Session number: 1031
Abstract title: A Proposal For Improving Glycemic Control In Insulin-Treated Veterans With Type II Diabetes Mellitus
Author(s):
WC Duckworth - Carl T. Hayden VA Medical Center
JH Shah - Southern Arizona VA Health Care System
RM Hoffman - New Mexico VA Health Care System
KD Adam - New Mexico VA Health Care System
CS Wendel - Southern Arizona VA Health Care System
SU Bokhari - Carl T. Hayden VA Medical Center
C Dalton - Southern Arizona VA Health Care System
P Solvas - Southern Arizona VA Health Care System
GH Murata - New Mexico VA Health Care System
Objectives: Recent studies have provided convincing evidence that tight control of blood glucose reduces the risk of microvascular complications in type II diabetes mellitus. The purpose of this study is to propose a strategy for improving glycemic control in insulin-treated veterans based upon data from an intensive program of self-monitoring.
Methods: Prospective observational study. Stable patients were asked to test their blood sugars before breakfast, before lunch, before dinner and at bedtime for 8 weeks. Hemoglobin A1c (HbA1c) was measured at 8 weeks. Mean glucose values were calculated for each testing time. Stepwise multiple linear regression was used to examine the relationship between these values and HbA1c.
Results: One hundred fifty patients completed the protocol. The mean (+/-SD) age was 65.6+/-9.6 years, and 95% were male. Subjects obtained 28,956 (or 86.2%) of the 33,600 readings specified by the protocol. The 8-week mean glucose was 172+/-39 mg/dL, and the week 8 Hba1c was 7.48+/-1.43%. Repeated measures ANOVA showed that there were significant differences in mean glucose for the 4 testing times (P<0.001). The bedtime sample gave the highest reading (194+/-45), followed by the pre-dinner (175+/-48), pre-lunch (170+/-46) and pre-breakfast samples (153+/-43 mg/dL). Significant increases in glucose occurred between dinner and bedtime (mean change 18.9+/-37.4 mg/dL; P<0.001) and between breakfast and lunch (16.5+/-34.6 mg/dL; P<0.001) but not between lunch and dinner (5.0+/-34.0 mg/dL; P=NS). Stepwise multiple linear regression showed that all 4 readings were significant determinants of the week 8 HbA1c (R=0.789; P<0.001). The standardized coefficients for the pre-breakfast, pre-lunch, pre-dinner and bedtime values were 0.274, 0.175, 0.195 and 0.282, respectively.
Conclusions: In insulin-treated veterans with type II diabetes, bedtime glucose is the highest reading of the day, the increment in glucose between dinner and bedtime is one of the largest of the day, and bedtime glucose may be the most influential determinant of glycemic control.
Impact statement: Greater emphasis should be placed on treating postprandial glucose elevations, especially after dinner. Improved glycemic control might be achieved by the increased use of short-acting insulin preparations at meals.