About the Author

Patty Colombe has been a Registered Nurse for twenty two years and for the past seventeen years has been in diabetes education.

She currently works in Stephenville, NF. One of her projects has been working with their clinical dietitian to transform their rural DEC into a structured program which focuses on self management.

Ms Colombe has a great interest in interpreting patterns of blood sugar to determine most probable cause of poor control. She held the position of Director of Quality with the National Executive of the Diabetes Educators Section of the CDA for three years. During that time she was involved in the DES strategic plan, clinical practice guidelines and the diabetes standards of care.

 

Diabetes Management is Continuously Evolving

By Patty Colombe

Finding the most appropriate management regime for each client is similar to finding the right blend of ingredients for a “new” recipe. Often, old standards are the best choice, but sometimes you need a different “recipe” when old methods will not work for your hyperglycemic client.

Magnesium level is a routine component of blood values I check on all referrals I receive. Research has shown magnesium can affect blood glucose levels. A number of my clients displayed magnesium levels which were low normal (0.7 – 0.8) or just below normal (0.6 – 0.69) values. This prompted me to research the effects of magnesium and study its effects on my own clients.

The person with diabetes who has elevated blood glucose levels combined with low magnesium levels will find themselves in a “Catch 22” situation. Low magnesium levels mimic and exaggerate insulin resistance. This will often cause blood glucose levels to rise. High blood glucose levels cause magnesium to be excreted from the body at an excessive rate preventing the body from maintaining circulating levels.

Here is the catch; normal serum magnesium levels are 0.7 or greater. A person with elevated glucose levels may have a low normal serum magnesium level but may not have adequate circulating levels. This is caused by the body’s attempt to expel excess glucose during periods of prolonged hyperglycemia. As the body flushes out excessive glucose, magnesium is also expelled causing great difficulty in acquiring adequate circulating levels. Keep in mind the main source of magnesium for the body, as is its main source of glucose, is found through the food we eat. Both find their way into the blood stream and, if hyperglycemia is present, both will be flushed out through the renal system before the magnesium is able to be adequately absorbed into general circulation.

How is this significant to successful diabetes management?

Over several years of tracking magnesium levels of my clients, I discovered a trend which identified commonalities with uncontrolled blood glucose and magnesium levels less than 0.85. These people appeared to have adequate magnesium but their blood glucose levels remained elevated or took on an erratic pattern of moderately high to uncontrolled. It would mimic rebound hyperglycemia without a pattern of consistency.

Food records from these clients were gathered and reviewed for areas requiring improvement. Often, they were eating a well balanced diet. Occasionally, fiber or magnesium rich foods were limited or omitted. Advice on increasing intake of both would be given. Blood glucose records, A1c, food records and magnesium were reassessed after a 6-8 week period. The majority of food records reviewed demonstrated good balance to include increased magnesium intake.

Serum values of glucose and magnesium displayed little or no improvement. As the magnesium decreased, the glucose increased. Which was the initial cause of the imbalance is unknown. However, each appears to affect the other, as I witnessed with the following clients. The following case studies outline 3 clients with varying magnesium treatment strategies which prove interesting. The question it poses is: Is nutritional intake of magnesium adequate treatment in the presence of uncontrolled hyperglycemia?

Case #1

• Male – 54 years old with NIDDM diagnosed 11 years. Within 3 years of diagnosis, he has increased blood glucose levels ranging from 8.3mmol – 21.8mmol, an A1c of 12.3% and a magnesium level of 0.69, just slightly below normal.
• Insulin was started 5 years post diagnosis with a dosage of Humulin N 13uts HS. His blood glucose continued to climb despite changes in eating habits. His insulin was changed to 30/70 14uts AM and 8uts PM.
• His blood glucose became increasingly erratic and the A1c fluctuated between 12.3% - 14.2%.
• He increased his magnesium rich foods in 1 year following initiation of insulin. Over a 6 month period, his A1c was checked every 2 months and serum magnesium levels were checked monthly to monitor progress. The magnesium levels fluctuated between 0.6 – 0.76. A1c levels during this period were 12.9% - 13.4%. A1c levels reflected periods of change with magnesium. For example, if the serum magnesium was on the lower end of the scale, the A1c would be slightly increased and vice-versa.
• Unfortunately, this gentleman did not continue follow-up.

Case #2

• Male – 69 years old with NIDDM for 12 years. His blood glucose levels began to increase over the past 9 months with a range of 10.2mmol-26.4mmol and A1c of 9.3%.
• He began to closely follow his meal pattern and included more magnesium rich food. He was also started on Novolin NPH insulin, 6uts AM and 12uts PM. His insulin dosages were increased over the following 2-3 months with little improvement.
• His magnesium level was checked 3 months following this regime. It remained low at 0.57. He began magnesium supplementation after consultation with the healthcare team. Within 1 month, his magnesium increased to 0.95. His blood glucose levels were less erratic with a range of 9.8mmol-18.0mmol, and more frequently below 10mmol than the previous month.
• On advice of his family doctor, who feared his magnesium level would rise above normal, he discontinued supplementation less than 2 months after its introduction.
• He was careful to maintain his dietary intake of magnesium. Despite this, his serum level began to decrease while his glucose level increased to 12.7mmol-26.6mmol. Significant increases in blood glucose were noted as early as 2 weeks following the discontinuation of supplements. One month following cessation of supplement, magnesium level was 0.84. The following month it was 0.8.

Case #3

• Female – 39 years old with NIDDM for 11 years. Eight years following diagnosis, insulin was initiated. She was started with Humalog at mealtime and Humulin N at bedtime. The initial dosage was:
  • Breakfast 5uts
  • Lunch 4uts
  • Supper 5uts
  • Bedtime 8uts
• Her blood glucose range upon initiation was 4.3mmol – 13.0mmol and A1c of 7.4%. Magnesium was not available at that time.
• Six months post initiation, her blood glucose range was 3.9mmol – 10.6mmol, A1c 7.9% and magnesium 0.76.
• Within the following 12 months, her insulin dosages were adjusted various times but total daily dosage increased a maximum of 5uts. Her blood glucose range was 7.1mmol – 12.6mmol, A1c 8.4% and magnesium 0.64. Magnesium rich foods were reviewed and introduced into her meal plan.
• Her control had taken a turn for the better 6 months following introduction of magnesium rich foods into her meal plan. Blood glucose range was 4.2mmol – 7.9mmol, A1c 6.8% and magnesium 0.74.
• This improvement was achieved despite minimal changes with insulin. Her insulin was changed to Novolin to accommodate smaller adjustment amounts made possible with the Novolin Junior pen. Her regime at that point:
  • Breakfast 5.5uts
  • Lunch 6.5uts
  • Supper 5uts
  • Bedtime 9.5uts
• Initially, her blood glucose levels were mildly elevated and magnesium levels slightly decreased. It may be due to only mild hyperglycemia that she was able to retain circulating magnesium more effectively than the previously cases.

This comes back to the posed question: Is nutritional intake of magnesium adequate treatment in the presence of uncontrolled hyperglycemia?

These are only 3 cases of many I’ve encountered with similar challenges. A common factor which continues to appear is with prolonged, severe hyperglycemia serum magnesium levels of less than 0.85 cannot effectively improve insulin uptake. Therefore, magnesium supplementation may be necessary for clients who have A1c greater than 9%.