Learn Prediabetes Is Not Diabetes

Since 2003, when the American Diabetes Association (ADA) convened a group of “experts” to declare the blood glucose levels between 100 and 125 mg/dl (3.9 to 6.9 mmol/L) as prediabetes, all people were aware of was that diabetes started at 126 mg/dl (7.0 mmol/L).  This classification applies only to type 2 diabetes.

Since then the ADA has done little to encourage doctors to screen for prediabetes.  A few doctors have been screening for prediabetes and doing an excellent job at this, but the bulk of people with prediabetes are still unaware they even have this.  The ADA, for all their “expert” knowledge, has done little in the way of education or helping the people that might have prediabetes become aware of what might happen if they do nothing to prevent the onset of full type 2 diabetes.  

Receiving a diagnosis of prediabetes is a serious wake-up event.  It does not necessarily mean that type 2 diabetes is a foregone conclusion.  There are changes that you can make to slow the progression to diabetes and for some people to prevent diabetes.  The following are some suggestions to consider:

Develop an exercise regimen you enjoy.  Doing this is one of the best things you can do to make diabetes less likely.  If it has been a while since you exercised or you are medically able, start by building more activity into your routine by taking the stairs or doing some stretching during TV commercials.  Physical activity is an essential part of the treatment plan for prediabetes, because it lowers blood glucose levels and decreases body fat.  Check with your doctor to see if you have limitations.

Lower your weight if this is needed.  If you're overweight, you might not have to lose as much as you think to make a difference.  In one study, people who had prediabetes and lost 5% to 7% of their body weight (just 10-14 pounds in someone who weights 200 pounds) cut their chances of getting diabetes by 58%.

See your doctor more often if possible.  It is recommended to see your doctor every three to six months.  If you're doing well, you may get positive reinforcement from your doctor.  If it's not going so well, your doctor can help you get back on track.  If you are like me, you will appreciate words of encouragement, and even words needed to put you back on the right path.

Develop a good food plan that your meter approves.  Load up on vegetables, especially the less-starchy kinds such as spinach, broccoli, carrots, and green beans.  Aim for at least three servings a day.  Add more high-fiber foods into your day.  Enjoy fruits in moderation - 1 to 3 servings per day. Eliminate whole-grain foods as much as possible and do eliminate processed grains.  In general, eliminate white rice from your food plan.

Also, swap out high-calorie drinks.  Drink whole milk rather than skim milk and diet soda rather than regular soda.  Choose cheese, yogurt, and low carb salad dressings. Choose fresh fruit when it is available and not fruit juice.

Make sleep a priority and sleep the suggested hours when possible.  Not getting enough sleep regularly makes losing weight more difficult.  A sleep shortfall also makes it harder for your body to use insulin effectively and may make prediabetes and diabetes more difficult to manage.  Set good sleep habits.  Go to bed and wake up at the same time every day. Relax before you turn out the lights.  Don't watch TV or use your computer or smartphone when you're trying to fall asleep.  Avoid caffeine after lunch if you have trouble sleeping.

Get support and ask for help when needed.  Losing weight, eating a healthy diet, and exercising regularly is easier if you have people helping you out, holding you accountable, and cheering you on.  Consider joining a group where you can pursue a healthier lifestyle in the company of others with similar goals.  The right diabetes educator and nutritionist may also help you learn about what you need to do to prevent your prediabetes from becoming diabetes.  Sometimes this will be a doctor, a nurse, or just a friend.

Choose and commit to the task of managing your diabetes.  Having the right mind-set and a positive attitude can help.  Learn to accept that you won’t do things perfectly every day, but pledge to do your best most of the time.  Make a conscious choice to be consistent as possible with everyday activities that are in the best interest of your health.  Learn to tell yourself, I’m going to give it my best.  I’m going to make small changes over time that will become good habits.  These changes will add up over time and help you manage your prediabetes or diabetes if it progresses that far.

Sleep Apnea May Cause Blood Pressure Increase

I am finding some consistency in articles about sleep apnea and how it affects other diseases or conditions the patient may have. A new meta-analysis conducted by an international team of sleep and respiratory researchers suggests that untreated sleep apnea may be a major factor in causing medications to be less effective in reducing hypertension (high blood pressure) in some people.

In reading the entire article, there are several things mentioned that makes this meta-analysis more valuable. These include:

1. Using continuous positive airway pressure (CPAP) therapy may be a key to helping people with hard to treat hypertension.
2. Most people with resistant hypertension also have obstructive sleep apnea (OSA).
3. OSA and resistant hypertension is a deadly combination that exponentially increases the risk of death or disability from a stroke or heart attack.
4. The study indicated that the patients with resistant hypertension and the very highest blood pressure experienced the greatest reduction in blood pressure after using CPAP therapy
5. This response suggests that untreated sleep apnea may be why these people haven’t seen improvement in their blood pressure despite the concurrent use of three or four medications.

Ulysses Magalang, MD, the study’s principal investigator and director of the Sleep Disorders Center at The Ohio State University Wexner Medical Center and co-author Christopher Valentine, MD, a nephrologist at Ohio State’s Wexner Medical Center both say that these findings suggest that physicians may need to be more aggressive with screening for sleep apnea and ensuring CPAP therapy compliance in patients with resistant hypertension.

Dr. Valentine did say, “That there is evidence about the benefits of CPAP in people with hypertension and OSA, but ours is the first analysis to systematically review CPAP use in people with difficult to treat hypertension and apnea.” He continued, “The results are clinically relevant because the effects that we found are significantly higher than what’s been previously observed in a more general hypertensive population. CPAP use could offer this subset of patients a new chance to reach a healthier blood pressure goal, or even to reduce their medication burden.”

Drs. Magalang and Valentine say that their findings also support the idea that resistant hypertension and OSA represent an “extreme phenotype” of those who have OSA, but never develop hypertension. The researchers further suggest that resistant hypertension in those with sleep apnea may be caused by a less common gene variant that nonetheless has significant impact.

It’s a hypothesis that will likely be put to the test over the next decade. The researchers who collaborated on the paper all belong to the Sleep Apnea Genetics International Consortium (SAGIC), a partnership of scientists from five continents who are building the first-ever international biomedical database to uncover the genetic causes of sleep apnea. By collecting biological material from thousands of patients with sleep disorders, the group hopes to amass enough data to start identifying underlying genetic causes of different conditions.

“We’re only just now beginning to appreciate the link between sleep apnea and disease,” said Magalang. “We hope that one day we will find common genes shared between people who have uncontrollable blood pressure and sleep apnea, and that will open up a whole new world of interventions and treatment strategies.”

HbA1c Test May Not Be Applicable in Some Cases

This article shows why the American Diabetes Organization may be in the minority and not in the forefront of diabetes diagnosis. It raises some valid concerns and reasons not to rely on the gold standard American doctors are relying on for diagnosing type 2 diabetes.

New research published in Diabetologia (the journal of the European Association for the Study of Diabetes) highlights how anemia--a common condition in the general population, especially in women--can lead to a false diagnosis of diabetes based on HbA1c, when a person's blood sugar control is actually normal. The research is by Dr Emma English, University of Nottingham, UK, and colleagues.

In recent years, the World Health Organization (WHO) and the American Diabetes Association (ADA) have both pushed and advocated the use of the HbA1c for diagnosing type 2 diabetes. Following the recommendations of the WHO to use HbA1c as the diagnostic method for type 2 diabetes, the United Kingdom (UK) has issued expert guidance that one of the major issues affecting this usage was anemia.

With approximately 29% of non-pregnant women worldwide having anemia (the latest estimate from 2011), this translates to a significant number of people where the use of HbA1c for diagnosis of diabetes is unsuitable. The latest WHO estimate for anemia prevalence in men was 13%, likely to be higher in elderly men, although data are scarce.

I have several other blogs about the ineffectiveness of the HbA1c for diagnosis. That being said, generally, the HbA1c is effective for white Anglo-Saxon adults with the following exceptions:

1. The HbA1c should never be considered for anyone undergoing dialysis – read my blog here.
2. The HbA1c cannot be used for people with iron-deficiency anemia.
3. The HbA1c has been shown by this study that it is unreliable for diagnosis of diabetes in children – see my blog here.

There is also much doubt about many other ethnicities not relying on the HbA1c as some significant variances have been proven. Some in the medical profession are openly stating that the A1C test needs to be standardized for each ethnic group

The review of research between 1990 and 2014 included studies which had at least one measurement of HbA1c and glucose, and at least one index of anemia involving non-pregnant adults not diagnosed with diabetes. The authors identified 12 studies suitable for inclusion, the majority of which focused on iron deficiency anemia and, in general, demonstrated that the presence of iron deficiency with or without anemia led to an increase in HbA1c values compared with controls, with no corresponding rise in blood glucose, thus rendering any diagnosis of diabetes in such individuals unreliable without further tests.

“Calling for more research in view of the relatively small number of studies they were able to include in their review, the authors conclude: "The key questions that are still to be answered are whether anemia and red blood cell abnormalities will have a significant impact on the diagnosis of diabetes using HbA1c in the general population--something that is now widely performed."”

Until the ADA realizes these deficiencies in the HbA1c, some people will be diagnosed with type 2 diabetes that do not have diabetes. Others will not be diagnosed when in fact they may have type 2 diabetes. The ADA belief that one-size-fits-all approach to diabetes may someday be a liability that the ADA can no longer afford.

Are You Using Your CPAP?

I wish the people who title some of these articles could use the correct terms. I had to cringe when I read this - "Are You Wearing Your CPAP?" To begin with, it is impossible to wear a CPAP machine and that is the reason for my title. Yes, if you have obstructive sleep apnea, you should use a type of CPAP, but you will only wear the mask.

The article in Diabetes in Control is a good reminder of what can happen when people do not use the CPAP equipment. In addition to elevated blood glucose levels, the person's hypertension was also worse and he was gaining weight. The patient was complaining about exhaustion, but eating right and taking his medications.

The office did not make any medication changes, but encouraged the patient to resume using his CPAP at night, and monitor. They established remote patient monitoring, and in the following week saw the blood pressure and glucose levels return to his targets. In addition, the weight started to drop. When contacted at the end of the week, the patient declared that after using the CPAP for one night, his energy was better and he thanked the office.

What lessons can be learned from this? For the patient:

• Assess your sleep habits.
• Respect sleep apnea as an underlying cause of increased blood pressure, glucose, weight, and more.
• Have yourself screened for sleep apnea, and referred to sleep labs/sleep specialists if you suspect a sleep issue.

For the patient's provider:

• If you know your patient has sleep apnea, ask the simple question, "Are you using your CPAP machine?"
• If your patient is not using his/her CPAP, ask why. Sometimes the answer is simple, and a simple solution can turn things around. Sometimes it is because it is uncomfortable. If uncomfortable, encourage your patient to contact their sleep medicine team to help recommend a device that is more comfortable.
• Follow up with your patients to make sure they use the recommended treatment. If they aren't using the recommended treatment, find out why, and help problem solve.

I can say from experience that using my CPAP machine makes my diabetes and blood pressure (hypertension) easier to manage. While my weight loss is not as rapid as I would like, using my CPAP is helping me avoid weight gain.

Who Will Take Care of Us As We Age?

Yes, the baby boomer generation is here and the American Geriatrics Society (AGS) is starting to take notice. Where will we find the workforce to care for the aging population? Most doctors are not prepared, and this will leave a large portion of the care to retired doctors that don't want to work. I presently know two doctors that have reentered the medical community to help care for their elderly friends and others of the elderly.

Have they had the training? No! Like one of them says, but neither does the rest of the medical community in this area. He continued that many in today's medical profession do not want the elderly patients. He said that he found this out shortly after he retired and could not find a doctor to treat him. In the past, young doctors took good care of the older doctors, retired or not. Today, the young doctors are not interested and only want younger patients.

The author of this blog says, “Most residency education in the US is funded through Medicare. Given Medicare’s charge is primarily to care for adults over 65, you would think that Medicare would emphasize training physicians to meet the needs of an aging population. Yet the statement that sticks with me from AGS is this: “10,000 new beneficiaries enroll in Medicare every day, yet we lose 5 geriatricians every week.””

The author, Paul Tatum, goes on to say, “Moreover, the additional trends in geriatric education actually point to less support for training physicians to care for older adults. The Reynolds Foundation, which has been a tremendous supporter, is a foundation designed to spend down its assets and will soon no longer be a source for innovative grants to improve delivery of care to older adults. Likewise, the main grant for training geriatrics clinician educators, the Geriatric Academic Career Award, will not be funded by the Health Research Services Administration this year. How will we create the clinicians that we need for our future without support for the educators who will teach them?

The National GPS Corps (National Geriatrics and Palliative Service Corps) should consist of three elements:

1. To promote geriatric or palliative care training, all residents who complete a geriatric or palliative care fellowship shall have half of their student loan burden relieved through federal debt forgiveness or payment to private lenders. Crushing student debt is a key factor driving trainees to higher paid specialties and this will make geriatric and palliative care training more feasible. 
2. To promote excellent geriatric and palliative care academicians, those who opt for a second year of additional academic or research training will have all subsequent student loans forgiven or paid.
3. To promote clinicians practicing in geriatrics and palliative care rather than further specialty training and to allow for appropriate geographic distribution across the country, those who only complete one year of fellowship will be eligible for further debt forgiveness after completion of a three or five year clinical commitment in a designated geriatrics/palliative care service area.

I agree that teachers must be created to train the workforce needed to care for the elderly. Congress needs to act now to meet this need.

My Thoughts Over the Last Few Weeks

The last few weeks have been worrisome for me and most of the members of our diabetes support group. We have had meetings almost every day and often using the phone, or computers using Skype. We have had disruption after disruption to our daily activities and we don't know when it will end. After last Friday, 23 of our members are very upset and angry at the person causing the disruptions. Not a pleasant way to spend Memorial weekend.

I may vent some, so you will have to leave this page or follow with me. I need to write about several of the articles I have read about research in the last few months. Granted many of the studies are using 18 to 24 participants and the length of the studies is less than three months (most only one month) and contain many premises without factual data. Even two of the studies that I received the full copy of are not reliable in my estimation.

The blog from yesterday (go back and read it if necessary) is important for many reasons and shows that not everyone follows the big two from this blog written on July 12, 2013. These two big Pharma supporters are recommending harm to those of us with diabetes. In addition to advocating the stacking of oral medication on top of oral medication, they don't wish us to learn self-monitoring of blood glucose or even to learn how to test.

It seems that many doctors follow the ADA and AACE advice and don't realize the harm they are doing to patients. To be able to manage diabetes and avoid the complications of diabetes, we cannot follow the orders of these doctors. I don't care whether you are managing your diabetes without medications or using insulin. You need to know how the different foods and food combinations affect your blood glucose levels. This will give you information about which carbohydrates to limit or remove from your food plan.

Granted, once you have determined how the different carbohydrates affect your blood glucose levels, often you may be able to reduce the number of times you need to test. It is still wise to test before and after several meals to check when trends are moving upward. Yes, it is easy to become lax and miscount the carbohydrates you are consuming. Been there, done that, and it is a rude awakening when it happens. This makes a person feel very small and look for a place to hide while also wanting to have

a big punching bag available.

Back to the first paragraph. This has caused several of our members to have some blood glucose problems and we are working with each other to limit the excursions into hyperglycemia. Our resources are doing everything possible to stop further disruptions to our lives, but still we don't know when this will end. The person is now after each of us as individuals and this is what has everyone upset.

More on this when we are allowed to say anything in a public way.

Access to Test Strips Linked to Mortality Rates

This is a shock, but makes common sense. The title used is, “Access to Glucose Monitoring Supplies Linked to Mortality Rates.” Yes, those that can obtain sufficient test strips live longer. This is another reason for taking every advantage possible even if the Centers for Medicare and Medicaid Services (CMS) and the Veterans Administration (VA) don't like it as shown in my blog here.

Even the American Diabetes Association and the American Association of Clinical Endocrinologists (AACE) don't think people with type 2 diabetes need to test and want us to rely on the A1C two or four times a year. That is why this was such a shock to have this come out during the AACE meeting in Nashville, TN during the 24th Annual Scientific & Clinical Congress.

The researchers conducted an analysis of the importance of Medicare patients with diabetes having the proper supply of blood glucose monitoring tools (test strips). They found higher death rates among patients who received fewer supplies than the prior year. Then found lower death rates among patients who received more supplies than the year prior.

Study author Jaime Davidson, MD, who is the President of Endocrine and Diabetes Associates of Texas and is also a clinical professor of medicine at the University of Texas Southwestern Medical School in Dallas stated that safeguards must be put in place to monitor changes in the acquisition and to ensure patient lives are not being put at risk.

Davidson and his colleagues investigated the potential disruption of patent access to blood glucose monitoring supplies and its impact on health outcome after the recent implementation of the CMS competitive bidding program. Then the researchers assessed to impact of full acquisition of blood glucose testing supplies compared with partial acquisition on death among insulin-treated Medicare patients. The researchers defined full self-monitoring blood glucose (SMBG) acquisition as greater than 80 test strips covered, based on three test strips used per day.

The researchers found that 71.1% of the beneficiaries were treated with rapid-acting insulin, including analog pre-mix, and 20.4% with rapid-acting and long-acting insulin, including analog, recombinant human pre-mix. They reported that 4-year survival was negatively associated with partial or no SMBG acquisition in both groups.

The mortality rates were higher among beneficiaries with full SMBG acquisition in

2010 who migrated to partial SMBG acquisition or no SMBG record the next year compared with maintaining full SMBG acquisition.

However, the mortality rates were lower among beneficiaries with partial SMBG acquisition or no SMBG record in 2010 but migrated to full SMBG acquisition the next year, according to the researchers.

Davidson stated, “As a physician, I'm concerned that CMS did not report any changes in acquisition of SMBG supplies in their initial report of the competitive bidding program. We're continuing to look at the data to understand more about the full impact, but at this stage, given that acquisition of blood glucose monitoring supplies is indicative of actual blood glucose monitoring, anything that disrupts acquisition has a very strong potential to impact patient safety.”

Medical Care of Older Diabetes Patients

I am glad that someone else is writing about this. And she is right, older patients with diabetes are not receiving adequate medical care. Doctors are so busy spending more time looking at the computer, checking off “something” and not really listening to what the patients are saying. Older patients repeatedly expressed frustration at the lack of time they spend with their doctor and feel they are not being heard.

Now not all doctors are doing this, I know, as some of my doctors are using recording devices and either having someone enter the information later or are doing this themselves later.

Recent standards for treatment of older patients with diabetes include more flexibility in setting goals for this population, including current health status (comorbid conditions) and expected lifespan. Due to the many pathways to help monitor and control diabetes, along with the variable and ever changing goals, more individualized time is required to assess and set a disease management course during the patient’s visit to their health care provider. This one on one time, in reality, is shrinking.

I am fortunate to have doctors and nurse practitioners that are helping me along the way. I have left the Diabetes Clinic that served me well until I reached 70 years of age and then they kept telling me to let my A1c rise to 7.0% to 7.5%. Then in a fortunate move, the local Veterans Clinic added a Clinical Pharmacist specializing in diabetes that encourages me to manage my diabetes to the best of my abilities.

I can say that I do not agree with the author when she writes, “We as diabetes educators have such an important job. We can have a huge impact on the lives of the older person with diabetes and help to achieve the 2020 healthy goals for Americans which includes: “Reduce the disease and economic burden of diabetes mellitus (DM) and improve the quality of life for all persons who have, or are at risk for, DM””. This could true if most certified diabetes educators did not teach to a one-size-fits-all mantra. Plus most CDEs do not and will not work with type 2 diabetes people, especially the elderly.

Then with the lack of clinical evidence from trials that confirm treatment therapies for the elderly, those of us over the age of 65 have nothing to compare to for determining whether we are even being treated properly.

The last AACE conference heard of a trial promoting oral medications over insulin in a very small study of only 18 individuals under the age of 60 when oral medications were effective in lowering A1Cs effectively for people starting at 9.0% or higher. Many had stacked oral medications and lost weight as a result. The presenter emphasized that this was better than insulin which often caused weight gain. This only happens when endocrinologists do not advise patients to reduce the quantity of carbohydrates consumed and to find an exercise regimen they can follow.

Since the study did not include people over 65, we don't know if people with other conditions such as kidney problems and heart disease will be able to tolerate this therapy. Yet many doctors will force this therapy on the elderly because it worked for younger patients. This is just another case of elderly discrimination.