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Diabetes Management Lecture 4

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  • 1. Blood Glucose Monitoring (You Can’t Achieve Tight Control Without It) Lecture 4 by Eric Holzman
  • 2. A Diabetic’s Guide to Managing Diabetes Without blood glucose testing, a diabetic is “blind” • A normal person’s blood glucose control system does not need external adjustment because his body – continuously monitors his blood glucose level – releases insulin or glucagon Type 1 – stores or releases glucose • A diabetic’s blood glucose control system requires external adjustment. – Insulin and/or Medication – Food – Blood glucose testing to determine what to do Type 2 • A diabetic who knows his blood glucose level can decide whether he needs to do nothing, take medication, exercise or eat food. 9-18-07 by Eric Holzman 2
  • 3. A Diabetic’s Guide to Managing Diabetes Blood glucose level— what does the number mean? • Successful diabetes management aims for a normal blood glucose level all day, every day. Blood Glucose What it means What a diabetic Level (mg/dL) should do Below 60 Hypoglycemic (low Eat food with 5-10 blood glucose) grams fast acting carbohydrate 60-80 Below normal Eat food with up to 5 grams carbohydrate goal 80-100 Normal Do nothing 100-120 Above normal Exercise or take insulin Above 120 Hyperglycemic (high Take insulin blood glucose) 9-18-07 by Eric Holzman 3
  • 4. A Diabetic’s Guide to Managing Diabetes Can you know what your blood glucose level is without measuring it? • If your blood glucose level is high (above 100 mg/dL), it’s doubtful that you will be able to tell how high. – I have no symptoms if I’m within or above my normal range (80-100 mg/dL). • Hypoglycemia (60 mg/dL or lower) may be indicated by symptoms. – Disorientation, lethargy, fatigued limbs, shakes, numbness, nausea • Low blood glucose is a relative term: you may experience hypoglycemic symptoms if your blood glucose level drops significantly below its “usual” range. – When I was diagnosed, my blood glucose level was 300-400 mg/dL. – I implemented carb-reducing changes in my diet immediately. – I experienced low blood glucose symptoms such as “shakes” as my blood glucose fell from 300-400 to 200-300 mg/dL in a few days. • Hypoglycemic unawareness is a major reason why testing is necessary for insulin users. – If my blood glucose level drops to 50 mg/dL several times over a period of a few days, many symptoms go away—sometimes I feel almost normal. 9-18-07 by Eric Holzman 4
  • 5. A Diabetic’s Guide to Managing Diabetes How frequently should you measure your blood glucose level? • How often you should test depends on – how stable your blood glucose level is throughout the day, – Your ability to predict changes in your blood glucose level, – the chance you might have a hypoglycemic reaction, – how tight you want to control your blood glucose level. • Tight control means more frequent testing. – In a normal person, continuous monitoring is done by the pancreas. – A diabetic on insulin tests • before eating to determine how much insulin to take, and • after eating to determine whether the dose was correct 6:30 AM 78 12:00 PM 77 6:00 PM 79 8:30 PM 97 Good day Breakfast 3.5 units Lunch 6 units Dinner 2.5 units snack 3 units 8/30/06 8:30 AM 102 2:00 PM 97 Bike for 22 minutes 10:30 PM 79 7:00 AM 94 12:30 PM 72 6:00 PM 77 9:00 PM 109 Bad day Breakfast 4 units Lunch 4.5 units Dinner 4.5 units snack 3.5 units 9/10/06 work outside 3:00 PM 63 8:00 PM 125 10:30 PM 113 9:00 AM 49 9-18-07 by Eric Holzman 5
  • 6. A Diabetic’s Guide to Managing Diabetes When do you test and why? • Fasting—before eating – A type 1 diabetic must know his blood glucose level to choose his insulin dose. – Your fasting level tells you if your slow acting (basal) insulin dose requires adjustment. • Post prandial—after eating provides important feedback – Did you take the correct amount of medication? – Did you eat too much? – Did you over-exercise? • Post prandial measurements should be made about two hours after eating. – Your meals should be sized to digest in about two hours because – fast acting insulin (Lispro and Aspart) operates for about two hours. – If you overeat, 2:00 PM 71 • Digestion will take longer than two hours, and Lunch 5.5 units • you may need to re-test after another hour. 4:30 PM 100 • Testing at bed-time is essential for insulin users. 6:00 PM 130 • You should test any time you think your blood glucose is too low. 9-18-07 by Eric Holzman 6
  • 7. A Diabetic’s Guide to Managing Diabetes Frequent testing enables you to reduce your blood glucose level • If you do not test after eating, your blood glucose level could remain high until the next meal. • Your bedtime test is the most important—your life may depend on it. – Not testing at bedtime could mean disaster if your blood glucose level is low. – A high blood glucose at bedtime means a whole night at the wrong level. – Your bedtime and morning fasting tests give you essential feedback for setting your long-acting insulin dose properly. 120 Snack Blood glucose level 110 100 Testing more often Dinner means a lower average 90 Breakfast 7 tests/day blood glucose level 80 4 tests/day Lunch 70 6:00 AM 10:00 AM 2:00 PM 6:00 PM 10:00 PM Time of day 9-18-07 by Eric Holzman 7
  • 8. A Diabetic’s Guide to Managing Diabetes Portable blood glucose measurement equipment is essential for tight control • A glucometer is a device that measures your blood glucose level. • The test requires a spring-loaded lancing device and lancet to draw a small drop of blood from your figure or arm. • The blood sample is absorbed by a test strip, which is inserted the glucometer. 9-18-07 by Eric Holzman 8
  • 9. A Diabetic’s Guide to Managing Diabetes How to choose a Glucometer— Accuracy and precision matter the most • Accuracy: correctness, degree of conformity of a measure to a standard or true value. • Precision: repeated measurements produce the same results. • American Diabetes Association recommends accuracy goals to meter manufacturers. – < 10% for blood glucose levels between 30 mg/dL and 400 mg/dL – Example: 90 mg/dL could really be anything from 81 mg/dL to 99 mg/dL • A laboratory meter is the standard. • Cardiovascular system carries blood throughout the body to feed our cells. – Arteries carry blood from heart to smaller arteries, which carry blood to capillaries. – Glucose and oxygen leave capillary blood to supply cells. Cells return waste. – Capillaries deliver blood carrying waste to veins, which return blood to heart. V. Peragallo-Dittko, “How Accurate is Your Meter,” Diabetes Self-Management, 9/10 2000. 9-18-07 by Eric Holzman 9
  • 10. A Diabetic’s Guide to Managing Diabetes How to choose a Glucometer— why lab and glucometer tests may not agree • Blood in capillaries has more glucose than that flowing in veins. – After fasting, the difference is small. – After eating, the difference is large. • Laboratory samples are from veins, while glucometers measure glucose in capillary blood. – For closest comparison of lab and glucometer measurements, lab samples should be taken during fasting periods. • Laboratories measure glucose level of plasma, the fluid in blood, while some meters measure glucose level of whole blood (plasma and red blood cells). – Measurements of whole blood are 10% to 15% lower than of plasma only. • Most meters provide an average of 100 or more readings, which should compare well with the result of an HbA1c test. V. Peragallo-Dittko, “How Accurate is Your Meter,” Diabetes Self-Management, 9/10 2000. 9-18-07 by Eric Holzman 10
  • 11. A Diabetic’s Guide to Managing Diabetes How to choose a Glucometer— other features that make your life easier • Small blood sample—mine takes 2.5 microliters of blood. • No coded entry for each new batch of strips reduces chance of error. • Quick analysis time: 15 seconds or less. • Storage of 100+ readings and calculation of long term averages. – Averages tend to be very accurate—should compare with HbA1c. This is a small – Take an even mix of pre and post-prandial readings. sample: a few microliters • Too many fasting readings may bias the average to the low side. • Too many post-prandial readings may bias it high. • January Issue of Diabetes Forecast Magazine lists latest equipment from all manufacturers. 9-18-07 by Eric Holzman 11
  • 12. A Diabetic’s Guide to Managing Diabetes How to choose a glucometer— the most overrated feature • Some glucometers can transfer stored results to a computer. • By themselves, the readings don’t tell you that much. – Many things determine your blood glucose level at any one time: time of day, activity level, medication dosage, when, what & how much you last ate,… – Unless you transfer all these additional data to your PC, plotting blood glucose readings by themselves will not be useful. • Your test results should be kept as part of a written record containing your food Use this intake, medication dosage and level of instead of physical activity. this • I write all my data in small book, with 7 days of records viewable at a glance, so I can see the trends. 9-18-07 by Eric Holzman 12
  • 13. A Diabetic’s Guide to Managing Diabetes Testing--a small amount of preparation means accuracy and consistency • Wash your hands with soap prior to testing. – I always wash my hands in the bathroom. – Not near a washroom? Carry some small towlettes with you. • Dry your hands with a clean towel or a paper towel—not a kitchen towel, which might have food residue on it. • It is easiest to get a blood sample from warm hands. – If your hands are cold, shake your fingers towards the floor to get the blood flowing to your fingertips. 9-18-07 Bernstein, pp. 69-72 by Eric Holzman 13
  • 14. A Diabetic’s Guide to Managing Diabetes Measuring your blood glucose level is quick, easy and almost painless • Lance your finger • Try to apply the • Often, you must from the side for blood sample to the insert the strip into minimum pain. strip as quickly as the meter before possible without applying the blood • You may need to rushing. sample to the strip. squeeze your • If the sample is too finger to get a small (it does not fill large enough blood the strip), ignore the sample. reading, and start again with a new • Switch fingers for strip. your next test. 9-18-07 by Eric Holzman 14
  • 15. A Diabetic’s Guide to Managing Diabetes You should question your glucometer’s result if it is not what you expect • Even a glucometer that works perfectly can give an inaccurate reading. – Some meters require a code for each batch of strips—make sure the correct code is in use. • A false high reading can cause you to take medication and lead to a hypoglycemic reaction. • What should you do? Test a 2nd time from a different site. – If the 2nd reading differs greatly from the 1st (>10 points difference), wash your hands and test a 3rd time. – Usually, 2 of the 3 readings will be in close agreement. Average the closest two readings. 9-18-07 by Eric Holzman 15
  • 16. A Diabetic’s Guide to Managing Diabetes Sore Fingers--what about other test sites? • Other test sites generally do not give real-time results like fingers (see Roche glucometer manual). • Evaluate a new site by comparing it with a result from a finger stick taken at the same time. – Take two readings, one from your finger and one from the new site. – If the difference is greater than 5 points, retake both readings. – You want to see a majority of readings at each site in close agreement. • For example, you want to test from your arm instead of your fingers. – Since the two readings at each site are close, you can conclude, that the roughly 20 point difference is due to the site choice. TEST 1 TEST 2 90 87 110 105 9-18-07 by Eric Holzman 16
  • 17. A Diabetic’s Guide to Managing Diabetes The A1C test: a diabetic’s report card • The glycosylated hemoglobin (HbA1c) test gives an indication of “average” blood glucose control over previous 2-3 months. – fasting not required • Red blood cells allow glucose to freely enter and leave without aid of insulin. – Concentration of glucose inside a red blood cell is the same as that in the blood. • Hemoglobin: a molecule found in red blood cells. – Carries oxygen from lungs to body’s cells. – Variety of types; HbA1c is the type that interests diabetics. – HbA1c joins with glucose (is glycosylated) for the life of the blood cell, about 4 months. • This test measures the % of hemoglobin HbA1c molecules that are glycosylated. • Since your blood contains a mix of blood cells of different ages, blood cells aged 0-4 months contribute to the test result. – 50% determined by blood glucose levels in the month before the test. • Take an A1C test at least twice a year. • Result is a percentage—5% is normal: 1 out of 20 hemoglobin are glycosylated. M. Nakamoto, “H-B-A-1-C (what it is and why it matters),” Diabetes Self-Management, Jan/Feb 2004, pp. 84-89. 9-18-07 by Eric Holzman 17
  • 18. A Diabetic’s Guide to Managing Diabetes Relating A1C test results to your glucometer readings • Two weeks of carefully taken glucometer readings (80-100 readings), half pre- and half post-prandial, can be an indicator of your long-term blood glucose level. • The HbA1c test, taken by your doctor, provides an independent confirmation of how you are doing. A1C Plasma Glucose Whole Blood Glucose result (%) level (mg/dL) level (mg/dL) 5 100 90 5.4%, my average 6 135 121 7%, ADA recommended 7 170 152 maximum 8 205 183 9 240 214 9-10%, diabetic average 10 275 246 11 310 277 12 345 308 12.2%, my level at diagnosis 9-18-07 by Eric Holzman 18
  • 19. A Diabetic’s Guide to Managing Diabetes How Accurate is the A1C test? • My experience: two tests at two different labs taken 10 days apart: 6.2%, 5.3% • There are more than 30 different methods to measure A1C. • Different brands of instruments using the same method can give different results. • All hemoglobin are not created the same. • Go to the same lab so that you can compare your results and track changes over time. • Finger-stick HbA1c meters are as accurate as laboratory meters that use blood from veins. 9-18-07 by Eric Holzman 19
  • 20. A Diabetic’s Guide to Managing Diabetes The DCCT tells us to aim for normal blood glucose • DCCT: Diabetes Control and Complication Trial – a ten-year study of 1441 Type 1 diabetics – to evaluate the effects of improved control of blood glucose – diabetics split between intensive and conventional therapy – Intensive group averaged 7% HbA1c; conventional averaged 9% HbA1c • The reduction in complications was huge in patients with near normal control – test was stopped early so the results could be made available to all – reduction in HbA1c corresponded to proportional reduction in risk of complications – risk of complications drops to zero for normal glucose levels – Intensive group had 3x higher risk of severe hypoglycemia (BG< 50 mg/dL) • Any reduction in HbA1c means reduced risk of complications. – 10% reduction: 30-40% reduced risk of retinopathy (eyes), nephropathy (kidneys), neuropathy (nerves) – Dropping from a 9% to a 6% HbA1c means a 75% drop in risk of complications. 9-18-07 Bernstein, pp. 37-38 by Eric Holzman 20
  • 21. A Diabetic’s Guide to Managing Diabetes HbA1c test—normal should be your goal • The average diabetic’s HbA1c test result is 9%. – Equivalent to greater than 200 mg/dL all the time. – Twice as much blood glucose as a normal person. • The ADA’s recommends 7%, but you should do better. – 7% is not normal. – Complications will develop slowly. • A Normal HbA1c—4.8% to 5.8%—should be your goal. • With today’s glucometers, dieting, exercise and medication, normal is achievable. 9-18-07 by Eric Holzman 21
  • 22. A Diabetic’s Guide to Managing Diabetes Do short term, high blood glucose readings affect your health? • Because fast-acting insulin does not reduce blood glucose as fast as a normal pancreas, post-prandial spikes in blood glucose can occur. • Bernstein says that damage done by high blood glucose can be stopped or reversed by returning blood glucose to normal levels. • How quickly you catch and reduce a high blood glucose level is what matters. – Frequent testing enables you to spot high glucose levels soon after they occur. – You reduce your blood glucose level quickly with insulin and/or exercise. • Short-term spikes in glucose may not influence HbA1c results. – Glucose takes time to join with blood cell hemoglobin – Unless blood cells are joined with glucose, they won’t affect your HbA1c. – However, glucose not joined to hemoglobin is still carried in your blood, and may cause damage to your body. • My experience—despite my “normal” HbA1c tests and near normal blood glucose control, I developed low level retinopathy in my left eye 7 years after diagnosis. 9-18-07 by Eric Holzman 22
  • 23. A Diabetic’s Guide to Managing Diabetes Short term spikes in blood glucose level can occur when you are most insulin resistant • Spikes in blood glucose level occur when we are most insulin resistant, which is in the morning for many people. • 30 minutes after eating breakfast, my glucose level had climbed to 129. • 1 hour after eating, my level was at 140. • But 2 hours after eating, it was down to 97. • A 50% reduction in my breakfast carb intake (to 10 grams) and 10 minutes of exercise after eating reduced the spike from 40 points to just 10 points. 9-18-07 by Eric Holzman 23
  • 24. A Diabetic’s Guide to Managing Diabetes What should you know about glucose testing to manage your diabetes? • A diabetic who knows his blood glucose level can decide whether he needs to do nothing, take medication, exercise or eat food. • Successful diabetes management aims for a normal blood glucose level all day, every day. • Your bedtime test is the most important—your life may depend on it. • Your blood test results should be kept as part of a written record containing your food intake, medication dosage and level of physical activity. • The HbA1c test is a diabetic’s report card—it is a measure of “average” blood glucose control over the last 2 to 3 months. • Any reduction in HbA1c means a reduced risk of complications. • A Normal HbA1c—4.8% to 5.8%—should be your goal. 9-18-07 by Eric Holzman 24
  • 25. A Diabetic’s Guide to Managing Diabetes Metric Units • 28 grams (g) = 1 ounce • 454 grams (g) = 1 pound • 1 gram (g) = 1000 milligrams (mg) • 1 liter (L) = 34 ounces • 1 liter (L) = 10 deciliters (dL) • Normal blood glucose level: 90 mg/dL 9-18-07 by Eric Holzman 25
  • 26. A Diabetic’s Guide to Managing Diabetes References 1. R. Bernstein, Dr. Bernstein’s Diabetes Solution, Little, Brown and Company, 1997. 2. V. Peragallo-Dittko, “How Accurate is Your Meter,” Diabetes Self- Management, 9/10 2000. 3. M. Nakamoto, “H-B-A-1-C (what it is and why it matters),” Diabetes Self-Management, Jan/Feb 2004, pp. 84-89. 4. S. S. Roberts,”Are A1C Results Reliable,” Diabetes Forecast, March 2005, pp. 23-26. 5. “The Absence of a Glycemic Threshold for the Development of Long- Term Complications: The Perspective of the Diabetes Control and Complications Trial,” Diabetes, Vol. 45, October 1996, pp. 1289-1298. 6. Images from Google™ Image Search at http://images.google.com 9-18-07 by Eric Holzman 26

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