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Use of Continuous Glucose Monitoring to Evaluate the Glycemic Response to Food. Diabetes Spectrum. 21(2): 134-137. Spring 2008.

This article considers the use of continuoug glucose monitoring (CGM) to evaluate the glycemic response to food in patients with diabetes. CGM can be used to track glucose levels 24 hours a day, observe glucose trends and patterns, and send alarms or alerts for actual and impending hypoglycemia and hyperglycemia. Glucose values, trend arrows, line graphs, and alarms viewed on the device screen provide real-time perspective. The authors discuss factors affecting postprandial glycemia (PPG), how to evaluate personal glycemic responses to food, PPG response to mixed meals, prandial insulin dosing, timing of the meal bolus, different types of boluses, and insulin sensitivity determined with CGM. The authors conclude by supporting the use of CGM for clinicians and patients to more effectively and easily evaluate the patient’s glycemic response to various types of foods and meals. This information gives patients the ability to more effectively adjust prandial insulin and lifestyle therapy based on their food choices. However, clinicians must take the responsibility for training patients in how to interpret the data and make appropriate decisions. 3 figures. 11 references.

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Acute Complications of Diabetes. IN: Scobie, I.N. Atlas of Diabetes Mellitus. 3rd ed. New York, NY: Informa Healthcare USA. 2007. pp 63-68.

This chapter about the acute complications of diabetes is from an atlas of diabetes mellitus that offers text and pictures to familiarize clinicians with the most current information about diabetes and its diagnosis and treatment. The volume portrays the wide and varied expressions of diabetes and its complications as an aid to their more ready recognition in clinical practice. This chapter discusses hypoglycemia, diabetic ketoacidosis, and hyperosmolar nonketoacidotic coma. The chapter offers full-color photographs and figures representing these same topics, including the symptoms of hypoglycemia in diabetes, brain activation in patients with hypoglycemia, the biochemical features of diabetic ketoacidosis, the causes of death in diabetic ketoacidosis, and the biochemical features of diabetic hyperosmolar nonketotic coma. 5 figures. 5 references.

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Advances and Emerging Opportunities in Type 1 Diabetes: A Strategic Plan. Nephrology News & Issues. 21(3): 28-31. February 2007.

Type 1 diabetes develops as a consequent of the body’s failure to produce insulin and is associated with an array of microvascular complications such as kidney and eye disease, macrovascular complications such as cardiovascular and peripheral vascular disease, and neuropathy. The National Institutes of Health (NIH) recently announced the Type 1 Diabetes Research Strategic Plan (www.T1Diabetes.nih.gov/plan), designed to guide research in type 1 diabetes for the next decade. This article reviews this plan, describing the key objectives that will guide NIH efforts to achieve six goals: identify the genetic and environmental causes of type 1 diabetes, prevent or reverse type 1 diabetes, develop cell replacement therapy, prevent or reduce hypoglycemia in type 1 diabetes, prevent or reduce the complications of type 1 diabetes, and attract new talent and apply new technologies to research on type 1 diabetes. The author notes that, as the leading cause of kidney failure and blindness in the United States and a major contributor to cardiovascular disease and early death, diabetes is a disease deserving of further intensive research to identify its causes, prevention, management, and, ultimately, its cure. 2 references.

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American Diabetes Clinical Practice Recommendations 2007. Diabetes Care. 30 (Suppl 1): S1-S103. January 2007.

This supplement to the Diabetes Care journal contains the American Diabetes Association’s (ADA) Standards of Medical Care in Diabetes, the major position statement of the organization. In addition, this issue includes selected position statements on certain topics not adequately covered in the Standards of Medical Care in Diabetes. The introductory materials explain the differences between a position statement, an ADA statement, a technical review, and a consensus statement. The position statements included are: Standards of Medical Care in Diabetes, 2007; the Diagnosis and Classification of Diabetes Mellitus; Nutrition Recommendations and Interventions for Diabetes; Diabetes Care in the School and Day Care Setting; Diabetes Care at Diabetes Camps; Diabetes Management in Correctional Institutions; Hypoglycemia and Employment or Licensure; and Third-Party Reimbursement for Diabetes Care, Self-Management Education, and Supplies. The supplement also includes a list of technical reviews, committee reports and consensus statements, a list of position statements and ADA statements, and the National Standards for Diabetes Self-Management Education. Each standard includes a statement of the problem, and then lists recommendations; relevant references are also included.

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Are You Low? Hypoglycemia Unawareness. Diabetes Forecast. 60(2): 25-27. February 2007.

This patient education article helps readers understand hypoglycemia unawareness, a condition that can develop over time in patients with diabetes. In hypoglycemia unawareness, the patient stops having symptoms of low blood glucose and thus cannot know when they need to treat their hypoglycemia. Typical symptoms of hypoglycemia include shakiness, nervousness, dizziness, hunger, lightheadedness, increased heartbeat, sweating, headache, problems with concentration, confusion, clumsiness, heightened emotions, and nausea. The article reminds readers of how to treat hypoglycemia and of the importance of treating the condition right away to prevent going into a coma. People who develop hypoglycemia unawareness tend to be people who have had diabetes for several years. Readers are encouraged to consult with their health care providers if they experience hypoglycemia episodes without any warning or symptoms ahead of time. A final section presents suggestions for people who have hypoglycemia unawareness to help them avoid episodes of hypoglycemia. 1 figure.

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Assessing Glycemic Control Using Home Blood Glucose Monitoring, Continuous Glucose Sensing, and Glycated Hemoglobin (A1C) Testing. IN: Unger, J. Diabetes Management in Primary Care. Philadelphia, PA: Lippincott Williams and Wilkins. 2007. p. 321-362.

Self blood glucose monitoring (SMBG) allows patients to take charge of their own diabetes management. This chapter about SMBG, continuous glucose sensing, and glycated hemoglobin (A1C) testing is from a textbook that offers primary care physicians evidence-based guidelines for evaluating and treating all patients with diabetes. In this chapter, the author discusses blood glucose meters and computer-based data management systems, the link between glycemic variability and long-term diabetes-related complications, glycated hemoglobin testing, improving the utility of SMBG, and the role of continuous glucose monitoring. The author emphasizes that both the chronic and sustained levels of hyperglycemia, as well as the acute daily fluctuations of glucose levels, are important factors in managing diabetes. The degree of chronic hyperglycemia is determined by A1C testing. The chapter includes a list of “take-home points” that summarize the concepts discussed, as well as case reports that illustrate the topics covered. 17 figures. 4 tables. 38 references.

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Bronx Bilingual Diabetes Education Address Diversity: Spanish-English Diabetes Education Program Reflects Community Needs. Diabetes Educators Handbook. p. 18. July 2007.

This brief article describes a bilingual, Spanish-English diabetes education program in the Bronx, New York, which addresses diversity and reflects community needs. The author notes that knowledge of nutrition and diabetes self-management can be particularly problematic in communities where many of the people do not speak English as their native language. This program supports the needs of the bilingual community by providing classes in two languages and concentrating on hands-on activities to enhance learning. Program goals include assisting the patient in moving from information to action, tackling nutrition labels, identifying signs and symptoms of hypoglycemia and hyperglycemia, managing multiple medications, and preparing for doctor visits. The program uses the down time while patients are waiting to see the physician, as well as 2-hour diabetes education classes, as the basic opportunities for education. One sidebar lists a few possible teaching approaches to enhance learning.

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Case Study: Diagnostic Dilemma in a Patient With Insulinoma. Clinical Diabetes. 25(4): 152-154. Fall 2007.

This article presents a case study of a diagnostic problem in a person with insulinoma. The patient was a 70-year-old woman who was referred to the diabetes clinic for work-up for hypoglycemia. She had known coronary artery disease (CAD) and had had a coronary artery bypass graft. Her symptoms included fatigue and some depression. Despite very low blood glucose levels, the woman had hypoglycemia unawareness. The authors describe the various diagnostic tests used to evaluate this woman, including the need for three fasting studies and repeated drug screens. A magnetic resonance imaging (MRI) and angiogram of the abdomen finally showed a 1.6 centimeter enhancing mass at the head of the pancreas. Surgical excision was recommended for curative treatment, and the surgical pathology was consistent with insulinoma. In follow-up, the woman had mild hyperglycemia, suggesting that the insulinoma may have been masking mild type 2 diabetes. The authors review the symptoms of hypoglycemia, offer suggestions for the work up of hypoglycemia, consider why one of the sulfonylurea drug screen came back positive in this woman, and discuss the best imaging modalities for the diagnosis of insulinoma. 2 tables. 8 references.

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Case Study: Exercise-Related Hypoglycemia in Type 2 Diabetes Treated With Oral Glucose-Lowering Medications. Clinical Diabetes. 25(4): 150-151. Fall 2007.

This article presents a case of exercise-related hypoglycemia in a person with type 2 diabetes who was being treated with oral glucose-lowering medications. The case is a 58-year-old African-American man who was diagnosed with type 2 diabetes at the age of 52 years. In addition to diabetes, he had a history of hypertension and coronary artery disease (CAD). The man had completed 2 months of supervised exercise when he returned to his primary care physician after experiencing hypoglycemia both during and after exercise. He was exercising three mornings per week from 7:30 a.m. to 8:30 a.m. in the rehabilitation program and was walking 30 to 45 minutes on weekend days. The author describes the changes in medication that the man followed, notably discontinuing glyburide and initiating glimepiride; his metformin dosage did not change. Follow up demonstrated that his blood glucose values during and after exercise were subsequently within his target range. The author discusses how metabolic adaptations to exercise contribute to improved glycemic control and reduced cardiovascular risk factors in type 2 diabetes, how these adaptations contribute to the development of hypoglycemia in individuals treated with sulfonylureas, and why medication adjustments are the first option to consider when a pattern of exercise-related hypoglycemia occurs. 6 references.

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Comparing Oral Medications for Adults With Type 2 Diabetes: Clinician’s Guide. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ). 2007. 4 p.

This guide helps clinicians understand the current thinking on oral hypoglycemia agents used for adult patients with type 2 diabetes. The guide summarizes evidence from both observational studies and controlled trials that compare the effectiveness and safety of oral hypoglycemia agents. Standard oral hypoglycemic regimens include single drugs and combinations of two or three drugs from different classes, such as metformin and a sulfonylurea. Choosing among available oral hypoglycemia agents requires consideration of their benefits as well as their adverse effects and cost. The dose and prices of the drugs reviewed in the comparative studies are listed on the back page. As single agents, all second-generation sulfonylureas, thiazolidinediones, metformin, and repaglinide work well to reduce hemoglobin A1C levels by about 1 percentage point on average. Combination therapies reduce HbA1c levels about 1 percentage point more than single drug therapies. People taking sulfonylureas, thiazolidinediones, and repaglinide gain about 2 to 10 pounds. Metformin does not cause weight gain. This guide does not address insulin, combining oral medications with insulin, older first-generation sulfonylureas, or the new class of DPP-4 inhibitors. Readers are encouraged to consult the Agency for Healthcare Research and Quality’s website at www.effectivehealthcare.ahrq.gov for more information.

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