Reasons Behind Varying Blood Glucose Readings

We should be happy that Joslin has highlighted some of the less talked about variables in our blood glucose readings. When they have a blog that many people read, I am concerned that they are not including information that many bloggers do cover and complain about incessantly. Surely, Joslin has a larger reading base and could reach more people, but time after time, much information is totally ignored. Back to why blood glucose readings can vary dramatically even eating the same meal day after day.


#1. Food consumption can be a large component of blood glucose reading variability. Then when we remember that food labels, meaning carbohydrate count, can vary by 20 percent and sometimes more. And, we wonder why we get readings that vary.


#2. Meter accuracy can be a factor. With the exception of a few meters that are accurate within 15 percent on the low side in their test strips, all meters are supposed to be within 20 percent of actual blood glucose. Now we are learning that many test strips, once they have received FDA approval, do not meet that requirement in their test strips and yet the FDA is doing nothing about it. There is even greater questions about the test strips being brought into the US from other countries by CMS.


#3. Exercise and physical activity is another variable. The amount of exercise or other physical activity can draw glucose from our liver and put it to work in our bodies, shorting us later when we take our readings. Being sedentary can also affect our blood glucose levels when we are normally physically active and they can affect our readings.


#4. Insulin is also a variable. Yes, even our insulins are not that dependable. I quote what Joslin wrote. “One of these is the insulins we have available. NPH insulin is notorious for having large intra-individual variability (meaning you can get widely different results each time you use it), but even the newer insulins, Lantus® and Levemir®, are not anywhere near 100 percent reproducible every time. One study by Heise et al published in Diabetes found that the serum concentrations of insulin Lantus® and insulin Levemir® varied by 24 percent and 18 percent when participants received four same- quantity doses of the medication.” This is even more dramatic than I had thought.


#5. Liver output of glucose is a variable. Our liver puts out glucose when it is called upon by our bodies. When we have lost some of our pancreas capability, this can become a larger variable than we realize. This is especially true for those of us with type 2 diabetes.


#6. Emotions and stress are variables. Some people try to ignore this, but these are factors in our blood glucose production. It also can become a larger variable if you become stressed before taking a reading.


#7. Illness and injury is a variable. When you are on the verge of an illness, your liver can be called upon to supply more blood glucose to help in the battle of an illness. A severe injury can affect blood glucose readings as well, while a minor injury will have a smaller effect.


#8. Hormones are variables. In addition to a woman's normal monthly cycle, other things in our daily lives can increase or decrease our level of hormone activity and this will affect our blood glucose readings.


#9. Food consumed at other meals and snacks are variables. People are forgetful and often do not remember the extra carbohydrates they consumed the previous meal. It is that second small serving they had or the small 15-gram carbohydrate snack that turned into 25 grams of carbohydrates. Or maybe you had less to eat that anticipated. It is little things like this that can cause variances in our blood glucose readings.


If you think about it, whether you are a type 1 or a type 2 on insulin, calculating a dosage is a crap shoot. It is surprising that we are as close as we are most of the time. Knowing this also confirms why doctors are so nervous about hypoglycemia. Is it any wonder that when people forget to inject insulin or take their oral medication, we sometimes have very high spikes in blood glucose? Or when we take our medicine and then don't eat what we anticipated that we can have hypoglycemia.


Doctors will very seldom remind patients to not take a medication if they are not feeling like eating unless there is a blood glucose reading above a certain level. Doctors also forget to review the correction ratio for insulin to assist people for injections when they are ill or don't feel they can eat.


The above are not intended to be all inclusive of all variables, but should point out why people with diabetes have burnout from all the calculations and variables to keep track of on a daily basis. Our diabetes health is dependent on these considerations and our calculations. Sorry folks, the doctor can't do this for you.

mHealth Needs Scientific Health

This is an unusual topic for a blog, but needs publication and familiarization. The world of mHealth is growing everyday and according to Dr. Robert M. Kaplan needs to be done with good scientific health behind it. He feels that there is real scientific value once we move away from the hype.


I agree with him, as there is too much hype surrounding much of the mobile health devices on the market today and much of the hype is just to prevent you from seeing how little value or usability is in the devices. This is part of the reason the Office of Behavioral and Social Sciences Research (OBSSR) in the Office of the Director, NIH (National Institute of Health) was created by Congress in 1995.


The OBSSR mission is to stimulate behavioral and social sciences research throughout NIH and to integrate these improving our understanding, treatment, and prevention of disease. Read the full mission statement here.


There is a lot of excitement surrounding the use of new mobile and wearable health information and sensing technologies. Their potential to enhance health research, improve health, while also reducing the cost of health care is needed. However, strong scientific research is needed to examine their potential and challenges of their use. This will put companies on notice that hype will not get them a pass to use.


The OBSSR has funding opportunities to help in the development of devices that can fulfill these goals and this can be read here. Unfortunately, it is not all about devices, but includes social sciences and behavioral sciences as well. Take time to explore the site.

Is the Doctor-Patient Trust On Life Support?

The answer is not a straightforward yes or no, but is dependent on where you live, your current age and whether you have good insurance. Yes, Medicare is considered insurance, but some doctors are no longer accepting patients on Medicare. And here I am not including doctors that are operating on contract medicine. In largely rural areas, often the patient must travel long distances to see a primary care physician or even further to see a specialist.


If you live in a doctor dense area, then you have an easier task of finding a doctor that may be the right fit for you. Under the law changes happening because of the Affordable Care Act, the next couple of years may be difficult for some patients. As the changes take place, some patients may become dissatisfied with the doctors they are required to see, as it appears there will be a team approach once you become a more complex patient with two chronic illnesses or diseases. Once you are on Medicare, this may become even more problematic.


No one can say with certainty how we will be affected by the physician shortage or where the physician shortage will be in relation to the population most needing physicians. Many physicians are leaving private or small practices for employment with hospitals. Other physicians are leaving smaller towns for larger cities and larger practices. A few are setting up small practices in larger communities.


Dr. Shirie Leng has a blog about the doctor-patient relationship and why the trust is waning in this relationship. While she does not become severe about patients, I may be reading between the lines, but I do come away with the feeling that she feels many patients would be better off putting more trust in their doctors.


Her statement here is very much on target. “Trust has many components. It is based partly on compatible communication styles. The Journal of General Internal Medicine points to the patient’s assessment of the physician’s communication, level of interpersonal treatment, and knowledge of the patient. In these times of short visits, short-tempered doctors and patients, and fragmented treatment, all those factors are in jeopardy. Patient dissatisfaction implies poor trust. Race and gender of both patient and doctor has an impact. Patients who genuinely like their doctors tend to trust them more.”


Dr. Leng does balance the scale when she uses information to put her own profession in a poor light when she talks about the paternalistic approach to medicine. Does she mean that female doctors are better? I had to ask this question as I have seen both sides of this issue and the bad female doctors are often worse that male doctors in similar situations. Yet on balance, more female doctors empathize with their patients than male doctors ever have.


In the 1950's, it was thought that physician trust was based on doctors treating everyone equally. Today the media has promoted this as not true and that there are other reasons to be concerned, such as regional differences in the standard of care.  A number of stories are used for breaking this thought. Doctors that over-prescribe, take money from drug companies, and turn down Medicaid patients are just a few of the things the media makes sure we are aware of.


All the data is soft and outdated in the research on doctor-patient trust. Current discussions suggest doctors are losing ground on this issue. The following things might help a little: (I will quote Dr. Leng's ideas, as they are relevant.)
1. “Doctors cannot take money from drug companies. Ever. Not even a pen. Just don’t do it.
2. Practice good communication, or learn how if you don’t know. This goes on both sides. If you don’t understand, ask. If you are the patient, bug the doctor until you are satisfied. If you are the doctor, ask and answer for as long as it takes.
3. Take money out of the conversation. Universal health care is the only way to do this successfully.
4. There is nothing wrong with finding a doctor who is the same gender or ethnicity as you.
5. Understand that nobody has all the answers. Doctors don’t know everything, patients don’t always know what they want, and none of us like this fact. We like to think medicine is an exact science but it is not.
6. Doctors must keep up with the latest real research. We must go to our annual conferences. Where I work, the only people who get to go to the annual conference are the people who are presenting, who are the researchers, who always go, and who do less clinical work. No. Everyone goes. Close the ORs. Close your office. Can’t afford to close your office? Use the databases like UpToDate, which has a hundred doctors employed solely for the purpose of gathering the latest clinical info.
7. Tort reform. All the research and conferences in the world don’t do anything if people are afraid to follow what the research says.
8. Patients cannot expect miracles. Those days are over. Patients cannot expect that they can get every test and treatment known to man. Those days are over too.
9. Let’s all recognize our humanity.”

What Is A Patient to Do – Provide BG Data?

This has been a sore point with me and several of the “diabetes coaches” I have come across in the last few years. Of the five, four were of the opinion that you should never take your blood glucose meter to a doctor appointment. They felt that this was your information and the doctor did not need it. The fifth said take it or not, it was your data and it was up to you whether you shared it or not.


Now I understand why I could not do business with these “diabetes coaches.” I have always been one that believed the more eyes on the data, the better I would be, because what I missed, the doctor might catch and prevent problems down the road. Plus, I have found it easier to convince the doctor that I was doing things correctly and not to be so uptight about my A1c's. This is because they worry too much about hypoglycemia. I am glad they have the concern, but as long as I don't have severe episodes, I don't get concerned about readings above 55 mg/dl. Below 55 mg/dl, even I have concern. They worry about anything below 80 mg/dl and with the new guidelines for 70 mg/dl they had better not complain about mine above 70 mg/dl.


This study, presented at The Endocrine Society Annual Meeting and Expo; June 15-18, 2013 in San Francisco does point out that those that bring their meters to their appointments, have a lower A1c than those that don't. The difference is significant at 1.2% less for those that brought their meters to appointment for Medicaid and Medicare patients.


Therefore, I will continue doing what I do and bring my meter, which is downloaded and the data used during my appointment. And I will continue to stay away from “diabetes coaches” that advise not taking my meter.

When Does Hypoglycemia Happen?

This is another reason many, if not most, doctors will not prescribe insulin. It seems this is the nemesis that many doctors just can't accept because once the patient leaves the office; they are no longer in control. Hypoglycemia has now been proven to happen at any level of HbA1c and this can only make physicians more nervous. The upsetting information for me is that this is for type 2 diabetes patients.  The study did included several ethnic groups and was evenly divided between male and female.


This study, DISTANCE (diabetes study of Northern California) was a survey. Making the study more useful was the fact that the survey data was linked with clinical, pharmacy, and laboratory data from participants' electronic medical records. The researchers studied the relationship between HbA1c levels and hypoglycemia using a sample of 9094 diabetes patients between the ages of 30 and 77. The patients were from Kaiser Permanente Northern California and were surveyed in 2005 and 2006.
They were treated with glucose-lowering medications in a usual care setting. The patients were asked about severe hypoglycemia requiring assistance during the prior year.


Dr. Kasia Lipska of Yale University, and colleagues reported that as many as 10 percent of patients with type 2 diabetes reported experiencing severe hypoglycemia. Dr, Lipska reports that the risk is high across all levels of glycemic management. Instead of the usual expectations of hypoglycemia being more of a concern as patients are brought to normal glycemia levels, the survey showed that patients at the highest risk of hypoglycemia also included those with very poor glycemic management.


The authors note, few studies have indicated any conclusive relationship between patients in the usual care setting and changes in glycemic management. The duration of diabetes was based on self-report and was categorized as "10 years or less" or "more than 10 years." Participants were evenly split between men and women. The majority of patients were older than 50, with 32.2% of participants ages of 50 to 59 and 33.7% of participants ages 60 to 69.


Participants with diabetes for more than 10 years were more likely to report severe hypoglycemia than those with a duration of 10 years or less (13.9% versus 8.3%). Hypoglycemia was most common in patients receiving insulin therapy (19%) and least common among those using oral glucose-lowering therapies (5.8%). Despite those differences, there was no distinguishing relationship between HbA1c and age, diabetes duration, or category of diabetes medication. Regardless of what you may have read before, hypoglycemia occurs just as often among those with poor blood glucose management as it does for those with excellent blood glucose management.

Guidelines and Those That Develop Them

When I read this by Dr Malcolm McKendrick, I had to think how like some other guideline committees I have written about lately. Dr. McKendrick writes about the group that wrote the cholesterol guidelines and how they attempted to hide the conflicts of interest that those on the guideline committee had. For that digging and forcing the issue, I hope that I am able to properly thank Dr. McKendrick someday.


This paragraph from Dr. McKendrick's blog really makes the point. “In 2004 this committee decided that cholesterol levels should be lowered far more aggressively than in the past. Based on, as far as I could see, very flimsy evidence. Could it be that that committee was, in some way, biased in favour of cholesterol lowering companies? A number of people, including me, demanded to see if any of the eight invited members of this hugely important committee had financial conflicts.”


Yes, they certainly did have financial conflicts and this has to mean that there needs to be more concern about statins our doctors insist that we consume.


This type of digging was necessary for the American Association of Clinical Endocrinologists diabetes algorithms issued on or before April 24, 2013. At first they did not give out any information about the algorithm, conflicts of interest, and missed many points. After a Medscape article and a New York Times article, they still took over a month to issue a consensus statement for the algorithms. Many points were still omitted because they won't accept them as being what happens in the real world. Yet many of us with type 2 diabetes know better and think that the members of the committee are out of touch with what happens outside their towers.


Members of our support group have been thinking that we are the fortunate ones to have doctors that do not completely align themselves with the AACE. We are in agreement that people with conflicts of interest have no business being on committees that develop algorithms or guidelines because we know the bias they bring to the discussions. Whether it is true or just supposition on our part, we feel that some of the conflicts result in extra fees for many of the committee members.


I personally feel that if they had issued a consensus statement with the algorithms, there may have been less criticism, but the criticism they received was well placed and pointed out the shortcomings of the algorithms. It showed us how incomplete the algorithms are in opposition to Dr. Garber's “comprehensive” statement.

Patients – Use the Internet!

First, let me give you a few warnings. You will be better served by most doctors by not telling them that you are using the internet. Why? Because they have overly sensitive feelings and it is their job to diagnose and treat you, and not the internet. One way to help you determine if you have one of the doctors that will be upset is to ask if they will suggest any internet sites that might be helpful for the problem, illness, or disease you are seeing them for as a patient.


If you are ignored, can see them bristle, or they say they don't want you on the internet, take them seriously. Some doctors will not answer your question. You will need to be prepared to educate yourself and you do not want to discuss your findings with this doctor. Do not bring reams of paper to your appointments as this can only create problems for you and may mean that you will not obtain the treatment you need. Yes, doctors have been known to dismiss patients that use the internet. Other doctors will give you some treatment, but not necessarily, the treatment or attention you need.


If you are seeing a doctor or doctors employed by hospitals or members of a large medical practice, (probably 10 or more doctors), expect them not to use emails with you and to balk at internet discussions. Their time is so restricted for each patient that they do not want to spend time in internet discussion. In addition, their emails are often monitored to the point that they only will use them for official office business and nothing for the patients. There may be a few exceptions, but I have not encountered any. Now that does not mean that doctors in single or small practices may not do things differently and there are those that do. I have been able to have some valuable discussions with a few. Blogging can have some positives, but you can expect some negatives.


One of the members of the diabetes support group I belong to, was told not to use the internet. Because he knew he would, he asked the doctor why. The doctor was more forthcoming than expected and stated that there was very little information on the web that was reliable. He said that there was information, but most of the reliable information was behind the pay wall and even then, much of the information was incomplete or misleading. In addition, when a group of us searched, the doctor was correct. There was conflicting studies, articles with no study basis, and in general we could tell that most was unreliable. At his next appointment, he asked the doctor where he could read reliable information. The doctor handed him a medical book that was well marked up and said if he would return it in two weeks, he could read the information in it. After he had read the relevant information, his comment to us that if it was not for the doctor's notes, even that was not the most explanatory. And admittedly, for a rare disease, this was the best source available to-date.


An acquaintance who likes to research on the internet commented to his doctor about information he had found and the next thing he knew, the doctor was leaving the room and telling him not to come back. Surprised? He was as he knew the information he had made a comment about was reliable and was on the professional organization web site this doctor belonged to. When he found another doctor, this doctor said he knew why he was looking for another doctor – that he had mentioned the internet and was dismissed by the doctor. The new doctor said he could use the internet and ask questions as long as he did not bring stacks of paper to the appointment. As their doctor – patient relationship grew, the doctor gave him the email address with the stipulation of not to abuse it, but that if he had a question about something he was reading, to send him the URL and his question and the doctor would either answer it in an email, or at the next appointment. This has worked out very well for both of them.


Second, there are doctors that are not bound by restrictions because they don't work for a hospital or a large practice and they are willing to talk freely about internet use. They will work with you and direct you to reliable internet sites. They may ask that you do not abuse their time, but in general will answer questions related to the problems you see them for as a patient. They may answer a question with a question to get you to think and often this can provide the answer if you carefully do your reading. If you are truly stumped, they will provide an answer.


My own personal advice is to treasure these doctors and do not abuse the privilege of emails and asking them questions. I have one doctor that I now have the home email address because the doctor knows I will not abuse it. It has been several months since the last question, but that was answered promptly and with many references that answered the questions I was encountering. The doctor could tell from my question where I was going and I know anticipated many of the future questions. I did send a thank you when I completed my reading as the references were great and I did not need to ask more questions.


I hope this gives you some thoughts and provides some ideas for your internet use and especially avoiding or creating problems with some doctors.

An Unplanned August Group Meeting – Part 2

Part 2 of 2 parts


After thinking about the events surrounding what we were able to accomplish for George, I felt it would be good for all of us to have some points to refer to and for George to consider when he finds friends that have type 2 diabetes. Do not push unless you are a good friend and they do not balk at your offer for help. Even then, you may need to take time to gain their confidence. It does not always work as easily as it did for George or like it did for A.J.(first of four parts). Even the person from this blog has refused help, but his wife is talking to Tim and me rather frequently. He just does not want to take ownership of his diabetes and his wife is working patiently in the background to do what she can to encourage him.


Points for helping friends with type 2 diabetes:


#1. Determine what their level of diabetes knowledge is. This may require some time if the person is secretive. In the case of Barry's friend, it was just that he was not aware and he had not been told or received any education. We as a group were also fortunate that everything happened as it did and we had the resources to take action. Even Tim sent a letter from the group thanking the doctor for his efforts.


#2. Assess what they have been told by their doctor. Our case was easy as George's doctor had basically left him in the dark and had not given him any resources to help guide him. For some people this may take time, as they do not wish to talk about what is between their doctor and him/her. This is where we sometimes may need to back off and just let them know we are available to answer questions and that we have a support group available to call on.


#3. Evaluate what they are doing. Have them explain what they do for their daily care and then determine what they can afford to do differently. Explain the different lifestyle changes to them and where they might be able to make beneficial changes.


#4. Determine how insurance is helping and if necessary what it will cover. This may be an area that will be difficult to draw out, but if the person is not getting supplies, it may be necessary to strongly encourage the person to discuss this more openly.


#5. Is there anything that we can do immediately. We were fortunate with George that he was willing to let his friend help him. In this case, he needed to know his A1c and to obtain some testing supplies. He was very appreciative and surprised when he tested by how little pain he was having. He even stated that he would be buying extra test strips since he could afford them to be able to test more frequently and felt that this would decrease once he learned more.


#6. Talk about self-monitoring of blood glucose and its value. Barry told us the talk that he had with George about self-monitoring of blood glucose and how to interpret the readings. He even said he would be combing my blogs for reading material for him and George was surprised at my blog when he read a couple of blogs. Barry included the URL in an email to George.


Information that may be helpful for friends and others:


#1. Talk about medic alert jewelry and senior alerts if they live alone. This blog has this information and links to other information. Tim did cover this after a few of us needed to leave.


#2. Find out if they might qualify for VA benefits. For people that have served in the military, this is one benefit that can really save the day for some. If you are uncertain, contact your local Veteran Affairs Office listed in your phone book and find out when you qualify and how to apply.


#3. Find out if they are interested in self-education and research. I do encourage people to self-educate themselves, but not everyone is interested and many will not. Relying on the doctor is not the best thing to do, as there are many things only you can do to maintain your health with diabetes.


#4. Discuss locating financial aid and develop a list of sources. Many medication and diabetes supply manufacturers do have assistance programs. You need to contact them and follow their directions to receive assistance. I am still collecting information on this.  One of the great sources is on David Mendosa's site at this link.


#5. Be available to answer questions. Often it is difficult to get people to ask questions because they honestly have no idea of what they need to ask. A few are bold and ask a question not knowing how it will be answered. What can be discouraging is receiving questions that are stated in an attempt to elicit the answer the person asking desires to hear. I know these people and they get the answer they did not want. At least most of the people that are aware of our group are asking questions they want an honest answer they can use.


#6. Discuss food plans and talk about different types of plans. Here again Tim covered this with George and there was more questions. Even Ben and Barry had a few questions. Since there are so many food plans, it is often difficult to know what plan is best. I can only suggest using your meter to discover what the different foods or combinations of foods do to your blood glucose levels. This is the way I developed my food plan, but with each person being unique, you need to develop your own.


After Tim, Allen, and I discussed the above, Allen stated there has to be more, but he would work on this and I could add those to a future blog.