pink panther - diabetes management - chapter 7

TOPICS:MonitoringDiabetes (testingblood sugar)TEACHING OBJECTIVES: 1. Present blood sugar (glucose)

testing concepts (rationale,testing times, frequency anddesired ranges for theindividual).

2. Provide instruction for themeter of choice.

3. Discuss how to trouble shootproblems with their meter.

4. Introduce the concept ofrecording blood sugars andobserving trends.

LEARNING OBJECTIVES:Learners (parents, child, relative orself) will be able to:1. Describe rationale for blood

sugar testing and list testingtimes, frequency and theirdesired ranges.

2. Demonstrate use of meterincluding setting time and codewhen necessary.

3. Locate and state the 1-800number listed on the meter tocall for problems.

4. Choose and apply a method forrecording blood sugars andrecognizing trends.

Chapter 7

Blood Sugar(Glucose)Testing

H. Peter Chase, MD Rosanna Fiallo-Scharer, MD

MEASURING BLOOD SUGARSThe ability of people (or families) with diabetes to check

blood sugar levels quickly and accurately has changed diabetesmanagement more than anything else in the past 20 years. Priorto this, diabetes was primarily managed by measuring urinesugars, which were very unreliable. The people in the intensivetreatment group of the Diabetes Control and ComplicationsTrial (DCCT) did at least four blood sugars every day (see

49

Graphs can be obtained from some of the blood sugarmeters when they are brought to the clinic. This youngman had a HbA1c (see Chapter 14) of 7.1 percent, butwas having too many lows. We like no more than 14percent of values to be low and for at least 50 percent ofvalues to be below the upper range level (see suggestedranges for different ages in Table 2).

Figure 1: Blood Sugars

High = 35%

OK = 36%

Low = 29%

50 Chapter 7 Blood Sugar (Glucose) Testing

Chapter 14). They were able to achieve excellentdiabetes control as a result of frequent bloodsugar testing, more frequent dosages of insulinand following a dietary plan. The improvedglucose control was shown to significantly reducethe risk for eye, kidney and nerve complicationsof diabetes. Clearly, for people who are able tocheck blood sugars more frequently, improvedsugar control is now possible. The Standards ofDiabetes Care (see Chapter 20) recommendsfrequent blood-glucose monitoring (at least 3-4 times per day). This is a reasonable goal for allpeople with diabetes.

WHY DO BLOOD-SUGAR(GLUCOSE) MONITORING?

There are many reasons why measuring bloodsugars at home has become a cornerstone ofdiabetes care. A few of these will be discussedhere (and are listed in Table 1):

Safety: A big reason for the use of bloodsugar testing relates to safety. Almost noone feels all the low blood sugars that occur(and very young children may not reportfeeling any lows). Checking the bloodsugar before the bedtime snack may help inchoosing ways to prevent low blood sugarsduring the night.

Improving sugar control: Studies haveclearly shown that testing a minimum offour blood sugars daily and using the resultswisely can result in improved sugar control.This results in a reduced risk for diabeticeye, kidney and nerve complications. Bettersugar control also reduces the risk for heartattacks in later life!

Adjusting the insulin dosage: If bloodsugars are checked regularly, and the resultsare recorded to look for patterns of lows orhighs, the insulin dosage can be adjusted asneeded. People who take a rapid-actinginsulin (Humalog/NovoLog/Apidra)before meals should use the blood sugarlevel (along with the amount of food andplanned exercise) to decide how muchinsulin to take.

Managing illness: Being able to checkblood sugars at home when a person is sick(or before or after surgery) allows for safemanagement at home. In the past, peoplewith diabetes were sometimes kept in thehospital because accurate blood sugarscould not be done at home. People who donot test their blood sugar frequently duringillness are more likely to become seriously illand be admitted to the hospital.

To understand the effects of variousfoods, exercise or stress: By checking ablood sugar two hours after eating a certainfood or doing a certain amount of exercise,one can better plan the insulin dose the nexttime. Pizza, for example, tends to raiseblood sugars more than other foods forsome people. If this is found to be true,

Table 1Reasons for Blood Sugar(Glucose) Testing

Safety

Improve sugar control

Adjust the insulin dosage

Manage illnesses

Understand the effects of variousfoods, insulin doses, exercise orstress

Discriminate a rapid fall in bloodsugar from a truly low blood sugarvalue

Know the blood sugar levelimmediately

Sense of control

Indicate a need to test for urine orblood ketones

Chapter 7 Blood Sugar (Glucose) Testing 51

extra rapid-acting insulin can be consideredfor the next time it is to be eaten. Similarly,some people lower or raise their blood sugarwith a certain exercise, whereas others donot. Knowing the blood sugar value afterdoing the exercise a few times will help infuture planning.

To discriminate a rapid fall in bloodsugar from a truly low blood sugar value:Some people report frequent symptoms ofan insulin reaction (see Chapter 6). Thisoccurs when the blood sugar falls rapidly(for example from 300 to 150 mg/dl [16.7to 8.3 mmol/L]) or when a low bloodsugar truly occurs. A blood sugar test at thetime of a reaction will help determinewhether the symptoms are due to a rapidfall (false reaction) or a seriously low bloodsugar. We consider a truly low blood sugarto be below 60 mg/dl (3.3 mmol/L) orin a preschooler, below 70 mg/dl (3.9mmol/L). Sugar can be given if the level islow, but it is not needed if the symptoms arejust due to a rapid fall in sugar. If the levelis between 60 and 100 mg/dl (3.3 and 5.5mmol/L), it is often helpful to eat food thatis not high in sugar. These differences willnot be known unless a blood sugar level istested at the time of the insulin reactions.

To know the blood sugar levelimmediately: A blood sugar test will giveimmediate results when the value isimportant to know. For example, a childmay be irritable and the cause may beunknown. A blood sugar test will quicklyhelp the parent decide if the irritability isdue to a low blood sugar level or anothercause. Another person may have animportant event and just want to know theblood sugar prior to the event.

Blood sugar testing gives people a senseof control over their diabetes: Manypeople feel better knowing how their bloodsugars are running. However, it isimportant to remember that there may notalways be an exact relationship between theblood sugar level and what one expects it to

be. There are always unknown factors thatresult in occasional high or low levels. Thiscan be very upsetting for the person whoexpects blood sugars to always be in thetarget range. It is important not to becomediscouraged when blood sugars do notalways match the expected results.Questions or concerns about the bloodsugar tests should be discussed with thediabetes team.

As an indicator to do a urine or bloodketone test: A fasting blood sugar above240 mg/dl (13.3 mmol/L) or a valueabove 300 mg/dl (16.7 mmol/L) duringthe rest of the day should indicate a needfor a blood or urine ketone test. (Somemeters now even flash this advice.) Testingfor blood or urine ketones when the bloodsugar is high may help to prevent an episodeof ketoacidosis (see Chapter 15).

WHEN TO DO BLOODSUGAR TESTS

We now encourage people to do at least fourblood sugar tests every day. When four bloodsugar tests are done each day, they are oftenscheduled before breakfast, before lunch, beforethe afternoon snack or before dinner, and beforethe bedtime snack. Occasional values shouldalso be done two hours after meals and duringthe night. The blood sugar goals for beforemeals and two hours after meals are shown inFigure 2 and Table 2. Suggested bedtime andnighttime values are given in Table 2.

1. Pre-breakfastThe morning blood sugar test reflects the

values during the night and is probably themost important blood sugar related to diabetescontrol. It directly reflects the dose of Lantusinsulin (no matter when its given during theday). As shown in the figure at the beginningof Chapter 2, this value reflects the turningoff of internal sugar production by the liver.The rapid-acting insulin dose at breakfast is alsousually based, at least in part, on the bloodsugar result. Using Lantus insulin or an insulin


pump, it is now usually possible to get themajority of fasting blood sugars in range (seeTable 2).

2. Pre-lunchA blood sugar test before lunch helps to

decide if the morning rapid-acting insulinand/or Regular insulin dosage is correct. Forpeople using morning NPH insulin, it may alsobe having an effect at this time. Most familiesnow routinely request that a test be done priorto eating lunch. For most children (andschools), this is not a problem and can be donewithout interfering with the childs normalschool life. Other families (or children) preferto do blood sugars at school only if the child isfeeling low. This is discussed in more detailin Chapter 23, The School and Diabetes.

3. Pre-dinnerThe test before dinner reflects the dose of

morning NPH insulin (if taken) and the dose ofrapid-acting insulin given at lunch and/or forthe afternoon snack. It may also reflectafternoon sports activities and the food eatenfor an afternoon snack. A test should not bedone unless it has been at least two hours sincefood was last eaten. Otherwise, the result willbe high from the food eaten in the previous twohours. If it is time for dinner and the personhad an afternoon snack one hour earlier, it maybe best to just wait and do the test prior to thebedtime snack. If this is a common occurrence,change to doing the blood sugar tests BEFOREthe afternoon snack. Some youth, who like alarge afternoon snack, will now routinely useHumalog/NovoLog/Apidra to cover the risein blood sugar. The dinner value will then tellif the dose given was correct.

4. BedtimeThe blood sugar test prior to the bedtime snack

is important for all people with diabetes. It isparticularly important for:

people who tend to have reactions duringthe night

children who play outside after dinner orwho have had heavy exercise that day

anyone who did not eat well at dinner

knowing if the rapid-acting insulin dosegiven at dinner is correct

As can be seen in Table 2, suggestedbedtime blood sugar values are given for thedifferent ages. If the values are below thevalues in brackets (two stars), doing afollow-up blood sugar check during thenight is wise. These values may be differentfor a given person.

5. After mealsIn recent years, more emphasis has been

placed on doing a blood sugar two hours aftereating a meal. The highest blood sugars of theday occur after meals and these values add tothe HbA1c value (Chapter 14). More peopleare now using carbohydrate counting. Theymay inject insulin prior to meals based on theirexpected carbohydrate intake (Chapter 12).The blood sugar two hours after the meal tells ifthe Insulin to Carbohydrate ratio (I/C ratio Chapter 12) and estimated carbohydrates arecorrect. The sugar values listed in Table 2 byage can also be the goals for two hours aftermeals. Others just aim for values below 140mg/dl (7.8 mmol/L) two hours after meals.We would recommend that families try to checkblood sugar two hours after each meal at leastonce or twice weekly. Values obtained twohours after meals can perhaps be flagged by asymbol such as a star.

6. NighttimeIt may be necessary to occasionally do

blood sugar tests in the middle of the night (seeChapter 6 on Low Blood Sugar) to make surethe value is not getting too low. This isparticularly true if it has been a heavy exerciseday. The diabetes care provider may suggestthis if very erratic results are noted for themorning blood sugars.

A nighttime blood sugar test is particularlyimportant for people who tend to havereactions (low blood sugars) during the night.More than half of the severe low sugars occurduring the nighttime hours. Many families will


routinely do a test during the night. Otherschoose to do a test once weekly. IT ISIMPORTANT TO TEST ON NIGHTSWHEN THERE HAS BEEN EXTRAPHYSICAL ACTIVITY. The extra activitymight be a basketball game in the evening. Fora younger child, it might be playing hardoutside on a nice summer evening. The besttime to do a check varies with each person. Forsome, between midnight and 2 a.m. is the best.For others, the early morning hours are the

most valuable perhaps when a parent isgetting ready for work. Table 2 also givessuggested values for during the night.

7. With low blood sugarAs noted above, doing a blood sugar when

feeling low helps to separate a rapid fall in bloodsugar from a true-low (< 60 mg/dl [or < 3.3mmol/L]). A food with sugar must be given fora true-low whereas other food may be given(e.g., cheese, peanut butter) for a false-low.

Figure 2Blood Sugar Level in mg/dl (mmol/L)VERY HIGH400-800 Stomachache (22.2-44.4) Difficulty Breathing

HIGH200-400 Low Energy(11.1-22.2)

GOALS80-200 Under 5 years Fine(4.5-11.1)

70-180 5-11 years(3.9-10.0)

70-150 12 years(3.9-8.3) and up

LOWbelow 60 True-Low Sweating(below 3.3) Hunger

Shakiness

NON-DIABETIC NORMAL VALUES FOR CHILDREN*

70-100 Normal (fasting)*(3.9-5.5)

70-130 Normal (random)*(3.9-7.3)

*The DirecNet Study Group showed that approximately 95 percent of values for non-diabetic children arein this range. However, occasional values down to 60 mg/dl (3.3 mmol/L) and, for random values, upto 144 mg/dl (8.0 mmol/L) are still normal.


HOW TO DO SELF BLOODSUGAR TESTS

Finger-poking

A finger-poking (lancing) device is used toget the drop of blood. There are many gooddevices on the market, and these can now oftenbe set at different depths for different people.The adjustable pokers are particularly good foryoung children who have tender skin and maynot need much lancing depth.

The hands should be washed with warmwater (to increase blood flow and to make surethey are clean). Any trace of sugar on thefinger may give a false elevated reading. We donot recommend routinely wiping with alcoholbecause any trace of alcohol left on the skin willinterfere with the chemical reaction for theblood sugar test (Table 3). Alcohol also driesand toughens the skin. Occasionally, whenaway from home (e.g., camping, picnics), it isnecessary to use alcohol-free travel wipes tocleanse the finger. Air dry the finger beforedoing the blood sugar check.

It is often helpful to place the finger to beused on a table top (to prevent the naturalreflex of withdrawing the finger and not gettingan adequate poke). The side of the fingershould be used rather than the fleshy pad onthe fingertip, which is more painful. If the dropis not coming easily, hold the hand down to theside of the body to increase the blood in thefinger. IT IS IMPORTANT TO ROTATEFINGERS SO THAT ONE FINGER DOES

Table 2Suggested Blood Sugar Levels

Fasting (a.m.) or Bedtime (before bedtime snackno food for 2 hours or during the night)

Age (years) mg/dl mmol/L mg/dl mmol/L

Below 5 80-200 4.5-11.1 Above 150* [80**] above 8.3* [4.5**]

5-11 70-180 3.9-10.0 Above 130* [70**] above 7.3* [3.9**]

12 and above 70-150 3.9-8.3 Above 130* [60**] above 7.3* [3.3**]

*If values are below these levels, milk or other food might be added to the solid protein andcarbohydrate bedtime snack.

**If values are below these levels, the test should be rechecked 10-30 minutees later to make certain ithas come back up. If this happens more than once within a week, either reduce the dinner rapid-acting or Regular insulin or call the diabetes care provider for advice.

Note: The ADA recommended sugar levels for children of different ages vary somewhat from oursuggestions. The levels for before meals and during the night recommended by the ADA can be found inTable 1 of Chapter 14.


NOT BECOME TOO ABUSED. If thefingers become sore, the toes or the ball at thebase of the thumb may be used.

Alternate Testing Sites

Many children are now poking sites otherthan the fingers or toes. These sites are used asthey may not hurt as much. The poker mayneed to be dialed to the maximum depth toget enough blood. The most common site isthe forearm. Meters approved for the arminclude The FreeStyle, The FreeStyle Flashand the One Touch Ultra. The FreeStyle isalso approved for use on the fleshy pad at thebase of the thumb, the upper arm and the thighand calf. The main problem has been that theblood flow through the arm is slower thanthrough the fingertips. The slower blood flowmeans the blood sugar value from the arm maybe 10 minutes or more behind the fingertip. Itis important to rub the site to be used on thearm prior to doing the stick. The rubbing willincrease the blood flow in the area. The personmay feel low or have a low value from a finger-stick, but the arm level will not be low. Weadvise families to use the fingertip if the child isfeeling low. Also, people who do not feel theirlows (hypoglycemic unawareness; Chapter 6)should always use their fingertips for bloodsugars. Remember to change the lanceteveryday. A sharp lancet will lessen injury tothe site and help prevent an infection.

upper arm

forearm

fleshy pad atbase ofthumb (notdelayed)

back of calf

thigh

Table 3Common Problems Causing Inaccurate Blood Sugar Test Results

Finger is not clean and dry (sugar on finger will raise result; alcohol or water will interfere)

Adding more blood after the first drop has been put on pad (now ok for some meters)

Meter parts are dirty (e.g., with dried blood)

Codes on strips and meters are not matched (some meters now read the codes automatically)

Too small a drop of blood on pad

Strips have expired

Strips have been exposed to heat (> 90, e.g., left in hot car) or frozen (e.g., left in cold car)

Alternate sitetesting: Thevalue may bedelayed andshould NOTbe used iffeeling low.


Blood Sugar (Glucose) Meters

Some of the desirable features in selecting ameter are listed in Table 4. The meter chosenshould meet the persons needs. Some peopleleave a meter at school or at work. If testing isdone on more than one meter, try to use nomore than two different brands. Families tendto prefer small meters that are easy to slip into apocket. They also prefer meters that take ashort time for the glucose determination.Particularly for younger children, the need foronly a small amount of blood is helpful. Mostof the strips now have a capillary action to pullthe blood into the strip. This may be helpfulfor a small child who has difficulty holding still.For some people, accuracy in cold, heat, highhumidity or high altitude is important. If astrip has been in a cooler or refrigerator (most

strips spoil at above 90 or if they freeze), theyshould always be brought to room temperaturebefore using.

Often the main reason one meter is selectedover another in the U.S. is that the familyshealth insurance will pay for that meter and itsstrips. The glucose strips usually add up to acost of $3-4 (U.S.) per day, and so insurancecoverage is important. The cost of strips isusually a more important factor than the cost ofthe meter.

It is important with most meters to test acontrol strip or solution at regular intervals tomake sure reliable results are being obtained.Some clinics with a more accurate meter maywish to intermittently check the familys meterwith the clinics. Some common problemscausing inaccurate blood sugar test results areshown in Table 3.

We do request that families choose a meterwith a memory for at least the last 100 glucosevalues. The meter(s) must always be broughtto the clinic visit so that it can be downloaded.The values as well as graphs, such as the pie-chart(Figure 1), can be printed. Some families like todownload their blood glucose results in theirhomes. Research from our Center showed that ifat least half of the blood sugar values are belowthe upper limit of the goal for the age (see Figure2 and Table 2), the HbA1c values will usually bein the desired range for the age (see Chapter 14).During the honeymoon phase (Chapter 2), orwhen one still makes much of ones own insulin,most of the blood sugars will be in the desiredrange for age. For other people with diabetes, itis a reasonable goal to try to get half of the bloodsugar values at any time of day within range forthat persons age.

Most meters read within 10 percent of ahospital laboratory determined value. Most ofthe meters currently on the market read thesugar in the plasma (the clear part of theblood). Research done by the DirecNet studygroup has confirmed that two meters, the One-Touch Ultra and the FreeStyle (or Flash), readwith a high degree of accuracy.

Table 4Desired Features of Blood Glucose Meters

Accurate (in environment where it is tobe used)

Storage of at least the last 100 values

Able to be downloaded at clinic and/orat home

Small in size

Short determination time

Small drop of blood (capillary action ofstrip)

Blood is applied to the end of the stripand does not get into the meter

Cleaning is easy or not necessary

A control solution or strip can be usedto check for accuracy

Strips are paid for by the familysinsurance


Record Keeping

Examples of daily record sheets are includedin this chapter. The pages record either the lastone week or the last two weeks of blood sugars.Many families will now fax the page to theirdiabetes care provider at regular intervals. Ifthis is done, make sure the insulin dosages andinstructions for return fax or phone contact areincluded. These sheets may be copied andstored in a notebook to bring along to clinicvisits. Keeping good records to look forpatterns in blood sugar fluctuations is essential.It is wise to keep written records even if yourmeter is able to store results (these may be lostif the meter malfunctions). Patterns of highor low blood sugars will be missed if resultsare not recorded. It is important to note allreactions and possible causes. Some people alsocircle or highlight all values below 60 mg/dl(3.25 mmol/L) or put a star on days ofreactions so that these can be easily noted bythe diabetes care providers. If times of heavyexercise are recorded, it may be possible to seethe effects of exercise on blood sugars.Illnesses, stress and menstrual periods mayincrease the blood sugar and should be noted.It may be helpful to record what was eaten forthe bedtime snack or if there has been heavyexercise to see if these are related to morningblood sugars. Hopefully, occasional tests willalso be done at the time(s) when routine testsare not usually done. Also included is a place torecord urine or blood ketone checks, as newlydiagnosed people must check their ketonesfrequently. Ketone checks are essential with anyillness or anytime the blood sugar level is above240 mg/dl (13.3 mmol/L) fasting or over 300mg/dl (16.7 mmol/L) during the day.

The insulin dose can be recorded with theunits of rapid-acting insulin on top (e.g., 5H or5NL) and the units of intermediate-actinginsulin on the bottom (e.g., 15N).

Good record keeping and bringing theresults to clinic visits allow the family anddiabetes team to work together mosteffectively to achieve good diabetesmanagement. Complacency and not

recording values often results in missingpatterns of high blood sugars and a resultanthigh HbA1c value (see Chapter 14).

Continuous Glucose Monitor (CGM)

It had been expected that CGMs would bedeveloped more rapidly than has happened.Accurate CGMs will be essential in thedevelopment of the closed-loop insulin pump(an insulin pump automatically regulated bysugar levels as measured by CGMs).Unfortunately, the CGMs have not measuredthe sugar levels with adequate accuracy(particularly at low glucose [sugar] levels) topermit the closed-loop pump. In the meantime,CGMs can be useful in improving glucosecontrol. They have been most helpful for:

4 detection of high sugar levels after meals

4 detecting low sugar levels and for peoplewho have trouble telling when they are low(hypoglycemic unawareness)

4 measuring sugar levels duringhospitalizations (when better sugar controlmay result in a better outcome)

4 during pregnancy (when better sugarcontrol may result in a better outcome)

Continuous Glucose Monitors (CGMs)

1. The Guardian RT Continuous GlucoseMonitoring System (CGMS), made byMedtronic MiniMed, is a home-use devicewith alarms for high and low glucose levels,which displays glucose values every fiveminutes. It was approved by the FDA foruse in adults, 18 and older, in August,2005. The small flexible wire is insertedunder the skin with a needle that is thenremoved. The sensor then transmits theglucose levels to the receiver box (about thesize of an insulin pump). The receiver is notattached to the sensor and people canshower while wearing the sensor. Theaccuracy of the Guardian (particularly forlow sugar levels during the night) has notyet been tested by an independent group.We have found past CGM devices to be


more accurate at high sugar levels than atlow sugar levels. They are thus best utilizedin showing how high the blood sugar levelsgo following meals. The Guardian requirestwo blood sugar values per day (every 12hours) to be obtained by finger poke forcalibration purposes.

2. The DexCom STS was approved by theFDA for use in adults in April, 2006. A small wire is inserted under the skin using an automatic inserter. Subcutaneousfluid glucose readings are obtained every 5 minutes after the initial two hour warm-up period. It can be set to vibrate at thedesired high and low glucose settings. Itsaccuracy has not yet been checked by anindependent group.

3. The Navigator, made by Therasense/Abbott Diabetes Products, is beingconsidered by the FDA for approval. Aswith the Guardian and DexCom STS, thesensor is not connected to the receiver, butcommunicates by radio waves (showering isthus possible). The sensor is inserted underthe skin using an automatic injection device.Two glucose levels (done by the FreeStylemeter built into the receiver) must beentered into the Navigator in the first 24hours and then one test daily. The companyhopes to be allowed to state that furtherroutine sugar testing by finger-poke will notbe necessary (for 3-5 days). Ourrecommendation is to do a finger-pokeblood glucose level if the high glucose alarmsounds (and more insulin is to be given), orif the low glucose alarm sounds (for safety).Arrows on the face of the receiver can pointstraight up or down, meaning that theblood sugar is changing by > 2 mg/dl/min.In this case we recommend approximately a20 percent change in correction and foodbolus (compared to what would usually be

given). The change should be in the samedirection as the arrow. For example, if thearrow is straight up and the plannedcorrection bolus is 4 units and the plannedfood bolus is 4 units (total bolus = 8 units),the new bolus amount should be 9.6 units(20% of 8 is 1.6). If the arrow were straightdown one would subtract the 1.6 units (8 1.6 = 6.4 units). If the arrow is eitherup or down at 45 degrees, then thecorrection and food insulin dose change isalso up or down by 10 percent (compared towhat would usually be given). If the arrow ishorizontal, the standard bolus is taken. TheNavigator has been found to be reasonablyaccurate by our DirecNet study group.

DEFINITIONSDCCT: Diabetes Control and ComplicationsTrial. This trial was completed in June 1993and clearly showed that eye, kidney and nervecomplications of diabetes were related toglucose control. More recently (June, 2005),the likelihood of later heart attacks was alsoshown to be reduced by the earlier betterglucose control.

Glucose: The scientific name for the sugar inthe blood or urine.

Insulin reaction (hypoglycemia): Anotherterm for a blood sugar level that is too low. SeeChapter 6.

Monitoring: As used in this chapter, keepingtrack of and following blood sugar levels athome and writing them down in a record book.

Self blood-glucose monitoring: Checkingones own blood sugar rather than going into aclinic or hospital to have the tests done.

Subcutaneous: Under the skin (but not in ablood vessel).


QUESTIONS AND ANSWERSFROM NEWSNOTES

What is the best range for myblood sugars?

This is not an easy question to answer.It depends on the individual personand family as well as the age of the

person with diabetes. Most textbooks list anormal fasting level (or when no food is takenfor two or more hours) as 70-100 mg/dl (3.9-5.5 mmol/L). It is unrealistic for most peoplewith diabetes to aim for normal non-diabeticsugar levels. Understanding Diabetes (thePink Panther book) suggests ranges by ages:

Under five years old: 80-200 mg/dl (4.5-11.1 mmol/L)

5-11 years old: 70-180 mg/dl (3.9-10.0 mmol/L)

12 years old and above: 70-150 mg/dl (3.9-8.3 mmol/L)

However, these are generally suggestedranges for fasting or if there is no food intake forat least two hours, and they do not takeindividuals or families into account. For example,a 10 to 11-year-old who does blood sugar testingregularly so that the chances of unrecognized lowblood sugars occurring are unlikely, and who doesnot have severe insulin reactions (e.g.,unconscious episodes), can probably safely aim fora level of 70-150 mg/dl (3.9-8.3 mmol/L). Thereason for aiming for the lower level would be sothat the glycohemoglobin ( HbA1c) levels may belower with a reduced long-term likelihood ofcomplications.

On the other hand, an adult who has severeepisodes of unrecognized hypoglycemia might bewiser to try to achieve the middle range of 70-180 mg/dl (3.9-10.0 mmol/L). This mighthelp to reduce the severe insulin reactions.

It is generally wise to discuss the level ofblood sugar to aim for with your physician ateach clinic visit.

Should bedtime blood sugar valuesbe in the same range as morningblood sugars?

No!

Table 2 in this chapter listssuggested blood sugar levels for the morningand bedtime. We ask that values be 60-70mg/dl (3.3-3.9 mmol/L) higher at bedtime forthe three age groups in comparison to themorning values.

This is particularly important for the springand early summer. As the good weather comesand children play outside in the evening, it isimportant to reduce the pre-dinner rapid-actinginsulin and to check the blood sugar before thebedtime snack. If the blood sugar value is belowthe suggested lower limit for the age, anadditional snack should be given (and the insulindose further reduced the next day). Levels arealso suggested in Table 2 for when it would bewise to check another blood sugar during thenight. It is only by constant monitoring thatsome families are able to prevent severe insulinreactions in their children.

With the data from the DCCTbeing in everything we read aboutdiabetes, what can we do to

improve glucose control for our 17-year-oldson? His morning blood sugars are fine, buthe is extremely variable (60-340 mg/dl or3.3-18.9 mmol/L) before dinner.

Blood sugars before dinner areinfluenced by lots of factors.

For example:

The size and sugar content of the afternoonsnack

If it has been at least two hours withoutfood intake when the blood sugar is done

Exercise, which makes some peoples bloodsugar higher (due to adrenaline[epinephrine] output) while causing otherpeoples to become lower

QA

QA

Q

A


One helpful practice is to do a blood sugarbefore the afternoon snack. If the value is high,the snack can be limited to low carbohydratefoods such as diet pop, popcorn, string cheese,carrots, celery, etc. Then see if the value isdown by dinner. Obviously, if the value is low,calories are needed. Each family has to decide(on the basis of exercise, school lunch, stress,etc.) what a low value is at that time of day fortheir child.

Another alternative might also beconsidered. I know a 17-year-old (whose fatherasked this question) whom I would guess isgoing to eat regardless of the blood sugar level!He might take some rapid-acting insulin if thevalue is above a certain level to hold him untildinner. In this boys case, I suggested he takefour units of rapid-acting insulin if the bloodsugar is 150-200 mg/dl (8.3-11.1 mmol/L)and six units if greater than 200 mg/dl (11.1mmol/L). The dose would vary for differentsized people and different sized appetites.

A third alternative which works for manypeople is to exercise for 30 or more minutes(shooting baskets, riding an exercise bike ordoing other activities). This brings the sugardown for many people, and the exercise isobviously important for many other reasons.

I should also stress that with the DCCTdata and the push for better control, morefrequent blood sugar monitoring and extrainsulin when the value is high may be the keyfor many people. Sometimes the extra shot maybe in the afternoon or at lunch. This adds extrapressure to families, but the results will berewarding in the long run.

Do I need to test my childs bloodsugar every morning at 2:00 a.m.?

For most children, this is NOTnecessary. Occasional checks duringthe night (e.g., once every one or two

weeks) are helpful. Special circumstances thatmake nighttime checks important are:

An illness. A sick child who may not haveeaten well during the day, or who had urineketones and/or extra (or less) insulinsecondary to the illness.

A low pre-bedtime snack blood sugar. Ifvalues are below 80 mg/dl (4.5 mmol/L) ina preschooler, below 70 mg/dl (3.9mmol/L) in a 5- to 12-year-old, or below60 mg/dl (3.2 mmol/L) in a person age 12or above, the blood sugar should be checkedlater (when the parents go to bed or duringthe night) to make sure the value has risen.This is recommended in Table 2 in Chapter6. It might also be good to give an extrasnack (or a larger amount) at bedtime.

Variable morning blood sugar levels.When some morning blood sugar values arelow (e.g., below 60 mg/dl [3.3 mmol/L])and other values are high (e.g., above 200mg/dl [11.1 mmol/L]), many careproviders suggest doing a value during thenight to make sure rebounding from lowvalues is not causing the high values. Othercare providers believe that rebounding isvery unlikely and that the difference inmorning values is due to other factors suchas variability in insulin absorption.

Frequent low blood sugars during thenight. If a child is awakening two or moretimes during the week with symptoms oflow blood sugar, it may be wise to routinelydo some middle-of-the-night blood sugarsto make sure this is not happening morefrequently. The physician caring for thechild should also be called.

If blood sugars are fluctuating withoutexplanation. A more intensive testing

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schedule for a week or more, including earlya.m., can often determine where the insulindosage needs to be adjusted.

With all of the good glucose metershaving memories of blood sugarvalues which can be printed out in

clinic, do I still need to write down everyblood sugar value?

Unfortunately, the answer is YES. It isjust as important to write values downnow as it was when meters did not

have memories. It is important to look fortrends in blood sugar levels in order to knowwhen to make changes in insulin dosages. If aperson or family does not do this, they are notdoing a good job of home diabetesmanagement. One of my top pet peeves indiabetes care is to have a patient (or family)who does blood sugars and constantly hasvalues that are too high or too low, but theydont make changes between clinic visits or faxthe values to a diabetes care provider who canmake suggestions.

Our general rule of thumb is that if morethan half of the values at any time of day areabove the upper level (usually 180 for 5-11years old or above 150 if 12 years or older), anincrease in the insulin dose is needed. Forexample, if an 11-year-old has all morningvalues above 180 mg/dl (10.0 mmol/L) for aweek, the Lantus insulin should be increased byone unit. Similarly, if the pre-dinner values areall above 180 mg/dl (10.0 mmol/L) for aweek, the morning intermediate-lasting insulindose should be increased by one or two units.If the values are not being recorded in such away that values done at the same time of daycan be easily compared, it is possible that thesetrends will be missed. The opposite is alsotrue; if there are more than one or two valuesin a week below 60 mg/dl (3.24 mmol/L) atany time of the day, the insulin dose working atthat time can be reduced. If there is a questionwhether doses should be changed, the fax pagein this Chapter can be faxed to the healthcare

provider (most schools and work places nowhave fax machines). The faxing of the bloodsugars saves valuable doctor/nurse time inhaving to sit at a phone and write down results. Our Center now averages over 20patient faxes per day, and it is considered partof the service of the quarterly (every threemonths) clinic visits.

For the young child or teen who does notwant to write values down, it is often acceptablefor the parent to push the M (memory)button at the end of the day and record thevalues. This is a way for the parents to stayinvolved and most teenagers agree to acceptthis help. The parent is often the familymember who does the faxing to the healthcareteam as well.

Are blood sugar levels after mealsimportant?

Blood sugar levels after meals havepreviously been largely ignored bychildrens doctors and families.

Yet, the highest blood sugars of the day occurin the 1-2 hours after meals. Recent data showsthat these high values affect the HbA1c and arethus important in relation to many of the latercomplications of diabetes. Thus, it is nowrecommended that you check the blood sugar two hours after each of the meals at leastonce weekly.

Part of the problem in the past was thatthere was not a-rapid acting insulin to help tolower the sugars after meals. NowHumalog/NovoLog/Apidra insulins fill theneed. Many of our teens working for improvedglucose control (a lower HbA1c level) will nowtake a shot of rapid-acting insulin with lunchand/or with their afternoon snack. If this isdone consistently, it can be just as effective asusing an insulin pump. The insulin pens areeasy to carry and often work effectively for thispurpose (see Chapter 9).

continued on page 64

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Daily Record SheetName _____________________________________________________________________________________

Fax To _______________________________________ At __________________________________________BBrriinngg tthheessee rreessuullttss ttoo yyoouurr cclliinniicc vviissiitt

Sun Time

BG/Ket

Mon Time

BG/Ket

Tues Time

BG/Ket

Wed Time

BG/Ket

Thurs Time

BG/Ket

Fri Time

BG/Ket

Sat Time

BG/Ket

Sun Time

BG/Ket

Mon Time

BG/Ket

Tues Time

BG/Ket

Wed Time

BG/Ket

Thurs Time

BG/Ket

Fri Time

BG/Ket

Sat Time

BG/Ket

Reminder: 1. Make sure insulin doses are included under the Insulin Dose Heading.2. How to reach you: FAX _________________________________ or Phone_________________________________________

if by phone, best time to reach you:_________________________ (between 8 a.m.- 5 p.m.)3. Person to be reached: _____________________________________________________________________________

BG = Blood Glucose, Ket = Ketones

BBrreeaakkffaassttResults Insulin Dose

LLuunncchhResults Insulin Dose

DDiinnnneerrResults Insulin Dose

BBeeddttiimmeeResults Insulin Dose

CCoommmmeennttss:: Reactions,exercise, illness, bedtime snack


Daily Record SheetName _____________________________________________________________________________________

Fax To _______________________________________ At __________________________________________BBrriinngg tthheessee rreessuullttss ttoo yyoouurr cclliinniicc vviissiitt

Sun Time

BG/Ket

Mon Time

BG/Ket

Tues Time

BG/Ket

Wed Time

BG/Ket

Thurs Time

BG/Ket

Fri Time

BG/Ket

Sat Time

BG/Ket

Reminder: 1. Make sure insulin doses are included under the Insulin Dose Heading2. How to reach you: FAX _________________________________ or Phone ______________________________________________

if by phone, best time to reach you:_________________________ (between 8 a.m.- 5 p.m.)3. Person to be reached: _________________________________________________________________________________________

CCoonncceerrnnss::

The Daily Record Sheets may be photocopied as often as desired.

BG = Blood Glucose, Ket = Ketones

BBrreeaakkffaassttResults Insulin Dose

LLuunncchhResults Insulin Dose

DDiinnnneerrResults Insulin Dose

BBeeddttiimmeeResults Insulin Dose

CCoommmmeennttss:: Reactions,exercise, illness, bedtime snack


Our family does everything by e-mail now. Is there a way I can getthe blood glucose fax sheets from

Chapter 7 of the Pink Panther book on mycomputer?

Yes, this can now be easily done.Families wanting to use these forms toe-mail to their doctor or nurse, can

get them from these links:

The Barbara Davis Center home page is at:www.barbaradaviscenter.org. Then go to Books Online, to Understanding Diabetes, and you can then e-mail them to your doctor

and nurse at your Center. The e-mail address atmy clinic is:

________________________________________

It is essential for you to give phone numbersand the time to get back to you as it is oftenbest to actively discuss the blood sugars andinsulin doses.

Please note: depending on the resolution ofyour monitor, the lines on the sheets may notappear continuous. They will, however, printout accurately.

Appendix Some Meters with Programs to Allow Downloading at HomePROGRAM AND COST VENDOR/ADDRESS METER SUPPORT

PHONE/WEBSITE

In OneTouch Diabetes LifeScan, Inc. OneTouch Diabetes Management 1000 Gibraltar Drive ManagementSoftware is free with connecting Milpitas, CA 95035cable; cable = $29.99 800-382-7226

www.lifescan.com

Precision Link and Software: Abbot Diabetes Care Precision Xtra, connecting cable = $39.95 1360 South Loop Road FreeStyle,

FreeStyle/Flash Alameda, CA 94502 FreeStyle/Flash

free software is available on 888-522-5226the website www.abbottdiabetescare.com

AscensiaWinGlucofacts: Bayer Corp. Ascensia Contour,software can be downloaded 7750 West Morris Street Ascensia Breeze,from website for free Indianapolis, IN 46231 Ascensia Dex 2,(www.bayercarediabetes.com) 800-348-8100 Ascensia Elite,connecting cable = $29.95 or $49.95 if bayercarediabetes.com Ascensia Elite XL you purchase the cable and software

Accu-Chek Compass: Roche Diagnostics Accu-Chek Active System,software = $29.95 9115 Hague Road Accu-Chek Advantage System,connecting cable = $30.00 P.O. Box 50457 Accu-Chek Compact System,

Indianapolis, IN 46250-0457 Accu-Chek Complete System800-858-8072www.accu-chek.com

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pink panther - diabetes management - chapter 7

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