We have developed some less than optimal habits in diabetes management. I'm going to publicly confess, tell you why we do what we do, and then beseech Dr. Cogen to put these habits in perspective for us.- How bad are they? - Which ones should we work to correct? - Do we need to make some diabetes care New Year's Resolutions?
Blood Sugar Testing
Our early training gave a very clear procedure for doing a finger stick. It went something like this: wash hands, insert new lancet, swab finger with alcohol, test, wipe blood from finger, dispose of test strip and used lancet in a sharps container. In actuality blood sugar testing goes something like this: pick least dirty finger, test with lancet that may have been changed in the last few days, lick blood from finger. (The latter is a disgusting habit my son brought home from diabetes camp; however, it's better than the blood stains he used to leave in his pump case.) For the record, and knock on wood, we have had no infections at the site of finger pricks. I wrote about the problem of residual sugar on a finger, so if we get an unexpected out of bounds number, we wash hands and retest. While I know clean fingers and sterile procedures may be optimal, getting a fast test done on the sidelines of a soccer game or before retaking the field in a baseball game takes priority over the testing procedure. How bad is our lack of sterile procedure?
Dr C's response: It is more important to test than not to test, even if the chosen site is not pristine. However, I would make a few suggestions. I love diabetes camp, but it is true that some less than ideal behaviors are acquired. It isn't always practical to have an alcohol swab on one's person at all times, so yes, pick a clean finger and test. It would be even better to rinse the finger in water and dry it off before testing to prevent dilution and sticky residue from sweets (if at all possible). MRSA (Methicillin Resistant Staph Aureus) is on the rise so you should at least try to keep sites as clean as possible. Licking the blood from the finger after testing is even done by some professionals. I do not think it is the greatest idea as the mouth is a huge reservoir for gross bacteria. On a scale of 1-10 (1=not an issue and 10=big issue) I would say (in my opinion) it is a 4, for lack of sterile procedure.
I know we're supposed to wipe the top of the insulin bottle with alcohol before inserting the syringe. I admit to skipping this step most of the time. We stopped wiping the injection site with alcohol years ago because the alcohol was really drying out Josh's skin. How dirty can his upper arm or covered thigh really be?
Dr. C's response: Not really dirty. This skipped step would be a "3".
PS: A question was posted on the Diabeteens site about reusing syringes and needles. I do not recommend reuse of disposable medical equipment if at all possible: especially needles. Use of needles through clothing is also not a good idea to avoid the potential for infection.
Pump Infusion Set Change
The potential for infections at an infusion set site makes me nervous. I keep a prescription strength tube of bactroban around and use it if any site looks reddish, swollen, or even slightly weird. We also try to adhere to the three-day maximum for any one site. We set an alarm on the pump to remind of site changes, but sometimes my son forgets to tell us the alarm went off. Sometimes the site stays in for four days instead of three. When numbers start to creep up we're quick to change the site even if it's less than the prescribed three days. How bad is it to leave a site in for longer than three days?
Dr. C's response: Hopefully that last pump infusion set change was three days or less. For several reasons, this is an important principle to follow when using an insulin pump. Yes, there is a huge potential for infection around an infusion site (such as MSRA). I also prescribe bactroban to have available (use no more than two or three days) if the site has any evidence of more than the usual redness, swelling, or tenderness. In addition, as the infusion set is a foreign body, your tissues react and the site becomes dysfunctional with resultant higher blood sugars. If blood sugars start increasing, even if the site has been only 1-2 days, it is time to change. I also would recommend changing the infusion site during the day instead of in the evening so if it is problematic you will know sooner rather than waking up to high blood sugars and ketones in the morning.
Guessing at Carb Counts
This is one area where we are already taking action. David Mendosa's recommendations on nutrition scales inspired our family to purchase the Salter scale. Using a scale and weighing the food has a profound effect on accuracy. Ball park guesstimates are okay when no scale is around but it is extremely useful to check yourself at least occasionally. Who knew that a slightly bigger apple was really 10 carbs more than my usual apple guess? Miscounting carbs has the greatest negative effect on my son's blood sugar. How often do you see inaccuracy in carb counting negatively affected blood sugar?
Dr. C's response: Every day. Effective carb counting is essential to successful control of blood sugars especially in basal bolus therapy, including injections (Lantus/Levemir and rapid acting insulin) and insulin pump therapy. In fact, at Children's National Medical Center, we are very hesitant to even consider insulin pump transition if our patients cannot carb count. Even if you know the carbohydrate amounts, it is essential to consider portion sizes. So, the carbohydrate amount for a small bagel is clearly not the same as for a large bagel. Good carb counters really can help themselves to improved blood sugar control.
Bolusing After Eating
I suspect this one will have a bad affect on my son's next A1C. We always bolus before he eats and if he eats more than expected, we simply do another bolus. In the new middle school cafeteria we have no idea what he might eat. For safety's sake, the school nurse requested he check his blood sugar before lunch, then eat lunch, and then come to her office after he eats to tally up the carbs and bolus. Safe but not optimum. Bolusing before eating matches insulin to food better. How much of an effect does pre-dosing have on blood sugar numbers and the A1C?
Dr. C's response: The latest scientific literature based on continuous blood glucose monitoring strongly suggests that bolusing before meals and snacks will markedly decrease the variability of blood sugars and allow you to be proactive rather than retroactive. It is very clear after looking at sensor downloads. However, realistically, given the constraints of schools, eating behavior of small children etc. it is not always possible to bolus before eating. Therefore, I would suggest trying to bolus before eating as much as possible at home. If it is difficult to know how much one is going to eat, I would suggest to bolus the amount required for correction immediately and then add the food bolus in the middle of the meal. If you do not bolus before eating, there is a greater tendency to forget and then you are trying to catch up later with those high blood sugars.
Logging Blood Sugar Numbers
For years we were diligent in writing down every number. Then when my son started pumping it gave us new motivation to be diligent in our record keeping, but now, six years into diabetes and four years of pumping later, we rarely log the blood sugar numbers. Yes, I do the pump/meter download the night before our endocrine appointment or if the numbers seem really out of whack. I'm always impressed with how helpful it is to see the numbers, the patterns, and how much easier it is to tweak basal rates when the data is staring us in the face. But the day to day logging of numbers...we are so over that . . . unless the A1C creeps up.
Dr. C's response: I am "so over" written logs as well (especially if the numbers are fabricated). My exception is if someone does not bring in his meter to download or does not download the pump/meter the night before his diabetes visit. It is a good idea to write numbers down to see daily patterns. And, suppose the computers decide to have a bad day? We appreciate it enormously if you bring in all the meters for us to download so that we have an accurate picture of what has occurred during the last few weeks to three months.
Testing Too Much
Some parents may argue there can be no such thing as testing too much, but I think there are some real issues with overzealous blood sugar testing. We test about seven times a day. I once tried to just test five times (before breakfast, before lunch, before dinner, bed time and 11 pm) but couldn't do it. We needed to do a test before the after-school snack, and I couldn't let him play a sport without a test before the sport. We also check one to two hours after any blood sugar correction is given. Could we really go one whole day with just four to five tests? I don't think so. Seven tests may sound excessive, but I know families that get up to 12 on a regular basis. Please get them a CGMS!
Here's a question I tend to ask myself - am I asking my son to test to keep him safe, or am I testing for my own piece of mind? Both are valid but the latter may give me pause to consider if the test can be delayed. Is there ever a problem with too much testing?
Dr. C's response: Moderation is the key. My standard of practice is to test minimally four times per day. This is not enough, but with adolescents that may be all that you can get realistically. Optimally, I recommend testing between six to eight times per day depending on activity, food choices, illness, or stress. Twelve times a day is excessive and I worry about the anxiety that is provoking the testing behavior. As far as a CGMS: it has been shown that having a CGMS actually provokes people to test more frequently as they observe the upward and downward trends. A study about CGMS in different age groups was published in the New England Journal of Medicine and suggested its most optimal use in adults over the age of 25. Teens did not take advantage of the benefits and eventually took it off. The improvement in hb A1C was only statistically significant in the adult group. More studies will be conducted in school age children (but diabetes is most managed by parents in this group). In truth, as a parent, I can totally understand testing a bit more frequently for not only your child's safety, but for peace of mind. We can't help ourselves as it is embedded in our protective parental natures.
Extremely Bad and Unproductive Habits
1) Lying about blood sugar test numbers
2) Skipping meal boluses
3) Not testing before getting behind the wheel of a car (the four test minimum that Dr. Cogen talked about horrified me as being way too infrequent)
What are some of the worst "bad habits" Dr. Cogen has seen?
Dr. C's response:
1. Lying about blood sugars. My patients know that this is one of the most upsetting behaviors that I face. I simply cannot manage their diabetes without truthful blood sugars. If they lie, I tell them that the behavior is unacceptable. Unfortunately, nearly every adolescent has tried once. After I discovered the fabricated blood sugars (and I always do), the visit becomes very unpleasant. They rarely repeat this behavior after I explain that I become a dangerous doctor without truthful information, and if I don't see real blood sugars, no driver's license. That about does it. IMPORTANCE: 10
2. Skipping meal boluses. It is an absolute disaster and wreaks havoc with blood sugar control. Missing boluses contributes to the incidence of diabulemia, diabetic ketoacidosis, and poor hb A1c's. This issue is in the top five of unproductive diabetes management schemes. IMPORTANCE: 10
3. Driving.To sum it up, No blood glucose testing? No learner's permit! IMPORTANCE: 100
Other significant dysfunctional diabetes behaviors:
4. Omission of insulin boluses/ and or injections to control weight can lead to eating disorders. An increasing number of teens and young adults manipulate insulin to maintain or lose weight. This process can lead to poorly controlled diabetes and frequent episodes of diabetic ketoacidosis.
5. Missing appointments, which prevent necessary interventions early on.
6. Not informing significant others about the diagnosis and therefore ignoring self-care skills.
7. Not using insulin/carb ratios, or correction factors.
8. "Guestimating" carbs and blood sugars!
Published On: January 13, 2009