Diabetes Monitoring

Diabetes is a metabolic disease which is characterized by persistently high blood glucose levels which if not controlled, in the long run, damage our blood vessels and vital organs. TYPE 2 DM has become a huge social and economic burden for the general adult world population especially India which is also known as the diabetes capital of the world. Presently we have around fifty million people suffering from diabetes and this figure is going to double in the next thirty years.

Diabetes monitoring is crucial to prevent the known complications associated with Diabetes. This involves not only knowing your blood glucose levels, but also other parameters like Blood pressure, blood lipids, screening of your eyes for diabetic retinopathy, screening for your foot for Neuropathy and vascular disease, and testing for diabetic nephropathy.

Glucose Levels

Regular monitoring of blood glucose is useful as it helps to maintain day-to-day control, detect and prevent hypoglycemia, and maintain control during any illness. The two primary ways to monitor glycemic control are self-monitored blood glucose and Hemoglobin A1c.

Self-blood glucose testing

Home blood glucose testing (SMBG) gives a fairly accurate picture of your blood glucose level at the time of the test. It involves pricking the side of your finger (as opposed to the pad) with a finger-pricking device and putting a drop of blood on a testing strip. A meter will read the result automatically. SMBG is generally checked before meals and at bedtime, with periodic checks of glucose during the postprandial period and during sleep. The frequency of SMBG ranges from 1 to 4 or more readings per day, depending on the intensity of therapy and risk of hypoglycemia. Keeping a diary of your results will help you and your healthcare team work out whether your treatment needs to be adjusted.

Testing tips

  • Make sure your hands are clean before you begin. Use water rather than wet wipes (wet wipes contain glycerin that could alter the result).

  • Prick the side of a finger – avoid the forefinger and thumb – not the middle, or too close to a nail, because this will really hurt.

  • Use a different finger each time and a different part – this will hurt less.

  • If you don’t get much blood, hold your hand down towards the ground. This should make more blood flow to the fingers.

  • Make sure your hands are warm – if they are really cold it’s hard to draw blood, and finger-pricking will hurt more

Self-monitoring of blood glucose is a beneficial part of diabetes management. As part of the day-to-day routine, it can inform of necessary lifestyle and treatment choices as well as help to monitor for symptoms of hypo- or hyperglycemia or signs of long-term complications.

It is important that the blood glucose levels being aimed for are as near normal as possible (that is in the range of those of a person who does not have diabetes).

These are:

  • Fasting and pre-prandial blood glucose 90-130 mg/dl.

  • Post prandial blood glucose < 180 mg/dl..

The goals for glycemic control should be set for an individual patient based on age, the risk of hypoglycemia, and the presence of comorbidities.

Hemoglobin A1c (HbA1c) reflects blood glucose levels over the previous 2 to 3 months. The HbA1c should be monitored every 3 months until a patient reaches the goal, and then every 6 months if the patient is at target and stable. The ADA recommended glycemic target is Hemoglobin A1c <7% using a DCCT referenced assay. The HbA1c goal for individual patients may be near normal (<6%) if possible to achieve without hypoglycemia, and less stringent targets may be appropriate for very young patients, very old patients, those with a history of severe hypoglycemia or limited life expectancy. Targets for children are adjusted to permit scrupulous avoidance of serious hypoglycemia.

Blood pressure

Hypertension is present in more than 75 % of persons with Type 2 DM, and more than one-half of persons with Type 1 DM.Blood pressure reduction has been shown to reduce the frequency of myocardial infarction, cerebrovascular disease, and diabetes-related deaths. In addition, blood pressure reduction slows the progression of Diabetic nephropathy, retinopathy, and vision loss. Blood pressure should be checked at every patient visit in a patient with diabetes. Lifestyle modifications and medical treatment should be considered if the blood pressure is>130/80 mm Hg.The AACE suggest a lower target blood pressure of 120/75 mm Hg in patients with high-risk conditions such as nephropathy.

Blood fats (Lipids) Diabetic patients should have a fasting lipid profile checked yearly. Targets

  • Your total cholesterol level should be below 200 mg/dl.

  • LDL levels should be less than 100 mg/dl.

  • HDL levels should be 40 mg/dl or above in men and 50 mg/dl or above in women.

  • Triglyceride levels should be 150 mg/dl or less.

Therapy is initially directed toward meeting the LDL cholesterol goal. A secondary goal is to raise HDL cholesterol above the gender specific target.

Eyes (Diabetic retinopathy) 

Diabetic retinopathy is damage to the retina (the ‘seeing’ part at the back of the eye) and is a complication that can affect anyone who has diabetes. To monitor for this complication, yearly dilated ophthalmologic evaluations are recommended. Newly diagnosed T 1 DM patients should have an initial dilated eye examination within 3 to 5 years after the onset of their disease. Persons with T 2 DM should have a comprehensive eye examination at the time of diagnosis and yearly thereafter. Women who are planning a pregnancy, or who present early in pregnancy, should have a comprehensive eye examination due to the risk of development or progression of retinopathy during pregnancy.

Feet (Neuropathy and vascular disease)

Foot problems can affect anyone who has diabetes, whether they are being treated with insulin, tablets or diet and physical activity only. People with diabetes are more likely to be admitted to hospital with a foot ulcer than with any other complication of diabetes. This is because diabetes may lead to poor circulation and reduced feeling in the feet.

A neurologic examination should be performed annually and should evaluate deep tendon reflexes and various sensory modalities (pain, temperature, vibration, light touch, and joint position sense).Sensory testing with a 10 g monofilament detects the presence or absence of protective sensation. At every visit, the foot should be visually inspected for skin breakdown, callus, discoloration, or signs of vascular (peripheral pulses) or neurologic disease.

Nephropathy

 Diabetic nephropathy accounts for nearly 50 % of end-stage renal disease and a leading cause of diabetes-related morbidity and mortality. The earliest sign of diabetic nephropathy is microalbuminuria.The most common screening test for kidney damage due to diabetes is a measurement of the microalbumin to creatinine ratio in a spot urine sample. Testing for albuminuria should be performed in patients with T 1 DM within 5 years of diagnosis and in patients with T 2 DM at the time of diagnosis and repeated annually. For an accurate initial diagnosis, microalbuminuria should be confirmed in two of three tests within 3 to 6 months to eliminate positive tests due to transient conditions such as exercise, UTI, and hyperglycemia. Similarly, serum creatinine should be annually measured in patients wit both T 1 DM and T 2 DM.

 

Quote: Diabetes management is not just about monitoring and controlling blood glucose but is more about prevention of the various complications associated with Diabetes. This can be achieved only by regular monitoring of Blood glucose and the various other parameters like blood pressure, lipids, eye examination, feet examination, tests for nephropathy and cardiovascular disease. Most of the complications of diabetes can be prevented or stopped from getting worse only if they are detected early and treated early.

 

Dr. Vinod Methil

 

Dr. Vinod Methil
Consultant Diabetologist,
SSD Hospital.

 

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