Topics for Our September and October Meetings

Wednesday evening, August 24, Tim called and asked if he could meet with me and said he would come to my place with his portable so we could both look at some of my blogs as he was pulling together some ideas for the meetings for the next two or three months. I said okay and he was there about 10 minutes later.

I listen to him as he reviewed the purpose of the September meeting - dues and the purpose of the dues, and elderly diseases. We spent a few minutes researching the diseases and Tim said with the slides from the one article he was happy and could use the numbers from two other articles where needed.

1. Osteoporosis - One man per four women
2. Breast Cancer - One Man Per 108 Women and highest in Afro-Americans
3. Thyroid Problems - Women are five to eight times more likely to have some form of thyroid disease than men, but men can still be affected.
4. Bladder Infections - Bladder infections are much more common in women, but men can get them, too.
5. Eating disorders - Approximately 10% of eating disordered individuals are male.
6. Lupus - Although 90% of people diagnosed with lupus are women, men can also develop this autoimmune disease. One Man Per Nine Women
7. Fibromyalgia - An estimated 5 million adults have fibromyalgia in the U.S., but as few as 10% are men. Many doctors deny this exists in men.

Next, we talked about the need to change some of the ways we do things and find a way to better educate our members. Barry had told him too many are talking supplements and not telling their doctors, Tim said and I said I agree. The problem is not new and we have almost half of the members that do this. I asked what would happen if we split the group into two groups. Tim said he was thinking that as well, but was not sure if it could be done without causing problems. I said we have moved members away before and we can again. Or we can talk to a few of the members and suggest what we are considering and we could meet in a different place with instructions to one or two of those not invited to elect their own officers. Tim thought about this for a while and finally admitted that was what a few others had suggested, but he was not sure I would agree and he had mixed feelings about doing this. I said that with the new members in October, we would be back over 50 members and I was not sure we could handle that many members. Tim then said that I was being invited out of the group.

I told Tim that if the group did not want me, I could handle it and start another group or join another group if that worked out. At that point, I asked Tim to leave and thanked him for letting me know the lay of the land.

Telemedicine Being Stopped by Legal Wrangling

Legal concerns are the nemesis of telehealth. While many are blaming legal roadblocks, I say it is many doctors and state medical boards that are erecting legal roadblocks to telehealth or telemedicine. Currently, there is no uniform legal approach to telehealth.

States retain significant control over what telehealth services are covered and will be reimbursed by Medicaid. Forty-nine states and the District of Columbia have some coverage for telehealth, and nearly all reimburse for live video telehealth. The majority of states do not restrict Medicaid reimbursement for telehealth to rural locations, unlike current Medicare requirements.

Thirty-two states and the District of Columbia have parity laws that cover private insurers and reimbursement to telehealth services. These laws require commercial health insurance companies to cover services provided through telehealth to the same extent as those services are covered in person. Many variations exist across the states, though, in how states and private insurers pay out these reimbursements and what they cover. The variations in these parity laws created large differences in telehealth coverage across the country.

While many states mandate reimbursement, not all require reimbursement to be equivalent to or at the same rate as in-person services. Colorado, Missouri, and Virginia require payment on the same basis as in-person services, which allows them to take into consideration the cost differences of telehealth versus in-person services. Twenty-three states and the District of Columbia have full parity, meaning coverage and reimbursement is comparable from in-person to telehealth services. Arizona is the only state that limits parity to geographic regions and specific services. Michigan, Oregon, and Vermont only authorize reimbursement for telehealth that uses interactive, audio-visual systems, and Arkansas places "arbitrary limits" on patient locations and provider types, as well as requiring an in-person visit to establish a patient-provider relationship. Nevada is the only state to extend parity to workers' compensation programs.

Proponents of telehealth and parity in reimbursement laud the potential cost savings over in-person care. Telehealth could achieve such substantial savings for a number of reasons, including the potential reduction of chronic condition-associated readmissions through mobile health monitoring technologies and a decrease in unnecessary use of emergency appointments through remote visits with nurses instead.

Likewise, consumer demand for telehealth services is on the rise, with more and more patients looking to mobile applications, online services, and health tracking devices to monitor blood pressure and heart rate continuously. Additionally, many consumers see the positive benefits of telehealth: access to care, efficiency in services, saved time and energy, less stress and anxiety, and even improved well-being for family caregivers.

Opponents of telehealth, however, argue that telehealth services are not equivalent to in-person services and therefore should not receive parity to in-person services in reimbursements.

1. First, opponents suggest that new technology should be approached with caution, as it sometimes proves unreliable and might lead to improper diagnosis and treatment, absent the physical examination. For example, the American Optometric Association opposed online eye exams (and parity in their reimbursement) and called such methods "substandard model[s] of care."
2. Second, many express concerns about the overall quality of care that can be provided using telehealth and worry that instead of correcting issues of access, telehealth might actually create greater inequity in the quality of care available in rural areas.
3. Third, there are also concerns that many telehealth appointments might be one-time engagements, which creates problems when the health data from that appointment might not be added to a patient's primary care physician. This creates gaps in records, which ultimately could have major effects on diagnosis and treatment at later times. Some telehealth services might place the burden of communicating telehealth appointments and results on the patient.
4. Fourth, many are concerned about patient privacy, an area of growing concern in traditional services. The move toward telehealth programs means moving toward more digitalization of medical records, which then could leave records vulnerable to hacking and infiltration.
5. Fifth, some argue that telehealth simply should not be reimbursed the same amount as in-person care precisely because of the cost savings associated with it. If telehealth services save money and are more efficient, the opponents argue, reimbursement for services should mirror those savings. Because of the high risks, possible lower quality of care, and cost savings of telehealth, many physicians believe that telemedicine should not be reimbursed on the same levels as in-person care.

Personalized Nutrition Better Than One-Size-Fits-All

My cousin Beverly and I had an excellent discussion about this study. She knows I detest one-size-fits-all advice and with this study having four personalized groups and a control group makes for an interesting comparison. We both agreed that the study had some very weak points and could have been altered by the participants without anyone knowing it.

The study, called Food4Me, was innovative in that participants were recruited online and then reported their dietary and other data via the web. Participants collected their own blood samples using kits provided.

In the study, 1,607 adults across seven European countries joined through the Food4Me website and were randomized to one of four treatment groups. In addition to a Control group who was given conventional dietary advice, they were allocated to one of three different personalized nutrition options:

• personalized nutrition based on analysis of current diet
• personalized nutrition based on diet and phenotype (adiposity (body fatness) and blood markers)
• personalized nutrition based on diet, phenotype and genotype (five genes were examined for which there was strong evidence of diet-gene interactions and the opportunity to tailor dietary advice based on genotype)

At the end of six months, 80% of the participants completed the study successfully and the researchers discovered that those randomized to the personalized nutrition treatment groups had significantly bigger improvements in their eating patterns than those randomized to the Control group. To their surprise, the researchers found that there was no evidence that the different bases for personalization made any difference to the outcome.

Beverly and I both agreed that some of the advice given may not have been the best and could lead to reversal after the study was complete. A 20 percent dropout may have been the result to some not liking the advice of the reduction of red meat, increasing whole grains for fiber intake, and reducing full fat dairy products to reduce saturated fats.

We both agreed that people receiving personalized nutrition advice develop healthier eating habits including consuming less red meat and reducing their salt intake, as the study has found. Nothing is mentioned about whether highly processed foods elimination helped reduce the salt intake.

In this study, they found that personalized nutrition advice helped people to make bigger and more appropriate changes to their diets than the conventional healthy eating advice, which was followed by the control group.

Like many food studies, a six-month study can lead to a few conclusions, but some of the conclusions of this study are suspect.

The Loss of CDEs as Care Coordinators

There has to be a reason for some of what I reading about coming out of the 2016 AADE convention of educators. This seems to point to more reasons for the shortage of CDEs teaching diabetes education. Don't get me wrong, I believe in people being able to improve their lives and earning a better living while doing something they enjoy.

Now if the AADE would do things correctly and be honest with their membership list, they should state the number of CDEs actually doing full-time education, those doing part-time education, those not doing any education, and those that are retired. Presently they just list dues-paying members and let us speculate why so many people with type 2 diabetes receive no diabetes education.

Then we have CDE members with dual and triple titles that must work in their primary occupation to earn a living. Those with the titles of registered dietitians spend most of their time teaching poor nutrition and go almost no diabetes education.

Now we learn that CDEs are taking on another job as care coordinators. During her presentation at the American Association of Diabetes Educators (AADE) 2016 Annual Meeting, Mary Ellen Wolf, BSN, RN, CDE, helped answer some of these questions in her presentation titled “Diabetes Educators as Care Coordinators.” Wolf described how she was able to parlay her skills as a CDE into her role as care coordinator to help the most vulnerable patients stay out of the hospital. Wolf is employed by Healthways, a population heath management company.

Wolf explained that care coordinators help identify chronically ill patients and facilitate the delivery of health care in the right order at the right time in the right setting. Her presentation defined care coordination as patient-focused, comprehensive, and accessible. The value of care coordination is proven in its ability to provide higher-quality outcomes at a lower cost.

I am sure that her RN title also helped her in her chosen field of work and made care coordination all that much easier. So count another CDE out of the diabetes education field. And those of us with type 2 diabetes continue to receive little to no diabetes education.

With Peripheral Neuropathy, Foot Protection Is Key

Peripheral neuropathy is the most common form of diabetic neuropathy with this condition affecting about 60 to 70 percent of all persons with diabetes. It damages nerves in the feet, legs, arms, and hands.

Symptoms include:

• Numbness or reduced ability to feel pain, altered sensations, and changes in temperature, especially in the feet
• A tingling, burning or prickling sensation that begins in your toes or the balls of your feet and gradually spreads upward
• Sharp, jabbing or electric shock-like pain that’s worse at night
• Extreme sensitivity to the lightest touch or no feeling at all
• Loss of balance and coordination
• Muscle weakness and difficulty walking
• Serious foot problems, such as ulcers, infections, deformities, and bone/joint pain
• Loss all feeling in the affected limb/limbs (for example if you get a small rock in your shoe, you might not feel it and continue walking on it, causing further injury to your foot)

Knowing the symptoms means that you must take action. Most people with diabetes and peripheral neuropathy do nothing and ignore their feet. This is when ignorance can cause an amputation. Am I scaring you yet? I hope I have your attention because being part of a support group has taught several of us many valuable lessons and caring for our feet is as important as managing diabetes. Examining your feet, especially the bottom of your feet daily should be as important to you as taking a blood glucose reading. It's important to protect your feet from injury, especially if you have little or no sensation in them. This means wearing good shoes or slippers, even indoors.

In the Southwest, patients should shake out their shoes before they put them on just in case a scorpion crawled in.

Foot protection is the key issue with peripheral neuropathy. Take care of your feet on a daily basis and if your doctor is not inspecting them, get yourself set up with a podiatrist for at least twice a year foot inspections. It is always wise to be safe rather than have an amputation.

Men Can Have These Women's Diseases

A few of us were meeting to discuss other problems, but Ben made sure that Sue and Brenda were there. After we had finished the topic for the meeting, Ben asked Sue if she was concerned about getting breast cancer since their mother had passed from it. Sue said that her mammograms were always negative and she had one this last spring.

Ben then surprised all of us when he blurted out that he had breast cancer. He would be having surgery this coming Wednesday and radiation the following Wednesday. If necessary, he would have chemotherapy in September. Sue crossed the room to give her brother a big hug and Barry joined her. Tim asked him if he wanted to keep it quite or should we talk about it. Ben said he would prefer not keeping it a secret and then Brenda said we would provide support if and when he wanted it.

Ben turned to me and asked how I had managed finding a lump on my breast? I said I had an operation to remove the lump and it was benign which made it much easier for me. I still check myself and have a mammogram about every three years and last year I had a biopsy of another lump, which was also benign. It was then removed also. None of my family has had breast cancer, so I am hoping that will never happen.

I told Ben that I had blogged about this about six years ago and I would write about it again. I said one man could get cancer for every 108 women. Since it was already in his family, it was good that it had been discovered and that he was being treated.

Jason then asked if men had thyroid cancer as often as women did. I said I have no information about that. Jason said that he was having his thyroid removed also the following Wednesday and it was cancerous. He was not sure what the follow-up treatment would be, but he suspected he might have some radiation from his research. He knew that he would be on synthetic thyroid medication and the doctor had told him the prognosis was good.

Tim commented that the older we become, the more likely some of us will have more problems. If we out live our parents in age, we may encounter health problems they did not. This is the reason we need to continue to support each other beyond type 2 diabetes. Ben said this was what I was hoping to hear, as I feel very scared right now.

Sue asked if he needed transportation on Wednesday and Barry said he was already on board and they would call her over when they were back home. Barry admitted he was not looking forward to being checked, but with his brother having been diagnosed, he would be sure that he was checked. Tim asked me what the prior blog was and I directed him to this blog.

Tim said we had a lot of material for September and even with the voting on dues, and how the dues would be spent, we should cover the information about these diseases and make people aware of what can happen if the symptoms are ignored. We all agreed and we left Ben and Barry's home.

Intensive Treatment of Glucose Levels Creates Problems

Doctors are publishing more and more about overtesting, overtreatment, and just about over everything, except about reducing medications as patients age and fewer patients reap the benefits of some medications. This blog is about intensive treatment that doctors at the Mayo Clinic think is being overdone.

With a more-is-better mindset common in society, frequent commercials encouraging checks of glycated hemoglobin (HbA1C) levels, and ads for new diabetes medications to lower HbA1C in adults with Type 2 diabetes, Mayo Clinic researchers were not too surprised to find overtesting occurring.

Beyond overtesting, however, such focus on HbA1C levels can lead to serious harms for patients, reports the research team, especially as more diabetes medications are needed to keep HbA1C within desired targets. This is particularly important for older patients with other medical conditions, they report in a new study, published online on June 6 in JAMA Internal Medicine.

What surprises me about what the doctors are saying is more what they are not saying. Nowhere in the article is nutrition and management of carbohydrate consumption even mentioned. Most do not even suggest insulin and remain fixated on oral medications.  All they seemed concerned about is piling on more medications to keep the HbA1C on target.

"At first, we were surprised to find how much overtesting for HbA1C is occurring among adults of all ages with Type 2 diabetes who were already well-controlled," says Rozalina McCoy, M.D., a Mayo Clinic primary care physician and endocrinologist, and lead author of the study. "But, then, we realized that not only were patients being tested frequently, they were also being treated with more medications than we would expect considering how low their HbA1C already was. So, this led us to do this study, to see how frequently patients are treated so intensively that they may be overtreated and what that does to their risk of hypoglycemia."

"In this study, we found that, particularly among older patients and patients with serious chronic conditions, intensive treatment nearly doubled the risk of severe hypoglycemia requiring medical attention, including hospitalization," says Dr. McCoy.

Hypoglycemia is a serious potential complication of diabetes treatment. It decreases quality of life and has been associated with cardiovascular events, dementia, and death. Most professional societies recommend targeting HbA1C levels less than 6.5 or 7 percent, with individualized treatment targets based on patient age, other medical conditions, and risk of hypoglycemia with therapy.

"Treating patients to very low HbA1c levels is not likely to improve their health, especially not in the short term, but can cause serious harms, such as hypoglycemia," says Dr. McCoy.

For the purposes of this study, "intensive treatment" was defined as being treated with more glucose-lowering medications than clinical guidelines consider necessary given a patient's HbA1C level. Patients whose HbA1C was less than 5.6 percent (Diabetes is defined by HbA1C 6.5 percent or higher.) were considered intensively treated if they were taking any medications. Patients with HbA1C in the prediabetes range, 5.7-6.4 percent, were considered to be intensively treated if using two or more medications at the time of the test, or if started on additional medications after the test, because current guidelines consider patients with HbA1C less than 6.5 percent to be optimally controlled already. For patients with HbA1C of 6.5-6.9 percent, the sole criteria for intensive treatment was treatment intensification with two or more drugs or insulin.

The researchers examined medical claims, pharmacy and laboratory data of 31,542 adults with stable and controlled Type 2 diabetes who were included in the OptumLabs Data Warehouse between 2001 and 2013. None of the patients were treated with insulin or had prior episodes of severe hypoglycemia -- both known risk factors for future hypoglycemic events. None of the patients had obvious indications for tight glycemic control, such as pregnancy.

"Our goal was to specifically assess the degree to which intensive treatment -- not other known risk factors, such as prior hypoglycemic events or insulin therapy -- caused hypoglycemia," says Dr. McCoy. "We also wondered if young and healthy patients may be better able to tolerate intensive treatment than older patients or those with complex medical problems, so we specifically looked at the impact of intensive treatment on these two groups separately."

Therefore, the patients were separated by whether they were considered clinically complex, as defined by the American Geriatrics Society: 75 years or older; having end-stage kidney disease or dementia; or having three or more serious chronic conditions. This distinction has been made to help identify patients, for whom adding glucose-lowering medications is more likely to lead to treatment-related adverse events, including hypoglycemia, while not providing substantial long-term benefit.

Of the 31,542 patients in the study, 18.7 percent of clinically complex patients and 26.5 percent of non-complex patients were treated intensively. Clinically complex patients had nearly double the rate of severe hypoglycemia than non-complex patients, and intensive treatment increased it by an additional 77 percent, from 1.74 to 3.04 percent over two years.

According to Dr. McCoy, "This means that 3 out of 100 older or clinically complex patients with diabetes who never had hypoglycemia before, whose HbA1C is within recommended targets, and who are not on insulin, will experience a severe hypoglycemic episode at some point over two years."

"This does not even capture the more mild episodes of low blood sugar that patients can treat at home, without having to go to the doctor, emergency department or hospital," she says.

"These findings are concerning for many reasons," says Dr. McCoy. "Overtreatment results in greater patient burden, higher risk of medication side effects, and more severe hypoglycemia, which can lead to serious injury and even death. It adds more unnecessary costs for patients and the health care system. And, at the same time, there is often little or no benefit from such intensive treatment -- not in the long term and certainly not in the short term."

"As clinicians, we need to understand not only what tests and medications are necessary, but also determine which ones are not, and which ones may cause more harm than good," she says. "We need to individualize treatments to the needs and goals of our patients, and be comfortable saying 'sometimes, doing less is ultimately giving our patients more.' My hope is that others will be able to apply our findings in their practices for the benefit of patients everywhere."

The goals of the AACE and ADA seem to be the only concerns and anyone below 6.5 percent A1C are considered overtreated. I say this is BS and this does not mean blood sugar. I feel that keeping A1Cs near normal levels with proper nutrition is a worthy goal for everyone. Doctors that use the goals of the professional organizations should be put out to pasture.