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.

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.

Understanding Your Average Blood Sugar :: Diabetes Education Online

Glysolated Hemoglobin (or A1c) is a measure of your average blood glucose control over the previous three months.

Glucose attaches to hemoglobin the oxygen carrying molecule in red blood cells. The glucose-hemoglobin unit is called glycosolated hemoglobin. As red blood cells live an average of three months, the glycosolated hemoglobin reflects the sugar exposure to the cells over that time.

The higher the amount of glucose in the blood, the higher the percentage of hemoglobin molecules that will have glucose attached. Think of the A1c as a long-term blood glucose measure that changes very gradually as red blood cells die and are replaced by new cells.

The A1c is not used to diagnose diabetes and it doesn’t replace self blood-glucose monitoring. Because the A1c is an average of all your blood sugars, it does not tell you your blood sugar patterns. For example, one person with frequent highs and lows can have the same A1c as another person with very stable blood sugars that don’t vary too much.

So what’s the point?

A1c is yet another indicator of how well you’re doing.

• An A1c measurement between 4-6% is considered the range that someone without diabetes will have.
• The American Diabetes Association goal is an A1c less than 7%. Research has shown that an A1c less than 7% lowers risk for complications.
• The American College of Endocrinology goal is an A1c less than 6.5%.
• For some people with diabetes an A1c goal of less than 6% is appropriate.
• Talk with your doctor about your A1c goal.

Use this chart to view A1c values and comparable blood glucose values:

A note of caution: the A1c measurement is not always accurate. For example, if someone has certain type of hemoglobin mutations (variation in the hemoglobin structure), is severely anemic (low red blood cell count), or is being treated blood transfusions or medications to increase the production of new red blood cells, the A1c test may not be accurate.

If your finger-stick blood tests give an average blood sugar that is much higher or lower than your A1c test, ask your doctor if the A1c is the right test for you. An alternative test to the A1c is a fructosamine test. Unfortunately, the fructosamine test and the A1c are not interchangeable because they are measuring different things. The fructosamine test reflects the average blood sugars only over a 2-3 week period.

Self-assessment Quiz

Self assessment quizzes are available for topics covered in this website. To find out how much you have learned about  Monitoring Your Diabetes, take our self assessment quiz when you have completed this section.  The quiz is multiple choice. Please choose the single best answer to each question. At the end of the quiz, your score will display. If your score is over 70% correct, you are doing very well. If your score is less than 70%, you can return to this section and review the information.

Continuous Glucose Monitoring in Type 2 Diabetes Is Not Ready for Widespread Adoption – Editorials

SANDY L. ROBERTSON, PharmD, Atrium Health, Concord, North Carolina

ALLEN F. SHAUGHNESSY, PharmD, MMedEd, Tufts University School of Medicine, Malden, Massachusetts

DAVID C. SLAWSON, MD, Atrium Health, Charlotte, North Carolina

Am Fam Physician. 2020 Jun 1;101(11):646.

There is great interest in technology to improve health; however, new devices do not always live up to the hype. Although continuous glucose monitoring may benefit patients with type 1 diabetes mellitus, there is limited evidence that it offers similar benefits in patients with type 2 diabetes, regardless of whether they are taking insulin.

Rather than directly measuring blood glucose levels, continuous glucose monitoring devices track levels indirectly by measuring interstitial fluid glucose levels via a subcutaneous sensor attached to an external transmitter located on the upper arm or abdomen. Some monitors communicate continually with a receiver such as a smartphone and will send alerts for hyperglycemia or hypoglycemia. Flash glucose monitoring devices (e.g., Freestyle Libre) do not notify patients but transmit data when the receiver is in close proximity to the transmitter.1

Continuous glucose monitoring can alert patients with type 2 diabetes that they are becoming hypoglycemic, especially those using insulin who are at risk of severe hypoglycemia requiring urgent medical care. Although three studies have shown fewer episodes of hypoglycemia with continuous glucose monitoring, the ability to decrease the risk of severe hypoglycemia has not been demonstrated.2–4

No long-term studies have been performed to determine whether continuous glucose monitoring improves patient-oriented outcomes in type 2 diabetes. Compared with finger-stick monitoring, continuous glucose monitoring has not been shown to improve AlC levels after six months in patients receiving multiple daily insulin injections (7.7% vs. 8.0% in one study and 8.4% vs. 8.3% in another study).2,3 In a randomized study of 158 patients, there was no difference in overall or diabetes-specific quality of life at six months between patients using continuous glucose monitoring and those who were self-monitoring.3

The cost of continuous glucose monitoring ranges from $2,500 to $6,000 per year. A flash reading device costs approximately $100, with replaceable sensors costing another $120 to $200 monthly.5 Other devices cost $1,000 to $1,400, with replaceable sensors costing an additional $35 to $100 every seven to 10 days. Yearly battery replacement costs about $500.6 The cost-effectiveness of continuous glucose monitoring in patients with type 2 diabetes has not been studied. Currently, Medicare pays for continuous glucose monitoring only in patients receiving insulin via a pump or multiple daily injections who require four or more daily finger-stick glucose measurements.7 Insurance companies, if they provide coverage, may require a letter of medical necessity and possibly additional documentation.

Continuous glucose monitoring has a few potential advantages. The ability to get in-the-moment glucose readings without a finger stick may be appealing to patients. Physicians may appreciate the longitudinal data on blood glucose excursions that the devices offer. However, as with other technology introduced into health care, the promise that more data will lead to better patient outcomes has not yet been realized. Most people with type 2 diabetes do not require self-monitoring of blood glucose, and unnecessary monitoring not only wastes money but can negatively impact quality of life.8 Until we have research supporting continuous glucose monitoring for patients with type 2 diabetes, especially those not receiving regular insulin injections, there are no patient-oriented benefits to justify its great expense and additional hassles for patients and physicians.

Editor’s Note: Dr. Shaughnessy is an assistant medical editor for AFP.

Type 2 diabetes mellitus in adults – Monitoring

Optimal diabetes care requires a long-term relationship with the patient, appropriate use of consultants when needed, and regular monitoring and control of blood pressure, HbA1c, tobacco use, and statin/aspirin use. Most patients require diabetes assessments every 3 to 4 months, and some patients may benefit from more frequent (monthly) visits, especially when motivated to improve their care. Use of diabetes educators is recommended, although traditional information-based diabetes patient education mandated by some professional organizations is only moderately effective in randomized studies.[208]Norris SL, Nichols PJ, Caspersen CJ, et al. Increasing diabetes self-management education in community settings: a systematic review. Am J Prev Med. 2002 May;22(suppl 4):39-66.
http://www.ncbi.nlm.nih.gov/pubmed/11985934?tool=bestpractice.com
[209]Powers MA, Bardsley J, Cypress M, et al. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Care. 2015 Jul;38(7):1372-82.
https://care.diabetesjournals.org/content/38/7/1372.long

http://www.ncbi.nlm.nih.gov/pubmed/26048904?tool=bestpractice.com
A multidisciplinary team with access to nurses, educators, dietitians, clinical pharmacists, psychologists, and other specialists as needed is recommended. Patient readiness to change is a strong predictor of improved care, and readiness to change may vary across the clinical domains of blood pressure, statin use, aspirin use, glucose, smoking, physical activity, and nutrition. Rapid assessment of readiness to change, and directing care to the domain with maximum potential to change, is advised.[210]Prochaska JO, Velicer WF, Rossi JS, et al. Stages of change and decisional balance for 12 problem behaviors. Health Psychol. 1994 Jan;13(1):39-46.
http://www.ncbi.nlm.nih.gov/pubmed/8168470?tool=bestpractice.com

Self-management by regular blood glucose monitoring is not routinely recommended in patients with type 2 diabetes, because it does not significantly improve glycemic control, health-related quality of life, or hypoglycemia rates.[211]Young LA, Buse JB, Weaver MA, et al; Monitor Trial Group. Glucose self-monitoring in non-insulin-treated patients with type 2 diabetes in primary care settings: a randomized trial. JAMA Intern Med. 2017 Jul 1;177(7):920-9.
http://www.ncbi.nlm.nih.gov/pubmed/28600913?tool=bestpractice.com
[212]National Institute for Health and Care Excellence. Type 2 diabetes in adults: management. Dec 2020 [internet publication].
https://www.nice.org.uk/guidance/ng28
[Evidence C]b4311e29-592d-4616-87d1-c2ca310323c9guidelineCWhat are the effects of self-management by regular blood glucose monitoring in people with type 2 diabetes?[212]National Institute for Health and Care Excellence. Type 2 diabetes in adults: management. Dec 2020 [internet publication].
https://www.nice.org.uk/guidance/ng28
However, self-monitoring of blood glucose is recommended for those who (a) are on insulin; (b) have had prior hypoglycemic episodes; (c) drive or operate machinery and use oral medications that increase his or her risk of hypoglycemia; or (d) are pregnant, or planning to become pregnant.[212]National Institute for Health and Care Excellence. Type 2 diabetes in adults: management. Dec 2020 [internet publication].
https://www.nice.org.uk/guidance/ng28
Continuous glucose monitoring may be helpful in people with type 2 diabetes (particularly those on insulin therapy) to create a more complete picture of patients’ actual glucose status throughout the day and night.[2]American Diabetes Association. Standards of medical care in diabetes – 2021. Diabetes Care. Jan 2021;44(suppl 1):S1-232.
https://care.diabetesjournals.org/content/44/Supplement_1
[213]Carlson AL, Mullen DM, Bergenstal RM. Clinical use of continuous glucose monitoring in adults with type 2 diabetes. Diabetes Technol Ther. 2017 May;19(s2):S4-11.
https://www.liebertpub.com/doi/10.1089/dia.2017.0024?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed

http://www.ncbi.nlm.nih.gov/pubmed/28541137?tool=bestpractice.com
[214]Johnson ML, Martens TW, Criego AB, et al. Utilizing the ambulatory glucose profile to standardize and implement continuous glucose monitoring in clinical practice. Diabetes Technol Ther. 2019 Jun;21(s2):S217-25.
https://www.liebertpub.com/doi/10.1089/dia.2019.0034?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

http://www.ncbi.nlm.nih.gov/pubmed/31169432?tool=bestpractice.com
The data form an ambulatory glucose profile showing time in range and times of hypoglycemia, which can be used for personalized therapy decisions.[215]Carlson AL, Criego AB, Martens TW, et al. HbA1c: the glucose management indicator, time in range, and standardization of continuous glucose monitoring reports in clinical practice. Endocrinol Metab Clin North Am. 2020 Mar;49(1):95-107.
http://www.ncbi.nlm.nih.gov/pubmed/31980124?tool=bestpractice.com

In addition to care required to achieve recommended levels of blood pressure, statin use, aspirin use, tobacco non-use, and glucose control, the following periodic monitoring for complications is advised:

• Dilated eye exam every 1 to 2 years

• Annual assessment of renal function including both a urinary albumin excretion test and a serum creatinine test with estimated glomerular filtration rate (eGFR) based on the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation or equivalent

• Annually or more frequent foot exams including assessment of ankle reflexes, dorsalis pedis pulse, vibratory sensation, and 10-gram monofilament touch sensation. All patients with insensate feet, foot deformities, or a history of foot ulcers should have their feet examined at every visit and are candidates for specialized footwear.[2]American Diabetes Association. Standards of medical care in diabetes – 2021. Diabetes Care. Jan 2021;44(suppl 1):S1-232.
  https://care.diabetesjournals.org/content/44/Supplement_1

Due to disease progression, comorbidities, and nonadherence to lifestyle or medication, a substantial fraction of patients who achieve recommended goals for HbA1c, blood pressure, and lipid management relapse to uncontrolled states of one or more of these within 1 year. Relapse is usually asymptomatic; frequent monitoring of clinical parameters is desirable to anticipate or detect relapse early and adjust therapy.

Factors that may lead to loss of adequate glycemic control include medication nonadherence, depression, musculoskeletal injury or worsening arthritis, competing illnesses perceived by the patient as more serious than diabetes, social stress at home or at work, substance abuse, occult infections, use of medications (such as corticosteroids, certain depression medications [paroxetine], mood stabilizers, or atypical antipsychotics) that elevate weight or glucose, or other endocrinopathies such as Cushing disease.

Loss of control of blood pressure and lipids is also a common phenomenon. Close monitoring of patients with diabetes through frequent visits and lab work helps to maintain patients at treatment goals and proactively identify upward trends in blood pressure or HbA1c, and to reinforce the importance of statin adherence and nonsmoking.

Primary care docs need to prepare for CGMs for type 2 diabetes

In the last year, Jai Smith has cycled through 13 primary care doctors. Ever since being diagnosed with type 2 diabetes in 1995, she’s tried her best to manage a disease that has devastated her family: Her grandmother and four uncles died from its complications.

But she’s struggled to find a doctor in her hometown of Little Rock, Ark., who will give her what she wants to manage the condition: a continuous glucose monitor. Like many patients with diabetes, Smith uses fingerprick glucose tests to help dose her medications. The 44-year-old was immediately interested when she heard about CGM, which uses an embedded sensor to collect a proxy for blood glucose around the clock.

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‘Painless’ Glucose Monitors Pushed Despite Little Evidence They Help Most Diabetes Patients

In the nation’s battle against the diabetes epidemic, the go-to weapon being aggressively promoted to patients is as small as a quarter and worn on the belly or arm.

A continuous glucose monitor holds a tiny sensor that’s inserted just under the skin, alleviating the need for patients to prick their fingers every day to check blood sugar. The monitor tracks glucose levels all the time, sends readings to patients’ cellphone and doctor, and alerts patients when readings are headed too high or too low.

Nearly 2 million people with diabetes wear the monitors today, twice the number in 2019, according to the investment firm Baird.

There’s little evidence continuous glucose monitoring (CGM) leads to better outcomes for most people with diabetes — the estimated 25 million U.S. patients with Type 2 disease who don’t inject insulin to regulate their blood sugar, health experts say. Still, manufacturers, as well as some physicians and insurers, say the devices help patients control their diabetes by providing near-instant feedback to change diet and exercise compared with once-a-day fingerstick tests. And they say that can reduce costly complications of the disease, such as heart attacks and strokes.

Continuous glucose monitors are not cost-effective for Type 2 diabetes patients who do not use insulin, said Dr. Silvio Inzucchi, director of the Yale Diabetes Center.

Sure, it’s easier to pop a device onto the arm once every two weeks than do multiple finger sticks, which cost less than a $1 a day, he said. But “the price point for these devices is not justifiable for routine use for the average person with Type 2 diabetes.”

Without insurance, the annual cost of using a continuous glucose monitor ranges from nearly $1,000 to $3,000.

Lower Prices Help Propel Use

People with Type I diabetes — who make no insulin — need the frequent data from the monitors in order to inject the proper dose of a synthetic version of the hormone, via a pump or syringe. Because insulin injections can cause life-threatening drops in their blood sugar, the devices also provide a warning to patients when this is happening, particularly helpful while sleeping.

People with Type 2 diabetes, a different disease, do make insulin to control the upswings after eating, but their bodies don’t respond as vigorously as people without the disease. About 20% of Type 2 patients still inject insulin because their bodies don’t make enough and oral medications can’t control their diabetes.

Doctors often recommend that diabetes patients test their glucose at home to track whether they are reaching treatment goals and learn how medications, diet, exercise and stress affect blood sugar levels.

The crucial blood test doctors use, however, to monitor diabetes for people with Type 2 disease is called hemoglobin A1c, which measures average blood glucose levels over long periods of time. Neither finger-prick tests nor glucose monitors look at A1c. They can’t since this test involves a larger amount of blood and must be done in a lab.

The continuous glucose monitors also don’t assess blood glucose. Instead they measure the interstitial glucose level, which is the sugar level found in the fluid between the cells.

Companies seem determined to sell the monitors to people with Type 2 diabetes — those who inject insulin and those who don’t — because it’s a market of more than 30 million people. In contrast, about 1.6 million people have Type 1 diabetes.

Helping to fuel the uptake in demand for the monitors has been a drop in prices. The Abbott FreeStyle Libre, one of the leading and lowest-priced brands, costs $70 for the device and about $75 a month for sensors, which must be replaced every two weeks.

Another factor has been the expansion in insurance coverage.

Nearly all insurers cover continuous glucose monitors for people with Type 1 diabetes, for whom it’s a proven lifesaver. Today, nearly half of people with Type 1 diabetes use a monitor, according to Baird.

A small but growing number of insurers are beginning to cover the device for some Type 2 patients who don’t use insulin, including UnitedHealthcare and Maryland-based CareFirst BlueCross BlueShield. These insurers say they have seen initial success among members using the monitors along with health coaches to help keep their diabetes under control.

The few studies — mostly small and paid for by device-makers — examining the impact of the monitors on patient’s health show conflicting results in lowering hemoglobin A1c.

Still, Inzucchi said, the monitors have helped some of his patients who don’t require insulin — and don’t like to prick their fingers — change their diets and lower their glucose levels. Doctors said they’ve seen no proof that the readings get patients to make lasting changes in their diet and exercise routines. They said many patients who don’t use insulin may be better off taking a diabetes education class, joining a gym or seeing a nutritionist.

“I don’t see the extra value with CGM in this population with current evidence we have,” said Dr. Katrina Donahue, director of research at the University of North Carolina Department of Family Medicine. “I’m not sure if more technology is the right answer for most patients.”

Donahue was co-author of a landmark 2017 study in JAMA Internal Medicine that showed no benefit to lowering hemoglobin A1c after one year regularly checking glucose levels through finger-stick testing for people with Type 2 diabetes.

She presumes the measurements did little to change patients’ eating and exercise habits over the long term — which is probably also true of continuous glucose monitors.

“We need to be judicious how we use CGM,” said Veronica Brady, a certified diabetes educator at the University of Texas Health Science Center and spokesperson for the Association of Diabetes Care & Education Specialists. The monitors make sense if used for a few weeks when people are changing medications that can affect their blood sugar levels, she said, or for people who don’t have the dexterity to do finger-stick tests.

Yet, some patients like Trevis Hall credit the monitors for helping them get their disease under control.

Trevis Hall’s insurer gave him a monitor last year at no cost as part of a program to help control his diabetes. He says it doesn’t hurt when he attaches the monitor to his belly twice a month.(Lynne Shallcross / KHN)

Last year, Hall’s health plan, UnitedHealthcare, gave him a monitor at no cost as part of a program to help control his diabetes. He said it doesn’t hurt when he attaches the monitor to his belly twice a month.

The data showed Hall, 53, of Fort Washington, Maryland, that his glucose was reaching dangerous levels several times a day. “It was alarming at first,” he said of the alerts the device would send to his phone.

Over months, the readings helped him change his diet and exercise routine to avert those spikes and bring the disease under control. These days, that means taking a brisk walk after a meal or having a vegetable with dinner.

“It’s made a big difference in my health,” said Hall.

This Market ‘Is Going to Explode’

Makers of the devices increasingly promote them as a way to motivate healthier eating and exercise.

The manufacturers spend millions of dollars pushing doctors to prescribe continuous glucose monitors, and they’re advertising directly to patients on the internet and in TV ads, including a spot starring singer Nick Jonas during this year’s Super Bowl.

Kevin Sayer, CEO of Dexcom, one of the leading makers of the monitors, told analysts last year that the noninsulin Type 2 market is the future. “I’m frequently told by our team that, when this market goes, it is going to explode. It’s not going to be small, and it’s not going to be slow,” he said.

“I believe, personally, at the right price with the right solution, patients will use it all the time,” he added.

Phil Galewitz:
[email protected],
@philgalewitz

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Blood Glucose Monitoring in Patients With Type 2 Diabetes

Type 2 diabetes mellitus (T2DM) is an extremely common problem in the United States and around the world. It is estimated that by the year 2030, there will be approximately 366 million individuals with diabetes.¹ This article will provide an overview of T2DM; discuss the current glycemic and self-monitoring blood glucose (SMBG) recommendations; discuss the effectiveness of and the adherence to SMBG regimens; and discuss a recently proven, relatively simple SMBG method that was shown to improve the level of glycemic control in patients with T2DM.

Overview of T2DM

The occurrence of T2DM has reached epidemic proportions. As the incidence increases, so do the health care costs associated with the management of T2DM and its complications. The most recent estimates claim that more than 23 million adults and children in the U.S. are presently diagnosed with diabetes.² This figure will be driven upward in the future due to the fact that 1.6 million new cases of diabetes are diagnosed annually in Americans aged 20 years or older. Approximately 6 million Americans currently have T2DM but have not been diagnosed.² These large-scale missed diagnoses will ultimately generate a great deal of morbidity and mortality secondary to the unrecognized and unmanaged hyperglycemia. In the past, T2DM was considered a disease of adults. In fact, one of the diagnostic clues was the age of onset, and the condition itself was called adult onset diabetes mellitus. The past two decades have witnessed a dramatic shift in this historic pattern because young adults and children are now frequently being diagnosed with T2DM. This trend is expected to continue, and an American Academy of Pediatrics committee anticipates that the prevalence of T2DM among American children will, for the first time in history, exceed that of T1DM in the next few years.³

Several landmark trials have demonstrated the importance of strict glycemic control in patients with T2DM. These studies have shaped the guidelines that are presented in the next section. Strict glycemic control (as well as control of lipids and blood pressure) correlates with a reduction in diabetes-related complications.

It is clear that the negative metabolic/physiologic effects of chronic, prolonged hyperglycemia are grave. The sixth leading cause of death in the U.S. is diabetes.⁴ Microvascular disease includes retinopathy and nephropathy, while peripheral arterial disease (PAD), cerebrovascular disease, and cardiovascular disease fall under the rubric of macrovascular disease.⁵ The vast majority of patients (80%) with diabetes die secondary to heart disease.⁴ Rates of heart disease-related death in adult patients with T2DM are two to four times greater than in similar individuals without diabetes.⁴ It is estimated that 60% to 70% of patients with diabetes have some form of neuropathy.⁴ Diabetes is the leading cause of nontraumatic lower limb amputation in the U.S., due to the impact of PAD and neuropathy. The number-one cause of renal failure in the U.S. is diabetes. Lastly, the most common etiology of new-onset blindness in working-aged Americans is diabetes.

Glycemic Goals and Monitoring

Unfortunately, there is not universal consensus regarding the glycemic goals and SMBG use and methods in patients with T2DM. There are, however, two widely accepted and scientifically based sets of guidelines that address these issues. One is published by the American Diabetes Association (ADA) in collaboration with the European Association for the Study of Diabetes (EASD), and the other is published by the American Association of Clinical Endocrinologists (AACE) in collaboration with the American College of Endocrinology (ACE).^5-8

The ADA/EASD suggests the following glycemic goals for patients with type 2 diabetes: glycated hemoglobin (A1C) levels of <7%, premeal glucose levels of 70 to 130 mg/dL, and postmeal levels (1-2 hours after the beginning of the meal) of less than 180 mg/dL.⁶ The AACE/ACE glycemic guidelines are slightly more strict than the ADA/EASD recommendations: A1C £6.5%, fasting plasma glucose levels of <110 mg/dL, and 2-hour postmeal glucose concentrations of <140 mg/dL.⁵

Recommendations regarding SMBG by these two collaborative sets of guidelines do offer some guidance; however, every patient is different and must have the SMBG regimen tailored to his or her specific situation. Selected AACE/ACE guidelines for glucose monitoring in patients with T2DM are shown in TABLE 1.⁵ The ADA/EASD guidelines for SMBG in patients with T2DM are less specific than the AACE/ACE guidelines, and some of the more salient recommendations from these organizations are shown in TABLE 2.⁷ The guidelines listed in these tables are purposefully vague and are intended to be applicable to multiple situations. They do not, however, offer a comprehensive method for managing and interpreting testing values.

Is SMBG Useful or Cost-Effective in T2DM?

The efficacy and cost data supporting the use of SMBG in patients with T2DM are mixed. Generally speaking, there is much less controversy regarding the utility SMBG in patients with T2DM who are using insulin. Conversely, the literature regarding the use, frequency, appropriate pattern, and cost-effectiveness of SMBG in non-insulin-treated patients is much more conflict-ridden and ambiguous. Some studies support and some do not support the use of SMBG in patients with T2DM. The more recent and salient of these studies are mentioned below.

One study in the United Kingdom evaluated 453 non-insulin-using patients with T2DM.⁹ The patients were randomized to standardized usual care without SMBG, usual care plus SMBG with advice to contact their provider for interpretation of results, or usual care plus SMBG with instruction on interpretation and application of the results to their lifestyle. At 12 months there were no statistically significant differences in A1C among the three groups. The authors concluded that the evidence was not convincing on the effect of SMBG on glycemic control with or without instructions for incorporating findings into self-care when compared to usual care without SMBG. There were, however, several limitations of the trial. The mean A1C level upon enrollment was 7.5% and, therefore, was already fairly well controlled. Additionally, it appears that the patients were instructed not to measure glucose in a systematic fashion but to choose various days of the week instead.

In another evaluation, researchers evaluated the cost-effectiveness and quality of life associated with SMBG in the population from the trial above.¹⁰ They concluded that SMBG with or without additional training in incorporating the results into self-care was associated with higher costs and lower quality of life in patients with non-insulin-treated T2DM. The same limitations that were mentioned above also apply to this trial.

Another recent trial in Ireland evaluated 184 newly diagnosed patients with diabetes over a period of 1 year.¹¹ These patients were randomized to SMBG or no SMBG and were all treated with usual care. Usual care in this study included an algorithm-driven escalation of oral agents and insulin. Baseline A1C values were 8.8% and 8.6%, respectively, in the SMBG and the no-SMBG groups. At the end of the trial, both groups had a mean A1C of 6.9%. Additionally, the patients in the SMBG groups had a 6% higher depression score (out of a 100-point scale). The investigators concluded that the addition of SMBG had no impact on glycemic control and was associated with a higher depression score in newly diagnosed patients. This study, however, was severely limited. First, all of the patients were managed very aggressively with an escalating dose/medication algorithm. Following this approach, virtually any patient could have a reduced A1C. However, using this approach without monitoring can result in more hypoglycemia and undetected or unconfirmed hypoglycemia. Based purely on self-reporting from the non-SMBG group, this did occur.

A large study of over 20,000 Kaiser Permanente Diabetes Registry patients with T2DM evaluated the correlation between SMBG frequency and A1C.¹² Patients who monitored more frequently had A1C levels that were statistically lower than those who monitored less frequently. The researchers concluded that their findings supported the clinical recommendations suggested by the ADA.

Another insightful evaluation compiled previous studies of SMBG in non-insulin-using patients with T2DM.¹³ The authors identified 97 studies on the topic. Of these, only six trials met their strict inclusion criteria and were included in the analysis. Their analysis concluded that the six randomized,  controlled trials, when combined, demonstrated a statistically significant reduction (0.39%) in patients who monitored versus patients who did not. They further commented that this was a clinically significant reduction because previous trials had demonstrated that an A1C reduction of 0.39% correlated with an approximate 14% reduction in microvascular complications.

Structured Testing

It seems clear from the discussion above that SMBG is useful in patients with T2DM regardless of whether they are treated with insulin, oral medications, or no medications. This leads us to a very interesting area of investigation. Is the pattern of testing important? Is a structured testing method more efficacious and cost-effective than the SMBG utilized in usual care situations? This would on its face seem a much more difficult proposition to prove since nonstructured monitoring in this population is associated with an A1C reduction of 0.39%, and it seems unlikely that a significant further drop in A1C would occur simply by structuring the testing. This, however, was recently proven to be so in a well-controlled trial that compared structured testing to usual testing patterns.¹⁴

This study was a 12-month, prospective, cluster-randomized trial of several hundred patients. Subjects were patients with T2DM who were insulin-naïve and were recruited and studied in 34 primary care practices across the U.S. Patients were randomized to an active control group (ACG) with enhanced usual care or to structured testing (STG) with enhanced usual care. The patients in the ACG were managed with visits at baseline, then at 1, 3, 6, 9, and 12 months that focused directly on their diabetes. They received free blood glucose meters and strips and office point-of-care A1C testing. They were instructed to use their meter following their physicians’ recommendations but did not receive any additional SMBG instruction or prompting. Patients in the STG received the same level of care but had specific direction regarding their SMBG. They were asked to use the ACCU-CHEK 360° View Blood Glucose Analysis System of testing (FIGURE 1). The patients were asked to use this pattern of testing for 3 days prior to each visit. This entailed intensive monitoring for 3 days (7 points per day) and plotting of these data along with information regarding meal size and energy level. Physicians in the STG arm were trained to use the SMBG tool and were contacted during the study to ensure consistent intervention.

At the end of the 12-month study, the STG patients who completed the trial had A1C values that were reduced by a mean of 1.3% compared to a 0.8% mean reduction in the ACG. This difference of 0.5% in the STG is clinically and statistically significant. All of the patients in the study experienced an improvement in general well-being during the trial (measured by the standardized World Health Organization [WHO]-15 assessment tool).

The reason for this significant drop in A1C levels in the STG is probably multifaceted. First, the use of this tool provided prescribers with useful metabolic information. They could detect patterns and causes for those patterns based on diet, medication, and activity level. This allowed the prescribers to make informed decisions regarding medications. In fact, patients who completed the trial in the STG had treatment changes at more clinic visits (threefold greater) than did those in the ACG. Additionally, the information from the tool was probably used by the patients to help them understand the impact of diet, exercise, and medication on their blood glucose levels as well as the relationship between energy levels and glycemic control. To put it succinctly, this tool provides and presents blood glucose data in a meaningful format as opposed to the inscrutable results in the usual paroxysmal pattern of blood glucose testing.

Finally, one concern of doing such periodic intensive testing is the cost and frequency of testing. This study revealed that there were no significant differences in SMBG frequency between the two groups. Overall, those in the ACG measured their glucose as frequently as those in the STG; however, the data from the STG were probably more clinically meaningful and allowed for adjustments in therapy. In fact, one of our greatest problems with SMBG data in patients with T2DM is that the gathered data do not demonstrate significant patterns and are often clinically meaningless.

Based on this study, the use of this system of testing would therefore not increase cost compared to routine testing. The structured pattern of testing seems to offer a very useful and effective manner of glucose testing that is cost-effective and lowers glycemic indices significantly more than conventional testing patterns.

Conclusion

SMGB is an important tool in the management of patients with T2DM. While some studies have questioned its use, particularly in non-insulin-treated patients, SMBG has been shown to be effective overall in all patients with T2DM. The question of how monitoring should be structured is probably more germane to the question of whether it should be used. A recent prospective, controlled study suggests that the use of structured testing is cost-effective and is associated with significantly greater glycemic lowering than the use of conventional testing patterns.

REFERENCES

1. Wild S, Roglic G, Green A, et al. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27:2569.

2. Centers for Disease Control and Prevention. National Diabetes Fact Sheet. 2007. www.cdc.gov/diabetes/pubs/pdf/

ndfs_2007.pdf. Accessed February 7, 2011.

3. Gahagan S, Silverstein J. Prevention and treatment of type 2 diabetes mellitus in children, with special emphasis on American Indian and Alaska Native children. American Academy of Pediatrics Committee on Native American Child Health. Pediatrics. 2003;112(4):328-347.

4. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). National Diabetes Statistics. 2007. http://diabetes.niddk.nih.gov/

dm/pubs/statistics. Accessed February 7, 2011.

5. AACE/ACE. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. Endoc Pract. 2007;13(suppl 1):1-68. www.aace.com/pub/pdf/

guidelines/DMGuidelines2007.

pdf. Accessed January 11, 2011.

6. American Diabetes Association. Clinical practice recommendations. Diabetes Care. 2011;34(1):S1-S98.

7. Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2009;32(1):193-203.

8. Rodbard HW, Jellinger PS, Davidson JA, et al. Statement by an American Association of Clinical Endocrinologists/American College of Endocrinology consensus panel on type 2 diabetes mellitus: an algorithm for glycemic control. Endocr Pract. 2009;15(6):540-559.

9. Farmer A, Wade A, Goyder E, et al. Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomized trial. BMJ. 2007;335:132-139.

10. Simon J, Gray A, Clarke P, et al. Cost effectiveness of self monitoring of blood glucose in patients with non-insulin treated type 2 diabetes: economic evaluation of data from the DiGEM trial. BMJ. 2008;336:1177-1183.

11. O’Kane MJ, Bunting B, Copeland M, et al, on behalf of the ESMON study group. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ. 2008;336:1174-1176.

12. Karter AJ, Ackerson LM, Darbinian JA, et al. Self-monitoring of blood glucose levels and glycemic control: the Northern California Kaiser Permanente Diabetes Registry. Am J Med. 2001;111:1-9.

13. Welschen LM, Bloemendal E, Nijpels G. Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin: a systematic review. Diabetes Care. 2005;28(2):1510-1517.

14. Polonsky WH, Fisher L, Schikman CH, et al. Structured self-monitoring of blood glucose significantly reduces A1C levels in poorly controlled non-insulin treated type 2 diabetes. Diabetes Care. 2011;34:262-267.

To comment on this article, contact [email protected].

^{90,000 6-day glucose monitoring}

6-day glucose monitoring

Glucose Monitoring, iPro2

The glucose level is continuously monitored using a small special device attached to the body. The diameter of the sensor is only 3.5 cm, it is fixed on the body with a special plaster. The results obtained are recorded, put into a report and analyzed by the attending physician for more effective diabetes treatment, selection and correction of therapy.

During the day, the device measures 288 times the blood glucose level, a total of 1728 times within 6 days . The conclusion on the measurements is given in the form of graphs, which can be used to track the general patterns of glucose fluctuations, diagrams of high, low and normal blood sugar during the day in percent. The graph shows food intake and fluctuations in glucose, physical activity and other indicators and fluctuations in blood glucose associated with these conditions.

The indications for 6-day glucose monitoring are wide; in many situations, this study allows the most effective diagnosis and selection of therapy, showing changes that cannot be tracked in another way.

Main readings:

1. In case of disease with type 1 diabetes mellitus for the selection of adequate doses of insulin, as close as possible to the usual daily regimen, detection of insulin overdose, detection of hypoglycemia, especially implicit, nocturnal. To compare the effectiveness of therapy when changing several schemes of insulin therapy.

2. In case of type 2 diabetes mellitus for the formation of recommendations for diet therapy and hypoglycemic drugs, comparison of several schemes.Resolving the issue of switching to insulin therapy. For detection of nocturnal, latent hypoglycemia, for physical activity or overdose of hypoglycemic drugs.

3. To clarify the debut of gestational diabetes and monitor the effect of diet or insulin therapy during pregnancy. For planning pregnancy against the background of existing type 1 and 2 diabetes mellitus.

4. To clarify the reaction to foods with different glycemic index and physical activity.To identify the individual characteristics of the absorption of carbohydrates against the background of diet therapy for diabetes or alimentary obesity.

5. With hypoglycemic states of an unspecified nature. To clarify the causes of fainting states , states of episodes of weakness and short-term loss of consciousness without previously diagnosed diabetes mellitus.

While researching:

• there is no need to change the usual way of life, you can swim and play sports.
• the patient additionally performs at least 4 finger-stick blood glucose tests daily.
• all meals and medications, as well as other significant actions and physical activity must be recorded in the log

More details about the technique in the blog of our endocrinologist http://www.mc21.ru/blogs/murzaeva/172.php

You can sign up for 6-day glucose monitoring by calling (380-02-38).

Setting up the monitor takes 30 minutes, carried out in the department at B. Sampsonievsky 45. Removing the monitor takes 5 minutes. The monitor is set for 6 days from Tuesday morning to Monday morning. The results can be obtained the next day after removing the monitor by e-mail (having previously written an application indicating the e-mail address) or in printed form from the department administrator.

FreeStyle Libre | Flash glucose monitoring system

When using the Internet resource www.freestylelibre.ru in the order of Art. 9 of the Federal Law of 27.07.2006 N 152-FZ “On Personal Data” (hereinafter – the Federal Law “On Personal Data”), the user of the www.freestylelibre.ru site gives consent to Abbott Laboratories LLC for automated processing, including, but , not limited to the transfer to third-party visitor analysis services Yandex.Metrica, Google Analytics processing of visitor data (namely cookies, IP address, page URL, page title and referrer, estimated geographic location, time zone, age, gender, version and browser language, display resolution, version of the operating system and auxiliary software, accounting for interaction with the site, device model, search engines, viewing depth, list of downloaded files, visitor interests, list of visited pages and time spent on the site).

© 2021 Abbott. The site of the official representative of the manufacturer FreeStyle Libre in Russia. Designed only for persons located on the territory of the Russian Federation. Abbott Laboratories LLC. 125171, Moscow, Leningradskoe shosse, 16A, building 1, OGRN 1077746154859. FreeStyle Libre scanner of the FreeStyle Libre Flash glucose monitoring system with accessories RU No. RZN 2018/6766 dated 11.12.2020 (issued instead of RU No. RZN 2018/6766 dated 11.03.2020 ). FreeStyle Libre sensor of the Flash glucose monitoring system FreeStyle Libre RU No. RZN 2018/6764 dated 11.12.2020 (issued instead of RU No. RZN 2018/6764 dated 12.03.2020)

© 2021 Abbott. FreeStyle, Libre and related trademarks are the property of the Abbott Company.

* It is required to determine the glucose level with a glucometer during periods of sharp fluctuations, since the level of glucose in the interstitial fluid may not accurately reflect the level of glucose in the blood, as well as in cases of hypoglycemia or its threat, and in cases where the symptoms do not correspond to the indications of the system …

** The sensor must be scanned at least once every 8 hours.

¹ FreeStyle LibreLink is only compatible with certain mobile devices and operating systems. Please check the website for device compatibility information before use. LibreView registration is required to use FreeStyle LibreLink.

90,000 Olga Fateeva, Abbott: “New technologies allow us to expand the boundaries of lifestyle”

There are 422 million patients with diabetes mellitus in the world.Two thirds of them do not control blood glucose

Olga Fateeva / Personal archive

There are 422 million people suffering from diabetes in the world, according to the World Health Organization (WHO). In Russia, according to the Ministry of Health, there are more than 4.5 million such people. There is no cure for diabetes, but controlling blood sugar levels can push the boundaries of your lifestyle and avoid complications. In recent years, a new type of continuous glucose monitoring technology – Flash Glucose Monitoring (FGM) – has been used for such monitoring abroad.It is available in a number of countries through software programs. Its use not only leads to better control of the disease, but also opens doors for people with diabetes to activities that were previously not available to them, and as a result, can even lead to changes in labor laws.

This technology is now available in Russia. Olga Fateeva, Head of the Diabetes Diagnostics Department at Abbott in Russia, the CIS and the Baltic States, spoke about how the Flash glucose monitoring technology works in an interview with Vedomosti &.

– Why should people with diabetes monitor their blood sugar?

– Patients with type 1 and 2 diabetes, if they are using insulin therapy, are forced to constantly monitor their blood glucose levels and the effect of food and exercise on it in order to calculate when and how much insulin to inject. For this, special devices are used – glucometers. The patient pierces the pad of the finger with an automatic lancet, and applies a test strip to the formed drop of blood.Then it inserts it into the device, and after a few seconds the result appears on its screen. This should be done at least several times a day, in some cases up to 12 times.

– How did the idea of ​​technology come about? How is it different from the usual one?

– The number of people suffering from diabetes is growing, this is the data of the National Medical Research Center of Endocrinology of the Ministry of Health of the Russian Federation. There are more than 4.5 million patients with diabetes in the country, including about 1 million with an insulin-dependent type, among which 40,000 patients are children and adolescents.Between 2000 and 2016, the total number of people with diabetes increased by 2.3 million. That is, this is a fairly large social group of people who are forced to constantly monitor their blood glucose levels.

People with diabetes mellitus, upon learning about their diagnosis, as a rule, become more attentive to their eating behavior, introduce physical activity into their routine, and their lifestyle improves markedly.

Type 1 diabetes is an autoimmune disease in which the beta cells of the pancreas are destroyed and the pancreas does not produce enough insulin.Its causes are not known, according to WHO.

Type 2 diabetes usually develops in the presence of obesity. The pancreas works normally, but the sensitivity of the body tissues to insulin decreases. Insulin therapy is necessary for all patients with type 1 diabetes and some people with type 2.

Diabetes cannot be called a sentence today. The technologies for daily measurement of blood glucose are being improved. Diagnostics has become more progressive and accurate: disorders of insulin production can now be detected in the early, pre-diabetic stages.By adjusting their lifestyle, members of the risk group remain healthy.

Yet studies show that less than a third of patients follow the doctor’s recommendations for blood glucose control. Two thirds of patients do not have glycemic control due to the pain and inconvenience of the procedure. In turn, test strip meters cannot solve many problems. For example, monitoring and preventing nighttime hypoglycemia (a sharp drop in sugar), building daily trends in glucose changes, and a number of other issues.The FreeStyle Libre minimally invasive glucose monitoring system developed by Abbott is the only Flash glucose monitoring technology registered in Russia, based on which users can make decisions on changing insulin dosages / adjusting therapy. Clinical studies have shown that FreeStyle Libre can successfully and safely replace blood glucose meters. FGM technology is presented in 46 countries, today it is used by more than 1 million people.

The main difference of the FreeStyle Libre Flash glucose monitoring technology is that the analysis does not use blood, but intercellular fluid – a thin layer that surrounds tissue cells under the skin.A small 3.5 cm transducer is attached to the back of the shoulder with an applicator and adhered to the skin with an adhesive base. Together with the sensor under the skin – to a depth of no more than 5 mm – a thinnest thread with an electrode is installed, which creates a current with a power of no more than 40 MV, oxidizing glucose in the intercellular fluid. The scanner reads the sensor readings, allowing you to find out your glucose level in a fraction of a second. With each measurement, it also displays the previous 8 hour glucose level and its trend.

– The readings of conventional glucometers, according to ISO standards, can deviate from laboratory values ​​by up to 15%. And what is the accuracy here?

– The FreeStyle Libre System is clinically proven to provide accurate, stable and reliable measurements over 14 days without the need for meter calibration or finger pricks. Proven measurement accuracy with a Mean Absolute Relative Difference (MARD) of 11.4% compared to blood glucose monitoring values.99.7% of glucose readings fall within Zone A or Zone B of the Parkes Consensus Error Grid, which is considered clinically accurate.

It should be borne in mind that the level of glucose in the intercellular fluid lags behind its level in the blood by 5-10 minutes. This can be important in case of severe hypoglycemia, so that in this case, the scanner advises to measure sugar additionally in the usual way. But studies show that the patient applies the scanner to the sensor 15 times a day or more, in this case he has time to notice the approach of hypoglycemia in advance.

– How much information can be stored on the scanner? How is it handled?

– The scanner stores 90 days of data. The measurement results are converted into reports that can be viewed directly on the scanner or downloaded to a computer by connecting the scanner to it via a USB cable. The reports show daily changes in sugar, average glucose for 7-14-30-90 days, cases of hypoglycemia, as well as time in the target range – the limits of blood sugar norms, which, according to the recommendations of the attending physician, are set by the patient in the device settings.These reports can be stored in a special program that can be downloaded for free from the official website.

– In Russia, the state provides people with diabetes with glucometers and partly with test strips. In which countries do patients receive FGM systems free of charge?

– In a number of countries, technology is available to people with the support of software: for example, in France, Germany, Czech Republic, Argentina. There are countries where more than half of insulin-dependent patients with type 1 and 2 diabetes use a Flash monitoring system on a daily basis.

Moreover, the use of the Flash-monitoring system now leads to a discussion of the issue of changing labor legislation in some European countries: in the future, to allow people with type 1 diabetes mellitus to work in professions that were previously unavailable for them for medical reasons, for example become a pilot. For other people with diabetes, Flash monitoring also allows them to visit the clinic less often: the patient can simply send reports about his condition to the doctor. Technology is constantly evolving, and perhaps soon the doctor will be able to monitor the change in the patient’s blood glucose on his computer and make recommendations in real time.

Experience of using continuous glucose monitoring in the treatment of diabetes mellitus in children and adolescents of the Omsk region Text of a scientific article in the specialty “Health Sciences”

ORIGINAL ARTICLES ■

O.A. Prikhodina, L.A. Aleksyushina, O. Yu. Sinevich, S.V. Surikova, T. Ya. Prikhodina

Regional Children’s Clinical Hospital,

m.Omsk

EXPERIENCE IN APPLICATION OF CONTINUOUS GLUCOSE MONITORING IN TREATMENT OF DIABETES MELLITUS IN CHILDREN AND ADOLESCENTS OF THE OMSK REGION

After using continuous daily glucose monitoring (CGMS) in 28 children and adolescents with type 1 diabetes mellitus, 50% with HbAlc> 7.5% had an insufficient dose of long-acting insulin. In 18% of patients in the younger age group, recurrent nocturnal hypoglycemia was recorded.Correction of the insulin dose during the study significantly improves the average blood glucose level, allows patients to achieve psychological readiness to adjust the insulin dose. 3 months after the end of CGMS, there was a significant decrease in the level of HbAlc from 9.3% to 8.2%. CGMS provides a more complete picture of the state of carbohydrate metabolism, in comparison with the determination of glycated hemoglobin and self-monitoring data using a glucometer; allows you to record in detail fluctuations in glycemia during the day.

Keywords: children, type 1 diabetes mellitus, continuous daily glucose monitoring (CGMS), treatment.

After trying on a continuous glucose monitoring system (CGMS), on 28 children with the type 1 diabetes mellitus, 50% children with HbAlc> 7.5% an insufficient dose of insulin of continuous action was fixed. 18% patients of the youngest group had a repetition of night glipog-likemias.A correction of the insulin dose while leading an inspection improves a middle glucose level in blood and allows to achieve a psychological ready to the correction of an insulin dose. 3 month later after GGMS there was a descent of level HbAlc from 9.3% to 8.2%. GGMS shows us a full condition of carbohydrate exchange in comparison with definition of gemog-lobin and of given selfcontrol with the help of glukometre. It also allows us to fix an oscillation of glykemia in the day.

Key words: children, type 1 diabetes mellitus, continuous glucose monitoring system (CGMS), treatment.

Due to the constant increase in the incidence of type 1 diabetes in children around the world, a change in the age composition towards rejuvenation, a high prevalence of vascular complications, the question of optimizing treatment methods is of great urgency [1].

To date, the only way to prevent or delay the development of complications is strict self-control with the maintenance of blood parameters at a level close to normoglycemia [2].However, in children, this goal is not always feasible due to the labile course of the disease.

New modern technologies that have come to diabetology in the last few years can effectively solve this problem. One of

of these technologies is CGMS – continuous glucose monitoring system. This mobile system, worn on a belt, records blood glucose levels every 5 minutes for several days [3].The data are computer processed and presented in a visual form – in the form of a graph, which shows the fluctuations in glycemia during the day. Thus, it became possible to record latent hypoglycemia, episodes of rising blood sugar levels and, based on new data, quickly optimize the insulin therapy regimen. The CGMS provides information on the direction, magnitude, duration, frequency and cause of changes in blood glucose levels. Differences between until

■ EXPERIENCE OF CONTINUOUS GLUCOSE MONITORING IN TREATMENT OF DIABETES MELLITUS IN CHILDREN AND ADOLESCENTS OF OMSK REGION

sensors obtained by self-monitoring with a glucometer and using the CGMS are presented in Table 1.

Table 1

Differences between self-monitoring glucometer and CGMS

Glucometer Daily monitor

Measures individual level points 288 measurements per day,

sugars, doing it very accurately but with less precision

It is impossible to predict further You can see the change

change in glycemic glycemia every 10 minutes

Requires constant effort No effort required for

from the patient’s side (skin puncture) determination of each point

to measure each point of the glycemic profile

Indications for setting CGMS, as a rule, are suspicion of asymptomatic, especially nocturnal, hypoglycemia, suspicion of the phenomenon of morning dawn, determination of the adequacy of the basis and duration of basal insulin action, determination of the adequacy of bolus doses, assessment of the effect of physical activity, planned therapy with an insulin pump, ” uncontrolled diabetes mellitus, patient education [4].

The aim of the study is to assess the possibilities of CGMS in the optimization of insulin therapy in children and adolescents with type 1 diabetes mellitus (DM 1) in the Omsk region.

Objectives:

1. Using CGMS, study the fluctuations of glycemia during the day in children with type 1 diabetes depending on age, compensation of carbohydrate metabolism, type of long-acting insulin.

2. To identify the main problems in carrying out intensive insulin therapy with the use of insulin analogues.

3. To assess the effect on the compensation of carbohydrate metabolism 3 months after monitoring.

4. To assess the impact of CGMS on the quality of life of patients with type 1 diabetes and their families.

MATERIALS AND METHODS

Glycemia monitoring was carried out using the CGMS gold system.This system consists of three parts: a sensor, a monitor and a device for transmitting data to a computer.

The sensor is a thin, sterile, flexible platinum electrode that is inserted subcutaneously. The sensor detects the level of glucose in the interstitial fluid and sends the signal to the monitor via a flexible wire. It records your blood sugar every 5 minutes (288 times a day). In addition, with its help, you can record the fact of food intake, insulin administration, physical activity, feelings of hypoglycemia.The principle of operation of the sensor is based on the glucose oxidase method: glucose under the influence of glucose oxidase (on the sensor) is converted into gluconic acid with the release of two electrons. Electrons form an electric potential, which is fixed by the electrode and trans-

is given to the monitor. The higher the glucose content in the interstitial fluid, the more electrons are released, the higher the electrical potential. After the end of monitoring, the data from the monitor are downloaded to the computer and processed using special software.After processing, they are available both in the form of digital data (288 glucose measurements per day with indication of time, the limits of glycemic fluctuations, average glycemic values ​​per day and for three days), and in the form of graphs, on which the fluctuations of glycemia are marked by day.

CGMS was performed on 28 patients, the average age was 10.7 ± 3.7 years (2-17 years), there were 15 boys, and 13 girls. The duration of the disease was 5.1 ± 2.7 years (from 1 to 11 years). … The duration of monitoring was 6.4 ± 2.1 days (4-9 days).The distribution of patients according to the compensation of carbohydrate metabolism (HbAlc) was carried out in accordance with the recommendations of the ISPAD Consensus Guidelines (2000) and was as follows: compensation group (HbAlc <7.5%) - 14%, subcompensation group (HbAlc = 7.6-9 %) - 29%, decompensation group (HbAlc> 9.1%) – 57%.

As a baseline insulin, 64% of children received Lantus, 29% – Levemir, 7% – Protafan. The “food” insulin in all cases was Novorapid.

Statistical processing of the results obtained was carried out using parametric and nonparametric methods of statistical analysis. Results are presented as mean ± standard deviation [SEM]. Statistical processing was performed on an IBM-compatible computer using the Primer of Biostatistics Version 4.03 and Statistica 6.0 programs.

RESULTS

During CGMS, the monitor registered 47405 blood glucose control points in 28 patients, while self-measuring with the Ultra glucometer, children entered 986 measurements.The measurement data of the CGMS and the Ultra meter were comparable.

The main problems in insulin therapy identified during CGMS were as follows: 50% of children with HbAlc> 7.5% had an insufficient dose of long-acting insulin (Fig. 1). With an increase in the dose of basic insulin, an improvement in fasting and intraday glycemic parameters was achieved (p <0.05, subcompensation group) (Fig. 2). The daily insulin dose in this group at the end of monitoring was 1.12 U / kg of body weight from the initial 0.99 U / kg.Almost no hypoglycemia was recorded in the decompensation group.

The phenomenon of “morning dawn” (an increase in glucose levels in the early morning hours after the release of con-trinsular hormones) was confirmed in 2 cases. With the appointment of an early additional injection of insulin, the fasting glucose level returned to normal (Fig. 3)

ORIGINAL ARTICLES ■

Figure 1

SCMB graph with insufficient dose of background insulin

s ■ ‘■ V V /

I! ‘

bi ———————————————— –

“] __________________ 4

Repetitive nocturnal hypoglycemia was recorded in 5 children (18%), mainly from 2 to 7 in the morning.All children were under 8 years old and received Protafan (7%) or Lantus (11%) as baseline insulin. Reducing the dose by 1-2 U led to a decrease in the risk of nocturnal hypoglycemia (Fig. 4).

Violation of the diet (consumption of sweets) with imaginary hypoglycemia in 3 cases (11%) was deliberately provoked by patients. Parents have been shown to control sugar levels when they experience hypoglycemia.

When analyzing the distribution of the number of samples (%) according to the blood glucose level, depending on the state of carbohydrate metabolism according to HbA1c, no statistically significant fluctuations were revealed (table.2). There was a tendency for more frequent registration of low glucose levels in children in a state of compensation – 6.2%. And, on the contrary, in patients from the decompensation group, high sugar levels were more often detected – 57.7%. In the general group, the target glucose values ​​were 40.6%, a low level was found in 3.8% of cases, and a high level in 57.7%, respectively.

The proportion of cases of low blood sugar (less than 3.9 mmol / L) depending on the time of day in the general group was maximum at night (night 24.00-7.00) and amounted to 7.5 ± 0.4% (p <0.001). High sugar levels, on the contrary, were more often recorded in the morning hours - 62.9 ± 1% (p <0.001) (Table 3).

There were no significant differences in the distribution of samples in terms of blood sugar levels depending on the type of baseline insulin.

Three months after the end of CGMS, the HbA1c level decreased from 9.3% to 8.2% ((p <0.001) (Fig.5)

At the end of the monitoring, most of the children had smoother glycemic profiles and psychological readiness to further change the insulin dose.

0.800

0.600

0.400

0.200

0.000

Figure 2

Comparison of doses of prolonged-release insulin (U / kg body weight) in individuals with varying degrees of compensation before and after SSMP, M + 95% trust.inter.

0.355

0.310

0.420

0.564

0.521

0.588

□ BEFORE |] after

compensation

subcompensation

Figure 3 The phenomenon of “morning dawn” when using SSMB

decompensation

Figure 4

The phenomenon of “rebound” after night and day hypoglycemia with the use of SSMB

■ EXPERIENCE OF CONTINUOUS GLUCOSE MONITORING IN TREATMENT OF DIABETES MELLITUS IN CHILDREN AND ADOLESCENTS OF OMSK REGION

Figure 5

Change in HbA1c level 3 months after SSMP,%, Me, P

before monitoring after 3 months

I am

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Table 2

Distribution of sample fractions (%) depending on the state of carbohydrate metabolism and blood glucose level according to the SSMB

HbAlc Patient Groups Low Glucose (<3.9 mmol / L) Target Glucose (3.9-10 mmol / L) High Glucose (> 10 mmol / L)

HbAlc <7.5% b, 2 48.1 41.7

HbAlc 7, b-9% 3.1 43 48.9

HbAlc> 9.1% 3, b 38.5 57.7

General group 3.8 40, b 51.1

Table 3

Distribution of the number of samples (%) by blood sugar level depending on the time of day in the general group

Time of day Low glucose (<3.9 mmol / L) Target glucose (3.9-10 mmol / L) High glucose (> 10 mmol / L)

Morning (7.00-11.00) 3.1 ± 0.31 34 ± 0.94 b 2.9 ± 0.9 b

Day (12.00-17.00) 5.1 ± 0.39 44.4 ± 0.9 50.5 ± 0.9

Evening (18.00-24.00) 4.3 ± 0.35 41, b ± 0.89 54.1 ± 0.89

Night (24.00-7.00) 7.5 ± 0.43 43 ± 0.81 49.5 ± 0.83

CONCLUSIONS:

1.The CGMS monitoring system provides a more complete picture of the state of carbohydrate metabolism, in comparison with the determination of glycated hemoglobin and self-monitoring data using a glucometer; allows you to record in detail fluctuations in glycemia during the day.

2. The use of the CGMS monitoring system allows for more effective detection of latent hypoglycemia, impaired counter-regulation syndrome, the phenomenon of “dawn”; reach psi –

Chological readiness of patients and parents to increase the insulin dose.In 50% of patients, a statistically significant lack of basic insulin was revealed, especially in the group of subcompensated patients. Increasing the dose leads to an improvement in blood sugar levels.

The maximum number of hypoglycemias occurs during the night period, and most often they are recorded in the group of children with good compensation of carbohydrate metabolism.

5. In 3 months after the end of CGMS there was a significant decrease in the level of HbA1c from 9.3% to 8.2%.

6. This method is safe and convenient for the patient, can be widely used at the outpatient and inpatient stages of treatment.

REFERENCES:

Diabetes mellitus in children and adolescents: A guide for doctors / Dedov I.I., Kuraeva T.L., Peterkova V.A., Shcherbacheva L.N. – M., 2002. Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes melli-tus.// N. Engl. J. Med. – 1993. – N 329. – P. 977-985.

Experience with the Continuous Glucose Monitoring System in a medical intensive care unit / Goldberg P.A., Siegel M.D., Russell R.R. et al. // Diabetes Technol. Ther. – 2004. – N 6. – P. 339-347.

Gross, T.M. Ffficacy and reliability of the continuous glucose monitoring system / Gross T.M., Mastrototaro J.J. // Diabetes Technol. Ther.-2000. – N 2 (suppl. 1). – P. 19-26.

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90,000 Miniaturization to improve diabetes management with continuous glucose monitoring devices

The world is moving towards convenient and accurate continuous glucose monitoring devices, moving away from finger puncture devices and approximate glucose calculations.Meiqi, a leading China manufacturer of innovative continuous glucose monitoring devices, is leading the way. China has over 125 million people with diabetes and has the largest number of diabetics in the world. To meet the needs of this growing market, Meiqi pushes the boundaries of technology and partnered with Analog Devices Inc (ADI) to develop the next generation integrated wearable continuous glucose monitor (Meiqi Gen 3).

This continuous glucose monitor uses a tiny sensor under your skin to measure your blood sugar levels throughout the day and send the data to your smartphone or watch and then to the cloud. This real-time information helps diabetics quickly change their physical activity, food intake or insulin levels, and helps prevent severe hyperglycemia or low blood sugar levels.

In addition, such continuous glucose monitoring devices provide significant savings. Thus, by using these devices throughout their lives, diabetics will be able to significantly save on needles and test strips, and the continuous information they receive helps them successfully track symptoms and thus avoid expensive medical procedures or hospital visits. Continuous glucose monitoring devices enable patients to manage their health and change the way they eat or when they take medication, while improving the quality of life, which is an invaluable gift for many.

How blood sugar monitoring helped me set up my daily routine

A new sensor for continuous blood glucose monitoring from the Finnish startup VERI has not yet entered the market. I managed to get early access to it at the very end of 2020. Before that, like most people without diabetes, I knew little about the importance of blood sugar and even less about how to control it. But in just two weeks of testing, he reached a completely new level of understanding of the work of his body.The English version of the report on this experiment can be read on my personal blog.

Why measure your blood glucose if you don’t have diabetes?

For diabetics, constant glucose monitoring helps to keep blood sugar levels in a more or less safe range to avoid the worst complications. The rest of the doctors recommend donating “blood for sugar” no more than once a year. Let’s say you took this test and made sure that your glucose level does not exceed the maximum allowed value.Why measure more?

A standard one-time fasting finger or vein test is like a snapshot. It doesn’t show how your diet and lifestyle affects carbohydrate metabolism over the long term. According to the standards of the American Diabetes Association, the norm is no more than 5.6 mmol / L of fasting blood plasma. But many recent studies have convincingly shown that even within this norm there are indicators that are more dangerous and less dangerous. For example, if your glucose level is above 5.5 mmol / L, your risk of developing type 2 diabetes is three times higher than with 4.6 mmol / L.Namely, diabetes often sets the stage for deadly pathologies: cardiovascular disease, cancer and Alzheimer’s disease. Diabetes is usually preceded by so-called prediabetes. According to the estimates of the American Center for Disease Control and Prevention, in the United States more than 25% of the population suffers from it, and in Finland it is just under 20%. (In Russia, it is estimated that they are about the same. – Reminder.) This means that almost one in five blood sugar after a meal is above normal and remains at its peak longer than a healthy person.But fasting can be normal. Bye.

Recently, Levels Health, also a real-time glucose monitoring company, published an excellent guide to blood sugar guidelines based on the latest medical research. These are the indicators it calls optimal.

Disease risk is not the only fact that convinced me of the importance of this indicator. Productivity – physical and mental – directly depends on the level of glucose in the blood.Lethargy and fog in the head are very often associated with fluctuations in sugar, but this factor is usually not taken into account at all.

You need constant monitoring of blood sugar if:

• you strive for longevity and preservation of physical fitness;
• want to eliminate the potential factor of reduced productivity;
• You have relatives with diabetes – a tendency towards it is often transmitted genetically.

How does VERI work and what does it measure?

In Finnish, veri means “blood”, but when you install the sensor, you will not see it.It is a coin-sized round applicator that attaches to your forearm. Although it has a thin, flexible needle to measure blood sugar, it is painlessly inserted under the skin. After a one-hour calibration process, the VERI is ready to go. Its readings can be taken with a smartphone, bringing the camera to the sensor. (Gadgets of this type are already on the market, we wrote about them in detail in our review. – Reminder.)

All data is processed and visualized in the VERI application – so far only on an iPhone. In the near future, the developers are planning to add a personalization mechanism to the application, which will calculate the minimum and maximum values, taking into account age, weight, diet and other individual parameters.The difference between VERI and other wearable glucose sensors is that it not only measures blood sugar. The manufacturer calls this device a “metabolic health compass.” In practice, this means that it records some more interesting metrics.

• Stability Index – calculated on the basis of three indicators: 1) the peak blood glucose concentration immediately after a meal, 2) the glucose level two hours after a meal, and 3) the number of minutes during which the glucose level after reaching the peak value exceeds the norm.For example, when I ate fresh salmon salad, my stability index was close to ideal – 9/10. The spike in glucose levels was minimal, and after two hours, its concentration steadily returned to average.

• Metabolic flow : summarizes and evaluates on a scale of up to 100 points a number of indicators; the most important two: 1) how much time per week the sugar level is in the optimal range (+/- 1 mmol / l) and 2) how much the glucose concentration deviates from the average level during the day.The best indicator is less than 0.6 mmol / l.

• Number of peaks in sugar level per day . Ideally, there should be no more than one of them. Here is one such peak, recorded in my morning.

Another useful option is the ability to photograph food in order to establish a correlation between the stability index and the consumption of certain foods. Even more convenient, products can be sorted by this criterion. This is a very simple and visual way to determine which food suits you best.In addition, there is the ability to monitor blood sugar levels during exercise and integration with the Apple Health app so that all sensor data is automatically uploaded to your personal cloud log. During testing VERI, I noticed a couple of shortcomings. Four times in two weeks, the application recorded a data gap – in the interval from 2 to 10 hours. It also turned out that when visiting a sauna or when it is strongly cooled, the sensor may give incorrect information.

One sensor costs 129 euros and is valid for two weeks.At the end of this period, you receive a final report that summarizes all the indicators. Here’s what I got: the average glucose level is 4.3 mmol / L.

Course of the experiment

To make the results of the experiment more revealing, I decided to start by asking three simple and specific questions:

1. Does the blood sugar level depend on a 30-minute walk after lunch?

2. Does standing work affect glucose concentration?

3. Is there a relationship between fluctuations in blood sugar and sleep quality?

During the experiment, only such parameters as choice of food for lunch, walking and position during work were varied; other conditions (breakfast menu, sleep and wake-up times) remained unchanged.

Walk After Meal

For the first two days I ate a standard 30cm SUBWAY tuna sandwich for lunch. According to the manufacturer’s official information, it contains 75 grams of carbohydrates, including 9 grams of added sugar. Enough to trigger a glucose spike right after a meal. Indeed, the stability index on a day without a walk was 7 out of 10. But the next day, when I walked only half an hour after lunch, it went up by two points. Other indicators also differed greatly.Based on this dynamic, if I lengthened the walk by another 30 minutes, I would not have a sharp rise in my glucose level after lunch at all.

Standing

This test was inspired by a study that found that 2 hours of standing in an office reduced peak post-meal glucose values ​​by as much as 43%. On the day of the experiment, I increased the standing time to 3 hours and ate a decent 600 grams of salmon lasagna.The result was overwhelming, especially considering that lasagna is not the healthiest food: according to Myfitnesspal, I had 60 grams of carbs in my serving. So, the stability index is 10 (maximum), the glucose concentration at the time of the peak is only 4.8 mmol / L, and after 2 hours – 4.5 mmol / L.

Holidays and Sugar

Part of my experiment fell on New Year’s holidays, which gave me the opportunity to test how disturbances in the usual eating rhythm affect the glucose balance.Spoiler alert: The worst metabolic rate for the entire experiment was recorded by the sensor on Christmas Eve after a large portion of rice pudding with blueberry sauce. I drew up a graph of fluctuations in metabolic flow, compared them with my diet and found a clear pattern: the worst indicators fell on those days when I often had snacks – I ate chocolates, bananas, gingerbread; the highest were clearly correlated with healthy eating such as fresh lettuce and physical activity, including standing work.But not all delicious food was equally harmful. For example, Kombucha, Raisin Curd, Blueberry Smoothie, and Collagen Protein Bar, on the other hand, improved my metabolic flow by 9-10 points. As a champion of healthy snacks, it was especially pleasant for me.

Sleep and Sugar

There is scientific evidence that blood sugar levels and sleep quality are linked. Sleep problems increase the risk of type 2 diabetes, and frequent fluctuations in blood sugar levels are seen in people with sleep apnea.To test this relationship for myself, I took the sleep tracking data collected during the Oura ring experiment and compared it with the VERI scores. The strongest correlation was found between the number of glucose peaks and the quality of sleep. The more spikes in my blood sugar levels during the day, the worse I slept the next night.

Conclusions

Of course, a two-week study without benchmarks is not enough to draw far-reaching conclusions. But if you, like me, were wondering if there is a biohacking gadget that can help you lower your sugar level by 50%, improve sleep, give you a boost of energy and mental clarity, then this experiment will give you an unexpected answer: no gadget for you for it is not needed.You already have everything you need. It is enough to walk for half an hour after lunch, periodically stand during work – and your physical performance will noticeably improve. I have always believed in non-training physical activity and standing work. But to be convinced of their effectiveness with your own eyes is a valuable experience.

Diabetes mellitus glucose monitors – huge selection at the best prices

Over-The-Counter Diabetes Glucose Monitors

Using a meter to self-test blood sugar levels is one way that people who have diabetes manage their illness.The test can be done at home using an electronic over-the-counter diabetes glucose meter. It helps patients measure their sugar level throughout the day.

Why should you test your blood sugar levels?

By self-testing and monitoring sugar levels, you receive helpful information to manage your diabetes effectively. Self-monitoring can help you with the following determine if your sugar levels are high or low. It can also help you assess if you are reaching treatment goals your health care provider has set.Glucose monitors can also help you see what effects your diabetes medications are having on your sugar levels.

How do you perform a test with a traditional glucose meter?

Always carefully read and follow manufacturers instructions for use. Generally speaking, the procedure for conducting a self-test typically is as follows:

• Use a lancet to prick your finger and draw a drop of blood.
• Place the droplet onto the test strip, which you should have already inserted into the meter.
• Wait for reading. In the United States, this gets displayed as milligrams of sugar per deciliter of blood (mg / dl).

How does a continuous glucose device work?

As an alternative to traditional meters that require skin pricks, blood droplets, and test strips, people are choosing a continuous glucose monitor, or CGM. For a CGM to function, a tiny catheter pierces the skin. By monitoring the fluid that encompasses the fat cells under the persons skin, the device can provide a blood glucose reading every five minutes.Most CGMs have either a vibratory alarm, an auditory one, or a combination to inform the user of low or high sugar levels. For Apple Watch users, the sensor data from the device can also be synched with the watch.

Can you only test from fingers?

Meters are on the market which allows for alternative site testing, so testing on your fingers isnt a must. Such areas would include the calf, palm, thigh, forearm, or upper arm. Medical professionals advise that you do not test from alternative sampling sites during times in which your blood sugar level could be changing quickly.For accurate results, it is strongly suggested that you not perform AST and instead check levels only with a drop taken from the fingertip if any of the following cases are true:

• You are stressed.