CLINICAL MONITORING

1. CLINICAL MONITORING Health professionals working in the field of diabetes now recognise that people with diabetes are key members of the diabetes management team and are the deliverers of their own care. Health professionals can support and educate, but it is the person with diabetes who has the responsibility for day-to-day management. In order to do this, the person with diabetes requires appropriate knowledge and skills. The role and responsibility of the health professional is to work in collaboration with people with diabetes in order to enable them to self manage successfully with appropriate knowledge, skills and experience. However self-management is not easy. It takes hard work and lots of trial and error. No one expects that a person can do everything at once or that change occurs quickly and can be sustained. Getting support from family, friends and others with diabetes is critical for success The person with diabetes is central and the interdisciplinary team should keep this as a constant principle of care. Recognising that even though there will be times when it is necessary for the team to be in control, this should always be the exception. Ask the participants to briefly suggest times when the health professional should be in control: DKA Surgery Etc.Health professionals working in the field of diabetes now recognise that people with diabetes are key members of the diabetes management team and are the deliverers of their own care. Health professionals can support and educate, but it is the person with diabetes who has the responsibility for day-to-day management. In order to do this, the person with diabetes requires appropriate knowledge and skills. The role and responsibility of the health professional is to work in collaboration with people with diabetes in order to enable them to self manage successfully with appropriate knowledge, skills and experience. However self-management is not easy. It takes hard work and lots of trial and error. No one expects that a person can do everything at once or that change occurs quickly and can be sustained. Getting support from family, friends and others with diabetes is critical for success The person with diabetes is central and the interdisciplinary team should keep this as a constant principle of care. Recognising that even though there will be times when it is necessary for the team to be in control, this should always be the exception. Ask the participants to briefly suggest times when the health professional should be in control: DKA Surgery Etc.

2. Objectives

3. Importance of self monitoring of blood glucose (SMBG) A person lives with diabetes all the time. They cannot rely on healthcare providers to manage their diabetes on a day-to-day basis. People need to be taught how to self-monitor their diabetes and how to respond to the results. Checking the blood glucose and writing down numbers is not useful unless the person understands what the numbers represent and knows what to do about the results (better planning next time, different food, different activity, different dose of medication). Some people will say they know what their blood glucose is by how they feel. Unfortunately, this is not always the case, especially as the time living with diabetes increases and responses to highs and lows change. Several studies have shown that people who test their blood glucose more often have better HbA1 results. Similar studies have not been done for urine testing. If someone says they know what their blood glucose is, ask them to guess their level and write it down before checking. People are usually quite surprised at the difference! People with diabetes should be encouraged to learn from experience. They should check their blood glucose before eating something “special”, and then check it again 1½ to 2 hours later to see what effect the food has had on their blood glucose level. This can help the person decide whether to eat the food again, or perhaps to have a smaller portion next time. The International Diabetes Federation Clinical Guidelines Task Force, in conjunction with the SMBG International Working Group. Guideline on Self-Monitoring of Blood Glucose in Non-Insulin-Treated Type 2 Diabetes, 2009. Austin M.M., Haas L., Johnson T., Parkin C.G., Parkin C.L., Spollett G., Volpone, M.T.  (2006). AADE Position Statement:  Self-monitoring of blood glucose: benefits and utilization. The Diabetes Educator, 32:835-847.McAndrew L., Schneider, S.H., Burns, E., Levethal, H. (2007). Does patient blood glucose monitoring improve diabetes control? The Diabetes Educator, 33:991-1011.Bode, B.W. (2007). Incorporating postprandial and fasting plasma glucose into clinical management strategies.  Insulin, 2:17-29.Parkin C.G., Hinnen, D., Campbell, K., et al. (2009). Effective Use of Paired Testing in Type 2 Diabetes: Practical Applications in Clinical Practice, The Diabetes Educator, 35, 915. A person lives with diabetes all the time. They cannot rely on healthcare providers to manage their diabetes on a day-to-day basis. People need to be taught how to self-monitor their diabetes and how to respond to the results. Checking the blood glucose and writing down numbers is not useful unless the person understands what the numbers represent and knows what to do about the results (better planning next time, different food, different activity, different dose of medication). Some people will say they know what their blood glucose is by how they feel. Unfortunately, this is not always the case, especially as the time living with diabetes increases and responses to highs and lows change. Several studies have shown that people who test their blood glucose more often have better HbA1 results. Similar studies have not been done for urine testing. If someone says they know what their blood glucose is, ask them to guess their level and write it down before checking. People are usually quite surprised at the difference! People with diabetes should be encouraged to learn from experience. They should check their blood glucose before eating something “special”, and then check it again 1½ to 2 hours later to see what effect the food has had on their blood glucose level. This can help the person decide whether to eat the food again, or perhaps to have a smaller portion next time. The International Diabetes Federation Clinical Guidelines Task Force, in conjunction with the SMBG International Working Group. Guideline on Self-Monitoring of Blood Glucose in Non-Insulin-Treated Type 2 Diabetes, 2009. Austin M.M., Haas L., Johnson T., Parkin C.G., Parkin C.L., Spollett G., Volpone, M.T.  (2006). AADE Position Statement:  Self-monitoring of blood glucose: benefits and utilization. The Diabetes Educator, 32:835-847.McAndrew L., Schneider, S.H., Burns, E., Levethal, H. (2007). Does patient blood glucose monitoring improve diabetes control? The Diabetes Educator, 33:991-1011.Bode, B.W. (2007). Incorporating postprandial and fasting plasma glucose into clinical management strategies.  Insulin, 2:17-29.Parkin C.G., Hinnen, D., Campbell, K., et al. (2009). Effective Use of Paired Testing in Type 2 Diabetes: Practical Applications in Clinical Practice, The Diabetes Educator, 35, 915.

4. Blood glucose monitoring Blood glucose meters are reliable if used properly. Results are available in just a few seconds, and meters are very easy to use. Meters are very small and can be carried around easily. A big disadvantage in almost every country is the cost of the strips. Some countries may have programs to assist people in purchasing the strips. Ask the participants what financial coverage is available in their countries. Some people find pricking the finger painful. However, some meters allow for the blood to be drawn from the arm or the heel of the thumb, which is less painful.Blood glucose meters are reliable if used properly. Results are available in just a few seconds, and meters are very easy to use. Meters are very small and can be carried around easily. A big disadvantage in almost every country is the cost of the strips. Some countries may have programs to assist people in purchasing the strips. Ask the participants what financial coverage is available in their countries. Some people find pricking the finger painful. However, some meters allow for the blood to be drawn from the arm or the heel of the thumb, which is less painful.

5. Blood glucose monitoring How often a person should check is defined by the individual and what information is required. There is no right or wrong time to check! People should be told to check as often as they want to know a result. Finances may limit the frequency of monitoring, but people can be shown how to stagger times over a period of time to show results over the whole day. People should monitor frequently enough to be able to identify patterns or trends in their results that are reflective of the level of glycaemic control.How often a person should check is defined by the individual and what information is required. There is no right or wrong time to check! People should be told to check as often as they want to know a result. Finances may limit the frequency of monitoring, but people can be shown how to stagger times over a period of time to show results over the whole day. People should monitor frequently enough to be able to identify patterns or trends in their results that are reflective of the level of glycaemic control.

6. Activity

7. Blood glucose monitoring People may find filling in the diary boring and tedious. Indeed, many people do checks but never write the results down. The problem is that while they may have an idea of what is going on at the time of the check, they never see patterns in their levels. In order to ensure good self-management, it is important that people recognize and act on patterns. Diaries of blood glucose results allow the person with diabetes and the health professional to review the day-to-day management. Sometimes people with diabetes will only record the results that they want the health professional to see. Be sure to develop a trusting relationship with the people in your care so that they record all results. Tell them that it is just as important for you to see the results that are out of range as it is to see the ones that are in range. Encourage people with diabetes to add their comments to their diaries, such as food eaten or activity undertaken. This will help explain highs and lows. A good diary is one of the keys to self-management. Stress that the diary will help them manage their condition, it is not just for the health professional.People may find filling in the diary boring and tedious. Indeed, many people do checks but never write the results down. The problem is that while they may have an idea of what is going on at the time of the check, they never see patterns in their levels. In order to ensure good self-management, it is important that people recognize and act on patterns. Diaries of blood glucose results allow the person with diabetes and the health professional to review the day-to-day management. Sometimes people with diabetes will only record the results that they want the health professional to see. Be sure to develop a trusting relationship with the people in your care so that they record all results. Tell them that it is just as important for you to see the results that are out of range as it is to see the ones that are in range. Encourage people with diabetes to add their comments to their diaries, such as food eaten or activity undertaken. This will help explain highs and lows. A good diary is one of the keys to self-management. Stress that the diary will help them manage their condition, it is not just for the health professional.

8. Keeping a diary This diary on the left is not a good example of a log book. As you can see, this person had no idea why she was checking her blood glucose so often because there is no attempt to separate days or time of day. However, this log book can tell you something about the person. These results are in mmols/L so there should be a decimal (“.”) between most numbers. Her overall levels are mostly in target range. Reviewing this log book should make the educator question literacy level of the person with diabetes – this needs to be assessed further. The diary on the right is another example. This logbook offers clear data gathered from SMBG, from the person’s daily life and the affect of their diabetes management.This diary on the left is not a good example of a log book. As you can see, this person had no idea why she was checking her blood glucose so often because there is no attempt to separate days or time of day. However, this log book can tell you something about the person. These results are in mmols/L so there should be a decimal (“.”) between most numbers. Her overall levels are mostly in target range. Reviewing this log book should make the educator question literacy level of the person with diabetes – this needs to be assessed further. The diary on the right is another example. This logbook offers clear data gathered from SMBG, from the person’s daily life and the affect of their diabetes management.

9. Blood glucose monitoring This is some of the information that can be determined by monitoring. Note to the educator: Ask the group for more examples.This is some of the information that can be determined by monitoring. Note to the educator: Ask the group for more examples.

10. Post-meal glucose monitoring Post-meal monitoring is particularly important when there is suspected hyperglycaemia at that time. For instance if the HbA1c is elevated but the pre-meal glucose results are within normal range, one would suspect high post-meal levels. For people taking rapid-acting oral agents or rapid-acting insulin, post-meal monitoring reveals the efficacy of the medication. There is now increasing evidence that post-meal hyperglycaemia is associated with increasing cardiovascular risk. Ceriello, A., Hanefeld, M., Leiter, L., et al. (2004). Postprandial glucose regulation and diabetic complications. Archives of Internal Medicine, 164(19), 2090-5. Parkin CG, Hinnen D, Campbell K et al. (2009). Effective Use of Paired Testing in Type 2 Diabetes: Practical Applications in Clinical Practice. The Diabetes Educator, 35, 915. Post-meal monitoring is particularly important when there is suspected hyperglycaemia at that time. For instance if the HbA1c is elevated but the pre-meal glucose results are within normal range, one would suspect high post-meal levels. For people taking rapid-acting oral agents or rapid-acting insulin, post-meal monitoring reveals the efficacy of the medication. There is now increasing evidence that post-meal hyperglycaemia is associated with increasing cardiovascular risk. Ceriello, A., Hanefeld, M., Leiter, L., et al. (2004). Postprandial glucose regulation and diabetic complications. Archives of Internal Medicine, 164(19), 2090-5. Parkin CG, Hinnen D, Campbell K et al. (2009). Effective Use of Paired Testing in Type 2 Diabetes: Practical Applications in Clinical Practice. The Diabetes Educator, 35, 915.

11. Blood glucose targets It is important that targets be individualised for people with diabetes depending on their specific needs. For example, the targets for young children or the elderly may be different from the average person. The targets in mmol/L are from the Canadian Diabetes Association Clinical Practice Guidelines. The targets in mg/dl are from the American Diabetes Association Clinical Practice Guidelines. IDF. (2007). Guideline for Management of Postmeal Glucose. Brussels: International Diabetes Federation. American Diabetes Association. (2010). Standards of Medical Care. Diabetes Care, 33(suppl 1), S19. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2008). Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diab 2008, 32(suppl 1). IDF Clinical Guidelines Task Force. (2005). Global Guideline for Type 2 Diabetes. Brussels: International Diabetes Federation. It is important that targets be individualised for people with diabetes depending on their specific needs. For example, the targets for young children or the elderly may be different from the average person. The targets in mmol/L are from the Canadian Diabetes Association Clinical Practice Guidelines. The targets in mg/dl are from the American Diabetes Association Clinical Practice Guidelines. IDF. (2007). Guideline for Management of Postmeal Glucose. Brussels: International Diabetes Federation. American Diabetes Association. (2010). Standards of Medical Care. Diabetes Care, 33(suppl 1), S19. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2008). Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diab 2008, 32(suppl 1). IDF Clinical Guidelines Task Force. (2005). Global Guideline for Type 2 Diabetes. Brussels: International Diabetes Federation.

12. Activity Note to the educator: Discuss with your group the common problems people encounter with blood glucose monitoring. Ask them to find reasons for each of the above problems. If results do not coincide with how one feels, perhaps: The meter is wrong, old dirty, not coded properly The strips are out of date The strips have been left open to the air There is interference from other medication If the person cannot get enough blood on the strip, ask them to ensure that: The side of the finger is poked The finger is gently milked, not squeezed If it hurts to prick the finger, recommend: Adjusting the depth of the lancing device Trying another finger Being sure to use the side Using an alternate site, such as the forearm, if using an appropriate meter In case the results do not reflect the HbA1c, check if: The person is writing all results in the diary The person is checking at times known to be high The memory on the meter is functioning correctly The number of results is sufficient to reflect the average. The meter may be reading mg/dL instead of mmol/L or vice versa Note to the educator: Discuss with your group the common problems people encounter with blood glucose monitoring. Ask them to find reasons for each of the above problems. If results do not coincide with how one feels, perhaps: The meter is wrong, old dirty, not coded properly The strips are out of date The strips have been left open to the air There is interference from other medication If the person cannot get enough blood on the strip, ask them to ensure that: The side of the finger is poked The finger is gently milked, not squeezed If it hurts to prick the finger, recommend: Adjusting the depth of the lancing device Trying another finger Being sure to use the side Using an alternate site, such as the forearm, if using an appropriate meter In case the results do not reflect the HbA1c, check if: The person is writing all results in the diary The person is checking at times known to be high The memory on the meter is functioning correctly The number of results is sufficient to reflect the average. The meter may be reading mg/dL instead of mmol/L or vice versa

13. Continuous glucose monitoring (CGM) Continuous glucose monitoring (CGM) systems use a tiny sensor inserted under the skin to check glucose levels in tissue fluid. The sensor stays in place for several days to a week and then must be replaced. A transmitter sends information about glucose levels via radio waves from the sensor to a pager-like wireless monitor. The user must check blood samples (fingerstick) with a glucose meter to program the device. Glucose levels in interstitial fluid lag temporally behind blood glucose values. People with diabetes require traditional fingerstick measurements for calibration (typically twice per day) and are often advised to use fingerstick measurements to confirm hypo- or hyperglycaemia before taking corrective action and making a change in treatment. CGM is useful for professional use at hospital and personal use at home. It shows real time glucose levels. The software is useful for retrospective analysis. Continuous glucose monitoring (CGM) systems use a tiny sensor inserted under the skin to check glucose levels in tissue fluid. The sensor stays in place for several days to a week and then must be replaced. A transmitter sends information about glucose levels via radio waves from the sensor to a pager-like wireless monitor. The user must check blood samples (fingerstick) with a glucose meter to program the device. Glucose levels in interstitial fluid lag temporally behind blood glucose values. People with diabetes require traditional fingerstick measurements for calibration (typically twice per day) and are often advised to use fingerstick measurements to confirm hypo- or hyperglycaemia before taking corrective action and making a change in treatment. CGM is useful for professional use at hospital and personal use at home. It shows real time glucose levels. The software is useful for retrospective analysis.

14. CGM is beneficial for CGM is beneficial in different groups and conditions with diabetes. CGM in conjunction with intensive insulin regimens can be a useful tool to lower A1C in selected adults (over age 25 years) with type 1 diabetes. Although the evidence for A1C lowering is less strong in children, teens, and younger adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing use of the device. CGM may be a supplemental tool to SMBG in those with hypoglycaemia unawareness and/or frequent hypoglycaemic episodes. American Diabetes Association. Standards of Medical Care in Diabetes—2010 A, Diabetes Care, 2010; 33(Supp 1): S17 JDRF Continuous Glucose Monitoring Study Group, Continuous glucose monitoring and intensive treatment of type 1 diabetes, N Engl J Med. 2008 Oct 2;359(14):1464-76. Intermittent use of CGM is recommended for youth with type 1 diabetes having nocturnal hypoglycaemia/dawn phenomenon, hypoglycaemia unawareness and postprandial hyperglycaemia. AACE Consensus Statement, A Continuous Glucose Monitoring, Endoc Pract, 2010; 16(5). CGM is beneficial in different groups and conditions with diabetes. CGM in conjunction with intensive insulin regimens can be a useful tool to lower A1C in selected adults (over age 25 years) with type 1 diabetes. Although the evidence for A1C lowering is less strong in children, teens, and younger adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing use of the device. CGM may be a supplemental tool to SMBG in those with hypoglycaemia unawareness and/or frequent hypoglycaemic episodes. American Diabetes Association. Standards of Medical Care in Diabetes—2010 A, Diabetes Care, 2010; 33(Supp 1): S17 JDRF Continuous Glucose Monitoring Study Group, Continuous glucose monitoring and intensive treatment of type 1 diabetes, N Engl J Med. 2008 Oct 2;359(14):1464-76. Intermittent use of CGM is recommended for youth with type 1 diabetes having nocturnal hypoglycaemia/dawn phenomenon, hypoglycaemia unawareness and postprandial hyperglycaemia. AACE Consensus Statement, A Continuous Glucose Monitoring, Endoc Pract, 2010; 16(5).

15. A1c (1 of 4) The HbA1c result gives an average of the blood glucose over the past three months but is weighted to the last 4 to 6 weeks, meaning that the more recent glucose levels impact the result more. The person with diabetes does not have to fast for this test. People with diabetes often get confused between their HbA1c and their blood glucose results. They can think the numbers mean the same. Therefore, it is important to explain the difference in a clear but simple manner. The HbA1c result gives an average of the blood glucose over the past three months but is weighted to the last 4 to 6 weeks, meaning that the more recent glucose levels impact the result more. The person with diabetes does not have to fast for this test. People with diabetes often get confused between their HbA1c and their blood glucose results. They can think the numbers mean the same. Therefore, it is important to explain the difference in a clear but simple manner.

16. A1c (2 of 4) For most people the target HbA1c is less than 6.5%. Some people will experience too much hypoglycaemia when they try to lower the HbA1c below 7%. If the HbA1c is not within target range, then intensification of management should be implemented. This could mean: 1. A better meal plan and/or more physical activity 2. Increasing the oral medication or adding oral medication from a different class 3. Adding insulin in type 2 diabetes, usually at bedtime, to the oral medication 4. Intensifying the insulin regimen International Diabetes Federation. (2005). Global Guideline for Type 2 Diabetes. Brussels. For most people the target HbA1c is less than 6.5%. Some people will experience too much hypoglycaemia when they try to lower the HbA1c below 7%. If the HbA1c is not within target range, then intensification of management should be implemented. This could mean: 1. A better meal plan and/or more physical activity 2. Increasing the oral medication or adding oral medication from a different class 3. Adding insulin in type 2 diabetes, usually at bedtime, to the oral medication 4. Intensifying the insulin regimen International Diabetes Federation. (2005). Global Guideline for Type 2 Diabetes. Brussels.

17. A1c (3 of 4) The frequency of testing HbA1c is dependent on the treatment regimen used and the clinical judgment of the treating physician or team member. Some experts recommend testing HbA1c at least two times a year for those with good metabolic control and more frequently for those who are not well controlled or whose treatment has been changed. International Diabetes Federation. (2005). Global Guideline for Type 2 Diabetes. Brussels. The frequency of testing HbA1c is dependent on the treatment regimen used and the clinical judgment of the treating physician or team member. Some experts recommend testing HbA1c at least two times a year for those with good metabolic control and more frequently for those who are not well controlled or whose treatment has been changed. International Diabetes Federation. (2005). Global Guideline for Type 2 Diabetes. Brussels.

18. A1c (4 of 4) HbA1c is referred to as A1C in many countries. Certain conditions will cause the HbA1c test to be inaccurate such as haemolytic diseases such as sickle cell anaemia, and high levels of haemoglobin F, S or C. Sickle cell trait may affect some assays and many may not know they have the trait. As well as profound blood loss, severe anaemia or recent blood transfusion may cause the HbA1c to be inaccurate. American Diabetes Association. (2010). Standards of Medical Care. Diabetes Care, 33(suppl 1), S19.HbA1c is referred to as A1C in many countries. Certain conditions will cause the HbA1c test to be inaccurate such as haemolytic diseases such as sickle cell anaemia, and high levels of haemoglobin F, S or C. Sickle cell trait may affect some assays and many may not know they have the trait. As well as profound blood loss, severe anaemia or recent blood transfusion may cause the HbA1c to be inaccurate. American Diabetes Association. (2010). Standards of Medical Care. Diabetes Care, 33(suppl 1), S19.

19. Correlation of A1c with average glucose American Diabetes Association. (2010). Standards of Medical Care. Diabetes Care, 33(suppl 1), S19. American Diabetes Association. (2010). Standards of Medical Care. Diabetes Care, 33(suppl 1), S19.

20. Urine glucose testing Urine glucose testing is widely used in some developing countries, and may be the only viable monitoring method that people can access. It is simple, inexpensive and provides information on hyperglycaemia. There are, however, limitations: results are semi-qualitative and give no information on hypoglycaemia. Urine testing is not as informative as blood glucose monitoring for the following reasons: Renal threshold – it is only when the blood glucose is above the renal threshold that glucose starts to show in the urine. The renal threshold is usually about 12 mmol/L (216 mg/dl) but varies from one person to another: in the elderly it may increase; in pregnancy it may decrease. The result will show negative anywhere below the renal threshold. 2. Time delay – blood glucose results tell you the level at the time. Urine glucose results are delayed by 1 to 2 hours as the glucose gets through the kidneys and the person urinates. This means that the urine glucose you see reflects the blood glucose levels several hours in the past. 3. Colour dependant – urine tests rely on the person being able to match the colour on the strip to the colour on the bottle. As people age, their ability to decipher small changes in colour may be compromised. However, if meters are not available, urine testing provides a viable alternative. Remember that it will never indicate when glucose is low but only when it is high.Urine glucose testing is widely used in some developing countries, and may be the only viable monitoring method that people can access. It is simple, inexpensive and provides information on hyperglycaemia. There are, however, limitations: results are semi-qualitative and give no information on hypoglycaemia. Urine testing is not as informative as blood glucose monitoring for the following reasons: Renal threshold – it is only when the blood glucose is above the renal threshold that glucose starts to show in the urine. The renal threshold is usually about 12 mmol/L (216 mg/dl) but varies from one person to another: in the elderly it may increase; in pregnancy it may decrease. The result will show negative anywhere below the renal threshold. 2. Time delay – blood glucose results tell you the level at the time. Urine glucose results are delayed by 1 to 2 hours as the glucose gets through the kidneys and the person urinates. This means that the urine glucose you see reflects the blood glucose levels several hours in the past. 3. Colour dependant – urine tests rely on the person being able to match the colour on the strip to the colour on the bottle. As people age, their ability to decipher small changes in colour may be compromised. However, if meters are not available, urine testing provides a viable alternative. Remember that it will never indicate when glucose is low but only when it is high.

21. Urine ketone testing Urine ketones are the result of fatty acids that break down to give the body a form of energy from fat. They are present in the urine for different reasons.   If the person is starving or losing weight they will show ketones in the urine. In this situation the ketones are often “starvation ketones”. These are not dangerous and just show that the person is burning fat for energy as they have reduced their energy intake. However, in the presence of hyperglycaemia, ketones indicate a relatively inadequate level of insulin and are a sign of potential ketoacidosis. They need to be taken seriously. Urine ketones are the result of fatty acids that break down to give the body a form of energy from fat. They are present in the urine for different reasons.   If the person is starving or losing weight they will show ketones in the urine. In this situation the ketones are often “starvation ketones”. These are not dangerous and just show that the person is burning fat for energy as they have reduced their energy intake. However, in the presence of hyperglycaemia, ketones indicate a relatively inadequate level of insulin and are a sign of potential ketoacidosis. They need to be taken seriously.

22. Blood ketone monitoring The ability to check blood for ketones in the home setting is available in some areas of the world. This home test allows for the very early detection of ketones and therefore is an indication of impending diabetic ketoacidosis (DKA). People with type 1 diabetes, especially children, should check for blood ketones when ill or if blood glucose levels are elevated and should know what to do to prevent the development of DKA.The ability to check blood for ketones in the home setting is available in some areas of the world. This home test allows for the very early detection of ketones and therefore is an indication of impending diabetic ketoacidosis (DKA). People with type 1 diabetes, especially children, should check for blood ketones when ill or if blood glucose levels are elevated and should know what to do to prevent the development of DKA.

23. Lipid and blood pressure targets This chart shows target values as recommended in evidenced-based clinical practice guidelines. IDF Clinical Guidelines Task Force. (2005). Global Guideline for Type 2 Diabetes. Brussels: International Diabetes Federation. American Diabetes association. (2010). Standards of Medical Care. Diabetes Care, 33(suppl 1), S19. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2008). Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diab, 32(suppl 1). This chart shows target values as recommended in evidenced-based clinical practice guidelines. IDF Clinical Guidelines Task Force. (2005). Global Guideline for Type 2 Diabetes. Brussels: International Diabetes Federation. American Diabetes association. (2010). Standards of Medical Care. Diabetes Care, 33(suppl 1), S19. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2008). Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diab, 32(suppl 1).

24. Urinary albumin target values The ACR is a random urine test. If positive the first time it must be repeated twice between 12 weeks and 2 months apart. If two out of three are positive the person is said to have microalbuminurea. IDF Clinical Guidelines Task Force. (2005). Global Guideline for Type 2 Diabetes. Brussels: International Diabetes Federation. American Diabetes association. (2010). Standards of Medical Care. Diabetes Care, 33(suppl 1), S19. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2008). Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diab, 32(suppl 1). The ACR is a random urine test. If positive the first time it must be repeated twice between 12 weeks and 2 months apart. If two out of three are positive the person is said to have microalbuminurea. IDF Clinical Guidelines Task Force. (2005). Global Guideline for Type 2 Diabetes. Brussels: International Diabetes Federation. American Diabetes association. (2010). Standards of Medical Care. Diabetes Care, 33(suppl 1), S19. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2008). Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diab, 32(suppl 1).

25. Summary Studies have shown that self-monitoring of blood glucose results in improved HbA1c for both people with type 1 diabetes and type 2 diabetes. Although monitoring itself does not improve the blood glucose, being aware of the level of blood glucose may result in the person making choices that result in lower glucose levels. Self-monitoring of blood glucose is especially helpful in lowering HbA1c if the person understands the results and knows how to make adjustments to the management plan. Studies have shown that self-monitoring of blood glucose results in improved HbA1c for both people with type 1 diabetes and type 2 diabetes. Although monitoring itself does not improve the blood glucose, being aware of the level of blood glucose may result in the person making choices that result in lower glucose levels. Self-monitoring of blood glucose is especially helpful in lowering HbA1c if the person understands the results and knows how to make adjustments to the management plan.

26. References