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Blog: Feed or FEEHD?
In keeping with the theme of this blog, I will not delve into the crux of the FEEHD research that our group has been undertaking at Michigan State University.
But what is FEEHD, you may ask?
FEEHD is an acronym that we coined to describe a circumstantial form of hypoglycemia: Fasting-Evoked En-route Hypoglycemia in Diabetes.
We hoped to draw attention to his under-reported and overlooked problem in patients with diabetes. In brief, physicians have been strictly compliant with the recommendation first proposed by William Friedewald, MD, and his colleagues in the early 1970s: When ordering a lipid profile (cholesterol) blood test, instruct patients to fast for 12 to 14 hours.
What about patients with diabetes who take insulin the night before, and/or on the morning of the test?
What about patients who take sulphonylureas (eg, glipizide or glimepiride) the night before or on the morning of the test?
These patients would skip breakfast, stay fasting and then drive to the laboratory, right? But they were not instructed what to do with the insulin or sulphonylurea.
Their blood sugar can drop dangerously low. They are at risk of having a hypoglycemic event while driving.
Hence the acronym, FEEHD.
And hence the title of this blog: Feed or FEEHD!
The irony is that fasting for the cholesterol test has been questioned in recent literature and in the cholesterol guidelines. Europeans and Canadians recently recommended that fasting for cholesterol tests in routine clinical practice is largely unnecessary.
Similar guidelines in the U.S. are still not as explicit or as powerful as compared to the aforementioned European or Canadian guidelines. Therefore, the tradition of fasting for cholesterol tests is strictly adhered to by clinicians and patients alike.
So, as promised, no more in-depth scientific discussion, but I would refer the readers to our recent study ( https://www.hindawi.com/journals/ije/2018/1528437/ ), as well as to some of our publications on this topic (list of references, below).
I wish to share some behind-the-scenes stories relating to our FEEHD research going back to 2009 in Cape Girardeau, Missouri, and subsequently, from 2010 onward, in Lansing, East Lansing, Flint and Lapeer, Michigan, which have not been published in scientific journals.
Our first, pilot study, published in 2011 in Diabetes Care, was prompted by nurses (LPNs) at our diabetes clinic at St. Francis Medical Center in Cape Girardeau. They were the ones who alerted me to the occurrence of this form of hypoglycemia. Without their observation, meticulousness, care and passion, this 9-year research journey could have never materialized.
At the same time, the pivotal case who prompted our nurses to bug me to look into this was a patient in her 70’s who was driving from another town in rural southeast Missouri. I (or another clinician) had prior ordered a fasting lab test, scheduled for the morning of her clinic appointment, scheduled for 1:30 p.m... The laboratory called our clinic for a critical sugar of 45 mg/dL for that patient. The nurse came rushing to me:
“Dr. A., the lab called with another low sugar,” she said.
“Did you call the patient?” I asked.
“She is not answering,” she said.
I was so concerned about the patient. The patient must have driven to the lab, perhaps took her insulin the night before or on the morning of the test, and then skipped breakfast and stayed fasting until she went to the lab. The phlebotomist took her blood and sent it over for processing. The patient left the laboratory.
When the lab technicians finally analyzed the patient’s blood, it was already late morning, and the patient had already left the facility few hours earlier.
When the patient finally showed up for her afternoon appointment, alive and well, all of us in the clinic gave her big hugs. We were thankful that she was OK.
“I felt the shakes and the palpitations,” she said. She had to rush to the cafeteria to eat. Luckily, she was not harmed.
We have encountered similar patient stories, not only in my former practice in Cape Girardeau, but also in our clinics in Michigan.
We asked the fellow to review patient charts at the diabetes clinic — an audit of sorts — to see how common FEEHD was in our clinic. The fellow reviewed 60 charts in the preceding 3 months. She found 3 cases, a rate of about 5%. This frustrated me, because I could not make a strong case.
The fellow went to visit her parents, and when she returned, she came rushing to me.
“Dr. Aldasouqi, I am now a believer,” she said with excitement.
“Believer in what?” I asked.
“It happened to my father,” she said. She told me her dad had a severe hypoglycemic event while fasting for labs (he was on a sulphonylurea, if I remember correctly). She then strongly encouraged me to pursue the research of the FEEHD problem. And we did.
The irony in this research journey was that it was difficult to convince clinicians, including colleagues, that FEEHD is a real problem that is overlooked. This is an iatrogenic problem and it is entirely preventable. If clinicians insist on the fasting prerequisite, then the preventive measure is to educate patients to adjust the diabetes medications the night before and the morning of the blood test.
In our group, and since we became aware of FEEHD back in Cape Girardeau in 2009, we have almost eliminated ordering fasting before a cholesterol test. We order cholesterol tests in the non-fasting state, and there are guidelines to interpret non-fasting cholesterol labs. Such guidelines have been elucidated in recent publications, including publications by U.S. investigators.
Our group has been trying to spread the word about FEEHD. We hope that diabetes organizations take the lead in this campaign, as was emphasized in a recent press release (https://msutoday.msu.edu/news/2018/fasting-for-lab-tests-isnt-good-for-patients-with-diabetes/ )
Our motto is Feed or FEEHD!
References:
Aldasouqi S, et al. Diabetes Care.,2011; doi:10.2337/dc10-2402..
Aldasouqi S, et al. Int J Clin Med. 2012; doi:10.4236/ijcm.2012.37A132 .
Aldasouqi S, et al. Postgrad Med.2013; doi:10.3810/pgm.2013.01.2629.
Aldasouqi S, et al. Int J Clin Med. 2016; doi:10.4236/ijcm.2016.710071.
Aldasouqi S, Grunberger G. Postgrad Med. 2015; doi:10.3810/pgm.2014.11.2837.
Aldasouqi S, Abela G. Circulation. 2015; doi:10.1161/CIRCULATIONAGA.114.012564.