Dr. Qaadri

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Medical Post Diabetes Interview - 2

By Dr. Shafiq Qaadri, MD

Three million Canadians have diabetes, yet substantial numbers remain undiagnosed. Why?
They haven’t been screened on a prudent basis. It can actually take several years for a patient to be diagnosed, because the condition can remain completely asymptomatic.

That’s why often the condition is picked up during a routine office check-up, and not necessarily because the patient had symptoms.

What are the general signs and symptoms that a family doctor should look for in diagnosing type II diabetes?
These include excessive urination, excessive thirst, unexplained weight gain or weight loss, frequent infections, slow wound healing, visual disturbances, numbness and tingling, and so on.

Because accurate blood glucose measurement is necessary for proper treatment, how frequently should patients measure their sugars?
According to guidelines of the Canadian Diabetes Association, people over the age of 40 should be screened for type II diabetes every three years.

This can be increased to every year in those who have additional risk factors—such as a family history of diabetes, obesity, and other indications of the metabolic syndrome.

In my own practice, I include a fasting glucose as part of routine screening, starting earlier than age 40. I think this is important as we are seeing much younger patients being diagnosed with type II diabetes, including teenagers.

How often is a person with diabetes supposed to measure his glucose?
Generally speaking, I advise patients to measure their sugar at least once per day. But this also depends on the degree of diabetes, the number of medications, how good their general sugar control is, and so on.
If a patient is on insulin, particularly if they are on a multiple injection regimen, they would be required to measure their sugars even several times a day.

What are normal blood glucose levels?
A fasting blood glucose should be between 4.0 to 6.0 mmol/L. Once a patient is in the range of 6.1 to 6.9 mmol/L, that is considered to be impaired glucose tolerance, otherwise now known as pre-diabetes.

What steps can a diabetic patient take to ensure that their blood glucose is well-managed?
There are a number of issues that patients must involve themselves in to obtain adequate control. The first is proper education, and then proper dietary control. In my practice, once a patient is diagnosed with type II diabetes, or even pre-diabetes, I recommend referral to one of the designated diabetes education centres.

These centres have been shown to be very useful in helping to educate patients about the essentials of diabetes management—for example, issues concerning the glycemic index of foods, meal planning, calorie restriction. The level of interaction is usually beyond that what most family doctors would have time for in the practices.

As well, a regular exercise program is strongly encouraged. Patients need to increase their level of activity. We encourage at least 30 minutes of exercise three to four times per week, and if possible, even daily.
If diet and exercise is not enough, then we move to medications to achieve tight glycemic control.

Can the obesity battle be won?
This is probably one of the greatest challenges of the century, certainly in North America. Unfortunately, the issue of obesity is getting worse, and this is likely the reason why there is such a rapid increase in the number of patients diagnosed with type II diabetes.

It’s going to take a lot of effort, education, and reinforcement in assisting our patients in battling the bulge. It’s not easy, but it can be done…I have often seen in my own practice individuals who are quite overweight, who have very elevated sugars, but who normalize with concerted effort and without medication.

Once you are a ‘pre-diabetic,’ how long does it take you to be diabetic?
That’s a very individualized question. In general, diabetes is a progressive disease, but the timeframe can vary. Unfortunately, most pre-diabetics do seem to go on to become fully diabetic. This may be a matter of one year, two years, sometimes beyond, but not very much longer than that.

How do fluctuations in blood glucose levels cause complications?
Hyperglycemia is what causes diffuse organ disease. It results in microvascular and macrovascular complications: coronary artery disease, nephropathy, ultimately end-stage renal disease requiring dialysis, peripheral vascular disease leading to gangrene and possible limb amputation, neuropathy causing chronic pain and tingling in extremities, retinopathy leading to blindness, erectile dysfunction in men.
Hypoglycemia, perhaps as a result of too much medication, particularly with insulin, or not eating at the proper time, or not eating enough—causes a range of signs and symptoms include feeling faint, sweats, loss of consciousness, seizures, and even coma.

How often should a diabetic patient see a doctor in order to optimize sugar management?
Once patients are stabilized—when their glycemic control is at a reasonable level, say a HbA1C of less than 7.0%--then I suggest the patient follow up every three months. This would then include repeating the HbA1C test.

What are the options available to patients for home blood glucose monitoring?
I recommend that all patients who are diagnosed with diabetes, or even pre-diabetes, obtain a blood glucose monitor. There is a huge selection to choose from, and all glucometers, when operated properly, perform well.

There’s some attention being given to this idea of coding or calibrating a glucose monitor. What is this?
Most glucose meters require calibration prior to a new batch of glucose strips being utilized. This calibration ensures that test results are going to be accurate…This coding is an electronic calibration done to the meter, equivalent to setting a weight scale to zero prior to weighing yourself.

What’s involved in doing this coding depends on the type of meter one has. Certain meters require a special electrode being inserted into the test strip slot, prior to a new batch of strips being used. Then the meter is coded for that batch…Other meters actually require the replacement of a chip within the meter itself. And some machines require you to select a digital code from a menu on the glucometer display, from up to 69 different codes, to match your new box of test strips.

The problem with coding is that it is highly prone to error. For example, according to a recent survey, only 54% of diabetic patients even knew that they were supposed to code their meter in the first place. Another study showed that of the patients who did code their meters, 20% did so incorrectly.

The implications are great: if you miscode a meter, your results can be off by as much as 40%. That may lead to mismanagement of the patient’s diabetes, as practitioners do rely on these results for making adjustments to therapy.

Who is generally responsible for telling patients to do this?
Doctors recommend that their diabetic patients pick up a glucometer. They don’t generally recommend a specific meter, or much else. So it’s left to the pharmacist.

But pharmacists tell me that teaching patients how to code is particularly time-consuming, especially for elderly patients…Our elderly diabetics may just not get it.

What is this idea of automatic coding?
Automatic coding means that there is no manual procedure that has to be done to the meter prior to using the test strip. You simply insert the strip or the disc, and measure away…There is a certain reassurance that we can then be sure that the glucose monitoring is going to be as accurate as laboratory testing each time.

Can you graph these results?
Yes. Very quickly I’m able to have a snapshot of their glycemic control, including trends, daytime variations and longterm variations. This helps me to make management decisions efficiently.

One of the most useful features, for example, is the graph of the daily average glucose over time. I have graphs of some patients that have all their sugar measurements over several years.

It surprises me that these tools are being used by relatively few doctors.

With a view of three years of glucose data, that’s a broader view than even the HbA1C, which covers only three months. Can you comment?
One could think of it that way. These tools are providing all the patient measurements, hundreds of data points, with analysis.

Of course, this does not mean we stop measuring the HbA1C, but I do find that this powerful data complements therapy with a view to assessing longterm control.

Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education lecturer. www.doctorQ.ca

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