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It is also possible that PPG monitoring may be beneficial to evaluate the effect of changes in nutrition or exercise patterns. The following should be considered in selecting your Target Group: For information and examples on selecting a Target Group, see the SDPI Diabetes Best Practice and Target Group recorded webinar. 11 Fructosamine is a compound formed when glucose sticks to other proteins in the blood that only exist for 14 to 21 days. QUESTION 4: Under what circumstances should people with diabetes be tested for PPG? Good glycemic control, as measured by A1C, reduces the risk of diabetes complications. The more recent days contribute a greater percentage to the measure than the distant days. To address this fundamental question, studies must be designed to control FPG versus PPG levels while aiming to achieve similar and acceptable HbA1c levels. There appear to be no unique risks associated with the specific lowering of PPG to achieve HbA1c goals. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. B. Studies should be performed in well-defined patient groups; at a minimum, separation of patients by type of diabetes is necessary. Curre Res Diabetes & Obes J. It is also quite likely that results of studies in patients with impaired fasting glucose and/or impaired glucose tolerance may be different from those in patients with type 2 diabetes and different degrees of fasting hyperglycemia. Therapeutic goals for HbA1c and preprandial glucose levels have been established based on the results of controlled clinical trials. The relationship between timed blood glucose measurements and HbA1c in type 1 diabetic patients was examined in recent analyses of DCCT data presented at the conference. In type 2 diabetic patients, peak insulin levels are delayed and are insufficient to control PPG excursions adequately. C. In the presence of equivalent HbA1c values, does an excessive rise in PPG uniquely affect chronic diabetic complications? Specific clinical conditions, such as gestational diabetes or pregnancy complicated by diabetes, may benefit from testing at 1 h after the meal. A seven-member panel of experts in diabetes, endocrinology, and metabolism heard selected abstracts and presentations from invited speakers. Although foods are usually tested one at a time rather than as whole meals, there is interest in determining not only the GI of meals but also the GI of whole diets. What is the contribution of PPG to the long-term complications of diabetes? Individuals with diabetes are at increased risk of developing microvascular complications (retinopathy, nephropathy, and neuropathy) and cardiovascular disease (CVD). A CGM uses a sensor inserted under the skin to measure â¦ Performance measures based on control of risk factors such as A1C, BP, and LDL cholesterol are appealing because these risk factors predict clinical outcomes. Enzo Bonora, MD, PhD; Frederick L. Brancati, MD; Michael M. Engelgau, MD; Thomas Erlinger, MD, MPH; David E. Goldstein, MD; Francine Ratner Kaufman, MD; M. Sue Kirkman, MD; Elizabeth Koller, MD; Romano Nosadini, MD; and Thomas M.S. A continuous glucose monitor uses a sensor to measure blood sugar levels. The glycemic index (GI) (/ É¡ l aÉª Ë s iË m Éª k /;) is a number from 0 to 100 assigned to a food, with pure glucose arbitrarily given the value of 100, which represents the relative rise in the blood glucose level two hours after consuming that food. Alpha-glucosidase inhibitors, rapid-acting oral insulin secretagogues, and rapid-acting insulin analogs predominantly lower PPG. What, if any, are the documented benefits of specifically lowering PPG? Glycemic control remains a delicate balancing act. The relative contributions of FPG and PPG to HbA1c have been studied only recently. It is unclear whether excessive excursions of PPG have a significant impact on the development of diabetic microvascular and macrovascular complications independent of HbA1c levels. The purpose of a glycemic index (GI) diet is to eat carbohydrate-containing foods that are less likely to cause large increases in blood sugar levels. 4. Optimization of glycemic control requires a careful balance that allows patients to reach target A1C while avoiding â¦ For example, if a patient has an extremely high or low average glucose level, this alone demands attention regardless of the SD. It reflects the exposure of erythrocytes to glucose in an irreversible and time- and concentration-dependent manner. In another study in type 2 diabetic patients, the effects of different glucose lowering therapies on the relationship among HbA1c, FPG, and PPG were analyzed in a 24-week randomized clinical trial involving three treatment groups (a rapid-acting insulin secretagogue, an insulin sensitizer, and a combination of both agents) and a placebo group. Blood Glucose Monitor Kit (Auto-Coding), CareSens N Diabetes Testing Kit with 1 Glucose Meter, 100 Glucose Test Strips, 1 Control Solution, 1 Lancing Device, â¦ Clinical trials over time have used a variety of approaches for both measuring tight glycemic control and reporting results. In general, FPG, PPG, and especially mean plasma glucose (MPG) concentrations, defined by the average of multiple measurements of glucose taken throughout the day, are highly correlated with HbA1c. In the management of diabetes, health care providers usually assess glycemic control with fasting plasma glucose (FPG) and premeal glucose measurements, as well as by measuring HbA 1c. Because CVD is the major cause of morbidity and mortality in patients with diabetes, and in type 2 diabetes in particular, understanding the impact on CVD events of treatments directed at specifically lowering PPG is crucial. In patients who achieve their premeal glucose targets, but whose overall glycemic control as determined by HbA1c is inappropriately high, PPG monitoring and therapy to minimize PPGEs may be beneficial. Since people with type 1 diabetes have no endogenous insulin secretion, the time and height of peak insulin concentrations, and resultant glucose levels, are dependent on the amount, type, and route of insulin administration. Several therapies targeted toward lowering PPG excursions are now available and have been shown to improve glycemic control as measured by HbA1c. 4 glucose tablets (4 grams per tablet), or 1 glucose gel tube (15 grams per gel tube), or 4 ounces (1/2 cup) of juice or regular soda (not diet), or 1 tablespoon of sugar or honey; 3. The diabetic patient is tasked with maintaining euglycemic blood glucose levels, a goal requiring education, decision strategies, volitional control, and the wisdom to avoid hyper- and hypoglycemia, with the latter defined as plasma glucose less than â¼60 mg/dl. The glycemic index measures how much a food boosts blood sugar compared to pure glucose. No specific time point or combination of time points, including mean preprandial or mean postprandial glucose levels, correlated as well with HbA1c as the MPG. Elevated postprandial glucose (PPG) concentrations may contribute to suboptimal glycemic control. The Relationship between Composite Measures of Glycemic Control and Beta-Cell Function in Type 2 Diabetes. The Diabetes Control and Complications Trial (DCCT)1 and U.K. Paul J. Beisswenger, MD; Antonio Ceriello, MD; William C. Duckworth, MD; William C. Knowler, MD, DrPH; James B. Meigs, MD, MPH; Michele Muggeo, MD; and F. John Service, MD, PhD. No clinical trial data address whether PPG, independent of other measures of glycemia, plays a unique role in the pathogenesis of diabetes-specific complications. Prospective Diabetes Study (UKPDS)2 showed that treatment programs resulting in improved glycemic control, as measured by HbA1c, reduced the microvascular complications of diabetes. For this purpose a formula using the GI of individual foods, weighted according to â¦ Enter multiple addresses on separate lines or separate them with commas. In the DCCT, the primary focus of intensive therapy was to lower preprandial (up to 1 h before meals) and bedtime self-monitored blood glucose levels. However, studies show mixed results regarding the ability of these conventional measures to predict adverse surgical outcomes. QUESTION 3: What is the contribution of PPG to the long-term complications of diabetes? The interventional studies in type 1 diabetes aimed to lower glucose levels with the goal of maintaining HbA1c as close to the nondiabetic range as safely possible. In contrast, postprandial glucose excursions (PPGEs), defined as the change in glucose concentration from before to after a meal, and the incremental glucose area, defined as the area under the glucose curve above the premeal (or pre–oral glucose tolerance test [OGTT]) value, are poorly correlated with HbA1c. Randomized clinical trials have demonstrated that a reduction in the long-term complications of diabetes is proportional to average glycemia as determined by HbA1c. Given these general principles, the following specific questions should be addressed: A. Furthermore, it is not clear whether therapies that target PPG provide unique benefits relative to other pharmacological therapies that lower HbA1c comparably. Under what circumstances should people with diabetes be tested for PPG? The decision to recommend a glucose monitoring plan should be made judiciously, accompanied with specific patient education, and reviewed and modified regularly by the health care team. While the measurement of glycated hemoglobin A 1c (A1C) is considered the gold standard for assessing glycemic control in patients with diabetes, this measure does not take into account fluctuations in blood glucose levels known as glycemic variability (GV). Epidemiological analyses of the DCCT5 and UKPDS6 results reinforce the relationship between chronic glycemia, as measured by HbA1c, and risk for developing long-term complications. These claims have not been consistently supported by randomized, controlled studies. Measurement of Glycosylated Hemoglobin (Glycohemoglobin or Hemoglobin A1c) Periodic Measurement of Glycated Hemoglobin. Because the absorption of food persists for 5–6 h after a meal in both diabetic and nondiabetic individuals, the optimal time to measure postprandial glucose concentration must be determined. The word postprandial means after a meal; therefore, PPG concentrations refer to plasma glucose concentrations after eating. It has been suggested that agents that specifically lower PPG may decrease the risk of hypoglycemia and weight gain. Many factors determine the PPG profile. Therapeutic goals for HbA 1c and preprandial glucose levels have been established based on the results of controlled clinical trials. The availability of oral agents and insulin analogs that specifically target postprandial glucose levels has provided tools to perform such studies. DOI: 10.19080/CRDOJ.2017.4.555626. A doctor inserts the sensor under the skin, usually in the abdomen â¦ In the management of diabetes, health care providers usually assess glycemic control with fasting plasma glucose (FPG) and premeal glucose measurements, as well as by measuring HbA1c. The authors propose using specific measures of central tendency and dispersion for reporting glucoseâ¦ The glycemic control performance measure that the NDQIA recommends for public reporting is A1C >9% to indicate poor control (12). Must be reported by grantees that select this Best Practice. 2017; 4(1): 555626. If it is still below 100 mg/dL, have another serving of 15 grams of carbohydrate. How Do We Diagnose Diabetes and Measure Blood Glucose Control? It is unclear, however, to what extent HbA1c is lowered by these drugs because of their effects on PPG as compared with their effects on FPG. Use a blood sugar meter (also called a glucometer) or a continuous glucose monitor (CGM) to check your blood sugar. The magnitude and time of the peak plasma glucose concentration depend on a variety of factors, including the timing, quantity, and composition of the meal. A blood sugar meter measures the amount of sugar in a small sample of blood, usually from your fingertip. Postprandial hyperglycemia is also one of the earliest abnormalities of glucose homeostasis associated with type 2 diabetes and is markedly exaggerated in diabetic patients with fasting hyperglycemia. Small differences were detected in the relationship between HbA1c and plasma glucose at different times during the day (r = 0.66–0.76), with bedtime and postlunch plasma glucose correlating most strongly with HbA1c and fasting and postbreakfast plasma glucose correlating less well. The meter measures the amount of sugar in a small sample of blood, usually from your fingertip, that you place on a disposable test strip. Challenges and Strategies for Inpatient Diabetes Management in Older Adults, Challenges and Strategies for Diabetes Management in Community‐Living Older Adults, Palliative and End-of-Life Care: Vital Aspects of Holistic Diabetes Care of Older People With Diabetes, Institutional Subscriptions and Site Licenses, Special Podcast Series: Therapeutic Inertia, Special Podcast Series: Influenza Podcasts, QUESTION 2: What is the relationship among PPG, FPG, and HbA. Because blood sugar levels fluctuate throughout the day and glucose records are imperfect indicators of these changes, the percentage of hemoglobin which is glycosylated is used as a proxy measure of long-term glycemic control in research trials and clinical care of people with diabetes. For most people with diabetes, the A1C goal should be <7%. IMPORTANT NOTICE For most people with diabetes, the A1C goal should be <7%. In type 2 diabetes, a study performed in Pima Indians showed that correlations of HbA1c with FPG and PPG measured 1 and 2 h after an oral glucose load or a test meal were indistinguishable (r = 0.6–0.7). However, the HbA1c level does not provide a measure of the magnitude or frequency of short-term fluctuations of blood glucose, which are particularly great in type 1 diabetes. The review by Finfer and colleagues in this issue of Critical Care is a step toward consensus within the research community to standardize the way blood glucose is measured and reported in clinical trials. These ingredients are vital to creating a solution with the following properties: Has a concentration of glucose that can be used to test the functionality of your meter and test strips. Take the total glycemic value of the meal from step 7 and multiply it by the net carbs of the meal from the previous step and then divide your answer by 100. In addition, the average glucose value must be taken into consideration. In patients with type 1 or type 2 diabetes who are treated with glucose-lowering agents expected primarily to reduce PPG, monitoring may be useful in titrating these treatments or in confirming that patients have in fact responded to the intervention. You are required to report Required Key Measure data for one Target Group for your selected Best Practice. These terms are often used by people who are suffering from diabetes to control their blood sugar levels. Even before these clinical trials were completed, observational studies demonstrated a positive association between retinopathy and hyperglycemia. The Big Picture: Checking Your Blood Glucose. Hemoglobin A1c is a measure of the degree to which hemoglobin is glycosylated in erythrocytes and is expressed as a percentage of total hemoglobin concentration. In one study, women with gestational diabetes were randomly assigned either to a treatment program in which therapy was adjusted to achieve predefined FPG and PPG levels or to one targeting premeal and bedtime glucose levels.7 The women assigned to postprandial monitoring achieved a lower HbA1c and required fewer Caesarian sections for cephalopelvic disproportion, and their babies suffered less frequently from macrosomia and neonatal hypoglycemia. Some of the most obvious unresolved issues related to the definition of PPG include: 1) use of a carefully defined meal test versus the OGTT; 2) variations in size and macronutrient content of test meals; 3) timing of blood sampling after standard meals or glucose challenge; and 4) how often any of these measurements should be made in order to provide meaningful information. To address these issues and to provide guidance to health care providers, the American Diabetes Association (ADA) convened a consensus development conference on 24–26 January 2001 in Atlanta, Georgia. Losing 5-10% of your body weight has shown to help with your blood glucose control. Example: 55.53 (GI value) * 39 (net carbs) = 2165.67; 2165.67 / 100 = 21.66 (rounded) Whether the FPG or a postchallenge (OGTT) glucose level is an independent risk factor for CVD in these studies is controversial and requires further study. The epidemiological studies relied predominantly on measures of chronic glycemia, such as HbA1c. Glucose concentrations begin to rise ∼10 min after the start of a meal as a result of the absorption of dietary carbohydrates. David M. Nathan, MD*, Chair; John B. Buse, MD, PhD, CDE*; Edward S. Horton, MD*; Harold Lebovitz, MD*; Gerald Reaven, MD; Robert A. Rizza, MD*; and Bruce R. Zimmerman, MD*. These include studies in established diabetes, which are designed to measure the effects of glycemic control on chronic complications, and studies in pre-diabetes, which are designed to â¦ glycemic control performance measure that the NDQIA recommends for public reporting is A1C 9% to indicate poor control (12). Glucose levels must be controlled continuously and without holidays. Monitoring treatment aimed at specifically lowering PPG. Specifically, the mean level of blood glucose in the 30 days immediately preceding the â¦ Foods are classified as low, medium, or high glycemic â¦ In the relatively few studies in which HbA1c, FPG, and 2-h OGTT value were measured, all were similarly associated with the risk for retinopathy. QUESTION 6: What additional research needs to be performed to clarify the role of PPG in the medical management of diabetes. Traditionally, hemoglobin A1c (HbA1c) and plasma glucose are utilized as measures of glycemic control. Check your blood sugar again after 15 minutes. It is calculated as the incremental area under the curve (iAUC) for blood glucose after consumption of a test food divided by the iAUC of a reference food containing the same amount of carbohydrate. The definitive answer to this question can only come from well-designed, randomized, controlled clinical trials. Itâs important for blood glucose levels to stay in a healthy range. Sign In to Email Alerts with your Email Address. The panel was then asked to develop a consensus position on the following questions: What is the relationship among PPG, FPG, and HbA1c? In studies of the impact of PPG on diabetic complications, it is important to differentiate between microangiopathy and macroangiopathy as end points. There are insufficient data either to support or to refute the need for extensive or routine PPG monitoring in diabetes, except in the setting of pregnancy. However, some epidemiological studies suggest that there may be a relationship between glycemic levels and CVD. Even if you use a CGM, you'll still need a blood sugar meter to calibrate your CGM device daily. Considering the interrelationships among these glycemic measures (described in the previous section), these results are not surprising. In particular, elderly patients, in whom postprandial hyperglycemia may be the most prevalent abnormality in glucose homeostasis, may warrant special attention. © 2020 by the American Diabetes Association. Similarly, no clinical trial data outside of studies in gestational diabetes have examined the need to treat postprandial glucose levels specifically to prevent complications. The only setting in which PPG monitoring has been shown to improve outcomes is gestational diabetes. They also reduce HbA1c. Whether similar outcomes could have been achieved with premeal monitoring if lower premeal targets had been selected is unknown. This information is also necessary to address broader issues, such as the relative importance of PPG and FPG in assessing glycemic control and/or predicting the risk for diabetic complications. HbA1c levels provide an indication of the average blood glucose concentration during the preceding 2–3 months, incorporating both pre- and postprandial glycemia. If HbA1c goals were not achieved, further attention was focused on lowering the 90- to 120-min postprandial levels. Wolever, MD, PhD. Below are selected resources and tools specific to this Best Practice. QUESTION 5: What are the benefits and risks of specifically lowering PPG in an effort to achieve better glycemic control? Glycemic load and glycemic index are variables that measure the actual impact of foods that contain carbohydrates on blood glucose levels. A Target Group is the largest number of patients/participants that your grant program can realistically serve. Blood glucose (blood sugar) monitoring is the primary tool you have to find out if your blood glucose levels are within your target range. Because blood glucose concentrations vary widely during a 24-h period and from day to day in diabetes, the measurement of HbA1c is the most accepted indicator of long-term glycemic control. In type 2 diabetes, the UKPDS adjusted glucose-lowering therapy to attain fasting glucose goals. Find the glycemic load of the meal. Less stringent goals may be necessary for people who are older and/or have multiple comorbidities. This article reviews those RCTs that have addressed glycemic control. STANFORD HOSPITAL AND CLINICS GLYCEMIC CONTROL OF DIABETES MELLITUS STANFORD COORDINATED CARE Glycemic Control of Diabetes Mellitus Protocol â Stanford Coordinated Care Page 1 PURPOSE: To enhance collaborative patient care by referral of patients with a diagnosis of type 1 or type2 diabetes (DM) to be co-managed by the clinical pharmacist, pharmacy resident or RN following this However, it is unclear whether reducing PPG provides additional improvements in HbA1c. There was no significant correlation between HbA1c and PPGE. Another method to monitor the control of blood sugar in people with diabetes is through a blood test called hemoglobin â¦ Interventional studies have not demonstrated a convincing beneficial effect of glucose lowering on CVD outcomes,1,2 and no clinical trials have examined whether treatments that primarily lower PPG decrease cardiovascular events. At present, HbA1c measurements are the “gold standard” for assessing long-term glycemic control. How To Measure Compliance With Glucose Control? Associations of CVD and CVD risk factors with glycemia have been demonstrated over a broad range of glucose tolerance, from normal to diabetic, in several epidemiological studies. Hypoglycemia in the postprandial period is rare except in response to exercise or rapid-acting insulin analogs. It appears that FPG is somewhat better than PPG in predicting HbA1c, especially in type 2 diabetes. There are several issues that should be considered when designing studies to examine PPG. There are no adequate randomized clinical trial data to answer this question, but the following are clinical situations in which PPG monitoring could be considered: Suspected postprandial hyperglycemia. The diet could be a means to lose weight and prevent chronic diseases related to obesity such as diabetes and cardiovascular disease. In nondiabetic individuals, fasting plasma glucose concentrations (i.e., following an overnight 8- to 10-h fast) generally range from 70 to 110 mg/dl. The fundamental question to be answered is whether measuring premeal glucose, FPG, or PPG, alone or in combination, will be most helpful in adjusting treatment to achieve HbA1c goals while minimizing hypoglycemia. The PPG profile is determined by carbohydrate absorption, insulin and glucagon secretion, and their coordinated effects on glucose metabolism in the liver and peripheral tissues. Summary: Glycemic control represents a modifiable preoperative risk factor in surgery. A food with a glycemic index of 28 boosts blood sugar only 28% as much as pure glucose; one with a glycemic index of 100 acts just like pure glucose. The A1C measure, taken with a blood test, evaluates an average of blood glucose levels as a percentage of red blood cells over the past 2 to 3 months. 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