Frequently Asked Questions


Why are my blood sugars higher in the morning than when I go to bed the night before?
Why are my blood sugars all over the place?
Why do I need to keep a log book of my blood glucose readings and insulin doses?
What is carb counting all about and do I need to do it?
What is the difference between type 1 and type 2 diabetes (and what if I don't fit either type)?
Three related questions:
1.    Why are my blood sugars getting worse even though I’m working so hard at keeping them down?
2.    If I have type 2 diabetes, why would I have to take insulin injections?
3.    Now that I'm taking insulin injections, does that mean I now have type 1 diabetes?
Should I take an ACE inhibitor or ARB to lower the risk of diabetes damaging my body?
Should I take a statin to lower the risk of diabetes damaging my body?
I eat a low fat diet, so why is my cholesterol level still high?

Why are my blood sugars higher in the morning than when I go to bed the night before?
This typically occurs due to the dawn phenomenon. The dawn phenomenon is the rise in blood glucose levels in the dawn (that is, the morning) due to excessive release of glucose from the liver into the blood. Here is a graph of a person’s blood glucose readings measured with a device (a “continuous glucose monitor”) that automatically measures the body’s glucose level about 300 times per day (each colour represents a different day):

As you can see in the preceding graph, every day starting at about 3am this person’s glucose levels started to go up. This individual, like so very many others living with diabetes who have high blood glucose levels first thing in the morning, blamed themselves and attributed their elevated morning blood glucose to having overeaten or snacked the night before. Not so! What they (and you) eat at bedtime (or suppertime) seldom is a significant factor in leading to high blood glucose levels the next morning; heck, the food you ate the night before is long since digested, absorbed into the body, and metabolized well before the following morning’s breakfast. This graph nicely illustrates that point.
One colourful term for the liver’s tendency to release glucose into the blood overnight is a liver leak. How much sugar (glucose) gets released from the liver if you have the dawn phenomenon? How about this: Almost as much as is contained in TWO CANS OF COLA!
If you have the dawn phenomenon this is something that is not simply to be accepted. Rather, your therapy should be adjusted to fight it so that your blood glucose levels are kept within target of 4-7 mmol/L before breakfast. The usual best way to deal with the dawn phenomenon is to take a dose of NPH, Lantus, or Levemir insulin at bedtime. If you are already taking one of these insulins at bedtime then it may be that your dose needs to be adjusted. Speak to your doctor or diabetes educator to find out what the best measure is for you.
If you are already on NPH, Levemir or Lantus insulin yet your morning time blood glucose is still elevated, then it is likely either that:
·         Your insulin dose is not sufficient, or
·         Your insulin has worn off. This is particularly likely to be the case if you are taking NPH insulin at supper or Levemir insulin (only) in the morning.
Rebounding (the so-called Somogyi phenomenon) is commonly cited by diabetes health care practitioners as a cause of high morning blood glucose readings. If you are rebounding it means that you had a very low blood glucose overnight, slept through it, and your liver poured out so much glucose into your blood to bring your blood glucose back up that it ended up making too much and overshot the mark and as a result your blood glucose was high when you awakened. Okay, that makes sense. Except that recent medical studies suggest this doesn’t actually happen and that rebounding doesn’t even exist! My strong expectation is that within the next few years we will have conclusive evidence for the non-existence of rebounding. (Of course, if you have a low blood glucose overnight and over-treat it – as, by the way, most people would; awakening overnight with a low blood glucose is scary! – that will make your morning blood glucose level elevated.)


Why are my blood sugars all over the place?
Many people (perhaps including yourself) – especially if they are on insulin therapy and, in particular, have type 1 diabetes - find that, try as they might, their blood glucose levels go up down, down and up – ostensibly for no reason. As people in this situation often say, “my blood sugars go up and down like a toilet seat.” If you are in this situation you may find yourself feeling incredibly frustrated. (I sure would!)
Sometimes people with erratic blood glucose levels are said to have brittle diabetes. Well, if you’ve been labeled as having ‘brittle diabetes’ hang on to your hats ladies and gentlemen, because I’m going to be really frank here and tell you that in the great majority of cases (maybe all cases) this is an inappropriate label which erroneously implies that you’re stuck with these erratic blood glucose levels and you’d better get used to it. Geesh, nothing could be further from the truth! There is always a reason for erratic blood glucose levels and if you’re having this problem, you and your health care providers need to play Sherlock Holmes and find out what is the cause!
There are many possible causes of erratic blood glucose levels including:
* There’s a problem with your diet: either you’re on the wrong nutrition program or your diet is overly variable or you need to be (re-)taught ‘carb counting’ or you need to eat healthier or...
* There’s a problem with your exercise regimen: either your exercising inconsistently or the intensity/duration of your exercise is exceptionally variable, or your treatment schedule (in particular your insulin) needs to be changed to account for your exercise, or...
* You have a problem with your digestion such as celiac disease or diabetic gastroparesis. (If nutrients are being eaten but not absorbed into the body properly, that is a sure fire way to muck up blood glucose levels.)
* Stress. Yup, stress does affect blood glucose levels. But if stress is part and parcel of your life (as it is of so many lives) your blood glucose levels can still be well controlled so long as your treatment program is tailored appropriately to your needs.
* Menstrual cycles. Some women find that around their periods their blood glucose control worsens. If this happens to you, your insulin treatment may need to be adjusted for “that time of the month.”
* Shift work. Shift work is a notorious cause for erratic blood glucose levels. Diabetes loves consistency and shift work is anything but. If you are able, try to have a straight shift (regardless whether this is days, nights, or something else). If this is not possible, your blood glucose control can still be maintained but your insulin schedule may need to be overhauled. My preferred strategy for my patients with type 1 diabetes who perform shift work is for them to use an insulin pump or, failing that, using Lantus (or Levemir) insulin once daily (given at the one time of day they are always certain to be awake) and a rapid-acting insulin (Apidra, Humalog, or NovoRapid) before meals (whenever those meals happen to be for a particular shift).
* Your insulin isn’t working optimally for you. This can occur if:
* The insulin is not being consistently absorbed from your injection sites as may happen if you are injecting into areas of your skin affected by lipohypertrophy. Lipohypertrophy is fat build-up that develops in areas in which insulin is injected overly often. (Therefore you must ensure you don’t repeatedly inject your insulin into “a favourite spot”...something so many people, unfortunately, do.) Here’s a picture of someone’s thighs that were affected by lipohypertrophy:

* You are taking NPH insulin. For many people NPH insulin work perfectly fine, but for some people it acts inconsistently in which case you’d be better off taking Lantus or Levemir instead of NPH. (Lantus and Levemir often act more predictably than NPH insulin.)
* You are missing insulin doses. (Of course.)
* You are on a “cloudy” or “milky” insulin (that is, NPH or a premixed insulin like 30/70) and aren’t sufficiently mixing the insulin vial or cartridge.
Gee, I could get writer’s cramp listing every possible cause for erratic blood glucose readings. The above represents just a partial list! The point is: don’t ever let anyone label you as having brittle diabetes unless every single other possible reason (including the ones in the preceding list) have first been considered and ruled out.

What should my blood sugars be?
The Canadian Diabetes Association recommended targets for blood glucose are:
  • Before meals: 4 to 7 mmol/L
  • Two hours after (the start of) meals: 5 to 10 mmol/L (5 to 8 mmol/L if your A1C is above target despite having your before-meal values 4-7 and after meal values 5-10).
  • A1C 7 or less
What is the best medicine for me to take to help me control my blood glucose levels?

Any medicine used to control blood glucose levels should be seen as complementary to the benefits you can achieve with healthy eating, regular exercise, and weight control.

If you have type 1 diabetes then insulin is the absolutely essential medicine you must take to help you control your blood glucose levels (and to keep you alive!). (There is some early - that is, not-yet-proven - evidence of additional benefit to the occasional person living with type 1 diabetes who has high blood glucose levels despite taking substantial doses of insulin, by taking a GLP-1 anaolgue such as Victoza (liraglutide) or Byetta (exenatide); or a SGLT2 inhibitor such as Invokana (canagliflozin.)

If you have type 2 diabetes there is a wide variety of different medications available to help you control your blood glucose levels. I look at their pros and cons here.


What is an A1C (and what should my A1C be)?

The A1C (also know as hemoglobin A1C, glycosylated hemoglobin, Hgb A1C, HbA1C) is a blood test that you should have performed several times per year if you have diabetes. Your result indicates what is your overall blood glucose conrol over the preceding seveal months.

The Canadian Diabetes Association recommends that you strive for an A1C of 7 or less.

How important is it to monitor and optimize your A1C level? Well, how about this...the landmark UKPDS study showed that if you drop your A1C by one percent (which is equivalent to about a 2 mmol/L drop in your average blood glucoselevel), you will reduce the likelihood of many diabetes complications by almost 40 perdent! Therefore, even if you aren't yet at the target A1C (and indeed even if you never reach target) it is important that you know that any reduction in your blood glucose (and, hence, your A1C) will substantially reduce your risk of diabetes damaging your body. So if your A1C was 10 and you get it down to 9 pat yourself on the back; you've just reduced your risk of eye and kidney damage by almost 40%!

Hemoglobin is the substance in red blood cells that carries oxygen to the cells. Glucose (the sugar your body uses for fuel) attaches to red blood cells. The A1C test measures the amount of glucose that has become attached to your red blood cells throughout the lifespan of your red blood cells (about 3 to 4 month).

It is important to be aware that A1C levels are measured in different units and on a different scale than is blood glucose; hence an A1C level of 7 is not the same as saying that your average blood glucose is 7. Here is a table that estimates what one's average blood glucose level is for a given A1C
 

 A1C (%) 

 Average blood glucose (mmol/l) 

5

5.4

6

7.0

7

8.6

8

10.2

9

11.8

10

13.4

11

14.9

12

16.5

 
 



How do I adjust my insulin?
If you are being treated with insulin, in order for you to achieve the best possible blood glucose control it is essential that you learn how to adjust your insulin doses. Unlike the great majority of prescription drugs, insulin is not to be taken in a fixed dose day-to-day. Think of it this way; if you are giving yourself insulin, it is to replace what your pancreas should be doing, but is unable to. A normal pancreas makes a different amount of insulin every day so you need to do this also.
Learning how to adjust one’s insulin dose isn’t easy, but it is definitely do-able. The single most important step in learning how to adjust your insulin dose is to be taught this skill by an expert like a diabetes educator or a physician who specializes in diabetes.
Of the many factors involved in determining your insulin dose, these four are especially important:
* What your blood glucose level has been running for the preceding several days.
* What your blood glucose level is at the moment you’re about to give your dose.
* What food (especially, carbohydrates), if any, you’re about to eat.
* What exercise, if any, you’re about to do.
The most common exception to the rule about needing to take a different amount of insulin day-to-day is the person whose life (eating, activities, stress level, etc) is remarkably consistent and whose blood glucose levels are consistently within the target appropriate for them. In this case, taking the same insulin dose day-to-day may work just fine. (The group of people for which this is most likely to be the case are people who are both elderly and sedentary.)
Although learning how to adjust your insulin dose requires some work, following some basic principles will get you quickly headed in the right direction:
(Remember my disclaimer about this web site: This info is only of a general nature and make no change to your therapy until you first get advice specific to your needs from your own health care providers.)
1. If you are taking NPH, Lantus or Levemir insulin at bedtime:
If your blood glucose is above target before breakfast, increase the dose of your bedtime NPH, Lantus or Levemir by 1 unit nightly until your before-breakfast blood glucose is in target (4 to 7 mmol/L). (This does not apply if the reason your blood glucose is up before breakfast is because you treated an overnight low.)
Do not make the ever-so-common mistake of adjusting your dose of NPH, Levemir, or Lantus bedtime insulin based on your bedtime blood glucose level. Your bedtime blood glucose level, regardless of how elevated, has no bearing on what dose of bedtime NPH, Levemir, or Lantus insulin you need! If your bedtime reading is high this is dealt with by adjusting other aspects of your therapy.
2. If you are taking Apidra, Humalog or NovoRapid (called NovoLog in some countries) before your meals:
Determine your dose based on:
* Your blood glucose before the meal. The higher the reading the more insulin you will need in order to bring your blood glucose level down (this is called a correction factor).
* Your blood glucose levels the past few days after that meal. If they are running above target (target is usually 5 to 10 mmol/L) then you will need a higher dose.
* How much carbohydrate (apart from fiber) you’re about to eat.
* Other factors may also be need to be considered such as what exercise you’re about to do (you do exercise, don’t you?), whether you’re going to be drinking some alcohol, etc.
Sound complex? Sure it is! But if your lifestyle (food choices, activities, etc) is pretty consistent day-to-day then it can be pretty straightforward. Here’s an illustration…let’s say the following table illustrates your average readings (and insulin doses) for the past few days:
 
Before-breakfast
2hours after breakfast
Before lunch
2 hours after lunch
Before supper
2 hours after supper
Bedtime
Blood glucose
4.5
10.4
9.9
8.6
7.0
6.9
7.4
Insulin Dose
Humalog  5 units
 
Humalog  9 units
 
Humalog  6 units
 
Lantus   12 units
So what do you notice about the preceding values? You likely observed that this person’s blood glucose readings are within target except for after breakfast and before lunch. Solution? Well, the first thing is to make sure breakfast doesn’t consist of 8 pancakes washed down with 4 Tim Horton’s “double doubles” in which case it’s not your insulin that needs changing; it’s your diet! Anyhow, trusting your breakfast is reasonably healthy, if your blood glucose is, like in the preceding illustration, too high after breakfast (and, in this case, carrying over to the before-lunch period of time) then what you need is more insulin with your breakfast. So, in this example, taking 5 units of Humalog isn’t enough you should increase your dose by 1 unit daily until your after-breakfast blood glucose is within target. See? Simple!
3. If you are taking premixed insulin (such as 30/70…called 70/30 in the US) before breakfast (and before supper):
Adjusting premixed insulin can be easy or tricky. If you are taking premixed insulin before breakfast and your blood glucose is consistently too high all day (including before lunch and before dinner) then you need to increase your dose daily until your readings are in target. Conversely, if your readings are consistently too low all day then you need to progressively reduce your dose.
Similarly, if you are taking premixed insulin before supper and your blood glucose is consistently too high in the late evening, overnight, and before breakfast, then you need to increase your dose daily until your readings are down into target.
But what about the situation where your blood glucose is, for example, good before lunch, but too high before dinner? If you increase your morning premixed insulin dose (as you attempt to bring down your dinner-time reading) you’ll end up going too low before lunch. That’s the main problem with premixed insulin; by definition its premixed with a short-acting insulin and a longer-acting insulin and so if you need more of the one and not of the other you’re stuck. That’s why for most people who require insulin (and for virtually all people with type 1 diabetes) I prefer using a rapid-acting insulin before meals and a longer-acting insulin at bedtime; this gives infinitely more flexibility when it comes to adjusting insulin doses.


Why do I need to keep a log book of my blood glucose readings and insulin doses?
Many people tell me that they do not need to keep a log book of their blood glucose readings and insulin doses, "because my meter has a memory." True enough. It does. But, if you don't keep a log book then you are not going to be able to recognize trends and patterns in your readings. An up-to-date log book stares you in the face. It reveals the patterns and provides the clues as to what changes to make to your therapy, be they dietary, insulin or otherwise. A log book is not meant to simply be a historical record and it is most definitely not a report card. It is an interactive tool to assist you in deciding how much insulin to give every time you are due for an insulin injection. If you don’t use your log book as an interactive tool, then you’ll likely find keeping a log a waste of time; sort of like entering data into a computer program every day and never running the software to analyze it.
You can find an illustration of the best format for a log book here.



What is carb counting all about and do I need to do it?
Carb counting (short for "carbohydrate counting") is a technique wherein you give an amount of rapid-acting insulin (Humalog, NovoRapid, Apidra) based primarily on the amount of "carbs" you are about to consume. The idea is that a certain amount of carbohydrates is likely to raise your blood sugar level by a predictable amount and thus, you can take an amount of insulin proportional to your carb intake to prevent this rise in blood glucose from occurring. Carbohydrate counting is essential if you are using an insulin pump and is often of major value if you are taking injections of rapid-acting (Humalog, NovoRapid, Apidra) before meals; especially if you have type 1 diabetes. Speak to your diabetes educators (in particular, your dietitian) to see if this would be a helpful technique for you.



What is the difference between type 1 and type 2 diabetes (and what if I don't fit either type)?
Typically, type 1 diabetes in children, adolescents or teenagers and require immediate institution of insulin.
Typically, type 2 diabetes develops in middle-aged or older persons who are overweight and can – at least initially - be managed with lifestyle therapy and non-insulin medications.
Okay, so that’s how things are “typically,” but as with so many things in life, there are very many exceptions. Indeed, there are many middle-aged people who develop type 1 diabetes and there are increasing numbers of children who develop type 2 diabetes.
There are also a large number of adults who, based on their age (and, often, based on their body size) are thought to have type 2 diabetes, but who don’t get their blood glucose levels down despite usual therapy with lifestyle and non-insulin medications and, soon after diagnosis, require insulin therapy. Such people often have a form of type 1 diabetes called LADA (Latent Autoimmune Diabetes in Adults). Just to make things even more complicated, there are a whole bunch of other names for LADA:
  • Slowly Progressive Diabetes (SPIDDM)
  • Type 1 1/2 diabetes
  • Type 1.5 diabetes
  • Antibody Positive Type 2 Diabetes
  • Youth Overt Diabetes of Maturity
  • Latent Type 1 Diabetes
  • Progressive Insulin Dependant Diabetes Mellitus
  • Double Diabetes
  • Latent Autoimmune Diabetes of Youth (LADY)....hmm, I wonder how many of my male patients would like to be told they have LADY?
One helpful way to distinguish type 1 from type 2 diabetes is to do a blood test for a special protein called a GAD antibody. This antibody is almost always present if a person has type 1 diabetes and is almost always absent if someone has type 2 diabetes.
Does any of this matter? Well, often it doesn’t, but there is at least one situation where it does; that is, the instance where a person with LADA is unsuccessfully treated with oral medicine after oral medicine in a fruitless attempt to control their blood glucose levels when what they really need is insulin!



Three related questions:
1.    Why are my blood sugars getting worse even though I’m working so hard at keeping them down?
2.    If I have type 2 diabetes, why would I have to take insulin injections?
3.    Now that I'm taking insulin injections, does that mean I now have type 1 diabetes?
If you have type 2 diabetes, your pancreas is gradually losing its ability to produce insulin. This graph illustrates the point:


As you can see, if you have type 2 diabetes then at the time you were diagnosed your pancreas was only making ½ of the insulin it was supposed to and, as time passes, it progressively loses more and more of its ability to make insulin. Eventually, your pancreas simply can't make enough insulin to keep up with your body's needs and all the non-insulin diabetes therapies in the world won't be sufficient to keep your blood glucose levels in check.  When that happens, insulin injections become a necessity. This is not your fault! It is your pancreas that is failing, not you that is failing. (So don’t feel guilty!)
If you have type 2 diabetes and are on insulin therapy you still have type 2 diabetes, not type 1 diabetes.



Should I take an ACE inhibitor or ARB to lower the risk of diabetes damaging my body?
ACE inhibitors and ARBs (I list the various types below) are medications that were created years ago to help control high blood pressure, but medical research subsequently discovered that even if a person with diabetes does not have high blood pressure, taking an ACE inhibitor or ARB will still reduce the risk of having a heart attack or stroke if you are at high risk for these complications. These medicines also can help prevent existing kidney malfunction from worsening.
So the answer to the question is “yes,” you should take an ACE inhibitor or ARB to protect your organs if you are have diabetes and any of the following:
·         High blood pressure
·         High risk of a heart attack or stroke (You can find out if you are at high risk here.)
·         Kidney malfunction
These are the generic names for the available ACE inhibitors and ARBs (you can find the generic name for your medicine on the label affixed to your pill bottle or box):
ACE INHIBITORS
ARBs
Benazepril
Candesartan
Captopril
Eprosartan
Cilazapril
Irbesartan
Enalapril
Losartan
Fosinopril
Telmisartan
Lisinopril
Valsartan
Perindopril
 
Quinapril
Ramipril
Trandolapril
 


Should I take a statin to lower the risk of diabetes damaging my body?
Statins are medicines that improve cholesterol levels in your blood and they do this very well indeed. Particularly effective are atorvastatin (Lipitor) and rosuvastatin (Crestor).