By William H. Polonsky, PhD, CDE
Checking blood sugar is now so quick, easy, and relatively painless — and the information you can obtain is so valuable — that you would think everybody would be monitoring regularly. But this is far from true. If you don’t check your blood glucose as often as you should, you aren’t the only one. An American Diabetes Association survey found that 21 percent of adults with Type 1 diabetes never checked their blood glucose. Of those with insulin-treated Type 2 diabetes, 47 percent never monitored. And among those with Type 2 diabetes who were not using insulin, 76 percent never checked.
It’s possible that some people never monitor because their doctors never told them to. But even people who do receive instructions to monitor don’t always follow doctor’s orders. In two studies, my colleagues and I found that approximately one-quarter of the people we interviewed followed their doctor’s recommendations for monitoring less than half the time.
If monitoring is so easy and valuable, why do so many people find it difficult? Is it a lack of willpower? A deeper psychological problem? As it turns out, the answer is more straightforward: People stop checking their blood glucose levels when they begin to believe the whole process involves a lot of hassles and few benefits. They may not even be aware of having these beliefs. But even subconscious beliefs have a powerful influence on motivation and behavior.
There is no doubt that blood glucose monitoring hassles abound. There seem to be lots of good reasons — some big, some small, and some silly — to hate checking your blood glucose. Here are the top 10 reasons not to monitor:
You may have realized, to your dismay, that your meter results have become the way you judge your own self-worth. Whether you feel like a good person or a terrible person depends on your blood glucose levels.
When you see a high blood glucose reading, do you realize that it is just a number? Or do you imagine that your meter is speaking to you: “What did you do wrong this time?” or “Another high blood sugar? You are such a loser!” When you “hear” these messages from your meter, you are no longer aware of the actual reading, nor are you considering what action to take. Instead, you just feel bad about yourself. You might have had a terrific day in all other ways, but one unwanted number can ruin it all.
Part of the trouble is that blood glucose monitoring is often referred to as “testing.” And the word “test” can lead you to consider the resulting number a grade. Depending on the number that appears on your meter, you have either passed or failed. If you have high blood glucose levels frequently, this can become a big problem. Your meter may seem like a critic who is constantly telling you that you are a failure. Not surprisingly, you may soon want to end this relationship. One of the most common ways to do this is to put the meter away in a drawer where it can’t make you feel bad anymore.
Imagine how frustrating it would be if you were extremely overweight and your doctor’s major recommendation was that you look at yourself in a full-length mirror three times a day. How annoying! This wouldn’t help you to lose any weight.
Many people think about blood glucose monitoring in the same way: “Why bother checking? It’s always high anyway!” If you don’t know how to use the information from your meter to adjust your diabetes-care regimen, then it is easy to believe that the whole monitoring process is a big waste of time. This is especially frustrating if you’ve been working hard to manage your blood glucose and you are still getting crazy results, blood sugar levels that seem to rise and fall for no reason whatsoever. If that’s what you get for your efforts, it almost seems sensible not to bother checking at all.
No one wants to worry about his diabetes all the time. But some people feel so upset about living with diabetes that they work hard to avoid ever thinking about it. If you feel this way, the act of monitoring can become an in-your-face reminder that “yes, you still have diabetes,” so you don’t do it. And instead of learning to use blood glucose information to manage your diabetes more successfully, you view it simply as irritating and unwelcome feedback. If you avoid monitoring, it is possible to go for many hours or even days without having to think about diabetes at all.
If you are feeling constantly pushed around by your meter, it may seem reasonable to stop monitoring. You might not like to check before meals, for example, because a high blood sugar reading makes you feel that you cannot eat as much as you really want. Or you might not like to check before exercising because a low blood glucose reading means that you have to eat something before you exercise. A low blood glucose reading before driving means that you should not drive until you bring your blood sugar level up.
Rather than seeing these numbers as simple information on which you can take some corrective action, you see your blood glucose readings as commands from your meter that limit your freedom. And few grown-ups like to be told what to do, especially by a puny little machine.
If diabetes is a private matter for you, frequent monitoring (especially if done in public view) could lead to conversations that you would prefer to avoid. You might be reluctant to check regularly because you fear that your loved ones will “butt in” on your diabetes management. You worry that your friends and family will blame you (“You obviously did something terribly wrong! You’re probably eating too much”), offer stupid advice (“Y’know, this wouldn’t happen if you’d just develop some willpower!”), or worse, if they see a high or low reading. If you worry that regular monitoring will lead to bad feelings at home, a loss of personal control over your own diabetes care, or family arguments, it would seem reasonable to avoid checking your blood glucose as much as possible.
If your doctor doesn’t bother looking at your blood glucose records at all, or if he examines them only superficially (“Hmmm, nothing really interesting here, so let’s just keep observing your sugars over the next few months and see what happens”), why would you keep monitoring?
Blood sugar readings can be used to fine-tune your diabetes self-care. The feedback they provide can help you make decisions about diet, insulin, exercise, and other parts of life. But if you don’t know how to use the information, and your doctor isn’t actively using it either, checking your blood glucose might seem like a huge waste of time.
It’s true that recent technological advances (slimmer lancets and a laser lancet, for example) mean that there is much less pain associated with monitoring than ever before. If you’re checking correctly, it should be relatively painless most of the time. However, there are those occasions when you will strike a tender spot, and it will hurt. (Tip: If it hurts most of the time, remember to prick the sides of your fingers, where there are fewer nerve endings, not the central pads, where there are lots of nerve endings.) If you check your blood sugar a lot, your fingers can get sore or irritated, especially if you get dirt in those teeny holes. And even the sight of those little puncture marks can be upsetting.
Monitoring equipment is small and growing ever smaller, but if you need to check your blood sugar when you are out of the house (say, before dining out), you still have to remember to bring the darned stuff with you! Planning is sometimes necessary, and forgetfulness is a major reason for not checking blood glucose at the appropriate times. Monitoring can take time (though not that much) and may require you to interrupt what you are doing. If you are out in public and want to check your blood glucose in private, you have to find a place to do so. If you believe that monitoring is a big nuisance in a life that is already trying enough, then it may be difficult to convince yourself to check your blood sugar regularly.
If you don’t have good insurance, you probably know that test strips can be costly, especially for those who check many times each day. I remember a frustrated endocrinologist referring one of his patients to me because she was “noncompliant” with his request that she monitor her blood glucose regularly. As I soon discovered, Sarah didn’t need to see a behavioral specialist; she simply couldn’t afford to check as frequently as necessary. When financial constraints are combined with one or more of the hassles described above — for example, you feel that monitoring is essentially pointless AND it’s costing you several dollars a day to perform an exercise in futility — it is even less likely that you will be willing to continue with frequent checking.
The idea of monitoring blood sugar regularly seems simple and reasonable at first — until you realize you must juggle it with the many other demanding tasks and stresses of daily life. Check before dinner each evening? An excellent idea! But if you’re the one responsible for making dinner while also keeping your young children amused, everyone wants to eat as soon as possible, and you’re very hungry RIGHT NOW, then maybe — even though your intentions are good — you just won’t find the time to check this evening. In other words, life gets in the way.
Now that you’ve read through this list, you may be even more discouraged than when you started. Even those of you who have always monitored regularly may now be ready to stop doing so. This is certainly not my intent! In fact, the good news is that most of the barriers to blood glucose monitoring can be overcome. You may never decide that regular monitoring is great fun, but neither does it have to be such a burden. So what to do?
First, let’s be clear about the powerful benefits of regular monitoring. To date, the research results are overwhelming: Checking your blood sugar regularly can help you manage your diabetes more effectively. This can help you to feel physically better almost immediately and well into the future. Regular monitoring can also give you a wider range of options regarding food, medication, and activity. You can experience a much greater sense of personal freedom.
So monitoring is well worth doing, if only the barriers that lie in the way can be removed. Here are some strategies for overcoming the barriers and getting into the habit of regular blood glucose monitoring:
If you avoid checking because your meter makes you feel bad about yourself, you’d rather not be reminded that you have diabetes, or your meter seems to control your life, you may have developed an unfriendly relationship with your meter, a relationship that is working against you. Now this may seem silly to you — after all, it’s just a little machine — and you may not have even considered that a relationship of any sort exists, but clearly it does.
How do you end the antagonism? How do you befriend your meter? The most important job will be to challenge your normal way of interpreting what your meter says and to realize that your meter does not have to be the enemy. Remember that there are no “bad” or “good” blood glucose readings, and that you cannot fail. In all cases, the reading is just a number. This can be tough to keep in mind, especially if you’ve also had years of comments from friends, family members, and perhaps even doctors that one particular reading is “terrific” and another is “terrible.”
People who are successful with monitoring view their readings as simple pieces of information and opportunities for taking action. They may be frustrated by a high blood glucose level at first, but frustration quickly turns to action. Think of the gas gauge in your car. When it nears empty, do you avoid looking at it? Do you yell at yourself for being so stupid as to allow it to get this low? Probably not. You don’t tend to think of the amount of gas in your tank as “good” or “bad”; the gauge is just providing information that allows you to make the best possible decision. And this is exactly the mind-set to use with your blood glucose meter. But how?
First, stop referring to the process as blood glucose “testing.” Instead, think of it as “monitoring” or “checking.” Once you stop viewing this as a test, you will be less likely to see your readings as grades. Also, stop referring to readings as “good” or “bad.” Instead, think “high” or “low.” This is more accurate and less judgmental.
Second, remind yourself how silly it is to let a blood glucose reading determine your self-esteem, to think that your meter is trying to control your life, or to think that it is tormenting you about the fact that you have diabetes. Challenge these automatic thoughts when they occur, and remind yourself that these readings are just numbers. One way to help this change process is to get silly and give your meter a name and, perhaps, a personality. Then imagine what this character might say to you: “My meter Fred told me that my blood glucose was 275 mg/dl this morning, and he went on to lecture me about what a numskull I am.” But don’t let him get away with talking to you like that; argue back!
Third, respond to your blood sugar readings by thinking about what action you want to take. For example, if the number is high, rather than thinking, “How did I mess up this time?” ask, “What can I do about this right now?” (If the answer is “I don’t know,” think about making an appointment with your doctor or diabetes educator to learn how to respond to high and low blood sugar levels.) By focusing on problem-solving, you can empower yourself and free yourself from self-blame.
You may have unrealistic expectations for what you can accomplish. To avoid becoming discouraged by a high or low reading, consider what a fair and acceptable range of blood glucose values would be for you. At what numbers would you consider your blood glucose to be too high or too low? In consultation with your health-care provider, decide how often you should be within that range to be successful.
For example, you and your doctor may decide that your goal for the next three months is to keep your blood glucose values under 150 mg/dl at least two-thirds of the time. Of course, it would be great if you could keep all your readings under 150 mg/dl. But if you have had no readings under 150 for the past three months, trying for all under 150 may be too ambitious right now. So while you may decide to tighten up your goals later, it is important that the target you choose now fit your current circumstances; it must be reasonable for you.
If you set goals that are too tough, you’re likely to become discouraged when your readings are out of range. This sense of failure won’t inspire you to work harder on your diabetes management. Instead, it will make you want to stop monitoring altogether. So establish clear and reasonable goals, and be kind to yourself. Remember that, despite your best intentions, erratic blood glucose levels will occur at times. Sometimes they’ll be high and sometimes low. And these crazy numbers often cannot be explained.
Establish a clear plan with your diabetes-care provider about what exactly to do in the case of high or low readings. In what situations do you adjust the amount or timing of your medicine? In what situations do you change your food intake or activity level? If you discover your plan isn’t working, that doesn’t mean it’s time to give up; rather, it’s time for a new plan! You should have a health-care provider who is willing to work with you, someone who is active in giving you timely feedback and suggestions about your blood sugar results. If your doctor can’t or won’t do this, you may need a new doctor.
Sometimes the biggest barriers to regular monitoring are the little things, the hassles of daily life. But there are ways to make monitoring fit into your daily routine more easily.
If life is so busy that you are frequently skipping blood glucose checks, consider “anchoring” your monitoring to other, already established habits. For example, if you want to take a fasting blood glucose reading in the morning, but can’t seem to get it done, think about the first thing you typically do each morning, and try to add blood glucose monitoring to that habit. For example, if the first thing you do in the morning is brush your teeth, try leaving your monitor next to your toothbrush in the bathroom. If it’s make coffee, leave the monitor next to the coffeemaker. Think about how you can connect monitoring to other daily tasks for checks at other times during the day.
If it is inconvenient to take along your meter on your daily travels, consider something as simple as purchasing another meter and leaving it where it may be needed most — at work, at your best friend’s house — but not in your car, where extremes in temperature can affect the accuracy of readings. By having another meter conveniently located, you won’t have to remember to bring your equipment with you everywhere you go. Think creatively about other ways to modify your daily environment to make regular monitoring easier.
If you find finger pricks particularly painful, you might not be using the best lancet and lancing device for you. Most people find that the narrower the lancet, the less painful the prick. (With lancets, the higher the gauge, the smaller the hole in your finger. So a 30-gauge lancet makes a smaller hole than a 23-gauge lancet.) But if you use a lancet that’s too narrow, you might not get enough blood, and then you’ll have to do another fingerstick. You may need to experiment to find the lancet that allows you to get a large enough drop of blood for an accurate reading but with the least amount of pain. Ask your diabetes educator for samples of different lancets to try.
If you find that your fingers bruise from fingersticks, it may mean that the lancet is penetrating too deeply. Many of the newer lancing devices allow you to adjust the depth of penetration so you can find what’s right for you. Generally, children and adults with sensitive fingers prefer a shallower puncture; adults with callused fingers may need a deeper puncture to get an adequate blood sample. A certified diabetes educator can help you choose a lancet and lancing device that’s right for you.
The supplies needed for regular blood sugar monitoring can get expensive, particularly if your insurance doesn’t cover them completely or even partially. To lower your out-of-pocket expenses, make sure you are taking full advantage of your health insurance coverage. Then shop around to find the lowest prices on supplies. Mail-order houses, local and chain pharmacies, and diabetes specialty stores can vary quite a lot in what they offer and what they charge for it. Keep an eye open for frequent-buyer programs, sales, and discount coupons. You can often save money on supplies by buying them in bulk. But before you buy test strips in bulk, make sure that you can use them all before the expiration date marked on the package.
Although the makers of lancets don’t recommend reuse, most health-care professionals think it’s OK to reuse a lancet within a 24-hour period. The main concern about reusing lancets is infection. To help protect against infection, wash your hands well before lancing your finger. Do not use alcohol on your finger unless you don’t have access to soap and water and your hands are dirty. (Alcohol can dry out your skin and alter your blood glucose reading.) If you must use alcohol, make sure your finger dries completely before you lance it.
You should also know that reusing lancets can make fingerpricking more painful. The point gets duller every time you use it, making it harder to draw blood. Using alcohol on a lancet can have the same dulling effect, because alcohol removes the protective coating on the metal. So don’t try to clean the lancet between uses.
In all likelihood, your friends and family members care about you and want you to be as healthy as possible. That’s why they may take such an interest in your diabetes care. But if you feel like your loved ones are constantly “policing” your behavior, you might become reluctant to check your blood glucose — and bring further attention to your diabetes — in front of them.
The diabetes police are well-intentioned; they’re just trying to be helpful. They may know that their actions are irritating you, but they worry that your self-care will deteriorate if they don’t keep a close watch on you.
The best way to rid yourself of the diabetes police is to prove them wrong. By publicly taking charge of your diabetes, you will convince your friends and family that you can take care of yourself. If you don’t need your loved ones to remind you of your diet or exercise regimen, then prove it. Tell them about your diabetes care plan and your ongoing efforts to follow it. Tell them about the parts that are easy and the parts that are difficult.
If friends and family members continue to make comments about your diabetes that upset you, sit down and talk to them about how their behavior makes you feel. Tell them that you appreciate their concern, but their policing actually makes you less likely to check your blood glucose when they’re around. Offer suggestions as to what sort of support you would prefer. (If you’re having a hard time with the diabetes police, you may want to consider purchasing the book Diabetes Burnout, which contains a good deal of information about this topic. See the ordering information at the end of this article.)
So what have you learned? Regular monitoring is important, yet for many people it remains tough. It can be burdensome when you give monitoring the power to make you feel bad about yourself, when you feel helpless to do anything about erratic readings, or when the demands of daily life intrude. The good news is that these barriers can be successfully overcome once you take the time to identify which of them may be keeping you from regular monitoring.
Want to learn more about managing blood sugar? Read “What Is a Normal Blood Sugar Level?” “Managing Your Blood Glucose Ups and Downs”, and “Making Your Blood Glucose Monitor Work for You,” then see our blood sugar chart.
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