I Think I May Have Diabetes...

"I think I may have diabetes....and I don't want to die..."

The wording varies but I see this question with increasing frequency on all the forums I read. I have written replies to these posts so often I felt it was time to archive a standard response.

The web is a wonderful source of information but too often people who really should be asking questions like this of their doctor are asking strangers on the net. 

My usual answer is very brief and says exactly that: see your doctor. I highlighted that because it needs to be emphasised.

Unfortunately that isn't always immediately possible for everyone. There can be many reasons for that.  The most common excuses are lack of money, lack of availability of medical support or simply fear of hearing bad news. 

For those with an urgent need and obvious hypo or hyper symptoms or who have tested repeatedly high on a glucometer the suggestion changes from "see your doctor soon" to "get to an ER (emergency room) fast". 

For others unable to see their doctor soon I urge them to at least make the appointment. Do what is necessary to find the money or time or courage but not seeing the doctor can turn out to be much more expensive in the long term. 

Another variant has appeared recently. Some doctors appear hesitant to diagnose if A1c is OK but fasting or casual blood glucose are just over diagnostic thresholds even when the patient has some symptoms. Too many doctors appear to have forgotten that A1c was only recently approved as a diagnostic tool because the patient can be diabetic if other indicators are high despite a normal A1c. I see an increasing number of posts from people in those circumstances who were told they are “borderline” - whatever that means - or “you are not diabetic yet, just eat healthy and exercise and you'll be fine” without a meter or other advice being prescribed.

At this point I will remind readers: I am a diabetic, not a doctor, and only a doctor can diagnose diabetes.

What follows are suggestions for people whose situation is not urgent, who have a long wait to see their doctor or who have seen their doctor but are still unsure. 

Part 1. Discovery

Obtain a home blood glucose test meter and an adequate supply of test strips. How you do that will vary depending on your local health support system. In the US cheap meters and strips are available from several sources; Walmart's Relion Prime was one of the first cheap meters but you may find others if you search. Note that the cost of test strips will be more important than the cost of the meter in the long term. In Australia you will have to pay full price until you are officially diagnosed, but check with the chemist because there are often discount specials.

When you get your meter read this (click on it): Painless Pricks.

 

Test four times a day for two or three days: immediately on waking (fasting) and one hour after your last bite of breakfast, lunch and dinner. The results you are hoping for are as follows:

• Fasting: 4 to 5.5 mmol/l (Australia, Canada, UK or other millimole countries) or 70 to 99 mg/dl (USA and other milligrams countries).
  
• Post-meal: 4 to 8mmol/l or 70 to 140mg/dl.
  

If all your tests are inside those ranges, relax. Diabetes is most unlikely to be your problem. Don't throw your meter away because it may be wise to occasionally test in future years to see if anything has changed. In that case be aware that test strips have an expiry date.

If any of your results are outside those ranges immediately wash your hands and re-test. If, after re-testing, it is still out of range just record it the first time. If a second test at another time is out of range make an appointment with the doctor for qualified diagnostic testing. 

Part 2. Action.

If your tests were outside the ranges read this while you wait for your appointment with the doctor: Getting Started

 

For those unable to obtain a meter, this may help while waiting to see the doctor: What to Eat at First

Cheers, Alan, T2, Australia.

Everything in Moderation - Except Laughter 

There is nothing I could eat I like more than my eyes

Blood Glucose Targets 2015

Several years ago I investigated the different targets suggested by three major respected US diabetes authorities. As a result I wrote this: Blood Glucose Targets. My 2006 summary included this comparison table:

Over the years those have changed very little. The 2015 comparison noting significant changes in bold is:

Sources: ADA, Joslin (up-dated 2018), AACE. 

The ADA and Joslin now agree on the looser 2hr post-prandial target of 180(10) and both have also lowered the threshold for fasting. The AACE guidelines are unchanged. If you read the details on the linked pages all add caveats concerning relaxation of targets in case of other medical conditions, age etc.

Thirteen years after diagnosis, thankfully still free of complications, I see no reason to significantly change my closing remarks originally written nearly ten years ago.

The AACE advise much tighter post-prandial targets. I doubt that anyone would consider the American Association of Clinical Endocrinologists, a professional community of several thousand physicians specializing in endocrinology, diabetes, and metabolism as a bunch of fanatical radicals. Nor would they be promulgating guidelines impossible to be attained by the majority.

Unfortunately, nobody but pro-active type 2 diabetics talks much 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? Those AACE guidelines then agree very closely with Jennifer's Test, Test, Test advice. Make your own judgment on which of those guidelines you think will lead to fewer complications.

Sadly, it appears that only 1/3 of senior diabetics are achieving even the loose ADA targets, but that is a discussion for another topic.

Cheers, Alan, T2, Australia.
Everything in Moderation - Except Laughter

I'm a New Type 2. Do I Really Have to Test so Much?

I see that question a lot. 

The answer is no, nobody has to.   

But I believe it is wise to. Your meter, properly used, is the bright beacon that will light your way through the dark and confusing maze of food advice that bombards type 2 diabetics. You will get advice from every side. If you have not encountered the Food Police yet, you will. Expect to be told that you should change your diet in all or any of the following ways: low fat; low carb; lots of wholegrains; lots of fruit; vegetarian; vegan; raw; no red meats; avoid sweeteners; sugar-free; no dairy; add expensive herbs and supplements; the list goes on and on. What is right and wrong for you? Is no food safe?

Let your meter guide you to the answer. 

There is no doubt that the Test, Test, Test method is a lot of testing at first when compared with the minimal testing prescribed for type 2s by most doctors. But I believe it is well worth it. The investment of time and test strips in a concentrated effort in the short term has tremendous long term benefits that will last you the for the rest of your hopefully longer, healthier life. And, fairly swiftly, the need to test so much is reduced. The initial period is the heaviest testing load because at that stage you have a blank slate. As you fill in the blanks the load swiftly decreases.

I recommend the following intensive testing routine for people newly diagnosed with type 2 diabetes. It can also be very useful for those who have been diagnosed for a while but who feel they have "hit the wall" in their progress towards good control. 

For the first couple of days test fasting blood glucose (on waking, before breakfast) and also at one and two hours after absolutely everything you eat, unless you eat again before the second test. That includes breakfast, lunch, dinner and all snacks. This may help if you are not used to testing so much: Painless Pricks

Log everything on the menu including drinks, sides and portion sizes. Every evening spend a few minutes reviewing that log and use it to plan the following day's menu with a view to achieving better results. 

Some people are adamant that you must also test before meals. I agree that it may help to know the starting point when assessing a rise, but I do not think it is necessary to add an extra half a dozen tests every day to an already heavy initial load when the other tests will still achieve your goal. 

On the evening of the second day take some time to review all the results. Some of them will seem crazy, but you should see some patterns emerge. The first thing to look for is the timing of your most consistent peaks. That may be a little different for breakfast, lunch and dinner. Is it closer to one hour or two? If you can pick the most consistent peak time then replace the one and two hour tests with just one test at the peak time after each meal. If the peak time is unclear then continue to test at one and two hours and re-assess each evening until it is clear. If necessary add tests at 30 or 90 minutes to be sure; you won't need to do those for long.

Use of the peak post-meal time reduces your test load to fasting and peak time after every meal and snack. My own peak time is about one hour after my last bite, but yours may be different. Over the next few days, using this Test, Review, Adjust technique you should be able to discover several "safe" menus for various meals. You will also find that some meals are OK for the morning but not for the evening or vice-versa. Treat breakfast, lunch and dinner as quite separate results. 

When deciding your goals I suggest you start with the targets suggested in Test, Test, Test:

Fasting............................Under 110
One hour after meals.......under 140
Two hours after meals.....under 120

or for those in the mmol parts of the world:

Fasting............................Under 6
One hour after meals......Under 8
Two hours after meals....Under 6.5

Do not be distressed if your starting numbers are much higher. It took you a long time to develop your diabetes; you should not expect to correct those numbers overnight. 

Give yourself some time. It may take a few weeks, or even a few months, but the investment in strips and testing you make now will pay you dividends for years or decades. Eventually, when you find you can easily hit those targets consider revising them as I did. See my present targets at the foot of Test, Test, Test. 

Proceed cautiously if you use insulin or one of the insulin-stimulating medications. You do not want to go from hyperglycemia to hypoglycemia. Make modest adjustments to your carbohydrate intake, test the results and continue modest changes every meal until you achieve your goals. Eventually you may need to discuss reduction of your insulin or medications with your doctor as the numbers improve.

During the second week repeat some of those safe meals. Before your post-meal test try to guess what the result will be. If you can usually predict good results note that menu for future use; you will only need to test after that meal occasionally in future for reassurance. That removes another test from your day.

Gradually, over successive weeks, your knowledge of safe meals and food portions will grow and your need to re-test them will reduce. Fairly swiftly you should be able to plan menus that you know in advance will not cause blood glucose spikes; as a consequence your need to test so often will drop quite dramatically within a few weeks. Also, as my fasting blood glucose became fairly predictable I reduced that to just a couple of times weekly. 

You are building a database that is unique to you. I know it seems like a lot of effort at first, but believe me it will be worth it. 

These days I sometimes don't test for several days unless I am trying a new menu item or a new restaurant. If you have insufficient strips, time, or motivation to do it that intensively, that is OK. This will work too, but it will take a lot longer: Testing on a Budget

Cheers, Alan

Everything in Moderation - Except Laughter. 

SMBG - A Doctor Who Understands

Over time I must admit to developing a certain degree of cynicism about researchers and doctors in the medical research field. I get a little jaded and dispirited about the entrenched attitudes in the fields of diabetes research, especially concerning diet.

Recently, in SMBG Research, Or The Lack Of It, I wrote “There are so many areas of diabetes crying out for research. There are some that have never been studied at all, including those dealing with diet modified by structured testing or similar methods which can lead to minimal medication or insulin needs.”

A friend from the Netherlands has gently chided me by sending me a copy of a paper that shows I may have been a little harsh. Time is the enemy and I only read it in full for the first time today. It's not a research study, more a position or discussion paper, but it is the closest statement from a qualified doctor that I have seen yet to Jennifer's Test, Test, Test advice or my own version of Test, Review, Adjust.

The paper is written by Dr Lois Jovanovic and includes references to other studies in support. Not a lot of other studies, most are small and some are only obliquely relevant, but at least there is some research happening in the field. It is so pleasant, after years of reading so many doctors ignoring so many patients on this subject, to finally read a paper like this one. They can ignore diabetics like me and dismiss us as unqualified; but Lois Jovanovic is someone who may be harder to ignore.

I think two unique factors make this particular doctor more aware of the close relationship between carbohydrate input and post-prandial hyperglycemia than most doctors. First, she has a depth of experience especially in gestational diabetes and pregnancies in patients already diagnosed as type 2. That has led to experience in trying to attain and manage normoglycemia much tighter than the levels usually expected for most type 2s. Her bio, in part reads:

Dr. Jovanovic has authored over 240 articles, including 135 for refereed journals, and 25 books on the topic of diabetes and pregnancy and islet cell transplantation. She serves as an Associated Editor of Diabetes Care and is on the editorial boards of Clinical Pharmacology and Therapeutics and the American Journal of Perinatology and is a contributing editor for the Journal of the American College of Nutrition and special editor for Endocrine Practice, the official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. In addition, Dr. Jovanovic serves on the national board of directors of the Society for Experimental Biology and Medicine.

Not someone whose opinions on diabetes can be lightly dismissed.

Second, Lois Jovanovic is a type 1 diabetic. Uniquely, she is the grand-daughter of an 8-year-old type 1 girl in the original group treated by Banting when insulin was discovered. I found this fascinating article on her story here: Dr. Lois Jovanovic's Story. The discovery of insulin did not just save her life as a Type 1; she would never have existed at all without it.
The abstract of the paper can be found here: Using Meal-Based Self-Monitoring Blood Glucose (SMBG) Data to Guide Dietary Recommendations in Patients With DiabetesLois Jovanovic, MD, MACE
The Diabetes Educator, Vol. 35, No. 6, 1023-1030 (2009)DOI: 10.1177/0145721709349587

The purpose of this article is to describe how self-monitoring of blood glucose (SMBG) data is a useful tool for identifying and managing postprandial hyperglycemia (PPHG).

PPHG and postprandial glucose excursions occur frequently in patients with diabetes even when hemoglobin A1C is controlled below 7.0%, and convey increased risk of cardiovascular morbidity and mortality. Consequently, effective management of diabetes must include control of postprandial glucose levels. Postprandial plasma glucose (PPG) depends on the composition of meals, specifically the amount of carbohydrates.

Reduced-carbohydrate diets offer short-term improvements in glycemic control and other metabolic parameters, but await the support of long-term efficacy and safety studies. Glucose profiling and paired-meal SMBG are useful tools for detecting PPHG and glucose excursions. They provide immediate feedback to patients on the effect of foods and meals, thereby allowing appropriate food and medication adjustments to improve postprandial glycemic control.

But that abstract does not give an inkling of the specific recommendations in the full text or the pleasant shock I received when I read this marvellous “To Do” list for guiding dietary recommendations that is included as Table 1:

Educate your patients on the risks associated with high peak-postprandial glucose concentrations (≥150 mg/dL)

Ensure patients understand that postprandial glucose concentrations are determined by the total amount of carbohydrates consumed

•• Encourage patients to measure their carbohydrate consumption

•• Recommend that patients keep a food diary

Remind patients of the benefits of monitoring their blood glucose levels with SMBG and construct a testing plan that optimizes these benefits

•• Have patients determine the best time for postprandial SMBG by testing 45, 60, 75, 90, 105, and 120 minutes after a meal to detect their peak postprandial glucose concentration

•• Using preprandial and postprandial SMBG, together with a food diary, patients can understand how certain foods influence their glucose concentrations

•• If preprandial glucose concentrations are already high, there is no room for carbohydrates in the upcoming meal

Review recent SMBG and food diary data with your patients to help them recognize trends in out-of-target readings

•• Use this information to recommend a specific SMBG testing schedule including number of tests per day and appropriate testing times

•• Have patients meet with a nutrition specialist if they are having trouble identifying or controlling their carbohydrate consumption

Personally, I was particularly pleased to read the recommendation to find the post-prandial peak and use that as the best time.

I could hardly have asked for a better list of advisory guidelines from a doctor. I hope her paper is widely distributed among her peers. It should be required reading on the boards of organisations such as the ADA, NHS, CDA and Diabetes Australia.

Cheers, Alan, T2, Australia.
Everything in Moderation - Except Laughter

SMBG Research, Or The Lack Of It

Nearly three years ago I challenged the authors of a particularly poor paper titled "Impact of self monitoring of blood glucose (SMBG) in the management of patients with non-insulin treated diabetes: open parallel group randomised trial" in the British Medical Journal to conduct a study based on Test, Review, Adjust.

When I first read Jennifer's Test, Test, Test I used to wonder why a study of that method had never been performed.

Of course now, with a little more experience, the reasons are fairly obvious to me. To start with, no researchers are even vaguely aware of the technique. That is apart from the fact that the results are unlikely to lead to increases in medication sales. Over five years ago, back when I naively thought someone would listen, I rang the Australian offices of Roche and Lilly to suggest it. They were polite and totally uninterested. I thought that at least the major test-strip manufacturers may have a vested interest. Apparently not.

My response to that paper was another small attempt to interest somebody in the appropriate field in the concept. But I have to be realistic; not many researchers read the "Rapid Responses" and Farmer et al certainly were not going make any attempt to prove themselves wrong.

The idea surfaced again today when Stuart, a Type 1 diabetic on the dLife forum, posted this very interesting question:

"If you wanted someone to explore something, to do a STUDY on a subject(s) about our diabetes, what do you want them to research? What areas do YOU want to know far more about that don't seem to be being done??? "

He had some very interesting replies. You can read them here. I would like to expand slightly on my answer there.

There are so many areas of diabetes crying out for research. There are some that have never been studied at all, including those dealing with diet modified by structured testing or similar methods which can lead to minimal medication or insulin needs. At the moment research tends to be focused on finding new medications or new ways to use old medications. In the real world "who pays the piper calls the tune".

No researchers are asking us, the diabetics, "what should we be researching?"

My own area of interest is just one of many possibilities. Despite understanding the reasons I still find it hard to believe that after more than three decades of home self-testing of blood glucose by diabetics no medical researcher, anywhere, has researched the use of structured self-testing for dietary modification to reduce blood glucose excursions.

Thousands of type 2 diabetics like myself have been "researching" the method personally and reporting their individual successes on many different forums since before I was diagnosed eight years ago, but we don't count in professional medical and research terms. We are diabetics, not scientists and our reports are anecdotes, not data.

I will offer the basic idea. Who knows, maybe there is a bright scientist out there looking for a PhD subject who has the ability to find a grant or research funds.

I propose a study comparing two groups of type 2 diabetics, all within their first 12 months of diagnosis. The only exclusion criteria would be that none should be using insulin or an insulin-stimulating medication such as a sulfonylurea at the commencement of the study.

Group 1, control, would be treated as individuals by their physicians and other specialists in exactly the same way as the present guidelines for their country. For example that would be the ADA or AACE and American Dietetic Association guidelines in the USA, Diabetes Australia here, or the NICE/NHS guidelines in the UK.

Group 2 would would also be treated as individuals by their physicians and other specialists in exactly the same way as the present guidelines for their country with the exception of dietary and testing guidelines. Instead, they would be given basic dietary guidelines to understand the differences between carbohydrates, fats and protein and their effect on blood glucose levels, and would also receive training and support in using feedback from peak post-prandial blood glucose testing to modify diet and lifestyle. The method taught would be based on the technique described in Test, Review, Adjust. If that needs clarification I am available as a consultant :)

The period of study would be three months initially, with weekly support and review to record indicators for both groups for the first four weeks, then monthly for the next two months with a preliminary report prepared after three months. Periodic follow-up review and reports would be performed at 12 months, five years and ten years. Indicators recorded would include A1c, fasting and peak post-prandial blood glucose levels, lipids, weight, blood pressure and any others the researchers felt valuable.

The five year and ten year reports would follow up all the earlier results and also include morbidity and mortality and any differences in progression to, or of, diabetes complications.

An inexpensive pilot study would not need very large populations and could be restricted to the first three months. The results of that could support further study over the longer period with a larger population.

I can also see other possible studies. For example, the possibility of combining Gannon and Nuttall's LoBAG20 or LoBAG30 diet with the above study as the starting diet for Group 2 is one that intrigues me. But it may be unwise to put too many variables in the mix. One thing at a time.

My area of interest may be quite different to yours. If you were the person asked by the researchers "what do you want us to study?" what would your answer be?

Cheers, Alan

Everything in Moderation - Except Laughter

Good Targets, Bad Methods

There has been a lot of discussion in the media and the blogosphere about an Early Online Publication in the Lancet on 27 January 2010.

Survival as a function of HbA1c in people with type 2 diabetes: a retrospective cohort study

"Methods
Two cohorts of patients aged 50 years and older with type 2 diabetes were generated from the UK General Practice Research Database from November 1986 to November 2008. We identified 27 965 patients whose treatment had been intensified from oral monotherapy to combination therapy with oral blood-glucose lowering agents, and 20 005 who had changed to regimens that included insulin. Those with diabetes secondary to other causes were excluded. All-cause mortality was the primary outcome. Age, sex, smoking status, cholesterol, cardiovascular risk, and general morbidity were identified as important confounding factors, and Cox survival models were adjusted for these factors accordingly

[snip]

Interpretation

Low and high mean HbA1c values were associated with increased all-cause mortality and cardiac events. If confirmed, diabetes guidelines might need revision to include a minimum HbA1c value."

What has saddened but not surprised me is that the reaction in on-line medical discussions has been much the same as that when the ACCORD and ADVANCE studies appeared. No-one has questioned the methods used to attain targets, all appear to accept that there may be a problem with attempting to aim for tight targets for type 2 diabetics. Thus, the targets are bad and should be eased.

I was not going to write about it because so many others have, but eventually I responded in Present where a doctor posed the following question based on this study: "Are we treating our patients to death?"

This was my response to the doctors.

The answer depends, of course, on the method of treatment and the individual nature of your patient's diabetes.

All of these studies, including ACCORD, ADVANCE and these recent ones have a common thread. They presume that the only way the physician can reach lower A1c and blood glucose goals in a patient is by medication. None of them consider using lifestyle – diet and exercise - changes to complement minimal medication or insulin to achieve those goals.

You all presume that a patient would not use diet and exercise. And, of course, to some degree you are correct, especially when the most generally prescribed diet is directly counter-productive for achieving better A1cs and blood glucose levels.

So you prescribe diet and exercise, the numbers go up, you presume non-compliance and prescribe metformin or a sulf or add insulin, they keep going up so you increase those and add more meds. But you also stress that the patient should eat more carbohydrates – and less fat - to be absolutely sure there are no hypoglycemic episodes as a result of the sulfs or the insulin and so the cycle continues, chasing it's tail.

Lower blood glucose and A1c targets do not cause higher mortality and morbidity. I have read success stories from many thousands of pro-active diabetics of all types on many forums since I was diagnosed eight years ago who have clearly demonstrated the opposite is true.

On the other hand, over-medication to attempt to counter poor dietary advice DOES cause higher mortality and morbidity; that is the consequence these studies are showing.

The solution? First, stop promoting the terrible “heart-healthy” high-carbohydrate AHA diet to your patients, or allowing the dieticians you send your patients to to do so. Instead, suggest that the patient use their meter at their post-prandial peak blood glucose timing to find out what foods are killing them and they will quickly reduce those foods, and their levels, and substitute others. The technique is described here: http://loraldiabetes.blogspot.com/2009/04/test-test-test.html

Some patients will do that and succeed; some will need further medication, but much less than you usually prescribe. And others will be non-compliant whatever you prescribe. They are the ones to prescribe higher medication to – but they are also the ones you should set easier targets for. Because they are the ones dying from over-medication.

Cheers, Alan.

Everything in Moderation - Except Laughter.

Lancet Change - St Swithun's Day

Today, July 15th, is St Swithun's Day.

When I first started learning about diabetes on misc.health.diabetes I discovered that most of the old-timers changed their lancets rarely. Most could not remember the last time they changed it, because they only bothered if it started to get dull or they were testing someone else.

Consequently, the practice of announcing that it was time for the annual lancet change on St Swithun's Day became traditional. Whether the change was needed or not.

So I have decided to continue the tradition.

Today is lancet-change day; even if your lancet is nearly brand new and has only been in use for a few months or a few hundred tests. I must admit I can't remember when I last changed mine.

I intend to hold a small ceremony, involving a nice glass of Shiraz, an hour after dinner before I test :-)

PS. For those who are changing their lancets every time they test, please read Painless Pricks.

Cheers, Alan

Everything in Moderation - Except Laughter.

Test, Test, Test

The best advice I received from any source, professional or otherwise, since I was diagnosed with type 2 diabetes was written by a lady named Jennifer. I first met her in cyber-space posting on the alt.support.diabetes usenet group where she regularly greeted newly diagnosed people with the advice I repeat below. It appeared as Jennifer's Information for the Newly Diagnosed on the a.s.d. home page and has now been repeated on many other web-sites. Some years ago she graciously gave me permission to spread it far and wide. I have been doing that ever since by providing a link to that a.s.d page.

The web-master made some improvements to the site which I just noticed today so I will be revising the link wherever it appears in earlier blog posts. It occurred to me that this may happen again, so I have decided to repeat Jennifer's original advice here in full so that it will always be available for me to reference.

Jennifer's Information for the Newly Diagnosed

"Sounds like you're planning a move to take control of your diabetes... good for you.

There is so much to absorb... you don't have to rush into anything. Begin by using your best weapon in this war, your meter. You won't keel over today, you have time to experiment, test, learn, test and figure out just how your body and this disease are getting along. The most important thing you can do to learn about yourself and diabetes is test test test.

The single biggest question a diabetic has to answer is: What do I eat?

Unfortunately, the answer is pretty confusing. What confounds us all is the fact that different diabetics can get great results on wildly different food plans. Some of us here achieve great blood glucose control eating a high complex carbohydrate diet. Others find that anything over 75 - 100g of carbs a day is too much. Still others are somewhere in between.

At the beginning all of us felt frustrated. We wanted to be handed THE way to eat, to ensure our continued health. But we all learned that there is no one way. Each of us had to find our own path, using the experience of those that went before, but still having to discover for ourselves how OUR bodies and this disease were coexisting. Ask questions, but remember each of us discovered on our own what works best for us. You can use our experiences as jumping off points, but eventually you'll work up a successful plan that is yours alone.

What you are looking to discover is how different foods affect you. As I'm sure you've read, carbohydrates (sugars, wheat, rice... the things our Grandmas called "starches") raise blood sugars the most rapidly. Protein and fat do raise them, but not as high and much more slowly... so if you're a T2, generally the insulin your body still makes may take care of the rise.

You might want to try some experiments.

First: Eat whatever you've been currently eating... but write it all down.

Test yourself at the following times:

Upon waking (fasting)
1 hour after each meal
2 hours after each meal
At bedtime

That means 8 x each day. What you will discover by this is how long after a meal your highest reading comes... and how fast you return to "normal". Also, you may see that a meal that included bread, fruit or other carbs gives you a higher reading.

Then for the next few days, try to curb your carbs. Eliminate breads, cereals, rice, beans, any wheat products, potato, corn, fruit... get all your carbs from veggies. Test at the same schedule above.

If you try this for a few days, you may find some pretty good readings. It's worth a few days to discover. Eventually you can slowly add back carbs until you see them affecting your meter. The thing about this disease... though we share much in common and we need to follow certain guidelines... in the end, each of our bodies dictate our treatment and our success.

The closer we get to non-diabetic numbers, the greater chance we have of avoiding horrible complications. The key here is AIM... I know that everyone is at a different point in their disease... and it is progressive. But, if we aim for the best numbers and do our best, we give ourselves the best shot at heath we've got. That's all we can do.

Here's my opinion on what numbers to aim for, they are non-diabetic numbers.

Fasting............................Under 110
One hour after meals.......under 140
Two hours after meals.....under 120

or for those in the mmol parts of the world:

Fasting............................Under 6
One hour after meals......Under 8
Two hours after meals....Under 6.5

Recent studies have indicated that the most important numbers are your "after meal" numbers. They may be the most indicative of future complications, especially heart problems.

Listen to your doctor, but you are the leader of your diabetic care team. While his /her advice is learned, it is not absolute. You will end up knowing much more about your body and how it's handling diabetes than your doctor will. Your meter is your best weapon.

Just remember, we're not in a race or a competition with anyone but ourselves... Play around with your food plan... TEST TEST TEST. Learn what foods cause spikes, what foods cause cravings... Use your body as a science experiment.

You'll read about a lot of different ways people use to control their diabetes... Many are diametrically opposed. After awhile you'll learn that there is no one size fits all around here. Take some time to experiment and you'll soon discover the plan that works for you.

Best of luck!
Jennifer"

As an engineer, when I read that, it made sense immediately. So simple, yet so powerful. And it has certainly worked for me. Thanks again Jennifer.

Post-script. I've been musing on Jenny's comment below and decided to add this.

I used Jennifer's wonderful advice to gain control of my numbers fairly quickly. Once I understood it I did not mess about and I used a lot of test strips in those early days. I fairly rapidly achieved the goals she set and I realised that I could do better. At the time, despite their poor advice on carbs and goals the ADA recommended something that stuck in my mind "Keeping your blood sugar (glucose) as close to normal as possible helps you feel better and reduces the risk of long-term complications of diabetes." That sounded logical to me so eventually I changed Jennifer's goals for myself to my present ones of:

Fasting............................Under 100
One hour after meals.......under 126
Two hours after meals.....under 100

or for those in the mmol parts of the world:
Fasting...........................Under 5.5
One hour after meals......Under 7.0
Two hours after meals....Under 5.5

Cheers, Alan
Everything in Moderation - Except Laughter.

I Ate Nothing! Why Are My BGs high?

Most of us discover fairly quickly after we start testing after meals that eating carbs leads to a rise in our blood glucose levels. That seems logical, and it is, so managing those carbs and the resulting spikes becomes a cornerstone of home treatment.

But pretty soon we also discover that logic has limitations. We go to bed at night with good numbers and wake with high numbers. But we didn't eat in our sleep. Or we make the mistake of thinking 'food = spike, fasting = no spike' and find that after eating nothing for six hours we might be normal or even high when we expected to be low.

It doesn't seem to make sense, does it? "I Ate Nothing! Why Are My BGs high?".

I am no expert on this, but I am pretty good at looking things up and then testing the things I read against my own results. My body, my science experiment. So I checked this out a long time back when I first came across the term "liver dump". Here is my rough version, based on the best explanation I've seen (or that I could understand at my level:-) . This is the medical-speak version:

"Stores of readily available glucose to supply the tissues with an oxidizable energy source are found principally in the liver, as glycogen. Glycogen is a polymer of glucose residues linked by a-(1,4)- and a-(1,6)-glycosidic bonds. A second major source of stored glucose is the glycogen of skeletal muscle. However, muscle glycogen is not generally available to other tissues, because muscle lacks the enzyme glucose-6-phosphatase.
*snip*
The major site of daily glucose consumption (75%) is the brain via aerobic pathways. Most of the remainder of is utilized by erythrocytes, skeletal muscle, and heart muscle. The body obtains glucose either directly from the diet or from amino acids and lactate via gluconeogenesis. Glucose obtained from these two primary sources either remains soluble in the body fluids or is stored in a polymeric form, glycogen. Glycogen is considered the principal storage form of glucose and is found mainly in liver and muscle, with kidney and intestines adding minor storage sites. With up to 10% of its weight as glycogen, the liver has the highest specific content of any body tissue. Muscle has a much lower amount of glycogen per unit mass of tissue, but since the total mass of muscle is so much greater than that of liver, total glycogen stored in muscle is about twice that of liver. Stores of glycogen in the liver are considered the main buffer of blood glucose levels."

For the really detailed version click on the links.

Below I put that in words that I understand. I am no biochemist, so if any experts are reading this please correct any errors I make or omissions from over-simplification.

Liver Dumps.

We need glucose for energy. When we eat a meal it is usually a mix of carbohydrates, protein and fats. Carbohydrates are an easily converted source which quickly appear as glucose in our blood. We also, more slowly, obtain glucose by gluconeogenesis from protein or even fats and also from the stored energy in our liver and other organs.

When we create more glucose than our immediate needs some is stored. Some is stored as fat, especially if we have excess insulin floating around, and some is converted to glycogen. Glycogen is stored mainly in the liver and the muscles. The muscles are selfish because the glycogen stored in the muscles can usually only be used for the muscles, but the glycogen stored in the liver is our supply for any glucose needed by the rest of the body. When the body needs it the right amount is automatically released to the right places. As a result there is always a steady flow of energy to meet a person's needs, regulated to demand, regardless of when or what they eat.

At least, that is how it works in non-diabetics. It is the body's version of a fuel tank. Unfortunately, for type 2s, the system can be flawed. Type 2s on the internet use the term "liver dump" for the release of excessive glycogen fr0m the liver to become blood glucose at times when it wasn't really needed or wanted.

For example, one cause of the Dawn Phenomenon is thought to be the body sensing our need for energy when we are about to wake, leading to excessive glycogen release until we eat and send the signal to stop the release. That's why a breakfast soon after we wake is an essential meal for many of us. Similarly, fasting, exercise or heavy physical activity can lead to a liver dump if the body senses the reduction in blood glucose levels and over-compensates with excessive glycogen release.

Preventing liver dumps is complex and I know no general solution. For dawn phenomenon the most common treatment is to eat a late night snack; but the reports of successful snacks vary widely so it's best to perform your own experiments until, hopefully, you find the one that works for you. A minority never does, and others find that the only solution for them is basal insulin.

For those who experience liver dumps after fasting the solution is easy. Don't fast for long periods. Eat something every few hours, even if it is only a small snack.

For those who get them during or after exercise, I have seen reports of success from people who spread small carby snacks across the period of exercise, including a snack before starting.

Sorry I can't be more specific with answers on this one, just suggestions. Once again it's your body, your science experiment

Cheers, Alan, T2, Australia.

Everything in Moderation - Except Laughter

Postscript: Another good comment on the "Dawn Phenomenon can be found in the Misc.Health.Diabetes FAQs. Click on the link and scroll down to "Why is my morning bg high? What are dawn phenomenon, rebound, and Somogyi effect?".

How Often Should We Test?

Over the past few years there have been some truly abysmal scientific research papers published on the futility of frequent self-testing by type 2 diabetics. Three that come to mind are The Fremantle Diabetes Study from Western Australia, Self-monitoring in Type 2 diabetes: a randomized trial of reimbursement policy from Canada; and Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial from the UK.

All of these papers have three things in common: they were published in countries where the government subsidises test strip supplies to diabetics, and thus has an interest in cutting health budget costs; they considered testing more than once a day to be "frequent"; and they did not educate the subjects being studied on how to interpret test results with a view to adjusting their lifestyle to improve results. I previously discussed the UK paper by Farmer et al in Self-Testing and Type 2 Management a year ago. Those same comments apply to all those papers.

The ignorance of the mainstream medical establishment concerning the benefits that can be gained from systematic self-monitoring of blood glucose appals me. Worse than that, many doctors and diabetes educators seem to feel that "obsessive" testing is much more dangerous to our health than the possibility of amputation, blindness or kidney failure so they actively discourage newly diagnosed diabetics from testing more than a couple of times per day - and usually only for fasting or pre-meal.

That fear of obsession is misplaced. I believe that it is partly due to two things. The first is the ignorant assumption that extra tests only lead to extra worry. My experience has been that, after newly-diagnosed type 2s discover that they can actually improve their test results by modifying their diet or lifestyle, worry is reduced. Action conquers fear. To me, the tests that lead to worry are those ordered by the doctors; the tests their patients do religiously for fasting and pre-meal that tell the patient nothing and that the doctor barely glances at during the next consultation.

The second reason is the equally ignorant assumption that those doing the extra tests will continue doing them frequently forever.

I always test with a purpose, to either learn or confirm knowledge. When I first read Test, Test, Test I put it into practice - totally. For a short period I tested before EVERY meal and snack, then at one hour after the last bite and then at two hours. On some days I tested over 20 times; that period also taught me how to achieve Painless Pricks.

But that was just the start. Very quickly I found that some tests became very predictable. I quickly dropped my pre-meal tests as unnecessary when I could predict them with good accuracy. Then, as I discovered that my own peak post-prandial time is one hour after I finish eating, I dropped the two-hour tests unless the one-hour was unusual. Within a couple of weeks I was testing fasting and my peak post-prandial after every meal or snack, usually 6-8 times daily.

With time those tests became predictable too, as I slowly modified my diet from disastrous (as taught to me by the dieticians) to low-spike using Test, Review, Adjust. Within a few months I was testing only 1-4 times daily.

Now that my personal data base of food BG effects is fairly comprehensive I only test for "maintenance", to check that things haven't changed. For several days I may not test at all, others I may test 3 or 4 times if trying a new recipe or menu.

I consider the invention and development of the blood glucose test meter one of the true miracles of modern science for diabetes self-management; a wonderful benefit for all diabetics. But, sadly, after over three decades of continual development and improvement of meters the medical establishment still has not come to terms with the correct ways to educate patients in their use.

Cheers, Alan
Everything in Moderation - Except Laughter

What to Eat at First

Every so often a newly diagnosed person arrives on the various forums I read who has no meter and is unlikely to get one for a period. Of course, I suggest they don't delay in correcting that, but that doesn't help in the short term. So this page is some suggestions for people in that position. Not advice for a permanent menu, but as a temporary measure until a meter is available and blood glucose testing can be started.

These are broad guidelines that should help minimise post-meal blood glucose spikes without jeopardising overall nutrition. Note that these are just my opinion, I'm a diabetic, not a doctor. If you are on insulin you should discuss them with your doctor - but if you are on insulin you should also have a meter.

Minimise:

Anything made in a bakery.
Pasta.
Rice.
All wheat products.
All corn products.
All cereals and other processed grains.
Starches - especially root vegetables.
All sugared drinks - sodas, sport drinks, milk.
All juices.
All fast foods.
And ignore colour, fibre content, or advertising hype about wholegrain or low-GI.

Be wary of:

Fruits, good in small portions, possibly harmful in large portions.

Maximise

All vegetables, apart from root vegetables.

Use in appropriate portions:

Fish
Meats
Eggs
Beans
Nuts
Avocado

Those lists are not exhaustive but I think you'll pick up the trends.

Cheers, Alan

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

Millimoles and Milligrams

I live in a country that uses mmol/L (mmol per litre) as the units for measurement of blood glucose and cholesterol levels, the most common lab numbers used for diabetes management. Most of the world uses that system – but the USA does not. The USA and several other countries use mg/dl (milligrams per decilitre). I havent the faintest idea why, but it can be very useful to be able to convert from one to the other.

My source for the conversion numbers is GlobalRPh.com.

Cholesterol

To convert from mmol/L to mg/dl for Cholesterol (total, LDL, HDL, VLDL) divide by 0.0259 or multiply by 38.6.

For Triglycerides divide by 0.0113 or multiply by 88.5.

Lipids ratios are mentioned in several papers discussing their relevance to cardiac risk and insulin resistance; remember to use conversions before applying US numbers. For example, based on those papers the triglycerides/HDL ratio should be under 1.3 for mmol/L and under 3.0 for mg/dl.

Blood Glucose

The conversion rate can be done either by multiplying by 18 (so 5.5 mmol becomes 99, but I usually round to the nearest 5, so 5.5 => 100) or divide by .0555 if you want to get totally accurate. The exact multiplier is 18.018. When accuracy is not critical, using a multiplier of 20 can be quick and useful.

Finally, a quick ready reckoner to convert blood glucose meter readings:

mg/dl mmol/L
100.........5.6
105.........5.8
110.........6.1
115.........6.4
120.........6.7
125.........6.9
130.........7.2
135.........7.5
140.........7.8
145.........8.0
150.........8.3
155.........8.6
160.........8.9
165.........9.2
170.........9.4
175.........9.7
180.......10.0
185.......10.3
190.......10.5
195.......10.8
200.......11.1
250.......13.9
300.......16.7
400.......22.2
500.......27.8

Cheers, Alan

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