Specialists. Given the complexity of diabetes and the many organ systems that are affected, adding a few other specialists to your health team would be wise. These include:
•podiatrist (for preventive foot care and treatment of foot problems)
•ophthalmologist (for routine eye exams and treatment of eye disorders)
•dentist (for ongoing tooth/gum care and treatment of periodontal disease)
•nephrologist (for treatment of kidney disorders)
•neurologist (for treatment of nerve disorders)
•cardiologist or vascular surgeon (for treatment of large blood vessel diseases)
The Right Skills
Modern technology is useless without the know-how to utilize it properly. Take my wife (please . . . and please don’t show her this!). Her computer at work is equipped with a powerful processor and all the latest software, but she prefers to use it as a place to tack up her sticky notes. Likewise, high-tech diabetes management devices are nice, but ultimately, your skill is what gets you the control you want.
The following are skills that everyone using insulin should adopt.
Self-Monitoring
From my experience, people who check their blood sugar levels four to eight times daily tend to have the best overall control. Checking less frequently is like taking your hands off the steering wheel while driving: You might stay on the road for a few moments, but before long you are going to veer into dangerous places. Frequent checks allow you to detect (and fix) high glucose levels so that you don’t go for long stretches above your target range. They also give you a chance to detect (and fix) dropping glucose levels before hypoglycemia develops. However, too much of a good thing may not be so good. Checking obsessively (e.g., every hour of every day) may actually do more harm than good. Besides creating unhealthy dependence and anxiety, it may cause you to overreact to mild highs or lows before your insulin (or your food) has a chance to take effect. And remember one of our requirements for quality diabetes control: Managing your diabetes should not get in the way of enjoying the rest of your life.
In general, the best times to check blood sugars are
•before each meal and snack (to determine if a correction dose is needed and to evaluate the effectiveness of the previous dose);
•prior to exercise and driving (particularly if a reading has not been taken recently);
•periodically, one hour after meals (to assess postmeal control);
•before going to sleep; and
•periodically, in the middle of the night (to verify that your basal insulin is holding you steady while you sleep).
To help ensure the accuracy of your readings, be sure to use test strips prior to their expiration date. Keep the strips sealed in their bottle or foil wrapping, and be sure to apply enough blood to cover or fill the test area completely. Never expose your strips to extreme hot or cold temperatures—so don’t leave them in your car. If your meter requires coding, make certain that the code number in the meter matches the code number on the test strip packaging.
A clean finger is also a must. There is no need to wipe your finger with alcohol, but the presence of dirt, grease, food, or other foreign substances on your finger can affect the accuracy of the reading. Last week I had an opportunity to try some of the finest barbecue Kansas City has to offer. After devouring a few ribs, I checked my blood sugar and was very surprised to see a reading of 438 mg/dl (24 mmol/l). After cleaning my finger and rechecking, the reading was 108 (6)—quite a difference. At that point, two thoughts crossed my mind: I’m glad I didn’t take insulin for the high reading, and man, that’s some powerful sauce! If you ever suspect that your meter reading may be inaccurate, recheck—twice if necessary. If you’re still in doubt, use the “control solution” that came with your meter to verify its accuracy. The reading obtained with the control solution should fall within the designated range on the test strip package. If the result is outside of the reference range, try a new package of strips. If that does not solve the problem, call the meter manufacturer and ask for a replacement meter.
Self-monitoring also means checking your HbA1c about every three months. This will keep you accountable and provide feedback regarding the effectiveness of your current program. Many diabetes clinics can perform A1c tests using a simple fingerstick procedure. One-time-use home A1c kits are also available. (See Chapter 10.)
A few other measures of long-term glucose control are also available. A glycosylated fructosamine test assesses glucose control over the past two to three weeks. This lab test can be used if you have blood abnormalities that may interfere with the accuracy of an A1c. It can also be used if you need to maintain very tight control for special situations such as pregnancy or preparation for surgery. Another test, the GlycoMark, evaluates the degree to which blood glucose levels spike after meals. It evaluates how often (and how much) glucose levels are above the renal threshold, which is usually 160–180 mg/dl (9–10 mmol/l) over a one- to two-week period. This test can be useful if your A1c is much higher than your premeal fingerstick readings would indicate. Strategies for managing after-meal spikes are covered in Chapter 9.
Record Keeping
It’s a fact: People who keep written records have better glucose control than those who don’t. Of course, you could say that those who keep records do so because their numbers look good on paper, but you can’t deny that keeping records makes us feel accountable for our actions, and maintaining organized, detailed records and analyzing them on a regular basis allows us to catch problems and fine-tune more easily.
Any good record-keeping system begins with blood glucose readings. For those taking only basal insulin (once or twice daily), blood sugar readings should be taken twice daily—at least while control is being fine-tuned. Ideally, the readings should be taken at two meals in a row and rotated from day to day. For example, on day one, test before breakfast and lunch. On day two, test before lunch and dinner. On day three, test at dinner and bedtime. Then repeat the process from day one. This approach lets you see when blood sugar levels may be rising or falling.
For those taking basal as well as mealtime insulin (or two injections of premixed insulin daily), blood sugar should be checked a minimum of four times daily—upon waking, midday, predinner, and at bedtime.
Blood sugar readings by themselves are not of much use unless they are all running high or low. For most of us, however, that just isn’t the case. When inconsistencies exist, you need to figure out why the readings went high or low. Were they caused by too much or too little food? Incorrect insulin doses? Changes in physical activity? Stress or illness?
To figure out why your blood sugar levels vary, record the amount of insulin taken; the grams of carbohydrate consumed at each meal and snack; the type and length of exercise and other physical activities performed, including housework, yard work, shopping, and extended walking; as well as stresses that tend to affect blood sugars (e.g., illness, menstrual cycles, emotional events, and hypoglycemic episodes). Pump users should also note when infusion set changes take place.
To get the most from your record keeping, organize the information so that it will be easy to analyze. Forms like those in Appendix A have been very helpful to my patients. These forms are also available at my website in a printable and downloadable form, http://www.integrateddiabetes.com/logs.shtml.
If you’re sitting there saying, “No need. I can just download my thingamabob to the computer. It keeps all the information for me.” Sorry, bud. At this point there is no good replacement for a written record-keeping system. Downloadable devices and electronic databases fail to capture many of the key events that influence our blood sugar levels, and none present the information in a format that is practical to analyze. So at least for the time being, get out the pen and paper, or save the forms from our website to your computer and type the data in. Do you need to do it forever? Probably not. I find that once the insulin doses have been properly fine-tuned, written record keeping can be do
ne periodically (perhaps one week per month) or any time blood sugars are starting to fall outside of your desired range. Of course, some people take comfort in keeping ongoing records, feeling that it keeps them on track. If you’re one of those people, then keep on loggin’!
At this point, there is no good replacement for an organized written record-keeping system.
Data Analysis
Learning how to interpret your self-monitoring records is also essential. Otherwise, your log sheets are nothing more than pieces of paper with a bunch of numbers and little blood spots on them.
Review your own records on a weekly or bimonthly basis. Keep track of how many readings are above, below, and within your target range for each time of day that you test. If more than 25 percent of your readings are above target, or more than 10 percent are below your acceptable range, changes to your insulin program or dosing formulas may be in order. Because low blood sugars can sometimes produce high readings a few hours later, eliminating the lows before addressing the highs is usually the best course of action.
Besides evaluating your blood glucose levels by time of day, see if you can detect what may be causing the highs and lows. Here are some questions to ask yourself:
•Are the patterns different on certain days of the week? Certain phases of the month?
•Is physical activity having an immediate or delayed effect?
•Do certain types of foods always seem to make your blood sugar rise?
•Are you always high after experiencing a low? Or do lows tend to repeat themselves?
•Are you often low (or still a bit high) after taking extra insulin for a high reading?
•Are emotional situations impacting your control?
•Does your control vary based on how long you have used an insulin pen, vial, or pump infusion set?
When it comes to reducing the frequency of the highs and lows, the culprit is not always one of the “usual suspects.” One of my clients, a curbside baggage handler at the airport, discovered that how much luggage he processed greatly influenced his daytime blood sugar. On the busiest travel days—Fridays and Sundays—his blood sugars were much lower than the rest of the week. A simple reduction in his mealtime insulin on busy days solved the problem.
Another client had nice, consistent readings except for highs on certain evenings. A look at her logbook showed that choir practice usually preceded her high blood sugars. It seems that the passion and emotion she felt while singing were causing an adrenaline-induced rise in her blood sugar. A little extra insulin before practice solved the problem nicely.
One of our young clients, a second grader using a bright pink insulin pump, had very erratic readings when reporting to the nurse before lunch—some highs, some lows, but rarely on target. Her records revealed that the lows were on days she had gym class in the morning, and the highs were on nongym days. A slight tweaking of her morning insulin based on her level of activity put her blood sugars back on track.
Remember, managing diabetes isn’t about achieving instant perfection; rather, it’s about making improvements. Every time you make a sensible adjustment based on your records, your control should get just a little bit better.
Analyzing Meter, Pump, and CGM Downloads
When written records are not available, electronic devices such as blood glucose meters, insulin pumps, and continuous glucose monitors can provide useful information, if you know what to look for. Beautiful pies and bars (charts) are better suited for eating than insightful data analysis. The information and reports that can yield valuable insight include the following:
Statistics
When viewing data over the past couple of weeks or more, focus on the overall average glucose, standard deviations, and percentage of readings that are above, below, and within your target range. The average should correlate well with your HbA1c, although it may underestimate a bit if you don’t do much after-meal testing (BGs tend to spike up for a short while after meals and snacks).
The standard deviation (SD) reflects the amount of variability in your readings. Lower is better. If the SD is more than half of your average, your readings include many extreme highs and/or lows. An SD that is less than one-third of your average means that your readings are fairly consistent from day to day, without too many in the extreme ranges.
The percent of readings (or time) within your target range is the gold standard for assessing the quality of your diabetes management. Though a couple of extreme highs or lows can greatly influence your average and SD, they won’t necessarily wreck your percent in-range. In your software be sure to set your target range (the default setting is often unrealistic).
The percent of readings in-range (or time spent in range) is the gold standard for assessing the quality of your diabetes control.
In some meter and pump software packages more detailed statistics are sometimes available. These include averages by day of the week (to see if you are having control issues related to your weekly schedule) and averages and percent high/low/in-range by mealtime.
Downloads of continuous glucose monitors offer another level of statistical information: percentage of actual time spent above, below, and within your target range; area under the curve (AUC), which reflects the time and magnitude of above-range glucose levels; cumulative average glucose, which should correlate closely with HbA1c; and the number of excursions above and below your target range.
Modal (or Standard) Day Reports
This report provides a scatter plot of blood glucose values arranged by time of day. It serves as a quick visual summary of the quality of your blood glucose control, grouped according to your usual mealtimes. (See Figure 4-1 below.) As was the case with setting your target BG range, be sure the meal schedule in the software corresponds with your usual schedule. (Many are preset for the “early bird special” crowd, with meals and bedtime at very early times of day.)
Figure 4-1. Example of a modal day report
Take a look at your modal day report for the past several weeks. Are there frequent highs or lows at certain times of day? Are the readings consistent or widely scattered? When you view it in conjunction with the averages and percent high/low/in-range statistics described above, you will have a very nice overview of your daily control.
Sensor Overlay Reports
CGM download software can superimpose multiple days of sensor data onto a single report. (See Figures 4-2 and 4-3 below.) This report reveals unique insight into the glucose ebb and flow on a typical day, helping you answer questions such as:
•When are most highs and lows occurring?
•Are glucose levels peaking very high after certain meals?
•Is there an upward or downward trend overnight?
•Do lows trigger rebound highs?
•How long does it take for bolus insulin to finish working?
•Are lows occurring without warning signs or symptoms?
Figure 4-2. Example of a sensor overlay report
Figure 4-3. Example of a sensor overlay report
Logbook Report
Summary statistics (averages, SD, percent in-range) and modal day reports can be misleading if you check more than once when your blood glucose is high or low or if you tend to check more often when you feel that something isn’t quite right. The logbook report permits a more accurate assessment of your blood glucose history, listing readings in chart form according to the time of day. Once again, be sure to set up the software so that the time intervals correspond with your typical schedule.
A detailed look at your logbook can answer questions such as:
•Do lows tend to occur after highs? (Perhaps you are overdosing for the highs.)
•Do highs tend to occur after lows? (Perhaps you are overeating or rebounding.)
•Do you tend to run several highs in a row? (Perhaps your correction doses are insufficient.)
•Do glucose levels change overnight or between meals? (Perhaps your basal insulin needs adjustment.)
•A
re there patterns related to when you do—or don’t—exercise?
•Are there patterns after you eat restaurant or take-out food?
Glucose Trend Graphs
Trend graphs provide a plot of glucose values over an extended period of time, such as a month or several months. By highlighting periodic peaks and valleys, these graphs can shed light on whether therapy adjustments are needed for things like menstrual cycles, off/vacation days vs. work/school days, and seasonal variations in physical activity. Trend graphs are also useful for illustrating control changes over prolonged periods of time. Gradual upward trends often indicate a need to intensify therapy. Downward trends may indicate that your therapy is on the right track as long as you are not experiencing hypoglycemia too often. In Figure 4-4 below, the trend graph shows that glucose levels are becoming steadily less erratic and more consistent.
Figure 4-4. Example of a glucose trend graph
Think Like a Pancreas Page 9
