tseverson <terryseverson@comcast.net> wrote in news:1b0a1216-76ec-4973-
ac0d-797dc5652c57@a26g2000yqn.googlegroups.com:

There is a great deal of inter patient variability when it comes to the
absorption of insulin so it is impossible to give specific answers to
questions like these.  There is no way that anyone on this side of the
internet can know enough about your mother's condition and her specific
reactions to various stimuli to tell you at what specific times she
should, or should not, eat her snack.  Not to mention that those specific
answers depend not only on her insulin regimen and meal schedule, but on
the exact contents of her previous meal and how much more or less
activity she had relative to her normal activity level.

The disclaimer having been disclaimed, it is possible to give you some
advice on how to go about getting some of the information that will help
you determine if any adjustments need to be made.  Note that it will
require a good deal of work on your part, both reading to understand how
diabetes works and keeping track of your mother's bg levels at different
times and under different conditions.

Insulin regimens of one or two shots of NPH/day were standard when your
mother was diagnosed.  They are still fairly common, especially at the
initial start of insulin treatment or in the elderly.  The rationale is
that the regimen is very simple for the patient.  After an initial period
of experimentation, the shots are always the same and the insulin
delivery matches, to the first order, the demand produced by a rigid meal
regimen both in timing and carbohydrate content.  While this is in at
least one sense simple, it is not a particularly optimal treatment
program for most insulin requiring diabetics if the goal is to minimize
blood glucose excursions.

On the far other end of insulin regimen spectrum is the insulin pump, an
order $5000 programmable syringe which allows tremendous patient
controlled variability in insulin delivery.  This requires that the
patient to understand his/her own particular circadian rhythms in
background metabolic insulin requirements, estimate the insulin demand
required by individual meals, and predict the effect of exercise and
activity variability on each and test bg levels frequently during the
day.  (The standard minimum testing necessary is quoted as 4 bg tests/day
but the average is 7 tests/day and 19% test 10 or more times/day.)  This
treatment is by no means simple but can be very effective in control of
blood glucose levels.

Between these 2 extremes there are a bewildering number of insulin
regimen choices which, in a general sense, are all trade offs between
simplicity and freedom.

Rather than discuss the idea of modifying her insulin regimen with your
brother, you should both discuss it with her doctor and then, if
appropriate, with her.

The timing of bg testing is based on what you are trying to test for and
what you are going to do with the information the test revels.  While the  
manager was technically wrong (8-12 hours is the normal fasting period
for diagnostic work) 4 hours will get you mostly past the effects of most
meals.  So it sounds like the manager is skewing things to try to have a
quasi-fasting test.  Although you can't say much based on a single value
without any understanding of average results at similar times as well as
the values of previous tests, if it were my mother, a 240 mg/dl post
prandial or quasi-fasting test would require more intervention than
simply skipping a snack.  At the very least it would involve a day or
more of multiple glucose tests to determine her typical daily glucose
pattern.