Self-Testing and Type 2 Management

A paper denigrating the value of patient self monitoring of blood glucose (SMBG) was published in the British Medical Journal a few days ago. Once again I am mystified that highly qualified medical researchers can spend tens of thousands of dollars (or, in this case, Pounds) to come up with a worthless result.

BMJ, doi:10.1136/bmj.39247.447431.BE (published 25 June 2007)
research-article

Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial

Read the full paper here: http://www.bmj.com/cgi/content/full/bmj.39247.447431.BEv1

Their conclusions:

Conclusions
Evidence is not convincing of an effect of self monitoring blood glucose, with or without instruction in incorporating findings into self care, in improving glycaemic control compared with usual care in reasonably well controlled non-insulin treated patients with type 2 diabetes.

How did they arrive at that conclusion? In my opinion they failed to understand how to use SMBG systematically and had no concept at all of the process of using test results as feedback to change input for better results.

Rather than say it all twice, I'll repeat below my post to the BMJ "rapid response" section after the article. Hopefully, they will publish it; if not, at least it will appear here:

***
Response to BMJ

I am not a doctor. I am a type 2 diabetic patient who has a keen interest in patient self-management of diabetes, and who has spent far too much time over the past four years discussing this with other diabetics around the world on the net and personally. My only relevant publication is a patient's view online at http://loraldiabetes.blogspot.com/

This is not the first poorly performed study of blood glucose testing techniques published in the past twelve months, including one in my own country. All have suffered from the same basic flaw. SMBG is pointless – as is any testing of any sort – if the results are not used to either confirm that things are as expected or to assess what changes need to be made to improve the results next time.

However, if SMBG is used systematically to assess the success of past treatments and to then make changes in those treatments, in a continuously iterative method, it can be spectacularly successful. I accept that BMJ readers will consider anything I say as anecdotal; however I have seen it happen hundreds of times over the past five years.

This study was a waste of time and effort because the patients in the "most intensive" group were given no training in evaluating their test results with a view to improvement. In fact the basic premises of their training doomed them to failure: "They were also given training and support in timing, interpreting, and using the results of their blood glucose test to enhance motivation and to maintain adherence to diet, physical activity, and drug regimens." That was the worst thing they could have done - to maintain adherence to their present regimens, particularly diet. In fact they maintained it so well that they hardly changed their poor HbA1c levels at all.

As an aside, for the authors to consider A1c's in the mid 7's as "reasonably well controlled" is appalling to me. I would refer the authors to the EPIC Norfolk study which found that "HbA1c was continuously related to subsequent all cause, cardiovascular, and ischaemic heart disease mortality through the whole population distribution, with lowest rates in those with HbA1c concentrations below 5%. An increase of 1% in HbA1c was associated with a 28% (P<0.002) increase in risk of death " BMJ 2001;322:15 [Full] ( 6 January )

Now, back to SMBG. The single most important thing that the patient can do at home is modify diet. They should not change medications without doctor’s advice, there are realistic limits to the exercise they can add to their routine – but they can make dramatic changes in blood glucose levels with a diet modified by feed-back from post-prandial peak blood glucose levels.

I, and many of my friends around the world, have been following a systematic testing regimen that works for some years now. It is intensive in the initial stages, then becomes much more relaxed once individuals have created their own personal databases of foods and activities, so we know what foods and activities will cause blood glucose spikes (at the peak, not necessarily at two hours), and which won’t. It’s as simple as that.

I challenge the authors of this paper – or any other researchers for that matter, to repeat the study but train the "most intensive" group as follows:

Eat, then test after eating at your peak spike time and if blood glucose levels are too high then review what you ate and change the menu next time. Then do that again, and again, and again until what you eat doesn’t spike you. You will get some surprises, particularly at breakfast time. The so-called "heart-healthy" breakfast is NOT for most type 2's. Similarly, you will find variations through the day - the same thing will have different effects at breakfast, lunch, dinner and supper

As you gradually improve your blood glucose levels, review the resulting way of eating to ensure adequate nutrition, fibre etc are included and adjust accordingly. Test, review, adjust until you have a flexible and interesting menu that is nutritious but does not "spike" your post-prandial blood glucose; a menu you can follow for the rest of your life.

Studies such as the one in question are meaningless if the SMBG is not performed systematically and with a defined purpose.
***

Cheers, Alan

Ki Si Ming

This is one from my better half. Despite using a commercial Chicken Noodle Soup as part of the base it is surprisingly low in carbs and calories.

As usual, all quantities are very approximate and should be adjusted to your own taste.

Ingredients

Chicken Noodle Soup: One 50gm packet
Water: 5ooml (1pint) (use half the soup pack recommendation)
Mince steak (ground beef): 500gm (1lb)
Cabbage, shredded: 2 cups
Carrot, shredded: one medium
Onion, chopped: one medium
Curry powder: flat tablespoon
Olive oil or melted butter: 2 tablespoons
Salt and pepper to taste

Method

Fry the chopped onions in the oil or butter in a small saucepan until translucent and stir in the curry powder. Mix the packet of soup thoroughly with the water, then add it to the onions and bring to a gentle boil. Simmer for 15 minutes.

While the liquid is simmering fry the meat in a larger saucepan until browned, breaking up any lumps. Add the shredded carrot and cabbage, mix thoroughly and then pour the soup and onion mix in when it is ready.

Bring to a simmer and cook for 20-30 minutes, stirring occasionally. The result should be moist, with a light curry gravy, not soupy. Adjust by adding extra water if too dry, or cooking longer to reduce it if it's too liquid.

Serve with brown rice or noodles if your carb limit can handle that, or for your non-diabetic partner. Personally, I eat it as is without sides.

Serves 4 on it's own, 6 with rice or noodles.

Nutrition Count, will vary slightly depending on your packet soup.
Based on 4 serves.

Calories 210
Protein 8.2 gm
Total Fat 11.2 gm
Carbohydrate 13.5 gm
Fibre 2 gm
Sodium 800 mgm

Jennifer's Story

Five years ago when I started searching the net for advice on type 2, after I realised that the standard Diabetes Australia advice wasn't working for me, I discovered misc.health.diabetes on usenet. A guy from the UK calling himself Flying Rat sent me to his web-page to read "Jennifer's Advice". Since then I've found that advice in several other places.

It was the single most important thing I read after diagnosis. Jennifer's advice changed my life and I will always be grateful. I now repeat it to every newby I meet who stands still long enough:-)

Today, on a different forum, Jennifer posted the story of her first eight years after diagnosis. Here it is.

From Jennifer.
Eight years ago today I was diagnosed with T2 diabetes. I was very afraid...but fortunately for me I turned to this list and others for a shoulder and advice. And I found all of that and more. I utterly appreciate the patience and help I got in those first months/years, and can't fathom where I would have been without the internet, this list and you people. Truly.

So on my 8th diabetic anniversary I thought I'd look back. Here's my story... long but hopefully interesting. (Some of you may already know most of this, I ask your indulgence).

First a disclaimer. These are just my experiences. I believe with all my heart that each of us will respond to different things. Some folks do just perfectly on an ADA food plan... others find that low carb is the only thing that keeps their BG stable. The only way to know what works for you is to test, try, test, try. The idea of one size fits all NEVER works... in pantyhose or in health. ;-)

Now you should know, I am a decorated veteran of the diet wars... until age 36 when I decided never to diet again. I worked very hard at accepting my body and my life and I was finally able to let go of all that wasted mental energy I spent worrying and obsessing about diets and fat. It was wonderful.

So at 40, when I was dx'd with DM. I was petrified... I just knew I would walk into the doctors office and they'd take one look and say, "Well, just lose weight". And I would try and I would fail. As I had on every diet known to man since the beginning of time. But this time failure would mean blindness, amputation and other horrible complications, not just a bigger dress.

I immediately dove into the internet searching for any shred of hope. Everything I read said that carbohydrates raised your glucose levels. Atkins was not yet the total fad (that would happen a year or two later)... but there were a few books out and I read them all.

I started out with a very low carb approach. I didn't use any one plan, but read a number of books and took something from each of them. Including Protein Power, Dr. Bernstein and Atkins. At first I just (just! as though it was a snap... it wasn't!) cut out all "classic" carbs... bread, rice, pasta, cereal, sugar, beans, corn, potato, fruit etc. My BG dropped dramatically and quickly.

My A1c at dx 6/99 was 15.3
By 7/99 it was 8.5
By 9/99 it was 6.6
By 12/99 it was 4.9

I hovered in the 4's for awhile, but then chose to add back in some high fiber - non-white carbs and I've been in the 5's ever since. (with a small detour upward due to some urological problems)

Interestingly, I found something else occurred as well. I found an amazing correlation for me with regards to low carb and cravings and binges. I've spent my whole life fighting cravings and bingeing. I could eat a pound of pasta (with the "regulation" fat free sauce) and an hour later be standing in the kitchen in front of the fridge, starving. Needing to eat something, anything. Unable to stop thinking about food.

I grew up believing it was me. Something was wrong with me. I must have low self esteem or I was eating to fill up an "emotional hole". However, none of the rest of my life supported those theories. I was happy... except with my eating and my size. The low carb approach worked very well controlling my diabetes, But more amazing to me was that those almost daily crave attacks disappeared completely. Entirely. And so far they have never returned.

I must believe that for me, has to be some sort of metabolic disorder. Some kind of carbohydrate malfunction within me. It was the first time in my 40 years that I had not had these cravings. It's been wonderful. If they discovered a "cure" tomorrow for diabetes I would still eat this way.

After six months or so of very low carb, I used my meter to help add in other carbs at specific meals. I found, through testing, that I could eat a piece of whole wheat toast at breakfast with no appreciable rise in BG... I could eat some corn with a meal... On the downside: Pasta doesn't work for me at anytime... (until I found Dreamfields) Neither does rice.

I don't count carbs... I don't count calories... I don't count fat or protein grams. I eat whenever I'm hungry, I just restrict my carbs. I think the reason I've been able to maintain good BG numbers is because I didn't go on any one eating plan. I read many many books and took information from each. I was not going to sit down and write out a food plan for the week. That was too diet-like. I was not going to count anything, not portions, not calories, not anything. That was too diet-like. I wasn't going to weigh anything, not me or my food. That was too diet-like. I knew if I headed down those paths I would never survive. I had to find a way that fit my current life and yet would keep my BG in line. My personal history with dieting necessitated this for me.

I used my meter like a mad fool. Testing testing testing. I learned how my body used food. I learned which foods I could eat in great abandon, and which I had to limit. My meter is still a constant companion. When I stop testing I find my control slips. Using my meter keeps me aware and connected to my diabetes. The number I see isn't there to judge me, but to give me valuable information. Information is power.

Now I can walk into any restaurant, party, or other food situation and know what foods will raise my BG and what won't. It's enabled me to travel to Italy for a friends wedding which included three big dinners and many many other "eating" events and survive. It's enabled me to continue eating out many many times a week. And because it's not a DIET, I don't feel like I'm on something, therefore when I do eat a food that may spike my BG, I haven't gone "off"
something, so no guilt.

Giving myself permission to eat when I feel hungry, is a big difference from every diet I've ever been on. Where I netted out is that if I had to add them up I'd say I eat between 80g - 150g of carbs a day. Spaced out over 3 meals and 2 - 3 snacks. I have found that I can handle about 30g of carbs at any one "eating moment".

You may have noticed that I haven't mentioned exercise. I am a firm believer that exercise is vital to all bodies. Thin, fat, diabetic, not... I am a believer, but I have a hard time putting into practice what I believe ; ) It is my achilles heel. I feel so much better when I get regular movement, but can always find a "reason" to put it off. Since this is a journey that will last a lifetime (a long lifetime I hope)...exercise is something I will continue to work on.

All of this works for me! The answers all lie in an individuals blood glucose testing. Use any method that works. Keep hunting until you find one that does. Between food, exercise, oral meds and insulin, you can strike a balance to acheive numbers you can live with.

And I'm off to start my next 8 years.

Jennifer

Thanks Jennifer, for being there. Alan