Type 2 diabetes monitoring

Monitoring Blood Sugar With Type 2 Diabetes

People with type 2 diabetes need to know, on a daily basis, how well they’re doing with medications, diet, and lifestyle changes.

Kathy Honick, RN, CDE, a diabetes educator at Barnes Jewish Hospital in St. Louis, explains that not only does regular blood sugar testing tell you if you’re doing well, it can “identify a pattern of highs and lows, which may be out of range,” if your levels are not well-controlled.

Type 2 Diabetes: When and How to Check Blood Sugar

Usually, testing occurs before meals, particularly before breakfast, but your doctor will tell you what’s best for your situation. You may test after meals or in the evening to check for low blood sugar levels before you go to sleep. Your doctor will tell you what numbers you need to be concerned about and when you should get in touch for more treatment or advice.

If your medical team has decided it’s okay for you to decrease the number of times you test each day, it’s essential you resume testing more often if you’re sick or your body is particularly stressed. Honick says people with diabetes should monitor their blood glucose levels at least four times per day when they’re sick and should report the results to their doctor.

To test your blood sugar level, you must first wash your hands with soap and warm water, and dry them thoroughly. Then you’ll prick your fingertip using a small device called a lancet — just a drop or two of blood is needed for the test. After putting the blood on a test strip, you insert the strip into a small machine or reader, called a glucometer. The glucometer tells you how much sugar it detects in your blood.

Type 2 Diabetes: Getting a Glucometer

There are many types of glucometers to choose from — in fact, deciding on one may be overwhelming. But, there are ways to help you do that.

For example, diabetes educators or nurses at diabetes clinics have glucometers that they are most familiar with and may recommend. Other times, companies may have promotions and will give away free monitors so you’ll try their product.

Phoebe, a registered nurse in Baltimore who has had type 2 diabetes for a few years, says she has no preference and has tried many different glucometers. “I use whatever my doctor gives me when I go for my yearly check — it’s free!”

Regardless of which type of system you use, a logbook is an important tool. You should be using a logbook to record your blood sugar readings according to the times of day you check them. You can use a small notebook, or track your numbers online. Whatever method you choose, be sure to bring the notebook or a printout of the online chart with you to your medical appointments. Your doctor or nurse can look at it to check for patterns or problems.

Type 2 Diabetes: Does Blood Sugar Testing Hurt?

While pricking your finger isn’t pain-free in the beginning, it does become easier as your fingers become used to it. And the monitoring systems have improved greatly over the years, requiring less blood so that the smallest of pinpricks will often do the job.

Honick says newer machines claim to be more convenient and comfortable because they don’t require that you draw blood from your fingertips, but she warns, “It’s recommended that the fastest and safest way to perform blood glucose monitoring is with a finger stick — particularly when monitoring for episodes of low blood glucose.”

Phoebe agrees; she’s drawn blood from her forearm. She explains, “The only thing that I can say is that while the forearm is a much ‘nicer’ place to check, I feel it isn’t as accurate — my blood sugar readings are always 10 points off. So I use my fingers.”

Over time, you should become more comfortable with performing this essential and critical part of daily diabetes care.

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It’s a central tenet of diabetes treatment: monitor the blood sugar closely, then adjust your diet, exercise, and medications to keep it in a good range. And that makes sense. Poorly controlled blood sugar is a major risk factor for diabetic complications, including kidney disease, vision loss, and nerve damage.

While efforts to carefully monitor and control the blood sugar in diabetes are worthwhile, “tight control” is not always helpful — and it may even cause harm. For example, in studies of people with longstanding type 2 diabetes, the type that usually begins in adulthood and is highly linked with obesity, those with the tightest control either had no benefit or had higher rates of cardiovascular disease and death. Meanwhile, studies of people with type 1 diabetes — the type that tends to start during childhood due to an immune attack against the insulin-producing cells in the pancreas — suggest that tight control may help protect against cardiovascular disease. So, it seems the benefits and risks of tight control depend on the situation.

Home blood sugar monitoring for type 2 diabetes

People with diabetes are often advised to check their blood sugar levels at home by pricking a finger and testing the blood with a glucose meter. They can review the results with their doctors over the phone, online, or at the next office appointment. The value of this for people with type 2 diabetes is uncertain.

In a study published in JAMA Internal Medicine, researchers enrolled 450 people with Type 2 diabetes, none of whom were taking insulin. They were randomly assigned to one of three groups:

  • no self-monitoring of blood sugar
  • once daily self-monitoring of blood sugar
  • once-daily self-monitoring of blood sugar with “enhanced feedback” from their blood glucose meters with messages intended to educate and motivate the study volunteers.

After one year these researchers found that, compared with those not self-monitoring blood sugar, those who self-monitored had no improvement in the control of their blood sugar, and had no improvement in measures of quality of life.

So what?

The impact of this study could be enormous. Of the enrolled study subjects, three-quarters routinely checked blood sugar at home. If that’s typical of people with type 2 diabetes, these findings could allow thousands of people to stop sticking themselves and save money on monitoring equipment, with no ill effects on their health.

But even if these findings are confirmed, there may be situations when home monitoring is still useful and important. For example, home monitoring might be a good idea when people like those in this study:

  • develop an infection
  • change the dose of their diabetes medications
  • add or stop taking one of their medications
  • gain or lose a significant amount of weight
  • begin taking insulin.

This study did not examine these situations and so could not draw conclusions about them. It’s also worth noting this study lasted only one year. It may take longer to see a benefit from home monitoring. Finally, this study did not include individuals with type 1 diabetes, so the results do not apply to them.

The bottom line

This new study suggests that doctors treating people with type 2 diabetes may not need to recommend routine self-monitoring of blood sugar. However, while that may be true for the average person with type 2 diabetes who is not taking insulin, we’ll need more studies and longer-term studies to identify which people with type 2 diabetes will benefit most from home monitoring and when it’s just not worth the effort.

Monitoring Your Blood Sugar

Regular blood sugar monitoring is the most important thing you can do to manage type 1 or type 2 diabetes. You’ll be able to see what makes your numbers go up or down, such as eating different foods, taking your medicine, or being physically active. With this information, you can work with your health care team to make decisions about your best diabetes care plan. These decisions can help delay or prevent diabetes complications such as heart attack, stroke, kidney disease, blindness, and amputation. Your doctor will tell you when and how often to check your blood sugar levels.

Most blood sugar meters allow you to save your results and you can use an app on your cell phone to track your levels. If you don’t have a smart phone, keep a written daily record like the one in the photo. You should bring your meter, phone, or paper record with you each time you visit your health care provider.

Make Friends With Your Numbers

Sometimes having high blood sugar can feel like a test you didn’t pass. But numbers are just numbers. Think of them instead as information. Did a certain food or activity make your levels go up or down? Armed with that knowledge, you can make adjustments and get closer to your target range more often.

How to Use a Blood Sugar Meter

There are different kinds of meters, but most of them work the same way. Ask your health care team to show you the benefits of each. In addition to you, have someone else learn how to use your meter in case you’re sick and can’t check your blood sugar yourself.

Below are tips for how to use a blood sugar meter.

  1. Make sure the meter is clean and ready to use.
  2. After removing a test strip, immediately close the test strip container tightly. Test strips can be damaged if they are exposed to moisture.
  3. Wash your hands with soap and warm water. Dry well. Massage your hand to get blood into your finger. Don’t use alcohol because it dries the skin too much.
  4. Use a lancet to prick your finger. Squeezing from the base of the finger, gently place a small amount of blood onto the test strip. Place the strip in the meter.
  5. After a few seconds, the reading will appear. Track and record your results. Add notes about anything that might have made the reading out of your target range, such as food, activity, etc.
  6. Properly dispose the lancet and strip in a trash container.
  7. Do not share blood sugar monitoring equipment, such as lancets, with anyone, even other family members. For more safety information, please see Infection Prevention during Blood Glucose Monitoring and Insulin Administration.
  8. Store test strips in the container provided. Do not expose them to moisture, extreme heat, or cold temperatures.

Recommended Target Ranges

The following standard recommendations are from the American Diabetes Association (ADA) for people who have diagnosed diabetes and are not pregnant. Work with your doctor to identify your personal blood sugar goals based on your age, health, diabetes treatment, and whether you have type 1 or type 2 diabetes.

Your range may be different if you have other health conditions or if your blood sugar is often low or high. Always follow your doctor’s recommendations.

Below is a sample record to discuss with your doctor.

Getting an A1C Test

Make sure to get an A1C test at least twice a year. Some people may need to have the test more often, so follow your doctor’s advice.

A1C results tell you your average blood sugar level over 3 months. A1C results may be different in people with hemoglobin problemsexternal icon such as sickle cell anemia. Work with your doctor to decide the best A1C goal for you. Follow your doctor’s advice and recommendations.

Your A1C result will be reported in two ways:

  • A1C as a percentage.
  • Estimated average glucose (eAG), in the same kind of numbers as your day-to-day blood sugar readings.

If after taking this test your results are too high or too low, your diabetes care plan may need to be adjusted. Below are ADA’s standard target ranges:

Questions To Ask Your Doctor

When visiting your doctor, you might keep these questions in mind to ask during your appointment.

  • What is my target blood sugar range?
  • How often should I check my blood sugar?
  • What do these numbers mean?
  • Are there patterns that show I need to change my diabetes treatment?
  • What changes need to be made to my diabetes care plan?

If you have other questions about your numbers or your ability to manage your diabetes, make sure to work closely with your doctor or health care team.

Self-monitoring of blood glucose levels for adults with Type 2 diabetes (March 2017)

Over the last two decades it has been firmly established that tight glycaemic control is associated with a significant reduction in serious long-term diabetes-related complications. Self-monitoring of blood glucose (SMBG) is an effective tool in the self-management of glucose levels in people with Type 1 diabetes and people with Type 2 diabetes using insulin therapy and other medication that carries a risk of hypoglycaemia. It helps people with diabetes using insulin achieve tight glycaemic control and to identify low blood glucose levels before the development of severe hypoglycaemia.

The exact role of SMBG for people with Type 2 diabetes who are not on insulin or medication that carries a risk of hypoglycaemia is less clear and has been widely debated. Critics say that there is no cost effective benefit, as highlighted in a 2012 systematic review. Supporters (including people with Type 2 diabetes) say that there are significant quality of life and patient satisfaction benefits which empower people to self-manage their diabetes, and that these outcome measures were not measured in most of the studies evaluated.

Ultimately, the lack of clinical evidence does not mean there is no evidence but that it has not been possible to gather and interpret it. Therefore this paper explores the issues of importance concerning access to and appropriate use of SMBG by those who live with Type 2 diabetes and how this can best be tackled in relation to the increasing costs associated with diabetes in the UK.

Download the full position statement on: Self-monitoring of blood glucose (SMBG) for adults with Type 2 diabetes (PDF, 2MB).

About 8 million American adults have Type 2 diabetes — and many don’t know it. And Type 1 diabetes often remains undiagnosed until symptoms become so severe that hospitalization is required.

Both of these facts speak to a larger truth: Left untreated, diabetes can cause numerous health complications. That’s why it’s crucial to know the warning signs and to see a healthcare provider regularly for routine wellness screenings.

Symptoms

Prediabetes has no symptoms.

Similarly, those with Type 1 or Type 2 diabetes may have no symptoms — or such mild symptoms that they go unnoticed for quite some time.

Still, since some people experience warning signs, it’s worth familiarizing yourself with the symptoms below:

Prediabetes Type 1 Diabetes Type 2 Diabetes
No symptoms Increased or extreme thirst Increased thirst
Increased appetite Increased appetite
Increased fatigue Fatigue
Increased or frequent urination Increased urination, especially at night
Unusual weight loss Weight loss
Blurred vision Blurred vision
Fruity odor or breath Sores that do not heal
In some cases, no symptoms In some cases, no symptoms

If you have any of these symptoms, see your health care provider right away. Diabetes can only be diagnosed by your healthcare provider.

Who should be tested for prediabetes and diabetes?

The U.S. Department of Health and Human Services recommends that you should be tested if you are:

  • Overweight and older than 45 years
  • Overweight, younger than 45 and have one or more additional risk factors, such as:
    • High blood pressure
    • High cholesterol
    • A family history of diabetes
    • African-American, Asian-American, Latino/Hispanic-American, Native American or of Pacific Islander descent
    • A history of gestational diabetes (diabetes during pregnancy) or delivering a baby more than 9 pounds

If your blood glucose levels are normal, you should be tested about every three years. If you have prediabetes, you should be checked for diabetes every one to two years after that diagnosis.

Tests for Diagnosing Prediabetes and Diabetes

Three types of tests can help healthcare providers make a diagnosis of prediabetes and diabetes:

HbA1C (A1C or glycosylated hemoglobin test)

The A1C test can diagnose prediabetes and diabetes. It measures your average blood glucose control for the past two to three months. This test is more convenient because no fasting is required. An A1C of 5.7 percent to 6.4 percent means that you have prediabetes, and you’re at high risk for the development of diabetes. Diabetes is diagnosed when the A1C is 6.5 percent or higher.

Fasting Plasma Glucose Test (FPG)

A fasting plasma glucose test requires fasting (nothing to eat or drink except water) for eight hours before the test.

For this test, the healthcare provider draws blood from the patient. Then the plasma (the fluid part of the blood) is combined with other substances to determine the amount of glucose in the plasma, as measured in mg/dL.

The chart below contains the FPG test’s blood glucose ranges for prediabetes and diabetes, and describes what each diagnosis means:

Blood Glucose Range Diagnosis What It Means
100 to 125 mg/dL Prediabetes (also called Impaired Fasting Glucose) Blood glucose levels are higher than normal, but not high enough to be diagnosed as diabetes. This condition increases risk for developing Type 2 diabetes, heart disease and stroke.
126 mg/dL or more Diabetes mellitus (type 2 diabetes) Type 2 diabetes develops when your body doesn’t make enough insulin or develops “insulin resistance” and can’t efficiently use the insulin it makes. It greatly increases your risk of heart disease and stroke.

Oral Glucose Tolerance Test (OGTT)

This test measures how well the body handles a standard amount of glucose.

To conduct this test, your healthcare provider will draw blood before and two hours after you drink a large, premeasured beverage containing glucose. Then, your doctor can compare the before-and-after glucose levels contained in your plasma to see how well your body processed the sugar. These levels are measured in mg/dL.

The chart below contains the oral glucose tolerance test (OGTT) ranges for prediabetes and diabetes, as well as what each diagnosis means:

Blood Glucose Range Diagnosis What It Means
140 to 199 mg/dL Prediabetes (also called Impaired Fasting Glucose) Blood glucose levels are higher than normal, but not high enough to be diagnosed as diabetes. This condition increases risk for developing Type 2 diabetes, heart disease and stroke.
200 mg/dL or higher Diabetes mellitus (type 2 diabetes) Type 2 diabetes develops when your body doesn’t make enough insulin or develops “insulin resistance” and can’t efficiently use the insulin it makes. It greatly increases your risk of heart disease and stroke.

Tests for Monitoring Diabetes

If you’re diagnosed with Type 2 diabetes, you can monitor your blood sugar level several ways to evaluate how well your treatment plan is working:

HbA1C (A1C or glycosylated hemoglobin test)

Your healthcare provider may regularly perform a test called HbA1c (A1C, or glycosylated hemoglobin test).

An A1C test provides a picture of your average blood sugar control for the past two to three months. Blood sugar is measured by the amount of glycosylated hemoglobin (A1C) in your blood.

Home monitoring

Easy-to-use home monitors allow patients to test their blood sugar on their own. A variety of these devices are on the market.

If you’re managing diabetes with the help of a home monitor, be sure to consult with your doctor to learn what to do when your results are too high or low for you.

Tests to Measure Heart Health

People with diabetes are at increased risk for a range of health complications, including cardiovascular disease.

Learn more about non-invasive and invasive tests doctors may use to check heart health.

PMC

The Diabetes Control and Complications Trial (DCCT) (1) would not have been possible without the advent of several technologies, including self-monitoring of blood glucose (SMBG). After the results of that landmark study were reported in 1993, SMBG was considered the standard of care for type 1 diabetic patients. The same was true for insulin-requiring type 2 diabetic patients after the report of the UK Prospective Diabetes Study (UKPDS) in 1998 (2). However, cost pressures have now caused some to question SMBG in type 1 diabetes (3), and we continue to struggle with conflicting evidence for those patients with type 2 diabetes not receiving insulin. The fundamental problem has been difficulty in trial design with many of the challenges carrying over from clinical trials to clinical practice.

For example, is the patient with type 2 diabetes even willing and able to perform SMBG? And, based on the glucose data, is the patient engaged enough to make behavioral changes that would improve glucose control? And even for those individuals who are able to make significant lifestyle changes, will they be willing to initiate insulin therapy if indicated? From the provider’s perspective, is there time to review the data and potentially intensify therapy with that information? Can the provider even easily access the data, especially if there is a large amount of information in the 2 or 3 weeks before a clinic appointment? If the clinician cannot download the data, will the patient be willing to share the information either with a paper logbook or perhaps a computerized tool such as a spreadsheet or even a smart-phone app? What becomes clear is that for data to be exchanged successfully, both the patient and the provider (including in a clinical trial) need to appreciate that exchange.

Another very practical question for SMBG among type 2 diabetic patients is what is its ideal frequency for a patient on metformin, with or without a sulfonylurea or glucagon-like peptide 1 agonist? For Medicare beneficiaries, patients not receiving insulin are allowed 100 test strips every 3 months (4). For these 100 strips, would it be best to test daily (at the same time or at different times of the day?) or to cluster the testing over a few days during this 3-month period?

The answers to some of these questions are addressed by Polonsky et al. in this issue of Diabetes Care (5). In this 12-month trial performed in 34 primary care practices, 483 type 2 diabetic patients (mean A1C = 8.9%) were randomized either to an active control group (ACG) where patients were instructed to use their meter based on their physicians’ recommendations (but no additional prompting, training, or instruction) or to a structured testing group (STG) where subjects used a paper tool to help analyze SMBG results and patterns. Subjects in the STG were asked to record/plot a 7-point SMBG profile on 3 consecutive days prior to each of the 5 clinic visits scheduled in the 12-month period. Importantly, these participants were also taught how to identify glycemic patterns and how to best address problems with changes in physical activity, portion sizes, and/or meal composition. These completed forms were reviewed at each clinic visit and, accordingly, patients were instructed on how to make further adjustments in their lifestyle and medication changes were made.

The results were not surprising. Intention-to-treat analysis resulted in an A1C change favoring the STG participants by −0.3% (P = 0.04), while the per-protocol analysis showed an even greater reduction by −0.5% (P < 0.003). This difference is noteworthy in that it takes into account how well the participants complied with the protocol—a fact not necessarily appreciated when only reporting the intention-to-treat results. No matter the population studied (in this report, over half the population did not have any college education)—and even if the providers are engaged and the SMBG technology and the ability for analysis are ideal—patient behavior and desire for improved diabetes control are required.

Also not surprising is that structured, intensive SMBG performed in the STG compared with random testing in the ACG resulted in more treatment change recommendations, most notably at the 1-month visit. In the STG, almost twice as many subjects started insulin therapy, though the authors note that this alone was not responsible for the group’s overall improvement. It is important to appreciate that the overall frequency of SMBG was lower in the STG, further emphasizing that structured, intensive SMBG when performed at key predetermined times can be an effective strategy. Averaging less than one test daily, the per-protocol STG had a twelve-month mean A1C of 7.6%. While not ideal, control was improved, hypoglycemia was not increased, and resources used (in terms of strip use) were minimal and not greater than what is currently allowed by Medicare for individuals not receiving insulin therapy.

That the ACG had a 0.9% reduction in A1C at the end of the study compared with baseline is noteworthy. This points to how additional attention (including free meters, strips, and additional clinic visits) to diabetes management can directly influence overall control. Further attention on top of this as seen in the STG resulted in additional reduction in A1C. The good news is that this supports a fundamental fact we all should appreciate: many patients can achieve reasonable diabetes control in a primary care setting without a dazzling array of sophisticated technology. The recipe for success would include a well-intentioned and motivated patient, an interested and engaged clinician, the usually available agents to treat type 2 diabetes (including basal insulin), glucose testing to be performed only at specific times to allow for pattern recognition, and at the very least a paper tool to allow both physician and patient to understand where changes need to be made. If any one of these factors is not present, success (as we have seen so many times) will be unlikely.

What else can we conclude? First, these results do not apply to patients who require more sophisticated diabetes regimens, including prandial insulin, where more frequent SMBG will be necessary to determine appropriate insulin doses and to minimize hypoglycemia.

Furthermore, it also seems to me that while we have spent so much time, energy, and money examining the impact of SMBG on the management of type 2 diabetes, the more important problem is determining how we can better improve our systems of care so that the time spent by the primary care physicians in this study is the norm and not a contrived component of a study protocol. This is a fundamental problem with most of the studies assessing the impact of SMBG in the management of type 2 diabetes: the study protocols do not necessarily replicate a real-life practice setting. In this era of “clinical efficiency” and “increased productivity,” the significance of much of this type of research is reduced.

While the article by Polonsky et al. is an important contribution to the literature, we have to be realistic that many if not most primary care physicians do not have the time or infrastructure to replicate these findings (6). While one could argue that time with the provider is as important as the glucose test strips themselves, future research should focus on how to better achieve improved glycemic outcomes with less clinician intervention. Potential solutions would begin with better use of web-based or smart-phone technology for patient instruction and management. Additional strategies would include more group visits, less physician and greater nonphysician interaction, and some degree of peer-to-peer involvement, all in addition to a strategy of care similar to the STG in the current study. Our future clinical trials will need to better replicate our current system of care. Until then, the controversy regarding SMBG in type 2 diabetes will not be resolved.

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