Tag Archives: diabetes

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A weight loss drug complication

People are ordering versions related to semaglutide (ozempic) and dulaglutide (trulicity) from compounding pharmacies for various reasons. Their insurance may not cover the prescription or they may actually not qualify by their weight and complications. Here are the guidelines from the American Gastroenterological Association: https://www.aafp.org/pubs/afp/issues/2023/1000/practice-guidelines-medications-weight-loss.html. Those criteria: a body mass index (BMI) greater than 30 kg per m2 or BMI of 27 kg per m2 or greater with associated complications (e.g., hypertension, diabetes mellitus, and hyperlipidemia).

I have already had requests in clinic for a prescription sent to compounding pharmacy. I am refusing to send prescriptions out of state or to compounding pharmacies, because of the FDA warning. Here: https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/fdas-concerns-unapproved-glp-1-drugs-used-weight-loss. There are a bunch of issues: some compounding pharmacies are not using the FDA approved medicines, they are using something similar, but not the same. Also, the medicine does not come in the pen that injects a controlled amount. People have to draw the drug up and inject it. Some have injected ten times the amount that they should and have been hospitalized. It’s also worrisome that the compounding pharmacies, unlike state-licensed pharmacies, do not have to report complications.

A recent patient has deteriorating kidney function, with his creatinine jumping from 1.10 to 1.58. Creatinine is produced as a waste product by our cells and the kidneys need to clear it. His 1.10 was normal but the 1.58 is high, indicating the his kidneys aren’t clearing well, and that was only a six month interval. He is taking compounded semaglutide and compounded testosterone, with some online approval. That is, he did not get a prescription from our clinic. He started the semaglutide five months ago. The testosterone has been for years. “Stop the semaglutide and we will recheck your kidney function in a month.” His creatinine drops back to 1.10. Acute renal failure is listed as an uncommon side effect of the FDA approved semaglutide, but we don’t know if that is what he’s getting. I tell him the good news about his kidney function and say, “I think you should stay off the compounded drug.” I have not seen the same thing with the FDA approved semaglutide.

It’s complicated, isn’t it? We picked up the problem because he is on other medications and I do yearly labs on people who are on prescription medicines, to check whether their kidney or liver function is deteriorating. Almost all drugs, prescription or over the counter or supplements, are metabolized by either the liver or the kidneys. I only know of two that are not absorbed and not metabolized.

For the Ragtag Daily Prompt: pristine. I would like a pristine pill free body for as long as possible. Ok, I took one tylenol last week and I’d be dead three times over it wasn’t for penicillin.

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On line weight loss drugs

Don’t buy it. Apparently a company call Him is selling a compounded GLP-1 like drug, have worked around the DEA for the moment, but people are getting really sick and there have been some deaths. Article here.

The workaround is that the DEA will let compounding pharmacies make a drug if there is a shortage. Unfortunately, online companies are doing 734,000 prescriptions a month. People can get them on line without a doctor visit or labs, though there may be a doctor signing off. Remember that they are selling an untested GLP-1, and the side effects of the tested ones can include gall bladder disease, pancreatitis and gastroparesis, where the food sits in the stomach and doesn’t leave. And yes, there have been deaths. This may be the salt of the drug, so that it doesn’t have the slow absorption when injected, and hits all at once. Is weight loss that important?

The guidelines for weight loss drugs are here: https://www.aafp.org/pubs/afp/issues/2023/1000/practice-guidelines-medications-weight-loss.html. This article is from October 2023, so doesn’t have the latest offering. I recently saw a person who did not fall into those guidelines. I refused to prescribe. The person responded, “I’ll go to Mexico and get it.” I reply, “Be sure that they do laboratory work and talk to you about the potential side effects.” I am also reading that now there are faked weight loss injector pens circulating. I don’t know what is in them. Fentanyl? Floor sweepings? Who knows.

Meanwhile I am still working on a little weight loss myself. I don’t know if I’ve lost much but clothes are fitting better. The climbing gym and hiking are having an effect. Muscle burns 9 kcal per gram and fat only 4 kcal per gram, so building muscle slims one even if the weight stays the same. My endurance is rising. That feels so good after being on oxygen for a year and a half. I am still trying to eat 1/2 green/yellow or orange vegetables at each meal and I think that is helping too. All this discipline stuff, eeyuk. Oh well.

Anyhow, be careful out there. I do not recommend getting weight loss drugs off the internet or buying it from “friends of friends”. Bad news.

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Food, food, food

When I get pneumonia, I drop ten pounds the first week. Since I had influenza viral pneumonia in 2003, I don’t run a fever. I just have a fast heart rate resting and get short of breath walking across the room. With Covid, I needed oxygen.

Each time, it takes longer to gain the weight back. Then I go over my normal weight and eventually have to rebuild muscle. This time I did not gain any weight back for over a year. But now it’s been three years and I am in the muscle rebuilding and weight loss section.

It does get harder as I get more mature. Older and wiser, right? Well, maybe. At any rate, I am trying to lose weight without any drugs or injectables or herbs. I am trying to eat the way the diabetic educators tell us to: half the meal should be vegetables. Every meal. A small grain and a small protein and not too much fat and vegetables. Corn really falls into the grains.

In clinic I often do a diet history of the day before. What did the person eat? I think about half of the histories come back with almost no vegetables. Pizza is NOT a vegetable, it’s mostly in the grain department. Grains are plants, I agree, but they send blood sugar up a lot more than celery and kale and collards.

Meanwhile, where is CHOCOLATE on that plate half covered with vegetables? Darn. My dessert could be a small piece of chocolate with a carrot on the side? Chocolate dipped carrots? I honestly do not like celery. Celeriac yes, celery no, though I have it in the curried chicken salad I made yesterday. That chicken salad is not half vegetables. It has some celery for crunch but it also has grapes. So, I ate it last night with an equal amount of mixed lettuce and sugar snap peas from the Farmer’s Market.

I do not have diabetes, but if I am recommending a dietary change, I think I should be able to do it too. We shall see. I think right now my diet is about 1/3 vegetables. Fruit does not count as a vegetable for this.

The other thing about vegetables is you have to cut them up. Ok, wash them too. And it’s not like one doesn’t have to cook beans or rice or meat, but vegetables do take time. If I have a person with low blood sugar or who is feeling awful, saying make half the meal vegetables may not be realistic. When someone is really frail or ill, it may be that getting out of bed, washed and dressed and to the table is overwhelming. Cut up vegetables? Cook from scratch? Maybe not.

For the Ragtag Daily Prompt: lunch.

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G6PD deficiency and diabetes

Today I follow an online trail to this article on diabetes from Nature Medicine here.

It is talking about a genetic variant that is found in people with African-American heritage called G6PDdef. This genetic pattern makes the HgbA1C test inaccurate. It will look low and “in control” even when blood sugars are high. Since the blood sugars are NOT in control, complications from diabetes can happen: damage to vision, to kidneys, to nerves in the hands and feet.

I have been reading articles about current and changing guidelines about diabetes. The current guidelines say that checking blood sugars at home doesn’t make a difference. I REALLY disagree with this and at the same time, I don’t think that physicians are approaching blood sugars in a practical manner.

I saw a man recently who is diagnosed with “insulin resistance”. His HgbA1C is in between 5.6 and 6.0. Normal is 4.5 to 5.6. Over 6.5 is diabetes. He has prediabetes. He has not checked blood sugars at all, but he is on metformin.

There is evidence that metformin is helpful, and still, I think it is putting the cart before the horse. I ask my people to go buy an over the counter glucometer. Ask for the one that has cheap strips, 6 for a dollar instead of a dollar apiece. Then we go over the normal and abnormal blood sugar ranges and I ask them to start checking blood sugars. If I give them a medicine right away, they don’t learn how to control their blood sugar with diet. ALL of my patients can figure out how to bring their blood sugars down with diet. If we can’t get to a good range, then we will add metformin. I do explain that the guidelines say use a medicine right away, but I ask, “Would you like to see if you can control your blood sugars with diet?” The answer is overwhelmingly “YES!” I have never had someone say no. If we do not give them the chance and explain the goals, why would they even try?

Also, I read the dietician handouts for diabetes yesterday and I am not satisfied. I do not think they explain carbohydrates well. Foods have fats, proteins, and carbohydrates, and anything that isn’t fat or protein has carbohydrates. I think of carbohydrates as a line, from ones with high fiber that do not send the blood sugar up fast, to ones that shoot it way high. At the low end is kale and lettuce and chard and celery. Then the green and yellow and red vegetables that are not sweet. Then beets and sweet peas. Next come the fruits, from blueberries up to much sweeter ones. Fruits overlap with grains: bread and pasta and potatoes and rice. The whole grains have more fiber and are slower to digest. Candy then sweet drinks (sodas are evil) and sugar.

Sugar has 15 grams of carbohydrate in a tablespoon. Kale has 7 grams of carbohydrate in a cup. That’s a pretty huge difference. A small apple has about 15 grams of carbohydrate and a large one 30 grams. Read labels for grains. There is a lot of carbohydrate in a small amount. The issue with fruit juice is that most of the fiber is gone, so the sugars are broken down and absorbed much faster. A 12 oz coke has 32 grams of carbohydrate and a Starbucks mocha has 62! I quit drinking the latter when I looked it up.

Most people with diabetes are supposed to stay at 30 grams of carbohydrate per meal, or 45 if it is a big person or if someone is doing heavy labor. Snacks are 15 grams.

Avocados are weird. They have about 17 grams of carbohydrate in a whole one, but they also have a lot of fat. They do have a lot of fiber, which surprises me.

Diet control takes a combination of paying attention to what is on the plate and serving amounts. Three servings of pasta is not going to work, unless you are out fighting forest fires or are on the swim team. Fire fighters are allotted 6000 calories a day, but most of us do not get that much exercise.

At the same time that articles are telling me that home blood sugars are not useful with a glucometer, everyone is pushing the continuous glucose monitors. I think we like technology. And other articles say that diabetes can be reversed with major lifestyle changes.

Articles: about not using home glucose checks, here. Starting metformin, here. Starting with one of the newer medicines, here.

I think people feel a lot more successful if they get a glucometer and can bring their blood sugar down by messing about with diet. I tell them to check after what they think is a “good” meal and after a “bad” one. How much difference is there? Contrast that with being handed a pill to control it, while someone talks about diet and says all the same stuff that we’ve heard for years. Nearly all of my people want to avoid more pills and are willing to try a glucometer to see if they can avoid a pill. People who have been on diabetes medicine for a while are less willing to try, but sometimes they do too. And sometimes they are surprised that some meals do not do good things for their blood sugar.

This is all type II diabetes. For type I, we have to have insulin. If type II has been out of control for a long time, sometimes those people have to have insulin too. Right now insurances will usually cover continuous glucose monitors for people with diabetes who are on insulin, both type I and II. I do hope that they really make a huge difference for those people!

The spectrum from the low carbohydrate vegetable, the green and yellow and orange ones, up to the really high simple sugar ones is also called the glycemic index. There are lists of low to high glycemic index foods. Perhaps some people with diabetes find that helpful, but I think it’s simpler to say, ok, the stuff that doesn’t taste sweet will send the blood sugar up less. Also, since we are all genetically different and then our gut bacteria and microbiome are all different, it is individualized care to say how does this person at this time respond to this food? We change over time!

There are other examples of the HgbA1C not working to track diabetes. A resident and I looked over a person with diabetes and spherocytosis. The HgbA1C was nearly normal but the blood sugars were in the 300 range. Spherocytosis is a genetic blood cell abnormality, and the red blood cells don’t live as long. People with a past bone marrow transplant also have red cells that live for a shorter time. The G6PD deficiency is thought to help people survive malaria, so persists in the population, like sickle cell anemia. Isn’t genetics fascinating?

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Diabetes update

Friday I attended a Zoom diabetes update all day. Sigh. We are really doing diabetes wrong.

Diabetes affected every system in the body and so the guidelines want us to check everything. They made the point that controlled diabetes does NOT lead to blindness, kidney failure, and amputations. Only uncontrolled diabetes. There, do we feel better now?

There are three NEW things to check for. One is CHF, aka Congestive Heart Failure. Heart Failure is pump failure. It makes a lot more sense if you think of the heart as a pump. Diabetes doubles the risk of heart failure in men and increases it by five times in women. We are now to do a yearly BNP (Brain Natriuretic Peptide, got that?) except that it is useless if the person is in renal failure, because that raises it artificially.

The second NEW thing is liver problems. Liver failure is back in the top ten causes of death, having fallen off that list for a while. People drank more alcohol during COVID, there was more drug abuse adding to hepatitis B and C, but the biggest cause is NASH and NAFLD. More acronyms: NASH is Nonalchoholic Steatohepatitis and NAFLD is Nonalcoholic Fatty Liver Disease. This is related to overweight and obesity. Being overweight or obese messes up fat storage and over time this inflames the liver and then cells die, leading to cirrhosis. We are to watch liver tests, think about an ultrasound, and then there are two specific tests for cirrhosis.

Third NEW thing is Diabetes Distress. This is not depression. People score “depressed” on the PHQ-9 test, but don’t respond to anti-depressants. The lecturer said that we have to talk to the patient and find out why they are distressed, or what part of diabetes is getting them down. I thought that we should have been talking to the patient all along. There is a convenient 30 question tool we can use for this, if we have time. Will we?

Now, the old guidelines said that we are to check these things:

HgbA1C every 6 months if not on insulin, every 3 months on insulin and even more in pregnant patients.

Microalbumin/creatinine ratio: a urine test that tells us if the kidneys are starting to leak albumin. They shouldn’t.

Yearly eye test to check for diabetes damage.

Specific blood pressure ranges.

Keep everyone’s LDL cholesterol under 70. So nearly every person with diabetes gets a statin drug.

Do a foot check yearly for neuropathy.

So six things plus the new three. Can’t explain that in one visit and can’t do it in one visit either. I think we should revamp the Diabetes Distress tool and check if physicians and nurses have Guideline Distress. Diabetes is the most complicated set of guidelines other than pregnancy.

Diabetes also takes a lot of time for the person who has it. To check things “correctly”, it takes a minimum of two hours a day for Type II not on insulin and more like three or more for Type I and II on insulin. Think if you have to take two or three or more hours away from your current daily activities and devote it to diabetes. No wonder people are distressed.

The medicines are also confusing. Wegovy is in the same class as Ozempic, but is FDA approved only for weight loss in people who are overweight and have a complication, or people who are obese. Ozempic is for diabetes but people often lose weight so think about it if the person is overweight. Some of the medicines in that class also are approved to reduce the risk of heart disease, which goes up with diabetes. Another class has medicines some of which have approval for diabetes and others for diabetes and renal problems, BUT don’t use it if the eGFR is under 20, got that? The lecturer on medicines said that we’ll see less in each of those classes after they fight it out for dominance of the market. He’s been an endocrinologist for 30 years and remembers when the very first non-insulin medicine was approved. Cool! He is not discouraged, but another lecturer said that we have one endocrinologist for 5000 people with diabetes, which is not enough. We were encouraged to do more continuing medical education.

There is one guideline that I disagree with and would like to see changed. I will write about that next. After I memorize all of the different things the new medicines do, which is changing every month as new research comes out! Stay tuned!

I think I will put the clutch in and coast a bit. Or perhaps clutch handfuls of hair and pull at them, I don’t know.

For the Ragtag Daily Prompt: clutch.

I hiked again yesterday and had a very cooperative bunny stop for a snack in camera range.

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A yarn about paper

On Friday in the morning I took notes on paper. I was attending a conference on diabetes on Zoom. There are three new things added to the diabetes guidelines. It is now impossible to do a visit about diabetes and actually talk to the human being who has diabetes. We’ll be too busy doing the stupid checklists.

The personnel person stopped by. I said I was taking notes. “On PAPER? You are killing me!”

“Ok. I will use yarn this afternoon.” I drove home and got my knitting and worked on a sock in the afternoon. All the clinics were having a slow day. I guess the kids are getting out of school and everyone is feeling good. Or panicked.

I retain as much information knitting as I do taking notes. Tactile-auditory learner and the controlled fidgeting of knitting helps me stay awake, retain information, and produce socks and others items. I wear the socks more than I reread the notes.

I still like paper. I keep a paper journal. I wanted notes from the most complex lecture. The new medicines are jockeying for position but right now there are different indications for each one, so it’s rather confusing. They said that Type II Diabetes takes two hours daily to manage “correctly”. And that Type I and Type II on insulin take 3 or more. We are supposed to check for Diabetes Distress, which is not depression, exactly. I think I need to be checked for Guideline Distress and Contact Diabetes Distress, sigh. At least the Diabetes Distress speaker thought we should talk to the patient, though I think the talking should have been long before that. Medicine in the US is a mess.

I used the back of the clinic schedules for notes. I do print it out daily. It’s to try to run on time. What time am I supposed to see the patient, but they can be up to 7 minutes late and then the medical assistant still has to “room” them (yes, room has been verbed). Then I can go see them. So the theoretical starting time and the actual starting time can vary quite a bit. I don’t feel bad about being twenty minutes late if I didn’t get to go in the room with the last patient until twenty minutes late. Maybe a no show will let me catch up. Or not.

Anyhow, I still like paper.

For the Ragtag Daily Prompt: paper.

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Keep it simple

Sometimes I just despair as I read new guidelines. Don’t you? Maybe you are not a physician and don’t try to keep all of this impossible stuff in your head. Mine is full. Tilt.

Diabetes alone: if someone has type II diabetes, there are specific blood pressure guidelines, cholesterol guidelines, we are to do a hgbA1C lab test every six months minimum and more often if they are out of control, and a urine microalbumin/creatinine ratio yearly. If that starts being abnormal we are to start one of two classes of blood pressure medicines even if they have normal blood pressure.

Oh, and don’t forget: a yearly eye test and we are supposed to check their feet at EVERY visit to make sure they are not getting diabetic ulcers.

Got that? And that is just type II diabetes. And there are a whole raft of medicines, about forty right now. Some are weekly shots, some are daily tablets, some are twice a day or with every meal and they all have their own side effects, how fun. Check drug interactions, are their kidneys ok? Is their liver ok? Diabetes increases the risk of heart attack and stroke and don’t forget those feet.

Diabetes is one of the most complicated sets of guidelines, but there are a rather appalling number of guidelines. Maybe we should sic an AI on that job: Mr. Smith has type II diabetes poorly controlled, hypertension, erectile dysfunction, feels a little short of breath and has a bruise on his left shin after tripping yesterday. Please, AI, organize a twenty minute visit to cover as many things as possible efficiently and have the note finished and followup arranged by the end of it. Then it turns out that what Mr. Smith really wants to talk about is his niece who has just overdosed and nearly died from heroin, so everything else goes out the window. Maybe I should see him weekly for the next month.

Do you want to keep it simple and stay out of the doctor’s office and more importantly out of the hospital? If you are 25 and healthy, you don’t much care because old is unimaginable.

But there is a very nice study that looked at just five things regarding health, over 28 years for men and 34 for women: “The researchers looked at NHS and HPFS data on diet, physical activity, body weight, smoking, and alcohol consumption that had been collected from regularly administered, validated questionnaires.”

Here is an article about the study: https://www.health.harvard.edu/blog/healthy-lifestyle-5-keys-to-a-longer-life-2018070514186

Here is the study: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.117.032047

So let’s break the five things down. Here are the more formal definitions: “Using data from the Nurses’ Health Study (1980–2014; n=78 865) and the Health Professionals Follow-up Study (1986–2014, n=44 354), we defined 5 low-risk lifestyle factors as never smoking, body mass index of 18.5 to 24.9 kg/m2, ≥30 min/d of moderate to vigorous physical activity, moderate alcohol intake, and a high diet quality score (upper 40%), and estimated hazard ratios for the association of total lifestyle score (0–5 scale) with mortality.”

First: never smoking. I would add never vaping and not living in a cave and burning wood and hopefully not living right next to a 12 lane superhighway, all of which are bad for the lungs. Ok, while we are at it, don’t use methamphetamines or heroin or cocaine or krocodil, right? They didn’t even include those in the study.

Second: Body mass index 18.5-25. If you aren’t there, it is diet and exercise that need to change.

Third: Thirty minutes or more per day of moderate to vigorous physical activity. That can be ten minute intervals. Three can have an enormous effect on number two.

Fourth: moderate alcohol intake. Ok, alcohol is bad for the heart, period. So is tobacco. They defined moderate as less than or equal to “5 to 15 g/d for women and 5 to 30 g/d for men”. Let’s do the math: a 12 ounce beer that is 5% has 14gm of alcohol. Here: https://www.niaaa.nih.gov/alcohols-effects-health/overview-alcohol-consumption/what-standard-drink. The 8.9% 16 ounce beer at our local pub has quite a bit more. Here is a website where you can calculate how much alcohol is in a drink: https://www.rethinkingdrinking.niaaa.nih.gov/Tools/Calculators/Cocktail-Calculator.aspx.

Fifth: Diet. There is an overwhelming amount of confusing information on the internet and some of it is not only confusing but wrong. “Diet quality in the NHS, HPFS, and NHANES was assessed with the Alternate Healthy Eating Index score (Methods in the online-only Data Supplement), which is strongly associated with the onset of cardiometabolic disease in the general population.” I have not assessed my own Alternate Healthy Eating Index score. However, there are a couple very straightforward things that help with diet. First: No sweetened drinks. That means that sugary coffee with the syrup should go. I quit drinking mochas when I read that a 12 ounce one has 62 grams of carbohydrate. I would rather have a small dark chocolate. And sodas are just evil and juice not much better. Eat the fruit instead. Second: eat vegetables, every meal. A fruit is not a vegetable and no, potato chips don’t count. I mean a green or yellow or red vegetable. You can saute any vegetable, or any that I can think of. I am not counting grains as a vegetable, so pasta, pizza, potato chips and so forth do not count. Beans do count. Third: the DASH diet recommends only a tablespoon of sweetener per day. That is not very much. You can make that cheesecake slice last a week! A small piece of dark chocolate daily or tablespoon size chunk of that cheesecake.

I had a diabetic patient who would be fine, fine, fine, then out of control. “WHAT are you eating? And drinking?” The first time it was two 16 ounce Mochas a day. Then he was fine for a year and a half. Then labs went haywire again. “What are you drinking?” “Well,” he said, not wanting to admit it, “Ok, I decided to try Caramel Machiattos.” “No, no, no! You can’t do that! You’ll end up on insulin!” “Ok, ok, got it, got it.”

And what is the difference if I try to do those five things, you ask, skeptical. “We estimated that the life expectancy at age 50 years was 29.0 years (95% CI, 28.3–29.8) for women and 25.5 years (95% CI, 24.7–26.2) for men who adopted zero low-risk lifestyle factors. In contrast, for those who adopted all 5 low-risk factors, we projected a life expectancy at age 50 years of 43.1 years (95% CI, 41.3–44.9) for women and 37.6 years (95% CI, 35.8–39.4) for men.The projected life expectancy at age 50 years was on average 14.0 years (95% CI, 11.8–16.2) longer among female Americans with 5 low-risk factors compared with those with zero low-risk factors; for men, the difference was 12.2 years (95% CI, 10.1–14.2).”

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I took the photograph from Marrowstone Island. What does a healthy seal diet look like? I am so lucky to have miles of beach to hike, as long as I watch the tides and don’t mind rain.

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rural doctoring

I read Grampa’s Solo Visits this am and it makes me laugh.

Since I have been a family doctor in my town of 9000 for 22 years, the grocery store and coffee shops can be interesting. When I moved here, my daughter was two and my son was seven. We have three grocery stores. I usually go to the one 7 blocks from my house. I would see patients. My diabetics would sometimes look guilty and scurry away when they saw me. Another patient comes to peer in my cart.

“I want to know if YOU are eating healthy food.” he says.

I laugh.

“I don’t see any vegetables.” he says.

“I am in a CSA,” I say. “I get a box from the farm once a week.”

He frowns. “Do you get to choose?”

“No,” I say. “But since I hate throwing vegetables out, we eat more vegetables. Also, we eat ones that are unfamiliar. The first time I got celery root, I had to look it up. I didn’t know what it was.”

He nods. “Hmmm. Ok. We want to be sure you practice what you preach.”

I laugh again. “I sneak in to get the ice cream at midnight, ok? And where is YOUR cart?”

“My wife has it,” he says. “You don’t get to see it.”

“Ok, then. Have a great day.”

When we were first in town, occasionally someone would come start talking about their health in a store.

“I can’t discuss your health in front of my children. HIPAA.”

“Oh,” they’d say, “Uh, yeah. I should call the clinic Monday?”

“Yes, please.”

We had a coffee shop that made the best pastries that I’ve had since I was an exchange student in Denmark. I wished they’d make tiny pastries, bite size, for the diabetic folks. Those folks would slide a newspaper over their plate when I walked in with my family. They looked terribly guilty. I might nod, but I wouldn’t say anything. Sometimes they would confess at the next visit.

There are lots of jobs in small towns where people are very much public figures. Not just doctors, but the people who work for the city and the county, the ones who redo the taxes for homes, the realtors, all sorts.

After I was divorced, another doc at the hospital asks, “Dating someone new?”

I frown, “How do you know?”

She grins, “He lives on my street. I saw you.”

Dang it. The rumor mill is very very efficient and can often be fabulously wrong. That time it was correct, though I don’t think she passed it around. Other people live on the street.

A few days ago someone that looked familiar walks by me. “What are you doing with so-and-so?”

I laugh. “Rumors abound.” I say. “You would not believe the rumors!”

I took the photograph of the coyote yesterday, driving home. Stopped dead in my lane, no one else on the road. People will be stopped in the road here, talking to each other in two cars going opposite directions, or talking to a friend on foot.

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Make America sick again: diabetes

The trend in diabetes treatment is clear: keep Americans sick.

The guidelines say that as soon as we diagnose type II diabetes, we should start a medicine. Usually metformin.

A recent study says that teaching patients to use a glucometer and to check home blood sugars is useless. The key word here is teach, because when I get a diabetic transferring into my clinic, the vast majority have not been taught much of anything.

What is the goal for your blood sugar? They don’t know.

What is normal fasting? What is normal after you eat? What is the difference between checking in the morning and when should you check it after a meal? What is a carbohydrate? What is basic carbohydrate counting?

I think that the real problem is that the US medical system assumes that patients are stupid and doesn’t even attempt to teach them. And patients just give up.

New patient recently, diabetes diagnosed four years ago, on metformin for two years, and has no idea what the normal ranges of fasting and postprandial (after eating) are. Has never had a glucometer.

When I have a new type II diabetic, I call them. I schedule a visit.

At the visit I draw a diagram. Normal fasting glucose is 70-100. Borderline 110 to 125. Two measurements fasting over 125 means diabetes.

After eating: normal is 70-140. Borderline 140-200. Over 200 means diabetes.

Some researchers are calling Alzheimer’s “Type IV diabetes”. The evidence is saying that a glucose over 155 causes damage: to eyes, brain, kidneys, small vessels and peripheral nerves.

Ok, so: what is the goal? To have blood sugars mostly under 155. That isn’t rocket science. People understand that.

Next I talk about carbohydrates. Carbohydrates are any food that isn’t fat or protein. Carbohydrates range from simple sugars: glucose and fructose, to long chain complicated sugars. Whole fruits and vegetables have longer chain carbohydrates, are absorbed slowly, the body breaks them down slowly and the blood sugar rises more slowly. Eat green, yellow, orange vegetables. A big apple is 30 grams of carbohydrate, a small one is 15, more or less. A tablespoon of sugar is 15 grams too. A coke has 30 grams and a Starbuck’s 12 ounce mocha has 62. DO NOT DRINK SWEETENED DRINKS THEY ARE EVIL AND TOOLS OF THE DEVIL. The evidence is saying that the fake sugars cause diabetes too.

Meals: half the small plate should be green, yellow or orange vegetables. A deck of card size “white” food: grains, potatoes, pasta, whole wheat bread, a roll, whatever. A deck of card size protein. Beans and rice, yes, but not too much rice.

For most diabetics, they get 3 meals and 3 snacks a day. A meal can have up to 30 grams of carbohydrate and the snacks, 15 grams.

Next I tell them to get a glucometer. Check with their pharmacy first. The expensive part is the testing strips, so find the cheapest brand. We have a pharmacy that will give the person a glucometer and the strips for it are around 4 for a dollar. Many machines have strips that cost over a dollar each.

I set the patient up with the diabetic educator. The insurance will usually cover classes with the educator and the nutritionist but only in the first year after diagnosis. So don’t put it off.

For type II diabetes, the insurance will usually only cover once a day glucose testing. So alternate. Test 3 days fasting. Test 1-2 hours after a meal on the other days. Test after a meal that you think is “good”. Also after a meal that you think is “bad”. I have had long term diabetics come in and say gleefully “I found a dessert that I can eat!” The numbers are not always what people expect. And there are sneaky sources of carbohydrate. Coffeemate and the coffee flavorings, oooo, those are REALLY BAD.

For most of my patients, the motivated ones, they have played with the glucometer for at least a week by the time they see the diabetic educator. I have had a person whose glucose was at 350 in the glucose testing. The diabetic educator called and scolded me for not starting metformin yet. The diabetic educator called me again a week later. “The patient brought their blood sugars down!” she said. “She’s under 200 after eating now! Maybe she doesn’t need the metformin, not yet!” Ah, that is my thought. If we don’t give people information and a tool to track themselves, then why would they bother? They eat the dessert and figure that the medicine will fix it or they can always get more medicine.

Type I diabetes has to have insulin. If a type II diabetic is out of control, high sugars, for long enough, they too will need insulin. The cells in the pancreas that make insulin are killed by prolonged high blood sugars.

I went to a lunch conference, paid for by a pharmaceutical company, at the AAFP conference in September. The drug company said start people on metformin at diagnosis and if they are not in control in 3 months, start a second medicine, the drug company’s new and improved and better and beastly expensive medicine!!!

Yeah, I don’t think so. All of my patients are smart and they all can figure it out. Some get discouraged and some are already on insulin, but they are still all smart.

Fight back against the moronization of US citizens. Keep America healthy, wealthy and wise.

by

Fraud in medicine: Diabetic supplies

There is a subtle ongoing fraud in diabetic supplies for diabetic patients and especially medicare patients.

The fraud is in the paperwork. An order form will arrive for me to sign for Mr. Smith. I read the fine print and it says that all of the supplies on the form will be renewed for Mr. Smith, unless something is crossed out. It lists six supplies: lancets to draw blood, strips for the glucose machine, a new glucometer, a new lancet machine and control solution to check that the machine is working correctly.

This is all good and necessary, right? Maybe.

I call Mr. Smith and say, “What do you need?”

“I just need lancets,” says Mr. Smith. “That’s what I asked the company to refill.” He is wondering why I called, because he only asked for lancets.

I cross everything out but the lancets: because that is where the fraud lies. Mr. Smith only renewed his prescription for the lancets, but the medical supply company knows exactly what interval medicare and the other insurances will pay for all of the supplies. They want me to sign a blanket order and then they will send Mr. Smith a new glucometer every time medicare allows, whether he wants and needs it or not. So if you have visited a parent or family member and wondered why they have a closet or a drawer full of some medical equipment, that is why. The doctor did not read the fine print and signed a blanket order and the patient is getting more equipment than they need or want. This is waste and it costs us all money.

Another fraud in diabetic supplies is in getting the first glucometer. I was taught to send the patient to the [diabetic educator] where they would get a “free” glucometer. However, now I tell them to check their local pharmacy instead. The “free” glucometers have the most expensive strips and lancets, and diabetics are supposed to check blood sugar at least once a day. If the strip costs one dollar, that adds up. The pharmacy often has a house brand where the strips and lancets are less expensive. I give the patient the choice. Most of them choose the house brand.

One diabetic equipment company got a hold of one of my patients and wouldn’t let go. They sent paperwork to me saying that they needed every note back to the date that I had prescribed his equipment and copies of his blood sugar records. I wrote them a letter, saying, “I am sending the notes, but I don’t photo copy the patient’s blood sugar records. You are being unreasonable. My notes contain the records I made about his blood sugars.” The company is in Florida and the patient is in Washington. The company kept demanding the notes, all the way back to the first visit, every two months. After we sent them twice, we sent a letter saying, “We already sent those twice. We’re not doing it again.” They continued to fax renewals. I talked to the patient. He wanted them gone too, because they kept calling him and wanting to send him more supplies. I called them. They did not desist. I sent them a letter and tried calling medicare fraud. The medicare fraud department said, “Call the company.” Now we just shred anything they send us, including the threatening notes saying that medicare will be after me.

The diabetic supplies aren’t terribly expensive, but when there are millions of diabetic people, this adds up. Also, most physicians are so busy that they sign papers without reading all that fine print and don’t have time to check what the patient really needs. And the companies are targeting the frail, sick and elderly, though many diabetics are otherwise healthy. I think it is a shameful scam to have a person call a company and say “I need more lancets,” and then to try to send them more of everything. Isn’t that illegal? It should be, to fill prescriptions that have not been renewed. I am tired of seeing more and more clearly how our United States medical system is a system to make money any way possible, and morals don’t matter, and it has nothing to do with people’s health.

http://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html
29.1 million diabetics in the US
21.0 million diabetics diagnosed in the US

published on everything2 on November 26, 2014 and on Sermo today