The Annual Congress of the AACE and the European Congress on Obesity 2013
Downloading data, CGMs and insurance coverage, and how the Mediterranean is good for your heart.
By Margaret Nguyen, diaTribe
We attended many conferences in the past two months and have been blown away by the work researchers are doing to better understand and treat diabetes and obesity. Often, the talks centered on novel molecules or techniques to care for both conditions better, but there were also sessions on the practical day-to-day management of diabetes. The following are the lessons we've learned from the best thinkers in the field.
Downloading Data is a Key Part of Diabetes Care
During his talk at the Annual Congress of the American Association of Clinical Endocrinologists (AACE) in sunny Phoenix, Arizona, Dr. Bruce Bode (Atlanta Diabetes Associates, Atlanta, GA) emphasized the critical importance of downloading insulin pump data. Unfortunately, he stated that about 30-40% of endocrinologists and 80% of internists do not download pump data (for patients, we have heard estimates that around 90% do not regularly download data). Dr. Irl Hirsch (University of Washington, Seattle, WA) also urged providers in the audience to download diabetes data. He credited the lack of insurance reimbursement and limited time as the reason why more providers do not work with the data from blood glucose monitors, pumps, and continuous glucose monitors (CGM). However, Dr. Hirsch also noted that he did not understand how it is possible to make treatment recommendations without data.
Once data is downloaded, Dr. Bode said there are two red flags that usually get his attention and cause him to change insulin doses. First, when a patient's blood glucose average minus the standard deviation (a calculation that measures the fluctuation between blood glucose measurements) is less than 75 mg/dl, it suggests that there is a lot of glycemic variability. Some researchers believe that large fluctuations in blood sugar can cause oxidative stress and contribute to long-term complications like blood vessel damage; however, this is still an ongoing debate in the academic community, and the effects of glycemic variability need to be further studied. Second, Dr. Bode often makes changes if bolus insulin accounts for less than 50% of the total daily insulin dose — in his view, these patients often have a higher likelihood of hypoglycemia.
To guide therapy adjustments, Dr. Hirsch recommends that the blood glucose standard deviation should ideally be no more than a third of the mean blood glucose, though less than half of the mean is still acceptable (e.g., for an average blood glucose of 100 mg/dl, a standard deviation less than 33 mg/dl is ideal, though less than 50 mg/dl is acceptable). Dr. Hirsch acknowledged a standard deviation less than one third of the mean is often very difficult for people with type 1 diabetes; those who are able to achieve this goal might be making some of their own insulin.
Dr. Hirsch also advised that patients do best when they override their bolus calculator 20-25% of the time. Overriding the bolus calculator means that users are adjusting for things in real-time, such as blood glucose trends or anticipated exercise. In his view, adjusting over 30% of the calculations often means one of the bolus calculator's settings is incorrect.
Should a Meal's Fat Content Affect How Much Insulin to Dose?
During the European Congress on Obesity in Liverpool, UK, researchers discussed Dr. Howard Wolpert's paper on the impact of dietary fat on blood sugar (Wolpert et al., Diabetes Care, April 2013). The participants were put on a closed-loop system and monitored for 18 hours after eating. While on the closed-loop system, they ate two meals — both had the same carbohydrate and protein content, but had different amounts of fat. When the participants had more fat in their meals, they needed more insulin (as measured by the closed-loop system's inulin dosing) and had higher blood sugars.
The question is how much insulin should be taken? Dr. Hirsch said that there is often no way to know how to do this accurately every time, as the blood glucose change due to a meal's fat and carbohydrate content is different for every meal. Dr. Bode discussed one way he knew to take account of fat content for insulin dosing: with a high-fat meal, add 20-30% more insulin and give the insulin dose as a dual wave bolus (a combination of a normal bolus and an extended bolus over several hours). Dr. Hirsch's rule of thumb was to add 10-20% more insulin for meals with a lot of protein or fat.
On the other hand, Dr. Hirsch commented that it's already difficult to calculate how much insulin is needed from carb counting alone — adding other layers of calculations might not be that helpful. In any case, both physicians asserted that a CGM is the best tool available to figure out if the right amount of insulin is taken. Additionally, Dr. Hirsch expressed optimism for upcoming technologies like Medtronic's MiniMed 530G (a low-glucose-suspend insulin pump currently under FDA review) and eventually, the artificial pancreas.
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