I entered the diabetes education field six-and-a-half years ago, when the landscape of treatment was changing rapidly.
New medications were debuting left and right. New technologies were (and still are!) smacking me in the head. Even after all these years, there’s always something new to learn.
How a healthcare professional monitors diabetes
There was a time when a healthcare professional didn’t have a good way to determine how well-managed their patient was. Now, fortunately, we have many tools at our disposal. Here are some of note.
Also known as HbA1c, glycohemoglobin, glycated hemoglobin, glycosylated hemoglobin, and simply A1c, hemoglobin A1c is a three-month average of how glucose levels are trending.
Glucose attaches to the hemoglobin, which is the part of the blood that carries oxygen. This test can detect how much glucose has been transported over a period of three months, which is the average lifespan of a red blood cell.
Hemoglobin A1c values are:
- Normal: below 5.7%
- Prediabetes: 5.7% to 6.4%
- Diabetes: above 6.5%
Worth noting: blood disorders like anemia can cause a hemoglobin A1c to be inaccurate.
Fructosamine is a helpful lab test when a hemoglobin A1c is thought to be inaccurate, or when a healthcare professional is attempting to determine the effectiveness of a treatment plan.
Also called glycated serum protein and GSP, fructosamine ameasures the amount of fructosamine in the blood. Fructosamine is a compound that forms when fructose is combined with protein. According to LabTestsOnline.org, “Glucose molecules will permanently combine with proteins in the blood in a process called glycation. These proteins include albumin, the principal protein in the fluid portion of blood (serum), as well as other serum proteins and hemoglobin, the major protein found.”
Though not commonly ordered, a fructosamine test is very helpful when the hemoglobin A1c is thought to be inaccurate, when a healthcare professional wants to specifically measure the blood glucose values for the past two to three weeks, and during pregnancy.
Time-in-range (TIR) is a specific measure used for people with diabetes who use continuous glucose monitors (CGM). TIR is the time that is spent in a glucose range of 70-180mg/dl for those with type 1 and type 2 and 63-140mg/dl for those with gestational diabetes and preexisting diabetes.
Researchers have found that hemoglobin A1c alone does not tell an accurate clinical picture of how well diabetes is managed. For example, a person may have a hemoglobin A1c of 6.7% but spend much of their type with hypoglycemia.
According to the Association of Diabetes Care & Education Specialists (ADCES), “Monitoring TIR enables people with diabetes to see the effects of small changes in real time rather than waiting for their next HbA1C to be checked, which can help motivate them to either continue doing well or make additional changes to their therapeutic regimen.”
The downfall to using TIR is that it is not available to everyone, but rather only to people using CGM technology.
How a person with diabetes monitors glucose
A person with diabetes typically monitors their blood sugar values using two different methods: fingersticks using a meter, or CGM.
A glucometer, called meter for short, is a portable device that allows the user to check their glucose levels at a single point in time. Meters require the user to prick their finger with a lancet, which draws a drop of blood. The drop is then placed on a testing strip where the meter can read the glucose level.
Each person with diabetes has different monitoring needs. Someone who with type 1 diabetes and is fully insulin-dependent, for example, likely checks their glucose four or more times per day, while someone with type 2 diabetes who is on metformin may check their glucose once daily.
A CGM is a meter that monitors continuously monitors glucose. In fact, for most systems, these monitors measure glucose levels every five minutes.
Users wear a CGM continuously. They insert the sensor themselves, often in the abdomen or the upper arm. The sensor uses a tiny cannula that sits in the interstitial fluid, allowing it to read glucose values. Generally, users must change their sensor every 10 to 14 days.
Some devices use a transmitter connected to the sensor, which is reusable for several months. Some devices contain both the sensor and transmitter. CGMs allow users to see their glucose date in real-time, allowing them to make the most informed treatment decisions. Several devices also provide alarms for hyperglycemia (high glucose) and hypoglycemia (low glucose), which can be life-saving.
Recommended for nurses: Clinical Advances in Oral Antihyperglycemic Medication and Insulin Pump Therapies
How a person with diabetes manages glucose
A person with diabetes manages the condition by following several key recommendations by their doctor or other healthcare professional:
- Monitoring glucose levels as recommended by their doctor using a meter or CGM
- Eating a balanced diet
- Taking medications as prescribed
- Keeping appointments with healthcare professionals and diabetes educators and having labwork as prescribed, such as hemoglobin A1c or fructosamine
Each person with diabetes will have a specific monitoring plan for monitoring. Whether the plan utilize a meter or a CGM, their healthcare professional will recommend specific guidelines, such as “Monitor once daily, first thing in the morning before eating” or “Monitor before eating and when feeling symptoms of hypoglycemia.”
All food affects the glucose levels, but carbohydrates have the biggest impact. A person with diabetes will often manage using a specific diet plan that states how many carbohydrates they should consume at each meal. Those with type 1 diabetes may not have a limit to their carbohydrates, but may need to “match” their rapid-acting insulin to their carbohydrates. They must give insulin every time they eat carbs.
Often, registered dietitians (RD) meet with people with diabetes to ensure that their diets are meeting their unique needs.
Many people with diabetes require individualized medication to control their glucose levels. Individuals with type 1 diabetes require insulin for survival because their body no longer makes insulin. They can inject insulin directly, or use an insulin pump, which gives insulin through tiny doses throughout the day.
A person with type 2 diabetes may not require any medication if glucose values are at target with diet and exercise. However, there are various treatment options available if glucose becomes elevated:
- Metformin: is the first-line treatment for type 2 diabetes and helps glucose get into the cells as well as reduces glucose production from the liver; examples include metformin (Fortamet, Glucophage, Glumetza, Fortamet, Riomet, Glucophage XR)
- Thiazolidinediones (TZDs): help the cells use insulin glucose; examples include pioglitazone (Actos) and rosiglitazone (Avandia)
- DPP-4 inhibitors: help the body release more insulin when eating; examples include sitagliptin (Januvia), saxagliptin (Onglyza), alogliptin (Nesina), linagliptin (Tradjenta)
- SGLT-2 inhibitors: cause glucose to be excreted through the urine; examples include dapagliflozin (Farxiga), canagliflozin (Invokana), empagliflozin (Jardiance), ertugliflozin (Steglatro)
- GLP-1 agonists: help the body release more insulin when eating; examples include lixisenatide (Adlyxin), exenatide (Bydureon, Byetta), semaglutide (Ozempic), albiglutide (Tanzeum), dulaglutide (Trulicity), liraglutide (Victoza)
- Sulfonylureas: help the body release more insulin; examples include glimepiride (Amaryl), glyburide (Diabeta, Glynase), glipizide (Glucotrol, Glucotrol XL)
- Insulin: can be used in combination with oral medications. People with type 2 diabetes may require insulin daily (long-acting) as well as with meals.
This post was originally published in the Elite Learning Resource Center on Jan. 6, 2021.
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Hemoglobin A1C (HbA1c) Test. (2018). Medlineplus.Gov. https://medlineplus.gov/lab-tests/hemoglobin-a1c-hba1c-test/
Insulin, Medicines, & Other Diabetes Treatments. (2016, December). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/diabetes/overview/insulin-medicines-treatments
Krans, B. (2018, August 20). Blood Glucose Monitoring: How It Works. Healthline. https://www.healthline.com/health/blood-glucose-monitoring#preparation
Ramchandani, N. (2019, July 11). ADA Time in Range Guidelines: What They Are, Their Importance and How This Affects Diabetes Educators. Association of Diabetes Care & Education Specialists. https://www.diabeteseducator.org/news/perspectives/aade-blog-details/adces-perspectives-on-diabetes-care/2019/07/11/ada-time-in-range-guidelines-what-they-are-their-importance-and-how-this-affects-diabetes-educators