November 06, 2019 Managing high and low blood sugar

[00:00:05] Thank you for your kind introduction, Jen. It's a great pleasure to be asked to provide some insights about managing high and low blood sugar for people with type 2 diabetes. First, I would like to acknowledge that I am presenting today from Regina, which is located in the traditional lands referred to as Treaty 4 Territory, the original lands of the Cree, Ojibwe, Soto, Dakota, Lakota and on the homeland of the Metis nation. This acknowledgement is important to me because much of the work that I do is with indigenous peoples in various community communities across the country where type 2 diabetes presents a challenge to keep blood flowing now and several generations from now. I have learned so much from our First Nations peoples about diabetes and we share hope about the possibilities for the future as we sit alongside each other and roll up our sleeves together to learn about managing high and low blood sugar in type 2 diabetes. So it's much to their credit that I share some insights today. I'd like to also acknowledge Diabetes Canada in the invitation and also in the great work that has been done continuously over a long period of time. And also that this is based on evidence, this presentation, and comes from our Clinical Practice Guidelines which guide our practice in Canada. And this is a short 20 minute presentation, so is meant not to be comprehensive, but is to inspire you to go seek the information, to tailor your responses and understanding about type 2 diabetes and to work with your team to make sure you have the best things possible for you. So you'll see on the second screen that the full guidelines are available for you to look at with all the chapters. And in each of the chapters there is a special section, one particular section that is written for people with diabetes. So that's important to go have a look and to share in the discussions with your health professional who are on your team to help you assist and understanding what's possible for you. So we have some objectives for the short 20 minute webinar, and that is to discuss really what it means to manage high and low blood sugar, which is essentially the essence of self-management. So what is this all about? This is about self-management and empowerment. So you are at the centre of the model. You are the expert. And as my dietician colleague and I like to say, we like to put you in the driver's seat of diabetes self-management. With that there's balance and we're always striving for the quality of life combined with happy blood vessels. We try to share the knowledge around what's happening in our bodies as they were designed. So we use Mother Nature terminology, so mimicking Mother Nature as closely as possible and find that balance between your quality of life and all the parameters around happy blood vessels. Keeping in mind that Mother Nature is very, very precise and that's what we're trying to do. We want to understand that there is knowledge to action. So understanding what affects blood sugar, how to check it and most importantly, knowing what to do and that knowledge informs action. And also to advocate how do you talk to your team to individual your plan of care, keeping in mind that new science and evidence is emerging every day. And what you learned when you were first diagnosed with diabetes may not have may not be what's currently recommended or at least not the top of the game, so to speak. So we want to make sure that you're aware of all the very innovative devices, medications, insulins and tools to support you in your living with type 2 diabetes, because there are great options and you absolutely deserve the best. So our pathway today is going to be talking about Mother Nature, physiology, understanding that what's going on in our bodies in a brief kind of way relating to high and low blood sugar. What's happening in Type 2 diabetes that interrupts that Mother Nature approach? And also, what are the medications and monitoring things to consider? Again, just touching upon them lightly and then emphasizing individualized targets. And then we'll get into a little bit of the meat of highs and lows. So let's get started. What makes blood sugar go up or down? So in our sessions, we have people on a flip chart discuss what are the things that make blood sugar go up and down and there are numerous, numerous things that impact blood sugar. There we had the opportunity to hear a guest speaker from the United States at our professional conference in October, and Adam Brown, and he spoke about I think it was 42 or 43 reasons blood sugars go up or down. He has a website or a blog named Diatribe so you may want to have a look at that to see what resources are available. But it was a quite an invigorating discussion around diabetes management from the perspective of a person with diabetes. So in quite simple terms, they're the two primary things topping the charts in terms of what makes blood you grow up or down is glucose and insulin. So essentially, glucose or sugar is what fuels our bodies. So whether it's from the food that is broken down into sugar and goes into our cells to be burned for energy or whether it's sugar coming from our bodies in the absence of food, say, for example, from the liver, which surprisingly for some people is a source of sugar to keep our bodies going in the absence of food. So overnight, sometimes you might have a higher blood sugar when you wake up, and that's from the sugar that's coming from your liver. And also, there are other things at play like hormones and we'll talk about that in a bit. And of course, insulin is the hormone produced in the pancreas that lowers blood glucose based on the glucose that's available. So there is a signal to say we need this much insulin to match the glucose. And then Mother Nature produces exactly the right amount of insulin to match that. Now, in the communities that we go into, when we describe that insulin is is the hormone that lowers blood glucose and is essential to to keep living we were asked to describe this, how this works. And so that the most common analogy is that insulin is like the key in the door, opening up the cell door to allow glucose or sugar to go in to be burned for energy. So we were asked to come up with an analogy that would be easily explainable in another language, for example, in Ojibwe or Cree when they're explaining diabetes and insulin to some of the elders. So that particular day there is a wood stove being installed in one of the communities in the home of one of the women. And it triggered my mind to think about this possibility where insulin is like the poker on a wood stove. So if the cell is the wood stove and the poker is the insulin, the poker opens the door and then you can put wood in to be burned for energy. And if there is insulin present, then you can if you have a poker, you can open the door and if you don't have insulin present then or not enough, then you can't get the door to the woodstove open. There is another example, though, or another situation called insulin resistance, where there may be insulin present, but you can't get the door open even though you have a poker. So that's a simple analogy that describes how insulin, what insulin's role is is in our bodies. Now, Mother Nature is the the language that we use and it's a respectful language, so rather than saying normal physiology, we say Mother Nature physiology and Mother Nature is amazing. In our language around diabetes, we're always talking about what we're trying to achieve, not what we're trying to avoid. So very positive language. And Mother Nature is part of that - that language discussion. So Mother Nature produces exactly the right amount of amount of insulin based on the sugar in the bloodstream. This is in non diabetes in the way our bodies were designed and and produces that insulin in response to meals. So this particular person has three meals that you can see the rise in insulin production and then there's always a little bit of insulin being produced to match the sugar that comes to keep ourselves alive. So you can see in the non food times, there's still a little bit of glucose or sugar and a little bit of insulin being produced. This is what we're striving for in type 2 diabetes is to mimic this as closely as possible in the language discussion here to this particular chart shows breakfast, lunch and dinner. We tend to say first meal of the day rather than breakfast because we don't want to assume that anyone necessarily has breakfast. It's a respectful approach. So this is what we're doing is as trying to mimic Mother Nature as much as possible because Mother Nature keeps blood flowing. So this is where the red blood cells can flow throughout our vessels and keep blood flowing now and several generations from now. So that relates to, you know, blood flow and later on we'll talk a little bit about A1 C and this is where the sugar attach to the red blood cells and if there's an excessive amount of sugar or glucose in the bloodstream, then it becomes more difficult for blood to pass through the vessels. And the tiniest ones, I've been told, are the size of a human hair. So imagine a blood trying to pass through those tiny, tiny capillaries like in our eyes and kidneys and so on. So we want to protect the vessels, keep blood flowing.

[00:11:09] Just like Mother Nature designed us to to operate. So in type 2 diabetes, there are a couple of things going on. One, most often the two things that are happening most often are that there may not be enough insulin or the insulin can't work properly called insulin resistance in order to meet the body's requirements. So here's one of the coolest things I can think of with respect to Mother Nature and the response to insulin resistance, so I'll just back that up for a minute. When we think about insulin resistance in the second point, that's where the insulin can't work properly. So what causes insulin resistance? Well, our knowledge is is a little bit more challenged around understanding it fully. I would say. But we do know that as we age. There's more insulin resistance, as we carry more body weight, there's insulin resistance. And we also know that hormones will cause insulin resistance. So hormones, like stress hormones are stressing and illness, you'll have higher blood sugars based on that insulin resistance and the greater demand for insulin in our bodies. Now, one of the most exciting opportunities that comes to us in life is for people who are of reproductive age and can have pregnancies and new life coming into our world. And what happens during this time is that the hormones of pregnancy that are produced by the placenta for the first, as you can see along here, I'm not sure, oh you can see macros. Good. So as you go through the first few weeks of pregnancy, right up to about 24 to 28 weeks, there are very few hormones produced by the placenta and then it takes off and by the end of pregnancy, or near the end of pregnancy, our bodies need to produce two to three times the amount of insulin compared to before we were pregnant. And then the baby is born. The placenta is born and the hormone levels drop off and so does the demand for insulin. So this is what happens in every pregnant person. And so the body then doubles or triples its insulin supply to meet the needs and keep the blood sugars in the safe range. And then in a smaller percent of the population where there's not enough of a response to produce that much insulin, that's when gestational diabetes occurs. So that's just to touch upon an example, a really great example, of how hormones cause insulin resistance. And Mother Nature responds by doubling or tripling insulin supply when no diabetes is present. So that's a really, really great example of hormones and insulin resistance. So what we're trying to do then is mimic the pancreas as closely as possible. Well, so we've used, I guess, cry of four to eight feeling great. And that's merely miles per liter. Now the guidelines will say, you know, that's a premeal level that we'd be aiming for. And that post meal we're looking for up to ten millimoles after eating because blood sugar will rise with food. And we we also are looking at A1C, which is a measure that you need to think about.

[00:14:48] And we're trying to find a balance between our A1C, which in our clinical practice guidelines, we're aiming for six point five to seven percent. That needs to be individualized. And we're learning a lot more about an ambulatory glucose profile. And that's what we're looking at.

[00:15:06] What is your total time in range for blood sugar? How close are we mimicking the pancreas and Mother Nature? So what that looks like, in the roughest way possible, on a sticky note. If I were to draw it, it would be on a sticky note or on a flip chart. And I'd say, OK, here's how it works. Is that on the bottom you'll see that the time of day. So this is 4:00 in the morning, 2:00 to midnight. So this goes through the whole 24 hour period and then four to eight or the millimoles per litre. So hours and the millimoles per litre for blood sugar and essentially we're looking at that range.

[00:15:45] And then how, if we're looking at continuous blood glucose readings which are provided. Now we have the technology to have people understand they're ambulatory glucose profile with various devices. So whereas the line that demonstrates where the blood sugars or continuously over a period of time and what percentage of the blood sugars are in that range. So this is an example of how it might look in the blue line is the median. You can see the two lines and then the blue line is the median. And then there is the 25th to 75th percentile with the majority of the readings over the course of several days up to 14 or more. And some with some devices and showing, so you can see it this time of day there is a low reading and that period of time over 4 o'clock in this particular case is higher. So that's a broad look at ambulatory glucose profile. But if this discussion is about managing highs and lows, having the information to make some decisions around, where are those patterns happening and how can I know what steps are next for me, this is a really good way to look at it. And you don't knowing exactly how to work with your team to adjust and see how much adjustment can be made with medicines and so on to spend greater time in your range.

[00:17:22] So there are medications for type 2 diabetes that are laid out very clearly in our clinical practice guidelines. And there are very many exciting possibilities. This is where I think it gets really exciting. There are so many options for type 2 diabetes and ones that will limit risk for hypoglycemia or low blood sugar and also limit the the likelihood of weight gain, which, you know, also causes insulin resistance and also those that protect the heart. So this is where I would suggest to go right into the guidelines. Talk with your team to figure out which medications you're on, for starters, and where they work, as well as which options might be best for you given all of our new information around those goals where you want to become in range for blood sugar, reduce risk of any sort of challenges with blood vessels and improve quality of life so that hypoglycemia, low blood sugars, less risk and you can manage diabetes really effectively. So we want to know especially which of your medications are those that will increase the risk of low blood sugar. And so we know from our list of medications for Type 2 diabetes that insulin is one that will cause low blood sugar because it's being injected and keeps working despite what's on board. So there's no regulation of that insulin. Once it's injected and also there are medications that stimulate the pancrease to produce insulin. So in our guideline document, the medications that are most recommended are those that, as I said, will not stimulate low blood sugar, will not cause waking and those that will most effectively protect the heart. So that is certainly something you want to have a discussion with.

[00:19:26] So our targets are individualized. It's based on all kinds of things that are are specific to you. One way you're going to know how things are going is by monitoring and using the tools that are available to you. That is the key to self-management. And when it comes to monitoring and you know, when we said we want you to be in the driver's seat, we often use the analogy about monitoring being like having a speedometer in your car. You will refer to it, when you need that information about how fast to go, how fast you're going, or if you're in a school zone or on an icy patch using it as a tool to help guide your decision making. So understanding about monitoring and how to use that effectively and knowing how it relates to your A1C as well.

[00:20:19] We need monitoring because when it comes to highs and lows, symptoms are not always reliable. We don't always know when we're having a low blood sugar or high blood sugar and using these tools will be really important. Also thinking about what is your A1C target, what is tailored to you for your A1C? And monitoring the time in range. So what is your range that you're aiming for? And how can you work with your team to understand what are the things that affect the peaks and valleys and so on so that you know exactly how to respond? Often people become quite exhausted with monitoring because they don't know exactly what to do with the results, so working alongside your team and and determining what is in your best interests will make sense. So this is what also can be happening, is that you may have an A1C that is 7 percent, but there can be some fluctuations and still come up with an A1C that's 7 percent. So on left you'll see time in range, 100 percent time in range. And then as you move to the right, less percentage of time and range. And then on the right, sometimes high, sometimes low. And I had a colleague who described this as having your head in the freezer and your feet in the oven. You'll come up at the right, temperature in the middle. So the A1C takes on average the blood sugars over that period of time. So you would not want to look at A1C in isolation. And we're looking more and more in the literature suggesting we look more and more to the time and range so that we're mimicking Mother Nature as closely as possible.

[00:22:19] So let's get to the highs and lows. So lows, by far, are the most feared by people with diabetes. There's a whole chapter in the clinical practice guidelines on lows. You can see Chapter 14 is about hypoglycemia. So you'll want to go in and have a look at that chapter. Hypoglycemia is hypo is low and low blood sugar. You might if you're having trouble distinguishing hypoglycemia from hypoglycemia, hypo and low rhyme with each other. There's an "o" sound in both of those. But essentially if people are talking about lows they're talking about hypoglycemia. So they can be categorized as mild, moderate and severe and severe is typically requiring outside assistance. In the moment, you'll need to know exactly what to do about hypoglycemia. So the immediate response needs to be taking 15 grams of rapid acting sugar to replace the deficit. Waiting 15 minutes, which is very difficult for a lot of people because your biology, your body's saying, "send me sugar. I'm really desperate." And so overconsumption is very common. It's a biological response. So if you can have a systematic response where it's 15 grams of rapid sugar, wait 15 minutes and then reassess at 15 minutes. Repeat step 1 if the glucose is less than 4 millimoles per liter. And if it's over four millimoles per liter, but it's more than an hour before your next meal, then have a snack that consists of a carbohydrate and a protein.

[00:24:03] What that looks like is this. So this is the pamphlets from Diabetes Canada that's exceptional and it's in relation to the diabetes and driving chapter about how to treat a low blood sugar. So there's a rapid acting 15 grams of glucose. And it's interesting because the word how to treat a low blood sugar, "treat" is an interesting word because it means treatment in this case but we often think of treat as in a special treat. So I know people with diabetes who will have glucose... they'll have something readily available to them that is not necessarily good tasting. Many of the people I know say that the glucose tablets are OK, but it's not something they enjoy particularly. So that's not associated then with with a sweet taste in terms of candy and so on.

[00:25:00] However, those candies also will treat low blood sugar. So 15 grams of carbohydrate, wait 15 minutes and then if blood sugars above four, as I was saying before and the next meal is in the next hour, you're good to go. If blood sugars were four and the next meal is longer than one hour away, then you're going to take a starch and a protein. And if blood sugars below for repeat these steps above. So again, having a rapid acting sugar. Now, the other part of this pamphlet is driving safe, so always having rapid acting sugars with you to treat low blood sugar. So prepare, have it with you. Be aware of your blood sugar before you drive. If you're having a low blood sugar stop, for example, if you don't feel well after treat, wait until your blood sugar is above 5 to start driving again. Your brain might need up to 40 minutes to recover after you've treated a low before, you can safely drive again.

[00:26:08] So very important resource from Diabetes Canada and I would encourage you to go onto the diabetes.ca website to get one for yourself. Also, medical alert bracelet is important. If you're on insulin and letting people know that you're at risk for low blood sugar. So there's that pamphlet. And then once you've had the immediate response hypoglycemia, it's an important time to do a postgame analysis, post low analysis, where the first step is to determine what were the contributing factors, what contributed to the lows? Is it a pattern that's existing over time? And speaking with your team to create a plan of action.

[00:27:03] Now back to Mother Nature, a little bit I've inserted this yin yang symbol to recognize another Mother Nature cool response. And that is that while our bodies produce insulin to lower blood sugar, our body also produces glucagon in the event of low blood sugar that triggers the dumping of sugar from the liver to protect you. So glucagon is an important hormone as well. And also glucagon can be used in low blood sugar emergencies and can be injected. And more recently on the market is also a nasal glucagon treatment that would be worth looking into.

[00:27:54] So, time in range. Generally speaking, we suggest that you sort out the lows and then bring the top end, top end into range. And that's also suggested in the clinical practice guidelines as well. So the clinical practice guidelines say that you're aiming for a target of A1C of 7 percent. And if it cannot be achieved with a fasting target of 4 to 7 millimoles and a post prandial (post meal) of 5 to 10 millimoles, then further lowering of the fasting to 4 to 5.5 millimoles and for post prandial (post meal), 5 to 8 millimoles may be considered, but that must be balanced against the risk of hypoglycemia. So we need to consider what's happening in your system. Having those discussions with your health care providers will be essential.

[00:28:52] So we need to find a balance. And advocating for yourself to understand your medicines, to know what's in your best interests, what we're aiming for and also to strive for that time in range and quality of life and not sacrificing the things that you enjoy. But instead finding that balance so that you can live well with diabetes. In summary, in the spirit of self-management, education and support, we really want to work together to achieve the balance of blood sugar in the Mother Nature range as appropriate and for you to live a long, healthy and happy life. We understand and recognize and respond to low blood sugar levels or blood glucose levels. To have that knowledge and to act on it and determine why they're happening and working with your team to reduce them. Getting rid of the lows is the first step in pattern management. Then work with the team to make adjustments to your plan to achieve time in range as close to Mother Nature as possible. So I'd really like to take the time to thank you today. I've really enjoyed presenting information and it's just a tip of the iceberg when it comes to this balance between managing low blood sugar and managing high blood sugar.

[00:30:08] And I wish you all the very best. Take care. And thank you, Jen, from Diabetes Canada once again. Thank you.