RE: A1c office testing

October 17, 2011

I agree that a low carb diet works best for these people and, yes, intensive lifestyle changes worked better. The problem is that I live in Iowa, one of the fattest states! I didn't mean to imply that I only give them metformin. It is part of a bigger picture of ADA diet plus exercise plus meds. Helps with weight loss, etc. Here is a good summary of the followup findings published in Lancet 2009. http://www.theheart.org/article/1017341.do

Lynette I Iles MD 301 South Iowa Ste 2Washington IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee. If you have received this email in error, please notify the sender immediately and delete it from your computer.

October 17, 2011

jim,

i found it on uptodate and the green journal about 2005...

very interesting...

to top it all, i had a psych-iatrist friend who had neuropathy about 5 years

prior to overt DM... and he kept on poking his toe years prior and in fact was

his only complaint. he thought it was due to his pointy fashionable shoes.

grace

>

> Also agree on statins, little data for primary prevention.

> I have looking all over for an article that shows that diabetic neuropathy can

precede long term hyperglycemia. If you have the reference, can you send it?

>

> ________________________________

> From:

[ ] On Behalf Of Lynette Iles [liles64@...]

> Sent: Monday, October 17, 2011 10:03 AM

> To:

> Subject: Re: Re: A1c office testing

>

> Correlation between fingerstick hgb a1c and venous was excellent, never more

than .2 difference. We double tested almost everyone for 2 months. Now, we do a

double test/ spot check every 4-6 months. Still running very accurate.

>

> Since I did ob for so long, I got used to watching post-prandial sugars. My

brain made the jump that this was probably also the best indicator of early

diabetes (ie 2hr GTT). The easiest way to get a handle on PP sugars was to do a

hgb a1c. By the time 'diabetes' is diagnosed, something like 50% of islet cells

are already gone. I use ALOT of metformin due to the studies that show a

postponing of diabetes for up to 5 years, even after use is stopped. I actually

spend alot more time addressing insulin resistance than I do mild to moderately

high cholesterol, as DM is so much worse of a disease than the risk of high

cholesterol.

>

> Agree with the NNT data on the statins. Unless secondary prevention,

definitely not motivating to use. I come from a family with high cholesterol on

both sides. Extensive DM on my mother's side. The young die in their 80's from

smoking or ignoring their diabetes. Otherwise, 90's-100's. I'm not thinking the

high cholesterol genetics are very significant!

>

> Lynette I Iles MD

> 301 South Iowa

> Ste 2

> Washington IA 52353

> Flexible Family Care

> 'Modern medicine the old-fashioned way'

> This e-mail and attachments may contain information which is confidential and

is only for the named addressee. If you have received this email in error,

please notify the sender immediately and delete it from your computer.

>

October 18, 2011

I found some interesting things in Up-to-date: Patients with prediabetes (defined by the American Diabetes Association as a fasting glucose of 100 to 125 mg/dL [5.6 to 6.9 mmol/L] or a two-hour serum glucose between 140 and 199 mg/dL [7.8 and 11.0 mmol/L] on an oral glucose tolerance test) may present with intensely painful feet. Patients with frank diabetic neuropathy may also present with pain, paresthesias, or dysesthesias of their feet. Some patients, however, have few complaints but the physical examination reveals mild to moderately severe sensory loss Natural history — The rationale for regular monitoring (see 'Monitoring' below) is the observation that the incidence of diabetic neuropathy (and other microvascular and macrovascular complications) increases over time. This was illustrated by a study from Finland that evaluated the natural history of peripheral neuropathy in patients with newly diagnosed type 2 diabetes [3]. Polyneuropathy was diagnosed on the basis of both clinical (pain and paresthesia) and electrodiagnostic (nerve conduction velocity and response-amplitude values) criteria. The prevalence of definite or probable polyneuropathy progressively increased from 8.3 percent at baseline to 41.9 percent at 10 years; comparable values in normal subjects were 2.1 and 5.8 percent, respectively. DIFFERENTIAL DIAGNOSIS — When evaluating diabetic patients with neuropathy, it is important to appreciate that there are other causes of neuropathy (table 3). These should be considered if there is any aspect of the history or clinical presentation suggesting features atypical of diabetic neuropathy (eg, signs of a systemic disease such as vasculitis).Certain forms of neuropathy (other than diabetic polyneuropathy) occur more frequently in patients with diabetes than in the general population and should be excluded. These include chronic inflammatory demyelinating polyneuropathy (CIDP) and neuropathy due to vitamin B12 deficiency, hypothyroidism, and uremia [13]. So, some prediabetics do have neuropathy. But there is an element of neuropathy in the nondiabetic population which cannot be ignored as not insignificant. And the literature also says that other forms of neuropathy are more common in diabetics too. I was surprised to learn that prediabetics can present with “intensely painful feet” which is a form of neuropathy but subjective. This article did not say that they have objective evidence of a peripheral neuropathy though. It almost sounded like you were saying that if you found a patient with neuropathy that you would pretty much advise them they were diabetic. I was cautioning that there are many other causes. And I am sure there is still a lot more to learn. How many of us have had diabetics always in wonderful control who develop neuropathy and some diabetics always in horrible control who don’t develop neuropathy. Obviously, there is more to it than sugar. Kathy Saradarian, MDBranchville, NJwww.qualityfamilypractice.comSolo 4/03, Practicing since 9/90Practice Partner 5/03Low staffing From: [mailto: ] On Behalf Of pricklyfinger2007Sent: Monday, October 17, 2011 3:12 PMTo: Subject: Re: A1c office testing jim,i found it on uptodate and the green journal about 2005...very interesting...to top it all, i had a psych-iatrist friend who had neuropathy about 5 years prior to overt DM... and he kept on poking his toe years prior and in fact was his only complaint. he thought it was due to his pointy fashionable shoes.grace>> Also agree on statins, little data for primary prevention.> I have looking all over for an article that shows that diabetic neuropathy can precede long term hyperglycemia. If you have the reference, can you send it?> > ________________________________> From: [ ] On Behalf Of Lynette Iles [liles64@...]> Sent: Monday, October 17, 2011 10:03 AM> To: > Subject: Re: Re: A1c office testing> > > > Correlation between fingerstick hgb a1c and venous was excellent, never more than .2 difference. We double tested almost everyone for 2 months. Now, we do a double test/ spot check every 4-6 months. Still running very accurate.> > Since I did ob for so long, I got used to watching post-prandial sugars. My brain made the jump that this was probably also the best indicator of early diabetes (ie 2hr GTT). The easiest way to get a handle on PP sugars was to do a hgb a1c. By the time 'diabetes' is diagnosed, something like 50% of islet cells are already gone. I use ALOT of metformin due to the studies that show a postponing of diabetes for up to 5 years, even after use is stopped. I actually spend alot more time addressing insulin resistance than I do mild to moderately high cholesterol, as DM is so much worse of a disease than the risk of high cholesterol.> > Agree with the NNT data on the statins. Unless secondary prevention, definitely not motivating to use. I come from a family with high cholesterol on both sides. Extensive DM on my mother's side. The young die in their 80's from smoking or ignoring their diabetes. Otherwise, 90's-100's. I'm not thinking the high cholesterol genetics are very significant!> > Lynette I Iles MD> 301 South Iowa> Ste 2> Washington IA 52353> Flexible Family Care> 'Modern medicine the old-fashioned way'> This e-mail and attachments may contain information which is confidential and is only for the named addressee. If you have received this email in error, please notify the sender immediately and delete it from your computer.>

October 18, 2011

kathy,

thanks for this.

i dont recall whether this was the article of a while back.

i think there is a biomolecular basis for this when sugar dips and peaks within

nanoseconds that affect end organs in the long run.

and for those who are needlephobes such as moi, it may take years to prove such

a thing.

but i aint waiting so....

psst... im seriously sitting down and talking to jean bout her hersheys...

grace

> >

> > Also agree on statins, little data for primary prevention.

> > I have looking all over for an article that shows that diabetic neuropathy

> can precede long term hyperglycemia. If you have the reference, can you send

> it?

> >

> > ________________________________

> > From:

> <mailto:%40yahoogroups.com>

> [

> <mailto:%40yahoogroups.com> ] On Behalf Of Lynette Iles

> [liles64@]

> > Sent: Monday, October 17, 2011 10:03 AM

> > To:

> <mailto:%40yahoogroups.com>

> > Subject: Re: Re: A1c office testing

> >

> > Correlation between fingerstick hgb a1c and venous was excellent, never

> more than .2 difference. We double tested almost everyone for 2 months. Now,

> we do a double test/ spot check every 4-6 months. Still running very

> accurate.

> >

> > Since I did ob for so long, I got used to watching post-prandial sugars.

> My brain made the jump that this was probably also the best indicator of

> early diabetes (ie 2hr GTT). The easiest way to get a handle on PP sugars

> was to do a hgb a1c. By the time 'diabetes' is diagnosed, something like 50%

> of islet cells are already gone. I use ALOT of metformin due to the studies

> that show a postponing of diabetes for up to 5 years, even after use is

> stopped. I actually spend alot more time addressing insulin resistance than

> I do mild to moderately high cholesterol, as DM is so much worse of a

> disease than the risk of high cholesterol.

> >

> > Agree with the NNT data on the statins. Unless secondary prevention,

> definitely not motivating to use. I come from a family with high cholesterol

> on both sides. Extensive DM on my mother's side. The young die in their 80's

> from smoking or ignoring their diabetes. Otherwise, 90's-100's. I'm not

> thinking the high cholesterol genetics are very significant!

> >

> > Lynette I Iles MD

> > 301 South Iowa

> > Ste 2

> > Washington IA 52353

> > Flexible Family Care

> > 'Modern medicine the old-fashioned way'

> > This e-mail and attachments may contain information which is confidential

> and is only for the named addressee. If you have received this email in

> error, please notify the sender immediately and delete it from your

> computer.

> >

>

October 18, 2011

thanksI'm good:)

kathy,

thanks for this.

i dont recall whether this was the article of a while back.

i think there is a biomolecular basis for this when sugar dips and peaks within nanoseconds that affect end organs in the long run.

and for those who are needlephobes such as moi, it may take years to prove such a thing.