Bring on the comfort food.

Hey Dad,

While it has been unseasonably warm in Chicago, the light is still waning as we get into autumn and I'm struck by how much I am craving comfort foods.  I also feel like I have less awake time as the days get shorter (even though that's not actually true), so I'm disinclined to spend much time after a workday cooking food or doing dishes.  It just feels a lot easier to just order takeout than to take the time to prepare a healthy meal.  This is the beginning of hibernation mode.

I'm lucky in that I don't do the kind of physical work that you do.  Sure, my days start stupidly early because I teach an early class, but I'm not wiped out by 4:00 p.m. the way you are since you were already at work for an hour when I got out of bed around 5:15 a.m.  If I'm tired when I get home from my cushy research and teaching job, I can only imagine your exhaustion when you've been out in the Florida heat lifting heavy things and sitting in traffic all day.

I'm pretty hungry looking at this.

But even with the warm weather, my body still knows it's time for comfort food.  Soup, chili, roasts, etc. just don't taste as good in the spring and summer.  I find it's a lot easier to eat healthfully with minimal day-to-day food prep time when I use a crockpot a couple of times per week.

Why I love the crock pot:

It saves you time because when you get home from work, your food is ready to eat.  All you have to do is prepare the vegetables ahead of time, which you can do in bulk and keep in the refrigerator.  You set up the food in the ceramic liner (the crock) the night before, take that out of the refrigerator in the morning before you go to work, set it in the heater, turn it on, and that's all.

They even make liners so cleaning it is super easy.  Personally, I spray mine with an olive oil spray to keep stuff from sticking too badly.

Bonus!  You will probably make more than enough food so you can freeze a couple of portions to eat for dinner on a different night or take it for your lunch if you will be able to use a microwave.

The next time I'm visiting, I'll have to make a pot roast in the crock pot so that I can introduce you to leftover pot roast soup.  It's inexpensive because I can use whatever type of roast is on sale because it will cook slowly.

Leftover Pot Roast Soup

1. Make a pot roast about twice as big as you'll need for one night's dinner in the crock pot using whichever recipe you like. I liked this recipe most recently and I skipped the thickening part at the end that used butter and flour so that my housemate could eat it (tip: use cheap wine you might drink, not cooking wine).  There are any number of recipes out there that will do, like these, these, or these that are also dead simple.  You can also use a pre-mixed seasoning packet, like onion soup mix, but be careful about the sodium content since those tend to be crazy high.  Cook vegetables like celery, onions and carrots with your roast, but use very few white potatoes or skip them entirely.  You can make most recipes less likely to wreak havoc with your blood sugar with some minor modifications.
2. Have an awesome pot roast and vegetables dinner.  
3. Put all of the leftovers back into the ceramic part of the crock pot and keep it in the fridge until you're ready to make soup (no more than a day or two).
4. To make it into soup, cut up the leftover pot roast and add about 4 cups of low sodium beef broth (again, watch the sodium content).  Stir it all together so that the broth is mixed into the drippings from the roast.  Add more vegetables to the leftovers. If you need more liquid, add a little water until the solid ingredients are just barely covered.  As it cooks down, there will end up being more broth compared to vegetables and beef in the end.  To season it, add garlic, pepper, and more of whatever herbs you used in the pot roast seasoning.  Hold off on the salt until it is nearly done cooking so that you don't end up over-salting it.  I highly recommend a heavy dash of curry powder to make it more interesting.  If you have a cold, give it a little cayenne pepper to help your sinuses drain.
5. Set the up the crock pot on low heat if you're going to be gone for 8+ hours.  Put it on high heat if you'll want to eat in about 6 hours.
6. If you want a thicker soup, I think adding a little bit of whole grain to it like barley is a better bet than thickening it with corn starch or rice. A little goes a long way.  I wouldn't add more than 1/4 cup of quick cooking barley to that pot of soup.  If the soup has too little broth at the end, add some boiling water.
7. Have an awesome leftover pot roast soup dinner.

The specific nutritional content will vary depending on the original cooking method, how lean the roast was to begin with, which vegetables you used, and whether you added a grain to the soup, but overall this is a really sound way to get two filling, hearty meals with minimal prep time, few carbs, and little money.  It's also friendly for people who have dietary restrictions because they can leave out the parts they're allergic to.  Since I know you're more interested in counting carbs than calories, I think this approach will work pretty well for you.

Hopefully, I'll be able to get down there to see you soon and to force some curry on you since I suspect that is the one suggestion you most definitely will not follow.  I'll save trying to convince you to eat mushrooms for another visit.  First, though, I have to go back into the dissertation cave for a bit. When I come back out of it, I imagine I'll have more to say about health insurance reform and other cheerful topics.

Love,
Mel

Why does diabetes care cost so much?

Hey Dad,

It was good to get your feedback about the Affordable Care Act summary I wrote. I agree that it's still confusing, even with it broken down the way I have it.  I promise I will return to it and make it simpler as it becomes clearer to me.  I'm afraid, though, that it will never be simple enough because of the politics around making that legislation happen in the first place.  The bottom line for you will be that it means no change because you already have health insurance through your union that I'm positive covers the minimum that the ACA covers and you are not an hourly employee.  You might get even more preventive services with no co-pay because of the new regulations.


We talk a lot about why health care is so expensive and I'm sure we're not getting bored with it because it's very complicated.  I was pretty excited when I came across John Green's explanation of the system.  I think he's able to talk about it clearly in part because he's not a health care researcher.  Also, he's way funnier than I am when I talk about it.

So in the US, we spend about $245 billion per year just on diabetes care.  This is a lot, but it's especially a lot when we consider that in 2007 it was only $174 billion.  In contrast, in the UK diabetes care costs about £14 billion (about $22,400 billion USD), Canada spends about $12 billion CDN (about $11.6 billion USD), and Australia spends about $10.3 billion AUD (about 21.5 billion USD).  None of this should be surprising after hearing Green talk about the overall massive differences in health care spending.

The UK, Canada, and Australia all have some form of universal health care, which means that basic health care is funded through taxes and administered through a centralized system. Countries differ about how much people pay for medications and supplies, but since those costs are much lower to begin with, the out of pocket costs for people with diabetes is lower than in the US.  It is hard to pin down figures because the systems all report things differently, but considering that in the US individuals with diabetes incur about $7,900 worth of expenses directly related to the disease and that health care coverage is so varied, it is safe to say that it's a lot more expensive to live healthfully with diabetes in the US than other leading industrialized nations.


All of the issues that Green brings up are absolutely part of the problem of the expensiveness of diabetes care in the US.  Getting back to the question I raised last time about the effects that the ACA will have on out-of-pocket diabetes costs, I still don't think it will make any difference for people who have already been insured mostly because even with increasing access to health insurance, since the payors (private insurance companies and Medicare/Medicaid) are not centralized, folks who do not qualify for government benefits will not benefit from the economy of scale (negotiation of prices for massive contracts) that Green was talking about.  We will also continue to have huge inefficiencies in the system and high administrative costs because there are differences in billing, coverage, reimbursement, etc., so I don't think the ACA is going to do anything to reduce the cost of health care in the bigger picture, because it is not in the interest of the health care industry to cut its profits.

I'm glad that the out-of-pocket costs are manageable for you and that you have a union that has advocated for you and your coworkers.  Not all union members are in as good a position, though, since there are some unintended consequences that might hurt them.  As much as I hate to say this, I am grateful that your coverage is already through a for-profit insurance company.

Love,

Mel

What does the Affordable Care Act mean for diabetes care?

The next phase of the Patient Protection and Affordable Care Act (ACA, "Obamacare") will go into effect starting October 1, 2013, when the Health Insurance Marketplace goes live.  From what I gather, it will be kind of like shopping online for car insurance, but for health coverage.  I was hoping to be able to write something specific about what the coverage means for people with diabetes, but those details are not available yet.  I think that will depend entirely on which coverage you or your employer buys.

Given that the open enrollment period begins in just a few weeks, I'm a bit dismayed by the lack of concrete information.  A lot of people who are currently uninsured receive discounts or free medications through Patient Assistance Programs and they have access to free or low cost health clinics that are designated for the uninsured.  But what sort of affordable coverage will be there for these folks who have historically been uninsured or under-insured?  Will the out of pocket costs of diabetes medications be even higher for folks who might no longer qualify for Patient Assistance Programs?

The ACA is so complicated that I even though I read policy jargon all the time, I had to re-read even the summaries several times to get the main points, especially around penalties and fees. Here's what I have figured out so far:

Download the PDF at https://dl.dropboxusercontent.com/u/6989183/PPACADownload.pdf

What it means for you:

• You have to purchase health insurance, either through your employer or the Health Insurance Marketplace.  You cannot be denied new coverage due to pre-existing conditions.

• If you don't purchase insurance, then you will receive a 2014 tax penalty of the greater $95 for an individual/$285 for a family or 1% of the household income.  This will increase to $325/975 or 2% for 2015 and $695/$2,085 or 2.5% in 2016.  Beyond 2016, it will adjust for inflation.

• You are exempt from penalties if you earn too little to file a federal tax return (below $9,530 for singles and $18,700 for couples) or the lowest price plan exceeds 8% of your income.

• If you do not like or cannot afford the insurance plan your employer offers, you can purchase insurance through the marketplace instead.

• If you earn 133-400% of the Federal Poverty Line (FPL), then you will qualify for government subsidies for premiums and cost-sharing for plans purchased through the marketplace.  The 2013 FPL (in the contiguous 48 states and Washington DC) for an individual is $11,490 and it is $23,550 for a family of four.

• You may qualify for Medicaid even if you didn't before (for example, if you are a single, child-free adult living near the FPL) if it is expanded in your state.  If your state does not expand Medicaid, there might be a state Basic Health Plan for you if you earn 133-200% of the FPL.  If you receive Medicaid or participate in a state Basic Health Plan, then you would not receive the subsidy.

• If your insurance company mis-spends your premiums on stuff other than health care services, you will receive a refund.

Since I wasn't getting anywhere with specific policy coverage, I then tried to figure out what is included in the minimum essential benefits that qualifying health care coverage is supposed to deliver.  All I have found are discussions that center around how frustratingly obtuse the legislation is and ways that employers might exploit loopholes by offering inadequate coverage and not reporting their compliance activities.  Even descriptions of the Basic Health Plans that states could offer in lieu of expanding Medicaid do not give any meaningful details.  

The U.S. Supreme Court ruled that the individual mandate to buy health insurance is constitutional, so in order to reduce the burden on low income individuals, Medicaid has been expanded.  However, since Medicaid is administered by the states, it is up to them to decide whether to expand that coverage.  This means that states that do not expand Medicaid eligibility per the federal guidelines will also not receive the additional federal monies, leaving many low income, working people uninsured due to their inability to afford insurance coverage through the health insurance exchanges.  They would be exempt from tax penalties for being uninsured, but they also would disproportionately bear the risk of devastating medical expenses in the event of serious illness or injury and they would not benefit from the discounted negotiated rates for services and prescription drugs that members of group plans enjoy.

So what does all of this mean for people with diabetes?

My informed, though unscientific, guess is that more people will have insurance and so they will use preventive health care services.  There should also be higher numbers of office visits which will hopefully reduce emergency room visits.  The ACA could be great for people who have had earnings above the thresholds for Patient Assistance Programs and government programs, but who could not get insurance due to lack of employer sponsored coverage or the pre-existing conditions clauses.  Of course all of this assumes that there are enough physicians who are taking new patients and who will accept the new insurance plans for payment to handle the increased numbers of patients.

Another issue is that there are some ways that practitioners are limited in what they can do if they are billing for it.  For example, in some free clinics for the uninsured, diabetes education and nutritional counseling are unlimited.  In clinics where patients are insured, the availability of those services depends on how much the insurance will cover.  I suspect that instead of expanding these critically necessary services for diabetes care, it will impose tighter limits across the board (for example, many insurance companies will cover three group diabetes education classes the first year of diagnosis).  The best we can hope for is that educational, nutritional and behavioral services for people with diabetes will included as unlimited preventive health care services under the basic health plans.

It is also hard to say what will happen to the affordability of medications and testing supplies.  I suspect that on the whole there will be greater access to a broader range of drugs for middle-income folks, but that the out of pocket costs will still severely limit what is accessible for individuals and families that are struggling to make ends meet.  There are some ways in which having too little prescription drug coverage is worse than having none at all when pharmaceutical companies are willing to subsidize or provide drugs free of charge for the uninsured.

I am cautiously hopeful that this health insurance reform can increase health and well-being in our society. I am also very skeptical and wishing we could have real health care reform.

Talking about/to fat people.

Hey Dad,

I don't mean to keep coming back to issues around obesity since I am focused on diabetes, but there's no way around it.  No matter where I look in my research I am no more than one step away from obesity--as a cause of diabetes, barrier to effective diabetes treatment, or a moral failure of the patient.

A couple of posts ago, I wrote about the problem with "diabesity," and I got a few high-fives for it. The thing people who are heavy talk about most with me is their frustration that doctors think that because they're heavy they are necessarily sick and that their weight will absolutely lead to diabetes and other conditions later on.  I know many healthy people who carry a lot of weight; they are still fully functional in terms of their ability to move and work.  Even into their 40s, they don't have issues with blood pressure, cholesterol or diabetes.  Some people are just bigger than others.  There are a lot of activists working to change the way the general public and the medical field see fat people because it just isn't so simple.

Since I spend so much time looking at the scientific research on obesity, I can see where doctors and other practitioners get the idea that having significant extra weight makes people sick (a lot of the time it actually does), but like so many other things that are driven by supposedly objective science, it is only part of the story.  I don't know how many times I have experienced unwanted discussion of my weight (since, despite a few decades of effort, I'm still a little fat) at a medical appointment when I was there for a sinus infection.  My experience is not unique.  I regularly hear from people how much that specific conversation keeps them from making an appointment even when they know that they need to go to the doctor.

The thing is, doctors are not the enemy; they are trained to behave with less compassion and it is only recently that any real attention has been paid to bedside manner around obesity.  In fact, the topic of obesity has been controversial for the American Medical Association, the main authority over the practice of medicine in the U.S. The shift in thinking about obesity as a disease means that now doctors have an obligation to bring it up in medical visits with patients, something they are woefully unskilled at as a whole.

I've been dreading what this means for people who already don't want to go to the doctor because they don't want to be lectured about their weight and was delighted to hear a talk at the American Association of Diabetes Educators (AADE) conference a few weeks ago that gave me hope that doctors can do so much better.  Dr. Arya Sharma of the Canadian Obesity Network presented a set of tools that they have put together to help physicians have productive, respectful conversations about obesity:  The 5 As of Obesity Management. In this model, they start with asking the patient's permission to have the conversation and then proceed to assess the degree to which obesity is actually causing illness or disability, moving far beyond the BMI measure that most practitioners use, the Edmonton Obesity Staging System.  In this video, Dr. Sharma talks about the stuff that got me most excited at the conference.

So all of that is to say I'm excited that there are researchers and clinicians trying to make it easier for us to get medical and other professional help for losing weight when we need it.  I'm also hopeful that doctors and their staff will become more compassionate and will have better tools for having these sorts of difficult conversations in respectful ways.

After all, if we don't feel respected by our doctors, there's no way we're going to listen to them--even when they might have something relevant to say.

Love,

Mel

Diabetes and your right to work.

Hey Dad,

A few weeks ago, I had lunch with a friend who has type 2 diabetes and has been having a rough time at work.  She's not had much luck with oral meds, so she's been trying different types of non-insulin injectables over the past few years.  The latest one has been a really rough adjustment and has caused her to take time off of work--eating all of her paid time off very early in the year--and to have incredibly personal conversations with HR about what her needs are regarding going to the bathroom (GI problems are common in people with diabetes and some medications intensify them) and testing.  For a lot of folks, going to the bathroom however often they need to isn't a problem, but she works in a call center, so they pay attention to the time she is available for calls.  In my friend's case, the accommodation has been extra bathroom time and she's had to rely on FMLA leave due to extreme side effects, but it's much more involved for people with complications.  She's lucky to have health insurance and a clean place to test and do her injections, but she is still stressed about the effects of controlling her diabetes at work.  It took her a while to get this job and even if she doesn't enjoy it, she needs it.

I can't imagine how difficult GI side effects from diabetes meds must be for people who don't work in an office, who are on the road and need to stop off frequently, or who work on a job site that doesn't have plumbing.  I don't know about you, but one of the last things I want to discuss with my employer is my bathroom needs.  Frankly, I don't want to discuss my health problems at all where I work.

This got me to wondering what kinds of accommodations employers are required to provide for people who have diabetes.  Here's what I found.

Diabetes is a diagnosis that is included in the Americans with Disabilities Act, so employers cannot legally discriminate against persons with diabetes.  It wasn't initially included in the act, presumably because not all persons with diabetes are disabled by the disease, but that changed in 2008 due in to the increasing prevalence of diabetes in working-age people and the efforts of organizations like the American Diabetes Association.  In fact, they have a thorough section on their website devoted to the topic of employment discrimination and they put out a report that addresses a lot of employers' concerns about the safety issues around having employees with diabetes.  It is such a big deal that there is even a government sponsored website all about diabetes in the workplace, primarily geared toward employers and occupational health professionals.

These are all great for knowing what your legal rights are, but what does it actually mean for working people?

The thing is, these legal rights don't apply if the employer doesn't know a person has diabetes--and there are all kinds of reasons that people don't want anybody, much less an employer, to know that they have it, especially stigma.  I know we've talked about how much your employer knows about your health problems and you've brought up some very real concerns about whether management would use it as an excuse to withhold the best earning opportunities from you or if they would assume you are unsafe on the job even if your diabetes is well-controlled.  Your fear is reasonable because that sort of thing happens a lot.

Last night I was hanging out with a bunch of diabetes educators as part of the AADE conference and had the chance to ask them if they've had patients talk about problems getting accommodations at work.  All eight that I asked said yes and that it was a big problem for their patients.  Most of what they see is that even with the change in the law, patients who need their jobs the most, like you, regularly have to make choices between taking care of themselves and keeping their jobs.  It sounds like it's extra hard on 3rd shift workers because their schedule is all goofed up to begin with.  I was talking with four educators from Connecticut and they went on at length about the problems their patients who work at Walmart face, in particular.

"Walmart is the worst.  Unless they work a full 8 hour shift, they don't get lunch, just a 10 minute break.  Our patients need to eat more often than that and there's just no time for them to eat once they get off the floor.  It's the worst for gestational patients."

So what can you and other working folks do about it?

First, do your best to avoid needing insulin.  Eventually, it is quite likely that you will still need insulin despite your best efforts, but there is a lot you can do to avoid or slow down the need for it. Keep eating well, testing your blood sugars, and taking meds when diet and exercise are not enough. The key is controlling the disease so that you can slow down its progression.

Second, it sounds like the bottom line is you can't be protected by the laws if you do not disclose.  If you need an accommodation or you go on insulin, you have to disclose it.  The laws that would legally allow an employer to prevent you from doing a particular job, as it is related to diabetes, pertain only to folks who take insulin.  In that case, the employer has to demonstrate that episodes of hypoglycemia would be dangerous.  Kris Halpern, "the diabetes attorney", notes that even if you disclose to your employers, you still need to let a co-worker know what happens if you have a low because management's policies aren't necessarily carried out by the people who would be your direct supervisors (see the comments at the end of this very useful article).  You will have to be prepared to educate the people you work with about your disease because there's a very good chance they won't know about it or they will have misinformation.

Third, do everything that you can in writing because if you ever need to go to court you will need documentation of what happened.  Because you're a union member, make sure your shop steward knows what's going on.  The union has been good about protecting your job when you've needed time off for kidney surgeries and I imagine they will continue to fight for you if the time comes that you need to go on insulin.  You might want to consider getting involved in leadership to help ensure that this will be the case.

I hope that getting this information helps you feel better about letting people you work with know what's going on with you.  It's hard to keep secrets from people, especially when they are such a big part of your everyday life.  There may still be some grief from it, but you are within your rights to expect reasonable accommodations and they cannot legally fire you for having diabetes.

http://www.rv.net/forum/Index.cfm/fuseaction/thread/tid/26353957/

Most of all, dad, you need to worry about taking care of yourself so you can enjoy your eventual retirement.

Love,

Mel

The problem with "diabesity."

Hey Dad,

Things continue to be busy with working on my dissertation, but the good news is I'm learning things that I can pass along.

Even health care providers and researchers
don't take the stairs.

A few weeks ago, I was at the American Diabetes Association scientific meetings in Chicago. This is the big annual event where researchers, industry, doctors and other clinicians all get together to learn about and discuss the latest and greatest in diabetes care, prevention, and treatment research--and you'd be amazed at the breadth of the stuff they're doing.

Something I heard a lot when I first started doing diabetes research was "diabesity."  The way that people said it just bothered me because it seemed like they were dismissing the seriousness of diabetes because a person was also obese and they were clearly less sympathetic, calling it a "lifestyle disease."  So I looked into it and found that the way most folks are using it comes from Francine R. Kaufman's book, which you can take a peek at here.  Originally, though, “diabesity” was a diagnostic category for type 2 diabetes that was directly caused by obesity in laboratory studies of animals (see this and this if you're curious).  The way it is used now is much more generic, a shorthand for talking about fat people who have diabetes or prediabetes--and it doesn't matter which came first.


The more I learn about diabetes and the more scientists I get to hear talk about this issue, the more I'm convinced that there's some underlying metabolic disorder that causes both diabetes and obesity independently of each other.  This explains why weight loss helps both issues, but is not enough to cure either.  The problem with "diabesity" is that there's a lot of cultural stigma in our society around obesity and to lump the problems together into a single word oversimplifies the causes of diabetes.  We tend to blame fat people for all of their health problems and they are treated poorly as a result.

Blaming obesity for type 2 diabetes hides the fact that it is possible for diabetes to be a cause of obesity (not the other way around) and that weight loss alone does not actually cure diabetes. If the issue were as simple as balancing energy consumed with the energy expended (“don’t eat more than you’ll burn off with activity”), then reducing carbohydrates would cure both diabetes and obesity.

In a recent TED Talk, Dr. Peter Attia did an excellent job of laying this out and describing how his belief that type 2 diabetes was the patient's fault affected the care he gave a patient and how his own experience with metabolic syndrome changed the way he sees diabetes.  Please watch this.

I wish every doctor who ever wrote off my bigger health problems because I was fat could have this awakening so that they would know how they hurt people and they wouldn't keep doing it.

Many people with diabetes are able to live with high blood sugars for their entire lives without complications and no matter what medications and lifestyle changes are made, they never achieve an A1C below 7.5.  There are others who have known genetic mutations within their families that create a condition that looks a lot like type 1 diabetes, but doesn't respond to conventional treatments.  There aren't any conclusions just yet and there aren't any changes being made to the way that diabetes care happens (like new tests and treatment plans), but I was glad to know that the research is happening.

Language matters in how we understand the world and how we relate to each other. I hope that as people who do diabetes care learn just how much they don't know, their language will change. Diabesity is inaccurate and it hurts people.  It is great for marketing and media soudbytes, but it is not a human diagnostic category.

So when it comes to weight loss, diet, exercise, and controlling type 2 diabetes, here's the jist of what I learned at ADA:

"We don't really understand the relationships just yet, but we're working on it.  

In the mean time, please eat some salad because it can't hurt."

I'm glad you're doing so great with weight loss and managing your blood sugar, but if that stops working so well, I want you to know you're not the only one.  It's so frustrating that the one behavior that is pushed over and over again for managing diabetes is not always under your control. I'm looking forward to when the scientists figure it out and they come up with new ways to treat it. For now, though, keep eating what you've been eating since it's working for you.  Also, never take that kind of abuse from a health care provider.  Just because you're overweight doesn't give anybody the right to bully you about it, least of all the people you trust with your health care.

Love,

Mel

Sad news and a plea.

Hey Dad,

I am sorry it's taken me a while to write.  The last thing I wrote about was trying to find public diabetes education and information events.  I did attend the Chicago ADA Diabetes Expo and collected some samples for you and got to talk to folks who do different community-based work, but I've not felt much like writing about it.  You see, just a few hours after I got home from that event, my family got the call that another one of our dads was dying and that we needed to get down to Missouri immediately.  So we packed up the car and arrived in time to sit vigil with even more family for L's last hours.  We were only home for a few days before heading back down for the memorial mass.  It's been a long couple of weeks and I'm just now trying to get back to work.

L was diagnosed with type 2 diabetes over 30 years ago and had managed the disease, when he managed it, pretty well with diet and oral medications.  He wasn't a model patient--we toasted him with bourbon, after all--but he did pretty well considering the lack of resources that were available when he was diagnosed.  In fact, it wasn't until the last year that he needed insulin, which only started after he went on dialysis for kidney failure.  L had been investigating transplant options for a kidney when he developed other complications with his gall bladder.  When his recovery from gall bladder surgery became severely complicated by the dialysis, they discovered he had liver cancer.  There was less than a month between diagnosis and his passing, nowhere near enough time to process the reality of the situation before it was time to say goodbye.  L was only 67 and he will be missed dearly.  

You would have liked L and I am so sad that you never had the chance to meet.  He had a generosity of spirit and acceptance that put the people he welcomed into his life at ease and he laughed loudly and easily.  I smiled when I heard his laugh from 3 rooms away the same way I do when I hear you laugh like that.  He reminded me of you.

So, Dad, I am so grateful that you've been doing well with keeping your blood sugar in check.  Please do what you can to spare us from suffering this kind of loss again, even if it means going in for regular checkups when you feel just fine.  Just do it, please.

Meanwhile, I'm gonna do what I can to help improve access to meaningful help for people with diabetes.

I love you.

-Mel

In search of diabetes events.

One of the things I do for my research is I attend conferences and educational programs about diabetes care.  Those meetings are targeted for health care professionals, industry, and researchers and cost quite a bit of money to attend--especially if you are not a member of a big professional organization like the American Diabetes Association (ADA) and the American Association of Diabetes Educators (AADE).  These folks are really excited to travel to spend several days with people who do the type of work that they do so they can geek out together share ideas about diabetes care.

No joke, I took this picture at the AADE conference in Indianapolis last year.  I swear it was for an opening plenary session around 8:45 a.m. and not an evening rock concert.  I had not had enough coffee for the blaring conference theme song, but now that I've seen the video I kind of wish there had been a big dance number on that stage.

Normal folks would be lulled to sleep by most of the stuff they talk about in these conferences.

I might have been a lot like that woman in the second row who is slouched so far down the seat that she might startle herself awake when she falls off if I weren't studying the audience as much as the stuff they were talking about.

Even so, I have learned a lot about the state of diabetes treatment, new technologies, and information that diabetes educators are using to help their patients bring down their A1Cs and keep them there.

You should have access to this information, too.  The industry assumes that patients will get information from their health care providers and diabetes educators, but if you can't make, keep or afford those appointments, it cuts you off from really important information that coud make a big difference in how you live with diabetes.

So what sorts of educational events do the big diabetes organizations put on for the general public?

So far, the only widely publicized event I have found from the major organizations is the ADA's Diabetes Expo where they do health screenings, activities, cooking demos, product samples, etc.  They even have family activities programming so that folks who wouldn't be able to attend due to child care issues can bring their kids along.  They have these events in various cities throughout the year and I will be attending it in Chicago this Saturday (4/13).

A smaller not-for-profit organization, Taking Control of Your Diabetes also has one-day events in several cities.  These aren't free, but they are pretty inexpensive if you don't have to travel to get to them.  I hope to attend one of these conferences because it looks like their approach is much more tailored to the needs of the attendees by having two different tracks for people with type 1 vs. type 2 diabetes since their experiences are different.

I keep searching for big community health events around diabetes and it leads me back to the ADA and the National Diabetes Education Program at the NIH that offers free resources for community organizations to do diabetes education events in their communities.  So I think this means that if you're looking for a chance to talk about diabetes or to be screened for it free of charge, your best bet is to look for local clinics and health centers to see if they have any upcoming events.  You might also find that your local park district or department of public health has events.

I would suggest doing a Google search on:  diabetes event <city> <year> (fill in the city and year; if there's nothing for your city, try a nearby city, county, or state).  Doing that search for Chicago 2013, I was able to find listings for a few other events that are happening in the area, including Living Well with Diabetes at the University of Chicago Medicine Kovler Diabetes Center.

Also, event organizers often leave fliers at coffee shops, cafes, grocery stores and other public bulletin boards.  If you're looking for an event, just take a moment to read the signs that you see posted. If you can't make it to the event that's advertised or if you just missed it, you might be able to call or email the organizers to find out about other opportunities that will be in your area.

What do you find when you search for diabetes events in your area?

Retooling for the job.

Hey Dad,

You have information about diabetes care and have blood glucose testing down.  You have information about good food choices and a restocked pantry.  Unfortunately, cooking still takes time and energy, especially if you don't start with boxed something.  Very often I'm happy to order takeout even though I actually like cooking because I am too tired or too lazy or too unmotivated to do all of the food prep and cleanup that happens when cooking.  I get it.

Imagine trying to install a fence when the only tool you have for sinking the posts is a garden spade.  Sure, it would get the job done...eventually.  But it would also be tedious and shoddy and I hope you would abandon the job pretty quickly.  On the other hand, if you have PHD, the useful kind, (not the type I'm working on, as you've pointed out), those posts will go in much faster.  Having the right tools for food prep and storage makes a huge difference in the time it takes to prep meals and in practicing good portion control--and they don't have to be expensive.  Let's get you better food tools.

So I went to a dollar store and a large discount store to collect quite a haul.  What's here:

• Baking sheets (because you'll be baking more of your foods)
• A composition book and sticky notes (to write down notes about things you do and don't like, ideas you have for foods to try, nutritional information you figure out with a nutrition counter book, and to add notes to pages of your cookbooks)
• Plastic shoeboxes and small tubs (for keeping your tools, spices, snack packs, etc. neat and easily accessible)
• Cutting boards (it helps to have at least two when you are prepping food for more than one meal at a time)
• Measuring cups
• Food thermometer
• Small kitchen gadgets (tongs, lettuce knife, basting brush, egg slicer, small grater, strainer)
• Food storage bags and containers
• Portioned spill-proof, microwave safe bowls
• Digital food scale (for portioning)

The majority of these items costs $1-3.  The food thermometer and covered sectioned bowls were a little more.  The only splurge item here was the digital food scale and you can get those for about $20 if you poke around online.  You can use an analog scale, but it is way, way easier to do this with a digital scale that you can reset (tare) with the push of a button.  Here's a good review of an analog vs. digital scale that also shows you how to use them.

So now what do you do with all this crap?  This is going to sound like a lot of trouble, but I promise it will save you time and energy in the long run.

First, measure your food. It's amazing how much we underestimate how much we eat when we aren't accustomed to  measuring it.  To keep measuring from becoming tedious, I highly recommend writing down portion weights and using the scale to make portioning easier in the future.

Pre-portion snacks and meals that you can make ahead of time.  If you measure out the portion by following the food label (How many grams are in one serving?), then you can weigh it.  If there isn't a weight on the label, just a volume, measure out the volume and then put it on the scale to see what it weighs (subtract the container).  Write down that weight in the composition book so that you don't have to do it again.  Now when you go to portion your snacks out, just put the container on the scale, reset it to 0, and then fill up the container until you get to the weight you are looking for for the portion.  It's cheaper to get a large bag of baby carrots than to buy packs of the small bags, so if you do it this way you can make several little packs using snack size bags and the scale to measure. If you portion out snacks so that each pack has 15g of carbs, it's a lot easier to count the carbs.

When it comes to controlling portions at dinner, put your plate on the scale, reset it, and then portion foods out by weight if you can.  If it's a liquid and you don't yet know the weight, then use measuring cups and spoons (and write the weight down on a sticky note on the recipe!).  If you made enough for leftovers, portion them out into food storage containers while you plate your dinner.  This way it's more difficult to get seconds since you've already put the food away and you will know how many carbs are in tomorrow's lunch or dinner because you already did the math.

Finally, if you know you are going to need to chop vegetables to make 3 recipes over the next few days, it's a lot easier to do all of the peeling and chopping in one longer food prep session than to have to do it every time you want to cook.  Use the bigger food containers to hold the vegetables you pre-chopped.  Doing it this way also means kitchen cleanup will be easier since you already did the messy vegetable prep part days ago.

I hope that between these tools and making some new routines around food prep this will get easier and less time consuming for you.  It's a drag to have to measure food and to have to think about it so much, but if you're using the right tools for the job, you'll spend a lot less time having to do it.  After all, it's not like you would use a spade instead of a PHD because you really enjoy the process of digging holes for fence posts.  The point is to get through the tedious part so you can get to the stuff you enjoy faster.

Now, please go play with your new tools.

Love,

Mel

Restocking the shelves.

Hey Dad,

So at this point you've gotten a lot of information about diabetes.  That's excellent, but I worry that if you don't also get the stuff you need to make it easier to make healthier lifestyle changes, the information won't do much more than stress you out.  I think a mistake a lot of folks who write books about diabetes--and even some of the dietitians I've encountered in my own life-- make is that they assume that everybody has the skills, time, money, and equipment that would make huge dietary changes a no-brainer.  Even if the writers and dietitians are aware of these obstacles, there isn't really a list of the things you need to get motivated and to keep up the changes in the long run.

When I was growing up, you were the cook in the family and I'm glad you taught me how to work with what I have on hand to make something that is filling and tasty.  Your basic formula used to start with a boxed side dish like au gratin potatoes or dirty rice mix, some meat either on the side or cooked into the mix, and maybe a canned or frozen vegetable--usually corn or peas.  When I want comfort food, this is what I still do even as an adult.  Last night, I added some leftover chicken from the other night to some boxed macaroni and cheese and called it dinner.  It wasn't healthy, but it was delicious and filling and made me feel better at the end of an otherwise blah sort of day.

You're a great cook, but these foods are not the ones that will help you keep your blood sugar and blood pressure under control because they are so full of carbs, starches, sugars and sodium.  Even if you have low-carb prepared foods, there's still a good chance they're full of sodium and doing your blood pressure no favors.  The easiest thing to do is to cook all your own food from scratch so that you know what all is in it and can control it.  Problem solved.

Really?  Who actually thinks this is easy?  Maybe people who don't have to think about preparing healthy food, or those who grew up learning how to cook from scratch and actually like to do it.  Most of the working people I know don't have those luxuries.

It's not easy, but it can certainly be less difficult.  I have an idea.

Step 1:  Purge the pantry of most of the prepared foods.  Donate them to a food pantry or someone else you know who likes them.  As someone who buys macaroni and cheese in 2s, I understand how one can accumulate so much Hamburger Helper when it's on sale more frequently than it gets eaten.

Note that I didn't say you should get rid of all of it, since we all need a little junk food every once in a while.  Just don't keep enough of it in the house that it makes sense as your automatic dinner starter.

Step 2:  Get stuff that will make foods taste good so that you can buy meat and vegetables and cooking them will be easier.  If you stock up on meat and frozen vegetables when they're on sale, then you'll be able to pull together a meal with the stuff on hand just like you did before, but it will be much healthier.

I looked through the cookbooks I gave you and it occurred to me that while the ingredients are pretty basic, they're not so basic if you don't have them on hand.  Why would you have all of those herbs and seasonings when the food you usually make comes with its own seasoning?

So I looked at the ingredients lists for the recipes in the cook books and made a quick list of the herbs, seasonings, etc. so that I could figure out what sorts of things you would need to have on hand if you wanted to try those new foods.  Here's what I came up with:

Dry stuff:

• garlic powder (not garlic salt)
• oregano
• chili powder
• dill weed
• basil
• cumin
• sage
• sea salt
• parsley
• onion soup mix
• steak grilling seasoning mix
• chicken grilling seasoning mix

Wet stuff:

• worcestershire sauce (reduced sodium)
• stone ground mustard
• vinegars (apple cider and white)
• oilve oil
• light italian salad dressing
• low sodium soy sauce
• spray canola oil

It also turns out that from those ingredients, you can make all sorts of marinades for meats.  In fact, that's why I included the light Italian dressing.  One of my favorite ways to marinate pork chops is to put them in a gallon plastic bag with half a bottle of a dark beer, a heavy squirt of that stone ground mustard, a teaspoon of minced garlic, a pinch of sea salt, and a splash of olive oil.

You can get those supplies at just about any grocery store and even some dollar stores.  I recommend that you go to an ethnic market or look for the ethnic foods section of your grocery store for the herbs and spices because they are a lot less expensive than the main US national brands.  In this case, the small bottles cost less than $2 each.  At some stores, you can get the spices and herbs in bulk and put them in your own bags/bottles.  I don't recommend buying a spice set because they are often much more expensive than getting individual bottles, you don't get to pick and choose what's in them (so you'll get stuff you don't want or need), and you have no idea how fresh or stale they are.  At least with individual bottles on a grocery store shelf, you can look at the dates.

If you can spare a few extra dollars for any one thing on this list, I recommend getting a nicer extra virgin olive oil.  A little goes a long way, so you don't need a huge bottle.

Step 3:  Restock the shelves with the new stuff so that it's in front of you when you are looking for food and so that you can find what you're looking for easily.

Now that you've got a good base set of seasoning ingredients, it won't be too expensive or annoying to pick up just one more if a new recipe calls for it--like the rosemary I forgot to include with this list.  Sorry about that!

Love,

Mel

Diabetes by the books.

Hey Dad,

What happened to February?  It was good to talk to you now that I've come out of my work productivity cave.  I was especially happy to hear that things have been going so well with the books I found for you and mom.  I tried very hard to find books that would give you information in plain language and not overwhelm you with too much information or long, dry chapters.  I think the set I came up with for you does a decent job of this.

I've seen a lot of books about diabetes and they tend to go over the same basic information about what happens with the disease and the guidelines of the American Diabetes Association (ADA) for treating it.  If you take a look at the guidelines, you'll see why it's so important that there are books that translate them into something that resembles English.  Every year they update the guidelines based on new research that has come out so that they are based on the most up-to-date information.

Here are the books that I think do the best job of giving you practical information about what you need to actually do with the information.  You might notice that three of them have the ADA logo, which means they are published by the ADA and you can purchase them directly from their website.  All of the books can be ordered from Amazon.com and that is where you'll find the most customer reviews for books.  Since books are expensive, it's always a good idea to give them a try before you buy them by checking them out at the public library.  If your branch doesn't have them, talk to someone at the circulation desk to find out how to request it from other libraries in the library system.  Usually you can check out a book from your local library even if the local library doesn't have it--you'll just have to wait a while for it to come in.

I know you like your meat and potatoes.  Usually when we think of health food we come up with images of twigs and tofu or, worse, the Weight Watchers recipe cards from the 1970s.  Fortunately, nobody is asking you to like tofu or kale and even Weight Watchers has long abandoned those crazy, gross recipes.  I think these books do a good job of showing you ways that you can eat foods that will taste good to you and make you feel like you've actually eaten a meal.

What Do I Eat Now?:  A Step-by-Step Guide to Eating Right with Type 2 Diabetes by Patti Geil and Tami A. Ross cuts directly through the guidelines to give you the information about the part of diabetes care that is giving you the most stress.  It's an easy read because it's broken up into chunks and they pull out the parts that you'll refer to in the future into tables and charts.  If they just did the tables and charts or just the text, I don't think it would be nearly as useful.  Of all of the practical guides I've read in doing my research, this is really the most useful that I've found.

Next, there's The 4 Ingredient Diabetes Cookbook by Nancy Hughes.  The recipes really do have very few ingredients (occasionally 5 or 6 ingredients due to spices, but mostly just 4) and very few steps in meal preparation.  When one of the reviewers wrote that the recipes were too simple for them, I figured this was a good cookbook for people who aren't used to cooking things from scratch.

Then there's One Pot Meals for People with Diabetes by Ruth Glick and Nancy Baggett.  This book is full of the sorts of recipes where you throw a bunch of ingredients into a pot and let it cook--a real time-saver when you think about the amount of clean-up that comes with cooking from scratch.  The ingredients are also pretty basic and you can do a lot of the food prep ahead of time so it's easy to pull a healthy meal together without having to think about it too much.  I know cooking a complicated dinner is not what you want to deal with after you've been at work all day.

Finally, there's The CalorieKing Calorie, Fat, & Carbohydrate Counter by Allan Borushek.  This is a tool that any person who is trying to eat lower fat, lower carb, etc. should have because it is a fairly comprehensive listing of nutritional values for not just raw ingredients that you'll cook, but for food that you buy already cooked.  It's hard to get an accurate count for restaurant foods or something at a potluck, but this guide can give you a rough estimate.  It's a small book so you can take it with you wherever you go.  For folks who prefer to access it online or through a smart phone app, the CalorieKing website has other options, including an online weight loss program.  You can get the nutritional counts for free on the website, even if you don't subscribe.

I am glad that you and mom have been giving these a go and I look forward to hearing which ones actually work for you.  Please let me know if any of these are dead wrong for what you need so I can keep looking.

Love, 

Mel