Tuesday, February 26, 2013

I apologize for lack of almost daily posting. I have been busy for the last few months . Things should slow down for me soon.  In the mean time I will repeat some of my slightly used older post and comments.
Dr. Calder


Fixing The 9 ,prevents heart disease and amputation

I was reading Internal Medicine News this morning and one article got my attention.

 Amputations decline 65% in Diabetic patients 
      by Diana Mahoney
    The major finding was , the rate of hospitalizations for non traumatic amputations has decreased from 11.2/1000 persons in 1996 to 3.9/1000 persons in 2008. This informations was collected and reported by the Centers  For Disease Control (CDC )

This is good news and probable means that we are all doing a better job with preventive  health care.

The bad news was reported in Diabetes Care 2012;35: 273-7. They reported that even with the significant decline in amputations , the amputation rate is still eight times higher than in the non-Diabetic population.
(3.9 vs 0.5 persons per 1000)

comment ;
      When was your last Diabetes Foot Exam ?

      Do you know what a Diabetes Foot Exam is ?  It is more then a quick look at your foot

 This  subject brings up something that has bothered me for years about our approach to diabetes care. 

Diabetes  risk management by default is primarily physician and institution based .
I helped develop a  computer assisted Diabetes Wellness Assessment Program  (DWAP) for my medical group with a goal of reducing the risk of heart disease and other diabetes complications. This was very successful in improving diabetes risk factor management . However, even with the  great effort and expense by the doctors , nurses , diabetes educators and administration , we were not 100% successful .
We had the most success in test and exams that were set up to be done automatically such as lab. test and we had the least success with test and exams requiring input and recall by patients, physicians and staff with things like foot exams and achieving some of the goals.

I have felt for a long time that one essential ingredient in our plan was overlooked. 

We neglected to adequately empower each patient with the responsibility for their own care and
we also made risk management to complicated.

 Finding a way to Simplify diabetes care and Empower Patients to be more involved in their own care was the reason for me writing  , Diabetes Office visit 

The basic principle of the book and iPhone , iPad app is to empower patients to set target goals for their test and exams, then reach those goals with the help of their doctor and prevent the complications of diabetes.

 I manage to hide these basic concepts with to much verbiage, discussing back ground and studies supporting the reasons for the test. 

 My son in law, Vince,  and Herman Cain  helped me simplify and make my idea more useful. 

Herman Cain promoted the idea of his 9-9-9 plan for simplifying our tax code.

My son in law helped me realize that reaching diabetes treatment goals is simply a game of numbers and that understanding the numbers is not necessary for fixing them.

 The understanding and meaning of those numbers will come with time and repetition .

So I have now shortened my book  concept to Fixing the 9 for people with Diabetes and Fixing the 6 for non -diabetics with a primary goal of reducing the number one killer for all of us , Heart Disease

Fixing those 9 risk factor will have a little side benefit of reducing the risk of eye and foot problems

please go to the Diabetes office Visit Training Video  tab above for more information on goals setting and risk management ideas . I developed the video for Iphone and iPad users but it help you understand the ideas behind goal setting and risk management .

Have fun , Be Smart  and Defeat Diabetes,
David Calder,MD


  1. We had the most success in test and exams that were set up to be done automatically such as lab. test and we had the least success with test and exams requiring input and recall by patients, physicians and staff with things like foot exams and achieving some of the goals.



    1. We had the same experience with a Diabetes Wellness Assessment Program (DWAP )  in Peace Health Medical group.. .
      Dr. Calder

Saturday, February 16, 2013

Do you order medications online ? Things you need to know

 Do you order medications online ?
       Things you need to know

             *   counterfeit prescription medications is a 75 billion doller a year business  that is attractive to

              *  FDA test results of prescription Drugs, Viagra , Lopitor and Ambien, from a
                  bogus Canadian website show all products were fake and substandard
                   FDA news release po4-65 july 13, 200


                *  The National Board of Pharmacy(NABP) has established a program called VIPPS
                    designed to certify web sites that meet industry standards.
                    Click on consumer on the website below for more information
                   www.nabp.net  the site needs a little update . Go to the consumer section and look under
                    programs . Also copy and paste the address below for more information on Rogue web 
                    sites .
                *Look for the VIPPS logo on website or go to  www.nabp.net to search for a pharmacy that
                   meets your needs
                * Please watch the attached video . It has 4 segments explaining the problem. The last is 
                   on  " How to order medications on line".

'60 Minutes' Segment Features VIPPS

Concerned about safely ordering medication online? 60 Minutes' segment on how to order medication safely offers help. VIEW THE VIDEO

Have fun , be Smart and be careful using medications ordered online
David Calder,MD


More about VIPPS
Welcome to the VIPPS information and verification site of the National Association of Boards of Pharmacy.
The National Association of Boards of Pharmacy (NABP) was established in 1904 to assist state licensing boards in developing, implementing, and enforcing uniform standards to protect the Public Health. NABP’s member boards of pharmacy are grouped into eight districts that include all 50 United States, the District of Columbia, Guam, Puerto Rico, the Virgin Islands, eight Canadian provinces, and New Zealand.
In response to public concern of the safety of pharmacy practices on the Internet, the association developed the Verified Internet Pharmacy Practice Sites (VIPPS) program in the spring of 1999. A coalition of state and federal regulatory associations, professional associations, and consumer advocacy groups provided their expertise in developing the criteria which VIPPS accredited Pharmacies follow.
To be VIPPS accredited, a pharmacy must comply with the licensing and inspection requirements of their state and each state to which they dispense pharmaceuticals. In addition, pharmacies displaying the VIPPS seal have demonstrated to NABP compliance with VIPPS criteria including patient rights to privacy, authentication and security of prescription orders, adherence to a recognized quality assurance policy, and provision of meaningful consultation between patients and pharmacists.
VIPPS pharmacy sites are identified by the VIPPS hyperlink seal displayed on their Web site. By clicking on the seal, a visitor is linked to the NABP VIPPS site where verified information about the pharmacy is maintained by NABP. The public is also welcome to access the VIPPS site at www.nabp.net to search for a VIPPS Internet pharmacy, which matches their needs.
We at NABP hope you find the information helpful and invite your comments to continuously improve our service to you.
To verify a specific website, please enter the site's URL (e.g. www.vipps-pharmacy.com) at the bottom of this page and click the verify button.



Friday, February 15, 2013

The aging kidney starts sooner than you may think

I was reviewing medical articles this morning and noticed that metformin , this very old medication , is mention in a new medical article almost daily. Today I noticed an article on the controversial risk of lactic acidosis and metformin use in " older " people.  I believe it was 1968 with a drug in the same family as metformin was taken off of the market because of it's association with lactic acidosis. Metformin was approved for the treatment of Type 2 diabetes but has alway had the cloud of lactic acidosis in its family pedigree. This risk is increased in people with liver  or kidney problems.

 Most doctors are concerned about starting metformin in " older people " because of the known deterioration of kidney function with increasing age.

 Another problem of getting older is the loss of muscle mass complicating the interpretation of a commonly used test, Creatinine. The test result will  be lower and and becomes a less accurate test of kidney function as we age.

 This leads to todays topic , the effects of age on kidney function.

Aging Kidneys
A good discussion of the aging kidney was discussed in an article published in ;
Clinical Geriatric Medicine 2009August;25 (3) : 331-358
Acute Kidney Injury in the Elderly

The bad news
Our kidneys lose mass , get smaller and lose function with increasing age
 *  Kidney mass can decrease by 75 to 80 % by age 80 to 90
 *  A reduction in blood  flow to the kidneys of up to 50% can occur from age 20 to age 80
 *  Decreased function of our kidney can be observed by age 30 resulting in increased problems
     handling salt and water.

A word of caution
  Medication dose adjustment may be needed as we get older.

The good news
 Despite all of the above , "the kidneys of healthy elderly people are able to compensate  and maintain homeostasis under normal conditions". Also 30 % of people do not demonstrate the age related decrease in function.

Have Fun , Be Smart and take care of your body and it will take care of you
David Calder,MD


Tuesday, February 12, 2013

The Hertz Rent a Car approach to Diabetes care !

The concept,  "patient activation and engagement", reviewed by Susan Dentzer below is , I believe , one of the primary ingredients for successful chronic disease management. I suggest clicking on theHealth Affairs website or reading the article in The British Medical Journal  listed below.

 I initiated the idea of a Diabetes Wellness Center in Eugene Oregon over 30 years ago . My patients  and me then had the good fortune of working with outstanding certified diabetes educators (nurses, dietitians and physicians assistents). Our goal was to maximize patient involvement in their own care with continued emphasis on basic management skills and better understanding of their disease.

The goal of this website is to improve communications between patients with diabetes or any chronic disease ( especially sleep apnea ) and their physician or other health care provider.
 I believe this goal is achieved by " patient activation and engagement" in their own health care. 

In my book Diabetes office visit , I simplified the diabetes care concept into one of the  Hertz rent a car  slogans, " Let us put you in the drivers seat".

Have fun , Be Smart and get into the drivers seat of your health care
David Calder, MD

ps- what about the Gray Hound approach to health care ?

Rx For The ‘Blockbuster Drug’ Of Patient Engagement
Even in an age of hype, calling something “the blockbuster drug of the century” grabs our attention. In this case, the “drug” is actually a concept—patient activation and engagement—that should have formed the heart of health care all along.
The topic of this  issue of Health Affairs, patient engagement is variously defined; the Institute for Healthcare Improvement describes it as “actions that people take for their health and to benefit from care.” Engagement’s close cousin is patient activation—“understanding one’s own role in the care process and having the knowledge, skills, and confidence to take on that role,” as Judith Hibbard and coauthors explain.
More holistic definitions broaden these concepts further, describing patients and families working with providers all across health care, in such areas as patient-centered outcomes research. Two …

Health Aff February 2013 vol. 32 no. 2202

From The Editor-in-Chief

Potential benefits of "well engaged patients" are akin to those from a blockbuster drug, say experts
BMJ February 2013 346:feb08_2f886

Saturday, February 9, 2013

Beta cell regeneration ?

Beta cell regeneration . 
Some of our new diabetes medications preserve beta cell function .  The idea of regenerating Beta cells would be game changer in diabetes care. I have attached an abstract  of some early mice studies that offers some hope for the future.
Have Fun , Be Smart ,The future holds many wonders
David Calder, MD

 2012 Feb 17;287(8):5562-73. doi: 10.1074/jbc.M111.305359. Epub 2011 Dec 22.

FTY720 normalizes hyperglycemia by stimulating β-cell in vivo regeneration in db/db mice through regulation of cyclin D3 and p57(KIP2).


Division of Experimental Diabetes and Aging, Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA.


Loss of insulin-producing β-cell mass is a hallmark of type 2 diabetes in humans and diabetic db/db mice. Pancreatic β-cells can modulate their mass in response to a variety of physiological and pathophysiological cues. There are currently few effective therapeutic approaches targeting β-cell regeneration although some anti-diabetic drugs may positively affect β-cell mass. Here we show that oral administration of FTY720, a sphingosine 1-phosphate (S1P) receptor modulator, to db/db mice normalizes fasting blood glucose by increasing β-cell mass and blood insulin levels without affecting insulin sensitivity. Fasting blood glucose remained normal in the mice even after the drug was withdrawn after 23 weeks of treatment. The islet area in the pancreases of the FTY720-treated db/db mice was more than 2-fold larger than that of the untreated mice after 6 weeks of treatment. Furthermore, BrdU incorporation assays and Ki67 staining demonstrated cell proliferation in the islets and pancreatic duct areas. Finally, islets from the treated mice exhibited a significant decrease in the level of cyclin-dependent kinase inhibitor p57(KIP2) and an increase in the level of cyclin D3 as compared with those of untreated mice, which could be reversed by the inhibition of phosphatidylinositol 3-kinase (PI3K). Our findings reveal a novel network that controls β-cell regeneration in the obesity-diabetes setting by regulating cyclin D3 and p57(KIP2) expression through the S1P signaling pathway. Therapeutic strategies targeting this network may promote in vivo regeneration of β-cells in patients and prevent and/or cure type 2 diabetes.

Thursday, February 7, 2013

Dawn Phenomenon and hypoglycemia

  Question - What time of day are you the most resistent to the effects of insulin ?

Clinically there seems to be an increased need for insulin from about 6 to 9 AM  which resulted in the term , Dawn Phenomenon.

 Efforts to explain the  physiology for this apparent increased need for insulin are interesting . I like a study , reported in Diabetes 38: 273-89 , 1989 - Morning Insulin Requirements , suggesting that the Dawn Phenomenon may be more apparent than real.
Their studies suggest that the " Dawn Phenomenon " may be " more related to the sleep- associated decrease in insulin requirements than any putative insulin resistance at dawn " . Other possible causes  include growth hormone , glucagon and catacholamines .

The mechanism of the increase in morning glucose may be unsettled. However, the reality of the increase is there and has to be considered when adjusting insulin and other medications to correct fasting glucose results into specific target ranges.

 Adjusting medications to correct your fasting glucose without monitoring  3 am glucose may increase the risk of nocturnal hypoglycemia.

Have fun , Be Smart and remember , unrecognized hypoglycemia is common ,  and your 3 am glucose may be lower than your 8 am glucose 
David Calder, MD

Monday, February 4, 2013

Home glucose test . Which test to test ?

 Your doctor and insurance carrier recommended testing  at least once or twice daily.

   chose your test wisely
         # 1   2 to 3 am glucose
          #2    fasting glucose
          #3    before lunch
          #4    before dinner
          #5    bedtime
          #6    1 or 2 hours after meals

     From the list above , rate the test as to its value in managing your 

           first ____   second____  third____ fourth____  fifth ____  Sixth____ 

My choices
         - first choice is - Fasting blood glucose a good indicator of your basal insulin production )
         - second choice - 3 am glucose ( the time of day when you are the most sensitive to insulin )
         - third choice - before dinner ( after noon hypoglycemia is common )
         - forth choice - bed time ( after dinner snacks may be a issue )
        -  fifth  choice - before lunch  ( if you are high before breakfast , you will probable be high before lunch )                        
        -  sixth choice -1 or 2 hours after a meal  ( not of much value unless your A1c is below 7.5 and and you are
                                                                                                           trying to reach 6 )

      What would you do if your choice of test is above or below your
     recommended target goal 

       It may depend on which test is not in the target range

            Low fasting glucose - check 2 or 3 am glucose for 2 to 3 days days to rule out unrecognized hypoglycemia.
            Persistent high fasting glucose - indicates basal insulin deficiency

            Low 3 am test - you may be at risk of a severe insulin reaction

            High 3m test -   Test your bedtime sugars and reevaluate your bedtime snack

            Third, forth and fifth choice - are effected by your glucose test before the previous meal and, amount of
                                                                                    carbohydrates eaten at  that meal and your diabetes meds.

        Ideal - Switch from your routine to a diagnostic Testing ?

           Diagnostic testing
              Testing before each meal , bedtime and 3 AM and look for a *patterns.
    Tomorrow --  more on patterns with a few examples
    Question - What time of day are you the most resistent to the effects of insulin ?

Have fun ,  Be  smart and focus on basic diabetes management skills
David Calder, MD

       *  Pattern defination - a combination of glucose results forming a consistent arangement




Saturday, February 2, 2013

Home glucose testing . Which test to test ?

Glucose recording and management decisions. 
Home glucose testing is not just a have to do monitor of your glucose. 
Home glucose testing is a  valuable  tool , guiding you and your health care provider along a path to to preserving your good health.

Type 2 diabetes on oral medications
You may have a testing routine that can vary from 0 to 8 or 9 times daily . Many people with type 2 diabetes on oral medications may test once or twice daily and  fail to use the information wisely.
I have some suggestions to help you become more involved in your diabetes management decisions.

Specific Target Goals
Have specific target goals for your test results.
Discuss the ADA goals with your physician to make sure they are the best fit for your specific situation

American Diabetes Associations guide lines 2012    
           Pre prandial glucose 70 to 130 mg/dl  ( 3.9 - 7. 2 mm/l )
           post prandial glucose < 180 mg/dl ( < 10 mm/l )
           Goals should be individualized base on;
               -   duration of diabetes
               -   age/ life expectancy
               -   comorbid conditions
               -   known cardiovascular disease or advanced microvascular disease
               -   hypoglycemic awareness
               -   individual patient considerations

Which test to test
   chose your test wisely
  # 1   2 to 3 am glucose
  #2    fasting glucose
  #3    before lunch
  #4    before dinner
  #5    bedtime
  #6    1 or 2 hours after meals

    Your doctor and insurance carrier recommended testing  at least once or twice daily?
    * From the list above , rate the test  as to value in managing your diabetes.

              first ____   second____  third____ fourth____  fifth ____  Sixth____ 

    * What would you do if your choice of test is above or below your recommended target goal ?

    * How would you record and discuss  the collected data with your physician ?

The post below are related to the above topic, click to view
Unexplainable glucose elevations? Look for Pattern..

Have fun ,Be Smart and use your home testing results to help preserve your good health
David Calder, MD