text: Milt Bedingfield 2016-02-07T12:37:22-05:00 Milt Bedingfield http://www.huffingtonpost.com/author/index.php?author=milt-bedingfield Copyright 2008, HuffingtonPost.com, Inc. HuffingtonPost Blogger Feed for Milt Bedingfield Good old fashioned elbow grease. Type 2 Diabetes and Peripheral Neuropathy: To Walk or Not to Walk? tag:www.huffingtonpost.com,2015:/theblog//3.7188266 2015-05-11T09:23:02-04:00 2015-05-11T09:59:02-04:00 Milt Bedingfield http://www.huffingtonpost.com/milt-bedingfield/ What the ADA says... It has also been recommended that people with peripheral diabetic neuropathy that have reduced or absent feeling in their feet should not engage in any form of weight bearing exercise activity. The American Diabetes Association recommends that people with diabetes-related peripheral neuropathy should limit the amount of weight-bearing physical activity they perform due to their increased risk of foot ulcers and amputation (1, 2). This is based on the fact that with peripheral neuropathy there is either a decreased ability or total inability in the feet to feel pain or discomfort. As an example, standing barefoot on hot asphalt maybe in a parking lot in the middle of the summer would be very uncomfortable for someone with normal sensation in their feet, however go unnoticed for someone with peripheral neuropathy. Similarly, the person with peripheral neuropathy may develop a painful nickel-sized blister after walking too far or when wearing new shoes and not even feel it. Without daily inspection of the ankles and feet (which a lot of people do not do) this blister could go unnoticed for days resulting in a potentially infected, slow to heal, or non-healing wound. In the worst case this could lead to an amputation. All of this is the result of losing what is called the protective sensation in the feet. In the absence of peripheral neuropathy whenever there is insult to the foot or feet such as a blister, a cut or scrape or stepping on a small piece of glass or nail, there would be pain which would cause you to notice the injury and hopefully treat the wound accordingly. There are also painful stages of neuropathy that can precede lack of sensation which are characterized by frequent but intermittent pain in the feet throughout the day, having pain only in the evening while in bed to constant pain. This stage of neuropathy can result in changing the way you walk, that is your stride length, which part of your feet you strike the ground with first and ultimately what part of your feet support your body weight. Because of everything I have just mentioned above this leads to the unfortunately recommendation that discourages walking for a great many people with diabetes. To Walk or Not to Walk? So where does that leave us? Exercise is arguably the best treatment there is, particularly in controlling Type 2 diabetes, and preventing diabetes related complications, such as peripheral neuropathy, however once you have peripheral neuropathy in your feet you should avoid doing any weight bearing exercise. I have wrestled with the dilemma for years about how to guide my patients that would benefit immensely from starting to exercise or increasing their exercise however have various stages of neuropathy. According to the Centers for Disease Control and Prevention, from 2000-2002, approximately 60 percent of lower-extremity amputations in the United States were diabetes-related, with the majority of those amputations being preceded by a foot ulcer (3). Almost all diabetic foot ulcers occur in those people that have lost feeling in their feet due to diabetic peripheral neuropathy (4, 5). On the other hand poorly controlled blood glucose control contributes greatly to peripheral neuropathy. Eight-year cardiovascular mortality is 34 percent lower among people with diabetes who walk two hours per week compared with non-walkers (6). Feet First Randomized Controlled Trial The Feet First Randomized Controlled Trial was designed to look at the effect of weight-bearing activity on foot ulcer incidence in people with diabetic peripheral neuropathy. The study, conducted over a 12-month period by Lemaster and colleagues, showed that participants in the Feet First intervention group achieved a modest increase in activity, with no increase in foot lesions, compared with those in the control group. The group also recommended additional research be conducted in this area to investigate the current guidelines and close supervision for patients with diabetes and peripheral neuropathy (7). Tuttle and colleagues found that people with Type 2 diabetes and peripheral neuropathy experienced no negative consequences when performing moderate-intensity, weight-bearing exercise in their study (2). Dr. Sheri Colberg reports in her article "Exercising with Peripheral Neuropathy" that recent descriptive studies suggest that patients with a lack of feeling in their feet who participate in daily weight-bearing activity are at decreased risk of foot ulceration compared with those who are less active (8, 9), especially if their daily routine is very similar with little variation from day to day regarding their physical activity (9, 10). As a result of the above information, I am going to continue evaluating each of my class participants on a case by case basis, however, for those patients with peripheral neuropathy that I believe will be prudent in checking their feet and following the recommended foot care guidelines and stand to gain significant benefit from performing some weight bearing exercise, I will be more likely to recommend it to them. References: 1. Singh, N., D. G. Armstrong, and B. A. Lipsky: Preventing foot ulcers in patients with diabetes. JAMA 293 (2):217-228, 2005 2. Tuttle, L. J., M. K. Hastings, and M. J. Mueller: A moderate-intensity weight-bearing exercise program for a person with Type 2 diabetes and peripheral neuropathy. Phys Ther 92 (1):133-141, 2012 3. Centers for Disease Control and Prevention. History of foot ulcer among persons with diabetes -- United States, 2000-2002. MMWR. 2003;52:1098-1102. Medline 4. Pham H, Armstrong DG, Harvey C, et al. Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial. Diabetes Care. 2000;23:606-611. 5. Reiber GE, Smith DG, Wallace C, et al. Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. JAMA. 2002;287:2552-2558. CrossRefMedline 6. Gregg EW, Gerzoff RB, Caspersen CJ, et al. Relationship of walking to mortality among US adults with diabetes. Arch Intern Med. 2003;163:1440-1447. CrossRefMedline 7. Lemaster, J. W., M. J. Mueller, G. E. Reiber, D. R. Mehr, R. W. Madsen, and V. S. Conn: Effect of weight-bearing activity on foot ulcer incidence in people with diabetic peripheral neuropathy: feet first randomized controlled trial. Phys Ther 88 (11):1385-1398, 2008 8. Richerson, S., and K. Rosendale: Does tai chi improve plantar sensory ability? A pilot study. Diabetes Tech Ther 9(3):276-286, 2007 9. Ko, S. U., S. Stenholm, C. W. Chia, E. M. Simonsick, and L. Ferrucci: Gait pattern alterations in older adults associated with type 2 diabetes in the absence of peripheral neuropathy--results from the Baltimore Longitudinal Study of Aging. Gait Posture 34 (4):548-552, 2011 10. Kanade, R. V., R. W. van Deursen, K. Harding, and P. Price: Walking performance in people with diabetic neuropathy: benefits and threats. Diabetologia 49 (8):1747-1754, 2006]]> Type 2 Diabetes and HIIT tag:www.huffingtonpost.com,2015:/theblog//3.7171752 2015-05-11T09:15:26-04:00 2015-05-11T09:59:02-04:00 Milt Bedingfield http://www.huffingtonpost.com/milt-bedingfield/ HIIT is not new This type of training is not new, in fact coaches, athletes and even casual athletes have used this method of training for many years. I first was introduced to interval training when I was only ten years old swimming on the country club swimming team. The coach would have us swim 50 yards, rest 30 seconds and repeat until we had completed it 10 times. This was known as 10 x 50s with a 30-second rest. There are many, many variations of doing interval training, but what they all have in common and what makes it interval training is alternating periods of work with periods of rest. The beauty of interval training is that it allows the person doing the training to accomplish greater amounts of work then if they were doing what is called steady state training. Steady state training is just as the name implies where the person runs, bikes, swims, performs the elliptical or rowing machine at the same pace without speeding up or slowing down for the entire duration of the exercise. Because there is no change in speed once the person's heart rate gets acclimated to the work load the heart rate will generally stay constant or steady (hence the term steady state) during the entire duration of the exercise. It is well known by true professionals in the exercise industry that interval training can produce the greatest gains in fitness and conditioning when used appropriately. No, don't stop doing cardio It has been suggested recently by some supposed fitness experts (none of which I have ever heard of) that cardio, or what we have traditionally referred to as aerobic conditioning, where someone exercises at a steady state for an extended period of time, is not the way to go if you want to lose weight fast, regain vitality and get "ripped." I saw yesterday where one "fitness expert" (does having a body builder physique make you a fitness and weight loss expert?) suggested that you should stop doing cardio exercise, implying that it was hurting you. Now is a good time to remember what your parents taught you about not believing everything you hear or read. First of all, not everybody is looking to get "ripped," and there are greater risks involved when doing high intensity exercise vs. cardio. This is particularly true with people that are obese, have heart disease, high blood pressure and diabetes. Depending on the duration of someone's diabetes and how well they have cared for it they may already be experiencing diabetes-related complications which in that case HIIT would be definitely contraindicated whereas a lower level of intensity might be acceptable. At this particular time, any disparaging comments made about any type of exercise that is safe to do is not productive. I say this during a time when most people are not getting anywhere near the amount of exercise they need and many people are not regularly engaging in any regular exercise. For some people the increased health risk associated with performing high intensity exercise training may be of less concern due to their age, fitness level, genetic history, etc. For them burning more calories in a shorter period of time, the greater cardiovascular conditioning and the discomfort involved while doing HIIT is not too much to be a deterrent, great. For others the promoted benefits of HIIT may not be worth the risk. This does not mean that I would necessarily shy away from interval training altogether as it is a great way to do exercise but I would definitely avoid recommending HIIT for the majority of the population I see. Interval training at ALFs Interval training, the act of alternating periods of work and rest can be implemented for almost anyone as long as they are capable of handling even minimal stress. Even people in assisted living facilities that can lift their leg 10 times in front of them and then rest for one minute and then do it again, these people are doing intervals but at a low, far less intense level. It's not the interval training that I take issue with, it's the high intensity half of the high intensity interval training that concerns me. Interval training can be very beneficial and provide sometimes quicker and greater fitness gains than long sustained cardio, however that in no way should demean the many benefits of cardio training regimens. Any time increased workloads are placed on the heart the heart is more vulnerable to what is referred to as a cardiac event. There is a relationship between the amount of stress placed on the heart and circulatory system and the risk of suffering a cardiac event, that is the greater the workload placed on the heart the greater the risk of suffering a cardiac event during the time the heart is under that increased stress. So then why do people that want to be healthy subject themselves to this increased risk even for a short time? Because it is believed that due to training adaptations that occur as a result of high intensity training the likelihood of suffering a cardiac event during non-exercise times is reduced to a level that is less than those that do not exercise at high intensity levels. Long, slow to moderate cardio still the way to go for many Lower intensity cardio exercise performed at a steady state or even intervals performed at a lower intensity can provide significant health and fitness benefits for the largest majority of people that are exercising today and there is no need to switch to an intensity of exercise that may be more risky in terms of injury and less pleasant. Countless people over the past 40-50 years have changed their lives for the better doing lower intensity steady state exercise and it pains me when it is suggested that people stop doing it in favor of more difficult, less comfortable and for many people more risky type of exercise. Granted HIIT may burn more calories quicker and provide a higher level of fitness and is appropriate for some I suggest that it is a minority of the exercising population. There is truly an exercise for everyone out there and slower less intense exercise whether it is incorporating low level intervals or not is a valuable one.]]> Trying to Control Uncontrolled Type 2 Diabetes and Hypertension Without Meds Is a Bad idea tag:www.huffingtonpost.com,2015:/theblog//3.7164480 2015-04-30T13:09:18-04:00 2015-06-30T05:59:02-04:00 Milt Bedingfield http://www.huffingtonpost.com/milt-bedingfield/ Avoiding taking diabetes and blood pressure medicine Several weeks ago a patient was referred to our 10-hour comprehensive diabetes class. When reviewing the patient's health questionnaire with her she spoke up and said that she had listed all of the medications she was supposed to be taking but that she was not taking any of them. I repeated back to her what she had just told me to make sure that I had heard her correctly. When she confirmed what I thought she had said was true I asked her why she was not taking the prescribed medications. She told me that she wanted to try and control her blood pressure and blood sugar levels without having to take medications, and that is why she was attending the class. I can certainly understand her desire to do this and respect her attitude for being willing to do what it may take to accomplish her goal, if it is possible. At this point no one knows if it is possible or not. As I reviewed her list of medications I saw she had been prescribed at least one diabetes medication as well as one for high blood pressure. She then offered to show me the sheet where she had been recording her blood sugar values and blood pressure readings. The blood sugar readings were not horrible but were definitely too high. A hemoglobin A1C was not available. Of real concern were her recent blood pressure readings with frequent diastolic pressures in the 90s and on occasion in excess of 100 mm/hg. Her systolic readings were in the 140-upper 160 range (1). I reiterated to the patient that trying to manage her diabetes and blood pressure without medications definitely had some advantages and was a goal to shoot for down the road -- however, that until she was able to achieve good blood sugar control and blood pressure control she was increasing her risk of diabetes related complications and stroke. I am not sure about this but I suspect that either the look on my face, or the tone of my voice, in combination with what I said was enough to cause the patient to rethink her decision. She responded, "So you think I should be taking my medications? OK, I'll start taking them then." (I wish things were this easy with my kids.) I told her I thought that would be a good idea. When is it OK not to take your prescription medications? If your doctor has prescribed medications to treat a condition or illness it is never a good idea to not take the medications as directed without first discussing it with the prescribing doctor. When rosiglitazone was under suspicion for causing heart attacks and being investigated a few years ago one of my patients spoke up in class one day and said that as soon as she heard the news on the television she never took another pill. I can certainly understand the patient's concern -- however, I would have advised her to talk to the doctor as soon as possible to discuss the situation first. Suddenly discontinuing certain medications can be very dangerous so if a patient wants to do that it should be done with the advice of the doctor so as to do it safely. Want to control your diabetes without medication? If I had Type 2 diabetes I would want to be able to control it without having to take diabetes medication for sure. But this is how I would do it. If my HbA1c was elevated above what I wanted it to be, let's say under 7 percent, and it was more than 0.3 or 0.4 above 7 percent I would ask the doctor to prescribe medication for me even if the doctor was not planning to. What! Why would anyone in their right mind do that? This is why. We know from studies as far back as the Diabetes Control and Complications Trial that people that are able to maintain a HbA1c score under 7 percent have far less likelihood of developing diabetes related complications (2). We also know that eating better, losing some excess body fat and getting plenty of exercise can many times have a normalizing effect on blood sugar levels. I would tell the doctor that I definitely plan on making all of the desirable lifestyle changes and that I would expect my HbA1c to drop below 7 percent as a result of making these changes, however, just to be sure that I get it under 7 percent as quickly as possible I would appreciate a prescription for some diabetes medication, probably metformin to help ensure that I accomplish my sub 7 percent HbA1c. Once under 7 percent then I would talk to the doctor about weaning me off of the medication. Don't take your time getting your HbA1c down Something I always tell my patients is not only is it important to get their HbA1c less than 7 percent but also important is to do it as quickly as possible because the longer it is elevated the more likely complications will occur (2). So to summarize my patient's situation, for the time being she needs to take both her diabetes medication and her blood pressure medications until such time as her blood sugar levels and blood pressure are far better controlled at which time she should discuss her situation with her doctor again. Hopefully making some positive lifestyle changes will make it possible to reduce or eliminate her medications but that remains to be seen. References: 1. http://www.diabetes.org/are-you-at-risk/lower-your-risk/bloodpressure.html 2. http://www.nejm.org/doi/full/10.1056/NEJM199309303291401]]> There Are Now 86 Million People With Pre-Diabetes -- Sadly, Most Will Get It tag:www.huffingtonpost.com,2015:/theblog//3.7163606 2015-04-30T11:10:32-04:00 2015-06-30T05:59:02-04:00 Milt Bedingfield http://www.huffingtonpost.com/milt-bedingfield/ I predict this because most of those diagnosed with pre-diabetes are not well enough informed as to what they need to do to prevent getting worse and later going on to develop Type 2 diabetes. To be clear, pre-diabetes is diagnosed when a person's fasting blood glucose level (has not eaten or drank in at least eight hours) is between 100 mg/dl and 125 mg/dl (2). When someone has been diagnosed with pre-diabetes they do not have diabetes, yet, however they are on their way (normal fasting blood glucose levels are less than 100 mg/dl) (2).The good news is that there are now studies that show that if people with pre-diabetes make some significant lifestyle changes they may be able to normalize their blood glucose levels and not progress to having Type 2 diabetes (3,4). Pre-diabetes is reversible, Type 2 diabetes is not A key point to realize here is that pre-diabetes in many cases can be corrected, or reversed if you like to think of it that way, and Type 2 diabetes never develops. If corrective measures (lifestyle improvements) are not made while pre-diabetic and pre-diabetes progresses to Type 2 diabetes, that is not reversible. Once you have Type 2 diabetes you will have it forever. There is no going back. After your diagnosis you may do a great job of taking care of your diabetes, in fact your blood glucose levels may be normal most of the time even without any diabetes medication, but you still have diabetes, and any time you get careless with your self care your blood glucose levels will rise. It is so very important that people diagnosed with pre-diabetes do something about it as soon as they are diagnosed to see if they can prevent it from turning into Type 2 diabetes. Sometimes private insurance will cover diabetes education for people that have been diagnosed with pre-diabetes. Considering what's at stake here it is always worth a call to the insurance company to see if they will cover the cost of a comprehensive diabetes class. Enrolling in a comprehensive diabetes education class is probably the first and most important thing to do after being diagnosed. Don't wait until you develop diabetes to do something A huge mistake that many, many people make, including too many professionals in the health care industry, is that they wait until they actually have been diagnosed with Type 2 diabetes or the person they are treating is diagnosed with Type 2 diabetes before they take any significant action. The diagnosis of pre-diabetes appears to be taken far too lightly by a lot of people. Patients that were once diagnosed with only pre-diabetes that later progressed to developing Type 2 diabetes will tell me when I interview them that three months or maybe six months or even a year or so before developing diabetes they had been diagnosed with pre-diabetes. I always ask them when they tell me this if they made any changes in their lifestyle after finding out they were pre diabetic, or if they did anything as a result of the diagnosis. There are several answers that I hear the most often. By far the most frequent being: "The doctor told me we just need to keep an eye on it." Another frequent response is, "I watched what I ate for a while." And occasionally, " I started walking in the evening." Pre-diabetes needs to be aggressively treated When told you have pre-diabetes, that is not a time to be passive and take a let's-see-what-happens attitude. It is a time to leap into action and see if you can prevent Type 2 diabetes. It's a time to ask, "Doc, what can I do to keep this from turning into Type 2 diabetes!" And by all means the doc's response should be more than just, "Let's keep an eye on this for now." Pre-diabetes is in some ways like a ticking bomb. If nothing is done when pre-diabetic it is more than likely only a matter of time before developing Type 2 diabetes. A diagnosis of pre-diabetes is a warning to change direction towards a healthier lifestyle, one that includes being much more physically active and making wiser food choices. DPP and Da Qing diabetes studies The Diabetes Prevention Program Trial and the Da Qing Diabetes study are two studies that showed adding 150 minutes of exercise per week to an otherwise sedentary lifestyle and reducing bodyweight by 7 percent could return pre-diabetes blood glucose levels to normal in greater than 50 percent of study participants (3,4).These studies prove that the majority of the people headed towards Type 2 diabetes have a choice in the matter as it does not have to happen, however they need to be made aware of the things they need to do to avoid it. It is my belief that instead of only working to improve the lives of people with diabetes, we need to put significant effort into preventing people from ever developing the illness. That, I believe is where health care professionals can have the greatest impact. Doctors, nurses, diabetes educators, etc. all have the responsibility to enthusiastically emphasize to their patients at risk for Type 2 diabetes, including those with pre-diabetes, what they can do to prevent it. Unfortunately, I don't think that is always happening now, at least not as often as it should. Let's work on that. References: 1. http://www.cdc.gov/diabetes/pubs/images/prediabetes-inforgraphic.jpg 2. http://www.diabetes.niddk.nih.gov/dm/pubs/diagnosis/ 3. Effects of Diet and Exercise in Preventing NIDDM in People With Impaired Glucose Tolerance: The Da Qing IGT and Diabetes Study / http://care.diabetesjournals.org/content/20/4/537 4. The Diabetes Prevention Program (DPP) Description of lifestyle intervention / http://care.diabetesjournals.org/content/25/12/2165.full]]> Diabetes Treatment Should Focus on Metabolizing More of the Sugar in the Blood for Best Results tag:www.huffingtonpost.com,2013:/theblog//3.4174800 2013-11-04T11:18:37-05:00 2014-01-23T18:58:21-05:00 Milt Bedingfield http://www.huffingtonpost.com/milt-bedingfield/ If you happen to fall into one or both of those categories, I suggest you read on and give some careful consideration to what I am going to suggest. Many years ago the standard treatment for Type 2 diabetes was to follow a low-carb diet, recommending to patients that they eat as little sugar as possible and take their medication as prescribed by their doctor. They were also encouraged to get some exercise if possible and to reduce their level of stress. Exercise was thought to be beneficial for someone with diabetes, and stress was known to elevate blood sugar levels. The wisdom behind this seemed logical at the time and was based on the following reasoning. Since people with Type 2 diabetes tend to accumulate sugar in their blood due to their inability to efficiently remove sugar from the blood, then drastically limiting the amount of sugar that enters the blood should help maintain blood sugar levels at a more normal level. This approach appeared to produce good results and was adopted as pretty much the standard treatment for Type 2 diabetes at the time. Then a growing body of evidence began to support the idea that there was more to treating Type 2 diabetes than simply watching your carb intake and taking your medicine on time -- that making another major lifestyle change could have a tremendously positive impact on blood glucose control. As a result, some doctors and some diabetes educators (the emphasis on some is intentional) began to recommend to their patients with Type 2 diabetes that they become more active. There were reasons to believe that being more physical and leading a more active lifestyle was beneficial in helping people with Type 2 diabetes maintain better blood sugar levels and reduce the risks of diabetes related complications. Although doctors and diabetes educators both encouraged the people they treated with Type 2 diabetes to be more physically active (usually being careful not to use the word exercise for fear they may scare off their patients) often times their suggestion was over shadowed by questions and conversation about food choices (what can I eat, is this food OK to eat, etc.). Focus On Metabolizing More Of The Sugar Even though efforts have been made to get people with Type 2 diabetes up and moving more in recent years, the major focus still continues to be encouraging them to eat less carbs -- or in other words, since you have a hard time getting sugar out of your blood, let's work on putting less sugar in your blood so you have less to worry about getting back out. Consider this. You go to take a shower. In the middle of your bathing you notice the water is not running out of the shower as fast as it used to. The next week you notice water is starting to collect around your feet and when you turn the knob and increase the amount of water that comes out of the shower head, the water level starts to rise. Everyone else in the house has long hair -- except for you. Pretty soon, as you stand there with water now up to your ankles you guess that the drain has gotten clogged up with hair. So now, water that enters the shower can't get out of the shower at the same rate at which it enters and it accumulates in the floor of the shower. So what do you do? Quit taking showers? No, that's a bad idea. As the drain gets more and more clogged, should you gradually use less and less water when you shower to keep the amount of water in the shower floor from climbing too high? Yet another bad idea. Or, do you unclog the drain so the water can run out of the shower at the same rate it enters the shower through the shower head? Now there's an idea! I bet you had already thought of that. Applying this reasoning to diabetes, when sugar enters the blood it has a hard time getting out just like when you have a partially clogged drain. What if we could figure out a way to get sugar to leave the blood at the same rate at which it enters (or as close as possible)? That way the sugar wouldn't accumulate in the blood and blood sugar levels would remain closer to normal more of the time. Let's focus a great deal more on getting the sugar out of the blood faster and easier, as well as somewhat reducing the carb or sugar intake. Performing regular exercise will have a huge impact on this. Yes, I did say huge. Get exercise, or more of it, and you improve your ability to get more sugar out of your blood and faster and easier. Let me explain. Insulin, which is made in the beta cells of the pancreas, in response to sugar entering the blood, enters the blood and looks for a sugar molecule to grab a hold of. Once an insulin grabs a sugar molecule, it then takes it to a muscle, fat, or liver cell. Once there, the insulin is supposed to find a door to the cell, open it, and escort the sugar into the cell. In the case of Type 2 diabetes, when there is insulin resistance, which there almost always is, the doors to the cells do not open as easily as they are supposed to. This is what we refer to in my office as "Rusty Hinges." This makes it much harder to get the sugar out of the blood and into the cells throughout the body. For the person with Type 2 diabetes, every time they engage in exercise, in a sense, it's as if they are getting the rust sanded off of their hinges and having them sprayed with WD-40. Exercise directly deals with the root of the problem -- insulin resistance -- like no other treatment. Exercise facilitates like nothing else getting sugar out of the blood. For a very large percentage of people with Type 2 diabetes, exercise is the most important thing they can do to manage their diabetes, followed closely by being more careful with what they eat. I do want to make it clear that when I recommend exercise to a patient, it is first and foremost to help in reducing insulin resistance -- that is, to help clear excess sugar from the blood. Secondarily, it is to assist a patient in their weight loss efforts. So, in summary, I would like to see you discuss this with your doctor, and if OK with him or her you give the exercise a good honest try for a month or two. Usually performing 30 of minutes of exercise, five to six days a week, at a moderate but comfortable pace, regularly, should do you a world of good. Performing up to 250 minutes per week is further recommended for those trying to lose some weight. For more by Milt Bedingfield, click here. For more on diabetes, click here.]]> One Excellent Reason for Not Keeping Your Diabetes a Secret tag:www.huffingtonpost.com,2012:/theblog//3.1786259 2012-08-16T17:29:51-04:00 2012-10-16T05:12:28-04:00 Milt Bedingfield http://www.huffingtonpost.com/milt-bedingfield/ On occasion your blood glucose level may start to dip a bit too low -- not seriously low yet, but low enough to where you start acting a little odd. You may drop low enough to where you might become the topic of conversation over lunch or in the break room, and not because of your good looks. You see, there are times when your blood glucose is coming down and you may not notice it at first, particularly if you are wrapped up in a project or intensely concentrating on something else. You may fail to notice that you are beginning to shake and sweat, that your heart is beating fast and hard. or that you are not speaking clearly or making good sense. This situation is even more likely if you have had diabetes, particularly Type 1, for a long time. This is when it becomes helpful to have someone there that knows you have diabetes and that also knows what to do if you start acting odd or looking odd (such as sweating and shaking in a 72-degree office or making inappropriate remarks during a staff meeting). In such situations, your confidante can encourage you to excuse yourself from the staff meeting to check your blood glucose level and then treat it if necessary. I have heard frequent reports over the years where it seems that the last person to know they had a low blood glucose level was the victim that had it. I have had patients tell me that they are fine unless they get below 40. This comment usually inspires responses by loved ones to the tune of, " What are you, nuts? Are you kidding me?" If these people believe they are fine until their blood glucose drops below 40, then that means that they may try to drive, cook, or do something else in this impaired state. In a more extreme situation, if you were to lose consciousness and people were standing around wondering the cause and what to do, your confidante would likely know (depending on the events leading up to your loss of consciousness), and be more likely to do the right thing in a prompt manner, like call 911. In summary, you need to have someone that knows what is going on with you. Someone that you have told ahead of time, "Look if I ever start to act goofy, or do this or that, or start sweating and get lightheaded, this is what it means and this is what you need to do." This person becomes your safety net. I would recommend letting more than one or two people know. I think you would feel more comfortable in the long run. For more by Milt Bedingfield, click here. For more on diabetes, click here.]]> So Which Is it, With Type 2 Diabetes? Do You Make Too Much Insulin or Not Enough? tag:www.huffingtonpost.com,2012:/theblog//3.1684246 2012-07-19T17:05:53-04:00 2012-09-18T05:12:17-04:00 Milt Bedingfield http://www.huffingtonpost.com/milt-bedingfield/ Has this information been filed away in the part of your brain labeled, "Information I don't understand and sounds too confusing to learn," just waiting to be purged when possible? Whenever I hear a patient being told this I often wonder if they're going to ask, "Well, which is it, do I make too much insulin or not enough, and why does this happen?" I think if I had diabetes I would want to know. Let me see if I can explain it here. I will start off by reminding you that it takes approximately 10 years to go from completely normal to actually having diabetes. I am sure this varies somewhat from person to person, however on average it takes 10 years. After you eat a meal that has sugar in it, the sugar will enter the blood stream. In response to sugar entering the blood the beta cells, located throughout the pancreas, start making insulin. Typically, the greater the amount of sugar that enters the blood, the greater the amount of insulin produced by the beta cells in the pancreas. At least, this is the way it is supposed to work. The insulin produced in the beta cells then enters the blood stream and looks for some sugar. Once it finds a sugar molecule it swims over and grabs a hold of it. (A little-known fact is that insulin only has one arm, so it can only grab ahold of one sugar.) The insulin then takes the sugar out of the blood vessel and over to a muscle, fat or liver cell. Once close to the cell the insulin starts heading over to one of the cell's many doors. The insulin then opens the door to the cell and escorts the sugar inside. Once this is accomplished the insulin is not reused and is basically put out to pasture. Meanwhile, other insulins are finding sugar in the blood and taking them to other muscle, fat and liver cells, thereby returning the level of sugar in the blood to pre-meal levels. Once blood sugar levels are back to normal the beta cells stop making insulin (except for little drips of insulin that constantly leak from the liver into the blood throughout the day) until sugar enters the blood stream again, perhaps after the next meal. In the case of Type 2 diabetes, about 10 years before actually developing the disease, when insulin tries to open the doors so that the sugar can enter, the insulin finds that the doors have become much more difficult to open, and one insulin is no longer enough to get the doors open (I call this rusty hinges. Officially it is called the onset of insulin resistance.) This means the beta cells must make additional insulin to help get the doors open due to their rusty hinges. Over the course of the next 10 years, or thereabouts, increasing amounts of insulin are required to get the doors to the cells open so that the sugar can enter. (This is why you hear that you may be making plenty of insulin, however, it is not being used properly.) Eventually, these beta cells that have been working so hard begin to fail (as would anything that is working in a manner in which it is not designed) and insulin production drops as a result. (This is when you hear that you are not making enough insulin.) As a result of this reduction in insulin production, sugar can no longer enter the cells as it is supposed to and remains trapped in the blood stream. So you see, in the development of Type 2 diabetes, there is an overproduction of insulin followed by a reduction in insulin production. For more by Milt Bedingfield, click here. For more on diabetes, click here.]]> What Researchers May Say About Diabetes, Obesity and Heart Disease tag:www.huffingtonpost.com,2012:/theblog//3.1614274 2012-07-03T17:32:41-04:00 2012-09-02T05:12:16-04:00 Milt Bedingfield http://www.huffingtonpost.com/milt-bedingfield/ Someday, after I am long gone, I foresee a headline on the front page of the local paper -- oh no wait, we probably won't have newspapers then, probably news updates will only appear on our personal information devices, commonly referred to as PIDs (I made that word up, but I think it will certainly catch on). Anyway, the headline will read, "Thumb size may be best predictor of longevity." The article will say something like this: Researchers from an online university have discovered that the size of the thumb bones of men and women living in the early 21st century are inversely proportional to the size of the muscle mass in their thighs. Thumb size was also found to be highly correlated with longevity. The study conducted by a group of scientists from the Silicon Valley Virtual University (hereafter referred to as SVVU) looked at both men and women between 25 and 50 years of age who died of obesity, Type 2 diabetes or heart disease between 2060 and 2070. Radioactive isotope studies and basically looking through a high-powered microscope revealed that the thumb bone, which is connected to the wrist bone, which is connected to the arm bone, was more dense and contained a higher mineral content than persons born 100 years earlier. Furthermore, evaluation of the thumb's surrounding musculature revealed a statistical significant 52 percent increase in size of the muscles that flex and extend the thumb. Dr. Tom Thomas Thomason, lead researcher of the study was quoted as saying, "We are puzzled by the findings at the moment but will enlist the support of the world's best minds and try to make sense of what we have found." Off the record, Dr. Thomason said that once all of the data is looked at carefully by everyone involved, he believes that the present theory that anyone with a larger than usual thumb is caused by adolescent sucking of the thumb will be debunked in favor of a newly-emerging theory that larger thumbs are now the result of evolutionary changes adapting to the increasing reliance on remote control devices in the 21st century, such as remotes for the garage door, remotes for the television, remotes to lock and unlock the car, video game controllers, and texting. In response to the highly repetitive nature of texting and the use of video controllers, muscles controlling the thumb(s) must become stronger and have greater endurance. We have uncovered some unpublished data that indicates the average male or female of high school age texts an average of 50-100 times per day. This places a tremendous overload on the flexion and extension muscles of the thumb. Additionally, with all of the time spent using remote control devices for gaming and to make physical jobs easier, people in the early 21st century became far less active. It is my belief that this has led to the increase in death due to obesity, heart disease and diabetes. For more by Milt Bedingfield, click here. For more on personal health, click here.]]> When You Go to Exercise, Do It on Your Terms tag:www.huffingtonpost.com,2012:/theblog//3.1623807 2012-06-27T10:25:02-04:00 2012-08-27T05:12:06-04:00 Milt Bedingfield http://www.huffingtonpost.com/milt-bedingfield/ On many of those days I was not particularly excited or looking forward to going to the gym. I knew how those workouts could hurt and quite frankly, on many days I didn't really feel like hurting. On most days, I would go ahead and get it done, but often, put it off until the end of the day. Back then, way back then, I was a competitive athlete and needed to train daily to get better for my competition. In order to train my body the best I could, I needed to work hard when I trained, which usually translates to the workout being uncomfortable. Remember the old saying, no pain, no gain? For competitive athletes that may be true, however, for the other 99 percent of the world that is not competitive, it simply is not true and following that advice is very rarely if ever a good idea. What I do now and have done for years, is go to the gym with only a rough idea of what I want to accomplish with no formulated plan as to what I will be doing. I fly by the seat of my pants, I am spontaneous, I exercise in the moment (no, that's going a bit too far). And you know what? I look forward to going to the gym again. I have had some really good workouts the last several years with some good results. The big difference for me is that there is no pressure to run at a prescribed speed or for a predetermined amount of time. I run, or walk, or jog or a combination of all three as I feel the urge. Or maybe I would ride the stationary bike, then walk on the treadmill for a while, then get back on the stationary bike and then lift some weights. As an example of this, I get on the treadmill with little motivation. "I think I will just walk for a while (I will watch the news on the video screen)." Three minutes later, " I think this is too slow, I have only walked .2 miles. I guess I will speed it up a bit. I think I will give myself a little elevation too, say 5 percent at 4 mph." I start to break a slight sweat. "This is too easy, I think I would feel better going a little faster but not at 5 percent elevation. I will speed it up to a fast jog at 7 mph at 1 percent elevation." I may be happy here for three to four minutes. Then I slow it down to a fast walk at 4 mph and raise the elevation to 10 percent until I get bored with it or tired, whichever comes first. By now I have worked up a good sweat, I am warmed up and have a pretty good workout going. Oftentimes by now the mood strikes me to run fast for a while so I may speed up to 8 mph. Then once I am starting to get more tired than I want to, I will slow down long enough to catch my breath. Then, if not too tired, I will go lift weights for a while. If the chest press machine is busy I will go lift barbells or dumbbells etc. Then when I get tired of doing that I go home. Great workout, no pressure, little mental stress -- what could be better? If the treadmill is just not doing it for me today, no big deal, I will find some exercise that I feel like doing. Perhaps you have heard of "fartlek" training. I am told fartlek means "speedplay." This is where you have no set plan for a run, you simply speed up and slow down, when you get the urge. It is known to be very effective and is a form of interval training. In my eyes I have simply taken this concept and applied it to the entire workout. In summary, I have gone from a far more rigid type of workout to one that allows for more flexibility, and it works for me. Why don't you give it a try. It might be just what you need to spice up your workout. For more by Milt Bedingfield, click here. For more on fitness and exercise, click here.]]> New Study Explains Why Doctor's May Be Apprehensive To Recommend Weight Loss And Exercise tag:www.huffingtonpost.com,2012:/theblog//3.1597406 2012-06-20T11:40:00-04:00 2012-08-20T05:12:05-04:00 Milt Bedingfield http://www.huffingtonpost.com/milt-bedingfield/ Obesity suggests physicians that maintain a more normal body weight themselves are more likely to recommend to their overweight or obese patients the need for weight loss and feel comfortable doing so. The objective of the study, conducted between February 9 and March 1, 2011 by researchers in the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health, was to look at the impact of physician BMI on obesity care, physician self-efficacy, perceptions of role-modeling weight related health behaviors, and perceptions of patient trust in weight loss advice. Bleich and colleagues discovered that physicians with a normal BMI were more likely to discuss weight loss with their obese patients than their colleagues with a higher BMI score. As I mentioned previously, the study showed that physicians with a normal BMI also had greater confidence in their ability to provide diet and exercise counseling to patients (53 percent vs. 37 percent, P=0.002). Eighty percent of the physicians with a normal BMI felt that overweight or obese patients would be less likely to pay attention to weight loss advice from overweight or obese physicians, while only 69 percent of the physicians with an elevated BMI felt the same way. Physicians with a normal BMI were more likely to believe that they should serve as role models to their patients in regards to maintaining healthy weight-related behaviors and performing regular exercise. And finally, something that I find very interesting, physicians with an elevated BMI were far less likely to record an obesity diagnosis or bring up the subject of weight loss with obese patients, unless the physician's perceptions of the patients' body weights met or exceeded their own body weight. I find this study useful in helping us to understand why doctors, within the same specialty, diagnose and treat patients with the same illness in different ways. As this study suggests, perhaps it is influenced by the physician's own state of health. Could it be that the medication the doctor prescribes a patient for high cholesterol is the one that seems to work best in treating his own cholesterol? Maybe a lot of health care providers do feel uncomfortable prescribing exercise and weight loss, and therefore don't do it, if they themselves are quite overweight and cannot find the motivation to get out and get it done. Interestingly, I have heard countless times of physicians that tell their patients that they need to quit smoking but smell of cigarettes themselves. I do believe that people involved in the health care industry, particularly doctors, nurses, dietitians, therapists and educators, should serve as healthy examples to their patients and that they be people that patients can aspire to. Maybe this is one reason why doctors don't recommend exercise to patients with diabetes with the enthusiasm that patients need to hear. Maybe it's because of their own personal situation and the attitudes they have toward exercise. In any case, good study. We need more on this topic. For more by Milt Bedingfield, click here. For more healthy living health news, click here.]]> Experts Say Wear Your Diabetes Detectives Badge on the Left tag:www.huffingtonpost.com,2012:/theblog//3.1590442 2012-06-19T16:58:57-04:00 2012-08-19T05:12:08-04:00 Milt Bedingfield http://www.huffingtonpost.com/milt-bedingfield/ In case you are new at this and don't know what I am talking about, let me explain. This is certainly something you will need to know about. Have you ever watched any of the police or crime shows on TV? It seems to me that they all begin about the same. A cell phone rings, a shirtless man or scantily-clad woman awakens from sleep and reaches over to the bedside table, switches on the lamp, and picks up the phone. All you hear is a one-sided conversation. "Sanders... (pause)... When?... (another pause)... Any witnesses?... Be there in 20 minutes." The next scene: The sound of an approaching siren, lights flashing and an unmarked car screeching to a halt. A crowd is standing around something, usually a dead person. You see Sanders walk up, now in some sort of a long coat, holding a steaming cup of coffee. A uniformed officer comes up. Sanders speaks. "Hey Johnson, what do we got?" The uniformed cop reads notes off his note pad. "White male, approximately 30 to 40 years old, found dead, laying face down in the street about 1:15 a.m. this morning, by this lady, Joan Doe, while she was out walking her doberman." "Anything else?" Sanders asks. "Well, some witnesses say the dog was walking her," Johnson states. Sanders turns his attention to the small woman, "How did you know the man was dead?" "There was a chalk line around his body," she replies. So you ask, what does any of this have to do with diabetes? Does any of this sound familiar? I believe just about every police show starts off with a murder being committed. Then what? A detective appears on the scene, asks a lot of questions and looks for clues that would help the detective solve the crime. Just before the end of the show, the detective has enough information to solve the murder. So, what does this have to do with you and your diabetes? Every time you test your blood sugar and it's not what it's "supposed to be," either too high or too low, then a crime has been committed. What's the crime? A blood sugar that's out of range. When you get a reading that is too high or too low, you should figuratively, pin your detective badge on and begin looking for clues as to what caused it. Let's say you test your blood sugar two hours after breakfast. Your reading is 227mg/dl. Not so good. You turn your work ID around to its back side, the side that's got the picture of the detectives badge glued to it. That's right, for the next several minutes you are not Jim the software engineer, you are Detective Jim. Let's get started. "So Jim, why is your blood sugar level so high two hours after breakfast? What could have caused it?" "I don't really know," you say. "Is it possible you ate too much for breakfast?" Jim asks. "No, I counted my carbs, only had about 50 grams, 60 at the most, which is on my meal plan." "Tell me," continues Detective Jim, "did you happen to check your blood sugar before breakfast, and if so what was it?" "It was 180mg/dl." you answer. "So, your blood sugar was high before you ate?" Jim acknowledges. "Yes sir," you respond. ""So if it was high before breakfast, it's likely that it would be high after breakfast, even if you ate the right food." Jim comments. "Well, yeah." "So, now we know why you were high after breakfast, because you were already high before breakfast. Now the direction of the investigation needs to turn to look at why the blood sugar level was elevated before breakfast." "Let's go back about two hours from when you woke up. What were you doing?" "Sleeping." "Did you eat anything in the middle of the night?" Jim asks. "No," you reply. "No, I never eat anything in the middle of the night unless my blood sugar goes down too low," you tell Jim. "Okay, is it possible you forgot to take your diabetes medication last night?" "I took one of my diabetes medications but not the other one because I ran out." "What is the name of the medication you did not take and how much are you supposed to take?" "Metformin, and I take 1000mg with dinner." "We may have just solved the crime! Missing that evening dose of medication may be the cause of your high blood sugar before breakfast. Just to be thorough, let me ask just a few more questions. Did you have a snack just before you went to bed?" "No, not last night." "Did you eat later than usual, or did you eat more than usual?" "Well, both, I ate about two hours later than I usually do, and I ate more than I usually eat. "I'm going to close your case now. My report will indicate that your elevated blood sugar after breakfast was primarily caused by your elevated blood sugar before breakfast, that is likely the result of two to three factors: missing your evening dose of metformin eating later than usual, and eating more food than usual. "Learn from this investigation and try to do better next time," Jim suggests. You flip your badge over and you are back to being Jim the software engineer. I am going to speculate that well over half of the time, when a patient has elevated blood sugar levels above what they should be or below what they should be, if that patient plays detective for a couple of minutes, looking for clues that may have caused the high or low, they will be able to figure it out. In summary, the motivated patient can then initiate steps to prevent the same problem from occurring in the future. For more by Milt Bedingfield, click here. For more on diabetes, click here.]]> When Newly-Diagnosed With Diabetes Do This, Not That (Part 1) tag:www.huffingtonpost.com,2012:/theblog//3.1569603 2012-06-11T11:15:11-04:00 2012-08-11T05:12:07-04:00 Milt Bedingfield http://www.huffingtonpost.com/milt-bedingfield/ 1. Get yourself signed up for a comprehensive diabetes class. Don't go ask someone you know that has diabetes what to do. Although there are people who are quite knowledgeable about diabetes, there are considerably more people who are not. Over the many years I have been a diabetes educator I have often found that people that have had diabetes for long periods of time know far less than they think they do, in part due to the fact that a lot of what they may have learned about treating the disease at the time of their diagnosis is outdated and has been replaced with current strategies as a result of new knowledge of the disease. It is a common and often harmful misconception to assume that people that have had diabetes for many years know a lot about it. On frequent occasions patients have come in to our class making the comment, "I could teach this class." As I previously stated, treatment for diabetes has changed tremendously over the years and many longstanding patients hold steadfast to the less-modern way of treating the disease. These are not the people you want to learn from even though they are often more than willing to offer advice to try to help you out. Because of this, we subtly try to discourage people newly diagnosed with diabetes from sitting next to someone in class that has had diabetes for many years. 2. Get your very own blood glucose monitor. Do not use a monitor that was ever used by someone else. No exceptions! Newly-diagnosed diabetes patients show up at our classes weekly with a blood glucose monitor that was given to them by a friend, relative, or colleague. This, on the surface, does not seem to be a problem, but it can end up being a big one. It is never recommended to use a monitor that was used by someone else due to the risk of passing on dangerous blood borne pathogens to the new user. A relatively clean looking monitor could potentially have germs you want nothing to do with all over it. Get a prescription for a blood glucose monitor from your doctor, or better yet, your doctor may even give you one. 3. Watch your carbohydrate intake until you can see a dietitian or attend a diabetes self-management class. Do not eliminate all carbohydrates and sugar from your diet. It is natural to be scared or nervous when first diagnosed with diabetes. Usually it is far more of a concern of mine when people aren't at least a bit upset. Having diabetes is a big deal, a very big deal. It will affect most of what you do for the rest of your life. As a result, it is common that once the doctor tells you that you have diabetes you go overboard and start cutting all foods out of your diet that contain sugar. Again, a completely normal response, but don't do it. This is of particular concern if the doctor has put you on insulin injections or a class of medications known as sulfonylureas. The combination of taking these diabetes medications plus significantly reducing your carbohydrate or sugar intake (the same thing) could allow your blood sugar levels to drop well below normal, resulting in you feeling very poorly (shaking, experiencing cold sweats, particularly above the neck, a pounding and racing heart and light headed). For more by Milt Bedingfield, click here. For more on diabetes, click here.]]> An Appeal to Physicians Regarding Exercise tag:www.huffingtonpost.com,2012:/theblog//3.1562932 2012-06-08T11:31:10-04:00 2012-08-08T05:12:10-04:00 Milt Bedingfield http://www.huffingtonpost.com/milt-bedingfield/ So, you have had your surgery two days ago, and the surgeon walks into your room while making rounds. After he does a quick review of your vitals and asks you how you are feeling, you ask the doctor, "How do I keep this from happening to me again?" The doctor replies, "You got to get out of that recliner at home and start being more active." "What should I be doing?" you ask, expecting something detailed -- after all, you are lucky to be alive. You had three mostly-blocked arteries. "Just walk, " he says. "How fast?" you ask, expecting a bit more. "Just start slow and build up," the doctor responds very casually. After all, he is not the one that suffered a major heart attack several days ago. The doctor appears to be finished talking about it as he makes his way toward the door. Where is this story going you ask? Is there a point to imagining this happened to you? Most definitely, that is, if you are at all like me. And here it is. If I had just had a serious health scare such as the one just described, I would want far more detailed exercise advice than just being told to be more active or just walk. Being told to "be more active" or "just walk" would simply not be good enough. I wouldn't know how far to walk or how long, how fast to go or how often. How much is enough? How much is too much? If I do too much am I likely to have another heart attack? Doctors need to take the time to be a bit more detailed when giving instructions to their patients regarding not only the need for exercise, but how to do it. That is, doctors need to know the current guidelines for prescribing exercise so that they feel comfortable doing so. Ideally, patients need to leave the doctor's office with an exercise prescription in hand, complete with frequency, intensity and duration guidelines. I believe providing patients with written prescriptions for exercise that contains all of the pertinent details as to how to do it, would increase the total number of people that exercise. The American College of Sports Medicine, in conjunction with the American Diabetes Association, has published a position paper on exercise prescription guidelines that explains in detail their current recommendations. For more by Milt Bedingfield, click here. For more on personal health, click here.]]> What Is It Going to Take to Get Exercise on an Even Keel With Diet for People With Diabetes? tag:www.huffingtonpost.com,2012:/theblog//3.1553833 2012-06-01T14:05:02-04:00 2012-08-01T05:12:19-04:00 Milt Bedingfield http://www.huffingtonpost.com/milt-bedingfield/ Increased physical activity (I just go ahead and call it what it is, exercise) and maintaining a normal body weight, usually referred to as making positive "lifestyle choices," has been cited repeatedly as central to preventing and/or controlling prediabetes and diabetes. The problem with this is that it seems not enough people with Type 2 diabetes are heeding this advice, and health care professionals such as doctors, nurses and certified diabetes educators are not explaining the need for exercise in strong enough terms. Patients newly diagnosed with diabetes commonly realize the need for eating better, which in their minds means eating fewer carbohydrates, even if they don't recognize the need for reducing their fat intake and losing some weight, but they don't often see the relationship between having diabetes and the increased need for exercise. It has been my experience that when patients are willing to make a change in their lives to better manage their diabetes, it usually has to do with limiting the number of carbohydrates they consume, not increasing their activity level. Limiting carbohydrates is a good start, but is not at all likely to be enough to effectively manage Type 2 diabetes long-term. It's only half of the equation, only part of the solution. Exercise is vitally necessary, as well as limiting carbs, because as more and more beta cells cease to function and less insulin is produced, carbohydrate intake will out of necessity need to be at a bare minimum, which still may not allow for good management of blood glucose levels. It is my contention that health care providers, including physicians, nurse practitioners, and diabetes educators, need to impress upon their patients with Type 2 diabetes that getting regular, almost daily exercise is equally as important as watching what they eat. Not only that, we need to take the time to explain to patients the latest exercise guidelines established by the American Diabetes Association. If patients express concern about whether or not they can perform exercise due to a health condition, every effort should be made to help the patient problem-solve their situation so that some form of exercise is possible. Exercise is too valuable a treatment for patients to simply dismiss it due to a medical problem. I believe health care providers need to make the need for exercise more clear to patients with Type 2 diabetes and go the extra step in recommending current exercise guidelines. For more by Milt Bedingfield, click here. For more on diabetes, click here.]]> People Newly Diagnosed With Diabetes Should Be Taught by Certified Diabetes Educators tag:www.huffingtonpost.com,2012:/theblog//3.1535783 2012-05-30T11:42:30-04:00 2012-07-30T05:12:13-04:00 Milt Bedingfield http://www.huffingtonpost.com/milt-bedingfield/ I always politely tell them it doesn't matter, because five $20 bills is the same as ten $10 bills, they both add up to $100. Some companies are not concerned as to what time you arrive at work or what time you leave, just as long as you get your 40 hours in. The end result is the same. When I was much younger, I remember hearing my dad say, "Six of one or a half-dozen of the other." I heard that so many times, but never could figure out what it meant. Eventually I got it but I wasn't so young anymore. Closer to home, if your blood sugar is low and you are in the midst of a hypoglycemic episode, I doubt you care if you are treated with grape juice, candy corn, or glucose tablets. For most people experiencing hypoglycemia, it is so miserable they don't care how it's treated or what its treated with, just get the numbers up as quickly as possible. In so many instances in life, the end result is going to be the same no matter how you got there, as I have tried to illustrate in the previous examples. But then there are cases where the end result is totally dependent on how you got there. Imagine traveling by car from Florida to California with Albert Einstein as your companion, or maybe Mother Teresa. Think of the conversation, the questions, the great stories. Contrast that with the same trip, but with a different companion, a regular guy like me. I can tell you the little that I know about Albert Einstein or Mother Teresa, but there's no way I can tell you what they can tell you. This would definitely not be a situation where my dad could say that taking a trip to California in their company vs. riding with me was "six of one or a half-dozen of the other," because it's not. By the same token, learning about diabetes from a certified diabetes educator is not at all the same as spending time with a diabetes coach. The amount of diabetes knowledge that each possess could be worlds apart. This is not at all meant as a critical remark or to put diabetes coaches down in any way, as I do feel there is a valuable role for them, however, certified diabetes educators must pass a certifying exam every five years, indicating a high level of competency. By the time most educators achieve the CDE credential, they have accumulated a significant level of knowledge and considerable experience in the field of diabetes. Diabetes coaches are frequently well-meaning volunteers with little to no diabetes experience who have a desire to help others with diabetes. The diabetes education that prepares them to be a diabetes coach may range from several hours to two days. I see the role of a diabetes coach as a motivator to help keep the person with diabetes on track with their exercise and meal plan. This is of significant importance. Health care associations recommend that someone newly diagnosed with diabetes receive a minimum of 10 hours of diabetes education within the first year of being diagnosed. This is considered comprehensive education. Anything less than this, in my opinion, is shortchanging the patient and not preparing them optimally to properly manage their disease. No, this is definitely not a case where being taught by a certified diabetes educator is six of one or a half-dozen of the other to being taught by a diabetes coach. Diabetes is far too serious to mess around with. Get education immediately after diagnosis and get it from a certified diabetes educator. For more by Milt Bedingfield, click here. For more on diabetes, click here.]]>


text:
- Home
- Programs
- News
- Talk Shows
- HPR Events
- Community Calendar
- Support
- Donate Now
- Sustaining Membership
- Matching Gifts
- IRA Charitable Rollover
- Underwriting / Program Sponsor
- Donate Your Vehicle
- Gift of Stock
- HPR Legacy Society
- Volunteer at HPR
- East Hawaiʻi HPR-2 (KAHU 91.7) Transmitter
- West Hawaiʻi HPR-2 (KHPH 88.7) Transmitter
- About Us
- Contact
Korea's Peninsular Politics
For the first time in nearly twenty years, the leader of North Korea kicked off the new year with a nationwide address. So far, there's been a quiet reaction from South Korea to the unusual event. But analysts are watching what happens later this year, as South Korea goes through some political change of its own. HPR's Bill Dorman has more in today's Asia Minute.
audio file:

subset: commoncrawl


text:
In this country we can commit all kinds of abominations, and they are legal!
Abortion, gay marriage, pornography and euthanasia in some states, all legal!
Perhaps praying will be illegal one day. Wickedness is swallowing up this nation and the world. God have mercy on us.
Camille Sanchez
Location, ST | website.com


text:
Master of Business Administration (International)
Course summary for international studentsClick here for the local course option
2016 course information
|Award granted
Master of Business Administration (International)
|Offered at Burwood (Melbourne)
|Cloud (online)
|2 years full-time or part-time equivalent
|Next available intake
March (Trimester 1), July (Trimester 2), November (Trimester 3)
|Fee paying annual fee - commencing 2016
|Higher Degree Coursework (Masters and Doctorates)
|CRICOS course code
|IELTS Requirement
IELTS overall score of 6.5 (with no band score less than 6) or equivalent
|Deakin course code
|Faculty contacts
|Deakin International
Tel +61 3 9627 4877
Online enquiry
Course sub-headings
- Course overview
- Fees and charges
- Course rules
- Specialisations
- Course structure
- Entry requirements - general
- Entry requirements - specific
- Credit for prior learning - general
- Credit for prior learning - specific
- How to apply
- Key dates
Course overview
Deakin's Master of Business Administration (International) is designed to give high-performing students an opportunity to gain industry experience as part of a world-class MBA.
The course is available to applicants who may not have had experience as a business manager. It includes an optional business practicum project unit, which is completed in an operating business environment to equip you with valuable practical managerial expertise.
High achieving students are able to move directly from their undergraduate degree to postgraduate MBA studies, saving time and money.
The course also features a research project option, which can allow you to conduct research into specific organisational issues, and may allow you to articulate into a research degree. Emphasis will be placed on issues associated with international business management.
Fees and charges
Equivalent Full Time Student Load (EFTSL)
EFTSL is the standard annual full time load. Eight credit points is considered a standard full time load for one year. Each unit you study has an EFTSL value. You can add these together to calculate your study load each year. Depending on enrolment, you may be enrolled in more than or less than the one EFTSL each year.
Fee paying place - International (IFP)
A fee paying place is one for which the University does not receive any Government funding. As such, students enrolled in these places are required to contribute the full cost of their course.
Fees for international students apply to persons living in Australia with Temporary Resident status, provided that there is no limitation on study and persons living abroad who are not Australian citizens and do not have Permanent Resident status in Australia.
The actual course fees charged by Deakin University, is based on the course and the study load (EFTSL) being undertaken. The study load (EFSTL) value of each unit offered in 2016 can be viewed from the Unit Search.
The fees per course/unit/credit point may be otherwise subject to an annual increase due to rises in the cost of course delivery and service.
This indicative and annual course fees provided are a guide only. No representation is made that the information provided is current or accurate. Deakin assumes no responsibility for persons relying on indicative course fees to calculate the total future cost of their course. Applicants can email firstname.lastname@example.com au for more information about 2016 fees.
Course rules
The degree requires completion of 16 credit points comprising 12 credit points of core units plus 4 credit points of elective units from a specified list (students may choose other units with prior written approval of the Course Team Chair). The 4 credit points of elective units may form one of the specialisations listed below, or students may choose these units from the range of specialisations including the general elective units. Students must complete at least four credit points of units from the core at Deakin.
Students may choose to exit the MBA (International) early with either a Graduate Certificate of Business Administration (International) or a Graduate Diploma of Business Administration (International).
Refer to the details of each specialisation for availability.
- Business Consulting
- eBusiness and Supply Chain Management
- Finance
- Human Resource Management
- International Business
- Marketing
- Project Management
- Research
- Retail Management
- Social Media and Mobile Strategies
Course structure
Core units
|Business Communication for Managers
|Critical Thinking for Managers
|Analytical Skills Foundations
|Ethics for Managers
|Financial Interpretation
|Business Process Management ^
|Economics for Managers #
|International Business Management #
|Marketing Management #
|International Banking and Finance
|Business Strategy and Analysis
|Business Internship Experience
#MPT code denotes study tour version of the unit
^MPM701A is a Start Anytime unit.
Elective units
The 4 credit points of elective units may form one of the specialisations listed above, or students may choose these units from the range of specialisations or the general elective units listed below:
|Indian Law
|Sustainable Environmental Marketing
|Operations Management
|Audacious Leadership #
|The Leadership Adventure
or any other units with prior written approval of the Course Team Chair.
#MPT code denotes study tour version of the unit
Course Learning Outcomes
|Graduate Learning Outcome
|Course Learning Outcome
|Discipline specific knowledge and capabilities
|Demonstrate an advanced and integrated understanding of a contemporary body of knowledge and apply research skills and theories to the evaluation of complex business issues in a global context.
|Demonstrate advanced communication skills and intercultural understanding in a diverse range of business and management contexts.
|Digital literacy
|Select and use digital technologies to find, organise, analyse and disseminate complex business ideas.
|Critical thinking
|Apply critical analysis skills to evaluate complex ideas in business and international contexts.
|Problem solving
|Apply problem solving skills to conceptualise, construct and recommend solutions for complex business issues facing local and international organisations.
|Work and learn independently and take responsibility for personal and professional actions.
|Demonstrate advanced team work skills in diverse organisational contexts.
|Global citizenship
|Analyse and interpret the impact of ethics, culture and internationalisation on contemporary business.
|Approved by Faculty Board October 2014.
Entry requirements - general
Deakin University offers admission to postgraduate courses through a number of Admission categories. In all categories of admission, selection is based primarily on academic merit as indicated by an applicant's previous academic record. The minimum requirements are successful completion of a three-year undergraduate degree, or equivalent, from an approved university or other educational institution or successful completion of other equivalent qualifications gained by examination, or approved professional or industrial experience. International students must also meet the postgraduate English language requirements..
Entry requirements - specific
Minimum entry requirements:
- Bachelor degree in any discipline with minimum weighted average mark (WAM) of 65%
- Masters degree with a minimum WAM of 65%
- Graduate certificate in a related discipline with minimum WAM of 65% and 5 years relevant work experience
- Deakin Business and Law Postgraduate Qualifying Program (PQP) (with a minimum overall average of 65% in each discipline based unit undertaken)
IELTS / English language requirements
Please note that English language requirements exist for entry to this course and you will be required to meet the English language level requirement that is applicable in the year of your commencement of studies.
It is the students' responsibility to ensure that she/he has the required IELTS score to register with any external accredited courses.
Credit for prior learning - general
If you have completed previous studies which you believe may reduce the number of units you have to complete at Deakin, indicate in the appropriate section on your application that you wish to be considered for credit for prior learning. You will need to provide a certified copy of your previous course details so your credit can be determined. If you are eligible, your offer letter will then contain information about your credit for prior learning.
Your credit for prior learning is formally approved prior to your enrolment at Deakin during the Enrolment and Orientation Program. You must bring original documents relating to your previous study so that this approval can occur.
You can also refer to the Credit for Prior Learning System which outlines the credit that may be granted towards a Deakin University degree.
Credit for prior learning - specific
Credit for prior learning into the Master of Business Administration (International) may be granted to students who have successfully completed appropriate postgraduate studies in managment. Students must complete at least four credit points of units from the core at Deakin. There are negotiated credit arrangements for prior learning arrangements in place for CPA members.
How to apply
- Applicant Portal: Use our online application system to submit and track your application now OR
- Apply through a Deakin International office: Fill out an application form and submit it to a Deakin International office OR
- Apply through a Deakin representative: Take your application form to your preferred agent for assistance.
Tracking your application
If you have already applied and wish to enquire about your application please refer to the relevant area through which you originally applied.
- If you applied through a Deakin representative please contact your representative.
- If you applied through a Deakin International office please contact email@example.com


text:
Looks like Wickshire West Apartments is no longer available on Rent.com which means this information is likely out of date.
Make sure to check out these similar properties in the area.
This is a senior living community. A minimum age requirement of 55 or 62 will apply. Not all renters will qualify. Please contact the property for details.
Contact for details
Our property is conveniently located near TCC, YMCA, China Lake Park, 6th Avenue, Titlow Beach Park, University Place. The beautiful grounds feature Oversized decks and patios, fully fenced back yard/community courtyard. Units include the following great amenities: Extra large square footage, washer & dryer, double closets in bedrooms, storage, screen doors.
Lease Terms: 6,9,12 month leases.
Pets are not allowed, other than service or companion animals.
No Pets. Call for service animal policy.
64 units
Don't have a Rent.com account? Create one.
Creating an account allows you to acccess your saved and contacted properties on any device. Already have an account?
Log In
We are experiencing technical difficulties at the moment. Please try again later.


text:
- Subscribe
- Magazine
- Contract Packaging
- Education
- Leaders in Packaging
- Calendar
Article | August 31, 1995
Semi-automatic case sealer
The SK-300BD semi-automatic case sealer is new from Sekisui TA (Booth 3228). Designed for use in cold and wet environments, it's suited for frozen foods, meat and poultry.
Driven by bottom belt it reaches speeds to 90'/min. Can use 1- 1- and 2-yd rolls of p-s tape.
Related Sponsored Content
44 Best Package Designs
Sign up to receive timely updates from our editors and download this e-book of our editors' selections for most innovative package designs of the past year.


text:
Definitions for walther hermann nernst
This page provides all possible meanings and translations of the word walther hermann nernst
Princeton's WordNet
Nernst, Walther Hermann Nernst(noun)
German physicist and chemist who formulated the third law of thermodynamics (1864-1941)
Find a translation for the walther hermann nernst definition in other languages:
Select another language:
Discuss these walther hermann nernst definitions with the community:
Word of the Day
Would you like us to send you a FREE new word definition delivered to your inbox daily?
Use the citation below to add this definition to your bibliography:
"walther hermann nernst." Definitions.net. STANDS4 LLC, 2016. Web. 10 Feb. 2016. <http://www.definitions.net/definition/walther hermann nernst>.


text:
Hawkes Bay Today
Hawkes Bay Today
Most Popular
What do you think?Have your say
600–650 votes
HBT: Are you confident that Hawke's Bay's economic fortunes are rising?
Christmas message from Aunty's Garden
It's that time of year again when families gather together to eat, to reminisce, to enjoy, to admire the oodles of gifts…2Comments
Local gym tops in excellence
Dr Adele Whyte: Challenging the status quo3Comments
AGM Pa sports day a huge success
Brand InsightWhat's this?
Brand Insights
New Zealand Herald's Brand Insight connects readers directly to the leadership thinking of many prominent companies and organisations.
KPMG: Good corporate conduct brings big benefits
Companies which address the burgeoning threat of conduct risk stand to be winners in the marketplace, according to a top…
University of Auckland: Robots as judge, jury and lawyer
Fisher Funds: Willpower keeps bears at bay
University of Auckland: Making money not the biggest reward
KPMG: Conventions centres $940m investment in new visitors
Cricket: Stags face big target to avoid home loss
Is it a hangover from the one-day Ford Trophy victory last weekend? That may well be the case but Devon Hotel Central Districts…
Cricket: NTOB earn tilt at NZ crown
Football: Battle for second position hots up
Woman, 20, missing after run
Young woman failed to return from a run with her dog last night in south-east Auckland.


text:
Atlante Star Hotel, Rome
- Free WiFi
Main amenities
- Restaurant and bar/lounge
- Rooftop terrace
- Breakfast available
- Internet in the lobby
- Self parking
- Business center
- Airport shuttle
- 24-hour front desk
- Air conditioning
- Daily housekeeping
- Car rentals on site
- Front desk safe
What's around
- In Vatican
- St. Peter's Basilica (0.5 mi / 0.8 km)
- Castel Sant'Angelo (0.3 mi / 0.5 km)
- Vatican Museums (0.5 mi / 0.9 km)
- Roman Forum (1.7 mi / 2.7 km)
- Piazza Navona (0.9 mi / 1.4 km)
Enter dates to check prices
Hotel Info: 866-539-8117from $96
- Superior Double or Twin Room
- Apartment, 2 Bedrooms
- Superior Double or Twin Room
- Superior Triple Room
- Family Room
- Deluxe Double or Twin Room
- Superior Single Room
- Junior Suite
Also popular with travelers from the USA
At a glance
Key facts
Hotel size
- This hotel is arranged over 7 floors
- Check-in time 2 PM-Midnight
- Check-out time is 11 AM
Required at check in
- Credit card or cash deposit required
- Government-issued photo ID required
Travelling with others
- Children (12 years old and younger) stay free when occupying the parent or guardian's room, using existing bedding
- Pets allowed
Extra people
- Roll-away beds available, charges may apply*
- Free WiFi in public areas
- Free WiFi in rooms
- Self parking *
Nearby Four Star Rome hotels
In the hotel
- Breakfast (surcharge)
- Restaurant
- Bar/lounge
- Room service (during limited hours)
- Business center
- Conference space
- 24-hour front desk
- Concierge services
- Limo or Town Car service available
- Dry cleaning/laundry service
- Laundry facilities
- Free newspapers in lobby
- Luggage storage
- Wedding services
- Number of buildings/towers - 1
- Elevator/lift
- Safe-deposit box at front desk
- Rooftop terrace
- In-room accessibility
In the room
- Climate control
- Air conditioning
- Minibar
- Iron/ironing board (on request)
- Blackout drapes/curtains
- Turndown service
- Private bathroom
- Shower/tub combination
- Bidet
- Free toiletries
- Hair dryer
- Premium TV channels
- Desk
- Free newspaper
- Free WiFi
- Phone
- Daily housekeeping
- In-room safe
Top Rome hotels
Recently reviewed hotels in Rome
- B&B all'OrologioFrom
"Breakfast included juices, cappuccino, pastries, cheeses, breads, sliced meats, toast with butter, jams, cream cheese, and any requests we made. My husband requested mortadella…"Feb 4, 2016
- Holiday Inn Rome- Eur Parco Dei MediciFrom
"The staff here was wonderful. The room was comfortable and clean. The shuttle driver was so helpful and friendly. I was easily able to catch a train into the city for only a euro.…"Feb 4, 2016
- Gambero Guesthouse - My Extra Home
"The apartment (We stayed in D) is very nice and the location is great for all the reasons you go to Rome. Very centrally located to all the sites and shopping. Dining is a bit…"Feb 3, 2016
- Le Stanze di ElleFrom
"Lovely little 7 bedroom hotel. More like an apartment and was really cool. Staff was really helpful and great. Right in between 2 metro stops so it was pretty convenient. Very…"Feb 3, 2016
Nearby hotels
Atlante Star Hotel, Rome's small print
Also known as
- Atlante Hotel
- Atlante Star
- Atlante Star Hotel
- Atlante Star Hotel Rome
- Atlante Star Rome
- Hotel Atlante
- Hotel Atlante Star
Cash transactions at this property cannot exceed EUR 2999.99, due to national regulations. For further details, please contact the property using information in the booking confirmation.
This property's policy is to refuse certain bookings for the purpose of group events or parties, including pre-wedding stag/bachelor and hen/bachelorette parties.
Only registered guests are allowed in the guestrooms.
For transfers, guests must contact the property 72 hours prior to arrival at the number on the booking confirmation.
Mandatory fees
You'll be asked to pay the following charges at check in or check out:
- A tax is imposed by the city: EUR 6 per person, per night, up to 10 nights. This tax does not apply to children under 10 years of age.
Optional extras
Self parking is available for an extra charge
High-speed Internet access (wired) is available in public areas for an extra charge
We have included all charges provided to us by this hotel. However, charges can vary, for example, based on length of stay or the room you book.
Is the description of this hotel not correct? Tell us


text:
Knock Your Wool Socks Off With New Latin Music
Depending on where you live, spring is at your doorstep. So we thought it was a good time to invite the hosts of Alt.Latino, NPR's weekly Latin music and culture show, to share some fresh new music with us. We've got a Brazilian hip-hop star, a rising Chilean folk artist, a moody Mexican singer and more.
As always, be sure to hop into the comments to let us know what music you've been using to help usher in the warmer weather.
Knock Your Wool Socks Off With New Latin Music
Karol Conka
- Song: Boa Noite
- From: Batuk Freak
Rebel Tumbao
- Song: Rebel Music
- From: Rebel Tumbao
- Song: Mi Viejo
- From: Viejo
Ani Cordero
- Song: Panis Et Circensis
- From: Recordar
You must be signed in to leave a comment. Sign In / Register
Please keep your community civil. All comments must follow the NPR.org Community rules and Terms of Use. NPR reserves the right to use the comments we receive, in whole or in part, and to use the commenter's name and location, in any medium. See also the Terms of Use, Privacy Policy and Community FAQ.


text:
Melvin Anthony Maceau
Position: C
Height: 6-0 Weight: 203 lbs.
Born: December 25, 1921 in Milwaukee, WI
Died: February 16, 1981 in Bowling Green, OH
High School: Rufus King
College: Marquette (school history)
Drafted by the Cleveland Rams in the 14th round (141st overall) of the 1944 NFL Draft.
Weighted Career AV (100-95-...): 0 (15060th overall since 1950)
Our primary support comes from users like you. Sponsor this page for $5. Your message will replace this ad.


text:
Combo Discount:
It is effective.. but there can be sideeffects.
8 people found the following review helpful
Posted by Reviewer1742806 on Mar 27, 2009
This is a potent supplement. It did make me feel better, until my hair started falling out and it stopped my periods. I guess it can become testosterone and other hormones that will reap havoc in some people. This is buyer beware.
Was this review helpful to you?
Note: iHerb does not imply any medical claims from this review. Disclaimer.