Tag: Diabetes Plan

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To Check or Not to Check Blood Sugars.

The question is: To Check or Not to Check Blood Sugars.

For patients on insulin the answer is that we always recommend checking blood sugars. For patients on only oral medications, there is an ongoing clinical debate about the benefits of Self-monitoring of blood glucose (SMBG). There are Health Systems and insurances that limit quantity due to high cost. Many practitioners do not see the need or benefit for patients to monitor unless they are on insulin, I don’t agree as many of those patients can benefit from SMBG to better control their blood sugars.

In a recent article published in JAMA Internal Medicine, a randomized study of 450 individuals originally enrolled, 418 completed the study. The objective of the study was to look at hemoglobin A1C levels and health-related quality of life (HRQOL) of the enrolled patients based on their randomization to one of three groups: no Self-monitoring of blood glucose (SMBG) once-daily SMBG or once-daily SMBG with enhanced messaging feedback on the blood glucose meter. The measured outcomes were change in hemoglobin A1C and HRQOL at 52 weeks. The results of the data were no significant difference in the three groups hemoglobin A1C and HRQOL. Leading the authors to conclude that regular testing of the blood glucose by patients with non-insulin treated type 2 diabetes is not necessary. Here is the citation for the study: Young, L et al. “Glucose Self-monitoring in Non–Insulin-Treated Patients with Type 2 Diabetes in Primary Care Settings: A Randomized Trial”, JAMA Intern Med. 2017;177(7):920-929.

Many insurances like Medicare B will cover strips for patients with diabetes on oral medications but just one strip per day. Choosing carefully when to ask patients to test becomes very important to get the information and patterns needed to maximize treatment.

In practice, I manage patients whose blood sugars are very uncontrolled diabetes which for my Health System means any patient with an A1C greater than 9. While an A1C can give us a lot of information, it cannot give us detail information such as how high blood sugars are going in the morning or after meals. I often ask patients to check fasting blood sugars first in the morning and work on controlling these sugars first. Once the morning fasting blood sugars are under control, I will ask to ROTATE time of finger stick check (before meals, at bedtime) over the course of 1-2 weeks. This allows reducing testing frequency while allowing me to see patterns over time. At every visit re-assess the need for continue SMBG, frequency and timing.

Why Test?

Testing for the sake of testing does no one good. For the patient, testing can help see what certain foods do to their blood sugars, what helps or make the blood sugars worst and when to act. For this to happen, patients need to be educated and shown how SMBG can help them manage their diabetes.

For the Health Care professional, SMBG can give feedback regarding daily choices such as foods, alcohol, exercise, illnesses and stress. SMBG can also help make informed decisions about foods, activity level and medications. It can help see what the impact of stress, injury, illness and disruption in routine do to the patient’s blood sugars. The use of data to know when to advanced therapy and when to stop certain therapies that might not be right for the patient.

Data shows that in type 1 diabetes, patients who test tend to have a lower A1C and a lower number of acute complications. Data also shows that patients who do SMBG have better control regardless of treatment or type of diabetes.

Other reasons why to consider SMBG, it can emphasize the importance of medication adherence for the patient. Another thing is that we want patients to be familiar with the process, and able to accurately self-monitor, once they are using insulin. Learning how to use the glucometer, insulin injection techniques, storage, and when to inject tend to be too much to spring on a patient all at once. Introducing the concepts more gradually may help them adopt the information easier and not feel overwhelmed.

When to Check

• Before and after exercise: can help prevent low blood sugars and it can show the patient the benefits of exercise in lowering blood sugars.

• Before and after meals: to determine insulin to carb ratios, adequacy of meal time insulin dose, effects of foods or portion size on blood sugars.

• Illnesses: patients should check more frequent when they are sick, patients should be educated about a sick day plan.

• Pregnancy: will need to check more frequent before, after meals and before bedtime; to avoid complications for the unborn baby.

What if the Patient is Resistant to checking Blood Sugars?

Sometimes patients who are VERY resistant to checking, it could be because they don’t see the need for SMBG, they dislike needles, checking hurts, they don’t want to check when they are outside the house, they work overnight or financially checking can be a burden. Trying to find out the barriers to checking is the first step, then working closely with the patient to problem solve those barriers and get them to check their blood sugars.

Sometimes I can only convince the patient to check 3 times per week. Once SMBG readings and A1C are at goal, I advise the patient to continue to check BG 2-3x/week and contact me if pre-meal BG rises above a certain level (150mg/dl OR 180mg/dl if elderly or higher A1C goal). I also encourage them to continue to learn what the different foods do to their blood sugars by checking after meals.

Patients who “fall off the wagon” and glycemic control worsens is usually because they stop testing, taking their medications and managing their diabetes. If you don’t know how high your blood sugars are going, you can not do anything about it. For these patients not being motivated has a lot to do with it. Sometimes patients are depressed, ashamed of not being able to manage their blood sugars, have social barriers such as financial barriers, homelessness, job loss and food insecurities.

It is my belief that SMBG is a very good tool in self management of diabetes, when used correctly can help patients and their Health Care providers manage blood sugars. SMGB should be part of every diabetes plan to get blood sugars to goal. To the question to check or not check? When ever possible educate and motivate patient to use this tool to get their blood sugars under control.

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Weight Loss in Diabetes

There is a known connection between obesity and Type 2 diabetes. It is known that the obesity epidemic is driving the Type 2 Diabetes epidemic world wide. There is strong evidence that modest weight loss can delay the progression from pre-diabetes to type 2 diabetes (1,2,3).  Weight loss in diabetes is beneficial in managing type 2 diabetes. Why lose weight question, for many type 2 diabetics is an important one to get their diabetes under control.
Studies have shown that reduction in calories lead to a reduction in A1C of 0.3% to 2.0% in adults with type 2 diabetes, leads to reduction in medication doses and improvement in quality of life (1). Maintaining weight loss is challenging (4) but offers long-term benefits. For example, maintaining weight loss for 5 years is associated with sustained improvements in A1C and cholesterol levels (5). Weight loss in diabetes can be attained with lifestyle programs that offer a 500–750 calorie energy deficit or offer 1,200–1,500 calorie for women and 1,500–1,800 calorie for men. For many obese individuals with type 2 diabetes, losing >5% can produce beneficial outcomes in sugar control, cholesterol, and blood pressure, and sustained weight loss of ≥7% is optimal (4).

Definition of Obesity

Body Mass Index, or BMI, is used as a screening tool for overweight or obesity.
• If your BMI is less than 18.5, it falls within the underweight range.
• If your BMI is 18.5 to <25, it falls within the normal.
• If your BMI is 25.0 to <30, it falls within the overweight range.
• If your BMI is 30.0 or higher, it falls within the obese range.
To calculate BMI, see the Adult BMI Calculator or determine BMI by finding your height and weight in this BMI Index Chart.

How does Obesity Lead to Type 2 Diabetes?

Increase weight leads to increase fat (adiposity), increase adiposity leads to insulin resistance which eventually will lead to diabetes.
To have weight loss in diabetes, there are three modalities: bariatric surgery, weight loss medications (pharmaceuticals) and energy deficit. A combination of any of the three modalities with behavior modification can help patients achieve weight loss.

Bariatric surgery

Bariatric surgery is indicated for patients with a BMI equal or greater than 40 or a BMI equal or greater than 35 with co-morbidities such as diabetes. The two most popular types of bariatric surgery are Roux-en-Y gastric bypass and Gastric sleeve surgery also known as vertical sleeve gastrectomy. Gastric sleeve is more popular because the number of side effects are less than with the Roux-en-Y bypass but is not as effective.

Weight loss Medications (Pharmaceuticals)

Prescription weight loss drugs: Belviq, Contrave, Saxenda, phentermine, and Qsymia. Over the counter you can find orlistat. Lifestyle intervention plus pharmacotherapy intervention lead to better response to calorie restriction. For patients on weight loss medications see an increase magnitude of response, average percentage of weight loss is greater. Overall pharmaceuticals can help extend weight loss sustained response. SEQUEL study data showed amount of weight loss group on pharmaceutical treatment lead to greater weight loss more than the placebo group.

Who can benefit from the use of Pharmaceuticals for weight loss?
Patients who report early hunger shortly after eating, patients who tend to have more than one plate of food to feel full, Patients with persistent food thoughts, strong emotional response to food or eating, and less than robust response to dietary plan. For some, pharmaceuticals can be use indefinitely or in maintenance can be use when needed.

Calorie Restriction

Type 2 diabetes is potentially reversible via an 8-week, very low-calorie diet followed by careful weight management for up to 6 months, new research shows. The findings were published online March 21, 2016 in Diabetes Care by Dr Sarah Steven of Newcastle University, United Kingdom, and colleagues.

The best weight loss response was seen in Younger age patients, in those with shorter duration of diabetes and not on insulin. STAMPEDE trial followed 150 patients with a BMI of 27-43 1 for five years 1 out of 3 patients were in remission after 5 years after bariatric surgery. Look AHEAD and DIRECT trial achieve 50% remission on an average weight loss of 10 kgs.
Calorie restriction paired with exercise provides patients with type 2 diabetes with a plan to lose weight and control blood sugars. Before starting any exercise, program consult your Primary care physician.
Lifestyle is always recommended to manage diabetes, for some patients with type 2 diabetes it may not be enough. Pharmaceuticals and bariatric surgery are other tools that can help. For patients who are morbidly obese bariatric surgery maybe the best alternative. Talk to your Primary Care Physician to find out what they recommend for you.
Weight loss in type 2 diabetes can lead to remission or well control diabetes at the levels of prediabetes leading to decrease complications from diabetes. Make weight loss part of your diabetes action plan.

References
  1. https://jandonline.org/article/S2212-2672(17)30333-7/abstract
  2. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002095
  3. http://annals.org/aim/fullarticle/2395729
  4. https://jandonline.org/article/S2212-2672(15)00259-2/fulltext
  5. http://drc.bmj.com/content/5/1/e000259
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What is Self-Management?

Self-management is the key to good diabetes control.

• Self-management is what people with diabetes do to manage their chronic condition and the effects on their health, daily activities, social relationships and emotions.

• Self-management uses education and strategies to increase diabetes management skills and confidence. It can also refer to the organizational structure such as your Primary Care Doctor’s office educational programs for diabetes patients.

• The goal of self-management is to help people achieve good quality of life and improve those aspects of life worsened by diabetes.

Self-Management is the Use of Skills to…

• Deal with your illness (medication, physical activity, doctor visits, changing diet)

• Continue your normal daily activities (chores, employment, social life, etc.)

• Manage the changing emotions brought about by dealing with a chronic condition

(stress, uncertainty about the future, worry, anxiety, resentment, changed goals and expectations, depression, etc.)

Road to self-managing includes the follow wing steps

1.    Set goals

2.    Making an action plan

3.    Feed back

4.    Problem solving if needed

5.    Making a new Action Plan

6.    Acknowledge progress

Always check with your Primary Care physician or endocrinologist to see if there is a diabetes education program, a Certified Diabetes Educator or a diabetes group that can help you manage your diabetes.