Help in Diabetes Management Education – Part 9

Part 9 of 12

Exercise can be a contentious topic for some people. I agree because too often the doctor or other healthcare professional just orders exercise and suggests walking or jogging. I even become upset when they do this to me and I ask them if they have heard of weight lifting, dancing, swimming, or other types of exercise.

I ask if aerobics is not considered exercise or if because it is recommended to do some resistance exercise with aerobics that they don't consider this exercise. I sort of get in their face and ask why they only consider walking and jogging as exercise. Do they even know that the person is capable of jogging or the area in which they can walk is even safe? I then ask if they know that the person will enjoy walking or jogging and why they do not recommend the period of time for walking and jogging.

I am probably the last person they want talking about this, as they know now that I just don't let it go. One doctor asked me to write something up for his office to use. I was a fool for not making copies of what I wrote for him more than three decades ago. I did a lot of research and talked to several people in the business side of training people and those that supplied different equipment. It amounted to more than 15 typed and double spaced pages. I thought all had been lost when the doctor died about 13 years ago, until last month when another patient of his asked me one day if I knew of a paper on exercise written by a person with the same name.

I asked him which doctor he had received it from and when he said the doctor's name, I asked if I could get a copy of it. I now have a copy and it is what I had written with a few notes and other references added. Now I can rewrite it and keep it.

An important part of any exercise regimen is doing something you enjoy, as this will help you maintain it. Please read this by Tom Ross. This is not his normal place for exercise, but he makes use of it.

When it comes to changes in lifestyles, my blog about components of lifestyle changes is a good blog to read. This will vary from person to person as not everyone will need to change every component, but others will need to change many of the components,  This blog may also help. The last blog is also about lifestyle changes, but emphasizes lifestyle changes over medications, which is refreshing.

Food plan changes and exercise seem to be the changes most often emphasized. I do believe that these are necessary, but there are other changes that can help as well. Please be careful with stress, as this is one of the most damaging and can cause any food plan to blow up and cause weight gain and make diabetes more difficult to manage.

Stress in managing your diabetes can be very upsetting for some. Another term for this is burnout as you are the only person in charge of managing your diabetes. Yes, your doctor can give your tips and advice, but in the 15 minutes that you see him or her, this will not be a lot of help. Consider that about half an hour or an hour out of the year, that you see the doctor, the responsibility rests on you, the person with diabetes.

This can cause stress and even depression. This needs to be recognized and if you have family, they can help reduce the stress by supporting you. Unfortunately, they can also increase stress. Exercise can reduce and possibly eliminate much stress.

Our Group's February Meeting

With two relatives doing the topics for this meeting, I had to be there. Yes, I had several emails from them and a few phone calls asking questions about what we had discovered in our meetings and if there was a lot of secrecy among our new members.  Both said Tim had warned them that this could be a possibility and I had to agree with Tim. I did say that our long time members would not be a problem and that some of the new members would not be either.

Beverly asked if she should avoid calling on people and I suggested that she ask for volunteers the first time. I knew the topic she had planned and knew some of our new members might not appreciate the topic. Suzanne said she had several minor topics to discuss and would see how Beverly was received before using one of her topics.

Saturday, February 7, arrived and everyone was present plus a few from the third support group in our town. Tim called the meeting to order and thanked the group for being present. He introduced Beverly and she started her program. She explained that she was a nurse that assisted several surgeons during operations, but that in the last two months she had been part of a team involved in amputations. She continued that before you tune me out, I have been informed about the last meeting you had with two podiatrists and I think you have a great group that cares and this should prevent the members from needing this surgery in the future.

Next, she asked A.J and Jerry to stand and explain what had happened that possibly had prevented them from needing an amputation. A.J said he and I had been talking about diabetes and while he had not wanted to hear what I was saying, when I described some of the symptoms of diabetes; he knew that he had better listen. When I had mentioned sores that were slow to heal, A.J said he had to show Bob a sore on my leg. A.J said I had not hesitated, but had called his doctor for an appointment and told the nurse about the symptoms he had and made a special point of telling her about his sore.

A.J said the doctor had carefully cleaned the sore and applied a gel to the sore and told him to bring his diabetes under quick management to help it heal. He covered the sore with breathable gauze and had told him how to take care of it with the prescription he gave me. Next, he started me on insulin for managing diabetes and within 30 days, my sore was healed. I still have a small scar to know that it was there, but I am a lot more careful now with sores.

Next Beverly asked Jerry to talk about his problem. Jerry said he had a foot ulcer and A.J had asked Bob to have a look at it. They had me see a doctor that day and the doctor had discovered a new ulcer developing on my other foot. The doctor had prescribed medications and coverings for both ulcers. The new one was gone in three weeks, and the bad one is almost completely healed and Jerry said he has been given permission to walk on that foot without crutches before having his shoe fitted with orthotics later this month. He explained that he still uses his mirror to look at his feet daily, but is thankful that A.J and I have been there for him when he needed assistance.

Gale was next and she was still using crutches, but was happy to have a ride to the meeting. She explained that she had never thought about foot problems until she noticed blood in her slipper. She said she had called Sue for help and had also been taken to the doctor immediately. She said that she was sorry for missing the last meeting, but felt that even with crutches, she should not come. She commented that she was still using medication for her foot ulcer and had a mirror to look at her feet now. She commented that belonging to this group was a good thing as they wanted to help and went out of their way to help when other members were in need.

Beverly thanked them and said this is the way to prevent problems and avoid amputations. She explained that she had been present at six amputations and the problems following the operations. She believed five of them could have been prevented if those people had been members of a support group like this. Four were from sores on a leg and two were from foot ulcers that had not been cared for properly or early enough.

Next, she opened the discussion up for questions and questions that took the rest of the meeting. Suzanne had a few questions as well and she answered them. She said she would schedule anyone that wanted help after Valentines Day. Tim was ready to end the meeting, but I took the floor and asked Beverly to introduce her husband, Tom, to the group and she did, explaining that he had type 2 diabetes and was taking metformin. Tom then asked if we were taking new members, as he was not aware of any groups in the town they lived in that were this positive or active.

Tim thanked him for asking and asked him a couple of questions. Then Tim asked our members for a vote and it was unanimous. Tom was accepted and Tim said the meeting was over. Questions happened for another half-hour and people started leaving. Beverly and Tom came to talk to me. Tom said I am about finished reading your blogs, and asked if I took suggestions. I said yes, but some topics are difficult and if he has a topic with articles, I do ask for a copy of the article. Tom said he had my email address and would send me a couple of articles. Tim then obtained Tom's email address and told him about the summary of the meeting that he would receive even when he was in attendance. We did this for everyone and this way people could miss a meeting if they needed to and still be kept up to date on the meetings. With that, we left the meeting.

Diabetes 'Experts' Forcing Complications on Patients

Yes, I am making this accusation and it makes sense to me. Why else would people of importance in the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) speak so confidently about type 2 diabetes not needing to test regularly and to rely on their A1c results only.

Dr. Robert Ratner, chief scientific and medical officer of the American Diabetes Association and Alan J. Garber, M.D., Ph.D., Professor of Medicine, Biochemistry & Molecular Biology, and Molecular & Cellular Biology at Baylor College of Medicine, Houston, Texas are both recipients of money from Big Pharma. I also have to wonder if they also receive large sums of money from Big Food, Big Agriculture, and Big Chemical. These two doctors and others within these organizations received big sums of money to limit what most patients can do.

This is why they insist that we do not test to make the complications happen. This in turn is a favor to the rest of the doctors to give them patients to treat. It is a shame that the insurance industry has to go along with the pronouncements of these doctors, but they are in the business of showing a profit. Therefore, their leaders are more than happy to limit testing supplies. What they do not realize is that the complications will cause greater expenses in the future than the test strips will cost now.

This is part of the reason I have such a dislike for the people in the ADA and the AACE that are in a position to influence guidelines and position statements. This in turn affects most of the actions of other healthcare professionals in the American Association of Diabetes Educators (AADE) and the Academy of Nutrition and Dietetics (AND). This is also the reason most of their members do not talk about testing or promote testing.

This leaves people with type 2 diabetes who cannot afford extra test strips, managing their diabetes in the dark without the means to use testing supplies that will aid them in more efficient diabetes management. These patients will not be able to determine the most reliable time to test postprandial and often find it impossible to test in pairs to help them decide how a meal affects their blood glucose levels. Those of us that have been able to do this have found that we are better able to manage our diabetes.

We have found that by reducing the number of carbohydrates consumed, we are better able to manage our diabetes. Yet both members of the AADE and AND continue to promote carbohydrates and reduced fat and this makes diabetes management more difficult for most people with diabetes. Yes, the ADA has opened the door for low carbohydrate consumption, but the members of these organizations have yet to put this into practice. Maybe the officers have accepted this, but the general membership still follows the old guidelines and the two organizations have not produced new position statements to affirm to the membership the acceptance of anything but the prior guidelines.

All of this creates an uphill battle for people with diabetes that desire to manage diabetes at a level to prevent complications. It is still possible, but takes more effort and education which most with type 2 diabetes do not receive. Most are required to self-educate to be able to manage their diabetes.

Afrezza, Is It the Answer for People with Type 2 Diabetes?

I had not expected to write this, but after seeing this on another blog by Scott Strumello and a comment to it, I felt it was time to open a dialog about it and hopefully see other bloggers write about it.

Several of our support group members have been talking about Afrezza and how they want to see if they will be allowed to use it. Brenda, Allen, and I have decided against it because there is still a big question about determining the correct dose. Tim and Jason are still considering it. Barry has taken a wait and see and warns that it may not even be available to those of us receiving VA benefits. He also wonders if Medicare will allow it.

After reading Scott's blog, we have to wonder from the early hype, will Afrezza even become a product for use in the United States. As of February 3, it supposedly is available in the US, but will every pharmacy carry it.  Currently one local pharmacy has it, but doctors are only prescribing for type 1 diabetes, but not for type 2.  The other pharmacy currently is not carrying Afrezza and offered no reason.  When I first wrote about Afrezza, I had some concerns which are still valid. This has caused me to start listing the pros and cons:

Pros -

• May help many type 2's that have needle phobia
• May help type 2's that are afraid of other insulins
• May be prescribed earlier and not as a medication of last resort

Cons -

• Acute bronchospasm has been observed in patients with asthma and chronic obstructive pulmonary disease (COPD)
• No testing has been done for the elderly and health illiterate
• No testing on people with diabetes that develop pneumonia
• No testing on people with other respiratory problems that often necessitate oxygen use.
• Hypoglycemia may become an even greater concern with Afrezza

Afrezza is not recommended for the treatment of diabetic ketoacidosis, or in patients who smoke. Even with the hype, there are too many unanswered questions about Afrezza that we have not been provided answers to, as of yet. Many of these questions may be answered after it has been on the market for a period of time.

If you are a person that is using Afrezza, please consider responding to this request at Diabetes Update, as this is one place to put the information to use and spread the word about your results.

Help in Diabetes Management Education – Part 8

Part 8 of 12

Developing a food plan (not a diet) and counting carbohydrates is the topic for this blog. Lately the buzz has been about the DASH diet and most of us with diabetes find that it is often too high in carbohydrates and low in the fats. I have found that some diets promote great ideas, but end up not being something that can be followed for the long term. This is the reason that I suggest that each person with type 2 diabetes develop the food plan (not a diet) that fits their way of living.

Some can eat very few carbohydrates while other can consume larger amounts. I do encourage people to limit the amount of whole grains they consume. Beyond this the food plan needs to be what your testing shows is best for you.

The following links will help you in determining the number of carbohydrates in your meal. This site if free and all you need to do is sign up at this link. There is several things that are explained at the link and there is a mobile app that you can download.

This link is the one I use when my wife uses her own recipe and I can enter the ingredients. The following image is what you will find.

 

What I also like is that you can use a link to recipes on the internet. Some recipes have the nutritional information and this will provide a check of the nutritional information provided. The next thing that you need to do is determine the number of servings you will be using for the recipe. This can even be done after the food is prepared and you have a better idea of how much you may want to consume. If you like it and your meter tells you that it raised your blood glucose more than you wanted, you now can get a better idea of the serving size you need to consume.

Having this information can go a long way in counting carbohydrates. Many of us count carbohydrates the hard way but reading the number of carbohydrates from the labels on the products we use for recipes and then determining the serving size and dividing the total carbohydrates by the number of servings. This is also when a scale becomes a tool to help determine carbohydrates. I have used a scale for about 10 years and in the last five years, I have used it less and this is because when using the same recipes, the carb counting has been easier. I highly recommend using one to help in the accuracy of counting carbohydrates.

I am no longer surprised by variances in the number of carbohydrates. Manufacturers and processors are allowed to vary by up to 20 percent also. And the USDA tables used by most calculators are only an average and have a variance. So if you are wondering why those of us that have had diabetes for more than a decade get up tight about all the variances we have to take into account, you would be right, as we do have to wonder ourselves. This won't change anytime soon, so we need to go with the flow.

Help in Diabetes Management Education – Part 7

Part 7 of 12

This is a difficult topic to explain to people and at the same time not confuse them. I have talked about testing in pairs and how important this is. Again, I will advise people to set their own goals based on what they are willing to tolerate for blood glucose numbers. I would urge everyone to manage their goals below or near those promoted by the American Association of Clinical Endocrinologists (AACE).

The medication you are taking will also affect your goals. This means that you should discuss this with your doctor for ideas – if your doctor will allow this. Many doctors are not knowledgeable about the diabetes medications and their effects on the body. Most doctors refuse to allow patients to use insulin and make insulin the medication of last resort. This means that many doctors will harm patients by prescribing insulin only when the complications are happening and oral medications are no longer effective. If your doctor has stacked (prescribed) three or more oral medications, it is time to become knowledgeable about insulin and seriously consider using it before the complications set in.

This blogger uses the AACE guidelines and has some well thought out blogs about the ranges and why they are important. Again, many doctors only follow the ADA guidelines and become extremely anxious when patients obtain lower readings. This is because of their fear of hypoglycemia and they have not taken time to read many of the follow-ups to the ACCORD study. Studies are good, but when they are using targeted participants and not a range of different medications, they are not reliable.

I also suggest reading my blogs from January 23, 2015 and January 24, 2015. Testing in pairs is important if you can afford the test strips. The before meal test and the test at your best time after meals will tell you how your blood glucose level is based on the two tests. If your preprandial is 83 mg/dl and at 90 minutes, your postprandial is 153 mg/dl, this means that you had a total increase in blood glucose of 70 mg/dl. This says you ate too much food or grams of carbohydrates. This will vary by individual and how each body reacts to carbohydrates and the medication the person is taking.

I try to eat between 20 and 25 grams of carbohydrates at each meal so I would expect to have an increase of 24 to 30 mg/dl in my blood glucose level. Again this would depend on the food, the type of carbohydrates, and how I was feeling. Always remember to wash your hands and fingers with soap and warm water and dry before testing.

The other factor to remember is your health and recording this in a health log. This can have an effect on your blood glucose. A fever can increase your blood glucose reading and can even extra pain or stress. These are all factors that must be resolved to know what your blood glucose increase is and how best to treat it.

In the 70 mg/dl increase, was the count really 70 grams of carbohydrates, or were your wife and you have a verbal battle of some not so nice words? Were the carbohydrates the kind that really spike your blood glucose? There is always a variable that needs to be resolved. Sometimes it can be two or more variables. Read my blog here for some of the variables.

Blogger Bad Habits

I know I have some bad habits in writing about diabetes, as a reader reminds me of them. I make occasionally mistakes in medical terminology, but I have to be concerned when group like this one fails to follow editorial policy or at least enforce a good policy. With the errors appearing lately, the editor may be on vacation.

I am referring to this blog from January 27, 2015. I know the author should have used blood glucose meter for most of the blog in place of glucose monitor and uses the term monitor correctly when talking about continuous glucose monitor. A monitor does not use test strips.

The only thing I can figure out from this -Quote - “It will be easier on your pocketbook if the monitor you chose is popular. You will find the test strips everywhere with no trouble, often at lower cost because they are widely available.” - Unquote is that the author has unlimited funds and can purchase any test strips desired.

Most of type 2 diabetes and type 1 need to stay with the meter and test strips that are what the insurance provider will reasonably reimburse or pay. Each insurance company is different in their formulary and therefore what is popular may not be the brand that the insurance company will allow.

Quote - “Blood glucose monitor test strips are sealed in packs and vials. Keep the ones you are not using in their original packages.” - Unquote. The author may desire the containers to be sealed, but I have not found any that are sealed and I have never needed to break a seal to use them. I have had to open the box, then open the container lid, and carefully remove the first test strip.

Quote - “Make sure your hands are freshly washed before handling test strips, and be careful not to get the strips wet with water or alcohol. After using an alcohol wipe, let your finger dry before pricking it to get the drop of blood.” - Unquote. Yes, it advised by most test strip manufacturers to wash your hands and dry thoroughly and this is in the instructions that come with each box containing the container of test strips. Alcohol pads or wipes should only be used when water and soap in unavailable. Never rely on alcohol pads when you have been handling or cutting fruit or certain foods and you will receive very elevated readings. Only washing with soap and warm water will remove the sugar of fruit from your hands.

Using alcohol pads on your fingers during late fall to early spring is asking for cracked fingers and very painful testing. Alcohol dries out the skin and this is a serious problem.

This is the type of information we don't need. I have had several emails asking me what the information meant as they had not heard of glucose monitors requiring test strips. It is blood glucose meters that require test strips.

Continuous glucose monitors (CGMs) are very expensive and very few people with type 2 diabetes can have them approved for use, but a few do. Mostly they are used by people with type 1 diabetes.

Help in Diabetes Management Education – Part 6

Part 6 of 12

Learning to interpret your blood glucose readings and how they should guide your food intake is part of self-monitoring of blood glucose (SMBG). A few certified diabetes educators (CDEs) will actually teach this, but most will only use mandates and mantras. If you are fortunate to have one that is teaching this, learn from them. Those of you in the rural areas will most likely need to learn this on your own. Some rural doctors are working with diabetes patients that want to learn and training them to be peer-to-peer workers or peer mentors. In turn, they work with the doctor to help educate other patients.

I will state before I go further, each patient needs to discuss with their doctor what reasonable goals they should consider. Then you will need to decide what you are willing to tolerate for diabetes management. The numbers I will use are reasonable, but you should still select your own goals. This is not a topic that can be neatly wrapped in a bow. It needs to be individualized to the person and their goals and abilities. I would urge you to read the many links I will provide as it will give you ideas for goals.

The first link is this with tables and a discussion on managing blood glucose. There are suggestions that need to be considered. The second link is a blog of mine that I wrote about from a book published by Joslin. This surprised me and Joslin is not always talking about this and often discouraging to people with type 2 diabetes.

One factor where most authors fail is talking about “testing in pairs.” Dr. William Polonsky of the Behavioral Diabetes Institute is the person that coined this and promotes this as the best method for determining how food affects you body. This is important because by taking only one blood glucose reading either before or after eating will not give you any meaning and just a reading that tells you nothing except what the reading was at that time. This does not help in determining how the food you consumed affects your blood glucose.

This also tells the doctor nothing toward finding the correct amount of medication. Granted the doctor uses your A1c to determine how well you are managing your diabetes, but more doctors are using the readings from either your testing or from your meter to help them do this. I will cover counting carbohydrates in a future blog.

While I do not like the numbers used in this blog at DiabetesMine, this will give you more of an idea why testing in pairs is important.

The last blog I refer you to is this one where CDEs think about us a round pegs and they want to put us in square holes. I wrote this with tongue in cheek, but it is very applicable today because CDEs teach to the lowest level and don't want to work with people with type 2 diabetes when they can avoid it.