Answering Loaded Questions: How are your sugars?

Melinda Seed writes for Twice Diabetes
Melinda Seed writes for Twice Diabetes

One of the most irritating things about type 1 diabetes is that it sentences you to a lifetime of stupid questions.  It’s not the uninformed questions from colleagues and acquaintances that bother me, in fact these are usually asked with genuine interest and concern and I’m happy to advocate for diabetes by sharing my diabetes experiences and knowledge.  What bugs me are meaningless and useless questions asked by health care professionals who aren’t asked for input on your diabetes. They’re usually asked by nurses or assistants at ophthalmologists or GPs and non-diabetes specialists and they go something like this”

“How are your sugars?”

“What was your highest sugar in the last month? What was your lowest?”

“What do your sugars usually vary between?”

To a type 1 diabetic these questions are so loaded it’s extremely difficult to answer them without sounding evasive or defensive and it’s impossible to answer honestly without ending up labelled as a “bad diabetic”.  If you say your sugars usually vary between “20mmol/l (360 mg/l) and 2.5mmol/l (45 mg/l) expect at least an eyebrow raise, perhaps a shake of the head as a minimum and most likely a lecture about diabetes and complications and further queries that imply your IQ is lower than last weeks lowest BSL reading.  Your protestations that your hba1c was 7.0% or elucidation on the intricacies of managing type 1 diabetes to reassure that you are a “good” diabetic are met with silence or the raised eyebrow again and you end up feeling as though you’re trying to convince the teacher that the dog really did eat your homework.someecards.com - I'm not judgemental, I just assess type 1 diabetics by comparing their sugars to non-diabetics.

Logically I know that I shouldn’t worry about stupid questions. My a1c is well within the range recommended by my endo and the DCCT and other studies showed that blood sugars will fluctuate markedly in type 1 diabetes and no matter how intensive/infinitely creative the management you will have sugars that spike significantly outside the non-diabetic range.  I know all this and I know that people who ask me silly questions are doing so out of ignorance but it still bugs me and I think at heart it is the knowledge that they’re judging me on unfair criteria and there’s not a damn thing I can do about it. No matter what I say they’re not going to change their mind, I’ll just end up sounding defensive and guilty. 

So what is the best way to answer these questions?  Try to deliver a lecture about type 1 diabetes? Just provide minimal information and ignore the judgement because you know the truth?  Answer “how long’s a piece of string?” or “My sugars have their ups and downs?”  or “I refuse to answer that on the grounds that I might incriminate myself”.

A suggestion that I saw somewhere on Facebook was to answer with a question “How is my treatment at this practice/clinic going to be influenced by my answer to that question?”. I think this is my favourite response because it should force the questioner to examine their presuppositions and the clinical significance of their questions. How do you deal with such questions?   Are you a health professional? Have you asked this question and how does the information figure in to clinical decision making?

29 thoughts on “Answering Loaded Questions: How are your sugars?

  1. Hi,
    I am often guilty of asking my daughter this, more out of concern that if her bsl are consistently high, she is struggling to manage on her own and may need/ want support. I realise it is a loaded question; do you have any suggestions on how to approach it? In the past we have got to the point where she is ill with dka and has ended up in hospital. She’s 21 so I don’t like to interfere and be on her back all the time about it, but at the same time I don’t want her to struggle on her own.
    I would appreciate your comments and advice!
    Thanks
    Teresa

    1. Great question Teresa. I do believe context is everything, so somebody who knows me & my diabetes, like my endo or partner saying “how are your sugars”? if I am ill or recently had a cortisone injection or something is quite different from being asked that in the context of a non-diabetes related medical appointment.

      In relation to your daughter (like you don’t take medical advice from the internet, same goes with relationship advice, I speak only from my experience, I have no expertise or quals in this regard) I would try to be generally supportive about diabetes rather than specifically “nosy”. Let her know that you understand how hard it can be to manage d and that it’s a drag, maybe talk to her about her a1c in a non-naggy, non-jugemental way, ask her if she’s happy about her control and if there’s anything you could help her with or courses or Drs or something that might help with diabetes-either with control or with life w d in general.

      You could start by saying “I read this blog where the writer was ranting about how much she hated being asked about her sugars” Do I do that? Does it annoy you?

      Thanks for your interest and FWIW you sound like a great supportive Mum.

      Mel xox

  2. Love your post Melinda. I’m off to the GP today and think I’ll use the ‘How long is a piece of string” response. Honestly, I’m at a point where I am reluctant to visit my GP these days except to get script repeats and I have health concerns that I put off getting seen to all because of his blaming attitude to my diabetes. I’m feeling a bit better this morning because of your post and ready to face the dreaded visit. Bless you.

    1. I’m really glad the post helped and was timely. You’ve totally brightened my day by your comment. Hope the GP appointment goes ok.

      Nil Desperandum Illegitimi Carborundum

  3. I gave a practice nurse the lecture about T1 when she asked me when I had ‘changed’ from T2. Now she doesn’t ask silly questions (to me) any more. It is very annoying when an HP asks these questions. I had an ophthalmologist (try spelling that after a wine) who always asked what my sugars were like. If anyone asks me that now, I just give them the latest A1c. I don’t think that most of them realise how patronising and annoying these questions are, probably because it’s a matter of not thinking on their side. One of my aims is to educate all the HPs I come across; that way we can be friends.

    1. I think I gave a nurse the a1c answer once and she persisted with the variance question, I may, perhaps have let my irritation show 🙂 I think if the questioner is well intentioned then I don’t mind so much it’s just the patronising attitude that grates and the sense that no matter what you say they don’t think that you know anything anyway. A radiologist once asked how long I’d had diabetes “30 Years”, he pulled a face and said “you look very young to have a 30yr history of disease”. Grrr how do you respond to that, thanks for the compliment on my youthful appearance, I am only 31 yrs old!!!

  4. As a practicing ophthalmologist, I ask my diabetic patients these exact questions on a regular basis. Addressing a couple of your points:
    1. How is my treatment at this practice/clinic going to be influenced by my answer to that question? The answer to this question influences how concerned I am by whatever level of retinopathy I see. HgbA1c certainly is informative, but variance in daily blood sugar also affects the retina.
    2. I encounter your suggested generalized answers to this question on a regular basis. On further questioning, many patients reveal that they didn’t check their blood sugar this morning, or yesterday or for the past several weeks. Again, daily variation in blood sugar matters.
    3. While I’m certain you take immaculate care of your blood sugars, many people do not, and a certain level of apprehension regarding your doctor asking you questions you’re not comfortable with can help be an impetus to take better care of yourself. Dentists do the same thing.

    1. Every diabetic (and non-diabetic for that matter) have variance in daily blood sugars. I think this is the point Melinda is getting at. How are your sugars? Well, which particular sugars are you asking about. My last test, my midday one yesterday, my Hba1c? A person can take immaculate care of their blood sugars to a degree. There are too many variables that influence blood sugars that cannot be identified and/or are out of the person’s control. My ophthalmologist prescribed 4 different eye drops to be taken several times a day but neglected to tell me they were steriods and predisone and would give me a rise in blood sugars. After several months of blood sugars in the high teens, I worked out which variable was influencing it. He also commented that if I had taken better care of myself in my earlier years I wouldn’t have trouble with my eyes. I did my best with what was available to me in 1966. Sorry about the rant but I don’t think you are getting the point of this thread.

    2. Stephen,

      Thank-you for engaging with us on this question. I sincerely do appreciate that you have taken the time to tell us why you ask those questions and I do understand that in your professional judgement, you deem those questions to be significant.

      From my position as the patient with type 1 diabetes of lengthy duration my perspective is:

      !.By all means ask about the latest hba1c, I would think that if somebody’s a1c is above a certain level and/or has been for some time or even was for a few years prior, that might necessitate more frequent review by an ophthalmologist and I can see that as being relevant and I have never indicated otherwise.

      2.I have yet to meet a person with type 1 diabetes who is not in their “honeymoon” period who does not experience marked excursions in their blood glucose level and studies like the DCCT confirm this is to be expected. Could it perhaps, be appropriate to accept marked variation in blood sugars as a “fact” with people with type 1 and to expect this to affect their retinas as appropriate. Given that many people with type 1 diabetes find it difficult to give a meaningful answer to this question I wonder what sort of credence you can place on the results as an aid to clinical decision making?

      Further to this, I’m sincerely and extremely interested in your comment that patient-provided information about daily bsl fluctuations influences “how concerned [you] are about the level of retinopathy [you] are seeing.” Could you expand on this? If they declare little variation or lots or that they never test their bsl-how are your decisions and level of concern affected?

      3.I would suggest that any type 1 diabetic who did not check their blood sugar at least 3-4 times a day could not have an hba1c of less than 8% (I would suspect that it would more likely be well into double figures if they hadn’t checked for weeks), therefore, asking about daily fluctuations in order to ascertain the frequency of bsl monitoring is rather redundant. I’m also a fan of keeping things simple, asking directly “How many times a day do you test your sugar?” may yield more information.

      4.An ophthalmologist asking about daily fluctuations in sugar as a tool to improve self-management in type 1 diabetes as you suggest in point 3 is surely, untested as a clinical intervention? I would suggest that the question particularly when accompanied by surprise and head shakes when people answer this question honestly is as likely to disempower and depress people and lead them to doubt their self-efficacy which has been shown to worsen control, as it is to encourage them to “take better care of themselves”.

  5. Melinda: Being a relatively internet literate person, I want to address some issues you raised on twitter.
    1. I am a practicing ophthalmologist
    2. Data on intensive control of blood sugar reducing complications: I’ve seen you quote the DCCT at other times on this site. Being a well informed diabetic patient I know you’re familiar with both the positives and negatives of intensive control (positives: reduce risk of diabetic retinopathy by 76%, slowed progression of DR by 54%, reduced development of severe NPDR or PDR by 47% etc etc; negatives: 2-3x increase in severe hypoglycemia)
    In short: lower blood sugar on a daily basis reduces the likelihood of having vision loss.

    1. Stephen I am fully aware of the statistical link between glycated haemoglobin and retinopathy and other diabetic complications. I have stated that fact in several of my blog posts, most recently here, http://twicediabetes.com/diabetes-blame-complications-truth/

      You are 100% correct and I endorse the fact that lower blood sugar on a daily basis reduces the likelihood of having vision loss. I’d add, as I have elsewhere that thanks to the wonders of modern ophthalmology most vision loss is avoidable and severe vision loss from retinopathy is preventable in places like Australia, so long as you see your ophthalmologist regularly.

      Twitter is a flawed medium and if I have given anybody any reason to think that I am suggesting on twitter or elsewhere that hba1c is not linked to the risk of retinopathy, please let me know where I have done this and I shall amend/delete/apologise for the falsity or possibility for misinterpretation. I HATE misinformation about diabetes and am distressed that I could in any way be contributing to it. Please let me know either here or via email, mel@twicediabetes.com or twitter message @twicediabetes and I shall fix immediately.

  6. Jen:
    It certainly sounds like you’ve had some frustrating interactions with physicians. I’m sorry thats something you’ve had to deal with. Building a trusting relationship with your physician is an important but difficult task.
    The question I ask virtually every diabetic patient I deal with is how was your fasting blood sugar this morning before breakfast. The reason I ask this is the Diabetic Control and Complications Trial (DCCT, specifically designed for type 1 diabetics) has shown that intensive blood sugar control on a daily basis reduces visual complications and diabetic retinopathy, and 1 of the definitions used for intensive control in that trial (the easiest to keep track of) is pre-meal blood sugar 70-120.
    Questions may seem arbitrary and simply designed to make you feel bad, but every question I ask has a purpose. Some are to help me make decisions regarding your care. Others are designed to help me explain the alternatives, risks, benefits and consequences of choices the patient and I make. I am aware that no diabetic has complete control over their blood sugar, but every diabetic is capable of influencing this number for better or worse, and there are logical consequences to the numbers. This discussion, done in a considerate and caring fashion, is tremendously important and omitting it seems irresponsible.

    1. Stephen I have read the DCCT and yes they did give various treatment goals for intensive management and indeed one of them was a goal for fasting bsls. It included many things including a weekly 3am blood test that was >3.5mmol/l

      You seem, however, to be making a leap that is not statistically justified to assert that a fasting bsl on one particular day is related in any, way shape or form to your risk for developing complications. The risk of complications was assessed using the HBA1c NOT fasting bsls. If there is a study that directly links a one-off fasting bsl to the risk of complications in people with type 1 diabetes and shows this indicator has a better correlation than a1c then I’d be interested to see it.

      Interestingly, the DCCT showed that fasting bsl did NOT correlate well with HBA1c levels, post-lunch and bedtime bsls correlated much better. Link to an analysis here http://www.ngsp.org/A1ceAG.asp So I’m struggling to see a strong justification for asking about 1 day’s fasting bsl.

      On another note, given that the fear of losing your vision is a cause of stress and anxiety in people with diabetes, did you consider that the stress of an upcoming ophthalmology appointment might elevate a type 1 diabetic’s bsl on the morning of the appointment. Your reliance on this measure of control, might be skewing your clinical judgement.

  7. I agree WITH Jen, Stephen. I appreciate your comments as an ophtho, but I happen to test 8-10 times a day, and I still cannot get a smooth result, even with a pump. We all do the best we can, even those whom you say may not have tested for some time. Some people just cannot cope with the fact that they have a chronic condition/disease from which there is no relief, no holiday – 24/7 365 days of the year, and 366 in a leap year. Could you live with that, Stephen and keep a sense of humour, or equilibrium? Do you know what your BSL is at any given time? We learn to test and to cope with it as best we can, but it takes bloody years. I’ve had this thing for over 49 years and I’m still learning. Don’t lecture us, please, without thinking about the realities we face every day. We can do all ‘the right things’ and still develop retinopathy, CKD or other complications. None of us live wrapped in cotton wool.

    1. Yes Jane, agree entirely. Stephen, you seem one of the good guys with regards to your patients. All we ask is to be treated with the respect we deserve in our ongoing battles with diabetes. To ask about fasting BGLs is certainly very different from asking “How are your sugars?” as it is much more specific but these levels can also fluctuate wildly for no known reason. One final point. EVERY diabetic knows about the complications of this disease. It is on our minds constantly we do not need reminding. To discuss the risks, benefits and consequences of treatment you are considering for your patients is what we need from you. Also to be treated as an intelligent human being and have the decisions I make about my diabetes respected is all I ask.

  8. MODERATOR COMMENT: It has become clear to me that Stephen of no disclosed email address cannot be who he claims to be. I have given lengthy consideration as to whether or not to just delete all his comments but have decided to give readers the opportunity to see why I believe Stephen is not an ophthalmologist. I have deleted the last part of Stephen’s very lengthy response because he makes a lot of assertions without any evidence other than his anecdotes about his supposed ophthalmology experience. These would be relevant and appreciated if he hadn’t posted things which indicate very clearly he has very limited knowledge of diabetic eye disease.END MODERATOR COMMENT

    All:
    There are several concerns that have been raised here. Lacking the space to appropriately address them all, I will attempt to expound upon a few
    1.Marked excursions on blood sugar throughout the day are indeed normal. This does not negate the responsibility of the diabetic to minimize the fluctuation through the use of dietary modifications and medication. It would seem to me that saying, “my blood sugar is out of my control and I can’t do anything about it because I’m doing the best I can,” does far more to disempower and discourage a patient than my asking about what your sugars have been during a physician visit. MODERATOR COMMENT NOBODY SAID THIS AT ALL! END MODERATOR COMMENT
    2. Regarding patient responses influencing how concerned I am about the level of retinopathy I see. I was mildly amused to see that one of your twitter followers was “shocked” that I would say such a thing. It seems intuitive to me,but I’ll use an example to illustrate. If I see someone who has moderate retinopathy with borderline clinically significant macular edema which is borderline ready vs not ready for treatment via laser or injection, their responses influence how aggressively I might pursue these treatments. If someone can readily tell me their fasting blood sugar from the past 3 days, or gets out their chart to show me, I know they are at least paying attention to it and may give them some extra time to see if improved blood sugar control may avert the need for invasive treatment. On the other hand, if someone gives me vague answers about, “doing the best they can” but cannot tell me any of their readings, I may consider treatment sooner rather than later. Additionally, this aids me in discussing the likely coarse of their disease and its complications being more or less likely which aids me in counseling the patient.MODERATOR COMMENT PLEASE SEE MY RESPONSE BELOW,AN OPHTHO WOULD NOT SAY THIS END MODERATOR COMMENT
    3. I couldn’t agree with Melinda more regarding the necessity of frequent testing. Alas, many diabetics do not share her alacrity. Asking how many times a day they check as you suggest may reveal some information, but this is easily glossed over when answered in a general way. In my practice, I have found that asking for specific levels results in a much more realistic impression of who is checking their blood sugar, how often, and what the results actually are.

    1. Stephen says “…may give them some extra time to see if improved blood sugar control may avert the need for invasive treatment. On the other hand, if someone gives me vague answers about, “doing the best they can” but cannot tell me any of their readings, I may consider treatment sooner rather than later.”

      Really Stephen, really? You are obviously not an ophthalmologist (but some sort of bizarre troll with a superficial knowledge of diabetes) because no ophthalmologist would say something so demonstrably false. The worsening of retinopathy after tightening of glycemic control is well documented and proven. Readers please speak to your ophtho and/or your endo about this if you have any queries or concerns. I reiterate that nothing anywhere on this blog is intended to be medical advice.

      “Tighten the control and the retinopathy worsens. This is not new. It was shown in the CROCK study, the Oslo study, and the Steno Diabetes Center study. We have known for some time that over the first year or 2 of tightening control, complications can worsen. That is something of a conundrum: glucose heading towards normal, retinopathy getting worse.” http://www.medscape.org/viewarticle/460902_4

      For anyone who is interested the following studies from respected, peer-reviewed journals show this counter-intuitive to the uninformed but well documented impact that improving control worsens retinopathy over the first year or 2.
      1LauritzenT,Frost-LarsenK,DeckertT,theStenoStudyGroup. Effect of 1year of near-normal blood glucose levels on retino-pathy in insulin-dependent diabetics. Lancet 1983; i:200-4.
      2 VanBallegooieE,HooymansJMM,TimmermanZ,etal .Rapid deterioration of diabetic retinopathy during treatment with continuous subcutaneous insulin infusion.DiabetesCare1984;7: 236-42.
      3 The Kroc Collaborative Study Group. Blood glucose control and the evolution of diabetic retinopathy and albuminuria. N EnglJ Med 1984;311:365-72.
      4 Dahl-J0rgensen K, Brinchmann-Hansen 0, Hanssen KF, SandvikL,Aagcnas0,AkerDiabctesGroup .Rapid tightening of blood glucose control leads to transient deterioration of retinopathy in insulindependent diabetes mellitus:theOslo Study.BrMedJ 1985;290:811-5.
      5 Brinchmann-Hansen 0, Dahl-J0rgensen K, Hansscn KF, SandvikL,theOsloStudyGroup. Effects of intensified insulin treatment on various lesions of diabetic retinopathy. Am J Ophthalmol 1985; 100: 644-53

      I am not going to approve any more comments from Stephen because he obviously isn’t who he claims to be, if any “real” health professionals would like to respond to the questions raised in my post and the subsequent comments, then I’m happy to open up the blog for guest posts from bona fide health professionals who would like to refute or put a different view on these questions. Contact me via this website or email.

    2. Yes I doubt Stephen’s credentials too. He just doesn’t sound like a doctor, more like an 1st year nursing student. What doctor would say “coarse of disease” or misuse words like “alacrity”.

  9. I was excited that a health care professional was engaging in our discussion and now feel a little let down. I would encourage other HCPs to submit comment on all the posts. We may challenge your comments and put our points of view across but debate is healthy and empowering. It also gives you an unique look at things from the patients’ perspectives. Here I was hoping that Stephen would stop and think before asking his next diabetic patient about their blood sugars. Ah well, not to be.

  10. I am disappointed that ‘Stephen’ was not who he claimed to be. But I would certainly expect an ophtho to be able to spell. ‘Coarse of disease’?? Really?? A red pen would be wonderful here – ‘Course of disease’ would at least make sense. A lot of his comments take me back to ‘a little knowledge is a dangerous thing’.

    Melinda, thanks for writing the original post, and for giving us all the opportunity to comment. I really appreciate it.

  11. I loved your suggested response to the “how are your sugars?” question which I have been asked several times in the last week… but I never have the presence of mind to be so clever and measured in my response. It p$%$es me off so much every time, and puts me on the defence… anyone got tips on how to keep calm and answer stupid, loaded questions with a cool head? Or perhaps it’s just me, or dumb-question-fatigue…. Kate

  12. Teresa – Mel gives very good advice, but also my partner often asks “are your sugars behaving?” which I like as it asks the same question without implying judgement.

  13. I would love to know the compliance of most GPs and other health professionals in their daily lives. The majority I see are overweight, I could assume that they are not following the recommended exercise levels, or non compliant in portion control, or not following the guidelines on drinking. Life is non-compliant. I as a Type 1 take extreme insult at health professionals that use this term. My BGLs will vary based on stress, traffic, workload, travel, exercise (it does not make control easier, it makes it more complicated) and yes even the weather. I test 7-8 times a day only to be questioned by GPs if this isn’t excessive. My HBA1C isn’t good enough for some (6.7% last month in case people want to question this) yet my endo has no issues.
    My blood sugars are varied, they always will be. That is life, that is my reality.

    1. Rebecca that’s an excellent point and one I hadn’t thought of. You’re right – many of those who judge diabetics are far from perfect in other health related respects. Diet, exercise, alcohol consumption…. a well made point and interesting perspective.

  14. It’s very annoying, I agree. I usually answer something like “My sugars are (relatively) good and stable”, although that actually means nothing. But the question itself also means nothing.
    That usually means the end of that part of conversation. “OK, so you’re not problematic, that’s cool.” I hate that a bit (it implies that I am “a good diabetic”, contrary to some “bad examples they meet”), but it helps to avoid further annoyance.
    My ophthalmologist usually asks my latest A1c number, she also always asks me how I feel generally, did I have some major health issues (unrelated to D) since last visit, also asks about family, work, emotions… but never asks about my BG from that morning!

  15. I saw this featured on the end of year post and remembered I meant to comment a while ago. I was asked this question at my optho appointment this year. I said “fine” or similar, she asked a follow up question and I said “I see my endocrinologist 6 monthly and he manages my diabetes” which is my go-to phrase. Frankly I manage my diabetes myself, but I find “my endo says….” or “my endo is happy with…” to be magic bullets in stopping inquisitive HPs giving me the third degree. That’s harder if you don’t see an endo regularly though.

    Later in the appointment I had a word about the “how are your sugars” question, and my optho said she asks it to find the people who are feeling completely out of control and need referral to someone who can help them with D management. She gets someone like that on a regular enough basis to make it worth asking. I suggested she instead ask something more to the effect of “how are you feeling about your blood sugar control at the moment?” and she was actually very receptive. I wonder whether providing alternatives to “how are your sugars” could sometimes work out well and I’d be interested in other people’s suggestions for better questions.

    I had a go at my periodontist a while back about attitude to HbA1c. She was quite receptive too and they obviously put a note on my file because they haven’t brought up diabetes with me since.

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