Heads or Tails

Deciphering case studies of unexplained glucose levels.

Theresa Garnero By Theresa Garnero, APRN, BC-ADM, MSN, CDE

Several readers asked questions about glucose fluctuations. Figuring out glucose patterns can be quite difficult given the multiple variables at play. Keep in mind this over-simplistic statement: a single glucose reading provides somewhat historical data leading up to the point the blood sample was taken; medications, food, exercise, stress and illness are just a few of the factors that can impact future readings. It's the pattern or trend that can unveil the answer to some of these perplexing case studies as well as exploration of specific clues presented.

Let's review the 7 cases:

Q. If the only time I have a blood glucose level above 100 is upon awakening, is this really "pre-diabetes? Both of my siblings have type 2 and I am determined to prevent this in myself.

A. Unfortunately, yes. The research is solid in this regard. Have you had an oral glucose tolerance test to see how your body responds to a glucose load? You indicated a strong family history. The rising, fasting level is usually a late sign (after meal highs are typically the first glucose to go high). The Diabetes Prevention Program showed by walking about 30 minutes a day can prevent diabetes. You didn't mention exercise. This could be your key.

Q. What are the signs of high glucose? I had a 211 and it felt like I was drunk.

A. Typical symptoms of hyperglycemia (glucose levels above 200) include tiredness, increased thirst/urination/hunger, blurred vision, and dry/itchy skin. Ironically, when glucose values are high, the cells within the body are not getting enough glucose. They do not have the "fuel" to function. Feeling drunk and extremely tired share similar qualities. A 211 reading is not that extreme (yes, it's above target), and yet, it may have been high enough to feel like this. Was the 211 reading taken 2 hours after a meal? Could it have been higher previously and not captured?

Q. How does illness affect blood sugar levels? My readings while on antibiotics for a chronic sinus infection have been much higher than normal.

A. Illness causes a release of hormones in order for the body to fight infection, or deal with injury or stress. The issue here is not the antibiotic. How high did your glucose get? Your body is trying to deal with an infection, which is a classic culprit for raising glucose levels, sometimes to an extreme level. (The highest I noted was 1,600; that didn't happen over night.) Keep testing and let you doctor know if your glucose stays consistently above 250.

Q. My mother is 87, weighs less than 100 pounds and has been having a lot of dizziness, weakness, double vision, night sweats and bad dreams. I have a feeling it is low blood sugar. What is too low? Maybe she should eat something to keep her sugars up while she sleeps.

A. Less than 70 with symptoms (as described) is considered hypoglycemia. Please call the doctor who is prescribing her diabetes medication at once. Bad dreams are a classic sign of hypoglycemia, as are the other symptoms you described. You could also give her a snack before bed, or even a time-released glucose bar (like Extend or NiteBite), but the cause needs to be addressed before simply trying to treat the effect. Do you have a meter to see how low she is going? Hypoglycemia is dangerous business. Have this looked into immediately.

Q. I have a patient with extremely high evening glucose values (400-500s) who will bottom out in the next morning in the 30-70s if we give her insulin sliding scale coverage (she takes Lantus 30 units in the morning). She has seen an endocrinologist to no avail for an explanation to this phenomenon. She has had type 2 for over two decades. What could explain these events?

A. More questions arise than insights: Has a continuous glucose monitor been considered to help figure out patterns? What is happening in the food department (has she seen a registered dietitian as of late)? Are there other diabetes medications on board that could prolong hypoglycemia? How is her kidney function? What kind of short-acting insulin is she taking? Does she have mealtime and correction factor insulin regime (sliding scale chases blood sugars at best). Has her insulin administration technique been double checked? She may also benefit from a change in long-acting insulin (Levemir). There are many things to consider.

Q. Is there any publication that lists fruits, vegetables, and meats that a type 2 diabetic with normal weight should avoid, as well as foods to indulge?

A. Yes. It's called, "Everyone should eat as healthily as people with diabetes," and I'm going to write it now. Seriously, I am not aware of any list. It is a matter of making wise food choices most of the time. What holds true for the general population rings true for people with diabetes: avoid fried stuff, eat more vegetables, minimize fat intake, and check those glucose levels to see how your body responds to the food choices. A list could never tell you how your body will react. Plenty of books are available that help you to identify the amount of carbohydrates, fat, and protein in a particular food which can help you to make an informed choice.

Q. I have type 2 diabetes and am on the maximum doses of Actos, Glucotrol, and Glucophage. I exercise and am reasonably diet conscious. My fasting is around 100. Then, in about an hour, it starts to climb, even though I've started my morning medication and only had decaf coffee. I've seen it rise well over 200 sometimes when I exercise and don't have breakfast. I get a burning sensation on my face and feel tired. Sometimes it goes low in the evening. If I drink alcohol, it goes below 80 and then back up to above 200. My A1C is 6.6% and I am at a loss as to what it is due to.

A. Your frequent glucose excursions paint an illusion of control with an ideal A1C level. You raise several issues.

Being on the maximum dose of these medications may mean your pancreas is thinking about going on vacation without you, in which case switching to insulin could be a smart move (ask your doctor or diabetes specialist for their opinion). We tend to overlook that diabetes is a progressive disease and therefore treatment needs to change from time to time to keep ahead of escalating glucose levels.

Taking medications (in particular Glucotrol) without breakfast is asking for trouble — hypoglycemia. The liver puts extra glucose into the system during periods of lows or lack of food for more than 5 hours, as it does during exercise. If you check your glucose immediately after exercise, it may seem as though you are too high when in fact it is the liver response (this typically resolves 30 minutes after exercise).

Alcohol is risky business, especially with fluctuating glucose values. Best to wait until you speak with your diabetes care provider to figure out the next step before imbibing.

Read Theresa's bio here.

Read more of Theresa Garnero's columns.

NOTE: The information is not intended to be a replacement or substitute for consultation with a qualified medical professional or for professional medical advice related to diabetes or another medical condition. Please contact your physician or medical professional with any questions and concerns about your medical condition.

Last Modified Date: May 24, 2013

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