Friday Tidbits 05-11-12

I have had this article for a while, but did not want to write an entire blog about it. I feel that it needs some exposure, especially since the president for medicine and science of the American Diabetes Association, Vivian Fonseca, MD, of Tulane University in New Orleans had to vehemently criticize it. If there is any truth to the study, you know that with the guidelines just issued, the ADA would have to criticize it to protect their newly published guidelines.

There does seem to be some discrepancies in the study, but it is still worth knowing about and pondering. Maybe this will encourage more studies that are more definitive rather than the multitude of short studies which cannot lead to accurate conclusions.  One thing that does stand out is noted by the authors - “an overlooked finding in the UK study was that in non-overweight diabetes patients, the drug, when combined with sulphonylurea, actually appeared to increase mortality.” This combination of medications (metformin and sulphonylurea) is part of the new guidelines and we should know about this.

The next items are all about the company Living Cell Technologies. Things are beginning to move rapidly for this Australian company, headquartered in New Zealand.  First – LCT has been successful in their patent applications to the United States and the European Union. This will allow them to begin FDA trials in the near future with their DIABECELL porcine cell transplantation into people with type 1 diabetes who are hypoglycemia unaware.

The product is already on the market in Russia and trials are underway in New Zealand and Argentina. DIABECELL will improve the quality of life of people with unstable type 1 diabetes though the normalization of blood sugar levels, a significant reduction in sometimes fatal episodes of unaware low blood glucose, as well as potentially allowing significant reduction of insulin dependency. The biggest plus is that no immunosuppressants are required (my emphasis).

I am continuing to read every press release I can to see what may be next and when. We know that when dealing with FDA, little or no information will be available until such time as it is coming out of trials and approval has been granted for use or it has been rejected.

Also recently Dr Andrea Grant has been named the new CEO of Living Cell Technologies. She replaces Dr Ross Macdonald.

Ten Bad Assumptions Patients Should Not Make

If you wonder why I praise Dr. Rob Lamberts, take time to read a few of his blogs. Not only are they doctor oriented, but they are also meant for the patient to read and learn. He stopped blogging for some time last year, but is back and putting more common sense out for patients to use. This blog is excellent reading and should be paid attention to since he openly admits doctors are fallible and make mistakes. Even I picked up some good pointers. Others I have been aware of and have picked up the slack when my doctor forgets. If only our or I should say my doctors were this open to admitting they were fallible.

I like several of his opening statements. Patient – pay attention! “Don't assume anything. Assumptions can kill.” Does he mean this? Yes, and then he lists ten potentially harmful assumptions. I can only add – if you don't read this, then you have a lot to lose and it could be fatal.

I am taking his list and adding my thoughts as a patient:

Standard care is the right care

That is right; do not assume that you are receiving the right care. The medical community has attempted to make this clear in several ways. You should be aware of this regardless of where you are a patient. I suggest you read this by Trisha Torrey about the Choosing Wisely Campaign. Dr. Lamberts uses several from different specialties, but they are good pointers and you do need to question your doctor if any of these are suggested.

My doctors communicate

I have found this to be a problem. Doctors do not communicate as much or as often as they should. Even though doctors may not like this, I have been forced on numerous occasions to tell a doctor something that another doctor should have already told him. One instance was a recent surgery where I made clear reference to the fact that I was a person with diabetes on insulin and unless they could guarantee that my IVs were dextrose free, and then they had better be matching with an insulin input. Well, you guessed it, no communication. Surgeon felt it was not necessary until I filed a formal complaint. Then he had reasons for ignoring me saying I had not informed him of my endocrinologist. I had also stated that in my complaint that he had ignored the policy for treating people with diabetes established by the endocrinology department.

Therefore, I learned two lessons here. Make sure everything is in writing and that the signature indicates that they (the doctor and maybe some of the staff) have read and understood what was stated. I did have to correct my blood glucose reading of 300 that was recorded by me, as soon I was able to get my hands on my testing supplies. So much was ignored by the surgeon and his staff.

My doctor has accurate records

Never fall into this pitfall. Most medical records are very incomplete! Items that should be part of your records seldom are. Some of it may be, but even then may not be as complete or comprehensive as the information should be. Few patients have doctors that will let them review records for completeness and not without many delaying tactics and attempts to remove information they do not want you to see. Doctors are notorious if not nefarious for their personal notes about the patient. Often this contains personal observations about you they would be embarrassed to have you see.

Few, if any, patients keep notes about their visits to the doctor with updated lists of medications, surgeries, problems, and family/home situations and bring it with you on visits to your doctor. However, this is a recommendation that you should start. Often doctors will have much of this information in your first visit and will often copy this for you, so don't be afraid to ask.

If you have a doctor that openly allows you to look at you own records and makes corrections pointed out by you, you have a rare doctor and need to cherish this doctor and cooperate with the doctor. For more information when there is reluctance to let you review your records, please read this.

No news is good news

This is one assumption that could kill you. Doctors do forget, and office staff personnel are not the best as relaying information back to the doctor. Too many office staff just assume that the doctor already knows the information and even though it came in a fax they just received or they opened it from the mail, they file it in the patient’s record file. Now what good does this do the doctor and you as the patient waiting to know the results of the tests. This is why you must pick up the telephone or the cell phone and call the doctor's office. Explain the purpose of the call and the test you are waiting to receive the results. Do not accept the answer that the results are in the mail. This is a ploy some office staff people have to get rid of calls quickly so they can get back to the important gossip they were discussing. Over the years, I have seen and heard this and more. Always make sure that you get a copy of all lab results, as this is one way to help track your own health.

I will be notified when things are due

I would not try to take this to the bank. Doctors are busy and the doctor’s office staff thinks they are busy, but they do not have a daily file of when to call patients or when something is due. Even most offices with computers do not have this programmed to call a patient the day before to remind them of their appointment the next day. A few do, but do not use it. Others have found it and do make use of it. Even in this day of electronic health records, or electronic medical records, the saying of garbage in equals garbage out holds true. If it is not entered in the records, that test you were to have had will not happen, unless you make yourself a note and remind them that it is due. Do not be afraid to ask. It is rare to have a doctor’s office that records things timely and keeps the office operating efficiently. Even then, mistakes are made.

Hospitals care

Yes, hospital do care – about one thing and one thing only – the bottom line. If you believe they care about anything else, then make sure you are not in the obituary column of today’s paper. By all means, read Dr. Lamberts discussion on this.

He make it very plain the intent of hospitals and their profit motives. So if your doctors work for the hospital like mine do, be very aware of what Dr. Lamberts has to say, it could save your life. The hospitals like to use unneeded tests and tests with high profit margins on unknowing patients.

And. if you do not believe Dr. Lamberts or even me, read this article about our uncaring and unscrupulous hospitals and their desire for profits.

More is better

Dr. Lamberts is right on about this. This is an assumption that can be costly and cause more problems than it cures. We have all been bombarded with the commercials for different medications they want you to talk to your doctor about and get a prescription to take the medicine. If you are a hypochondriac, then I can understand your instance that you have this condition and want the medication. But chances are your doctor will not agree with your assessment and you will be better off and not lighter in the pocket as a result.

New is better

Oops, I made a mistake and mentioned this for the last item. Well they can apply in both cases. New is not always better. Please read what Dr. Lamberts has to say on both items.

The doctor will think I am stupid

Dr. Lamberts has the right attitude on this one and I hesitate to say more. But what the heck, with the exception of a few doctors, most already have this opinion of patients, so why disappoint them. Just remember when you have this thought, you might actually teach them something new or give them a challenge they have no answer for. I enjoy making a doctor squirm when he wants to prescribe a new medication. I ask what the side effects are and whether this will be a lifetime medication or a trial to possibly replace another medication. If it is to replace another medication, then I let them know if the veterans administration does not carry it in their formulary, forget it. If I do not recognize the drug, I make sure I get the name correctly spelled out and say I will look it up and talk to them the next visit. Needless to say, my doctors are now onto me and know better than to bait me on this.

They also know if I am complaining about something, they had better listen, as I do not mince words when I think a doctor is ignoring me. When a doctor did not believe me, and would not give me a referral, I got the referral from another doctor and was right in requesting it. The ear, nose, and throat doctor made a point of letting him know how bad my inner ear infection was and how I had gotten there.

Doctors don’t want to be questioned

I will admit it has been a few years since I have had a doctor tell me to be quiet and listen. Most doctors do want questions, but the right questions to let them know you want to be in compliance with their instructions. Even this is wrong in my opinion, but it is a game that must be played with some doctors just to get to the questions you really need to ask. Just be careful how you ask as not all doctors have the qualities of Dr. Lamberts. A few doctors are so full of their own importance that they will not answer your questions. These are doctors to avoid, as you never know whether they have heard you or not. Their egos are blocking their view of you and you will be lucky to get out of their office unscathed.

Do – repeat – do take time to read Dr. Rob Lamberts and his blog. We need more doctors as straight forward as he is. He sets the bar pretty high for other doctors to get over.

Diabetes Has Its Bad Habits to Avoid

No, diabetes is not a cakewalk. It has its own set of problems and they can sneak in when least expected. They can wreck havoc with blood glucose levels and destroy will power when you need it most. Some use the following terms - traps, pitfalls, weaknesses, and lack of discipline. I don't care what you use for your favorite term, but these bad habits can really make of mess of good blood glucose management.

In good blood glucose management some things should become habits or for those that do not like habits at least daily tasks. These should become part of your routine just like brushing your teeth. Why is it then that people have such problems with this list (sorry, the link is broken now)? There may be others, but I have seen this list several times in the last few years, so there must be something to it. I can only find the one now on the internet and my second source is a clipping my daughter sent me about seven years ago – sorry no source information came with the clipping. It lists two additional items beyond the link above.

The items listed in lists of bad habits are:

1. Not testing blood glucose.

2. Not taking diabetic medications at the right time.

3. Skipping meals.

4. Emotional eating.

5. Binge eating.

6. Drinking too much sugar.

7. Skipping veggies.

8. Avoiding fish in favor of red meat.

9. Not losing at least 10 percent of body weight (if needed).

10. Skipping exercise – stop being a couch potato

11. Getting too little sleep

For many of us, number nine above could be an excellent idea, but some people do not need to lose weight so I leave this in only for those of us that need this reminder.

Since the link has a video and explanation with of the eleven bad habits, I will let you read them there.

The two additional items from the clipping are avoiding most alcohol and not seeing your doctor when scheduled. Alcohol does strange things to blood glucose and may mask BG readings. Many people continue to have more alcohol than they should, but small quantities occasionally may still be okay for some individuals. Others should stop consuming all forms of alcohol with diabetes.

Not keeping a doctors appointment when scheduled seems to be more common than I would have thought. Unfortunately, there are more reasonable and practical excuses, but still excuses for missing an appointment. Meet the doctor that uses fear to make patients follow instructions and I will show you patients that will consistently miss appointments. Also, doctors that ignore your questions and talk at instead of with you and you will find patients missing appointments. Not every patient misses appointments, but there are too many patients missing appointments.

There are other bad habits that I occasionally see listed and they are health centered and need to be added to any list.

Not paying attention to your nutrition. This is becoming more difficult because of the on going actions of the Academy of Nutrition and Dietetics (AND) and their takeover of the activities of nutritionists. We may now have to learn nutrition on our own to circumvent the dogmas and mantras of whole grains and low fat. Obtaining unbiased and balanced nutritional information may become a thing of the past.

Not inspecting your feet daily. As a person with diabetes, I know the importance of doing this daily. Daily inspection of your feet becomes important because of peripheral neuropathy. One statement I will make is something a cardiologist made to me in the day following my diagnosis. He said always wear shoes or thick sole slippers around the house. This has stayed with me and has proven very good advice, as I know that more than once it has saved me from inflicting myself by stepping on broken glass shards. Yes, accidents do happen and dishes and containers happen to slip out of our hands and break on the floor. You may think you have cleaned all of it up, but you can always miss something. I know because I have found pieces in the bottom of my shoes and slippers on more than one occasion.

Have not stopped smoking. Even I did not stop smoking for some time after my diagnosis. It took several doctors asking me appointment after appointment to get me to stop finally. Add to this my wife politely asking and then begging me. I will admit I enjoyed smoking and had not wanted to quit, but when confronted with this again and again, I finally gave it up. After the fact, yes, I wish I had stopped sooner.

Stop yo-yo dieting. Since I do not believe in dieting, I have no problems with this. Yes, I need to lose some more weight; however, with the changes I have made now, I am starting to shed some of it. I have seen many people that go from diet to diet, find that they lose some weight, and as soon as they stop, gain it all back. This is actually harder on your health than maintaining weight and then slowly changing what you consume healthfully to reduce your weight.

Stop Self-Diagnosing and let your doctor(s) do their job. This does not mean that you should stop keeping daily records such as blood glucose readings, a food log, and records of your lab test results. For the right doctor, this may give him/her the answers as to why things are heading in the direction they are. Always keep a written sheet of questions to ask your doctor. Your doctor does not live with you 24/7/365 and you must learn how to manage your diabetes in the interim, but self-diagnosing is taking matters into your own hands and often conflicts with your doctor's efforts to keep you well. If you believe your doctor isn't up to par, or if his diabetes treatment methods aren't working for you, find another diabetes specialist.

Lack of self-discipline. This is often the one that gets more people in trouble with their diabetes. Call it lack of will power, or a bad habit of self-indulgence, but this spells real trouble for people with diabetes. This also contributes to higher A1c's and earlier onset of diabetes complications. A positive attitude of “I can do this” can help this in many ways.

The last item I want to discuss is one I hear from type 2 people more often that I care to – My doctor did not say anything about this. This is the excuse they use for not wanting to do something that they should. I know that some doctors do not cover everything, but the problem is often with the patient when they do not listen to their doctor when he is talking. My term for this is “selective hearing.” Many patients do this when they hear certain words from their doctor. This often happens and is as bad as the doctors that go on “autopilot” and ramble on.

If you feel something else needs to be added, please leave a comment.

Study - Rationing May Not Be Right for Older Diabetes Patients

For older adults with diabetes, they will generally live long enough to benefit from interventions and research. A new University of Michigan Health System study of retirees showed substantial survival rates for middle age and older adults. Take that people in our nation’s capital, who are using the “R word”, or at least realize that those of us with diabetes are not the ones to euthanize in your attempts to salvage the failing economy. We have shown we live long enough to make interventions beneficial.

Yes, we know that you will set up studies and carefully select only participants near death to refute this study. We know that this will be the government response. At least this time, we have a study we can point to and not be ashamed to call you out. We know that the Center for Medicare and Medicaid Services (CMS) and the National Institutes of Health (NIH) will start these studies; therefore, we will be watching.

It saddens me that it is necessary to have discussions along this line, but when one of your congressional members is determined to level the playing field and talking about the scarcity of resources, you know the talk is about rationing. When someone asked if he was talking about government rationing, the meeting ended quite abruptly. This should be on everyone's agenda this election year, to ask these questions. Unfortunately, this senator has two more years on his term so the discussion will have to wait. In the meantime, many of us will have to figure out how we may oppose this senator when his term is up for reelection.

While this study is showing positive outcomes for people with diabetes and for those of us with diabetes that the battle can be favorable if we work for it. We still need to be aware that our elected representatives may continue the make it more difficult to obtain the medications and testing supplies necessary because of the costs in our flailing economy. While money is the scarce resource, our congressional people will continue to use the “R Word”, not for the money, but for the medical necessities we as people with diabetes will need in our daily battle with diabetes.

Take time to read this study and then speak up to your congress people and ask them about how they view the “R word” (rationing). Unless they are aware we are watching their actions, they may vote for something we cannot support. Or, they may give the green light to CMS and NIH for actions we may find unconscionable.

Beyond the “R Word” Equals Gov’t Euthanasia

Call it rationing, government euthanasia, or even death panels, but the issue is alive and well in Washington, D.C., and politicians are using the “R word” very frequently of late. They see this as a way of stopping fiscal ruin. Some are quietly using the term “allocation of scarce resources” to avoid the term rationing. I prefer to call it government euthanasia and others will insist on using the term death panels.

Two articles appeared in the New England Journal of Medicine on May 2, 2012 about the “R Word” and the need to consider this that is making the rounds in our nation's capital. I will quote from the article by Howard Brody, M.D., Ph.D., “Whereas the “R word” is a proverbial third rail in politics, ethicists rush in where politicians fear to tread. The ethics of rationing begins with two considerations. First, rationing occurs simply because resources are finite and someone must decide who gets what. Second, rationing is therefore inevitable; if we avoid explicit rationing, we will resort to implicit and perhaps unfair rationing methods.

The main ethical objection to rationing is that physicians owe an absolute duty of fidelity to each individual patient, regardless of cost. This objection fails, however, because when resources are exhausted, the patients who are deprived of care are real people and not statistics. Physicians collectively owe loyalty to those patients too. The ethical argument about rationing then shifts to the question of the fairest means for allocating scarce resources — whether through the use of a quasi-objective measure such as quality-adjusted life-years or through a procedural approach such as increased democratic engagement of the community."

This discussion is not new, but is becoming more earnest as our nation tries to cope with the run-away spending of the current administration. Lest you think I am picking on one political party, this has cut across both political parties in the past and been carefully debated on both sides of the isle. It just happens that the current administration has forced the issue because of its financial overspending.

Much of this started in the 1990s with the advent of HMOs and the furor they caused with denying treatments. Then in 2000, the Supreme Court said, “inducement to ration care goes to the very point of any HMO scheme,” it acknowledged what health plans had not. The Court allowed such “inducement” under the federal law governing employee benefits. And, this does not go away under the current health care law that has been termed Obamacare. Expect to see more lawsuits if the law is not overturned and those wanting to prevent rationing start filing their objections.

What to do? I urge you to read carefully both NEJM articles and the comments posted with each. Think about your feelings and then avail yourself of every means to write your congressional representatives and senators and let them know what you think. There may be no way to undue this if we wait.

The link to the first article is here and the second article is here.

Friday Tidbits 05-04-12 on Saturday

With so many things in the news this week, and many of them worth writing about, I felt it necessary to put Friday tidbits on a Saturday this time. I hope you think this is worth your time as much as I enjoyed reading and writing about these topics.

The first item is about using oxygen to regenerate bone. This could be very important for our soldiers, and then for others like those with diabetes having healing and amputation problems. The results of the Department of Defense-funded study were presented at the American Society for Biochemistry and Molecular Biology annual meeting, held in conjunction with the Experimental Biology conference in San Diego.

Multiple research teams have been trying to figure out what makes that huge difference between regrowth here and no regrowth there. The Tulane lab, in particular, has been investigating which genes are turned on, which proteins are expressed and which molecular activities change at the site of amputation over time.

The second article or blog exposes some of tricks our “caring” hospitals play on unsuspecting Medicare patients. Since Medicare will not cover some of the tricks hospitals commonly play, the full cost gets shoved on patients and some of these costs are exorbitant and falsely inflated as high as 800 percent for some over-the-counter pills.

What hospitals are doing is admitting patients as observational patients and not an inpatient status. This is their way of billing full costs to the patient and saving money for Medicare program payments. If there is a way to get the money, hospitals are finding ways of passing costs onto the patients and at the same time registering the patient for savings in the Medicare program. This is what I would term getting money in both hands and overcharging the patient and Medicare. Double dipping is another term that comes to mind.

What patients on Medicare are advised to do is check with their supplemental coverage plan to find out if indeed hospitals in their coverage can get by not notifying them of their status and billing requirements. Medicare does not care and will not cover, but in some states the supplemental plans require a hospital to notify the patient and get their signature before they can bill them.

I strongly suggest that you take the time to read this and then familiarize yourself with the rules in your state. Whether this is for yourself or another family member, know that forewarned is forearmed. This is one way to prevent being taken advantage of by our uncaring and unscrupulous hospitals.

The last item is on the American health care system and why we have less to say in our healthcare costs than any other developed country. What Americans do control in healthcare spending has declined faster than it has in any other developed country in the last few decades for which we have data.

The data shows that the United States has been moving in the wrong direction by removing health dollars from patients' control. In turn it has been putting your healthcare dollars in the hands of the government and insurers to spend. No other developed country has allowed its citizens to lose almost half of their healthcare dollars in the last twenty years.

In Canada, where a government monopoly over residents' access top health care is in place, the share of health spending controlled by patients has remained unchanged. With this happening, Canadians now enjoy more direct control over their health dollars than Americans do.

This tells us that we need to make some changes and regain the advantage by making long-term goals to return control of our healthcare funds and make this a top priority in the coming election.

What Is Best for Young Type 2 Patients?

This was to have been part of my Friday tidbits, but this is getting fever pitched publicity so I am publishing this.

A youth study of type 2 diabetes patients to determine optimal potential glycemic control seems to have determined that a drug pulled from the market for adult type 2 patients is the drug of choice for our youth. The ages of people eligible for the study included youth from age of 10 to 17. In light of Avandia being pulled from the market, I have to wonder at the value of the study. Or, is this another attempt to bring it back on the market for the youth with type 2 diabetes. I can only hope this will not happen.

Realizing that the ages selected for the study is the age when our youth are trying to spread their own wings, find their own place in this world, and rightfully the most rebellious about authority, it is not surprising that overall failure rate is above 50 percent. I can also understand the need to establish evidence for clinical application in the treatment of young patients with type 2 diabetes.

The study was funded by the National Institutes of Health. Three groups were analyzed, one on metformin and Avandia, one on metformin only and one with metformin and intensive lifestyle intervention. None (that is right – none) of the groups did that striking well to clearly say one was better by far than the others. The two-drug regimen did do enough to be declared the better treatment option.

Some youth did lose weight at the start, but most did not and the majority actually gained some weight over the study period. Not a stellar performance by any standard. Read the results posted by NIH, and two articles in the New England Journal of Medicine here and here.

I am wondering, aloud or in writing if you prefer, why we expect our youth to lose weight on the information on food put out by the USDA and advocated by the American Diabetes Association, the Academy of Nutrition and Dietetics, the American Association of Clinical Endocrinologists, and the American Association of Diabetes Educators. Even a few nutritionists follow this, but more are finding it more important to actually teach nutrition and keep the preferred diet of many with diabetes nutritionally balanced rather than loaded with carbohydrates.

I also wonder why doctors prefer medications over any other form of treatment, when it is obvious that our youth needs to reduce their carbohydrates and whole grain consumption. Input some physical activity, less cell phone use, and less time spent sitting, and our youth may realize some real weight loss. There is some excellent discussion about this here. I am not a member so I can only read, but the discussion is good and some excellent points were raised.

Do keep your eyes open, this is making the rounds in the different medical circles and publications. Read the article in WebMD for a slightly different perspective. I suspect the newspapers will be featuring it also.

Finally, With Eyes Wide Open

This is an odd title, but an even odder message from an unexpected source. I guess if you believe in something long enough it may just happen. I have been saying that others should be promoting insulin earlier for the treatment of type 2 diabetes and not be the medication of last resort. Finally, Jonathan Marquess, PharmD, from the Institute for Wellness and Education Inc in Atlanta, Georgia is saying it.

I do not mind that it is a pharmacist saying this as long as this happens more frequently. He does not criticize the American Diabetes Association (ADA) for setting the A1c level at 7.0%, but at least he is saying, “We know that diabetic complications happen at a more prevalent rate when the A1c is above 7. Those diabetic complications are where we're really spending big, big money in this disease state.”

I agree, but would say that we need to ignore the ADA and adopt the American Association of Clinical Endocrinologists (AACE) level of 6.5%. At least then, there would be some room for error although even this could or should be lower. I also appreciate this statement by him, “All too often, physicians, nurses, and pharmacists, will advise patients to take oral agent #1, then oral agent #2, then oral agent #3, and then say, "Wow, I guess it's time to start insulin."”

He does cite some statistics that are alarming, but believable. Of the approximately 43 percent of people having A1c levels above 7% he does not make any statement about how important blood glucose testing should be. This I think is where he misspoke or possibly was misquoted as these people with diabetes need to be testing more and moved over to insulin to prevent or delay the development of complications.

It is true that people with diabetes need to be concerned with morning fasting blood glucose levels and their two-hour postprandial glucose levels. This should be important whether their A1c is above or below 7%.

When he answers the question about insulins, he is correct that we have some great basal insulins and rapid-acting mealtime insulins. His answer about misconceptions about insulin is a little outdated and he missed a great opportunity to dispel a few more of the insulin myths. He concentrated more on fear of needles and people being afraid of the past big needle size. He did mention that people think of insulin as inconvenient and many have the fear of hypoglycemia. I will give him credit for attacking the perception that going on insulin means you did something wrong and had been a bad patient. Sometimes this cannot be helped so it is not their fault.

He did mention insulin pens, which are not available to everyone, but are becoming more popular and available. These will be easier to teach and should help by reducing medication and dosing errors. Insulin pens may also help patients overcome dexterity problems.

Dr. Marquess did shine when talking about education and that it takes time. He talks about patients needing to watch what they eat, learn what the numbers mean in blood glucose monitoring. He talks about physical activity and the potential for problems of hypoglycemia and how to treat with glucose tablets. He did an excellent presentation about needing to go back and reinforce many ideas on a continuous basis and ask the patient how they are doing.

For such a short interview, he covered a lot of material fairly well and I commend him for that. I have heard doctors fumble and make a mess of less material. Read the interview here.