Tag: Hypoglycemia

Health

Driving and Diabetes

Posted on by mghdiabeteseducation

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NPPossessing a driver’s license is a rite of passage in our society.
A driver’s license is seen as a gateway to independence and is a necessity for survival in many instances since many places in the US don’t have adequate public transportation. Driving is such a huge part of our lives, but there are instances when the ability to drive competently is also at issue. The American Diabetes Association (ADA) published a Position Statement on Diabetes and Driving in the 2014 Clinical Practice Recommendations. I would like to summarize the key points of this Position to provide an overview to help both people with diabetes and their health care providers have the best information about driving with diabetes.

The process for identifying drivers with diabetes varies from state to state, depending on what type of vehicle the driver needs to be licensed for. In some states, questions such as “Do you have any medical condition that may interfere with the safe operation of a motor vehicle?” are asked at the initial application for license. These questions may then prompt the need for further medical evaluation. There is no need for a medical examination just because the driver has diabetes. Most often a medical evaluation would be requested when there has been a documented episode of hypoglycemia while driving. Visit the ADA Website for more information on specific rules for each state.

Drivers with diabetes that are commercial drivers in interstate commerce have different rules and follow a set of uniform federal regulations. ALL drivers are subject to an examination every 2 years to update the driver’s ongoing general fitness. Drivers with diabetes managed with diet, exercise, and oral medications do not have any further requirements. Drivers who use insulin often require a more detailed medical evaluation so an exemption to drive and medical certification can be granted. Drivers for commercial motor vehicles, such as school bus drivers and vehicles that transport passengers or hazardous materials are subjected to more strict evaluations that differ state to state.

There are many factors to consider when caring for the driver with diabetes. I want to be clear: a diagnosis of diabetes or the use of oral medications or insulin does not mean that driving ability is compromised. The ADA has determined that the single most significant factor associated with collisions for drivers with diabetes appears to be a recent history of severe hypoglycemia regardless of diabetes type or treatment. The ADA Workgroup on Hypoglycemia defines severe hypoglycemia as an event that disrupts cognitive motor function and requires the assistance of another person to treat the hypoglycemic event.

The plan of assessment and care of the driver with diabetes needs to be individualized. It is important to not only review hypoglycemia awareness, but to also review the other conditions that could interfere with safe driving. These conditions may include decreased visual acuity due to retinopathy or cataracts, neuropathy that diminishes the sensation of the right foot, or sleep apnea which can result in daytime sleepiness. Drivers that have had a hypoglycemic event will need much closer evaluation and education. The driver may need re-education to address issues with mealtimes and dosing of medications (or medications may need to be adjusted altogether), further education about hypoglycemia awareness, and the best methods of treating low blood sugars. Drivers who have had episodes with severe hypoglycemia may also need to perform additional glucometer testing.

People driving for long distances should have a good supply of glucose tablets easily available in the glove compartment or in the console. A supply of snacks such as packages of cheese and peanut butter crackers or nuts should also be stored in the front of the car with the driver and checked before each trip. Drivers who feel hypoglycemia occurring while driving should pull off the road immediately, put on their blinkers, and treat with a fast acting carbohydrate. Do not resume driving until blood sugar values are normalized.

Finally, I advise that all of my patients with diabetes have a medical ID with them at all times. Symptoms of hypoglycemia may appear as if driving under the influence of alcohol or drugs, which can lead to losing precious treatment time if there is an incident where you are unable to identify yourself as having diabetes.  First responders are trained to look for things like a bracelet or necklace, or a card in the wallet.

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Uncategorized

On Insulin and Weight Gain

Posted on by mghdiabeteseducation

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

Does my insulin make me look fat? The answer to this question is …it might. That would make it the wrong answer because none of us want to take a medication that may cause weight gain, especially as maintaining a healthy weight is such a crucial aspect of good diabetes management. The purpose of this post is to discuss how insulin works and how it may affect your weight. I hope after reading this you’ll have fewer reservations about using insulin if it becomes necessary.

Maintaining a healthy weight is so important for general health and is particularly important for people with chronic diseases such as high blood pressure, high cholesterol, heart disease, arthritis, and diabetes. A healthy diet and weight may mean fewer daily medications or a lower dose of medications you still require. Many medications have the potential for side effects; diabetes medications are no different. Weight gain IS a possible side effect of insulin, but it may also happen with oral medications.

Let’s talk about insulin as a first step. It is, simply put, a lifesaving medication. Insulin was discovered in 1921 at the University of Toronto and has been extensively studied and improved upon since. The job of insulin is to move the glucose from the food we eat into our cells so they’re able to stay healthy and work well. It then takes the remaining glucose from the bloodstream and stores it so it can be used for energy later. People with Type 1 Diabetes are totally dependent upon this medication for survival as their pancreas does not produce insulin. People with Type 2 Diabetes can manage their disease many different ways: diet, exercise, oral medications, and insulin. Diabetes is a progressive and chronic disease that as yet does not have a cure. That is why so many people with Type 2 Diabetes will require insulin as part of their management over time.

Two common symptoms of poorly controlled diabetes are significant weight loss and excessive urination. The weight loss happens because stored fat gets broken down to provide enough fuel for bodily functions (heart and lungs, for example) to operate and maintain life. You may start to notice the numbers on the scale decrease, regardless of what you eat or drink. This is because calories consumed aren’t being properly metabolized but rather directly excreted with urination.

The treatment for extreme hyperglycemia is insulin therapy. The insulin corrects the high blood sugar, correcting the excessive weight loss in the process. The insulin is helping the body work correctly; it’s not causing new weight but rather replacing what was lost when the body was in crisis. It’s a sign the body is healing and starting to work more normally again. This is a good thing, but it can also be frustrating for people who struggle with their weight regardless of their level of glucose control. If your weight is still creeping up after your blood sugar is better controlled, there are probably other reasons for this and further investigation is needed.

Frequent episodes of hypoglycemia (low blood sugars) can cause added weight. I’ve discussed hypoglycemia in more detail in the past, but I want to review a couple of points now. Under eating, over exercising, and both oral medicines and insulin are potential causes of this frightening and potentially life threatening condition. Proper treatment is key, but it’s common for people to over treat low blood sugars because they feel so poorly and think more is faster and better. This is not the case, and the extra calories may cause added weight over time.  The strategy I encourage my patients to use is trying things like glucose tablets and gels for treatment more often than juices or regular soda because they are pre-packaged for the correct carbohydrate (15grams). It can be hard to measure out 4 oz of juice or regular soda when you are feeling so poorly and anxious during an episode of low blood sugar. I also strongly encourage all of my patients to see our RD CDE on a regular basis to review meal plans and make any adjustments as needed to assist with better weight control. It is also important to be as active as possible as any type of movement will decrease insulin resistance and improve weight and blood sugar numbers.

Insulin initiation is a daunting prospect for some. Many of my patients, especially those who are really struggling with their weight, have told me the fear of gaining weight is why they refuse insulin. I hope that my explanation helps to minimize this fear. So, this brings us back to where we started. Does my insulin make me look fat? I prefer to answer this way: It makes your body healthy so you look marvelous!!!

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Health

Hypoglycemia Unawareness

Posted on by mghdiabeteseducation

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NPWhen you have diabetes, regulating your blood sugar is a full time job without any time off for good behavior. Good control of your blood sugar is necessary to prevent potential complications but sometimes, regardless of how hard you’re working, it may seem that outside forces conspire to ruin your good control.  One of these issues can be hypoglycemia.

Hypoglycemia, or low blood sugar, is defined as a measured blood sugar that is less than 70 mg/dL. It may occur if you haven’t eaten enough, had unplanned strenuous activity, or taken too much medication. It may be accompanied by many symptoms including (but not limited to) feeling sweaty, shaky, extremely hungry, agitated, or experiencing blurry vision. If blood sugar reading is less than 70 mg/dL the recommendation is to have some fast acting carbohydrate like orange juice or glucose tablets at once and check again in about 15 minutes.

Hypoglycemia is a very serious complication of diabetes and left untreated can result in seizure, coma, and even death. When the sugar level gets too low, the body releases two hormones: glucagon and epinephrine.  Epinephrine is responsible for the early warnings signs of low blood sugar, such as the hunger and sweating mentioned earlier. It also signals the liver to start making more glucose. Glucagon signals the liver to release this stored glucose into the circulatory system to correct the low blood sugar. However, people living with diabetes may also experience another type of hypoglycemia that is extremely dangerous: hypoglycemia unawareness.  Someone with hypoglycemia unawareness does not feel the early symptoms of low blood sugar. People who have had diabetes for a long time are at risk for developing this condition, as are those with a history of frequent low blood sugars, frequent and extreme fluctuations in blood sugar values, and people who have very tightly controlled blood sugars.

The most important way to address this condition is AWARENESS. Check your blood sugar frequently so you’re aware of your patterns. Medication changes, activity changes, and illness are a few situations when checking your blood sugar can really pay off.  Sometimes it’s necessary to check in the middle of the night on a regular basis if nocturnal or fasting hypoglycemia is happening to you. This way you can identify the exact timing of the low and not only treat it, but take steps with your health care provider (HCP) to find a way to manage your medications or diet to avoid these episodes. Targets for your blood sugar goal may need to be adjusted. Not every person, especially the elderly or people with a history of severe hypoglycemia, needs an A1C between 6.5 and 7 so discuss this with your HCP.

It’s important to work with your CDE to identify any issues you may have with managing stress, diet factors, or even recognizing what your low blood sugar reaction is. I’ve told you some of the common symptoms, but no two people have the same experience when it comes to low blood sugar. I like to compare low blood sugar symptoms to poker: everyone has their own “tell.”  I’ve had people tell me “I know when I’m getting low. I see black spots/my tongue tingles/I get jumpy inside like I have bugs on me/I can’t hear clearly.”  This is also an opportunity to incorporate your support network (spouse, family, and friends) into the education about low blood sugars. Remember, some people get low so fast they’re not aware of the symptoms but a coworker or spouse can quickly pick up that they’re speaking without making any sense or sweating profusely. It’s also important to curtail your alcohol consumption when low blood sugars are an active problem.

I hope this information gives you the chance to start a conversation with your HCP about hypoglycemia AWARENESS so your full time job of diabetes management can be as successful as possible.

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Health

2013 ADA Clinical Practice Recommendations (Part 1)

Posted on by mghdiabeteseducation

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen W

Every year the multidisciplinary Professional Practice Committee of the American Diabetes Association (ADA) publishes a set of guidelines and recommendations on the diagnosis and treatment of diabetes for both adults and children. These standards guide us in how and when to screen for, diagnose and treat diabetes; how to monitor for complications; and how to educate patients in their self-management strategies.

These standards of care provide concrete data about goals of treatment, but they are not meant to be the only approach to care. Rather, they provide a guideline for the care of a person with diabetes;  providers rely on their best clinical judgment for each individual they care for and adapt the guidelines as needed.  Last year I did a review of the ADA Guidelines along with the specific updates published (you can refer to that post here). This year there were 12 revisions published which I will highlight this week and next. Please remember that these are guidelines— always review your personal health care plan with your health care provider(s).

Screening for Type 1 Diabetes

Type 1 Diabetes is generally diagnosed with an acute presentation of hyperglycemia and even ketoacidosis. There is no evidence that screening the general population for Type 1 Diabetes is helpful, but there is valid evidence that measuring islet autoantibodies in relatives of people with Type 1 Diabetes will identify at-risk individuals. Those identified can be referred to clinical studies where they can learn about their potential for developing Type 1 Diabetes and what symptoms to watch for.  Lifestyle education would also be provided and more frequent screening instituted.

Prevention/Delay of Type 2 Diabetes

There are several random controlled studies showing that people at high risk for developing Type 2 Diabetes can decrease their rate of onset with certain interventions. These interventions may include lifestyle changes and even medication in some instances. ADA supports formal education for people with impaired glucose tolerance and an A1C between 5.7 and 6.4%. People who fall into this category also need to be monitored annually for their blood sugar values and assessed for cardiovascular risk factors (obesity, hypertension, and high cholesterol).

Glucose Monitoring

I think one of the most important things we do as diabetes providers is helping people learn how to monitor their blood sugars at home and follow these patterns for better control. However, there has been some discussion in the literature about the clinical utility and expense for self-monitoring of blood glucose (SMBG) in people who aren’t on aggressive insulin or not on insulin at all. ADA has approached this issue by stating that frequency and timing of SMBG should be decided on an individual basis based on the person’s needs and goals for treatment. People using MDI or an insulin pump need frequent SMBG to assess for control and monitor for hypoglycemia. People using less frequent insulin or non-insulin therapies may check SMBG on a more variable schedule that should be determined with the health care provider. It’s also important to review testing technique at times to be sure the results are accurate.

DSME and Support Groups

ADA has always advocated for education and support for people with diabetes, and now is supporting formal education for pre-diabetic patients. ADA supports third-party payer reimbursement for both these services.

Hypoglycemia

Hypoglycemia awareness and management should be frequently reviewed with patients. The self-management plan should always be re-evaluated if there have been one (1) or more episodes of severe hypoglycemia (inability to handle the episode on your own).  People with severe hypoglycemia or hypoglycemia unawareness may need the targets for glycemic control raised. People with declining cognition need to be assessed frequently for hypoglycemia by their providers and family members.  Adjustments in their glycemic management plan will also need to be made.

To view the full set of Clinical Practice Recommendations for 2013, click here.

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Diabetes ABCs

Diabetes ABCs: H

Posted on by mghdiabeteseducation

Hyperglycemia and Hypoglycemia
By Paula Cerqueira, Dietetic Intern

H

Hyperglycemia is the medical term for high blood sugar.  It occurs when the pancreas produces too little insulin, or when the body becomes resistant to insulin.  Hyperglycemia happens every now and then to all people living with diabetes.  If your blood glucose values are consistently running higher than the norm, talk with your healthcare provider.

Hypoglycemia is low blood sugar (< 70 mg/dL) and results from too much insulin and too little sugar in the blood. If blood glucose drops below 50 mg/dL, this could result in unconsciousness, a condition sometimes called insulin shock or coma.  Hypoglycemia can be caused by skipping or delaying meals, eating too few carbohydrates, exercising longer or more strenuously than normal, taking too much insulin and drinking alcohol.  It’s important to learn to identify the symptoms of hypoglycemia so you can treat it quickly.  Symptoms include: shakiness, dizziness, sweating, hunger, headache, pale skin color, sudden moodiness, seizure, and confusion.  Hypoglycemia can be treated by following the 15/15 guideline to raise blood glucose above 70 mg/dL – test blood sugar, consume 15 g of carbohydrate and test blood sugar in 15 minutes.  If blood sugar remains low, consume an additional 15 g of carbohydrate and test blood glucose in 15 minutes and then in 60 minutes. Once normal, consume a regular meal.  Fifteen grams of carbohydrate is about 4 oz of juice, 6 oz of soft drink, 5 hard candies, 4 glucose tablets, or 1 tablespoon sugar.

(Post reviewed by Debra Powers, MS, RD, CDE, LDN, Senior Clinical Nutritionist)
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