Do You Understand Depression - Part 2

Many people will not come right out and state that they are depressed or feel depressed. Normally, the doctor should know the signs as they can accompany other real problems the person goes to the doctor to resolve.

Because of how depression can affect people diagnosed with diabetes, I would propose that the following be made mandatory for all adult people with diabetes and all parents of children with diabetes. Once a diagnosis has been made, the diagnosing doctor should schedule a session with a psychiatrist. And yes, this should be mandatory with penalties for not keeping the appointment. Insurance should be required to pay for this.

This would not be the normal visit, but an educational appointment to learn about depression, the warning signs of depression, and maybe some tests as described in this blog. Many people with diabetes (about two-thirds) do develop some depression because of the daily chores with diabetes. No stigmatism should be attached to this appointment and questions should be allowed. The psychiatrist should build a file for future assistance and learn what medications you might be willing to take. This should also build a doctor patient relationship that can be used later if needed and allow for open communications in the future.

Understand that this does not lock you in with this doctor. If you don't have a rapport with the doctor, you should be able to get a referral in the future to another psychiatrist. Some even use telemedicine to chat with you later to answer questions about depression. Don't forget the problem with burnout and these doctors may be able to assist during this and help shorten the length of the burnout.

Back to the information about depression. People that are depressed can have trouble falling and staying asleep, or conversely, they will find they want to sleep all the time. Interest in things commonly enjoyed can disappear. Feelings of guilt and hopelessness can be intense and constant. Concentration is often impaired, and appetite can be minimal or, conversely, voracious. This is when a visit with a psychiatrist could be important. The American Psychiatric Association provides a screening tool for depression that could be of help.

While about 19 percent of depression can become severe, it is better to ask for help when you recognize some of the early symptoms than say I will get better and then not get better, but worse.

When the depression gets worse, this is when thoughts often happen such as I'd be better off dead, or turn to killing oneself or others. Depression is dangerous when it distorts thinking, judgment, and decision-making. The disease of depression can make it hard to remember the last time you felt "normal" and hard to believe you will ever feel "normal" again. It can be hard to believe someone we have known as a happy, well-adjusted, and successful friend, neighbor, family member, or colleague would want to kill himself or herself. However, depression is extremely powerful.

Without this information, patients can feel lost or, worse, defeated if their symptoms progress. It is very important to become educated to get help right away if their mood worsens or if they have any of these additional symptoms.

It is important to provide crisis numbers, including the national suicide hotline (1-800-273-8255), which is available 24/7. I would advise everyone that if they are feeling dangerous to themselves, they should not wait to see a psychiatrist in the community; they should go to the nearest emergency department or call 911.

Do You Understand Depression - Part 1

Although the article is written for all people and about depression, I will be limiting my discussion to people with diabetes. About two-thirds of people with diabetes develop depression and about 19 percent of these develop severe depression. We are more susceptible to depression because diabetes is a chronic disease, there is no vacation, and we must battle it 24/7/365. Then add stress and other variables and it is easy to understand why depression can affect us.

Then because of the stigma attached to depression and it is easy to understand why many people with diabetes refuse to talk about or even see a doctor for depression. Yes, I have had ignorant doctors say it's all in your head and tell me I was just too lazy to deal with it. I could not leave that doctor fast enough – never to return. Then some people write me about getting help because when the subject was mentioned in a meeting with a certified diabetes educator, the educators all seem to want to end the session and leave the room. These examples are not the way to treat depression in people with diabetes.

What is depression and what causes it? These are often the questions people with diabetes want to know and they often start with their primary care doctors. In diabetes patients with severe depression, many visit their doctor the week before committing suicide. Yet many doctors do nothing to help people with diabetes and won't deal with depression, mild or severe.

Some people with diabetes attribute their depression to personal weakness or lack of will power. This stigma often becomes a barrier to seeking help. Not seeking help can often make those who suffer from depression feel worse. Now if doctors would understand the importance of helping those with depression, both mild and severe. This may only be a dream with the numbers of doctors that either ignore the patients' pleas for help or ridicule them for being weak.

Depression can be a feeling and often a feeling that is difficult to explain or describe. Doctors that are knowledgeable about depression do try to educate, when possible, their patients and work to dispel the stigma associated with depression. Some of the better doctors will prescribe a medication to help and other doctors will refer them to people that are knowledgeable about the different levels of depression.

Most people experience a “down” or a “blue” period every so often, but these normally resolve after a few hours or days. These are a normal part of living and life and should be expected. It is when these or feelings of sadness last for more than two weeks that we should seek help. A doctor that expresses empathy, concern, and a supportive environment can lift a large part of the burden and this can be very therapeutic.

Some of the problems associated with diabetes can bring on depression. These can include hypoglycemia, diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar nonketotic coma (HHNKC). The last two require immediate medical intervention and hypoglycemia may require immediate medical intervention if the blood glucose levels become too low.

In addition, just the fact that diabetes requires attention 24/7, can lead to mild or severe depression depending on other circumstances in a person's life.

A Dilemma for a Person with Diabetes

I find myself in a real predicament. This is a very real problem for husbands and wives, but I had not envisioned this happening to me. What you ask? My dearly beloved ignored prediabetes and said very little to me except to ask a few questions as if it were someone else's problem. On January 19, she was notified she had type 2 diabetes and the problems started.

She accepted a regular metformin prescription and not a prescription for extended release. I suspect she will have the common symptom of nausea and the rest of the side effects as she is of Asian nationality.  So far, she has had few problems.  When I try to discuss diabetes with her, she ignores my questions. She knows I blog about diabetes and she clearly stated that she did not want advice from me.

Her latest A1c is 6.9% and her A1c from a month prior was 7.0%. This is what the doctor used to confirm her type 2 diabetes. When we went grocery shopping, I did notice a few improvements in the purchases. She was looking at calories and not carbohydrates though. I did get to show her a few of the higher carbohydrates counts, but she said that I why she would only eat one serving. It will be interesting if this comes to pass.

She did surprise me when she started looking at her lab results and asking good questions about them and the ranges. The lab is using the old, and I mean old, prior 1997 ranges for diabetes even though she said the doctor told her she had type 2 diabetes. This brought out questions and I had her read this blog and the link it contained.

I know I will have to be very careful in what I say and how I say things, but if she is in denial, not much will make that change until she realizes she has diabetes. I am cautiously optimistic that a few statements made in the days since her diagnosis on January 19, 2015 will lead to acceptance.

Now she is taking a class with a dietitian and I need to be extra careful. When she talks about carbs, she is using the term to mean one carb equals 15 grams of carbohydrates. A few of my readers have asked me why I use grams of carbohydrates as they also learned what my wife has learned. Well, this is because I learned on my own and in reading labels of food containers; everything was in grams of carbohydrates. I naturally followed this and learned that it was easier for me than dividing everything by 15 to come to carbs. If I eat 35 grams of carbohydrates for a meal, this is easier than calculating 2 and one-third carbs.

Veterans with Dual Coverage Under Scrutiny

Being a veteran, this article creates resentment in me. It is as always; blame the veteran for having served the country and find ways to deny medical supplies where possible. It is bad enough that the Centers for Medicare and Medicaid Services (CMS) and the Veterans Affairs severely limit testing supplies, but now the veterans that are taking advantage of both are being put under the scope.

The researchers who are reporting this are determined to put these veterans in a bad light and prevent them from gaining the upper hand in diabetes management. Their reasoning is cost must be limited. They cite the costs of self-monitoring of blood glucose in the United States as being substantial. Medicare contractors paid more than $1.2 billion for test strips and/or lancets in 2007, and the VA, where use and cost are lower, approximately $50 million per year is spent on test strips alone.

Both Medicare and the VA, however, place restrictions on the number of test strips used per a specific time period based on the patient's diagnosis and treatment regimen. The researchers are upset with the veterans using both systems for obtaining test strips, and thereby side-stepping each system's attempts to discourage overuse.

The researchers defined overuse of test strips as more than one strip per day, or more than 365 strips per year, for those taking no diabetes medications, oral diabetes medications only or long-acting insulin without short-acting insulin. For those taking short-acting insulin, overuse was defined as more than four strips per day, or more than 1,460 strips per year.

The researchers showed their bias because a few of the oral medications do cause hypoglycemia and the users need more test strips. Data from 363,996 veterans aged at least 65 years with diabetes who used the VA health care system who received strips in 2009 were included.

A total of 260,688 veterans (71.6%) with diabetes received strips from the VA only, 82,826 (22.8% from Medicare only and 20,482 (5.6%) from both the VA and Medicare, according to the data. The researchers found that those receiving strips from the VA and Medicare received more strips (median, 600), as compared with Medicare only (median, 400) and VA only (median, 200; P<.001).

The researchers could not do the work necessary to confirm information as evidenced by this statement, “Odds for overuse also appeared to be considerably greater for those receiving coverage from both the VA and Medicare versus the VA only.”

“Patterns remained similar, the researchers noted, even when more conservative thresholds of overuse were employed.”

Then the researchers make this statement, “These findings illustrate the profound importance of understanding dual health system care and are emblematic of waste and inefficiency that must be addressed.” The researchers apparently did not confirm that there was actual waste, but concluded that there was waste and blame the veterans for trying to manage diabetes more effectively.

Another Gathering of Members

On the February 12, Tim called us for a meeting that evening, as he wanted a final discussion on members leaving the group. When we arrived, we could tell that Tim was very upset like many of us had not seen before. Even Allen was surprised when he was not greeted.

Tim called the meeting to order and asked if there were any other members that were thinking of leaving the group. Then he went through the members, name by name. Everyone answered no, and Tim said that he had contacted Tom with the same question and received the same answer. He then explained that the three not present had quit the group this week and Tim stated that he is not happy.

Tim continued that the three that quit would not give him a reason or even answer any questions. Jerry asked to speak and said he may have an answer. Jerry said that his now ex-wife had said she would do what she could to destroy our support group and this could be why some of the members have left. With that Norm asked to speak. Jerry said go ahead. Norm said you may have noticed that those leaving to-date are not part of the VA as I am not. Yes, Jerry's ex-wife did contact me and gave me a bunch of lies that I knew were lies because I am friends with Allen and Max. I knew better and told her she was lying and I wanted to stay with the group.

Jennifer said she contacted me as well and if the group had not helped me, I might have believed her. I hung up on her and when she called again, I would not answer. Gale said she will be contacting those that are veterans as she had called her. Gale said that after Sue's help, she would not leave. She said that anyone that had received nutrition advice from her will probably be contacted, so be prepared and decide now where you want to place you loyalty. Rose spoke up and said she had also been contacted, but had told her she was not leaving. Julie added that she had also turned her down.

Jerry asked Earl and he said he had not been contacted yet, and the last three said no also. Jerry asked if they would be considering leaving now and all four said that now they would not listen to her and had planned on staying with the group. If they had been contacted before the last two meetings they might have been easier to sway. The last two meetings made us realized the group did have our best interests in mind and while the topic was not what they wanted to hear, this has been a wake up call about how serious diabetes could be.

Ken said he would also like topics about the other complications now and Jay said this would be good. Dan said he had an appointment with the nutritionist cousin of Bob's and the few questions she had answered during the meeting meant that he was happy.

Now Jerry was unhappy and asked if he should contact those that had left. Tim said no and Allen asked him to take a vote of the members before the new group had joined. Tim asked for a show of hands and it was in favor of no. Tim did say that we would consider them if they asked to rejoin, but that it should be their request.

Tim thanked everyone for coming on short notice and told everyone to have a happy
Valentines Day. Now that he understood what was happening, he was not as unhappy as he was.

Help in Diabetes Management Education – Part 12

Part 12 of 12

This will conclude the blogs in this series. One factor in diabetes management that is often overlooked by people helping others and especially certified diabetes educators (CDEs) is the proper assessment of the person you are trying to help. Most CDEs omit this altogether or if speaking to a group will only assess to the lowest common denominator. When I wrote this blog, it was done with a little tongue-in-cheek, but does fit this discussion.

We, as people with type 2 diabetes, are often better equipped to relate to other people with type 2 diabetes. No, we do not have the training that the CDEs have, but we have our experience to rely on and are not afraid to ask questions. We are finding out that some in our support group and a few that have left want secrecy. Those of us that have been in the group since the beginning, have no time for this and we want people to help us and for us to be able to help others. This is one reason that most of us are happy to have Brenda as part of our group and the rest respect her.

We are attempting to help the new members and this has turned into a challenge for those of us that have been with the group for the longest. Even Sue's husband, Bob, is asking why they are not listening to us and trying to manage diabetes and their health more effectively.

In some email exchanges, we are asking ourselves what we are doing wrong. Are we missing some clues? Do we not understand what they are feeling? We are all trying to reassess them and figure out why we are being ignored. We have a good feeling about some of them and we are concerned about the rest. We are thankful for Jerry and James as they are listening and learning. Even James's wife Jill has become a great support for him and another of our new members.

We are dividing the older members into groups of three to approach those that are not as open about their diabetes to see what we can do to help them. Barry, Ben, and Allen are asking to work with those that are veterans and we have agreed, but will help if needed. Allen has agreed to let Brenda take his place for the three women veterans. Sue and her husband Bob will work with the other two women with Jason.

Tim and I are available to anyone needing help and will support other members that feel the need. We are not sure where this is going, but all have stated that we must find out those that want secrecy and those that are willing to learn. We have decided to take our time and assess and reassess to help us find a common basis for an open dialogue and overcome the secrecy within the group.

Tim did receive one phone call after we started, telling Tim he would not stay in the group and some of the questions we were asking were none of our business. He did listen to Tim when he explained that we are a caring support group and may be taking some things too far, but we don't believe we are being nosy. The fellow said he did not feel we were being nosy, he just did not feel we needed to know the information. Tim did let him go with the understanding that if he could accept us in the future, we would be willing to reconsider him for membership again.

Help in Diabetes Management Education – Part 11

Part 11 of 12

Traveling with type 2 diabetes will depend on the medication(s) you are taking. I would advise having a letter from your doctor on the doctor's letterhead about the fact that you are a person with type two diabetes and are taking the medication(s) that you are prescribed. If you are on insulin, this should also be stated and that you are using insulin pens or vials and syringes.

I did this for several trips overseas and had no problems except for a slight delay while they located a translator for English. I had my medications in the original container with the prescription label on them and these were accepted with no questions. One of the TSA employees in the USA made a point of looking at each vial of insulin and each medication. The rest of the times, all they needed was a look at the doctor's letter.

How do you handle sick days? Many people refuse to say they have diabetes and can be fired for unexplained sick days if they do not have a doctor's letter explaining the reason for an absence. Then, if they find out you have lied on your application, you also risk losing your job. Developing diabetes while working for a company can also create problems, but not as serious.

Wellness campaigns by many companies today will also disclose your diabetes. Therefore, I think it is wise to have a talk with the human resource department and be honest with them. They may respect you more as an employee and even be willing to move you out of jobs that are more hazardous if you develop neuropathy. Not all companies do this, but more are learning. Some companies are only concerned that you show up for work and can perform your job. In small companies, there may be even more latitude in what they allow. If you have allowed sick days, or paid sick days, use them wisely and don't abuse the system.

Problem solving skills is part of daily life and diabetes makes them more important. I had one individual with diabetes laugh at me when I said this and could not believe that daily living required problem solving skills. I just said you had someone side swipe your auto and it was going too fast for you to get a license number, what do you do. He said just call my insurance agent and if the car is driveable, I will go to the repair shop. I said you failed.

First, you call the police to report a hit and run. You should have them check for evidence of paint and file a report. Then you request a copy of the report for the insurance company. Then you may call your agent and do what he directs you to do.

With diabetes, this means that if you can't solve the problem by observation, you look at the logs you keep and try to analyze what needs to be done. Then if you are unable to solve the problem, decide how serious the problem is at the moment and whether you should call your doctor, drive to the hospital, or call an ambulance. All cost different money and this may affect your decision as will whether this is a true emergency or a perceived emergency. Or it may be as simple as doing some additional exercise and eating a little less at the next meal. But problem solving it is and your skills should improve as you gain experience, ask questions of your doctor, and talk to other people with type 2 diabetes.

Help in Diabetes Management Education – Part 10

Part 10 of 12

Goals and how to set them is up to you. Beware of doctors that set the goals for you and will not discuss the reasons or why they are what they are. These paternalistic doctors need to be in control, but do not want you in charge of anything. Never mind that you only see them at most about one hour per year. If you don't make their goals, be prepared for a tongue-lashing. If you want to find out how bad they are, tell them that your goals are different short-term and you will consider their goals long-term. Be prepared to be told to find another doctor.

No, a doctor should suggest goals and give you the reasons, but if you have other ideas, they should listen. If they feel you are not setting the correct goal, they may encourage you to try for a different goal. This means that they are trying to help you, and will listen to you. Suggestions are always appropriate from doctors, until they know you and how hard you work or don't work to attain goals.

I have supplied you with reading to help you set your own goals in the last nine blogs.

Depending on the progress of your diabetes at the time of diagnosis, you might want to consider a goal of getting off medication. This will depend on many factors; the first is whether you have a doctor that will accept this. Second, you will need a plan of action that your doctor approves. Then you will need a food plan that will help keep your blood glucose levels in acceptable range.

Next, make sure that you have an exercise regimen that you will enjoy and are capable of accomplishing. Many fail when it comes to the last two items. You will need to keep testing and seeing the doctor for appointments. The next thing will be whether you are succeeding or having problems. Testing will let you know as will the A1c that the doctor sees. The important thing to realize is if you are having trouble keep your blood glucose levels down that you don't stay off medication for too long.

One of our new members tried three times before giving up when his blood glucose levels kept rising each time. The third time his doctor told him not to try again until he had kept his blood glucose levels below a set level for at least six months on medication and then for another six months at a lower level of medication. His doctor is supporting him and this makes him want to keep trying until he knows it is no longer possible.

Besides goals, people need to understand that as they age, their bodies can stop being efficient enough in obtaining the vitamins and minerals necessary for health from many foods. Most of the time the correct foods will supply everything you need.

People that are on metformin need to be concerned that they are not becoming deficient in vitamin B12. Folic acid (vitamin B9), especially when taken in high doses, can mask the symptoms of a vitamin B12 deficiency. Older and even a few middle age people with type 2 diabetes can become unable to absorb or manufacture vitamin B12 from animal foods. Vitamin B12 is found only in animal foods. Liver, sardines, and salmon rank highest, with liver running away with it. Kidney, eggs, beef, and pork are also good sources. There are no vegetarian sources.

If you develop neuropathy – a tingling or burning in your feet, and especially the toes may indicate that you may have a vitamin B12 deficiency. The quicker you have the test the more likely you will be able to prevent the neuropathy from spreading. Some of our members have had vitamin B12 shots and then prescribed a supplement and a few others have been told to start a vitamin B12 supplement.

The final bit of information on this is your blood glucose levels need to be managed to keep them below 140 mg/dl. With about 60 percent of the people with diabetes developing neuropathy, this tells us that many people are not managing diabetes and may vitamin B12 deficient.