29 July 2011

Another Bad Science Study - Type 2 Diabetes

When are researchers and doctors going to wake up and learn? Apparently never! Another study published in the British Medical Journal (BMJ) warns doctors about placing their Type 2 diabetes patients on intensive glucose lowering treatments. Again they say that most doctors do this believing the patient will have a reduced risk of heart complications.

This time the study was done in France. They did not name this study shamefully so that we had something to refer to like we did in previous studies. Plus no mention was given as to whether this meta study used much of the same data used in other studies - ACCORD and ADVANCE or even the study done by the German group IQWiG, the Foundation for Quality and Efficiency in Health Care. For all we know they could have used the same information.

Again the researchers arrive at the same conclusion that there was no compelling reason to use intensive glucose-lowering treatment, also known as glycemic lowering therapies as are commonly prescribed in order to reduce the diabetes type 2 patient's risk of having cardiovascular complications, as well as renal and/or visual problems.

The researchers found the following benefits were identified with intensive glucose lowering treatments - the risk of non-fatal heart attacks dropped by 15% and the risk of microalbuminuria fell by 10% (an indication of heart disease and kidney problems). However, the treatment was associated with a 100% increase in the risk of dangerously low blood glucose levels (severe hypoglycemia).

The the authors felt it necessary to say - "Intensive glucose lowering treatment of type 2 diabetes should be considered with caution and therapeutic escalation should be limited."

It is not surprising that researchers and doctors repeatedly analyze data looking for information that is not there. Like others have said, bad results are obtained when the incorrect premise is used. In other words, bad science because they were looking for the wrong answers. Like Alan said in his blog (here) and I repeated in my previous blog (here), no consideration was done for changing lifestyle habits of diet and exercise.

If people will not change their lifestyles and are put on intensive glucose-lowering therapies, there is no reason to expect anything other than the results obtained. I say that they should stop spending money on worthless analysis of things that we already know, and concentrate on ways to get the results needed to reduce cardiovascular events and the other complications diabetes can cause. This means looking at what lifestyle changes will accomplish this and how best to work with patients to obtain these results.

This needs to be a lengthy study as it does take time for people to get into an exercise routine that they can sustain and enjoy. Changes in eating habits also take time as people have developed bad habits over time and will have to be shown how to sustain good eating habits and get past the hunger pangs and into good dietary habits. Other lifestyle changes will also be necessary such as regular eating times and carbohydrate counting will become necessary.

Then once these are in full operation and patients are seeing results, then glucose-lowering therapies can be gradually introduced if needed to assist patients in achieving their goals and possible reduce or prevent the related diabetes complications. It should be possible to patients to do lifestyle changes to manage diabetes and lower the risks for complications – if done properly.

The press release of this study may be read here.

28 July 2011

Should We Strive for Lower BG Levels?

Everyone seems concerned with Type 2 diabetes and the advantages and disadvantages of maintaining near or normal blood glucose levels. What no one is willing to tell us is a way to maintain stable blood glucose levels.

The advantages of maintaining lower blood glucose levels are less risk of heart attacks, kidney failure, neuropathy, and loss of eyesight. The disadvantage generally is listed as one problem and that is hypoglycemia. Generally hypoglycemia is listed as blood glucose readings below 70 mg/dl. I would agree that this should be the lower limit for most people and for some nearer to 80 mg/dl. I admit that I do not get concerned until I get lower than 65 mg/dl, but this is not good for most people.

I will not discuss the study from Germany that has so many flaws in it that it is easy to understand why they take the position they do. When a healthcare system is operated by the government, cost is always at issue and often best results are deemphasized at the harm of the patient. Alan at loraldiabetes does an excellent job of analyzing the study and showing its weaknesses and I urge you to read his blog about this.

I do need to quote Alan here though – Quote  The problem (of the study) is not the goals but the methods. Sadly, all they have done is confirm something that has been discussed by type 2 diabetics on diabetes forums ever since ACCORD and ADVANCE (both are included in this meta-study) were published. Those papers did not show that tight control is harmful, instead they showed that intensive use of oral medications and/or insulin to push A1c or FBG down can be hazardous to the health of a diabetic.

The factor missing from all of these studies is use of lifestyle changes, particularly diet and exercise, to achieve near-normal A1c and blood glucose levels. Repeatedly in all these studies the subjects were advised to follow the traditional (since Keyes) extremely low-fat high-carbohydrate diet and to then use medications and insulin to combat the results of that way of eating. I wrote some brief comments on the ACCORD and ADVANCE trials back in 2008 when they came out; nothing has changed since then. Unquote.

This is so typical of studies and points out why we should not rely on them for our own care. They do not consider the essential lifestyle changes that need to be made in diet and exercise. Until researchers understand the value of people and what is reasonable, studies like this will proliferate and doctors will continue to discourage people from attempting to manage diabetes to their abilities and benefit. Doctors will use studies like Alan covers to instill fear by citing them.

So now, not only is it necessary for us a patients to be more proactive in our care, but we need to be aware of these studies and how to refute them when they are used by doctors to discourage testing and bringing our A1c's closer to the normal range.

27 July 2011

'Dignity Therapy' Often Not Used In Nursing Homes

Dignity therapy, this is a topic that does need more publicity. Especially for those in nursing homes, hospice care, and hospitals. Having visited with people that have parents or relatives in a nursing home, it seems that this is one place that very sorely needs some guidance in providing “dignity therapy”. For nursing homes and hospice care, dignity therapy may need to be adapted to fit the needs of the people.

So places the provide care for the elderly need to learn how to use dignity therapy and allow time for the elderly to be properly cared for. It is not just a nursing home or care facility here and there, but on a nationwide basis, the level of care and treating the elderly with dignity sometimes is very lax. I would even say that some of those housed in nursing homes are often stripped of their dignity more than they are helped in maintaining even a small semblance of dignity. While many of the nursing homes are working to be better and meet state mandates, it takes time to weed out undesirable employees.

What makes the application of dignity therapy so difficult in most settings is that many people are housed in nursing homes and care facilities and are put there because they no longer are capable of caring for themselves. The fact that the majority cannot verbalize their feelings any longer makes it difficult to know whether they are happy or even being allow to keep any dignity.

This needs to change and those working in nursing homes need formal training on caring for people in nursing homes to allow them as much dignity as can be managed.
Yes, this can be difficult. Some people are not easy to deal with and many have been dumped in a nursing home (yes, I said dumped) because the family can no longer deal with them. Others have signed a medical power of attorney for a family member that does not exercise good management and listens to other family members wanting access to whatever assets the parent has.

Sometimes there are few family members available to spread the care-giving around and the one person has no choice for their health, but to put a parent in a nursing home. The care has become too much of a health burden for them to continue without damaging their own health.

Therefore, dignity therapy needs to be taught not only to nursing homes in a modified format, but to family caregivers as well. If done early on and properly, this can easy the transition when a nursing home is no longer unavoidable. Often there are alternatives which can assist family caregivers and allow a single family caregiver the break that they need for managing their own health.

Dignity therapy can have many forms and be a useful tool in not only caring for the terminally ill, but for the elderly that find they cannot care for themselves any longer.

26 July 2011

'Dignity Therapy' Gives Comfort to Dying Patients

Dignity therapy involves a short course in psychotherapy that focuses on helping patients with life-threatening or life-limiting illnesses, that are capable of verbalizing themselves, to do so in a manner that allows them to feel that they can accomplish needed activities in the end-of-life setting.

It encourages these patients to heal family relationships and express themselves in what they desire for the following generations plus pass along information to the younger generations. This form of therapy also encourages saying things to loved ones that have remained unsaid to achieve closure. The therapist then helps the patient craft a meaningful document based on the 60-minute sessions.

By using dignity therapy for those that had less than six months to live, it helped them find some meaning and purpose to the end of life and to share their life's story and experiences with family members. When you talk to people about their life, you allow them to step out of the current situation and become the parent, business person or what their occupation was. This allows the patient to be someone and not just a number.

Getting to know the person, not the patient, allows them the opportunity to explain what their role has been in the family, the community, and express what they are happy about in what they have accomplished. The researchers comment that the patients who received dignity therapy “often has a quality-of-life experience that they could not have expected and although this is difficult to assess, it can be poignant and profound.

As an example, it is stated that a 56-year-old woman said: “Mostly, I want my family to know that I'm okay with dying and they must move on. The therapy showed me that I am not the cancer, I am still in here. I am so grateful for that because I lost myself.... It really helped me remember who I am.”

Several authorities who reviewed the study commented that this type of therapy should be offered to all patients with terminal illnesses. The feeling has been that if you don;t have a long time to be in therapy, it won't be helpful, but that is not true. Dignity therapy will help patients finish their lives on a positive note and can go far in healing familial relations that might be undone otherwise.

The transition from active treatment to palliative care is often difficult for patients and their families, and this can even be true for healthcare professionals intimately involved with the care of the patient. Psychotherapeutic interventions, such as dignity therapy, offer timely opportunities for patients and families to address important issues.

This stood out as an important issue in the study report. There are some other thoughts that are helpful in the results of the study that you can read here and another report here.

25 July 2011

Not Being Referred To A Diabetes Educator

This is not surprising, and even with this study being done in the country of Canada, the truth of the study is applicable in the USA. I think this is a good thing and every person with diabetes would be better off if they could eliminate this profession. Replace this with people specializing in diabetes that can educate, give sound nutritional advice and not spout dogma from the professional associations. Most people have to find this out on their own and suffer because of the carbohydrate advice spouted by certified diabetes educators (CDEs).

I have started this blog several times and always end up erasing it. So I might as well vent my feelings. Yes, there are some excellent CDEs, but they are few and far between and in positions where they do not need to worry about losing their license for not spouting the dogma that is outdated. If you have one of these that is concerned about your health and your desires for lifestyle changes to lower carbohydrates, do everything possible to stay with this person.

If you are fortunate enough to have a dietitian specializing in diabetes that is more concerned about the nutrition of the food you are eating and not the number of carbohydrates, work with this person and you will benefit in your diabetes management. I have needed to go outside of my doctor's office to find these people and I am happy I did.

I will let you read the article and the abstract on diabetes educators and the problems in Canada, but I think you will agree that these same problems exist in the USA and maybe on a larger scale. The good diabetes educators are in high demand and can be found with some diligent searching. The largest problem is finding them in largely rural areas.

Many of those not utilized by doctors are the ones that contradict the doctor and do other things that are not in the best interest of the patient. Doctors soon realize this and refuse to refer patients. And patients that are proactive in their care will tell their doctors about poor CDEs.

CDEs can be very useful in educating patients about diabetes and using the equipment, taking medications, and providing support – if they would leave nutrition for the nutritionists or dietitians specializing in diabetes.