American Diabetes Association Complete Guide to Diabetes: The Ultimate Home Reference from the Diabetes Experts

CHAPTER 9

Setting Blood Glucose Goals

• ADA Guidelines

• Intensive Diabetes Management

Setting your blood glucose goals is one of the first steps you’ll make in order to manage your diabetes. Your goals include the blood glucose levels that you want to aim for on a daily basis.

No matter what kind of diabetes you have, your goal will be to keep blood glucose as close as possible to the level of someone without diabetes. This will help prevent long-term diabetes complications, such as heart and nerve disease and foot and eye problems.

However, keep in mind that blood glucose goals are entirely personal, so you’ll want to talk with your health care provider about creating reasonable goals and the strategies to achieve these goals. Some people with diabetes find that keeping blood glucose levels close to normal is not realistic or even desirable. For example, elderly people or people who live alone may be more concerned about preventing severe low blood glucose episodes than avoiding long-term complications.

ADA Guidelines

Choosing blood glucose goals can be easy. You can simply use the guidelines supported by the American Diabetes Association (ADA). These recommendations are based on the findings from research about preventing complications.

However, the ADA’s goals may not be easy for you to reach. Or they may not be right for you. Why not see what your blood glucose levels are before and after meals and compare them to the goals in the box below? Then choose a realistic goal for the short term. Perhaps you can make a few small changes to slowly lower your blood glucose levels.


ADA Blood Glucose Goals

Before meals: 70–130 mg/dl

Two hours after the first bite of a meal: less than 180 mg/dl


Things to Change to Lower Blood Glucose

• How much food you eat

• Kinds of food you eat

• Your activity level

• How much insulin or other medication you take

Write down an acceptable blood glucose range for you at this time. The range could be something like 70–200 mg/dl. This means that any reading below 70 mg/dl is too low. Anything over 200 mg/dl is higher than you want. This range includes lower blood glucose levels before meals and somewhat higher glucose levels 1–2 hours after meals. You should see the high end of the range come down as you work toward reaching your goals.


Children’s Blood Glucose Goals

Blood glucose goals for children are broader. For example, the target range may be 100–200 mg/dl. Most children under the age of 6 or 7 are not yet able to be aware of and respond to oncoming low blood glucose. So it’s important to limit episodes of low blood glucose. Tailor goals to the age and abilities of the child and be flexible with goals as the child grows.


Intensive Diabetes Management

Some people may want a more rigorous approach to setting goals and managing blood glucose. Intensive diabetes management, also referred to as IDM, can help prevent long-term complications and make you feel better every day. However, it is hard work, and it is not for everyone.

You’ll find out more about the treatments required for intensive diabetes management in chapter 13 on insulin and chapter 10 on healthy eating. For now, let’s discuss why you may or may not want to pursue intensive diabetes management.

Research behind Intensive Diabetes Management

It always seemed obvious that keeping blood glucose levels as close to normal as possible would prevent diabetes complications. Yet, researchers needed to prove it for sure. For example, what if something else related to diabetes caused the complications? What if lowering blood glucose had no effect on complications?

In recent years, two major research studies confirmed what many diabetes health professionals and people with diabetes had long suspected. The two studies are called the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS).

The DCCT followed 1,441 people with type 1 diabetes for 10 years. Some people received a conventional treatment therapy of 1–2 shots of insulin a day, whereas other people received intensive diabetes therapy, which included either an insulin pump or multiple daily injections of insulin.

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DCCT Results

Among those receiving intensive diabetes therapy, the following findings were made:

• Reduced the risk of developing diabetic eye disease, called retinopathy, by 76%.

• Slowed the progression of retinopathy by 54% in people who already had early signs of eye disease.

• Reduced risk of kidney disease by 50%.

• Reduced risk of nerve disease by 60%.

• Reduced risk of high cholesterol levels by 35% (a major contributor to heart disease).

Before the DCCT, many people with diabetes thought that complications would progress no matter what they did. After the DCCT, we know that way of thinking is wrong. Keeping blood glucose levels close to normal matters.

The other study—the UKPDS—followed 5,102 people with newly diagnosed type 2 diabetes for 20 years. People were treated with conventional therapy of mainly diet alone or intensive therapy of insulin or diabetes pills.

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UKPDS Results

• People who on intensive therapy reduced their risk of microvascular complications, such as eye and nerve disease, by 25%.

• People who lowered their blood pressure reduced their risk of stroke by 44% and their risk of heart failure by 56%.

• Improved blood glucose control also reduced the risk of heart attacks and diabetes-related deaths.

• The long-term benefits of glucose control were seen even 10 years after the study ended.

What do all these numbers mean? Intensive management of blood glucose and blood pressure can significantly reduce your risk of diabetes complications. However, intensive diabetes management has some negatives.

Drawbacks to Intensive Diabetes Management

• It is more expensive.

• It takes more time and effort.

• You’ll have more hypoglycemia episodes. People in the DCCT using intensive diabetes management had three times as many severe low blood glucose episodes than those on the conventional treatment program. This happened because their overall blood glucose levels were much lower.

• You may gain weight. People in DCCT following intensive management tended to gain more weight than those using a conventional treatment program because they were no longer losing calories in the form of glucose in their urine. Taking more insulin also made their bodies more efficient at capturing and storing calories.

Is Intensive Management Right for You?

Are you already reaching your blood glucose and blood pressure goals? Do you firmly believe that you are doing fine without intensifying your diabetes management? Do you dislike the idea of having your life dictated by your diabetes care or schedule? If you answered yes to any of these questions, then intensive management may not be right for you.

However, if you want to reduce the long-term risk of complications, you may decide that intensive diabetes management is worth the extra effort, time, and side effects. In the end, intensive management may offer you more flexibility in your day-to-day living. You monitor your blood glucose more frequently so that you can make adjustments in your insulin dose to accommodate variety in your eating and activity patterns.

Intensive diabetes management can benefit almost anyone with diabetes. For years, women with type 1 or type 2 diabetes who were planning a pregnancy and women who developed gestational diabetes have been advised to take an intensive approach to their diabetes. It is particularly important during pregnancy to keep glucose levels close to normal to avoid problems in the development and growth of the baby.

Keep in mind, intensive diabetes management is not safe for some groups of people: children, elderly people, and people experiencing severe complications of diabetes, such as life-limiting illnesses or trouble with cognition or function.

Intensive Diabetes Management May Not Be Right for You If…

• You have a history of severe hypoglycemic episodes or hypoglycemia unawareness.

• You are younger than 10, unless you have motivated parents and/or caregivers.

• You are elderly, with other health problems or impairments.

• You have cardiovascular disease, angina, or other medical conditions complicated by hypoglycemia or you take certain medications like beta-blockers.

• You have severe complications of diabetes. Although intensive therapy can slow down the development of complications, there is no evidence that it can reverse the process.

• You have conditions, such as debilitating arthritis or severe visual impairment, that would make it difficult to carry out tasks.

• You have drug or alcohol abuse problems or are unable to make reasonable decisions about your everyday diabetes management.

• You are unable or unwilling to carry out the tasks associated with intensive management.

Intensive diabetes management in children can be risky because it raises the risk of hypoglycemia. Severe hypoglycemia can interfere with normal brain development, particularly in very young children. Intensive diabetes management in children also requires close supervision, usually from a diabetes specialist.

The increased risk of hypoglycemia can also be an issue with the elderly. Hypoglycemia may make it harder to live alone or be independent. Some older people may find the potential benefits are not worth the risk, particularly if they have other health problems or impairments. However, if you are in good health, believe the benefits are worth the wait (they may take 10 years), and are willing to take on the responsibility, then let your health care team know.

Intensive Diabetes Management Education

The idea of embarking on an intensive diabetes management plan may seem overwhelming. There is a lot to remember, but keep in mind that it is an ongoing process. You can’t learn it overnight, and no one expects that of you. Your health care team is there to help you.

You’ll have many questions as you begin. How many units of insulin should you take if you blood glucose is a little high? How should you change what you eat for your next meal? It will require trial and error and coordination and advice from your health care team as you learn to make adjustments. Over a short period of time, you will gain the confidence to make these adjustments on your own.

Talk to your health care team about the best way to approach intensive management. Maybe your local community hospital or health care team offers classes in intensive management. Maybe your diabetes educator wants to arrange several one-on-one sessions with you.

Intensive Diabetes Management Classes

Look for these topics when considering an intensive diabetes management class.

• Nutritional guidelines and carbohydrate counting to determine the effect of food on blood glucose levels.

• Insulin action and dosage adjustment or dosing of other injectable medications.

• How to measure the effect of exercise.

• Blood glucose and urine ketone monitoring and interpretation of the results.

• Strategies to help you make changes in your lifestyle and cope more effectively with diabetes.

Choosing Intensive Diabetes Management Goals

The goal of intensive diabetes management is to keep blood glucose levels as close to normal as possible. You may want to tailor this approach to goals that are reasonable and safe for you. It is a group decision that you, your family, and your health care team need to make together.

People with diabetes need to take action to lower their blood glucose either by injecting insulin or compensating with food or insulin at the next mealtime. You may hear that keeping your blood glucose below 130 mg/dl is the magic number. In fact, your target range may be a little higher or lower depending on several factors such as your age, capabilities, and life situation.


For people without diabetes, blood glucose levels rarely go over 120 mg/dl, even after eating a meal.


Factors to Consider When Setting Goals

• Your age

• How long you’ve had diabetes

• Type of diabetes

• Frequency and severity of hypoglycemia

• Lifestyle and occupation

• Other medical conditions

• How much support you get from family and friends

• Your personal motivation for diabetes self-management

The American Diabetes Association has established recommended targets for glucose levels. The ADA recommends that patients keep blood glucose between 70 and 130 mg/dl before meals and less than 180 mg/dl after meals. You may choose these or different goals. But remember, the DCCT showed that any improvement in lowering blood glucose levels provides real benefits.

Another way to measure blood glucose control is with an A1C test. An A1C test is a test that measures a patient’s blood glucose levels over 3 months. It can be used to diagnose diabetes (as mentioned in chapter 2) and to monitor your blood glucose control over time. Usually, your health care provider will give you an A1C test at your appointments. A reasonable goal for most people with diabetes is an A1C of less than 7%, as the risk for kidney disease, eye disease, and other complications increases as A1C goes up.


A1C in the DCCT

Researchers took patients’ A1C measurements in the DCCT to see how well they 

were doing with overall control. The study subjects on intensive management lowered their A1C values dramatically—even though they did not often reach their daily blood glucose goals. This improvement was seen after about 3–6 months of intensive management.


It Can Be Hard to Reach Goals

Even though your goals may seem reasonable at first, they may be hard to reach on a day-to-day basis. It is difficult to keep blood glucose levels close to those found in people without diabetes, no matter how hard you work at it.

For example, people in the DCCT study had a hard time reaching their goals (near-normal blood glucose levels before and after meals and at bedtimes). Most people just could not consistently reach these goals.


Type 1 Diabetes and Intensive Diabetes Management

If you have type 1 diabetes, you’ll be using insulin and other injectable medication to intensively manage your diabetes. You’ll probably be taking more and different types of insulin in intensive diabetes management. You’ll find more information using insulin plans, insulin pumps, and other injectables in chapter 13.

Keep in mind that you’ll also need to monitor your blood glucose much more frequently with intensive diabetes management.

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Type 1 Monitoring and Intensive Diabetes Management

• You’ll probably want to check your blood glucose often, at least as often as you inject insulin or other injectables and sometimes more.

• You could be monitoring seven times a day depending on how often you eat: before your three meals, after each meal, and before bedtime.

• Bedtime monitoring. You may even check at 3 a.m. once or twice a week. For instance, you will not want your blood glucose level to become too low during the night. So if you’ve experienced several severe hypoglycemic episodes, you may want to aim for a higher overnight blood glucose level.

• Every bit of checking gives you more knowledge of how your body reacts to food, exercise, insulin, stress, and illness. Once you’ve settled into a comfortable routine, you may be able to do fewer checks. Remember that monitoring gives you the information you need to make wise decisions in managing your diabetes.

• You may want to wear a continuous glucose monitor that records your glucose level throughout the day and night.

Type 2 Diabetes and Intensive Diabetes Management

If you have type 2 diabetes, your blood glucose targets are not that different from those of people with type 1. However, the way you reach those targets may be different. Talk to your health care provider about strategies you may need to pursue.

Special Considerations for Type 2 Diabetes and Intensive Diabetes Management

• If you manage your blood glucose with food and physical activity, you may need to add an oral diabetes medication.

• If you already take medication, you may need to add another pill, once-a-day insulin, or other injectable medication.

• If you already take insulin, you may need to take a more aggressive approach such as three or four shots a day. Your therapy might even be similar to a person with type 1 diabetes.

• You may choose to wear an insulin pump if you begin taking more frequent insulin shots.

• Watch out for weight gain that accompanies lowered blood glucose levels. You may need to add an extra workout a week to counteract the fact that you’re not losing as much glucose in your urine anymore.

Pregnancy, Gestational Diabetes, and Intensive Diabetes Management

Getting and keeping tight blood glucose control is especially important during pregnancy to prevent complications for the mother and baby. Intensive diabetes management is recommended for mothers-to-be with diabetes.

If you have type 1 or type 2 diabetes, it’s important to plan your pregnancy. Your blood glucose should be as close to normal as possible before you become pregnant. You increase the baby’s risk of birth defects if your blood glucose is too high in the first 2 months of pregnancy. It also increases your risk of miscarriage. It’s important to take care of your general health, too. Pregnant women with diabetes who do not closely manage blood glucose are more likely to develop hypoglycemia and a temporary worsening of complications, such as eye disease.

Talk to your health care provider about your individualized goals for blood glucose management and targets. Striving for tight blood glucose control requires extra effort and diligence. Although it is hard work, you are doing all that you can to ensure good health for yourself and your baby. Read more about specific treatments for pregnant women in chapter 13 on insulin and chapters 10 and 11 on food and exercise.

Support for Intensive Diabetes Management

As you embark on an intensive approach to diabetes management, you may find that you need more support and encouragement while adjusting to the new routines. Sometimes you might just need someone to talk to, to discuss common problems, to air your concerns, or to just ask questions. Sometimes it will help to know that someone cares and understands what you are going through.


Sources of Support for Intensive Diabetes Management

• Family and friends may provide you with the encouragement you need to affirm your commitment to intensive management.

• Your health care team can provide you with technical support, answering questions as they arise and reassuring you that you’re doing the right thing and making wise decisions.

• Your health care team can also help you locate financial resources and brainstorm ways to ease financial concerns.

• Support groups may introduce you to other people with whom you can share stories and commiserate. They may also give you the opportunity to help others, which can be therapeutic.


In Conclusion

Whatever blood glucose goals you choose, remember that your goals will probably change over time. Use this chapter as a resource for setting and then redefining your goals when necessary. Looking ahead, you will find out more about specific strategies for managing your blood glucose such as healthy eating, exercise, medications, and insulin.



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