Blood Sugar Check

Blood sugar can be checked by patients at home. This is called SMBG (self-monitoring blood glucose) or in the laboratory. Small portable hand held battery operated devices are in common use. The accuracy has about 10% variability as compared to laboratory testing.

Indications :

All cases of Type I Diabetes mellitus should frequently check blood sugars. This should be done multiple times daily in most cases as fluctuations are more common in Type I DM

  • by those on multiple insulin injections daily,
  • while adjusting insulin doses,
  • when hypoglycemia is suspected,
  • before exercise /games etc
  • before driving.
  • During travel

It is required less frequently in Type II Diabetes. It is checked for patients on insulin and those having hypoglycemic episodes. Once a week check may be enough for most patients. Those who are on a tight control of sugars require more frequent checks.

It is also recommended during treatment of hypoglycemia to ensure that blood levels of glucose have improved and remain improved.

Time of Testing :

For type II cases and those suspected to have hypoglycemia often, morning and before dinner levels are useful. However, treatment should not be delayed in serious hypoglycemia suspicions as delay in correcting glucose levels may cause permanent injury to some organs especially nervous system.

Methods :

Venous or capillary blood is used for measurement of blood sugar. It can be measured in plasma or serum. Capillary and plasma levels are 10% lower and higher compared to venous and serum levels due to glucose utilization by tissues and RBCs.

Glucometers use strips impregnated with glucose oxidase. Most show plasma glucose rather than whole blood levels.

Calibration is required before using a fresh set of strips.

Best results are obtained if a lancet is used for puncture of the skin. Blood should come out easily rather than being squeezed from the fingertip. Sides of terminal digits should be used as punctures in front areas would be painful when hands are used. Hands should be washed and dried before a sample is taken.

Higher values may not be measured precisely and are often shown as High levels.

Test strips should be fresh and manufacturers guidelines should be adhered to.

Units of Measurement :

Old methods report sugar level in mg/deciliter while the newer methods are in mmol/liter. To convert from mg/dl to mmol /l the former values are divided by 18.

HbA1C or glycated Hb measures level over previous 12 weeks or so. The test, however, should be done in a fasting stage and is a good guide for overall diabetic control.

Diabetes Care

For patients suffering from type II /adult onset diabetes :

In type II diabetes, diagnosis is often late (after the disease has already been present for some time). In early days T2DM (short for the adult type of diabetes) are often without symptoms. Hence the delay in diagnosis. This means complications will be seen early after diagnosis.

Foot Care :

Foot disease in diabetes may lead to difficulty in walking, pain and may lead to infections. If neglected amputation may be required.

Inspect feet with a mirror before going to sleep every night.

Use well fitting shoewear.

Do not walk bare feet even in the house.

Socks should be clean and correct size.

In case of deformities of feet, special shoes can be worn.

Eye Care :

It is nowadays the commonest cause of blindness throughout the world.

Check for refractory error at the time of diagnosis and once sugars are controlled.  In T2DM every year examination for changes in retina are required. If there are already changes, check up is required more often.

Retina is checked after dilating pupil with an ophthalmoscope.

Kidneys :

It is one of the common causes of kidney failure leading to requirement of dialysis and renal transplant. Early treatment may reverse diabetic kidney disease or slow its progression.

In early cases urine is checked for passage of extra amounts of albumin. This can be quantified to see response to therapy. This test is called urine for microalbuminuria, and urine albumin /creatinine ratio. If the disease is already present, USG, S Cr and testing for voiding function (Uroflowmetry) etc may be useful.

In those without evidence of kidney disease these tests are carried out every year. Frequency otherwise may depend on the stage of involvement. More severe involvement necessitates more frequent reviews.

Nerves :

Nerve involvement is checked by touch, pain, vibration sense.

During winters, hot water should be checked with either a thermometer or elbows. If fingers are used for checking temperature, very hot water may lead to burns.

Precautions should be taken to avoid falls.

Sugar Levels :

HbA1C level may be done every 3 months to monitor overall sugar control in blood. In most cases a level of < 7 is desirable.

If hypoglycaemia is frequent , a level of < 8 may be  all that can be achieved safely. In cases of some microvascular complications, a level < 6.5 may help but is difficult to achieve. Home sugar monitoring is done from capillary blood. The levels are different from venous blood levels tested in laboratories. Only sides of fingers should be used and not the areas used for holding functions of the hand. In T2DM once weekly sugars may be enough. In T1DM almost daily or before each meal sugars are required. Levels for control should not be done within 2 hours of meals. Check if there is uncertainty about diagnosis of hypoglycaemia. Do not wait for giving sugars, if testing takes time or symptoms are severe (loss of consciousness, confused talk, fits etc.) Treatment presumptively may prevent permanent damage to the brain. However sugar is not the treatment in diabetics for every small symptom. Record times of sugar checking and dates in a notebook for planning of drugs. Lipids and Statins : If there are more cardiovascular risk factors, age > 50 yrs in man, smoking, lower levels of LDL cholesterol are desirable. Daily 75 or 150 mg  of aspirin or statins may decrease risk of heart attacks. Bleeding complications however increase with aspirin.

Regular exercise, monitoring weight, smoking cessation all are essential parts of diabetic care.

Metabolic Syndrome

(Syndrome X, MetS, Insulin Resistance Syndrome)

It is being increasingly identified in the urban population. The importance lies in its association with risk of developing diabetes mellitus and cardiovascular disease. The incidence in South Asian Population during middle age groups is estimated at 30 to 40%.

The criteria for diagnosis (ATPIII) are

  1. Waist circumference >40 inches in man and > 35 inches in woman
  2. Fasting blood glucose >100 mg/dl or treatment for high sugars
  3. BP of >130/85 mm Hg or drug treatment for hypertension
  4. S Triglycerides >150 mg/dl or drug treatment for elevated triglycerides
  5. HDL cholesterol <40 mg/dl in man or <50 mg/dl in woman

Any 3 of these 5 criteria qualify for a diagnosis of metabolic syndrome. In some modifications, waist circumference has been made an essential criterion while in some waist circumference has been modified for different ethnic groups. In South Asians now the waist circumference has been reduced to 90 and 80 cms respectively for man and woman.

The factors associated with high risk for metabolic syndrome are

age, race, weight, postmenopausal status, smoking, lack of physical activity, alcohol intake, household income etc.

The syndrome gains importance as it has been found to

  • Increase risk of diabetes mellitus by 5 to 5 times
  • Risk of Cardiovascular ailments by 5 to 2 times.

It is also associated with increased risk for

  • Chronic kidney disease
  • Fatty liver,(steatosis), fibrosis and cirrhosis of liver
  • Cholangiocarcinoma and hepatocellular carcinoma
  • Obstructive sleep apnea
  • Polycystic ovary syndrome
  • Hyperuricemia and Gout.

Treatment requires multimodality approach with modifications of diet, physical activity, cessation of smoking, and drugs as needed. Aggressive treatment reduces the risk of diseases associated with syndrome X and is thus rewarding.

Treatment of Diabetes Mellitus

Treatment of Diabetes Mellitus

The drug treatment of Diabetes mellitus consists of Insulin therapy and oral hypoglycemic (glucose lowering) drugs. In Type I diabetes insulin injections are almost always required and started at the time of diagnosis. In Type II Diabetes many drugs are available and are tailored to the patients’ needs.

There are some drugs which can result in weight gain (sulfonylureas) and Insulin while some facilitate weight reduction (GLP 1 agonists), Metformin etc. Some of these produce hypoglycemia more often then others (long acting sulfonylureas). While others may not cause hypoglycemia (DPP 4 inhibitors. Some of these are long acting, while others act only for a few hours.

Some of the newer drugs (GLP 1 agonists ) are also available as injections only.

The initial therapy in Type II cases is usually Metformin. The goal of treatment is to bring HbA1C to < 7.

Therapy is usually started when HbA1C is 7.5 to 8.5 or when symptomatic diabetes is present at onset or complications are evident.

All diabetic patients should be familiar with symptoms of hypoglycemia. Meals and exercise both should be regular.

Hypoglycemia should never be neglected and treated as early as possible while taking care that all symptoms in diabetics are not taken as due to hypoglycemia and treated with sugars.

Insulins

These are injectable drugs. They can be injected by patients themselves.

Most are now available as Insulin Pens, where the dose of insulin can be dialled by patients and the pain of injections is negligible. Insulin injections site should be rotated. Always cleaned before injections and monitored for infections.

Various types of insulins are now available. Some are long acting while others may act for a few hours and a third variety may have an intermediate duration of action. Some of these are taken before and some immediately after the food.

Monitoring of diabetes

In children (Type I Diabetes ) sugars need to be monitored more often as high and low sugars are common. Daily sugar check is recommended in most.

In Type II Diabetes, sugar monitoring may be done less often. During checking days, do not alter the diet, exercise or drugs. A true state is required rather than one that pleases the doctor and patient.

Learn to do home glucose monitoring. HbA1C levels are checked once in 3 months or so. Eyes need to be checked every 6 months for changes of diabetic nephropathy.

Kidney check up, heart check up is done every year to detect early diabetic complications.

Feet are examined every day by the patient at home by seeing the sole in a mirror, to look for cuts, ulcers etc.

Treatment of Diabetes in Type II Diabetes Mellitus

Treatment of Diabetes in Type II Diabetes Mellitus

Treatment of diabetes starts with educating patient about this disease. He is also educated about symptoms related to low and high sugar levels so that he can recognise these. He is encouraged to carry a diabetes card with his medication, and the name of his doctor written on it. He is also encouraged to carry with him sugar candies etc near him to treat hypoglycemia. Home blood glucose monitoring can be taught to nearly all patients.

The various risk factors are noted and the complications if any are studied. The goal of treatment is to reduce the sugar to near normal levels to ward off complications of diabetes and reduce risk to life, vital organs while permitting a good quality of life.

Non-pharmacologic measures

To reduce risk of heart disease and stroke, weight should be reduced to normal levels. If a person is overweight (BMI ie Wt in kgs/ ht in meters squared) and BMI is between 25 to 29.9 wt can be reduced gradually to with in limits. If a person is obese BMI >30 then more urgent weight reduction is required.

A weight reduction of about 10 kgs will make a substantial difference in diabetic control

Diet

If overweight or obese calories are cut down. About 15% calories should come from proteins and < 30 % from fats. The rest of calories may be from complex carbohydrates. Simple sugars are not advisable. Sugar substitutes can be taken.

If weight does not reduce after 6 months of trial, weight reduction tablets (Orlistat) etc may be considered. In severe obesity cases bariatric surgery may be the only alternative if all else fails.

Exercise

About 150 mins of exercise in a week is recommended. Aerobic exercises are preferred though in younger patients who do not have heart disease or advanced diabetic retinopathy weight lifting twice a week is encouraged.

The exercise should be done on most days of the week and be sufficiently vigorous to be of cardiac benefit.

Smoking

Smoking is a huge risk factor for heart disease. Since diabetes itself is a high-risk state for angina and myocardial infarction continued smoking increased the risk manifold. Smoking should be stopped totally to reduce this risk.

Drugs are required in nearly all cases for sugar control. More about drugs later.