While You’re Sleeping . . . Your A1c May Go For A Ride

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Even if your blood glucose level is in target range when you go to bed and when you get up, it could go travelling while you’re asleep. And that nighttime variation could make your A1c goals harder to reach.

We read about this in a post by Ginger Vieira on diabetesdaily.com.

(As newcomers to the website and blog scene, we’re educating ourselves—and learning a lot—by visiting the many good diabetes blogs out there; diabetesdaily.com is one of them.)

Ginger’s post tells why you should check your nighttime blood glucose levels (if you don’t have a continuous glucose monitor), and suggests what to keep track of and ways to adjust your eating habits, if you need to.

http://www.diabetesdaily.com/voices/2014/06/your-a1c-while-you-were-sleeping/

(While you’re at the site, we suggest you sign up for the weekly “best of diabetes daily” emails and check out the posts. They illustrate how widely patients vary in their symptoms of diabetes and in their responses to food and medications. The posts also reveal how knowledgeable and helpful some patients are, sharing experiences and offering support.)

A Walk on the . . . Wild Side?

Getting back to blood glucose levels—when they go travelling in the wee hours, they could even take someone on a different ride—to the police station.

We sat in on a session led by a registered dietitian, certified diabetes educator (RD, CDE). She fielded a question from a newly diagnosed type 2 patient—a sleepwalker—who would arise in a trance in the middle of the night and head for the kitchen. His wife recently found him at 3:30 a.m. eating a sandwich, roaming around the front lawn—naked.

What, he asked, should he do?

The dietitian didn’t lose a beat. “Wear pajamas!”

The next step: he should set his alarm that night for 2 a.m., check his blood glucose level, and eat something appropriate. To be followed the next day by possible adjustments in medication, food intake, and testing times, and perhaps a conversation with his doctor.

Bottom line: The A1c test measures the average blood glucose level 24 hours a day, over the previous two to three months. If daytime blood glucose readings are within normal range, indicating good daytime control, but blood glucose levels are consistently elevated during the night, the A1c reading—indicating overall average control—is likely to be high. The high reading can come as a surprise to patients who haven’t been checking their nighttime blood glucose levels.

 

Glucose Meters and Strips—How Accurate?

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As part of our education as newbies, we’ve been delving into some of the excellent diabetes blogs out there. And we found an interesting item in Diabetes Mine, posted by MikeH, about an upcoming meeting of endocrinologists, diabetes specialists, and patient advocates, on Capitol Hill in late September.

http://www.diabetesmine.com/2014/06/news-update-big-endo-groups-plan-meeting-on-d-device-accuracy-and-access.html

Participants will discuss legislation involving, among other things, the accuracy of blood glucose meters and test strips.

Diabetes Mine links to a businesswire news release:

“The blood glucose monitoring initiative will be uniquely structured to gather input from all major stakeholders involved in the diabetes arena and will examine critical factors such as regulatory challenges, post-FDA-approval monitoring of safety and accuracy of glucose strips, glucose sensors and devices, patient access and economic/reimbursement issues.”

http://www.businesswire.com/news/home/20140527006510/en/Major-Medical-Association-Announces-Gathering-Key-Diabetes#.U621YpRdUoH

We’ve had some doubts about the accuracy of meters and test strips, having watched the results of our daughter’s testing effort some time ago. So the Diabetes Mine posting propted us to do some additional digging, and we found more information in the same highly rated blog. This item, written by guest poster Riva Greenberg, is a few years old, but the information probably is still apt.

Riva interviewed several MDs and Chief Medical Officers at meter manufacturers, and shares what she learned, listing many factors that affect the accuracy of readings. “The biggest contributor to inaccuracy is the strips,” she comments, noting that according to an expert she interviewed, the best we can probably expect “a meter to ever produce is plus/minus 8% accuracy.”

http://www.diabetesmine.com/2012/09/why-meters-cant-tell-us-our-blood-sugar-levels.html

We hope that the September meeting on Capitol Hill is successful, so that patients will have more confidence in what their meters and test strips tell them about their blood glucose control.

The legislation, known as the National Diabetes Clinical Care Commission Act (H.R. 1074/S. 539), would create a 3-year Diabetes Clinical Care Commission to improve clinical outcomes for diabetes and prediabetes. Major organizations such as the American Diabetes Association and the Endocrine Society have endorsed the legislation, which needs to be passed before December 31. The consensus conference will be held September 29, 2014.

BMI Fails to Identify More Than One-Fourth of Obese Children

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We’re not the first to have pointed out the shortcomings of the Body Mass Index (BMI), a useful but imperfect measurement of obesity. The authors of a new meta-analysis published online in Pediatric Obesity on June 24, 2014, have found that the BMI relies on body weight regardless of body composition, and fails to distinguish between lean and fat mass. They credit BMI with being “an invaluable epidemiologic tool to assess population-level risk and track national trends in obesity,” but point out that it “has limitations in diagnosing obesity at the individual level.”

In our third publication, Prediabetes: Beating the Odds of Getting Type 2 Diabetes, we point out that waist circumference is a far better indication of obesity. Obviously, it’s impractical to use for mass studies.

You’re probably familiar with the BMI. When you step on the scale in your doctor’s office, the nurse asks you your height and jots down a number on your chart. That number is your BMI—your weight in kilograms divided by your height in meters squared.

BMI Used in Children: High Specificity, Low Sensitivity

The current meta-analysis included 37 studies that evaluated more than 53,500 patients whose average ages ranged from 4 to 18 years. The authors concluded that when used in children, BMI “has a high specificity but low sensitivity to detect adiposity and fails to identify over a quarter of children with excess body fat percentage.

(Specificity pertains to how well a test or procedure identifies only the patients who actually have a given condition, such as obesity. Sensitivity has to do with how good a test is at identifying patients with the condition. So the authors were saying that if the IBM indicates that a child is obese, the diagnosis is almost certainly correct. But the IBM fails to identify a lot of children [more than 25%] who are in fact obese.)

So, what is the solution? A clinician who suspects obesity—despite a normal BMI—could use secondary tools, such as skin-fold measurements or imaging studies. The authors see a need for additional studies to develop reference values for skin-fold thickness and for ADP and DXA (imaging studies), and to determine how well these test can—independently or together—predict whether a child is likely to develop conditions associated with obesity.

http://www.uptodate.com/contents/treatment-of-type-2-diabetes-mellitus-in-the-older-patient?topicKey=ENDO%2F1776&elapsedTimeMs=4&view=print&displayedView=full#

 

Improving Glucose Meter Quality and Providing Continuous Glucose Monitoring Through Medicare

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On June 27, 2014, we published a post questioning the accuracy of some blood glucose meters, and mentioned a Consensus Conference on Glucose Monitoring to be held in September 2014. The conference explored the quality and safety of glucose monitors and the most efficient and effective uses of blood glucose monitoring (BGM) and continuous glucose monitoring (CGM) to optimize health outcomes. The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) sponsored the conference.

Diatribe Post in Diabetes Daily

Diatribe posted a conference update on diabetesdaily.com, noting a widespread concern among meeting participants that about 50 percent of currently marketed meters—“usually meters made by obscure manufacturers”—fail to meet current accuracy standards, partly because of lack of ongoing post-approval quality assurance mechanisms.

Diatribe also commented on a promising update on the Diabetes Technology Society’s Surveillance Program for Cleared Blood Glucose Meters, designed to identify meters of low or high quality and make the data publicly available.

Another encouraging development: according to Diatribe, momentum is increasing in support of bills currently in the House and Senate to establish Medicare coverage of CGM. http://www.diabetesdaily.com/voices/2014/12/consensus-conference-on-glucose-monitoring/?utm_source=Diabetes+Daily&utm_campaign=f74bd8b41a-2014_01_14_Needle_Reuse1_14_2014.

AACE/ACE Summary PDF

A conference summary published in Endocrine Practice covers topics discussed during the conference. In a closing statement, the summary stresses the need for Medicare to establish a benefit category for CGM. also calls forcing patients to stop CGM when they go on Medicare “one of the most egregious distortions,” leaving patients “more vulnerable to hypoglycemia at exactly the stage of life when it is most dangerous.” https://www.aace.com/files/may_ep.pdm.pdf.

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