Nurses have told us that DMII is a chronic condition; that once you have it, you always have it. And to never go off the restricted diet or risk suffering terrible side effects.
When we lived in a senior apartment complex in MN, we saw some of those side effects including foot amputation of an attractive slender woman in her sixties. Just do a Google images using the search term “diabetes amputated leg” to see this particular horrific consequence in graphic detail.
But the VA has a different belief/standard, one that doesn’t see DMII as chronic. If a veteran’s DMII is under control, his chart may be coded “prediabetic” and that is not accurate.
One afflicted Vietnam vet decided to stop taking his DMII medications because three ROs: San Diego, WRJ (VT) and Detroit all claimed he did not meet the VA’s criteria. Why? Because his medications successfully managed his diabetes mellitus, type II. So he decided put himself at risk and fight on.
BVA Veterans Law Judge BARBARA B. COPELAND set this case right
(Citation Nr: 1422344)
and possibility saved this vet from further physical disability when he rebelled at the idiocy and injustice and went off his meds (link). She wrote:
At a February 2010 hearing before a DRO, the Veteran testified that he was treated with Metformin for his diabetes mellitus but had recently stopped taking the medication because of VA’s continued denial of his claim for diabetes. He stated that he had been medically treated for diabetes for two years. He testified that his peripheral neuropathy was related to his diabetes mellitus.
His private doc went to bat for his patient:
Dr. Hanson noted that the VA examiner has disputed that the Veteran has diabetes mellitus at all based on the ADA’s outmoded standard definition of diabetes which requires two fasting blood sugars 146 or above on two separate occasions; a two hour post 75 gram glucose load come back above 200 mg/dl on two occasions; and random blood sugar 200 on two occasions. Dr. Hanson noted that the Veteran had a hemoglobin A1C of 6.4 percent in 2007 despite running vigorously and regularly and having a lean body mass that exceeds most Americans’ fitness.
Thank you Dr. Hanson and Judge Copeland for caring.
The DIABETES MELLITUS DISABILITY BENEFITS QUESTIONNAIRE (LINK) uses the outmoded standard (See page 3) of diagnostic testing to deny benefits (exception of 146 versus 126.) In this case, a non-VA provider is essential to writing a good nexus letter or to fill out this form.
According to the NIH, the A1C and the blood glucose are the two most important tools; but like political polls–there is a margin of error. VA Doc David Aron provided these charts to the NIH (link) to illustrate.
Oddly, the VA QUESTIONNAIRE does not ask about heredity. Why? Because special, more accurate tests, are needed if a hemoglobin variant is present.(LINK)
People of African, Mediterranean, or Southeast Asian descent, or people with family members with sickle cell anemia or a thalassemia are particularly at risk of interference. People in these groups may have a less common type of hemoglobin, known as a hemoglobin variant, that can interfere with some A1C tests.
That’s a whole lot of vets...and many are unaware of their DNA roots. I didn’t find out about my thalassemia until I was 50. We confirmed Mediterranean heredity via DNA private testing (ancestory.com) origins, and other genes, and should probably request the most accurate tests now.
False A1C results may also occur in people with other problems that affect their blood or hemoglobin. For example, a falsely low A1C result can occur in people with
- heavy bleeding
A falsely elevated A1C result can occur in people who
- are very low in iron, for example, those with iron deficiency anemia
Other causes of false A1C results include
- kidney failure
- liver disease
So if one suspects diabetes, it behooves us all to find out if you have a hemoglobin variant and if so, request the right lab tests.
The Veteran in the story was taking Vitamin B12. Low vitamin B12 can also cause anemia. I wonder if he’s anemic.
A big yay to Dr Hanson. He not only diagnosed his patient early and controlled his blood sugar, he also did a great job defending him. The only thing I would have done different…I would have added some of the other symptoms of diabetes in his record to back up his diagnosis…frequent urination (which I bet he has because of prostate), thirst, fatigue, etc.
Kiedove, you see what you started?
yes, I think that might have been an error introduced at one of the ROs-but still it hurt the vet.
126 is the current ADA #.
Your additions could go under the remarks area..and would be important in rating too I think.
This was good current info from ADA.
“National Health and Nutrition Examination Survey (NHANES) data indicate that an A1C cut point of ≥6.5% (48 mmol/mol) identifies one-third fewer cases of undiagnosed diabetes than a fasting glucose cut point of ≥126 mg/dL (7.0 mmol/L) (4).
It is important to take age, race/ethnicity, and anemia/hemoglobinopathies into consideration when using the A1C to diagnose diabetes.”
I just looked at the DIABETES MELLITUS DISABILITY BENEFITS QUESTIONNAIRE, page 3 and it says a fasting of 126 not 146.
What do you say we ask some of the diabetes orgs what they think about using a fasting of 146 to diagnose diabetes.
I’m thinking that might be a typo?
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I would love to be able to see the “VA diabetes Training letter”. I seem to remember that their guideline for low blood sugar was too low. I love being able to use their own documents against them.
I’m very sorry about your husband. Trying to prevent this from happening to other Veterans is a wonderful way to honor his memory.
Yes, we need to get that training letter. Maybe Bertha can email it to Alex and post it.
By the way, the VA does “Point of Care” research. They inbed research into regular office visits. For example, if they want to do a study on diabetics to see what works better, diabetes pills or insulin, when a diabetic is seen, the computer randomizes him to take either pills or insulin without letting the Veteran know what they’re doing.
I don’t know how they get away with shit like that. I used to work in research and if we’d done that we would have been blacklisted. It’s unethical and it violates federal regulations.
Silvia, I was hoping you would have time to tell us what this all means. I’m stunned to learn that the A1C is not the first diagnostic tool–if it can be considered one at all! If you can call in to Jerrell’s show, that would be great. Explain why this is BS.
Thanks for the invitation. I’ll do that.
It’s BS because if they require two fasting blood sugar results of 146, that means they are not diagnosing diabetes on many Veterans who have it.
Let’s say a Veteran has a fasting blood sugar of 135 and a second one of 130. According to the American Diabetes Association he’s diabetic but according to the VA he’s not. It’s absolutely criminal because he’ll suffer damage from the diabetes and not be aware of it.
HgA1C (Hemoglobin A1C) is the average blood sugar over the past 3 months. It’s not supposed to be used to diagnose diabetes. It’s supposed to be done every 3 months to check progress. For example if you have a HgA1c of 10 and 3 months later it’s 8 and 3 months later it’s 6, you can see the progress is good. But if it goes up then you know you need to do something to lower it.
It’s not used to diagnose diabetes because in 3 months you can have high readings and low readings and they’ll average to a good number. So it may not show that you have diabetes. As you said, anemia (like the one caused by Ribavirin and cirrhosis) can also impact the results.
A fasting blood sugar is used to diagnose diabetes. According to the American Diabetes Association:
Prediabetes fasting blood sugar 100-125
Diabetes fasting blood sugar >126 on two separate occasions.
Glucose tolerance test (you drink a sugary drink and your blood is tested in 2 hours) >200 is diabetes.
Once you’re diagnosed as a diabetic you can control it but you don’t go back to being a pre diabetic.
What I find shocking in this story is that the HgA1c test result they had was from 2007, for a test that is usually done every 3 months. The 146 number for diagnosing diabetes is incorrect and you don’t need TWO glucose tolerance tests because your blood sugar should never go above 200 so if it it does once, that’s enough to know you’re diabetic.
Great story, my mouth is still hanging open.
The smoke clears…thank you.
Sorry you lost your spouse to this. You should write this whole story down and the actions you took because many can learn from your experience. Email it to NOD. Thanks for the tips you share here.
Much of the actions I took ,on this claim and all of my other claims,are at http://www.hadit.com.I have been at hadit for almost 20 years, as a volunteer claims advocate, And with Jerrel at the old SVR radio broadcasts since around 2005.
The VA diabetes Training Letter is here:
Click to access va_training_letter_00-06.pdf
For some reason VA changed the 1997 VA TL I used.
It was more detailed then the one above they use now.
It will also all be in a book my daughter ( a veteran 7 yrs USAF) insisted I start writing…
I proved my deceased husband had undiagnosed and untreated DMII by going over the VA diabetes Training letter carefully.I found that his driver’s license, a pre employment VA Physical, his dental records, and his autopsy proved without a doubt he had DMII from AO, along with a VA med rec that was crossed out but I managed to decifer that it said to’ confirm diabetes’ which they crossed out and never did in his lifetime.
I had 3 very strong IMos as well but convinced myself first before spending all that IMO cash, that I had prepared an excellent claim with plenty of documented evidence. This above is quite a case.
HBIAC tests involve a calibration of the equipment from time to time , as I understand it.
and I wonder if VA calibrates that equipment properly.
Diabetes doesn’t kill anyone…it’s horrific complications do- to include stroke, TIAs, heart disease,
PN, PAD, renal dysfunction, candidiasis, etc etc etc etc. His FTCA/1151 wrongful death was changed by VA to a service connected death due to the untreated DMII 2009 -contributing to his death from IHD from AO in Vietnam. 2012 (Nehmer)