Diabetes Guidelines You Can't Avoid

In diabetes it is not what the patient wants, but what the doctor can command and bully his way into making the patient do. Now the American Association of Clinical Endocrinologists (AACE) has developed another way, an algorithm this time, to force, where possible, patients into submission. Much of what is shown in the layout of the algorithm is aimed at convincing the patient to follow their doctor's wishes and desires. How else will they, the doctors, meet their goals? I wonder how soon this will be put into effect. The algorithm is available herehttps://www.aace.com/publications/algorithm in PDF format.

Following the Table of Contents, the first page is – Complications-Centric Model for Care of the Overweight/Obese Patient. They start the information off with Step 1 - evaluation for complications and staging. This is not a nice way of saying how we are to be treated. Step 2 is treatment options where only three options are allowed – lifestyle modification, medical therapy, and surgical therapy (a must if body mass index is equal to or greater than 35) They will push medication on top of medication in the medical therapy and insulin is one of those mentioned when we exhausted our options with the oral medications. They leave no doubt that surgical procedures will be sought for BMI's over the limit.

Step 3 is where they may actually dismiss us as patients as they state, “If therapeutic targets for improvements in complications not met, intensify lifestyle and/or medical and/or surgical treatment modalities for greater weight loss.” Apparently, diabetes patients will no longer have a choice and must be made compliant.

The next page is the Prediabetes Algorithm. In searching the page, they do not allow patients to stay off of medications or start and then wean themselves off medications. The assumption is that prediabetes will progress to diabetes. There is one improvement and that is the use of metformin for those at low risk. Maybe now we will see some action by Medicare and insurance. The counter to this is multiple medications when fasting plasma glucose is greater than 100 mg/dl with two-hour plasma glucose greater than 140 mg/dl.

The next page covers - Goals for Glycemic Control. They leave no doubt about where they are coming from and what they will be setting for their patients. If you are a compliant healthy patient without concurrent illness and at low hypoglycemic risk, you will be allowed to have an A1c of 6.5% or lower. If on the other side (greater than 6.5%), they will individualize goals for patients with concurrent illness and at risk for hypoglycemia.

On the next page, we come to what should make anyone with diabetes nervous. The page is titled Glycemic Control Algorithm. It is further subtitled Lifestyle Modification (Including Medically Assisted Weight Loss). So not to forget, they are supposedly talking about a couple of the weight loss medications approved by the FDA. Still in my mind, this should be classified as medication weight loss therapy and not medically assisted weight loss. This sounds more like surgery than medication therapy.

There are three entry A1c listings - 1) A1c that is less than 7.5%, 2) A1c that is equal to or greater than 7.5%, and 3) A1c greater than 9.0%. 1) above starts out as Monotherapy. Metformin is listed first, but they also list several others and even some that should be used with caution because of studies lately that show problems affecting the heart and other side effects. The bottom should raise alarm bells as you are only given three (only three) months to show improvement, or you will be moved to Dual therapy. Here basal (long acting insulin) may be part of the therapy, but this is supposed to be done with caution.

If you don't show improvement in dual therapy by the end of three months, you are to be moved to Triple therapy. This means three oral medications and with the order of suggested usage, they are going with oral medications that should be used with caution or basal insulin. If you don't succeed in three months here, you are to be moved to insulin therapy and oral medications.

Now look at 2) above. Here you will start on Dual therapy and if no improvement in three months, you move to Triple therapy. If you don't succeed on triple therapy in three months, insulin therapy is up next. If you started at 3) above, then if you have no symptoms (probably meaning no complications or concurrent illness) you may start at Dual therapy if your A1c is under 8.0%, otherwise you may start at Triple therapy and this is when basal insulin is recommended in Dual or Triple therapy. Now if you have symptoms, then you are to start on basal insulin and other oral medications as necessary.

The page following this is – Algorithm for Adding/Intensifying Insulin. The left side of the page is for basal (long-acting insulin) and not using sulfonylureas but other oral medications. I will not get into the titration part. That is between you and your doctor. On the right side is more intensifying of oral medications and adding prandial (mealtime) insulin (or short- or rapid- acting insulin).

The last three pages discuss cardiovascular disease (CVD) risk factor modifications algorithm, profiles of antidiabetes medications. I was surprised that for the most part, the page is right on. For comparison on most, use the different inserts here for each medication. The cardiovascular page discusses statins and blood pressure lowing medications.

The last page summarizes the guiding principles for the algorithms. I some ways this is difficult to swallow as it explains the importance of a lifestyle modification, the individualization of treatments, and their targets. The minimization of weight gain and hypoglycemia are worthy discussions.

I summary, I am surprised at what is not included. This would be exercise (covered in a blog by Tom Ross) and allowing patients to start without medications or using medications for bringing prediabetes and diabetes under excellent management and then weaning off medications as lifestyle goals are met. No mention is made of working at the prediabetes level of lifestyle changes to prevent the onset of type 2 diabetes.  Also missing is the option for those patients wanting off oral medications and onto the full insulin therapy.  Apparently this is not allowed under the algorithm.   For these reasons, I feel strongly that the algorithm is shortsighted and presents a defeatist attitude.

As a patient, I am very concerned about how they feel that diabetes is progressive and they offer no hope of people preventing this. One article about the algorithm may be read here and another here.

Diabetes Tips and Applications

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

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

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

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

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

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

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

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

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

Diabetes – Does It Define You?

In March 2010 when I wrote about diabetes defining me, I had no idea of how much it defines me and shapes my daily schedule. Blogging about diabetes is my hobby and as such, I enjoy my time learning about different topics. Some are admittedly not about diabetes, and some are on the extreme periphery. Yet I still enjoy reading and learning about many of the topics. Many topics may not appear to be about diabetes, but often they are in one way or another.

Yes, I am aware that we are all involved in other activities and can have non-diabetes related hobbies, but without diabetes, would the hobbies be the same ones. Diabetes is what has driven many to certain types of exercise and other activities that help in our daily exercise. I think without diabetes, many of us would not be in as good health as we are today.

A great blogger and a mentor to me, David Mendosa says, “he thinks a lot about diabetes because that is his job. And since I do think a lot about it, I manage it. ” He continues, “But I hardly think about diabetes all the time. I think a lot more about getting out in nature and being there, hiking and taking pictures. I am also a big reader. And hardly just books about diabetes.” Yes, David, and thankfully we all gain from your writing, and photography. I do have to question, if it were not for diabetes and the management of diabetes with nutrition and exercise; would you be such a great photographer of nature and scenery? Probably – that is your nature.

Some of the defining points that I have noticed in people and especially friends with type 2 diabetes is the attitude about diabetes and the importance of diabetes education. The attitude pervades our daily activity, reminding us to care for ourselves and often care for others. Our daily activity incorporates our feelings about diabetes and how we perceive diabetes in our daily activity.

Then our attitude reflects about how we feel about diabetes management and mixes the education into our management routines. Our diabetes management efforts are reflected in our attitude, daily activities, and how we accept others with diabetes. This is often revealed by people that have diabetes and avoid contact with others that also have diabetes. This desire for diabetes secrecy is the unhealthy side of diabetes that prevents open discussions and often leads to poor diabetes management that is fostered by a poor attitude about diabetes.

So does diabetes define you? To some extent, diabetes may not completely define you, but I think that diabetes does strongly define us and who we are. It affects our attitudes, daily activity, and most importantly our diabetes management, whether it is the good or bad definition. Since diabetes is a 24/7/365 disease with no vacations, it has to affect us and define us to some extent.

When people actually stop and think about it, diabetes does affect the decisions those of us with diabetes make on a daily basis. It affects the foods we choose, which fortunately are healthier for us than the ones we were eating before diagnosis. It affects the restaurants we patronize, the snacks we eat and to a large extent, what we do.

While I could say I don't want my life defined by diabetes, I find it is, and in some ways, this definition is a good thing. It has caused me to be more conscious of my health and to be much more proactive in my health care. While some of my doctors may not be overly happy with my being proactive, most are happy and actually talk with me rather than at me. My diabetes has also forced me to be more social in the way I look at things, and more important, more willing to accept changes. While I am still feisty and ill tempered at times letting my negative side get me into hot water, I am finding myself mellowing and becoming more even in my approach to life.

Finally, thoughts of denial are no longer part of me. While I can't make the same claim about depression, it sneaks in now and then, but even these episodes are lighter and easier to conquer. Life with diabetes is better for me and I am more positive about life.

Incentives Needed for Docs to Engage Patients

I wonder why doctors need incentives to engage patients. Many doctors don't communicate well with patients, but give them incentives like more money – why? Their practices will shortly become extinct as it is and this is because patients are learning that they don't like being talked at, looked down on, or ignored while the doctor rushes to complete his time with you and move on to the next poor sole to treat them the same. I say let these practices fall by the wayside and good riddance.

In more studies, communication, aka, “patient engagement” is being stressed more and more. The studies are also hauling out more terms to hang on us as patients. My blog here describes one term “patient activation” as measured by the Patient Activation Measure. This is one of the measurements that they take of us so they can decide if we are compliant or non-compliant. The more activated we are the more compliant we become. This article also uses this as if it is a key to patient engagement (communication). Read my blog here on communications.

Now I will say something as I'm becoming very aggravated with how the authors treat us as patients. I say, let us use terms we are all familiar with hearing. Call us “patients” and we will use the term “doctors” and if you need to muddy up the terminology among yourselves, don't do it in writing we can read or in communication when we can hear you. Communication is the exchange of ideas and is needed to improve doctor/patient relations. If you wish to engage us in conversation during our appointments, that is fine with us, just don't label us and what you are doing as “patient engagement.” If the only way you have of communicate with us is by “patient engagement,” tell us so that we can move on to another doctor that is willing to communicate with us and not because it is the only way to earn your additional fee.

As patients, if we are viewed as a way to earn additional fees, sooner or later we will devise a way to cut these fees off and leave you wondering what you have done to be severed from your fees. I am not sure which group is to be blamed for this, but it is part of this article and shows just how doctors want to have that money to do something they should already be doing. “Several panel members, including Kaplan, noted doctors aren't incentivized to allow patients to ask questions or take a greater role in their care. A day-long workshop hosted by Health Affairs earlier this month included comments from many participants that pay models need to be developed to reward doctors for helping patients take a greater role in planning their care.” The bold is my added emphasis.

Another article echoed much the same feeling and there it was stated that the team approach could be handled by the nurses. To me this is a farce because the doctors have dug the hole they are in and want more money to be bailed out of their own system. They could not use communications before and now want to be paid for communicating. I have to disagree and say to these doctors – eat what you have fed us for years. It is your just desserts for your attitudes that you are so far above us that we don't deserve to be communicated with for our better health.

That we need to pay you more for your own ineptitude, and years of not communicating with us as patients; and now needing to communicate with us just to justify “meaningful use” criteria for additional monies, sounds like a lot of malarkey to me. We know what will happen. Just as soon as you have your hands on this handout, it will be back to business as usual and communications will cease.

Drug Ads Misleading for OTC Medications

Do you wonder why over the counter drug ads sound so appealing? You should, all the benefits are hyped, risks are downplayed, and most are completely absent, especially in short TV ads. Researchers have analyzed the ads for four drugs that have made the change from prescription to generic over the counter drugs (OTC). “The researchers looked at a sample of 133 television and print direct-to-consumer ads for Claritin (loratidine), Zyrtec (cetirizine), Xenical/Alli (orlistat) and Prilosec (omeprazole).”

Before going further, let’s be clear about the agencies overseeing drug ads. The U.S. Food and Drug Administration (FDA) is in charge of ads for prescription drugs and requires these ads to present a balance of both harms and benefits. Ads for the nonprescription drugs (OTC) are regulated by the Federal Trade Commission (FTC). The FTC has none of the requirements of the FDA. And now with an appeals court declaring that it is open season for free speech to promote “off label” use of prescription drugs, where are we headed for fairness in advertising?

It is becoming obvious that Congress needs to take corrective action to bring unregulated advertising under some regulation. As it is now, companies are getting away with less and less oversight in advertising and doctors are paying the price. Even I have heard some patients complaining about a doctor not being willing to prescribe a newly advertised drug. Yes, the complainers are hypochondriacs and think that what they hear is what they have and that the advertised drug is the answer to their problems.

Even I had a rather bad discussion recently when I asked a doctor about a different medication. This was not a newly advertised drug and is in a class of drugs I am already taking, but the doctor had apparently had a bad day and did not even pick up on this. He said I did not need any more medications – which I don't, but I was interested if the drug would be a better fit with the ones I was taking and would replace the one I was taking. When he realized this, he did say that he would look it up and see if there was a reason to change. About 9 days later, he called and said that at present he would not recommend a change. He did suggest that in a couple years when the current medication went generic, we should revisit to subject. He said the manufacturer did not have a good reputation with generics and we may need to switch to a name drug at that time.

When the researchers reviewed ads for the above four drugs that have gone from prescription to generic, they found only eleven percent of the ads mentioned side effects after the drugs became available without a prescription. This tells us that the drug manufacturers think sales are more important than safety. The study, which was published in the American Medical Association Journal, was supported by CVS Caremark.

Other articles can be found here, and here on the same topic,  This article here is about the "off label" advertising.