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Evaluating Patient Education: A Case Study Of A Diabetes Program.

Abstract This paper presents an evaluation of a diabetic education program for patients at Stephens County Hospital in Toccoa, Georgia. An analysis of covariance is employed along with multiple classification analysis to determine the effect of the program in reducing hospital readmissions. The major finding is that the teaching program is an important variable in the reduction of readmissions. A second outcome is that the occurrence of diabetic ketoacidosis (DKA) on initial admission is a second factor in determining readmissions. Patients having the benefit of instruction are less likely to experience readmission than those not being educated; those having DKA are more likely to be readmitted within six months from release than those not having this degree of loss of control. Implications of this study suggest that in designing a diabetic education program, greater attention must be focused upon the needs of the ketosis-prone patients. Continue reading >>

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  1. David199

    http://blog.sethroberts.net/2013/11/05/honey-at-bedtime-improves-sleep/#more-11906
    I found this article interesting on taking honey before bedtime to improve sleep.
    ———————————–
    Does Bedtime Honey Improve Sleep? Nine Reasons to Think So
    Stuart King, an Australian musician in his thirties, recently commented:
    Most days I wake up feeling more tired than when I went to bed the night before, however I find that if I take up to a tablespoon [15 ml] of raw honey immediately before bed I almost always wake up feeling totally refreshed. I’ve suffered from low energy, brain fog, fatigue and sore muscles for years. I tried eliminating food groups (dairy, grains, nightshades, etc) but that didn’t fix the problems (although wheat has been problematic) but taking the honey did. I usually sleep without any problems that I’m aware of — even if I awaken feeling unrefreshed I will still sleep through the night and won’t awaken early or whatever, but the crucial thing is I feel rested when I wake up, if I get that right I can even eat bad food and feel good all day. I tried coconut oil and coconut oil combined with honey but they didn’t work.
    I hadn’t heard that before. I searched “health benefits of honey” but didn’t find it. A Wikipedia entry about the health benefits of honey doesn’t mention it. In China, many people think honey is a health food, yet a Chinese friend of mine, who eats honey daily, hadn’t heard this. The uses of honey in Traditional Chinese Medicine lie elsewhere. Honey as sleep aid is briefly mentioned (with a question mark: “Key to a restful night’s sleep?”) in The Honey Prescription (2010).
    Many say or assume something quite different. According to Dr. Mercola, to sleep well “avoid before-bed snacks, particularly grains and sugars”. A Huffington Post writer says, “You already know which edibles to avoid before bedtime — namely, alcohol, coffee and sugary desserts.” Honey is half fructose, which UCSF professor of pediatrics Robert Lustig calls “poison”. Lustig says fructose is “one of the most egregious [= worst] components of the western diet, directly contributing to heart disease and diabetes, and associated with cancer and dementia.” John Yudkin, a well-known nutrition professor, wrote books about the harm done by sucrose. He considered fructose even worse. Nutrition researchers rarely study time of day effects. For example, nutritional epidemiologists ask what you’ve eaten but don’t ask when.
    I found a bit of evidence supporting what Stuart found — namely, two comments here:
    Just started honey and vinegar hot drink 2 weeks ago. Am amazed at the increased quality of sleep and relief of night time pain. Thought I was imagining it so did not have my drink one night. Didn’t sleep and was racked with pain again all night. . . [my recipe:] 2 tbsp apple cider vinegar and 1 tbsp honey with 1 cup hot water.
    Honey knocks me out and I actually wake up in the morning feeling refreshed and ready for the day–amazing. I’ve been using the honey for a few months now. The difference has been “night and day!”
    In addition, a 2007 study found that honey at bedtime was slightly better than no treatment at reducing the symptoms of coughing children. A 2010 study and a 2012 study found the same thing.
    I asked Stuart how he discovered that honey improved his sleep. He replied:
    I read something that Tim Ferriss said about having a small snack before bed [Ferriss advises protein and fat, not honey — Seth], I think he mentioned that unrefreshed sleep was due to low blood sugar. At the time I was doing carb back loading (I’ve since stopped that as carb restriction gave me problems). I would have a snack before bed but it didn’t always work. I think the small fructose amount in honey was what helped, starches didn’t always help. I did some research and came across your blog and Dave Asprey’s blogs on sleep, Dave mentioned raw honey. He encouraged people to take MCT oil with the honey to stay ketogenic, I tried coconut oil with the honey instead but it didn’t work. If anything it made my sleep worse with stomach cramps. I think there is an amount where benefits end, I think anywhere between a teaspoon or a tablespoon is about right. . . . The first time I did it I couldn’t believe it, I felt so good the next day.
    He added later:
    I have noticed that if I eat a lot of sugar during the day (soft drinks, desserts and so forth) then I don’t feel refreshed [when I wake up] regardless of the honey. Perhaps there’s something about honey that helps regulate blood sugar. I think it works better on an empty stomach/lightly fasted. So if you had dinner at 7 pm you might not eat anything after and take the honey at 9 or 10. In the past I’ve had a late dinner then maybe some dessert or fruit in the following hours, then added the honey just after and I don’t think it worked as well. When I first tried it I used commercially available heated honey and it worked great. I’ve tried 2 tablespoons, but I don’t think that worked any better than one and sometimes as little as 1 teaspoon is enough.
    In summary, three people reported great improvement in sleep from honey at bedtime. Stuart found several other things: 1. If he ate a lot of sugar during the day, the effect went away. 2. Other carbs didn’t work. 3. An empty stomach was important. 4. Effective doses ranged from 1 teaspoon to 1 tablespoon.
    I believe Stuart has discovered something very important. My belief rests on several things:
    1. Repetition. I started eating honey (1 tablespoon) at bedtime. My sleep (much better than Stuart’s to begin with) clearly improved, even with 1 teaspoon. I felt more rested when I awoke and more rested throughout the day. The improvement happened night after night. One evening I didn’t eat the honey on an empty stomach. The improvement didn’t happen, just as Stuart would have predicted. I told a friend about it. He took 1 tablespoon at bedtime. His sleep immediately improved by a large amount. He stopped waking up in the middle of the night and stopped needing a nap in the afternoon. Another friend has tried it once (so far). “When I woke up the next morning,” she wrote, “I’d realised I’d slept all the way through the night without waking up in the early morning (a nice change) but had a terrible case of the jitters (a not-so-nice change).” A third friend tried it twice. She slept better the first night but not the second. Maybe she failed to eat it on an empty stomach or had too many sweets during the day.
    2. Strength increase. As soon as I started the honey, I got stronger — a complete surprise. For years I have done one-legged standing to exhaustion several times per day because it improves my sleep. To reach exhaustion sooner, I stand on one bent leg. Recently I’ve been doing it four times per day (right leg twice, left leg twice). For a year, I’ve averaged about 3 minutes to exhaustion. After I started the honey, the length of time until exhaustion quickly increased. Here are the measurements:
    Each point is a different day; each is the average of the two durations for the first right and first left leg standing of the day. The 2013 tick marks the start of 2013. Nothing changed except the honey. The strength increase was also clear in other ways. In Beijing, I live on the sixth floor of a walk up. It became noticeably easier to climb the six flights of stairs.
    The strength increase astonished me. The dietary change was tiny, did not happen before exercise, and involved a safe widely-available food (in contrast to the drugs athletes use, such as steroids). I believe better sleep increased muscle growth. I predict that taking the honey at other times, such as in the morning, would not have the same effect. My earlier observations that lots of standing and one-legged standing improve sleep make more plausible causality in the opposite direction: something that improves sleep will increase muscle growth.
    When I described my strength increase to Stuart, he replied:
    I have noticed that when I do the honey, my weight goes up over the next week or two, perhaps by 400-500 grams [yet] my waist doesn’t increase (I measure it with a tape measure) even after a few weeks. I also have been sure that I noticed rapid muscular growth around my chest, shoulders and arms, similar to what I have noticed when going hard at the gym after a few months off. I kind of assumed that maybe I had more stored muscle glycogen from the honey, but had also considered that improved sleep as you said was the reason.
    3. Evolutionary explanation. It has been a mystery why evolution shaped us to like sweetness so much. Israel Ramirez (whose research led to the Shangri-La Diet) pointed out that the usual explanation (sugar is a source of energy) makes no sense. If it’s because sugars provide energy, why don’t potatoes and rice taste just as good? They don’t. Nutritionists lump sugars with other carbohydrates, thereby ignoring the puzzle. No anti-sugar advocate — not Yudkin, Lustig or anyone else — has provided a good explanation of why evolution shaped us to like the taste of a “poison”.
    There are several related puzzles. Why are meals divided into main course and dessert? In other words, why do we eat the sweet part separate and later? If we like sugars because they provide energy, this makes no sense. If sugars are simply carbs, this makes no sense — we eat plenty of carbs during the main course. The separation of dessert and main course, if it reflects brain mechanisms, must mean that sugars are quite different than other carbs. Somehow we benefit from this division. A few people, in particular Elizabeth Capaldi, an experimental psychologist, have figured out that sweet food tastes worse if we are hungry (enough). This is why dessert comes after the rest of the meal. Yet other carbohydrates do not taste worse. Stuart pointed out something else along these lines, which I had not heard before but which is clearly true: We eat dessert much more after dinner than after lunch.
    Stuart’s observations explain these mysteries. All four observations (liking for sweetness, separation of main course and dessert, sweet things taste bad when hungry, dessert after dinner but not lunch) make sense if we have evolved mechanisms to push us to eat sweet foods near bedtime. Long ago, these foods would have mainly been fruit. Because sleep is so important for health, there would be powerful selection for anything that improved sleep.
    4. Basic physiology. The brain runs on glucose. In my brain tests, sugar drinks, cupcakes, and other sugar-rich foods make an obvious difference 30 minutes to 2 hours later. (I get faster.) And the brain controls sleep, an enormously complicated and time-sensitive process. Too little blood sugar during sleep could easily disrupt sleep.
    5. Basic nutrition. Honey is half glucose, half fructose. When you eat it, the glucose enters the blood quickly and would supply glucose to the brain in the first half of the night. In contrast, the fructose turns into glucose and enters the blood slowly (fructose has a low glycemic index). This would supply glucose to the brain in the second half of the night. Many fruits, such as bananas, figs, and grapes, have a similar composition (similar amounts of fructose and glucose). Most fruits have plenty of fructose and glucose. A 50/50 glucose/fructose mixture makes honey near the start of sleep a good source of blood glucose over an extended period without food. Notice that you need both — glucose and fructose — in roughly equal amounts to get a roughly steady supply over six or seven hours.
    6. Basic engineering. When you are asleep, there can be no “course correction”. You must subsist for the next six or so hours without any behavioral help, such as drinking water when thirsty. So it makes design sense to do something shortly before sleep that will provide a relatively steady supply of glucose throughout the night (“time-release”). That won’t be a lot of glucose at once. You need a food that is a mix of sugars.
    7. Support for general idea. A few weeks ago a woman told me that when she ate very low-carb her sleep suffered, so she ate more carbs and her sleep got better. This supports the general idea behind what Stuart found — that the brain needs a certain amount of glucose to work well during sleep and it is best if it gets at least some of it from carbohydrate.
    8. Explanation of correlation of sugar and bad health. Why is sugar consumption often correlated with poor health? This is easy to explain: sugar at the wrong time is the problem. Too much sugar during the day interferes with the bedtime benefit (and may also interfere with sleep in general). Stuart found exactly this: Eating lots of sugary foods during the day disturbed his sleep and eliminated the honey effect (“if I eat a lot of sugar during the day . . . then I don’t feel refreshed [when I wake up] regardless of the honey”). Too much sugar during the day could make it harder to get optimal glucose levels during the night. For example, too much sugar during the day might raise insulin levels, causing too-low blood sugar at night and/or causing a fructose/glucose mixture eaten at bedtime to be digested too quickly. Anything that harms sleep will increase disease. Good health, good sleep and good immune function are closely connected. An example of the evidence is that shift workers get more cancer than non-shift workers.
    9. Reichenbach’s Common Cause Principle, in my paraphrase, is lightning doesn’t strike twice in one place for different reasons. If two rare events might have the same cause, they probably do. In this case, lightning has struck three times in one place. 1. Huge sleep improvement from tiny dietary change. 2. Huge strength improvement from tiny dietary change far from time of exercise. 3. Evolutionary explanation of why sugars taste good, why dessert exists and follows the main course, and so on. Before this, no one has come close to a plausible evolutionary explanation. The absence of an explanation is remarkable because two of the phenomena — sweetness tastes good, sweets are eaten separately after the rest of the meal — are so obvious.
    I believe Stuart’s discovery is important for two other reasons that might not impress anyone else. One is similarities with my earlier work. First, I’ve found other “cross-over” interactions with time of day, where something helpful at one time is harmful at another time. Vitamin D in the morning improves sleep, Vitamin D at night harms sleep. Morning faces improve mood, evening faces harm mood. Second, wondering why we like sour, umami and complex flavors was the first thing to suggest to me that we need to eat plenty of fermented food to be healthy. Many facts later, I’m sure this is true. Finally, evolutionary reasoning has helped me find several new experimental effects (morning faces, Shangri-La Diet, flaxseed oil, standing and sleep).
    Finally, Stuart’s discovery explains something puzzling I’d noticed repeatedly for years. Now and then I slept unusually well. I’d wonder why — how was yesterday different from usual? — and see that the only unusual thing was that I’d had dinner at a friend’s house. At the times, I guessed that seeing faces in the evening was somehow improving my sleep. This did not make sense in terms of my morning faces work, but a connection between social contact and sleep was well-established. Now I realize that dinner at a friend’s house is one of the few times I eat dessert. A friend told me that when his partner has dinner parties, she serves dessert long after the main course.
    This report suggests that different honeys may differ in important ways.
    I told a Dutch friend about this. She said it was common in Holland to have milk and honey at bedtime, although she herself didn’t do this. I asked why. No clear reason, she said. An excuse to have something sweet? Could this be why the Dutch are so tall? Children grow when asleep. Better sleep, more growth. My strength increase suggests what a big effect this could be.

  2. Dutchie

    @david199 Apparently theres something called the hibernation diet which talks about eating a spoon of honey&its benefits and have some similarities to your article. I don’t know what’s true of it though.
    http://www.benefits-of-honey.com/hibernation-diet.html

  3. David199

    Thanks Dutchie. I spent much of last night reading about the Hibernation Diet and i have bought the book. I have insomnia where i wake up in the middle of the night around 4am and can’t get back to sleep. Ironically, i first bought Robb Wolfs book on Paleo because he asked: “Do you wake up in the middle of the night?” but Paelo didn’t help and then i found Matt and his Paleo myths which asked: “Do you wake up in the middle of the night?” but Diet Recovery has not helped my sleep. I am seeing a sleep doctor and working on sleep restriction therapy but i still wake up every night and have for the last decade. So i was a total sucker for an idea that i should fuel my liver/brain to sleep better since that is a very specific problem that i have. I found this website that has a good Q&A from the author of the book (you have to click on the comments for each question) http://www.hibernationdiet.blogspot.com
    The basic premise is that during sleep, the brain is burning a large percentage of your energy requirements and it needs a steady stream of glucose which it gets from the liver – and you need fructose to nurish the liver. Honey, being roughly half glucose/fructose is perfect as it provides a little initial insulin spike to get sleep moving forward and then the melotnin secreted during sleep keeps the insulin in check and the fructose through a variety of reasons provides fuel for the liver to supply the brain with glucose. If the brain is happy, it will keep the stress hormones to a minimum which provides deeper rest, if the brain is not getting anough glucose from the liver, its going to secret stress hormones to get it from other tissues or produce ketones. Matt has recommended sugar and salt under the tongue in the middle of the night if you wake up but 1) why not use it before bed to sleep all night and 2) the author of the Hibernation Diet does not like sucrose and prefers the sugar in fruit and honey. While sucrose is also 50/50 glucose/fructose, the author believes (for reasons that i hope are explained in the book) that refined sugar has a much different effect than fruit or honey. We’ll see. Anything that can improve my sleep (I fall asleep fast but awake every night at ~4am) is worth investigating. Worst case scenario i eat some honey. Not a bad trade-off. As a side note, there was a very interesting series of posts on the Crossfit blog years ago where all those paelo and zone dieters found that eating ice cream at night made them leaner and none of them could figure it out. Sounds like it might coincide with the advice in Hibernation Diet as well as opposing the conventional wisdom mantra of not eating late a night. As Matt says in Food Ninja: The key to vitality is play hard, eat hard and sleep hard.

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