Is Your A1c Just Another Number?

Do you consider your A1c just another number? I admit I do not understand people that treat it this way and ignore what it is telling them and their doctor. One of the people in our informal group looks at the A1c just this way. Granted, his current A1c was a great improvement over his last A1c of 7.3%. He is unexcited with this one and says it is just one more reading. Yes, 6.6% is still above the AACE (American Association of Clinical Endocrinologists) recommendation of 6.5%; and he is still in an area where his complications can continue to develop.

When the three of us that were with him asked what number would excite him, his answer was none. He said he does not pay attention to the A1c's and only watches his daily blood glucose readings. He says those are important to him and is worth the extra cost of test strips as he tests as high as nine times a day.

Why do I care? Because I see articles on this almost on a quarterly basis and like this one, they are too short and often have missing information. Can the A1c be used initially to screen for diabetes? Some doctors do use it for screening. Other doctors prefer a fasting blood glucose (FBG), the oral glucose tolerance test (OGTT), and the A1c before they will diagnose diabetes. Another test in the diagnosis arsenal is the fasting plasma glucose (FPG) test. Still other doctors will use other tests to make sure it is type 2 and not type 1 or LADA. The C-peptide is also used to determine insulin resistance or the amount of insulin your body is producing. Levels of autoantibodies to insulin and the beta cells can be of some value but even these do not lead to an airtight diagnosis. This is because not all people with type 1 have these antibodies. Therefore, the diagnosis is still largely a clinical one.

There are others writing about A1c tests. David Mendosa has an explanation I have not seen before and you can read it here. I was aware that there is a variation in how long our red blood cells do live and that this can affect our A1c readings. David's blog covers much information that needs to be learned and retained by everyone. Tom Ross blogs about the A1c almost monthly lately by listing some of the search questions bringing people to his site. They are also very informative and he often adds some humor. The October blog is here and the September blog is here.  Next we can read Gretchen Becker's blog here about the A1c as she discusses accuracy.

The source that I use and depend on is the lab tests online dot org website. The reason I like it for my reference is that it covers topics most blogs and articles about the A1c do not even mention. Did you know that the A1c is not reliable for the following?

1. diagnosis in pregnant women,

2. people who have had recent severe bleeding or blood transfusions,

3. those with chronic kidney, liver disease, or are on dialysis.

4. people with blood disorders such as iron-deficiency anemia, vitamin B12 anemia, and hemoglobin variants.

“Only A1c tests that have been referenced to an accepted laboratory method (standardized) should be used for diagnostic or screening purposes.” Too many doctors tend to ignore this statement and diagnose anyway. This begs the question of what doctors are thinking when an A1c test results in excess of 7.0% and you are only given this statement, “Be care what you eat as your blood sugar is a little high.” Oh really – do they think they are being kind when they don't schedule you for more tests or have you return another day for the other tests to check if you are a person with diabetes. Any A1c over 7.0% should require more testing to determine if you have diabetes.

Other facts you may be wise to know:

1. The A1c test will not reflect temporary, acute blood glucose increases or decreases. The glucose swings of someone who has "brittle" diabetes will not be reflected in the A1c.

2. If you have a hemoglobin variant, such as sickle cell hemoglobin (hemoglobin S), you will have a decreased amount of hemoglobin A. This may limit the usefulness of the A1c test in diagnosing and/or monitoring your diabetes.

3. If you have anemia, hemolysis, or heavy bleeding, your test results may be falsely low.

4. If you are iron deficient, you may have an increased A1c measurement.

5. If you have had a recent transfusion, then your A1c will be falsely increased (blood preservative solutions contain high glucose levels) and not accurately reflect your glucose control for 2 to 3 months.

The following formula ADAG (A1c-Derived Average Glucose) is used to calculate your estimated Average Glucose (eAG) from your A1c result.

28.7 X A1c – 46.7 = eAG

An example of this is an A1c of 6%. The calculation for this would be:

28.7 X 6 – 46.7 = 126 mg/dl

for an estimated average glucose of 126 mg/dl. I repeat this is an estimated average because your blood glucose readings from your meter will generally not be close to this average. The variance is due to the timing of your meter readings and will not reflect an average.

What this means is that for every one percent that your A1c goes up, it is equivalent to your average glucose going up by about 29 mg/dl. For a printable chart conversion table for eAG click on this link.

Today's Doctors Are Without a Moral Code

Normally I do not write about women's health or gestational diabetes. This is one time I feel I must as the doctors are showing their true colors and arguing against making changes to the guidelines for gestational diabetes. If they were supporting changes, then I would not be writing this. However, this time I think they have abandoned the Hippocratic Oath in favor of profits and this does not seem the proper thing for doctors to come out in favor of doing.

At issue is some in obstetrics and gynecology and maternal-fetal medicine have advocated for change to the diagnostic criteria for gestational diabetes for some time now, while others, including the American College of Obstetricians and Gynecologists, say it is not clear that change is needed. Some information is needed here. Under the Affordable Care Act (ACA), money will be available for doctors to reduce medical costs at all levels of medical care. This is what doctors are afraid of losing if new guidelines are put in place tightening the diagnosis and treatment of gestational diabetes.

The upcoming Consensus Development Conference in early 2013 is to assess available scientific evidence for gestational diabetes. In advance of this conference, the opposition is writing articles in opposition to possible changes. The authors advised that "such a change would dramatically increase the number of women identified as having this disease and place a significantly greater burden on an already overburdened primary health care system. We have concluded that before change is made, there needs to be careful analysis of the possible risk, cost and benefit involved in any revisions. If the data aren't available to answer these questions, it would seem prudent and advisable to delay change at this time."

Follow the dollar signs is all I can derive from the discussion. Normally doctors look to the health of the patients (mother and unborn child in this case) and forget about the cost-benefit analysis in favor of health. This time the medical community is placing the emphasis on the cost-benefit analysis instead to the health issues. “Gestational diabetes is a condition that can be potentially devastating to pregnancies. Even mild forms of hyperglycemia could potentially pose significant adverse health consequences for pregnant women and their children. Advocates for changing diagnostic criteria - increasing the number of women diagnosed with and thus treated for the condition - could reduce morbidity and health care costs. Those cost reductions, however, could be offset by an increase in patients diagnosed and treated.”

Each side is bringing in the big guns to bolster their arguments and they are quoting study after study on both sides of the issue. For those on the “do not change” side, I feel they have lost their moral compass and are only interested in the dollars they can divert to their pockets. I can only suggest that you read the article and decide for yourself, which side of the issue you favor. The second article is here.

This just came to my attention - Tom Ross has an excellent blog on the same topic.  Read it here.

Physician-Assisted Suicide – For Real?

The election is over and we know what the vote result is in the Massachusetts vote on Physician-Assisted Suicide proposition 2. I may as well state now that I am not in favor of this proposition in any way, shape, or form. I am not a resident of Massachusetts, but this will possibly be on the ballot in other states in the years ahead and I feel it is necessary to speak out now.

It was narrowly defeated thank goodness. At least this will give other states pause for rushing this to a vote. Is the battle over? Don't count on it as there may be an appeal to the state supreme court and if the justices do like they have in some other states on other issues, it may be necessary to take it to the US Supreme Court to have the vote upheld.

This is one reason I am grateful to David Mendosa for using the words of Pastor Martin Niemöller in his blog, on page 2. I have been searching for this for many years and it sure fits this situation.

Pastor Martin Niemöller said it:

First, they came for the socialists,
and I didn't speak out because I wasn't a socialist.

Then they came for the trade unionists,
and I didn't speak out because I wasn't a trade unionist.

Then they came for the Jews,
and I didn't speak out because I wasn't a Jew.

Then they came for me,
and there was no one left to speak for me.

One piece of information that I have not seen in the discussion is the crimes committed by unethical physicians and other medical personnel that take the lives of people that are ill and may or may not be near death. With these crimes happening, and physician-assisted suicide made legal, prosecuting these offenders will be made much more difficult, if not almost impossible.

The laws may be well crafted, but they may be sidestepped quite easily by those that are greedy and think this will limit continued rising healthcare costs. Under the current healthcare law, the incentives may be there for more physicians to practice euthanasia on a much larger scale rather than spend the money possibly to extend life. They will argue that quality of life was the deciding issue when in fact it may not be.

In a discussion, David Mendosa asked me to think about what many people do to their pets when the pet is seriously ill or near the end of life. Yes, I have had pets put down when they had a disease with no cure possible, but most of the time I let nature take its course. Animals are one thing, but when is comes to humans, several religions view human life as given by God and not to be taken by anyone including suicide. This seems like a conflict to many people and I will not argue the point. I am against medical personnel being able legally to assist suicide or having any right for euthanasia.

I will continue to speak out against physician-assisted suicide or medical euthanasia as practiced in many hospitals. Yes, I have said it, and know that many doctors and nurses practice medical euthanasia and report it as adverse events or often don't even report anything about it. Under the Affordable Care Act, hospitals will have monetary incentives to reduce medical costs – hence the medical euthanasia topic is on the table and will be practiced to reduce costs and reap the monetary rewards offered by the Centers for Medicare and Medicaid Services.

Don't Over Compensate If Using Artificial Sweeteners

This article does point out what some people think they can do if they use artificial sweeteners. I even have some friends that do just what they should not do. They have their morning cup of coffee and use artificial sweeteners. Then they order a stack of waffles or pancakes and say they can do this because they did not use sugar in their coffee. What a mistake they make. Granted they do not have diabetes, but they knew I did. When I had steak and fried eggs, they said I was overdoing the protein and fat. I was not the fattest and probably near the lowest weight of the group that morning.

We did have a lively discussion about carbohydrates, protein, and fat. Except for one other person, all of us generally eat more protein and fat than we do carbohydrates, however, I am the only one slowly losing weight. Nothing to brag about as I am still overweight and need to lose a lot of pounds. For my height, I was the shorty in the group of six of us as they were all over six feet tall. Yet, they will do just what is advised against – overcompensate for using artificial sweeteners.

It is understandable why the American Heart Association (AHA) and the American Diabetes Association (ADA) were hesitant to approve using artificial sweeteners. They have issued a joint scientific statement giving a cautious recommendation to the use of non-nutritive sweeteners to help people maintain a healthy body weight and for diabetics to aid in blood glucose control.

“The American Diabetes Association stated that for diabetes patients, using artificial sweeteners on their own or in foods and drinks may help aid glucose control if "used appropriately".” Emphasis is mine.

"While they are not magic bullets, smart use of non-nutritive sweeteners could help you reduce added sugars in your diet, therefore lowering the number of calories you eat. Reducing calories could help you attain and maintain a healthy body weight, and thereby lower your risk of heart disease and diabetes. But there are caveats."

Both associations stressed that their statement permitting the use of artificial sweeteners is not to be understood as declaring them safe ingredients. This can only be determined by the FDA (Food and Drug Administration). The authors also state that human studies about the specific, practical, and public health aspects about artificial sweeteners are needed.

The authors also stated that people often compensate or overcompensate, making it necessary to state that they need to be used wisely to be successful. Consider the artificial sweeteners like a nicotine patch; they are much preferable than real sugar, but not part and parcel of an optimal diet. The authors concluded that the artificial sweeteners on the market today are safer than consuming large amounts of sugar, which is definitely harmful when consumed in large amounts.

Are Doctors Lobbying Themselves Out into the Cold?

When I wrote this blog, I had suspicions that this was the case, but not enough information to include it then. And did it happen – three days after my post. Nurse Practitioners (NPs) are being targeted very heavily as medical boards lobby state legislators to limit what NPs can do and not do. If they continue to lobby for restrictions on NPs, you can almost understand what patients are going to say when they have to wait to see a doctor when NPs are available. It isn't going to be pretty when they learn why the NP cannot see them and they must wait many months to resolve a health problem. If you think emergency rooms will pick up the slack, this may or may not happen

This is some startling facts you need to be aware of and understand about the positions of our medical professionals. Currently there are 18 states and the District of Columbia that allow nurse practitioners to diagnose and treat patients and prescribe medications without a doctor's involvement. On the other side, 32 states require a physician's involvement to diagnosis and treat or prescribe medications, or both. The National Conference of State Legislatures reports that as of February 2012, 245 bills had been introduced in various state legislatures related to changing scopes of practice. About 50 of these bills would affect nurses, including advanced-practice nurses. It looks like our physicians are out to hamstring their own profession, by shutting out the people that could come to their assistance.

What are the issues? Nurse practitioners are a type of advanced-practice registered nurse. They are registered nurses who have also obtained a postgraduate nursing degree, usually a master's degree. Doctor groups are claiming that NPs will create safety concerns and must be restricted in their scope of practice. At the state level, the battles are being waged by the medical boards and the legislatures to determine the scope of practice for non-physicians, including nurse practitioners. At the federal level, the problems are on the NP's ability to be reimbursed for the care they provide.

Because of the predicted shortage of primary care as the population grows and as millions of people become newly insured starting in 2014, one of the proposed solutions is to expand the role of nurse practitioners in many more areas of the country, and to allow them to provide a wider range of preventive and acute health care services. Many areas of the country will be without medical care if the physician shortage becomes as severe as some are predicting. Rural areas will be particularly hard hit and residents will face long commutes to see a doctor. Even some small cities will have limited numbers of physicians.
 

The above map presently shows where nurse practitioners are appreciated and valued and the states where physicians in general don't want them. I am pleased that my state still values them.

Some of the problems inherent in the physician shortage will be the compromise of a broad range of medical services. This will include initial valuation of new symptoms, ongoing care for chronic diseases, and many of the preventive services. If continued restrictions are placed on nurse practitioners, the absence of availability of primary care will mean increased mortality, increased emergency department visits (if these remain available), and increased hospitalizations at hospitals distant from the patient's residence.

I wish there were maps available to depict the areas that the Health Resources and Services Administration (HRSA) says that people are uninsured, isolated, or medically vulnerable. The HRSA says it has identified roughly 5700 geographic areas containing 55 million residents as being in primary care health professional shortage areas. To satisfy the target ratio of one primary care practitioner for every 2000 residents, more than 15,000 additional practitioners would be required. Primary care shortages will increase if the current trend continues.

For the last decade at least, there has been less medical graduates entering the primary care arena. The pay for specialists is the biggest reason for the decline in primary care. Some policy makers are urging that there be pay equality to bring more physicians into primary care. They are suggesting loan forgiveness programs for physicians who practice in under served areas.

What many physicians are unhappy about is the increasing research that clearly demonstrates that patients want primary care and this is more important that who is providing these services. A careful review of 26 studies published since 2000 found that health status, treatment practices, and prescribing were consistent between nurse practitioners and physicians. Two other factors that are important are – patients say they have higher levels of satisfaction with their care from NPs, and NPs have a better reputation than physicians when evaluating patient follow up, time spent in consultations, and other measures. I don't agree with this, but it may be part of the equation to fill in the gaps in primary care. “Nurse-led clinics may provide care in under served areas or meet the demand for more convenient care by providing a limited number of low-intensity, commonly needed services, in locations such as retail stores.”

Many advocates say that changes in federal and state laws need to be made to remove barriers to the advancement of nurse practitioners. However, many physician groups, chief among them, the American Medical Association, assert that encouraging patients to see nurse practitioners rather than primary care physicians may put patients' health at risk. This assertion is not supported by evidence and even the Institute of Medicine (IOM) is speaking out in favor of allowing nurse practitioners to fill the gap being created by the primary care physician shortage.

“The IOM recommended specifically that state legislatures reform scope-of-practice laws and regulations to conform to the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules, which outline scopes of practice for advanced-practice registered nurses. It further recommended that state legislatures require fee-for-service plans within the state to similarly cover nurse practitioner services. At the federal level, the IOM recommended that the Federal Trade Commission identify state regulations related to advanced-practice nursing that have an anticompetitive effect without contributing to the health and safety of the public, and that states be urged to change such policies.”

“The IOM recommended that Congress change the Medicare law to make coverage of nurse practitioner services consistent with coverage of physician services. It further recommended that the Centers for Medicare and Medicaid Services clarify that hospitals participating in the Medicare program must allow nurse practitioners to have clinical and admitting privileges and to be eligible to be on the medical staff. The IOM also endorsed the notion that the federal government should require plans participating in the Federal Employee Health Benefits Program to cover services provided by nurse practitioners operating within state laws.”

Whether the Institute of Medicine's recommendations will be enough to tip the scales for nurse practitioners, at lease members of state legislatures around the country have something to support changes and no longer have to listen entirely to self-serving physicians.