Dietary Guidelines by DiabeticDogmalysis

I typed up a nutrition teaching sheet to give to patients in the clinic. Since my 7th-grader is writing an essay about school lunches, I thought that I might as well make public my dietary guidelines.

3-24-16 Mark’s Dietary Guidelines

The fact is, the USDA food guidelines are not science-based. School lunches are mostly fast, cheap carbohydrates. The last time that I ate a school lunch with one of my kids, we had mashed potatoes, bread, a pasta dish, a cup of fruit, and a carton of milk. Basically just crap, crap, crap, crap, and a side of crap, with crap to drink. (I added an extra crap because of the cookie for dessert.)

I got downgraded on a Toastmaster’s speech for saying “crap” when I was talking about weight loss. But, when talking about simple carbohydrates, crap is the best adjective.

You need to eat fat and protein. And leafy green vegetables.

You need to avoid simple sugars and simple carbohydrates, like mashed potatoes and bread.

Milk is obesogenic (makes you fat). My grandfather (and my parents and I, for awhile) were dairy farmers, so I understand the milk addiction thing, as well as the milk lobby who pushed for getting milk onto the USDA guidelines.

The USDA guidelines are a billion dollar industry, because every school in the country has to follow them. In my 7th-grader’s school cafeteria, there are at least 15 huge poster advertisements for milk!

It is advertising!!! I wish they would just advertise Mountain Dew instead. Milk and Mountain Dew will make you fat and give you Type 2 Diabetes.

Another side note/rant: If your diet sounds spiritual, it probably is not. If it is called “Genesis” or “Daniel” or something like that, it is just somebody making up diet guidelines. Don’t believe it just because you want to be spiritual. God made plants and animals for you to eat. Eat plants and animals, and you will be pretty healthy. (I do like the idea of trying new ways of eating, so short-term fasting, or going vegetarian for a time is a good idea. That is actually what got me into eating healthy for the first time, by changing the routine ways that I dealt with food.)

 

 

 

 

 

 

 

Five Things To Know When First Diagnosed with Type 2 Diabetes

When you are first diagnosed with Type 2 Diabetes, your healthcare provider will be concerned about protecting your body from this horrible disease. In fact, when I visit with you, I have a head-to-toe checklist of things that need to be taken care of.

Here is a quick summary of five items on that checklist:

One: Eyes

When did you last get an eye exam? You need one done as soon as possible since you were just diagnosed with diabetes. Diabetes damages the tiny blood vessels in the back of your eyes.

One symptom of diabetes is blurry vision. If your blood sugars are sky high, sometimes it is better to wait a few weeks to get your blood sugar down before you get an eye exam. However, if you have had a sudden change in your vision, you need to get that checked out right away!

Once you have Type 2 Diabetes, plan on getting a full eye exam every single year.

Two: Kidneys

Type 2 Diabetes will fry your kidneys.

Diabetes is one of the main causes of kidney failure that requires dialysis. High blood pressure, and taking ibuprofen or naproxen are other causes of kidney (renal) failure.

You need to take a certain type of blood pressure pill, even if your blood pressure is not very high, in order to protect your kidneys. Your healthcare provider will probably start you on a medication to protect your kidneys. Also, it is very important to avoid NSAIDs, which is a category of pain medication that includes ibuprofen and naproxen.

Three: Heart and Brain

It is very important that you quit smoking, and keep your A1C down below 7. Otherwise, you will have a heart attack or stroke. A lot of people benefit from taking a baby aspirin (81 mg) every day, to help protect them from heart attacks or strokes. Make sure to ask your healthcare provider if this is something that you should be taking.

Four:  Feet

Uncontrolled Type 2 Diabetes can lead to poor circulation in your feet. It is easy to get toenail fungus (onychomycosis), cracks and ulcers, and foot infections. It is important to check your feet every day. I remember pulling a 6-inch piece of metal wire out of a guy’s foot, because he had diabetes, couldn’t feel his foot, and didn’t know why it was smelling so funky. He did not check his feet (and I think that he slept with his work boots on).

Eventually, if you don’t get your A1C down and control your blood sugars, you will get an amputation. As a healthcare provider, my job is to check your feet at least once a year.

Your job is to check your feet every day.

Five:  Nerves

Type 2 Diabetes damages nerves. This is why your feet go bad, and you get peripheral neuropathy. You might have burning pain in your feet, maybe in your hands. Other nerves act up also. The only way to protect nerves is to be as healthy as possible, don’t smoke anything (including marijuana), and avoid inflammatory foods as much as possible.

 

 

 

 

I want to eat carbs!

Carbohydrate (carb) craving is what makes you fat and gives you Type 2 Diabetes!

When I am craving carbs, it is because I am stressed, tired, and don’t have time to think about eating real food. If I plan ahead, then I am able to beat the carb craving by having real food readily available.

This morning, I knew that I would be craving carbs because I went for a long barefoot run last night. When my muscles are rebuilding after hard exercise, I get way hungrier. I have noticed that I get hungry more since I am not drinking fatty coffee (I gave up coffee for Lent). So, before work, I fried two eggs in butter. That gave me energy and filled me up for about 4 hours! I didn’t start carb craving again until about 11 am (eggs at 7 am).

Eat fat and protein for breakfast, and you will not crave sugar and carbohydrates. That’s the secret! We call it Low-Carb, High-Fat (LCHF). It is the best way to lose weight, and the best way to level our your blood sugar.

You have to eat fat to burn fat.

Carbohydrates are what make you fat.

White fluffies are carbohydrates. DO NOT EAT things like rice, bread, pasta, corn, tortillas, potato chips, sugar, pop, soda, kool-aid, fruit juice.

DO EAT meat and vegetables. Green veggies are the best, like kale and spinach. And add a lot of fat into your diet, like butter, olive oil, avocado, coconut, and almonds.

 

 

don't eat sugar

 

 

 

 

Customer Service at a Free Medical Clinic

Photo (6) (2) PNG HIGH QUAL
Photo by Mark W. Harvey APRN (me).

Maria bravely walked into the clinic for the first time. She was new to this country, and needed healthcare for her diabetes. She spoke very little English, spoke a little Spanish, and was more comfortable with a Mayan dialect.

The unsmiling person who eventually came out from some back room said impolitely, “Can I help you?” Maria responded in either Spanish or Mayan, but the unsmiling person did not give her a chance to finish. “You will have to come back when you have an interpreter, and bring proof of income from whoever pays your lights, gas, and rent.” Maria tried to say something else, but the rude person was already talking to someone else on the phone.

Maria left confused. What did that unkind person say? What papers did they need? Why did a health clinic not have an interpreter available? Do they need immigration papers? Why was that lady so mean?

Maria went another 6 months without her diabetes medication, until she got really dizzy and was taken to the Emergency Department. They referred her back to the free clinic. She was afraid to go there, so she waited another two months until she could find someone who spoke English to go with her.

How can you improve customer service at a free clinic? 

Working a free clinic is hard. Half of the staff are volunteers. Everyone is underpaid. It is hard (though not impossible) to prove that quality of care and good customer service impacts health expenses for the local clinically integrated network, hospital, or emergency department.

I started writing this article to get back to the basics of good customer service.

Here are five things that I have observed through my years as a nurse, a free-clinic nurse practitioner, and prior to that when I was a shift manager at Burger King.

  1. Smile.

It is vitally important that you smile when you first greet a customer. In fast food, you are required to practice smiling and saying “Welcome, how may I help you?” or some variant of that immediately after someone walks in the door.

A few weeks ago, I went for an eye exam. The person at the front desk ignored me while she was working on something on her computer. It took almost 10 minutes before she actually looked up and said anything to me. I was furious! I love my eye doctor, but I was livid going in to see him. Why? Because all humans hate to be ignored!

So, number 1 should really be,

  1. Smile and greet.

Acknowledge a person IMMEDIATELY when they come in. I don’t care if you are on the phone with the Pope, and a narcissistic neurosurgeon is texting you about his unpressed boxer shorts. Just look up, smile, and nod. That way the customer knows that you saw them. If you have a split-second while the verbose Pope is catching his breath, say something to the patient like, “I’ll be with you in a moment.” That way, they are comfortable waiting, because they don’t want to feel like they are interrupting something important.

There is nothing worse than being ignored when you walk into a waiting room!

Side note, the only thing worse than being ignored is being blamed for a problem. Don’t blame the customer. The customer is (nearly) always right. Staff should be trained to fix errors and mistakes immediately and not be allowed to blame the patient in the process. Blaming patients erodes their  trust and confidence. Treat your customers as valued ambassadors of your business.

  1. Encourage questions.

I always try to finish a patient interview with “Do you have any questions?” Even when I am in a hurry, I have found that just asking them for questions speeds up the clinic visit and my time with them. It gives the patient control over the interview, lessens their anxiety, and enables them to hear your answers more clearly.

The front office staff and the nursing staff should also pause and ask “Do you have any questions?” Give control back to the customer whenever possible.

  1. Remember good old AIDET?

I found some great resources on AIDET here:

A – Acknowledge Acknowledge the patient by name. Make eye contact, smile, and acknowledge everyone in the room (patient and families).
I – Introduce Introduce yourself, your skill set, your professional certification, and experience.
D – Duration Give an accurate time expectation for tests, and identify/communicate next steps. When this is not possible, give a time in which you will update patient on progress.
E – Explanation Explain step by step what will happen, answer questions, and leave a way to contact you. Use language a patient can understand.
T – Thank You Thank the patient. You may thank them for choosing your medical practice, and for their communication and cooperation. Thank the family for assistance and being there to support the patient.

And here are sample AIDET® guidelines and key words specifically for providers.

  1. Always communicate with the customer in the language that they prefer.

In our free clinic, the local hospital has generously provided access to interpreter services, including their expensive language line and video interpreting. This service should be used at the front desk, during financial screening, over on the dental side, and in the medical exam rooms.

In summary,

Customer service and performance improvement should be driven by the provider, with energetic support from the staff, clinic manager, director, and everyone else involved. Doing the right thing means helping people when they are vulnerable, making them feel comfortable, and being sure that they leave happy and confident that their felt needs were addressed. When the customer is happy, the staff, nurses, and providers are happy. Job satisfaction increases, and we find joy in practice.

 

Don’t be afraid of insulin.

If you have Type 2 diabetes and your blood sugar is still running high, your healthcare provider may try to convince you to take insulin.

Don’t be afraid of insulin! 

There are about a million fears that people have when I start to talk to them about taking insulin.

Fear: “I won’t be able to cure my diabetes with diet and exercise!”

Insulin is not a death sentence. If your blood sugars are too high, you might need insulin for a while. However, if you clean up your diet, and start exercising every day, you might not need insulin for very long. (Caveat: On this blog I talk about Type 2 Diabetes, the kind that you got from eating crap, not Type 1 Diabetes, which is a whole different thing. With Type 1 Diabetes, you always need insulin or you will die within a few days! Just ask the guy with Type 1 who I saw today in the clinic. He landed in intensive care last week after skipping his insulin for just 3 days.)

I remember one guy who came in to the clinic because he was losing weight, always thirsty, peeing several times an hour. When I checked his blood sugar, it was about 600, and he had not had anything to eat that day. So, we started insulin right away, to keep him alive. His A1C was around 11 at first. But then, he quit drinking 4 liters of Mountain Dew and Coke every day.  Within a few weeks, his blood sugars were back to normal, and when I re-checked his A1C, it was below 6! He stopped insulin, and has gone several years without his blood sugars going back up.

Fear: “Insulin will cause kidney failure.”

I deal with this question every single day. Kidney failure is caused by diabetes. Also, by taking ibuprofen and naproxen. Taking your insulin is the most important thing to do to protect your kidneys! Control your diabetes, keep the A1C below 7, and your kidneys will be happy. You also should probably take a blood pressure pill to protect your kidneys if you have diabetes, so don’t be surprised if your health care provider starts you on Lisinopril or something similar, even if your blood pressure is not too high. Insulin prevents kidney damage, and eye damage, and feet damage, and circulation damage, because insulin is the main treatment for high blood sugars.

Fear: “Insulin will put me into a diabetic coma!”

Modern day long-acting (basal) insulin almost never causes low blood sugars. If you are worried about low blood sugars, talk to your provider. Things that cause super-low blood sugars (hypoglycemia) are fast-acting, mealtime insulin, and certain medications like Glipizide (a sulfonylurea). If your blood sugar gets low, it is really easy to fix. Guess what? You just have to eat food! Most people who have really high blood sugars feel like their blood sugar is low even when it is still really high. For example, if your average blood sugar is 300 (A1C of 12), then you will feel shaky and hungry when your blood sugar gets down to 200.

Every day, I have a patient or two who says “my blood sugar got low” even though they did not check their blood sugar. So, I don’t believe them. But, you should be afraid of insulin if you do dumb things, like taking mealtime insulin without eating and then going back to bed (had a patient doing that today), or taking mealtime insulin in the middle of the night for no reason (had a patient today who used to do that until I found out about it).

Basically, if you are smart enough to be worried about a “diabetic coma” then you are probably smart enough not to take meal time insulin, or take Glipizide, without actually eating.

Diabetic coma is really a concern for people with Type 1 Diabetes, but much less of a concern for you with Type 2 Diabetes.

Fear: “It will hurt!”

I know. This is a for-real excuse in my book. However, shots in your belly with a tiny needle is nothing like poking your finger to check your blood sugar. I can think of 3 patients this month who refused insulin “because it will hurt” but obsessively check their blood sugar 5 times a day. Like, how does checking your blood sugar help anything if you won’t change your diet or take insulin? But, as a banjo player with sensitive fingers, I think that sticking a needle in your fingertip to draw blood is the worse thing EVER! Poking a needle in belly fat is really not a big deal AT ALL! It is just a reminder that you should get rid of that belly fat so you don’t have this problem in the first place. 🙂

Fear: “I will get fat!”

Yes, you might get fat if you start insulin. Before insulin was invented, people with diabetes wasted away to skeletons before they died. So it is possible that you will gain weight when you start insulin. However, you can control that by changing what you eat! If you keep eating carb-filled, processed, white fluffies (rice, pasta, wheat, bread, potato chips, tortillas, fruit juice and sugary beverages) then it is your own fault that you gain weight.

There are other medications that are way worse for weight gain. For example, several mental health medications really make you gain weight.

With Type 2 Diabetes, there are medications like Metformin, and some of the newer expensive drugs, that help you not to gain weight.

Fear: “I can’t afford it!”

True, you can’t afford insulin. However, the companies who make insulin have drug assistance programs. In my free clinic, we help everyone fill out the applications for the good quality insulin. You can also buy super-cheap insulin at Walmart, but it will still cost $20-40 a month at least.

There are other ways to get insulin, such as medication samples, or borrowing from a friend. Seriously, I know people who get plenty of insulin from family members who don’t want to take it, but who get tons of it from the VA or their health insurance plan. (I’m not saying it’s legal or anything, I just know that it happens.) There are free clinics that help with insulin, or vouchers that you can get from community groups or churches.

Fear: “It won’t work as well as pills.”

Even after I sent a patient to the ER last week because her blood sugar was 850 (and then it was 1,000 in the ER) and she spent a week in the hospital, today she said, “switch me back to pills because I think they will work better than this insulin.”  I said, “NO WAY!” She will seriously die if she stops her insulin. Insulin is the most important treatment for sky-high blood sugars. Nothing else works for high blood sugars like insulin does. That patient was sent home on 4 shots of insulin a day. One basal insulin in the morning, and three shots of mealtime insulin with each meal. I hope to eventually simplify her insulin regimen, because she is relying on family members to give the shots, but for now she needs to keep do 4 shots a day.

 

Here is an old diagram that I found in my drawer at the clinic. I can’t figure out who orginally created it, but it is pretty neat: 

Photo (3)

Metformin

Once you have been diagnosed with Type 2 Diabetes, the first medication that you usually start taking is Metformin.

Metformin is great, because it does not cost very much. If you are paying much more than $4 a month, then you should shop around and find a cheaper pharmacy. Do some research, and you can save hundreds of dollars per month. Even local, small-town pharmacies may have a $4 list!

Just because we start Metformin now, it does not mean that you will be on it forever. If you change your diet, you might be able to get back off of the Metformin.

I talked to a guy last week who got his A1C from 10 down to 6.0 by riding his bike and changing his diet. He got a little crazy (in a good way) and was riding his bike 50 miles a day, so we took him off of his Metformin and his blood sugars were great. However, life got in the way of his exercise (meaning, he landed back in jail for 6 months) and when I rechecked his A1C last week, it was back up to 9.1. He agreed to restart the Metformin, but I expect that he will only need it for a few months, because he is back to riding his bike every single day.

Metformin can cause gut aches, foul stomach, gas, and diarrhea. This is the main reason that people do not tolerate it. If you come in to the clinic with gut problems and you are on Metformin, the first thing that I do is to take you off of it for a while. After a few weeks or a month, if you still have gut problems, then we have to investigate further (hint: it is almost always because you are eating something that you shouldn’t, like milk, corn, or wheat).

If Metformin bothers your stomach, try taking it with meals. This fixes the problem for a lot of my patients. If you are on 1,000 mg twice a day, sometimes cutting down to 500 mg once or twice a day can fix the diarrhea. Talk to your medical provider before you make those changes.

Off-topic rant: At my clinic, it is a $5 suggested donation to come in to talk to a provider. However, if you are forking out $150 a visit to talk to a medical provider, then you should try to find a cheaper clinic to go to. This is why many people with diabetes are so lost and don’t know how to improve. I have a decent job, but there is no way in heck that I am going to fork out $150 to go talk to some doctor for 10 minutes! Get a life! Seriously. Rich people forget that money is hard to come by for most people.

Metformin is SAFE for your kidneys! Your diabetes is what is going to kill your kidneys, so controlling your diabetes is the most important thing that you can do to protect your kidneys! (For kidneys also keep your blood pressure down, and don’t take ibuprofen or naproxen.) However, if you get dehydrated or run a marathon or start Crossfit, you might get acidotic. Acidosis is bad, and Metformin can make it worse. If you have a test in the hospital that uses dye, then ask whether it is safe to take Metformin for the next couple of days.

I like Metformin, because you don’t gain weight just from taking it (like you do with some other medications, and insulin). The NIH has a lot more information about medications.

If you change your diet, and stop eating all of those white fluffies, you might be able to get off of the Metformin. Quit pop, bread, pasta, corn, maseca, maiz, potatoes. I talked to a sweet lady last week who got so scared a year ago when I told her that she had diabetes (A1C 10.1), that she quit pop, quit bread, quit oatmeal, quit corn, quit fruit and fruit juice, and BOOM! her A1C after 6 months was 6.1. She also started running and riding her bike, which was awesome, because she is almost 60, has low intellect, but just got scared of diabetes and changed what she was eating. She is off of her Metformin, but still comes in every 3 months to get her A1C checked, “because I start to obsess and panic about diabetes!”

how do you spell diabetes maseca (2)

 

 

 

how do you spell diabetes (2)