that protect our feet and minimize the risk of foot ulcers. Foot ulcers are one of the problems for people with diabetes and often cause the need for amputation.

Researchers completed the study that involved 114 Swedish patients with diabetes who were at risk of developing foot ulcers. The results show that shoe inserts, podiatry, information, and regular foot checkups can prevent the ulcers. This could eliminate the need of amputation by more than 50 percent.

This should shine the emphasis on foot care and the reason to see your podiatrist on a regular basis. Discuss the need for shoe inserts and talk about areas of the foot carefully to examine on a daily basis. I know that too often, I became bored with seeing my podiatrist because it was just a toenail clipping and looking at calluses. This study has renewed my desire to see my podiatrist and have a discussion about the areas to watch on a more earnest basis.

Another area of concern happened during the month of February in another press release showing that foot ulcers are more resistant to hyperbaric oxygen therapy and that this could be the reason for more amputations. I will be blogging about that study in another blog, but wanted this to be on your mind as a way to prevent foot ulcers before this need ever became a concern.

This was not part of the study and therefore is just my thoughts, but in previous conversations with my podiatrist, he would always ask what my last A1c results were.  This leads me to believe that maintaining A1c's will help minimize the effects of foot ulcers to a point if you need shoe orthotics and use them. It may not prevent all foot ulcers, but should aid in their being taken care of before they become a problem. Maintaining blood glucose management that keeps blood glucose levels, as near to normal as possible should be the goal of every person with diabetes to prevent foot ulcers from becoming a problem with diabetes.

Image courtesy of madisonpodiatrist.com

Also, read my blog here for keeping happy feet. Many of the points used in that blog apply here as well and should become part of your routine for good footwear and foot care. I will not use more images as they are not pleasant to look at, but if you wish to satisfy your curiosity, use your search engine and type in “foot ulcers” and then click on images. This is why bloggers stress foot care as being an important part of diabetes management.

AADE – Is It Heading In the Right Direction?

According to Tami Ross, the current president of the American Association of Diabetes Educators (AADE), writing a comment to a recent blog in Diabetes Mine - “Second, contrary to the assertions raised, membership in AADE is not shrinking. In fact, membership has grown by more than 20 percent in the past 4 years.” If this is true then the membership numbers should have changed in the last four years, but unless there is a lot of secrecy behind this, their information published first on their home page and now in their fact sheet shows they have not had a membership increase in at least the last three years. The AADE Fact Sheet states, “With more than 13,000 members, AADE advocates on behalf of diabetes educators and the patients they serve.” To see this you need to download it with a PDF compatible reader and currently is the first item under the tab ABOUT US.

A 20% increase should have meant they had a membership increase by at least 2,600 new members. In any calculation, this means 13,000 plus 2,600 equals 15,600 members. This means somewhere in their calculations, growth has been stagnant, or the numbers had been inflated in the past. Why would they claim a 20% growth and not reflect this in their own membership numbers?

Then Tami Ross states, “First, to be clear, as it appears there may be misunderstanding on Diabetes Mine’s part, AADE is not a patient advocacy organization. As AADE’s name reflects, we are a professional membership organization for diabetes educators – an organization whose objective and mission is to support the needs of diabetes educators.” Their own fact sheet must be in need of revision then as in the above italicized statement in the last sentence of the first paragraph clearly states the “AADE advocates on behalf of diabetes educators and the patients they serve.” If we are to believe Ms. Ross then the only patients they serve are those that are educators. Sorry Ms. Ross, you can't have it both ways. Please correct your site's Fact Sheet if you do not agree.

This would also explain why the AADE has published nothing about the National Standards that they worked on with the American Diabetes Association (ADA) – the officers of the AADE know they can't live up to them. I have stated this before and I have even more reason to believe this now – Those at the headquarters (ivory towers) are not aware of what is happening in the trenches where mantras, mandates, and platitudes are the rule of the way business is accomplished. I have met certified diabetes educators that do not know what the word assessment means, except that they teach to the lowest common denominator and teach very little.

The AADE Fact Sheet also includes this statement, “Our mission is to drive practice to promote healthy living through self-management of diabetes and related chronic conditions.” From experience, I cannot agree, as I have found very little self-management of diabetes taught. I have experienced only mandates and mantras. Fortunately, I was able to use the internet and discern for myself how to self-manage my diabetes. And being on insulin as a person with type 2 diabetes, I was fortunate that the diabetes clinic became available to me and has an endocrinologist and nurse practitioners on staff.

The nurse practitioner that I was seeing confirmed my own self-education and kept encouraging me to learn. As a result, I have not needed to listen to any additional mantras and mandates from certified diabetes educators.

If professional organizations wish to have strictly internal documents, so be it. Then they need to become thick skinned when slammed for what they do make public. We need transparency, not whining when they are criticized for something that is public. We do realize that most professional organizations are for the preservation of the profession and not directed at the patients. But when whining and complaining become the way of doing business, we must wonder if the organization is worth the money.

Low Carb Diet and Its Healthful Effects

Low carb living has advocates and detractors at every turn. I enjoy reading most blogs on both sides of the issue when I know whom the author is and the blog has the information available to see what credentials they may have or not have. If those that are putting down low carb living would say that it is just their opinion, I could accept that, but I dislike not having some information about the author.

I have no training in nutrition and write about type 2 diabetes where I have researched and learned a lot in the last five years. Still this blog upsets me. First, this is subject material I object to from registered dietitians (RDs) from the Academy of Nutrition and Dietetics when they promote carbohydrates and whole grains. Second, the missed vitamins and minerals can often be obtained from other foods, or if necessary from supplements. RDs will seldom tell you this, as they want you to eat whole grains. Yes, you need to be aware of what you may be missing, but a good nutritionist can provide assistance. Read my blog here on the “whole grain stamp” and the unwanted sugars and calories they provide.

Thankfully, more people are writing about low carb living and we are learning from them. David Mendosa has an excellent blog here about the book Living Low Carb by Jonny Bowden. David starts of his blog with this, “The high-carbohydrate, low-fat diet that the authorities recommend we follow has been the longest uncontrolled nutritional experiment in history. The results have not been good.” These are words of wisdom that need no explanation. The review of the book is great and this book is on my “must obtain list”.

Do I agree with the high carb/low fat (HCLF) rhetoric of the blogger, not even slightly? All you need to read is Dr. William Davis's book Wheat Belly to know that whole grains and especially wheat do more damage than good. Then consider high fructose corn syrup that is manufactured from corn and you can understand why I am against the HCLF lifestyle promoted by the blogger. Dr. Davis also has a second book, Wheat Belly Cookbook.

I urge people to read about the different lifestyles and diet plans before deciding the path they wish to follow. There are so many diet plans available that it will take almost a lifetime to become versed in all of them. This is also why I follow Adele Hite and her blog here. She says many of the same ideas that I can relate to, and she is not hesitant to back them up. Granted she is a registered dietitian, but she does not agree with many of the guidelines and tenets of her own organization.

People who received emails with virus

I hope people that received emails with a virus attached have not had problems.  In the last 36 hours, I have had many returned emails because people had changed their emails so I know they did not receive them.  Three people have asked if I sent them - which i did not. 

The culprits hijacked three of my email accounts and sent out a lot of emails as if they were from me.  Shame on them.  I have changed my passwords on two of my email accounts that I was able to able to recover, but of course I can't recover the emails sent in my name.

One of the viruses was a keylogger so be careful here, the other that I have been able to determine is a rather nasty trojan virus.

Be sure that you have stopped the email and run your virus checker to remove them.

Thank you,

Bob

Should I Take Vitamin And Mineral Supplements?

I am very happy to find others are also urging caution when it comes to vitamins and minerals. There may be health consequences of overdosing on vitamins and minerals. Caution is the right description and in some cases, certain supplements should only be taken under a doctor’s supervision.

A distinction often not explained is whether a supplement is water-soluble or fat-soluble. Most vitamins that are water-soluble are the safest as the excess that is not needed is passed from the body and does not build to toxic levels that create health concerns. On the other side, fat-soluble vitamins do build to toxic levels and excesses of these do create levels that can become toxic, cause severe illness and sometimes, but rarely, even death.

The best advice I can share with you is to do your homework before taking vitamins and minerals, and this includes multivitamin supplements. Do you know what foods are fortified and with what vitamins and minerals. This is an area that many people forget about and often overcompensate as a result.

How do you determine if you need supplements? This is one time that you seriously need to consider getting a referral to a registered dietitian (RD). Make sure they know that this is a consultation for vitamins and minerals. Most medical insurance will cover this, but if in doubt, call the medical insurance company and ask. They may have a suggestion or even be able to give you a referral to one they respect. Medicare does cover this for the people on Medicare.

Then before your appointment, you will need to do your homework. List the foods that you eat daily and do this for several weeks. List foods that you do not like and won't consume so that the RD will have alternate foods. Do not be afraid to say that you won't eat something if the RD suggests this. Do not let them bully you into saying that you will eat something. It may be that this will be the key to knowing that a particular vitamin may be needed as a supplement. If you are not fond of certain foods, decide whether you can eat them once a week or only once a month. And then, live up to this.

Then use these URLs to lookup and read information about vitamins, minerals, and even drug information if needed. Do not read part of the topic, but read to the end of the vitamin or mineral to find the conflicts with medications. Also note that it may say to only take them under the supervision of a knowledgeable healthcare provider or doctor. This is wise advice and should be followed.

http://www.umm.edu/altmed/Supplement.htm

http://www.umm.edu/altmed/Herb.htm

http://www.umm.edu/altmed/

http://www.nlm.nih.gov/medlineplus/druginformation.html

http://www.nlm.nih.gov/medlineplus/healthtopics_d.html

http://www.nlm.nih.gov/medlineplus/minerals.html

http://www.cdc.gov/nutrition/everyone/basics/vitamins/

http://lpi.oregonstate.edu/infocenter/minerals.html

http://lpi.oregonstate.edu/infocenter/multivitamin-mineral.html

http://lpi.oregonstate.edu/infocenter/vitamins.html

The above are sources I use for information on vitamins and minerals. There are other sources if you use your search engine and want additional information on a particular vitamin or mineral. The sources above are more complete that many I have found. Be healthy, but know whether you need additional vitamins and minerals before spending money on these.

Recommendations for Management of Diabetes

I had to look carefully at this area, but again some minor changes. Sugar-sweetened beverages (SSBs) get the blame for obesity and type 2 diabetes. At least they did not change the recommended daily allowance (RDA) for digestible carbohydrate and left this at 130 g/day. This is still high for those in some low carb diets, but is much more realistic that the 200 to 230 g/day they used to recommend.

ADA does make this statement about the 130 g/day, “It is based on providing adequate glucose as the required fuel for the central nervous system without reliance on glucose production from ingested protein or fat. Although brain fuel needs can be met on lower carbohydrate diets, long-term metabolic effects of very low-carbohydrate diets are unclear and such diets eliminate many foods that are important sources of energy, fiber, vitamins, and minerals and are important in dietary palatability.”

Yes, if much of the information is taught to people with diabetes by dietitians from the Academy of Nutrition and Dietetics then we will be short of nutrients and the food will not be tasty. Other nutritionists not following the ADA, will work with people with diabetes to balance the nutrition or add supplements for those that are short. They will correctly assess the patients for their needs and work within what the patient will or will not eat and make sure that the patient understands what is happening and what is needed. They will not preach mantras and mandates at the patients.

In the next paragraph, they state the following, “Saturated and trans fatty acids are the principal dietary determinants of plasma LDL cholesterol. There is a lack of evidence on the effects of specific fatty acids on people with diabetes, so the recommended goals are consistent with those for individuals with CVD.” This means to me that they are aligning with the American Heart Association when they are talking about cardiovascular disease and do not want people with diabetes on any medium to high fat regimens. I would appreciate it if they were discussing Omega 3 versus Omega 6 and see if they can get the idea.

The medical nutrition therapy (MNT) is again emphasized and again it is to be taught by “a registered dietitian who is knowledgeable and skilled in implementing nutrition therapy into diabetes management and education be the team member who provides MNT.” Again, I say “no thanks,” I will get my nutrition advice elsewhere and avoid having an RD on my team.

The ADA does admit that there is no diabetes diet per se, and there is not a mix that applies broadly (no one-size-fits-all) enough and that regardless of the macronutrient mix; caloric intake must be in line with the individual weight management goal. They even say that metabolic status also applies, meaning lipid profile, renal function, and food preferences. While they don't list all the diets, they are saying that all need to be considered in managing diabetes. For ADA to admit this, means there maybe hope yet for other changes, but the patients need to maintain the pressure and hold their feet to the fire.

Prevention or Delay of Type 2 Diabetes

The American Diabetes Association is very subtle in their discussion when it comes to prevention or delay of type 2 diabetes. Only where they need to, do they use the term prediabetes. Instead they prefer to use the term elevated risk for type 2 diabetes. To be on the same page requires some definition. “In 1997 and 2003, the Expert Committee on Diagnosis and Classification of Diabetes Mellitus recognized an intermediate group of individuals whose glucose levels do not meet criteria for diabetes, yet are higher than those considered normal.”

This is a reasonable definition, and a little further into the definition they say, Individuals with IFG (impaired fasting glucose) and/or IGT (impaired glucose testing) have been referred to as having prediabetes. The 2003 ADA Expert Committee report reduced the lower FPG (fasting plasma glucose) cut point to define IFG from 110 mg/dl (6.1 mmol/l) to 100 mg/dl (5.6 mmol/l). The World Health Organization (WHO) and many other diabetes organizations did not adopt this change in the definition of IFG.

People with IFG and IGT often have other cardiovascular risk factors, such as obesity, hypertension, and dyslipidemia. Assessing and treating these risk factors is an important aspect of reducing cardiometabolic risk. IFG and IGT are associated with obesity (especially abdominal or visceral obesity), dyslipidemia (a condition marked by abnormal concentrations of lipids or lipoproteins in the blood) with high triglycerides and/or low HDL cholesterol, and hypertension.

Individuals with an A1C of 5.7–6.4% should be counseled about their increased risk for diabetes as well as cardiovascular disease and counseled about effective strategies, such as weight loss and physical activity, to lower their risks. As with glucose measurements, the continuum of risk is curvilinear, so that as A1C rises, the risk of type 2 diabetes rises disproportionately. Interventions should be most intensive and follow-up should be particularly vigilant for those with A1C levels above 6.0%, who should be considered to be at very high risk. They emphasize that just as an individual with a fasting glucose of 98 mg/dl (5.4 mmol/l) may not be at negligible risk for diabetes, individuals with A1C levels below 5.7% may still be at risk, depending on level of A1C and presence of other risk factors, such as obesity and family history.

The experts have carefully tied diabetes to cardiovascular risks to promote the use of statins, though they don't say as much. It is a fact that the two are closely related and must be considered together, but with changes in lifestyle, both diabetes and cardiovascular risks may both be reduced. This means weight loss, exercise,stopping smoking, and other poor health habits.

Table 2 in this section describes the categories of increased risk for diabetes.

IPG 100 mg/dl (5.6 mmol/l) to 125 mg/dl (6.9 mmol/l) [IFG]

2-h PG in the 75-g OGTT 140 mg/dl (7.8 mmol/l) to 199 mg/dl (11.0 mmol/l) [IGT]

A1C 5.7–6.4%

For all three tests, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at higher ends of the range.

Communication, Communication

Communication is the latest buzzword in medical circles today. Only they are calling it something else now. The medical professionals want us to think of it as “patient engagement.” How obtuse do they think we patients are? Communication by any other name is communication and I do not think they are doing us as patients any favors by trying to divert our attention away from this.

Dr. Rob Lamberts must be pointing this out to his colleagues in his blog of March 11, 2013 after attending the HIMSS conference. He admits he is snarky about this and from his blog you should have no doubts. I think a statement he makes needs repeating, “Communication isn’t important to health care, communication is health care.” Too many doctors forget this! That is why they have come up with the term “patient engagement” to muddy the waters.

We as patients need to have and use more communication with our doctors and not just when we are in the exam room. There, too many doctors talk at us and not with us, go on autopilot as if we aren't there, and too often come up with the incorrect cause of why we are there. I am upset because now doctors will use this term as a way to convince others that they have meaningful use of their medical health records (MHR) or electronic health records (EHR) when in reality, it is only the records they are interested in.

By using and adding data to your health record, they can become more efficient at billing us or our insurance carrier for more money. This in turn will garner them large sums of monies from the government for implementing the electronic health record system. Few patients currently have access to their complete medical records and this may become even more difficult in the future as more of our records are hidden from us behind a cloud of ambiguity and as programmers figure out how to make this more difficult with systems that are more proprietary not available to patients. Yet, every day we read that more of our electronic health records have been compromised and information stolen by electronic thieves.

I would like to quote Dr. Lamberts blog, but that would not accomplish anything. He says it much more eloquently than I can. I would rather you took the time to read his blog and hopefully arrive at the same conclusion. If you do not, then don't be afraid to tell me so.