Preventing Hypoglycemia

My patience with the American Association of Diabetes Educators (AADE) is wearing very thin. It appears they are totally abandoning diabetes education for patients and concentrating on hospitals, outpatient and long-term care settings like nursing homes and group homes. I am happy that they are concerned for the elderly, but this emphasis seems a little over the top because many patients in these facilities in rural areas will not see any of this education or benefit from any of this education.

With the joint statement that was issued in conjunction with the ADA and AACE, at the ADA meeting, it appears the AADE is redirecting their efforts away from individual patients and to institutions serving patients. This could be great for the elderly, and the people in these institutions that are served by the AADE, but does not sound that great for those in rural areas and those not served by the educators.  With my blog from Sept 19, I need to change my mind and think those people living in rural areas and being cared for in rural hospitals and nursing home may have the advantage and they may not have carbohydrates shoved at them.

Often preventing hypoglycemia becomes a cognitive challenge for the elderly and many times, it is managed by others. This includes nurses and caregivers. Will caregivers receive any of this education – highly doubtful?

“During a presentation at AADE 2015, the annual meeting of the American Association of Diabetes Educators, Linda Gottfredson, PhD, professor emeritus at the University of Delaware in Newark, and Kathy Stroh, MS, RD, LDN, CDE, of Westside Family Healthcare in Wilmington, Delaware, said that emergency department (ED) visits and hospitalizations due to hypoglycemia are on the rise, and clinicians have an essential role in educating patients about the risk factors.”

Severe hypoglycemia is preventable in many cases. Insulin and sulfonylureas are essential drugs in the fight against diabetes. Some patients require these medications, but some are at risk for hypoglycemia by not using these medication properly, including when and how much insulin to inject or failing to recognize when they are at risk for hypoglycemia. In addition, many diabetes patients using the various sulfonylureas take their medication when they do not eat or are not feeling like eating.

It is this improper use of insulin or sulfonylureas that are causing the increase in emergency department (ED) use and hospitalizations. Why doctors will not educate these people about the dangers of insulin or sulfonylureas is a real puzzle to me. I have been fortunate to learn on my own and have been able to prevent the need for ED use.

Many cases of hypoglycemia occur during transitions of care. These include transfers for a hospital to a nursing home, or when there are changes in health care providers. It is not uncommon for doctors to provide ineffective communication between providers.

When it comes to individual risk factors, these include some of the comorbid factors, such as depression, cognitive impairment, epilepsy, cardiovascular disease, and advanced diabetes complications.

Age is also an added risk factor, pointing out that older adults are two to three times more likely than younger patients to have an adverse drug event requiring a physician office visit or an ED visit. Older adults are also seven times more likely to have an adverse drug event requiring hospital admission.

Diabetes self-care is a complex, cognitively demanding job for patients. It requires continual vigilance, learning, reasoning, judgment, planning, anticipating, and spotting problems. Then solving them in a timely and appropriate manner under constantly changing or frequently ambiguous circumstances that are unique to the individual.

Diabetes, Why Isn't Medicine Doing What It Should?

This was published in the British Journal of Diabetes and Vascular Disease. Some of you might like to read the article. In reading this, I have to wonder why the doctors in the United States cannot do anything right. For this, I think some of the blame belongs to the American Diabetes Association and the American Association of Clinical Endocrinologists. More of the blame belongs to the certified diabetes educators that do not educate, but use mandates and mantras.

Most of the blame has to fall on our medical insurance industry that listens to the Centers for Medicare and Medicaid Services (CMS), especially now that the insurance industry has learned how to sidestep the no prior exclusion part of the Affordable Care Act, by almost monthly changing the formulary from which they will reimburse for diabetes and other medications. Some insurance companies are doing exactly this and as a result, many people with diabetes are having a difficult time staying on one medication that is doing well for them. Some of the better companies are consistent in their formulary which is a good thing.

Diabetes care cannot prevent complications in every patient, but surely, doctors could prevent much of the tissue damage that happens in their patients' lives. Unlike in England, here the electronic medical records (EMRs) are very proprietary so that data on diabetes is impossible to obtain. Presently there is not a government agency that can collect data on a national basis to track diabetes and what works and what does not work. These same government agencies rely on information provided on a voluntary basis, which leaves gaping holes in the successes and adverse events that happen with diabetes medications.

The information collection and sharing needs to improve or more doctors will be leaving the practice of medicine. Yet, with the government not staying ahead of the progress, it could be another decade or more before EMRs become usable for the benefit of all – government, health care providers, and patients. Maybe then, the insurance industry will be forced into compliance.

The United States medical system relies on voluntary reporting for much of the data that the different government agencies rely on and report to the public. They cannot give accurate numbers of people at different ages with any type of diabetes. They presently use algorithms for most reporting which gives a very good estimate, but not an accurate number.

When people with diabetes are in the hospital, care has been improving, but still too many errors happen. The first is some nurses that don't understand the ratio for insulin to grams of carbohydrates for each individual. Then many doctors over use basal insulin and cause hypoglycemia. The other big problem is that the food plan for people with diabetes that is promoted by dietitians. It is overloaded with carbohydrates at a time our body needs fat and protein to aid healing, but the dietitians will not allow this.

I can understand that young doctors are less likely to choose Diabetes and Endocrinology as a career. It is a well-known fact that medical, nursing, and other healthcare students have little training in diabetes. There are not enough certified diabetes educators to serve the current diabetes population and with the projected increase, there is little effort to train more. One CDE organization says they are working on this, but when everything is tied up in committee, who is to know what intentions have priority. The other CDE organization is trying to put a strangle hold on who can practice as a CDE. Both organizations work with so few people with type 2 diabetes that I must wonder when they will force their members to stay away from mandates and mantras and start teaching diabetes education.

Until the Federal and State governments start requiring insurance to cover telemedicine, little growth in treating rural diabetes patients will happen. When I think of the diabetes education that could be taught by a form of telemedicine, it stinks that most healthcare providers will not use this. Then we have other medical professions working to stop telemedicine through state medical boards. This is protectionism rather than education at its worst.

Improving Type 2 in the Hospital

The more I read about diabetes management in hospitals the less I like the idea of having to utilize them. Some hospitals are better than others are, but all are inept in handling diabetes and maintaining management for diabetes patients. No, I did not make an exception – all are in one form or another inept.


The largest fault I find is the doctors and nurses do not attempt to find out from the patient what the insulin to carbohydrate ratio is that is used by the patient. This is a critical error and probably what drives policies of letting blood glucose levels stay in the 180 to 200 mg/dl. They generally do better for type 1 patients, but not for type 2 patients. I become so belligerent about managing my own diabetes that I am normally allowed to decide my own dosage based on the number of grams of carbs I consume after the fact instead of giving the injection before I eat or even see the food.


One time, I knew that I was not feeling like eating and was told that the carbohydrates for my meal was going to be 65 grams. I refused the short acting insulin until after I saw the food and knew I would only be eating about 15 grams of carbs from the tray. When the nurse started to give me the injection, I refused, as I could not see how many units of insulin were to be injected, and I was worried that I would have an episode of hypoglycemia. When I explained this to the nurse, she said that what she had would be injected and if I did not eat what was on my tray, I deserved hypoglycemia. And, I am to trust these people?


Yes, I called my doctor and the hospitalist and both were there shortly. After my explanation and the nurse's excuses, I was no longer hungry and said I did not feel like eating. My doctor was able to talk to me a little longer and supervised the removal of the tray of uneaten food. Just as he was ready to leave, back came the nurse with the syringe to give me an insulin injection. When the doctor examined the syringe, he laughed and told me to take it. After the nurse left, he said I know you calculate your dosage per grams of carbohydrates, but the nurse calculated it based on carb units so you should end up with a blood glucose level of about 120 gm/dl. After his office closed he came back to see me and measured my blood glucose and the reading was 116 mg/dl.


He in turn, called the head nurse and explained what had happened and that I was to tell the nurses what to inject. If they could not or insisted on their own calculations, I was to call him and then he would call the hospital administrator and the issue would be settled by the removal of a nurse if this would be required. The head nurse said she had complete faith in her nurses to calculate to correct amount of insulin so the doctor called the hospital administrated then.


The head nurse continued to back her nurses and the doctor and administrator put up a sign that I would calculate my insulin dose and they were to let me inject it. Instead of allowing me to submit my meal requests, the nurses took over this and every meal for the next day was about 80 grams of carbs or about 5 1/3 carb units. I still could not eat that many carbohydrates and refused. I was told that I needed so many units of insulin and the nurses would not bring any unless they agreed with me. The doctor said I was be discharged the following morning and to adjust as soon as I could. He was there early to get me discharged and once clear of the hospital, I took my blood glucose reading, which was 231 mg/dl. I injected my Novolog to my scale and drove home. Four hours later, I was back to where I wanted to be at 95 mg/dl and back on my schedule.


This leaves one more operation to undergo and I am still not sure where I will allow it to take place. I will be conferring with three doctors before I make up my mind and probably will be calling the new to me hospitals to find out what their procedures of diabetes management will permit and their guidelines are.