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Picture this: You’re sitting in an exam room at your doctor’s office. The nurse pokes her head in and says, “Sorry for the wait. He’ll be right with you.” Yeah, you’ve heard that before. To kill some time, you start building a miniature fort out of tongue depressors on the examination table. Add some gauze for fences and an odd instrument for a flagpole, and you have quite a little scene going.
Suddenly, the door swings open, creating a gush of air that flattens your fort. In rushes your doctor, sporting a freshly pressed white lab coat and a chart with someone else’s name on it.
“Miss Baxter, how are we today?”
Now, you sure as heck don’t know who “Baxter” is, but after waiting this long, you’re not about to let him get away.
“OK, I guess. Want to see my logbook?”
You hand him your blood glucose logbook, in which you have scribbled down several dozen readings since your last visit.
“I’ll check that in a minute,” he says. For the next five minutes, he takes you through a virtual medical whirlwind: asking the routine questions; checking your eyes, ears, heart, and feet; reviewing the status of your lab work (the nurse caught the chart error and thankfully brought him the correct one); and asking if you need prescriptions for any of your diabetes supplies. Then he opens up your logbook to a random page, thinks for a moment, and offers the kind of insight that can only come from years of schooling, clinical practice, and intense study in the diabetes field:
“Looks like you’ve had some ups and downs. Are you following your meal plan?”
If you’ve heard this sort of off-the-shelf observation before, you’re not alone. Today’s physicians are charged with so many responsibilities and have so little time to spend with patients that diabetes care rarely receives the attention it deserves. If a physician is lucky enough to offer a team of diabetes educators (or can practice medicine without the pressures of managed care), you might get some help with the day-to-day control of your diabetes. Otherwise, you had better prepare for some serious self-management.
Let’s picture that visit to the doctor once again, except this time, you were prepared. When it came time to discuss your blood glucose control, you presented a chart indicating a trend of high blood glucose readings on the weekends and low readings the mornings after exercise. You ask your doctor if it would be OK to reduce your overnight insulin by a couple of units after exercise and reduce your carbohydrate intake by 15 grams per meal on the weekends. Your doctor agrees with these suggestions and adds that the high fat content of your restaurant meals on weekends may have a carryover effect to the next day.
Sounds a bit more productive than “follow your meal plan,” doesn’t it?
Becoming a recording artist
For those who take insulin once daily, use oral diabetes medicines, or control their diabetes with diet and exercise, blood glucose readings should be taken twice daily, at least while control is being fine-tuned. Ideally, the readings should be taken at two meals in a row and “rotated” from day to day. For example, on day one, check before breakfast and before lunch. On day two, before lunch and before dinner. On day three, before dinner and at bedtime. Then repeat the process from day one. This approach lets you see when your blood glucose level may be rising or falling.
Blood glucose readings by themselves are not of much use unless they are all running high or low, and for most people, that just isn’t the case. Most people have a mix of highs, lows, and normal readings, and the goal is to figure out what’s causing the highs and lows. So in addition to checking and recording blood glucose levels, it is important to record the amount of insulin or medicine taken and the time it was taken, the grams of carbohydrate consumed at each meal and snack, the type and length of exercise and other physical activities (such as housework, yardwork, shopping, and extended walking), as well as stresses that tend to affect blood glucose level such as illnesses, menstrual cycles, emotional events, and episodes of hypoglycemia.
For those who check their blood glucose twice a day, try to record the pertinent information between the two checks. For example, if you monitor your blood glucose before breakfast and lunch, record all carbohydrates, activities, insulin, and medicines taken from the time you wake up until just before lunch.
To get the most from your record-keeping, organize the information so that it is easy to analyze. A simple daily chart like the one here might serve as a good system. It is often helpful to line up several charts like these in a column so that a pattern of high or low blood glucose at a particular time of day can be detected.
Try it yourself
Nobody expects your blood glucose control to be perfect. But it is reasonable to expect good control most of the time. Every time you make a sensible adjustment, you get one step closer to good control.
So the next time you have an appointment with your doctor, show up armed with useful information and your own personal insight. Who knows? You might both learn something new!
How it works
Connie. The example here was provided by Connie, a 51-year-old woman with Type 2 diabetes who uses diet, exercise, and oral medicine to control her diabetes. Do you notice anything unusual about her blood glucose levels? What could possibly be done to get them closer to normal? Here are some observations based on her records:
Daniel. A 20-year-old college junior, Daniel takes multiple injections of insulin. He provided the table here. Can you pinpoint the reasons for Daniel’s erratic control? Here are some observations:
Renee. Renee, a 9-year-old girl, uses an insulin pump. Renee takes a unit of insulin for every 15 grams of carbohydrate plus a “sliding scale” to correct highs and lows at mealtimes. Insulin sliding scales are prescribed increases or decreases made to your mealtime insulin dose based on your premeal blood glucose level. Your health-care provider may advise you to take a larger insulin dose if your blood glucose is above a certain level or a smaller dose if it is below a certain level. While using a sliding scale may be appropriate in some instances, it is not a substitute for good control. So if you are adjusting your insulin doses more than twice a day, you may need to examine your diabetes logbook to find the source of your erratic blood glucose levels or consider the possibility that changes are needed in your overall insulin regimen.
What could account for Renee’s dramatic blood glucose changes, especially during the night?
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