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Saturday, December 09, 2006

Testing Etiquette

Once newly diagnosed diabetics have started using Jennifer's Test, Test, Test advice, and they've learnt to do it with painless pricks , the next question is usually something like "how can I test in public without embarrassing myself or upsetting others".

Well, I learnt fairly early that my health was more important than their sensibilities. That doesn't mean I make a spectacle of testing, or that I get aggressively "in-your-face" about it, and I do use a little tact and discretion, but I normally test anytime and anywhere I need to. I treat it as no different to blowing my nose or clearing my throat.

In my Newly Diagnosed period I tested publicly quite often. I found my peak timing by testing up to a dozen times daily; I would set my watch count-down timer to alert me at that peak timing at the end of a meal or snack and when it went off I tested - no matter where I was or who I was with. Of course, I don't test so much these days because I can predict most results - but I still use that timer when I need to and still test whenever it goes off.

No-one seeing me test has ever fainted, or become upset in any way. In fact I occasionally met other diabetics that way and had some interesting chats - Accu-chek as a conversation piece (read the detail:-)

If your friends have a problem with it, change your friends; if your relatives have a problem with it, you can be a little blunter and drop some unsubtle hints about the genetic component of type 2. A few times relatives have said something and I offered to test them too (with a fresh lancet of course). For one of them that may have been a preliminary to their own diagnosis. If it's your workplace - then, of course, don't jeopardise employment; you'll need to use your own judgement of the effect on employers and peers there. Sadly, ignorance will always exist and you must cater to it occasionally.

The only places I will NEVER test is in places full of possible infection - a public restroom or toilet, or a doctor's waiting room. And of course, there are certain exceptions where a tactful delay is appropriate - but not a lot.

It's your life. Literally. Test when and where you need to.

Cheers, Alan
Everything in Moderation - Except laughter

Saturday, December 02, 2006

Blood Glucose Targets

One of the things that becomes obvious when speaking to other diabetics is the confusion and variation in their understanding of "tight control" or "good control" of their blood glucose numbers.

That's not surprising when you start investigating and find that the major medical authorities neither agree on the targets, nor on the need to make the patient clearly aware of them - or on whether the patient should even try to improve them by their own actions.

The ADA web-site includes this section on "tight control":

"Good control means getting as close to a normal (nondiabetic) blood glucose level as you safely can. Ideally, this means levels between 90 and 130 mg/dl before meals, and < 180 two hours after starting a meal, with a glycated hemoglobin level < 7 percent."

However, the ADA is not the only respected authority out there. Nor do they seem to have the same concept of non-diabetic numbers that the others have. In 2005 the American Association of Clinical Endocrinologists published their 2005 Implementation Conference for ACE Outpatient Diabetes Mellitus.

Consensus Conference Recommendations included this Position Statement:
"A1C ≤6.5%
Fasting/Preprandial plasma glucose <110>

and they reinforced the need for SMBG:
"Self-monitoring of blood glucose (SMBG) is a critical resource for the management of diabetes. When performed with sufficient frequency, SMBG readings allow patients and their healthcare professionals to make informed decisions about lifestyle choices and adjustments in pharmacologic therapy. SMBG can also provide ongoing feedback to patients about their nutrition and physical activity. It is a very important educational tool. A key obstacle, however, to implementing effective interventions is a lack of supportive healthcare systems."

That's a paragraph that many health insurance companies and the government Health bureaucrats would do well to read. In my opinion, we could do with the head of the AACE on the ADA board. I say "we", because, although I am Australian the decisions and guidelines of the ADA often tend to re-appear as policy of Diabetes Australia.

They repeated those targets in para 4.1.1 of their
AACE Medical Guidelines for Clinical Practice for the Management of Diabetes Mellitus © 2007:
o HbA1c ≤6.5%
o Fasting plasma glucose concentration <110
o 2-hour postprandial glucose concentration <140

Or you could try the Joslin advice. It's still not as tight as most I know aim for, but they are just as reputable an authority as the ADA:

"Goals for Blood Glucose Control

People who have diabetes should be testing their blood glucose regularly at home. Regular blood glucose testing helps you determine how well your diabetes management program of meal planning, exercising and medication (if necessary) is doing to keep your blood glucose as close to normal as possible. The results of the nationwide Diabetes Control and Complications Trial (DCCT) show that the closer you keep your blood glucose to normal, the more likely you are to prevent diabetes complications such as eye disease, nerve damage, and other problems. For some people, other medical conditions, age, or other issues may cause your physician to establish somewhat higher blood glucose targets for you.

The following chart outlines the usual blood glucose ranges for a person who does and does not have diabetes. Use this as a guide to work with your physician and your healthcare team to determine what your target goals should be, and to develop a program of regular blood glucose monitoring to manage your condition. "

(modified to post here; wo=without diabetes, wd=with diabetes)

Before breakfast (fasting): wo < 110; wd 90 - 130
Before lunch, supper and snack: wo < 110; wd 90 - 130
Two hours after meals: wo < 140; wd <
Bedtime: wo < 120; wd 110 - 150
A1C (also called glycosylated hemoglobin A1c, HbA1c or glycohemoglobin A1c: wo < 6% ; wd < 7%"

To summarise:


...................pre-meal......2hr PP.....A1c

ADA ...........90-130....... <180.... ...<7%

Or, in mmol/L, rounded
...................pre-meal......2hr PP.....A1c
ADA ...........5.0-7.0.......<10.0......<7%

The AACE give the tightest targets. I doubt that anyone would consider the AACE, which is an organisation of 5200 endocrinologists, as a bunch of fanatical radicals. Nor would they be promulgating guidelines impossible to be attained by the majority.

Unfortunately, nobody but us talks about 1hr PP targets. My personal logic is that I treat their 2hr as my recommended max peak for any post-prandial, as I discussed in When To Test After Meals. Those AACE guidelines then agree very closely with the Test, Test, Test advice by Jennifer.

Make your own judgment on which of those guidelines you think will lead to fewer complications.

Cheers, Alan,
Everything in Moderation - Except Laughter.