Factors in Managing Your Blood Glucose – Part 2

This is a continuation of the previous blog.

Activity:

Light activity - Light activity can have a surprising glucose-lowering effect. Walking could be considered light exercise.

High-intensity and moderate exercise - Please read my blog on safe blood glucose levels for exercising. Also talk with your doctor before beginning exercise that fits in this category.

Exercise is often described as something that always lowers blood glucose; however, high-intensity exercise, such as sprinting or weight lifting, can sometimes raise blood glucose. This stems from the adrenaline response, which tells the body to release stored glucose. But this is not a reason to avoid high intensity exercise – studies show it can improve blood glucose for one to three days post-exercise! Please note that in some cases high-intensity exercise can also drop blood glucose very rapidly (2-3 mg/dl per minute), especially if you are taking insulin. This also happens to many people on oral medications until they have been exercising for a couple of weeks or longer. The best way to see how individual exercise sessions affect your blood glucose is to test prior and after exercise.

Biological:

Dawn phenomenon - The “dawn phenomenon” normally occurs in people with type 2 diabetes. The term refers to the body’s daily production of hormones around wake up time. During this time, the body makes less insulin and produces more glucagon, which raises blood glucose. The best way to figure out how dawn phenomenon affects you is to wear a CGM or wake up and test your blood glucose early in the morning. Not everyone experiences dawn phenomenon, but it is common for about 50 percent of type 2 patients on oral medications,

Scar tissue and lipodystrophy – If you are taking oral medications only, this will not affect you. Using the same sites on the body for injections sights can lead to lipodystrophy and scar tissue buildup. These result in erratic absorption of insulin, leading to glycemic variability and making it harder to spend more time in range. To avoid these issues, rotate your injection sites and don't reuse needles.

Insufficient Sleep - In my experience, I have found that I need more insulin on days following less than seven hours of sleep. The highest blood glucose of the day is even higher on days following little sleep. These findings are consistent with many studies, which have found that not getting enough sleep leads to worse diabetes management, insulin resistance, weight gain, and increased food intake.

Stress and illness - Stress and illness can cause the body to release epinephrine (adrenaline), glucagon, growth hormone, and cortisol. As a result, more glucose is released from the liver (glucagon, adrenaline) and the body can become less sensitive to insulin (growth hormone, cortisol). In some cases, people are much more insulin sensitive right before getting sick and can tend to run low blood sugars.

Allergies – Research did not yield any results and apparently is not worthy of study. I do have one friend that suffers from ragweed allergy and has problems with his blood glucose levels during ragweed pollen season.

A higher glucose level (“glucotoxicity”) - Hyperglycemia can lead to a state known as “glucotoxicity,” which can actually cause insulin resistance. People going on insulin after being on oral medications can experience this and spend a few days up to two weeks adjusting insulin to bring this under management.

Periods (Menstruation) - There is not an easy answer to the question of how periods affect women’s blood sugars. Many women report having higher blood sugar levels a few days prior to their period starting, but some women notice a sharp drop in sugar levels. To figure out how you respond, your best bet is to test your blood glucose often during this time of month.

Smoking - Some studies suggest that smoking can increase insulin resistance, and people with diabetes who smoke are more likely than nonsmokers to have trouble with insulin dosing and managing their diabetes. Smokers also have higher risks for serious complications.

Environmental:

Medication or insulin that has gone bad – Some people stop taking oral medications and when they need to restart, use the old medications, and get little or no help. Others ruin their insulin by exposing it to direct sunlight or leaving it in the car on a hot day. The worst part is that it’s hard to know if it has actually gone bad unless you try a new vial. In addition, the insulin may work unpredictably. Unopened insulin should be stored in a refrigerator at approximately 36-46 °F. According to the FDA, insulin can be left unrefrigerated at a temperature from 59-86 °F for up to 28 days.

An accurate blood glucose reading - While this seems fairly obvious, I occasionally find myself testing multiple times in a row, since I do not believe the initial value. In some cases, the second time I get a much lower value, and it’s because I failed to wash my hands. I suggest retesting if you don’t believe the value on the meter.

Altitude – People on oral medications generally notice little difference with being at higher or even lower altitude. People using insulin need to be careful as insulin resistance can increase insulin needs. Others that are climbing or skiing may need less insulin. Testing more frequently may be a necessity.

To the above and the previous blog, I would be remiss if I did not mention attitude. A positive attitude makes diabetes management easier and helps make diabetes burnout and mild depression easier to conquer. Then add developing good habits that become part of a daily routine and burnout seldom happens.

Another blog about the reasons for variability of blood glucose levels is this one.  There are overlaps with the ideas included in the blog from yesterday and this blog of today.

Factors in Managing Your Blood Glucose – Part 1

This was somewhat surprising and made me realize how different each person can be when it comes to factors that affect the management of blood glucose. This is also why I become frustrated by the medical and non-medical professionals that use a one-size-fits-all approach in the advice they give to us. I have even had doctors not want to change a medication when I tell them that a medication is causing a particular side effect.

I am also upset by those that say there are only three things necessary to manage your blood glucose – diet, exercise, and medications. Oh, if only it were that simple. It is more complex than that by a country mile. With a couple of months short of 12 years with diabetes, I know that other factors can override the best of management skills. Even keeping a positive attitude gets tested severely at times. I have learned that blaming myself does not solve the problem and at first I occasionally let this happen.  I have rounded up seven categories that can have an influence on our blood glucose levels. They are human factors, biological factors, environmental factors, food/fluids, medication(s), activity, and health. Some writers only consider five and ignore human and health factors.  There are probably more that I have missed.

Human Factors:

Procrastination – okay, I realize some people don't like this, but I have seen this done and do it myself. I get to researching and writing, and it is time to test my blood glucose and I say to myself – in a bit, and then it is an hour later. I have seen other type 2's on insulin in a restaurant and instead of injecting the insulin before the meal; they wait until after the meal. Own up and admit that you have done something similar. Blood glucose can go high when you procrastinate.

Forgetfulness - We can forget and it is easy. Have unexpected visitors and they stayed longer than normal and you are tired and want to go to bed. What happens? You forget to take your before bed medication(s). None of us intends to do this, but life happens. Again, blood glucose can go high when you forget a medication.

Cognitive abilities -  As people age, cognitive abilities can decrease causing blood glucose levels to go high or low.  These people need help and careful management by caregivers and doctors.

Health Factors:

Hospitalization – This can create all types of blood glucose problems. Hospital food can be notoriously high in carbohydrates, especially the meals for diabetics. Then add to this the reason you are in the hospital. Operations can become bothersome and create high blood glucose levels.

Other diseases – Other comorbid conditions can also affect blood glucose levels at different times. It is wise to discuss this with your doctor to learn if other medications for them can cause higher blood glucose levels. Also consider a talk with the pharmacist if one doctor does not communicate with another doctor and you are not sure if he checks your medication list.

Food/Fluids:

Carbohydrates - Carbohydrates affect blood glucose the most. Accurately counting carbohydrates can be very difficult, and getting the number wrong can dramatically affect blood glucose. The type of carbohydrate also matters – higher glycemic index carbohydrates tend to spike blood glucose more rapidly. Lowering the amount of carbohydrates consumed is often to wisest choice.

Fat - Fatty foods tend to make people with diabetes feel full sooner and curb the desire for carbohydrates. A medium to high fat meal plan with low carbohydrates will generally assist in helping you lose weight.

Protein - If you’ve ever eaten a protein-only meal with very few carbs (e.g., salad with chicken), you may have seen a noticeable rise in blood glucose (20-50 mg/dl). Though protein typically has little effect on blood glucose, in the absence of insulin, it can raise blood glucose. When I am eating a carbohydrate-free, protein-only meal, I still take a bit of insulin to cover it. This can raise blood glucose or have a neutral effect depending on your system and body chemistry.

Caffeine - Many studies have suggested that caffeine increases insulin resistance and stimulates the release of adrenaline. I know that if I have any caffeine in the morning, I’ll see at least a 20-30 mg/dl rise in blood glucose, particularly when I’m more insulin resistant.

Alcohol - Normally, the liver releases glucose to maintain blood glucose levels. But when alcohol is consumed, the liver is busy breaking the alcohol down, and it reduces its output of glucose into the bloodstream. This can lead to a drop in blood glucose levels if the alcohol was consumed on an empty stomach. However, alcoholic drinks with carbohydrate-rich mixers (e.g., orange juice) can also raise blood glucose. When drinking alcohol, make sure you test your blood glucose often and that someone responsible nearby knows you have diabetes.

I include this because many people just have to have their alcohol. Another good precaution would be having a designated driver to avoid legal problems.

Medication(s):

Medication dose - For those of us with diabetes on any medication (pills or insulin injections), the dose of medication directly impacts blood glucose. In most cases, but not always, taking a higher dose of a diabetes medication means a greater blood glucose-lowering effect. Care needs to be taken to avoid stacking if possible.

Medication timing - In addition to dose, medication timing can also be critical. For instance, taking rapid-acting insulin (Humalog, Novolog, Apidra, and Afrezza) 20 minutes before a meal is ideal for me - it leads to a lower spike in glucose vs. taking it at the start of the meal or after the meal has concluded. Note that this works best for me, although this can vary among individuals – please consult your doctor to discuss the optimal timing of insulin. The timing of many type 2 diabetes medications matters a lot – some can consistently be taken at any time of day (e.g., Januvia, Victoza), while others are most recommended taken with meals (e.g., metformin).

Medication interactions - Non-diabetes medications can interfere with your diabetes medications and blood glucose. Consult the information included in both your diabetes and non-diabetes medications. If your doctor does not give you information, have a talk with your pharmacist.

Continued in tomorrow's blog.

Patient Mentors Are Important

Over the last few weeks, I have been doing more research about what patients with type 2 diabetes can do to improve their care and learn at the same time. Since the Certified Diabetes Educators (CDEs) are doing battle between the two organizations and haven't enough trained professionals to meet the need of people with type 2 diabetes to say nothing about those with pre-diabetes, this blog drew my interest.

What this medical student says makes a lot of sense. I am aware of some doctors in the more rural states doing peer diabetes mentor training and some peer-to-peer diabetes workers. In correspondence with one doctor, he is being pressured by a CDE member of the ACDE not to train peer diabetes mentors. He asked the CDE if she would be available to work with the 30 plus type 2 diabetes patients he sees. She said she would not and she already had a full caseload of patients.

If members of the Academy of Certified Diabetes Educators are going to work against doctors trying to improve education for people with type 2 diabetes, then we don't need them and their hoity-toity attitudes. Most CDEs do not have type 2 diabetes, do not properly assess those of us with type 2 diabetes, use a one-size-fits-all education, avoid dealing with anyone talking about depression, and in general do not want to deal with the round pegs that don't fit in the square holes they want to put us in.

Heather Alva writes that she was advised to find herself a mentor for medical practice and she says why not take this idea farther. While this medical student is a person with type 1 diabetes, her thoughts do work well for those of us with type 2 diabetes. I will list a few of her points.

#1. Introducing patients to a person who has controlled their blood glucose and managed a healthy and fulfilling life is a far more powerful motivator than fear alone.

#2. As our population ages and more of our patients have an online presence, these online patient networks may become an increasingly valuable resource.

#3. Consider the positive impact of asking if our chronic disease patients are networking with other patients and of knowing good resources to which we can direct them.

#4. Perhaps it is a kinder practice to link our patients to other patients who are successful individuals who lead rich, happy, fulfilling lives, who have been enriched and deepened by life’s challenges, medical or otherwise.

She covers other points and I suggest reading her blog

What Is Unmanaged Diabetes?

When reading this blog, some very definite thoughts came to mind. I do like the topic,

but I become nervous with the wording. I would like to be a little more definitive and clear a couple of points.

The American Diabetes Association (ADA) does use the HbA1c measurement of 7.0% for their guidelines. At least the American Association of Clinical Endocrinologists (AACE) uses the guideline of 6.5%. For those that are very capable of managing type 2 diabetes, many like to keep their A1c's in the 5% range. Others feel great if they can maintain A1c's in the 6% range.

Because doctors and endocrinologists are so fearful of patients having episodes of hypoglycemia, or low blood glucose they become very cautious of anything below the guidelines. Then, when we consider people aging, again they become even more cautious about peoples' A1c. At age 65, they start encouraging A1c's of 7.0 to 7.5%. Then at the age of 70, they want the range to increase to 8.0%.

This is where I disagree with their one-size-fits-all philosophy. I could agree if they were properly assessing us and individualizing our treatment. Some people are able to manage diabetes and maintain lower A1c's. Some lose diabetes management abilities as they age and this must be properly assessed and adjusted to maintain quality of life. Hopefully as they become less capable of managing their own diabetes, there will family or other caregivers available. They will lose quality of life when incarcerated in nursing homes or care facilities.

So what is unmanaged diabetes? Following the above discussion, there are many variables depending age and patient capability. My suggestions would be that for people on oral medications and below the age of 65, then unless they are on medications or a combination of medications that can cause hypoglycemia, the daily blood glucose readings should be used to see how often they get below 70 mg/dl. If they consistently show readings below 60 mg/dl then they need to be assessed to see if they are capable of managing their own diabetes.

This assessment needs to be continued as patients continue to age. Even more careful assessments will be needed if the patient is on insulin. Warning: Insulin should never be the medication of last resort. This is the habit of too many doctors and can lead to complications setting in before insulin is used.

Pardon Me, I Have to Release Some Pressure

No, this is not gas I need to vent, it is just a few things I need to vent to relieve the build up of frustration, and I don't want to become angry, as that solves nothing. Blood glucose levels are difficult as it is to manage when anger isn't in the mix.

In the last few weeks, emails have been coming in at a good number, but I am surprised at the number asking why I don't blog about the cure and even more about natural remedies. Let me be very clear readers, as of yet there is no cure – read that – there is NO cure!

Yes, I know there are people on the internet claiming there is, but they did not have diabetes in the first place. Then they claim to be cured so that they can separate you from your money. They sound very convincing, but are part of the low-life that preys on people to make their life easier because they do not want to work for a living to earn money. They know there are suckers that will easily part with money for false information.

I could write many blogs about natural remedies, but people would not understand that diabetes does not go away and natural remedies only help in the short-term and once what the body needs is replenished, seldom will there be more benefits. Why, you ask? Most people want the quick fix so they can continue living life and consuming the same foods. They are unwilling to change the way of living they are accustomed to and to use exercise and nutrition changes necessary to stop diabetes from gaining a strong foothold in their lives. They are very comfortable living the current lifestyle and refuse to change.

I do blog about two of the natural remedies, exercise and proper meal plans, but most will not use these because it requires some effort which they are unwilling to put forth. I personally know two individuals with type 2 diabetes that go from natural healer to natural healer looking for the help they want.

One just had two toes amputated and still believes in natural medicine. Allen and I have both asked what his last A1c was, but he says he doesn't go to that doctor anymore. The other fellow is now legally blind and very upset that the doctor did not tell him that was possible. Allen said his last A1c was 12.3. He still is looking for a natural remedy. Neither will fill their prescriptions for diabetes medications and tell us we should not be taking insulin.

It is difficult just being around the two individuals, as they believe there is a cure that the doctors are not telling them about and the one that is blind has filed a lawsuit to have the doctor disclose the cure. Is he in for a shock!

More Myths about Type 2 Diabetes

I admit I have a difficult time following some people and where they come up with some of the ideas about diabetes. Fortunately, those in our support group know better and even we get tired of some of these ideas. A few will listen to us, but others have some of these ideas buried in their psyche and nothing we say can change their mind.

Myth 1 Obesity and laziness cause diabetes. Being obese and not exercising can be risk factors for type 2 diabetes, but they are not the cause of diabetes. Most people forget about genetic factors and heredity of type 2 being in some families. Even thin people develop type 2 diabetes, but many people conveniently forget about this. In type 2 diabetes, the body can no longer make or use insulin properly.

Myth 2 You won’t always have diabetes; your doctor can cure it. This is a belief that is hard to beat back. We are told that this is the twenty-first century and there has to be a cure. Another statement many make is that your doctor is not telling you everything and holding back the cure so there is something to treat. All I can say is BS, and I don't mean blood sugar.

Type 2 diabetes is incurable; once you have it, you will always have it. However, you can keep your diabetes under tight management with diet, exercise, and medications so that you can live an otherwise normal life with minimum damage.

Myth 3 You can’t prevent diabetes. Eating a healthful meal plan and getting daily physical activity can prevent almost 80 percent of Type 2 diabetes cases. Keeping weight in the ideal range will also help.

Myth 4 You can feel when your blood glucose is too high or low. There is no guarantee that what you are feeling is accurate. Some people are irritable during elevated blood glucose and after a recent type 2 diagnosis, many can experience shaky, dizzy, or lightheaded when blood glucose drops rapidly. Other experiences can be an increase in urinating when blood glucose is elevated, but this could indicate a bladder infection. Testing is the only way to be sure if your blood glucose is high or low. Do not trust your feelings.

Myth 5 When you have diabetes, you can’t eat sweets. This is partly true and most people don't need them. Many people think that if you eliminate other carbohydrates they can have sweets, but they don't realize that most sweets have more carbohydrates than they have allowed. Others say that they are doing extra exercise to make eating sweets possible, but again they eat more than the exercise relieved. Many people overeat sweets when their blood glucose levels drop below 70 mg/dl. Generally, they would be smarter eating glucose tablets of known glucose amounts rather than sweets which might not be known. Then they wonder why they go high and often yo-yo up and down, especially on certain oral medications and insulin.

Myth 6 If you eat right and exercise, monitor your blood glucose, and take your meds or insulin correctly, you can keep your diabetes under tight management.

Oh, if it was that easy! However, there are other factors that affect your management. Illness, injuries, stress, hormone changes, and periods of aging that can cause blood glucose to become unmanageable. Even when you do everything correct, managing diabetes isn't always easy and corrections are needed. Many people do not believe this and diabetes becomes progressive and the complications flourish.

Myth 7 Diabetes only affects old people. Diabetes affects all age groups and the sooner people wake up to this, the better prevention can become.

Myth 8 Diabetes is not a killer disease. Diabetes is a global killer, rivaling HIV/AIDS in its deadly reach. The disease kills more than 4 million people a year. Every 7 seconds a person dies from diabetes-related causes.

Myth 9 Diabetes only affects rich countries. Diabetes affects all populations, regardless of income. It is becoming increasingly common everywhere.

There are many other myths and misconceptions, but I will halt this for now. This blog and thisarticle are sources used.

Do You Know This About Diabetes?

Many of the people I correspond with and those members of the support group I belong to know most of this information and many other points. Yet, many people are not familiar with some of this information while others ignore any information about diabetes until it is too late.

Most of the following can be found in reading this.

#1. About one quarter of people with diabetes, don’t know they have it. This is unfortunately true and approximately seven million people have no idea they have diabetes. I would urge people that think they have risk factors and relatives with diabetes to be checked regularly at their doctor's office.

#2. You can reduce your risk of developing type 2 diabetes by losing a moderate amount of weight. If you are overweight, consider losing about 10 percent of your body weight. Exercise is one lifestyle change that is not easy, but losing a few pounds by walking, swimming, or dancing almost every day can help in preventing diabetes. If you have risks, talk to your doctor and make sure he understands you are sincere in your desire to prevent diabetes.

#3. Insulin isn’t just for people with Type 1 diabetes. Right, approximately 30 to 40 percent of people with type 2 diabetes are using insulin. If you are moving from oral medications to insulin, this does not mean you have failed. Fact is, the sooner you start insulin, the better you will be able to manage your diabetes. A popular myth is that starting insulin means you are near to going blind or about to lose a foot. Doctors promote this because they don't know insulin and are afraid of hypoglycemia.

Insulin is the most effective treatment for diabetes and if you keep an open mind, you should be better able to manage your diabetes. If your doctor will not prescribe insulin or says you are failing on oral medications, then it is time to change doctors.

#4. Diabetes is a leading cause of blindness in American adults. I wish this wasn't true for so many people. This happens because people with diabetes do not have a dilated eye exam every year or as often as your eye doctor recommends. It is not recommended to use the eye clinic at your local mall or retail store. If you have retinopathy or diabetic macular edema, there are effective treatments to prevent it from becoming worse.

#5. Bariatric (weight-loss) surgery is a highly effective treatment for Type 2 diabetes. I am not encouraged by this and have a difficult time even including this as there is so much they fail to tell you. Once you have the surgery, you have to eat such small amounts of food that many people cannot do this. When people are unable to lose weight and all others attempts have failed, bariatric surgery is certainly an option. There are definitely risks to this surgery and people with type 2 diabetes can only expect a remission for an undetermined amount of time and not a cure of their diabetes.

#6. An “artificial” pancreas should soon be available to help people with Type 1 diabetes more easily manage their condition. For people with type 2 diabetes, this is probably one device that will not be available to you. And if you are on Medicare, don't expect to receive one of these tools that type 1's will receive until they turn 65.

#7. Medical providers and the related professions advocate a 'one-size-fits-all' way of treatment. The harried doctors of today do not have time to individualize treatment and if something does not fit their thoughts, you will be told 'it is all in your head', or you will be referred to another doctor. Doctors are so afraid of hypoglycemia that they will accuse you of failing and threaten you with insulin to keep you on oral medications. These doctors are wrong in so many ways that you should be afraid of them. Insulin should never be a medication of last resort for excellent diabetes management.

I could really use a rant, but I will end this here before I say something I will regret later.