low blood glucose/sugar (hypoglycemia)

How to Use Average Blood Glucose to Estimate HbA1c

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Checking blood glucose

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March 23rd, 2018

By John Pemberton, Head Coach at Diabetic Muscle and Fitness and Diabetes Specialist Dietitian/Educator 

Do you have this essential diabetes management skill?

Most adults only get their HbA1c checked once a year, sound familiar?

This means you have an idea how things have been going for the previous 90 days, but what about the other 275 days?

The most effective way of keeping on top of your diabetes control is by regularly checking your average blood glucose (BG).

How Often Do You Check Yours?

Do you know how to use the results to predict HbA1c?

This table shows where your HbA1c will be very close to, depending on what level your average BG has been at for 90 days. The table also shows the benefits and consequences of having different levels of control for long periods of time.

What has your average BG been for the:

  • Last 90 days?
  • Last 30 days?
  • Last 14 days?

If you are currently in the red zone – don’t freak out!

This article is your wake up call. It’s time to take action. You can change this around very quickly, that is the beauty of using average BG to guide you.

How Do I Achieve Better Average Blood Glucose Levels?

Make small incremental changes to your daily diabetes habits and regimen. You can evaluate your progress by tracking the change in average BG every two weeks.

Top Diabetes Management Tips Based on 1000s of Hours Spent in Clinical Practice

  • Test BG at least five times per day – this allows you to correct high glucose levels more often.
  • Aim to be in target before bed; this means 8 hours per day of in target levels.
  • Bolus 15-30 minutes before food to prevent high glucose levels after, remember BIFF:
    • Blood test,
    • Insulin dose,
    • Fifteen minutes wait,
    • Food, eat it.
  • Keep to 3-4 meals per day, spread equally with 3-4 hours in-between.
  • This matches with the action of quick acting insulin (Apidra, NovoRpaid, Fiasp, Humalog) perfectly.
  • Frequent snacking makes in target glucose control very difficult.
  • Eat mixed macronutrient meals. Avoid carb only snacks, unless using for exercise management.
  • Review the patterns of your glucose trends every 14 days to identify where you need to change your habits and diabetes regimen.
  • Use a written log; there is a lot to be said for writing it down. Why? You process and identify patterns as you write.
  • Use an online platform where you can upload your meter, pump, and CGM devices:
    • Diasend & Glooko
    • They are both the same platform – they have just merged.

I personally use this platform and love it. I have even made guides and videos of how to set up an account, how to review control, and how to make changes in my day job as a Diabetes Specialist Dietitian. You can access these guides and videos here.

  • Use APPS such as MySugar and Diabetes:M
  • If you are struggling to identify solutions and find it hard to make changes, get professional help.

Your diabetes team or a professional with the requisite skills and qualifications should be able to guide and empower you.

If they just tell you what to do without teaching you how to do it, they are not setting you up for long-term success!

I work on the premise that as long as my average BG is less than 8.0 mmol/L (145mg/dL), I am all good.

If it’s above there, I need to focus on improving my control.

A special note: it’s no good having an average BG of 6.0 mmol/L (110mg/dL) if it means you are hypo all the time.

Research suggests having 3-4 mild hypos a week that you can treat yourself is usual for people with good control. 1 But if more than this you are at risk of becoming hypo unaware. This research is from people on MDI and pumps who adjust their doses based on food intake and activity.

Being hypo unaware will mean you will not be able to drive (in the UK and most places if your physician knows or you call out an ambulance), and you will be at much higher risk of having a severe hypo. This is not a worthwhile trade-off for a HbA1c of 5.0%!

It’s all about balance.

Everyone is different, so set your target according to your circumstances.

As a general rule these are two good markers to aim for:

  1. Average BG less than 8.0 mmol/L (145 mg/dL).
  2. Less than 3-4 mild hypos per week, but no severe hypos and you can detect your hypos.

Checking average BG every 14 days will mean you stay in control and catch issues early! A Wiseman one told me: “If you’re not assessing, you’re guessing!”

Hope that helps!

References

  1. DAFNE Research Database Study

Does Having Diabetes Mean You Have a Disability?

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 diabetes as a disability

oes having diabetes mean that you have a disability or are disabled?

It depends.

Some people with diabetes do not think they are disabled. I don’t presently think of myself as disabled, but I do see diabetes as potentially and temporarily disabling. Sometimes my blood sugar is low, and for a few minutes, I have to stop what I’m doing and treat it no matter what is going on. If my blood sugar is high, I don’t feel my best, and my productivity may be temporarily diminished by some degree until my blood sugar comes back down.

To me, it’s not too different from the way the average individual will sometimes get sick or injured and require assistance, time off work, or the need to follow some treatment plan.

Maria Muccioli, Ph.D., writes for Diabetes Daily and also lives with type 1 diabetes. She gives the example that if someone has a stomach virus, “it would be difficult to carry on with work tasks; this difficulty is for sure more pronounced than for someone who does not have diabetes” she shares.

Circumstances Matter

Maria also doesn’t consider it a disability for herself, personally, but she notes that she does work a desk job that doesn’t involve physical labor or other aspects that can challenge managing blood sugar as needed. “I can see how someone (even if they would normally have excellent control) may be in a profession that makes it more difficult to manage blood glucose and would thus be more likely to claim a disability,” she says.

Some people with diabetes do consider themselves as having a disability. They may have other medical conditions, complications, or hypoglycemia unawareness. The circumstances of people with diabetes vary like the weather, and that’s why you’ll get different opinions on the matter.

Maria also mentions pregnancy as “another example that may make one more likely to view having diabetes as a disability – between the need for very stringent blood glucose management, frequent adjustments, and increased number of appointments, the condition makes it more challenging to continue working as usual.”

“Personally, I worked until 39 weeks with my daughter, but I was lucky to have my doctor only a five-minute walk from where I worked and an accommodating boss who allowed me to work 7-3 so I could go to all my appointments after those hours,” she says.

What Does the Law Say?

The American Diabetes Association says that “under most laws, diabetes is protected as a disability.”

In 2008, the Americans with Disabilities Act Amendments Act (ADAAA) was signed, and it meant that you could no longer be denied a job just for having diabetes. It also meant that you could go to court for that discrimination and the defense wouldn’t be able to say you take good care of your diabetes and aren’t disabled. In other words, whether we take great care of ourselves or not, we are given disability status and protection by law.

What people with diabetes can and can’t do is highly individualized, but it may be useful to know these protections exist.

What about you? Does having diabetes mean you have a disability?

 

The Artificial Pancreas: What Is It and When’s It Coming?

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You’ve probably heard about the artificial pancreas, but are you up to speed on what’s happening in this rapidly evolving field?

First of All, What Is It Really?

The artificial pancreas (AP) is a device that mimics the blood sugar function of a healthy pancreas. It has three parts: a sensor for continuous glucose monitoring, a pump to deliver insulin, and a laptop or cell-phone component that directs the pump to deliver insulin as needed.

Most systems will deliver insulin alone, but some will be able to deliver both insulin and glucagon*.

How It’s Different from CGM

Artificial pancreas systems are often called “closed-loop” because they talk to both the sensor and the pump, bridging the gap between the two. The goal is to make a continuous loop without the need for human intervention. In testing so far, AP systems have often resulted in more time in target glucose ranges with less hypoglycemia, and they have also shined in controlling blood sugars overnight. They are not a cure by any means, but they are a huge improvement and will allow for diabetes management to go a little more on autopilot in the near future.

50 Years in the Making

The first precursors of the artificial pancreas date back to the 1970s. In the 50 years since, improvements have been made on all fronts: control algorithms are getting more predictive and less reactive, and pumps and glucose sensors are getting more accurate. Yet many challenges remain, such as the need for faster insulin, more stable glucagon, and systems that can work without user intervention, e.g., during meals and exercise.

The Future Is Almost Here

In June of 2017, Medtronic launched the first commercialized product, Minimed 670G.

The Medtronic device is a “hybrid” system due to the need to manually interact for meals and exercise. Hailed as a major advance towards a fully-automated artificial pancreas system, the 670G will be followed by other closed-loop systems in the coming months and years, with more and more academic group and industry collaborations being announced.

MiniMed 670G

One such effort – the IDCL (International Diabetes Closed Loop) Trial – is another example of the degree of collaboration between academic centers and industry. Led by the University of Virginia in conjunction with centers in Europe, companies like TypeZero Technologies, Tandem Diabetes Care, Dexcom and Roche Diagnostics are also involved. Other companies like Insulet (Omnipod) and Bigfoot are developing AP systems as well.

If You Just Can’t Wait

Alongside conventional development of AP systems, “Do It Yourself” or DIY movements spearheaded by patient and engineering communities are gaining visibility with a reported 400+ PWD currently using DIY artificial pancreas systems. Initiatives such as DIYPS.org and #wearenotwaiting are providing information on the internet to help people with diabetes build their own AP systems using commercially available CGM and pumps while providing information on how to set up control algorithms.

These systems require a great deal of user learning and commitment. While probably not for everyone and regulatory authorities sending out caveats on the potential risks involved, they can be a way for people to access artificial pancreas technology now before other systems are cleared for use.

At the 2017 Taking Control Of Your Diabetes Conference & Health Fair in San Diego, there was a panel discussion with five people who experimented with DIY systems and shared their thoughts, advice, and personal experiences.  You can watch the seminar and hear what they had to say here.

As a result, we can expect several artificial pancreas options in the coming years, which is amazing news! Systems will differ, but the goal will be the same: to reduce the burden of living with diabetes until a cure is found. We look forward to seeing more and more options in this space, and send kudos to all involved for their perseverance, passion, and commitment!

*Glucagon causes the liver to release stored glucose, raising blood sugar levels. It can be used to treat severe hypoglycemia.

Supercharge Your Insulin Sensitivity Naturally with These 5 Proven Daily Routines

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Insulin sensitivity refers to the biological response of target tissues such as muscle to the actions of insulin. In other words, insulin sensitivity refers to how well insulin performs its role of transporting and storing fuels in specific cells in the body, particularly glucose.

Insulin sensitivity varies between individuals and is reduced in people with diabetes.

Medication aside, lifestyle plays an important role in helping boost insulin sensitivity and prevent impaired tissue responses (insulin resistance), which, in turn, supports blood glucose disposal and improves diabetes management.

Lifestyle choices do this in a number of ways:

  • Strength training increases muscle mass which serves as a major storage house for glucose.
  • Walking and other forms of low-intensity exercise can reduce blood glucose.
  • Stress management including meditation and a good quality sleep pattern help control excess production of counterregulatory stress hormones, such as cortisol and adrenaline, which increase blood glucose levels.

All of the above help improve the action of diabetes medication and whatever is left of natural insulin production. Obviously, the effects of each lifestyle factor will vary depending on how often they are conducted, their intensity and, of course, inter-individual physiology and genetics.

Treat this article like an accountability checklist.

If you live with diabetes and aren’t following any of the five lifestyle behaviors listed, you might be missing a few tricks for improving health, managing your diabetes, and building that body you always wanted.

Daily Routine #1 – Perform at Least 20-45 Minutes of Anaerobic Exercise Every Single Day

Anaerobic exercise is defined as physical exercise that is intense enough to generate lactate.

You know you have generated lactate when you start feeling a burning sensation in your muscles. High rep squats and sprint intervals get you burning pretty quick. Strength training and high-intensity interval training are prime examples of anaerobic exercise.

The human body responds differently when trained with anaerobic exercise compared to aerobic exercise. The adaptions that occur to the muscle energy systems are of particular interest and benefit to people with diabetes.

Anaerobic training increases insulin sensitivity and stimulates skeletal muscle tissue to absorb glucose from the bloodstream independently of insulin. This is achieved through the stimulation of specific glucose transporters called GLUT-4. The more anaerobic work a muscle fiber has to contend with, the greater number of GLUT-4 rise to the surface of a muscle cell for the purpose of glucose extraction. Once glucose is absorbed from the bloodstream it is stored as muscle glycogen.

Increased insulin sensitivity is just one of the many benefits of anaerobic exercise. There are plenty more, which I will cover another time.

How often and how much anaerobic training should I perform?

Perform anaerobic training at least 3 times per week in the form of:

  • 20-60 minutes of strength training – whole body, body part splits, etc.
  • 10-20 minutes high-intensity interval training – skipping, spinning, battle ropes, sprints etc.

All of these training bouts will improve glucose uptake and improve blood glucose management in people living with diabetes.

Daily Routine #2 – Get and Stay Lean

It is well-established that high levels of body fat result from living in a calorie surplus for a prolonged amount of time. Excess body fat accumulation is not only unsightly, but highly inflammatory and detrimental to the effectiveness of your insulin.

Also proven is the fact that the biological response of target tissues to the actions of insulin (insulin sensitivity) are majorly affected by adiposity, or the amount of body fat one carries. 1

The leaner you are, the better your insulin will work. Period.

5 top tips for getting lean with diabetes:

  • Create a calorie deficit by sensibly increasing your physical activity and reducing food intake in a controlled way.
  • Strength train at least 4-5 times per week.
  • Manage your diabetes.
  • Achieve at least 7 hours sleep each night.
  • Aim to lose between 0.5-1% of your body weight each week.

Daily Routine #3 – Have a Toolbox of De-Stressing Activities

In today’s modern day age, we are increasingly exposed to more chronic stress than ever before: mobile phones, social media, traffic, bills, etc.

Stress stimulates a flight or fight response within the body, a physiological reaction that occurs in response to a perceived harmful event, attack, or threat to survival. The body responds to stress by activating the sympathetic branch of the central nervous system. Stress increases muscle tone, constricts blood vessels, and increases the production of counterregulatory stress hormones which increase blood glucose.

In small doses stress is healthy. It can save your life.

However, excessive stress is unhealthy and works against diabetes management.2

The greater and more prolonged the stress, the more insulin is required to balance blood glucose. It is well established that stress can influence whole-body glucose metabolism and promote insulin resistance. 2,3

Any forms of stress management, like meditation, massage, yoga, breathing exercises, or personal development, are worthwhile if they help reduce stress. Reducing your daily stress is a surefire way to improve insulin sensitivity and reduce incidents of high blood glucose.

Even Apple have cottoned on to this with their new “take a minute to breathe” reminder on their Apple Watch.

Daily Routine #4 – Have a Structured Sleeping Plan

Sleep could also be considered a form of stress management, especially for individuals who are highly active and live with diabetes.

I hate to tell you the obvious, but sleep is essential for good health and diabetes management.

Many laboratory and epidemiological studies suggest that sleep loss may play a role in the increased prevalence of insulin resistance and diabetes.4,5,6,7

One of the best pieces of advice is to set a fixed bedtime and wake time. Not only does this provide structure for your day, but it ensures you get enough restorative sleep for health and optimal diabetes management.

Again, the major tech company Apple and their recent focus on health tech apps have included a set wake/bedtime function in their alarm clock.

At Diabetic Muscle and Fitness, we take sleep seriously. We even developed a 3.5+ hour video module on sleep optimization for improving hormone profiles and body composition.

Daily Routine #5 – Perform Aerobic Exercise Daily

Aerobic exercise such as a light jogging or a brisk walk can increase glucose disposal and lower blood glucose levels – independently of insulin.

One of the main reasons aerobic exercise lowers blood glucose levels so well is due to the fact that there is little to no counterregulatory hormone response like that which occurs during high-intensity anaerobic exercise.

Please bear in mind, it is important to monitor insulin intake around aerobic exercise in order to avoid hypoglycemia.

I highly recommend buying an activity monitor like a Fitbit, Apple Watch, or Garmin. These are awesome for building the habit of doing more aerobic exercise throughout your day.

Take Home

Each and every daily routine I’ve shared in this article will improve insulin action and help your body clear glucose easier. Each and every one of these routines is a prerequisite for a great looking body and high levels of mental and physical performance.

Identify which areas you need to work on and get to it!

References

  1. Wilcox G. Insulin and insulin resistance. Clin Biochem Rev. 2005 May; 26(2):19-39.
  2. Li L et al. Acute psychological stress results in the rapid development of insulin resistance. J Endocrinol. 2013 Apr 15;217(2):175-84.
  3. Nolan et al. Insulin Resistance as a Physiological Defense Against Metabolic Stress: Implications for the Management of Subsets of Type 2 Diabetes. Diabetes Mar 2015, 64 (3) 673-686;
  4. Kripke DF, Garfinkel L, Wingard DL, Klauber MR, Marler MR. Mortality associated with sleep duration and insomnia. Arch Gen Psychiatry. 2002;59:131–6.
  5. Ayas NT, White DP, Manson JE, et al. A prospective study of sleep duration and coronary heart disease in women. Arch Intern Med. 2003;163:205–9.
  6. Ip MS, Lam B, Ng MM, Lam WK, Tsang KW, Lam KS. Obstructive sleep apnea is independently associated with insulin resistance. Am J Respir Crit Care Med. 2002;165:670–6.
  7. Punjabi NM, Shahar E, Redline S, Gottlieb DJ, Givelber R, Resnick HE. Sleep-disordered breathing, glucose intolerance, and insulin resistance: the Sleep Heart Health Study. Am J Epidemiol. 2004;160:521–30.

Reactive Hypoglycemia: A Cautionary Tale

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reactive hypoglycemia

For many people, losing a lot of weight results in blood glucose (BG) levels at or close to normal, and your doctor may tell you that you’re no longer diabetic. If this happens to you, first of all you should be congratulated for the difficult job of losing weight. That’s wonderful.

But you should also be vigilant to make sure you don’t get reactive hypoglycemia, which means very low BG levels after you’ve eaten a lot of carbohydrates. This can happen even when you’re not diabetic.

I had reactive hypoglycemia about 20 years before I got the diabetes diagnosis. At the time, I was a night owl and hated getting up early in the morning. But occasionally, at the daily newspaper where I worked, I had to do the “wire desk,” which meant arriving at 7:00 a.m. Because I hated it so much, I’d treat myself to a chocolate doughnut. Usually I didn’t eat breakfast at all.

Then at almost exactly 4 hours after the doughnut and black coffee, I’d get the shakes and feel as if I’d die if I didn’t eat something. In fact, I could almost set my watch by this phenomenon. “Oh. The shakes. It must be 11 o’clock.” Then I’d eat a candy bar and feel fine for the rest of the day.

Why does this happen?

Insulin secretion is biphasic. When a non-diabetic eats a carbohydrate food, the pancreas quickly spurts out a pulse of insulin. This pulse doesn’t last very long but it’s enough to keep the carbohydrate that reaches the intestine from going very high. It also suppresses the production and release of glucose from the liver. This is called the phase 1 or first phase insulin response.

Then insulin is secreted continuously as long as carbohydrate comes into the system in proportion to the amount of carbohydrate reaching the intestine. This is the phase 2 or second phase insulin response, and it lasts much longer than the first one.

The food that we eat, including carbohydrate, isn’t dumped into the intestine all at once. Instead, the stomach releases only a certain amount at a time, usually containing about the same number of calories, so the insulin release is pretty steady. Liquids leave the stomach faster than solids.

Unfortunately, those of us with type 2 diabetes tend to lack a first phase insulin response and may have lacked it for a long time before we were diagnosed with diabetes. This means that when we eat carbohydrate, our BGs aren’t knocked down by that first insulin pulse, so they go much higher than they would in a non-diabetic who ate the same amount of carbohydrate. Then the body sees these high numbers and assumes they’re that high despite a first phase insulin response. So the second phase response is extra strong, and with all that extra insulin, we may go low. Some people call this “too much too late.”

Now, no one really knows at what point in our life the first phase insulin response is eliminated, although there is evidence that first-degree relatives of people with diabetes have impaired first-phase insulin responses despite having normal BG levels. We also don’t know if or when the first phase is restored when people normalize BGs enough to be considered non-diabetic again.

I was in a clinical study in which they did an intravenous glucose tolerance test that measured both BG and insulin after a huge dose of glucose. I started with almost no phase 1 response. But after I was on the study drug (salsalate) for a couple of weeks, the phase 1 response was restored to about 70% of normal, which is consistent with the idea that the situation is reversible.

Weight loss alone may or may not restore the phase 1 response, but there’s some evidence that phase 1 is restored after weight-loss surgery.

So if you’ve managed your diabetes so that your BG levels are in normal ranges, you may still lack that phase 1 response and be sensitive enough to large carbohydrate loads that you’ll have reactive hypoglycemia.

That happened to Joseph recently. He had lost a lot of weight after gastric bypass surgery, and his BG levels were usually normal, but he still watched his diet and didn’t go overboard with the starches. Then one day he was at a football game, and it was very cold and his friends had a lot of tasty crackers with them, so he ate some. No, he ate a lot. A few hours later, he felt odd and tested his BG. It was 35. Luckily, he wasn’t alone, and someone gave him some juice and he recovered.

I have no idea how low I was when I worked the wire desk and got the shakes after eating a doughnut with black coffee. But I do know it was very unpleasant. So if you’re diabetic, be vigilant and don’t let this happen to you. Avoid carbohydrate fests, especially on an empty stomach. And if you can’t avoid them, make sure you have available some glucose tablets or other food that will raise BG quickly in case you do go low.

Reactive hypoglycemia is counterintuitive (“How could I be low when I just ate all those carbs?”), but it can be serious. You can outsmart it, though, if you’re prepared.

The Latest and Greatest in Insulin Pumps and Sensor Technology

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diabetes pumps and sensors

I love pumps and sensors!

As a certified diabetes educator (or as I prefer to say, type 1 coach), I have started literally hundreds of patients on insulin pumps over the last few decades. I have a disclaimer: I do not wear a pump and do not have type 1 diabetes. But I have worked in the field from clinics to ski and summer camps, as a dog sled driver for little munchkins with our team of sled dogs, to backpacking and canoe trips – all with people who do have type 1 diabetes. Sometimes I grunt and groan when I get up to start an adventure, but then I meet up with the group and see someone taking shots! My emotions turn to glee when someone has a pump and a sensor…I realize it sometimes feels like being the bionic man or woman with all this technology but hey, what’s wrong with being such a diabetes stud or studdette?

So what is so cool about pump and sensor technology?

Well, if you’re like me and you like to participate in group sports or activities, the technology is amazing. Let’s say you are just starting off on an adventure (whatever that may be) with a group and you note on your sensor that your blood glucose (BG) is 50 mg/dL.

Argh.

Who wants to stop the whole team from proceeding? But then you realize you can take in some carbohydrates, lower your basal rate temporarily, and watch your sensor to see if you are coming up and are not only good to go, but where you will be in 5, 10, 15, 20 minutes…you get the idea.

What are the options available right now to help you manage your diabetes?

The Omnipod insulin pump is the only full functioning patch pump, meaning it is programmable with insulin-to-carb ratios, target BG, correction factors, etc. so your math is done for you. At this time, the Omnipod pump does not integrate with a sensor but you can certainly use the Dexcom sensor independently.

There are also two patch pumps that are not programmable and have a bolus only option (OneTouch Via) and basal/bolus option (V-Go). These are more likely options for those with type 2 diabetes.

The Tandem insulin pump does have a tube that most folks find a minor inconvenience. Its great new claim to fame is that, as the software is updated (and technology is changing so fast!), you can update your pump via the cloud. How cool is that! Your pump does not get outdated since the pump software is updated. This includes future changes, such as Dexcom sensor data on the screen, auto-suspend as needed with hypoglycemia, and the eventual goal of a fully integrated sensor and pump where the pump responds to the data from the sensor and alters insulin delivery.

tandem and dexcom cgm

The Medtronic insulin pump company has led the charge not only with a sensor integrated pump where the sensor data is seen on the pump screen, but where the pump responds to low blood glucose values and impending lows, and adjusts basal rates as needed based on your basal history. Be warned, this is not a cure and still requires diligence on your part or the system will fail. Fasting blood glucose values have been shown to be excellent – generally close to the pump set target range of 120 mg/dL.

MiniMed 670G

You can always choose to continue with injections and utilize one of two sensors. Dexcom (glucose readings every 5 minutes on a receiver or your cell phone) or the new Freestyle Libre that allows you to scan your sensor patch and see your glucose on a receiver.

And where is all of this going?

Oh – it is so exciting! I am confident that in the next five years a fully automated system will be available with minimal input from the user. Tandem, Omnipod and Medtronic are all working on fully integrated pumps as responsibly fast as they can. In addition, other options are coming too, including a dual hormone system that has reservoirs for insulin and glucagon to keep you safe. And with the new insulin from Novo Nordisk that is reputed to start absorption in 2.5 minutes (wow!) one of the big barriers to insulin delivery may have just been resolved.

Although a cure is what we are all hoping for, technology is the next best thing.

Embrace it and stay tuned!

Libre vs. Dexcom: A Diabetes Educator’s Experience

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Libre vs. Dexcom

When I heard the news that the Freestyle Libre was coming to the U.S., I was so excited, especially since it adds to the options for self-management technology for people with both type 1 and type 2 diabetes.

So, last week, I took advantage of the free Freestyle Libre reader and sensor offer for current Dexcom users.

I was so excited to try out the Libre and wear it with the Dexcom G5 to compare the two as a self-management experiment. I was prepared for the two devices to differ as one is a continuous glucose monitor (Dexcom) and the other is a flash glucose monitor (Libre). Here are my thoughts.

Ten Thoughts of a Certified Diabetes Educator

1. Filling the Prescription: Win for the Libre

I was able to get my hands on a Libre within 36 hours of claiming the offer. I contacted my endocrinologist to write me a prescription and almost immediately Walgreens worked on obtaining a Libre system for me. My Walgreens didn’t have the Libre in stock, so they placed an order, and I was able to pick it up the next day. Whenever I try to re-order Dexcom supplies through my third party distributor, it seems to be disastrous, and it takes a week or so to receive my shipment.

Considerations: If you do not have insurance coverage for a CGM, have a high deductible, or cannot afford your out-of-pocket cost with coinsurance, the Libre is a much more affordable option. However, make sure that your insurance will cover the Libre. If insurance covers the Dexcom (and you have good insurance coverage), but not the Libre, then Dexcom may be a more affordable option.

2. Insertion Process: Win for the Libre

The insertion instructions for the Libre are understandable and easy to follow which differs from the difficult Dexcom insertion process.

Considerations: If you are unfamiliar with diabetes technology, have low dexterity or have vision problems, the insertion process for the Libre may be much smoother than insertion of the Dexcom.

3. Sensor Life: Win for the Dexcom

The Libre sensor lasts ten days, and the Dexcom sensor lasts only seven days. However, many people have discovered how to trick the Dexcom sensor into continuing for much longer than seven days. The Libre is too smart to be fooled and requires a new sensor after ten days.

4. Sensor Start-Up: Win for the Dexcom

The Libre takes 12 hours to warm-up. I put it on before bed, but I still had to wait a few hours to use it when I woke up. I was anxious to get started! The two-hour start-up for the Dexcom isn’t so bad after all.

5. Calibration: Win for the Libre

The Libre is factory calibrated, so it does not need to be calibrated after warm up or throughout its ten-day session. The Dexcom requires two calibrations after its two-hour warm up and then one calibration every 12 hours.

At first, I thought this was an absolute win for the Libre. However, I noticed that there were a few instances where my Libre was significantly (60+ numbers off) from my meter reading and Dexcom reading. I understand that the Dexcom will be closer to the meter reading since it uses the meter reading for calibration but I felt scared that I couldn’t tell the Libre it was wrong to re-adjust it. I don’t think I’m fully ready to trust factory calibration yet.

Considerations: The factory calibration is a beautiful feature as it reduces user-burden. All the user has to do is insert the Libre before starting the session. This feature is beneficial for those who cannot or will not check their blood glucose manually throughout the day.

6. Graphs: Win for the Dexcom

The Libre gives a similar graph as the Dexcom. Both graphs showed comparable glucose variability patterns even if the numbers differed slightly. The Libre reader device reports and the Dexcom clarity reports have similar information.

The trend arrows are to be used similarly on both devices. However, my Dexcom seemed to be much more accurate with arrows when I was dropping. I self-manage based on my Dexcom trend arrows, so this was concerning to me.

One benefit of the Libre though is that it does not seem to lose signal like the Dexcom does, leaving lapses of glucose data in the graph.

Considerations: The Libre is still an excellent tool to look at average daily glucose patterns and make adjustments with your healthcare provider.

7. Accuracy: Win for the Dexcom

The Libre was significantly off from my Freestyle meter which is built into the Omnipod PDM, but the Dexcom matched up pretty closely due to calibration from the meter reading. However, since the FDA approved the G5 to dose off, I think it is safer to use the Dexcom reading for treatment decisions.

Considerations: My personal experience may differ from others. Additionally, research has found that the Libre’s mean average relative distance (MARD) is less than the Dexcom G4’s MARD—meaning that the Libre is more accurate than the Dexcom G4. There is limited research on the G5 MARD vs. the Libre though. If you just want a device to look at glucose trends and not to dose off of, there is no problem with the Libre (from my personal experience).

8. Reading Blood Glucose: Win for the Dexcom

The Libre requires that the user presses a button on the reader device to see their current blood glucose reading. Though I thought it would be annoying to carry around the reader device, it did not bother me!

dexcom integration

However, I do depend on looking at my blood glucose and trends throughout the day on my Apple Watch (through the Dexcom app) when I am at work, so having to pull out the device to check my blood glucose was much more apparent to my co-workers. The Libre doesn’t (currently) have any mobile apps with sharing features in the U.S. I also depend on the sharing feature for safety. Now that I have used a CGM with alerts and continuous glucose data for the past four years, missing continuous data makes me anxious.

Considerations: If you self-manage fine by checking your glucose a few times per day, the Libre may be less annoying and work very well for your needs.

9. Alarms: Win for the Dexcom

The Libre has no alarms like the Dexcom. I am not hypo-unaware (as of now), but I still worry about not waking up for a low blood sugar overnight. The alarms provide a safety net.

Considerations: If you are hypo-unaware or live alone, it may be safer to consider a device with alarms. Additionally, it appears there is a company (BluCon by Ambrosia) that does make an add-on device for the Libre so that you can receive alerts continuously and overnight for lows and on a mobile application.

10. Adhesive: Tie

I cleaned off my site area with alcohol before inserting the Libre. I was unsure of the guidelines for using skintac, so I did not use any before insertion.

After two days the Libre began to peel off, and I had to reinforce it with Tegaderm. The Dexcom also does not have great adhesive.

However, I have been using the Dexcom long enough to figure out the best way to make it stick for me (donut-shaped application of liquid skintac before insertion, gifgrips on after insertion, followed by additional liquid skintac on top).

Considerations: Both the Libre and the Dexcom seem to cause allergic reactions in some.

Final Thoughts

Trialing the Libre was an awesome opportunity as it gave me a sense of having patient choice for self-management tools.

However, I am not sure I am mentally ready to use the Libre over the Dexcom. I am used to using my Dexcom G5 CGM and have become somewhat dependent on its benefits for my peace of mind and sense of safety.

There are still many clear clinical benefits to using the Libre, however, and the best fit depends on individual self-management needs.

The 5 Necessities of an Effective Weight Loss Diet for People With Diabetes

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weight loss for people with diabetes

This is not just another general “eat salad and completely avoid carbs” article. I’m tired of seeing generalized diet information that, to be brutally honest, is pointless and inapplicable to most people’s lives. This article is aimed to help the diabetic community focus on and prioritize what works.

Weight loss is science, not magic or voodoo or luck. There is a specific set of requirements needed to lose weight efficiently as a person with diabetes (type 1 or type 2). Yes, you may have heard of your friend’s cousin’s mother doing a no carb detox cleansing bath scrub to lose belly fat who lost 10 pounds, but I highly encourage you to check in with that person who does every fad diet possible in a few weeks or months. Chances are they gained the weight back and then some.

That’s because while some diets cause people to lose weight initially, they don’t employ the basic principles of continued effective weight loss. Whether it’s water weight loss, weight loss from severe calorie deficit, or avoidance of food, a lot of diets promise and sometimes produce acute results — that is temporary or short term results.

From helping hundreds of diabetics lose weight on social media, I was nicknamed the “T1D Fat Loss Coach” and now help people with all kinds of diabetes and chronic illnesses get on effective diets.

I have a 3 “E” rule for an effective diet before you continue on in this article. A diet must be all three of the following for you for it to be effective:

  1. Easy to adhere to long term
  2. Enjoyable or at least not miserable and affecting quality of life (socially or mood related)
  3. Effective in producing results long term (any diet change can produce short term results)

So, in deciding on a diet, make sure you have these rules in mind. These next five components of a diet will determine your success.

Optimal Weight Loss Blood Sugar

Blood sugar management is more important than exercise and diet combined for weight loss. Why? Because chasing blood sugars involves ruining your diet and training effectiveness.

You can’t optimally lose fat, build lean muscle, or get a healthier physique while mismanaging your blood sugars.

When your sugars are low, you are likely to (or at least more at risk to):

  • Overeat to correct lows
  • Overcompensate the overeating with medication that could lead to another low
  • Experience another low in the next 24-48 hours (“lows beget lows”)
  • Reduce intensity of exercise
  • Experience increased hunger and cravings which can be hard to fight

When your blood sugars are high, you are likely to (or at least more at risk to):

  • Overtreat with insulin which could lead to another low
  • Reduce nutrient absorption necessary to increase or preserve lean muscle mass
  • Decrease effectiveness of a workout
  • Experience a false sense of scale weight loss when in reality, you could be losing lean tissue which means reducing your metabolic rate and storing more body fat

In order to improve your metabolic rate and your body’s fat burning capability/processes, blood sugar management has to be a priority. In order to reduce cravings and hypo and hyperglycemic events that negatively affect diet and training, blood sugar management must be a main priority that isn’t overlooked.

Talk to your endocrinologist and diabetes management team as you decide on what the best approach is in conjunction with your changing diet and exercise habits. Then, you can get into specifics on calories and the makeup of those calories for fat loss optimization.

Specifying Calorie Intake

In order for you to lose weight, you have to be in a calorie deficit — that means burning more calories than you take in. You can do this by eating less, burning more calories through activity, or, ideally, a combination of both.

But first, you have to determine what is the appropriate number of calories you should be intaking based on your personal stats and goals. But can’t I just eat “healthy” and lose weight? You can and leave it to chance but even if you eat healthy foods in the wrong quantities, you will gain weight.

There is no universal fix to an individual problem.

That means what works for me doesn’t optimally work for your mom or for you. Specificity is optimal. To figure out how many calories you need to consume, you can find any TDEE calculator online like this one. This determines your Total Daily Energy Expenditure, or the calories you need to eat to maintain your current weight.

IIFYM TDEE calculator

Now if you want to lose weight, you need to be in a caloric deficit which means you need to eat less than what you expend daily. My personal, general rule of thumb is:

  • If you want to lose 5 lbs/2 kg or less, subtract 250 calories from your TDEE
  • If you want to lose 5-15 lbs/2-7 kg, subtract 500 calories from your TDEE
  • If you want to lose over 20 lbs/10 kg, subtract up to 750 calories from your TDEE

This is a general rule that has helped hundreds of my type 1 and type 2 online weight loss clients lose between 5-60 lbs/2-25 kg but always be sure to consult your doctor before starting a new diet and training program.

Once you have your daily caloric limits, you can be more specific and determine your macronutrient goals.

Identifying Your Ideal Macro Balance

Calories determine weight change, but macronutrient balance determines the kind of weight change. Macronutrients are your proteins, carbohydrates, and fats.

  • Protein has 4 calories per gram
  • Carbs have 4 calories per gram
  • Fat has 9 calories per gram

Why is macronutrient balance important? Take two people eating a 1500 calorie diet based on the advice above. Person A is eating 90% fat, 5% carbs, and 5% protein while person B is eating a balanced macronutrient diet of 35% protein, 30% carbs, and 35% fat. Who will get better results?

Person A is eating far too little protein and far too much fat. Higher protein diets are effective in helping people lose body fat, reduce hunger and cravings, and manage blood sugars. That little protein intake would increase risk of lean muscle loss which is the exact opposite goal. High protein diets are also proven to not be dangerous or harmful to the kidneys as long as there is no pre existing kidney damage.

That high of fat intake might make person A more hungry too as fat is more calorie dense meaning less total food intake. More hunger = more of a chance to fall off the diet when faced with opportunity to cheat.

The goal is to preserve or even build lean muscle while losing body fat. Losing muscle decreases your metabolic rate and lowers your body’s ability to burn fat. Keeping your protein around 30-40% of your total caloric intake is key for long term fat loss.

What about carbs?

Given that protein is 30-40%, carbs I leave up to my clients’ personal preference. Some people choose a moderate carb intake, some choose a lower carb intake, and some even choose to follow a ketogenic approach.

I personally don’t care as long as you are managing your sugars, eating the right protein amount, and hitting around your decided macronutrient intakes.

In terms of pure weight loss science, hundreds of studies have compared low-carb, high-fat diets to high-carb, low-fat diets and found no significant difference in weight loss when calories and protein are equated.

There may be some instances where clients with insulin resistance or hormonal issues (Type 2, PCOS, Hashimotos, post menopause, etc.) might be encouraged to be on the lower side of carb intake but, for the most part, it is a personal choice.

Carbs and fats usually have an inverse relationship — if one is higher the other is lower. If your protein intake is at 30% and you decide you want to do a moderate carb approach at 30% carbs, then you know your fat intake will be 40% (the remainder).

Some of my preferred macro percentages with my clients are:

  • Low-carb: 40% protein/20% carbs/40% fat
  • Moderate carb: 35% protein/30% carbs/35% fat
  • Moderate carb, high activity level: 40% protein/30% carbs/30% fat

These are just a few of the many possibilities and strategies to elicit fat loss. Simply download a calorie counting app like My Fitness Pal to track these numbers discussed above.

Navigating My Way Through a Food Heavy Culture

Food Choices

It is not necessarily the choices of food that affect us as much as the quantities of food in terms of weight gain and weight loss, directly speaking. Indirectly, food choice can be a major indicator of adherence to a diet.

Eating processed foods is shown to decrease satiety (feeling of fullness), increase cravings, and increase guilt. These repercussions of not eating healthy can slow or even reverse progress. I like to take an 80/20 approach with my diabetic clientele and myself.

80% of the food eaten should be whole foods. 20% can be your personal indulgent. That means if you are alloted 1500 calories a day, 20%, or 300 calories, can come from your craving foods. I believe this helps people cheat within the diet so they stay on track for longer and get far better results than being extremely strict.

An interesting note, a Kansas state nutrition professor ate twinkies and protein shakes for 10 weeks and lost 27lbs/12kg and improved his metabolic profile in the process. He wanted to show that quantity of food is extremely important when it comes to weight loss. Obviously, I don’t recommend doing this and neither does he, so please don’t replicate his experiment.

Meal Timing & Frequency

One of the biggest myths in the dieting world is having to eat every two hours to “stoke the metabolic fire.” There is no metabolic fire or fire inside of your body — I promise. Daily macronutrient & caloric totals matter most not meal timing or frequency. When you add diabetes to the mix, that’s when these variables become more relevant.

Meal timing prior to cardio or exercise can determine if you are going to have a great workout or diabetic emergency. Both hypo- & hyperglycemia can ruin a workout so timing meals according to your activity level can greatly improve blood sugar management, which indirectly improves your ability to adhere to your diet and training.

Meal frequency is a personal preference but some people with diabetes find it easier to minimize glucose variability with smaller, more frequent meals. Ultimately, that is your decision. Whatever fits into your lifestyle best is what you should do.

Effective Weight Loss With Diabetes

Blood sugar management, proper caloric intake, and macronutrient balance will help you lose body fat long term, the right way. There are tons of advanced strategies I’ve used to help people with diabetes transform their bodies but all progress stems from these basic principles. Yes, it takes some work. Yes, you have to type some stuff and do some math. Yes, it takes conscious, daily effort just like diabetes management. But, in doing so, your body will thank you.

ADA’s 2018 Standards of Medical Care Released

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Standards of Medical Care in Diabetes 2018

Every year the American Diabetes Association (ADA) puts out an updated Standards of Medical Care approved by their board of directors which is their official position and provides all of their current clinical practice recommendations.

In this year’s Standards they state that “To update the Standards of Care, the ADA’s Professional Practice Committee (PPC) performs an extensive clinical diabetes literature search, supplemented with input from ADA staff and the medical community at large.” they update it each year or as needed online based on incoming evidence or regulatory changes.

It should be noted that most current Standards supersedes all previous ADA position statements.

Citing the way the field of diabetes moves quickly, the 2018 Standards of Care reveals the following major revisions:

Limits of A1c and Diagnostic Recommendations

Since recent evidence shows limits to A1c measurements because of hemoglobin variants among individuals, conditions that affect red blood cell turnover, and assay interference, recommendations have been “added to clarify the appropriate use of the A1C test generally and in the diagnosis of diabetes in these special cases,” states the ADA.

The ADA now recommends pre-diabetes and type 2 diabetes screening in children and teens who are overweight or obese and have one or more additional risk factors.

Comprehensive Medical Evaluation and Comorbidities

Components of a comprehensive medical evaluation now includes “information about the recommended frequency of the components of care at both initial and follow-up visits.”

The ADA added information about “the importance of language choice in patient-centered communication.”

They also now recommend healthcare providers consider checking serum testosterone levels in men with diabetes who have signs/symptoms of hypogonadism.

Dietary Clarification

The ADA stresses a clarification regarding nutrition: the ADA states that “there is no universal ideal macronutrient distribution and that eating plans should be individualized.” They have also included text to “address the role of low-carbohydrate diets in people with diabetes.”

low-carb diet for people with diabetes

On this point the Standards state, “The role of low-carbohydrate diets in patients with diabetes remains unclear,” They write that some of this confusion is due to different definitions of low-carb diets. “While benefits to low-carbohydrate diets have been described, improvements tend to be in the short term and, over time, these effects are not maintained,”

They concede that some studies show “modest benefits of low-carbohydrate or ketogenic diets” which entail under 50 grams of carbohydrate per day and say that ” this approach may only be appropriate for short-term implementation (up to 3–4 months) if desired by the patient, as there is little long-term research citing benefits or harm.”

The ADA does recommend children and adults with diabetes to reduce their intake of refined carbohydrates and added sugars and to get carbohydrates from vegetables, legumes, fruits, dairy, and whole gains. They write that the “consumption of sugar-sweetened beverages and processed “low-fat” or “nonfat” food products with high amounts of refined grains and added sugars is strongly discouraged,”

CGM Recommendation

Considering the latest data, the ADA now recommends the use of CGM (continuous glucose monitoring) in adults with type 1 diabetes to all adults ages 18 and up who are not meeting their glycemic targets (recommendation was previously for age 25 and up).

Drug Recommendations for Blood Sugar Treatment

Recommendations have been added due to data from the recent cardiovascular outcomes trial (CVOT) which shows that people with atherosclerotic cardiovascular disease should start with lifestyle management treatments plus metformin and “subsequently incorporate an agent proven to reduce major adverse cardiovascular events and/or cardiovascular mortality after considering drug-specific and patient factors.”

Managing Blood Pressure from Home

All patients with high blood pressure are now recommended to monitor their blood pressure at home to find out if they have “masked or white coat hypertension” and to help motivate patients to take their hypertension medication via awareness of elevated blood pressure.

Caution in Older Adults

New recommendations have been added to indicate how important individualized drug therapy is in older adults in order to lower the risk of low blood sugar episodes and to avoid over-treatment, as well as simplifying complicated regimens if at all possible while keeping the A1c target.

Pregnancy and Diabetes

A new recommendation emphasizes that insulin is “the preferred agent for the management of type 1 and type 2 diabetes in pregnancy.”

Citing new evidence, the ADA now recommends that pregnant women with type 1 and type 2 diabetes take a low-dose aspirin beginning at the end of the first trimester for the purpose of lowering the risk of developing preeclampsia.

Diabetes Care in Hospital

Insulin degludec (Tresiba) has been added to the insulin dosing for enteral/parenteral feedings.

For all the revisions visit the Summary of Revisions. For the pdf of the 2018 Standards of Care go here.

The Two Levels of Hyperglycemia and a Separate Definition for People With Diabetes

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two stages of hyperglycemia

A Steering Committee made up of representatives from the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators, the American Diabetes Association, the Endocrine Society, JDRF International, The Leona M. and Harry B. Helmsley Charitable Trust, the Pediatric Endocrine Society, and the T1D Exchange formed a decision-making group for the Type 1 DiabetesOutcomes Program.

Their goal was to develop a consensus on definitions for hypoglycemia, hyperglycemia, time in range, DKA, and patient reported outcomes and while their decisions were informed via input from researchers, industry, and people with diabetes they relied on published evidence, their own clinical expertise, and Advisory Committee feedback.

We recently wrote about their definitions for hypoglycemia, here.

Level 1 Hyperglycemia

Level 1 hyperglycemia is defined by this group as a blood glucose concentration of >180 mg/dL (10.0 mmol/L) but ≤250 mg/dL (13.9 mmol/L).

The committee wrote that “In clinical practice, measures of hyperglycemia differ based on time of day (e.g., pre- vs. postmeal). This program, however, focused on defining outcomes for use in product development that are universally applicable.”

They believe that based on glucose profiles and post meal blood glucose data in those with no diabetes tell us that at or  over 140 mg/dL (7.8 mmol/L) is high blood sugar. However, since most people spend most of their day over that blood sugar level, they believe the guideline for measuring hyperglycemia should be different in those with diabetes.

Since the current guidelines for those with diabetes indicate that after meal blood sugar shouldn’t ever go over 180 mg/dL (10.0 mmol/L), the committee states that they would define high blood sugar starting at that point.

Changing Definitions to Keep Up With Patients?

It’s appropriate to clarify that this definition seems to be largely informed by the majority of patients with diabetes and not by what is deemed healthy in persons with no diabetes.

In other words, no matter what we call a blood sugar level of just under 180 mg/dL (10.0 mmol/L), the body will not discern between how hard it is to achieve a lower blood sugar and the damage that is known to be incurred through an elevated blood sugar.

The chronic and serious condition of type 2 diabetes is diagnosed with a fasting blood sugar of only 126 mg/dL (7 mmol/L) or higher on two separate tests, according to the Mayo Clinic. Some diabetes complications have been shown to occur with only slightly elevated blood sugar levels.

Is it a good idea to define high blood sugar differently for those with diabetes? Could this information be used by people with diabetes as a guide for their blood sugar goals? Would this be like the hypothetical example of telling an overweight person they’re not overweight if the definition of “overweight” has been changed due to a majority obese population?

Level 2 Hyperglycemia

Level 2 hyperglycemia is considered as “very elevated glucose as defined by a glucose concentration of >250 mg/dL (13.9 mmol/L).”

The committee states that over these levels, a patient’s risk for DKA is increased and the A1c levels associated with that glucose level are linked to a “high likelihood of complications”.

They write in their report that this definition “allows for the assessment of the ability of therapies and technologies to provide better glucose outcomes and to limit exposure to level 1 and level 2 hyperglycemic blood glucose values,” and that the definition is basically intended to apply to those with type 1 diabetes at any point of the day.

BG Levels

More Research Needed

The committee explains that we need more research in order to improve our understanding of how an individual high blood sugar vs sustained high blood sugar affects a person with diabetes over time.

They write that we could also use more research to improve our knowledge regarding to ties between high blood sugar and microvascular disease and other complications as well as ” the role of genetic factors and a patient’s ability to recognize when hyperglycemia is occurring”.