Objectives of Self Monitoring

{a work in progress}
[1stdraft September 21, 2010]
Todo: too much ranting, too many feelings, not clear
[2nd draft September 22, 2010]
Todo: need more direction on recording, too much ranting? Still too casual?


Why do we test our own blood sugars?

If you asked ten diabetics or ten physicians or ten diabetic nurses, you'd may get only one answer: to make sure our sugars are ok. This is an overly simplistic answer. It fails to acknowledge that there are multiple testing objectives and techniques.

There are a variety of insulin regimens and approaches directed by physicians for manageing blood sugars (BGs). Many insulin dependant diabetics (IDD) are taught that their insulin rates are to be set by a diabetes health professional, preferrably a family doctor or an endocrinologist, a doctor that specialized in the endocrine system which encompasses diabetes. Endo's are the kings-of-the-hill in the world of diabetes management. Your physician may provide you some guidance for making corrections and may even encourage you to discover your own dosages. In my experience, my endos have always taken a mixed approach. They set the rates, and then they provided me with a sliding scale to make corrections by. When you go to your endo, he or she will ask you for your test log, your daily test results. They will examine it, frown, ask you a question or two, then dictate how they want you to change your rates. In my opinion, it's a dangerous practice!

Why am I so opposed to endo-managed diabetes care? First is proximity. In business management it is considered best practice to put decision making in the hands of managers closest to the action. You don't find a manger in an office in Los Angeles managing a factory in Cleveland. You need to be close to the action. Doctors are not close to the action. If I need help, I can see my endo every three months; otherwise, it's once a year. I see my endo for ten minutes once a year. This is not good business, and it's not good clinical practice.

If we want excellent patient managed blood sugars, we need pateints to use better techniques to manage their own blood glucose levels. insulin dosing is a life and death decision. If I make an error, bad things will happen. If you make an error driving a car, say typing a text message at high speed, bad things will happen. Diabetes management is inexact and sometimes complex. I make life and death decisions about every two hours during a day, that's six to eight life threatening situations every day, day after day after day. .

Currently most physicians pay attention to studies that have suggested pushing A1Cs lower increases risks of death, mainly from heart disease but also hypoglycemia. The people in these studies get lower A1C's by increasing medications. They take more pills and more insulin. If you take more of a dangerous substance, more bad things will happen. You will now find that most doctors don't want to see your A1C below 6.5%.

So maybe I should slack off on control and run higher? There are risks to running high: long term complications such as amputation, kidney failure, blindness, and the already mentioned heart disease. Diabetes negatively affects arteries, and these complications are how that minifests. Most diabetics have or will experience long term complications. Some 80% of us will die from heart disease. Joy! Every 1% increase in my A1C will increate my risk of developing long term complications by 40%.

Unfortuneately the reality of physician led BG management is that most diabetics get stuck between a rock and a hard place. Too much effort is dangerous in the short term and too little effort is dangerous in the long term. What our doctors are basically telling us is that we are sick and there's no hope of getting better, of living life with normal blood sugars

Bullfeathers!

I and many others are approaching this disease differently. I follow a simple philosphy: work smarter, not harder! I follow a multi-faceted approach. I employ best-in-practice insulin dosing techniques, I eat a very nutritious diet, and I stay involved. I work smarter and I work closer too. I make all my own dosing decisions.

Patients need to learn how to control their own sugars. They need to know what makes them go higher and what makes them go lower. They need to understand and control every variable. The first step in understanding your blood sugars is testing, so grab your meter and test yourself. What does it mean? Let's find out.

I break my tests into three categories, that is each test may fulfill one or more objectives. Obectives may not apply to a diabetic controlled without medications or with various other medications, and they can omit tehm and modify their testing as needed. All three are important for IDDs, and they cannot be omitted, if you want good, safe control.

The first and most basic objective is Safety. First and foremost we have to be safe. There's a popular catch-phrase used in the online diabetes world that goes like this. Test, Don't Guess!

Guess? Do you think I'm guessing? I never guess! Now answer me truthfully. I should say answer yourself truthfully. Do you know what your BG level is before you drive your car home from work? Do you know what it is when you drive your kids to some event? Do you know what it is when you mow your lawn, start a fire in a fireplace, operate a chainsaw, or do anything else potentially dangerous?

I once got in my car after playing tennis for an hour an a half. I live 20km from the courts. I felt good, so I drove home. I came to 25km after my exit on the highway. I drove 45kn or about 25 miles at speed while unconscious. I was barely able to pull off and throw back a gatorade.

I was tiling my basement floor one night. While using a portable grinder to remove the paint, I dug an inch deep by three foot long groove. Why? I was hypoing.

One afternoon I woke from a nap with a very low BG. It was hot out, and I was totally soaked from my insulin reaction and heat. I told my wife I was going to jump in the pool. I started undressing in the living room, in front of the kids, and was going to dive right in off the back deck. My wife recognized I was hypoing and sat me down at the kitchen table and fed me. We don't have a pool. We have a 12ft drop onto hard ground which rolls into a bog.

You have to test for safety first. You might be young and respond well to hypoglycemia. Yes you can slack off on your safety. There was a time when I knew I was going hypo. I never had to test as a teenager to catch problems. That doesn't mean you don't have to. And please remember that time will catch up with you, and when it does, it is a shock! I was 34 years old during my first sneaky one. I bolused 16u of Humalog before breakfast and sat down in front of the TV to watch the news. My BGs were high and I wanted to give my insulin a head start. This is actually a good practice. I fell asleep. I'd always woken from hypos, so why would I bother worrying about nodding off? I woke up flying out the front door on a stretcher. If I was alone, I'd be dead. Yes, you have to test for safety first!

The second objective is compliance. You want to know if you are where you planned to be. You may be higher, lower, or just right. Where you are will result in a behavior modification to get you back on track. If I'm high, I may take a correction bolus. If I'm low I may eat. I say may because there are many variables at play. We need to understand all these variables, and we need to choose the best ones to modify. This involves assessing many factors from the percieved causes to the planned activities. It's not an easy task, and I can't begin to cover it all here. It's a life and death decision. I can recommend some good books though. Think Like a Pancreas by Gary Scheiner and Using Insulin byJohn Walsh are two wonderful texts on insulin management. Get one of them!

It is a similar question as safety. Both tests determine if you are where you need to be. The main differences are that compliance testing is done as set times while safety is done as needed. As type 1's we are taught to test seven times a day: fasting, breakfast post prandial (PP), lunch, lunch PP, dinner, dinner PP, and bed time. We are to log these results, record things like activity and food consumption, and bring our logs to our doctors.

We now have computerized logs which make this easier. My meters communicate wirelessly with my pump, and I can upload all my BG readings and insulin doses to an online management program. It's pretty cool technology, but it's totally useless. I throw my compliance tests away. My doctors never see them.

Blasphemy! You say. Lets try to understand why.

If you read my introductory chapter (The writing.com folder decription), you might remember I talked about my breakfast bolus compensating for my basal rates. IDDs have at least two distinct insulin doses working at any time. Our basal or background dose is taken typically once or twice a day, and our bolus insulin is taken with food.

We have four sources of glucose we need to account for, not two as you've been taught.

First there's consumed glucose. We generally cover that with bolus insulin. We use insulin to carbohydrate ratios to determine our dosages. Physicians like to start patients out with ratios of 1:10 or one unit of rapid insulin per ten grams of consumed carbohydrates. Then they titrate to find a ratio that works best.

Second there's basal sugars released by our livers 24 hours a day. It is a steady output that never stops. We cover this with a basal insulin. Different tchniques are used. There's long 24 plus hour insulins like Lantus or Levemir whcih have a fairly flat impact, that is the lowering effect at four hours is supposed to be the same at 8, 12, 16, and 24 hours. We know this isn't true, but that's what they tell us. Techniques for using these insulins is beyond the scope of this article. There's slightly shorter insulins like NPH which are also humpier, their ipact at 8 hours is much stronger than at 4 hours. Finally there's insulin pumps which use fast acting insulin released in very small doses about every three mnutes. Pumps allow for changes in rates. I can set 48 different rates a day.

A hormone called glucagon processes stored sugars, glycogen, and glucose is created. This process is called gluconeogenesis. It is a key metabolic activity that you should really learn more about. Our bodies only really need about 120g of glucose a day. Guess what our livers produce? Yup, about 120g a day. Of course our bodies will vary., but objectively, we don't need to eat any carbohydrates at all. Everything we need to function on is created by our livers. We won't get into that discussion here, because it's at the heart of nutrition controversey regarding low-carb or Atkins styled diets.

The third is protein. Our livers process protein in our blood and convert some of it to glucose. This is also gluconeogenesis, but it depends on protein we supply the liver. Technically about 10% of fats can be connverted as well, but I inlcude it with the protein. About 58% of protein is converted to glucose; though some will say it's much lower. Physicians don't usually account for protein when setting rates. It tends to come out in the wash as long as you eat fairly standard meals. Some patients do bolus for protein. I do.

The final source is an extra shot of glucagon type 1 dibetics recieve when consuming anything. This is an incretin process. Whenever we eat food, many things happen. We release glucagon, insulin, amylin, and other hormones. Glucagon increases sugar production, insulin increases sugar storage into glycogen and fat, and amylin suppresses the effects of glucagon. Like insulin, amylin is produced by the Islets of Langerhans, and like insulin, type 1's don't make any. Therefore whenever type 1's consume something, they make sugar. If I eat a handful of dirt, I'll make sugar. Dr. Richard Bernstein calls this the Chines Restaurant Effect.

So to summarize the the IDD's standard variables we have two sources of insulin (basal and bolus) and four sources of glucose (consumed, basal, protein, and incretin) .

Now take these six variables and your one set of tests and tell me what caused the variance. Please. I'd really like to see some techniques to determine the causes of my blood sugar problems.

You might come up with answers like trends or variance analysis or whatever, but they are all flawed. They all try to isolate problems caused by one or more of six variables with a single set of tests. I say it can't be done, and if it can be, doctors are not doing it. They most definately cannot do it by hovering over a log book for a minute or two. Perhaps a statistician can do a decent job, but do you want to rely on complex math when there are easier and better techniques?

Objective three is rate determination. I do not use my day-to-day compliance tests to set rates. I refuse to even consider it. I toss them away. When I need to know how to dose myself, I do controlled testing to eliminate as many variables as I can, so I can focus on one at a time. I have not taken on the task of testing for each glucose input. All of these objectives are superceded by a bigger one: live as normal a life as possible. Sometimes the effort involved is just too much work with too little payback. I isolate my efforts into determining basal rates and bolus ratios. I first tested to set my basal rates, and then I did each meal rate.

How do I do this? Again it's beyond this article's scope, but I will tease you. Basal testing tests the effects of your basal insulin without food. I skip meals and test hourly. If I stay flat, my basals are perfect. If I rise or fall, I need to make adjustments. Adjustments are very dificult to make, and I recommend getting your endo on board for this. Give him my articles!

Bolus rate determination cannot be done until basal rates are set. It's like focusing binoculars. Have you ever focused them? Did you know that each of our eyes has different focal lengths? We do it by focusing our left eye only. Once set, we open our right eye and adjust the center compensation dial until that eye is set. We do one, then we do the other. That's basically what we are doing with our rates. We set the left eye first, the basal, then the right eye, the boluses.

Do you really need to get into all ths detail when testing? Is it worth it? I think so. My A1C is now at 5.6%, a number considered normal. My incidences and severity of hypoglycemic events are greatly reduced. I have about two nasty ones a year compared to two a month previously. I honestly feel like I'm becoming a healthy human being. It's totally contrary to what doctors are telling us about A1C's, and that's because it works!That's quite a feeling.

It sure sounds like a lot of work, but is it? Yes we spend lots of time and effort rate setting. Yes we do the same amount or more compliance testing. We all test for safety anyway. But I don't log. I log my rate setting, but not my compliance. That log is a big ball and chain for many. It's a pain in the butt to keep updated, and it's frustrating when we can't figure out what it all means. Well throw it all away.

Work smarter, not harder!