Glycemic Diabetes Management

The American Association of Diabetes Educators has completed their annual meeting. It is not a surprise that most of the topics were about and for those with type 1 diabetes. After the ADA and the joint statement about education for all people with diabetes, I expected more topics for type 2 diabetes, but this did not happen. Yes, they can say that this topic was for all people with diabetes as they did include insulin and about 20 percent of people with type 2 diabetes do use insulin.

While educating hospital staffs about hyperglycemia is important, unless there is education about the use of oral medications, many with type 2 diabetes will continue be left out in the cold and receive little help when hospitalized.

This statement by the speaker Jane Jeffrie Seley, BC-ADM, CDE, CDTC, of New York-Presbyterian/Weill Cornell Medical Center leaves me wondering. “Inpatient glycemic management is best accomplished through interdisciplinary collaboration with physicians, NPs, PAs, RNs, RDs, diabetes educators and pharmacists. Errors can be greatly reduced by implementing system changes that make it easier to do the right thing. One example is auto-calculating the basal insulin dose based on weight and expected sensitivity to insulin instead of requiring prescribers to do the math.”

Best practices for improving inpatient glycemic control have been identified. There are many barriers to implementing them, Seley said. The biggest obstacle to coordinating and implementing successful strategies is the need for ongoing staff education. Successful strategies also involve policy changes, infrastructure adaptations and culture change. None of these will be effective until the hospital administrators and the hospital board of directors adopt them and make this known to those at all levels.

Many institutions across the United States have successfully launched glycemic control programs to improve inpatient insulin safety. One approach that appears to be highly effective is computerized order sets. This approach auto-populates the most recent weight gain into a dosing algorithm that gives a safe yet effective recommendation. This weight-based dosing can significantly reduce insulin dosing errors. Basal and bolus insulins are also listed in separate sections to avoid mixing up insulin types.

“Electronic medical record systems (EMRs) such as Sunrise and Epic have the capability to develop comprehensive insulin order sets and decision support tools such as a medical logic memory to remind prescribers to order basal insulin when a patient with type 1 diabetes is switched from prandial insulin to NPO status,” Seley told Endocrinology Advisor.

Currently, many hospitals still do not have comprehensive diabetes management programs in place. By having the AADE emphasize everything for type 1 diabetes patients, those patients with type 2 diabetes will continue to take a back seat in hospital diabetes management.

This means that type 2 diabetes patients will continue to need to champion their own cause and they will need to work harder to get what they need in diabetes management when they are in the hospital.

The other problem facing those with type 2 diabetes will be using insulin when they are in the hospital as most hospitals convert every patient to insulin use when they are an inpatient in the hospital. When it comes to food plans, type 2 patients will need to avoid asking for diabetes menus because the dietitians will overload the meals with carbohydrates instead of serving a meal that could be lower in carbohydrates.

Tips to Manage Blood Glucose on Insulin

Do you use insulin to manage your diabetes? How do I occasionally manage swings in my blood glucose levels? What can I do if my high blood glucose levels won't go down while using insulin? These are common questions I receive in emails.

First, I have to ask some questions. I ask if they have had classes given by a CDE/RD. What did they tell you about the food plan you should follow? I also ask if they need to lose weight that they have recently gained. This generally elicits the following answers – yes, they have had classes and they were advised to consume whole grains and eat between 45 and 70 grams of carbohydrates per meal. Many tell me they were overweight to start, are gaining more weight on insulin, and have not been able to lose any weight.

These answers tell me there are changes that need to be recommended. I always emphasize that diabetes is not their fault and ask if they are open to changing their food plan. I suggest that they avoid the whole grains and lower the amount of carbohydrates they consume. I suggest that they consider eating no more than 80 grams of carbohydrates per day and preferably only 60 grams with 20 grams for each meal.

I do tell people that for about two to three weeks, they may feel hungry, but after three weeks, this will often not be the case. This will vary by individual, some people can be hungry for two weeks, and some will take four weeks.

I do tell people that Dr. Bernstein recommends a lower carbohydrate food plan of 6-12-12, meaning six grams for breakfast, 12 grams for lunch, and 12 grams for dinner. I suggest that if they want to do this that they start out by lowering the number of carbohydrates over a period of about four weeks.

I warn these people to reduce the amount of insulin used as they reduce their carbohydrates. I do suggest that they immediately talk with their doctor about how fast they should reduce the amount of insulin, both basal (long acting) and rapid acting. I tell them that they want to do this to avoid hypoglycemia (lows).

I also warn then to be prepared to further reduce their insulin as their weight decreases, as insulin resistance can ease as well. I warn them that the doctor may want to take them off insulin and they should decide what they want.

If they are using oral medications, I give them the same advice and tell them that the amount of medication may need to be reduced and especially if they are taking a sulfonylurea.

I emphasize these three items, exercise, following a lower carb meal plan, and easing stress. I also tell them that if they cannot find a nutritionist that they trust, I will suggest one. Yes, I inform them that the person is a relative, but that they should find one that they trust and is not pushing carbohydrates. Find one that wants to work with them and balance the nutrition for a day, a week, and give them something to work with for the daily living.

Finally, I suggest that if anyone is pushing carbohydrates, they need to be careful and stay away from them. I tell them that it is not healthy to increase carbohydrates and expect to cover them with increased medication (oral or insulin). This will cause weight gain that will be difficult to lose. I do advise these people to stay away from low carb/low fat plans as this often causes weight gain, as the carbs are often not low.

Planning a Second October Meeting

This is becoming a very active October. Everyone seems to be worried about the newest members. They have been calling with many questions and are concerned about what they are being told by professionals with dual titles, CDEs and RDs. Both Tim and I have been in contact with Suzanne to schedule another meeting. She is busy and is not sure when she will have time. She suggested that maybe we should have Brenda's daughter talk to us.

Tim finally agreed and talked with Brenda and her daughter. She said she would do a presentation, but it would need to be on a Wednesday evening. Emails happened rapidly and all the newest members could meet on a Wednesday. A few of the rest had conflicts, but said to go ahead for helping the newest members.

Therefore, we are having a second meeting on October 21. Allison, Brenda's daughter, will talk about nutrition and how people can lower the number of carbohydrates they consume for improved blood glucose management.

Then another flurry of emails as Allison needed some information to help make the presentation relevant for the most people. When those that needed to answer had replied, Allison said that most everyone had the same interest and she would need to be prepared for low carb/high fat discussion and many of the questions were about acceptable fats. She put out a call for studies and discussions about high fat that she may not have seen.

The next day Allison asked us to stop. She said that most of us read the same articles and blogs and she felt that some were excellent, but for now, we could stop, as she understood what we were telling her. She also agreed with us about the high fat part and not the low fat that RDs insisted on teaching.

Allen and I asked to meet with Tim. We thanked him for getting Allison to talk to us. Then Allen told Tim that anytime we accepted new members, as we did in September, we needed to schedule Suzanne or Allison, and if Beverly had time, she should do something on education. I added this should be automatic because we always get questions and we need to prepare the new members for what they may encounter or have heard.

Tim said that he had thought about this, but thought we could have taught them. Allen said that we could have, but it sounds better coming from someone trained to teach and gives us easy reference for more authority. I said that even some of the members from the group Jerry brought in still have questions and it does not hurt to reinforce this. Allen did ask if we should consider dues to help pay for speakers. I stated we have avoid this so far, but we should talk to my cousins and listen to them. The only group that has dues is the group led by Greg and his wife.

Tim said I was right, but investigating this might be good for us. Then Tim thanked us for reminding him to have the lessons when we bring several new members into the group. He said that he had forgotten what happened to the group Jerry brought in and now the 14 members. Then he suggested we talk about bringing new members in during one month. Allen agreed, but said we also needed to consider limiting new members. I said we needed to discuss this at a meeting. Tim agreed and said he was thinking about this as well.

Even Doctors Complain about Polypharmacy

I suggest that you read this blog by Val Jones, MD. She tells the story of polypharmacy better than I can. The points she raises include:

• Patients are notorious for non-adherence
• Policy wonks say that more than half of patients do not take their medications as directed
• Missed opportunities to control chronic illnesses cost us billions of dollars and millions of quality life years annually

The reverse is just as serious:

• The costs of polypharmacy (over medication) is not known or discussed
• The unwanted side effects and medication interactions (both known and unknown) can be devastating
• An astonishing number of these incidents (falls and injury accidents) are related to drug side effects

Important factors to consider:

• There are costs to not taking medicines
• There are costs to taking medicines
• It is unknown how many injuries are accidentally prevented by patient non-adherence

This doctor considers it a victory each time she reduces the number of medications her patients use. What I like about this is she is not a geriatrician, but thinks like one. You should read her blogs on her website here.

HbA1c Test Important for Diabetes

The hemoglobin A1c test, also called HbA1c, glycated hemoglobin test, or glycohemoglobin, is an important blood test that shows how well your diabetes is being managed, or not being managed. Hemoglobin A1c provides an average of your blood glucose management over the past 4 months and is used along with home blood glucose monitoring to make adjustments in your diabetes medicines.

The past four months means the prior 120 days. Fifty percent of the prior 30 days is used for the A1c. Day 31 to 60 accounts for 25 percent and day 61 to 120 accounts for the remaining 25 percent of the A1c.

The A1c is important; however, many doctors only use the A1c and do not look at the records he asked you to keep. Some doctors even go one step further and do not suggest daily blood glucose testing. They follow the advice of Dr. Robert Ratner, chief scientific and medical officer of the American Diabetes Association, who says, “Many people with type 2 diabetes who are on medications don't need to do home glucose monitoring at all," in talking about oral medications.

Hemoglobin is found in red blood cells, which carry oxygen throughout your body. When your diabetes is not managed (meaning that your blood glucose level is too high), glucose builds up in your blood and combines with your hemoglobin, becoming "glycated." The average amount of glucose in your blood can be found by measuring your hemoglobin A1c level. If your glucose levels have been high over recent weeks, your hemoglobin A1c test will be higher.

For people without diabetes, the normal range for the hemoglobin A1c test is between 4% and 5.6%. Hemoglobin A1c levels between 5.7% and 6.4% indicate increased risk of diabetes (pre-diabetes range), and levels of 6.5% or higher indicate diabetes.

Because studies have repeatedly shown that poor diabetes management results in complications from the disease, the goal for people with diabetes is a hemoglobin A1c less than 6.5% (equals 140 mg/dl). The higher the hemoglobin A1c, the higher the risks of developing complications related to diabetes.

People with diabetes should have this test every 3 months to determine whether their blood sugars have reached the target level of control. Those who have their diabetes under good control may be able to wait longer between the blood tests, but experts recommend checking at least 2 times a year.

People with diseases affecting hemoglobin, such as anemia, may get abnormal results with this test. Other abnormalities that can affect the results of the hemoglobin A1c include supplements such as vitamins C and E and high cholesterol levels. Kidney disease and liver disease may also affect the result of the hemoglobin A1c test. A blood transfusion can also cause an unreliable A1c.

Grip Strength Measures Undiagnosed Diabetes

Whether you grasp it right away or not, your grip strength may indicate whether or not you have undetected diabetes and high blood pressure, University of Florida (UF) researchers say. I can say this is interesting for several reasons. I thought my age had something to do with my losing strength in my hands. Apparently, even those of us with diabetes loose some grip strength.

Grip strength is something many people don’t think about. Does it really matter whether or not you have a firm handshake? While that may be up for debate, researchers have found a link between how strong your grip is and your chances of developing diabetes.

Grip strength measures could be useful for identifying diabetes and high blood pressure in adults who have healthy weight obesity, also known as normal weight obesity or "skinny fat." The condition is characterized as having a body mass index within the normal range, but a high proportion of fat to lean muscle, typically more than 25 percent body fat in males and 35 percent in females. These individuals may be less likely to get regular screenings for diabetes and hypertension because they aren't considered overweight or obese by BMI measures alone, said Arch G. Mainous III, Ph.D., the study's lead investigator and chairman of the department of health services research, management and policy in the University of Florida (UF) College of Public Health and Health Professions, part of UF Health.

"We've had a significant amount of interest and focus on obesity, and rightfully so," said Mainous, the Florida Blue endowed chair of health administration. "But there is a concern that health problems in people who have decreased muscle mass, but don't fit the criteria of being overweight, are being missed because these people aren't targeted by screening programs."

People with healthy weight obesity are four times more likely than people with lower body fat to develop metabolic syndrome, which includes increased blood pressure, high blood glucose and abnormal cholesterol levels, according to a study by Mayo Clinic researchers. As many as 30 million Americans have healthy weight obesity and many don't know it.

For the UF study, researchers analyzed data from the 2011-2012 National Health and Nutrition Examination Survey, a nationally representative study that uses a combination of interviews and physical examinations. The team assessed grip strength measurements, blood pressure readings and blood glucose levels for nearly 1,500 adults age 20 and older that had a BMI within the healthy weight range—18.5 to 24.9. People with undiagnosed and diagnosed high blood pressure and diabetes had weaker grip strength than other healthy weight individuals who did not have those conditions.

"In our study, grip strength was able to identify people with undiagnosed hypertension and diabetes relatively easily, even after we adjusted the analyses for age, sex and whether or not they had a family history of disease," Mainous said.

The reason for decreased muscle strength in healthy weight individuals with high blood pressure and diabetes isn't well understood, but it could be caused by lower muscle quality or a condition called "diabetic hand syndrome," which limits finger movement.

“Because most patients visiting the doctor have their blood pressure tested, grip strength may be most valuable as a non-invasive, low-cost tool for identifying people who could possibly have diabetes. But more research is needed before it can be put into practice as a screening tool, including investigating how variables such as gender, age and height might affect grip strength levels,” Mainous said.

"We still have a ways to go before we can actually implement grip strength testing and make it clinically useful to a primary care physician, but I think this a good first step toward determining who might need further testing, particularly among this group of people who would otherwise not be recommended for screening," he said.

In Dealing with CDEs and RDs, Are You Confused?

You very easily could be. With so many having dual titles, they often switch from one profession to another without saying anything. If you have an appointment for diabetes education, it will start out as education, but somewhere in the education, they switch to telling you what to eat and you are in areas that a dietitian should be covering.

I haven't had this happen to me, but several of our new members have been asking questions about how to handle this when it happens. I thanked Jake for how he handled the situation. When diabetes education became about food and the number of carbohydrates, Jake told the instructor that he was there for diabetes education and not what a dietitian was to be teaching in a class he would be attending the following week.

Jake told me that he hadn't raised his voice and thought he was polite, but the CDE/RD turned on him and told him that she was qualified to teach both and would teach both. Jake said that this was only about 15 minutes into the session, but he decided it was time to leave. Once he was out of sight of the building, he called the insurance company and informed them about what had happened and said it was more about information than diabetes education.

His health insurance company was very thorough in their questions and when they had the information, they thanked him and said she would be paid for education only since that was what the class was supposed to be about. He was told that she would only be paid for 15 minutes. He was asked if he would be attending any more classes with her and Jake said no, after what happened.

Allen also thanked him and said that he could believe she would bill for the full time and for both education and diet advice. Another new member, Elmer, said something similar had happened to him, only it was in reverse. Both Allen and Jake advised him to contact his health insurance and let them know what happened. Allen said we don't believe they should be able to cover both topics during a session and be paid for both especially when they were referred for one topic only.

I said this is what more dual titled people are doing and we don't think this is right as even doctors are being limited in what they can charge for when you go in to see a doctor. I continued that is why we are asking my cousin to speak at our next meeting to give everyone a better understanding of nutrition and what balancing a meal plan means. Carbohydrates will not be pushed and she will work with you at the level of carbohydrates you desire to consume.

Jake said that then I would be wiser to not attend the meeting with a dietitian. Allen said that is up to you, but you will learn more with Bob's cousin. Most of us use her and she helped me when I needed help because I was vitamin B12 and vitamin D deficient and receiving shots to help. I had not been cleared for supplements, but she went with me to a special appointment and talked with the doctor after hours and had a meal plan I approved of and was able to use and with the supplements that were necessary.

She helped Jerry and others when they needed help. I said Brenda is the only one she has not worked with because her daughter helps her. Allen continued that even Brenda respects Suzanne and asked her questions from time to time, but does not use her, as she prefers to keep it in the family. I said Suzanne knows this and respects this.

Allen told the two new members that he would contact Tim and explain what had happened and ask Tim to send out an email to all members about this and suggest that the rest of the members hold up in any appointments with CDEs or RDs. I said that most of the older members could help with education and that my cousin Beverly already was helping members on education. Jake and Elmer said this sounds like what we should do.

Jake and Elmer thanked us for our time and Jake said he felt better after talking with someone.