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Know Your Numbers, Outlive Your Diabetes

New Book on Diabetes Gives Patients a Nice Framework for Their Care

Some years ago, as part of a routine physical exam, my endocrinologist instructed me to provide a 24-hour urine sample. I don’t recall that he told me why, but I assumed it was important. Then a funny thing happened – no one told me the results. So after about two months, I called the office and asked one of the assistants.

To my surprise, we had a problem.

The test showed trace amounts of albumin in my urine. I had no idea what that meant, and the assistant didn’t say much, except to note that I needed to speak with the doctor. (Thanks.) Fortunately, my brother is a diabetologist, so I promptly called him; and he explained that microalbumin is a protein, and its presence in urine indicates early damage to the kidneys. No need to panic, he said: if caught early and treated, the problem can be reversed.

I went on an ACE inhibitor, moved to a new city, got a new endo. Subsequent urine tests revealed no microalbumin, and my current doctor believes the original result was a false positive. (Improved testing has also eliminated the need for 24-hour urine samples.)

The episode is a reminder why patients will benefit from a new book, “Know Your Numbers, Outlive Your Diabetes,” which provides a wonderful framework for tracking your care. It describes five essential tests that patients need to take on an ongoing basis – what the exams measure, what the numbers mean, and what to do if the results indicate a problem.

The book is co-written by Dr. Richard Jackson, Director of Outreach at the Joslin Clinic and Senior Investigator in the Research Division at the Center, and Amy Tenderich, a journalist who, after developing type 1 diabetes in 2003, launched a successful diabetes blog (www.DiabetesMine.com). Part of the book’s strength is the blending of authoritative medical information with the real-world experience of living with the disease. The authors, for example, emphasize the need for patients to be realistic in their care – eschewing the Platonic ideal of glycemic perfection that some authors advocate. Breaking new ground in a diabetes book isn’t easy. As the epidemic has spiraled, dozens of “how-to” books have been published in recent years – how to maintain normal blood sugars, how to eat properly, how to care for your eyes, your feet, and your heart; how to exercise or, for that matter, how not to exercise and still maintain good control.

“Know Your Numbers, Outlive Your Diabetes” is also a how-to book. In straight-forward prose, the last two-thirds cover the usual bases (exercise, food, medications, hypos, complications, travel tips, etc.) It’s a good primer for newcomers to diabetes and a solid, if overly long, refresher for diabetic veterans. But the book’s real value is its first 100 pages, in which the authors isolate the five key areas, or “health factors,” that patients need to monitor to ensure a long and full life. My guess is that most patients know about some if not all of these areas, but the book lays them out in a clear, accessible fashion. You should know your numbers for these five areas:

A1c, which measures average blood sugar levels over a three-month period.
Blood pressure, which predicts cardiovascular risk and should be taken at least every six months.
Lipids, which refer to different types of fat in your blood and have been linked to increased risk of heart disease and stroke; should be tested annually.
Microalbumin, which, as noted, refers to protein in the urine and is a sign of kidney damage; should be tested annually.
Eye exams, which screen for retinopathy, or changes on the retina; should be tested annually.

Dr. Jackson and Tenderich recommend creating a “Diabetes Health Account,” in which you add or subtract “money” based on your scores. But the real value of the chart, at least initially, is not what the numbers say but simply that you know what they are. I have to admit that while I have my blood pressure taken once a quarter and my lipids tested once a year, I have no idea what my actual results are. I trust that my doctor would tell me if they were too high, but not every patient, myself included, should be that trusting.

The good news is that if any of these tests reveal problems, patients can do something about it – as long as the problem is caught early enough. In this sense, the authors not only create a coherent framework for your health but also deliver a message of empowerment. The burden falls to the patient to act and act now.

The book is actually written for patients with type 2 diabetes, though most of the material is relevant to all types of diabetes, and type 1 patients will appreciate the overview of insulins, pens, and pumps. The text also might have been better shorter – fewer “real people” sidebars and less repetitive. In describing rewards for good outcomes, the authors write on page 55: “Rewards shouldn’t be edible.” On page 72, they write: “Remember: rewards shouldn’t be edible.” Yes, we remembered.

I’m not exactly sure how you “outlive your diabetes,” as the title says. I suspect that my diabetes will end on the day that I end. But I salute the authors’ intentions: they don’t want your diabetes to cut your life short. Knowing your numbers – and having this book – will help you do that.

James S. Hirsch

Medical Literature

Preventing Cardiovascular Disease in People with Diabetes

Cardiovascular disease (CVD), which includes heart attack and stroke, is the leading cause of death in the US today, accounting for nearly 40% of all deaths. Cardiologists have become increasingly skilled at treating people who’ve already had one heart attack or stroke in order to minimize their risk of a second one. This kind of treatment is called secondary prevention. Unfortunately, many patients don’t survive their first event, which is why it is best to treat individuals before they get their first. This is called primary prevention, and it’s particularly important for diabetic patients, who are at twice the risk of developing myocardial infarction (MI), or a heart attack, and stroke compared to the general population. Diabetes is itself a risk factor for CVD and up to 80% of type 2 diabetic patients eventually develop cardiovascular disease as a complication of diabetes.

In January, the American Heart Association and American Diabetes Association published a statement giving their joint recommendations for the primary prevention of CVD in patients with diabetes. Below we present an abbreviated version.

Patients should be individually assessed for their CVD risk level, since not all diabetic patients are at the same risk for developing CVD. Our favorite risk calculator is the UKPDS Risk Engine, but also noteworthy is the ADA's Personal Health Decisions tool.
A healthy lifestyle is still the best way to avoid CVD. Overweight patients should strike for a long-term weight loss of five to seven percent through improved lifestyle. All patients should limit fat and total calories and increase physical activity – ideally to 150 min/week of moderate intensity aerobic activities or 90 min/week of vigorous intensity aerobic activities, spread over at least three days a week.
Blood pressure control is important and should be measured at every routine diabetes appointment. Diabetic patients should have blood pressure below 130/80 mm Hg. The ADA and AHA recommend ACE inhibitors as the best drugs for controlling blood pressure. Other options include angiotensin receptor blockers.
Lipid control is also important. Diabetic patients usually have low HDL (“good”) cholesterol and high (“bad”) LDL cholesterol and triglycerides. The ADA and AHA recommend annual lipid panel lab tests, except for patients under 40 with low-risk lipid values, in which case lipid tests can be done every two years (having low-risk lipid values means meeting the targets discussed below). Lifestyle modification should be the first step in improving lipid profiles, but statins can be very helpful for reducing LDL cholesterol. The recommended target levels are: LDL should be under 100 mg/dL, HDL should be over 40 mg/dL for men and over 50 mg/dL for women, and triglycerides should be under 150 mg/dL. Fibrates can be used to lower triglycerides and niacin can be used to increase HDL, though it’s not clear yet whether it is safe to combine statins with fibrates or niacin (a trial under way, called ACCORD, is studying this question).
Some doctors recommend that all patients over 40 years of age with diabetes should take statins – although it’s not part of this piece, it is something we would definitely recommend asking your doctor about, since studies have shown that when diabetics who have completely normal cholesterol take statins, they have a lower incidence of heart attacks compared to other people with normal cholesterol who did not not take statins.
All patients with diabetes should without a doubt stop smoking. Both smoking and diabetes are major risk factors for CVD. Part of the recommendation is actually that every tobacco user should be advised to quit.
Aspirin is recommended for patients at increased risk of CVD. These include people who are over 40 years, have a family history of CVD, have hypertension, smoke, have high-risk lipid profiles, or albuminuria (a measure of kidney disease). This means that a very large number of type 2 patients should be taking aspirin.
Of course, better glycemic control is critical for diabetic patients. Epidemiological studies including EDIC, the follow up to the landmark DCCT trial, have suggested that there is an 18% decrease in CVD risk for every 1% drop in A1c for type 2 patients. The ADA and AHA recommend a target A1c of less than 7% and as near to normal (under 6%) as possible without causing significant hypoglycemia.

The bottom line: If you have diabetes, you are at higher risk of developing cardiovascular disease. Make sure you know your CVD risk level, and that both you and your doctor are keeping tabs on your blood pressure, lipid levels, and glycemic control. If you are at high risk of developing CVD, you should probably be taking aspirin, and you should definitely not be smoking. While lifestyle management (exercise and diet) is the best way to avoid CVD, many drugs can also help you meet the ADA and AHA’s recommended goals for CVD prevention.

(Buse J. B. et al. “Primary Prevention of Cardiovascular Disease in People with Diabetes Mellitus: A Scientific Statement from the American Heart Association and American Diabetes Association.” Diabetes Care. Jan 2007. 30(1):162-172.)

Self-Monitoring of Blood Glucose (SMBG)

Intuition suggests that the more often people with diabetes check their blood sugars, the better their glycemic control will be. Frequent and careful blood glucose monitoring is unquestionably useful for people who take insulin, but is monitoring necessary for all patients? The American Association of Diabetes Educators (AADE) says: “yes.” Last winter the AADE published a position statement in The Diabetes Educator supporting the use of self-monitoring of blood glucose (SMBG) by all persons with diabetes, even the most ‘stable’ type 2 patients.

The introduction of blood glucose meters revolutionized diabetes care by empowering patients to manage their own disease, but sadly the technology is still widely underused. The AADE acknowledges the controversy about whether SMBG actually improves outcomes like A1c and diabetic complications in type 2 patients, but they recommend it for all diabetes patients despite this.

Without regular monitoring and therapeutic adjustments, glycemic control tends to worsen over time for type 2 diabetes patients – this is why type 2 is sometimes called a ‘progressive’ disease. In addition, SMBG provides data to evaluate the impact of lifestyle changes, events like exercise and meals, and other common occurrences such as illness, on glycemia. It also helps guide the adjustment of diabetic medications. SMBG encourages more active patient involvement, which leads to better outcomes.

We think this AADE statement is yet another reminder of the need in diabetes for more short-term investments in education in return for long-term payoffs in outcomes. The AADE advocates extensive education for preventive behaviors in people with diabetes. We agree, but unfortunately, diabetes education remains difficult to obtain and even more difficult to get reimbursed, which is why patients need to be as proactive as possible with doctors, nurses, and any other healthcare professionals.

The bottom line: Self-monitoring of blood glucose is recommended for all patients with diabetes, both type 1 and type 2. Short-term investments in diabetes education can make a big difference in long-term payoffs of better outcomes and fewer complications.