Bedtime Blood Glucose Research Articles

Diurnal glycemic pattern on inclusion of sucrose in daily meals in type 2 diabetes: Reflection of antecedent glycemic control

Background: Inclusion of sucrose in diabetic diets is not recommended in subjects with diabetes since effects of such diets on glycemic indices are not established. Some studies have documented lapse in metabolic control on consumption of these diets type 2 diabetes. However, most studies examined plasma glucose only for a few hours after ingestion of a single meal containing sucrose after an overnight fast whereas others recommended increasing insulin dose prior to the meal. None of these studies examined influence of inclusion of sucrose in daily meals in subjects with new onset diabetes at diagnosis and again after achieving desirable glycemic control. Objective : Study was conducted to assess glycemic responses to ingestion of all meals containing sucrose constituting 50% of carbohydrate calories. Methods: 12 subjects with new onset type 2 diabetes participated. They were administered the following isocaloric diets for 4 days each prior to and after achieving desirable glycemic control; Diet 1- Diabetic diet recommended by American Diabetes Association (ADA), diet 2- test diet containing sucrose, diet 3- ADA diet. Glycemic control was assessed by diurnal glycemia (average of pre-prandial, postprandial and bedtime blood glucose), fasting plasma glucose, HbA1c and fructosamine on 4th day of each dietary period. Results: All glycemic indices deteriorated after consumption of sucrose containing meals prior to initiation of treatment and remained worsened on return to ingestion of ADA diet. Glycemic responses after all meals improved markedly on achieving desirable glycemic control. Moreover, glycemic indices remained unaltered on consumption of sucrose containing meals after attaining and maintaining desirable glycemic control. Conclusion: Diurnal glycemic responses deteriorate on ingestion of daily meals containing sucrose in subjects with new onset uncontrolled type 2 diabetes. In contrast, diurnal glycemic pattern is unaltered following consumption of daily meals containing sucrose after attaining and maintaining desirable glycemic control.

Metabolic and sympathovagal effects of bolus insulin glulisine versus basal insulin glargine therapy in people with type2 diabetes: A randomized controlled study.

Aims/IntroductionThis study compares the effects of two different insulin regimens – basal versus bolus insulin – on metabolic and cardiovascular autonomic function in Japanese participants with type 2 diabetes.Materials and MethodsParticipants were randomly assigned to groups for therapy with insulin glulisine (IGlu) or insulin glargine (IGla). The primary efficacy end‐point was glycemic variability, including M‐values, mean of glucose levels, and a blood glucose profile of seven time points before and after the intervention. The secondary end‐points included pleiotropic effects, including endothelial and cardiac autonomic nerve functions.ResultsBlood glucose levels at all time points significantly decreased in both groups. Post‐lunch, post‐dinner, and bedtime blood glucose levels were significantly lower in the IGlu group than in the IGla group. Nadir fasting blood glucose levels at the end‐point were significantly lower in the IGla group than in the IGlu group. The M‐value and mean blood glucose levels were significantly decreased from baseline in both groups, although the former was significantly lower in the IGlu group than in the IGla group. IGla, but not IGlu, was found to elevate 24‐h parasympathetic tone, especially during night‐time, and it decreased 24‐h sympathetic nerve activity, especially at dawn.ConclusionsBoth IGlu and IGla regimens reduced glucose variability, with IGlu bringing a greater reduction in M‐value. IGla, but not IGlu, increased parasympathetic tone during night‐time and decreased sympathetic nerve activity at dawn. These findings shed light on the previously unrecognized role of night‐time basal insulin supplementation on sympathovagal activity in type 2 diabetes patients.

People with Type Diabetes Mellitus (T1DM) self-reported views on their own condition management reveal links to potentially improved outcomes and potential areas for service improvement

BackgroundThe self-management of type 1 diabetes (T1DM) has moved forward in many areas over the last 40 years. Our study asked people with T1DM what is their experience of blood glucose (BG) monitoring day to day and how this influences decisions about insulin dosing. MethodsAn on-line self-reported questionnaire containing 44 questions prepared after consultation with clinicians and patients was circulated to people with T1DM 116 responders provided completed responses. Fixed responses were allocated specific values (e.g. not confident = 0 fairly confident = 1). Multivariate regression analysis was carried out. Only those 5 factors with p-value <0.05 were retained. Results59% of respondents were >50 years old and 66% had diabetes for >20 years, with 63% of patients reporting HbA1c results ≤8% or 64 mmol/mol.Findings included; 75% used only 1 m; 56% had used the same meter for ≥3 years; 10% had tried flash monitors; 47% were concerned about current BG level; 85% were concerned about long-term impact of higher BG.72% of respondents keep BG level high to avoid hypoglycaemia; 25% used ≥7 mmol/L as pre-meal BG target to calculate dose; 65% were concerned they might be over/under-dosing; 83% did not discuss accuracy when choosing meter. However 85% were confident in their meter’s performance.The factors that linked to LOWER HbA1c included LESS units of basal insulin (p < 0.001), HIGHER number of daily BG tests (p = 0.008), LOWER bedtime blood glucose (p = 0.009), HIGHER patient’s concern over long-term impact of high BG (BG) (p < 0.009 but LOWER patient’s concern over current BG values (p = 0.009). The final statistical model could explain 41% of the observed variation in HbA1c. ConclusionMany people still run their BG high to avoid hypoglycaemia. Concern about the longer-term consequences of suboptimal glycaemic control was associated with a lower HbA1c and is an area to explore in the future when considering how to help people with T1DM.

Implementation of an inpatient hyperglycemia management program incorporating a nurse consultant

Background and aimsThe efficacy and safety of inpatient hyperglycemia management protocols using basal-bolus regimens have been widely demonstrated, but their implementation is insufficient. The aim of the study was to assess implementation and to establish the efficacy and safety of inpatient hyperglycemia management protocol based on a basal-bolus regimen and the incorporation of a nurse consultant. Material and methodsEvaluation was performed at 10 hospital units. Data were retrospectively reviewed during hospital stay and 90 days after discharge in 400 patients after protocol implementation and 200 patients before implementation.The degree of satisfaction of professionals was assessed using a questionnaire 12 months after implementation. ResultsThe proportion of patients with basal-bolus regimens upon admission was higher in the postimplementation group (58% vs. 9%, P < 0.001). Mean pre-prandial and bedtime blood glucose levels during admission were lower in the postimplementation group (164 ± 41 mg/L vs. 196 ± 50 mg/dL, P < 0.001). After implementation, there were less patients with blood glucose levels > 300 mg/dL (36.3% vs. 50.5%, P < 0.001) and more patients with values < 70 mg/dL (15% vs. 9%, P = 0.040). Insulin addition and intensification was the main change in treatment at discharge, and a significant HbA1c reduction was seen three months after discharge in the postimplementation phase (P = 0.04). The professionals assigned the protocol a score of 4.5 on a 1–5 scale. ConclusionsIncorporation of a nurse consultant expert in diabetes as key component of a hyperglycemia management program ensures that a majority of patients admitted to hospital for hyperglycemia receive treatment with a basal-bolus regimen and improves blood glucose control during hospital stay and after discharge.

Repeated measures random forests (RMRF): Identifying factors associated with nocturnal hypoglycemia.

Nocturnal hypoglycemia is a common phenomenon among patients with diabetes and can lead to a broad range of adverse events and complications. Identifying factors associated with hypoglycemia can improve glucose control and patient care. We propose a repeated measures random forest (RMRF) algorithm that can handle nonlinear relationships and interactions and the correlated responses from patients evaluated over several nights. Simulation results show that our proposed algorithm captures the informative variable more often than naïvely assuming independence. RMRF also outperforms standard random forest and extremely randomized trees algorithms. We demonstrate scenarios where RMRF attains greater prediction accuracy than generalized linear models. We apply the RMRF algorithm to analyze a diabetes study with 2524 nights from 127 patients with type 1 diabetes. We find that nocturnal hypoglycemia is associated with HbA1c, bedtime blood glucose (BG), insulin on board, time system activated, exercise intensity, and daytime hypoglycemia. The RMRF can accurately classify nights at high risk of nocturnal hypoglycemia.

Implantación de un programa para el manejo de la hiperglucemia en la hospitalización con la incorporación de la enfermera consultora

Background and aimsThe efficacy and safety of inpatient hyperglycemia management protocols using basal-bolus regimens have been widely demonstrated, but their implementation is insufficient. The aim of the study was to assess implementation and to establish the efficacy and safety of inpatient hyperglycemia management protocol based on a basal-bolus regimen and the incorporation of a nurse consultant. Material and methodsEvaluation was performed at 10 hospital units. Data were retrospectively reviewed during hospital stay and 90 days after discharge in 400 patients after protocol implementation and 200 patients before implementation.The degree of satisfaction of professionals was assessed using a questionnaire 12 months after implementation. ResultsThe proportion of patients with basal-bolus regimens upon admission was higher in the postimplementation group (58% vs. 9%, P<0.001). Mean pre-prandial and bedtime blood glucose levels during admission were lower in the postimplementation group (164±41mg/L vs. 196±50mg/dL, P<0.001). After implementation, there were less patients with blood glucose levels >300mg/dL (36.3% vs. 50.5%, P<0.001) and more patients with values <70mg/dL (15% vs. 9%, P=0.040). Insulin addition and intensification was the main change in treatment at discharge, and a significant HbA1c reduction was seen three months after discharge in the postimplementation phase (P=0.04). The professionals assigned the protocol a score of 4.5 on a 1 to 5 scale. ConclusionsIncorporation of a nurse consultant expert in diabetes as key component of a hyperglycemia management program ensures that a majority of patients admitted to hospital for hyperglycemia receive treatment with a basal-bolus regimen and improves blood glucose control during hospital stay and after discharge.

1065-P: The Effect of a Closed-Loop Insulin Delivery System on Glycemic Control in Type 1 Diabetes

Background: Using a software, which creates a closed loop between the pump and the monitoring glucose sensor is considered to be a progress in controlling and using insulin pumps in type 1 diabetes patients (T1DM). OpenAPS is a system which completes and closes the pump-glucose sensor loop. Aim: The aim of this study is to examine the effect of an independent closed-loop insulin system using the OpenAPS system on the glycemic control of T1DM patients. Material and Methods: 24 T1DM patients with insulin pump were included in the study. 11 started using the OpenAPS closed-loop system and 13 continued using an insulin pump without OpenAPS. The effect on glycemic control (HbA1c, Fasting Blood Glucose (FBG), pre-meal, post-meal and before bedtime glucose) was recorded before the beginning of the study and on 12±1 and 24±1 weeks. Hypoglycemic episodes were also recorded. Results: Patients using OpenAPS noted a significant reduction of HbA1c on the 3 and 6-month follow-up (7.70±1.14 vs. 6.85±1.17 vs. 6.63±1.05, p&amp;lt;0.001). The reduction of HbA1c in the other group ws not significant (7.78±1.12 vs. 7.44±1.18 vs. 7.21±1.09, p=0.058). A significant reduction on FBG was noticed on the OpenAPS group (154.14±26.17 vs. 128.33±21.41 vs. 117.74±8.73, p=0.010), while the other group’s reduction was not found to be statistically significant (p= 0.112). Statistically lower pre-meal (p&amp;lt; 0.001), post-meal (p&amp;lt; 0.001) and before bedtime (p= 0.016) blood glucose levels were found on the OpenAPS group. Before the beginning of the study all of the participants had at least one hypoglycemic episode in the last month, while after 3 months of using OpenAPS, no patient showed hypoglycemia. The other group’s participants continued having such episodes. Conclusions: Using a closed-loop in an insulin pump via OpenAPS system leads to a better glycemic control, less hypoglycemic episodes and lower daily blood glucose levels fluctuations compared to using an insulin pump with no closed-loop system. Disclosure A. Koutsovasilis: None. A. Sotiropoulos: None. A. Antoniou: None. V. Kordinas: None. D. Papadaki: None. T. Peppas: None.

941-P: Frequency of Blood Glucose Monitoring in Relation to Medical Cost and Glycemic Control in Hospitalized Patients with Type 2 Diabetes

The study aimed to investigate the effect of 7-point or 5-point glucose monitoring on medical costs, glycemic control and the incidence of hypoglycemia in hospitalized patients with type 2 diabetes (T2DM). A total of 4002 patients with T2DM (1490 male and 2512 female cases) with complete medical records were included between 2012 and 2017. The average age was 61.5 years and the mean disease duration 8.68 years. According to the frequency of daily monitoring of blood glucose during hospitalization, patients were divided into 2 subgroups of 5-point group and 7-point group. Patients in 5-point group received fasting blood glucose (FBG), 2h blood glucose (2hBG) after breakfast, 2hBG after lunch, 2hBG after dinner and bedtime blood glucose tests. Patients in 7-point group received additional tests of pre-lunch glucose and pre-dinner blood glucose. Blood glucose monitoring was performed using Johnson &amp; Johnson SureStep blood glucose meter. Comparison of two groups includes duration of in-hospital stay, medical costs, glycemic control and the incidence of hypoglycemia. Patients in 7-point glucose monitoring group had significantly shorter hospital stay (14.4 vs. 16.6 days, P&amp;lt;0.05) and less total medical costs (10324.4 vs. 12087.5 CNY, P&amp;lt;0.05) compared with 5-point group. Laboratory examination cost did not differ significantly between groups (p&amp;gt;0.05). At discharge, both fasting and 2-h glucose decreased significantly compared with baseline levels in either 5-point or 7-point group. In 7-point group, FPG decreased by 2.41mmol/L and 2hPG by 3.9mmol/L. In the 5-point group, the corresponding figures were 2.07mmol/L and 3.6mmol/L, respectively. The incidence of hypoglycemia were 24.2% in 7-point group and 33.1% in 5-point group (P&amp;lt;0.05). In-hospital 7-point daily glucose monitoring improves patients’ adherence to treatment, shortens hospital stay, reduces medical cost, improves blood glucose control, and reduces the incidence of hypoglycemia. Disclosure L. Zhang: None. Y. Gu: None. Y. Yang: None. N. Wang: None. W. Gao: None. J. Wang: None. X. Yin: None. Y. Dong: None.

Suboptimal behaviour and knowledge regarding overnight glycaemia in adults with type 1 diabetes is common

In people with type 1 diabetes (T1D), nocturnal hypoglycaemia (NH) can be slept through and can cause seizures, arrhythmias and death. Hypoglycaemia avoidance can induce hyperglycaemia and ketosis. Patient behaviour impacts clinical outcomes and may be changed by education. To develop and utilise a survey to evaluate patient self-management of overnight glycaemia in adults with T1D. Adults with T1D attending two Australian tertiary referral diabetes clinics completed a survey about their diabetes self-management and glycaemic control, including responses to hypothetical pre-bed blood glucose (BG) levels (4-20 mmol/L). Statistical analyses included t-tests, Chi square tests and ANOVA with significance considered at P < 0.05. There were 205 participants (103 females), with a mean (SD) age of 41 (17) years, T1D duration of 20 (16) years, HbA1c of 7.8(1.4)%, (61.3(8.2) mmol/mol), 38% on insulin pump therapy (CSII) and 36% with impaired hypoglycaemia awareness (IHA). Mean (SD) number of BG tests/day was 5.4 (2.7). Patients set higher BG target levels at bedtime and overnight: 7.5(1.4) and 7.1(1.3) mmol/L, respectively, compared to daytime (6.9(1.0); P < 0.0001 and P = 0.002 respectively). Only 36% of participants reported treating nocturnal hypoglycaemia (NH) with the recommended refined, then complex, carbohydrate. Only 28% of patients made safe choices in all bedtime BG scenarios, with higher rates for CSII users, P = 0.0005. Further education was desired by 32% of respondents, with higher rates in those with (44%) versus without IHA (25%), P = 0.006. Many adults with T1D have suboptimal knowledge and behaviour regarding overnight BG self-management. A survey, piloted herein, may facilitate the identification of patients who could benefit from further education.

Retrospective study on post-operative glucose level and insulin dose in patients undergoing total pancre-atectomy

Objective To evaluate the post-operative glucose level and insulin dose of patients undergoing total pancreatectomy. Methods From September 1980 to September 2014, 21 patients underwent total pancreatectomy in Peking Union Medical College Hospital, who were enrolled in our study. We reviewed the changes in their insulin dosage and glucose levels after operation, also summarized type and dose of insulin as well as glucose level in stable period. Results The required insulin dose reached peak within 4 days after surgery (maximum dose 300 U/d). The average dose was(143.5±62.8)U/d and decreased gradually. During the perioperative period (needing parenteral nutrition), the blood glucose level fluctuated markedly (1.52-29.06 mmol/L) and the average level was (11.18±0.95)mmol/L. During the stable period (without parenteral nutrition), patients on average had (5.3±2.0)U of preprandial rapid-acting insulin and (8.1±2.9)U of long-acting insulin before sleeping; the average fasting blood glucose was (6.69±1.48)mmol/L, 2 h postprandial blood glucose was (9.08±2.84)mmol/L, bedtime blood glucose was (9.66±2.49)mmol/L, and blood glucose level at night was (8.15±2.78)mmol/L. 67% of the patients had 13 hypoglycemic episodes monthly on average. For those five followed-up patients, the average hemoglobin A1c was (6.15±1.20)%. Conclusions Patients undergoing total pancreatectomy may experience marked fluctuation of blood glucose level and short-term increase of insulin need which gradually decreases afterwards. After entering the stable period, the glucose level could be well-controlled but with frequent hypoglycemia. There is no diabetic ketoacidosis. Key words: Total pancreatectomy; Blood glucose monitor; Continuous glucose monitoring; Insu-lin dosage

Factors associated with nocturnal hypoglycemia in at-risk adolescents and young adults with type 1 diabetes.

Hypoglycemia remains an impediment to good glycemic control, with nocturnal hypoglycemia being particularly dangerous. Information on major contributors to nocturnal hypoglycemia remains critical for understanding and mitigating risk. Continuous glucose monitoring (CGM) data for 855 nights were studied, generated by 45 subjects 15-45 years of age with hemoglobin A1c (HbA1c) levels of ≤8.0% who participated in a larger randomized study. Factors assessed for potential association with nocturnal hypoglycemia (CGM measurement of <60 mg/dL for ≥30 min) included bedtime blood glucose (BG), exercise intensity, bedtime snack, insulin on board, day of the week, previous daytime hypoglycemia, age, gender, HbA1c level, diabetes duration, daily basal insulin, and daily insulin dose. Hypoglycemia occurred during 221 of 885 (25%) nights and was more frequent with younger age (P<0.001), lower HbA1c levels (P=0.006), medium/high-intensity exercise during the preceding day (P=0.003), and the occurrence of antecedent daytime hypoglycemia (P=0.001). There was a trend for lower bedtime BG levels to be associated with more frequent nocturnal hypoglycemia (P=0.10). Bedtime snack, before bedtime insulin bolus, weekend versus weekday, gender, and daily basal and bolus insulin were not associated with nocturnal hypoglycemia. Awareness that HbA1c level, exercise, bedtime BG level, and daytime hypoglycemia are all modifiable factors associated with nocturnal hypoglycemia may help patients and providers decrease the risk of hypoglycemia at night. Risk for nocturnal hypoglycemia increased in a linear fashion across the range of variables, with no clear-cut thresholds to guide clinicians or patients for any particular night.

Randomized controlled trial of insulin supplementation for correction of bedtime hyperglycemia in hospitalized patients with type 2 diabetes.

OBJECTIVEClinical guidelines recommend point-of-care glucose testing and the use of supplemental doses of rapid-acting insulin before meals and at bedtime for correction of hyperglycemia. The efficacy and safety of this recommendation, however, have not been tested in the hospital setting.RESEARCH DESIGN AND METHODSIn this open-label, randomized controlled trial, 206 general medicine and surgery patients with type 2 diabetes treated with a basal-bolus regimen were randomized to receive either supplemental insulin (n = 106) at bedtime for blood glucose (BG) >7.8 mmol/L or no supplemental insulin (n = 100) except for BG >19.4 mmol/L. Point-of-care testing was performed before meals, at bedtime, and at 3:00 a.m. The primary outcome was the difference in fasting BG. In addition to the intention-to-treat analysis, an as-treated analysis was performed where the primary outcome was analyzed for only the bedtime BG levels between 7.8 and 19.4 mmol/L.RESULTSThere were no differences in mean fasting BG for the intention-to-treat (8.8 ± 2.4 vs. 8.6 ± 2.2 mmol/L, P = 0.76) and as-treated (8.9 ± 2.4 vs. 8.8 ± 2.4 mmol/L, P = 0.92) analyses. Only 66% of patients in the supplement and 8% in the no supplement groups received bedtime supplemental insulin. Hypoglycemia (BG <3.9 mmol/L) did not differ between groups for either the intention-to-treat (30% vs. 26%, P = 0.50) or the as-treated (4% vs. 8%, P = 0.37) analysis.CONCLUSIONSThe use of insulin supplements for correction of bedtime hyperglycemia was not associated with an improvement in glycemic control. We conclude that routine use of bedtime insulin supplementation is not indicated for management of inpatients with type 2 diabetes.

HbA1c can be a useful glycemic control marker for patients with neonatal diabetes mellitus older than 20 weeks of age

BackgroundThe accuracy of most HbA1c analysis methods is affected by the presence of increased fetal hemoglobin (HbF). The objective of this study was to investigate the age at which HbA1c measurements become useful for monitoring glycemic control in patients with neonatal diabetes mellitus (NDM). MethodsWe retrospectively analyzed the data of 5 NDM patients diagnosed at 38±20days of age, who each had several available HbA1c measurements during the first year of life, with a control group of HbA1c values over the course of 1year for 13 patients with type 1 diabetes mellitus (T1DM). Mean blood glucose (MBG) levels derived from premeal or premeal plus bedtime blood glucose measurements prior to HbA1c measurements were compared to HbA1c values. ResultsThe NDM patients' age at which the difference in the HbA1c/MBG ratios became not significant between the NDM patients and the T1DM patients was 21weeks of age and over. Even after the HbA1c was adjusted for HbF, this ratio was significantly lower in the NDM patients at <21weeks of age than in the T1DM patients. ConclusionsHbA1c can be a useful glycemic control marker for NDM patients >20weeks of age.

Effect of blood glucose monitoring frequency on blood glucose control in type 2 diabetes meilitus patientswith intensive insulin therapy

Objective To explore the effect of different blood glucose monitoring frequency on blood glucose fluctuation and control in type 2 diabetes mellitus patients with intensive insulin therapy. Methods One hundred and twenty type 2 diabetes mellitus patients With intensive insulin therapy were chosen and randomly divided into three groups. The three times group received 3 times monitoring including fasting, after breakfast and bedtime, and the five times group received 5 times monitoring including fasting, after breakfast, before supper, bedtime and before dawn, and the eight times group received the 8 times monitoring including before and after every meal, bedtime and before dawn, and the changes of the hemoglobin Alc （I-IbAlc） were observed for 4 weeks before and after the treatment. Results The average levels of HbA1 c in the three groups were decreased 4 weeks after treatment in the three groups, and the difference was not statistically significant （ F = 0. 301, P 〉0.05 ）. No difference was found in the fasting blood glucose and blood glucose before supper in the three groups （ F = 1. 450, t = 1. 760 ; P 〉 0.05 ）. The levels of blood glucose after breakfast were respectively （ 8.78 ± 0.90）, （9.08 ± 0.63 ）, （7.49 ± 1.01 ） mmol/L in the three groups, and the level of blood glucose in the eight times group was better than those of the three and five times groups, and the difference was statistically significant （F = 23. 340, P 〈 0.05 ）. The levels of bedtime blood glucose were respectively （ 8.07 ± 0.59 ）, （8.32 ± 0.75）, （7.28 ± 0.54） mmol/L in the three groups, and the blood glucose fluctuatian range in the eight times group was lowest, and the difference was statistically significant （F = 32.880, P 〈 0.0.5）. The levelof blood glucose before dawn in the eight times group was （6. 68 ± 0.59 ） mmol/L, and was better than （7.75 ±0.77） mmol/L in the five times group, and the difference was statistically significant （t =4. 170, P 〈 0.01 ）. The average levels of 24 h blood glucose in the three groups were respectively （8.33 ± 1.20）, （8.26 ± 0.97）, （7.84 ± 1.15 ） mmol/L, and the blood glucose control in the eight times group was best, and the difference was statistically significant （ F = 22.36, P 〈 0.05 ）, and the detection rate of hypoglycemia was 33.3% in the small hours. Conclusions The blood glucose fluctuation range in the eight times group is minimum. The many times blood glucose monitoring in type 2 diabetic patients with intensive insulin therapy, at least 3 times daily, can reduce and prevent the incidence of hypoglycemia. Key words: Diabetes mellitus, type 2 ; Blood glucose self monitoring; Frequency ; Intensiveinsulin therapy; Blood glucose control

Empirically Establishing Blood Glucose Targets to Achieve HbA1c Goals

OBJECTIVETo determine the average fasting, postprandial, and bedtime self-monitored blood glucose (SMBG) concentrations associated with specified HbA1c levels using data from the A1c-Derived Average Glucose (ADAG) study.RESEARCH DESIGN AND METHODSThe ADAG study was a multicenter observational study that used continuous glucose monitoring and SMBG testing to determine the relationship between mean average glucose and HbA1c. We used the SMBG data from 470 of the ADAG study participants (237 with type 1 diabetes and 147 with type 2 diabetes) to determine the average fasting, premeal, 90-min postmeal, and bedtime blood glucose (BG) for predefined target HbA1c groups between 5.5 and 8.5% (37–69 mmol/mol). t Tests were used to compare mean BG values between type 1 and type 2 diabetes groups.RESULTSThe average fasting BG needed to achieve predefined HbA1c target levels of 5.5–6.49% (37–47 mmol/mol), 6.5–6.99% (48–52 mmol/mol), 7.0–7.49% (52–58 mmol/mol), 7.5–7.99% (58–64 mmol/mol), and 8.0–8.5% (64–69 mmol/mol) were 122 mg/dL with 95% CI 117–127, 142 mg/dL (135–150), 152 mg/dL (143–162), 167 mg/dL (157–177), and 178 mg/dL (164–192), respectively. Postmeal BG to achieve the HbA1c level of 6.5–6.99% (48–52 mmol/mol) and 7.0–7.49% (52–58 mmol/mol) were 139 mg/dL (134–144) and 152 mg/dL (147–157), respectively. Bedtime BG was 153 mg/dL (145–161) and 177 mg/dL (166–188), respectively.CONCLUSIONSWe have determined the average BG at premeal, postmeal, and bedtime to achieve a variety of HbA1c targets. These results, based on empirical data, will help patients and providers set realistic day-to-day SMBG targets to achieve individualized HbA1c goals.

Enhancing Diabetes Management While Teaching Quality Improvement Methods

Six medical units realized that they were having issues with accurate timing of bedtime blood glucose measurement for their patients with diabetes. They decided to investigate the issues by using their current staff nurse committee structure. The clinical nurse specialists and nurse education specialists decided to address the issue by educating and engaging the staff in the define, measure, analyze, improve, control (DMAIC) framework process. They found that two issues needed to be improved, including timing of bedtime blood glucose measurement and snack administration and documentation. Several educational interventions were completed and resulted in improved timing of bedtime glucose measurement and bedtime snack documentation. The nurses understood the DMAIC process, and collaboration and cohesion among the medical units was enhanced.

Are bedtime nutritional strategies effective in preventing nocturnal hypoglycaemia in patients with type 1 diabetes?

Hypoglycaemia remains the major limiting factor for adequate diabetes control for patients with type 1 diabetes (T1D), especially during the night-time. Although nutritional strategies for nocturnal hypoglycaemia (NH) prevention are regularly suggested in clinical practice, there is no evidence-based recommendation for the usefulness and optimal composition of a bedtime snack. The aim of this narrative review was to analyse the current state of knowledge on nutritional strategies to prevent NH in individuals with T1D. A literature search was conducted, using PubMed and Medline (1946 to 2013); 16 studies were retrieved. Overall, the level of evidence was low. Results indicated that a calibrated bedtime snack based on bedtime blood glucose (BG) level could be effective to reduce NH occurrence for patients treated with human or animal insulin (short-acting combined with lente, ultralente and/or intermediate-acting insulin), but there is no evidence for patients treated with insulin analogues as part of multiple daily injections or insulin pump regimen. Some evidence suggests that including uncooked cornstarch or alanine in the bedtime snack composition could provide some benefits for the prevention of NH. Individualized recommendations of a bedtime snack intake for patients or situations at high risk for NH (long standing diabetes, hypoglycaemia unawareness, prior physical activity, alcohol consumption, bedtime BG close to hypoglycaemia threshold) appear as a prudent recommendation. On the basis of the available evidence, a bedtime snack cannot be recommended systematically but it might be useful if prescribed in an individualized fashion; further research is needed to evaluate these strategies.

Regular insulin, rather than rapid-acting insulin, is a suitable choice for premeal bolus insulin in lean patients with type2 diabetes mellitus.

The aim of the present study was to compare the usefulness of premeal rapid-acting and regular insulin in type2 diabetes patients. A total of 56 type2 diabetic patients were investigated during hospitalization. Premeal rapid-acting insulin was applied instead of other medications. Premeal insulin was titrated to adjust premeal and bedtime blood glucose levels to 81-120mg/dL. Premeal rapid-acting insulin was changed to regular insulin just before a meal at the same dosage if the postmeal blood glucose level was lower than the premeal blood glucose level. A total of 15 patients changed to regular insulin, and 41 patients continued rapid-acting insulin. The blood glucose level was comparable between these two groups. Body mass index was significantly lower in the patients using regular insulin. According to the multivariate logistic regression analysis, low body mass index was an independent variable accounting for the usefulness of regular insulin. Regular insulin, rather than rapid-acting insulin, is a suitable choice for premeal insulin in lean type2 diabetic patients.

Prediction of nocturnal hypoglycaemia with bedtime glucose level during continuous subcutaneous insulin infusion in type 2 diabetics

To find out the features of glycemic excursion via continuous glucose monitoring system (CGMS) during continuous subcutaneous insulin infusion (CSII) treatment in type 2 diabetics and discuss the possibility of predicting nocturnal hypoglycaemia with bedtime glucose level. A total of 257 diabetes patients (156 males and 101 females, aged from 27 - 88 years old) with 0.1 - 40 years diabetic history were recruited. Their HbA1c level was (10.97 ± 2.11)%. Glycated albumin level was (31.88 ± 7.51)%. All patients were switched to CSII therapy while a 72-hour period of CGMS was performed. Participants were divided into hypoglycemia group and non-hypoglycemia group according to the reading of hypoglycemic events from CGMS data. (1) From CGMS profiles, the investigators found that MBG was (9.66 ± 2.00) mmol/L and SDBG (2.98 ± 1.03) mmol/L. (2) A total of 243 hypoglycemia events occurred in 118 participants at early stage of CSII treatment. (3) When bedtime blood glucose was below 5.9 mmol/L, the youden index was maximal on a receiver operating characteristic curve. The sensitive was 54.8% and specificity 77.8%. Positive predictive value was 44.3% and negative predictive value 84.2%. So the cut-off point of bedtime blood glucose to predict nocturnal hypoglycemia might be 5.9 mmol/L. (1) Hypoglycemia as detected by CGMS occurs in almost 1/2 type 2 diabetics during CSII therapy. (2) There is a higher risk of nocturnal hypoglycemia if the bedtime blood glucose concentration falls below 5.9 mmol/L.

High day-to-day glucose variability: A frequent phenomenon in children and adolescents with type 1 diabetes attending summer camp

Background Day-to-day glucose variability may cause difficulty for patients trying to adjust their insulin dosages and for healthcare providers when they have to make recommendations. The aim of this research was to evaluate the frequency of high variability in a population of diabetic children and adolescents attending summer camp. Methods and Results The mean of the daily differences (MODD) in glucose concentrations was calculated from continuous glucose monitoring (CGM) over five consecutive days in 6 diabetic patients. This index was correlated to the MODD calculated from pre-meal and bedtime blood glucose (BG) measurements ( r = 0.87). We used the MODD calculated on these four BG measurements for five consecutive days to evaluate day-to-day glucose variability in 100 young diabetic patients treated with glargine and ultrarapid analogue insulin. Only one child had a MODD value lower than 36 mg/dl, considered a threshold for high day-to-day variability, and 94 children had a MODD value higher than 45 mg/dl. The median value was 78 mg/dl. The expected positive correlation between the MODD and its standard deviation ( r = 0.32, P < 0.01) suggested that the greater the day-to-day variability, the more variable the variability across five consecutive days. Conclusions The estimation of MODD from four pre-meal BG values correlated to that from CGM, and may represent a simple index of day-to-day glycaemic variability. High day-to-day glucose variability in glucose profile is frequently observed in diabetic children attending summer camp.