Unit IV: Monitoring and Complications
Diabetes is a condition that requires continual attention. It is a condition that is, for the most part, dependent on the individual herself or himself to maintain control. Research has concluded that the better one maintains control of blood glucose, the lower are one's chances for complications.
Recommended Monitoring Techniques for Control and Possible Prevention of Complications
Once a mainstay of self-care for the diabetic, urine glucose tests are now an obsolete and inappropriate way to monitor for control of blood glucose. In fact, they can give false assurance that the blood glucose is normal when it is actually quite high or quite low (Miller, 1986). Urine testing is quite useful for identifying ketonuria and albuminuria, however. This author does not recommend it for any other purpose. The American Diabetes Association does not include suggestions for checking urine for glucose anywhere in its most current standards of medical care in diabetes (American Diabetes Association, 2018).
The hemoglobin A1c blood test measures glycosylated hemoglobin and is an index of blood glucose levels over a period of time. (Real change in values can be detected only when at least two months (preferably three months) separate testing times). No longer can noncompliant diabetics attempt to provide a good blood glucose for the health care provider by watching their food intake closely one or two days before a visit, expecting to fool the provider into believing they are in good control.
The 2018 Standards of Medical Care in Diabetes (American Diabetes Association, 2018) include a caution about the use of the A1c to diagnose diabetes when hemoglobinopathies or any hematologic conditions exist that interfere with red blood cell turnover – such as "sickle cell disease, pregnancy (second and third trimesters), hemo-dialysis, recent blood loss or transfusion, or erythropoietin therapy, only plasma blood glucose criteria should be used to diagnose diabetes" (S14).
In the individual who is being treated for diabetes, it is possible for the blood glucose levels to vary between very high levels and very low levels. Consequently, since the A1C reflects an averaging of blood glucose values, it is possible for the A1c to be within normal limits even under such circumstances. In other words the highers and lowers tend to balance one another out. The A1c is a good test, but it is not a perfect test! Its utility is in providing evidence of blood glucose control in people with diabetes, and at present, it is the best test available to do that.
The American Diabetes Association (2018) recommends an A1c goal of ≤ 7.0% for most non-pregnant adults. If an A1c such as 6.5% can be achieved without frequent or significant hypoglycemia in this population, it would be an appropriate goal. The goal of a higher A1c, e.g. 8%, might be more appropriate for those who have a history of severe and frequent hypoglycemia or for those whose life expectancy is limited, or who have significant complications.
Since the mid-1970s, highly reliable devices called glucometers have been available to measure one's own blood glucose. Until then, blood glucose measurements were only available by venipuncture and laboratory testing. Monitoring with a glucometer makes use of a drop of blood, reagent strips, and electronic equipment to provide reliable information about one's current blood glucose level. The popularity of self-blood glucose monitoring in place of urine glucose monitoring has grown among health care providers and people with diabetes since research has demonstrated a lack of consistency between urine glucose and blood glucose values (Miller, 1986). Self-monitoring of blood glucose (SMBG) is now a mainstay of diabetes care and control. In fact, the American Diabetes Association now recommends the individuals who receive insulin by pump or by multiple-dose insulin should perform SMBG at minimum before the ingestion of any food – meals and snacks – and occasionally two hours after meals. Additionally, the American Diabetes Association recommends SMBG before engaging in exercise, when hypoglycemia is suspected, after treating an episode of hypoglycemia and continuing until the blood glucose rises to a normal level, and prior to driving or participating in potentially dangerous activities (American Diabetes Association, 2018, p. S55). "SMBG is especially important for insulin-treated patients to monitor for and prevent asymptomatic hypoglycemia and hyperglycemia" (p. S56).
If glucose monitoring equipment is available to you, run a test to determine your own blood sugar. Did you have difficulty remembering directions for calibrating or using the equipment? How did you feel about sticking your finger the first time? Consider the difficulties and concerns a patient might have who is a child or is uneducated, has poor vision, or is simply not motivated to learn.
The benefits of home-blood glucose monitoring (also referred to as self-blood glucose monitoring, or SBGM) have been well documented. Most insurance companies reimburse at least in part for the purchase of the electronic equipment (glucometers) and/or necessary supplies (blood glucose reagent strips, lancets, alcohol pads, calibration equipment, and sharps containers).
Another aspect of monitoring relates to the importance of weight control. Increases or decreases of five pounds or more without trying are not normal and should be identified early. The simplest way to do this is for the diabetic to get into the habit of weighing regularly. Significant changes may indicate the need to alter some aspect of the control regimen. Such decisions should be made with the health care professional most knowledgeable about the individual's care.
Daily Assessment of the Feet
Monitoring the condition of the diabetic's feet should occur on a daily basis. Because circulation and peripheral neurologic functioning are often compromised in diabetes, the feet are vulnerable to unfelt or unnoticed injuries. Left unattended, they can become infected and lead to serious complications of delayed healing and gangrene resulting in the need to amputate parts of the toes, feet, and legs.
The feet should be washed daily with warm (not hot) water and observed on the top and bottom for any breaks in the skin. If small, these should be treated with antibacterial ointments and covered, but monitored daily. Toe nails should be cut straight across to avoid ingrown toenails and subsequent infection. Calluses and corns should not be picked or trimmed. Podiatric care may be required in some cases.
Individuals with diabetes should never walk barefoot, even at home, but rather should wear some form of foot protection at all times. Likewise, they should wear shoes that do not pinch or otherwise irritate the toes or feet. New shoes should be broken in slowly.
Regular Medical Checkups
It is critical for the person with diabetes to have regular medical checkups. (Regular is defined below in terms of recommended frequency.) Blood and urine analyses are necessary to monitor the adequacy of control over the long term as well as to identify early changes in renal function. Blood pressure assessment and foot health should be assessed regularly as well. Regular medical checkups also allow for the administration of important immunizations and for verification that dental and ophthalmological examinations are being obtained as recommended. At the minimum, the person with diabetes should have a funduscopic exam (a dilated eye exam) performed by an ophthalmologist – a physician who specializes in diseases of the eye – performed annually; more frequently if recommended by the ophthalmologist.
An individual whose systolic blood pressure is ≥ 140 mmHg or whose diastolic pressure is ≥ 90 mm Hg should have his/her blood pressure taken on a different day. Repeat readings as high (or higher) on either parameter confirm the diagnosis of hypertension, and treatment should be initiated promptly. Treatment should include lifestyle modifications, and may include pharmacotherapy. The recommended initial medications are an ACEI (angiotensin converting enzyme inhibitor) or an ARB (angiotensin receptor blocker).
Adult patients with diabetes should have an annual (fasting) lipid profile. In addition, the American Diabetes Association (2018) recommends that every person with diabetes should have an A1c performed at least every six months. If the results are ≥ 7%, more frequent assessments (every three months) until the A1c is < 7% are advised (p. S57).
Additional laboratory tests should be performed regularly to determine the individual's degree of glycemic control and to identify complications as early as possible. In addition to those listed above, the American Diabetes Association recommends regular visits (at minimum, every six months) by the individual with diabetes with his or her health care provider. Flow sheets have been developed to assist in the comprehensive assessments recommended by the American Diabetes Association. An example of a flow sheet entitled "Diabetes Minimum Practice Recommendations for Children and Adults," published by the Texas Diabetes Council (2017) can be accessed at the following link: https://www.dshs.texas.gov/TDCtoolkitAlgorithms.asp.
Urine testing for proteinuria (performed via the microalbuminuria test) is recommended to be assessed at least annually along w/ a urine creatinine test. Together, these tests reflect renal function. People with diabetes should be informed that this is an expectation they should have for health care, along with foot exams (vascular, skin/lesions, and sensitivity) and assessments of blood pressure (at every visit), weight (at every visit), diet (at every visit), blood glucose (at least q6mos if at or below the goal of < 7.0%; more frequently (q3mos) if above this goal).
The urine assessment for ketones should be performed on the individual with DMT1 to verify that she/he is taking at least the minimum necessary dose of insulin/day or to assess for diabetic ketoacidosis (DKA), along w/ other lab tests. This test is useful on the individual with DMT2 if she/he has recently had an illness such as a severe infection as this can lead to the development of DKA.
All people with diabetes (children and adults) should receive immunizations according to the age-based recommendations provided by the Centers for Disease Control and Prevention (CDC) available at www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html. The schedule for adults (age 19 and older) can be found at https://www.cdc.gov/vaccines/index.html.
Influenza and pneumonia are associated with significant risks of morbidity and mortality in the elder population and among people with chronic diseases. Hence, the American Diabetes Association (2018) recommends an annual influenza vaccine for all persons with diabetes who are six months of age or older. Likewise, the American Diabetes Association recommends the pneumococcal polysaccharide vaccine for those with diabetes who are two years of age or older. An additional vaccination for this disease is recommended for those greater than age 65 who were immunized more than five years ago. (You might want to carefully re-read the previous sentence so that you can explain it to patients!) The pneumococcal polysaccharide vaccine is also recommended for those who have nephrotic syndrome or chronic renal disease, and for those who have had an organ transplant, or are otherwise immunocompromised.
The American Diabetes Association recommends the administration of the hepatitis B series of (three) immunizations to those adults with diabetes who are unimmunized and are 19-59 years of age. Included is the recommendation to consider administering hepatitis B vaccination to unvaccinated adults with diabetes who are aged ≥ 60 years (American Diabetes Association, 2018, p. S29).
The recommendations for tetanus boosters are no different for people with diabetes than they are for those who do not have diabetes, but the importance thereof with regard to the general welfare should be emphasized at this time. In the summer of 2005, the Advisory Committee on Immunization Practices (ACIP) advised the Centers for Disease Control and Prevention to recommend that health care providers routinely use Tdap vaccines (containing tetanus, diphtheria, and acellular pertussis) for tetanus boosters in people aged 11–18 years rather than tetanus and diphtheria toxoids (Td) vaccines, alone. Soon thereafter, a similar recommendation was made for individuals aged 19-64 as a one-time dose in place of their next tetanus booster. These decisions were made following the recognition of the results of an epidemiologic investigation by the Centers for Disease Control and Prevention of an upsurge in the incidence of whooping cough among the nation's children stemming from the waning of adults' immunity to pertussis. ACIP went so far as to recommend a Tdap booster for adult contacts of infants under 12 months of age in as few as two years since their previous Td booster (Kretsinger et al., 2006). The Centers for Disease Control and Prevention remain consistent in the recommendation for a tetanus booster every ten years. For those in the age groups identified, one Tdap is recommended to replace a regularly scheduled Td.
The Centers for Disease Control and Prevention recommends the vaccine against shingles (Herpes zoster) for people 50 years of age and older to prevent shingles, even if they have already had shingles. This is a one-time vaccination. Consequently, it is recommended that people with diabetes who are 50 years of age or older should receive a shingles vaccine (January 26, 2018 at https://www.cdc.gov/mmwr/volumes/67/wr/pdfs/mm6703a5-H.pdf).
The Cost of Diabetes Control
Compliance with a diabetes blood glucose control program is likely to be hampered by money problems. Investigate the adequacy of the patient's financial support including medical insurance. If control may be jeopardized because of financial concerns, contact a social worker for help. Insulin pumps are costly as is the equipment to operate them. Insurance may cover all, some, or none of these expenses.
Investigate the costs of some equipment and supplies needed by the diabetic and figure an approximate cost per year for routine care, assuming no problems. Call or visit a pharmacy to obtain this information.
*A1c (at minimum, every six months), and annual assessments as follows: CBC, lipid panel, comprehensive metabolic panel, TSH, urinalysis, and an assessment for microalbuminuria and urine creatinine.