Better Living information and advocacy : Diabetes monitoring, an easier way to keep track o...

Better Living information and advocacy : Diabetes monitoring, an easier way to keep track o...: D iabetes is a terrible disease that affects more than 29 million Americans. It is manageable, but requires life style changes and clo...

Better Living information and advocacy : Diabetes Remission - can you live a normal life ag...

Better Living information and advocacy : Diabetes Remission - can you live a normal life ag...:                               O ver the past few weeks I have personally experienced friends and relatives that have been affected by th...

Diabetes monitoring, an easier way to keep track of my numbers.

Diabetes is a terrible disease that affects more than 29 million Americans. It is manageable, but requires life style changes and close follow up from medical care providers.

The main parameter used to assess ongoing blood sugar control is the dreaded glucose monitoring (or self monitoring of blood glucose – SMBG) which requires patients to “prick” their finger and take a small blood sample, which is analyzed using a glucose meter. Patients are instructed to keep records/ logbooks of their readings along with other relevant information (such as how much food they ate or how much medicine they took). Theoretically the patient would share this information with their medical providers, who in turn would use it to make treatment adjustments (adjust diet, recommend exercise, and adjust insulin doses).

Patients usually have an established plan that guides how much and when they eat, how much insulin they take, and any other behaviors. But patients are not always fully adherent to these treatment plans - or at least not as diligent about the plan as they should be. And during periods when there may be dietary indiscretion, illness, or inactivity, they often require considerable support and guidance from their care team. Providers do not have a great deal of time or information at the point of care (visit) – and easy access to accurate data is a huge help. Commercially available glucose meters provide the basic blood glucose values. The basic meter will give a reading of the blood sugar and most have the ability to store information. Transcribing the information is generally done by the patient often manually and kept in a logbook.  The accuracy and completeness of the entries depends on the individual. And how the information is relayed to and interpreted by the healthcare team is also an issue. Some patients in an effort not to displease the medical provider and demonstrate that they are diligent in keeping the log may enter results of missing data points from memory after the fact or even all at once just before a visit. This does not help the patient or the provider.

The American Diabetes Association (ADA), on their website www.diabetes.org, has a basic log sheet to help guide record keeping. The logs are simple and provide the basic information needed to guide care.

But some logs can contain varying number of data points with some being quite complex (and can include: calories consumed, carbohydrate ratio, and even calorie expenditure during exercise). It is demanding and even tedious to keep track of and manually record all the data points that are required to produce a meaningful report. The glucose meters that provide the information are often nominally priced or may even be free, but there is an ongoing cost for the supplies such as test strips and reagents. The cost of these items can be considerable. If patient uses a branded (not generic) meter the cost of the strips could be substantial, whereas if the patient switched to a generic meter, the cost of strip could be significantly less. Patients will generally not switch meters for one of two reasons - insurance coverage or lack of access to data (if you switch meters you may no longer have access to your stored data).

A new concept in monitoring is emerging, which uses personal electronic devices such as smart phones to monitor store and collate data. The software (app) can upload the information to the smart phone, which is then formatted and used to help patients better understand how their actions impact their blood sugar levels, and by medical providers to better customize care to the needs of individual patients.  One such system is the Ditto Glucose Data System. This system is comprised of an FDA registered, class 1 medical device with HIPPA compliant storage and a mobile application. I think this device and ones like it will be the standard of care in the near future. The ditto-mobile app allows patients to review and track blood glucose results and add behavioral context and photos. Patients test normally, as directed by their health care provider. With ditto results from multiple meters can be put in the same report - or if one uses multiple meters - the data will not be lost. Therefore the patient has the option of using any meter – which could bring down cost of testing supply’s considerably. However the aim is to simplify the monitoring of diabetes through ditto’s sync, track, and share methodology. One can set high and low ranges, for various parameters and add context such as how much food you eat, or when you exercise, and review data in log book or calendar views. This information is shared with the healthcare team. And if the patient wants to use multiple meters all data will be in a single report.

Diabetes and its many complications remains a serious disease. It can be managed; however, the appropriate diet along with exercise and medication - as recommended by ones medical care team - is the key to maintaining control over the disease and avoiding complications. Consistent self-monitoring of blood sugar levels and management with systems like ditto is key in that effort. It cannot be over emphasized, however, that lifestyle changes (diet and exercise) are the corner stone of care.

Diabetes Remission - can you live a normal life again?

                           

 Over the past few weeks I have personally experienced friends and relatives that have been affected by the complications of diabetes mellitus (DM). One was a relative that succumb to the disease and died after many years of living with the disease and enduring many of the disease’s complications. This post as with so many other communications on DM is written as an informational tool so that persons may investigate the topic and communicate with their healthcare provider about management of the disease as it relates to them.

Diabetes is a very serious disease that is directly and indirectly linked to many serious medical conditions such as heart disease and kidney failure. DM can be controlled however. With the proper medications and lifestyle changes the disease’s progression and its complications can be slowed and even prevented. The lifestyle changes (rigorous diet control and consistent exercise) are at the center of care and not achieved by many because of their demanding nature. In all most all cases the lifestyle changes that are required are permanent, nevertheless the need for lifestyle modifications cannot be overstated.  It has been recently recognized that under certain circumstances the disease progression can be slowed or stop and medication may not be needed for long periods and in some cases indefinitely if the disease is identified and treated early. In the late 1990’s it was reported that following a hyperglycemic (high blood sugar) crisis persons that were treated with intensive insulin therapy - in a hospital - and were subsequently placed on low doses of oral medication (sulfonylurea) a subsequent crisis was prevented for several years.¹   In this study all the patients maintained lifestyle modifications of diet and exercise following the initial treatment. And approximately ten years later several studies cited remission (a temporary cure of a disease or condition) and the elimination of the need for medications altogether while markers of DM: blood sugar, insulin levels, and A₁C normalized (without medications) following the initial treatment of the crisis ^{2, 3}. All the studies integrated lifestyle modifications (diet and exercise) following resolution of the crisis so there was no free ride for those that achieved remission. And all patients continued the lifestyle modifications to maintain medication liberation. In those studies (where intense insulin therapy was used) the blood sugar control was supervised directly by a medical professional (most studies were performed in a hospital). So this is not a treatment strategy that can be attempted without medical supervision. Nevertheless, there may be a silver lining to the dark cloud of diabetes. Intensive therapy in the early stages of the disease may induce remission for years if lifestyle modifications are maintained. And if medications are needed following a crisis blood sugar levels may be controlled by the use of low dose oral medications (without the need for insulin). Lifestyle modification however, remains the backbone of care, and all care plans should be developed in conjunction with and under the supervision of a medical professional.

1-  Diabetes Care 1997 April 20(4): 479-83

2 - Diabetes Med. 2001 Jan; 18(1): 10-6

3 - Lancet 2008 May 24; 371 (9626): 1753:60

Obesity, diabetes, and the metabolic syndrome; a broad spectrum of disease.

Patient with the metabolic syndrome

Courtesy: James Heilman MD

Wikimedia Commons

When a patient visits a doctor with classic symptoms of diabetes (excessive thirst, urination and loss of weight) the patient often reports the symptoms have been present for a week or two when in reality the patient has been in the pre-diabetic phase of the disease for years.

Although there are few if any symptoms in the pre-diabetic phase of disease and these patients generally have normal blood glucose levels, they have high circulating blood insulin levels, sometimes up to ten times higher than normal. Insulin is the hormone that regulates the body’s blood glucose level, and is produced by the pancreas. In obesity the fat cells block insulin from reaching the proper target cells and those cells from properly utilizing the insulin. This is called insulin resistance. Increased secretion of insulin by the pancreas to keep the glucose level normal causes the pancreas (an enzyme rich organ) to work overtime to control the blood glucose but in so doing releases some of its other enzymes into the circulation. If the scenario persists a chain reaction is set up resulting in a increased production of triglycerides (fat in the blood) an elevation in LDL (bad cholesterol) and reduction in HDL (good cholesterol). There is also production and release of inflammatory mediators, (substances produced by cellular reactions) and associated with release of pancreatic enzymes. These inflammatory mediators can promote heart disease and liver disease. Elevated insulin level also has an effect on the kidney that results in elevated blood pressure.  So it is not unusual for the patient that is seen by the doctor for the first time with symptoms of type 2 diabetes mellitus (T2DM) will also have high blood pressure. In these patients the silent metabolic effects of obesity and pre-diabetes have been present for a long period.  And if abdominal obesity, high blood pressure, high blood glucose, and abnormal triglycerides and cholesterol exist together they fit definition of the metabolic syndrome.

The metabolic syndrome is a constellation of conditions that include central obesity, diabetes, high blood pressure, and derangements of cholesterol (good and bad). The syndrome was first described in 1988. When present together these finings form a perfect storm for the development of heart disease, strokes, and kidney disease. Body fat is thought to be essential for the condition to exist, although in certain ethnic populations visible obesity is not always apparent nevertheless the majority of persons are visibly obese. It is the fat within organs and surrounding organs (visceral fat) rather than fat directly under the skin (subcutaneous fat) that drives the metabolic derangement.¹ This explains why of removal of subcutaneous fat with procedures such as liposuction has limited effect in the treatment of T2DM (only subcutaneous fat is removed with the procedure). The metabolic syndrome is associated with T2DM, cardiovascular disease, strokes and kidney disease.  The good new is that a prudent diet and increased levels of exercise can mitigate the effects of the syndrome and its complications. But when diet and exercise is not enough medications will be needed to control glucose, blood pressure, and cholesterol. There is more good news however! There is a possibility of remission (slowing or reversing the disease) in newly diagnosed diabetics. This will be posted in the next discussion.

1- Int J Obes Relat Metab Disord 1995, 19:846–850