Awildina “Figgy” Figueroa MSN, RN, CDE, a Certified Diabetes Educator, counsels veterans at the Washington, DC, VAMC, on managing diabetes two years ago. The focus is increasingly on avoiding hypoglycemia, as well as hyperglycemia. Photo from DCVAMC website.

ROSEBURG, OR — For years, diabetes management was primarily concerned with keeping blood sugar from going too high. Now, and especially at the VA, keeping blood glucose from going too low is just as important.

“When thinking about likely reasons for rushing to the emergency department (ED), severe low blood sugar may not come to mind,” said Tracy Weistreich, PhD, RN, chief officer and nurse executive for the VHA’s Office of Community Engagement and Center for Compassionate Innovation. “The data tells a different story. Low-blood sugar, or hypoglycemia, episodes are among the top three most common drug-related events that send veterans to an ED.”

Hypoglycemia rises to the top of serious concerns for the VA because of a combination of unique factors. An average age of 65 puts the veteran population at greater risk of diabetes as the prevalence of disease rises with age. In addition, higher rates of overweight and obesity, more comorbidities, and social disparities that increase food insecurity and limit access to healthy, quality food increase the risk of diabetes and make managing blood glucose levels more challenging. Veterans are also slightly more likely to take insulin than most diabetes patients.

“We care for about 1.6 million veterans with diabetes, about one in four veterans who are treated in the VA. Three in 10, about 500,000 veterans, are treated with insulin,” said Paul Conlin, MD, chief of Medical Service at the VA Boston Healthcare System.

In comparison, the American Diabetes Association estimates that diabetes affects 10.5% of the total U.S. population or approximately 34.2 million people, of which just 26.8 million have been diagnosed. About 27% of Americans over age 65 have diabetes. Approximately 28% of all diabetics use insulin to manage their disease.

Throughout 2020, the VA has focused on helping more veterans and physicians mitigate the risks of hypoglycemia through the “Understand Your Diabetes Numbers” campaign. “This public health campaign encourages veterans to be proactive with their health care teams by improving their understanding of diabetes test results,” said VA Secretary Robert Willkie. “The campaign reflects VA’s ongoing commitment to improve the health care experiences of veterans by empowering them to be active partners in their care.

Videos developed as part of the campaign focus on tools that physicians can use to enable veterans to better manage their diabetes and to urge caution for both clinicians and patients who want to push their diabetes numbers down.

“If you reduce your blood glucose on the average lower and lower, you increase your risk for hypoglycemia and a trip to the emergency room or worse,” said David C. Aron, endocrinologist at the VA Northeast Ohio Healthcare System.

“To make matters even more complicated, symptoms of hypoglycemia can be anything from nothing to very subtle, to being absolutely outrageous, and in my 35 years of being a physician, I’ve seen it from one end to the other,” Aron added. “And patients may not always recognize what the symptoms are. So the caregivers have to be educated as well.”

Veterans and caregivers should be educated on some of the more easily overlooked signs of hypoglycemia like confusion and forgetfulness, which older patients may assume signal early dementia and fear mentioning to their care team. Out of character anxiety, impatience, and irritability may also be symptoms of hypoglycemia.

“When unusual symptoms are occurring, you take time and check that blood glucose,” advised Sharon A. Watts, DNP, FNP-BC, CDE, national advisor, VA’s Office of Nursing Services, Metabolic Syndrome and Diabetes. Even if the veteran or caregiver thinks that the symptom is not related to diabetes, a low reading may provide a new perspective.

At the same time, Watts recommended following the 15-15 rule when in doubt. “Fifteen grams of fast-acting glucose, such as three or four glucose tablets or four ounces of juice, if that truly is a symptom of hypoglycemia, it will be resolved.” In more severe cases that require immediate medical assistance, such as unconsciousness, Watts advised administering glucagon from a glucagon kit stored at room temperature while waiting for the arrival of paramedics.

To head off hypoglycemic crises, clinicians should encourage veterans to discuss any changes to their diet or activity levels or low readings that may indicate a need to adjust their medications, particularly for veterans on insulin.

Clear Instructions

They should also ensure that veterans fully understand how to manage their diabetes. “It’s estimated that about half of Americans and those that we think would be at high-risk for literacy issues, such as the uninsured or those with less education, have either a basic or below basic health literacy quantitative skills. That could mean that something as simple as trying to catch a bus to get to the clinic or reading a food label would be compromised,” Watts noted.

Giving simple, clear instructions and using the teach-back method when communicating about treatment goals, medication use, or nutrition information can ensure that veterans and their caregivers understand what they need to do. Writing out units of insulin so that patients do not need to calculate it themselves can help, as can providing visuals such as a Healthy Plate image to show the appropriate balance of foods.

“Understanding food and food labels in diabetes, especially for patients taking multiple daily injections of insulin is very, very important,” said Mary M. Julius, RD, CDE, program quality manager in VA’s Diabetes Self-Management and Support program.

Providing easy to remember ways to estimate carbohydrates can make a big difference for veterans who might not be able to visualize or track carbohydrates by grams. “An apple, orange or peach about the size of a tennis ball is going to contain 15 grams of carbohydrates or be equal to one carb serving,” Julius explained. “About a half a cup of most of your pastas and potatoes is going to contain 15 grams of carbohydrates. The average fist is equal to about 30 grams of carbohydrate.”

Accuracy in Numbers

Complete clarity on what other numbers mean—and do not mean—is critical for both clinicians and patients.

Glucose meters readings, for instance, imply a range—something that might not be obvious to patients who rely on them. “The FDA has issued guidance that 98% of all blood glucose values should be within 15 milligrams per deciliter when the actual value is below 75 milligrams per deciliter,” said Leonard M. Pogach, MD, VA’s national program director for diabetes and endocrinology. “From a practical perspective, an often used definition for hypoglycemia is 70. So, this could mean that if your glucose value is 70, the actual value could be between 55 to 80.” A reading that appears borderline could, in fact, indicate serious hypoglycemia, so veterans and caregivers should take appropriate action.

Clinicians can also assign too great a value to numbers, particularly lab results. “Hemoglobin A1c represents the average blood glucose over the past approximately three months or so,” Aron noted. But that seemingly precise number has a lot of wiggle room. “When you see one value, that value represents a number plus or minus a little bit. How big that little bit is depends on the accuracy of the test.”

The variability and range of results argue for care when using A1c to guide therapy decisions. A result of 7.2%, for instance, could really indicate anything from 6.85 to 7.4 or more. Additional information could lead to better decisions, particularly if there is discordance between the A1c and the blood glucose levels, Aron said: “If you’re making a decision about a major change in therapy, measure twice, cut once.”

Patient differences also matter. Hemoglobin variants such as sickle cell trait and other factors, including acute blood loss, thalassemia, anemia, liver disease, and chronic kidney disease affect A1c readings. “What’s less well recognized, though the VA/DoD guidelines point this out, is that multiple high quality studies have shown that on the average, hemoglobin A1c results were higher in African Americans than Caucasians who have the same exact corresponding glucose results,” Pogach added. “However, these studies also indicate that there’s a lot of individual variation, so you have to basically take into account the patient in front of you.”