Keeping Watch: Daily Diabetes Monitoring -- Brunilda Nazario, MD -- 11/12/2003

By Brunilda Nazario
WebMD Live Events Transcript

When living with diabetes, so much of your long-term success depends on what you do today to monitor your levels. What's the best way to do this? WebMD's in-house expert, Brunilda Nazario, MD, offered tracking tips as part of our Take Charge of Your Diabetes WebMD University course.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Support for this WebMD University course provided by GlaxoSmithKline.

Member question: There are a lot of new blood sugar meters on the market. Where can we find an impartial review of which one is best?

Nazario: One of the sites that offers information on the various advantages and disadvantages of blood glucose monitors would be the fda.gov site/diabetes/glucose.

As far as which is the best monitor, that depends on the individual patient. Monitors vary in ease of use, size of the screen, and timing, so you have to look at the site and review all the different meters and the characteristics of each to determine which one best fits your particular scenario. They're all basically equivalent but different features might make one better for you.

Member question: If I test and my levels are normal should I still take my blood sugar meds?

Nazario: The short answer to that is yes. Controlling your diabetes can fluctuate from day to day, and changes in your blood glucose control can change with activities. It is important that you continue to monitor your glucoses because this is a chronic disease, and in particular with type 2 disease the natural history shows that many medications will fail with time and/or the small amount of insulin you produce will become less and less with time.

In patients with type 1 diabetes, it is critically important to check blood sugars, because changes in your carbohydrate intake and activities will dictate what your total daily insulin dose is.

Member question: I'm frustrated because no matter what I eat my blood sugars spike to 300+ after eating. I'm noninsulin dependent type 2 and take medication twice a day. What can I do to control these blood sugar spikes after eating?

Nazario: After eating, in particular in type 2 diabetes, it is very common to see abnormally elevated sugars. It's also critically important to get those sugars under control. More and more evidence is pointing toward the importance of controlling postprandial sugars to reduce the risk of cardiovascular disease.

I think one of the recommendations I would make is to truly be aware of the amount of carbohydrates that are consumed per meal to make sure that when you are checking these sugars, that you're not checking a sugar immediately after eating; we know those sugars are going to be abnormal. The recommendations are to check sugars one to two hours after a meal.

It may be that, not knowing what medication you're on, either the medications are not targeting this particular timing of the day; it may be that these medications no longer function in you; it may be that you need to adjust your intake of carbohydrates per meal; or it may mean that you need to take insulin with your meals. Whatever the case is, if you are consistently seeing high sugars after a meal, this is truly the cause for concern.

So check your sugars one to two hours after, learn to calculate the consumption of carbohydrates per meal, and work with your diabetes health care team to get those closer to what the target goals should be, which is less than 180 milligrams per mg/dl.

Member question: Does it matter how often you test in a day? My doctor said to test in the morning and my blood sugar should be under 125. My husband's endocrinologist says his should be under 150.

Nazario: It is important that you check your sugars frequently. It really depends on the type of therapy that you take. The recommendations are that you check not only your fasting sugars, but that you check sugars one to two hours after eating. This, of course, is critical in patients who take insulin. It's probably less stringent of a guideline for patients who have type 2 diabetes and are taking oral medications.

The more frequently you check your blood sugars the better it reflects what goes on in a 24-hour period. In other words, one or two sugars checked a day unrealistically represents what happens in sugar fluctuations throughout a 24-hour period as we eat, we digest, and we have activity levels. So all of these things play a role in whether your sugars go up or down. Of course hormonally there are changes that can occur as well.

The bottom line is the more sugar checks you do the closer you get to really reflecting what's going on with your blood sugars over a 24-hour period. So why is that important? That's important because if indeed you have pretty normal control of your blood sugars the less you risk getting the complications of diabetes.

Member question: Does the blood sample have to come from a finger prick?

Nazario: No, not necessarily. We're all aware of the glucose watch. This mistakenly is thought to check blood sugars. In reality, it actually checks sugars in the fluids of the skin. Now, those sugars do come from your blood and go to the skin and then are detected by the watch. This is one example where your finger stick is not necessary.

There are other things also on the horizon, which are at this point in the lab and seen as nice alternatives to the finger stick. One is an ear thermometer-like monitor. I don't exactly understand scientifically how this works, but it basically reflects waves in the ear, and that determines or reflects what your blood sugar is.

You can also check sites other than the finger, like the forearm. They all tend to be less accurate and less reflective of what the actual blood sugar is.

Thus far, the recommendations are that all of these other ways of monitoring should not replace the standard blood glucose monitoring method.

Member question: Would you recommend pump therapy for type 2 diabetes when the post-prandial sugars remain out of control and they're having serious problems with control?

Nazario: This is going to be strictly my opinion, not a guideline. My opinion is assuming that the individual who has postprandial elevations in sugars has worked with a health care team and looked at all the factors that potentially could be the cause of the elevated sugars. With that in mind I would say yes, I'd try pump therapy.

Having said that, there are no studies that have shown ultimately that pump therapy would be superior if an individual is being treated intensely with multiple shots of insulin, is following strict nutritional guidelines, is participating in exercise, and doing everything they're supposed to do. Now, is it more convenient? I believe so. But again, this is my opinion.

Member question: You talk about testing dictating total insulin intake -- but my doctor has me on a fixed schedule: Lantus, 30 units at nights and NovoLog, 16/20/18 with breakfast/lunch/dinner. If I don't eat, I don't take the NovoLog, but that's it. He won't discuss any other options. I admit he brought me from 8.0 on pills to 6.4 with insulin, which he gradually increased to the levels mentioned. But I'm not comfortable with the rigid rules. Because I know there is no snack, ever, I eat more at each meal. And I've gained 40 pounds since May; this after having lost 26 in about six months attempting to stay off insulin. Are there alternatives, and how do I find out about them if he won't refer me to a place to learn?

Nazario: There are always alternatives. It sounds like your doctor might be trying to work out a plan that is best for you, but it almost appears he's looking at getting numbers in order and forgetting this patient, or person, behind that diabetes, and that being on insulin is a chronic lifelong illness.

Living with these strict guidelines and having to regiment your life has got to be exhaustive. Your doctor should be working with a diabetic health care team. Part of that team should be a nutritionist and a dietician, aside from other members of the team. It would be best to discuss with him the possibility of going on a more practical regimen.

Member question: Hi, doctor I've been diagnosed with GDM. I've been on a diet now for just over a week with daily monitoring. A few times I've taken multiple readings at one time, which have been up to 30 "points" different. Is this normal?

Nazario: The meters can have a 5% variability, meaning if you check your sugar and it's 120 and you check it again, the difference between the two could be 5%. So if you check your sugar and it's 120, say, as an example, then you recheck it again immediately after that 120 the difference should only be a 5% difference, either 5% higher or 5% lower than 120, which would be a range of 114 to 126. That would be an acceptable range.

A 30-point difference seems a bit much, but I don't know what your original blood sugar was. Try recalibrating your meter and make sure that you have a good drop of blood when you first do your finger stick check.

Member question: I take 240 units of Humalog, 150 units of Lantus at bedtime, plus oral meds. What else can I do to better control my sugars? I am eating the best I've eaten in years, and have lost a lot of weight.

Nazario: If you're doing an appropriate diet (appropriate meaning caloric restriction and a balanced diet) and you're doing exercise, that should help fight some of the insulin resistance. If you diminish the resistance your body has toward insulin then your doses of insulin at bedtime should also, with time, diminish.

I would look at your diet and exercise and also look at the medications you're taking. Many of the medications help sensitize you to insulin. If you've lost weight you're going in the right direction, but you have to continue to get to as close to an ideal body weight.

Member question: If someone is insulin dependent, when is the best time to check blood sugar?

Nazario: The recommendations are to check your sugars fasting and after your meals. Hemoglobin A1C should be less than 7%, pre-prandial should be 90 to 130, and your postprandials should be less than 180. Again, if you're on insulin therapy the more you check your sugars and act on those numbers to get to target range the more you diminish your risk of developing complications.

Of course, aside from those guidelines, if you're symptomatic with either symptoms of high sugar or low sugar, increased thirst or urination, or loss of concentration, those are other opportunities where you should check your blood sugars.

Member question: Would you recommend supplements such as chromium to help control blood sugar?

Nazario: I never recommend anything that's not regulated, that we don't have concrete studies on as far as safety goes. I know there are anecdotal reports of chromium leading to weight loss and improvements in blood sugars. But this is not a regulated substance; there are no controls of how these supplements are made, their ingredients, and if there are any safety studies on these they're small studies rather than large national studies having to pass vigorous FDA standards. So I try not to recommend supplement therapy.

When there are hard facts out there as to what works, I go with the hard facts. We know that an appropriate diet and exercise works (I know you're sick of hearing this). The real issue is sitting and helping patients understand what an appropriate diet is. Dietary recommendations are extremely difficult; many doctors have difficulty understanding them, and basically just tell patients you're go-to-go on a diet without taking them that one step further. So in order to improve the care of a diabetic patient I think it's very important to involve them and to teach them about nutrition.

I think the exercise part is the easy part; the guideline part is the easy part. The nutritional guidelines is what patients can really manipulate, and if you can sit and really teach and reiterate food consumption, calories, portion size, and content, patients with diabetes, whether it's type 1 or type 2, will be a lot more successful at controlling their disease and reducing their complications in the future.

Member question: Why do different brands of meters give different reading with same location blood sample?

Nazario: This is one of those "it simply is" situations. I think many people have the impression that the art of medicine is a perfect science, and it is not. Just like vehicles can vary in the amount of mileage you get per gallon of gas, meters work differently from one to the next. They can vary from the sensitivity of their strips to how old they are or the length of their shelf life to the solutions they use for calibrating them. The meters are not an exact science and they can vary from one meter to the next.

Member question: I have type 2 diabetes and take Glucophage and Acupril, but I still get some numbness in my arms and legs mainly when I sit and rest or sleep. Anything I can do to improve my circulation?

Nazario: Being a type 2 diabetic, improving your glucose control may improve the symptoms of numbness that you're experiencing in your hands and your feet. What you may be experiencing is not poor circulation but one of the common and one of the most disabling complications of diabetes: nerve damage, or neuropathy. In type 2 diabetes nerve damage many times precedes the diagnosis of elevated sugars and diabetes.

The goal should be for you to improve your sugars, and you may need to be on one of the medications that are used to treat nerve damage. The important thing is to make sure that your physician has done the good assessment and evaluated the nerves of your feet and hands, as well as your pulses in order to determine whether this is poor circulation or whether this is nerve damage or neuropathy. The treatments for the two are very different. So your doctor should:

  • Check your feet (of course without your shoes and socks on)
  • Check the temperature
  • Check the skin for discoloration
  • Check to make sure you have normal hair follicles on the skin of your feet
  • Check reflexes
  • Check whether you sense vibration and pin pricking

A good physical examination, as well as detailed information you can give your doctor, will help determine which is happening to you. You need to show him where the distribution of the numbness is and whether this is burning type pain, pinpricking type pain, or numbness. You have to give him the characteristics of what's happening in order for him to come to a diagnosis and then treatment.

Member question: Is there any PC software that could help us keep track of blood sugars?

Nazario: Yes and no. In the doctor setting there's actually something called the CGMS: continuous glucose monitoring system. This is almost like a small pump that you place on you and you wear for three days. This device will continuously check your sugar for a 24-hour period for three days. You down load this information onto the doctor's computer screen and you will see what's been going on with your sugar fluctuations almost on a minute-to-minute basis over the last three days.

That's not available for patients on a daily basis; this is something a doctor will do to evaluate a patient's blood sugar much more intensively than we're able to achieve with having the patient finger stick three or four or five times a day.

Member question: I check blood sugars before each meal and at night. You say check them to help control them. So what do I do if the pre-meal reading is high? Is this just a warning to behave better the next time around, or would I normally be adjusting the amount of insulin to inject?

Nazario: It really depends on what medications you're on. If your pre-meal/fasting sugars are continuously above the guidelines, which is 90 to 130, and if you're on insulin it could be a few things: Your insulin didn't last throughout the night or your insulin really dropped your sugar at night and you became hypoglycemic and the high sugars are a fighting response of your body to the low sugars.

If you're a type 2 diabetic it could certainly be the type of medication you're taking; either it's not a 24-hour tablet or it doesn't typically control what goes on in a type 2 diabetic at nighttime. At night your liver should slowly release sugars. In people with type 2 diabetes this tends to be an exaggerated response. Many times we will see an elevated fasting blood glucose. In cases like this there are medications targeting the liver, stopping the liver from secreting sugars at night. Metformin is a class of drugs that does this.

In either a type 1 or type 2, an elevated fasting can also be that bedtime snack that we sometimes recommend.

So every case is very different. I think we would need to know more about your particular case to answer your question more specifically. Are you a type 1 or type 2? What medications are you on? Do you take a bedtime snack, and are you talking about fasting sugars that are elevated or all of your pre-meal sugars before lunch and before dinner?

Moderator: And you can provide that information to Dr. Nazario on her message board here at WebMD for a more targeted answer. We also have a diabetes support board and dozens of message boards on many other health topics. Be sure to check them out. You'll be welcomed warmly!

Our thanks to WebMD's own diabetes expert, Brunilda Nazario, MD, for sharing her expertise. For more information, pick up a copy of The Diabetes Sourcebook, by our Take Charge of Your Diabetes WebMD University course leader, Richard Guthrie, MD.



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