No May Meeting, Not Intentional

Tim called me this morning and said we were not having a May meeting. He had called several others and would be sending out an email to that effect. He said with what Sue, Brenda, Allen, Ben, and Barry were working on, he felt that some were busy enough without a meeting taking up their time.

The woman had been discharged from the hospital and Brenda and Sue were busy counseling her as well as getting her to classes the doctor had ordered her to take. Her husband was taking vacation to be able to attend the classes with her. In addition, he had told his wife that the children knew and she could accept that. From what Sue has told us, she is very unhappy that the children know, but the doctor has told her that is the reason for the classes and he was the one that informed the children.

Barry had said that the three of them were working with the fellow and his wife to teach them about diabetes and how to plan meals and carb counting. Allen had been with him and his wife at his last appointment. With the information from the doctor for determining the insulin to carb ratio needed and how to adjust his insulin they were making progress and he was now injecting before eating.

Barry added that working with his wife, she now had foods available to treating lows and she was working with her husband on adjusting his insulin use. He is starting to lose the weight the doctor said he should and would need to be careful in his insulin use.

Tim also informed us about another individual that A.J and Jerry were helping and he was having a difficult time with depression. He was not on insulin, but using metformin and was having stomach problems. They had talked to his doctor and were able to change to the extended release pill and he was doing much better.

The individual needed to lose about 40 pounds and Jerry had brought in Allison to help set out a meal plan he could follow. He is protesting the reduced carbohydrates, but Jerry told him that this would help him lose the weight. Because he could not exercise other than sitting in a chair, he needed to reduce the carbohydrates he consumed. Allison had explained this to him and he still does not want to eat any fat. Allison told him that it was not the fat that added his weight, but the carbohydrates that had contributed to his weight gain.

A.J had told him that he should be on insulin, but his doctor will not prescribe it and started to ask him is he was failing to manage his diabetes. A.J happened to be waiting for him and when he said this, A.J said he needed to change doctors and he knew one that would work with him to help make managing his diabetes easier. The individual said you do this when a doctor will not prescribe insulin. A.J said especially one that tries to make patients feel like they have failed.

A.J continued that he had started on insulin and then moved to an oral medication and finally was able to get off of all medications. This surprised the individual and he asked if this was possible. A.J said the fact that he was confined to a wheel chair, the odds were not in his favor, but it may still be possible if he followed Allison's advice and continued to work on his weights.

The last paragraph of the email asked if everyone would like an early June meeting, possibly on June 4.

Transferring Health Information Still Slow

Every time I write about patients obtaining copies of the lab reports for their records, I always receive two or more emails telling me to stop as this is not necessary and they can always be transferred if the patients moves and transfers doctors. Some doctors are very possessive of patient's records and others are not and almost insist on the patient having a copy.

Even some patients do not want a copy of lab reports and don't know why they should have a copy.

Therefore, I will repeat myself – always ask your doctor for a copy of all lab reports and in addition, if you have an operation, ask for a copy of all reports pertaining to the operation.

I like that Dr. Leslie Kernisan complains about patients not maintaining at least a rudimentary personal health record. Here is her explanation:

1. Some of the problem is culture and habit.
2. The other problem is that so far it hasn’t been easy to maintain a personal health record.
3. What a lay person needs for the info to be easy to review might different from a clinician’s usability requirements.

Many people are aware of the idea that clinicians are the people who keep our health information and it is their responsibility to send this information to others when necessary. The problem here is that many clinicians fail in doing this.

Often other clinicians need to obtain the necessary information from other clinicians and then put it in physical records or digital records. Finally, the information needs to be easy to review.

Number 3 above does make sense for those patients that don't want copies of their medical records or lab reports. However, many clinicians would appreciate copies of lab reports because then they at least have some information about the patient until the transfer of records can take place.

Dr. Kernisan says, “I can’t help but think that by now it should be easier for people to get and keep copies of their health info. And it should likewise be easier to share or move health information, or at least allow another provider to access the data.”

In trying to obtain some records from my past, most of the records have disappeared when the doctor retired or died. Fires were the most common cause and it could never be determined if they were set or accidental. The police reports had also been lost. One doctor's records still existed and I was able to obtain a record of the diagnosis of my allergy to sulfa drugs and some sulfa derivatives, which the doctor tested. These were from October 1945. No records exist from 1952 to 1972. Some records from 1983 to 1994 no longer exist.

The Complications Diabetes Can Cause

The complications of diabetes are a topic few doctors even mention unless specifically asked. Recently, I have asked two doctors and one could only mention heart disease and blindness. The second doctor was able to mention most of them, but missed sexual dysfunction and deafness. He would not agree to deafness and had his doubts about sexual dysfunction.

We also had a difference of opinion about several items, hypoglycemia, hyperglycemia, diabetic ketoacidosis, and hyperglycemic hyperosmolar nonketotic. He said the first two were symptoms of diabetes and the second two were not part of type 2 diabetes. When I said that the hyperglycemic hyperosmolar nonketotic was limited to people with type 2 diabetes, he went to a book and when he read about it changed his mind. While he was there, he also looked up diabetic ketoacidosis and agreed that this happened to both types.

I suggested he look up sexual dysfunction and deafness. He finally changed his mind and agreed, but added there is conflicting evidence about deafness. I said I agreed, but a recent study showed in young people there is a definite relation, but among the elderly, there could be doubt.

Then he asked why I was concerned. I told him because few doctors even talk about the complications of diabetes and I said many cannot get beyond heart disease and blindness. I said many more cannot accept that diabetes can contribute to cataracts and glaucoma. He admitted he did not think that they were linked, but said he would look them up. I also mentioned that the website WebMD did a poor job of mentioning all the complications of diabetes.

Since I was the last patient of the day, he opened his computer on the web, typed in WebMD, and did a search for diabetes complications. When he had this article, he said they did a better than average job, but you are right that they ignore several, especially women's sexual dysfunction, and only cover a limited amount of heart disease. At least they covered infection and dental problems, which many do not consider. I added foot and lower leg problems and slow wound healing.

Outside of many doctors not being able to list most complications, what other reasons did you bring up this topic? I said that I have several blogs on the complications, and then several more on related problems affecting diabetes and diabetes management.

I admitted that I blog about the complications and related issues and that was the main reason I have been asking doctors to name complications. He asked me to show him and I moved to the computer, entered my blog address, and brought it up. He looked at it and asked me to click on the profile. After that page was up – he read it and said you have four blogs. I said I had, but two are inactive and I concentrate on diabetes at present. Then I clicked on this blog and went to the series on nephropathy.

I moved so he could read the screen and he skimmed the first three and said that he would send the URL to his home computer and read more as he had time. He thanked me and took me to be checked out.

FDA Requires New Food Labels by July 26, 2018

With the exception of manufacturers doing less than $10 million in annual food sales will have an additional year to comply with the new rules, all other manufacturers will need to comply by July 26, 2018. This is more than adequate time for the companies to comply, but several are already complaining.

Refreshed design and relevant information will help consumers make healthy food choices, but I agree hesitantly, as most people seldom read the food nutritional label.

The U.S. Food and Drug Administration (FDA) has taken a major step in making sure consumers have updated nutritional information for most packaged foods sold in the United States, that will help people make informed decisions about the foods they eat and feed their families.

First Lady Michelle Obama said, "I am thrilled that the FDA has finalized a new and improved Nutrition Facts label that will be on food products nationwide. This is going to make a real difference in providing families across the country the information they need to make healthy choices." Considering how the government has botched the school lunch program, thank goodness this first lady will not be around much longer.

Key Updates:

The new Nutrition Facts label will include the following:

• An updated design to highlight "calories" and "servings," two important elements in making informed food choices.
• Requirements for serving sizes that more closely reflect the amounts of food that people currently eat. What and how much people eat and drink has changed since the last serving size requirements were published in 1993. By law, the Nutrition Labeling and Education Act, requires that serving sizes be based on what people actually eat.
• Declaration of grams and a percent daily value (%DV) for "added sugars" to help consumers know how much sugar has been added to the product. It is difficult to meet nutrient needs while staying within calorie limits if you consume more than 10 percent of your total daily calories from added sugars, and this is consistent with the scientific evidence supporting the 2015-2020 Dietary Guidelines for Americans.
• "Dual column" labels to indicate both "per serving" and "per package" calorie and nutrition information for certain multi-serving food products that could be consumed in one sitting or multiple sittings. Examples include a pint of ice cream and a 3-ounce bag of chips. With dual-column labels available, people will be able to easily understand how many calories and nutrients they are getting if they eat or drink the entire package/unit at one time.
• For packages that are between one and two servings, such as a 20 ounce soda, the calories and other nutrients will be required to be labeled as one serving because people typically consume it in one sitting.
• Updated daily values for nutrients like sodium, dietary fiber and vitamin D, consistent with Institute of Medicine recommendations and the 2015-2020 Dietary Guidelines for Americans. Daily values are reference amounts of nutrients to consume or not to exceed and are used to calculate the %DV that manufacturers include on the label.
• Declaration of Vitamin D and potassium that will include the actual gram amount, in addition to the %DV. These are nutrients that some people are not getting enough of, which puts them at higher risk for chronic disease. The %DV for calcium and iron will continue to be required, along with the actual gram amount. Vitamins A and C will no longer be required because deficiencies of these vitamins are rare, but these nutrients can be included on a voluntary basis.
• "Calories from Fat" will be removed because research shows the type of fat is more important than the amount. "Total Fat," "Saturated Fat," and "Trans Fat" will continue to be required.
• An abbreviated footnote to better explain the %DV.

The FDA is also making minor changes to the Supplement Facts label found on dietary supplements to make it consistent with the Nutrition Facts label. The FDA plans to conduct outreach and education efforts on the new requirements.

Diabetic Foot, First-Ever Guidelines

The Society for Vascular Surgery, the American Podiatric Medical Association and the Society for Vascular Medicine collaboratively publish first-ever set of clinical practiceguidelines for treating the diabetic foot.

The new guidelines, “The Management of the Diabetic Foot,” were developed after three years of studies and were published online and in print in the Journal for Vascular Surgery.

Since diabetes mellitus continues to grow in global prevalence and to consume an increasing amount of healthcare resources the clinical practice guidelines were developed. One of the key areas of morbidity associated with diabetes is the diabetic foot. The guidelines seek to improve the care of patients with diabetic foot and to provide an evidence-based multidisciplinary management approach.

The committee made specific practice recommendations using the Grades of Recommendation Assessment, Development, and Evaluation system. This was based on five systematic reviews of the literature. Specific areas of focus included (1) prevention of diabetic foot ulceration, (2) off-loading, (3) diagnosis of osteomyelitis, (4) wound care, and (5) peripheral arterial disease.

Although they identified only limited high-quality evidence for many of the critical questions, they used the best available evidence and considered the patients’ values and preferences and the clinical context to develop these guidelines. They include preventive recommendations such as those for adequate glycemic control, periodic foot inspection, and patient and family education. They recommend using custom therapeutic footwear in high-risk diabetic patients, including those with significant neuropathy, foot deformities, or previous amputation. In patients with plantar diabetic foot ulcer (DFU), they recommend off-loading with a total contact cast or irremovable fixed ankle-walking boot. In patients with a new DFU, they recommend probe to bone test and plain films to be followed by magnetic resonance imaging if a soft tissue abscess or osteomyelitis is suspected. They provide recommendations on comprehensive wound care and various debridement methods. For DFUs that fail to improve (Less than 50% wound area reduction) after a minimum of 4 weeks of standard wound therapy, we recommend adjunctive wound therapy options. In patients with DFU who have peripheral arterial disease, they recommend revascularization by either surgical bypass or endovascular therapy.

Whereas these guidelines have addressed five key areas in the care of DFUs, they do not cover all the aspects of this complex condition. At least in the future as evidence accumulates, they plan to update recommendations accordingly.

Diabetes is one of the leading causes of chronic disease and limb loss worldwide, currently affecting 382 million people. It is predicted that by 2035, the number of reported diabetes cases would soar to 592 million. This disease affects the developing countries disproportionately as greater than 80% of diabetes deaths occur in low- and middle-income countries.

This progression from foot ulcer to amputation leads to several possible steps where intervention based on evidence-based guidelines may prevent major amputation. Considering the disease burden and the existing variations in care that make decision-making very challenging for patients and clinicians, the SVS, American Podiatric Medical Association, and Society for Vascular Medicine deemed the management of DFU a priority topic for clinical practice guideline development. These recommendations are meant to pertain to all people with diabetes regardless of etiology.

How Important Are Words to the Message?

I admit that some words do affect my blood pressure. A few years ago, it was the word diabetics. Now it is people with diabetes. I attended a lecture recently and the person speaking used those three words so much I finally got up and left the room. Grammatically the speaker made the same mistake over and over when saying, “Now you is people with diabetes,” or “If I were people with diabetes.” After I left the room, six others followed and then her assistant came out to shoo us back in and we were not going back in.

When asked why, one person said we keep waiting for her to replicate into several people so that her grammar would be correct. Has she not heard of person with diabetes and how to use it? I added that political correctness is the in thing for many people, but she is so incorrect, it is sickening. After finishing and answering a few questions, she came out to ask us why we left. When everyone started to move to her and forced her into a corner, I knew that she was to be lectured about political correctness.

Since I wanted to hear another speaker, I quietly walked away to find that room for later. When I found it, I went to my car to eat my lunch. Yes, lunch was part of the package, but apparently not too many were making use of it as there were a lot of people eating in their cars.

When the sessions resumed, the first speaker asked why so many had not eaten the provided meal. One brave soul said because it was more carbs than he wanted for lunch. This received a round of applause. Then the speaker asked for an estimate on the grams of carb and several said 45 to 50 grams. Okay said the speaker, you don't have a reason for not eating. How many grams did you eat at your car was the next question. Several said 15 to 20 grams and a few said 20 to 25 grams.

Then the speaker turned most of us off when he stated we should all eat 45 to 60 grams of carbs per meal. Several people stood and one person asked if the topic had changed from the publicized topic or if we were in the wrong room. No answer from the speaker, but I felt that this topic deserved some time. Several almost in unison said stick to the topic, or give us back our money.

The speaker made the mistake of adding more about carbs and everyone got up and left. It turned out that several other sessions emptied near the same time. Apparently very few wanted to hear information on eating many more carbs. The organizer followed up with letters saying that anyone that left early would not receive refunds and the speakers had already been paid. I don't know about the rest, but I will blog about the poor quality of speakers and remind people that the event is not worth the money. The lunch was over priced and loaded with carbs and not only were those of us that carried our own lunch ridiculed, but we were chastised for eating less by often more than half. This is not what we wanted to hear from people that are supposedly professionals.

Yes, most of the speakers were doctors and a couple were CDEs. In an impromptu meeting outside the building, many of us agreed we had been badly treated and we needed to let the different communities know how the doctors talked down to us as patients and chastised us for our choices. Several said they would send letters to the editor of their local paper and most agreed that other papers would pick up the story.

This is the reason for not naming the group or the organizers at this time. I am just sorry I spent the money and made the trip to be put down like we were.

What You Say and Hear Is Important

You will notice that I seldom use words in all caps. I don't like to shout which is what many interpret words in capital letters to mean. There are many times I find something important and I attempt to say so and hope people see it the same way.

The situation that is happening currently with a fellow person with diabetes has several of us very concerned about his health and well-being in his management of diabetes. The woman is still in the hospital and the doctors are very concerned about her recovery. Brenda and Sue are looking after the children and are very happy with the progress they are making in educating the two and answering their questions.

Barry and Ben did take Allen with them the last time they met with the fellow and Allen did make a lot of progress. They were then able to meet his wife and convinced him to tell his wife that he had type 2 diabetes and was taking insulin. She asked many questions which Allen did answer and Allen did cover both hyperglycemia and hypoglycemia and what she should be watchful for and actions she should take.

The fellow was not aware of either and had many questions also. Barry and Allen both addressed the issues and then asked about the food they were consuming. The fellow was not aware of carb counting and was wondering why he was gaining weight. He was only about twenty pounds over his ideal weight according to the calculation Allen used from the Health Central website. The wife asked Allen to bookmark the site so they could use it later.

Ben said he was happy to see that both used the computer and he asked them how often they used it. He said his wife used it the most, but that he did use it. Allen and Barry both suggested quite a bit of reading and the wife said she wanted all that they could give them. Allen gave them his email address and she sent him an email so he could send this onto the rest of them and they could all send them websites to read.

Next, they talked about food and asked for a sample meal. The wife listed that evening's meal she was planning and Allen laid out the approximate number of carbs they would be consuming. When he completed this, he asked how many units of insulin he would be using. He said he would test about two hours after eating and inject insulin based on the reading he received. He did this with every meal and then again at bedtime. When asked what the ratio to the reading was, he could not answer that, but guessed is was about one unit to every four for readings over 100. He said that if the blood glucose reading was 240 mg/dl he would subtract 100 and divide this by 4. So, 140 divided by 4 would be 35.

When asked what his latest A1c was, he did not know and he did not know what that was. In addition, he received no lab reports from the doctor. His wife asked if these were important. All three agreed that they were and he should chart them on a spreadsheet or a database. Barry told them to figure out the date of his diagnosis and any other dates when he may have been tested. Then go the doctor's office and complete a form to receive them.

Then Ben thought to ask them what other medications he was taking. Because they could not answer, Allen asked them to pull the a list together and include any dietary supplements he was taking. He said the dietary supplements were natural and not needed. Allen said if you want some help, you will provide what you take. Ben said that some dietary supplements can create problems with some prescribed medications.

Allen opened up this link and showed them the conflicts for vitamin-B12. While they were not serious conflicts, this surprised both of them and the wife asked him to bookmark this. Allen said we will send you more links like this and tell you why they are important.

Ben then asked about other family members, and they said they had two older children that were both married and visited occasionally. This meant they what they were told was not as important, but Barry did say that they may wish to tell them because of genetics and their need to watch their health. The wife said the son was more overweight than her husband was and Allen said it would be wise to talk to them.

Because it was mealtime, they said they would talk more another day and left. Allen said there was a lot to discuss to help the fellow.