Monitoring and Managing Diabetes

Diabetes

I entered the diabetes education field six and a half years ago and the landscape of treatment was changing rapidly. 

New diabetes medications were debuting left and right.  New technologies were (and still are!) smacking me in the head. It was enough to make me want to run.  But I stuck with it and I would like to think that after all these years, I have learned a thing or two.  I have learned, though, that there is always something new to learn.

How a Healthcare Provider Monitors Diabetes

There was a time when a healthcare provider did not have a good way to determine how well managed their patient was.  We have many tools at our disposal.

Hemoglobin A1c

Hemoglobin A1c, also known as HbA1c, glycohemoglobin, glycated hemoglobin, glycosylated hemoglobin, and simply A1c, is a three-month average of how glucose levels are trending.

Hemoglobin is the part of the blood that carries oxygen; glucose attaches to the hemoglobin.  This test can detect how much glucose has been transported over a period of three months.  Three months is the average lifespan of a red blood cell.

Hemoglobin A1c values are –

  • Normal: below 5.7%
  • Prediabetes: 5.7% to 6.4%
  • Diabetes: above 6.5%

Having a blood disorder such as anemia can cause a hemoglobin A1c to be inaccurate.

Fructosamine

Fructosamine is a helpful lab test when a hemoglobin A1c is thought to be inaccurate, such as when you have anemia or when you attempting to determine the effectiveness of a treatment plan.

Fructosamine, also called glycated serum protein and GSP, measures the amount of fructosamine in the blood.  Fructosamine is a compound that forms when fructose is combined with protein.  According to LabTestsOnline.org, “Glucose molecules will permanently combine with proteins in the blood in a process called glycation. These proteins include albumin, the principal protein in the fluid portion of blood (serum), as well as other serum proteins and hemoglobin, the major protein found.”

Though not commonly ordered, a fructosamine test is very helpful when the hemoglobin A1c is thought to be inaccurate, when a healthcare provider wants to specifically measure the blood glucose values for the past two to three weeks, and during pregnancy.

Time-in-Range

Time-in-Range (TIR) is a specific measure that is used for people with diabetes who uses continuous glucose monitors (CGM).  TIR is the time that is spent in a glucose range of 70-180mg/dl for those with type 1 and type 2 and 63-140mg/dl for those with gestational diabetes and preexisting diabetes.

Researchers have found that hemoglobin A1c alone does not tell an accurate clinical picture of how well diabetes is managed.  For example, a person may have a hemoglobin A1c of 6.7% but spend much of their type with hypoglycemia.

According to the Association of Diabetes Care & Education Specialists (ADCES), “Monitoring TIR enables people with diabetes to see the effects of small changes in real time rather than waiting for their next HbA1C to be checked, which can help motivate them to either continue doing well or make additional changes to their therapeutic regimen.”

The downfall to using TIR is that it is not available to everyone – only to people using CGM technology.

How a Person with Diabetes Monitors Glucose

A person with diabetes typically monitors their blood sugar values using two different methods – fingersticks using a meter or CGM.

Meters

A glucometer, called meter for short, is a portable device that allows the user to check their glucose levels at a single point in time.  

A meter requires the user to prick their finger with a lancet.  A drop of blood is placed on a testing strip and the meter can read the glucose level.

Each person with diabetes has different monitoring needs.  For example, someone who with type 1 diabetes and is fully insulin-dependent likely checks their glucose four or more times per day, while someone with type 2 diabetes who is on metformin may check their glucose once daily.

CGMs

A CGM is like a meter – it monitors glucose.  However, it differs because it can do it continuously.  In fact, for most systems, glucose is monitored every five minutes.

A CGM is worn continuously – a sensor is inserted by the user, often in a site such as the abdomen or the upper arm.  The sensor uses a tiny cannula that sits in the interstitial fluid, which allows it to read glucose values.  Generally, sensors are changed every 10 to 14 days.

Some devices use a transmitter, which is connected to the sensor.  The transmitter is reusable for several months.  Some devices are all-in-one – containing both the sensor and transmitter.

CGMs allow people with diabetes to receive real-time data – they can see their glucose levels when they need to make treatment decisions.  Several devices also provide alarms for hyperglycemia (high glucose) and hypoglycemia (low glucose), which can be life-saving.

How a Person with Diabetes Manages Glucose 

A person with diabetes manages by following several key recommendations by their healthcare providers –

  • Monitoring glucose levels as recommended by their provider using a meter or CGM
  • Eating a balanced diet
  • Taking medications as prescribed
  • Keeping appointments with healthcare providers and diabetes educators and having labwork as prescribed, such as hemoglobin A1c or fructosamine.

Glucose Monitoring

Each person with diabetes will have a specific monitoring plan for monitoring.  Whether the plan utilize a meter or a CGM, the provider will recommend specific guidelines, such as “Monitor once daily, first thing in the morning before eating” or “Monitor before eating and when feeling symptoms of hypoglycemia.”

Diet

All food affects the glucose levels, but carbohydrates impact levels the largest.  A person with diabetes will often manage using a specific diet plan that states how many carbohydrates they should consume at each meal.

A person with type 1 diabetes may not have a limit to their carbohydrates but may need to “match” their rapid-acting insulin to their carbohydrates.  This means that they must give insulin every time they eat carbs – for all meals and snacks.

It is recommended that all people with diabetes have a mix of all macronutrients at each meal – carbohydrates, fats, and proteins.  This ensures that the meals are balanced.

Often, a person with diabetes will meet with a registered dietitian (RD) to ensure that their dietary needs are being met.

Medications

A medication plan is individualized to the person, but many people with diabetes require medication to control their glucose levels.

A person with type 1 diabetes require insulin for survival because their body no longer makes insulin.  Insulin can be given through injections or through an insulin pump, which gives insulin through tiny doses throughout the day.

A person with type 2 diabetes may not require any medication if glucose values are at target with diet and exercise.  However, there are various treatment options available if glucose becomes elevated:

    • Metformin: is the first-line treatment for type 2 diabetes and helps glucose get into the cells as well as reduces glucose production from the liver; examples include metformin (Fortamet, Glucophage, Glumetza, Fortamet, Riomet, Glucophage XR)
    • Thiazolidinediones (TZDs): help the cells use insulin glucose; examples include pioglitazone (Actos) and rosiglitazone (Avandia)
    • DPP-4 inhibitors: help the body release more insulin when eating; examples include sitagliptin (Januvia), saxagliptin (Onglyza), alogliptin (Nesina), linagliptin (Tradjenta)
  • SGLT-2 inhibitors: cause glucose to be excreted through the urine; examples include dapagliflozin (Farxiga), canagliflozin (Invokana), empagliflozin (Jardiance), ertugliflozin (Steglatro) 
  • GLP-1 agonists: help the body release more insulin when eating; examples include lixisenatide (Adlyxin), exenatide (Bydureon, Byetta), semaglutide (Ozempic), albiglutide (Tanzeum), dulaglutide (Trulicity), liraglutide (Victoza)
  • Sulfonylureas: help the body release more insulin; examples include glimepiride (Amaryl), glyburide (Diabeta, Glynase), glipizide (Glucotrol, Glucotrol XL)
  • Insulin: can be used in combination with oral medications.  People with type 2 diabetes may require insulin daily (long-acting) as well as with meals.

Resources

Brown, G. (2020, September 30). What’s a CGM and How to Pick One. Healthline. https://www.healthline.com/diabetesmine/what-is-continuous-glucose-monitor-and-choosing-one#How-do-I-get-a-CGM?

Diabetes management: How lifestyle, daily routine affect blood sugar. (2020, June 6). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/diabetes-management/art-20047963

Diabetes Medicines. (2018). FDA. https://www.fda.gov/media/119148/download

Fructosamine. (n.d.). Lab Tests Online. Retrieved December 6, 2020, from https://labtestsonline.org/tests/fructosamine#:~:text=Fructosamine%20is%20a%20compound%20that

Hemoglobin A1C (HbA1c) Test. (2018). Medlineplus.Gov. https://medlineplus.gov/lab-tests/hemoglobin-a1c-hba1c-test/

Insulin, Medicines, & Other Diabetes Treatments. (2016, December). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/diabetes/overview/insulin-medicines-treatments

Krans, B. (2018, August 20). Blood Glucose Monitoring: How It Works. Healthline. https://www.healthline.com/health/blood-glucose-monitoring#preparation

Ramchandani, N. (2019, July 11). ADA Time in Range Guidelines: What They Are, Their Importance and How This Affects Diabetes Educators. Association of Diabetes Care & Education Specialists. https://www.diabeteseducator.org/news/perspectives/aade-blog-details/adces-perspectives-on-diabetes-care/2019/07/11/ada-time-in-range-guidelines-what-they-are-their-importance-and-how-this-affects-diabetes-educators

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