After Diagnosis, What Is Next?

After diagnosis, the questions do start. Many let the doctor set their goals and then when they cannot meet the goals, they often give up and forget to do anything to manage their diabetes. A few others ignore the goals that the doctors set for them and start reading on the Internet. Some will not find the right information and also give up.

Others keep searching and eventually discover what works for them and even if their doctor does not set them up with a blood glucose meter and test strips, they find a way to obtain them and learn how to test. They learn how to eat to their meter and find out what foods they can eat and which foods they must eliminate from the menu. The best thing they do is look for trends and test to know if the “way of eating” is working for them.

Some of the things I learned early after diagnosis was reading the website of David Mendosa and then later his blogs on Health Central. I also read the book by Gretchen Becker – The First Year, Type 2 Diabetes, which really opened my eyes to what the doctor had not told me or anyone else for that matter.

Here are some of the tips I learned:

1. Do not be afraid to take some time to learn about diabetes. You did not get diabetes overnight and bringing under great management can take some time.
2. Please take diabetes seriously. Unmanaged diabetes is deadly, but it doesn’t have to be. Properly managed diabetes can lead to a long and healthy life.
3. Make lifestyle changes. Please read two of my blogs about the components of lifestyles here and here. Most people only concentrate on diet and exercise and forget about the other components. I prefer using “way of eating” instead of diet and diet is at best a temporary change and the change needs to be something we do permanently.
4. Take your medications regularly, and as directed by your doctor. This is important; however, don't be afraid to ask about insulin and other medications. Also, if the doctor does not explain the side effect of the medication(s) prescribed, make sure to discuss this with the pharmacist.
5. Test your blood sugar regularly. Even if you need to purchase some test strips on your own, this is very important, especially if you learn to eat to your meter. Always test before a meal and one or two hours after a meal. This will tell you how the food you ate is affecting your blood glucose levels.
6. Meet with your doctors regularly. No, I did not say medical team and this will vary by individual and the competence of your doctors. Managing your health now means you must care for all of your health needs.
7. Get check-ups and other testing regularly. Blood pressure, lipid profile, dilated eye exams, kidney function exams, A1C testing, all of these will be important in making sure your body is in working order.
8. Find a Support System. This will vary by individual. Some will have a supportive spouse or even another family member. Others will rely on a good friend and some will need to be part of a support group.

Know that unmanaged diabetes is deadly and that good management of diabetes can be a blessing. Those that manage their diabetes often will die of old age before the diabetes complications can kill them. Most doctors consider diabetes as progressive, but people are proving them wrong. Keep a positive attitude.

Our March 2016 Meeting

When we gathered for our March meeting, we had five possible new members and Tim said we had two others that were unable to attend. Tim said we would be covering topics some of us have already heard, but felt with the new members, it would be good to have a repeat of many of the topics. First, he called on Allen to discuss VA benefits. Two of the new members needed to get paperwork completed for VA benefits. After Allen finished, he set up a time for the following week to accompany them to the local VA office.

Next, we had Allison cover carbohydrates and supplements. This totally surprised the potential new members as they all admitted that their doctors had recommended at least 60 grams of carbohydrates per meal. She covered that in general, the group members all consumed less than 50 grams of carbohydrates per day using a low carb high fat way of eating. Allison then asked the newer members if any of them were still eating more than 50 grams of carbohydrates. Two admitted they were, and Allison said she would want to talk to them later.

Next Allison asked how many were taking supplements and all the five admitted they were. Next, she asked Tim to put up the slides and he brought up the picture of a grapefruit. She asked the five how many were taking statins and four admitted they were. When she asked which statin, we were all shocked when they answered the same one and then Allison asked if any were eating grapefruit. Two answered that they were, but not that often. At that point Allison asked how many considered grapefruit natural. All five raised their hands and Allison continued that grapefruit could make the statin toxic in their body and be serious enough to cause death. Many, but not all statins were affected by a chemical in grapefruit that causes this toxicity and grapefruit is not to be eaten if you take certain statins, heart medications, and a few blood pressure medications.

Yes, you can claim that grapefruit is natural, but many natural foods have conflicts with some medications. Barry said that even a friend of his is now dead because he did not believe this. Even some natural supplements also can cause death when taken with some medications. Allison said this is true and when doctors ask you about supplements or medications you are taking, please do not leave any out of the list you provide. You should also be tested to determine if the vitamins, minerals, and supplements are needed. Yes, many doctors will not do the tests, but members of this support group are aware of doctors that will test, so ask when necessary.

Allison said the important point for the newer and new members would be the testing in pairs. Yes, many people will need to purchase extra test strips because insurance will not cover but one or two per day unless you are on insulin, but the information you will obtain from testing in pairs is important and will help you decide what foods should be eliminated from your menu or greatly reduced to stay within your goals. She said there is a good variance among the members and that 120 to 140 mg/dl are appropriate goals.

Always test before you eat (pre-prandial) and then test one to two hours after eating (post-prandial). Many do take the extra test strips to test starting about 30 minutes and test every 15 minutes until the readings start downward. Some do this from first bite and others do this at last bite. Allison concluded that either is acceptable, but it is important to always do this consistently.

Tim asked for a vote on the potential new members after they all agreed they still wanted to join.  The vote was unanimous for accepting them as members. 

Next, Tim opened the meeting up for questions and even a few of the newer members had many questions for Allison and some of the old-time members. After about 40 minutes, Allison asked to talk to the two eating 80 grams or more of carbohydrates, and Allen and Barry had a few questions about VA benefits. Tim and Brenda had a few questions about doctors that would do vitamin, mineral, and supplement testing. Then Tim announced that the meeting was over and the cleanup started.

Allison thanked us again and said she understood why she was asked and was appreciative for being asked.

We Are Upset at Others with Diabetes

Ben, Barry, Allen, Jason, and I have been in a discussion after reading a blog by another type 2. We agree with some of what she says about the CGM and insulin pump, but most of the rest, we are in full disagreement. We may be of thicker skin than most people with type 2 diabetes and we don't get too upset with people that make comments about not eating something and we just tell them off, if they become too bullying in nature.

In general, we look at most encounters as teaching moments and we sometimes are a bit aggressive in what we teach, but we never put a hand on anyone or physically threaten them. Three of us needed to leave a gathering for a birthday party recently, because of two people that thought they were diabetes experts, were just following us around making snide comments about the food we were eating and not eating. Education was not working and even suggesting that they leave us alone only caused them to become more annoying.

We felt better after leaving and called the host and before Allen even started to apologize, he said he was the one that needed to apologize as he was not aware of how they felt about people with diabetes and if he had, he would not have invited them. Allen thanked him and said if the party had been smaller, we might have acted differently.

None of our support group uses an insulin pump, except our honorary type 1 who is away at college. We don't use CGMs and therefore we don't have to answer questions about these that often, but occasionally we are asked why we don't use them. This is an easy question for us as Medicare will not authorize the use of continuous glucose monitors and won't pay for them.

Most of the people are very receptive to diabetes education, with the exception of the two above. We are not afraid to talk about diabetes and even the possible complications. Yes, we receive some of the classic dumb questions like, you ate too much sugar, but we use education to turn these into positives and often people are surprised and receptive as well.

We do have people that try to tell us what we should and should not eat, but they get the surprise when we explain why we won't eat what they suggest and then explain why we consume the foods we do. Most, but not all, really listen to what we are telling them and many ask good questions. Jason says he enjoys giving education when this happens. We agreed with him.

We are upset by several bloggers that nit-pick issues and are upset because people ask certain questions. We don't know why they are not able to turn these into positives and education. Maybe we are fortunate that we use each other to bounce ideas off and talk through difficult areas. We have plenty of experience doing this and being retired really helps us in knowing when to push education.

Tim stopped by as we discussing our disagreement with what a few bloggers have written and asked why we were so angry. Allen said because we don't understand them and why they are so thin skinned. Jason said we have each other to talk to and get prepared for some questions. He added that most of us have no problems of turning situations that they are complaining about into positives and good education.

Tim said that is why we try to have a positive attitude and use education whenever possible. He admitted that some people are not able to do this and have trouble in many situations because they are too busy and can't or won't take the time for education like we are able to do when the questioner is not in a hurry.

Allen said this is why we need to not become so upset with others that do not have some of the skills we have acquired.

Evidence Doesn't Back Eggs Causing Diabetes

The incredible edible egg is simple, yet it's attracted more vilification, and praise, than almost any other food. Recently, some have suggested that eggs are linked to risk of type 2 diabetes. Last month a meta-analysis sought to clarify that relationship.

Eggs are valuable because they are a cheap and reliable source of high quality protein (a complete protein), but they have also been suspected of increasing atherogenic cholesterol, lipoproteins, and ultimately, cardiovascular risk. But, the new 2015 dietary nutritional guidelines appropriately removed the dietary cholesterol restriction; the evidence just didn't support the adverse effects like elevated serum cholesterol.

The authors of the meta-analysis, led by Luc Djousse, DSc, MD, at the Harvard Clinical and Translational Science Center, used data from 12 prospective cohorts (eight of them unique) that evaluated the associated risk of egg consumption and risk of developing type 2 diabetes over a range of 5 to 20 years of follow-up. Seven of the studies were from the U.S., two from Japan, one from Finland, one from Spain, and one from France. These studies used self-reported data to organize egg consumption and compare highest category with lowest categories. There were nearly 220,000 subjects with almost 9,000 cases of diabetes in these cohorts.

The bottom line of what they found was that ingestion of fewer than four eggs per week was not associated with a statistically significant increased risk of diabetes, but when looking only at data from the U.S., there was a relative risk (RR) of 1.39 for intake of ≥ three eggs per week. The relative risk in the other countries was a nonsignificant 0.89. This is where the weakness of the study shows and there was no tracking of other foods consumed with the eggs like bacon, sausage, etc.

These results are similar to a meta-analysis in 2013 that showed similar risk of diabetes when comparing one egg daily to those who had never eaten eggs. That same meta-analysis did not show a relationship between eggs and cardiovascular disease, ischemic heart disease, stroke, or mortality. It did, however, show increased risk of cardiovascular morbidity in those with diabetes. That finding was consistent with another meta-analysis looking at similar data thus supporting the notion that whole eggs may best be limited in those at risk of or with type two diabetes.

The authors also noted that there is a lack of association between dietary cholesterol and type 2 diabetes in the literature and cited one trial in patients with type 2 diabetes or impaired glucose tolerance that showed weight loss and improved glycemic measures with high protein diets, including cholesterol from two eggs daily.

For years, there have been many people and organizations that have tried to vilify eggs. But the data simply don't agree with them. Eggs are a nutrient-packed food that seems to have little to no negative effects and even beneficial effects at low doses.

AACE Is Asking for More CGM Research

Apparently, the AACE did not see fit to add this to their consensus paper, but to make this statement after the conference and call for more research. This may be necessary because the experts disagreed and did not feel this was important enough. As I said in the blog about the consensus statement, the AACE missed a good opportunity to talk to Congress and point out what the CMS is doing by not allowing CGMs for people over the age of 65.

The participants in the conference must have felt something was important enough to issue this press release after the conference. Access to continuous glucose monitoring (CGM) should be available to all patients that could benefit from it, participants in a conference held by the American Association of Clinical Endocrinologists agreed.

I do appreciate that the attendees said the following - more studies are needed to show that CGM technology can benefit other populations, like patients with type 2 diabetes on intensive insulin therapy, according to a summary of the conclusions posted on the association's website. The conference, held late February, included representatives from scientific and medical societies, patient advocacy groups, the government, health insurers, and pharmaceutical companies.

Other conclusions from the consensus conference included:

• Use of CGM has reduced hypoglycemia and has improved control of blood glucose
• Recent technological advances have improved reliability and accuracy of CGM technology
• Robust data support a benefit in patients with type 1 diabetes

Medicare does not cover the use of CGM, but an administrative law judge recently ruled that a Medicare provider in Wisconsin had to cover it for one of its patients. That case is still ongoing, however, and George Grunberger, MD, the president of AACE, told MedPage Today earlier that, "All of our meetings, petitions, and lobbying have met with rejections thus far in spite of uniform recommendations of all relevant professional societies."

In an email to MedPage Today, Vivian Fonseca, MD, the chair of the conference, said that it appears that insurers are approving CGM more often. But, there are two remaining government-related issues, he added: constraints on budget, and the statute covering durable medical equipment doesn't allow for a CGM. "It may require a change in the law," wrote Fonseca, adding that at the conference it was mentioned that there are related bills before Congress.

He added that he thinks CGM will be covered by Medicare "well before" 5 years from now. "The science has advanced considerably and shows a clear benefits of CGMs – particularly in preventing hypoglycemia, which costs Medicare a lot of money," he wrote.

The fact that type 2 diabetes was even mentioned is a big step for the AACE.

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.