Continuous glucose monitors may need human back up

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This story from Diabetes in Control Disasters Averted series describes why it is a good idea to check a finger prick sample of blood if there is a discrepancy between your recorded results and how you feel.

CGM? Still Perform the Fingerstick!

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College student, type 1 diabetes, wears a pump and CGM. She has good family support. Several of her family members get her CGM readings on their phone. She received a call from her mother about 2:45 am waking her up. She told her to treat her low blood glucose, which patient reported to be 41. (UK 2.2)

Patient states her alarm had gone off, but she did not hear it. She performed a fingerstick because she didn’t feel like she was low. It was 149. (UK  8.2) (See report.) The CGM recalibrated. She did not treat because she did not need to.

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She was always taught to check a fingerstick before treating. She was glad she was taught that. Had she not checked she may have had to deal with a high glucose level later.

Lessons Learned:

  • Technology helps, but it needs human input.
  • CGM’s accuracy may have proved to be accurate enough to treat from, but experience tells us each person responds differently, and accuracy can vary from person to person.
  • If symptoms don’t match readings, perform a fingerstick.
  • My recommendation is to continue to perform a fingerstick before treating, even though some say one does not have to.

Double diabetes: watch out for ketoacidosis with some drug combinations

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The use of adjuvant drugs for obese, insulin resistant type ones is increasing. What can you expect from therapy with some of the newer add on drugs? This article in Diabetes in Control tells you.

Type I Diabetes Mellitus: A Triple Therapy Approach

Diabetes management strategies have evolved since the discovery of newer oral agents that provide glycemic control through various pathways. Type 1 diabetes mellitus treatment has changed from traditional insulin regimens to incorporating other agents for improving glycemic control.

Maintaining adequate glycemic control and preventing end-organ damage is of utmost importance when managing diabetes. Uncontrolled blood glucose levels can lead to retinopathy, neuropathy, and nephropathy, which affects overall quality of life in our patients.

Due to these effects and the increased rate of uncontrolled A1c levels in patients with type 1 diabetes, various researchers have devised various treatment approaches for these patients. Recent research efforts have looked into the benefits of SGLT-2 inhibitors and their effect on cardiovascular events and mortality.

Matteo Monami et al., have looked into the benefits of these agents in patients with type 2 diabetes in the EMPAREG OUTCOME study. The findings from this research study highlight the benefit from SGLT-2 inhibitor use.  Their use in T2DM was found to reduce the risk of all-cause mortality, cardiovascular mortality, and myocardial infarction, but there was no increase in the risk of stroke. These findings can also provide similar benefits in type 1 diabetes patients; however, more studies are needed to provide stronger evidence.

Previous studies with other SGLT-2 inhibitors (i.e. canagliflozin) showed an increased incidence of diabetic ketoacidosis (DKA) in T1D patients. The incidence of DKA is thought to be associated with an increase in glucagon and free fatty acids that induces insulin resistance, which can also predispose to renal complications.

Conversely, a recent study showed improvements in renal functions in patients taking dapagliflozin through reductions in ischemia and hypoperfusion. These findings are not seen in patients taking liraglutide due to suppression of ketogenesis.

Recently, Nitesh Kuhadiya and colleagues expanded on the use of SGLT-2 inhibitors in type 1 diabetes patients. In this randomized clinical trial, researchers looked at the reduction in glycemia and body weight when adding dapagliflozin to an insulin and liraglutide regimen. Researchers hypothesized that the addition of dapagliflozin to an insulin and liraglutide regimen would provide improvements in glycemia without leading to increased concentrations of glucagon and other ketosis mediators.

Eligible patients were enrolled based on the following characteristics: 18-75 years of age with type 1 diabetes, fasting C-peptide of <0.1nmol/L, on any insulin regimen for more than 12 months with or without history of DKA. All patients had an A1c of <9.2% and were knowledgeable on carbohydrate counting. Additionally, patients needed to be on liraglutide therapy for at least 6 months prior to the start of the trial. 30 patients were assigned in a 2:1 ratio to receive either dapagliflozin 10 mg or placebo for 12 weeks. Consistency of carbohydrate content was documented by a dietitian.

The primary end-point of the study was a change in mean A1c after 12 weeks of dapagliflozin. Each patient’s body weight, systolic blood pressure, carbohydrate intake, and ketosis mediators were measured throughout the study as secondary endpoints. 26 patients completed the study, out of which only 17 were part of the intervention group. Those in the intervention group received dapagliflozin 5 mg daily for one week followed by 10 mg daily for 11 weeks. All insulin doses were targeted to 3.8-8.8 mmol/L.

At the end of the study it was found that triple therapy with liraglutide, insulin, and dapagliflozin decreased A1c by 0.66% when compared to placebo (~0.1%) (p <0.01 vs placebo). No severe hypoglycemic episodes were reported even when weekly glucose concentrations fell by 0.83 + 0.33 mmol/L in patients receiving triple therapy; no significant changes observed in the placebo group (P< 0.05 vs baseline; P=0.07 vs placebo).

When looking at the effects of this regimen and body weight, it was observed that body weight fell by 1.9 + 0.54 kg in the triple therapy group (P<0.05 vs placebo). Furthermore, there was a significant increase in ketosis mediators. It was also seen that total cholesterol and LDL-C level increased by 6% and 8%, respectively. Blood pressure readings remained unchanged in both groups.

In conclusion, a significant decrease in A1c and weight can be obtained by incorporating dapagliflozin for type 1 into an insulin and liraglutide regimen. However, special consideration should be taken when utilizing this approach due to an increase in ketosis mediators that can predispose patients to develop DKA.

Practice Pearls:

  • Triple therapy with dapagliflozin, insulin, and liraglutide reduces blood glucose levels without increasing the risk of hypoglycemia.
  • Weight reduction and A1c reduction can be obtained in type 1 diabetes patients while providing cardiovascular and renal protection properties, however closer monitoring is warranted due to increases in cholesterol and LDL-C.
  • Frequent monitoring should be implemented when utilizing this triple therapy approach due to an increase in glucagon, free fatty acids, and other mediators of ketosis predisposing to DKA.

Researched and prepared by Pablo A. Marrero-Núñez – USF College of Pharmacy Student Delegate – Doctor of Pharmacy Candidate 2017, reviewed by Dave Joffe, BSPharm, CDE

References:

Chang, Yoon-Kyung, Hyunsu Choi, Jin Young Jeong, Ki-Ryang Na, Kang Wook Lee, Beom Jin Lim, and Dae Eun Choi. “Dapagliflozin, SGLT2 Inhibitor, Attenuates Renal Ischemia-Reperfusion Injury.” PLOS ONE PLoS ONE 11.7 (2016). Web

Kuhadiya, Nitesh D., Husam Ghanim, Aditya Mehta, Manisha Garg, Salman Khan, Jeanne Hejna, Barrett Torre, Antoine Makdissi, Ajay Chaudhuri, Manav Batra, and Paresh Dandona. “Dapagliflozin as Additional Treatment to Liraglutide and Insulin in Patients With Type 1 Diabetes.” The Journal of Clinical Endocrinology & Metabolism (2016). Web.

Monami, Matteo, Ilaria Dicembrini, and Edoardo Mannucci. “Effects of SGLT-2 Inhibitors on Mortality and Cardiovascular Events: A Comprehensive Meta-analysis of Randomized Controlled Trials.” Acta Diabetol Acta Diabetologica (2016). Web.

Jovina Cooks Italian: Pork tenderloin in mushroom wine sauce

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Fall Dinner

by Jovina Coughlin

This dinner serves four but can easily be doubled for a company dinner.

Pork Tenderloin in Mushroom Wine Sauce

Pork

·         1 pork tenderloin (about 1 lb)

·         1 cup fresh mushrooms, sliced

·         ¼ cup porcini dried mushrooms

·         ¾ cup boiling water

·         1 medium onion, chopped

·         1 garlic clove, minced

·         2 tablespoons olive oil

·         1 tablespoon fresh oregano leaves

·         1 tablespoon fresh thyme leaves

·         Salt and pepper to taste

Wine Sauce

·         1 cup dry red wine

·         Porcini broth

·         1 tablespoon butter

Directions

Preheat oven to 400 F degrees.

Combine the porcini and boiling water in a small mixing bowl. Set aside.

Heat 1 tablespoon of the olive oil in a large oven proof skillet. Add the chopped onion and saute until the onion is soft.

Add the garlic and fresh mushrooms and continue cooking for another 3 minutes.

Strain the porcini in a fine mesh colander and reserve the drained mushroom water. Add the porcini to the skillet with the fresh mushrooms.

Season with salt and pepper and stir in the oregano and thyme. Set aside.

Butterfly the pork, by cutting the pork down the center, without completely cutting through, so when the two halves are opened they resemble a butterfly.

Use a meat mallet to flatten the meat. Sprinkle with salt and pepper.

Spread the mushroom filling down the center of the pork and bring the 2 sides up. Use butcher string to tie around the roll at 1 inch intervals.

Season the stuffed pork with salt and pepper and in the same ovenproof skillet heat the remaining tablespoon of olive oil.

Sear the pork on all sides and place the skillet in the preheated oven.

 

Roast uncovered for about 20 minutes or until done to your preference.

Remove the skillet from the oven and place the pork on a platter.

 

Place the skillet back on the stovetop. Add the red wine and the strained porcini water and bring to a boil. Cook the sauce until it is reduced by half.

Remove the pan from the from the heat and stir in the butter.

Cut the strings off the pork and slice into thin rounds. Arrange the pork on a serving platter and pour the wine sauce over the slices.

 

Gut Changes and Type 1 Diabetes

How’s your tummy? We ask because a recent study has explored the link between type 1 diabetes and gut inflammation and changes to the microbiome.

It has been shown that people with type 1 diabetes have increased intestinal permeability – i.e. it is easier for undigested substances to enter the blood stream. This can result in symptoms such as persistent muscle or joint pain, poor concentration, indigestion, flatulence, rashes, recurrent bladder or yeast infections and more.

Type 1s also show changes in the microvilli. Microvilli are tiny projections that exist in, on or around cells that expand the cell surface area and enhance its ability to absorb nutrients. They are mostly found on the surface of the intestine.

Errant Gut Bacteria

While research can’t prove it, errant gut bacteria is thought to be the cause of the changes.

A new study published this week in the Journal of Clinical Endocrinology & Metabolism investigated the changes in the gut’s bacterial flora and levels of inflammation in type 1 diabetics.

Samples from the first section of the intestine were taken from 54 participants between 2009 and 2015. The researchers made sure the diets of those taking part were similar when the samples were taken.

More Signs of Inflammation

The results showed that people with type 1 diabetes had significantly more signs of inflammation than control participants and people with coeliac disease. Ten inflammation-related genes were expressed significantly more in type 1 diabetics. There were also reduced levels of proteobacteria – a major group of bacteria – and increased levels of firmicutes, a major category of disease-causing bacteria.

Studies in mouse models have seen similar changes to composition.

The next step is to see if changes in the gut are caused by type 1 diabetes or vice versa.

The report’s senior author Lorenzo Piemonti said exploring why type 1 diabetics get gut changes could enable scientists to find new ways to treat the disease by targeting diabetics’ unique gastro-intestinal characteristics.

 

Choosing medication in type two diabetes

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Cardiovascular Mortality of Diabetes Medications from Diabetes in Control

 

What should be the proper treatment selection for patients with type 2 diabetes?

The incidence of diabetes has been growing and the complications arising from uncontrolled blood glucose has been increasing along with it. It is estimated that more than 80% of deaths in developing countries are associated with life-threatening complications associated with diabetes.

Various treatment approaches have been implemented to avoid these complications and deaths related to diabetes. The mainstay of therapy for diabetes has been diet and exercise in conjunction with glucose-lowering drugs. Each of these agents are implicated with a potential benefit in health outcomes and mortality.

Agents from metformin have proven to be the first-line treatment due to its long-term benefits and improved glycemic control, to thiazolidinediones, which were falling out of favor due to their effects on heart failure and now proves to be beneficial in stroke.

Ongoing research efforts have compared various treatment modalities in head-to-head trials in order to understand glycemic events in diabetes. In a recent meta-analysis conducted by Giovanni F.M. Strippoli, PhD at the University of Bari, it is explained that sometimes these trials fail to dive into the cardiovascular mortality of these medications due to its inability to compare all treatment modalities simultaneously.

Strippoli and colleagues wanted to estimate the relative efficacy and safety of glucose-lowering medications. They extracted data from 301 clinical trials, which took into account 1,417,367 patient-months. All of these trials were 24 weeks of duration or longer. They included biguanides, sulfonylureas, thiazolidinediones, DPP-4 inhibitors, SGLT-2 inhibitors, GLP-1 agonists, basal insulin, meglitinides, and alpha-glucosidase inhibitors.

All of those studies that looked at medication regimens no longer supported by treatment guidelines or that have been withdrawn from the market were excluded from the study.

The primary endpoint of the study was the association of drug treatments with cardiovascular mortality.

Secondary endpoints were stratified into two endpoints, individual safety and individual efficacy. Secondary efficacy endpoints included all-cause mortality, myocardial infarction, stroke, A1c levels, and treatment failure.

Secondary safety endpoints included serious adverse events, hypoglycemia, and body weight.(My comment: the  pros and cons that patients and doctors are most interested in)

After randomization, trials were separated into those where patients were given a monotherapy regimen, other drugs were added to metformin, or where other drugs added to metformin and sulfonylureas.

In those trials where drugs were used as monotherapy, there was no significant difference in the drugs used as monotherapy and the odds of death from cardiovascular complications. Nonetheless, these were associated with lower A1c levels. However, there was insufficient data to determine treatment rankings for these effects.

There was a greater risk of hypoglycemia with basal insulin (OR, 17.9 [95% CI, 1.97 to 162]; RD, 10% [95% CI, 0.08% to 20%]) or sulfonylureas (OR, 3.13 [95% CI, 2.39 to 4.12]; RD, 10% [95% CI, 7% to 13%]) as monotherapy. Furthermore, when analyzing those drugs added to metformin there was no significant association between any drug classes and the risk of death, despite 45 cardiovascular deaths reported in 26 trials. Similar findings were seen in all-cause mortality and myocardial infarction when adding other drugs to metformin therapy. However, there was lower risk of stroke in those regimens that included metformin and DPP-4 inhibitors when compared to metformin and sulfonylureas (OR, 0.47 [95% CI, 0.23 to 0.95]; RD, −0.2% [95% CI, −0.4% to −0.04%).

Treatment failure was noted less often in those patients receiving metformin and SGLT-2 inhibitors. In terms of weight and hypoglycemia, the use of metformin and sulfonylureas ranked worse when compared to all different treatment modalities. Furthermore, in the third set of trials that looked at drugs added to metformin and sulfonylureas, there was no association between any of drugs and the risk of cardiovascular death. This same trend was seen with all-cause mortality and serious adverse events; no significant association was observed.

Alpha-glucosidase inhibitors provided the least A1c reduction when added to metformin and sulfonylureas, when compared to the implementation of basal insulin or thiazolidinediones (SMD, 1.42 [95% CI, 0.57 to 2.26]). Treatment failure was more notable in patients receiving DPP-4 inhibitors when compared to those patients where basal insulin was added. Hypoglycemia was observed less in those patients receiving GLP-1 agonists than those receiving thiazolidinediones. All drug classes provided weight reductions except thiazolidinediones and basal insulin.

In conclusion, these findings highlight that the use of glucose lowering agents alone or in combination are not implicated with cardiovascular mortality, all-cause mortality, or serious adverse events. Significant reductions in A1c can be obtained with the use of individual glucose lowering) agents. When these agents are added to metformin, clinically significant reductions can be obtained.

Practice Pearls:

  • Sulfonylureas or basal insulin should be avoided in the setting where hypoglycemia is of great concern.
  • Weight reductions can be obtained with regimens utilizing SGLT-2 inhibitors and GLP-1 agonists.
  • There is no significant association between the use of various glucose-lowering medications (alone or in combination) and the risk of cardiovascular mortality.

References:

Palmer SC, Mavridis D, Nicolucci A, et al. Comparison of Clinical Outcomes and Adverse Events Associated With Glucose-Lowering Drugs in Patients With Type 2 Diabetes: A Meta-analysis. JAMA. 2016;316(3):313-324. doi:10.1001/jama.2016.9400.

American Diabetes Association. Standards of medical care in diabetes: Summary of revisions-2016, 7: approaches to glycemic treatment. Diabetes Care. 2016;38(suppl):S4-S5

Anna: Let’s talk about depression

Diabetes and Depression |

Diabetes and Depression

What a combo.  As if having diabetes wasn’t enough, out comes depression to make it complete.  Or was it the other way around?  This is reminiscent of an old chicken and egg dilemma. Remember, which came first?

Chicken hatches out of egg

People with diabetes (PWD) are more likely to have major depression compared to those who don’t have it.  Diabetes is a chronic condition that requires attention on a daily basis.  This can feel overwhelming at times and can take a toll on both physical and emotional health.

Diabetes affects emotions and emotions can affect BG level.  It isn’t clear whether depression somehow triggers diabetes or if having diabetes leads to being depressed.  In either case, there is obviously a connection.

The mere sound of the word DEPRESSION is reminiscent of a low mood, feeling worthless, having low energy, feeling sad and whatnot.  The blues.

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While everyone can occasionally get sad, clinical depression is far more than that.  Oftentimes it’s a lifelong challenge.  It can affect people of any age or gender or life situation; depression doesn’t discriminate.

Depression can affect our lives in so many ways.  It can range from work issues to relationships to drug & alcohol use or suicidal thoughts.

When you feel low and down in the dumps, a feeling of despair follows.  You might start thinking that no one can help you since they can’t change the circumstances.  Well, and you’re wrong.  What can be changed is the way you look at the events surrounding your depression; a different angle, so to speak.  I know this for a fact; been there, done that, right around the time of my divorce.  But I finally bounced back although this took quite some time.

The symptoms of depression can include feeling sad or unhappy especially in the morning; at times, irritable and angry.  Frustrated, having low energy, loss of interest in activity that you usually enjoy.  This can affect your sleeping pattern; you might feel anxious and restless.  You may experience guilty feelings and can’t concentrate.  Your eating pattern can change as well; you can eat much less or more than you usually do; you may develop unusual cravings.

5 Causes of Depression |

1.   Depression can be genetic, although the exact gene causing it is presently unknown. If you have a family member with depression, you’re more likely to experience it, too.  This however might be hard to tell as clinical depression was formally recognized in the U.S. around 1970s.  Prior to that, it was known as melancholy, therefore undiagnosed.  It could have been misdiagnosed for a multitude of other reasons, especially in the old days.

2.   Depression can be triggered by imbalance of certain neurotransmitters in the brain.  Why this is happening, remains a mystery and is not fully understood.  Antidepressant medications work to balance these neurotransmitters, mainly serotonin.

3.   Hormonal changes certainly play a role in developing depression.  Generally, depression is more common in women than in men, due to the changes in hormone levels throughout a woman’s life.  Pregnancy, giving birth or experiencing a miscarriage, PMS, menopause are just a few examples.  Thyroid problems can cause hormonal fluctuations as well because thyroid is an endocrine gland.

4.   Enter the change of seasons.  Seasonal Affective Disorder or SAD is a form of depression that can happen as daylight hours get shorter as the winter approaches.  Around this time of the year, some people experience feelings of tiredness, lethargy and loss of interest in everyday tasks.  This condition usually goes away once the days get longer.

5.   Then there is a situational depression that can happen due to a change in life circumstances or struggle.   Such as for example, losing a loved one, getting fired from work, financial troubles or other serious changes.  PTSD or post-traumatic stress disorders is often diagnosed in soldiers returning from war.  However, it can also happen as a result of a childhood trauma, abuse or assault, a car accident, or being diagnosed with a life-threatening condition.  Some sources classify these as anxiety disorders.

The treatment of depression is a long and bumpy road.  It may include medications, psychotherapy, or both.  It can go by trial and error and takes time to find a working combination of these.  Exercises can definitely help but oftentimes it’s easier said than done.  When you’re feeling sad, worthless and having low energy, exercises can seem next to impossible.  Perhaps you can start out slowly.  Try to stay busy with something you enjoy doing … if you draw a blank, turn to chores.  Generally, anything that helps to take your mind of whatever bothers you.  If you feel like writing, keeping a diary might help; blogging is even better.  You can find plenty of understanding folks here on WordPress.

NourishedPeach: Tomato and basil soup

Garden Fresh Tomato Basil Soup | NourishedPeach

Garden Fresh Tomato Basil Soup

SONY DSCWhat a weekend!  Along with some much needed, totally relaxed family time we had a quite a bit of rain around here and it was so cozy.  Turned out to be perfect weather for a light, fresh soup.  And a giant bowl of Garden Fresh Tomato Basil was just perfection.

 

If you’ve got tomatoes laying around this is the perfect way to use them up.  Fresh, homegrown are mandatory here.  You wont believe the flavor and sweetness they lend this soup.  Seriously.  Epic.

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It’s light and fresh but still so comforting.   And its full of nothing but flavor and nutrients, a very, VERY welcomed combo around here!

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Garden Fresh Tomato Basil Soup

Ingredients

2 Tablespoons Olive Oil

1 Cup Roughly Chopped White Onion

1 Cup Roughly Chopped Carrot

1 Teaspoon Kosher Salt + more

1/4 Teaspoon Black Pepper

5 Cloves Garlic, roughly chopped

2 Tablespoons Balsamic Vinegar

1 1/4 to 1 1/2 Pounds Homegrown Tomatoes, roughly chopped

3 Cups Chicken Stock

1/4 Cup Roughly Chopped Basil

2 Teaspoons Honey (improves the flavour but you can omit if you wish)

1/4 Cup Heavy Cream

Directions

Heat a large soup pot or dutch oven over medium heat.  Add the onion, carrot, salt and pepper and cook, stirring often, until vegetables begin to soften, about 8-10 minutes.  Add garlic and cook for 1 minute.  Turn the heat up to medium high and add balsamic vinegar and cook for 2 minutes, stirring often.  Stir in the tomatoes and chicken stock.  Bring to a light boil, turn the heat down to medium low, and simmer for 25 minutes, stirring occasionally.

Add soup to a blender with the basil and process until completely smooth.  Return the soup to the pot and stir in the honey and cream.  Simmer for two minutes, season with additional salt and serve.  Serves 4

Resources for diabetics with severe visual loss

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This Diabetes in Control article gives some great USA based resources to help diabetics manage their condition even with severe visual loss.
 We Don’t All See the Same. See the World Through My Eyes
The patient lived alone with her Seeing Eye dog and was assisted by her brother. She lived a relatively normal life despite her blindness, working a clerical job and visiting the gym 2 days per week.
As an educator, I had never dealt with a truly sightless individual and was feeling ill-equipped to take on this challenge. The majority of the diabetes patients in our small rural clinic have sight enough to manage their disease. I started to think of all the things we take for granted when teaching our patients, such as lancing their fingers, reading a label, even simply putting the correct amount of food on their plate. All that was thrown out the window. How did I help this patient to see her diabetes care?

I accessed the National Federation of the Blind (https://nfb.org/literature-diabetes) and followed the path to gather information and tools to assist the blind patient who also has diabetes. Most of the resources through the National Federation of the Blind (NFB) are free, although I did purchase a braille edition of exchange lists for the patient in hopes that this would assist her and her brother as they shopped for meals. The NFB also provide an audio CD entitled Bridging the Gap: Living with Blindness and Diabetes. Our patient found this CD to be very helpful and empowering and included resources and articles from the Voice of the Diabetic, an out-of-print publication.

Challenges were many and required more effort on our part to make education visible to the patient. We used many hands-on items for the patient to touch to illustrate diabetes management.

The talking meter was an absolute necessity. Lancing fingers became hit and miss until we worked out a better method for the patient. We did use smart technology for her IPhone with apps that included Dragon Dictation, OMoby, and VizWiz that talked to her and assisted her in identifying items and package information. The app Evernote recorded all of our conversations to review and revisit later. Through the American Diabetes Association, we obtained a compartment plate to assist her with portion control.

Our staff spent a great deal of time making sure that our patient understood all the aspects of her care related to diabetes. Daily phone calls helped the patient to see her diabetes for what it is, a manageable disease.

We spent approximately 3 months working very closely with this patient to support her efforts at self-management.  In the end, her A1C dropped to 6%, 3 months after we began working with her. She was pleased with the outcome, had lost a little weight, and felt, overall, better equipped to manage her diabetes. Our primary goal was to allow the patient to maintain her independence and self-care ability by providing her the tools to manage her diabetes successfully.

Our staff walked away with a very valuable lesson regarding diabetes education and its need to be individualized. It is all about what the patient sees, or in this case, what they don’t see.

Lessons Learned:

  • Explore all resources possible when helping people with diabetes.
  • All patients have challenges, but each challenge is an opportunity to make a difference.
  • Assess each patients’ challenges. You may not feel equipped, but there are usually resources to help if you take the time to look for them.

Liz Whelan MSN RN CDE
Coordinator Health and Diabetes Education

 

And now… for something completely different:Guide cats for the blind.

 

Jovina cooks Italian: Cheese stuffed celery, salmon and crab rolls with salad

 

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Southern Pimento Cheese Stuffed Celery

Ingredients

  • 1/3 cup reduced-fat cream cheese (Neufchâtel), softened
  • 8 ounces shredded sharp Cheddar cheese (about 2 cups)
  • 8 ounces shredded Monterey Jack cheese (about 2 cups)
  • 3 tablespoons low-fat mayonnaise
  • 3 tablespoons drained chopped pimientos
  • 1 teaspoon grated onion
  • 1/8 teaspoon garlic powder
  • Pinch salt
  • Pinch ground cayenne pepper
  • Celery stalks, cut into 4 inch lengths

Directions

Process cream cheese in a food processor until smooth. Add Cheddar, Monterey Jack, mayonnaise, pimientos, onion, garlic powder, salt and pepper and pulse to combine.

Scrape into a serving  bowl, cover and refrigerate for 30 minutes or up to 2 days.

Use the spread to fill celery stalks and serve immediately.

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Grilled Crab Stuffed Salmon Rolls

  • 1 Salmon Fillet, about 8 oz, skin removed

Crab Stuffing

  • ½ cup shelled, fresh  lump crab meat
  • 1 tablespoon minced onion
  • 1 tablespoon minced celery
  • 1 tablespoon minced green bell pepper
  • 2 teaspoons mayonnaise
  • ¼ teaspoon seafood seasoning (Old Bay)
  • ¼ teaspoon ground garlic
  • 1 teaspoon lemon juice

Directions

For the stuffing

Mix the crab meat with the vegetables and seasoning.

For the salmon rolls

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Cut the salmon fillet in half lengthwise. Divide the stuffing in half and spread on the skinned side of the salmon fillet. Roll up tight and secure with metal skewers or Butcher’s string.

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Refrigerate until time to grill.

Preheat the grill to medium hot.

Place pinwheels on a sheet of heavy-duty foil that has been coated with olive oil cooking spray. Poke a few holes into the foil.

Slide the foil onto the hot grill and grill with the lid closed for about 10 minutes.

To cook indoors

Heat the oven to 400 degrees F. Lightly coat a glass baking dish with cooking spray.

Place pinwheels the pan. Brush pinwheels with butter, cover loosely with foil and bake 15-20 minutes..

An August Dinner For Two | jovinacooksitalian

Tomato Cucumber Arugula Salad

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Ingredients

  • 1 large tomato cut in half and sliced
  • 1/4 of a cucumber, cut in half and sliced
  • 2 scallions, finely diced
  • 2 cups arugula
  • Italian vinaigrette

Directions

Combine the salad ingredients. Add salt and pepper to taste. Add enough salad dressing to just moisten the ingredients and toss, Serve immediately

Eric Barker: Meditation for the distracted

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Welcome to the Barking Up The Wrong Tree weekly update for September 4th, 2016.

Neuroscience Of Meditation: How To Make Your Mind Awesome

Click here to read the post on the blog or keep scrolling to read in-email.

So is meditation just another fad that pops up from time to time like bell-bottom jeans? Nope. Research shows it really helps you be healthier, happier and even improves your relationships.

From The Mindful Brain:

The MBSR program brought the ancient practice of mindfulness to individuals with a wide range of chronic medical conditions from back pain to psoriasis. Kabat-Zinn and colleagues, including his collaborator Richard Davidson at the University of Wisconsin in Madison, were ultimately able to demonstrate that MBSR training could help reduce subjective states of suffering and improve immune function, accelerate rates of healing, and nurture interpersonal relationships and an overall sense of well-being (Davidson et al., 2003).
And it’s not some magical mumbo-jumbo at odds with the science of psychology. In fact, it is psychology. William James, one of the fathers of modern psych, once said this…

From Thoughts Without A Thinker:

While lecturing at Harvard in the early 1900s, James suddenly stopped when he recognized a visiting Buddhist monk from Sri Lanka in his audience. “Take my chair,” he is reported to have said. “You are better equipped to lecture on psychology than I. This is the psychology everybody will be studying twenty-five years from now.”
Last week I posted about the neuroscience of mindfulness. Long story short (and grossly oversimplified): the right side of your brain sees things literally. The left side interprets the data and makes it into stories.

But Lefty screws up sometimes. His stories aren’t always accurate. As the old saying goes, “the map is not the territory.” When you listen too much to Lefty’s stories and not enough to the raw data from the right brain, you can experience a lot of negative emotions. A big chunk of mindfulness is keeping Lefty under control. (For the full story, click here.)

But where does meditation fit into all this? What does sitting cross-legged and focusing on your breath have to do with Lefty, the brain and eternal happiness?

And how the heck do you meditate properly? Maybe you’ve tried it and only ended up taking an unexpected nap, or getting horribly bored, or feeling like your brain is noisier than the front row of a death metal concert.

Let’s look at the science and cut out the magic and flowery language. We’ll hit the subject with Occam’s Chainsaw and get down to brass tacks about what meditation really is, why it works, and how to do it right.

Time to put your thinking cap on…

What The Heck Is Meditation?

A good quick way to see it from a neuroscience perspective is as “attention training.” (You know, attention. That thing none of us have anymore.)

But what the heck does attention have to do with happiness, stress relief and all the other wonderful things meditation is supposed to bring you?

Paul Dolan teaches at the London School of Economics and was a visiting scholar at Princeton where he worked with Nobel-Prize winner Daniel Kahneman. Dolan says this:

Your happiness is determined by how you allocate your attention. What you attend to drives your behavior and it determines your happiness. Attention is the glue that holds your life together… The scarcity of attentional resources means that you must consider how you can make and facilitate better decisions about what to pay attention to and in what ways.
And Harvard professor Daniel Gilbert, author of Stumbling on Happiness, did research showing that “a wandering mind is not a happy mind.” We want to focus on what the right side of the brain is giving us and get free from Lefty’s endless commentary.

When Lefty gets going with his ruminating, he’s much more likely to end up feeding you negative stories than positive ones. You’re happier when your attention is more focused on the concrete info your right brain is feeding you: the “here and now.” That’s all that “being in the moment” stuff you hear about.

So improving your attention is like dog obedience training for Lefty. When you can keep your attention on the right brain data and learn to disengage from Lefty’s running commentary you stress less, worry less and get less angry.

Is meditation powerful enough to overcome that often critical, cranky voice in your head? Yeah. It was even able to improve attention skills in people with ADD.

From The Mindful Brain:

At the UCLA Mindful Awareness Research Center, we recently conducted an eight-week pilot study that demonstrated that teaching meditation to people, including adults and adolescents with genetically loaded conditions like attention-deficit/hyperactivity disorder, could markedly reduce their level of distraction and impulsivity.
(To learn the four rituals neuroscience says will make you happy, click here.)

Okay, so meditation helps you focus on good things and let go of the bad, which can help you be happier and less stressed. Makes sense. So how do you do it right?

How To Meditate

Focus your attention on your breath going in and out. Your mind will wander. Gently return your attention to your breath. Repeat. Repeat. Repeat…

That’s it. Really. That’s all you have to do. Here’s how fancy neuroscience explains what’s going on…

From The Mindful Brain:

If in mindfulness practice our mind is filled with word-based left-sided chatter at that moment, we could propose that there is a fundamental neural competition between right (body sense) and left (word-thoughts) for the limited resources of attentional focus at that moment. Shifting within mindful awareness to a focus on the body may involve a functional shift away from linguistic conceptual facts toward the nonverbal imagery and somatic sensations of the right hemisphere.
Translation: the more you pay attention to the concrete info your right brain is giving you about your breathing, the less attention you have for Lefty’s interpretations, evaluations and stories.

You’re building yourself a knob that turns down the volume on Lefty’s criticisms and ramblings.

But the process is slow. Lefty will start talking again and you need to keep returning to the breath. Over and over and over. Sound like a waste of time? Nope. Here’s that father of modern psychology again, William James…

From The Principles of Psychology:

The faculty of voluntarily bringing back a wandering attention over and over again is the very root of judgment, character and will… An education which should improve this faculty would be the education par excellence.
(To learn about the neuroscience of mindfulness, click here.)

Simple, right? Actually, I’m hesitant to call meditation “simple.” It is simple, as in “not complex.” Those instructions would fit on an index card with room for your grocery list.

But that doesn’t mean meditation is easy… You know why?

Lefty Fights Back

You try to focus on your breath and banish Lefty but he keeps storming back into the room banging a tympani drum and clashing cymbals together. He won’t shut up.

Even without any input except breathing he still keeps finding things to talk about. And he jumps from one idea to the next. You try to dismiss him but it’s like mental whack-a-mole.

This is where most people give up. Don’t. Your head is not broken and you’re not clinically insane. Buddhists have known about this problem for over a thousand years. They call it “monkey mind.”

From Thoughts Without A Thinker:

Like the undeveloped mind, the metaphorical monkey is always in motion, jumping from one attempt at self-satisfaction to another, from one thought to another. “Monkey mind” is something that people who begin to meditate have an immediate understanding of as they begin to tune into the restless nature of their own psyches, to the incessant and mostly unproductive chatter of their thoughts.
Lefty is like a puppy locked in the house by himself, tearing up the furniture until you come home from work and pay attention to him. But there’s actually a valuable lesson here…

Lefty’s ideas seem so important. But then he’s on to talking about something else. And that seems so important. But then that idea flits away and it’s replaced by another one. And then that idea evaporates and is replaced…

Remember, Lefty isn’t you. He’s merely part of you, doing his job. Your heart beats, and Lefty generates thoughts. But those thoughts — which seem so important in the moment — drift away if you don’t entertain them.

And when it comes to the bad thoughts you have, and the bad feelings those generate, this is crucial and wonderful. You can just let them slide away.

But you’re tempted to take Lefty’s hand and go down the rabbit hole wondering if you should stop meditating because maybe you left the stove on, or if now wouldn’t be a great time to watch TV or finally debate the meaning of life…

Don’t. Turn your attention back to the breath.

And Lefty will say things that worry you or make you sad. And he knows just what will get under your skin. After all, he’s in your head. He’ll play “Lefty’s Greatest Hits” which never fail to get you all worked up. Don’t take the bait.

Your normal reaction is to grab your phone, check Instagram, check email, turn on the TV or do anything to distract yourself.

But that’s how you got into this problem in the first place. You need to sit here where it’s all quiet and build that attention muscle. No Instagram. Return your attention to your breath. Again and again, despite Lefty’s wailing.

Now you can’t shove Lefty away. He’s like the world’s worst internet troll — but with psychic powers. If you engage him, you just make it worse. Thoughts don’t float away if you wrestle with them. It’s like that finger trap puzzle you played with as a kid. The more you struggle to get out of it, the tighter it gets.

Just gently turn your attention back to the breath. Yes: over and over. Build that muscle.

Or maybe Lefty isn’t fighting you at all. Maybe you’re just skull-crushingly bored by this whole meditation thing. But the truth is, you’re not bored…

Lefty is. He’s tricked you again. The voice saying, “God, this sucks. Let’s watch TV.”? That’s not you. That’s him.

What is it when you call something boring? Is it concrete data from the right brain? No. It’s an evaluation. That’s Lefty talking.

Writer and neuroscience PhD Sam Harris explains that boredom is just a lack of attention.

From Waking Up: A Guide to Spirituality Without Religion:

One of the first things one learns in practicing meditation is that nothing is intrinsically boring— indeed, boredom is simply a lack of attention.
When Lefty says he’s bored that means you need more meditation — not less. Train that attention span and shut Lefty up.

(To learn what Harvard research says will make you successful and happy, click here.)

Whether he’s banging pots and pans or trying to trick you into thinking “you” are bored, Lefty won’t shut up. How do you get him to pipe down?

The answer is quite fun. Because we’re going to get Lefty to work against himself…

Don’t Fight. Label.

Ronald Siegel, professor of psychology at Harvard Medical School, writes this about the brain: “What we resist persists.” Arguing with Lefty just keeps him talking. You cannot “force” him to shut up.

So what’s the answer? Acknowledge Lefty. And, for a second, step away from focusing on the concrete and “label” what he is saying:

Lefty: “We keep meditating and we might be late for dinner. Better stop now.”

You:Worrying.” (returns to focusing on the breath)

Lefty: “I wonder if we got any new emails…”

You:Thinking.” (returns to focusing on the breath)

This uses Lefty against Lefty. When you use the left brain to put a label on its own concerns, it’s like writing something down on a to-do list. Now you can dismiss it because it’s been noted for later.

From a neuroscience perspective, it dampens Lefty’s yapping and frees you to return your attention to your breath.

Via The Upward Spiral:

…in one fMRI study, appropriately titled “Putting Feelings into Words” participants viewed pictures of people with emotional facial expressions. Predictably, each participant’s amygdala activated to the emotions in the picture. But when they were asked to name the emotion, the ventrolateral prefrontal cortex activated and reduced the emotional amygdala reactivity. In other words, consciously recognizing the emotions reduced their impact.
In fact, labeling affects the brain so powerfully it works with other people too. Labeling emotions is one of the primary tools used by FBI hostage negotiators to get bad guys to calm down.

(To learn how meditation can make you 10% happier, click here.)

Okay, so you know how to meditate and how to overcome the biggest problem people face when doing it — Lefty’s protests. But how does meditation lead to mindfulness?

Meditation Skills + Life = Mindfulness

Daniel Siegel of UCLA’s School of Medicine says that when you practice meditation consistently it actually becomes a personality trait.

You gradually start to take that attention-focusing and Lefty-labeling and apply it during your day-to-day life.

From The Mindful Brain:

Mindful awareness over time may become a way of being or a trait of the individual, not just a practice initiating a temporary state of mind with certain approaches such as meditation, yoga, or centering prayer. We would see this movement from states to traits in the form of more long-term capabilities of the individual. From the research perspective, such a transition would be seen as a shift from being effortful and in awareness to effortless and at times perhaps not initiated with awareness.
But you can accelerate this process if you actively to try to perform it. If you’re frustrated in traffic, you can focus your attention on the beautiful, sunny day outside.

When Lefty cries, “Why does this always happen to us!” you can label his statement as “frustrated.” That’ll cool down your amygdala and put your prefrontal cortex back in charge.

You can return your attention to the sunny day around you and let his complaints slide away as they always do — if you don’t turn them into a finger trap.

Lefty gets quieter and quieter. You focus more on the good things in the world around you.

And this is how you become mindful.

(To learn more about how to practice mindfulness from the top experts in the field, click here.)

Okay, newbie meditator, we’ve learned a lot. Let’s round it up and see how mindfulness can lead to the most powerful form of happiness…

Sum Up

Here’s how to meditate:

  • Get comfortable. But not so comfortable you’re gonna fall asleep. This ain’t naptime.
  • Focus on your breath. You can think “in” as your breath goes in and “out” as your breath goes out if it helps you focus.
  • Label Lefty. When Lefty brings the circus to town in your head, use a word to label his chatter and dampen it.
  • Return to the breath. Over and over. Consistency is more important than duration. Doing 2 minutes every day beats an hour once a month.

What makes us happier than almost anything else? The research is pretty clear: relationships.

But winning the war with Lefty is so internal, right? It’s all about you. (And him, I guess… But he is you… So it’s still about you.) Does that mean meditation and mindfulness are hopelessly selfish and self-absorbed?

Nope. What’s one of the biggest complaints we hear from those we love — especially in the age of smartphones? “You don’t pay enough attention to me.”

And here’s where that meditation-honed attention muscle pays off. You can give them the focus they deserve. When you don’t have to spend most of the day hearing that chatterbox in your head, you can truly listen to the people you care about.

Daniel Siegel explains that those attention skills can powerfully improve relationships with those you love by an increased ability to empathize.

From The Mindful Brain:

Our relationships with others are also improved perhaps because the ability to perceive the nonverbal emotional signals from others may be enhanced and our ability to sense the internal worlds of others may be augmented… In these ways we come to compassionately experience others’ feelings and empathize with them as we understand another person’s point of view.
Spend a little time focusing on your breath every day and you can replace Lefty’s voice with the voice of those you love.

Remember: every time you hit a share button an angel gets its wings. (Or, um, something like that.) Thank you!

 

Email Extras

Findings from around the internet…

+ What’s the best way to take truly restful breaks during the day? Click here. (Written by the very smart Christian Jarrett.)

+ How can your choice of office furniture make you smarter? Click here.

+ Which over-the-counter painkiller works the best? Click here.

+ Miss last week’s post? You definitely need to read “Lefty Part 1.” Here you go: Neuroscience Of Mindfulness: How To Make Your Mind Happy.

+ What’s the best way to motivate people at work? Click here. (Written by that great reader of research Melissa Dahl.)

+ You made it to the end of the email. (I appreciate you waiting to meditate until *after* you finished the email.) Okay, Crackerjack time. Ever hear a song or read something that just “gets you.” It says how you feel better than you could say it yourself? Oh yeah. That feeling. Well, I felt like that yesterday when I read a great comic by the enviably talented (and funny) Matthew Inman. Oh, and it’s about happiness, passion, and doing what you love. Click here.

 

Thanks for reading!
Eric
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