We recently had a 46-year-old male patient booked into our jail who reported a history of diabetes but who had not seen a physician or taken any medications for “years.” He said he used to take a medication for diabetes “a long time ago” but he could not remember the name. He also could not remember the name of the doctor he had once seen. He reported basically no other medical history. Continue reading
In my previous post on Rethinking Diabetic Snacks for Type 2 Diabetics, I mentioned that there are two theoretical justifications for the practice or prescribing bedtime snacks for type 2 diabetics. I would like to expound on these two issues here and also comment on another issue that I failed to mention in the first article but that is important: the non-medical security issues of having diabetic snacks.
Myth: Four Meals are Better than Three for Type 2 Diabetics
The first justification for diabetic snacks is the idea that if Type 2 diabetics eat several small meals rather than 3 big meals, there will be more even absorption of calories and carbs. This would cause smaller blood sugar spikes at meals. In other words, four meals (counting the bedtime snack) is better than three meals. Continue reading
I had an obese Type 2 diabetic patient at one of my jails recently who wrote a long grievance about not receiving a bedtime snack. He argued in the grievance that he had received a bedtime snack at previous facilities where he was incarcerated (which was true) and a bedtime snack was “the standard of care” for Type 2 diabetics. I thought that this argument was ridiculous, especially since this patient routinely purchases lots of candy bars and Ramen Noodles from the commissary (think 30-40 candy bars a week).
However, despite the fact that bedtime snacks are routine at many correctional facilities, I believe that bedtime snacks for Type 2 diabetics in a correctional setting is, in most instances, a bad idea and bad medical care. I would like to discuss why this is so by discussing what our overall goals for Type 2 diabetic management are, where the whole idea of diabetic snacks came from in the first place, and then present three cases. Continue reading
Self Monitoring of Glucose in Type 2 Diabetics Does Not Work
The Cochrane Review did an analysis of 9 studies of self monitoring of blood glucose. In these studies, There was no beneficial long term effect of self monitoring of blood sugars in Type 2 diabetics not on insulin. The authors say “We did not find good evidence for an effect on general health-related quality of life, general well-being, patient satisfaction, or on the decrease of the number of hypoglycaemic episodes. ”
I had run into this concept before. This study randomized Type 2 diabetics into two groups. The first group received glucometers and were encouraged to check their blood sugars as frequently as they wanted. The second group had no glucometer and could not check their own blood sugars. At one year, there was no significant benefit to self-monitoring of blood sugars. In fact, the only significant difference between the groups was that the self-monitoring group had more depression!
Of course, all patients on insulin, whether Type 1 or Type 2, need to have their blood sugars checked at least every time they get insulin.
However, the take home message from these studies for me is that doing a lot of glucometer checks in Type 2 diabetics who are not on insulin is probably a waste of time, despite the fact that it is heavily marketed on TV. The proper way to follow diabetic control in these patients is by using the HbA1C every 3-6 months.
If you do frequent blood sugar checks in these patients at your facility, bring up the Cochrane Study at your utilization review committee meetings and talk about it!
I know that this can be a controversial topic. Any feedback?
Fun Reads of the Week
“Merely having an open mind is nothing. The object of opening the mind, as of opening the mouth, is to shut it again on something solid.”
- G.K. Chesterton