SUMMARY
Whats known
Background
Holidays may pose glucose management challenges
for individuals with diabetes. Religious fasts, for
example, have received attention because of the risk
of hypoglycaemia, especially in patients receiving
intensive insulin therapy or sulfonylureas (1). Both
the 25-h Yom Kippur fast and the shorter Ramadan
fast require careful blood glucose monitoring and
medical counselling regarding medication timing and
dose (1,2).
Feast holidays, on the other hand, may lead to
hyperglycaemic excursions. In a study of glycaemic
control during the Christmas holidays, a preholiday
increase in fructosamine persisted during the holiday
Whats new
This is the first report of the effect of holidays on
blood glucose in hospitalised patients. The direction
of the glucose pattern surrounding the holiday
period is contrary to the authors hypothesis.
Correspondence to:
Dr Mona Boaz, Epidemiology
and Research Unit, E. Wolfson
Medical Center, Holon 58100,
Israel
Tel.: + 972 52 475 4658
Fax: + 972 3 502 8384
Email: mboaz8@yahoo.com
Disclosure
None.
2011 Blackwell Publishing Ltd Int J Clin Pract, October 2011, 65, 10, 10551058
doi: 10.1111/j.1742-1241.2011.02707.x
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Methods
Data analysis
Objectives
This study was designed to compare POC blood glucose values in hospitalised patients with diabetes during the 4-day Rosh Hashanah holiday period to
those obtained during the 4 days preceding the holiday and the 4 days following the holiday.
Results
A total of 3403 POC glucose values were recorded
during the entire observation period: 1205 in the
preholiday period, 1006 in the holiday period and
1192 in the postholiday period.
The study population is described in each of the
observation periods in Table 1. As can be seen, POC
glucose values differed significantly across observation periods. Post hoc analysis demonstrated that values were significantly lower in the holiday period
than either the preholiday (p = 0.02) or postholiday
(p = 0.01) periods, but that preholiday and postholiday POC glucose values were similar (p = 0.69).
Age also differed significantly across observation
periods, and was significantly older during the holiday period than either preholiday (p < 0.0001) or
postholiday (p < 0.0001) periods; age did not differ
significantly between the pre- vs. postholiday period
(p = 0.62). Despite these differences, age predicted
less than 1% of the variability in POC glucose OC
glucose r = 0.02, p = 0.23.
An across-observation period difference in the
proportion of females was observed, driven by the
significantly greater proportion during the preholiday
2011 Blackwell Publishing Ltd Int J Clin Pract, October 2011, 65, 10, 10551058
Preholiday
(September 47)
n = 1205
Holiday
(September 811)
n = 1006
Postholiday
(September 1215)
n = 1192
p-value
181.44 78.8
74.9 12.0
56.6
176.8 81.3
77.4 10.9
47.8
184.9 83.02
75.3 11.8
46.1
0.03
< 0.0001
< 0.0001
period than either the holiday (p < 0.0001) or postholiday (p < 0.0001) periods; however, the proportion of females during the holiday and postholiday
periods did not differ significantly (p = 0.4). POC
glucose did not differ significantly by sex and was
182 84.3 mg dl in women vs. 180.2 77.7 mg dl
in men, p = 0.41.
Observation period was dichotomized into holiday
vs. non-holiday period. Characteristics of the study
population by this factor are shown in Table 2.
Patients hospitalised during the holiday period had
significantly lower POC glucose and were significantly older than patients hospitalised during the
non-holiday period. Somewhat fewer women were
hospitalised during the holiday than non-holiday
period, but the difference was not statistically significant.
In univariate analysis, holiday significantly, inversely predicted POC glucose: standardised beta =
)0.036, p = 0.04. A multiple linear regression of
POC glucose is shown in Table 3. As can be seen,
holiday
Holiday
n = 1006
Non-holiday
n = 2397
p-value
glucose
Constant
Holiday (Rosh Hashanah vs.
non-holiday)
Age (years)
Gender
Standardised
beta
p-value
)0.04
< 0.0001
0.03
0.02
)0.01
0.19
0.51
Discussion
Contrary to our expectations, holiday period was significantly inversely associated with POC glucose. This
finding persisted even after controlling for age and
gender. Although statistically significant, this 3.5%
relative decline in POC blood glucose may not be
clinically meaningful; nevertheless, that values did
not increase during the holiday period is surprising,
especially in view of the literature.
Establishing the decline in POC glucose as a true
decline and not simply measurement error is essential. Hospital protocol requires continuous calibration of the glucometer and no change in glucometer
or laboratory equipment occurred during the study
period. This suggests that the observed decline in
POC glucose is not attributable to measurement
error and is in fact a real decline. A true decline in
POC glucose may reflect increased physical activity
or decreased dietary intake. It seems quite unlikely
that hospitalised patients would spontaneously
increase their physical activity. This means that the
most likely explanation is a decline in dietary intake.
The patient population composition changed during the holiday period, Importantly, the population
size decreased by 16.5% relative to the preholiday
period, but a 30% reduction from preholiday proportion of females was observed concomitantly. This
suggests a selective discharge and or lack of new hospitalisations for females during the holiday period.
The reason for the shift in the gender distribution of
the hospitalised patient population during the holidays was not directly investigated. It can be postulated that female patients may have taken advantage
of a holiday furlow from hospitalisation to a greater
extent than males, perhaps responding to traditional
female roles of preparing the holiday; however, this
information is not recorded in the central database.
Point of care blood glucose measures in this
study were not limited to fasting values. As such,
2011 Blackwell Publishing Ltd Int J Clin Pract, October 2011, 65, 10, 10551058
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2011 Blackwell Publishing Ltd Int J Clin Pract, October 2011, 65, 10, 10551058
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