The need for monitoring

Monitoring is essential to know how well your diabetes is being controlled and whether any remedial steps are necessary to improve the level of control.

Monitoring includes home monitoring and clinical monitoring.

Home Monitoring

There are three steps:

1. Test your blood glucose before each major meal, 2-3 hours post-meal, at bedtime and between 2-4 a.m.
2. Record these results along with the timing and severity of hypoglycemic episodes, if any, in the home monitoring record book.
3. Interpret the results intelligently to assess the need for changes in the treatment regime. 
4. During periods when the carb content of meals has been constant from day the day a “pattern adjustment” of insulin doses can be done.
5. When using “advanced carb counting” with variable carb intake, the pre-meal blood glucose along with the proposed / anticipated carb intake is used to calculate the pre-meal insulin dose and the 2-3 hours post-meal blood glucose tells us whether the calculation was correct.
6. The target blood glucose is usually 70-130 mg% before meals, 100-180 mg% (or 30-60 mg% above the pre-meal value) at 2-3 hours post-meal and 90-180 mg% between 2-4 am.

Clinical Monitoring

This is recommended every three months for the following purposes:

1. Periodic evaluation of long-term control
2. Early detection of complications
3. Assessment of your knowledge and emotional well-being
4. Education reinforcement

Urine Glucose Testing Methods

In the past, urine testing was cumbersome and messy. You had to take 5 ml of urine in a test-tube, add 8 drops of blue solution called Benedict’s solution to it and then boil the tube over a flame. The colour of the precipitate formed on cooling told you the amount of glucose present in your urine sample.

Today, with the availability of urine glucose measuring strips, the procedure takes less than a minute, requires a single drop of urine and of course, no heating is involved. Further these strips can be cut in two lengthwise, thereby halving the cost.

Fallacies in Urine Glucose Testing

Urine glucose testing is far from being the ideal way of monitoring your diabetes control. There are a number of fallacies that must be understood when one relies on this parameter. Three important fallacies are discussed below:

1. Glucose spills into the urine only when the blood glucose exceeds a certain level called the renal threshold. This threshold is usually in the region of 180 mg/dl, but it varies from person to person and also varies in the same person from time to time. Thus, in a person with a high threshold, the urine may remain free of glucose even at very high values of blood glucose, creating a false sense of security. On the other hand, if the renal threshold happens to be low, the reverse would happen, i.e., the urine test would reveal a lot of glucose even though blood glucose is not very high, causing false alarm.
2. Urine tests do not help in diagnosing hypoglycemia. A negative urine test for glucose only means that the blood glucose is below the kidney threshold, i.e., usually below 180 mg/dl. But how much below 180 mg/dl is it? Is it high at 179 or normal at 100 or low at 20? This answer is not provided by urine testing. Obviously then, the only way to confirm a hypo is to test blood glucose.
3. Urine test results do not correlate with blood glucose at the moment of testing. Rather, they reflect an average of blood glucose since urine was last passed. Thus, we often find paradoxical situations such as high glucose reading in urine when the simultaneous blood glucose is actually low. The explanation for this being that the urine tested had been forming and was collecting in the bladder over 4-5 hours during the early part of which the blood glucose had been high.

Does this mean that urine glucose testing should be abandoned?

No! Certainly not. Urine testing is far cheaper, more convenient, painless and easier to perform than home blood glucose testing. Urine tests can provide a lot of useful information if it is done frequently, studying the pattern of glucose excretion. The renal threshold should be known. Knowledge of your meal threshold is mandatory for intelligent interpretation of urine glucose results.

A judicious combination of urine and blood glucose testing would be ideal.

How do you find out your renal threshold?

For this purpose, you will have to test several simultaneous second-void urine samples and blood samples. Studying the correlation between the two will give a fairly good idea about your renal threshold.

What do we mean by second void urine?

Passing the urine and discarding it is the first void sample. Then drink a lot of water and after half an hour pass urine again. This is the second void sample. This urine naturally will correlate well with the current bold glucose level, since it has formed very recently.

Home Blood Glucose Monitoring

Ideally, blood testing should replace urine tests and should be performed 4-5 times a day: before breakfast, before lunch, before dinner, bedtime, and between 2-4 am. This may not always be practical, and hence, we suggest you carry out blood tests at home at least for the following indications:

• Routinely: it is advisable to perform at least two, preferably more than two, home blood glucose monitoring tests daily at a different time of the day (pre-breakfast, post-breakfast, pre-lunch, post-lunch, pre-dinner, bedtime, and between 2-4 am) to study the pattern of blood glucose through the day.
• To confirm a hypo: does a particular symptom represent a hypo? Some symptoms such as palpitations in the chest may be due to a hypo or may merely represent a state of anxiety. Blood glucose monitoring results will provide the answer.
• On sick-days: when sick, you may have to take supplemental insulin at frequent intervals. Blood glucose monitoring is absolutely essential at such times.
• To find out your renal threshold: “Renal threshold” refers to the level of blood glucose at which your kidneys start spilling glucose into the urine. Knowing this has an important bearing on interpretation of urine tests. This can be determined by comparing several second void urine glucose values with simultaneous blood glucose.
• You should perform blood glucose monitoring to find out the correlation between your blood glucose level and how you feel at a given moment, and also to study the effect of particular foods or activities on your blood glucose level.

Home Blood Glucose Monitoring: Methods

Blood glucose monitoring has been made fairly painless and simple with the availability of:

1. Simple blood-letting devices
2. Easy to use strips and easy to operate glucometer

Points to note when using blood glucose monitoring strips:

1. The strips can be cut lengthwise into two thereby reducing the cost by 50%. This is permitted when the reading is to be taken by visual comparison, NOT when you use the meter.
2. Always keep the strips in their bottle and keep the bottle tightly closed, as moisture can damage the strips.
3. Keep the bottle containing the strips in a cool and dry place, away from heat and light.
4. To obtain blood, prick your finger on the sides and not the pulp. This would not only be less painful but also the chances of getting a large drop of blood are higher as this area is more vascular.
5. Let the drop of blood from your finger fall on to the reagent pad of the strip without the finger touching the pad.

Home blood glucose monitoring is meaningful only if:

• You perform it correctly
• You record the results in a diary
• Most important, you analyze the results and take remedial steps based on the results

Merely testing without acting on the results is futile.

Testing Urine for Acetone

Blood glucose testing may be a superior alternative to urine glucose testing, but to detect the build up of acetone in the body, there is no alternative to urine testing, at least not in the home setting.

What is ACETONE?

Acetone is the ‘Ash’ that is left behind when the body take to burning fat instead of glucose for energy.

When does Acetone appear in the urine?

This happens in two diametrically opposite situations:

1. When there is no glucose to burn, in other words, during periods of starvation. In this case, the urine glucose would be negative.
2. When there is a severe deficiency of insulin such that glucose, although present in plenty, cannot be utilized. In this instance, the urine glucose would be 4+. The line of action is to take additional insulin immediately.

How does one test for acetone in urine?

This is done with the help of strips: the GLUKETUR or the KETODIASTIX. These strips have two pads, one for measuring glucose and the other for acetone.

How frequently should one look for acetone?

You must test for acetone at least once each day as a routine. This will help you detect declining diabetes control at an early stage.

Further, whenever your blood glucose is high, it is important to test for urine acetone every 4-6 hours, until you stabilize.

Does a build up of acetone in the body cause any symptoms?

The most important clinical symptoms caused by acetone accumulation (called as “ketosis”) are

• Loss of appetite
• Pain in abdomen
• Vomiting
• Heavy breathing
• Drowsiness
• A peculiar “fruity” odour to the breath

At the same time, all symptoms of high blood glucose (excessive thirst and urination, weakness and weight loss) will be accentuated.

Record Keeping

You must maintain a home monitoring record book in which you jot down:

1. Your insulin dose for the day
2. Your blood/urine glucose and urine acetone results
3. The timing and severity of hypoglycemia attacks if any
4. Your remarks on whether any aberration in diet, physical activity and/or mental stress could have accounted for abnormal test results during the day

This information is to be analyzed by you every 3-4 days to decide whether there is any need to bring about changes in insulin dose/other aspects of therapy.

If you are on a single dose of insulin per day:

• The prelaunch blood/urine results as also hypo episodes are under the influence of the clear (short-acting) insulin.
• The cloudy or intermediate acting insulin controls the blood glucose from the post lunch period until breakfast the next day.

If you take two shots of insulin daily:

• The morning dose of clear insulin controls your pre-lunch results.
• The morning cloudy insulin controls the pre-dinner results,
• The evening clear insulin regulates the blood glucose between dinner and bedtime
• The evening cloudy insulin is responsible for blood glucose control overnight; thus, it controls the pre-breakfast results of the following day.

Armed with the above information, you may now proceed as follows:

• If your blood/urine glucose is high consistently for 3-4 days at a particular time, step up the dose of the appropriate insulin by 1-2 units. For instance, if the pre-dinner values are abnormal, the morning cloudy insulin needs revision.
• In case of symptoms of hypo, note the time when the attack occurs and step down the dose of the appropriate insulin by 1-2 units.
• If you happen to be on a single daily injection, then once your pre-dinner glucose is normal, do not step up the dose of cloudy insulin further if you find elevated glucose levels in the pre-breakfast or bedtime blood/urine samples. This will lead to hypoglycemia in the pre dinner period. Instead, you will need to switch over to 2 injections of insulin per day (after consulting your doctor).

Diabetes Clinic

It is very essential to keep your diabetes well controlled. In most cases, this prevents the development of the dreaded complications of diabetes.

Poorly controlled diabetes, as you all know, can damage the eyes, kidneys, nerves, and the heart.

If you have been careless in the past, it may not yet be too late.

Some of the complications may be reversible if detected and treated at a very early stage.

Regular clinic evaluation is therefore very important to know how well you are controlling your diabetes, whether any remedial steps are called for and for early detection of complications.

When you visit the clinic, you also get an opportunity to pick up any new developments in this rapidly advancing field, and of course, you can meet other diabetic children and their families and share their views and experiences.

Protocol for clinical check-ups

How often? You must report to the clinic at least once a month or earlier if you have any problem.

What does one bring along? Bring your insulin vials and syringes, your blood and urine testing equipments, your home monitoring record book, and your breakfast. Also, bring with you a 15-day diet record.

Clinical check-up

Evaluation of growth in height and weight and physical maturation is necessary. The check-up includes a search for pits (lipoatrophy) and mounds (lipohypertrophy) at insulin sites, for goiter, for limited joint mobility (an inability to approximate the opposing surfaces of your little fingers when doing a Namaste, this finding is sometimes though not invariably associated with diabetic complications in the internal organs), for blood pressure (if elevated, prompt treatment is most crucial), and for liver enlargement (again a sign of poorly controlled diabetes). A detailed examination of your nervous system should also be performed. Once in a year, a fundoscopy (eye check-up for retinopathy) should be performed. For the complete protocol of medical routine tests to be performed, visit …

Continuing medical education clinic visits will go a long way in refreshing your knowledge and keeping you abreast of new developments in this field of childhood diabetes.

Foot Care

Though foot problems are not common in young diabetics, they do manifest later in life after several years of diabetes and with aging.

What leads to a “diabetic foot”?

1. Nerve involvement leads to diminish sensations and so increases the likelihood of trauma and also leads to unawareness of injuries.
2. Diminished blood supply leads to delayed wound healing/gangrene.
3. Proneness to infections in uncontrolled diabetics aggravates the problem.

In order to prevent diabetic foot problems, control diabetes well, prevent injuries, identify foot problems at an early stage, and have them treated promptly and adequately. Take proper daily foot care.

Here are 10 do’s and donts’ for you to follow:

1. Inspect your foot daily for blisters cuts and scratches. Use a mirror to visualize the bottom of the feet.
2. Always remember to look in-between the toes.
3.  Wash feet daily with soap and lukewarm water. Avoid extremes of temperature. Do not soak feet in water for prolonged periods.
4. Dry the feet gently by patting, especially the toe webs. Do not rub the skin hard with rough towel.
5. Soften dry skin and nails with a thin coat of petroleum jelly after batting and drying. Do not put oil or cream in between the toes.
6. If there is moisture in between the toes apply talcum powder.
7. Avoid injuries to the feet: always use footwear (never go barefoot); wear well-fitting shoes (avoid narrow, pointed or high heeled, or open toed shoes); inspect the inside of the shoes daily for nail points, foreign objects or rough areas; cut your nails across after a bath; rub corns/calluses gently with a soft towel after bathing (avoid corn pads; do not cut corns with a blade).
8. Use clean, intact socks and change them daily. Do not use socks with holes or loose threads. Do not use adhesive tape over your feet. Do not use elastic bands.
9. Clean minor injuries/cuts with spirit. Cover the abrasion with a dry gauze piece. Do not use strong antiseptics such as tincture iodine, mercury chrome, etc.
10. Seek urgent medical advice in case of cold feet, redness, colour change, injury, corns, blisters, ingrown nails, interdigital fungal infections. Avoid tobacco.