Grace
Sun/Sep/08 10:02 PM
Today in Sunday School we
were discussing the concept of grace. Unmerited favor
is the way I have always thought of grace. In the
Christian world view this would mean that nothing
within me should have caused the God of the universe to
carry out a plan to remove the blood-guilt that my sin
demands. God’s act of grace starts and ends in the will
and action of God alone. I am the unworthy recipient.
Ah, but I must both see my need, confess my inability to save myself and then accept the grace that is given me by the act of Christ dying in my place. There’s the rub.
Accepting grace and then understanding that it was all sufficient and freeing is not easy. Grace frees us from the slavery to sin under which we lived and places us in a righteous (here I would say blameless or sinless) position free to live fully the way God intended. The problem is the way we think about it as humans.
I tend to look back or regret my sin....to wallow in my guilt. This is almost like a slave once freed who has no idea how to live free. I have patients who have a complaint and after an exhaustive work-up are told, “good news, there is nothing dangerously wrong with your body”, who seem unhappy with the news! Moreover many go from doctor to doctor trying to find something wrong rather than embracing their health and living. Too often I see myself in that pattern. Bound up by guilt of past sin or of future sin afraid to seize the joy that grace has given to me.
In the Screwtape Letters, C.S. Lewis outlines how Satan desires to keep humans focused on the past (regrets) or the future (fear) rather than living fully free in the present. He says that the present is the closest thing to the “eternal now” of heaven and if humans fully embraced the present as God intends our eternal nature would recognize its joy and Satan would lose his grip on our lives. Embracing grace would seem to be the first step. If you are a Christian saved by the death and resurrection of Christ then you indeed have received a clean bill of health.
Ah, but I must both see my need, confess my inability to save myself and then accept the grace that is given me by the act of Christ dying in my place. There’s the rub.
Accepting grace and then understanding that it was all sufficient and freeing is not easy. Grace frees us from the slavery to sin under which we lived and places us in a righteous (here I would say blameless or sinless) position free to live fully the way God intended. The problem is the way we think about it as humans.
I tend to look back or regret my sin....to wallow in my guilt. This is almost like a slave once freed who has no idea how to live free. I have patients who have a complaint and after an exhaustive work-up are told, “good news, there is nothing dangerously wrong with your body”, who seem unhappy with the news! Moreover many go from doctor to doctor trying to find something wrong rather than embracing their health and living. Too often I see myself in that pattern. Bound up by guilt of past sin or of future sin afraid to seize the joy that grace has given to me.
In the Screwtape Letters, C.S. Lewis outlines how Satan desires to keep humans focused on the past (regrets) or the future (fear) rather than living fully free in the present. He says that the present is the closest thing to the “eternal now” of heaven and if humans fully embraced the present as God intends our eternal nature would recognize its joy and Satan would lose his grip on our lives. Embracing grace would seem to be the first step. If you are a Christian saved by the death and resurrection of Christ then you indeed have received a clean bill of health.
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Vitamin D
Sun/Sep/08 09:51 PM
I know that I have
written about Vitamin D before but I have got to do so
again, albeit briefly. When the research on Vitamin D
deficiency’s link with depression was published a
couple of years ago I became curious about what I had
read. Then consistent research linked low levels of
vitamin D with not only depression but increased cancer
risk and, certainly, poor bone deposition. I started to
test patients, especially those who were elderly or at
risk of osteoporosis fractures or the ones that were
depressed. Gradually I began to test more patients in
my practice. The results have been astounding. Like
most silent epidemics, vitamin D deficiency is easy to
find when you are first testing in a population. The
prevalence is high and the yield of testing is also
high. I was not prepared for 8 of 10 tests to return
under the levels thought to be needed for good bone
health. That’s correct...80%. Both men and women are
testing low and largely middle aged to elderly. Those
who get little sunlight and little supplemented dairy
products are the largest group.
With supplementation I have seen levels rise to acceptable and those patients will be able to use OTC supplementation thereafter....we hope. The question will be “Is there a clinically relevant benefit to raising these levels? Given the associations with cancer and depression and osteoporosis one would hope so. Time will tell. More later.
With supplementation I have seen levels rise to acceptable and those patients will be able to use OTC supplementation thereafter....we hope. The question will be “Is there a clinically relevant benefit to raising these levels? Given the associations with cancer and depression and osteoporosis one would hope so. Time will tell. More later.
Olympics
Sun/Aug/08 11:55 PM
Of course I have been
watching the Olympics this past week....who could not.
The drama of sport at high levels is reality TV cubed.
I enjoy the races of all types. It seems a great way to
test your competitor. I’ll race you to the tree. Just
the type of race we all had when we were little. I like
but get frustrated with the judged competitions as it
seems there is way too much subjectivity. I do like the
stories and pictures of sportsman/womanship. The Games
seem to always bring some type of special stories out.
But I still don’t get Greko-Roman Wrestling. I will be
back from the summer hiatus soon and hope to have some
changes to put on the site.
Kids and Statins
Mon/Jul/08 09:31 PM
OK, so those of you who
know me already know where this is going. Today the
American Academy of Pediatrics released and expert
panel statement recommending more aggressive screening
of cholesterol in kids AND selective use of statin
drugs in kids as young as 8 years old AND a move away
from whole milk in children after the age of 12 months
especially if they are overweight. The first is in an
effort to identify those with risk of heart disease who
may benefit from intervention. The second is based on
some small studies that did not show harm if children
used the meds for a short term (long term followup does
not exist yet). The last is a major deviation from long
held belief that for younger kids a certain amount of
fat in the diet is crucial for brain development.
My take is mixed: Obesity in children is rampant in America. The causes are not that complex. We eat too many calories, too many calories as rapidly absorbed sugars and too little good protein and fiber. Parents eat poorly so their children follow suit. We have used sweet sports drinks to satiate our kids growing sweet teeth and as a society we “do exercise” rather that “live active”. Our schools and social institutions feed our kids poorly and cheaply and exercise them rarely. Our kids sleep too little (which in the < 8 year old crowd has been linked with obesity.
As health professionals we have also failed. We reach for pills because we don’t want/cannot spend time with patients trying to educate and change lifestyles. We have not been out front in advocating for healthy local school food and against corporate takeover of the lunchroom. We have reached for pills to correct ignorance or sloth from parents who seem not to understand that they are killing their kids and we have gone away from common sense approaches.
Medicine has not lead the way in nutrution even for the youngest amoung us (unless they have an illness). Did you know that nearly 1/3 of our baby boys in some surveys are drinking SOY forumla. At the same time we promote soy as a phytoestrogen to help with the sympotms of menopause. THINK ABOUT THOSE TWO STATEMENTS. Although obesity < 2 years of age has not been as strongly linked to adult obesity as in kids 3-8 we now seem poised to recommend against fats that nearly all science says may be cruicial for brain development in a toddler. (Oh, well, there’s always Ritalin for the consequences).
If you think that the pharmaceutical industry is not licking its lips anticipating a new group of “patients” who will take meds FOR LIFE you are kidding yourselves. Doctors will not want to be “behind the times” and will start screening (not a bad thing) and given meds. My experience over the years especially when I was teaching was that given a choice between educating and prescribing a medication, the Rx always won. Just look how quickly marginally effective drugs spread through our society. So do not be decieved, these recommendations will largely increase testing costs, prescriptions to younger kids and side effects from those meds.
My suggestions? Work on the parents with new kids. Obese parents who eat poorly and do not exercise may wish their children were fit and active but, in my experience, the children quickly adopt the parent’s livestyle. We must as a nation make obesity as high a priority as smoking. Sugars must become public enemy number one with high fructose corn syrup becoming our number one bad guy. We need to have health care integrate nutrition and exercise eduation for children. We need to insist on good independent sources of research on nutrition rather than relying of data compiled by manufactuers of medications. We need to see that consuming is not healthy when it comes to medications and that the hard road of personal discipline and long term view is far better for society than the short term gratification of our taste buds. We need to put patients back on the hot seat as active in their own health. We need to do it now.
My take is mixed: Obesity in children is rampant in America. The causes are not that complex. We eat too many calories, too many calories as rapidly absorbed sugars and too little good protein and fiber. Parents eat poorly so their children follow suit. We have used sweet sports drinks to satiate our kids growing sweet teeth and as a society we “do exercise” rather that “live active”. Our schools and social institutions feed our kids poorly and cheaply and exercise them rarely. Our kids sleep too little (which in the < 8 year old crowd has been linked with obesity.
As health professionals we have also failed. We reach for pills because we don’t want/cannot spend time with patients trying to educate and change lifestyles. We have not been out front in advocating for healthy local school food and against corporate takeover of the lunchroom. We have reached for pills to correct ignorance or sloth from parents who seem not to understand that they are killing their kids and we have gone away from common sense approaches.
Medicine has not lead the way in nutrution even for the youngest amoung us (unless they have an illness). Did you know that nearly 1/3 of our baby boys in some surveys are drinking SOY forumla. At the same time we promote soy as a phytoestrogen to help with the sympotms of menopause. THINK ABOUT THOSE TWO STATEMENTS. Although obesity < 2 years of age has not been as strongly linked to adult obesity as in kids 3-8 we now seem poised to recommend against fats that nearly all science says may be cruicial for brain development in a toddler. (Oh, well, there’s always Ritalin for the consequences).
If you think that the pharmaceutical industry is not licking its lips anticipating a new group of “patients” who will take meds FOR LIFE you are kidding yourselves. Doctors will not want to be “behind the times” and will start screening (not a bad thing) and given meds. My experience over the years especially when I was teaching was that given a choice between educating and prescribing a medication, the Rx always won. Just look how quickly marginally effective drugs spread through our society. So do not be decieved, these recommendations will largely increase testing costs, prescriptions to younger kids and side effects from those meds.
My suggestions? Work on the parents with new kids. Obese parents who eat poorly and do not exercise may wish their children were fit and active but, in my experience, the children quickly adopt the parent’s livestyle. We must as a nation make obesity as high a priority as smoking. Sugars must become public enemy number one with high fructose corn syrup becoming our number one bad guy. We need to have health care integrate nutrition and exercise eduation for children. We need to insist on good independent sources of research on nutrition rather than relying of data compiled by manufactuers of medications. We need to see that consuming is not healthy when it comes to medications and that the hard road of personal discipline and long term view is far better for society than the short term gratification of our taste buds. We need to put patients back on the hot seat as active in their own health. We need to do it now.
BFF
Mon/Jun/08 10:04 PM
The other great thing
about cyberspace is the fact that folks can find you
drifing out there. Recently I had a dear friend from
years ago contact me because they found my website.
This was amazing in and of itself as we have had <
5000 visits in the past year! Anyway I was found and
then contacted. I am so greatful that they took the
effort to connect. The other thing I have learned is
that certain things are eternal. I am sure that the
eternal part of each of us recognizes the eternal part
in our close friends. How else can it be that after
decades you can pick up almost without a pause? It
seems that certain types of human interaction just
trancend (or may suspend) time. Thanks for reachiing
out when you did. I have not had much to blog about
with a busy summer schedule and I try to avoid politics
other than bashing the
pharmaceutical/medical/industrial complex. There have
been some studies out recently that I am digesting and
trying to put into words to get out here. I am also
going to look at a podcast (because those of you who
know me know I can talk and talk and talk). Catch the
poem in the verses page look at some friendship
lines.
Forum on Hold
Mon/Jun/08 10:02 PM
OK so maybe it was not
such a good idea. I certainly don’t LIVE to sit at the
computer typing and trying to intice “friends” to
cyberchat. The forum will go into hybernation for now.
I still would like have ideas on how to develop a more
interactive site. I really would like to “ask the doc”
for both patients and others visiting the site but the
forum was not working and I don’t want to look at the
site with in on any more. The king is dead. Long live
the king.
Flippin Out
Mon/Jun/08 09:54 PM
If you check out
the last page on the site
you will find a video
of a trip I recently took with some friends and
family. The amazing thing is the camera on which the
video was shot. The Flip Mino is a new small video
camera that is about the size of my very small cell
phon. It looks a lot like a blak iPod with a lens on
one side. The back has a large red button around
which are four directional toggles and above which
are 2 selection buttons. The form is much like and
MP3 player and is very intuitive. There is a built
in microphone and electronic zoom and a 1.5 inch LED
screen in the back to watch what is being shot and
to review the video clips. Much like a digital
camera, you can trash the clip if you don’t like
them. It can record up to 1 hour of video/audio. Now
here it the kicker, it has a built in USB male port
that pops out at the push of a button alowing you to
link and download to a Mac or PC without much fuss.
If you want to use Quicktime or other players it is
pretty straight forward. And you can dump into movie
software. Thus the first effort you see posted. This
will be great for web video work. I’m just learning
the ropes and will let the kids take it on a trip to
North Dakota in July to shoot more footage. I love
the fact that you can be creative with minimal
investment.
What are you doing here?
Sat/Jun/08 11:07 PM
Last week we were looking
at the Old Testament story about Elijah and the
phophets of Baal. In the story Elijah is led to prove
once and for all that his God is living and supreme and
that Baal is an idol. He challenges 450 of the prophets
of Baal to build an altar and have their god produce
fire from heaven to come down onto their altar. Then he
taunts them while they futilily do so and finally stop.
He then produces a simple altar, soaks the wood and the
sacrifice with more water than was needed to make his
point and then prays simply that God would show who is
“the Lord”. The fire comes and consumes the wood and
sacrifice. Elijah has the false prophets seized by
people who had come to watch the contest and then he
has them all killed. He prays to God to end the long
drought that had ravaged the land and a torrent occurs.
Finally, he outruns the king’s chariot back down the
mountain.
Heady stuff. He has been filled by God’s Spirit and with that filling has done miraculous things and observed God’s power and constant attention to His people. Our discussion looked at the way he was locked in to being brave and faithful in the story.
What struck me was the next chapter (1 Kings 19) where Jezebel has been told of the outcome of the duel and the death of the prophets (whom she supported). She vows to kill Elijah. And fresh from his mountaintop experience and aware of God’s power, the prophet.....HIDES after asking God to let him die. He eventually wanders into the mountains and ends up in a cave apparently depressed and hiding.
And here comes the part I liked. God does not ridicule him, demand he have more faith or punish him. God asks him “Elijah, why are you here?” The man complains that all others have been unfaithful and he has tried to do God’s bidding and now he is in danger of his life. God again, does not punish or correct, He tells Elijah to go out of the cave and stand on the mountain so Elijah can be there when God passes by. Elijah does so and observes a great wind that shakes the mountain and shatters rock (and the text says “”But the Lord was not in the wind”. ) Next came an earthquake and then a fire with the same response. Finally, there is a quiet voice of God which says... “Elijah, why are you here?”!
The same question. No other great announcement. Elijah repeats his statements of before and again, God does not chide him. God gives him tasks to do which includes appointing a chosen successor (Elisha). Then God reminds the prophet there are still 7,000 men fiathful to Him during this time of turmoil.
The lessons for me are strong. Right now I am in a place where I am complaining, feeling sorry for myself and being generally depressed. But I don’t feel God’s chiding or ridicule. I hear Him say “why are you here?”
The answer is complex but certainly involves my own decisions and choices through the years. The story teaches me that there is more. God is always in the places where we are, waiting, full of action and hope. He has plans for us that He desires to tell us. He also is aware of our disappointments, our fears, our depression and our...humanness. He does not rebuke us for these but he wants us to move outside of the place where we are so that we can see Him. He can hear our complaints but desires to put us firmly into His plan. He also comforts us with the knowledge that we are never as alone as our emotions would tell us we are. Lastly, He certainly can show us His presence in big and powerful ways but He does not need to do so because the power He places inside us is sufficient as long as we look to Him and obey.
I hope that I can learn this lesson and move out from the cave to hear what He has for me to do.
Heady stuff. He has been filled by God’s Spirit and with that filling has done miraculous things and observed God’s power and constant attention to His people. Our discussion looked at the way he was locked in to being brave and faithful in the story.
What struck me was the next chapter (1 Kings 19) where Jezebel has been told of the outcome of the duel and the death of the prophets (whom she supported). She vows to kill Elijah. And fresh from his mountaintop experience and aware of God’s power, the prophet.....HIDES after asking God to let him die. He eventually wanders into the mountains and ends up in a cave apparently depressed and hiding.
And here comes the part I liked. God does not ridicule him, demand he have more faith or punish him. God asks him “Elijah, why are you here?” The man complains that all others have been unfaithful and he has tried to do God’s bidding and now he is in danger of his life. God again, does not punish or correct, He tells Elijah to go out of the cave and stand on the mountain so Elijah can be there when God passes by. Elijah does so and observes a great wind that shakes the mountain and shatters rock (and the text says “”But the Lord was not in the wind”. ) Next came an earthquake and then a fire with the same response. Finally, there is a quiet voice of God which says... “Elijah, why are you here?”!
The same question. No other great announcement. Elijah repeats his statements of before and again, God does not chide him. God gives him tasks to do which includes appointing a chosen successor (Elisha). Then God reminds the prophet there are still 7,000 men fiathful to Him during this time of turmoil.
The lessons for me are strong. Right now I am in a place where I am complaining, feeling sorry for myself and being generally depressed. But I don’t feel God’s chiding or ridicule. I hear Him say “why are you here?”
The answer is complex but certainly involves my own decisions and choices through the years. The story teaches me that there is more. God is always in the places where we are, waiting, full of action and hope. He has plans for us that He desires to tell us. He also is aware of our disappointments, our fears, our depression and our...humanness. He does not rebuke us for these but he wants us to move outside of the place where we are so that we can see Him. He can hear our complaints but desires to put us firmly into His plan. He also comforts us with the knowledge that we are never as alone as our emotions would tell us we are. Lastly, He certainly can show us His presence in big and powerful ways but He does not need to do so because the power He places inside us is sufficient as long as we look to Him and obey.
I hope that I can learn this lesson and move out from the cave to hear what He has for me to do.
Abba
Sun/Jun/08 11:48 PM
Today at Sunday School we
were discussing the issue of fear. The question at hand
was “where is God when I fear?” and the myriad
questions that sprout from that point. It is a very
relevant question. Daily in my practice I see people
whose lives are dominated by fears and anxiety. Some
have phobias, some reactions to past traumatic events,
some seem to be unable to leave daily worries alone and
many are ashamed of their fear.
My take on this may be a bit different. I believe God has given us all our emotions. I cannot tell you where fear would fit in before the fall of man but certainly the adrenaline rush and “fight or flight” reaction it can produce is not in and of itself an evil thing. God does not tell us to be ashamed of our fear. He asks us to understand we have reason to boldly face the things that make us anxious through his power.
The passage that caught my attention says that we have not been given a spirit of timidity but of power. We are not slaves but adopted sons and daughters and can call “Abba” or “daddy”. I bet I had read or heard that passage dozens of times but it struck me today that an orphan wandering in the world faced with a fearful situation will likely cry and dispair. A son or daugher yells “DADDY!” fully expecting the rescue, the comfort and the support of the father. The Spirit we are given is His Holly Spirit within us. This certainly is not a spirit of timidity and we can cry out for Abba to come and be with us in our time of deepest anxiety.
My take on this may be a bit different. I believe God has given us all our emotions. I cannot tell you where fear would fit in before the fall of man but certainly the adrenaline rush and “fight or flight” reaction it can produce is not in and of itself an evil thing. God does not tell us to be ashamed of our fear. He asks us to understand we have reason to boldly face the things that make us anxious through his power.
The passage that caught my attention says that we have not been given a spirit of timidity but of power. We are not slaves but adopted sons and daughters and can call “Abba” or “daddy”. I bet I had read or heard that passage dozens of times but it struck me today that an orphan wandering in the world faced with a fearful situation will likely cry and dispair. A son or daugher yells “DADDY!” fully expecting the rescue, the comfort and the support of the father. The Spirit we are given is His Holly Spirit within us. This certainly is not a spirit of timidity and we can cry out for Abba to come and be with us in our time of deepest anxiety.
Are You Confused Yet?
Sun/Jun/08 11:50 PM
This past
week the British Medical Journal (BMJ) published three
very interesting articles related to Type 2 diabetes.
This is the most common type of diabetes seen in the
world and is the one linked with central obesity and
diet. You see, over the past decade there has been a
wealth of new medications including new types of
insulin that have come on the market enhancing our
ability to bring sugars closer to normal in most
patients. Many folks are now on several drugs and may
be on drugs and insulin. They also are monitoring their
sugars multiple times per day to be more aware of their
control.
Much of the reasoning behind the desire to tightly control Type 2 diabetics was extrapolated from research on the other type of diabetes, Type 1 diabetes. In this form the body’s insulin production is impaired, often after a viral or autoimmune or other insult to the pancreas. The result is generally patients who absolutely need insulin to live. What was discovered years ago was that the rate of development of renal failure, blindness and other complications was slowed dramatically by tightly controlling sugars. Since these people needed insulin, you started to see testing with each meal and in between meals to help them decide how much insulin to use. Because of the pain with testing, new meters emerged that required less blood and caused less pain.
It was thought that diabetes was diabetes and if tight control was good for one type then it must be good for another. The results are not so clear cut. Certainly, it is a patient’s best interest to not have remarkably high sugars or wild fluctuations. It is also good for them not to have hypoglycemia and pass out. It’s the rest that is the trouble. Should we shoot for perfect sugars? If so it would require a lot of testing and more medications.
Enter coroprate America who was only too happy to settle the question.....if it gets paid for it should be done. We now have organizations that aggressively market to patients who have diabetes offering to supply their testing materials delivered to their door with no hassle. As a doc I get the “request” from these companies to test. They are only too happy to send out more supplies regularly (even if the old ones are not used up) and to provide reqular upgrades, batteries, reagents and even blood tests normally done at a doctor’s office. All of this is for the patient’s convenience AND to help with their control. And of course now patients are testing so much that they become afraid or ashamed of the results and request more medications to control them “to normal”.
Back to the BMJ. Three articles: the first was looking at whether it was cost effective to detect diabetics or prediabetics so interventions including diet, exercise, education and medication could be initiated: This one was simple....it was cost effective to find the prediabetics and diabetics so we could intervene mostly with non-drug methods. The second and third articles looked at the cost effectiveness and other outcomes of having patients monitor aggressively their sugars at home rather than seeing a doctor episodically and having adjustments to medications made at that time. (You seen in Great Britain they have BUDGETS for their health care and they want to know if they are spending the money wisely or not).
What they found was that aggressive monitoring by the patient was NOT cost effective, DID NOT result in better control but DID result in a LOWER QUALITY OF LIFE ASSESSMENT SCORE and HIGHER scores for depression!
Their editors questioned the value of aggressive home testing for the majority of Type 2 Diabetic patients and rightfully so. Makes you wonder why we are pushing so hard.
Much of the reasoning behind the desire to tightly control Type 2 diabetics was extrapolated from research on the other type of diabetes, Type 1 diabetes. In this form the body’s insulin production is impaired, often after a viral or autoimmune or other insult to the pancreas. The result is generally patients who absolutely need insulin to live. What was discovered years ago was that the rate of development of renal failure, blindness and other complications was slowed dramatically by tightly controlling sugars. Since these people needed insulin, you started to see testing with each meal and in between meals to help them decide how much insulin to use. Because of the pain with testing, new meters emerged that required less blood and caused less pain.
It was thought that diabetes was diabetes and if tight control was good for one type then it must be good for another. The results are not so clear cut. Certainly, it is a patient’s best interest to not have remarkably high sugars or wild fluctuations. It is also good for them not to have hypoglycemia and pass out. It’s the rest that is the trouble. Should we shoot for perfect sugars? If so it would require a lot of testing and more medications.
Enter coroprate America who was only too happy to settle the question.....if it gets paid for it should be done. We now have organizations that aggressively market to patients who have diabetes offering to supply their testing materials delivered to their door with no hassle. As a doc I get the “request” from these companies to test. They are only too happy to send out more supplies regularly (even if the old ones are not used up) and to provide reqular upgrades, batteries, reagents and even blood tests normally done at a doctor’s office. All of this is for the patient’s convenience AND to help with their control. And of course now patients are testing so much that they become afraid or ashamed of the results and request more medications to control them “to normal”.
Back to the BMJ. Three articles: the first was looking at whether it was cost effective to detect diabetics or prediabetics so interventions including diet, exercise, education and medication could be initiated: This one was simple....it was cost effective to find the prediabetics and diabetics so we could intervene mostly with non-drug methods. The second and third articles looked at the cost effectiveness and other outcomes of having patients monitor aggressively their sugars at home rather than seeing a doctor episodically and having adjustments to medications made at that time. (You seen in Great Britain they have BUDGETS for their health care and they want to know if they are spending the money wisely or not).
What they found was that aggressive monitoring by the patient was NOT cost effective, DID NOT result in better control but DID result in a LOWER QUALITY OF LIFE ASSESSMENT SCORE and HIGHER scores for depression!
Their editors questioned the value of aggressive home testing for the majority of Type 2 Diabetic patients and rightfully so. Makes you wonder why we are pushing so hard.