Meters & Monitoring

Monitoring of blood glucose levels and also monitoring of other blood chemistry tests together with monitoring for any alarming symptoms or signs are the corner stone of proper living with diabetes . blood glucose testing is essential for all people with diabetes. Typically a person measures their own glucose level with a meter and strips at homewhich is called Self Monitoring of Blood Glucose SMBG . its aim is to achieve an optimal glucose level nearer to the normal level as much as possible. testing is very important because the blood sugar level cannot be accurately determined by symptoms alone , so we should never rely on the symptoms and signs related to hyperglycemia to define if the blood sugar is normal or abnormal , the only tool to know the blood glucose level is simply to measure it .

Monitoring of blood glucose levels should be frequent and continuous as far as possible and so arising the importance of taking charge management which means that the patients should have an active role in controlling the blood glucose levels . Testing blood sugar often is the main mission of this management policy , however still there is a need to test more than just blood sugar. some tests usually done by the doctor or the lab like Hemoglobin or A1C testing, which gives an impression about the average blood sugar level over the last 3 months; also there is a need for ketone testing, which is an indicator for ketoacidosis. also continuous measurement of weight, blood pressure and blood fats are of great importance .
Again blood sugar levels either high or low could not at all be suggested only by symptoms and signs , many people think they can tell what their blood sugar is by how they feel and this is absolutely wrong. Some people can feel "high" when their blood sugar is low, and some can feel "low" when their blood sugar is normal or high. The only way to know for sure is to measure the blood sugar. testing also reflects the effects of various factors on blood glucose levels such as behavior , exercise , eating ….etc

The most recent and important studies support the fact that prevention and minimizing complications are strongly related to the good control of blood glucose which is achieved by proper management and frequent testing .

  • Diabetes Control and Complications Trial DCCT
  • The United Kingdom Prospective Diabetes Study UKPDS
  • The Kumamoto Study

The Kumamoto study was for people with type 2 diabetes. This study had similar results to the DCCT. People with good control had fewer problems with their eyes, kidneys and nerve damage.

Blood Glucose Level Targets:
Pre-meals 80-120 mg/dl
Post-meals--2 hours less than 180 mg/dl
Bedtime 100-140 mg/dl

How often testing is required ?

The frequency and timing of tests will vary depending on an individual's basis , type of therapy ( insulin , tablets or both ) , goals of that therapy ( conventional or intensive ) , and the presence or absence of the complications . the changes in food, exercise, medications, illness, or travel usually need more testing .

  • Type 1: before meals and bedtime, 1-2 hours after meals and during night as needed.
  • Type 2: before meals and/or bedtime, 1-2 hours after meals as needed.

Before testing, have your health care provider show you the best techniques. When testing be sure to follow the manufacturer's directions and these helpful suggestions:

  • Wash your hands (anything on your hands can change the reading).
  • Collect the amount of blood required.
  • Test again if reading seems incorrect. Use another meter to double check.
  • Clean your meter as often as required.
  • Record and date/time your test results

Here are some tips for accurate readings:

  • Be sure to match the code on the meter or the meter's code chip with the code on the strip container.
  • Check the date on the strips for freshness.
  • Store strips so they don't deteriorate (protect from heat, light, and humidity)
  • Check for low battery if results aren't accurate

Be sure to keep a good record of all tests. Discuss blood glucose goal ranges with your health care provider. Discuss how and when to make changes to your diabetes care--food, exercise, medications, insulin doses. A hemoglobin A1c test is a simple lab test that shows the average blood sugar level for the past two to three months.

You and your healthcare team have set up a plan to help you control your blood sugar. One of the best ways to be sure your plan is working is to test your blood sugar yourself. Research shows that good control of blood sugar can lower your risk of eye disease, kidney disease and nerve damage that can develop due to diabetes. Self-testing lets you learn how diabetes makes your body react to daily events. You can answer questions like, "What happens to my blood sugar during times of stress or when I am sick?" or "What happens to my blood sugar when I exercise?" Self-testing can help you decide how to take better care of yourself .
The more you test, the more you will know about your blood sugar control. Many things affect your blood sugar each day, like eating, exercise, medication, illness and stress. So, it is important to test your blood sugar at different times of the day. Research studies show that testing your blood sugar daily, up to 4 times or more, is a good way to learn how to better control your blood sugar. Good control of blood sugar will help you lower your risk of future problems with diabetes. Self-testing gives you the information you need to avoid too many high or low blood sugar levels day-to-day. Your healthcare team will help you decide how often to test.
Your healthcare team will also help you decide when to test. Testing at different times is a good idea. Here are some useful times to choose from:· Before breakfast. This is called the fasting blood sugar. Fasting means you have not had any food in 8 hours or more.

  • 1-2 hours after breakfast. This is called the postprandial blood sugar.
  • Before lunch.
  • 1-2 hours after lunch.
  • Before supper.
  • 1-2 hours after supper.
  • Before bedtime.
  • At 2:00 or 3:00 a.m., if you take insulin.

It is a good idea to do extra tests when:

  • There are changes in your treatment plan.
  • You start a new medication for diabetes.
  • You think your blood sugar might be too low or high.
  • You are sick.

Blood sugar levels 1 to 2 hours after eating are called postprandial. Research shows that blood sugar levels in people with diabetes can more than double after eating, even when their blood sugar before eating is normal. It is helpful to talk about your fasting and postprandial sugar goals with your healthcare team.
keep a written record (logbook) of your blood sugar readings. Also, write down the date, time and whether the self-test was done before or after eating. Some meters store this information for you. You can note information about diet, exercise, medication or how you are feeling. Always bring your record book when you visit your healthcare team. Together, you can look for patterns in your blood sugar readings. The patterns help you decide whether you need to adjust your plan.
Follow the directions that come with the meter you are using. Talk to your healthcare team about your meter and the way to self-test. These tips will help you get the most correct results.

  • Keep your meter clean.
  • Keep your testing supplies at room temperature.
  • Check the expiration date of your testing supplies.
  • Wash your hands in warm, soapy water.
  • Dry them well.
  • Put your hand down to let gravity help the blood flow to your fingertips.
  • Prick the side of your finger with a fresh lancet in a lancing device.
  • Get enough of a blood drop to apply to the test strip or test sensor.
  • Record your results.
  • Find out the reason for your high blood sugar level, or call your doctor or diabetes educator.
  • Drink more water and sugar-free fluids. (Limit fluids with sugar, including fruit juices).
  • Follow your recommended meal plan. (If you do not have a plan, meet with your dietitian).
  • Take your medication as prescribed by your doctor. If your blood sugar remains high, see your doctor or diabetes educator.
  • Test your blood sugar more often (every 3 to 4 hours).
  • If your blood sugar level is below 285 mg/dL and you feel well, increase your physical activity (for example, go for a walk). Always ask your doctor before starting a new exercise routine.
  • Eat or drink fast-acting sugar such as:
    • 3 sugar or dextrose tablets or
    • 4 hard candies or
    • 1/2 cup of juice or regular soft drink
  • Wait 10 to 15 minutes, then check your blood sugar again. If your blood sugar is still below 75 mg/dL, repeat treatment and blood sugar test again.

The more you test, the more you will know about your blood sugar management. Ask your doctor or diabetes educator what your levels should be.
For most people attempting to achieve good control, four or more tests a day are usually required.Readings should always be recorded, as well as the food or carbs eaten and medications or insulin doses taken. This information received can then be used in adjust, insulin doses, medications, meal planning, and exercise to greatly improve blood sugar levels. Although testing can clarify unclear symptoms, the major reason to test is to improve your blood sugar results, and to maintain excellent results once control targets are achieved.

For different meters see the link of Meters Companies

HbA1c , A1C

As mentioned before that home blood glucose testing is accurate and should be performed as frequent as possible , yet despite it is accurate , yet the main disadvantage that it is momentary , as it reflects the blood glucose level only at that moment regardless what was the case hours or days before , and because keeping diabetes in good control is the key to staying healthy. so checking blood sugar levels at different times of the day should be done to make sure that diabetes plan is working. These tests tell you what your blood sugar level is at that moment, which is very helpful. However, still there is a need to know about the state off blood sugar along the past months to judge the success of the diabetes management plan as just mentioned estimation of blood glucose ALONE does not give the whole image.

There is another test that can tell you your average blood sugar level over the last 2 to 3 months. This laboratory test is called a hemoglobin A1C. You may hear a few different names for it, including:

  • HbA1C or HbA1C
  • Glycohemoglobin
  • A1C or A1C

Note: In August 2001, the American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE) recommended that hemoglobin A1C be referred to as the "A1C". We will use this reference from here on.

A1C is a measure of how much sugar is stuck to your hemoglobin. Your A1C reading tells you and your healthcare team what your average blood sugar level has been over the last 2 or 3 months. If you have lots of sugar in your blood and your average blood sugar has been high for the past few months, then your A1C will be high. The A1C test allows you to see how good your overall control has really been. You should talk to your healthcare team about your daily blood sugar tests AND your A1C results.

*ACE/AACE A1C Target for Glycemic Control
A1C Reading Average Blood Sugar Level Your Blood Sugar Control
14% 360 mg/dL Very poor control, take immediate action to lower
10% 250 mg/dL Poor control, take action to lower
9% 210 mg/dL Poor control, take action to lower
8% 180 mg/dL Marginal control, take action to lower
7% 150 mg/dL Marginal, take action to lower
6.5% 135 mg/dL Good control - target
6% 120 mg/dL Very good control

According to the ACE/AACE guidelines on A1C higher than 6.5% is a warning sign that your diabetes is out of control. If your hemoglobin A1C is high, your healthcare team may change your diabetes plan to help control your blood sugar better. Changes in your plan are expected from time-to-time and will help bring your A1C closer to normal. When your A1C is close to normal, you know you are doing all you can to stay healthy.
Research shows that good blood sugar control may lower your risk of major health problems including:

  • heart disease
  • stroke
  • kidney disease
  • eye disease
  • nerve damage
  • amputations
  • circulation problems

By keeping your blood sugar close to normal, you will stop or delay the damage high blood sugar does to blood vessels and nerves. You can prevent the complications of diabetes.
Some doctors can do a A1C in their office by taking a blood drop from a finger stick. You can wait for the results and talk about them right away. The doctor may also send a blood sample to the lab for this test.
The ACE and AACE recommended that anyone with diabetes should have an A1C done every 6 months for people at or below the target of 6.5%, and every 3 months for those above 6.5% or changing therapy. If you inject insulin, you should have this test done every 3 months. Two major studies have shown the importance of good blood sugar control and the relationship of the A1C to diabetes complications. The first was the diabetes complications. The first was the Diabetes Control and Complications Trial (DCCT).

In this study, patients with type 1 diabetes had an A1C every month. This gave the healthcare team useful information to change treatment plans. In this study patients who had close to normal A1C were in better health and had fewer cases of eye disease, kidney disease and nerve damage.
The other study was called the United Kingdom Prospective Diabetes Study (UKPDS). This was a study done with patients with type 2 diabetes. People who had good blood sugar control were in better health in this study, too.
Both of these studies show that the hard work it takes to control your blood sugar is worth it. Your healthcare team will help you take good care of your blood sugar. They will tell you how often you should have a A1C.

HbA1c Measurement

In the blood, glucose binds irreversibly to hemoglobin molecules within red blood cells. The amount of glucose that is bound to hemoglobin is directly tied to the concentration of glucose in the blood. Since red blood cells have a lifespan of approximately 90 days, measuring the amount of glucose bound to hemoglobin can provide an assessment of average blood sugar control during the 60 to 90 days prior to the test. This is the purpose of the glycated hemoglobin tests, most commonly the hemoglobin A1c (HbA1c) measurement. Since the test results give feedback on the previous two to three months, getting an HbA1c test done every three months will give you good data on your average blood sugars. If you get an HbA1c every six months, you'll miss out on three months worth of information that could help you manage your diabetes.

Variations in Standards

There are several methods for measuring HbA1c, and results from one method cannot be compared directly with results from another method. You must compare your measurement with the standards for the method of measurement that was used, usually against the highest non-diabetic value. The National Glycohemoglobin Standardization Program aims to to standardize glycohemoglobin test results so that clinical laboratory results are comparable to those reported in the Diabetes Control and Complications Trial.

Note also that different patterns of blood sugar values can result in similar HbA1c values. For example, one person may have an irregular pattern of blood sugars, with lots of highs and lows, and an average blood sugar level of 200 mg/dl. Another person may have a very regular blood sugar level of around 200 mg/dl all the time. Though both will have similar HbA1c levels, they have very different situations that require different actions to remedy. Frequent home blood glucose monitoring will provide the detailed information about the pattern of blood sugars to help each person decide how to adjust the insulin to improve their average control.

HbA1c and Blood Sugar Values

Your HbA1c value can tell you what your average blood sugar has been for approximately the previous three months. The chart below shows the approximate relationship between HbA1c and average blood sugar values, as reported in the DCCT.

Factors that interfere with GHB (HbA1c) Test Results

Hemoglobin Variants and Derivatives: Genetic variants (e.g. HbS trait, HbC trait) and chemically modified derivatives of hemoglobin (e.g. carbamylated Hb in patients with renal failure, acetylated Hb in patients taking large amounts of aspirin) can affect the accuracy of GHB measurements. The effects vary depending on the specific Hb variant or derivative and the specific GHB method. information for most of the commonly used GHB methods for the some of the more common Hb variants and derivatives. Interferences from less common Hb variants and derivatives , When selecting an assay method, laboratories should take into consideration characteristics of the patient population served, (i.e., high prevalence of hemoglobinopathies or renal failure).

Shortened Erythrocyte Survival: Any condition that shortens erythrocyte survival or decreases mean erythrocyte age (e.g., recovery from acute blood loss, hemolytic anemia) will falsely lower GHB test results regardless of the assay method used . GHB results from patients with HbSS, HbCC, and HbSC must be interpreted with caution given the pathological processes, including anemia, increased red cell turnover, transfusion requirements, that adversely impact GHB as a marker of long-term glycemic control. Alternative forms of testing such as glycated serum protein (fructosamine) should be considered for these patients.

Other factors: Vitamins C and E are reported to falsely lower test results, possibly by inhibiting glycation of hemoglobin ; vitamin C may increase values with some assays . Iron-deficiency anemia is reported to increase test results . Hypertriglyceridemia, hyperbilirubinemia, uremia , chronic alcoholism, chronic ingestion of salicylates, and opiate addiction are reported to interfere with some assay methods, falsely increasing results.

Relationship Between HbA1c and Average Blood Glucose
% HbA1c HbA1cLevels Average BloodGlucose
mg/dL mmol/L
14.0    360  20
13.0 Seriously  330  18.3
12.5 Elevated    
12.0 Levels  300  16.7
11.0   270 15
10.0>   240 13.3
9.5 Elevated     
9.0 Levels  210  11.7
8.0 Slightly 180  10
7.5 Elevated    
7.0 Levels 150  8.3
6.0   120 6.7
5.5 Non-diabetic     
5.0 Levels  90 5
4.0   60 3.3

If your A1c is this: Your average mean daily plasma blood sugar is around this:
mg/dL mmol/L
12.0% 345  19.5
11.0%  310  17.5
10.0%  275  15.5
9.0% 240  13.5
8.0% 205  11.5
7.0%  170  9.5
6.0%   135 7.5
5.0% 100  5.5
4.0%  65  3.5
Ketone testing

this test is very important especially in children and all diabetics who are prone to ketoacidosis , Ketone testing involves checking how many ketones, or acids are in your bloodstream so you can make sure your body isn't burning fat instead of sugar and avoid a medical emergency, called ketoacidosis, which can lead to coma or death. Ketones are a type of acid that are left over when your body burns some of its own fat for fuel. Your body burns fat if it can't get enough sugar (glucose) to use for energy. When your body burns too much fat too quickly, there may be ketones in your blood. Ketones get removed from your bloodstream into your urine. People with type 1 diabetes develop ketones more easily than people with type 2 diabetes. Everyone with type 1 diabetes should test for ketones in their urine. People with type 2 diabetes are less likely to have problems with ketones, but everyone with diabetes should know about the warning signs and when to test. Ketone testing, like blood sugar testing, is very important. Finding ketones in your urine is a sign of trouble .

Ketone testing is often recommended for people with type 1 or type 2 who become pregnant or for women with gestational diabetes. Ketone testing may also be recommended for children with type 2 diabetes.

Your healthcare team will tell you when you should test for ketones. It is also a good idea to test if:

  • Before breakfast. This is called the fasting blood sugar. Fasting means you have not had any food in 8 hours or more
  • Your blood sugar is 250 mg/dL or higher for two tests in a row.
  • You are sick (even with a cold) because being sick can cause you to have ketones.
  • You are vomiting or have diarrhea.
  • You are under stress or are upset. nerve damage.
  • You are pregnant.

Testing your urine for ketones is very easy. You can use a simple dip-and-read urine test strip. The test strip is dipped into a sample of your urine. If the color changes there are ketones in your urine. You may want to try Ketostix® Reagent Strips, which are for testing only ketones in your urine. For testing your urine for both sugar and ketones, you may want to try Keto-Diastix® Reagent Strips.

You can get these strips at your drugstore. Ketone test strips are available in bottles and in individually foil-wrapped strips. They are sensitive to light and moisture, so it is a good idea to keep them stored in the container with the lid on tight. Always check the expiration date on the bottle or individually foil-wrapped strip, and do not use strips that are out-dated.

If the results show trace or small amounts of ketones:

  1. Before breakfast. This is called the fasting blood sugar. Fasting means you have not had any food in 8 hours or more
  2. Drink a glass of water every hour.
  3. Test your blood sugar and ketones every 3 to 4 hours.
  4. If your blood sugar is higher than 250 mg/dL and you have ketones, DO NOT exercise. Also, be sure to contact your healthcare team.
  5. If your blood sugar and ketones numbers are NOT going down after two tests, call your healthcare team.

If the results show moderate or high ketones:

  1. Call your doctor IMMEDIATELY.
  2. Drink a glass of water every hour.

Ketoacidosis can quickly develop into a very serious problem. Be sure to contact your healthcare professional if tests stay high or if you have any of the early signs of diabetic ketoacidosis (DKA).

Early signs of DKA include:

  • Pain in your stomach
  • Nausea or vomiting
  • Rapid breathing
  • Fruity-smelling breath

If you have any of these symptoms and have ketones in your urine, call your healthcare professional or go to the emergency room.