June 8th, 2009 by KerriSparling in Better Health Network, Patient Interviews
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Even though I do not like the disease, there are some diabetes-related simple pleasures that make me smile:
- I like when I change the battery and the insulin reservoir at the same time. Having my Medtronic 522 “full” on both sides makes me happy.
- I like when the carb count on something is exactly 10 grams of carbs because it matches my insulin to carb ration precisely. One snack, one unit, one oddly happy Kerri.
- I like the sound of the pump counting up a bolus. Boop boop beep!
- I like when the sound of the bolus is caught by Chris and he ends up whistling it back to me, almost without thinking. It’s a little soundtrack snippet of our life.
- I like when the cats wait patiently for me to remove the pump tubing from my body before they lunge for it.
- I like when new boxes of diabetes supplies show up and I can organize them in my little OCD supply closet.
- I like when the number on my meter is two digits, but higher than 89 mg/dl. It’s a tight range, I’m not usually in it, but it brings me weird joy.
- I like when the Dexcom beeps and my coworker (who works a wall away from me) IMs me quietly to check, “Low?” because she’s ready to get juice if necessary.
- I like not having to wear a watch.
- I like when I get to dump all the used test strips that have piled up throughout the day. Knowing I’ve tested a bunch makes me feel like I really stayed tuned in.
- I like the smell of white glucose tabs.
- I like when the new infusion set doesn’t sting at all.
- I like having someone in my life who is willing to get their hands covered in SkinTac in an attempt to stick a Dexcom sensor to random places on my body.
- I like that the hope of the parents of kids with diabetes rubs off on me, and makes me feel good for even just a few minutes.
- I like that diabetes gives two people, who wouldn’t otherwise have a thing to say to one another, a whole dinner’s worth of conversation.
- I like having coworkers who understand but don’t push.
- I like when my best friend clinks her beer to mine and says, “Bolus, baby.”
- I like when the cat licks my hand after I test.
- I like “free shower:” a shower without a pump site or a CGM sensor attached.
- I like having a whole network of people who understand – and do not judge – my diabetes life.
I like when I can focus on the silly, simple things when I feel a little overwhelmed by the tough stuff.
*This blog post was originally published at Six Until Me.*
May 20th, 2009 by Harriet Hall, M.D. in Better Health Network
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There is no question that patients on insulin benefit from home monitoring. They need to adjust their insulin dose based on their blood glucose readings to avoid ketoacidosis or insulin shock. But what about patients with non-insulin dependent diabetes, those who are being treated with diet and lifestyle changes or oral medication? Do they benefit from home monitoring? Does it improve their blood glucose levels? Does it make them feel more in control of their disease?
This has been an area of considerable controversy. Various studies have given conflicting results. Those studies have been criticized for various flaws: some were retrospective, non-randomized, not designed to rule out confounding factors, high drop-out rate, subjects already had well-controlled diabetes, etc. A systematic review showed no benefit from monitoring. So a new prospective, randomized, controlled, community based study was designed to help resolve the conflict.
O’Kane et al studied 184 newly diagnosed patients with type 2 diabetes who had never used insulin or had any previous experience with blood glucose monitoring. They were under the age of 70 and recruited from community referrals to hospital outpatient clinics, so they were likely representative of patients commonly seen in practice. They were randomized to monitoring or no monitoring. Patients in the monitoring group were given glucose meters and were instructed in their use and in appropriate responses to high or low readings, such as dietary review or exercise. They were asked to take four fasting and four postprandial readings every week for a year. Patients in the no monitoring group were specifically asked NOT to acquire a glucose monitor or do any kind of self-testing. Otherwise, the two groups were treated alike with diabetes education and an identical treatment algorithm based on HgbA1C levels.
Their findings:
We were unable to identify any significant effect of self monitoring over one year on HbA1c, BMI, use of oral hypoglycaemic drugs, or reported incidence of hypoglycaemia. Furthermore, monitoring was associated with a 6% higher score on the well-being depression subscale.
So home monitoring not only did no good but it made patients feel worse. Why? Perhaps because they were constantly reminded that they had a disease and worried when blood glucose levels rose, especially when the recommended responses of dietary review and exercise didn’t rapidly lead to lower readings.
We would not accept the results of one isolated study without replication, but in this case the new study adds significantly to the weight of previous evidence and arguably tips the balance enough to justify a change in practice.
The American Diabetes Association still says “Experts feel that anyone with diabetes can benefit from checking their blood glucose.” But they only recommend blood glucose checks if you have diabetes and are:
• taking insulin or diabetes pills
• on intensive insulin therapy
• pregnant
• having a hard time controlling your blood glucose levels
• having severe low blood glucose levels or ketones from high blood glucose levels
• having low blood glucose levels without the usual warning signs
Diabetes experts see the severe, complicated cases and have a different perspective from that of the family physician seeing mostly mild and uncomplicated cases. An article in American Family Physician said
Except in patients taking multiple insulin injections, home monitoring of blood glucose levels has questionable utility, especially in relatively well-controlled patients. Its use should be tailored to the needs of the individual patient.
An editorial in the BMJ pointed out that
Home blood glucose monitoring is a big business. The main profit for the manufacturing industry comes from the blood glucose testing strips. Some £90m was spent on testing strips in the United Kingdom in 2001, 40% more than was spent on oral hypoglycaemic agents.2 New types of meters are usually not subject to the same rigorous evaluation of cost effectiveness, compared with existing models, as new pharmaceutical agents are.
If the scientific evidence supporting the role of home blood glucose monitoring in type 2 diabetes was subject to the same critical evaluation that is applied to new pharmaceutical agents, then it would perhaps not have been approved for use by patients.
Conclusion
Home glucose monitoring in type 2 diabetes is not justified by the evidence. It does not improve outcome, it is expensive, and it may decrease the quality of life of patients.
Common sense suggested monitoring should improve outcome. We had assumed it would work. Scientists thought to question that assumption. They found a way to test that assumption. New evidence showed that it was a false assumption. In response to that evidence, the practice is now being abandoned. This is how science is supposed to work. Another small triumph for science-based medicine.
*This blog post was originally published at Science-Based Medicine*
January 3rd, 2009 by Dr. Val Jones in Patient Interviews
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Thanks to KevinMD for highlighting an interesting discussion about the ethics of disclosing another physician’s error. It reminded me of a case I witnessed many years ago.
A young man had been in a car accident and was transferred to the rehab unit after several orthopedic surgeries and a long inpatient stay. Prior to beginning physical therapy, he was sent for doppler ultrasounds of his deep leg veins to make sure that he didn’t have a thrombus (clot) that might break off and lodge in his lungs during exercise. The ultrasound was actually positive for a large DVT. Unfortunately, the radiology note listed all the large veins that were patent (had no clots) first, and then finished with a notation of (+) DVT in one of the veins. The patient was transferred back upstairs to the rehab unit, the physical therapist glanced at the radiology report (where the first several sentences indicated normal findings) and took the patient to group therapy.
The patient got up out of his wheelchair, stood for a few seconds, and immediately collapsed. His DVT broke off and traveled to his lungs, causing a massive occlusion of his vessels. The crash cart arrived as he coded, the vascular surgery team quickly took him to the OR to crack his chest and try to remove the clot, but he didn’t make it. It was shocking and terrible.
What happened afterwards was memorable. The rehabilitation medicine attending notified the family of the error, explained exactly what happened and apologized with tears. The hospital administration was notified, the physical therapist, radiologist, residents, and attending physicians got together for a meeting in which a new reporting protocol for positive doppler findings was created. To my knowledge, there has not been another case of pulmonary embolism on that rehab unit since.
The family members did not sue. They were deeply grieved, but grateful for the transparency. The dangers of DVTs were indellibly burned into the minds of all physicians and staff working in the rehabilitation unit – and I believe that our lifelong vigilance may save many other patients from a similar fate.
That’s what should be done when mistakes happen.
October 29th, 2008 by Dr. Val Jones in Health Tips, Medblogger Shout Outs
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My friend and fellow blogger Kerri Morrone Sparling (at the Six Until Me blog) was diagnosed with type 1 diabetes when she was in second grade. The diagnosis came a few short weeks before Halloween, and back then she didn’t realize the risks of sneaking candy bars behind her mom’s back.
Now that Kerri’s grown up, she has some excellent tips for parents of children with type 1 diabetes (or frankly, for anyone who wants to enjoy Halloween and manage their diabetes). You should check out her video blog on the subject here.
Some tips include:
1. Focus on the costume part of the holiday, not the candy part.
2. Make some “candy” corn with Splenda, Equal or a sugar substitute. Enjoy the salty-sweet treat instead of a Snicker’s bar (for example).
3. Work in a small amount of candy into your diet plan. Eat a half a candy bar during a period of high activity, for example, and the sugar spike will not be so bad.
Please check out Kerri’s post for more tips!
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And for a good laugh about candy, check out The Onion’s headline here.
October 25th, 2008 by Dr. Val Jones in Celebrity Interviews
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Ben Vereen
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I had the pleasure of speaking with Tony-award winning actor and Broadway star, Ben Vereen about his recent diagnosis of diabetes. Ben has had an extremely accomplished career, including recent guest appearances on NBC’s Law and Order, and ABC’s Grey’s Anatomy. He’ll appear in an upcoming Fox feature with Patti Labelle called, “Mama, I Want To Sing” so don’t miss it.
To listen to a podcast of our interview, please click here.
Dr. Val: Ben, how exactly were you first diagnosed with diabetes?
Vereen: Unfortunately, prior to my diagnosis I didn’t recognize the signs of diabetes and didn’t understand what was causing my symptoms. I had dry mouth, frequent urination, severe thirst, sugar cravings and fainting episodes and didn’t realize they were all caused by diabetes. One day my daughter saw me pass out and she took me to the hospital. It didn’t take them long to figure out that my blood sugar was out of control. They kept me overnight and told me the next day that I had diabetes. I was shocked because I thought I was exercising regularly and eating well – it never occurred to me that I could have diabetes.
Looking back I realize that I had been told once (about 8 years ago) that I had “a touch of diabetes” but I thought it had gone away because of my good eating habits and exercise. I wish I had thought to follow up on that diagnosis and ask my primary care physician to check my blood sugar regularly.
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