Type 1 Diabetes: Latest ADA Recommendations for Self-Blood Glucose Monitoring
The latest recommendations for Standards of Diabetes Care have been published online head of print (American Diabetes Association. Diabetes Care. 2012;doi: 10.2337/dc13-S003). Today I would like to share the recommendations that pertain to children and adolescents with type 1 diabetes. These recommendations are consistent with my previous comments and only serve to reinforce the significance and importance of blood glucose monitoring.
- Children and adolescents using insulin pump therapy or basal bolus therapy with multiple injections should perform self monitoring of blood glucose (SMBG).
- Before meals and snacks
- 2-3 hours after eating as much as possible
- At bedtime
- Prior to exercise
- When there are symptoms or suspicion of low blood sugars
- Post treating low blood sugars to make sure they are in range
- Prior to certain behaviors such as driving when low blood sugars may place you at significant risk
There is nothing new in these recommendations--they are now just stated more clearly than test at least 3 times/day.
- In terms of understanding glucose patterns, SMBG results truly help guide treatment decisions as well as parent/child/adolescent self-management, even for patients using 2-3 injections/day (such as conventional split-mixed insulin therapy with NPH/regular or rapid acting insulin).
- SMBG is an ongoing process that requires daily evaluation, telephone follow-up of patterns, and allows the physician during office visits to adjust insulin therapy.
- Continuous glucose monitoring (CGM) when utilized with intensive insulin regimens (basal bolus therapy/insulin pump therapy) “can be useful tool to lower A1c in selected adults (aged 25>/= years) with type 1 diabetes.”
- There is evidence, although less powerful, that CGM may lower A1c in children, teens, and young adults (emerging adults to 25 years of age). However, as I have mentioned, application of CGM is only useful if the child/adolescent/emerging adult uses the device consistently. (I should note that some people with diabetes use CGM one week/month to analyze blood sugar patterns when there is an increase in fluctuation of blood sugars.)
- CGM may be used as a very helpful tool in association with SMBG in those that experience frequent low blood sugars, hypoglycemia awareness as well as post-exercise induced hypoglycemia.
Evidence-based data from patients treated with intensive insulin therapy have clearly demonstrated that SMBG is a significant tool in helping to decrease microvascular (kidney, eye, nerves) as well as macrovascular (cardiac) complications. Increased frequency of SMBG is directly correlated to lower hb A1cs. According to the recommendations, SMBG enables patients to evaluate their own response to therapy and determine whether their glycemic goals are being achieved, allowing immediate feedback. As such, SMBG values are indeed useful in preventing low blood sugar and adjusting insulin doses (based on insulin/carb ratios and correction factors), medical nutrition therapy, and physical activity.
What is the suggested number of blood glucose checks /day? According to the ADA recommendations, 6-8 checks/day is suggested for most people on intensive insulin therapies (basal/bolus and insulin pump). However, many people choose to test more frequently. The recommendations site a database study of almost 27,000 children and adolescents with type 1 diabetes that demonstrated (as I mentioned above) “increased daily frequency of SMBG was significantly associated with lower A1c (-0.2 percent per additional test per day, leveling off at 5 tests/day) and with fewer acute complications.”
TAKE HOME MESSAGE: At least: Check, check, check, check, check, check/day and bolus/bolus/bolus/bolus /bolus for all meals and snacks based on your insulin/carbohydrate ratio and correction factor (insulin sensitivity factor) if you are using intensive insulin therapy (basal/bolus or insulin pump).