Now that you know the different factors that can affect blood sugar, we can begin to discuss treatment plans. Blood sugar normalization for most diabetics can be achieved through one of four basic plans. Although there are only two major types of diabetes—type 1 and type 2—there are so many variations, particularly in type 2, that a treatment plan that works for one diabetic won’t necessarily work for another. Each plan has to be tailored to the individual.
The basic treatment plans increase in complexity with the severity of the disease.
Level 1: Diet (and appropriate weight loss)*
Level 2: Diet (and appropriate weight loss) plus exercise
Level 3: Diet (and appropriate weight loss) plus exercise plus an oral insulin-sensitizing or insulin-mimetic agent
Level 4: Diet (and appropriate weight loss) plus exercise plus insulin injections, with or without an oral agent
Same as level 4 above, with the addition of multiple daily insulin injections, with questionable benefit from exercise in controlling blood sugars, and with benefit from oral insulin-sensitizing agents only when insulin requirements are excessive, as with those who are obese or who have polycystic ovarian syndrome (PCOS; see Appendix E).
What are normal blood sugar levels? What range do we find in nondiabetics? The answers depend upon whom you ask. I’ve seen figures in the scientific literature over the years ranging anywhere from 60 to 140 mg/dl. My experience checking random blood sugar readings on nonobese nondiabetics, as well as figures from large population studies, tells me that for most nondiabetics, blood sugar levels cover a pretty narrow range of about 75–90 mg/dl (by finger stick), except after meals containing large amounts of fast-acting carbohydrates.
After initial fine-tuning of blood sugar, I usually select a target of 83 mg/dl for most of my patients. This target is not an average, but one we try to maintain 24 hours a day. Even if you average 83 mg/dl but your blood sugars are bouncing back and forth between 60 and 140 mg/dl, you’re still on the roller coaster. Our object is to find a treatment plan that will get you off the roller coaster and keep you off.
Type 1 diabetics with severe gastroparesis (unpredictable stomach-emptying) are at such great risk for severe hypoglycemia after meals that I frequently set their target blood sugar higher, to play it safe. (See Chapter 22.)
One of the most important considerations in setting up an initial target is that people who have had high blood sugar levels for many months or years usually experience unpleasant symptoms of hypoglycemia as blood sugars approach normal. Someone who has grown accustomed to blood sugars consistently over 300 mg/dl may feel “shaky” at 120 mg/dl. In such a case, we might start with 160 mg/dl as the initial target. We’d then lower the target to its ultimate value over a period of weeks or months as treatment proceeds.
It’s unusual when an initial meal plan and dosage of medication instantly result in the desired blood sugar profiles. Some people, a few days into their regimen, may find something objectionable, such as not enough to eat for a certain meal. Because of this, it’s often necessary to experiment with a plan, making small changes based upon personal preferences and blood sugar profiles.
People tend to become discouraged if they cannot see rapid improvement, and so, where warranted, I try to make adjustments to the regimen every few days in order to demonstrate that our efforts are accomplishing positive results. To this end, I ask patients to bring, e-mail, or fax to my office their blood sugar profiles about one week after their final training visit, if initial treatment is by diet alone. If I’ve prescribed insulin, I like to see profiles within a few days. I certainly try to make sure that no blood sugars are below 70 mg/dl during this trial period. I ask all new patients to phone me at any time of the day or night if they experience a blood sugar under 70 or become confused about their instructions. Additional repeat visits or phone calls may be necessary every few days or weeks, depending upon how rapidly blood sugar profiles reach our ultimate target.
Many new patients come to my office from out of town, some traveling distances of thousands of miles. Clearly, frequent office visits would be impractical in such cases. For these patients, I often schedule follow-up “telephone visits” instead of office visits. Patients fax or e-mail their blood sugars to me on GLUCOGRAF III data sheets.
These subsequent office or telephone interactions enable me to fine-tune the original plan, and also to reinforce the training program by catching any mistakes that a patient may inadvertently make. This interactive training is much more effective for patients than just reading a book or hearing a few lectures.*
Although the protocol will likely differ at every doctor’s office, in the next several pages, I’ll try to give you an idea of how things work at our Diabetes Center. This way, you’ll get a general notion of how a comprehensive diabetes treatment program should work.
In my experience, most patients will cooperate with a treatment plan that shows them concrete results. Greatly improved blood sugars, weight normalization, halting or reversing diabetic complications, and a sense of improved overall health can go a long way toward convincing an individual to stick with a treatment program.
Much is written in the diabetes literature about the key role of patient “compliance.” Treatment failures are often blamed upon “lack of compliance.” I think it’s unreasonable to expect anyone to comply with a treatment plan that explains little and, as in the case of the standard ADA approach, isn’t really effective and offers little incentive to continue. What we must do is set up a sensible, workable plan that you understand and agree with. When I work with my patients in the office, I don’t just have my staff hand them a photocopied diet and expect automatic acceptance. This is something that has to be negotiated, worked out. Do you like turnips? Great, we can probably fit them into your diet, even though I don’t think I’ve ever eaten one in my life. Call it “physician compliance,” but the point is that it’s unreasonable to try to force my personal preferences on my patients. Only when one understands and agrees with the plan can we expect cooperation. For cooperation to continue, however, patients have to see positive, rapid results.
Not all people are able to follow a given treatment plan. For example, someone who’s been overeating carbohydrate for a lifetime may find it next to impossible to begin to follow a restricted diet immediately, but we have ways around this (see Chapter 13, “How to Curb Carbohydrate Craving or Overeating”). Some absolutely resist exercise. But for most people we are still able to develop a treatment plan that works. If, for example, someone whose blood sugar should be controllable with diet and exercise refuses to exercise, I might instead prescribe medication that lowers insulin resistance.
When seeing new patients, for those who live nearby, my preference is an introductory visit followed later by a series of treatment/training visits lasting 2–3 hours each. The continuity of time is invaluable to showing rapid results. However, most insurance companies don’t like to pay for lengthy office visits—especially for diabetes training—and so it may be necessary to break down the initial workup and training into multiple brief visits. Although I don’t like to, I may do this with local patients; but with patients who live a great distance from my office, it’s simply not workable to have successive short visits.
At the first visit I always get a drop of fingertip blood to measure the patient’s baseline (initial) HgbA1C. As time goes on and the patient sticks with the program, the inevitable progression of reduced blood sugar over the next few months can provide tremendous encouragement.
My preferred procedure for the first few days of treatment is to break down visits into three sessions. Before seeing a new patient, however, I send him or her a lab order form for the blood and urine tests listed in Chapter 2.
In addition to taking a brief history of the patient’s diabetes experience, I review with him or her the laboratory test results that I have received. We then negotiate plans for dealing with any abnormal results.
Since blood glucose profiles are so essential to formulating a treatment plan, prior to the introductory visit I usually ask a new patient to procure blood glucose testing supplies—GLUCOGRAF III data sheets and the other supplies listed in Chapter 3. I provide guidelines for blood glucose self-monitoring (like those you have seen in Chapter 4), and ask the patient to learn how to use the equipment so that later, on the first treatment/training visit, I can look over one or two weeks’ worth of blood glucose profiles. I also may give the patient a couple of large bottles so that a 24-hour urine specimen can be collected for a subsequent visit.
If I haven’t done so in the introductory visit, I take a medical history and begin a physical exam geared toward uncovering long-term complications of diabetes. For patients who have had diabetes more than about five years, I inevitably find a good number of these long-term sequelae (consequences), some of which may be reversed by blood sugar normalization. The exam will include some or all of the tests described in Chapter 2. We check to ensure that the patient has purchased the right supplies. If we haven’t done so already, we provide a supply list (Chapter 3) with the appropriate items checked off.
We discuss plans for treatment of medical problems other than blood glucose control. These may include conditions the patient already knows about, but also anything uncovered by blood testing or by the history and physical exam.* If the patient has already acquired supplies and begun measuring blood sugars, I review his or her technique and correct it if necessary.
Many of my patients come from out of town, and so the second visit may take place the day after the first. For local patients, however, it may be approximately a week later. At this visit we finish the physical examination. We also recheck the patient’s blood glucose measurement technique and proper use of the GLUCOGRAF form.
If I feel that the patient should be taking insulin, I give instructions for insulin doses to be taken the night before and the morning of the third visit. I also provide training in self-injection (see Chapter 16) to patients who have never injected before. For those who are veteran insulin users, I evaluate their self-injection techniques and correct them if necessary. It’s my experience that most insulin-using patients have previously been taught improper techniques for filling syringes and injecting insulin. Because anyone can get an infection (see Chapter 21) or may undergo treatment with steroids, both of which can dramatically raise blood sugars, I teach every diabetic how to inject.
To this visit the patient is expected to bring the blood sugar data he or she has collected over the prior week(s), together with a separate list of what he or she eats on a typical day. This information enables me to estimate if the patient will need medication for blood glucose control and tells me about foods the patient likes that might be included in our meal plans. The blood glucose profile also provides a snapshot of the patient’s status before beginning the new treatment regimen. We can review this at a later date to evaluate progress. As with each of the other initial visits, the bulk of our time will be devoted to training.†
Most important, this is the visit where we negotiate the meal plan (see Chapter 11).
This visit may take place anytime after the second. I continue training and enter all the “data to remember” at the top of a GLUCOGRAF data sheet (see Chapter 5). I use this visit to give verbal instructions and a printed handout regarding foot care (see Appendix D).
On this day, if the patient arises with a blood glucose above our target value, she’d have instructions to take a trial dose of fast-acting insulin to bring blood sugar down to the target value. If blood sugar on awakening is below the target, she’d use glucose tablets to bring blood glucose up to the target. By this means, we confirm or correct my estimation of how much a given amount of insulin or glucose will lower or raise the individual’s blood sugar.
Whenever I talk about blood sugars in this book, I’m referring to finger-stick, plasma blood glucose measurements. When I discuss “normal” blood sugar values, I am referring to those found in nonobese nondiabetics—and to those not taken within 5 hours of a high-carbohydrate meal.
In my experience, given the right blood sugar meter, these values will be almost exactly the same as you would get from plasma measurements of venous blood that your doctor would send to a clinical laboratory. I’ve seen finger-stick blood sugars measured on many nondiabetic, nonobese adults (for example, salespeople who come into the office trying to sell me meters—I insist on demonstrations;* or the nondiabetic spouses, parents, or siblings of patients). It usually is about 83 mg/dl. I therefore tell my patients that a normal to shoot for is 83 mg/dl, no matter what age. I haven’t had the opportunity to test a great number of nondiabetic children, but the literature shows that normal blood sugars in children will be lower.*
With respect to hemoglobin A1C, I have a sophisticated machine in my office that I’ve found correlates almost exactly with measures from a major clinical laboratory. I therefore check HgbA1C values on every patient at every routine visit, and frequently on nondiabetic relatives. Essentially what I see is that nondiabetics who are not obese have HgbA1C levels in the range of 4.2–4.6 percent. I have a number of diabetic patients who, under treatment, now have HgbA1C readings as low as 4.1 percent. This is a considerable deviation from the ADA’s recommendation of under 6 percent—with no intervention unless levels exceed 7 percent. In my opinion, this is yet another example of “the rape of the diabetic.”
The ADA recommendation for “tight control” of blood sugars, from its website, is as follows:
Ideally, this means levels between 90 and 130 mg/dl before meals and less than 180 two hours after starting a meal, with a glycated hemoglobin level less than 7 percent.
The recommendations go on to state that tight control (what I advocate) “isn’t for everyone,” which I believe is nonsense. But the ADA’s tight control as defined above isn’t very tight at all. I would call it “out of control.”
Many years ago, I reviewed dozens of HgbA1C values and thousands of blood sugars from data sheets submitted by my patients and came up with a formula for converting HgbA1C to mean (average) blood sugar.
My formula does not jibe with some other formulas, perhaps because others haven’t collected blood sugars throughout the day running into the hundreds or even thousands of patients covering four-month periods. The formula is very simple. An HgbA1C of 5 percent is equivalent to an average blood sugar reading of 100 mg/dl, and every 1 percent above 5 corresponds to an additional 40 mg/dl increase in blood sugars. So an HgbA1C of 7 percent would correspond to an average blood sugar of 180 mg/dl.
The formula is, in my experience, useless for HgbA1C values of less than 5 percent, and it may not work for average blood sugars greater than 200 mg/dl, for the simple reason that for a new patient running blood sugars greater than 200 mg/dl, we rapidly get them down into the 100s or less. Such new patients don’t come in bringing me hundreds of data points above 200 for me to compute an accurate formula at these values—nor would I ask them to.
In February 2002 a study published in Diabetes Care reported a formula that is valid for average blood sugars over a much wider range than mine, including values well above and below 100 mg/dl. It gives results close to mine in the 100–200 mg/dl range. The formula is: mean plasma glucose = (35.6 × HgbA1C) – 77.3 mg/dl.
So how do we go about setting a target normal value given all these numbers? Let’s take a look at a type 2 diabetic whose disease can be controlled by diet and exercise. Here, we’ll certainly shoot for blood sugars of about 83 mg/dl before, during, and after meals. It will then be up to both me and the patient jointly—if his blood sugars are, say, in the 90s—to decide whether we want to introduce medications to further lower blood sugar. Many patients these days are hesitant to take any medication that’s been approved by the FDA, despite many such medications being quite benign. If we have a type 2 diabetic who requires the insulin-sensitizing drugs like metformin, we certainly can shoot for a target blood sugar of 83 mg/dl before, during, and after meals, and indeed, I will work with the patient to juggle the medications, using long- or short-acting versions in order to achieve that target.
Type 2 diabetics who require very small amounts of insulin (say, 1–2 units per dose) are at very low risk for hypoglycemia and will usually automatically “turn off” the insulin they make themselves if blood sugars are too low. Such people are also good candidates for a target of 83 mg/dl.
When it comes to type 1 diabetics, where virtually all of the needed insulin is going to be injected, I temporarily increase the target to 90 mg/dl or higher, even though we know that the mortality rate—even in the general, nondiabetic population—is slightly greater for those with fasting or postprandial blood sugars of 90 mg/dl than it is for those with blood sugars of 83. If at all feasible without frequent hypoglycemic episodes, I will eventually lower the target to 83 mg/dl. I’ve been using 83 as a target for myself.
A target may imply corrections to get you to your target. As a rule, if you’re a type 2, your blood sugar goes down eventually—maybe quickly, maybe over many hours. If you’re a type 1 and injecting significant doses of insulin, if you make a mistake in your diet and your blood sugar goes up, you have to inject additional, calibrated doses of fast-acting insulin deliberately to bring down your blood sugar and, if it’s too low, take glucose tablets to raise it.
For a new patient in the very early stages of type 2 diabetes, I may see both hypo- and hyperglycemia. This is probably because one of the early “lesions” of type 2 is difficulty in storing the insulin granules your body makes. So such a person would make insulin for a meal, then make more after the meal. A nondiabetic would store that additional insulin as it’s being made, but the early type 2 might release some or all of it into the bloodstream as it’s generated, thereby bringing blood sugar too low. This explanation also accounts for attenuated (diminished) phase I insulin response—just not having enough insulin stored to cover a meal adequately (another reason to follow a low-carbohydrate diet). Such an individual could experience blood sugars in the 70s or even mid-60s from time to time, and these individuals must carry glucose tablets with them to bring blood sugars up to their target, usually 83. They don’t take injected insulin to bring blood sugar down if it goes too high when they make a mistake, because their bodies will do that for them, probably faster than injected insulin would.
On the third visit, it’s generally appropriate to prepare a list of treatment goals. Exactly what are we going to accomplish, how, and over what time frame? The patient and I discuss a list of goals to make sure that he or she understands and agrees. The following list is typical of the things I want to see any given patient accomplish. (Remember, the training I provide to my patients is the substance of this book, so if you don’t entirely understand all of these goals right now, don’t be discouraged. Mark this chapter and come back to it when you’ve finished the book. By then you should understand the whole philosophy of my approach and the goals will make sense. You may also by that time have developed—if you haven’t already—conscious goals of your own.)
• Normalization of blood glucose profiles.
• Improvement or normalization of the following laboratory tests that respond to blood glucose control (see Chapter 2):
hemoglobin A1C
red blood cell magnesium
lipid profile
thrombotic risk profile
renal profile
• Attainment of ideal weight (where appropriate).
• Full or partial reversal of diabetic complications, including pain or numbness in feet, diabetes-related retinal or kidney problems, gastroparesis, cardiac autonomic neuropathy, neuropathic erectile dysfunction, postural hypotension, and so on. If blood sugars are kept normal, some of these improvements will appear within weeks to years, depending upon the particular problem and its severity.
• Reduction in frequency and severity of hypoglycemic episodes (where appropriate).
• Relief of chronic fatigue and short-term memory impairment associated with high blood sugars.
• Improvement or normalization of hypertension.
• Reduction of demand upon beta cells. If C-peptide is present before starting our program (that is, if the pancreas is producing measurable amounts of insulin), glucose tolerance should improve if a regimen is pursued that minimizes the demand upon the beta cells. This is a very important goal. Remember that for type 2 patients, small sacrifices now can prevent the need for 5 or more daily insulin doses down the road. Beta cell burnout (see here) can frequently be prevented or partially reversed.
• Increased strength, endurance, and feeling of well-being.
• About 40 percent of my new patients show low thyroid function on initial testing. We therefore try to normalize blood levels of T3 and T4 by prescribing T3 and/or T4 replacement. When blood levels are normalized we expect correction of prior tiredness, coldness, hair loss, poor memory, dyslipidemia, and so on.
The patient may wish to add some personal goals. The doctor should respect these if at all possible. For example, I have several patients who are willing to do whatever I ask, provided I do not put them on insulin. I consider this a reasonable preliminary goal for some, even though it may increase the risk of beta cell burnout. After all, if we cannot enlist a patient’s cooperation, we achieve nothing.
I will personally answer questions from readers for one hour every month. This free service is available by visiting www.askdrbernstein.net.