Personalized Risk Assessment Aids Decisions

This is a generalized study about risk assessment. Diabetes is not among those discussed and this is a disappointment. With the fact that the American Association of Diabetes Educators (AADE) does not emphasize risk assessment for diabetes, and even the American Diabetes Association (ADA) does not have firm guidelines, this is a shame on these groups. There are many writers, bloggers, and other medical sources that write about risk assessment, but our professional organizations seem not to care. Stopping the diabetes epidemic should be a higher priority.

The ADA does have a program in place that people may use, but this is different from having a public policy or doctor recommended assessment procedure. In addition, the link here will take you to the diabetes risk test. This is not an assessment test, but a one-size-fits-all risk test. I admit I have seen poorly constructed risk tests, but this one does not properly evaluate your diabetes risk. The first panel only allows four age groups and stops at 69. Apparently, people over 69 are not at risk for developing diabetes. They may also figure that people over the age of 69 are not worth the effort of assessment. I have to call this age discrimination and add to this care discrimination. It is no wonder that the AADE does not have practice policies in place for the elderly.

Yes, the ADA does have several “stop diabetes” programs, but this is merely lip service. The ADA is not aggressively promoting diabetes risk assessment for doctors and does little to educate doctors. You say that they issue new guidelines every year. Yes, but how many doctors even read them, much less practice following them. If they really understood the ADA guidelines, then why do we encounter so much of what the next paragraph says?

Many of the sites having diabetes risk assessment tools available do a much more thorough task of assessment, but then bail on giving specific instructions about conferring with your doctor that is knowledgeable about diabetes. They do say to talk to your doctor. If your doctor is not current with the knowledge about diabetes, you may end up with a warning that “your blood sugar is above normal, watch what you eat” or something similar with no diagnosis of diabetes.

Always ask for your lab results so that you may see what the results of the tests state. If your fasting blood glucose or plasma blood glucose levels are above 125 mg/dl, then you may need to ask for the oral glucose tolerance test (OGTT). If your A1c level is above 6.4 this also applies. If the doctor balks, then I urge you to consider a change of doctors. The higher the results are above 125 mg/dl, the more urgent the need for a change of doctors. If your fasting or plasma blood glucose results are above 180 mg/dl, and your A1c is above 7.9%, then it is urgent that you find a doctor that will do the necessary testing for analysis. You need to know to be able to take actions to stop or prevent the development of any complications.

If the results are between 100 and 125 mg/dl, then you are at risk to develop diabetes. This is the range considered “prediabetes” and you should then learn what preventative measures you may take to prevent the onset of full diabetes. The A1c range is 5.7% to 6.4%. Most doctors seem to ignore this range, but there are preventive measures that are possible to take to prevent the onset of full diabetes.

This source is one of many risk assessments you may do yourself, but if you do not have diabetes now, take this seriously. If you are at risk, do your health a favor and schedule a doctor appointment with the specific instructions that you want to tested for diabetes.

Sleep Apnea - Are You a Prepared Patient?

What do you know about your sleep apnea? Do you know your equipment? Do you know what your options are – for equipment, equipment replacement, parts replacement, and other supplies? I am sorry to report that many people do not and some do not care. Others hate the equipment and still others let vanity rule. There are some things about my equipment that I do not like, but I still use the equipment as I feel better using it and know what will happen if I don't.

You will have to excuse me for a little ranting, but I have a friend that only wears his mask for short periods each night and then takes it off. Why does he do this? I don't know as I have helped him adjust the snugness and even had him order the nasal mask liners from this source, but still he would not wear it throughout the night. With the nasal mask liners, he was able to loosen the tension on the mask straps even more. Finally, I started kidding him that it was vanity that caused him to remove the mask. He questioned why I would say this. I said that he was so self-conscious about the lines the straps could cause that he did not want them when he woke in the morning.

He finally admitted that this bothered him and I won't go into some of the things I said to him, but if we were good friends, he would have told me to get lost and never see him again. We did settle on a weekend and I worked with his significant other (SO) to adjust the straps and he did give it an honest try. Even his SO said that he did not have lines an hour after he awoke. Then the following weekend to prove this, I took away his nasal mask liners and had him tighten the straps to prevent air leaks. It took almost three hours for the mask lines to go away. He was finally convinced and now he wears his mask all night.

Yes, there are many choices that are available to people with obstructive sleep apnea. One choice that you do not have is walking into a medical supply store and choosing a piece of equipment, a mask, and other supplies, paying for them, and walking out with them. You must have a prescription, obtain equipment that your insurance will cover, and have counseling by your sleep doctor or a sleep therapist. Even if you can afford to pay for the equipment, the law does not allow them to sell you the equipment without a prescription.

Equipment choice may be more flexible as the doctor can influence the choice and sometimes force the insurance to cover equipment they do not want to, but this still may be a point of contention. So be careful when writers claim that you can make the choice.

This article makes a lot of sense and does cover many of the facts that need to be covered. I do appreciate the fact that she mentions mild, moderate, and severe sleep apnea. I even needed to laugh at her analysis leading up to her question – are you a dead man walking. Yes, sleep apnea of any type can cause you to die if not properly managed.

The sleep study is the first step that needs to be accomplished. This will determine your apnea hypopnea index (AHI). This is then used for the type of machine the doctor may recommend, the pressure setting(s), and the type of sleep apnea you are diagnosed as having. The next piece of vital information is your oxygen level according the author and in checking with my sleep doctor, it is not a measure they do other than as part of the sleep lab at the beginning and end of the lab experience. This is something some sleep labs did not measure until recently. High blood pressure in connection with low oxygen levels puts us at risk for a heart attack or stroke.

In summary, to become a prepared patient, your objectives should be:

1. Take responsibility and lead your healthcare team.
2. Know your AHI and oxygen levels.
3. Understand the anatomical features that cause your OSA .
4. Know your equipment choices, machine pressure and take responsibility to learn patient controlled comfort and adjustment features.
5. Report all problems and challenges to your healthcare team as quickly as possible for resolution.
6. Maintain due diligence by scheduling routine follow up visits with your sleep doctor.

I would add that you need to forget about vanity and do some testing to see how long the lines from the straps actually last before giving up. This is when number 5 above should be used and discussed with your sleep team.

I admit I don't remember the exact number for my AHI, but in both sleep studies, it was over 100 apneas per hour. I have attended several of the maintenance sessions and not had any problems. They have called me in several times to download the data from the disk, but after doing it once or twice, the insurance company quit complaining and asking for more. My sleep doctor knows that I use my machine and asks how I keep it so clean. I say that I use only distilled water and clean the filter monthly or more often if needed. I use a clean cloth to wipe the outside of the machine.

My wife complains that I don't clean the nasal mask often enough, but with the nasal mask liners, they do a pretty good job of keeping it clean, so I don't need to clean it that often. Apparently, I take better care of my equipment than most do. The sleep specialist is always surprised that I don't need replacement parts at the frequency of many people. I am now happy that I do take care of my equipment as Medicare is monitoring how often people need to replace equipment parts and has set some limits.  For most supplies, it used to be quarterly, but now much of it is biannually, except for some parts.

Doctors Can Help Reduce Medications

Reading news articles sometimes is very unnerving.  Not only was I offended by this one, I was irritated and not sure I wanted to blog about something that might have value. The title is really a turn-off and made me think an overly aggressive doctor was the author of the press release. Then I read the second paragraph and when it stated a professor – then I knew that it was one of the academia that has little or no knowledge of the real-world happenings. This is still no excuse, but just another lesson on how the people they write for are belittled and thought of as minds they should be the ones molding for compliance – BS.

This is a Danish study and does have value as very few American doctors even consider this approach. In America, doctors push pills for type 2 diabetes and very few will listen to other alternatives. In Denmark, doctors are more patient oriented and encourage patients to take charge of their health and see what they can do for lifestyle changes to stay off medications.

A doctor in the United States refusing to hand out medication until the patient shows the need is almost unheard of. The doctors here would much rather push medications (notice I used the plural) than allow the patient to prove they can stay off medications with exercise, weight loss, and food habits. Occasionally you find a doctor that will allow this to happen, but very rarely. Many insist on medications and then when the patient demonstrates the ability of managing their diabetes, they are still reluctant to allow them off medications. Some doctors will allow this to happen, but not that many.

I would say that the Danish doctors are to be commended for their actions and maybe a few of these doctors should be allowed to teach in our medical schools on the topic of diabetes management for type 2 diabetes.

This is one time when better heads should prevail and articles not titled by people with little knowledge of the disease they write about. This is the title that I found so offensive - “Complications In Diabetes Treatment Can Be Avoided When Patients Cooperate With Their Doctor.” I personally think the title could be improved dramatically and made for people to want to read the article if a title like this was used, “Diabetes Treatment Can Be Improved When Doctors and Patients Share A Common Goal.”

Oxygen Treatment May Not Help Foot Ulcers

This was somewhat of a shocker when I received the email mail recently from a reader in Great Britain, and then later finding it in a newsletter. I have been following several news outlets about hyperbaric oxygen therapy for different types of topics, but had not seen this coming. I will admit at first I did not believe it and had to read it several times. I appreciate the reader for having alerted me to this as I may have missed this study otherwise.

Reuters Health reported this and I will attempt to analyze the study for materials not in the press release. The results of this study do call into question results of previous studies, but this study seems to vary and be about foot ulcers only. The prior studies were more centered on wounds and skin problems in areas above the ankle. This is a distinction that may or may not be valid, but still needs to be evaluated. Dr. Stephen Thom, a professor at the Perelman School of Medicine in Philadelphia was very realistic in his analysis and how this needs to be reviewed to see what differences there are.

Please note that HBO (hyperbaric oxygen) and HBOT (hyperbaric oxygen therapy) are usable interchangeably, although HBO may not be as rigorous in its application. This possible variable needs to be explored. The study authors did state that further study is needed to understand the current results and the effects of oxygen treatments. They are also concerned that the people chosen from the National Healing Corporation (NHC) may have had more severe problems although they tried to compensate for that.

Covariates are a continuous control variable that is observed rather than manipulated, but can affect the outcome included age, sex, wound duration at enrollment, wound size at enrollment, Wagner grade, number of wounds on the patient, wound location, history of neuropathy, history of wound recurrence, and history of osteomyelitisor abscess. Osteomyelitis is an infectious, usually painful inflammatory disease of bone that is often of bacterial origin and may result in death of bone tissue.

To minimize bias the researchers used a PS approach. The propensity score (PS) is the conditional probability of assignment to a particular treatment given a vector of observed covariates. This allowed the researchers to achieve balance on observed covariates between treatment groups so that the treatment groups were more comparable. The PS provides a summary value for the potential measured confounders.

The PS represents a summary value of the potential covariates for each patient and is defined, regardless of the actual treatment choice, as the probability that each patient would receive the treatment of interest given the background covariates of that subject. The PS model was used to balance a number of baseline covariates such as age, sex, wound age, wound size, Wagner wound grade = 2, the number of wounds on the patient, history of neuropathy, history of wound recurrence, and history of osteomyelitis or abscess. Importantly, wound age, wound size, and Wagner wound grade = 2 at first visit are highly predictive of the likelihood that a subject will heal and has been used in other PS studies of wound therapies.

Wagner Grading System for Diabetic Foot Infections is the following:

- 0 - Intact Skin
- 1 - Superficial ulcer of skin or subcutaneous tissue
- 2 - Ulcers extend into tendon, bone, or capsule
- 3 - Deep ulcer with osteomyelitis, or abscess
- 4 - Gangrene of toes or forefoot
- 5 - Midfoot or hindfoot gangrene

This study does point out how important it is to have our feet examined on a regular basis to head off problems before they get to this stage. I hope that this study is not reflective of other problems we may encounter with hyperbaric oxygen therapy in the future. I will be looking for more studies to see if there are further problems, or if it is the foot ulcers that are the problem.

For a past blog on hyperbaric oxygen therapy, read my blog here. 

HFCS Does Not Increase Liver Fat

This is one study that we must question. The doctor doing this study is heavily influenced by his position since, “He is an advisor to the food and beverage industry and has received unrestricted educational grants from the Corn Refiners Association.”

Since high fructose corn syrup is a product of industries represented by the Corn Refiners Association, we know that this study is quite likely biased and may well be rigged in results.

Rigged, yes, in a study only lasting 10 weeks, we must question the validity of the findings. This is not a length that would give other than the findings reported. A study lasting for one year or more would have given more trustworthy results, but would have done more harm to the participants.

Therefore, I can only say this is another junk science study and done by a person heavily indebted to the Corn Refiners Association. This is another of those studies that should have never made it into print. The study was done by James Rippe, MD, professor of biomedical sciences at the University of Central Florida and a paid consultant for the Corn Refiners Association.

Fructose May Affect Hunger Cues

More research on high fructose corn syrup (HFCS) keeps coming. Some of these are becoming more difficult for the corn refiners and corn producers to refute and even their experts are more careful in what they say. This is because they don't want to be caught in a misstatement and most are recycling old arguments to divert attention from more and more studies showing the damage caused by HFCS. Even if we want them to give up and admit defeat, they will not and will continue to recycle old arguments.

This study is more scientific in nature even though not a lengthy study since measurements were done in recording reactions in the hypothalamus, which helps to control appetite. The participants were not told which type of sugar solution they were given, fructose or glucose. Blood samples were also taken to check hormone levels that control feelings of hunger and fullness. The study participants were asked how satisfied they felt.

In as quickly as 15 minutes, people showed changes in brain flow and activity. After the glucose drink, the body seemed to recognize and respond to the extra calories with increases in glucose and insulin. This blunted the hunger and brain activity slowed in the hypothalamus. However, after the fructose drink, the hypothalamus activity stayed active with little increase in insulin. The study participants reported they felt hungrier. Other hormones known to regulate hunger, such as ghrelin and leptin were unchanged after either drink.

Of course, James Rippe, MD, professor of biomedical sciences at the University of Central Florida and a paid consultant for the Corn Refiners Association, the group that represents manufacturers of high-fructose corn syrup says, “When consumed together, as they almost always are, balance each other out and would likely have no effect on hypothalamic blood flow. Any suggestion that this artificial experiment has implications for human nutrition or obesity is unwarranted speculation.”

At least the authors of the study made no such statements and only alluded to the possibility that fructose may affect hunger cues. Even Rachel Begun, RD, a spokeswoman for the American Academy of Nutrition and Dietetics just stated that we need to try to limit added sugars in all forms. She was not involved in the study.

Caregiving to a Parent or Loved One – Part 3

Part 3 of 3 parts

Why is it that caregivers don't feel that they can take care of themselves? Yes, they feel that this is a luxury while caring for others, but stop and think about it. If you burn yourself out, you will have nothing left to give to those that need it!  Harsh, not even,  I have seen people that were caring for a parent or spouse that did not take time for themselves. One ended up in the emergency room because he hadn't taken care of his needs and was hospitalized, his wife died the same day. His family was left to take care of the funeral. The other killed herself with exhaustion and her parent who was near death, lived for six more years.

The only advice I can give is to call on others and locate service agencies, even hospice to help if this is necessary. To be able effectively to continue to be a caregiver, you must take care of yourself. You may not be able completely to avoid stress, but you should be able to reduce it. The following steps may help to minimize the stress pressure:

Stay Connected: Here I am not talking about the person you are caring for or even your immediate family. They are important, but will not give you the stress release you need. If you have a caregiver group where you live, investigate this before you become too busy to do so. Do not forget friends that you have and that you may have shut out as you have become busier with caregiving. Even a walk around the neighborhood can keep you in touch with your neighbors and walking will help relieve some stress. Sometimes is necessary to think outside the family or the box if you must.

Accept Help: Many caregivers pass on this and have only themselves to blame when they are overstressed. Many friends and people known to you or your loved one may sincerely make an offer of help, but because you haven't thought about it, you don't accept the help. Always think about what they could do or how they could help. Rather than dismiss them, say you have not thought about it, but you will and ask when it would be best to contact them. Then do think about it and if they are able, they may be able to sit with your parent or loved one while you take a two or three hour break. If special meals are not a requirement, maybe a cooked dish would prevent you from cooking a meal or two. They will appreciate being able to help and may help you relax. Never forget community resources which may give you a much-needed time to rejuvenate.

Find Time Alone: This is important for your well-being! If you are the sole caregiver, an hour or two way from duties may relieve stress and give you the needed break that will help your health and revitalize you. This may be the time to go for a brisk walk, or go to a nearby park and just sit and watch others. This also may help you avoid burnout.

Maintain a Hobby: This will depend on you and what hobbies you already have or maybe willing to start. Let you imagination run with this one. This link provides a few that may be possible, depending on the season and the type of care your parent or loved one requires. Some may provide the stress relief you need and others may add to the stress, but this can depend on you. I knew one caregiver of a spouse that used her photography hobby to do an inventory of the house and then the area of the neighborhood. Her children were later very happy with the results.

Stay Informed: I like the suggestion the article provides, but also stay informed about what the news is, the local weather, and what others are doing. One caregiver of a parent used letters to pass the latest news on the condition of the parent and then had letters to read to her parent about other family members.

Researching on the internet may yield unsettling information and if you are not aware of it, sometime very questionable information. Use this to converse with the parent's doctor and let them know you want accurate information. This will provide information about what to expect and how fast something may progress.

Stay Spiritually Grounded: I don't care what studies may say, if you are religious or spiritual, stay grounded. Reading the religious teaching of your faith may relieve stress and assist you in accepting the status of your parent or loved one.

Take Care of Yourself: I have stressed this before and I hope it is getting through to you. As a caretaker, you have to take care of yourself, if you want to take care of others. You are no good to them if you lose your health in the process. I will not cover them, but this link may give you additional ideas for self-care. If you experience persistent feelings of fatigue, resentment, or burnout, don’t be afraid to talk to a professional and get some extra support for yourself and your loved one.

Caregiving to a Parent or Loved One – Part 2

Part 2 of 3 parts

In this part, I will be discussing some of the other aspects of caregiving. If you are the caregiver, there are some things you need to realize to prevent your becoming a casualty of doing your best in giving care. Some of the pressures you need to be aware that caregivers may face.

Fear or Uncertainty: These are not uncommon and can paralyze your actions. As a caregiver for a parent or loved one, you will have concerns about their future and this can cause fear of the unknown. If this is a child of yours, uncertainty can be a real part of what causes you anxiety.

Shift in Roles: When caring for an elderly parent, this is where roles you have grown up knowing are now reversed and this can become very difficult for both parties. The parent can be embarrassed for depending on a child of theirs and the caregiver now. As the caregiver, you are anxious about their health, well-being, and how vulnerable the parent is now. If it is a spouse, this can create unforeseen complications and exact an emotional toll on both parties.

Financial Pressure: If there is not adequate health insurance, doctor bills and other treatment fees can become burdensome, leaving less energy left for work. Caregivers often find themselves facing financial pressures as well.

Isolation: Don't do this. Do not shut yourself off from others, especially friends and others that want to be there for you and your loved one. Find someone to spell you so that you can take time for yourself. If you are caring for a parent, schedule an evening meal out with your spouse or a friend. There are people or agencies that can stay with your friend or loved one while you have time away. With cell phones and telephones, there is no reason that if something happens, contact can't be made. Learn other ways to relieve the stress of the moment, even if doing nothing more than getting exercise, which brings up the next issue.

Little Time Alone: Caregivers can certainly feel isolated, but there are times when you need a little time alone. Some are capable of rejuvenating during this time and others just want the time alone to cry and relieve stress this way. On the other side, it is also possible to feel confused by having little time alone when also feeling isolated. Caregivers have both feelings, and then be very careful as this can sometime cause stress to multiply.

Demands of Constant Care: When a parent or loved one causes a situation where you are caring for them 24/7, this “always on duty” feeling can cause a heavy toll on you as a caregiver. This type of situation can happen at any time and this is one reason to have others you can call on to allow you to get away from this. This is a reason for not waiting for this to happen and bringing people in early to acquaint them and your parent or loved one with each other. Remember, your own health is important and needs repair from time to time.

Guilt: Having this feeling is not a sign of disloyalty, although when felt with caregiver burnout may be hard to dismiss. Often guilt can be part of frustration, but needs to be separated as the feeling of guilt should not be.

Interference by other family members: This creates an overabundance of stress and because you have been selected by the parent or loved one, creates family animosity and ill will among other family members. I have seen this in other families and wondered how the caregiver was able to survive. One caregiver just walked away and said enough is enough. Another caregiver had been wise and had papers allowing her to be the only family member involved. This played out in the courts and the family was split permanently because of a meddling member. Jealousy was a large player in this family even though the parent had clearly stated what her wishes were and the caregiver was doing what needed to be accomplished.

This is only some of the “stressors” that caregivers can feel. Hopefully, this list will give you ideas and relievers that will assist you when, and if, you become a caregiver. Remember that as a caregiver, it is important that you make self-care a priority.