AACE Consensus Statement on Glucose Monitoring

This is one consensus statement I don't expect to go far. The insurance companies don't listen to the American Association of Clinical Endocrinologists (AACE) and the Centers for Medicare and Medicaid Services (CMS) certainly does not pay attention to the AACE.

In addition, the AACE statement is not sincere. Why else would they ignore some of the prime issues and not direct their statement to Congress and others that could possibly address some of the problems. The American Diabetes Association stands in their way and the leaders of the ADA do not want to be outdone on testing supplies, CGMs, and other programs.

The AACE consensus statement does not address the need for testing supplies and CGMs for people over the age of 65 and this means that people that need CGMs will continued to be denied them as Medicare does not authorize or pay for them. With the numbers of the “baby boom” generation growing, it would have seemed that these issues should have been addressed.

As a result, I say that the consensus statement on glucose monitoring by the AACE is all but laughable. There is not hope of the ADA approving anything like this and with the current chief scientific and medical officer for the ADA, don't expect any improvements. If it even looks like the AACE is gaining any traction, you can bet that the ADA will find a way to bring insurance companies back in line and negate every advance by the AACE.

The statement, according to an AACE press release, incorporates new information that reflects evolving technology and provides clinicians with “detailed analyses to support precise recommendations for the type of system and frequency of use for either self-monitoring of blood glucose (SMBG) or continuous glucose monitoring (CGM) to reduce short- and long-term complications of diabetes.”2.

Yes, the statement is there, but it is just a statement with no enforcement and opposition by the ADA, CMS, and even the AMA. “In the past, glucose monitoring, which we now refer to as GM, was synonymous with fingerstick capillary glucose testing (SMBG or self-monitoring of blood glucose), which we now call BGM.” Why they found the need to rename some terms is also a puzzle and only serves to confuse people that are newly diagnosed.

While technology has already had a significant effect on GM, more changes are coming down the pike. For instance, data sharing via the Internet, which has already been started by Nightscout, Dexcom Share, and Medtronic, will alter management, the authors note. The use of smart watches and new mobile phones may enable patients to monitor and adjust their lifestyle and therapy on a continuing real-time basis. Also, CGM devices are now available with a longer duration of use (2 weeks) and some devices are factory calibrated, eliminating additional calibrations by the end user.

All this is great, but what percentage of patients are actually using the technology. I have met several people recently that have refused to use the new technology and have disabled what they have as they do not want the information available to their insurance companies or even their employers. Some are even willing to see their doctors on a weekly basis rather than use the new technology.

March 9 Is RDN Day

Every profession needs their day, but this profession needs something more than a day of celebration, Registered Dietitian Nutritionist day is not something I will celebrate as long as this group continues to promote low fat high carbohydrate meal plans.

Even in hospitals, one should seldom specify a meal for diabetics as it will be very high carbohydrate low fat with few exceptions. You would be better served specifying the food you want or accepting a normal meal and eating the low carbohydrate foods on the tray. The last time I was in the hospital, the doctor ordered my meals, they were very high carbohydrate meals, and I seldom consumed but a taste of a few of the foods on the tray.

Since 2008, the second Wednesday in March has marked Registered Dietitian Nutritionist Day. The Academy of Nutrition and Dietetics (AND) is trying to take control of National Nutrition Month and focus the attention all on them.

Registered dietitian nutritionists meet stringent academic and professional requirements, including earning at least a bachelor’s degree, completing a supervised practice program and passing a registration examination. RDNs must also complete continuing professional educational requirements to maintain registration. More than half of all RDNs have also earned master’s degrees or higher.

For some reason, I sincerely doubt the last statement above. I have read that the number is closer to one third only having a master's degree. Yet in the profession of nutrition that are not members of the Academy of Nutrition and Dietetics (AND) or the American Society of Nutrition (ASN), 82 percent have a master's degree or PhD in nutrition.

This tells me that there are reliable nutritionists available and our support group is fortunate to have access to two of them. We do not need to rely on members of AND and ASN that are shills of Big Food and Big Pharma. This is the reason our group will not celebrate a day for members of AND.

According to a spokesperson for AND, the majority of RDNs work in the treatment and prevention of disease (administering medical nutrition therapy, as part of medical teams), often in hospitals, HMOs, public health clinics, nursing homes or other health care facilities. Additionally, RDNs work throughout the community in schools, fitness centers, food management, food industry, universities, research and private practice.

March is National Nutrition Month, and this is the one reason we do recognize the two nutritionists that work with our support group.

Advocacy to Improve Global Access to Insulin

I say advocacy, but the title of the article is call for action. Either way this means that people around the globe often cannot get access to insulin 95 years after the discovery of insulin. This needs action to prevent this being a continuing problem when insulin reaches its century mark in 2021.

More effort needs to be devoted to ensuring people with diabetes have access to insulin. This is the finding of a new in-depth review by three public-health experts. The document was published online February 5 in Lancet Diabetes & Endocrinology by David Beran, PhD, of the division of tropical and humanitarian medicine, Geneva University Hospitals and the University of Geneva, Switzerland, and colleagues.

Much attention has been given to the access of medicines for communicable diseases, think Ebola; however, access to essential medicines for diabetes, especially insulin, has had almost no focus. Very little has been done globally to address the issue of access, despite the [United Nation's] political commitment to address noncommunicable diseases and ensure universal access to drugs for these disorders,

Insulin is essential for the survival of people with type 1 diabetes and is needed for improved management of diabetes for some people with type 2 diabetes. But, today, nearly a century after its discovery, poor access to insulin translates to a life expectancy as low as 1 year following onset of type 1 diabetes in a child in sub-Saharan Africa.

The problem isn't limited to low- and middle-income countries: even in the United States, one study found that discontinuation of insulin use due to high cost was the leading cause of diabetic ketoacidosis in people in an inner-city setting (Diabetes Care. 2011;34:1891–1896).

The new paper outlines the complexity of the problem, including the economic, regulatory, and political aspects, and provides a call to action with potential remedies. The document is aimed at all stakeholders, including professionals who care for people with diabetes, Dr Beran told Medscape Medical News.

"Healthcare workers play an essential role in ensuring that their patients have access to insulin and the necessary education for its use. I also believe that in many settings they should also help advocate for people's access to insulin where this is problematic....The call to action applies for all those who are concerned about the well-being of people with diabetes," he stressed.

In WHO and Health Action International surveys, there is a huge range in the price paid for insulin by governments — across 10 studies, for example, the cost of a range of insulin formulations varied from $2.55 to $48.25 per vial.

The experts stress that insulin also needs to be available, both at a national level, something that can be assessed by the presence of insulin on national essential-medicine lists and guidance as to where insulin should be present, for example health centers vs. hospitals, and at a global level.

The global control of the insulin market by three multinational companies means that countries have a small number of suppliers to choose from, and this has often resulted in people having to change the type of insulin they take as companies have withdrawn formulations from the market or hiked up the price of insulin analogues.

At the same time, regulatory aspects around biosimilars have limited the availability of cheaper alternatives. The shift from use of vials to the more expensive patented pen devices also plays a role, the authors note.

In linking both the availability and affordability elements, only six of the countries surveyed would meet the WHO's 80% availability target of affordable insulin in the public sector, the authors note.

They also point out that insulin alone "is not enough for proper diabetes management, which also requires syringes, blood glucose meters, education, information, and family support."

This is a complex problem that needs support.

Pregnant, Avoid the Potato

New research shows that eating potatoes during pregnancy may increase a woman’s risk of acquiring diabetes. The researchers conclude future intervention studies and randomized clinical trials are needed to further investigate these findings. To me this indicates a lack of confidence in their findings and that the research has faults.

Gestational diabetes, diabetes that presents in pregnant women who have high blood glucose levels, can affect the baby. Though patients with gestational diabetes do not typically present with birth defects, going untreated or having poor control may ultimately hurt the baby long term. It is imperative to identify modifiable risk factors that could potentially lead a woman to develop diabetes.

Currently, the development of gestational diabetes in women is unclear; however, a new study suggests that intake of potatoes by women during pregnancy could possibly increase their risk of acquiring the condition. After rice and wheat, potatoes are known to be the third most common food crop worldwide; the health effects of the vegetable are still inconclusive. Despite being rich in vitamin C, potassium, phytochemicals, and dietary fibers, potatoes are commonly associated with negative consequences on glucose metabolism due to containing large amounts of absorbable starch. Studies have long shown incidences of increased fasting plasma glucose and insulin resistance in patients who consume potatoes, ultimately increasing risks of developing type 2 diabetes.

The 10-year cohort study examined 15,632 women from the Nurse’s Health study who had no previous gestational diabetes or other chronic diseases prior to pregnancy. The researchers examined the patients’ consumption of potatoes along with other foods and relied on self-reports and physician diagnosis of gestational diabetes. The basis for the study is the amount of starch in potatoes, which is rapidly absorbed in the body leading to an increase in blood glucose levels. The research found that patients during their pre-pregnancy stage who consumed potatoes (especially in the form of french fries) showed a significant correlation with incidences of gestational diabetes. Correlation is the key word.

The proposed mechanism behind this spike is related to the high glycemic index of potatoes; starch in such large amounts is absorbed rapidly once it’s taken into the body, and that results in a significant post-prandial increase in blood glucose and prompt stress to pancreatic b-cells, leading to dysfunction or b-cell exhaustion.

In this study, they observed women for risks of gestational diabetes who consumed baked, boiled or mashed potatoes; they found that there was a greater likelihood that these patients would eat french fries, leading to increased incidences of diabetes. The misconception of french fries holding any nutritional value is a driving force for many women who develop gestational diabetes; it indicates an overall poor diet and less likelihood of getting enough exercise. Other vegetables such as whole grains and legumes have a much lower glycemic index and still contain the essential minerals, fibers and vitamins that are essential for every individual. Research indicated that substituting such vegetables in place of potatoes would essentially decrease women’s chances of acquiring diabetes.

There are several limitations to the study, including the observational nature of the trial, which precludes conclusions about whether potatoes actually cause gestational diabetes.

How I View Type 2 Medications

You may disagree with me and that is your right, but I do not like most oral medications used for type 2 diabetes. Why? The side effects and the side effects that are still being exposed. Yes, many of the newer drugs are still unproven and new side effects are still becoming known.

Other than Metformin, I would not touch any other medications with a ten-foot pole, other than insulin. I made a decision some time ago. Metformin, which the doctors have now stopped me from using a few months ago, I will stay on injected insulin. This works well for me and by using Dr. Bernstein's 'law of small numbers' my insulin units are starting to decrease.

I did get to the 5% club about six months after diagnosis. At diagnosis HbA1c of above 13 and average blood glucose meter readings above 250 mg/dl, I was very worried about what I was going to be able to do on a couple of oral medications. Fortunately, my doctor was not afraid of insulin and about three months later, after a discussion on insulin, I was moved off the oral medications to both Lantus and Novolog. I have tried a few of the other insulins which the VA moved me to, but did not have great management. I then needed to have a discussion with the VA doctor about moving back to the first two insulins where I have remained.

Think about it, most type 2's beta cells are not up to the job, how can so many people with type 2 diabetes remain injected insulin free? Most do not have great blood glucose numbers, yet most doctors refuse to prescribe insulin and now if the patients cannot manage their diabetes with dietary changes, they will need to change doctors to obtain the insulin they desperately need.

When the majority of clinicians and supporting paraprofessionals realize the oral diabetes medications are not doing the job of diabetes management, we will start making some progress against the epidemic of obesity and the management of diabetes more effectively.

Think I am blowing smoke, why are so many of our support group members so willing to change away from oral medications to insulin. When they see the blood glucose readings for many of our members and the HbA1C numbers below 6.0%, they start asking questions. Yes, most of the members not using insulin are using low carb, high fat way of eating, but having problems with fasting blood glucose levels and A1c levels above 6.5%. All but four members are under 7.0% and presently no one is over 7.4%.

Presently, only two members are off all diabetes medications and Sue's husband is on metformin and hoping to get back off that if he is able.

Our members have different backgrounds and have been on many of the different diabetes oral medications. Most have been on a sulfonylurea and a second medication from metformin to other injectables. Most are tired of the oral medication side effects and are asking many questions about insulin. Allen, Barry, and Ben are receiving most of the questions.

Seven Neglected Areas That Sabotage Healthy Aging – P8

When is comes to the elderly, too many have polypharmacy, me included. Diabetes also adds to the medications. In the elderly, the problem can become severe because of the risk of harm from medication side effects. The CDC states that every year, 177,000 older adults visit the emergency room for medication problems. This is not a great thing to happen to the elderly and it is unknown how many deaths happen because people cannot reach the emergency room.

Polypharmacy is often a burden for the elderly because of the cost of medications. Often a decision needs to be made between medications and food and a medication prescription is not filled as a result. In addition, real hassles occur for many of the elderly in timely taking their medications during the day, especially if they have too many medications. This often can make a chronic condition become worse and lead to doctors failing to realize that the patient has not been able to take all medications as directed.

The point to remember for many of the elderly is that doctors are taught to prescribe medications and often it may be a case that some medications need deprescribing. Research has documented that inappropriate prescribing of medications is common. A careful medication review will often identify medications that are marginally useful or no longer necessary, but you may not get such a review unless you request it.

For more information:

• How to Review Medications for Safety & Appropriateness
• How to Think Like a Geriatrician about Senior Medications
• A Prescription for Confusion: When to Take All Those Pills
• MedStopper.com (Pharmacist-created online resource designed to help with deprescribing)

My blogs:

http://bobsdiabetes.blogspot.com/2014/03/is-polypharmacy-in-your-future.html

http://bobsdiabetes.blogspot.com/2014/04/more-about-my-friend-on-polypharmacy.html

http://bobsdiabetes.blogspot.com/2014/04/polypharmacy-how-i-dislike-you.html

http://bobsdiabetes.blogspot.com/2015/04/polypharmacy-and-diabetes-part-1.html

http://bobsdiabetes.blogspot.com/2015/04/polypharmacy-and-diabetes-part-2.html

http://bobsdiabetes.blogspot.com/2015/10/even-doctors-complain-about-polypharmacy.html

Number 8 of 8 blogs.

Seven Neglected Areas That Sabotage Healthy Aging – P7

Isolation and loneliness are problems for people with diabetes and the elderly. I admit I have not blogged about this topic, as I have not felt isolated. However, lately some of my health problems are starting to make me withdraw from interaction with others. I do have a wife that can make life funny at times and since she also has type 2 diabetes (treated with metformin at present), we do have some tense discussions about my health.

Both isolation (not having a lot of social contact with others) and loneliness (the feeling of lacking social connection) have been linked to declines in physical health. A 2012 study found that 43% of older adults reported feeling lonely; over the next 6 years, they were more likely to lose physical abilities or die. Loneliness and isolation have also been linked to decreased immune function and greater risk of depression. I have not felt depression and feel fortunate that my positive attitude has prevented depression, as type 2 diabetes can be a strong risk for depression. In the past, I have had minor bouts of depression, but they have not lasted more than a week to 10 days.

The elderly who live alone or have been bereaved are at particular risk, especially if health problems are interfering with their ability to get out. But, even people who are in proximity to others, such as family caregivers or seniors residing in a facility, may suffer from feeling lonely.

Studies have found that certain psychotherapies, including mindfulness, can help reduce feelings of loneliness and even inflammation in the body. However, another study found that isolation seems to be a stronger risk factor for premature death than loneliness, so it’s important to relieve social isolation as well. Arranging more social contact usually helps. It’s also vital to address any health concerns (including fear of falling, incontinence, or pain) that may be keeping a senior from getting out and socializing.

For more information:

• Isolation V. Loneliness: The Difference And Why It Matters
• What Works for Health: Activity Programs for Older Adults
• 14 Ways to Help Seniors Avoid Social Isolation

My Blog:

http://bobsdiabetes.blogspot.com/2013/11/social-isolation-is-powerful-mortality.html

Number 7 of 8 blogs.

Seven Neglected Areas That Sabotage Healthy Aging – P6

Surveys suggest that about 50% of all adults aged 65+ experience bothersome pain every month, often in multiple parts of the body. Persistent pain is linked to decreased social and physical activity, depression, and taking worse care of one’s own health. Pain can also be a sign of a new health problem that needs attention or a chronic problem that’s being inadequately managed.

Pain can and should be treated with non-drug approaches whenever possible. Studies have found that pain can often be lessened through certain types of psychotherapy, exercises or physical therapy, and many other treatments. Treatment with medication may still be necessary, especially for short-term purposes or in combination with other treatments. Bear in mind that many over-the-counter pain medications (such as Advil and Motrin) are non-steroidal anti-inflammatory drugs (NSAIDs), which are risky for older adults when used chronically or in high doses.

People with type 2 diabetes often have neuropathy pain and this should not be treated with NSAIDs. Excellent blood glucose management does more to lessen the pain and will over time greatly reduce the pain. There are other medications that will help more than NSAIDs.

For more information:

• Dealing with Persistent Pain in Older Adults
• Pain Management in Older Adults: Tools & Tips
• Experts Warn Against Long-Term Use of Common Pain Pills
  

My blogs:

http://bobsdiabetes.blogspot.com/2015/09/do-you-have-needle-phobia-or-just.html

http://bobsdiabetes.blogspot.com/2014/08/leg-cramps-and-possible-prevention.html

http://bobsdiabetes.blogspot.com/2013/01/tips-to-make-testing-less-painful.html

http://bobsdiabetes.blogspot.com/2012/05/what-is-diabetic-neuropathy-part-1.html

Number 6 of 8 blogs.