A1c Should Not Be the Only Goal for Type 2's

The American Diabetes Association (ADA) has officers that are harming people with type 2 diabetes. Dr. Robert Ratner, chief scientific and medical officer for the ADA, is the doctor doing much of the harm to type 2 patients on oral medications. Dr. Ratner does not recommend blood glucose testing, but relying on the A1c test when you have a doctors appointment.

Studies have found glucose fluctuations and daily glucose control are something people with type 2 diabetes are often not aware of and may need to consider. For the many Americans living with type 2 diabetes, A1c is an important metric as it is a key clinical measure of a person's glycemic control over a two to three month period. A controlled A1c level, typically a level at 7 percent or less, has been shown to be associated with a reduction in risks for microvascular complications and cardiovascular events.

While A1c levels are a key component of determining long-term glycemic control, they provide very little information about blood glucose fluctuations that occur throughout the course of a day. A person with type 2 diabetes can experience substantial glycemic excursions following meals. Although there is no prospective clinical trial evidence, there is broad and robust experimental and epidemiologic evidence supporting the concept that excessive glycemic excursions may contribute to long-term risks. In the absence of confirmatory clinical trials, however, direct cause and effect remains controversial.

This points to the urgent need for research and trails exploring the results of daily testing on patients with type 2 diabetes and what these excursions may mean to the health of the patients. Testing programs need to be developed that will demonstrate the importance of blood glucose testing, especially self-monitoring of blood glucose (SMBG). There is much that needs to be accomplished to undo the actions of people like Dr. Ratner.

It is important for people with type 2 diabetes to be aware of glucose fluctuations throughout the day. As patients and physicians become more aware of excessive glucose excursions, both dietary and therapeutic strategies can be implemented to reduce these fluxes. Studies have shown an optimal treatment regimen not only helps bring patients' A1c to goal. It can also help improve daily glucose control throughout the day. Improved glycemic control helps reduce severe fluctuations that have been linked to short-term complications, and which may also lead to long-term microvascular complications and cardiovascular events.

Antidiabetic agents may reduce daily fluctuations and help patients achieve levels of glucose control within the normal range throughout the day. A1c is and will remain a key measure of glycemic control, but as understanding of diabetes grows, the quality of glycemic control may also become an important marker of treatment success.

While I agree that these are important reasons for people to know the importance of blood glucose testing, very few trials consider this in conjunction with low carb, high fat meal plans that can prove very beneficial in lowering the glycemic excursions to hyperglycemia and hypoglycemia. Most doctors ignore the teachings of Dr. Richard Bernstein and his 'law of small numbers' in the treatment of diabetes.

Self-Monitoring of Blood Glucose – Part 2

Continued from the previous blog.

One exception to hand washing is when you have not been eating fruit (and have fruit juice on your fingers) or are away from an area where you can wash, then using an alcohol pad is better than not cleaning you finger where you will test. Occasionally it might be wiser to use the second drop of blood and you may read my blog here about this.

The purpose or goal of SMBG is to collect information about blood glucose levels at different times during the day to assist you in creating a more level blood glucose. You will use this information to adjust your regimen in response to the blood glucose values. This will mean adjusting your food intake, physical activity, and possibly medications with your doctor’s direction.

This is the reason for testing in pairs. One reading postprandial is worthless and tells you nothing. It does not tell you what the increase may have been from the food consumed, or even if you need to reduce your food consumption. Okay, if the preprandial dinner reading was 105 mg/dl and at 90 minutes postprandial, the reading is 148 mg/dl, then this means that the increase was 43 mg/dl. Now this says something and depending on the goals you have set, you can make adjustments. Do you need to reduce your food consumption (the carbohydrates), do more physical activity, or if on insulin adjust the dosage injected? I would always encourage reducing the number of carbohydrates. With the information given, you need to potentially do a correction injection of insulin, but this is not the action you should take on a daily basis.

I found the extra expense for test strips well worth the money. I was able to determine what my high point after meals were. Yes, this has changed over time, first more minutes and now less. Presently, my high point is normally reached at 105 minutes. When I started testing, I quickly found out what foods needed to be eliminated from my food plan and which foods needed to be limited. Even this has changed, but not drastically. Learning what 'new to me' foods do to my blood glucose has helped.

Yes, in the first five years, I used a lot of test strips. I am happy that I did, as I often know when a food may spike my blood glucose and drastically limit it. Most of the time I am right and have good results. Yes, occasionally I have a surprise. Most of the time for the good, but some bad as well.

It is wise for anyone with type 2 diabetes to learn self-monitoring of blood glucose and what the readings mean. Testing in pairs is the best way to learn. Today's doctors do not have the time or the desire to teach. This applies to certified diabetes educators as well. The registered dietitians will be more than happy to teach anyone that isn't knowledgeable because then they can promote whole grains and other foods promoted by Big Food. I keep meeting people that learned the hard way that these teachings damage your health rather then manage diabetes.

Self-Monitoring of Blood Glucose – Part 1

Why is it that type 2 bloggers are the only ones that urge other type 2 people to test regularly? And yes, it can be tough on a budget. I will not deny that, but with the testing supplies and meter that can be purchased at Walmart, this should help many people. Other people can write the manufacturer of their meter and request financial assistance. You will need to follow their instructions carefully or financial assistance will be denied.

A great way to manage diabetes is through self-monitoring of blood glucose levels (SMBG). There are limitations and barriers to SMBG, which ultimately affect outcomes related to adherence of medications. Most people do not care and that is a shame that they are willing to let diabetes manage their lives. Even this article in Diabetes in Control does little to educate people about SMBG.

The study researchers felt the study revealed barriers to blood glucose testing and integration of testing in the lives of patients. The main outcome of this study was to find out the perspective of patients of SMBG in a clinical setting. The study suggests that patients are having a difficult time incorporating SMBG in their lives. Many patients are not even sure of their target glucose goal, which diminishes their motivation of SMBG. More education is needed to promote best practice for SMBG.

Most people on a budget refuse to use the supplies necessary to help them manage their diabetes. This forces them to operate in the blind and not manage their diabetes and then they become upset when their A1c trends upward. Others refuse to test because they don't want to prick their fingers because they fear the pain. I can only say that if the testing is done properly, there should be little pain and while I will admit that occasionally I test outside the best area on the side of my finger tips, I seldom have much pain.

This is wrong and you should expect pain here.

Still the wrong area and expect more pain here.

This is the area that is generally the best for testing.

Many people do not take the necessary steps to properly test. You should wash your hands with warm (or as hot as you can tolerate) water and soap. Then rinse and thoroughly dry your hands. Do not handle test strips with wet hands, as you will make the reading unreliable. Been there, done that, and it is a great way to waste test strips. Once your hands are washed and dried, then you may consider yourself read to test.

First, have the lancet device ready for use. Second, remove one test strip from the test strip container and carefully insert it into the slot on the meter. Now set the prepared meter down and use the lancet device to prick your finger. If you do not receive enough blood, it may be necessary to increase the depth the device will penetrate the skin and reprick your finger. It may be necessary to gently squeeze the finger to obtain sufficient blood. Now, take the meter with the test strip inserted and gently guide the test strip into the blood, letting the blood wick into the test strip. Gently set the meter, with the test strip still in place, on the counter so that the number that appears after about five seconds can be easily read. Now, you are ready to record the time and the reading.

Continued in the next blog.

Help in Diabetes Management Education – Part 2

Part 2 of 12

Blood glucose testing will depend on how many test strips your insurance company will pay for and then on your budget. I don't expect everyone to able to test for what is ideal, but I will list the ideal first to give you a basis. This is also one reason I urge people to ask their doctor for extra test strips at the beginning to help them determine what works for their food plan and which foods to limit or eliminate. This will also allow you to determine the time from first bite or last bite to the peak in your blood glucose. This varies for each individual and you should determine what your peak is for each meal. Many have their peak at one hour and others at two hours. Some like me peak at about 90 minutes and others a two hours and thirty minutes. This is a variable that you must determine for your body. This can change as you age, so be aware of this.

The first time for testing is when you wake. This is also your before breakfast blood glucose test (termed preprandial). Then you should test about one or two hours after breakfast. Do this for each of your meals and then before going to bed. Then you should always test before and after exercise unless you are on oral medications that do not cause lows (hypoglycemia). Read my blog on blood glucose levels that are safe for exercising. Some people with type 2 diabetes do exercise with blood glucose levels that are too low or too high.

If you are on insulin, you should test before and after exercise. With the position of the ADA and actions by some states on people driving with low blood glucose levels, it is also wise to test before starting to drive and stop and test if you feel low. Some states are suspending driver's licenses when it can be determined that an accident happens that is caused by hypoglycemia. Other causes include if you are stopped while driving during an episode of hypoglycemia. In other words, know the law in your state. The above link is to a prior blog on driving, and this is the link for the 2105 guidelines for diabetes and driving – actually a use of the 2014 guidelines which was not changed for 2015.

Most people on oral medications are limited to one or two test strips per day depending on the medication. Those using insulin are generally limited to three test strips per day. This means that you are limited in the testing you can do and what you can do for experimenting. I know quite a few people on oral medications and on insulin that purchase the extra test strips to be able to experiment and determine the best postprandial time to test. They also used the extra test strips at the beginning that their doctors were able to have approved to determine what foods they could eat, what needed to be limited, and the foods they needed to eliminate.

Developing their meal plan was also a priority for them and a few that needed to spend their own money for extra test strips to do this experimenting. When I meet someone that has done this or even receive an email about the success from doing this, I always feel good for the person. This is management at its best and means to me that the person wants to learn how best to manage his or her diabetes. Oh, yes, we all make mistakes or errors, we are human, but if we learn from these, we are better for these mistakes.

The Difference - A1C and Blood Glucose Monitoring

I do not like doctors and other medical professions that tell people with type 2 diabetes that they don't need to test and that a quarterly A1c test is sufficient. In attempting to find a doctor, I could relate to, I have run the gambit or gauntlet of bad doctors. Two have said they were taking me off insulin and would not give me a reason for doing this. They just stated that I should be on oral medications as a person with type 2 diabetes. One even told me the first statement and that he would not prescribe testing supplies. Needless to say, they obviously were not up to date about diabetes.

This is one reason the blog from the Mayo Clinic really hit home. The author asked, “A1C or blood glucose monitoring: Which one is better? Neither. You need both measurements to ensure you have good diabetes management.” The author discusses both and importantly their differences.

The A1c test: For doctors, this is their bread and butter. It tells them how you are managing your diabetes. Most doctors want this test every 3 to 6 months. How often will often depend on how well you manage your blood glucose levels as a person with type 2 diabetes.

“The goal standard set by the American Diabetes Association is for you to keep your A1c percentage at 7.0 or below. The American Association of Clinical Endocrinologists prefers the percentage to be 6.5 or below. The American Geriatrics Society recommends A1c levels of 7 percent or lower for healthy adults and less stringent levels for less healthy adults of 8 percent or lower.”

Now I don't agree with the upper limits that doctors recommend, but I do work to keep mine under the level set by the American Association of Clinical Endocrinologists. I will now get more technical by quoting from a blog by David Mendosa. “How much glycated hemoglobin we have in our blood depends first on the lifespan of our red blood cells. The “average lifespan is 120 days,” the book says, which is of course four months.

But the glycated hemoglobin in our blood is also “directly proportional to the concentration of glucose in our blood” and “represents integrated values for glucose over the preceding 8 to 12 weeks.” Most people seem to think that our levels at any time during this two to three month period are equal. But they aren’t.

“More recent values,” the book continues, “provide a larger contribution than earlier values.” How much more? “The plasma glucose in the preceding 1 month determines 50% of the HbA1C, whereas days 60 to 120 determine only 25%.” This is the key statement and the one that prompted me to change my testing strategy.” Note: David tests his A1c on a monthly basis.” If you missed reading his blog, you may want to read it. I did leave out some page references that were not adding meaning.

Blood glucose metering: There are several terms that may be used - “blood glucose testing” or “BG testing.” Yes, metering is not a generally used term for blood glucose meter and test strips. Checking your blood glucose level helps you immediately and gives you information to aid in diabetes management decisions.

If you are not on insulin, blood glucose testing several times per week can tell you how well you are managing your diabetes. It will let you know if you need to make lifestyle changes or if you need to contact your doctor.

The two tests together can tell your doctor how well the long-range management has been for the last 120 days. Consider the A1c as a movie for the last 120 days and the blood glucose meter readings as a snap shot in time.

A Problem for a Friend of One of Our Group

Problems can happen when you least expect them. Barry was having a friend from his previous town on a visit with Ben and himself. They had discussed and talked about diabetes, but nothing had been discussed in specifics. Then the second day, Barry did ask his friend what his last A1c had been. His friend said he did not know as the doctor had not told him. Barry said the only comment he could remember was something to the effect of watch what he was eating as it was creeping back up.


This caused Barry to ask what his blood glucose reading had been that morning. He got a puzzled look and a question about what was a blood glucose reading. Barry patiently took out his testing supplies and showed his friend. His friend did not know anything about what he was seeing. Barry asked if he could do one test as it was about time for the noon meal. His friend said okay, so Barry pulled out the lancet, inserted a new one, put the device back together, and armed it. His friend hesitated and said you aren't sticking me with that.


At that point, Ben took his out and asked Barry's friend to watch him. Ben pricked the side of his thumb, set the lancet device down, and reached for the meter he had previously inserted a test strip in, as it was now ready to receive the blood. After the blood was wicked into the test strip, the meter took about five seconds to give a reading of 96 mg/dl. Ben recorded the reading, with a tissue, wiped the excess blood from his thumb, used the tissue to pull the test strip out of the meter, and discarded both in a wastebasket.


Barry's friend asked why he had used the side of his thumb and not the tip or sole. Ben explained that the side had less nerves and he had little or no pain on the side and that he could use the tip or sole of his thumb or any finger as he had pain insensitive fingers at his age. Ben said that yes, he occasionally hit a nerve and could have a little pain, but in general he was not concerned. Barry's friend said that the doctor he went to, the nurse always used the tip of a finger and it always hurt, but if there was less pain on the side, he would give it a try.


Barry said he put a strip in his meter and adjusted the lancet device to the lowest setting. His friend held out his hand and Barry said he rested the device on his small finger and pressed the release. When Barry lifted the lancet device, he said his friend was still expecting a sting. There was sufficient blood with a small squeeze so he inserted the test strip to wick the blood and when the meter reading showed it was 298 mg/dl. Ben asked if he had taken his medications to which he stated not until the noon meal. Barry asked if he could see the medication and his friend hauled out the container. The directions said one at the noon meal and one at the evening meal. It was for one of the sulfonylureas and the dose was small.


After the noon meal, Barry called Tim who was not available. Then he called Allen who was also out of town but would be home shortly. Allen told Barry to call the local doctor and ask him the questions. Barry was hesitant, so Allen said he would call after he had talked with them. When Allen arrived about 2:30, he was given the information and Allen asked them to call Barry's friend's insurance company to find out which meters and test strips were on the approved list.


Then Allen called the local doctor and asked if he could do an A1c test and go over the medications Barry's friend was taking. The doctor could see him that afternoon, but did not have the A1c kit as the order had not arrived that day. That was when Allen called me. I told Allen where I was and that I would call back when I could get off the interstate which I did. That was when I started to hear of the problems. I suggested that they start calling the pharmacies starting with the pharmacy near the clinic at the hospital and ask for the Bayer A1c kit. Then if they did not have any to go to another pharmacy until they found one. Then I remembered and suggested he call the diabetes clinic first to see where to find one. Allen said he was grateful I knew where to start and said he would wait until I called to tell me where to go first.


When I got near the diabetes clinic, I called Allen and he said the clinic could sell me one and to go there first. Then I would need to go to the pharmacy to get a meter and two containers of test strips for which Allen gave me the name. I made the stop at the clinic and I asked if they could sell me a meter and if I needed a prescription for the test strips. I briefly explained the situation and was given the meter and a prescription for two containers of test strips. I paid for the A1c kit and went to the pharmacy to get the test strips and headed for home and Ben and Barry's residence.


At that time it was time to take Barry's friend to the doctor, so Allen, Barry, and his friend left with everything while Ben and I talked and waited. When they returned, Barry said the two of them would go to the pharmacy and get his new prescription filled and then he would pay me. Allen said the doctor had received permission for the charges to his insurance and for his prescriptions. Allen also stated that the doctor agreed that he should start on insulin and that was the prescriptions plus metformin. The doctor had also stated he knew an endocrinologist near him and would be calling him to set up an appointment as soon as possible.


When Barry and his friend returned, his friend said this is quite a community you have here. Barry said he hoped so as we had saved his hide. Barry's friend asked how we came together as he did not know of anything like this where he lived. Allen stated that most probably wanted to keep it a secret and therefore very few even talked about diabetes. Barry had to agree and said this was a unique group and he was happy to be part of it. At that point Barry's friend, thanked me and paid me saying that the delay was so he could get the extra cash when he used his debit card.


Barry asked how I knew where to find things so fast and I said it is just knowing who to ask. I explained that the meter had not cost him anything as my clinic had supplied that because of the people using it. I said knowing what his insurance covered also was a great help. Allen said that was good and he asked Barry's friend if he could remember this for the future is it became necessary. The answer was yes, and that he had learned a lot in about five hours and he would be working on reinforcing his memory. I said that with Ben and Barry he could learn quite a bit.


Tim arrived then and was introduced. Allen and I made our exit and received profuse thank you's for our part and it was agreed that those of us that could, should get together on Saturday to cover the events. Barry said he and Ben would send out emails about the events and lessons learned. Allen said he would add another if necessary.

What Are We Missing as People with Type 2 Diabetes?

This question has bugged me for the last several weeks. I have plenty of material to blog about so that is not bothering me. I have found several of my blogs lately lacking the extra little something that should give them more meaning. I like blogging and helping others, so that does not seem to be it. I am having more success at some of the things I am doing for diabetes and my last A1c was 6.3%. Granted it was not where I wanted it to be, but I still feel I am making progress.

Yes, my weight problem is a concern, but I have hope there. Today, I did have one of those ah-haa moments and I am hoping this will change some things and that this is not one of those bright flashes before the bulb flickers out. In reading David Spero's blog of March 13, I realize that many people tell us to eat this or don't eat this. Some say to limit this or eat plenty of that. David is one of the writers that tells you to test to find out how your food plan affects your blood glucose. This is the key. It is what I have been missing in the research I have been doing lately.

The American Diabetes Association (ADA) does talk about testing, but then pull the rug out and say eat this, but avoid telling you to test to see how the food they are promoting affects your blood glucose level. The same applies to the American Association of Diabetes Educators (AADE); they are not afraid to tell you what to eat, but they refuse even to suggest that you test to determine if the quantity of food is right for your body. Then we come to the Academy of Nutrition and Dietetics (AND), and they will not suggest testing to determine what a food or combination of foods will do to your blood glucose levels, but they will insist that you eat so many carbohydrates per meal.

So for the last few days I have been reading and reading to see if I can find writers from the above three professional groups that talk about food and even suggest testing to determine what these foods do to blood glucose levels. I did not find one that did this. My reading may have missed one or at most, two that accidentally did this, but it is discouraging that I found none.

Now bloggers that have type 2 diabetes and other writers not associated with the three above organizations do often suggest testing your blood glucose levels at different times to determine how a food or meal plan affects your blood glucose level.

All of this makes me question if the meal plans and foods the three organizations want us to eat, are not nutritious and they won't suggest testing because they know this. Why do you think they don't want us to find out by testing?

Are they so aligned with the US Department of Agriculture (USDA) and the food industry that they do not want people questioning their “expert” advice? Is this why they talk about testing to manage blood glucose levels in one place, but refuse to link to testing when they are talking about meal plans and foods they write about on other pages.

I have to laugh to avoid becoming angry when I read "Pharmacological and overall approachesto treatment" in the ADA guidelines. Why do they talk about MNT (Part E down a couple of clicks) under pharmacological therapy? MNT means medical nutrition therapy. Yes, they have used this term for several years, but this is done to put more emphasis on eating what they want us to eat – without testing. It is done “for medical reasons” and is therapy which is supposed to make us feel better about the nutritional nonsense they are feeding us. We are not supposed to question how bad this is for us.

I am very surprised the ADA has not picked up the additional term promoted by the Joslin Diabetes Center. In their book, Joslin's Diabetes Deskbook, when discussing medical nutrition therapy, Joslin uses “the nutrition prescription” to get people to just to accept the nutrition advice given us. This is emphasis on top of emphasis. By putting prescription in medical nutrition therapy, they are telling us we are to follow their advice blindly. Then they say that a dietitian is the person to be prescribing this meal plan to each of us after an assessment of each person. This assessment will determine how willing we are and compliant we will be to their prescribed medical nutrition therapy.

I say we need to recognize the terms for what they are and realize that the science behind the medical nutrition therapy is as weak as the USDA nutrition is. Why else would the USA be having the obesity epidemic? They don't want us to test to find out what the nutritional nonsense they are feeding us is, and how much it increases our blood glucose levels. Why do you think they have fashioned studies to prove we don't need testing supplies? They purposely do not want us to be able to test and prove them wrong, to say nothing about our health being put in jeopardy.

ADA Changes Blood Glucose Monitoring

If the American Diabetes Association believes they have undone the damage that their 2003 Guideline set in motion; they may have another thing to consider. What happened in the 2003 Guidelines was a recommendation for people with type 1 or type 2 diabetes who use insulin in multiple daily injections or with an insulin pump should self-monitor blood glucose “three or more times daily.” Most payers interpreted this to mean that three tests per day was sufficient for all patients on insulin.

To find out if the new 2013 guidelines had changed any minds, I have decided to correspond with my insurance company, Medicare, and inquire from a few other medical insurance companies that cover part D. I now have a response from the medical insurance companies and a brief statement of “no anticipated changes” from Medicare. Even the Veterans Administration stated that there are no anticipated changes. One medical insurance company said they are taking a wait and see stance about what other companies are thinking. My medical insurance company stated that since I don't use them for my test strips, they are not responding further. I talked with my agent and he asked. He was told there would be no changes at present. The last medical insurance company said they are still asking questions, but anticipate only minor changes if accompanied by an order from the doctor.

This made me contact another company and I was told in a phone conversation that there would be no changes until the ADA decided that a certain number was needed. This raised my hackles, and I said they did. We discussed the section and I was told the key words were “many patients” and that until ADA clearly stated for “most” patients, they would continue the current limit. Then I was asked about the Joslin blog of January 16. I stated I had read this. I was told that this also confirmed the current position of no change. This is about as big a slap in the face as you can get. This insurance company said the the Joslin blog is also the reason they will be limiting type 2 diabetes patients not on sulfonylureas to one test strip per day. It had been two per day.

I can also envision insurance companies requiring doctors to forward meter downloads to prove that the patients need as many test strips as requested. I know that this is on the mind of one of the companies I have corresponded with as they asked if I would be willing to do this. I know many diabetes clinics and a few doctors do have the software to do this, but most primary care physicians do not. Think of the cost and if you think they are not going to pass this on to the patient, you are in for a surprise. Another statement one insurance company clearly made is, “if this was that important, why did they (ADA) wait ten years to make a statement like this?”

I personally think that until ADA includes more people from the medical insurance industry and a few patients (type 1 and type 2), they will continue to be laughed at and not believed to be setting recommendations and guidelines for the patient, but in their interests only. In recent years, this seems to be the trend. Even we, as patients, have to wonder what they are doing for the patient. They are great at wording that means and says very little. This has to be what the medical insurance industry thinks about their wording and their reasoning for no anticipated changes. Even though ADA is saying they made some changes, in the real world, there may not be changes.

One section says the following, “The frequency and timing of SMBG should be dictated by the particular needs and goals of the patient. SMBG is especially important for patients treated with insulin to monitor for and prevent asymptomatic hypoglycemia and hyperglycemia. Most patients with type 1 diabetes and others on intensive insulin regimens (MDI or insulin pump therapy) should do SMBG at least prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving. For many patients, this will require testing 6–8 times daily, although individual needs may be greater.” The bold words is my emphasis and is the wording used by two companies below.

The above is the section quoted back to me by two of the insurance companies, one that will make no changes, and the one that will use a doctor's order and consider the need.

Another area that was also used is, “Because the accuracy of SMBG is instrument and user dependent, it is important to evaluate each patient’s monitoring technique, both initially and at regular intervals thereafter. Optimal use of SMBG requires proper review and interpretation of the data, both by the patient and provider.”

In reading the section, type 1 is specifically mentioned, but other areas only use the term MDI (multiple daily injections) and self-monitoring of blood glucose (SMBG). This leaves those of us with type 2 on insulin wondering if we will be excluded from obtaining support for intensive testing.

Again, the ADA has played down the importance for people with type 2 diabetes on oral medications and on no medications of the need for testing and also the need for being tested more than two times per year by the A1c. This statement is typical of the ADA's attitude, “The evidence base for SMBG for patients with type 2 diabetes on noninsulin therapy is somewhat mixed. Several randomized trials have called into question the clinical utility and cost-effectiveness of routine SMBG in non–insulin-treated patients. A recent meta-analysis suggested that SMBG reduced A1C by 0.25% at 6 months, while a Cochrane review concluded that the overall effect of SMBG in such patients is small up to 6 months after initiation and subsides after 12 months.”

For me this is almost criminal in both the attitude and actions they have about not educating these people with type 2 diabetes and then preventing those that know the importance from obtaining the necessary testing supplies.

And if you doubt what I am saying, why then would the Joslin Diabetes Center post the blog they did on January 16, 2013 (mentioned above), in which they ask the question, “When Should I Check My Blood Sugar?” “The answer depends on the medications you are taking, your current level of control and what information you are looking for. For example, people with type 1 diabetes who take insulin four times a day need to check at least as many times. People with type 2 who control their glucose levels with lifestyle or lifestyle and metformin may check only once, or perhaps twice, a day.”

Patients at Joslin need to be concerned about the side Joslin is on, as it clearly is not for the patient. This blog seems a clear rebuttal of the 2013 ADA Guidelines. Don't think the medical insurance companies won't see it this way (two companies have). This is just one more reason they have for not making changes. When a well known and prestigious diabetes clinic publishes information like this for patients, they are not doing us any favors.

The two companies (mentioned above), did have me call them and talk to an office that make the determination. They admitted that there will be controversy over this, but that with a leading diabetes clinic saying only four times in difference to the ADA of six to eight times, the decision will remain no change until everyone is in agreement. When I asked about meter downloads for proof that a person was testing more frequently, the answer was that this was under consideration, but that not all physicians would be capable of submitting this information. They did say that to force this issue now could be considered discriminatory, but that it is under consideration for future years. They said with a doctors order for the testing and the meter downloads being submitted, this could be a factor when everyone is in agreement as to the number of testing requirements for both type1 and type 2 on insulin.

In the phone conversations I also asked about those type 2 people on oral medications. Both companies stressed that they will be allowing two test strips for those on sulfonylureas and will be allowing more if there is a doctors order because of repeated episodes of hypoglycemia. Others, to include those on no medications will remain on one test strip per day without a doctors order proving the need for more test strips. They would not discuss what the doctors orders needed to state.

Then to read another article also questioning ADA's attempt to change the minds of insurance companies, read this from Diabetes in Control. Dr. Richard Grant, incoming chair of the ADA Professional Practice Committee says, "We're trying to say it's very situation-dependent …. both by the patient and the patient's context." This really says nothing even if they are claiming otherwise.

This statement really drives home the point that ADA has not succeeded, “With regard to the removal of the three-times-daily number, Dr. Yehuda Handelsman (Metabolic Institute of America, Tarzana, CA) expressed concern that insurers might actually interpret that as endorsing less frequent testing for patients who use insulin. How messages are conveyed matters, he said. "It's about how you define the goals and where you put the emphasis."

According to Grant, the new document was the ADA's best attempt to balance the evidence from the literature with the needs of the individual patient. "Evidence-based guidelines apply to populations of patients with diabetes, but we really need to tailor these population-level recommendations to the individual in front of us."” In other words, this is why insurance companies are saying loud and clear, “no anticipated changes” So forget what ADA claims.

For other perspectives and more hope in others areas of the country, read this blog from Diabetes Mine and this blog from Diabetes Self-Management.

Tips To Make Testing Less Painful

When I wrote the series on testing, I completely forgot that I had this tucked back for use. So rather than leave this for another blog on testing I will complete it now. There are other tips people should make use of when blood glucose testing to make the experience a little less painful and possibly help in setting the lancet device to a less deep setting.

Pain is caused when the lancet device is triggered and the lancet is released and it penetrates the skin. The deeper the lancet penetrates, the more pain it will generally cause. Also, this is necessary to produce enough blood for the test strip. The following tips may help reduce the pain and possibly provide enough blood for testing. I have covered this before, but it is still worth repeating. Always, if you are able, wash your hands with soap and warm water. This cleans the testing site and helps dilate (make larger) the blood vessels in the finger to increase blood flow. Always dry your hands and fingers carefully to not handle test strips with wet fingers.

The next step is to massage the finger downwards to the tip of your finger. The purpose for this is helping the blood move toward the fingertip and making more blood available when the area is pricked. While doing this, if possible have the hand pointing downwards below your waist. This helps gravity keep the blood in the hand and more importantly your fingertip.

If you use the tips to this point, try resetting the lancing device to a lower setting that you have been using or maybe set to the lightest setting. When you have enough blood, this should be your setting if you follow the above tips.

Many people say to find the correct meter that does not require much blood, but I will only say that you should contact you medical insurance company to find out which meters and test strips they cover. A free meter and only ten test strips does not go very far if the insurance company will not reimburse for the strips. If you are given a list of strips and meters that will be covered, then research the meters for the one you want to use.

Alternate the areas on your fingers and thumbs. Please do not use the same finger over and over. Using your fingers and thumbs, this will give you 20 areas to use, your fingers will recover rapidly, and blood flow will not diminish like it will when you use one finger over and over. Now if you have missing fingers from an accident, you will have less for testing. If you are a person with type 2 diabetes and your diabetes management if great, then you may wish to read the next blog about using alternative sites as well.

This tip is one I do use quite religiously. In the wintertime especially, my fingers can become harder on the surface and blood flow can be reduced. Therefore, I try to use a skin moisturizer on both hands at night and the hand I will not be using during the day. This softens the skin and creates better blood flow.

I have covered using the sides of your fingers near the fingernail (see this blog) so I will move on to the suggestion of using a new lancet each time. Many people do suggest this and this is generally less painful that doing like I do and change maybe three or four times per year. Fact is, I am changing to once a week just to see how it affects me.

Tips for Glucose Testing – Part 4

Part 4 of 4 parts

Financial Assistance

Those that have insurance or Medicare generally will not have problems with testing supplies, other than not being reimbursed for enough testing supplies. Not having insurance can create problems and needs answers. Getting free meters is not the problem; check the last paragraph of the Diabetic Connect article. That is still not a good answer, as it is the test strips that cost and without insurance, be careful. A free meter with expensive test strips is not a solution.

Ann Bartlett has an excellent blog on Health Central about finding financial assistance. It is over a year old, but is still good information. She also suggests talking to your pharmacist and it is possible that the pharmacist may have some suggestions that will be of help. Although this is now over two years old, there is some excellent information on test strips and meters, especially about where to find them. A price check on Amazon dot com can confirm prices of today.

Another alternative is to find some manufacturers and check their web site for assistance programs. You will need to follow their directions, but most do have fairly good programs.

Amy Campbell has an excellent blog on Jan 7 at Diabetes Self-Management on "Know your health plan," that covers many areas that I did not.  Dealing with most medical insurance companies requires every bit of help you can get.

Exceptions in Blood Glucose Testing

When doing blood glucose testing, there were some ideas that I did not want as part of the normal testing and I will discuss them here. The first is controversial, many can find no logical rules for it, and others say it does not exist. Most discussion happened prior to five years ago, but you should be aware it. The Somogyi effect, also known as the “rebound” effect", was named after Michael Somogyi, the researcher who first described it. It is caused by the tendency of the body to react to extremely low blood sugar (hypoglycemia) by overcompensating, resulting in high blood sugar. For many people with diabetes this does not happen because these hormone regulators are not functioning properly. For some people in the early stages of diabetes they can work - as when blood glucose levels drop too low, the body sometimes reacts by releasing counter regulatory hormones such as glucagon and epinephrine. These hormones spur the liver to convert its stores of glycogen into glucose, raising blood glucose levels.

Often the effect is mistaken for the dawn phenomenon (DP) when the liver dumps glucose to start the wake up process. People have been checked with continuous glucose monitors to prove whether it is the Somogyi effect or DP. The dawn phenomenon is much more prevalent in people with diabetes than the Somogyi effect.

The other problem is what people eat. People that eat a higher percentage of fat can develop the pizza effect for testing. This means that their blood glucose high level will not happen often at the two-hour point, but can happen between the two hour and five hour marks. This depends on the person's body and how much fat is consumed. The pizza effect got its name from those that had pizza for a meal and wondered why they were still low at the two-hour mark, but later were much higher. Therefore, when you eat pizza, do not be surprised to find a high level of blood glucose at a later time than you normally would and the same can hold true if you have any other high fat meal. Fat slows the digestive process and thus the release of glucose into the blood.

Understanding Self-Monitoring of Blood Glucose (SMBG)

SMBG is just what people need to learn to assist them in managing their diabetes. In addition we also have available to us diabetes self-management education (DSME) and diabetes self-management training (DSMT). These two are discussed in this blog and this blog. These are written primarily for the elderly, but may be adapted to the younger people.

I have stated this before and it is so true. “Each person has to learn about how their body reacts to diabetes, how much exercise they are capable of doing, and finding out what works for them. There are no firm rules other than what works for me, may not work for you. Much of what is taught is on a one-size-fits-all basis, which can be misleading for many and does not work for everyone. This is the reason for giving people other information so that they may try different approaches in finding what works for them.”

Even if this is not within SMBG, it is important to say that experimenting is allowed and encouraged to discover the best management of your diabetes. Never be afraid to take a one-size-fits-all point and adjust it to fit your needs and what works for you. Yes, I make a lot of fuss about one-size-fits-all discussions, because many times it is written as if this was the only right way to solve the problem. I have found through experimenting that what is written to be the only way is wrong and adjustments can be made and still have success.

This is why some bloggers write about SMBG being so important. I have found out that being my own lab rat has been beneficial and why testing has become so important to me. This has allowed me to become more efficient in managing my diabetes. Am I a model of perfection? No, I can still do things incorrectly, but this also teaches me what works and discover why some attempts fail. I use my testing records, food log, and daily health log to see patterns developing. Then when I get the results of the tests the doctors order for me, the light often comes on and, yes, I can see why something is improving or going in the wrong direction.

I always feel good when things go right, but I have found that when I make a mistake, sometimes they scare me, but by using them as lessons, I am able to continue to improve. Please take time to read several of my blogs on SMBG – blog 1,and blog 2.

Even though this blog was written with tongue-in-cheek, this is something that I have encountered, as have others of my friends. We need to be careful in what we accept as being the best for us and realize that some of the people that are to be considered as resources, often make it more difficult because they don't understand us. Others do and can help us.

Tips for Glucose Testing – Part 3

Part 3 of 4 parts

 

When Is It Best To Test?

This will depend on your budget and the amount of test strips you have available. It will also depend on the medication(s) you are using. Insulin will require, by its very nature, the most testing, especially is you are using a basal (long acting) and a bolus (short acting). Normally you will test upon waking and this will be the before breakfast test as well. Next will be your after eating (postprandial) for breakfast. You should consider doing this for all three meals and again before bedtime. This makes seven times at least per day. Then if there is a question about one of the tests, another test may be added. Doing the tests at approximately the same time each day will be of value in watching for trends and problem times when adjustments may be necessary. It is also wise to test before and after exercise. Read my blog here about safe blood glucose levels for exercise.

What the article from Diabetes Connect does not talk about is the reason for pre-meal testing. This is for determining if adding a correction factor to go with the bolus injection based on the carb count for the next meal is needed. One point I admit I have never understood is there are some sources that insist blood glucose testing should be done at approximately the same time every day. Do they mean within 15 minutes, 30 minutes, or two hours. In talking with my doctor, he suggested probably 30 minutes, but said he understood why I would be asking as being retired, I do not have a schedule. If I need to be up at 7:00 AM, that is when I do my fasting test. Other days I don't arise until 11:00 AM or later and that is my fasting test time. My wife has a work schedule and I gravitate to her schedule, but don't follow it exactly. The only thing I watch very closely is not overlapping my short-acting insulin injections.

If you are on oral diabetes medications, then I can understand holding to a more consistent schedule. By doing this you will generally get the most consistent and effective results from your medication and not be overlapping the same medication, which can cause serious problems. The other caution with oral medications is eating approximately the same number of carbohydrates per meal. This will depend on the dosage. It is wise to discuss this with your doctor and asking about times when you don't feel like eating or are ill.

Understand Daily Glucose Testing vs. Your A1C Result

Are you one of those people that believe because you have a quarterly A1c done or like some, buy the home A1c kit and test your A1c every month, think that you don't need to do daily blood glucose testing. This is the wrong line of thinking and for several reasons. For the most valid reasons for the error in thinking this, please read this blog by David Mendosa. One statement that really stands out is this, “The plasma glucose in the preceding 1 month determines 50% of the HbA1C, whereas days 60 to 120 determine only 25%,” This means that 75% of any A1c result in from the previous 60 days.

In reading the selection by Diabetic Connect, I must respectfully disagree with the use of the ADA standard of A1c levels of less than 7%. This is still in the danger zone for allowing the onset of diabetes complications and progression of diabetes. Even the American Association of Clinical Endocrinologists (AACE) standard is 6.5% is not the best for everyone. I do agree that it is closer to ideal than the ADA standard will ever be. As a person ages, allowing the A1c to creep up toward the AACE standard is more acceptable. Still if the person is capable of obtaining A1cs of 6% or less, there is less likelihood of complications developing.

Therefore, if you receive and A1c of 7.4%, you know that something is not right and changes need to be made, but what is the question. By having your daily blood glucose log, you can review this and maybe discover where you need to make changes, especially when matched with your daily food log. If you met your A1c goal, and have not had frequent or maybe one or two minor low blood glucose readings, you can feel fairly confident you are achieving your daily blood glucose levels. Clinical research is telling us that our A1c readings is vital in predicting our future health, but our daily blood glucose readings are important in meeting our A1c goal and tells us how we are doing on a daily basis.

No Judgments, This Test You Cannot "Fail"

“Always remember and never forget: testing glucose is not a judgment of your personal worth. This is not the kind of test that you either "pass" or "fail." In fact, all glucose readings are good! — good in the sense that if you hadn't checked, you wouldn't have that information.” This is what the author of the article in Diabetic Connect stated. Do you agree? I do and only because each reading is relative to that period in time and can be an indicator of the progress you are making in your diabetes management, or not. If your blood glucose readings are always above 200 mg/dl then your A1c will reflect this and your doctor will wonder what your goal is and what you are not doing to lower your A1c. So in that sense you have not succeeded, but the only person you have failed is yourself.

If your goal was an A1c of 6.5% and your A1c is over 9.0%, you have not been paying attention to your daily blood glucose readings, getting the exercise needed, adjusting your food plan, or asking the right questions of your doctor to assist you in getting lower readings. Occasional high readings can mean a lot of stress, you are becoming ill, are overtired, or had more to eat of the incorrect foods for a meal or two. Try to determine what caused the higher than expected readings.

A high reading will not bring on complications unless you have high readings consistently for months on end. Then your doctor may decide that you need to make some changes, often drastic, to reduce your A1c and stop the onset of complications. If you are consistently over 200 mg/dl, you may wish to consider using insulin for managing diabetes more effectively. At least do some reading about insulin to have an informative conversation with your doctor.

How to Choose (Or Obtain) a Meter

This is important and not to be dismissed as your meter will become a good friend and is a needed tool in your management of diabetes. Do not be put off, repeat, do not let the doctor discourage you from having a meter. It is unfortunate that there are many physicians with patients having type 2 diabetes, that won't give out meters or even encourage testing. If you have one of these doctors, I urge you to consider finding a doctor that will. I have even had a surprise that a doctor discouraged a type 2 patient on insulin from testing. This was a shock and I told the person this could be deadly to him without a meter and he should see another doctor before he even considered returning to his doctor. In discussing this with the individual, he had been told to eat only a certain number of carbs for each meal. I asked if he even knew what to do if he was ill – he was told not to inject insulin if he could not eat. Even this is bad advice without testing.

Today, many doctors and endocrinologists have meters that they will give you. If you have medical insurance, there is often nothing wrong with accepting one of these meters. Often the meter they will give you is one of the better and more reliable meters. If you do not have insurance, then read tomorrow’s blog (part 4) on financial assistance. Some medical insurance companies are very restrictive about what they will allow coverage for in test strips. Therefore, it may be necessary to talk to the insurance company before accepting a free meter from the doctor.

Be careful with some insurance companies and in some areas with the meters they want you to receive from medical supply companies. Often these meters are heavily promoted on TV and in magazines and some are not the most reliable. Some have annoying bells and whistles you don't need or will not use, some talk, giving you a vocal reading and if you are one that does not want others hearing this – forget these meters. Pain free meters don't exist and as one medical supply company advertises them as virtually pain free and you don't need to prick your finger. Unless you have forearms with no feelings or spots on you thighs that have no feeling then there will be pain. Also testing on your arms will give you readings that are about 15 minutes earlier and on your thighs that are about 20 minutes earlier than testing on your fingers. Why this lag time? Because you are testing from veins rather from your arteries. Review the part 2 of this series for less pain when pricking your fingers.

1. When accepting a free meter or shopping for a meter, consider these suggestions. Unless you are house bound, you will be carrying your meter and test strips with you wherever you go, so be sure that it has a good case.

2. Some people will look for a small meter, but this will depend on your dexterity.

3. The size of the blood sample needed is not as big a factor today as it was in the past, but still deserves some consideration.

4. Important for many people is the font size and screen brightness.

5. How long from blood wicking into the test strip to reading – should be five seconds or less.

6. Alternate site testing if desired – how easy is it?

7. Cost per test strip.

There are other factors, but they may not apply to you, but do your homework to know if your insurance covers the desired bells and whistles. That means you need to have a list of factors that you desire before you call your medical insurance company to know what they cover and will reimburse.

Tips for Glucose Testing – Part 2

Part 2 of 4 parts

Information that is important for all people with diabetes.

If you are newly diagnosed or an old hand, please take time to read or reread the instructions that come with your meter and the instructions in the box with your test strips. Instructions do change and I am of the habit of trying to read mine on at least a yearly basis. Every now and then, I learn something new or find that instructions for the test strips have changed. Example, it used to say to clean your finger to be used for testing with an alcohol swab and let air dry. Recently, this instruction change to wash you hands and thoroughly dry. Even I know this is better, and would add to wash with warm water and soap and thoroughly dry. It is important not to handle the test strips with wet hands as you could cause problems and receive an incorrect reading.

Learn How to Test Almost Pain Free

At first, pricking you finger to get blood for your test strip can be intimidating. With practice and knowing your equipment, this will become almost second nature. Unless you can prove that testing on the tip of your finger is painless, learn not to test there. Learn to test on the sides of your finger. About an eighth of an inch below your fingernail and on each side and for about three sixteenth of an inch is the best area for pricking your finger. Also use the area just behind where the nail extends (area you trim) to about where the nail emerges from your skin for the boundary front to back within the area in the previous sentence. The below image shows the appropriate pricking area.

Some people are able to test like in the picture below, but not many. There are more nerves in this area for most people. I know that this area does not work for me. However, that does mean that you can’t experiment.

Next, examine your lancet device. In the picture above near the left area near the lancet area and look for a dial or adjusting slide and select the lightest setting (usually the lowest number) and start with this. The above shows the dial area, which is on the reverse side of the lancet device. Then take a lance from the box and insert it in the correct area for holding it, then carefully twist off the round-like tip and you are ready to go.  One the above lancet device, just pull of the dial and you will see the insert for the lancet.

If you have not been shown how to do this, ask a pharmacist, or if you have one, a diabetes educator for instructions. Then press the top (on most devices) until the device is cocked. (See the right side of the Softclix picture above.)   Holding the device firmly against the side of one finger, press the release button (the button to the left of the Softclix name in the picture). If there is no or very little blood, move the dial or slide to the next higher number and repeat. There is no need to change lancets yet. If there is sufficient blood for the test strip, then this is the setting to use. Repeat the above until you have sufficient blood. Most of the time nearly enough blood could be enough if you gently press your finger and move the pressure toward the area of the blood. This is what we term as milking the finger to obtain sufficient blood. Do not use a lot of force, but set the depth of the lancet deeper.

A word of caution, please. Please know that if you hand write a lot, you may have some calluses on the finger you use the most for holding the pen, pencil, or other writing tool. If you want to use this area, you may need to adjust the lancet depth more and then reset it for the rest of your fingers and thumbs. Rotate finger sides and fingers for each time you prick for blood. The strategy for using the sides of the fingers is these areas contain fewer nerves and the sole and fingertips have many more nerves.

Now about changing your lancets. You may have been told to change for each finger prick. This is true and probably a good habit to get into. However, after using a single lancet for several months, I have gotten into the habit on only changing mine about every three months. Some people change weekly, biweekly, or even monthly. In other words, we don't change lancets for every use. I do change lancets if I use my lancet device on my wife or any other person and change it when I use it again on myself. I do keep alcohol pads around to sanitize the area of the lancet device that presses against the skin when testing on others. I also adjust the depth setting, as I don't normally need as deep a setting for people that do not test.  Read this by Alan Shanley for another viewpoint on painless pricks and then one from Jan 5 that covers much the same ground as mine.

Do not use alcohol pads to clean the area that you will prick. Alcohol pads will dry your fingers and during the winter, they will crack, becoming very painful. It is better to use warm water and soap to wash your hands and dry thoroughly. Read this for more reasons to use water and soap.  Also, David Mendosa has a blog on Health Central about operator error that is worth reading.

Learn and know the why of testing

Yes, learn about testing and the why of testing. There are many sources for this information. Don't be like many people and think you are doing the tests for your doctor. This is a fallacy and needs to stop now. Many, if not most, doctors outside diabetes offices, never look at the data or blood glucose reading log.  Most are only interested in your A1c.  Many diabetes clinics do download the readings from your meter, print out logs, and review them with you to ask questions and give you assistance in interpreting them early on. Then they expect you to know what the readings mean and how to use them.

The best reason for testing is helping you effectively manage your diabetes. Without testing, how are you going to be able to know what is happening, what needs to be changed, and if the change was even the right change? No, you will be in a fog with no direction and cannot even know what is happening.

Test with a Purpose

One of the best blogs about testing is this one by Alan Shanley. Although this blog may suggest testing more often than many people can afford to test, it is still applicable in learning the why of testing. Once you have read that blog, I suggest reading this blog, also by Alan. What I like about Alan's style is that he can be very insightful and lead to an understanding. In addition, he is not afraid to say that you need to find what works for you and not follow what works for him. For some, following his suggestions will work and for others they will need to read for understanding and find what works for them. Do not hesitate to bookmark anything you may want to review later.

Testing is important to know what your body is doing and what food is doing to your blood glucose levels. Testing gives you what your blood glucose is at that time. Therefore, I would encourage you to read this by Jenny Ruhl – here and here – to get some guidance also in testing. You may notice that the first link is the same information as the first link for Alan. This is because this is excellent information and important to know. There is also excellent information on Jenny's site.

No, this is not what the American Diabetes Association (ADA) preaches. The more you read and learn, the more likely you may find that the dogma preached by the ADA does not work for you. The levels they suggest using are in the range that encourages diabetes to progress and does not prevent complications from developing. Management of your diabetes is the goal to prevent or slow the progression of diabetes and prevent the complications from developing. Yes, it is possible and this should always be considered a goal of diabetes management. Many of us use this from William Polonsky, “Diabetes causes nothing! It is the lack of diabetes management that causes the diabetes complications.” This means that if you don't manage your diabetes, complications are quite likely.

Yes, there is a purpose behind testing your blood glucose. You are doing the testing for your benefit and to measure your blood glucose to know that at the one or two hour time after eating that you have achieved your goals. Intensive testing to find your general time of high blood glucose after eating, start testing about three fourths of an hour after eating (use first or last bite, but be consistent), and test every 15 minutes or every half hour until the three hour mark. If you notice the reading going down, stop testing. If you have learned from intensive testing that you reach your high blood glucose level about 90 minutes after eating, then you will generally desire to test at the 90 minute mark to make sure that you haven't exceeded your goal. No, I did not use the one or two hour mark to show you that these can hold true for some people and other people can vary when they reach their high point. Many people do reach their high at the one hour mark and some studies show for many people, the the high is reached at about the 78 minute mark.

Know What to Do With the Numbers

Numbers are just numbers unless you know what they mean. To start with, most normal people without diabetes the range for blood glucose is between 70 and 120 mg/dl (milligrams per deciliter - the American measure), or 3.9 to 6.7 mmol/l (millimole per liter – as the rest of the world measures). This is what the “experts” don't say after the previous statement. Most normal people without diabetes can have readings above 100 mg/dl, but they don't stay above 100 very long and are back below 100 quickly. This can happen after a very carbohydrate heavy meal and is not the normal happening. They also don't say that readings of 100 to 125 mg/dl are the range of people that have prediabetes.

If you have morning fasting readings of over 120 mg/dl, you need to consider making some food changes the evening before. Maybe a smaller snack (less grams) before bedtime or not eating for longer before bedtime other than the snack. If this does not help, then you need to discuss the dawn phenomenon with your doctor. This is or can be caused by the normal wake up reaction of your body and your liver dumping glucose into your blood in preparation for waking up.

Some people notice that after an evening meal that their blood glucose levels are elevated over 180 mg/dl. This may mean that the evening meal was too large or carbohydrate heavy and the number of carbohydrates need to be reduced. Or, it is possible that an evening walk will help bring blood glucose numbers back in range. Other people will notice that after exercise that they are low, (below 70 mg/dl) and need to consider having as least a 15 gram (or larger) snack before exercising.

By knowing your blood glucose numbers, this will help you adjust your food intake and possible changes in your exercise regimen that will help in maintaining lower blood glucose levels. This in turn will help return a lower A1c reading and help in your diabetes management.

Know what your blood glucose numbers are will also help you know if you need to talk to the doctor about reducing your carbohydrates or if the doctor will need to consider, reducing medications, adding   additional medications, a change in medications, or even the need for insulin.

Tips for Glucose Testing – Part 1

Part 1 of 4 parts

I continue to receive emails asking me about certain of my blogs. A concern is other type 2 patients asking where to get testing supplies and where to learn how to use these supplies. I have had two emails a few weeks ago now saying that their doctor had not even told them about testing and when they called asking for a prescription for a meter and testing supplies, they were told this was not what the doctor wanted them to do. Someone needs to hang these doctors up by their toenails and drip water over them for a few days.

Yes, I can be that heartless about doctors that do not want their patients to learn about diabetes and how to monitor their blood glucose. One of the doctors near here does not tell patients either. I happened to see him in a store recently and asked him why he did not prescribe testing supplies. He just said it was none of my business. Now, I should not have been rude, but I had to ask, which grain producers were subsidizing him not to promote testing? Or, was it the USDA giving him money not to teach people about testing? He did what I expected, turned his back on me and walked away. Another person that was with him I did not know, but he stopped and asked me what I was talking about. I said that the good doctor was not teaching his patients with diabetes about blood glucose testing. He would not tell them about testing or getting testing supplies.

The person introduced himself as a doctor and asked what I knew about this. I said that I am a person with type 2 diabetes and that I happened to know several of his now former patients that he had not told about testing. I explained that he was known for not discussing diabetes with his patients other than prescribing medications. He asked if I had been a patient of his and I said fortunately no. I did say that I knew several of his patients that had diabetes and knew he did not discuss diabetes with them and discouraged their testing. He seemed concerned, but wondered how it involved me. I said that I am asked questions by people when they find out I have diabetes and how I know about testing. I said I blog about type 2 diabetes and have several friends that have type 2 diabetes. I said we do not keep it a secret like many type 2 patients and are willing to answer questions. I told him that a group of us are an informal peer-to-peer group and teach each other and reach out to other type 2 people. Our discussion ended when the doctor came looking for his friend.

I do answer the emails and often get further questions. I can tell that they have read the list of URLs because many of the questions come from these. I have a list of blogs from Tom Ross, David Mendosa, Gretchen Becker, and Alan Shanley that I like to use for different questions. Many find it difficult to believe that people can get off and stay off medications. Tom Ross has never been on medications and David Mendosa has been able get off and stay off. One of the more frequent questions is about self-monitoring of blood glucose. Apparently, this is a question that many doctors fail to answer and even many certified diabetes educators only touch on for people with type 2 diabetes. For many of the people, I urge them to read many of Alan Shanley's blogs and several of mine.

Another question is often how to obtain more test strips when they do not have the resources to purchase them out of pocket. These are hard to answer without knowing what meter is being used and who manufactures it. This often requires several emails to get information. I admit I like people that are not secretive and realize they are the one asking the questions and give me the information I might need. In the next few blogs, I will try to answer some of these questions in general and in specific where possible. See part 4 in the financial aid section of obtaining assistance this Thursday.

Recently I did receive an email newsletter that I will probably use for a little information. This was from “Diabetic Connect.” I will use some of it along with information from other sources.

Even with all the information, until you have a meter and test strips, and have read the directions for the meter and for the test strips, you are not ready to use either. I have seen too many people not take proper care of either and then look for someone to blame. I will repeat what I have said before – the meter and test strips are delicate equipment and need to be treated as such. Don't jam test strips into the meter, store the meter in the case to keep as it as lint free as possible. Keep the test strips in the container they come in for best care. Do not throw the meter up on the car dash and let it bake in the sun. I have seen this more times, than I can count. Some may have been in the case (hopefully those cases were empty) and others not even in a case. I would be surprised if they even worked and probably were inaccurate. On several occasions, even a container for test strips was baking alongside the meter. Hopefully the container was empty, as I doubt the strips in that container would work. If the people with diabetes could do this with their testing supplies, I must wonder if they even take care of their diabetes.

Another question I receive is about food and why they can eat this, but should not eat that. This question is not easy to answer because I do not know your body chemistry and without testing, I have no idea what your body is capable of handling. Some people become horrified when I say that they are now their own lab rat in their own experiments. This is why testing is extremely important. This will let you know how different foods and even different quantities of food affect your blood glucose levels. And because something works today, does not mean that the same thing will work tomorrow. Your day-to-day health can cause variances and even large variances. If you think my suggestion of heaving intensive testing for two or three months is too long, just wait until a large variance happens and you are unable to tell from your food log and daily health log what caused the variance. This is part of the education of being your own lab rat. You will need to be honest with your food log and daily health log. The only person you will be fooling is yourself. Yes, a great doctor can look at these and maybe give you assistance in adjusting what you eat, but the A1c will give the doctor an idea if you are not being truthful. To be honest, he does not care if you lie to yourself, but if you lie to him/her, they may not be willing to spend time trying to assist you.

If you have a great doctor that gives you excellent information, great! Once you leave the office, you are generally on your own. You have to interpret your food log, health log, and blood glucose readings on your own and learn what the answer may be for a blood glucose reading that is excessively high or why you had the low blood glucose reading. I will advise people with blood glucose reading below 70 mg/dl (milligrams per deciliter) to have glucose tablets available to take one immediately and then 15 minutes later test again, and repeat if necessary. Why the chalky glucose tablets? Because these are not candy and it is important that you remember why you had to chew one or more of these 15-gram glucose tablets. They are fast acting and better than drinking (or over drinking) a juice pack or over consuming other food. These glucose tablets are available at most pharmacies without a prescription and it is advisable to have about 6 to 12 on hand at all times. This means carrying them when you are at work, travel, or are out for a walk.

Life with diabetes can be challenging, especially when you are new to diabetes. You may not appreciate this if you are new to diabetes, given that you may be in denial or haven't accepted the diagnosis, but when you finally come to realize that you must accept the fact that you have diabetes, learn how to deal with it, and what you are capable of in managing diabetes, you will be thankful for these abilities. Those of us that have had diabetes longer often feel that even with diabetes, we are healthier than we were before diabetes.

Type 2 Blood Glucose Testing Problems

When two people you respect write about the same topic with seemingly opposing viewpoints, it really can make you scratch your head. Gretchen Becker first covered this and I was in full agreement with her. Her blog is here. Then David Mendosa covered the same study on February 3 here.

Gretchen's statement, “Here we go again! It seems that every few years another group announces that blood glucose (BG) testing strips aren't useful in patients with type 2 diabetes who don't take insulin.” This is an explanation often faced by people with type 2 diabetes not on insulin.

David's statement, “A big new review shows that people who don’t use insulin are wasting their time and money when they test their blood glucose.” This is something that got me to thinking and rereading both blogs very carefully. Both statements seem to be heading in the same direction.

After reading and rereading both blogs about this study in done in Europe, it is important to understand that the same types of studies are done in North America. The governments in Europe, Canada, and the USA, plus the medical insurance companies in the USA are all looking for ways to lower costs.

What should offend every person with type 2 about these studies is they use the term SMBG (self-monitoring of blood glucose) as if it were the culprit. They then state that blood glucose testing is a waste of time and resources. What they omit is that the medical professions in all countries are lax in giving patients the education necessary to understand how to use the blood glucose readings. They provide very little in guidance to their patients for proper decision making when looking at blood glucose readings.

Some of us around the world have been fortunate to receive some education in what to do with our blood glucose test results. Others have been able to research online and self-educate themselves. It is knowing how to adjust diet and exercise to keep blood glucose levels as close to normal as possible that gives meaning to testing. The readings are truly of no value unless you know what to do to bring high readings down and how different foods affect your blood glucose levels. This also applies to preventing lows and all extreme highs and lows.

In essence, you need to become your own science experiment with yourself as your own lab rat or mouse. This is where the challenge is and where learning how diet and exercise affect your blood glucose proves knowledge can be very powerful. There are many factors like general health, other diseases, mental or medical conditions can make this even more of a challenge.

This discussion is for those people not using insulin. So read both blogs and you will see that they are in agreement. They have stated that education is the power in knowing how to use blood glucose readings to adjust diet and exercise and possible other lifestyle adjustments for better health.