LifeAfterDx--Diabetes Uncensored

A internet journal from one of the first T1 Diabetics to use continuous glucose monitoring. Copyright 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014, 2015, 2016

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Location: New Mexico, United States

Hi! I’m William “Lee” Dubois (called either Wil or Lee, depending what part of the internet you’re on). I’m a diabetes columnist and the author of four books about diabetes that have collectively won 16 national and international book awards. (Hey, if you can’t brag about yourself on your own blog, where can you??) I have the great good fortune to pen the edgy Dear Abby-style advice column every Saturday at Diabetes Mine; write the Diabetes Simplified column for dLife; and am one of the ShareCare diabetes experts. My work also appears in Diabetic Living and Diabetes Self-Management magazines. In addition to writing, I’ve spent the last half-dozen years running the diabetes education program for a rural non-profit clinic in the mountains of New Mexico. Don’t worry, I’ll get some rest after the cure. LifeAfterDx is my personal home base, where I get to say what and how I feel about diabetes and… you know… life, free from the red pens of editors (all of whom I adore, of course!).

Wednesday, October 27, 2010

Meters matter

At a recent state-wide meeting on medical research in clinic settings I overheard a doctor, who ideally should be taken out back and shot (but at a minimum shouldn’t be allowed to see diabetic patients), say that she didn’t think Type-2 on orals should test their blood sugar at all.

She didn’t see any purpose.

She didn’t think it did any good, as a Type-2 on pills can’t do anything about their blood sugar anyway.

I’m sooooooooo sick and tired of hearing bullshit like this.

Meters matter. For all of us. For Type-1s and Type-2s. For insulin users and pill poppers.

And I’m going to tell you why, Letterman style, with the top ten reasons meters matter for Type-2s well controlled on pills. I’m focusing on this group because there are waaaaay to many people who think T-2s on pills don’t need to test, including some of the patients themselves.

Many of the reasons why meters matter have more to do with our brains than our blood, but this shouldn’t belittle them as valid reasons. To control diabetes successfully requires some brain power, to say the least, and we have a boat load of evidence showing how life can “get in the way” of good diabetes control. If we accept that psychological issues can impact a patient’s ability to keep his diabetes under good control; why are we denying that psychological tools can help her keep her blood sugar under good control? Any tool that can aid us in any way is valid and important.

Meters matter reason number ten: Don’t wait for it to rain to buy an umbrella. Type-2 Diabetes is both chronic and progressive. It never goes away and it always gets worse. Insulin resistance, the corner stone of T-2, increases every day that passes, every minute that passes, every second that passes. In some folks it comes on like a tsunami, in others it resembles the slowly rising sea levels of global warming. The increasing insulin resistance taxes the pancreas. It’ll work overtime to keep up. It’ll put on swing and night shifts. But eventually, the levy is topped. And on top of that fact, our bodies adapt to our medications. My message here is actually several fold. First, get into good habits now, before you need too. Keep in good habits, before you need too. This also sets the stage for...

Meters matter reason number nine: Meters are the night watchman on the tower; looking for the barbarians on the horizon. If you test now, when all is quiet and wonderful, you’ll get the earliest possible warning of change. And one thing we can count on with diabetes is change. Forewarned is forearmed. And speaking of the troops…

Meters matter reason number eight: If you won’t do it for yourself, do it for me. Do it for your Diabetes Educator and your Doctor. Testing is not only good for you in both the short and long runs, it’s good for us in the medical world. Everyone’s diabetes varies. Truly, it has 31 flavors. Meters reveal the personality of your very own personal diabetes to us. Testing lets us put your diabetes on the couch and psychoanalyze it. Is your diabetes the kind that dumps sugar into your blood stream at night? Is your diabetes the kind that can’t handle the carbs in your meals, leaving you high for hours after eating? Is your diabetes one of those that just runs on the high side all the time? The differences drive the therapy. Oh, and speaking of eating…

Meters matter reason number seven: Meters let you know what your diabetes likes to eat. And what it doesn’t like to eat. OK, so there isn’t a “diabetes diet.” Not anymore. We’ve kicked that to the curb ‘cause it didn’t work out so well. But no matter what flavor of diabetes you have, no matter how well or how poorly controlled it is, I guarantee this: there are foods that will give you trouble and foods that won’t. Does that mean you can’t have the ones that give you trouble? Of course not. This is a disease, not a religion. But you may have to look at how much of the problematic foods you eat, what else you eat with them, and when you eat them. The meter is the perfect tool for a very small-scale scientific study, that I like to call a One Rat Study. Yes, you are the rat in your One Rat Study. We know that carbs turn to glucose in your gut. That’s the job of the digestion system. Some carbs turn to sugar faster than others. The marathon sprinters tend to be stuff made with flour, stuff made with potatoes, and stuff made with rice. Oddly, most D-folk seem to be able to tolerate two of the three just fine, but I’ve never been able to establish a pattern as to which one will effect who. Sadly, I’m one of those who has trouble with stuff made with flour, so I have trouble with bread, crackers, cake, tortillas, and (most devastatingly for me) pasta. Anyway, I digress. If you test before you take your first bite, and two hours after that first bite, you can see how various foods effect your blood sugar. You must “test in pairs” as William Polonsky has so elegantly termed it. What you need to look at is not whether the after meal number is at a specific goal, but how much the rise is. Food your diabetes and diabetes medications like is a rise of less than 50 points. And if the rise is waaaaaaay more than that…

Meters matter reason number six: Meters are Myth Busters. Many T-2s on orals (including my esposa in the past) buy into the myth that there is nothing that they can do about high blood sugar anyway, so why depress yourself by testing? Well… Well, for starters, in the future you could avoid doing whatever it was that got you in to this mess in the first place. And there are some things you can do if your sugar is high and you are on orals. You can drink water, walk briskly, and avoid eating high carb foods until you are back down where you belong. And speaking of denial…

Meters matter reason number five: Meters remind you that you are diabetic. OK, I’ll be first to admit that on the surface this sounds craaaaaaazy. But it is true and important. I know several otherwise very smart people who were diagnosed with diabetes, put on pills, and thought the problem was solved. And why wouldn’t you think that? Your blood pressure is fixed with your hypertensive med, your cholesterol is fixed with your statin. Your thyroid is fixed by your thyroid pill. Your blues are fixed with your anti-depressant. Most of our illness require no more than taking the right pill and seeing your doctor again in six months. Not true with diabetes. You are an important part of the picture. You are in the drivers’ seat. This illness takes some work, and I think meters serve as important daily reminders that we need to stay on the ball. Which is really the next reason meters matter…

Meters matter reason number four: Meters remind you of your responsibility in your self-management. They help you keep your head in the game, even when you are waaaaaay ahead of the opposing team. Just this week I had a guy in my office who told me that he realized that when he didn’t test he started to eat more sloppily; but that he realized that when he did test it kept his eye on the ball. So in many ways, meters are the best medicine. And you must take your medicine because…

Meters matter reason number three: Because nothing is more dangerous that deciding you are not diabetic any more. You’d be surprised how often this happens. And it never ends well. At some point folks who are detached from their diabetes often decide that they don’t have it anymore or maybe never had it in the first place. Not only are they not testing, but they stop taking their pills. The meter, and testing, keeps you in touch with your diabetes. It reminds you who and what you are, and what that requires of you to keep yourself healthy for your loved ones. Don’t get depressed. But speaking of depression…

Meters matter reason number two: Meters are the best anti-depressant. Yeah, I know, some folks get depressed by having to “poke their finger,” but this is diabetes. No wimps allowed! Meters are a powerful reminder that you are in control, and that is heady stuff. It is your diabetes and you own it. In many places, especially in minority communities where it seems everyone has had diabetes for generations upon generations, a certain degree of fatalism takes over. Bad outcomes are accepted as destiny. Bull-fucking-shit. Yes, diabetes has wrapped it’s slimy little tentacles around your family’s DNA. Yes, Grandpa had it, Dad had it, Uncle had it. Yes, Grandma had it, Mom had it, Auntie had it. Your sibs have it. Yes you have it and probably so will your children. And so what? Just because everyone had diabetes doesn’t mean everyone needs to die from it. Look, diabetes treatment has come a long way. You don’t have the same diabetes your parents and grandparents had. You have New and Improved Diabetes. Yep, same killing action as the old product, but now more controllable than ever. Used right, used often, the meter should not depress you. You should rejoice in the power it grants you to change your family’s destiny. In some areas of the county, having a first generation go to college is cause for great celebration. I think we are on the verge of a new celebration. The first generation of some families dying at very old age with eyes, kidneys, and toes all original equipment in the coffin.

And the number one reason that meters matter: The fucking A1C test lies. So I need to lay the back ground here. The A1C test has for years been the gold standard the Docs use to determine diabetes control, or lack thereof. Actually, the A1C test is not a particularly good tool to do this, as you will soon see, but it was all we had. So what exactly is an A1C test, you ask? OK, here we go. Red blood cells are the FedEx trucks of your body, delivering little packages of oxygen from the lungs to every cell in the body. The freeway system the little trucks drive on is your circulatory system. But of course, they aren’t the only vehicles on the road. Sugar is on the road too. Let us pretend it is a very cold snowy day. The sugar is snow on the highway. The FedEx trucks need to make their deliveries, snow or not. But driving in all that snow, the trucks get splattered with ice and mud and muck. So too with the red blood cells. If there is a lot of sugar in the blood stream, the red blood cells get all splattered with it. The worse the snow, the dirtier the trucks get. The A1C test is simply a way of seeing how dirty the fleet of trucks is, on average. The score, ranging from 4.0 to 14.0+ is simply revealing the percentage of the red blood cell’s skin that is coated in sugar. As red blood cells live about three months, an A1C score reveals the overall sugar environment in the blood stream for the last three months. Opinions vary, but generally speaking, somewhere in the sixes is considered in good control. For perspective, an A1C of 6.5 would tell us that the average blood sugar for the past three months is 140 mg/dL.

But giving us an average is the first way the A1C test lies to us. You can get an average of 140 by adding 65, 140, and 215 and dividing by three. I think most of us would agree that if your blood sugar was rollercoastering between 65 mg/dL and 215 mg/dL that you are most certainly NOT in good control of your diabetes. But if you only looked at your diabetes through the lens of the A1C test, you might make the fatal mistake of assuming that you are in control. That is critical because for years we thought that it was simply high average blood sugars that cause microvascular damage (your eyes, kidneys, penis, and toes), but now we are learning that excursions, rapid changes in blood sugar levels, may play as large a role in kindling these diabetes complications as does the average sugar.

And the A1C cannot and does not reveal excursions. It is a blunt sword. It only gives us averages. So beyond the insidious nature of mathematics, the A1C tests are also subject to false readings from anemia, hemoglobinopathies, and plain old-fashioned human error. But proper and creative use of a meter, on the other hand, can reveal what the A1C test is blind to. Don’t get me wrong. The A1C test has an important role to fill, and I think the test and the meter together provide an excellent set of checks and balances against each other’s weaknesses.

Oh yeah, but one more thing for those physicians who want to rely on controlling diabetics with A1Cs alone. As the test covers a three month period, the standard is that every diabetic should be tested quarterly. But that does not happen. Many diabetics are tested twice a year, and a shocking number only get a test once per year.

Care to wager how much damage high sugar levels could do in a year?

Meters matter.


End of subject.

Now go test your blood sugar, all of you.


Blogger Jonah said...

Funny, Wil. It's you I tend to link to when arguing that type 2s on oral meds shouldn't be required to test regularly. It's that post you wrote some time ago about the guy you put on Exubera and how amazed he was that he could do something about his blood sugar.

With the price of test strips being what it is, and meter inaccuracies being such that many of the cheaper brands and not infrequently the expensive ones, can have a difference of 50 mg/dl on the same drop of blood, I don't see regular blood sugar testing as a priority for type 2 diabetics. Especially since many are really unable to figure out what any of those numbers mean outside of "I am a fat and old person". And that (at least it seems to me) is how many of the type 2s I know feel about diabetes and I think it would be lots healthier for them not to know.

Also, if we believe (and I do) that some of the oral meds are worse than moderately high blood sugar, then we need for people to focus more on overall health and less on blood sugar, particularly if insulin is being discouraged by their doctor or whatever.

8:49 AM  
Blogger George said...

This post was awesome. I loved reason number 1. SO EFFING TRUE

One of the reasons i like being on a pump is that it requires me to check all day long. Knowing is Powerful.

12:55 PM  
Anonymous Sysy said...

Yikes, well done. Kind of "in your face" material, but, in a good way. I agree that testing is and should be one of any diabetic's priority. Even those who are pre-diabetic benefit greatly. My parents classify under pre-diabetic and have recently begun testing regularly. Next thing you know they've got this 140 staring them in the face and suddenly it's too hard to eat the dessert they were planning on eating. All of your reasons are right on. I hope people get the seriousness of what you wrote, despite all the good laughs they must have had.

6:16 PM  
Anonymous Tim said...

Great post Wil - I agree with you on every point. Here in the UK I often hear of health boards cutting down the number of test strips T2s can have (generally to save said health board cash). It's a stupid, short-sighted policy for all the reasons you give above.

2:48 AM  
Anonymous Bernard Farrell said...

Wil, another excellent post. I love your writing. I finished your Beyond Fingersticks book while waiting for an eyetest. I'm sure many folks wondered what I was laughing at.

8:40 AM  
Anonymous Anonymous said...

Thank you, Wil for your straightforward response on this issue.

4:11 PM  
Anonymous Stuart Schaffert said...

As a 5 year type 2 I know my A1C would not be in the mid 5's and I would be roller coastering through highs and lows if I hadn't had my meter to tell me how different foods affected me. The meter is essential to my understanding of this disease on a daily basis. A single fasting reading in the morning just doesn't cut it.


12:36 PM  
Anonymous Anonymous said...

The other problem with A1cs is that some people are high glycators, some average, and some low. So the same A1c doesn't mean the same thing to different people.
In 1991, I had a FBG of 138, and 3 months later, 131. At this time, these BGs would be diagnosable. BUT 2 months later, my A1c was 4.8! And no, I wasn't having hypos.
Last September, I had a life-threatening diabetic coma with an A1c of 10.7. And yet I know of people who were walking and talking with A1cs of 12, 13, and 14 or so.
So I am adamantly opposed (not that it matters!) to the new idea that diabetes can be diagnosed by A1c alone, and the cut-off would be 6.5.
Even after I was frankly diabetic, with fastings above 160, and PPs well above 200, but not yet on medication, my A1c's were in the low 6's.
I'll take my meter over my A1c any day.

1:07 AM  

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