A1C

A Landmark IDEA Aims to Change the Course of Diabetes Care

By: 
By Mary Green
IDEA article header

The American Association of Clinical Endocrinologists Spearheading Breakthrough Program

In the 19 years since the Food and Drug Administration first approved continuous glucose monitors (CGM) for use in the U.S., the still-evolving technology has become a potential game changer in diabetes care.

The small, wearable device consists of a sensor placed under the skin that relays information to an attached external transmitter that tracks blood glucose (BG) levels in the cellular fluid at regular intervals, 24 hours a day, without the need for a finger stick. The resulting contextual data, sent to a separate receiver, allows patients and – by extension – their caregivers and their diabetes healthcare team, to proactively manage glucose highs and lows while providing added, real-time insights about the impact that food intake, exercise, illness and even everyday stressors have on an individual’s BG levels, thereby reducing the guesswork that often goes into glycemic control decisions.

Despite CGM’s capacity to provide “actionable” BG information to guide daily diabetes management (and thereby decrease the potential for devasting disease complications), widespread acceptance of CGM has been slow-going, some would suggest. There are a number of reasons for this.

First, each CGM device manufacturer has its own proprietary software and, thus, produces a different report. The resulting lack of uniformity and standardization in CGM reporting has created significant challenges for healthcare professionals and their patients in how to best use CGM-generated information to improve everyday diabetes care.

"The project is now taking shape and has the potential to change how doctors help their patients and how people with diabetes can better manage their blood glucose safely and feel better as a result…"

“Additionally, physicians don’t fully understand CGM use or think it may require too much effort, plus many people living with diabetes and their caregivers are not aware of the CGM technology, how it works and the many benefits it may provide them,” says Nancy J. D’Hondt, a clinical pharmacist and immediate past president of the American Association of Diabetes Educators (AADE).

That’s all about to change.

A collaborative of powerhouse organizations in the diabetes health care space is intent on taking CGM use to the next level, joining forces in an unprecedented effort to ensure all diabetes health care professionals and patients have the information and tools they need to make the most informed clinical decisions possible about CGM use.

Known simply as IDEA (Innovating Decisions and Empowering Action in Diabetes), the focus of the multi-year initiative is to create and deliver comprehensive, easy-to-understand educational/awareness materials and learning aids to stakeholders across the diabetes care spectrum, with materials designed for patients, diabetes specialists, primary care physicians, nurse practitioners and physician assistants, and educators such as registered nurses, pharmacists and certified diabetes educators. The materials will provide the uniformity necessary for CGM use to reach its full potential, notes D’Hondt, a member of the IDEA steering committee.

“More widespread use and understanding of CGM can have benefits for all,” she says. “For physicians, it can help guide medication change therapies or insulin dosing and determine what’s working and, possibly, what’s not. For people living with diabetes, it will improve understanding of what and how food, activity, stress, medications and life in general affect blood glucose, mood, sleep and health. And family members will be able to monitor glucose values remotely and ensure safety for their loved ones.”

At present, A1c – a measure of a person’s average blood glucose levels over a two-to-three-month period – is widely used and generally considered to be the gold standard in assessing blood sugar control to mitigate long-term risks of complications from high blood sugar levels. However, A1c can’t capture other critical data that matter to a patient on a daily basis, for example, low blood sugar (hypoglycemia) episodes that can be potentially fatal.

“This effort will shift the focus of diabetes management from A1c-centric to time-in-range-centric blood sugar goals and thereby improve overall outcomes and improve the lives of people living with diabetes,” says J. Hyun (C.J.) Chun, president of the American Society of Endocrine Physician Assistants (ASEPA), also a member of the IDEA steering committee. (Time in range is the percentage of time that a person with diabetes spends in the ideal blood glucose range.)

Although the IDEA program team began its activities in early 2018, the groundwork for the initiative was actually laid several years ago when the American Association of Clinical Endocrinologists (AACE) held a CGM Consensus Conference to examine the growing body of evidence supporting CGM benefits and develop strategies for overcoming barriers to CGM use and access.

“We asked ourselves, ‘How do we have a call to action to develop a unified approach to interpretation of CGM data that we could use to manage a patient’s diabetes, realizing, of course, that patients are being managed by a variety of healthcare professionals, and who is going to teach the patients and those providing the care how to capture the real-time data to enhance understanding and use of the technology?’” recalls endocrinologist Dr. George Grunberger, an AACE member and IDEA project steering committee chair.

“From there, the idea was to first get buy-in and agreement from each CGM device manufacturer to develop a unified report that could be used for educational purposes by everybody, from endocrinologists to primary care physicians to diabetes educators and so forth, so that the patient could be properly educated and caregivers could define what comes next in that patient’s treatment routine,” he adds.

Despite the highly proprietary nature of CGM manufacturers’ technology, all of the companies in the arena agreed to the proposition.

Another key development was the involvement of the International Diabetes Center, which owns the copyright to the Ambulatory Glucose Profile, the report forming the backbone for the IDEA unified CGM report.

The AACE team then identified key organizations that had a stake in the issue and solicited their participation in the program.

“Buy-in was quick,” Dr. Grunberger says. “It was impressive and exciting to see how many organizations enthusiastically joined almost immediately.”

Program participants include AACE, AADE, American College of Clinical Pharmacy (ACCP), American Diabetes Association (ADA), ASEPA, College Diabetes Network (CDN), Diabetes Patient Advocacy Coalition, Endocrine Society, JDRF, The Leona M. and Harry B. Helmsley Charitable Trust, International Diabetes Center (IDC), T1D Exchange and The diaTribe Foundation/Close Concerns.

“Right now there’s a lot of work to be done,” Dr. Grunberger notes. “We are finally organizing all these pieces and gathering content for the learning program launch, which is planned in late 2018.”

“The project is now taking shape and has the potential to change how doctors help their patients and how people with diabetes can better manage their blood glucose safely and feel better as a result,” D’Hondt adds. “This technology can be a game changer when it comes to a better understanding of living and thriving with diabetes. We just need to make it a part of the care plan for all.”

To learn more about the benefits CGM has provided patients, read on for some first-hand CGM user stories.

Carol Logan

My CGM Story: Carol Logan

Minneapolis, Minnesota

To the casual observer, Carol Logan might seem an unlikely fit for a person at risk for diabetes.

An accomplished linguistics teacher who has lived, worked and traveled across the globe, from France, Yugoslavia and Finland to England, Greece, Russia and Israel, Logan has led an active, productive life and is fit, trim and exceedingly health conscious.

So nobody was more surprised than Logan herself when she was diagnosed with type 2 diabetes in July 2001, at the age of 58.

“I had none of the telltale signs of uncontrolled diabetes at the time of my diagnosis,” she notes. “I wasn’t thirsty, I wasn’t urinating excessively, I hadn’t lost weight, I wasn’t hungry. In fact, I found out about it from a random blood sugar test.”

Logan had been proactively having her blood tested every six months at her local pharmacy due to an extensive history of heart disease on her father’s side of the family. “They did a routine fasting blood sugar in addition to testing my cholesterol levels, which were excellent, as they usually are,” she says. “But they advised me at the time that my blood sugar was a little high.”

An A1c test done shortly thereafter – a measure of a person’s average blood glucose levels over a two-to-three-month period – was also slightly high, but still within a normal range, Logan says.

Her doctor subsequently advised her to buy a glucometer, a medical device used to determine the approximate concentration of glucose in the blood, and to test herself randomly four times a day.

“To my horror, I found that every time I tested myself after a meal, it was 170 or 180,” she recalls. For most people, a normal fasting (no food for 8 hours) blood sugar is between 70 and 130; a normal blood sugar level two hours after eating is less than 140.

“So, they put me on all different kinds of oral medications for type 2 diabetes to try to get my blood sugar back to normal, because they thought I had type 2 diabetes,” she says. “The medications never worked. I was constantly testing myself, and my results were always abnormal.”

In January of the following year, frustrated with the lack of results, Logan told her doctor she was willing to consider insulin therapy. Ultimately, Logan was correctly diagnosed with type 1 diabetes through a C-peptide test that indicated her body was producing no insulin. “And that’s when I started taking shots,” she says.

“In my case, I knew all about diabetes therapy because we had had a baby with the disease who was on insulin shots, so I wasn’t afraid of them,” Logan says. (Her son David now in his 40s, was diagnosed with type 1 diabetes at the age of 20 months, although nobody on either her side or her husband’s side of the family had ever been diagnosed with the disease.)

She continued conventional insulin therapy and tested her blood sugar frequently to stay on track in the ensuing years. “I’ve always been an advocate of tight control to avoid the horrible side effects of type 2 diabetes and know exactly what all of my blood sugars are at any moment,” she advises.

It was through an Adults with Type 1 support group that she first learned about continuous glucose monitoring (CGM). “Word-of-mouth from the many people with diabetes I knew who had a CGM and who raved about how fantastic it was and how much it helped their control was what piqued my interest,” she says.

The technology had particular appeal due to a potentially dangerous condition Logan suffers from called hypoglycemia (low blood sugar) unawareness, a complication of diabetes in which the patient is unaware of – or doesn’t experience – the hallmark symptoms that accompany a deep drop in blood glucose levels. Hypoglycemia unawareness can lead to seizure, loss of consciousness, even brain damage. It also makes intensified blood glucose control more difficult and puts the patient at risk for severe hypoglycemia-related complications.

Carol and Richard Logan in Jerusalem
Carol Logan with her husband Richard (left) and together visiting the famous Western Wall in the Old City of Jerusalem (above).

When she mentioned conversations about CGM with her fellow support group members to her endocrinologist, Logan’s caregiver agreed that it could be a valuable tool in her diabetes regimen. “Her concern was that with my having this unawareness problem, I could become unconscious while driving, for example,” Logan says. “But with the CGM, it starts beeping to warn you that your blood sugar is getting low.”

She began using the technology in 2008.

“The hardest thing about having diabetes is not taking your shots or testing your blood, it’s that you can never forget about it,” Logan concludes. “But still, it’s so much better now than when my son was diagnosed, when there was only urine testing available. I mean, it’s like a miracle when you compare the two time periods in history.

“To be honest, I can’t even remember what it was like in those days before I started using the CGM,” Logan says. “Because I’ve had diabetes for so long, it’s comforting to be able to look at the CGM at any time, day or night, and see what my blood sugar is approximately. And then if I have any doubts, I can always check my blood sugar with a finger prick. I still test myself about 6 to 8 times a day, and I don’t mind doing it.

“I’ve come to depend on it so much, if I ever happen to forget it and go somewhere without having it with me, it’s a horrible feeling,” she continues. “I feel like I’m naked. And I’m sure everyone who has a CGM feels that way.”

Stacey and Benny Simms

My CGM Story: Stacey Simms

Charlotte, North Carolina

Day-to-day life changes instantly for people when diagnosed with a chronic medical condition like diabetes. It often means big changes for their loved ones as well.

And so it was with Stacey Simms and her family – daughter Lea and husband Slade – when her youngest child, son Benny, was diagnosed with type 1 diabetes in December 2006, just before he turned two.

“I was slightly familiar with diabetes, and Benny had all the classic symptoms,” says the award-winning broadcast journalist. “Through the radio station I worked for, I had been involved in several local JDRF (formerly the Juvenile Diabetes Research Foundation) events, so I was familiar enough with the signs that I called my pediatrician and suggested our son needed to be tested.”

At the time of his diagnosis, the toddler’s A1c (a measure of average blood sugar levels over a two-to-three-month period) was 11.5. A level below 5.7 percent is considered normal. His blood sugar was over 800; less than 140 is considered normal.

“It was straight to the pediatric hospital, but he responded to treatment really well, so they only kept us for three days,” Stacey recalls. “He felt pretty good and was running up and down the hallways. The nurses were so happy, because a lot of kids with the same diagnosis don’t feel well enough to do that.”

Once the family brought Benny home, it was another matter entirely.

“Type 1 diabetes in a toddler is a very, very different thing,” Stacey notes. “The first two weeks were horrendous. He would run away from us, he would cry, he didn’t want the shots, he didn’t want the finger sticks, but after two weeks he began to adjust beautifully. Kids that age get used to things very quickly if you just get on with it.

“Our care at the time was to give fast-acting insulin when he ate, but our endocrinologist didn’t supply us with a strict eating plan, so whatever he ate, we gave him a shot to cover for that,” she continues. “He was up to six or seven shots a day, but he didn’t care how many shots a day he got, as long as he didn’t have to stop playing or interrupt his ‘fun’ time.”

Still, challenges remained.

The family had a big scare only a month after Benny’s diagnosis during an outing to visit relatives. “We were all at an indoor play area and I thought he was taking a nap, but I decided to check his blood sugar just in case,” Stacey says. “I don’t recall the exact number, but it was definitely under 50.

“We were terrified because it was so soon after we found out he had diabetes, and we were running to grab juice and gummies, but he was too tired to eat the gummies, so we went back to the juice to increase his blood sugar,” she continues. “After the episode was over, I remember thinking at the time how amazing it was that he bounced back from the low sugar so quickly.”

“Still, the most difficult thing was that we never knew if he was falling asleep or if he was experiencing a low, because most children that age can’t articulate how they’re feeling. No two-year-old says, ‘I have an ear infection,’” Stacey recalls.

“You’re checking blood sugars through your child’s crib’s slats at night, and finger-sticking before, during and after any activity, even if it was only half an hour, because his blood sugar levels could go down very quickly from 120 to 40,” she adds. “After all, he only weighed 35 pounds! It’s a combination of heartbreaking and funny in an odd way.”

Over time, Benny’s care became easier and the family settled into a routine, even though there were still ups and downs. And Benny eventually transitioned from shots to an insulin pump.

The Simms family
Stacey Simms with her son Benny (left) and family (above) – Benny, Lea and husband, Slade.

Meanwhile, Stacey had become a passionate advocate for her son and others with diabetes (a so-called “D-mom”), joining the local JDRF board in Charlotte six months after Benny’s diagnosis and blogging as an outlet for the emotions and challenges the family was experiencing. “It lifted the burden just to share it, to realize that we were not alone,” she says. That yearning for a sense of community ultimately led Stacey to launch her own podcast, Diabetes Connections (https://www.diabetes-connections.com/). The popular weekly talk show includes a mix of interviews with prominent diabetes advocates, authors and speakers, researchers, and people with diabetes, their friends and family members.

Stacey’s involvement with the diabetes community, as well as Benny’s participation in camps for children with diabetes, initially made the family aware of CGM technology, “We saw people using the gear, but Benny didn’t want something else on his body, and we didn’t want to push it,” Stacey notes. “And then he came home from camp in 2013 after seeing another child using CGM, and said, ‘I want to try this.’”

Her son began using CGM Christmas day 2013, “and it was just INCREDIBLE,” Stacey says. “We all could see his blood sugar number on the receiver and that was such an eye-opener. It was so interesting to see and absorb, I remember we just stopped in our tracks and stared at it for the longest time.

“It took a while for us to learn how to use it, because when you finger stick, even six to eight times a day, or 10 times a day, as we often did with him, you’re not getting the full picture,” she adds, “but you’re also not overreacting. It took me a little while to learn how to not overreact because with CGM you get so much information that you didn’t have before, it’s an art form to find balance.”

With the advent of CGM remote monitoring, in which CGM data from a receiver can be stored on a web-based server instead of specific devices, allowing multiple caregivers to remotely view a person’s glucose data in real time, there were more lessons to be learned…and gains to be had.

Although acknowledging her instincts after Benny’s diabetes diagnosis were to “put my child in bubble wrap and never leave his side,” Stacey and Slade had agreed that teaching their children independence and confidence were priorities. “So, our remote monitoring of Benny was, and continues to be, a whole other bag of beans. We’ve got his blood sugar numbers on our phones, we know our child can handle it, but at the same time he’s showing as having a high and you want to tell him, ‘knock that down.’ However, you can’t text your child 400 times a day. It’s taken some really honest conversations to work out a system that works for everyone in our family.”

The good news? Benny is now an active, strapping 13-year-old living the life of a typical teenager, thanks, in part, to CGM technology.

“CGM has taught us so much about how insulin works for Benny, when to dose and how certain foods affect him,” Stacey says. “My husband is one-half Italian and owned an Italian restaurant for many years, so food really plays a big part in our family’s life. If we’re going to eat a high-carb or high-fat meal, CGM helps tell us how his body reacts so we can time his insulin a lot better, and he doesn’t have to give up his favorite foods. It’s also helping us ride the swings of puberty.

“CGM has become integral, almost essential, to our care.”

Mike Ratrie

My CGM Story: Mike Ratrie

Mount Dora, Florida

Mike Ratrie’s pathway to continuous glucose monitoring (CGM) use was a long time coming.

Forty years, to be exact.

Diagnosed with type 1 diabetes (T1D) in 1973 at the age of 19, the active, outdoor enthusiast was being cared for by an internist who prescribed intermediate-acting NPH insulin once a day and was enduring “dozens of daily finger sticks” to assess his blood sugar levels. “Keep in mind, this was back in the day of peeing on test tape or measuring urine sugar level in test tubes,” Ratrie says, “long before there were meters for measuring blood sugar.”

Remarkably, Ratrie’s diabetes regimen remained consistent for more than two decades. Over time, however, his insulin dosage had increased from 35 to 40 to 55 units per day, “and I still wasn’t feeling that great,” he recalls.

Following his internist’s retirement, and after hearing from a male acquaintance about his state-of-the-art T1D care, “that got the wheels turning,” Ratrie says. “I did some research and discovered endocrinologists who specialize in treating patients with diabetes. I didn’t even know such an animal existed.”

Shortly thereafter, he made his first visit to a diabetes specialist. “She opened up a whole new world for me. She was truly, in diabetes care terms, really a world-class endocrinologist,” he says.

“She started me out doing finger sticks,” Ratrie recalls. “I came back after a month, and she took a look at my blood glucose numbers, which were mostly up in the 180 to 250 range, and she told me I really needed to be down below 120. And I was like, ‘Oh, no.’ At 120, I’m eating everything in sight because that’s too low a blood sugar for me,” he continues. “So she suggested we try to get the blood glucose down gradually.”

Ratrie’s endocrinologist also educated him about the complications that happen internally to a person with diabetes when their blood sugar isn’t under control. “Those were some really eye-opening times for me,” he says. “She wasn’t dogmatic, she talked about goals we could achieve together, as partners in my care.”

Mike Ratrie on a recumbent tricycle
Mike visiting Oregon's coast during his cross-country cycle journey.

Despite their productive partnership, Ratrie metaphorically “moved on from her” for five years while he lived on a sailboat, traveling from Maine to Chesapeake Bay to the Bahamas and down to the tiny southern Caribbean island of Aruba. “But she was my endocrinologist from afar, as I was coming back to the U.S. once a year to see her and get prescription renewals, test strips and so forth,” he says. “I actually had an area on the boat that was dedicated to these huge containers where I had my test strips to check my blood sugar levels.”

After his return to the U.S. in 2011, he noticed people were starting to talk about CGM. “I was doing a lot of reading on the technology and was involved in a lot of online forums, but I was resistant to it initially because I was reviewing literature that talked about how you calibrated CGM with a blood stick device, which had about 20 percent plus or minus accuracy, and the logic wasn’t really striking me as being very compelling,” he says.

“I finally got to the point where I wanted to get more data, because even doing finger sticks 12 or 15 times a day, which is what I was doing, you’re only getting a snapshot,” he adds. “Imagine trying to tell a story with 15 pictures, or with a movie that is a series of hundreds of pictures. That’s the difference.”

Ratrie began using a continuous glucose monitor in 2015…and has never looked back.

“I don’t recall if I was necessarily taking advantage of all of the information I was collecting, but I really picked up on the fact that this technology was going to help me immensely, because you can tell what’s going on with the blood glucose trending, which allows me to take corrective steps sooner,” he notes.

"The CGM helps me take advantage of the information and take steps sooner before I get in trouble from extreme blood sugar highs or lows. That’s really key."

“What was eye-opening was seeing things I had been missing,” he continues. “For example, I would do a finger stick and have a picture of a post-meal number of 180, and then I’d see on the CGM that that’s not my peak. My blood sugar was still going up. And it really helped me understand I needed to be a little more aggressive if I hadn’t counted my carbs correctly, or if there was something going on with my metabolism that would tell me that I was going to be out of range, either high or low. The CGM helps me take advantage of the information and take steps sooner before I get in trouble from extreme blood sugar highs or lows. That’s really key.

“I’ve realized how much better my level of care is with CGM than it is with finger sticks,” Ratrie adds. “I can’t tell you before I started using a CGM what percentage of time I was spending over 180, but just as an example, in the past six months I’m spending maybe 3 or 4 percent of the time above 180.”

Ratrie’s CGM use was crucial to his most recent adventure, a 2016 cross-country bicycle trip with his wife, Lucia. He says the four-month, 5,885-mile journey in which they rode their ICE (Inspired Cycle Engineering) recumbent tricycles from Seattle, Washington through 15 states and back to their Florida home would not have been possible without his CGM.

“Having that CGM with me so that I could understand where my blood sugars were was priceless,” Ratrie concludes. “CGM, for me, has just been so wonderful and so eye-opening, and it helps me not worry as much about my diabetes. Even though I have to spend time paying attention to it, it helps me live closer to a normal life.”

Can New Monitoring Technology Improve Your Diabetes Care?

By: 
By Felice A. Caldarella, MD, FACP, CDE, FACE
Man checking glucose monitoring app on cell phone

If you have been diagnosed with diabetes, would you like to know your blood sugar reading without having to do a finger stick? Would you like to receive automatic alerts if your blood sugar is dropping too quickly? Would you like to be able to share your blood sugar readings with friends and family? Would you like to be able to lower your A1C – a measure of the previous three months’ average blood sugar – without experiencing more frequent low blood sugar readings?

All of this is possible today with a continuous glucose monitoring (CGM) system. And depending on your insurance plan, the cost of a CGM might actually be covered by your policy.

A CGM is a device that continually tracks blood glucose (blood sugar) levels in the interstitial tissue fluid, the fluid that surrounds the cells of your tissue below your skin. The CGM contains a small sensor wire that is inserted under your skin, usually on your belly, to take blood glucose readings on set intervals. The wire is attached to a pad on the skin surface that acts as a receiver of information. A chemical reaction occurs on the wire in response to the fluid, which the receiver then sends wirelessly to either a monitor, smartphone display or tablet, allowing you to track your blood sugar average over the previous minutes without performing a finger stick. Sensors are changed every several days (timing depends on the device brand), which you can conveniently do yourself at home.

There are currently three FDA-approved CGM systems available in the U.S. They are the Dexcom CGM, the FreeStyle Libre and Medtronic Connect.

The beauty of CGM technology is that it allows you to see your glucose level any time at a glance and how your glucose changes are trending over a few hours or days. Accessing your glucose levels in real time and how they are trending can help you make more informed decisions throughout the day about how to balance your food, physical activity and medicines.

Some people think only those on insulin pumps benefit from a CGM system. This is not true. CGM systems have been shown to also benefit patients using multiple injections of insulin per day to manage their diabetes. So, if you require at least three injections a day – a combination of basal or long-acting insulin along with bolus or mealtime insulin – you could be a candidate for a CGM.

Research bears this out: In a recent trial, people with type 1 diabetes using injections of insulin wore a CGM system. Prior to wearing the CGM system, study participants were checking their blood sugar, on average, five times a day (many diabetes specialists often recommend four to six blood sugar checks a day). After 24 weeks, patients on the CGM system had better blood sugars on average and without increasing episodes of hypoglycemia (low blood sugar). This is an important finding given what we know about people with diabetes benefiting from lower, near non-diabetes-range blood sugars.

Plus, the A1c blood value (a measure of the previous three months’ average blood sugar) is a marker for the risk of developing diabetes complications such as eye, kidney and nerve damage. So, if you have type 1 diabetes, have been checking your blood sugar four to six times a day, and aren’t happy with your A1c value, perhaps a CGM system might be right for you.

Another reason to use a CGM system would be if you have hypoglycemia unawareness or severe hypoglycemia. Hypoglycemia unawareness is the loss of the ability to sense that blood sugar is dropping until the sugar is critically low. It typically occurs with people who have had diabetes for a long time and have frequent low blood sugars. This can be a very dangerous condition. Severe hypoglycemia is typically described as a person experiencing low blood sugar that requires assistance from another person to treat.

CGM benefits a user optimally when it is used continuously. Studies show that the improvement in blood sugar control wearing the CGM are lost when participants stopped wearing the CGM device. This is important to note if your insurance company decides to stop covering your CGM system because your diabetes went from uncontrolled to controlled on the CGM. In this circumstance, your doctor can advocate on your behalf with this information.

As with all technology, using a CGM takes some getting used to. One nice feature of CGM systems is that not only will they tell your current blood sugar reading, but also will let you know if your blood sugar is changing and in what direction. So, if you are going to eat and self-administer insulin but see that your blood sugar is 150 and dropping, you may give yourself less insulin. If instead your blood sugar is 150 and rising, you may decide to give yourself a little extra insulin with your meal. These adjustments can help fine-tune your diabetes management and might require a discussion or two with your diabetes clinical team as to what extra dosing (or less dosing) guidelines would be the best.

When you see your endocrinologist, be sure to bring your receiver to the office visit if you hadn’t already downloaded your device information to the Internet the night before the visit. The data helps your care team make the appropriate adjustments to your diabetes management program. Data can also be reviewed and analyzed between visits if you are having concerns with your diabetes control, but only when specific trends can be seen.

While CGM has proven its value to patients since its introduction in 2000, the device can be costly when not covered by insurance, especially for those who are older and on a limited income. Some good news on this front occurred in 2017, when the U.S Centers for Medicare and Medicaid Services (CMS) issued regulations allowing for coverage for CGM systems as “Durable Medical Equipment” under Medicare Part B, just like glucose meters. Until then, people with diabetes on CGM systems who aged into Medicare faced a tough decision, because the cost of the CGM systems were not covered. Medicare’s change in coverage meant patients who had benefitted from CGM would no longer be faced with this difficult decision.

There are, however a few specifics that must be met in order for a system to be eligible for Medicare coverage. First, it needs to be “therapeutic.” This means the blood sugar readings from the CGM system are accurate enough that a corresponding finger stick is not needed for the patient to act on the reading. There also has to be a non-disposable component to the CGM system which would last for three years – the receiver, for example. Two FDA-approved CGM systems meet this criteria: FreeStyle Libre and Dexcom CGM.

Also, in order for a Medicare patient with diabetes (either type 1 or 2) to receive coverage for a CGM system, he/she must be injecting insulin at least three times daily or using an insulin pump and checking their blood sugars by finger sticks at least four times a day, supporting the understanding that frequent adjustments in insulin dosing are being done based on blood sugar readings. Patients must also see their doctors every six months at minimum.

It’s hard to believe we’ve gone from testing a person’s urine in the doctor’s office to using technology advanced enough to predict if a blood sugar is going up or down, all without a finger stick. And CGM systems continue to improve rapidly. Measurement accuracy has more than doubled since the technology’s debut, device size and costs have been reduced, and patient and caregiver satisfaction with CGM therapy has increased. So, as you consider your diabetes care options, make sure to speak with your endocrinologist about whether a CGM should be in your diabetes toolbox.

Diabetes Care in My Part of the World — Rural America

By Anne Leddy, MD, FACE

I officially entered retirement on December 31, 2012 at 11:59 p.m., when I closed my medical office. Having practiced endocrinology for over 40 years, I felt a bit peculiar not heading off to my office every morning. Within a short time, however, I found a new place to do what I have always loved, serving as an endocrinologist at the Gloucester-Mathews Care Clinic in my rural county in Virginia.

One characteristic shared by the patients seen at our clinic is that they have all had very bad luck. They are not eligible for Medicaid in our state and cannot afford health insurance. Eligibility for care is based on income, and patients are rechecked for eligibility every six months.

More than 90 percent of my clinic patients have diabetes. Many have co-existing conditions such as obesity, hypertension, heart disease, stroke and complications of long-standing high blood glucose (blood sugar): nerve, kidney and eye damage.

Because of their circumstances, many of the people I see live on “the edge” of serious illness. Hearing stories such as them losing their job because of illness or an accident and then losing health insurance is common. Before finding their way to our clinic, some of our patients with diabetes have not had adequate insulin or other medication for diabetes in over a year. Their blood sugar control is often reflected in their hemoglobin A1C (a measure that reports a person’s average blood sugar in the past three months) of eight or nine or higher when they first come to the clinic for medical treatment; a person with no diabetes would typically show a value of under six. (The American Association of Clinical Endocrinologists considers an A1C level of ≤ 6.5 percent as optimal if it can be achieved in a safe and affordable manner, but higher targets may be appropriate for certain individuals.)

Keeping Patients Healthy by Managing Costs Creatively

The clinic staff works to lower drug costs for our patients through the pharmaceutical industry’s patient assistance programs, so with a lead time of about six weeks we can obtain many drugs still on patent. The clinic policy is to provide the people we see with as many glucose meter test strips as needed for appropriate testing. This is a great expense for the clinic, but is recognized as a priority.

The clinic is part of what is considered a “safety net” of medical care. Although the administrator of the clinic is skilled in securing grant support for clinic operations, there are still limitations on who can be seen as a patient. A patient may become disqualified from continued clinic eligibility because of even a slight increase in income; for example, a painter who gets a few more jobs during the summer or a house cleaner who adds another customer.

To help with insulin costs, we have had to reacquaint ourselves with NPH (neutral protamine Hagedorn) insulin and regular insulin. These insulin preparations first became available in the 1980s and represented a great advance at that time. Made synthetically, they are much less likely to cause an allergic reaction than insulins derived from the pancreas glands of animals. In my state, NPH and regular insulins can be purchased at pharmacies without a prescription. And although not cheap, their price ranges from $25 to $100 a vial, while newer types of insulin are priced much higher, from about $250 to over $500 for a vial (an average month’s supply).

NPH insulin has an “intermediate” duration of action. It begins to take effect at about two hours and builds to peak activity between four and eight hours. The effect then wears off by 12 to 18 hours. If continuous 24-hour action is required, then two injections of NPH insulin are used, one in the morning (usually before breakfast), and one in the vening at dinnertime or before bedtime. Many diabetes specialists prefer giving the second injection at bedtime to focus the peak effect of the medication on the following morning at breakfast time. This lessens the possibility of a hypoglycemia (low blood sugar) episode during the night when the person is sleeping, which can be very dangerous.

Regular insulin has a “short” duration of action. It is used to manage the glucose increase that occurs at mealtimes and to correct when the glucose is over target. Because the onset of action is in 30 minutes to two hours, regular insulin should be injected 20 to 30 minutes before eating. Peak action occurs at about four hours after injection, and the effect wears off over the next two to four hours. Regular insulin can be mixed in a syringe with NPH insulin. This must be injected immediately after mixing to avoid loss of insulin potency. Our clinic diabetes educators teach our patients how to mix NPH and regular insulin. No other insulin preparations can be mixed.

NPH and regular insulins are also available in a premixed form, 70/30, i.e., 70 percent NPH and 30 percent regular at a price per vial similar to a vial of NPH or regular alone. There is also a premixed 50/50 combination, i.e., 50 percent NPH and 50 percent regular. 50/50 is more expensive than the 70/30 combination.

Two combined injections of NPH and regular insulin can provide 24-hour coverage with insulin action peaks at breakfast, lunch and dinner. One needs to follow a consistent meal schedule to avoid hypoglycemia. This is different than what occurs with the long-acting insulins, such as glargine (Lantus®) and detemir (Levemir®), which do not have a peak action time. When using the long-acting insulins, there is relative freedom to eat at convenient times, covering the nutritional glucose rise with an injection of rapid-acting insulin at mealtime. However, these patients can’t afford to buy any of the long-acting insulins. And when a patient no longer qualifies, I teach them how to make the transition to more affordable insulin before their last visit.

Safety First

The dosage requirements of different insulin preparations are not the same for all people, so it is important to get the advice of your diabetes medical professional when making the change from the newer, and more expensive, insulin preparations to NPH and regular insulin. A larger dose of NPH insulin might be needed to replace one of the long-acting insulins. As with all diabetes care, each person with diabetes needs a personalized care plan. No two people with diabetes have the same requirement for treatment.

Doing well with diabetes requires more than medication alone. We emphasize a healthy lifestyle for all our clinic patients: proper nutrition, regular exercise, weight control and no smoking. Diabetes education and nutritional counseling is provided at our community hospital.

It has given me enormous pleasure to work at the Care Clinic and help patients return to good glucose control and good health. It is a privilege to participate in the care of this deserving and very appreciative group of neighbors with diabetes.

4 Steps to Manage Your Diabetes for Life

By: 
National Institute of Diabetes and Digestive and Kidney Diseases

Step 1: Learn about diabetes.

What is diabetes?

There are three main types of diabetes:

  • Type 1 diabetes – Your body does not make insulin. This is a problem because you need insulin to take the sugar (glucose) from the foods you eat and turn it into energy for your body. You need to take insulin every day to live.
  • Type 2 diabetes – Your body does not make or use insulin well. You may need to take pills or insulin to help control your diabetes. Type 2 is the most common type of diabetes.
  • Gestational (jest-TAY-shun-al) diabetes – Some women get this kind of diabetes when they are pregnant. Most of the time, it goes away after the baby is born. But even if it goes away, these women and their children have a greater chance of getting diabetes later in life.

You are the most important member of your health care team.

You are the one who manages your diabetes day by day. Talk to your doctor about how you can best care for your diabetes to stay healthy. Others who can help are:

  • dentist
  • diabetes doctor
  • diabetes educator
  • dietitian
  • eye doctor
  • foot doctor
  • friends and family
  • mental health counselor
  • nurse
  • nurse practitioner
  • pharmacist
  • social worker

How to learn more about diabetes.

  • Take classes to learn more about living with diabetes. To find a class, check with your health care team, hospital, or area health clinic. You can also search online.
  • Join a support group — in-person or online — to get peer support with managing your diabetes.
  • Read about diabetes online by visiting the National Diabetes Education Program website at: https://www.niddk.nih.gov/health-information/healthcommunication-program...

Take diabetes seriously.

You may have heard people say they have “a touch of diabetes” or that their “sugar is a little high.” These words suggest that diabetes is not a serious disease. That is not correct. Diabetes is serious, but you can learn to manage it.

People with diabetes need to make healthy food choices, stay at a healthy weight, move more every day, and take their medicine even when they feel good. It’s a lot to do. It’s not easy, but it’s worth it!

Why take care of your diabetes?

Taking care of yourself and your diabetes can help you feel good today and in the future. When your blood sugar (glucose) is close to normal, you are likely to:

  • have more energy
  • be less tired and thirsty
  • need to pass urine less often
  • heal better
  • have fewer skin or bladder infections

You will also have less chance of having health problems caused by diabetes such as:

  • heart attack or stroke
  • eye problems that can lead to trouble seeing or going blind
  • pain, tingling, or numbness in your hands and feet, also called nerve damage
  • kidney problems that can cause your kidneys to stop working
  • teeth and gum problems

Step 2: Know your diabetes ABCs.

Talk to your health care team about how to manage your A1C, Blood pressure, and Cholesterol. This can help lower your chances of having a heart attack, stroke, or other diabetes problems.

A for the A1C test (A-one-C).

What is it?

The A1C is a blood test that measures your average blood sugar level over the past three months. It is different from the blood sugar checks you do each day.

Why is it important?

You need to know your blood sugar levels over time. You don’t want those numbers to get too high. High levels of blood sugar can harm your heart, blood vessels, kidneys, feet, and eyes.

What is the A1C goal?

The A1C goal for many people with diabetes is below 7. It may be different for you. Ask what your goal should be.

B for Blood pressure.

What is it?

Blood pressure is the force of your blood against the wall of your blood vessels.

Step 3: Learn how to live with diabetes.

It is common to feel overwhelmed, sad, or angry when you are living with diabetes. You may know the steps you should take to stay healthy, but have trouble sticking with your plan over time. This section has tips on how to cope with your diabetes, eat well, and be active.

Cope with your diabetes.

  • Stress can raise your blood sugar. Learn ways to lower your stress. Try deep breathing, gardening, taking a walk, meditating, working on your hobby, or listening to your favorite music.
  • Ask for help if you feel down. A mental health counselor, support group, member of the clergy, friend, or family member who will listen to your concerns may help you feel better.

Eat well.

  • Make a diabetes meal plan with help from your health care team.
  • Choose foods that are lower in calories, saturated fat, trans fat, sugar, and salt.
  • Eat foods with more fiber, such as whole grain cereals, breads, crackers, rice, or pasta.
  • Choose foods such as fruits, vegetables, whole grains, bread and cereals, and low-fat or skim milk and cheese.
  • Drink water instead of juice and regular soda.
  • When eating a meal, fill half of your plate with fruits and vegetables, one quarter with a lean protein, such as beans, or chicken or turkey without the skin, and one quarter with a whole grain, such as brown rice or whole wheat pasta.

Be active.

  • Set a goal to be more active most days of the week. Start slow by taking 10 minute walks, 3 times a day.
  • Twice a week, work to increase your muscle strength. Use stretch bands, do yoga, heavy gardening (digging and planting with tools), or try push-ups.
  • Stay at or get to a healthy weight by using your meal plan and moving more.

Know what to do every day.

  • Take your medicines for diabetes and any other health problems even when you feel good. Ask your doctor if you need aspirin to prevent a heart attack or stroke. Tell your doctor if you cannot afford your medicines or if you have any side effects.
  • Check your feet every day for cuts, blisters, red spots, and swelling. Call your health care team right away about any sores that do not go away.
  • Brush your teeth and floss every day to keep your mouth, teeth, and gums healthy.
  • Stop smoking. Ask for help to quit. Call 1-800-QUITNOW (1-800-784-8669).
  • Keep track of your blood sugar. You may want to check it one or more times a day. Use the card at the back of this booklet to keep a record of your blood sugar numbers. Be sure to talk about it with your health care team.
  • Check your blood pressure if your doctor advises and keep a record of it.

Talk to your health care team.

  • Ask your doctor if you have any questions about your diabetes.
  • Report any changes in your health.

Step 4: Get routine care to stay healthy.

See your health care team at least twice a year to find and treat any problems early.

At each visit, be sure you have a:

  • blood pressure check
  • foot check
  • weight check
  • review of your self-care plan

Two times each year, have an:

  • A1C test. It may be checked more often if it is over 7.

Once each year, be sure you have a:

  • cholesterol test
  • complete foot exam
  • dental exam to check teeth and gums
  • dilated eye exam to check for eye problems
  • flu shot
  • urine and a blood test to check for kidney problems

At least once in your lifetime, get a:

  • pneumonia (nu-mo-nya) shot
  • hepatitis B (HEP-uh-TY-tiss) shot

This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. The NIDDK translates and disseminates research findings through its clearinghouses and education programs to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by the NIDDK is carefully reviewed by NIDDK scientists and other experts.

Myths and Misconceptions about Diabetes

By: 
By Zeke Trence, as told to Dace L. Trence, MD, FACE

I have been asked to share my story and to help shed some light on a few of the myths about human diabetes that I’ve learned on my journey living with the condition. While it’s an honor to be asked to tell my story, it’s not without some embarrassment.

I moved with a fellow feline from the Midwest to the Pacific Northwest about two years ago. Not a comfortable journey being stashed away in a carrier in the “animal hold.” And to add to my stress, no flight attendant offered any treats or even water on my trip, just some medicine to supposedly calm me – indeed – and my companion fared no better.

Settling into a new home that now had to be shared with a not-so-welcoming resident feline, as well as a resident dog, was traumatic. I tried to do my best to behave. Unfortunately, I began to “think (and other things!) outside the box,” so to speak. Yes, this was embarrassing and drove my human family crazy, particular my female caretaker. I tried a lot of finger (paw) pointing to pin my “accidents” on the others, to no avail. Soon, I was discovered and off to the vet clinic I was taken. And that’s when we first learned… diagnosis: Diabetes!

My reaction:

Once we came to grips with my “new normal,” I began to study up on the disease. I learned that, while uncommon in cats, diabetes is more and more prevalent with humans. And as with many things in the people world, there is a lot of information out there on diabetes, including some unfortunate myths. So, with computer mouse in paw, I proceeded to click around the internet to learn the truths about some of these diabetes myths:

Myth No. 1: Diabetes is easy.

For those who think diabetes is easy, think again. With both felines and my human friends, managing diabetes on a daily basis is important. For me, it was insulin twice a day, low-carbohydrate special cat food and ear pricks to check glucose. Both cats and people often initially wonder, “How do I pay for the insulin and the blood sugar testing equipment?” As a kitty, I’m not able to apply for affordable care insurance, and my job skills are limited to laying around in the sun. I haven’t caught a mouse in years, so no employer-sponsored insurance is possible. And the vet bills, ouch! And, how do I tell people about any low blood sugars I may be experiencing? Humans experience a lot of the same issues, what with checking blood sugar levels several times per day, decisions on which methods of insulin infusion and cost questions. No way is this disease easy.

Myth No.2: A1C is the absolute standard for measuring overall blood sugar control.

A1C is a blood test that is generally considered the gold standard for measurement of blood sugar control in the previous three months. The test does serve as a marker for the risk of developing eye, kidney and blood vessel complications. I can lick my ear and maybe fudge the pinprick sugar, but the A1C test is checked through blood work. I have learned it is a test that can be affected by many conditions, as well as drugs. For example, anemia, pregnancy, even age can make the A1C falsely lower or higher. Medications such as iron will decrease the A1C, as will drinking alcohol, taking aspirin, or vitamin C and vitamin E. It can be affected by ethnicity as well. African-Americans may have a higher A1C for a blood sugar average than Caucasians. High triglycerides (sugar fats), abnormal heart valves, even a low thyroid state can impact the accuracy of A1C.

And did you know that there is a considerable range of “average” associated with the A1C? So, if your human physician tells you your A1C is 7.0 percent – a rather good value – your average blood sugar over the previous three months could be anywhere from 123 to 185 (measured as mg/dL, or milligrams per deciliter). If your A1C is 8.0 (and this definitely means you need to refocus your attention on your blood sugar control), the average could be anywhere from 147 to 217, meaning that an average blood sugar of 150 in one person could win them kitty treats with an A1C of 7.0, but in another it would mean an A1C of 8.0 and a trip to visit their diabetes care team. In my case, a trip to the dreaded vet clinic, again.

Myth No. 3: An ACE or ARB drug is absolutely necessary for every person that has diabetes.

As I learn more about my condition by listening to my doctor and researching on my own, I’ve learned that there are certain requirements pertaining to specific medications. One such class of drugs included the ACEs (angiotensin converting enzyme) and the ARBs (angiotensin receptor blocker). Examples of these are lisinopril, enalapril, prinivil, captopril, candesartan, telmisartan and losartan. These are very common drugs recommended for blood pressure control. In humans with type 1 diabetes (the diabetes that comes from antibodies destroying the ability of the pancreas to produce insulin), taking these drugs to protect against the development of kidney disease is not supported by studies that I read in the medical literature.

In an article from The New England Journal of Medicine, 285 patients with type 1 diabetes with normal blood pressure and normal urine protein were followed for five years. They were on losartan (100 mg daily), enalapril (20 mg daily), or a placebo (a fake pill with no medicine in it). They were evaluated using kidney biopsy specimens and eye exams. There was no significant difference between the groups in the development of diabetes-associated kidney disease, although there was a decrease in the development of diabetes-associated eye disease. But as with all drugs, there are potential side effects, including lightheadedness, dizziness and a possible increase in blood potassium, which can interfere with normal heart function. Just wait until the vet brings up this topic. Am I ever ready to discuss “pros” and “cons.”

Myth No.4: Supplements will cure me.

It may not be entirely surprising that this is a myth, but what about prevention of the development of diabetes? I have undergone a certain operation that allows me to, *ahem*, decline any claim to being the instigator of more cats in this world, but what about preventing any risk of developing diabetes in my existing family members, knowing that they could be at risk? Where to start? There is so much information out there, and it’s all so confusing my little kitty head is beginning to spin.

Let’s look at just one supplement that caught my eye: nicotinamide. Nicotinamide is in the B vitamin family, closely similar to niacin (vitamin B3). In animals that develop either spontaneous or induced diabetes (induced occurs in studies where a toxic substance is given to destroy pancreas cells producing insulin), nicotinamide has been shown to increase insulin production and prevent development of diabetes if administered before onset of the disease. Since 1947, nicotinamide was shown to inhibit development of diabetes in rats and mice (Yum! You can see why this caught my eye). Two large, multi-center clinical trials evaluated the effects of nicotinamide in at-risk relatives of those with type 1 diabetes. A German study (named DENIS) identified siblings (age 3–12 years) of patients with type 1 diabetes thought to be of risk of developing type 1 diabetes within three years. The study participants were randomized to receive either high-dose nicotinamide or a placebo. But the results were disappointing. Alas, the rate of developing type 1 diabetes was similar in both groups and showed no protection in using the nicotinamide supplement.

Myth No. 5: You are alone in your struggle with diabetes.

There are many support systems and groups out there to help throughout this journey – your healthcare team can be a great resource in finding them.

For you humans, the American Association of Clinical Endocrinologists (AACE), the American Diabetes Association (ADA) and the Juvenile Diabetes Research Foundation (JDRF) are all purrrrific resources for information, finding the right physician healthcare team and the best healthcare management. There are also local support groups in many communities, some associated with hospitals, some independent, that your endocrinology team can tell you about.

There are even support groups for pet lovers whose companion animals have diabetes! If dogs are your preference (Really? Are you kidding me????), try visiting this site for help: http://caninesupportgroup.com/diabetes_in_dogs.htm. If cats are your favorite pet (and you know they are), here’s a website that’s chock full of helpful information: http://www.felinediabetes. com/FDMB/.

As far as my health, my blood sugar is down from 370 to 149 on glargine insulin 2 units twice daily. I eat a low-glycemic index dry food and DM cat food every day (of course, I do have a few special treats now and then). Most importantly, I think inside the box and my thirst is back to normal. Meow!

Understanding Markers of Blood Sugar Control

IS THIS FOR YOU? You’re doing everything right. You’ve decided to finally take control and to pay more attention to your diabetes. You’re checking your blood sugar often at home and at different times of the day. You’re paying close attention to your food choices and being careful on portion sizes. In fact, you’ve been doing so well you can’t wait to see your doctor to prove that your efforts have paid off!

Your glucose levels are way down but, when you do see your doctor, you’re surprised (and a little shocked) to discover that your average control is not as good as you thought it was. Your doctor checked your hemoglobin A1c and is concerned that your average blood sugar may be running too high (or too low). How can that be? Your blood sugars at home have been on target for the last several months. You and your doctor confirm your glucose meter is working properly.

What can be a possible explanation for this? It’s time to learn about some markers of blood sugar control!

HEMOGLOBIN A1C When sugar (glucose) is higher than it should be in blood, it attaches to proteins in the body. This is used as a marker or indicator of blood sugar control.

HERES' HOW IT WORKS : Many different types of cells are found in blood, among them are the red blood cells. They are named “red” blood cells because they contain a protein named hemoglobin [HEE-mo-glo-bin], which gives them the color red. Hemoglobin is the protein responsible for getting oxygen to the body’s tissues.

Because glucose/sugar can easily enter the red blood cells, when blood sugar levels increase, sugar molecules enter the red blood cells and attach to hemoglobin. The higher your blood sugar, the more sugar will enter the red blood cells and will attach to the hemoglobin. Glucose attaches to hemoglobin (also called glycated [gly-kay-ted] hemoglobin).

Measuring A1c allows providers to help patients evaluate their blood sugar levels so that problems related to chronic hyperglycemia [hie-per-gly-SEEM-ee-ah] can be prevented.

Red blood cells live for about 120 days. So, an A1c level reflects the average blood sugar in the last 120 days, but it more closely reflects levels of the last 60 to 90 days.

The A1c value is affected by how long red blood cells have been in the body. Some conditions can result in either a lot of older red blood cells or too many young red blood cells in the body. This can affect the accuracy of the test.

Scenario 1: If red blood cells are old, they’ll be exposed to serum glucose for a longer period of time. This will allow more glucose attachment to hemoglobin, possibly increasing the A1c level. This will make it seem like your average blood sugar level is higher than it really is. It is more likely that you are deficient in iron, folate and/or vitamin B12.

When red blood cells are old and A1c values show blood sugar levels to be higher than reality, insulin regimens can be mistakenly increased. This can cause hypoglycemia. Treatments that are actually working might be readjusted by mistake, and become less effective.

Scenario 2: Other conditions shorten the life span of red blood cells. The body will then produce many young red blood cells, which might lower your A1c level. The A1c level will be low because the red blood cells won’t have been in the body long enough to have glucose attached to them. This will make it seem like your average blood sugar level is lower (better) than it really is. The more common conditions that cause this to happen are hemolytic [heemo-LIT-ic] anemia, sickle cell anemia, and sickle cell trait.

When red blood cells are up and A1c levels are showing that average blood sugar levels are lower than reality, your doctor may wrongly assume that your blood sugar control is great. This could lead to lack of control of your A1c levels, which may cause health problems down the road.

People with chronic kidney disease can have falsely low or falsely high A1c values, making them tough for the doctor to interpret.

A1c is a valuable tool in medical practice and a good indicator of glycemic control that works for most people. However, one should be careful when home blood sugar levels are different from the average glucose value obtained by your doctor measuring A1c.

Other factors that can also affect A1c values are:

  • How A1c is measured, and abnormal hemoglobins.
  • Racial variation: African Americans, Hispanics, and Asians may have naturally higher A1c than whites.
  • Medications. Common ones include:
    1. Erythropoietin [eh-RITH-ro-POY-eh-tin] (this drug causes red blood cells to be created).
    2. Iron, folate, vitamin B12 treatment. Correcting low levels of any of these will make A1c levels change.
    3. The National Glycohemoglobin [gly-ko-HEE-mo-glo-bin] Standardization Program (NGSP) website (www.ngsp.org) contains information about substances that interfere with A1c test results.

If you think your blood sugar is better controlled than what your A1c says, you should discuss this with your doctor. The A1c test may not be the right test for you. By reviewing your medical history, medications, etc., your doctor should be able to determine if it is the right test or not. Luckily, there are other good tests. Some of the more commonly used ones are fructosamine [frook-TOE-sa-meen] and 1,5 AG (Glycomark). No test is perfect, but by talking about your options with your doctor, you should be able to find one that works best for you!

Dr. Lorena Alarcon-Casas Wright is board certified in Internal Medicine and Endocrinology, Diabetes and Metabolism. She is currently a Senior Research Fellow at the University of Washington where she is involved in clinical research, education and patient care. Dr. Wright’s main interests are in the areas of prediabetes, optimal diabetes care and pregnancy complicated by diabetes.

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