Home Management:

Glucose (Blood Sugar) Levels

Both low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia) are of concern for patients who take insulin. It is important, therefore, to carefully monitor blood glucose levels. In general, patients with type 1 diabetes need to take readings four or more times a day. Patients should aim for the following measurements:

• Pre-meal glucose levels of 90 - 130 mg/dL
• Bedtime levels of 110 - 150 mg/dL

Different goals may be required for specific individuals, including pregnant women, very old and very young people, and those with accompanying serious medical conditions.

Finger-Prick Test. A typical blood sugar test includes the following:

• A drop of blood is obtained by pricking the finger.
• The blood is then applied to a chemically treated strip.
• Monitors read and provide results.

Home monitors are about 10 - 15% less accurate than laboratory monitors, and many do not meet the standards of the American Diabetes Association. Most doctors believe, however, that they are accurate enough to indicate when blood sugar is too low.

To monitor the amount of glucose within the blood a person with diabetes should test their blood regularly. The procedure is quite simple and can often be done at home.

Some simple procedures may improve accuracy:

• Testing the meter once a month.
• Recalibrating it whenever a new packet of strips is used.
• Using fresh strips; outdated strips may not provide accurate results.
• Keeping the meter clean.
• Periodically comparing the meter results with the results from a laboratory.

Supplementary Monitoring Devices. Other devices are available for monitoring blood glucose. These devices are used in addition to traditional fingerstick test kits, and glucose meters but do not replace them:

• Continuous glucose monitoring systems (CGMS) use a needle-like sensor inserted under the skin of the abdomen to monitor glucose levels every 5 minutes. In 2007, the STS-7 System was approved. Using a disposable sensor, the STS-7 measures glucose levels for up to a week. An alarm will sound if glucose levels are too high or low. The older Minimed system measures glucose over a 72-hour period and has wireless communication between the monitor and an insulin pump.
• GlucoWatch is a battery-powered wristwatch-like device that measures glucose by sending tiny electric currents through the skin, a technique called reverse iontophoresis. It is painless and has a warning device when detecting high glucose levels. It takes 2 hours to warm up, and the sensor pads need to be changed every day. Glucowatch measures glucose levels three times per hour for up to 12 hours. About a quarter of the time, the results differ significantly from actual fingerstick tests, however.

Glycosylated Hemoglobin

Hemoglobin A1c (also called HbA1c , HA1c, or A1C) is measured periodically every 2 - 3 months, or at least twice a year, to determine the average blood-sugar level over the lifespan of the red blood cell. While fingerprick self-testing provides information on blood glucose for that day, the HbA1c test shows how well blood sugar has been controlled over the period of several months. For most people with well-controlled diabetes, HbA1c levels should be below 7%. Home tests are available for measuring A1C but they tend not to be as accurate as the laboratory tests ordered by doctors.

Urine Tests

Urine tests are useful for detecting the presence of ketones. These tests should always be performed during illness or stressful situations, when diabetes is likely to go out of control. The patient should also undergo yearly urine tests for microalbuminuria (small amounts of protein in the urine), a risk factor for future kidney disease.

Preventing Hypoglycemia

The following tips may help avoid hypoglycemia or prepare for attacks.

• Bedtime snacks are advisable if blood glucose levels are below 180 mg/dL (10 mmol/L). Protein snacks may be best.
• Some research has suggested that children (particularly thin children) are at higher risk for hypoglycemia because the injection goes into muscle tissue. Pinching the skin so that only fat (and not muscle) tissue is gathered or using shorter needles may help.
• Various insulin regimens are available that can reduce the risk. For example, taking a fast-acting insulin (insulin lispro) before the evening meal may be particularly helpful in preventing hypoglycemia at bedtime or during the night.
• Patients who intensively control their blood sugar should monitor blood levels as often as possible, four times or more per day. This is particularly important for patients with hypoglycemia unawareness.
• In adults, it is particularly critical to monitor blood glucose levels before driving, when hypoglycemia can be very hazardous.
• Patients who are at risk for hypoglycemia should always carry hard candy, juice, sugar packets, or commercially available glucose substitutes.

Family and friends should be aware of the symptoms and be prepared:

• If the patient is helpless (but not unconscious), family or friends should administer three to five pieces of hard candy, two to three packets of sugar, half a cup (four ounces) of fruit juice, or a commercially available glucose solution.
• If there is inadequate response within 15 minutes, the patient should receive additional sugar by mouth and may need emergency medical treatment, possibly including an intravenous glucose solution.
• Family members and friends can learn to inject glucagon, a hormone, which, in contrast to insulin, raises blood glucose.

Patients with type 1 diabetes should always wear a medical alert ID bracelet or necklace that states that they have diabetes and take insulin.

Foot Care

Measures to Prevent Foot Ulcers. Preventive foot care can significantly reduce the risk of ulcers and amputation. Some tips for preventing problems include:

• Patients should inspect their feet daily and watch for changes in color or texture, odor, and firm or hardened areas, which may indicate infection and potential ulcers.
• When washing the feet, the water should be warm (not hot) and the feet and areas between the toes should be thoroughly dried afterward. Check water temperature with the hand or a thermometer before stepping in.
• Apply moisturizers, but NOT between the toes.
• Gently use pumice to remove corns and calluses (patients should not use medicated pads or try to shave the corns or calluses themselves).
• Trim toenails short and file the edges to avoid cutting adjacent toes.
• Well-fitting footwear is very important. People should be sure the shoe is wide enough. Patients should also avoid high heels, sandals, thongs, and going barefoot. Shoes with a rocker sole reduce pressure under the heel and front of the foot and may be particularly helpful. Custom-molded boots increase the surface area over which foot pressure is distributed. This reduces stress on the ulcers and allows them to heal.
• Change shoes often during the day.
• Wear socks, particularly with extra padding (which can be specially purchased).
• Patients should avoid tight stockings or any clothing that constricts the legs and feet.
• Consult a specialist in foot care for any problems.