Does Type 2 Diabetes Have Subclasses?

Before getting started on this topic, I must state that these are my opinions only, based on my reading and are no way official opinions. While some people have been alluding to sub groups or subclasses of people with type 2 diabetes, I believe the evidence is mounting for more people to come out in support of this idea. We now know that ethnicity is a factor and I am not sure how to list the young type 2's that have more deadly type of diabetes than children with type 1.

I personally feel that an apples to apples comparison is not totally accurate for those adolescent and young adults with type 2 diabetes, but I could be in error. “The study population was derived from the Royal Prince Alfred Hospital Diabetes Database and focused on individuals diagnosed with diabetes between the ages of 15 and 30 years. Records were matched with the Australian National Death Index to establish mortality outcomes for all subjects until June 2011. Clinical and mortality outcomes in 354 patients with type 2 diabetes (mean age at diagnosis, 25.6 years) were compared primarily with 470 patients with type 1 diabetes with a similar age of onset (mean age at diagnosis, 22.0 years) to minimize the confounding effect of age on outcome; disease duration was 11.6 vs 14.7 years.”

While type 1 diabetes is generally considered a more severe type of diabetes, the results highlight that young people with type 2 diabetes have double the risk of dying when compared to those with type 1 diabetes and after a much shorter duration of having diabetes.

Therefore, I would think this should be considered one subclass of type 2 diabetes. Studies are finally being done to compare how different ethnicities are affected by type 2 diabetes. While much more study is need for those in Africa, they tend to have a lower insulin sensitivity, but seem to compensate by releasing greater amounts of insulin.

Among those of East Asian origin, they have very good insulin sensitivity, but seem to have a harder time releasing insulin when it is needed. This means in the clinical settings, they develop diabetes more easily and do so at a lower BMI. Because East Asians have more difficulty releasing insulin, generally they need to start insulin therapy at an earlier stage of diabetes.

Caucasians fall between the two extremes in both insulin release and insulin sensitivity. Now in addition to the above subclasses there are probably more that have not been studied, such as the Eskimos and American Indians, but until there are studies verifying this, we can only guess. I would even hazard a guess that the African Americans could also be a subclass separate in part from those from Africa itself.

I also believe that even among Americans, there could be several subclasses of type 2 because we have thin type 2's and obese type 2's. We have many people that are able to manage their diabetes with nutrition and exercise and others that have a difficult time even on low levels of medication.

Will we have any discussion within the ADA about this? I highly doubt this and would be more inclined to believe that with the current attitude of physicians wanting cut and died answers, that it will require a much stronger voice than mine to give them a wake up call. Plus, with their conflicts of interest, unless some of their corporate sponsors raise the question, this will never see the light of day in the American Diabetes Association discussions.

Diabetes Management under a Physician Shortage

In the next few years, what are we, as diabetes patients going to be able to do? There is going to be a physician shortage which we have been hearing about from doctors and their professional organizations. Even teaching professors are talking about this and a few patients. How long are we going to be forced to wait between appointments and think about how much time the doctor spends with you now. This can only be worse and your questions may not even be answered.

Ann Bartlett, who writes at Health Central dot com has an excellent blog on July 17 that deserves your attention. She is a type 1 and in this blog writes for all people with diabetes. Because of what she writes about the numbers of practicing endocrinologists, I will disagree with her statement that everyone should see an endocrinologist at least once a year. Some people will do very well in the early stages of diabetes, especially those with type 2 diabetes that do not need to lose weight or that are able to manage their diabetes with nutrition and exercise. Many people do probably need to lose some weight and are capable of doing so.

Where I do agree that people with type 2 needing to see an endocrinologist are those people with complex diabetes and often comorbidities requiring more attention than a primary care physician (PCP) has time to devote to the patient. Many of these patients are in the need of insulin therapy, but the PCP has not kept abreast of the knowledge required and so won't prescribe insulin. Instead, he has stacked one oral medication on top of another and in some unusual cases, the patients are taking up to four different oral medications. Too many and most of the time they still are having trouble maintaining good A1c's.

Ann is right when she says, “Third-party insurance providers, the big bad boy of this debate, are finally hearing the bell toll, and need to start offering fair reimbursement to doctors for services rendered.” Unfortunately, with the Centers for Medicare and Medicaid Services not expanding their payment to PCPs and endocrinologists, the rest of the insurance industry will not step forward and help, as they want to grow their profit margin. So our doctors are continually squeezed in the pocketbooks and wallets.

As a result, I will continue to advocate for state medical boards to loosen their strangle hold on nurse practitioners and physician assistants and allow them to operate with more independence. This blog has a map showing the states that are allowing NPs the freedom to practice medicine without supervision. Only 18 states are presently allowing this. It is a shame that the same information is not available for PAs. My endocrinologist has at least two NPs on his staff and I see one of them. I also see a NP at my Veterans Affairs (VA) appointments and I am very happy with both.

The American Association of Diabetes Educators (AADE) could really help with education, but at present, they are reluctant to do so. I have been on their case for some time now and all it has gotten me is derogatory emails. Even my CDE cousin will not talk to me anymore because she knows I am serious.

The AADE is not adding CDEs at a rate needed to serve patients adequately. Therefore, the AADE should be required to open up a classification or group for peer-to-peer workers and peer mentors, give them some training and classes, and let them move out into the diabetes community and help people with all types of diabetes. Then they should provide continuing education for them. This is supported by several studies where peer-to-peer workers have helped other type 2 patients lower their A1c's. This would work for type 2 helping type 2's and type 1 helping type 1's.

Even the ADA and AADE Task Force that developed the Diabetes Self Management Educations (DSME) and the Diabetes Self Management Support (DSMS) National Standards included lay people and peer workers in the area requiring more research, yet the AADE has chosen to ignore this. Oh, yes, they will take credit for the CDC programs that they participate in for training peer workers, but will they open a designation for them and continue to assist them with more education – no. They can't wait to be separate from them and let them go their way. This is not the correct attitude to my way of thinking, especially with the shortage of certified diabetes educators.

Fortunately, some doctors in rural areas and some not so rural areas are seeing the need for peer-to-peer workers and peer mentors and having them educated. Then they are returning to help their doctor and other doctors in their areas. One doctor that I started to work with in Montana, now has three peer mentors in three chronic diseases doing what needed to be done for education of his patients.

Another area that needs to be opened up is telemedicine where doctors could practice across state borders and others could assist people in doctor sparse regions of the country.

What To Consider in a Blood Glucose Meter

Are you confused by all the hype about blood glucose meters? You should be and there is a lot of hype. Every writer approaches this from a different perspective and promotes what they feel is best. There are some general guidelines that it is often wise to follow. I want it understood that I am not promoting any meter over another, but I do urge you to consider the points I lay out and do not be afraid to talk to pharmacists and others that may assist you and provide guidance.

#1. What will your medical insurance cover. This is often what will determine the type of meter that you will chose because the cost of test strips can be prohibitive and you may need to consider this first.

#2. If you do not have insurance, then economic considerations may be the most important. There are economical meters and test strips available that are reliable and that do not have all the bells and whistles that many people think they need and never use.

#3. If you are one of the fortunate people with few economic barriers and chose to go outside your insurance, then you have a wide range of considerations in making a choice.

Once you have determined which of the above applies to you, now the choices become even more difficult. They may be very limited in selection or you may have a wide range to choose from. This will depend on your insurance company and there are some real issues under Medicare which have yet to be resolved. Unless the courts act soon, many on Medicare may be caught with no supplies.

TV ads are very deceptive and often misleading, yet many people become suckered in and spend the money. Then when they receive the meter and test strips, they realize that they have been had, but there is seldom a way to return them. These companies will be very evasive in an attempt to make you keep what you ordered.

Many of the TV ads advocate for alternate site testing and this is okay if you seldom have a hypoglycemic episode and are fairly consistent in your readings from your fingertips. You need to know that the reading you receive from an alternate testing site is an indication from 15 to 25 minutes ago depending on the area used for alternate testing. Also, there are very few alternate test sites that are totally pain free. I urge anyone on insulin not to consider alternate site testing because if you are having a low, you need the now readings of your fingertips.

Many people were enticed into the talking meters and then wondered what to do when they were out in public. I have heard them in restaurants and other places and people just could not muffle the sound. So if you are a person desiring secrecy, forget these, as secrecy is next to impossible.

If you have a computer, you may wish to consider a meter that will upload to your computer. Normally the cost is for software and a cable from a USB port to the meter.

These two blogs seem to think you have all the choice and can purchase any meter which may not be the case.

There is a growing concern about the test strip accuracy and I strongly urge people to read two blogs of many (this one by Ann Bartlett and this one on Diabetesmine) about the declining accuracy and that apparently no one is doing anything about it. I can only feel fortunate that I have one of the top two meters listed in several reports – meaning that the tests strips are considered the most accurate.

Don't Get Caught in This Hospital Greed Trap

In April, I was in the hospital because they could not determine whether I was suffering from heart problems or severe indigestion. Shortly after being put in a room, I received a paper to sign saying that I was admitted as an outpatient and not as an in-patient. Since I knew what this meant, I asked to be discharged.

Guess what they told me? They would not discharge me as I needed to remain for observation. I requested a second time and refused to sign the paper because I knew that the total bill would become mine as Medicare and my supplement insurance would not cover anything but some of the tests. I knew that once the diagnosis was for severe indigestion that all the heart tests were going to be charged to me as well and they kept doing them even though I tried to refuse them. Surprising what some sedatives can do to your will to prevent the continual testing.

They even continued to push the paper for me to sign in front of me which I somehow was able to keep from signing. Even during discharge they tried to slip it in, but I still did not sign it. Now I have the Medicare statement showing what they did and did not pay for and the hospital and I will continue to argue about the bill. Medicare did cover the first blood work only to show that I had no enzymes from a heart attack and the first EKG showing no heart irregularities, but they paid for no more of the tests the hospital insisted I needed.

Medicare did pay for the medications for the severe indigestion for the first day only and then stopped that since I should have been switched to over the counter medications. This leaves me with a substantial medical bill which I will not be able to pay and they wonder why I wanted to be discharged. Next time I will discharge myself, if I even allow myself to be admitted. Yes, I will do this “against medical advice” and think nothing about it. I am tired of the hospital greed.

I regret now that I even went to the emergency room. Yes, I bypassed the ambulance services because of my experiences with them before, where I was forced to pay for their services because they incorrectly submitted the bill to my insurance. Plus, the ambulance is required by Medicare to take me to the local hospital which I refuse to let happen.

I was fortunate that my diabetes supplies and medications were not taken away from me and I was able to maintain reasonable control of my diabetes against doctors orders. He wanted my blood glucose levels at 180 mg/dl minimum, and I was constantly at 120 mg/dl to 145 mg/dl. When he finally figured out what was happening, I was being discharged. Prior to that, the nurses only knew that I was refusing to eat the hospital food except for some sugar free jello. The diabetic meals were carb loaded and beyond what I could handle. Even the tea was loaded with sugar and I could taste it and refused to drink it. The one nurse even poured a little in a small cup, spit it out, and had to agree with me.

Well, these are lessons learned and not to be repeated.

FDA Says It Shut Down 1677 Online Pharmacies

This has to be serious when the FDA and Interpol cooperate to bring down 1677 websites selling counterfeit and substandard medications. I can only say good and maybe many of these sites will not reappear as they so often do. Only arresting 58 people is small potatoes though, but seizing more than $41 million worth of illegal medicines will be a temporary hurt for most of these businesses considering the billions in profits they rake in every year.

Either way, I am happy to see that this has happened and can only hope that they can step up this sort of action. The main points in determining if the online pharmacy is abiding by federal and state laws are the following and can be read here. I will still give the main points, as these are important to know.

The signs of a rogue Web site are as follows: Quoting

1. No prescription required: Internet drug outlets are suspect if they dispense prescription medicine without requiring the patient or doctor to submit a prescription, or without contacting the patient’s doctor to obtain a valid prescription.
2. Prescription based solely upon online questionnaire: Be wary of Internet drug outlets that dispense prescription medicines based solely on the patient completing an online questionnaire without having a pre-existing relationship with the doctor, including an in-person physical examination. Most state boards of pharmacy, boards of medicine, US Food and Drug Administration, US Drug Enforcement Administration, the Federation of State Medical Boards, the American Medical Association, and NABP agree that this practice is illegal or fails to meet the standard of care.
3. No phone number or street address: Internet drug outlets should have a toll-free phone number as well as a street address posted on their Web sites. Drug outlets that allow customers to communicate with them only by e-mail should be avoided.
4. No pharmacist consultation: Legitimate pharmacies allow patients to contact pharmacists if they have questions about their medications, whether by phone or secure Web-based communication.
5. Waivers: Legitimate pharmacies do not require patients to sign waivers to place the patient in legal jeopardy or waive all rights before providing medication.
6. Limited medicines: Many untrustworthy Internet drug outlets offer only a limited number of medicines, particularly “lifestyle” or controlled substance medicines that treat such conditions as impotence, obesity, herpes, pain, and acne.
7. International Web sites: Because foreign medicines purchased online are unapproved and not subject to the safety and efficacy standards of US Food and Drug Administration, their authenticity, purity, and safety are unknown. The safety and security of the sources from which these Web outlets obtain foreign medicines is also unknown. Some Web outlets that claim to be Canadian pharmacies actually sell medicines obtained from developing countries in Asia, Central America, the Middle East, or Eastern Europe, where regulations are more lax, and the prevalence of counterfeit medicines is significantly higher than in the United States.
8. Spam solicitations: Many Internet operations that advertise through unsolicited e-mail messages (i.e., spam) operate illegally and are not a trustworthy source for obtaining anything, especially something as critical as prescription medicine. According to the Federal Trade Commission, spam e-mails can infect computers with spyware that can slow computer performance, install software that can record and report a customer’s every keystroke, spread computer viruses, and “hijack” a consumer’s computer to distribute more spam. Deceptive spam is also sometimes used to trick consumers into divulging sensitive or personal information, including credit card numbers and other financial data.

Trisha Torrey also speaks out about the same CNN News release and gives her thoughts. For more information about the safety of American drugs, read this by Trisha Torrey and follow some of the links she provides. Even our fellow countrymen are cashing in on counterfeit drugs and spreading them out to different distributors in our own drug-buying suppliers. Even some of our trusted pharmacies are duped by the counterfeit drug suppliers.

Insulin's Place in Type 2 Diabetes Treatment

This is scientific research at its poorest. When it comes to certain oral medications and their comparison or companionship with insulin, researchers do not want to expend the resources required or the time. The drug companies, of course, will not admit that there is anything at fault with their drugs and therefore will not help with any funding. And then we have the self-anointed “experts” at the American Diabetes Association and the American Association of Clinical Endocrinologists saying that the oral medications are the first line of treatment for type 2 diabetes. When you examine the funds that the two associations receive from Big Pharma, you will understand why they would say this.

And when people will make statements like this, “In some cases, insulin is the only therapeutic option remaining,” what does this tell us? Bold is my emphasis. This has to mean that doctors have waited too long to switch to insulin therapy and have forced patients to remain on oral medications longer than should have been used. Not only have doctors done harm to patients, they don't seem to care if they can avoid prescribing insulin. This is why we need more research and well funded research to identify people that have been kept on oral medications too long.

We also need research to identify problems researchers are loathe to do because they might learn something that could prevent certain oral medications from being used with insulin.

In this study, an epidemiologic analyses, they are able to establish associations between medications and outcomes, but they can never be completely positive that the findings are unbiased. Even though many covariates were included, such as the duration and glycemic control of diabetes, one factor is fairly important, the risk of each individual outcome produced similar results suggests 1 of 3 possibilities. These are that the residual confounding remains, the outcomes are associated with each other, or that they share the same causing event.

In this, the researchers blame insulin and quote previous studies for what they lack in results and then they do what is expected for a lackluster study and say that caution is warranted and demand further study. This tells me that their study was flawed to begin with and not well planned. Why they received funding for these flawed studies still remains a mystery and why the group or committee overseeing the funding allowed the study needs investigation. Funds for studies will continue to be short in the current economy, yet poorer and more faulty studies are being funded.

As a side note, it is interesting that metformin plus insulin went a long way to lessening the increased risk found in insulin monotherapy. This may be the impetus for continuing to add metformin when insulin therapy becomes necessary.

In a recent blog here, I discussed PCORI. PCORI is the Patient-Centered Outcomes Research Institute, and is a new federal institute mandated to figure out how meaningfully to involve patients in research. Under PCORI, patients will have the rare opportunity to help make decisions about what research is conducted, some of the design, and to be involved in the research activity from the beginning. After all, isn't it the patients with the disease that have the most at stake and the largest to gain from research?

I also think there is much to be gained from research conducted under PCORI. This may also open the door to putting patients on some committees overseeing funding approvals at academic centers that are currently mishandling research funds for poorly constructed studies. I can envision patients with the disease being placed on funding boards and in other capacities for oversight.

Activities of Our Diabetes Group

We are still attempting to have Hospice back to speak to us, but they have been busy. Even the county Public Health/Home Health Care person has been too busy. Both have been in contact with Barry and Allen according to Ben, but their time has been taken with clients needing attention. Allen even said that the speaker he wanted asked to hold off for the summer with the children being so busy.

We had one short meeting in June and have scheduled the next meeting for September, as several of our group will be on vacation for the month of August. Max and I were attempting to walk, but he is having a planters wart removed and the doctor has said no more walking than absolutely necessary. We agreed as this heat and humidity are making life difficult outside the air conditioning of our residences.

Allen is becoming very active online and is tackling a project that surprised the rest of us. He has become familiar with the FDA Patient Network and is doing correspondence with several people he met online there. Tim and I are attempting to help him when asked, but he has taken off on his own and is really into what he is doing.

Tim and I are attempting to monitor what is happening with the Medicare scandal and the CMS being sued for awarding non-approved companies contracts for medical supplies and medications. Not a fun task and I admit I am happy I have never dealt with any of the mail-order medical suppliers.

All of us must congratulate A.J. for being able to say goodbye to insulin and all medications. This extends to John as well, as both were able to be approved to stop all medications about the middle of July. I had a long conversation with A.J. when he said something, but he said the doctor had given him permission and since he is purchasing extra test strips on his own presently, the doctor just has him testing seven times per day. He and John are able to exercise each evening and John is happy to be off metformin.

Everyone is happy that four of our members are off medications and are doing very well with their new found freedom. Even Sue was happy to know that she and her husband were not the only ones off medications. Sue has asked for help, as her husband, Bob is having some troubles lately and his fasting is creeping upward. Barry told him to purchase some extra test strips and test on the frequency that A.J. is testing, and this seems to be the help he needed. A.J. also advised him to reduce his carbohydrate intake and cut more of the whole grains out of their food.

I loaned them my book, Wheat Belly to read and Sue said she is getting quite a lot out of the book. She and Bob do not like flax, so they are hunting other recipes. I sent the URL for Dr. William Davis blog site here. She said this has helped and they have ordered his second book Wheat Belly Cookbook. I also sent the following blogs for them to read starting with June 30 and then to explore more later. On the first – Fathead-Movie, I urged them to read the comments as there were often some great variations in the comments. On the second – Marks Daily Apple, I told them to explore and if that did not give them ideas, I would send some more.

Bob says he made the crust for the faux pizza and the paleo mayo and has really enjoyed the variety of sandwiches. He said that he had to make smaller sandwiches after the first time as he was over stuffed. He also commented that his blood glucose readings love the sandwiches. Sue commented that her blood glucose readings have come down as well.

Two of our members spent a couple of days in the hospital, but mainly it turned out to be for flu-like symptoms. Mostly the doctor said they were more dehydrated. Brenda is busy with her grandchildren for much of the summer.

Diabetes Experts versus Diabetes Patients

When a couple members from the support group saw this title, one made the comment, “Here we go again!” I asked what he saw in the title and he said that it was another blog about oral medications. I had to agree, as that is my intent. I must declare I am on insulin (long acting and short acting) plus a minimal dosage of metformin.

I do believe it is time for patients to declare their intentions, especially if they are on some of the medications that are being reported with serious side effects. I have nothing against metformin in the extended release version, as the gastrointestinal side effects are often minimal when taking it. Many people have no side effects with the extended release version. And the fact that it is generic and the cost is affordable and makes this an economical treatment for type 2 patients.

Yet, our diabetes experts want to stack one oral medication on top of another oral medication for several medications. I complain that this is not good and this practice by physicians needs to stop, the AACE Diabetes Algorithms not withstanding. The American Diabetes Association and the American Association of Clinical Endocrinologists don't want this to happen and advise keeping patients on oral medications. The sad part of this advice is the corporate sponsors of these two organizations are the beneficiaries and the officers of the ADA and AACE receive fees from these same sponsors.

It is convenient for me that one of the studies reported out of the ADA 2103 Scientific Sessions June 22, is about stacking three medications and the author reports starting people newly diagnosed with type 2 on triple drug therapy. You may read about this ongoing study here at Medscape. This has to make the ADA and AACE very happy.  I hope this becomes fully tested as the side effects may be great and dangerous.

This relationship with the pharmaceutical companies has to end for any trust in the ADA and AACE to be restored. How can we place trust in the guidelines issued and the recommendations of their officers when we know that they are influenced heavily by the fees they receive from the pharmaceutical companies? Then in addition, they are well paid as officers from the contributions or sponsorships of these same pharmaceutical companies to their respective organizations.

Yes, I will continue to blog about the guidelines issued by the ADA and AACE, but everyone needs to be aware of the biases built in and the underlying motives for some of their misdirected guidelines. Comprehensive the guidelines are not and with the built in discrimination by researchers when they exclude the elderly and the young from participating in research, the people that are using the majority of the medications have not had the medications tested on them. This adds more reason to take a jaundiced view of the guidelines. Insulin anyone?

And before I forget, I salute the people with type 2 diabetes that are able to manage diabetes without medications. Some have been able to manage without medications from the start while others have been able to wean themselves off medications and continue to manage without further medications.