When I have the opportunity to review a person’s blood glucose log, as opposed to just evaluating his most recent A1C result, it provides me with great insight into the daily fluctuations in his blood glucose levels and helps me identify areas for improvement. As a clinician, the daily blood glucose log provides the most important information to be taken into account for medication adjustments.
Some people will apologize to me if their log has some blood or coffee stains on it. But I actually welcome such logs, since it tells me the log has been a part of their daily routine. I always applaud my patients for taking the time and effort to provide me with such valuable information. My first priority is to look for low blood glucose levels, since these can be dangerous and need to be avoided. Next, I look for consistently high blood glucose levels to determine if medication changes are required.
Unfortunately, people often arrive at their first appointment without a blood glucose log. Many tell me they have stopped checking their blood glucose levels altogether. The most common reasons cited for this include discomfort from pricking their fingers or discouragement from constantly seeing high readings. Occasionally, someone will tell me that his previous provider never reviewed his log, which made him stop bringing it to his appointments.
While performing blood glucose monitoring takes time and effort, it is very important for helping people with diabetes understand how food, physical activity, medicines, illness, and stress affect their glucose levels. Monitoring can also identify when a person’s blood glucose is too low or too high so that it can be treated promptly. But the real value of blood glucose monitoring lies in using the information to make daily choices about how to balance all these factors.
The goal of this blog entry is to address some of the concerns people have about performing blood glucose monitoring and to provide some insight on why to do it, how to minimize the discomfort of it, and what to do with the results.
Reasons to check your blood glucose at home (versus relying on how you feel or on your A1C result)
People often tell me they don’t need to check their blood glucose because they can tell what their level is by the way they feel. When blood glucose is low, many people will indeed have symptoms such as shakiness or sweating, prompting them to take action. This is because the body responds to low blood glucose levels by initiating the release of adrenaline, which causes these symptoms. (People with hypoglycemia unawareness, however, do not experience any symptoms with low blood glucose levels.)
However, when blood glucose levels are elevated, people may or may not have or notice symptoms. That’s because symptoms of elevated blood sugar can be much more subtle, unless the level becomes high enough to cause changes in body chemistry. (This is why people often aren’t diagnosed with Type 2 diabetes until they’ve had it for years.) And if blood glucose levels are chronically elevated, the body may adjust such that people may not experience any symptoms at all. For these reasons, relying on how you feel is a very inaccurate way of monitoring for elevated blood glucose levels.
The hemoglobin A1C is a measure of your blood glucose control over the previous 2–3 months. It is a very valuable tool for determining overall control compared to looking at a single fasting blood glucose level. However, it is only an indicator of overall control: It is possible to have an A1C level of 7% even while having daily blood glucose readings that fluctuate between the high 200’s and the low 50’s.
As health-care providers, we look for correlations between what the A1C reveals and the results in someone’s blood glucose log. When his A1C level is elevated, we need to know the specific times of the day his blood sugar is high in order to make appropriate medication adjustments.
How to minimize the discomfort of blood glucose monitoring
I am always surprised at how many people are monitoring their blood glucose using their fingertip pads. It is recommended to use the sides of the top part of the fingers to perform checks. This is generally more comfortable because there are fewer nerve endings on the sides of the fingers, so you’ll protect the sensitive tips of your fingers from being sore. If you have trouble getting enough blood from your finger, make sure your fingertip is warm (not cold). Before cleaning your hands with soap and warm water, vigorously shake your hands to get the blood flowing to the tips.
Unfortunately, current blood glucose monitoring technology still requires the obtainment of a small sample of blood. When my patients mention experiencing discomfort during monitoring, I always ask whether or not they are using a lancing device. Lancing devices, which hold the lancets, or “pins,” help get an adequate blood sample with only a tiny skin puncture and minimal irritation. Many people are not using a lancing device.
Typically, a lancet is placed in the device and prepared for use by pulling back on a spring-loaded control. Pushing a button releases the hidden lancet and pierces the skin to get the blood drop. Most lancing devices offer different settings to adjust how deeply the lancet penetrates the skin. Puncturing the skin too deeply will cause more discomfort and make it take longer to heal.
To indicate the depth at which the lancet will pierce the skin, some devices use numbers and others use marks. When numbers are used, one is most commonly the shallowest depth. If marks (lines, circles, or dashes) are used, the biggest or longest mark indicates the deepest skin pierce. You want to use a setting that provides an adequate amount of blood without having to squeeze your finger, as squeezing may alter the composition of the blood sample and make your result less accurate. However, if you are having a lot of discomfort, try using a lighter setting.
Lancets also come in several thicknesses, called “gauges.” A higher gauge number means a thinner lancet tip, which is usually less painful. For example, a 30-gauge lancet would be less painful than a 28-gauge lancet. Keep in mind, however, that getting an adequate blood sample may prove more difficult with the thinnest 33-gauge lancets. Also, always use a fresh lancet for each check, as reusing lancets makes them dull, and therefore more painful to use.
Information to include in your blood glucose log
Write down everything that pertains to your blood glucose, including:
• Doses and times of your diabetes medicine(s)
• Times and results of your blood glucose checks
I also suggest including a column entitled “comments.” This area is to make note of anything else that may be impacting your blood glucose levels, such as:
• Meals eaten out
• Any exercise or strenuous activity
• More stress at home or work
• Missing a meal
• Starting a new medicine
• Changes in sleep patterns
• Hormonal changes (menstruation, menopause)
How to use the information in your blood glucose log: looking at patterns
I feel it is very important to show my patients how to look closely at their blood glucose records. Do patterns exist related to certain activities? Are blood glucose levels affected by when or what they eat? What happens to the blood glucose level if medicine is omitted? Or during or following exercise? Is there a pattern during a stressful event or illness? The answers to these questions can help people make decisions about what to change in their diabetes care plan.
A pattern exists when your blood glucose results are the same or similar at specific times of the day. For example, your blood glucose might always be low in the early hours of the morning. Or you might notice that your blood glucose is always high before dinner. If patterns exist, you can work with your health-care provider to determine the right steps to correct the highs or lows.
By highlighting any numbers that are out of range and trying to come up with a reason for them by referring to the comments section of your log, you can see what types of things are affecting your blood glucose. These results can be addressed with your physician. Additionally, if you make notes explaining why an occasional blood glucose reading was high or low, it will avoid having medication changes made unnecessarily.
Checking your blood glucose levels at home is an integral part of managing your diabetes. Even when your A1C result is at your target goal, you should continue to check your blood glucose levels on a regular basis. Living with diabetes is a dynamic and ever-changing process.
Even if you do a great job at managing your diabetes, you will still have occasional readings that are too high or too low. Remember, your blood glucose result is only a number to help you manage your diabetes. It is not a reflection of you as a person. If you have times when your blood levels fall out of your desirable range, it doesn’t mean that you’ve failed. No one is perfect. But if you start seeing patterns, it may indicate that changes in your therapy are warranted.
So the next time you grab your meter and check your blood glucose level, ask yourself: Why am I checking now? How will I use the information? This will make your blood glucose result more meaningful to you. The goal is for you to use the information gained from blood glucose monitoring so that you can enjoy good health. And don’t forget to take your blood glucose log with you to your appointments so that your health-care provider can use this information to find out how well your diabetes care plan is working and make appropriate adjustments as needed.