DIABETES CARE WITHOUT BORDERS

Dear Friends:
The Endocrine Society is objecting the fact that some of the anti diabetic medications would be sold over the counter, insisting that the diabetes care has to be under SUPERVISION of a medical doctor who would coordinate the other activities. Ever since I have begun working with the Indians, I have known that model to be faulty, the only way we can improve the health of the Indians, is work together, not in a hierarchical fashion but in a circular fashion and make the patient feel and understand that it is possible to take care of their health. I have always joked to Michele, My aim is to make my self Unemployed! Indian Health Services and the Tribal Programmes are leading the way and showing the light on how to better look after an indian patient with Diabetes: cooperation and consensus. I am becoming more and more an ornament, I happily admit!
Best wishes
I am enlosing a letter I wrote to Maurits Van Pelt who runs a diabetes are programme in Cambodia (mopotsyo.org) in which people from the community are taught to take care of people with diabetes , the so called Peer to Peer Education Programme. I know you have thousands of emails to read, but read my letter to him if you have a minute to spare.
Dear Maurits,
Recently I heard a comment, I am not sure where in Asia, that the doctor said: I am against medications being freely made available to the patient. Current studies show that up to 80 per cent of the patients (abstract presented at ADA last year) do not follow the regimen prescribed. Among my own patients I can be sure that they take the morning dosage and often do not take the afternoon dosage because of their social life balanced towards evenings and nights.
FDA in the USA, not always a user friendly organization seems to have decided to make available without prescription commonly used drugs. But Endocrine Society vehemently protests that Diabetes medications be excluded from this benevolence.
Just look at the tone of the letter from Endo Society, a little bit condescending and arrogant. We in the field recognize that the days of Doctor directed or supervised Diabetes Care is going to be history and that innovation is coming in from empowerment is given to the patient and not provide more authority to the Doctor.
My role in the team in our clinic, is to see the patient last, rather than first and organize their therapeutic regimen, but after they have been seen by: optometrist, podiatrist, diabetes nutritionist and diabetes educator, I am given time to counsel and talk about spiritual matters (this being possible among the Native American Indians). The Diabetes Educators would have already begun the change in treatment regimen if they thought so, I agree with them almost always. I do keep an eye on prevention factors on complications,especially nephropathy, again following very local criteria, such as
our patients normal BP is around 110-120/60-70.
There is unexplained haematuria with or without diabetes, possibility of IgA nephropathy.
Protein is always measured in the urine and followed. (this is also being automated without my participation) and i check that.
So the time given to me, which is about 45 min to 1 hour per patient: 25 % on medically related matters and 75% on non medical non pharmaceutical matters.
Our patients have easy access to medications and strips to measure blood sugars.
So our system is much closer to MOPOTSYO model than the model espoused by Endocrine society and here is their note:
Society Recommends Exclusion of Diabetes Medications from Nonprescription Drug Expansion

Endocrine Insider
April 4, 2012

To increase patients’ access to safe treatments for certain conditions, the U.S. Food and Drug Administration (FDA) is considering making some commonly used prescription drugs available without a prescription. FDA held a hearing on March 22-23 to receive public feedback on the expansion, which is proposed to provide more ready access for medications for highly prevalent diseases that can be self-diagnosed and treated. As examples of such diseases, FDA listed hyperlipidemia, hypertension, migraine headaches, and asthma in a February 28 request for comments. The Society is concerned that FDA might also include medications for diabetes under this expansion due to the high prevalence of the disease.

As a result of its concerns, the Society submitted a comment letterurging the FDA to exclude diabetes medications from this expansion due to the complexity of treating and managing diabetes. The Society recommends that diabetes medications continue to be prescribed by a physician and that allied health professionals should continue to provide education and assistance to patients in coordination with a supervising physician. The FDA is currently considering comments on the proposed expansion and the Society will inform its members once a determination has been made. Additional information can be accessed here.



as an anthropologist I have to question the motive of the society, which is primarily to protect the endocrinologists rather than the welfare of the patient? Medications are freely available in most parts of the world and in many countries patients never get to see a doctor but a pharmacist is the one that gives the advice.



Quantitatively speaking, the results of National Studies in the USA, does not show that the measurements are any better than poor, developing countries of the world. and of course if you compare, the results among the Mexican Americans in Texas or Blacks in Georgia or American Indians in South Dakota, most of the developing countries have similar or better quantitative profiles . In Basra, Iraq a war zone the average A1C is very similar to the above groups mentioned.



What Endocrine Society need to understand is that Diabetes as we see it (excluding type 1) is a social disease and the answers are going to be social in nature, with a good contribution from medications. In a study published in the last couple of days they wanted to show that injectable Exanetide was better than Metformin, but it turned out to be not superior to any of the medications we commonly use except Sitagliptin, another newer medication.



Today I will start reading about Outcome Measurements and also i was happy to see that the World Diabetes Foundation has taken an interest in the Diabetes among Indigenous peoples of the world! I will be in touch with you regarding how to approach them.



Enjoy your holidays. You deserve it. It is a beautiful day in Paris. I will be leaving for the Indians (Nebraska and South Dakota) on April 16th.



Yehuda

LIFESTYLE COUNSELING ON A REGULAR BASIS WILL GET YOU THE WANTED RESULTS IN DIABETES HYPERTENSION AND HIGH CHOLESTEROL

Lifestyle Counseling in Routine Care and Long-Term Glucose, Blood Pressure, and Cholesterol Control in Patients With Diabetes
Fritha Morrison, MPH1, Maria Shubina, SCD1 and Alexander Turchin, MD, MS1,2,3⇓
+ Author Affiliations

1Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts
2Harvard Medical School, Boston, Massachusetts
3Clinical Performance Measurement, Partners HealthCare System, Boston, Massachusetts
Corresponding author: Alexander Turchin, aturchin@partners.org.
Abstract

OBJECTIVE In clinical trials, diet, exercise, and weight counseling led to short-term improvements in blood glucose, blood pressure, and cholesterol levels in patients with diabetes. However, little is known about the long-term effects of lifestyle counseling on patients with diabetes in routine clinical settings.

RESEARCH DESIGN AND METHODS This retrospective cohort study of 30,897 patients with diabetes aimed to determine whether lifestyle counseling is associated with time to A1C, blood pressure, and LDL cholesterol control in patients with diabetes. Patients were included if they had at least 2 years of follow-up with primary care practices affiliated with two teaching hospitals in eastern Massachusetts between 1 January 2000 and 1 January 2010.

RESULTS Comparing patients with face-to-face counseling rates of once or more per month versus less than once per 6 months, median time to A1C <7.0% was 3.5 versus 22.7 months, time to blood pressure <130/85 mmHg was 3.7 weeks versus 5.6 months, and time to LDL cholesterol <100 mg/dL was 3.5 versus 24.7 months, respectively (P < 0.0001 for all). In multivariable analysis, one additional monthly face-to-face lifestyle counseling episode was associated with hazard ratios of 1.7 for A1C control (P < 0.0001), 1.3 for blood pressure control (P < 0.0001), and 1.4 for LDL cholesterol control (P = 0.0013).

CONCLUSIONS Lifestyle counseling in the primary care setting is strongly associated with faster achievement of A1C, blood pressure, and LDL cholesterol control. These results confirm that the findings of controlled clinical trials are applicable to the routine care setting and provide evidence to support current treatment guidelines.

IF THE VEGETARIAN DIET CAN MAKE YOU HAPPIER, WHY ARE THE INDIANS SO MOROSE?

iTHE POINT OF THIS ARTICLE IS NOT ABOUT VEGETARIAN DIET ELSEWHERE THAN USA BECAUSE THE MEAT PRODUCTS ARE SO TAINTED THAT GOING VEGETARIAN IS LIKE DETOXIFYING YOURSELF AND THE SENSE OF WELL BEING COMES FROM THE DE TOXIFICATION..

Vegetarian Diet Could Make You Happier And Less Stressed, Study Shows

Posted: 03/11/2012 10:59 am
By Elizabeth Nolan Brown, for Blisstree.com
Omnivores, take note: Embracing a vegetarian diet could make you happier and less stressed, according to new research published in Nutrition Journal.
The reason comes down to fatty acids: Diets that include meat and fish are higher in arachidonic acid (AA), an animal source of omega-6 fatty acids. Much of the meat Americans eat today is quite high in AA: The average omega-6 to omega-3 fatty acid profile of modern grain-fed meat is 5 times higher than grass-fed meat, like our ancestors ate. And previous research has shown high levels of AA can cause mood-disturbing brain changes.

High-fish diets also mean higher levels of long-chain, or omega-3 fatty acids, like eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Both EPA and DHA combat the negative effects of AA. High dietary levels of omega-3 fatty acids are linked to better brain health, better mood and a host of other health benefits. Most health experts recommend an omega-6/omega-3 ratio of about 4:1.

In theory, then, frequent fish eaters should have be protected against the damaging effects of AA because of their higher intake of omega-3 acids. But an earlier study found omnivores reported significantly worse moods than vegetarians, despite higher intakes of EPA and DHA.
In this follow-up study, 39 meat-eating participants were assigned to one of three diets. A control group ate meat, fish or poultry daily; a second group ate fish 3-4 times weekly but no meat; and a third group ate strictly vegetarian. After two weeks, mood scores were unchanged for the fish- and meat-eating groups, but vegetarians reported significantly better moods and less stress.
“Restricting meat, fish, and poultry improved … short-term mood state in modern omnivores,” the researchers concluded.
After two weeks on a vegetarian diet, participants had “negligible amounts” of EPA, DHA and AA in their bodies. Fatty acid levels in the control group were unchanged. Participants in the fish eating group showed 95 to 100% higher levels of EPA and DHA fatty acids—but their omega-6 to omega-3 ratios were still heavily skewed toward omega-6′s.
To work plant sources of omega-3 fatty acids (called ALA) into your diet, try chia seeds, hemp seed, cauliflower and purslane.

Red meat increases death, cancer and heart risk, says study

A diet high in red meat can shorten life expectancy, according to researchers at Harvard Medical School.

The study of more than 120,000 people suggested red meat increased the risk of death from cancer and heart problems.

Substituting red meat with fish, chicken or nuts lowered the risks, the authors said.

The British Heart Foundation said red meat could still be eaten as part of a balanced diet.

The researchers analysed data from 37,698 men between 1986 and 2008 and 83,644 women between 1980 and 2008.

They said adding an extra portion of unprocessed red meat to someone's daily diet would increase the risk of death by 13%, of fatal cardiovascular disease by 18% and of cancer mortality by 10%. The figures for processed meat were higher, 20% for overall mortality, 21% for death from heart problems and 16% for cancer mortality.

The study said: "We found that a higher intake of red meat was associated with a significantly elevated risk of total, cardiovascular disease, and cancer mortality.

"This association was observed for unprocessed and processed red meat with a relatively greater risk for processed red meat."

The researchers suggested that saturated fat from red meat may be behind the increased heart risk and the sodium used in processed meats may "increase cardiovascular disease risk through its effect on blood pressure".

Victoria Taylor, a dietitian at the British Heart Foundation, said: "Red meat can still be eaten as part of a balanced diet, but go for the leaner cuts and use healthier cooking methods such as grilling.

"If you eat processed meats like bacon, ham, sausages or burgers several times a week, add variation to your diet by substituting these for other protein sources such as fish, poultry, beans or lentils."

The New Pharmaceutical Company Representatives: The Professor Peons

Can we trust Medical Professionals in the employ of Drug Companies to teach us about Drugs?

I just received something in the mail about one of the many new drugs to treat Diabetes, this one a long acting GLP 1 agonist that the patient can use once a week.
So a professor is presenting and enthusiastically endorses her drug, brushing aside the possibilities of Thyroid Cancer and Pancreatitis as side effect:
“I am really excited that we now have another drug and perhaps a drug that for some patients will make adherence easier. Because this is now just a once-a-week injection.” This is Dr A… P for MEDSCAPE.

As is my custom, now jaded by listening to professor peons of the pharma industry, I looked up whether or not she was in the employ of the manufacturer of the drug, sure enough.
Served as Director, officer, partner, employee, advisor, consultant or trustee for: Amylin Pharmaceuticals

The very same company that manufactures the drug she is enthusiastically endorses.
Is this ethical?
Or is this just the way of life in this postmodern world?
My title for them Professor-Peons is a good designation indeed!
The same day ADA EASD recommendations arrived in a slide form

You can expect a reduction in HgA1c of 0.5- 1.0 with GLP agonists…
To put every thing in context we need interventions that would bring down the A1C levels by 2 or 3 in most patients, that is certainly not going to come from medications, or education but what will become a global way of looking after patients with Diabetes: to pay attention to the person who is suffering, find out all the sources of his suffering, not just at his A1C level or Medication list: Psychological/Philosophical counselling, taking into consideration the cultural context. I can say this after working with American Indians in the USA, various native and non-native populations around the world.
Medications account for only 25 % of the treatment of patient with Type 2 DM
Treatment is too sterile a word; Healing would be a better word. So these professor peons can be entrusted with that 25 % and let others take care of the other 75 % and be given the credit they are due!


WebMD owns MEDSCAPE
Which has come under increasing criticism for being a disguise for pharma advertising:
Allegations have been made that WebMD biases readers towards using drugs sold by their pharmaceutical sponsors in cases in which the drug is unnecessary.[12]
In February 2010, Senator Chuck Grassley of Iowa investigated WebMD’s financial relationship with drug maker Eli Lilly.

I personally wouldn't read WebMD magazine nor will I direct my patients towards it and in our clinics, those magazines do not make appearances since we serve poor people and of no economic importance to these glossy magazines and drug representatives.

HAPPY TO BE AN ENDOCRINOLOGIST

Where to we find enduring love? Answer: Oxytocin. Infidelity? Testosterone. Heartbreak? Low serotonin and endorphins. In fact, our loved ones are actually present in our brains - neurochemically - and when we lose them, it results in chemical trauma for the brain:
Where to we find enduring love? Answer: Oxytocin. Infidelity? Testosterone. Heartbreak? Low serotonin and endorphins. In fact, our loved ones are actually present in our brains - neurochemically - and when we lose them, it results in chemical trauma for the brain:

"An American study of over four thousand men found that husbands with high testosterone levels were 43 percent more likely to get divorced and 38 percent more likely to have extramarital affairs than men with lower levels. They were also 50 percent less likely to get married at all. Men with the least amounts of testosterone were more likely to get married and to stay married, maybe because low testosterone levels make men calmer, less aggressive, less intense, and more cooperative.

"The desire to commit to someone is strongly linked to ... oxytocin. ... Oxytocin is released by the pituitary gland and acts on the ovaries and testes to regulate reproduction. Researchers suspect that this hormone is important for forming close social bonds. The levels of this chemical rise when couples watch romantic movies, hug, or hold hands. Prairie voles [mammals related to the mouse], when injected with oxytocin, pair much faster than normally. Blocking oxytocin prevents them from bonding in a normal way. This is similar in humans, because couples bond to certain characteristics in each other. This is why you are attracted to the same type of man or woman repeatedly. In general, levels of oxytocin are lower in men, except after an orgasm, where they are raised more than 500 percent. This may explain why men feel very sleepy after an orgasm. This is the same hormone released in babies during breast-feeding, which makes them sleepy as well.

"Oxytocin is also related to the feelings of closeness and being 'in love' when you have regular sex for several reasons. First, the skin is sensitized by oxytocin, encouraging affection and touching behavior. Then, oxytocin levels rise during subsequent touching and eventually even with the anticipation of being touched. Oxytocin increases during sexual activity, peaks at orgasm, and stays elevated for a period of time after intercourse. ... In addition, there is an amnesic effect created by oxytocin during sex and orgasm that blocks negative memories people have about each other for a period of time. The same amnesic effect occurs from the release of oxytocin during childbirth, while a mother is nursing to help her forget the labor pain, and during long, stressful nights spent with a newborn so that she can bond to her baby with positive feelings and love.

"Higher oxytocin levels are also associated with an increased feeling of trust. In a landmark study by Michael Kosfeld and colleagues from Switzerland published in the journal Nature, intranasal oxytocin was found to increase trust. Men who inhale a nasal spray spiked with oxytocin give more money to partners in a risky investment game than do men who sniff a spray containing a placebo. This substance fosters the trust needed for friendship, love, families, economic transactions, and political networks. According to the study's authors, 'Oxytocin specifically affects an individual's willingness to accept social risks arising through interpersonal interactions.' ...

"What happens in the brain when you lose someone you love? Why do we hurt, long, even obsess about the other person? When we love someone, they come to live in the emotional or limbic centers of our brains. He or she actually occupies nerve-cell pathways and physically lives in the neurons and synapses of the brain. When we lose someone, either through death, divorce, moves, or breakups, our brain starts to get confused and disoriented. Since the person lives in the neuronal connections, we expect to see her, hear her, feel her, and touch her. When we cannot hold her or talk to her as we usually do, the brain centers where she lives becomes inflamed looking for her. Overactivity in the limbic brain has been associated with depression and low serotonin levels, which is why we have trouble sleeping, feel obsessed, lose our appetites, want to isolate ourselves, and lose the joy we have about life. A deficit in endorphins, which modulate pain and pleasure pathways in the brain, also occurs, which may be responsible for the physical pain we feel during a breakup."

Author: Daniel G. Amen, M.D.
Title: The Brain in Love
Publisher: Three Rivers Press
Date: Copyright 2007 by Daniel G. Amen, M.D.
Pages: 64-68


The Brain in Love: 12 Lessons to Enhance Your Love Life
by Daniel G. Amen M.D. by Three Rivers Press

at last something about Poverty and Diabetes

Food Insecurity and Glycemic Control Among Low-Income Patients With Type 2 Diabetes
Hilary K. Seligman, MD, MAS1,2⇓, Elizabeth A. Jacobs, MD, MPP3, Andrea López, BS1,2, Jeanne Tschann, PHD4 and Alicia Fernandez, MD1
+ Author Affiliations

1Division of General Internal Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California
2Center for Vulnerable Populations, San Francisco General Hospital, University of California, San Francisco, San Francisco, California
3Division of General Medicine and Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
4Department of Psychiatry, University of California, San Francisco, San Francisco, California
Corresponding author: Hilary K. Seligman, hseligman@medsfgh.ucsf.edu.
Abstract

OBJECTIVE To determine whether food insecurity—the inability to reliably afford safe and nutritious food—is associated with poor glycemic control and whether this association is mediated by difficulty following a healthy diet, diabetes self-efficacy, or emotional distress related to diabetes.

RESEARCH DESIGN AND METHODS We used multivariable regression models to examine the association between food insecurity and poor glycemic control using a cross-sectional survey and chart review of 711 patients with diabetes in safety net health clinics. We then examined whether difficulty following a diabetic diet, self-efficacy, or emotional distress related to diabetes mediated the relationship between food insecurity and glycemic control.

RESULTS The food insecurity prevalence in our sample was 46%. Food-insecure participants were significantly more likely than food-secure participants to have poor glycemic control, as defined by hemoglobin A1c ≥8.5% (42 vs. 33%; adjusted odds ratio 1.48 [95% CI 1.07–2.04]). Food-insecure participants were more likely to report difficulty affording a diabetic diet (64 vs. 49%, P < 0.001). They also reported lower diabetes-specific self-efficacy (P < 0.001) and higher emotional distress related to diabetes (P < 0.001). Difficulty following a healthy diet and emotional distress partially mediated the association between food insecurity and glycemic control.

CONCLUSIONS Food insecurity is an independent risk factor for poor glycemic control in the safety net setting. This risk may be partially attributable to increased difficulty following a diabetes-appropriate diet and increased emotional distress regarding capacity for successful diabetes self-management. Screening patients with diabetes for food insecurity may be appropriate, particularly in the safety net setting.

Footnotes

This article contains Supplementary Data online at http://care.diabetesjournals.org/lookup/suppl/doi:10.2337/dc11-1627/-/DC1.