From our friends at Lehigh

From our friends at Lehigh, we are pleased to provide this information. I disagree with their comments on many issues, but they provide a good starting point for discussion.

Advice given in m.h.d is *never* medical advice. That includes this FAQ. Never substitute advice from the net for a physician's care. Diabetes is a critical health topic and you should always consult your physician or personally understand the ramifications before taking any therapeutic action based on advice found here or elsewhere on the net.

bG (blood glucose) meters are not as accurate as the readings you get from them imply. For example, you might think that 108 means 108 mg/dl, not 107 or 109. But in fact all meters made for home use have at least a 10-15% error under ideal conditions. Thus you should interpret "108" as "probably between 100 and 120". (See above for conversion to mmol/L.) This is a random error and will not be consistent from one determination to the next. You cannot expect to get exactly the same reading from two checks done one after the other, nor from two meters using the same blood sample. This is generally considered acceptable because variations in this range will not make a major difference in treatment decisions. For example, the difference between 100 and 120 may make no difference in how you treat yourself, or at most might make a difference of one unit of insulin. With present technology, more accurate meters would be much more expensive. This expense is only justified in research work, where such accuracy might detect small trends which could go undetected with less accurate measurements. This discussion applies to ideal conditions. The error may be increased by poor or missing calibration, temperatures outside the intended range, outdated strips, improper technique, poor timing, insufficient sample size, contamination, and probably other factors. Contamination is especially serious since it can happen so easily and is likely to result in an overdose of insulin. Glucose is found in fruits, juices, sodas, and many other foods. Even a smidgen can seriously alter a reading. When comparing meter readings with lab results, also note that plasma readings are 15% higher than whole blood, and that capillary blood gives different readings from venous blood. Visually read strips are slightly less accurate than meters, with an error rate around 20-25%. For some meters, strips are available from manufacturers other than the meter manufacturer. Some m.h.d. readers have compared the strips side-by-side and found those from one manufacturer to read consistently lower than the strips from another. The differences are not likely to make a significant difference in your treatment, but are large enough to be noticeable and possibly confusing. For this reason it is not a good idea to change strip manufacturers without comparing the readings from one with the readings from the other. I've seen no such direct comparison of meters, but the possibility exists that some meters might read consistently lower than others. Be careful when changing meters. By "error rate" I mean twice the standard deviation from the mean. An error rate of 15% says that about 97% of the readings will be within 15% of the actual value. Subject: Ouch! The cost of blood glucose measurement strips hurts my wallet! ======================================================= The cost of blood glucose measurement strips is a complex interaction of R&D costs, manufacturing costs, marketing strategy, insurance practices, and undoubtedly other factors. You can ask on the net if you want; you'll get lots of comments but no answers. There are a couple of ways of reducing the cost of blood glucose monitoring. One is to seek out the best price for the strips; large stores such as FEDCO often have good prices, as do some mail order suppliers (see mail order section). A second way is to use visually read strips (Chemstrip bG and a couple of lesser known brands) and cut them in half or even in thirds. Do the cutting carefully with a pair of strong, *clean* scissors, and get the strips back into the vial as quickly as possible. There have been reports that some manufacturers claim this procedure will cause problems, but those who have used the technique report that it works well. Visually read strips are slightly less accurate than meters. Do *not* cut strips when using them in meters. The results will be totally incorrect. Most discussion on m.h.d of the cost of blood glucose measurement strips has centered on the US. I'm not sure why, though a good guess is that differences in health care systems and national policies make this issue more critical to the individual patient in the US. There is no dearth of non-US participants on m.h.d. Subject: What do meters cost? ============================= The flip side of expensive blood glucose measurement strips is that the manufacturers virtually (and sometimes literally) give away the meters to hook you on their strips. Don't pay full price for a meter; look for discounts, rebates, and giveaways. For example, as of this writing I'm looking at a catalog that shows a Glucometer 3 for US$45, with a US$30 manufacturer's rebate *and* a US$30 trade-in allowance if you already have a competing meter -- which means you make US$15. There are similar deals on other meters. But make sure you consider the cost of strips as well as the cost of meters, and find out which your insurance will pay for. The most fully featured meters, such as the One Touch II, don't have such widely advertised deals, though you can probably find ways of getting them at discount. If you have insurance that pays for strips but not for the meter, you should not have to pay anything for the meter. If it's worth the time to you, call the meter manufacturers' customer service departments or the mail order outfits (see "Where can I mail order XYZ?" in part 4, Sources). They will find a way to get you the meter for free. As with strips, this discussion of costs applies to the US, and there has been little discussion of meter costs outside the US on m.h.d., probably because fewer tradeoffs are available in most countries. An Australian correspondent notes a much narrower choice and higher cost of meters there, but subsidized (pardon, subsidised) measurement strips. In Britain, strips are covered by the National Health Service, but meters may be expensive. Elsewhere? Please post. Subject: Comparing blood glucose meters ======================================= This section is courtesy of Lyle Hodgson, who found the chart published by Hospital Center Pharmacy, got permission to reproduce it, and entered and formatted the data. Take it, Lyle. The following Blood Glucose Monitor Comparison Chart is published by the Hospital Center Pharmacy (433 Brookline Ave. Boston MA 02215; reprinted here with permission). After I mentioned it a couple weeks ago, Ed encouraged me to seek the permission to post it and helped in figuring out how to format it into 80 columns, which was hell since the original was an 8.5x14" landscape with 8-point text. Note that I haven't edited anything more than to patch in some grammar where it was lacking and to abbreviate the hell out of everything. I don't know what a Privacy Option is; whether the Previous Test, Last Test, and Latest Test under "Memory" are all the same thing; whether the cassette available from the Diascan manufacturer is Audio or Video; or the sizes of most of these meters. Hope you find this chart as informative as I found the hard copy. You can get your own hard copy of the original for free by calling the Hospital Center Pharmacy yourself, 1-800-824-2401. Ctrl Soln = Control Solutions. Trng Cass = training cassette available. A=audio, V=video. Power Srce= power source (wow): NR=non-replaceable Mem = memory. Number of results stored. D/T=date and time also stored. Wrty = length of warranty.

Product Name/ Range Time Ctrl Trng Power Manufacturer mg/dl (sec) Soln Cass? Srce Mem Wrty Accuchek III/ 20- 120 Lo/Hi A,V 9V 20, 2 yr Boehringer- 500 alka- D/T Mannheim line Rejects inadequate sample, must wipe and time. Displays date&time. Privacy option. Companion2 20- 20 Lo/Hi Video 3V NR 10 4 yr Sensor/ 600 lith Medisense Largest display of readings. No wiping, blotting, or timing; auto start. Easy strip insertion. No cleaning. Diascan-S 10- 90 Norm/ Yes 6V J 10 2 yr Meter/ Home 600 Elev/ cell Diagnostics High The only smearable strip. Must wipe and time. Large easy-to-read display. Privacy option. Exactech 40- 30 Hi/Lo Video NR last 4 yr Companion 450 lith or Pen/ Medisense One-button operation. No wiping, blotting, or timing. Glucometer3/ 20- 60 Norm A,V mem: 300, 3 yr Miles/Ames 500 NR; D/T AA for LED display Alarm clock, meter, & logbook. Privacy option. One Touch II/ 0- 45 Norm A,V 6V J 250 3 yr Lifescan 600 cell No wiping, timing, or blotting. Signals when meter must be cleaned. One Touch 0- 45 Norm Audio 6V J prev 3 yr Basic/ 600 cell Lifescan Pen2 20- 20 Hi/Lo Video NR 10 4 yr Sensor/ 600 lith Medisense Largest display of readings. No wiping, blotting, or timing; auto start. Easy strip insertion. No cleaning. Tracer II/ 40- 120 Hi/Lo Video two 10 2 yr Boehringer- 400 3V Mannheim lith Pocket-sized monitor, smallest strip needs less blood. Ultra/ 0- 45 Lo/ Video four 2 2 yr Home Diag- 600 Mid/ 1.5V nostics Hi "N" No timing, wiping, blotting; automatic temperatures; correction. Large easy-to-read display. Accucheck 20- 15- Lo/ Video 6V 30 3 yr Easy/ 500 60 Mid/ alka Boehringer- Hi line Mannheim Easy calibration; small drop of blood needed. No wiping, blotting. Glucometer 40- 60 Hi/ Video two latest 5 yr Elite/ 500 Norm 3V Miles/Ames lith No wiping or timing. Strip draws up amount of blood needed. *PARTNER 10- 90 Norm/ Audio "J" 10 2 yr Visually 600 Elev/ cell Impaired/ Abnorm. Home Diag. Elev Shoulder strap, durable carry case, extra battery, smearable strip. Large display earpiece. Privacy option. CheckMate/ 40- 60- Norm None two 40+ lifetime Cascade 400 90 3V D/T of pur- Medical lith chaser

Built-in lancing device, 4 programmable alarms. Strips are individually foil wrapped. Lyle, happy with her Companion2 thanks Subject: How can I download data from my One Touch II? ====================================================== You can get a cable to hook the One Touch II to a PC from the meter manufacturer, LifeScan. The cable includes some electronics, not just a cable, so you probably don't want to make your own. In the US the cable is free. Elsewhere, LifeScan lets each international office set its own policy on cable distribution, and some are charging substantial fees. North American telephone numbers are: U.S.A. 1-800-227-8862 +1 408 263 9789 Canada 1-800-663-5521 elsewhere (If you have trouble locating a phone number for your international office, let me know. If this problem is recurrent, we will add the list of offices here.) LifeScan provides some software for downloading the data. According to a recent posting, it is minimal download software, and you must use other software (for example, a spreadsheet) for analysis. Vic Abell's freeware TOUCH2 (described below), by contrast, downloads and analyzes data and has received rave reviews from its users for its analysis features. And Vic posts update announcements to misc.health.diabetes. There is a shareware Windows program called Diabetics Assistant which downloads from the One Touch II, saves the data in a file, and provides various analysis and display facilities. I haven't heard from anyone who has used this program. I know it is available on America Online. See also the mention of OTVIEW under "Other recordkeeping software", below. No comparable Macintosh software is known to be available. However, downloading the raw data using a basic telecom program (such as Kermit or ZTerm) is feasible. The meter responds to basic simple commands. LifeScan will send you a list of the commands and responses. Call and ask for the protocol specification, or FTP it from Vic Abell (see below). Info from Vic Abell : TOUCH2 is Vic Abell's freeware MS-DOS/PC application for downloading and analyzing data from the LifeScan One Touch 2 blood glucose meter. TOUCH2 interfaces to the RS-232 data port of the One Touch 2, downloads the data on command, and provides a variety of analytical displays. It's available via anonymous ftp from vic.cc.purdue.edu (128.210.15.16) in /pub/touch2.zip or /pub/touch2.tar.gz, with information in /pub/touch2.README. When ftp asks for a password, you must provide your valid email address of the standard form user@domain.typ. The protocol specification is available from the same site, same directory, filename lifescan.ot2. If you do not have ftp access, you can get a copy of a TOUCH2 distribution by email by sending an email letter to: ftpmail@decwrl.dec.com In the body of the letter put: reply connect vic.cc.purdue.edu anonymous chunksize 100000 binary uuencode get /pub/touch2.zip quit If you want touch2.tar.gz or lifescan.ot2 instead, put its name in place of touch2.zip in the "get" directive. Multiple "get"s are allowed. must be in the standard form user@domain.typ. If you want btoa encoding instead of uuencoding, replace the "uuencode" line with "btoa". If you can't receive email messages of 100K bytes, change the "chunksize" line. Be patient; the server sometimes takes two or three days to process the backlog, and recently up to a week. Using the World Wide Web, enter the URL ftp://vic.cc.purdue.edu/pub/ Subject: How can I download data from my Glucometer (tm)? ========================================================= Miles Inc, makers of the Glucometer M/M+ blood glucose meters, sells a program called Glucofacts+ DMS which -- downloads and analyzes data from the meters -- stores the data in files -- produces quite a variety of statistical reports and graphs on screen or printed -- runs under MS-DOS only -- supports only the Glucometer M and M+ -- requires a nonstandard cable which is supplied with the software -- uses a proprietary interface (unlike Lifescan, Miles will not provide the specifications of the interface) -- does not provide for manual entry of data -- a Data-Link Modem available separately provides the capability of transferring data directly from the meter to a PC at the physician's office, for those lacking a home PC. -- can upload the data to the doctor's office (a Data-Link Module provides standalone capability for users without a PC) -- is *not* available in a demo version Chris Trippel of Miles will answer questions unofficially and can email copies of a very good description, about 7K long, of Glucofacts+ DMS. You can also get information and place orders by calling 1-800-348-8100. If ordering, ask for Lloyd Bane, ask for product code 5044B, and provide the serial number from your meter. Subject: Other recordkeeping software ===================================== Michael Wolfe is maintaining a software review panel that is posted in conjunction with this FAQ. New and udpated software information is mostly going into that panel, so look there for more up to date information. I searched the PC and Macintosh software libraries on America Online using the key 'diabetes' and came up with programs running under MS-DOS, Windows and Macintosh (HyperCard) for blood glucose recordkeeping. Prices range from free to $30. The Control Diabetes program from Nutrisoft has received favorable mention in m.h.d; I haven't seen any of the others mentioned. The Diabetics Assistant can download from a One Touch II. CompuServe has software in the Diabetes Forum. _Diabetes Forecast_, from the ADA, carries some advertisements for commercial software. I don't know anything about the packages advertised. OTVIEW is a shareware PC DOS or Windows program to download and report data from a One Touch II, as well as managing other operational features of the meter. It's available on the Demon ftp site (see below) and elsewhere. For more information, contact the author, Tom McKeever, at Tom.McKeever@mit.com. Demon Internet Services is generously providing FTP space for software and information related to diabetes on ftp.demon.co.uk, directory /pub/diabetes. See the sections on Online Resources for details. From the WWW: ftp://ftp.demon.co.uk/pub/diabetes/ Subject: I've heard of a non-invasive bG meter -- the Dream Beam? ================================================================ ***The following information is incomplete, as another company has introduced a non-invasive meter for about $8000. It has been discussed in the newsgroup. Rumors of other non-invasive (and "non-evasive") meters abound. I won't be trying to keep this section up to date until the situation stabilizes. *** There is at least one development project in hot pursuit of a bG monitor which operates by shining light through flesh (through the thumbnail in one case) and analyzing the light that passes through. Glucose doesn't affect light much differently from many other substances in the body, so this is not an easy task. Some field trials have been done, but the developers have a way to go to reach acceptable accuracy. A successful product is far from guaranteed, and may be several years away if it arrives at all. One estimate is that such a meter might cost about US$1000. Assuming the per-check cost is zero, this would pay for itself in 1-2 years for many patients. Look for the insurance companies to throw up some roadblock to achieving these savings, at least in the US. Subject: What's HbA1c and what's it mean? ========================================= Hb = hemoglobin, the compound in the red blood cells that transports oxygen. A1c is a specific subtype. (The 1 is actually a subscript to the A, and the c is a subscript to the 1.) Glucose binds slowly but irreversibly to hemoglobin, forming a stable sub-sub-type which is only eliminated by the normal recycling of the red blood cells, which have a lifetime of about 90 days. In non-diabetic persons, the formation and destruction reach a steady state with about 3.0% to 6.5% of the hemoglobin being the A1c subsubtype. Since most diabetics have a higher average blood glucose (bG) level than non-diabetics, the steady state level is higher in diabetics. The HbA1c level thus is an indication of the average bG level over the past 90 days or so. Interpreting HbA1c values is tricky because several different lab measurements have been introduced over the last 15 years, measuring slightly different subtypes with different limits for normal values and thus different interpretive scales. All are still in use in some places. When you get a lab result, be sure to look at what the lab considers to be the normal range. Most discussion of HbA1c values in m.h.d appears to be based on the most recent lab measurement, where the normal range is approximately 3-6.5%. Caveat lector. Subject: Why is my morning bg high? What are dawn phenomenon, rebound, and Somogyi effect? ======================================================================== This section is written by Charles Coughran . There are three main causes of high morning fasting bg. In decreasing order of probability they are insufficient insulin, dawn phenomenon, and Somogyi effect (aka rebound). Insufficient or waning insulin is simple. If the effective duration of intermediate or long acting insulin ends sometime during the night, the relative level of circulating insulin will be too low, and your blood sugars will rise. Dawn phenomenon refers to increased glucose production and insulin resistance brought on by the release of counterregulatory hormones in the early morning hours near waking. It happens in normal people as well as in diabetics; in nondiabetics it shows up as measurably increased insulin secretion around dawn. Dawn phenomenon is variable in strength both within the population and over time in individuals. It can show up as either high fasting glucose levels or an increased insulin requirement to cover breakfast compared to equivalent meals at other times of day. Somogyi effect refers to a rebound in bg after nocturnal hypoglycemia which occurs during sleep with the patient not experiencing any symptoms. The hypoglycemia triggers the release of counterregulatory hormones. Somgoyi effect appears to be less prevalent than previously thought. While it does occur, some episodes of hyperglycemia following hypoglycemia are actually waning insulin levels following an insulin peak with medium acting insulin. This can be difficult to sort out. The best way to sort it out is to test every couple of hours from bedtime to morning. If your bg rises all, or much of the night, it is a lack of circulating insulin. If it is stable all night, but rises sharply sometime before you wake in the morning, it is dawn phenomenon. If your bg declines to the point of a hypoglycemic reaction, it is *possibly* Somogyi effect. You may have to test on several nights to nail the problem. Once you have figured out the problem you and your doctor can discuss changes in your insulin regimen to correct it. The answer depends critically on your particular circumstances. Mayer Davidson, in _Diabetes Mellitus: Diagnosis and Treatment_ p 252 in the 3rd edition) says that Somogyi effect rarely causes fasting hyperglycemia, and cites studies. Subject: Who did this? ====================== -- Edward Reid ed@titipu.resun.com PO Box 378 reide@freenet.tlh.fl.us Greensboro FL 32330 On the World Wide Web: mailto:ed@titipu.resun.com