Is Diabetes Perfection Possible?

This is why I read other bloggers. Every once in a while, an idea by another blogger speaks to me in ways that I was not prepared for and gives me an idea for a blog of my own. Ashley who writes at Bittersweet Diagnosis covers the topic of diabetes perfection because she was terrified of the complications. When she realized that striving for perfect blood glucose levels 24-7 is not realistic or sustainable, she realized that diabetes has taught her that diabetes shouldn’t hold you back from living your life.

We can all do our best to minimize the wild swings in blood glucose levels and we should do this, but to obsess about the levels is not good and generates stress which harms our management. I am learning that by getting the sleep my body needs and minimizing the stress in my life, my blood glucose levels are coming more into the range that pleases me.

Then by converting my food plan more to a low carb/high fat plan, I am starting to lose weight and my insulin needs are becoming less. Nothing significantly less yet, but I am seeing a change for the better.

Am I telling you how many grams of carbohydrates you should eat? No, I am not, as each person needs to use their blood glucose meter to test before and after meals (called testing in pairs) to discover for yourself the level you need to consume. I suggest starting at 100 grams total carbohydrates for the day - I suggest about equal carbohydrate grams per meal. Then by testing, you should adjust this up or down based on the testing results.

Why am I suggesting this? I know that until your body becomes comfortable with the number of carbohydrates, you will feel hungry, especially if you do not increase the amount of fat you consume. I know from experience that many doctors are still promoting low fat and some become very upset when patients increase the amount of fat consumed. That folks is why the food plan is named low carb/high fat (LCHF). Do keep the amount of protein at the level it has been and do not increase, especially if kidney problems exist.

Then over a period of a month, gradually adjust the grams of carbohydrates down or possibly up depending on what your meter is telling you. This from my blog on Sept 17 will explain, “eating to your meter” and this from the same blog will help further explain LCHF.

Because everyone is different, you cannot count on following what someone else has for numbers. Therefore, you must find what works for you, as this is the closest to diabetes perfection you will come. Just because someone else can obtain better or more consistent blood glucose numbers, you should not try to copy them as you may be able to better their numbers or maybe not obtain as good a set of numbers.

Forget about the perfection someone else obtains and work for your own perfection. It is often much easier to meet your own goals than another persons goals.  Remember that you are unique and must find what works for your body.

Communication Loses by Physicians

Several members of our support have changed doctors this summer, but most are still not happy with the current ones. Allen has had the most trouble, as none of his two new doctors believe he could have an A1c of 5.0 percent. He has been accused of having two or more meters and his last doctor asked him if he is on dialysis or has had a blood transfusion recently.

In both cases, Allen has explained that he is eating very low carb and high fat and both doctors won't believe him. Now he is planning to see Dr. Tom, as he is tired of not being believed. Now both Ben and Barry are changing doctors because they both had A1cs below 5.6 percent and their doctor would not accept that they could be that low. When both said, they were using low carb and high fat food plans, the doctor told them that they needed to get away from the high fat and go with a low fat plan. When both said they were having good lipid panels and were feeling great, the doctor told them that he was prescribing a statin anyhow.

Barry said he would not take a statin and the doctor could learn the advantage of high fat or they would be finding a new doctor. Ben says the doctor was most uncooperative and they are looking for a new doctor.

Jerry said he is happy that he is now under 6.0 percent and with his foot ulcers now healed, he has the proper footwear and is feeling the best in a long time. Even James is happy and had his wife tell us that his last A1c was 5.8 percent. He did say that he and Jill are both moving to lower carb and higher fat meals and he is hoping to bring his A1c down.

Even Sue is sputtering about her doctor wanting her to go back on medications. Her last A1c was 5.4 percent and while it was up, she felt that medication was not what she needed.

The group of us were talking about the doctors and why they seem to want to bully those of us that are older and think they can get away with doing this. None of us present were happy with communications by our doctors and felt that doctors are not keeping up with the needs of people with diabetes.

As we were getting ready to leave, Dr. Tom came in with his family. After they had seats, Dr. Tom came over and asked us how we were doing. Allen told him we had a bad taste from doctors at the moment, but it was not him, just that we felt doctors were trying to bully us and several of the group were upset that their doctors were pushing high carb and low fat. Allen then asked if he could become a patient of his. Barry and Ben said the same would apply to them. Dr. Tom said to call his office on Monday or stop by and get the necessary papers to have their files transferred.

With that, we left and wished his family well as we passed their table.

Just Diagnosed with Type 2 Diabetes?

When you received your diagnosis, how was it done? Did the doctor just state it as a matter of fact or was there a lot of other meaningless information that you were given. Some doctors do it right, but most can't say the word diabetes. Why – I don't have a clue. These same doctors use technical gibberish to mask the true word for any disease.

When you realized that you had type 2 diabetes, what did you do? Did you leave the panic panel intact, or did you punch holes in it and tear it apart? Some really damage the panic panel and others never even see it. They move from the diagnosis to managing their diabetes. Maybe later they have denial or mild depression, but at the start they are into managing diabetes and learning all they can about this chronic invisible disease. Shock or anger never enters their thoughts.

Other people feel shell-shocked after the diagnosis of diabetes. This is a perfectly normal reaction to news that has just turned your life upside down. Not only do you have this distressing new burden added to your life, you have to figure out how to deal with it.

Most of the newly diagnosed are starting from scratch and lack of knowledge about diabetes. Some writers advise relying on your doctor for information on diet, exercise, and medications. What many doctors refuse to recognize is that the day of diagnosis is not the day to give out a lot of verbal information. Too many doctors use this as the day to abuse their patients and accuse them of causing their diabetes. Then they set unreasonable goals for their patients and tell them not to fail in achieving these goals.

Many patients try and when they can't achieve the doctor's goals, completely give up and let diabetes take over their lives. This is how doctors make diabetes progressive and the complications become a reality.

This is one reason I always say to not accept the goals that a doctor says you must attain. I would urge you to tell the doctor you want to learn about diabetes, but you will discuss goals at the next appointment. Good doctors will accept this and maybe suggest alternate goals that may be attainable. I would urge everyone to learn about goals and how best to meet them. Always make small improvements to your goals that are easy to attain and this will help you be successful. Success always encourages more success,

The important point to remember is this – the diabetes is your diabetes. Learn to accept this and managing diabetes can become much easier. As you learn about diabetes, you need to remember you are unique and what works for someone else may not work for you. In type 2 diabetes, there is definitely not a one-size-fits-all therapy and finding your custom fit for your type 2 diabetes will be your main task over the first several months.

Like anything we do for the first time, we start out as novices. This means that it takes time to get comfortable in our knowledge. Yes, you are trying to learn rapidly and become an expert based on your circumstances. Others may have greater medical knowledge of your condition, but you will have a fine-tuned, hard-won intimate knowledge of your unique version of type 2 diabetes.

Glycemic Diabetes Management

The American Association of Diabetes Educators has completed their annual meeting. It is not a surprise that most of the topics were about and for those with type 1 diabetes. After the ADA and the joint statement about education for all people with diabetes, I expected more topics for type 2 diabetes, but this did not happen. Yes, they can say that this topic was for all people with diabetes as they did include insulin and about 20 percent of people with type 2 diabetes do use insulin.

While educating hospital staffs about hyperglycemia is important, unless there is education about the use of oral medications, many with type 2 diabetes will continue be left out in the cold and receive little help when hospitalized.

This statement by the speaker Jane Jeffrie Seley, BC-ADM, CDE, CDTC, of New York-Presbyterian/Weill Cornell Medical Center leaves me wondering. “Inpatient glycemic management is best accomplished through interdisciplinary collaboration with physicians, NPs, PAs, RNs, RDs, diabetes educators and pharmacists. Errors can be greatly reduced by implementing system changes that make it easier to do the right thing. One example is auto-calculating the basal insulin dose based on weight and expected sensitivity to insulin instead of requiring prescribers to do the math.”

Best practices for improving inpatient glycemic control have been identified. There are many barriers to implementing them, Seley said. The biggest obstacle to coordinating and implementing successful strategies is the need for ongoing staff education. Successful strategies also involve policy changes, infrastructure adaptations and culture change. None of these will be effective until the hospital administrators and the hospital board of directors adopt them and make this known to those at all levels.

Many institutions across the United States have successfully launched glycemic control programs to improve inpatient insulin safety. One approach that appears to be highly effective is computerized order sets. This approach auto-populates the most recent weight gain into a dosing algorithm that gives a safe yet effective recommendation. This weight-based dosing can significantly reduce insulin dosing errors. Basal and bolus insulins are also listed in separate sections to avoid mixing up insulin types.

“Electronic medical record systems (EMRs) such as Sunrise and Epic have the capability to develop comprehensive insulin order sets and decision support tools such as a medical logic memory to remind prescribers to order basal insulin when a patient with type 1 diabetes is switched from prandial insulin to NPO status,” Seley told Endocrinology Advisor.

Currently, many hospitals still do not have comprehensive diabetes management programs in place. By having the AADE emphasize everything for type 1 diabetes patients, those patients with type 2 diabetes will continue to take a back seat in hospital diabetes management.

This means that type 2 diabetes patients will continue to need to champion their own cause and they will need to work harder to get what they need in diabetes management when they are in the hospital.

The other problem facing those with type 2 diabetes will be using insulin when they are in the hospital as most hospitals convert every patient to insulin use when they are an inpatient in the hospital. When it comes to food plans, type 2 patients will need to avoid asking for diabetes menus because the dietitians will overload the meals with carbohydrates instead of serving a meal that could be lower in carbohydrates.

Tips to Manage Blood Glucose on Insulin

Do you use insulin to manage your diabetes? How do I occasionally manage swings in my blood glucose levels? What can I do if my high blood glucose levels won't go down while using insulin? These are common questions I receive in emails.

First, I have to ask some questions. I ask if they have had classes given by a CDE/RD. What did they tell you about the food plan you should follow? I also ask if they need to lose weight that they have recently gained. This generally elicits the following answers – yes, they have had classes and they were advised to consume whole grains and eat between 45 and 70 grams of carbohydrates per meal. Many tell me they were overweight to start, are gaining more weight on insulin, and have not been able to lose any weight.

These answers tell me there are changes that need to be recommended. I always emphasize that diabetes is not their fault and ask if they are open to changing their food plan. I suggest that they avoid the whole grains and lower the amount of carbohydrates they consume. I suggest that they consider eating no more than 80 grams of carbohydrates per day and preferably only 60 grams with 20 grams for each meal.

I do tell people that for about two to three weeks, they may feel hungry, but after three weeks, this will often not be the case. This will vary by individual, some people can be hungry for two weeks, and some will take four weeks.

I do tell people that Dr. Bernstein recommends a lower carbohydrate food plan of 6-12-12, meaning six grams for breakfast, 12 grams for lunch, and 12 grams for dinner. I suggest that if they want to do this that they start out by lowering the number of carbohydrates over a period of about four weeks.

I warn these people to reduce the amount of insulin used as they reduce their carbohydrates. I do suggest that they immediately talk with their doctor about how fast they should reduce the amount of insulin, both basal (long acting) and rapid acting. I tell them that they want to do this to avoid hypoglycemia (lows).

I also warn then to be prepared to further reduce their insulin as their weight decreases, as insulin resistance can ease as well. I warn them that the doctor may want to take them off insulin and they should decide what they want.

If they are using oral medications, I give them the same advice and tell them that the amount of medication may need to be reduced and especially if they are taking a sulfonylurea.

I emphasize these three items, exercise, following a lower carb meal plan, and easing stress. I also tell them that if they cannot find a nutritionist that they trust, I will suggest one. Yes, I inform them that the person is a relative, but that they should find one that they trust and is not pushing carbohydrates. Find one that wants to work with them and balance the nutrition for a day, a week, and give them something to work with for the daily living.

Finally, I suggest that if anyone is pushing carbohydrates, they need to be careful and stay away from them. I tell them that it is not healthy to increase carbohydrates and expect to cover them with increased medication (oral or insulin). This will cause weight gain that will be difficult to lose. I do advise these people to stay away from low carb/low fat plans as this often causes weight gain, as the carbs are often not low.

Planning a Second October Meeting

This is becoming a very active October. Everyone seems to be worried about the newest members. They have been calling with many questions and are concerned about what they are being told by professionals with dual titles, CDEs and RDs. Both Tim and I have been in contact with Suzanne to schedule another meeting. She is busy and is not sure when she will have time. She suggested that maybe we should have Brenda's daughter talk to us.

Tim finally agreed and talked with Brenda and her daughter. She said she would do a presentation, but it would need to be on a Wednesday evening. Emails happened rapidly and all the newest members could meet on a Wednesday. A few of the rest had conflicts, but said to go ahead for helping the newest members.

Therefore, we are having a second meeting on October 21. Allison, Brenda's daughter, will talk about nutrition and how people can lower the number of carbohydrates they consume for improved blood glucose management.

Then another flurry of emails as Allison needed some information to help make the presentation relevant for the most people. When those that needed to answer had replied, Allison said that most everyone had the same interest and she would need to be prepared for low carb/high fat discussion and many of the questions were about acceptable fats. She put out a call for studies and discussions about high fat that she may not have seen.

The next day Allison asked us to stop. She said that most of us read the same articles and blogs and she felt that some were excellent, but for now, we could stop, as she understood what we were telling her. She also agreed with us about the high fat part and not the low fat that RDs insisted on teaching.

Allen and I asked to meet with Tim. We thanked him for getting Allison to talk to us. Then Allen told Tim that anytime we accepted new members, as we did in September, we needed to schedule Suzanne or Allison, and if Beverly had time, she should do something on education. I added this should be automatic because we always get questions and we need to prepare the new members for what they may encounter or have heard.

Tim said that he had thought about this, but thought we could have taught them. Allen said that we could have, but it sounds better coming from someone trained to teach and gives us easy reference for more authority. I said that even some of the members from the group Jerry brought in still have questions and it does not hurt to reinforce this. Allen did ask if we should consider dues to help pay for speakers. I stated we have avoid this so far, but we should talk to my cousins and listen to them. The only group that has dues is the group led by Greg and his wife.

Tim said I was right, but investigating this might be good for us. Then Tim thanked us for reminding him to have the lessons when we bring several new members into the group. He said that he had forgotten what happened to the group Jerry brought in and now the 14 members. Then he suggested we talk about bringing new members in during one month. Allen agreed, but said we also needed to consider limiting new members. I said we needed to discuss this at a meeting. Tim agreed and said he was thinking about this as well.

Even Doctors Complain about Polypharmacy

I suggest that you read this blog by Val Jones, MD. She tells the story of polypharmacy better than I can. The points she raises include:

• Patients are notorious for non-adherence
• Policy wonks say that more than half of patients do not take their medications as directed
• Missed opportunities to control chronic illnesses cost us billions of dollars and millions of quality life years annually

The reverse is just as serious:

• The costs of polypharmacy (over medication) is not known or discussed
• The unwanted side effects and medication interactions (both known and unknown) can be devastating
• An astonishing number of these incidents (falls and injury accidents) are related to drug side effects

Important factors to consider:

• There are costs to not taking medicines
• There are costs to taking medicines
• It is unknown how many injuries are accidentally prevented by patient non-adherence

This doctor considers it a victory each time she reduces the number of medications her patients use. What I like about this is she is not a geriatrician, but thinks like one. You should read her blogs on her website here.

HbA1c Test Important for Diabetes

The hemoglobin A1c test, also called HbA1c, glycated hemoglobin test, or glycohemoglobin, is an important blood test that shows how well your diabetes is being managed, or not being managed. Hemoglobin A1c provides an average of your blood glucose management over the past 4 months and is used along with home blood glucose monitoring to make adjustments in your diabetes medicines.

The past four months means the prior 120 days. Fifty percent of the prior 30 days is used for the A1c. Day 31 to 60 accounts for 25 percent and day 61 to 120 accounts for the remaining 25 percent of the A1c.

The A1c is important; however, many doctors only use the A1c and do not look at the records he asked you to keep. Some doctors even go one step further and do not suggest daily blood glucose testing. They follow the advice of Dr. Robert Ratner, chief scientific and medical officer of the American Diabetes Association, who says, “Many people with type 2 diabetes who are on medications don't need to do home glucose monitoring at all," in talking about oral medications.

Hemoglobin is found in red blood cells, which carry oxygen throughout your body. When your diabetes is not managed (meaning that your blood glucose level is too high), glucose builds up in your blood and combines with your hemoglobin, becoming "glycated." The average amount of glucose in your blood can be found by measuring your hemoglobin A1c level. If your glucose levels have been high over recent weeks, your hemoglobin A1c test will be higher.

For people without diabetes, the normal range for the hemoglobin A1c test is between 4% and 5.6%. Hemoglobin A1c levels between 5.7% and 6.4% indicate increased risk of diabetes (pre-diabetes range), and levels of 6.5% or higher indicate diabetes.

Because studies have repeatedly shown that poor diabetes management results in complications from the disease, the goal for people with diabetes is a hemoglobin A1c less than 6.5% (equals 140 mg/dl). The higher the hemoglobin A1c, the higher the risks of developing complications related to diabetes.

People with diabetes should have this test every 3 months to determine whether their blood sugars have reached the target level of control. Those who have their diabetes under good control may be able to wait longer between the blood tests, but experts recommend checking at least 2 times a year.

People with diseases affecting hemoglobin, such as anemia, may get abnormal results with this test. Other abnormalities that can affect the results of the hemoglobin A1c include supplements such as vitamins C and E and high cholesterol levels. Kidney disease and liver disease may also affect the result of the hemoglobin A1c test. A blood transfusion can also cause an unreliable A1c.