Not A Game Plan for Type 2 Diabetes

While not really a game plan at all, there are some features that this site may bring to peoples attention. Probably the only reason I found this site is an article in Medscape. After researching on the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) websites, I did not find a link to BloodSugarBasics.com  http://bloodsugarbasics.com/. Is this intentional? Maybe. Both websites do little to promote what they hype in articles or interviews, so it is small wonder that little is accomplished in bringing visitors to their sites.

Even my own endocrinologists do not promote this during office visits or include information about it in handouts. Why am I writing about this? Someone needs to promote what the professionals are seemingly incapable of doing. I think the person that made this comment – quote - “Unfortunately, like the AAFP, the AMA and ACC have also let us down. The societies today exist for their own purposes and not for the benefit of members. The AMA owns the CPT code system and makes more money from this behemoth than from member dues. The ACC is enthusiastically offering "products" (read $$$) to "help" doctors meet their performance goals.

It is beyond time for new professional societies to emerge that actually advocate for physicians involved directly in patient care. Perhaps one big "Society for Patient Care Physicians" that could involve everyone who actually sees patients every day, rather than the academic guideline and rule-writing "doctors" who dominate societies today.” - Unquote.

I think the comment is on target and needs to be done so that doctors that care for and about patients could have a format to get information to patients in terms they understand and this could be promoted for patients. With the Internet of today, what could be of value to patients is often lost in the dogma of the medical organizations. Most could have on their home page a link to patient information and then links on the patient page for more pages of valuable information. This information could then be reliable information that can be used for the benefit of patients and used by patients.

Even the website for approved Internet websites on the AACE website no longer has a direct link to it on the home page. Plus, they are not adding anymore approved sites. They have fulfilled their promise so-to-speak, and now want to leave it alone. For the two sites of the AACE and ACE, there is so much information that could be included as part of their websites. However, at most, the information is limited for patients and not really informative for new patients that may be searching these sites for reliable information.

On the same site is a tab named “The ABCs of Diabetes Management.” This did not surprise me as they are A1c, blood pressure, and cholesterol. Surprise, no mention is made about statins. Blood pressure goals are different than recommended by the American Heart Association, but not significantly higher. From the way the material is presented, the emphasis seems very much on the HbA1c as the measurement for how well the goals are being accomplished not any individual blood glucose tests. At least the A1c goal is 6.5%, but then they say that maybe the goal will need to be higher. No mention is made about individuals that want to strive for lower A1cs or if they will even allow for this.

Then they use four topics to help in achieving the ABCs. They include healthy eating, getting more active, taking your medication, and tracking your ABC goals. I was totally surprised at the healthy eating. They rightly say to limit refined foods and eat vegetable and some fruits. Maybe a little heavy on the fruits, but no mention of whole grains. The limited discussion on getting more active was not bad, but the discussion missed a lot of physical activity. Taking your medication(s) did not discuss any particular medication(s), but the suggestion is there. The concern for hypoglycemia is present and that is a plus. Tracking your ABC goals missed more than it covered. It talks about tracking your blood glucose levels, but does not give any meaning to why track and what to be looking for in meaning. To me, it sounds more like the reason is for the doctor than looking for reasons to the daily numbers.

In the medscape interview, Farhad Zangeneh, MD, FACP, FACE did a good thing in answer to a question about why not use the more effective treatment of bariatric surgery for all obese type 2 patients than have them struggle with lifestyle changes to achieve treatment goals. I will quote his answer - “Not all patients with type 2 diabetes are candidates for bariatric or metabolic surgery, and no matter how much weight is initially lost, there is always weight rebound. There are no easy answers and no shortcuts in the management of diabetes. Even if patients are candidates for bariatric surgery, their psychology — mindset and eating behavior — has to change before their anatomy. There is also growing evidence that patients who undergo gastric bypass surgery are prone to hypoglycemia. For the majority of patients with diabetes, management still boils down to healthy eating, physical activity, and pharmacological medical management.”

As for the goals of “The Game Plan,” most of the information is on a need to be done basis and not education about diabetes and the reasons for doing what is all but demanded that patients do. Some information is there and for some patients that function in this manner, it may be of value.

What I think is that few people are going to find this site without a direct link to it from the AACE main page or even a link from the ACE page. Few patients with type 2 diabetes ever read the articles from the medscape dot com site and I have not seen any other mention of the site elsewhere. Granted I do not read every website, but I think Merck was sold an idea with no solid intention of promoting the website by AACE. Some people will find the website from search engine use, but that will be a small number. Great idea, but no support of the site by AACE.

Back to Diabetes Basics – Part 11

Insulins

It is often difficult to know which is the official term for the different types of insulin. One author will use one set of terms and a different author uses another set of terms. Then when you get out the magnifying glass and decipher the text on the materials supplied with the insulin, you will occasionally see a third set of terms. For someone new or even experienced with using insulin, this can be a little confusing.

Since I do not have but two types of insulin that I use, I cannot find the terms best used in the materials supplied with many of the insulins so if you have other types, do not hesitate to add comments with the terms used. The best chart I have found to-date for the terminology is this in WebMD. An incomplete listing of terms can be found here on the Joslin site and I will add other terms that I have been taught from various sources.

The medically correct terms listed here are from many sources and the most often used. I have added other terms I have been taught or that I have learned over the years.

• Onset refers to when the insulin starts to work. I was taught Begins or Activates.
• Peak refers to when the insulin works hardest. I was taught Effective Period and Period of Maximum Effectiveness.
• Duration refers to how long the insulin works. I was taught Length of Usefulness.
• Official sources list nothing about when insulin ends and I was taught End.

Next, we need to consider the types of insulin:

• Rapid-acting - I learned fast-acting insulin.
• Short-acting - This was never explained to me and I lumped it with fast-acting,
• Intermediate-acting - I learned this as 12-hour insulin.
• Long-acting - I learned this as 24-hour insulin.
• Pre-mixed - I learned was mixed insulin.

Now that you have an idea of the different terms used, understand that this applies to the average person with diabetes. All the directions and times used are for the average person. I take Lantus, which is a 24-hour insulin. I cannot count on this as through experience and my body chemistry, I have learned that I have an 18 to 20 hour effective period of insulin use. Others have no problem of Lantus lasting for 22 to 24 hours. I believe your own body chemistry has some effect on the effective period insulin will last.

After discussing this with my endocrinologist after changing times for injection and always having problems at the end of the 24-hour period, we decided to split my Lantus injection and take half the dosage twelve hours apart. To many this is stacking insulin; however, this has eliminated the dawn phenomenon for me and leveled out the total day for me. For some people this does not work.

If you look at this chart in NIDDK, you will see that Novolog duration is 3 to 5 hours. I normally get the 3 1/2 hours and no further benefits. For every person, you will need to monitor carefully your results to determine if you are in the average group, or if you fit another area.

I never thought that being my own lab rat would be any fun, but over the years, I have learned otherwise. More than once my own experiments have proven beneficial in managing my diabetes more effectively. This does not mean that I have not needed to repeat experiments, as I have. Sometimes, I need to make adjustments and other times they become temporary. Each person has to find his or her own level of comfort and tolerance.

Some weeks are great and sometimes days can become a nightmare trying to discover what needs to be adjusted. Keeping a positive attitude and realizing that some times an answer will not be discerned is important. Do not be taken aback when later you realize what happened. Just remember for the next time.

Two excellent insulin charts are available here and here. I will not reproduce them and urge you to bookmark them or print them out. The times shown in the chart are estimates. Your onset, peak, and duration times may be different. You should work with your health care professionals to come up with an insulin plan that works best for you. Learn the principles of insulin use and how they affect your body. Like oral medications, learn how you manage insulin and know that if you skip a meal, do not inject any of the rapid-acting or short-acting insulins as you are just asking for an episode of hypoglycemia.

Your doctor should work with you to prescribe the type of insulin that is best for you and your diabetes. Deciding what type of insulin might be best for you will depend on many factors, including:

Your body's individualized response to insulin. How long it takes insulin to be absorbed in the body and remain active in the body varies slightly from person to person. Here again, one-size-does-not-fit-all.

Your own lifestyle choices -- for instance, the type of food you eat, if or how much alcohol you drink, or how much exercise you get -- are all factors that influence your body's processing of insulin. Also taken into consideration should be the insulin resistance factor. If your doctor does not talk about this before prescribing, try to discuss this. This could make adjusting to insulin easier.

How willing you are to give yourself multiple injections per day. Many people with type 1 diabetes prefer insulin pumps and use them almost exclusively. That is their choice and I personally prefer the multiple daily injections and not having to worry about tubing or extra equipment being attached to my body.

How frequently you are willing to check your blood sugar level? I have been considering a continuous glucose monitor (CGM), but it is another piece of equipment to deal with. I will leave these decisions to each individual. If you choose to use a CGM, know that most readings are approximately 20 minutes behind what is actually happening. You should be looking at trends and acting on them. Always use your blood glucose meter to verify what the CGM is telling you.

Your age, and your blood sugar management goals are important considerations.

Follow your health care provider's guidelines on when to take your insulin. The time span between your insulin shot and meals will vary depending on the type of insulin you are taking.

In general, however, you should coordinate your insulin injection with when you want to eat. From the charts, the "onset" column provides useful information. Again, the "onset" refers to when the insulin will begin to work in your body. You want the insulin to begin working in your body at the same time your food is being absorbed. This timing will help avoid low blood sugar levels. I suggest printing out the chart you prefer and have it handy until you learn the timing.

One instruction I have not seen, but have learned over time, is a correction calculation when your blood glucose level is higher than planned either at the end of the duration, or prior to your next meal. Since this will vary for each person, I will only urge you to discuss this with your doctor and then work on refining from that point. I have my correction ratio figured out for myself, but you need to work with your doctor to refine how you arrive at your correction dosage of insulin.

For more information about when to take insulin, read the "dosing and administration" section of the insulin product package insert that came with your insulin product or talk with your doctor. Sometimes a doctor can think one thing and say another unintentionally, so please do not be afraid to ask. This is also a method of reinforcing what you need to do for best diabetes management.

On July 5, 2012, David Mendosa posted an excellent article about the value of being aggressive at the beginning with insulin and preserving the function of the pancreas for many years. This is worth reading even if you were just diagnosed with prediabetes or diabetes.

One WARNING is in order. If you are taking insulin with an oral medication, you are more susceptible for having hypoglycemia. Make sure you understand the symptoms and be prepared to test more frequently.

Series 11 of 12

Back to Diabetes Basics – Part 10

Insulins

No, I did not leave this for near the last because it is the treatment of last resort for most doctors. I wanted to do my research and leave this series with what I feel is a great topic that needs attention. And, being near the last topic, you may remember more about it.

We know that people with type 1 diabetes can't live without insulin, but the medical community (especially the American Diabetes Association (ADA)) seems to think that people with type 2 diabetes can. In this light, they promote oral medications and if the first one they prescribe does not take care of the problem, they keep stacking oral medications. They will not prescribe insulin until they deplete the oral medications or have no other choice. I say they are causing more harm with this method of treatment than they doing patients good. From the preceding blog, you can see some of the side effects caused by oral medications.

That is not to say that insulin has no side effects, as insulins can. Some people are allergic to the insulins not produced by their own body, and for them insulin can be very toxic. Fortunately, their number is small and sometimes can be overcome with the right introduction and treatment regimen. For an even smaller number some insulins (not analogue insulins) approved and still on the market outside the USA will work for them. The remaining people will never be able to tolerate insulin that they do not produce in their own bodies.

For many years, the insulin used by people with diabetes was produced from the pancreases of pigs and cows. Synthetic human insulin derived from genetically engineered bacteria first became available in the 1980s, and now all insulin available in the United States is manufactured in a laboratory. Although the development of synthetic human insulin was a boon for most people, especially those who were allergic to the animal insulins, a few people find that they can manage their diabetes better using animal insulins.

Although animal insulins are no longer produced in the United States, the FDA allows individuals to import animal insulins for their own personal use. See their Policy on Importation of Drugs (1998) for more information. The Insulin Dependent Diabetes Trust, a nonprofit group in the United Kingdom, has additional information on animal insulins, including contact information for a company in the U.K. that still manufactures them. Explore the site if you need more information.

The major side effect of insulin can be a dangerously low blood sugar level (severe hypoglycemia). A very low blood sugar level can develop within 10 to 15 minutes with rapid-acting insulins. Always have glucose tablets, 6 oz or 8 oz juice drinks, or other suitable fast acting carbohydrates available to treat hypoglycemia. Glucose tablets are the fastest acting and most reliable.

Insulin can contribute to weight gain, especially in people with type 2 diabetes who already are overweight. The myth about weight gain on insulin happens to be fact, although in reality it is muddied up by people. For people with type 2 diabetes, taking insulin can cause weight gain. There are several reasons for this. The one factor that comes to the front is people use insulin as the medication of last resort. Normally this is fought until there is no longer any choice, insulin cannot be postponed as blood glucose levels are out of control and oral medications cannot keep blood glucose levels down.

Because insulin is often the medication of last resort, two factors can cause weight gain. The first is inactivity or sedentary lifestyle. This may be caused by diabetic neuropathy, which makes it difficult to walk more than short distances. The second is people do not reduce the intake of carbohydrates when going on insulin.

Why is the second necessary? Because insulin is necessary, when first started, insulin makes management of blood glucose levels easier. Instead of losing some of your carbohydrates in your urine when your blood glucose exceeded your urinary limits, these carbohydrates are now put to work or stored as fat. This new efficiency in blood glucose management generally causes initial weight gain.

This is the main reason that people starting on insulin should consider reducing the total carbohydrate intake for a period of time while your body adjusts to the efficiency. However, if you are a person that is able to exercise on a regular basis and you do this, your carbohydrate intake may not need to be reduced greatly and may be resumed shortly after starting insulin.

Weight gain is always a possibility for some body types and these people must learn to manage their carbohydrate intake to avoid weight gain. The article did say that you should limit your insulin dosage, which is only possible, if you reduce your intake of carbohydrates. I will also reemphasize their statement of using exercise to aid in insulin use to burn calories and help keep insulin use low. This will aid in preventing weight gain.

Other possible side effects of long-term insulin use include the loss of fatty tissue (lipodystrophy) where the insulin is injected and, in rare cases, allergic reactions that include swelling, or edema.

What can affect insulin? Some factors that affect how fast and how well an insulin dose works are:

• Where the dose is given. If you give insulin into your abdomen (especially above and to the side of your belly button), the medicine will get into your system more consistently from day to day. If the medicine is given into a muscle or a small blood vessel instead of fatty tissue, the medicine will get into your system faster. This is generally not recommended by most doctors.
• How much insulin is given. Higher doses of insulin reduce the blood sugar level more than lower doses. Do not overdose!
• Whether you have exercised before or just after taking insulin. If you have just exercised the muscles in the area where you give your insulin injection, the medicine will get into your system faster.
• If you apply heat to the area. The medicine will get into your system faster if you take a hot bath or shower, put on a heat pack, or massage the area where you have just given your insulin injection.
• If you do not drink enough water and you are dehydrated, you will not have as much blood flow to your skin, so insulin will not be absorbed as well as it would be otherwise.

Things to do

• Label each insulin bottle when it is used for the first time, and discard unused medicine after 30 days. A bottle of insulin may lose its potency after 30 days of use. Most inserts accompanying your insulin will state 28 days.
• Store insulin properly so that its effectiveness is protected. Storing it in the refrigerator is the ideal place, but preferably not in the door to avoid vibrations when the refrigerator door is opened and closed.
• When you buy insulin, check the generic or brand names to make sure you are buying the correct type. For example, if you have been using Humulin-R (insulin regular), make sure you buy Humulin-R instead of Humulin-N (insulin NPH).
• Know when your prescribed types of insulin start working (onset), when they work most (peak), and how long they work (duration).
• Know how to give an insulin injection.
• Once you have started using the vial of insulin, it generally is not necessary to return it to the refrigerator. Only return it to the refrigerator if the temperature in the house or apartment will be above 85 degrees Fahrenheit for an extended period of time as this will shorten the life of the insulin or make it unusable.
• Keep insulin out of direct sunlight and in Frio packs or a cooler with cold packs if it is in a vehicle for any length of time or while traveling or hiking.
  

The Internet does have some good tips here and if you search, you may find more.

One word of encouragement you should take away is that a move to insulin does not mean you have failed in your diabetes management. Just the fact that you are reading this should mean that you are doing you homework and learning about insulin. True, most doctors use insulin as the medication of last resort and this should not be the rule. Once one or two of the oral medications have not worked, instead of letting your doctor stack on more oral medications, give insulin serious consideration.

Series 10 of 12

Back to Diabetes Basics – Part 9

Oral Medications

Without a medical degree and not taking oral medication for over eight years, I am not sure I will cover this as well as I should. There are six classes of oral medications, pills if you will. For some people who do well with being able to stay on schedules and can avoid timing problems, these may work very well for you. The six classes are -Biguanides, Sulfonylureas, Alpha-glucosidase inhibitors, Thiazolidinediones, (glitazones), Glitinides, and DPP-4 inhibitors.

The one thing about oral diabetes medications that makes me happy and not to be taking them is the side effects. Some of them are not too severe. It is the new side effects that happen with some classes that frighten me. Most may cause weight gain and one is weight neutral, and may help with minor weight loss.

No, the oral medications do not have insulin in them. This is what some people believe and are astounded when they learn that there is no insulin. This may be one of the myths of why people feel so strongly about taking oral medications over insulin shots. No, I am not forgetting that many people have an unhealthy fear of needles. Others have had a fear of needles and have learned to conquer this fear.

To learn more, let's take a brief look at the classes of oral medications – pills:

Sulfonylureas

These medications work on your pancreas to produce more insulin. When they overwork the pancreas, you will not be able to produce your own insulin.

Who should not take Sulfonylureas - talk with your doctor about whether to take this type of pill if you are allergic to sulfa drugs and you are pregnant, planning to get pregnant, or breastfeeding.

This class has the most numerous medications and causes hypoglycemia by itself or in combination with other medications. These pills are known to cause upset stomach, skin rash, and weight gain.

Biguanides

This medicine, which comes in pill or liquid form, lowers the amount of glucose made by your liver. Then your blood glucose levels don’t go too high. This medicine also helps treat insulin resistance. With insulin resistance, your body doesn’t use insulin the way it should. When your insulin works properly, your blood glucose levels tend to stay on target and your cells get the energy they need. This medication also works to improve your cholesterol levels.

It also may help you lose weight or can be weight neutral. Do not expect this medication to work immediately as this will depend on your body and the dosage prescribed. Because of the immediate side effects often, your doctor will start you out slowly and gradually increase the dosage. For some, results will happen in one week and for others, the benefits will not become effective for two to three weeks. It is strongly suggested that this medication be taken with food.

You should not take this medication and need to talk to your doctor if you have advanced kidney or liver disease, you drink large amounts of alcoholic beverages, or you are pregnant, planning to get pregnant, or breastfeeding. Sometimes you'll need to stop taking this medication for a short time so you can avoid developing lactic acidosis. If you have severe vomiting, diarrhea, or a fever, or if you can't keep fluids down, call your doctor immediately. You should also talk with your doctor well ahead of time about stopping this type of medicine if you will be having special x rays that require an injection of dye, you will be having surgery, or you will have having a colonoscopy. Your doctor will tell you when it is safe to start taking your medicine again.

This medication will not cause hypoglycemia by itself; however, they will increase your risk if taken with diabetes medications that cause low blood glucose, insulin, or certain other medications. Your doctor should advise you to lower your other diabetes medications while you take this medication.

The side effects are nausea, diarrhea, or an upset stomach when you first start taking this medication. These side effects normally go away or subside after a while. Rarely, a serious condition called lactic acidosis occurs as a side effect of taking this medicine. Call your doctor immediately if you become weak and tired. become dizzy, feel very cold. have trouble breathing, have unusual muscle pain and stomach problems, or have a sudden change in the speed or steadiness of your heartbeat

Alpha-glucosidase inhibitors

This medication helps keep your blood glucose from going too high after you eat, a common problem in people with diabetes. It works by slowing down the digestion of foods high in carbohydrate, such as rice, potatoes, bread, milk, and fruit. These are foods that you should not be eating or at least limiting in quantity.

You should not take this medication and need to talk to your doctor if you have bowel disease or other intestinal conditions, you have advanced kidney or liver disease, or you are pregnant, planning to get pregnant, or breastfeeding.

The side effects are risky if you do not follow careful guidelines. While it is said that this medication does not cause low blood glucose by itself, risks go up dramatically if combined with medications that cause hypoglycemia or insulin. Here again your doctor should advise you to lower your other diabetes medications while you take this medication. These medications may cause stomach pain, gas, bloating, or diarrhea. These symptoms usually go away after you have taken these pills for a while.

WARNING If you take Glyset or Precose, only glucose tablets or glucose gel will bring your blood glucose level back to normal quickly. Other quick-fix foods and drinks won't raise your blood glucose as quickly because Glyset and Precose slow the digestion of other quick-fix foods and drinks.

Thiazolidinediones (glitazones)

I do not want to discuss this class as one medication has been pulled from the market and the other should be. Actos has been shown to cause bladder cancer and now another study shows it raises diabetic macular edema. Read this link for all the warnings and the Food and Drug Administration advice. This is all I will say on this class.  Added Aug 17, 2012 - read this by Gretchen Becker.

Glitinides (Meglitinides)

Confusing isn't it? Yes, and it took me some time to decipher that both terms refer to the same class of medications. This is the medication needed to replace Sulfonylureas if you are allergic to sulfa. These are medications used to make your pancreas product more insulin for a short period following meals.

You should not take this medication (Prandin) and need to talk to your doctor if you are pregnant, planning to get pregnant, or breastfeeding, or you have liver disease. The side effects of Prandin include low blood glucose (hypoglycemia), weight gain, upset stomach, and back pain or a headache.

DPP-4 inhibitors

These are medications also used to make your pancreas product more insulin for a short period following meals. These medications also work to prevent stored glucose from being dumped from the liver into your blood stream.

You should not take this medication (Januvia) and need to talk to your doctor if you are pregnant, planning to get pregnant, or breastfeeding, you have kidney disease, you have type 1 diabetes and if you have a condition called diabetic ketoacidosis. The side effects while not causing low blood glucose by itself, do increase if you take medications that cause low blood glucose, or insulin. Here also your doctor may advise you to take a lower dose of other diabetes medications while on Januvia. Other possible side effects include a cold, a runny nose, sore throat, or headache. If you take Januvia and have kidney problems, your doctor should order blood tests to see how well your kidneys are working.

Combination Medications

I have chosen not to discuss this group of medications, but instead refer you to the charts. I would also suggest printing out the charts and keeping them handy for reference. They may be found here and here.

With all oral medications, you should communicate with your doctor and may sure you understand the answers to the following questions and keep this for your records as well:

1. What are the names of my medicine? Class Name:

Brand name: Generic name:

2. What does my medicine do?

3. When should I start this medicine?

4. This medicine is prescribed by:

5. How long will it take this medicine to work?

6. What is the strength (for example, how many milligrams, written as mg)?

7. How much should I take for each dose?

8. How many times a day should I take my medicine?

9. At what times should I take my medicine?

10. Should I take it before, with, or after a meal?

11. Should I avoid any foods or medicines when I take it?

12. Should I avoid alcoholic beverages when I take it?

13. Are there any times when I should change the amount of medicine I take?

14. What should I do if I forget to take it?

15. If I'm sick and can't keep food down, should I still take my medicine?

16. Can my diabetes medicine cause low blood glucose?

17. What should I do if my blood glucose is too low?

18. What side effects can this medicine cause?

19. What should I do if I have side effects?

20. How should I store this medicine?

These are important to your health and you need to understand the answers. I would even suggest printing out the list and covering them with your doctor. Also have an extra list to give the doctor to answer and mail to you if you are short on time. Most doctors will do this because they understand the importance. If your doctor says read the inserts that come with the medication, then keep the list and discuss the questions with the pharmacist. Some of the answers may also be found in the charts or in this discussion. You may wish to find your medication(s) in these inserts and print out the information relevant to each.

A study that may be of interest to you can be read here. It discusses the points about oral medications and claims it clarifies drug choices for people with type 2 diabetes.

Series 9 of 12

Back to Diabetes Basics – Part 8

Learn to Count Carbohydrates

Many people say this is too complicated and try to guesstimate. This is a bad habit to get into and should be avoided. Do I guesstimate? Not that often and with eight years plus of calculating carbohydrates I have gotten fairly adept at doing this. I do make mistakes, but not that often. I hope that you will find some tips that you can use.

If you are lucky enough to have a class with a certified diabetes educator (CDE) or a registered dietitian (RD) and they cover how to read and understand food labels, absorb everything they tell you. I did not have either one that knew what they were doing and labels were to be ignored by them. Therefore, I had to learn on my own. Lucky for me a neighbor, at the time, was a nutritionist and she saw me reading labels in the grocery store one afternoon and asked if she could help. I admitted that I was having some success and that I would like to make it easier.

Now let me back up and cover a couple of other things first. Do not go out and buy cookbooks that have the word diabetic in the title. You will find that most are written by someone without diabetes and the recipes are overloaded with carbohydrates. Most are also for foods that few of us can actually afford some of the ingredients in the recipes.

Do consider buying some of the new editions of the standard cookbooks, Betty Crocker's and Better Homes and Gardens that have the nutritional information with each recipe. They also have the servings per recipe making calculations easier. Example: the recipe makes 6 servings and there is 28 grams of carbohydrates per serving, you have the information. Now I would normally say that it made 12 servings and that would mean I would have 14 grams of carbohydrates per serving. Granted, I normally chose servings of four so that I would only have eight servings to eat since at the time I was living alone.

I did cheat and have a gram scale and an ounce scale and still do and I use both. I would always weigh the container in which the food was to be cooked and then I could subtract that from the total weight or have a tare weight. If I wanted the recipe to serve six servings, I would weigh the plate or container to transfer the food to and tare the scale and then I knew how many ounces to transfer and could compute the carbohydrates. I could then add so many ounces of vegetables and compute their carbohydrates.

I do not know what food this label came from, but I will use it for a brief discussion.

Before going further, I need to point out that the FDA allows food labels to vary by 20 percent. This is bad for us with diabetes, but is the reason I always stress that you need to use your meter to see if the numbers are high or low after eating. Then you can have a variance of 20 percent with your meter. Did someone say this is a crap shoot. You may be right, but over time I have discovered that in general most canned foods are fairly close to total weight and carbohydrates. Now recipes in any cookbook with nutritional values may not be as close. There are too many variables for precise accuracy. To begin with when you purchase the ingredients, there may be a difference in the quality you purchased compared to the sample tested to arrive at the figures used in the cookbook.

This label is still a good example to use. Each serving has 40 grams of carbohydrates and only 4 grams of dietary fiber. Since I follow the rule of counting half of the fiber when fiber is 5 grams or more, I do not subtract any grams for fiber.

This is a point of debate by many and my former neighbor said only subtract one-half of the fiber if the total fiber per serving is 5 grams or higher. Some subtract all fiber regardless and others will subtract one-half of any amounts of fiber. Unknown on most labels is whether the fiber is water-soluble or not. The total grams are 275 grams so that if I have a 30-gram serving, then the carbohydrates would be 5 times 40 grams or 200 grams. Multiply 200 by 30 and divide by 275, which equals 21.8 grams of carbohydrates. Or, multiply 40 by 30 and divide by 55, which equals 21.8 grams of carbohydrates.

This is one reason I find the scales so useful as they can resolve carbohydrates amounts very quickly. So with the costs of the scales and a hand held calculator, I have gotten my money out of them many times over. Yes, I do spend a little more time getting this information, but it does allow me to be more accurate and know what I need to cover with insulin. Then my meter reading will confirm this and I will know that the serving size was correct. For oral medications, the meter becomes even more important to determine if the serving size was too large, too small, or just right.

Here are a few tools that you may find useful. First a book by Gary Scheiner M.S., titled The Ultimate Guide to Accurate Carb Counting. I have a different book, but this does come highly recommended. A website that may interest some is this one that has nutritional values that can be determined from a recipe. It is my understanding that you need to join to have access to the information here, and it is free. You may also get the nutritional value from a list of ingredients. There are other websites that you may find by using your search engine.

Diabetes Burnout

Why do people with diabetes have diabetes burnout? There are probably many reasons, but I think a majority of people just get tired of managing diabetes 24/7/365 with no vacation or time off. You test, eat correctly, exercise when capable, take your medications timely when you should and still diabetes is there waiting for you to make a mistake so it can gain the upper hand.

Will Ryan has several blogs and an introduction that often can help with diabetes burnout. His site “Joyful Diabetic” is worth reading and it does reflect his positive attitude. For many a positive attitude with managing your diabetes can help you through a down time and even burnout.

William H. Polonsky Ph.D., CDE, has written a book titled Diabetes Burnout: What to Do When You Can't Take It Anymore. This is one that I will be adding to my library. It is also available on Kindle.

Series 8 of 12

Back to Diabetes Basics – Part 7

Medical Alert Jewelry

When I started this series, I did not realize that I would find so many topics that could be considered good basics, and I haven't even covered oral medications. Medical alert jewelry is something many people do not consider until it is too late. For many, this realization happens after they have their first episode of hypoglycemia. The police may become involved because of erratic driving and because people display symptoms very similar to a drunk driver, they are arrested and jailed without treatment.

Or, a family member discovers you on the floor passed out. They do the proper thing by calling 911, but forget to say you have type 2 diabetes and you are hooked up to an intravenous (IV) solution loaded with dextrose and this is continued when you arrive at the hospital. Now you are in hyperglycemia and nobody knows you have diabetes yet. Think of the damage that could have been prevented with medical alert jewelry.

If you think I am in favor of wearing a medical alert piece of jewelry, you are right. I have talked to the first responders in areas near my town and in my town, and they are trained to look for medical alert jewelry, and even tattoos in conspicuous places. They may not find some that are tattooed in private areas. I have written several blogs and while you may not agree with every thing I say, please consider wearing a medical alert piece of jewelry or a medical tattoo. The blogs are four and can be read here, here, here, and here.

Diabetes Management and Doctors

Here is where I normally get aggressive with the doctors, but this time I will try to cut them some slack. Diabetes management is primarily the responsibility of the patient and this is the focus for most of this discussion. Why? The doctors cannot live with you (unless you are married to the doctor), they see you less than one percent of the time in a year, and the rest of the time, you are generally on your own.

Now I know that you as the patient are not always supplied with all the information necessary to understand and manage your diabetes. Don't always blame the doctor, as there is only so much time available for an appointment. If you doctor gives you some information, this shows he/she is trying. He does have time constraints especially if he does not own the practice and works for another doctor or is employed by a hospital. Both can be so profit minded that they do not often allow for proper patient care. This is why other types of medical practice are finding openings and gaining acceptance rapidly.

So just who is stopping you from managing your diabetes? Is it family members? How I dislike saying yes, but family members can be the worst in preventing good diabetes management. Why would I say this about loving family members? Well, loving family members can be the least understanding and the most unwilling to learn about diabetes. They just want you to take a pill and return to the life you had with them before diabetes.

Many family members could care less about diabetes because you do not look sick and are doing the same things for them that you were doing before diabetes. Even your loving spouse can totally ignore diabetes and not want to learn about it. Why would I say these things? Because I read about this on many diabetes forums. Husbands or wives not supporting the spouse with diabetes.

Then the family members can be very irritating when they become the diabetes food police or the diabetes police. Asking you why you can still eat that piece of candy or cake when it is loaded with sugar. Even though you have allowed for this treat and compensated for it with what you have eaten, they will still not leave the subject alone. They don't understand that sugar is not the only thing you need to be careful of consuming.

They do not understand why you will not eat many foods and have very small servings of others. They start hearing horror from well meaning friends and translate this to fear about you developing the same problems. They become your worst nightmare as the diabetes police and some can become very belligerent in their actions.

Then there are those family members that will just not cooperate. You have gotten rid of the junk food and are working to convert everyone to more healthy foods and doing more cooking and serving more fresh foods. They insist on eating no differently than the past and won't accept the change like they won't accept that you have diabetes.

There are families that do support each other and do whatever they can do to make things easier. They know and accept the change in foods and understand that things are now different and they are benefiting as well by the changes being made. This makes for a much more loving family and home. If you are so blessed, do everything to keep this blessing and make it grow.

Now back to you! Yes, I am talking about the person with diabetes. No, I'm not going to give you a pass. We have all been through the stages of grief many people experience after receiving the diagnosis of diabetes. So get over the anger, put the denial behind you and make up your mind that you want to live and manage diabetes.

Learn that diabetes is not your fault. Could you have prevented it? Not likely. If doctors would have done screening on a regular basis, maybe, if they had paid attention to the results. The one chance you had may have passed. But if you are strong willed and decide, if you are medically able, to do the exercise and nutrition with enthusiasm, you may be capable to getting off medications for a period of time. This will depend on the damage already done to your pancreas. Some are able to stay off medications for decades while others only for a few years.

Many people do not comprehend that because diabetes is often different for each person, that they now have become their own science experiment. Testing can be very difficult as Medicare and most medical insurance companies are strictly limiting test strips that they will reimburse. Testing is necessary to determine how your body reacts to different foods. Testing is also necessary to give you a report on how you are managing diabetes. Numbers are just numbers if you don't make use of them.

Good luck and learn to manage your diabetes, deal with those around you, learn to make the best use of your doctor(s), and other resources.

Suggestions for Doctors

Yes, some doctors do accept suggestions. I hope that these make sense and will help them help patients with diabetes. I urge doctors to visit this page of the Association of Clinical Endocrinologists and at least give this as a handout to their patients with diabetes. Even family members could benefit if they are receptive. While this page has existed since September 27, 2011, their experts have not seen fit to add more websites to the list. Why? That I cannot answer, but I think they have decided to stop rather than promote more sites. Note: The above link no longer exists because AACE could not do what was necessary.

Certainly many doctors do use the Internet, and have their favorites for diabetes that they could add to this list. Some doctors do have contact with nutritionists and could have a handout for this as well. A very small number of doctors are making use of peer mentors in some locations to be mentors for certain aspects of diabetes, like proper hand washing and testing locations and even use of their meters. There may be other areas of use.

Series 7 of 12

Back to Diabetes Basics – Part 6

Exercise Is a Key in Diabetes Management

Maybe some of us emphasize this too much and too often, but it is one truth that many people with diabetes just feel they can ignore. You will get tired of this as well; many type 2 people just say, “Apparently the doctor did not feel it was important as he/she did not talk about it.” I am beginning to believe these people need a hearing test, but I do know a few doctors that are afraid to say anything also. This is a deadly set of circumstances to work with in attempting to get people to exercise.

Always consult with your doctor before beginning any exercise regimen. If you are on medications, your doctor may want to give you different dosages to use under different circumstances to prevent hypoglycemia. Even if you are not on medications, the doctor may have other health concerns that you may need to consider. I have discussed blood glucose levels for safe exercising in my blog here. Knowing this information will save you from problems while you exercise.

I have more information about how a neighbor made me realize how important exercise is. He has had the second operation and is walking with a cane today. He is still unable to drive, but he walks just about everywhere and will not accept a ride. Yes, I have driven when he has too far to walk or needs to travel to another town. Even when he needs groceries, he walks and shops for only what he can carry. You have to admire him for his determination. If anyone could have given up, he could have been the person, but he has met every opportunity to educate others and show them what a person can do.

Lifestyle Changes

Do you know what this means? Many people have some idea, but it can be very general. This may be just semantics; however, I would like to clarify some parts of the term “lifestyle”. The definition from an on line dictionary says lifestyle is a way of life, the attitudes, tastes, moral standards, economic level, etc., that comprise an individual or group.

This of course says nothing about diabetes and managing diabetes. In my reading, blogging, and participation in a few diabetes forums, I have seen lifestyle described many ways. I have a slightly different perspective as most writers start with diet. I believe the elements of lifestyle change should start with exercise if you are physically and medically able. It is the key that generally makes the rest of lifestyle fall into place.

What you need to recognize is that all are interlinked and bypassing one part of lifestyle change will normally make other changes generally unachievable. What different writers choose of emphasize depends on their philosophy and how they view their career. Most that work in the medical profession, be they doctors, nurses, educators, dietitians, or licensed caregivers, must follow the guidelines of the American Medical Association, the American Diabetes Association, and other professional medical groups if they want to have their license updated and current.

Since I answer to myself and a few bloggers that agree exercise should be listed first, this is where I will start. This is the list I have pulled together from various sources. It may not agree with everyone's list, but for me, the list needs to be updated as changes are found that affect the way we look at diabetes and lifestyle.

The main elements of lifestyle should or must include the following: exercise, food, sleep, food, medication, weight loss, illness, hormones, stress, heart health care, and two other elements, alcohol and smoking.

Exercise – If you are physically and medically able, get your doctors okay to exercise, and remember to exercise good judgment and don't do something that will be wrong and cause injury. Start out slowly and build up gradually. Regular exercise helps make insulin more readily available and reduces insulin resistance. Find a form of exercise or a mix of routines that you enjoy and follow through with it.

Food – Healthy eating is important and even more important if you are medically unable to exercise. It is good to be consistent in eating times and amount of food. Whether you eat low carb or another way, learn to use your meter to determine how different foods affect your blood glucose. Learn to coordinate your food with the medication you are taking. Also, learn to eat to your meter and learn to trust it.

Sleep – Where did this come from? It is not included on most lists, but should be after a study I wrote about here. I keep being surprised how important sleep is to our well-being as a person with diabetes. That is the main reason I am adding it to lifestyle and encouraging all to get the sleep needed. If you are having trouble getting enough sleep, change your habits and if that does not help, talk to your doctor about doing a sleep study to determine if you have a form of sleep apnea.

Medication – Be sure that you follow the doctor’s instructions. Yes, I know that you want to avoid all medications. This is an excellent goal if you are diagnosed early on and can make this work. Remember that you need to consider getting the diabetes managed as soon as reasonably possible. Do discuss with the doctor getting off medications if you do it. If you do bring diabetes under good management and the doctor wants to keep you on medications, then ask yourself if a change in doctors needs to be considered.

Heart health care – Because people with diabetes are at 50 percent risk of having cardiovascular events, many of the same changes for diabetes help with heart health. It may still be necessary to consider medications for heart health. Exercise and food choices become primary for heart care and managing cholesterol and hypertension.

Weight loss – This is easy for some people, while others struggle with this every day. The first goal should be stopping gaining any weight. Then adapt your food intake to help start reducing weight. Generally if you are overweight, a high carbohydtate, low fat diet will not help you reduce weight. There are more and more writing about low carb, high fat. However, you need to find what works for you in assisting to bring down the weight. I will not suggest how, since I am still working on this myself.

Illness – This was a little surprising until I thought about how illness affects our diabetes management. Therefore, as an element of lifestyle change we need to learn to take our medications timely and know when to talk to the doctor about variations like illness which can cause problems unless we know not to take certain medication to prevent hypoglycemia. This means having a plan with your health care team of what medications to take or not take during an illness.

Hormone levels – This is normally for women who have problems with blood glucose swings related to the monthly menstrual cycle. I personally think the authors failed to talk about the change in life for women and problems some men can have when male hormones cause problems and can affect blood glucose as well. You need to talk about this with your doctor to be prepared for these changes.

Stress – This is definitely a lifestyle change that affects everyone with diabetes. When stressed, almost anyone can toss aside their usual good diabetes management practices, forget to eat healthy foods, and lose control of your blood glucose. Prolonged stress may prevent insulin from working properly which also creates additional problems. Some find logging your stress level (1 to 10 scale) each time you log your blood glucose level helps them see patterns and allow you to adjust accordingly. Learn about ways to relax and find ways to reduce stress.

Alcohol – This can be a bad one if not thought out. First, you need to talk this over with your doctor. Alcohol can aggravate diabetes complications like nerve damage and eye disease. If your diabetes management is excellent, and the doctor agrees, an occasional alcohol drink with a meal may be okay, but a daily drink is generally discouraged.

Smoking - This is a habit that must be broken. Many writers do not want to cover this lifestyle change that needs to happen and the sooner the better. Not only does this increase the effects of neuropathy, but it can affect an increase in cardiovascular risks. Do not take this lightly; the effects of continuing to smoke do not make blood glucose management easier.

To sum up, these are the lifestyle changes that need attention for those of us with diabetes.

Series 6 of 12

Back to Diabetes Basics – Part 5

Diabetes Complications

Complication don't cause themselves. Poor or no management of diabetes – meaning not testing, not losing weight, not eating healthier, not making other lifestyle changes, and no blood glucose management is what causes the complications. So what are the complications?  Retinopathy, neuropathy, nephropathy, atherosclerosis, and deafness are the most common, and many don't include deafness. The first three and deafness are grouped together under the term microvascular complications because they result from damage to the small blood vessels. The macrovascular complication is atherosclerosis, which is caused by damage to the large blood vessels.

Retinopathy causes damage to the retina, which may lead to poorer eyesight or blindness. Neuropathy causes damage to the nerves, which cause pain and can be more than annoying pain. Nephropathy causes damage to the kidneys or increased renal problems leading to kidney failure or chronic kidney disease (CKD). Deafness or hearing loss is caused by the eardrum losing the ability to transmit sound because of short blood supply. Atherosclerosis can lead to heart attacks, stroke, or poor healing of wounds in the feet and legs. This is the cause of amputations.

These are the reasons those of us that blog about diabetes for people with type 2 diabetes discuss this so often. We are encouraging you to manage your diabetes by maintaining your blood glucose levels at or as close to normal as possible to prevent the complications from starting. The closer your A1c is to 7.0 percent or above, the greater the chances are for the complications developing. That does not mean that people with A1c's of 6.0 will not develop complications, just that their risks are smaller and increase the closer to 7.0 they become. Above 7.0, the risk of complications rises dramatically as A1c's goes up.

That does not mean that once you have an A1c above 7.0 that you give up. By managing your diabetes more carefully and bringing the A1c back to 6.0 or lower, you can stop the complication from progressing or slow it dramatically. Damage will still likely have been done, but if stopped or slowed, you may not notice any change and if early enough your body may be able to heal the damage. Continued forays above 7.0 may mean that the damage will become worse and your body may not be able to heal or repair the damage. Keep a positive attitude about managing your diabetes and work to manage your diabetes and not diabetes managing you.

Diabetes Myths

Diabetes myths are a dime a dozen and I keep hearing about them again and again. Why people have to believe them is not something I understand. I was not exposed to many of them until after I had diabetes for a year and had been on insulin for about as long. I knew immediately when confronted with them by a person that is no longer a friend that there was little or no truth in what he was telling me. In an hour, I lost track of the number of myths he was repeating and finally had to ask him to leave.

That evening after cleaning up after my evening meal, I did go on the computer looking for some of what this person was telling me. Even then, there was not a lot of information about some of what he said. I started looking on David Mendosa's website, but even he did not have a lot in December 2004 about what we refer to now as myths. I did locate this item and it got me started looking for more. Eventually I did find a site that today no longer has the page David wrote about, but back then, it was as David described it, “While several Web sites around the world have a page like this, Diabetes UK's is the best and most authoritative of any that I've seen.”

I now wish I had copied the page, as I am no longer able to locate it. They covered a lot of myths and then gave an authoritative explanation. There were sites that listed myths with no explanation, but many were like or similar to things my visitor had sought to enlighten me. The following evening, he returned with a fresh list and wanted to educate me with his diabetes knowledge. I patiently informed him that these were myths and had no basis in fact or scientific evidence. He went ballistic on me and said I did not know what he was talking about and if I truly had diabetes, I would understand what he was saying. With that, I walked him to the door and informed him that I had diabetes and was on insulin. “Oh,” he said, “I did not know you were that close to the end.” I then told him to leave and never come back if he was going to talk about diabetes.

I have also blogged about diabetes myths. Rather than repeat them, I will link them and let you read them - Blog 1, Blog 2, and Blog 3. Another blog that talks about a myth here and then this one on insulin and weight gain which is often a fact for many people, unless they are aware of the things to do right and prevent this from happening. One myth that I find little to support was told to me by a diabetes educator and it was that type 2 people could not see an endocrinologist. Funny, I see many type 2 people having appointments with an endocrinologist.

Diabetes Scams and Scammers

Diabetes is ripe with scams and scammers. To get you started, read this article by David Mendosa. In the article, the government list no longer is a valid link, but David did list some of them and I don't know if they all work, but I like the list just for show of the types of sites trying to scam us. Many more have appeared since David wrote this in October 2006. Some sites are very slick in their design and enticing to any readers they can lure to their sites. I have had several email me in the last year wanting me to advertise their products. After a thorough investigation of their site and the claims some make, I can see right through the scam or falsehood, if you will allow.

I am unlike David and I will not even give you a link to any scamming site as I will not give them any notice since they do not deserve being noticed. Yes, I could educate you by listing them, but I don't need the hate mail several of them are well known to retaliate. There would still be readers that would fall for some of the information so I feel better not listing them.

If you think these are the only types of diabetes and other scammers, guess again. Tom Ross has a blog here that uncovers some that are involved in research and scamming funds to do research. I was almost in disbelief, but after checking with a couple of sources within the pharmaceutical industry, they confirmed this blog, but would not be specific about what had been done.

Food for Diabetes Patients and Introduction to Glycemic Index

This is not a topic to be taken lightly by people with type 2 diabetes. However, the one comment I get all too frequently is, “the doctor just told me to eat more healthy,” or “my doctor said nothing about what foods to eat or not eat.” I often have to wonder if this is selective hearing, or the doctor really did say nothing. I know many doctors are not knowledgeable in nutrition for people with diabetes so this is possible. I also know some people bypass the appointments for a class in nutrition and feel it is too late for them to change. Unhappily their A1c results are reflective of their habits – above 8.0 and often much higher.

Even though I am a little over expressive in this blog on diabetes diet, it still covers some important points. Another blog is here. I have mentioned the glycemic index for foods. The best reference is here in the books blog, The New Glucose Revolution, New York, Marlow & Company, 349 pages, by Dr. Jenny Brand-Miller, et al. It is in a sense the best available currently.

Do take time to study the glycemic index tables for foods. Do not believe these are gospel because the index is determined by testing normal people and not people with diabetes. Do use it only as a guide for determining which foods may rapidly raise your blood glucose. By using your search engine, there are many available (key words – glycemic index). Table sugar has a glycemic index of 80, so compare that to the white potato.

My words of warning are good, and a guide is what it should be. It is not about complete food nutrition and is good for giving you guidance to foods that will not spike your blood glucose levels.

Series 5 of 12

Back to Diabetes Basics – Part 4

Proper Hand Care for Blood Glucose Testing

Hand washing is an important part of preparation for blood glucose testing. Laugh if you will, but about 95 percent of people testing blood glucose skip hand preparation over 50 percent of the time. I am also guilty as charged, but I calculate it is about 10 percent of the time that I don't wash my hands a well as I should. Being on insulin makes me more careful and much more concerned in obtaining the right reading before injecting insulin.

My eye opener was a reading before having my evening meal about two years after diagnosis. I knew what my carbohydrate count for my meal was and then added my correction to the reading. About three hours later, I was nervous, sweating, and wondering what was happening. I thought to test my blood glucose and it was over 200 mg/dl (11.1 mmol/l). I knew that was wrong as I would not be feeling nervous and sweating. I did think to wash my hands very carefully and dry them and retest. Reading then was 42 mg/dl (2.3 mmol/L). I grabbed three glucose tablets, started chewing, waited 15 minutes, and retested. Only up to 65 mg/dl (3.6 mmol/L), so had another glucose tablet and repeated. My blood glucose was 77 mg/dl (4.3 mmol/L) and I figured that I would wait another 30 minutes and test again. This time the reading was 81 mg/dl (4.5 mmol/L) and I knew I was okay.

Yes, the low reading scared me. I realized that I had eaten something with my fingers and one of them was the same finger I used for testing. From then on, I was careful about washing my hands and drying carefully. 

I had a very smart pharmacist who asked me why I was buying so many alcohol pads shortly after being diagnosed. I told her they were for cleaning my hands before blood glucose testing. She suggested that I put them back on the shelf and not use them. She examined my fingers and said no damage yet. She then said the alcohol pads would dry out my skin and the skin would start to crack. Since this was December, I knew what she was saying and when they did crack, my fingers would be sore. Testing would not be painless and I would dread doing it. Yet our companies still want us to use alcohol pads instead of warm water and soap to clean our hands before testing. Ignore their advice, please for the sake of your fingers and testing reliability.

One huge example of this appeared January 31, 2011 in Diabetes Care. The same study then appeared in Reuters Health on February 9, 2011 and is worth reading. If you needed to be reminded of the importance of washing your hands with warm water and soap, this should be a good reminder. So if you have a BG reading that seems too high or too low, please ask yourself if you washed your hands properly and thoroughly dried them (particularly the finger you will use for testing). If you are using insulin, this is very important. You want to inject the correct amount of insulin to prevent hypoglycemia especially, and you want to prevent your BG levels from rising into the levels for hyperglycemia.

Another good article with tips to make testing less painful is here. Please read tip number 8 because he does not mean the front of your fingertips so read the entire point.

Importance of Self-monitored Blood Glucose (SMBG) and Type 2 Bloggers

I started this topic in Part 2 of the series in “Some of the Testing Basics.” Knowing when, where, and how to test needs to be supplemented with the why. First, you should know where to test. Use the side of your fingertips. This has two advantages: there are less nerve-ends than on the pads, and it doubles the number of test-points so you can rotate through the positions. I also use the pads, which does get me to change the lancets a little more frequently, but you don't need to do what I do.

Alan Shanley has three blogs that are all on the topic of testing and for his perspective read his blogs – “painless pricks”, “test, test, test”, and “test, review,adjust.” You may use the search box on his site to search for and read his blogs on SMBG. Another website that should be on your listfor reading is by Jenny Ruhl. These sites cover the reasons, the why, how, where, and when.

You may also test on other parts of you body, arms being to next most popular area. If you are generally consistent in your blood glucose, you may be okay testing there. If you are inconsistent, please avoid other areas of your body. The blood glucose readings will be about 15 to 20 minutes behind your fingertips. When you are having hypoglycemia, you do not want this delay, as this could mean going lower than you want without treating properly. This is one reason many of us discourage using other body areas and staying with the fingertips.

When to test will depend on the number of test strips you are able to utilize. You should be able to test at least two times per day if on oral medications or no medications. If you are using insulin you should be able to use four test strips. Whether you are able to test more will depend on your own budget and possible assistance from the manufacturer of your meter and test strips. Some do have good assistance programs. It is generally suggested that one of the testing times be your fasting blood glucose test upon waking. If you are limited to two times per day and unable to afford additional test strips, then consider saving them for a needed time when you have messed up a strip, have an emergency, or need to use them to prevent them from passing the expiration date. You may also use them for testing after a meal. I suggest using them at the 1 hour mark after your heaviest meal, or the meal having the most carbohydrates.

Make sure you use a logbook or other form. I use a steno pad or wire spiral notebooks for recording my BG readings, the time, insulin injected, and food log and time of eating including snacks. Most meter manufacturers have software and cables available for use at a price. I do use mine and like the charts and graphs, which shows trends and readings in the hypoglycemia area and hyperglycemia range. Otherwise you have to chart your readings to see trends. This is the why, when, where, and how of testing for type 2 diabetes.

This is to inform you of the need for extra testing if you have an emergency and the doctor puts you on steroids. Make sure you know the name of the steroid to be used and discuss diabetes management with your doctor while taking steroids. I believe all steroids, and know most steroids cause blood glucose to be extremely elevated and make steroid use undesirable. However, they are often medically necessary. Do not be afraid of using insulin to assist temporarily in the management of blood glucose while on steroids. Oral medications can seldom manage blood glucose levels during steroid use.

For those looking for other good type 2 blog sites, David Mendosa writes here and here and the last one has pages and pages of excellent information. Gretchen Becker writes on the Internet here and here. Jenny Ruhl also writes here in addition to the above linked site. Tom Ross writes here and is not on medications as he has managed his diabetes with diet and exercise for ten plus years.

If you are looking for books, read my blog here. Check with your library to see if they have the book so that you may preview it. I own and have read all the books listed and own several more.

I have given you many links so that you become familiar with the sites and bookmark those that you enjoy, if you have not found them already.

Series 4 of 12

Back to Diabetes Basics – Part 3

Hypoglycemia and Hyperglycemia

Hypoglycemia and hyperglycemia are two terms to get to know and remember. Knowing how to treat low blood glucose episodes (hypoglycemia) and high blood glucose episodes (hyperglycemia) is important in your management of diabetes. In my last blog, some numbers were given for goals in blood glucose management and they are important.

Hypoglycemia is considered for BG readings below 70 mg/dl (3.9 mmol/L). Most people get noticeable symptoms when BG goes below 80 mg/dl (4.4 mmol/L), but others do not until BG gets lower. Readings of 70 mg/dl and above are normal for most people and generally of no concern. Trends below 80 mg/dl need to be watched carefully if they get near the 70 mg/dl level. Why do I use the mg/dl behind the numbers? This is what the meters are set to read in the USA. All other countries use the mmol/L.

Symptoms of hypoglycemia vary by individual, but may include extreme hunger, nervousness, excessive perspiration, rapid heartbeat (tachycardia), headache, fatigue, mood changes, blurred vision and difficulty concentration and completing mental tasks. Extremely low glucose levels can lead to disorientation and convulsions, even coma and death

People with type 2 diabetes still need to be concerned about readings heading downward from 80 mg/dl and especially if on insulin or Sulfonylureas as they can cause hypoglycemia very easily. Although Metformin will not cause hypoglycemia, in combination with Sulfonylureas, hypoglycemia can become a problem. Many doctors are not aware of oral medications causing hypoglycemia and this may lead to problems. Be especially aware of this if you skip a meal or if you are becoming ill. Test and if you are below 70 mg/dl, then take a glucose tablet, wait 15 minutes and test again. If you are below 60 mg/dl (3.3 mmol/L) take two glucose tablets and repeat. If you are below 45 mg/dl (2.5 mmol/L), and having a hard time thinking, have someone call 911 as you need treatment immediately unless you have a glycogen pen and can have someone inject you. Most people with type 2 seldom have these available unless they are on insulin and have had serious hypoglycemia previously.

Hyperglycemia is difficult to detect for most individuals. There is much disagreement as to where hyperglycemia starts. Irrespective of what number you choose to believe, the American Diabetes Association (ADA) has set the upper limit for A1c's at 7.0 percent. This equates to 154 mg/dl (8.6 mmol/L). I have also seen ADA use the number of 180 mg/dl (10.0 mmol/L). It is known that complication damage occurs at an A1c value of 7.0% and higher. Some will argue that damage occurs above 140 mg/dl (7.8 mmol/L). I prefer using the 140 mg/dl as the starting point for complication damage and as the starting point for hyperglycemia.

Most people can only detect hyperglycemia by testing. When your blood glucose levels are above 200 mg/dl (11.1 mmol/L) it may be several days before you may notice any signs. Some people do not notice frequent urination and increased thirst, even then. This is another reason to test regularly. If you are a person that exercises regularly, a blood glucose reading of 240 mg/dl (13.3 mmol/L) means you must not exercise until your BG is below 200 mg/dl. It is always advisable to talk to your doctor about the amount of medication to use to bring high BG numbers down. Unless you have previously discussed this with your doctor and know what to do, it is always wise to talk with the doctor.

Both hypoglycemia and hyperglycemia can cause death and it is important to know what to do and how to treat both. Many people with type 2 diabetes don't think this will happen and ignore the signs for hypoglycemia or think it is not important to test regularly for hyperglycemia. People with type 1 diabetes know the value of testing because they are on insulin, but people with type 2 diabetes are often not even told about this until they are prescribed insulin. I lay this problem at the feet of doctors because they do not stay current with oral medications and often do not understand what the combined side effects are for multiple oral medications. I also believe the ADA is responsible because they promote stacking (using more than one oral medication) of oral medications and do not give appropriate warning of the dangers.  Read this article on the Joslin website for a chart of oral medications and the side-effects. It does not cover the problems when using combinations or stacking. More on this in another blog.

Doctors and the Different Types of Practice

Doctors and those in the medical profession are mostly like you and I. The one difference is the amount of education they have and the type of experiences is what sets them apart. Some excellent doctors always work for the patient and strive to give the highest quality service. Like any profession, there are the “bad apples” and we need to avoid them as they give medicine a bad reputation. In between there is all types and variations. Do not forget the physician practitioners and physician assistants. We must also include the nurse practitioners. When I use the term medical profession I mean to include all of them. Doctors work with the other medical professionals, but many do not like them as part of their practice while other doctors welcome them.

Read a blog I wrote in May 2010 on patients and doctors. Also follow the links provided, as the information is still applicable and appropriate for this discussion. I do need to add a few new types of medical operations that exist today and are very important. For diabetes these can add value to the appointment and save many problems from developing. A few practices are beginning to see the value also. I am talking about shared medical appointments (SMAs). If you are a patient that insists on keeping your diagnosis a secret, they are not for you. You must be ready to talk and listen to others and have them know you. How many people participate in SMAs? This will vary by how much room a doctor has, how many patients are willing to attend, the size of the staff available, and how much preparation is needed. Doctors that are old hands at this and have the room have been known to have 25 or more patients. Others limit it to 10 to 15 patients. In my limited discussions with a few doctors using SMAs, they only have room for the smaller numbers. They utilize private rooms to talk with those patients unwilling to have the doctor tell them test results in the group setting or for someone receiving information that the doctor wants to share in private.

Most doctors use SMAs to dispense the same information to everyone at the same time. Examples include importance of testing, medication side effects, goal setting, lifestyle changes, foot care, and other information. Questions are answered and discussions on some points do happen. One endocrinologist uses this to mix new to diabetes patients with old hands with diabetes to breakdown the panic the new patients are experiencing. Other groups include people by experience, and some are with groups that want to stay together. Some doctors have registered dietitians (RDs) and certified diabetes educators (CDEs) assisting. Others use physician assistants and nurses. Other combinations also exist for the medical staff.

Concierge medicine is also gaining in popularity and doctors can spend varying time with the patients. Appointments can vary from a half hour to an hour and a half depending on the need. Some will have a secretary/receptionist and others will have no one but themselves. Some practices may be two or more doctors. For more information I suggest reading my blog here and follow the links to more on the topic. Investigate this site, which also is about concierge practices. I am aware of one husband and wife team in concierge practice that is investigating the use of shared medical appointments (SMAs) for different diseases, diabetes, cancer, multiple sclerosis, and one other disease.

Something being talked about and possibly happening is telemedicine. This study is the first I had read about it, but I think this will have a place in rural areas. By using nurses or nurse practitioners in the field, telemedicine may reach patients that otherwise would not have access to doctors because of the distance to be traveled and especially those no longer able to drive. It will be interesting to see this develop over the next few years.

An area of medical practice that is operating is retail clinics and pharmacy medicine. They are not quite as sophisticated as neighborhood or a few other inner city clinics that are staffed by doctors on a voluntary or small fee basis. The retail clinics are normally staffed by nurse practitioners, physician assistants, or pharmacists. There is opposition to these clinics, but they may have their place because of the coming shortage of primary care physicians. They may have a place to serve to take the pressure off primary care and emergency room medicine and they are more economical when compared to emergency room services. Patients rate most very high for service and satisfaction. Read about these services here and here.

In some states, actions are underway to regulate heavily many of the above practices and the state of California wants to force all doctors back into the practices or hospitals. The state hospital association is lobbying hard for this.

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