The Value of SMBG Testing – Part 3

I like the last paragraph and sentence in Gretchen's blog in the referenced blog, as I can agree with this. I would like to see the use of the continuous glucose monitor used for a minimum of 4 months after diagnosis.

I think every type 2 should be provided with a continuous monitor for the first 2 or 3 months after diagnosis. Then they could switch to test strips and intensive testing for the next year, and finally to testing only for new foods, sickness, new lifestyle patterns, or when they felt something was not right.

Test strips are much cheaper than dialysis.

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

SMBG can aid in diabetes control by:

• facilitating the development of an individualized blood glucose profile, which can then assist health care professionals in treatment planning for an individualized diabetic regimen;
• giving people with diabetes, and their families, the ability to make appropriate day-to-day treatment choices in diet and physical activity as well as in insulin, oral agents, and even no medication;
• improving patients’ recognition of hypoglycemia or severe hyperglycemia; and
• enhancing patient education and patient empowerment regarding the effects of lifestyle and pharmaceutical intervention on glycemic control.
  

Patients properly educated and with some experience with SMBG can benefit from the empowerment that SMBG bestows. Diabetes specialists believe that patients should use the SMBG data for daily regimen changes and health care professionals should use SMBG data to guide changes in medication regimens.

The use and frequency of SMBG is the area of much disagreement among the various specialists and advocates of SMBG. From my prospective, I feel it will depend on what your budget allows and insurance will cover. With all that is happening with studies it is surprising we still have testing supplies. Some doctors will not even give prescriptions for testing supplies and others will delay this until the patient insists. Most insurances will cover a meter and test strips up to what Medicare allows for the type of diabetes you have and the medication you are taking. SMBG is the battleground for all people that need testing supplies. Medicare restricts testing supplies and most insurance companies follow in lock step.

If you are able to afford additional testing supplies, by all means, make good use of them. Shortly after diagnosis, you need to use your meter to determine how different foods affect you blood glucose. This will assist you in knowing which foods to decrease in quantity, which to eliminate from the menu for now and which are safe to continue eating. Most people that are conscientious about their testing and realize that readings are trending upward will want to retest their foods again and find out what is changing.

We all need to understand the reasons for doing certain tasks and the more we understand about self-monitoring of blood glucose, the more effectively we will use it. I am not in agreement with the current trend in testing for people with type 2 diabetes. The powers that be just do not allow for proper testing or frequency of testing needed to cover periods when your body chemistry may change, for determining what foods do for your blood glucose levels, whether an illness is affecting your blood glucose, or if a medication, especially steroids, is driving your blood glucose above normal levels. These are concerns all insurance companies do not even allow for. Even our medical community shows little interest in this and will deem you to be not watching your blood glucose when your A1c rises unreasonably.

For patients with type 2 diabetes, optimal SMBG frequency varies depending on the pharmaceutical regimen and whether patients are in an adjustment phase or at their target for glycemic control. If a patient is on a stable oral regimen with A1c concentration within the target range, specialists recommend infrequent SMBG monitoring. In such cases, patients can use SMBG data as biofeedback at times of increased stress or changes in diet or physical activity.

Just remember that in testing at the beginning, you use “testing in pairs.” This means before eating and one or two hours after eating. This will tell you if the food combo you are eating is driving up your blood glucose and whether you need to reduce the quantity you consumed or possibly eliminate the combo completely.

If you have diabetes, you have responsibility in your medical care. The role means self-monitoring of blood glucose to manage the health you have. I find that managing diabetes is challenging. It can be a burden, but only if you let it. There are enough challenges to keep a person reaching for that higher level of diabetes management. One thing for all of us to remember is the importance of a positive attitude. This will generally help us through the tough times and keep us motivated to stay on top of our efforts to manage our diabetes.

With type 2 diabetes, our care may be sporadic from our health care providers and since they do not live with us 24/7. it is urgent that we learn how to care for ourselves. Is this easy at the start? I would be lying to myself and to you if I said it was, because there are many things to learn. It does get easier and at the same time more frustrating as we learn more about diabetes and its idiosyncrasies. We have to learn how to manage diabetes without assistance on many fronts.

The Value of SMBG Testing – Part 2

This is a continuation of yesterday's blog on SMBG. Gretchen's blog had this to say - “The Diabetes Educator article notes that the International Diabetes Federation has concluded that "simply recommending SMBG to patients without instructions for testing or use [of] results in [is] a waste of time, money, and resources." That's what we patients said.” In the long run, self-testing along with education about what to do with the results is one of the best way for our medical system to save money."  This is from the blog referenced in the August 1 blog.

When we think about the problems and complications that happen with unmanaged diabetes, we can see many costs escalate beyond the cost of test strips, yet the Centers for Medicare and Medicaid Services (CNS) is looking to the short-term cost savings only. And the insurance cartel follows the lead of the CMS. When they start seeing the rising long-term costs, they may begin to understand what their short-term cost savings have wrought.

First, I must point out that much of the research for self-monitoring of blood glucose (SMBG) is suspect. Not only are the participants carefully selected, but also most studies seem to exclude people with type 2 that have an interest in or knowledge of SMBG. Many of the studies are observational in nature or rely in participant-completed surveys, which are not reliable for scientific accuracy. In the USA, many of the studies are funded by the National Institutes of Health (NIH) or the Centers for Medicare and Medicaid Services (CMS). Then on the unscientific information, Medicare takes more test strips away from us.

I have made this accusation before and I will again. This is based on my research and in no way is it scientific. There is a conspiracy happening in the USA between government agencies and medical organizations to keep many people with type 2 diabetes unaware of the damage being caused by our grain industry and low fat mantra, which is promoted by the US Department of Agriculture (USDA). In turn, the NIH and CMS have cooperated by funding non-scientific studies giving Medicare the incentive to reduce our testing supplies.

Then the America Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE) promote the USDA line of thinking – whole grains, low fat, and people with diabetes that do not know better listen to them. Then the American Association of Diabetes Educators (AADE) and the Academy of Nutrition and Dietetics (AND) which follow the ADA and AACE do little do encourage people to think for themselves. They are pushing mantras and mandates and expect people with type 2 diabetes to accept the dogma blindly.

The AADE does nothing to promote and teach diabetes self-management education (DSME). They give mandates and mantras that patients are learning is bad for their diabetes health. Most CDEs will not teach patients about self-monitoring of blood glucose (SMBG) for fear that patients will discover the truth about whole grains and low fat. The monopolistic workers for the AND mandate that we consume a minimum number of carbohydrates per day and go ballistic when we do not and literally call us noncompliant and often refuse to work further with us. This refusal is the one good thing for us as patients.

Now some will say that the AADE does promote DSME, which in a small way they do, in some sources and pamphlets, but very little of the information ever reaches the patients. A few conscientious CDEs do teach DSME and even fewer teach SMBG until they are confronted by older CDEs and encouraged to stop.

We know there are doctors that are breaking ranks with the ADA and AACE because of the lack of diabetes education being taught.

I am also aware of doctors attempting to use peer mentors to dispense some diabetes education when CDEs are not available or have taken positions in conflict with the doctors. This may become more common as the increasing numbers of patients diagnosed with diabetes come into existence and the numbers of CDEs entering the field continues at a snails pace. With this gap widening almost daily, is it not surprising that doctors are exploring other avenues to assist in diabetes education. Even more doctors are investigating shared medical appointments to expand education by presenting it to groups of patients when there is not time to do it individually.

The controversy about the registered dietitians will need to play out in the court system before we will know whether their numbers will decline. Nutritionists that are joining other organizations to continue being able to dispense nutrition information may be able to step in and fill the widening gap. This should be great for those of us with diabetes as my experience with these nutritionists has been positive. They are interested in balancing nutrition and not issuing mantras and mandates for us to follow. They will suggest ideas that some of us may disagree with, but will work with us to help us balance our nutrition whether we follow a low carbohydrate, medium fat diet, a paleolithic diet, or even other diet plans. They are not locked into telling us we must eat a required number of carbohydrates.

Patients around the globe need education about diabetes and how to apply this to their daily lives. In the USA, we need Medicare to give us back our testing supplies in sufficient quantity that newly diagnosed patients can determine how the different foods and food combinations affect our blood glucose levels. Then allow enough test strips for people to use on a daily basis and to do random checks when adding new to them foods.

Okay, why do I use Medicare as the scapegoat? Because the medical insurance industry generally follows the lead of Medicare in lock step. If NIH and CMS are going to do studies, let’s have them do studies for three to five years and give continuous education during the studies. Have the education reinforce the principals set out at the beginning and ask the participants what they need in more information to help them. And, have the studies be scientific studies with the proper scientific methods applied and not the observational and survey format from the past. Do not exclude study participants that are interested or have knowledge of SMBG. Teach the study participants SMBG or DSME.

The Value of SMBG Testing – Part 1

Gretchen Becker's blog of August 1 got me thinking and now I want to review prior blogs of mine on self-monitoring of blood glucose (SMBG) to attempt to make the message of the value of SMBG testing stronger.

In the past several years, many reports have been published saying that self-testing of blood glucose (BG) by people with type 2 diabetes is useless, a waste of money, and simply increases rates of depression. I can understand this because there is no education of value given to help people use the testing data and change their way of eating that will help manage diabetes to lower blood glucose levels to near normal.

What the studies omit is that the medical professions in all countries are lax in giving patients the education necessary to understand how to use the blood glucose readings. They provide very little in guidance to their patients for proper decision-making when looking at blood glucose readings.

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

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

Alan Shanley at loraldiabetes has been writing about the lack of respect and understanding SMBG has been receiving since at least 2006 and he has not missed much in the lack of understanding by researchers and the medical community.

When I was diagnosed with type 2 diabetes, I wondered what was ahead. Experiences in my life have been varied, but in my research on self-monitoring of blood glucose (SMBG), I experienced something unlike anything else. I did not realize that whole industries and governments rely on and participate in funding studies fabricating false and misleading information to demean and direct fraudulent intent at a group of people with type 2 diabetes on no medications or oral medications.

These fabricated studies have been reported in trusted reviews, belying the truth in the way the studies were assembled and carried out. The editor of leading diabetes community website Diabetes.co.uk, Benedict Jephcote states: “There are a number of problems with the way results are presented within the Cochrane review. For instance, in the UK, there are many people with type 2 diabetes that are actively interested in self-testing and significant numbers of these people have to buy test strips from their own income. Studies which exclude these people cannot therefore give a fair representation of people with type 2 diabetes in the UK."

Cracks along the above line are already showing evidence to prove just that. In addition, in the future, researchers that are more honest will begin to refute these false studies. What is astounding is that the US Government has participated in this cover-up of studies that are done to show patients with type 2 diabetes do not need to self-monitor their blood glucose levels. The National Institute of Health leads the way and the Center for Medicare and Medicaid Services follows by cutting testing supplies for people needing them. By not educating Medicare and Medicaid patients about the value of self-monitoring of blood glucose and showing them how and when to test, they can support many studies proving that people with type 2 diabetes do not need the testing supplies.

Other writers proclaim that the studies are right and say that the results beyond a year do not hold up. I can understand this because these study participants are no longer given the supplies with which to self-monitor blood glucose. Many of the study participants probably are unable to afford the testing supplies and therefore without them the results would be expected to not hold up. That is one reason to have long-term studies of three to five years.

We have many factors working against us in the way people are selected for most of the studies and this discrimination and falsification in studies continues to harm people with type 2 diabetes. Tomorrow I will include more information about SMBG.

Testing to Manage Your Diabetes

If you have diabetes (any type), testing your blood glucose should be a part of your life. The test results will tell you and your doctor if your diabetes is well managed or not. The fallacy of this is that most doctors do not even look at your test results, but instead rely only on the HbA1c test they take.

This means that many people with type 2 diabetes especially, will need to learn how to interpret their test results and obtain copies of their lab results for comparison purposes. The WebMD article states that you and your doctors will work closely together to find the answers that will keep you healthy. For people with type 1 diabetes, this is probably true, but for people with type 2 diabetes, most doctors follow the ADA. They won't even prescribe the testing tools as they have been taught by the ADA that you are supposed to rely on the A1c results and not test.

This means that people with type 2 diabetes are operating in the dark about care for their diabetes and are not able to learn what foods or types of food raise their blood glucose levels dramatically and need to be eliminated from their food plan.

In goal setting, you’re aiming for an A1c level of 6.5% or less, which equals an average glucose (or eAG) of 140 mg/dl. Your doctor will give you an A1c test every 3-6 months.

When you should test and what goals you’re aiming for depend on:

• Your personal preferences – but testing should be before and after meals for 3 to 4 months after diagnosis – called testing in pairs.
• How long you’ve had diabetes.
• If you’re pregnant.
• Your age.
• Other health problems you may have.
• Medication(s) you’re taking.
• If you have complications like retinopathy or neuropathy.
• If you have low blood sugar (your doctor may call this hypoglycemia) without warning signs.

As mentioned above, testing times after diagnosis are important to help you establish a food plan and track what the different foods do to your blood glucose levels. You will also need to check the components of lifestyle change in my blog here, to determine the lifestyle changes you need to make.

A fasting blood glucose level, taken in the morning before you eat or drink anything, is the go-to test for many. Another test at bedtime is common. But what about other times? Testing 1 to 2 hours after breakfast or before lunch gives a more complete picture of what’s going on, says Pamela Allweiss, MD, of the CDC.

“Testing is really important, particularly if you take insulin or medicine that can cause hypoglycemia,” says David Goldstein MD, professor at the University of Missouri School of Medicine. And measuring both before and after meals is important in understanding what your blood-sugar patterns are and what to do about them.

This switch is part of a move away from a kind of one-size-fits-all thinking and toward more individualized care. Why? The old mantra was that better control led to fewer complications, Allweiss says. And that works OK for people who are healthy despite the diabetes.

In addition to understanding why you are testing, the following is important. All this testing means nothing if you don’t keep track of the results. Many glucose meters now do that for you. You should also keep a log. A full lifestyle diary that includes your eating and exercise habits, and how you feel at different times of the day, can also be a big help.

There’s lots to self-monitoring of blood glucose and lots to learn. Your self-testing is a big part of it. One number doesn’t tell the story. Looking for trends is also important.

A number by itself is just a number, Allweiss says. “We want to look at a pattern.” The steps to take after testing, of course, are simple enough. Talk to other people with type 2 diabetes and learn what all those numbers mean, and figure out how you can meet your blood glucose goals.

“Diabetes requires a lot of education. It isn’t like taking a pill and seeing a doctor twice a year. You have to be engaged,” Goldstein says. “We have great tools now, and we need to teach people how to use them. People have to know what to do -- and then they have to do it.”

Understand Your HbA1c

The HbA1C test is known as the A1C test by most people. The A1C test measures the blood glucose level for the last four months. The prior month accounts for 50 percent of the A1C. The month prior to the last month accounts for 25 percent of the A1C, and the third and fourth prior months contribute the remaining 25 percent of the A1C value.

Doctors use the A1C value as a measure of how well you are managing your diabetes or not managing your diabetes. This is the reason we as patients need to use our meters to measure our daily blood glucose readings.

If you did not have diabetes, your typical A1C level would be about 5 percent. For people with diabetes, the experts can't agree on what the A1C target level should be. The American Diabetes Association (ADA) recommends an A1C target of less than or equal to 7 percent. The American Association of Clinical Endocrinologists (AACE) recommends a target of less than or equal to 6.5 percent.

Hemoglobin A, a protein found inside red blood cells, carries oxygen throughout the body. When there is glucose in the bloodstream, it can actually stick (glycate) to the hemoglobin A protein. More glucose in the blood means that more glucose sticks to hemoglobin, and a higher percent of hemoglobin proteins become glycated.

Once glucose sticks to a hemoglobin protein, it typically remains for the lifespan of the hemoglobin A protein — as long as 120 days. The A1C test measures how much glucose is actually stuck to hemoglobin A, or more specifically, what percent of hemoglobin proteins are glycated. Thus, having a 7% A1C means that 7% of the hemoglobin proteins are glycated.

This is where disagreement often comes into play. For people with well-managed type 2 diabetes, visits to the doctor may only be required twice a year. However, for those that have poorly managed diabetes or are on insulin (not that these people have poorly managed type 2 diabetes) probably will see their doctor at least four time per year. Always be prepared to see the doctor on a different schedule.

The A1C test, typically performed by a health care professional, often doesn’t hurt. Only a single drop of blood is needed, and the sample is either analyzed on-site or is sent to a laboratory for testing. Some doctors prefer doing the A1C test from a blood draw.

While the A1C is a good measure of overall glucose control, it cannot replace self-monitoring of blood glucose (SMBG). Like other tests, A1C results may vary from lab to lab. The A1C test is not calibrated the same everywhere, though an international effort is underway to standardize the A1C test to a new International Federation of Clinical Chemistry and Laboratory Medicine standard.

A1C results can be misleading when red blood cell survival is prolonged or reduced; some health conditions can result in falsely high A1c results (as in cases of anemia) or falsely low (as in cases of hemolysis). There are other factors that can affect the A1C results.

One piece of good news: When someone has his or her A1C checked, that person does not need to worry about fasting; food eaten on the same day won’t affect the score.

My Thoughts Over the Last Few Weeks

The last few weeks have been worrisome for me and most of the members of our diabetes support group. We have had meetings almost every day and often using the phone, or computers using Skype. We have had disruption after disruption to our daily activities and we don't know when it will end. After last Friday, 23 of our members are very upset and angry at the person causing the disruptions. Not a pleasant way to spend Memorial weekend.

I may vent some, so you will have to leave this page or follow with me. I need to write about several of the articles I have read about research in the last few months. Granted many of the studies are using 18 to 24 participants and the length of the studies is less than three months (most only one month) and contain many premises without factual data. Even two of the studies that I received the full copy of are not reliable in my estimation.

The blog from yesterday (go back and read it if necessary) is important for many reasons and shows that not everyone follows the big two from this blog written on July 12, 2013. These two big Pharma supporters are recommending harm to those of us with diabetes. In addition to advocating the stacking of oral medication on top of oral medication, they don't wish us to learn self-monitoring of blood glucose or even to learn how to test.

It seems that many doctors follow the ADA and AACE advice and don't realize the harm they are doing to patients. To be able to manage diabetes and avoid the complications of diabetes, we cannot follow the orders of these doctors. I don't care whether you are managing your diabetes without medications or using insulin. You need to know how the different foods and food combinations affect your blood glucose levels. This will give you information about which carbohydrates to limit or remove from your food plan.

Granted, once you have determined how the different carbohydrates affect your blood glucose levels, often you may be able to reduce the number of times you need to test. It is still wise to test before and after several meals to check when trends are moving upward. Yes, it is easy to become lax and miscount the carbohydrates you are consuming. Been there, done that, and it is a rude awakening when it happens. This makes a person feel very small and look for a place to hide while also wanting to have

a big punching bag available.

Back to the first paragraph. This has caused several of our members to have some blood glucose problems and we are working with each other to limit the excursions into hyperglycemia. Our resources are doing everything possible to stop further disruptions to our lives, but still we don't know when this will end. The person is now after each of us as individuals and this is what has everyone upset.

More on this when we are allowed to say anything in a public way.

Help in Diabetes Management Education – Part 6

Part 6 of 12

Learning to interpret your blood glucose readings and how they should guide your food intake is part of self-monitoring of blood glucose (SMBG). A few certified diabetes educators (CDEs) will actually teach this, but most will only use mandates and mantras. If you are fortunate to have one that is teaching this, learn from them. Those of you in the rural areas will most likely need to learn this on your own. Some rural doctors are working with diabetes patients that want to learn and training them to be peer-to-peer workers or peer mentors. In turn, they work with the doctor to help educate other patients.

I will state before I go further, each patient needs to discuss with their doctor what reasonable goals they should consider. Then you will need to decide what you are willing to tolerate for diabetes management. The numbers I will use are reasonable, but you should still select your own goals. This is not a topic that can be neatly wrapped in a bow. It needs to be individualized to the person and their goals and abilities. I would urge you to read the many links I will provide as it will give you ideas for goals.

The first link is this with tables and a discussion on managing blood glucose. There are suggestions that need to be considered. The second link is a blog of mine that I wrote about from a book published by Joslin. This surprised me and Joslin is not always talking about this and often discouraging to people with type 2 diabetes.

One factor where most authors fail is talking about “testing in pairs.” Dr. William Polonsky of the Behavioral Diabetes Institute is the person that coined this and promotes this as the best method for determining how food affects you body. This is important because by taking only one blood glucose reading either before or after eating will not give you any meaning and just a reading that tells you nothing except what the reading was at that time. This does not help in determining how the food you consumed affects your blood glucose.

This also tells the doctor nothing toward finding the correct amount of medication. Granted the doctor uses your A1c to determine how well you are managing your diabetes, but more doctors are using the readings from either your testing or from your meter to help them do this. I will cover counting carbohydrates in a future blog.

While I do not like the numbers used in this blog at DiabetesMine, this will give you more of an idea why testing in pairs is important.

The last blog I refer you to is this one where CDEs think about us a round pegs and they want to put us in square holes. I wrote this with tongue in cheek, but it is very applicable today because CDEs teach to the lowest level and don't want to work with people with type 2 diabetes when they can avoid it.

We Need Self-Monitoring of Blood Glucose Taught

Many government agencies don't want this to happen. Chief among them is the US Dept of Agriculture (USDA) and the National Institute of Health (NIH). Other federal agencies also follow suit. This means that the Academy of Nutrition and Dietetics (AND), Certified Diabetes Educators, the American Diabetes Association (ADA), and the American Association of Clinical Endocrinologists (AACE) follow in lock step.

Naturally, the medical insurance industry follow the recommendations of the ADA and AACE. This means that we as patients have to work harder to obtain the test strips to know what our blood glucose levels are for us to manage our diabetes more effectively. Not knowing and operating in the dark is not the way effectively to manage diabetes.

Most blogs by CDEs and RDs never mention using our blood glucose meters with test strips because they don't want us to know how the different foods affect our blood glucose levels. This is part of the reason many people get discouraged and seldom test their blood glucose levels. This almost guarantees that diabetes will become progressive and that the complications will affect the quality of life. Self-Monitoring of Blood Glucose (SMBG) is shunned by CDEs and not talked about by RDs.

If it wasn't the leadership of the USDA and the blind following by AND, we might have reason to listen to a few that do teach SMBG. A few CDEs that do not have to worry about other CDEs looking over their shoulders, do teach Diabetes Self-Management Education (DSME) of which SMBG is a part. Many will not even teach DSME because they only believe in mandates and dogma and expect people blindly to follow. With the internet of today, this will only get worse as people learn what following these people will do to damage their health.

At least some people from the Duke University of Nursing at Durham, NC are doing something about what the CDEs are unwilling to accomplish. Read about this in a recent blog here. They are at least reviewing various methods of delivering diabetes self-management education (DSME) via the internet.

Then people with type 2 diabetes and those with prediabetes will have resources to learn about managing their diabetes. Then if the certified diabetes educators want to be exclusive and continue to make it more difficult to become a CDE and for their numbers to grow, we can ignore them and learn on the internet.

The unfortunate part of this is that it is just a study and there is no sources of DSME as such on the internet for easy access. This in one time I sincerely wish that people would put information on the Internet and then do a study instead of studying other studies. Yes, I was honestly thinking that there was a source of DSME on the Internet and that it could be available to all people with type 2 diabetes. While the study details were interesting, that is as far as it was taken.

Self-Monitoring of Blood Glucose, Lessons - P1

This is a continuation of previous blogs on self-monitoring of blood glucose (SMBG). In rereading several, I realized that they were okay, but not as complete as they should have been. In the blog over at DiabetesMine on September 27, 2014, Will Debois wrote about a few points I have been taught, but forgot about. Two of my fellow support group members, Allen and Tim called me after reading that blog and asked when I was going to write about it. I urge you to read the DiabetesMine blog at the link above.

Yes, I have talked about testing before meals and then after meals, but I have not been the best at explaining some of the reasons. So, here goes! The points I want to cover include are:

#1. Dr. William Polonsky of the Behavioral Diabetes Institute who came up with the concept and coined the accurate term “testing in pairs” to make it easy to understand.  Why you need the preprandial (before meal) and postprandial (after meal) blood glucose tests.

#2. The reason I can avoid the guidelines of the ADA and AACE.

#3. Facilitating the development of an individualized blood glucose profile, which can then assist health care professionals in treatment planning for an individualized diabetic regimen?

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

This is the reason for testing in pairs. One reading postprandial is worthless and tells you nothing. It does not tell you what the increase may have been from the food consumed, or even if you need to reduce your food consumption. Okay, if the preprandial dinner reading was 105 mg/dl and at 90 minutes postprandial, the reading is 148 mg/dl, then this means that the increase was 43 mg/dl. Now this says something and depending on the goals you have set, you can make adjustments. Do you need to reduce your food consumption (the carbohydrates), do more physical activity, or if on insulin adjust the dosage injected?

If on oral medications then the readings may mean that the physical exercise needs to be increased or the food consumed needs to be reduced. If the person is on no medications, then the person needs to consider medications or less food.

As Will explained, it does depend on whom you work for as to the guidelines followed. The ADA guidelines are the most lax and the AACE guidelines are somewhat better. When it comes to fasting blood glucose levels, I agree with Will that anything below 70 mg/dl causes concern and should be discouraged. I have had readings lower and being on insulin, I was very concerned. I do not work and am retired and as such only answer to myself. I can set my own ranges for my goals and if I don't meet them, then I have only myself to blame. Yes, all doctors try to set goals for me and I generally tell them that the goals are not realistic (an A1c above 7.5% - because of my age) and thus I will use my goals (6.5% and lower).

Yes, I am not cooperating with my doctors and am in the process of finding another so I am not facilitating number 3 above.

SMBG Can Be Valuable for Non-insulin Type 2's?

On Monday, March 31, A.J. called and asked if he could come over as he had several things he wanted to discuss. I told him to come on and I would try to answer some of his questions. We talked briefly about some of the activities recently and then he asked me to pull up this article. His comment was that he had not seen me do any blogs from this source and I showed him two that I had already posted and several others that I have been working with.

When I went to open this blog, he asked me to wait. He said that does not have many readers. I said this is one of the things to expect when blogging. He asked me to scroll down the list of previous blogs and he said a lot of them don't have great readership. He said I have read every one, except for today's post, which I will when I am on the computer. I then brought up the statistics page and he said, “oh goodness.”

I said this is expected when people are not interested in something I blog about. Then I went to the audience page and he looked again and commented if it was not for other countries and the readership by them where would you be.

I said this is expected at different times when I write about topics that people are not looking for and have no interest. He said they are of interest to me and I generally find something that may apply in the future. He continued that he had a doctor's appointment earlier that afternoon and he remembered to silence his cell phone after reading that blog.

A.J. then stated the purpose of his visit and that he was very concerned about what the author had stated about there being no benefit for Self-Monitoring of Blood Glucose (SMBG) for non-insulin using people with diabetes. He continued that if he had not been on insulin and learned from the rest of our support group how to use his test results, he might have believed the article. He said that his insurance had limited him to one test strip per day, but he felt fortunate to be able to afford the extra test strips and felt that the investment was well worth the money.

A.J. continued that it was better than operating in the blind and not knowing where his blood glucose levels were at for different times of the day. I stated, let's take the three points and analyze them.

#1. In patients with diabetes who don’t require insulin, self-monitoring of blood glucose had a modest effect on HbA1c levels at six-months, which subsided after 12 months.

I asked him what he thought and he stated he did not understand. I said that the studies used only supplies meters and test strips with no education or minimal education. Once the study ended, no more test strips were provided. Okay, A.J.'s face lit up and he said now that I can understand. They would not have understood what they were looking at and have even less knowledge about how to interpret their readings. I then asked A.J. to read this blog. After he finished, he stated your last thought about why diabetes is then considered progressive really highlights their lack of education.

#2. Self-monitoring of blood glucose in non-insulin treated diabetics had no effect on satisfaction, general well-being or general health-related quality of life.

I brought this blog up and after A.J. read it, he commented that now he had a better understanding of why they could make stupid statements like this. Education is everything and the key to understanding SMBG.

#3. Supplies required for self-monitoring of blood glucose (BG) are more expensive than for urine testing, a common alternative for non-insulin treated diabetics.

Now A.J. was laughing. Peeing on a test strip is not very accurate and almost worthless. He said he had a friend that used them for another purpose, but had the guide for blood glucose as well and he had tested a couple. The color of the test strip was higher after the meal, but he had no true meaning for the result. If it had not been for his meter and test strips, he would still not know the true meaning of the results.

Then when A.J. read the paragraph after the three points, he stated how idiotic the studies sounded. This is the paragraph, “For type 2 diabetics who are not on insulin, monitoring their blood sugar does little to control blood sugar levels over time and may not be worth the effort or expense, according to a new evidence review.”

I asked A.J. if he had not curtailed the number of times he was testing now that he was off medications. He admitted that he had, but did test at least after the evening meal to know what his BG level was. He said he still keeps his food log and stress log and this helps him when his AM fasting test is high and the postprandial test was higher than he wanted.

Then A.J. asked why he did not remember my blogs and others that would help keep him from being so concerned when he read articles like this. I said because he is only reading and not writing blogs.

We talked for another 30 minutes and he asked to read several of the other blogs the search on my site had collected. When he came to this blog and then read a link in it, he said this even gives more of a reason the discredit the Cochrane Review. I said they still like to trot this out every few years and make their pronouncements. I said there are just too many pieces of information that they leave out.

A.J. said it was time to get for home and eat, but he thanked me for giving him something to think over.

Should Type 2's Not On Insulin Use Glucose Meters?

Experts versus those that live with diabetes, how I dislike saying this, but it is down to this and this is the shame. Our so-called “experts” at the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), and supporting organizations and prestigious diabetes clinics all believe that patients with type 2 diabetes and not on insulin do not need to self-monitor blood glucose levels that frequently or not at all. Many feel that a quarterly A1c test should be sufficient.

To the above, add primary care physicians and other doctors that do not stay current with the latest information about diabetes, and it is the patients who are left without any guidance, or education on managing their diabetes. Yet, these “experts” could care less and discourage us from learning about self-monitoring of blood glucose because they don't think this would help us. Therefore, is was with great surprise and then appreciation that Amy Tenderich (Founder and Editor, plus a person with type 1 diabetes) of DiabetesMine was able to have a study printed in Diabetes Spectrum of the ADA website. I would strongly urge every person with type 2 diabetes to read the PDF version of her study which can be downloaded by clicking on this link, Use of Self Glucose Monitors Among Type 2 PWDs: Patient Perspectives . I repeat, the study is worth your time reading it and it may give you the boost to consider how you use your meter.

I was even more surprised that a CDE had asked her to do the study. Then the ADA published it as an editorial rather than a study or report. I can only guess that those in power did not appreciate learning what they found in the study. The ADA is not patient friendly.

The important part of Amy's work is that it reflects what the patients think and know compared to what the researchers normally look for and exclude from studies. This blog of mine shows how researchers set up a study to reflect the answer they desire. This is another reason to believe Dr. William Polonsky from the Diabetes Behavioral Institute in his presentation to the ADA that I discuss in my blog link above.  It has a link to a PDF file and his points to the ADA.

I do not know who titled her work, but they use the wrong term. Normally those who know better use the term meter because very few people with type 2 diabetes use a continuous glucose monitor (CGM) which is generally considered a type 1 instrument or tool for them. There is a great difference in cost as well. Some doctors and diabetes clinics give out meters and some receive a prescription for them which insurance will reimburse. People with type 2 diabetes are seldom able to obtain a CGM as their insurance will not cover it. Those that have the big dollars can purchase them, but even then, many find the meter easier to use.

Education is clearly the key to success with how to use the meter, when to test, and how to compensate when a reading is high or too low. Many were self-taught by reading and research on the internet, often on diabetes forums or other social media. I remember having a class on using the meter, but not when to test and how to interpret the readings. I was fortunate to find the series of blogs by Alan Shanley which can be found here. Then down the right side is a search box and type in the word “test.” This will bring up many blogs worth reading.

I am a member of the site where the survey was taken, but because I am very inactive there, I did not see the survey or questions. I am a person with type 2 diabetes, but I am on insulin. I have had questions about why I advocate for testing supplies and I can only say that I believe that testing is the only way correctly to manage diabetes. Understanding how foods affect your body and other variables that come into play will really assist you in preventing the onset of complications.

Diabetes does not need to be a progressive disease and self-monitoring of blood glucose (SMBG) is the only way I know of to manage diabetes and prevent progression to complications. Education is the key and learning what the readings on your meter mean to you when comparing them to your food log and health log is the only way to know what the food you have consumed is doing to your body.

Three schools of thought about the value of home glucose testing among type 2s on page 2 of the PDF have two people from the Joslin Diabetes Center at polar opposites. Dr. Richard Jackson, senior endocrinologist and researcher at Joslin Diabetes Center in Boston feels that an A1C value every three months can provide sufficiently useful information. Nora Saul, certified diabetes educator and 20-year licensed dietitian at Joslin Diabetes Center in Boston agrees that SMBG is under-utilized for gathering information about how patient’s blood glucose responds to different types and amounts of food – especially for judging the effects of high-carb food choices/ diets. Not only is Nora Saul making good statements, she is not following the line of the Academy for Nutrition and Dietetics, which discourages testing to learn what food does to the patient's body, but I wonder how she gets along with Dr. Jackson.

Amy did get three good views about SMBG, and Nora Saul and David Mendosa are both saying things I can agree with. Dr. Anne Peters and Dr. William Polonsky are agreeing that education is a missing factor of knowing what the meter readings mean and they are not being motivated. Apparently, the motivation to prevent the progression to the diabetes complications is sadly missing. With the exception of Dr. Richard Jackson, who must be on some medication that addles his brain, the rest understand the importance of SMBG.

ADA Relies On Faulty Studies, Not Good Advice

I wish I could copy all of the reasoning in this one file, but that would make for a long file. Dr. William H. Polonsky and Dr. Lawrence Fisher have some excellent points about self-monitoring of blood glucose (SMBG). The points run counter to the entrenched position of the ADA “experts” which rely on what I believe are faulty studies. I refer you to this blog from April 9, 2012. To read both sides of the point-counterpoint, you will need to download this file using Adobe Reader or a PDF compatible reader.  If you have one, clicking on the link should download it for you.

Yes, I am writing many blogs on self-monitoring of blood glucose (SMBG) and diabetes self-management education (DSME) because of the lack of support for this from the American Diabetes Association (ADA) and the American Association of Diabetes Educators (AADE). They both are using “feel good” hype, but doing nothing to turn words into actions. The AADE and ADA both participated in the development of National Standards, but do not have the personnel to make it a reality. In other words, they are ideal intentions, but no actions are taken to make it a reality.

The AADE is wrapped up in their own importance to the point they can't bare to see lay people even trained to assist in DSME. Yes, lay people (or better yet lay people with diabetes) could be trained to be able to give DSME as peer mentors or peer-to- peer workers with supervision, but this beyond the desires of AADE. They have to protect their position in the diabetes hierarchy. They are afraid that like the few studies have shown, people respond to fellow people with diabetes better than people that issue mandates and their only diabetes knowledge is what they have learned in books.

People with diabetes are generally open to listening to other people with diabetes that can speak to them at their level and not at the lowest common level that CDEs are prone to do. Every time I hear this from people that have met with CDEs, I know that they did not do the assessment they are supposed to do. They were only interested in making a few points and getting out rather than do what is required by their own policies and procedures. This says there is a disconnect between the upper levels of the AADE and the CDEs working in the field. This disconnect is almost large enough to say that there are two organizations, the AADE and CDE and each highly disregards the other.

This makes what Drs. Polonsky and Fisher even more important as they can see the value of SMBG and what the education would mean to people with type 2 diabetes. Yet, they see what the studies are doing that the ADA relies on and can see how they are set up to give predetermined results by asking the wrong questions. You don't have to rig the results if you carefully ask the wrong questions. You know that insurance has something to do with this and the National Institute of Medicine has to be involved.

Yes, I can see the USDA and their experts being involved in some of this because they don't want people to be testing and finding out how bad the nutritional information is that they are promoting through the ADA. In almost 100 percent of what we read about nutrition or food plans for people with diabetes, no mention is ever made of using our blood glucose meters to test what the different foods do to our blood glucose. This means that someone has a vested interest in not mentioning this as then there would be more available education for people with type 2 diabetes and more reason to have testing done.

Drs. Polonsky and Fisher state the following and discuss each.

1. Recommended frequency and timing of SMBG must be adequate

2. Patients need to be knowledgeable about SMBG and have the necessary skills to use SMBG data

3. Clinicians need to be knowledgeable about SMBG, actually see the SMBG data that patients collect, and have the necessary skills to use the SMBG data

4. SMBG data must be collected and recorded in a manner that permits blood glucose patterns to be readily observable and easily intelligible for clinicians and patients

5. Further concerns about study design
   
   
6. Conclusions

In the conclusions, Drs. Polonsky and Fisher clearly state how easy it is to arrive at the consensus the ADA arrived at by asking the wrong questions. A number of studies that Malanda et al. Explicitly excluded from their review have explored innovative ways of using structured and targeted SMBG testing for this patient population effectively, and have shown significantly reduced A1C, depression, and distress, and enhanced diabetes self-efficacy. The doctors feel that rephrasing the research question and retargeting studies to evaluate the specifics of effective use of structured SMBG are warranted.

Drs. Polonsky and Fisher clearly feel that asking the right questions and doing the studies properly would yield different results.

BG Testing – Use First or Second Drop?

Have you heard about this before? I admit I had not and I wondered what the significance could be. There is more significance than thought and I will try to cover the reasons and considerations. This originally appeared in February 2012, but has been getting some attention on several diabetes forums again. Some are concerned and others are trying to play it down as old news. I have found that old news can be just as valuable for people recently diagnosed with diabetes because they may not be aware of the old news.  On June 15, 2012, the diabetes blog on the Mayo Clinic diabetes page had this blog.

This is a Dutch study and the full text is free at this link. You will need a PDF reader. When they are talking about diabetes educators, they are referring to diabetes educators in Europe. Even these educators give different advice although the majority of the Dutch educators advised patients to wash their hands before testing. To address the different recommendations, they used the following to measure the capillary glucose concentrations. They also compared readings of greater than or equal reading of 10%.

#1. without washing hands

#2. after handling fruit

#3. after washing the fruit-exposed fingers

#4. during the application of different amounts of external pressure around the finger (squeezing).

For measuring equipment, the researchers used the Accu-Chek Compact plus meter with plasma-calibrated test strips (Roche, Almere, the Netherlands). The meter was calibrated prior to the start of the study as well as halfway through the study. No significant changes were observed.

A Speidel and Keller hand blood pressure meter was used to achieve different external pressures. The regular cuff was replaced by a neonatal cuff. One of two available sizes was used depending on the thickness of the finger (Philips, M1866A neonatal disposable cuff #1 and M1868A neonatal disposable cuff #2). This equipment was used to apply standard pressure for the finger pressure we often refer to as milking the finger.

Time interval during measurements were done so that capillary glucose measurements were performed directly following the finger puncture with a maximum delay of 90 seconds between measurements. When using the cuffs, the selected pressure was applied first and then the finger puncture was performed. The two pressures were 40 mmHg and 240 mmHg.

The interesting part of this study is the differences among the educators in their recommendations and then what the patients do in practice. Even more surprising was the number of patients that did not use the side of their fingers for testing.

The conclusions were about what I expected and only one source mentioned what I think many forget in talking about using the second drop of blood. When using the second drop of blood, the lancet must be set deeper, therefore potentially creating more pain in testing to be able to wipe the first drop away and to be able to have a second drop form. The authors do recommend washing hands with soap and water, drying them, and using the first drop of blood.

The authors do recommend using the second drop when washing is not possible and the fingers are not visibly soiled or have not been expose to sugar-containing foods or products. They tell us to wipe away the first drop of blood and use the second. They wisely and with proof from their study advise us not to use external pressure as this creates unreliable results. This applies to testing when the fingers have been exposed to fruit sugars and need to be washed for accurate results.

When using pressure or milking the finger, we need to be concerned about interstitial fluids affecting the results. This is what makes them unreliable. Also by using the second drop, the depth of the lancet can create unwanted pain, but is necessary to obtain the second drop of blood.

AAFP and Their Professional Website – Part 1

Part 1 of 3 parts

When I started reading this, I had some very mixed thoughts. Normally I would not even refer you to this, but I feel some education is in order. You need to understand why sites like this can be loaded with poor or incomplete information. This website is the example of incomplete information. Some of the information is good, but in my opinion, it does not out weight the incomplete information. I even had to do a double take when I really looked at the site for an address. It is on the American Academy of Family Physicians (AAFP) website. And yes, I stand by my statement. Some information I consider critically incomplete and some is just in the way a patient views it, or has learned it. This can happen in any medical information.

Yes, I do not like it when a professional organization chooses to ignore good policy when it is available and leave out important information. It would have been wiser of the AAFP to refer readers to other sites instead of leaving information out. They also do not update the information on a yearly basis. In some instances, this creates what I would term a fatal lack of information. Information changes rapidly and to not update the website is not a good promotion of their profession. Even the ADA issues new guidelines every year, faulty as they are.

At first I was attempting to do a blog for each topic or in some cases two or more blogs, but this would result in too many blogs. Therefore, I will try to limit the number of blogs and just highlight the incomplete areas and the areas I find that are critical errors. I will start with the critical errors.

I do not understand the reasoning when they say, “The other test is called SMBG, or self-monitoring of blood glucose.” This is stated here and here. Yes, I can understand how some people may think this is the test, but this is not the way I was taught.  Many people are just told to test and to consider this SMBG, but are told nothing more about SMBG.   I admit I know a fair amount about SMBG and have blogged about this quite frequently. To me SMBG is the process of using the blood glucose test results (not just one test) to monitor how well, or not, you are managing your blood glucose levels on a daily, weekly, and continuous basis. The test is done with the blood glucose meter and test strip. Then the meter translates the results from the test strip to a reading on your meter that we can all understand.

SMBG is the process of using the data from the different tests to look for trends and other relationships. SMBG should teach you the when, where, why, and how of testing for you to manage your diabetes more effectively and efficiently. We look to the food we have consumed from our food logs, how we feel from a health standpoint (our health logs), and the time of day. Then we analyze the test information to see if we are on target, or need to reevaluate what we eat and adjust to be on target for the next test. This will help us determine if we need to do more exercise, or if it gives us clues about our health care we may have missed.

This is the second critical error. And yes, I am being technical here, but the doctors or writing staff of the AAFP does not seem to want to use the correct terms. There are blood glucose monitors, but this is for having a device (canula) inserted under your skin and this reads the interstitial fluid glucose levels. This device is called a continuous glucose monitor (CGM). Even they cannot be relied on for obtaining blood glucose readings that are current. They have a lag time or time difference when compared to a blood glucose meter. They are excellent tools for determining trends and giving you an idea of where you were about 15 to 20 minutes ago. CGM devices measure glucose levels in interstitial fluid in 1- or 5-min increments (depending on the system used) on a continuous basis.

For most testing, we as type 2 patients use a blood glucose meter. Now if we have a glucometer, then we know the brand of our meter and that it is a registered trademark of Bayer. If you think the doctor is prescribing a blood glucose monitor, make sure that it is a CGM and that your insurance will cover it. Most insurance will not cover a CGM for patients with type 2 diabetes, as they are expensive. It may be easier today than a few years ago, because some doctors are more persuasive in their writing ability and doctors generally prescribe these only for type 2 diabetes patients that are unable to manage their blood glucose levels. Chances are that it is a blood glucose meter he may prescribe, but if the doctor is an owner of Bayer stock, it could be a glucometer.

The third critical error is here (at How can I deal with an insulin reaction?)  The AAFP says people who have diabetes should carry at least 15 grams of fast-acting carbohydrates with them at all times in case of hypoglycemia or an insulin reaction. The list is far from complete, the fastest carbohydrate tablet is about 4 grams each, and 5 grams are very uncommon, although some may exist and it may depend on the area of the country. Many people that have hypoglycemia problems have bottles of them. In checking with my local pharmacy, they carry tubes of 10 tablets of 4 grams of glucose in the various fruit flavors. They can get the 15-gram glucose gel tubes and bottles of 50 each of the 4-gram glucose tablets. I still have two strips of three each of the 15-gram glucose tablets. A person with type 2 diabetes on most oral medications may not need more than a tube or 40 grams. Anyone on insulin needs to have more glucose tablets available. Apparently, this is another area where they need to update to reflect what is available and specify the instructions for type 1 or type 2 (for oral medications and insulin) patients.

If you are a person with type 2 diabetes having problems managing your blood glucose levels and have been prescribed a CGM, then you will also need a meter for times when you are experiencing hypoglycemia. You will need the now factor for blood glucose testing. The lag time on a CGM may cause you real problems, which you do not need during a hypoglycemic episode. Not being able to adjust quickly enough can put you into a coma. If no one is around or you live alone, people have died.

The next critical error I feel needs mentioning is the list of quick energy sources for correcting hypoglycemia. The AAFP just listed some of the sources of quick energy. Then they list milk without specifying non-fat milk. Fat will slow down the speed needed to bring blood glucose levels back to near normal. I would encourage you to compare the AAFP list to this list from cardiosmart.org as well as the information with it.

The last critical error is the mixing of information for type 1 and type 2 diabetes. There is much information that can apply to both, but also a lot of information that needs to specify whether they are writing for type 1 or for type 2 patients.

Diabetes Tips and Applications

The previous month, I received an email asking questions that are quite common and important for people recently diagnosed with type 2 diabetes. First, this person wanted to know why he was having such a difficult time managing his diabetes. This reminded me of my blog here. Then he wanted to know if there were any applications that he could use to upload the readings from his blood glucose meter to his doctor. There were several other questions which I have answered in my emails with him and I may do another blog on reasons for using insulin and for avoiding some foods.

In exchanging emails, I discovered he was following the directions of a registered dietitian (RD) and eating the high carbohydrate – low fat meal plan. He also was still attempting to determine what I was talking about in self-monitoring of blood glucose (SMBG). He stated that the certified diabetes educator (CDE) had covered testing and how to do it and then just told him to test one hour after finish eating and moved on to confirm what the dietitian had told him about eating a set number of carbohydrates at each meal and snacks. Sounds like a mandate to do something without really educating him about the why, where, when, and how to use the results.

Is it any wonder I get upset with these “professionals” that cannot do education and live by mandates and mantras. I will not go any further with this, but get back to SMBG. I explained why we test our blood glucose so often at the beginning. This is done to determine how our bodies react to the foods or combination of foods and testing is the only way to determine this. His return email asked why the RD or CDE had not explained this to him. I explained to him that the CDE must tell him about testing and where to test, but generally this is where they stop, as they do not want you to realize the benefits of testing and finding out how the foods affect your blood glucose levels.

Of course, the RD will not explain this, as they want you to just follow their instructions without question. It is using the knowledge you gain from SMBG that tells you how the different foods affect your blood glucose levels and this in turn will let you know that what the RD and CDE issue in their mandates is not the whole truth. Some of the foods will spike your blood glucose readings to a high level. This tells you that you must limit the number of carbohydrates by reducing the quantity of these foods or removing them from your food plan. In addition, you will be looking for different results from different food combinations and also for determining if you are on the correct path to achieving your goals. If you are not moving in the right direction, as was the case for this person, you need to reevaluate the food plan and see what needs to be changed.

For this person, I suggested removing most whole grains and all highly processed foods. He reported back about a week later that his blood glucose levels were greatly improved and he had also reduced the quantity of potatoes he was eating. His fasting blood glucose levels were generally under 100 mg/dl and most of his after meal (post prandial) blood glucose levels were under 140 mg/dl. He was still having some problems with his evening and bedtime testing, but felt that with some additional reductions in food quantities and changing foods this was improving. His final comment was how much better he was feeling and that he was not gaining more weight and actually dropping a few pounds.

He commented that he felt he was gaining more benefits from his exercise and felt this was also translating into better blood glucose readings. Next we covered applications for transferring information from his blood glucose meter to an app and then on to the doctor. I discovered that he travels within a block of his doctor's office to and from work and asked if his doctor could read his meter. He checked and found out that his doctor could and had the software program to download his meter. They talked about how often the doctor wanted to do this and over the six weeks we have been corresponding, the doctor is happy with his readings and now has him doing it only at his appointments.

I had suggested that he purchase the software program and download the meter readings to his computer on a monthly basis. After comparing the two apps he had discovered, plus the cost of a new cell phone to handle the application and needing to manually log his readings to the application, he feels very good about not having purchased any and that the software cost was much cheaper, he wonders why he had not thought of that in the beginning. He now has the software download his meter daily and he is able to compare readings for the preceding week and any period of time.

He admits that he still has trouble maintaining his food log and health log, but as he solves more problems, he says that is getting easier as well. He is comfortable with his daily carbohydrates being in the 120g to 160 gram range and very happy that his weight is nearing the goal he and his doctor wanted. We have discussed his activity (exercise) level and carbohydrate level and he says that he may increase the carbohydrate level to avoid losing excess weight below the goal. He does not want to reduce his exercise level, as he feels good about this now.

He has a job that keeps him fairly active and is not a desk jockey. This helps him and he now feels much better with how he is managing his diabetes. His last A1c was 6.5 which is down from the 8.9 at diagnosis. He is now gaining confidence that he will get to 6.0 or lower in the months ahead. He is asking many good questions now and gaining confidence that he will be able to learn more on his own. He has canceled the next appointments with the RD and CDE, because he feels they would not be a help to him. I said that was up to him, but that maybe he should have kept the CDE appointment to see what was said, but he was determined not to waste any more time with them.

Joslin Advocates for SMBG

This is an interesting turn of events. Normally I am the one complaining about the lack of self-monitoring of blood glucose, but now Joslin Diabetes Center is asking in their book Joslin's Diabetes Deskbook, 2nd Ed, Excerpt #4: Do Your Patients Self-Monitor Their Blood Glucose Enough? For this, I have to ask if they will appeal to the Centers for Medicare and Medicaid Services (CMS) to up the number of test strips that diabetes patients can be reimbursed.

I complain because people do not test enough and use the results to help manage their diabetes in as more informed manner. I appreciate Joslin's statement, “It is imperative that people who are self-monitoring know what to do with the results of their glucose checking so that they can take active steps to improve their control. They should be given instructions on how to interpret their results, what they can do themselves in response to the results, and when they should call for help.” At least the authors know and understand the importance of education and that it should be part of every diabetes treatment plan.

Too many doctors do not even prescribe a meter and test strips for patients on oral medications, meaning patients with type 2 diabetes. This excerpt should be required reading for these self-important doctors. All doctors do either give out meters and prescribe test strips or inform their patients where to obtain testing supplies for people with type 1 diabetes and for people with type 2 diabetes on insulin.

I like what is covered in chapter 3. They state that, “Goals of diabetes treatment need to be defined in terms of self-monitoring results.” This is a great statement, which patients with diabetes need to understand. This brings both patients and physicians into the picture and makes each a participant. The patients are responsible for gathering the information, doing this diligently, and providing this information to the physicians. Then the physicians are responsible for taking this information and helping the patients set goals (whether new or revised) to help then manage their diabetes more effectively.

In summary, here are a few reasons why SMBG should be performed:

1. To provide data about glucose patterns that can be used by the healthcare team, working with the patient, to make treatment manageable.

2. To provide data with which patients themselves can make daily decisions on treatment adjustments.

3. To provide feedback on how effectively the individual is managing daily self-care routines, including medical nutrition therapy, physical activity, and medication use.

These are by no means the only reasons and the tables uses are adapted from the American Diabetes Association and are therefore not ideal, but can only be interpreted as suggestive for patients that are elderly or have other diseases, which affect their ability to manage their diabetes more effectively. Those patients that are younger and fully able to manage their diabetes need to consider using these tables.

Another area of concern is a few of the “diabetes coaches” that tell their people not to give the information to their doctors. Granted some doctors do not know what to do with the information, but they are on their way out of practice as patients become more empowered. I have crossed paths with a few of these “coaches” and know they are attempting to hide what they are doing. Not that they are giving out advice that is out of line, but too often these “coaches” are practicing medicine without a license. They may not have intended to, but they do cross the line time after time.

The Many Forms of Advocacy

Merriam-Webster's dictionary defines advocacy as the act or process of advocating or supporting a cause or proposal. This is just a general definition. There are other forms of advocacy and one that fits quite well - advocacy represents the series of actions taken and issues highlighted to change the “what is” into a “what should be”, considering that this “what should be” is a more decent.

For purposes of this discussion, the above is considered part of health advocacy. Health advocacy supports and promotes patient's health care rights as well as enhance community health and policy initiatives that focus on the availability, safety and quality of care. These are just a few of the forms of advocacy and each is important.

I can understand those that are just newly diagnosed with diabetes not being active advocates for diabetes. They are still trying to find the path of maintenance that works for them. However, others that have had diabetes for several years that say or do nothing need to realize that they must speak out for things they have found lacking in their own experiences. They must know that advocacy takes many forms and by remaining silent only lets people who might benefit by what they may say continue without information or direction that may be helpful. This is one reason why I blog, to put information out that may assist people and educate them that a diagnosis of diabetes is not a death sentence.

I feel better knowing that I am busy and working for the education side of diabetes. Those of us with type 2 diabetes have many causes that we can advocate for and most of them need our voices to be heard loud and clear. Some of these causes are:

1. The need for more test strips to help us manage our diabetes more efficiently, to determine what foods do not spike out blood glucose levels.

2. The need for better nutrition information tailored to our needs and not the needs of government.

3. To be recognized as individuals and not lumped into a one-size-fits-all category.

4. Training to be peer mentors or peer-to-peer workers to help others with type 2 diabetes.

5. Better information about oral medications - the limits of each, side effects, and changes dictated by the Federal Food and Drug Administration.

6. More information about insulin and the education of people with type 2 diabetes about the advantages of insulin when oral medications are not working for us.

7. More community involvement to educate not only the community, but assist other people with diabetes set realistic goals for themselves to not only manage diabetes to prevent the onset of complications, but to prevent those with prediabetes from developing diabetes.

This is a very incomplete list and leaves many items for people to expand and become advocates for their change. Some will say that education is not advocacy because it does not raise funds for research and the cure. I say that we have a great need for education to become aware of areas that need research.

I have been blogging about self-management of blood glucose (SMBG) because we need to know what to do for more efficiency in testing. The Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), the US Department of Agriculture (USDA), and the Department of Health and Human Services (HHS) all have funded research aimed at reducing the number of test strips we can use for testing our blood glucose levels. In selecting participants for the trials, they exclude people that are knowledgeable in SMBG and include people that do little or no testing of their blood glucose. How do they know there are people that do little or no testing? They know that there are doctors that do not encourage their patients to test so they look for these patients. These doctors do not encourage testing for many reasons. They don't want their patients to become depressed when they see high blood glucose readings and some follow the USDA logic of whole grains (high carbohydrates) and low fat and don't want their patients to understand what is happening to them. Most of the trials do nothing to educate the participants about what the testing will do and therefore the A1c levels change very little. The researchers can then say that testing makes no improvement in the health of the trial participants, and the CMS uses this information to reduce the number of tests strips covered and eligible for reimbursement.

This is why we need to advocate for proper research and education in blood glucose testing. We need to demand that the research be done scientifically and use education to show what proper blood glucose testing can do for reducing A1c's and improving the health of the trial participants. One such study has been done, but it is not getting the recognition it deserves. Roche Diagnostics performed the study using the Structured Testing Protocol (STeP). More studies are needed to show what proper blood glucose testing to do for lowering the A1c.

The other government agencies, the USDA and HHS do not want people to know that the problem with their nutrition guidelines are what is behind much of the diabetes epidemic and obesity epidemic and they support the CMS position on reducing the number of test strips. Until people with diabetes are taught the purpose and value of SMBG, this is widely publicized, and more trials are advocated for, we will have little to refute the CMS position and prove what USDA and HHS guidelines are causing much of the problem.

Yes, we will still have many people with type 2 diabetes that seem to not care and believe these government agencies can do no wrong. If only they knew!

Before stopping your reading on advocacy, please go to Health Central and read a recent blog by David Mendosa on his thoughts on diabetes advocacy.