Everyone's Health

Start The Day Right!

Fasting Blood Sugar is Essential to Control

Gary Scheiner, MS, CDE

Blood glucose (sugar) readings are like anniversaries.  They’re all important, but some take on special significance.

Of all the blood glucose readings taken during the day, the wake-up readings take on a great deal of importance.  Think of them as your “final exam” – they account for a big chunk of your A1c level since they represent a long time period (from evening until breakfast).  The other readings (pre-meals, post-meals, bedtime) are like quizzes: they represent only a few hours of control and have less of an impact on your A1c.

According to Dr. Laurence Hirsch, a practicing endocrinologist and Vice President of Medical Affairs for BD, fasting blood glucose is a good indicator of the balance between the glucose produced by the liver and the insulin present in the bloodstream. “The higher the fasting blood glucose, the greater the imbalance,” says Dr. Hirsch.   “Controlling the fasting blood glucose sets the stage for effective diabetes management the rest of the day.”  That’s why your doctor pays special attention to your wake-up readings, and you should too. 

A Time To Intensify

Given the importance of achieving excellent control of fasting blood glucose levels, how do you know when it is time to switch to more aggressive therapy?  Ultimately, this is up to your physician.  But if your fasting readings are above 120 mg/dL on a consistent basis, it is worth discussing. A general target for fasting blood glucose is around 100 mg/dL; the specific target will vary from one person to another.

For those trying to control their diabetes with exercise and a healthy diet, it may be time to start an oral medication.  For those already taking diabetes pills, it may be time to try a second or third medication, or to start insulin therapy.  In recent years, new types of insulin have been designed for just such purposes.  Unlike older NPH insulin which tended to “peak” in the middle of the night and often caused low blood sugar (hypoglycemia), the new long-acting insulins are relatively peakless. 

Even better news, the long-acting insulins (brand names Lantus® and Levemir®) come in a “pen” form that is very easy and comfortable to inject.  According to Dr. Hirsch, “Modern syringes and pens use very fine needles, so the injections are practically painless.  And in many cases, long-acting insulin lasts close to 24 hours, so it only needs to be given once a day.”  Note that some people taking the insulin analog Levemir at low doses or intermediate-acting NPH insulin may need two injections per day.

Dr. Hirsch also points out that for those who choose to use NPH insulin for controlling their overnight and fasting blood sugars, it is best to take the insulin at bedtime rather than dinnertime.  That way, the NPH “peak” takes place in the early morning (when the liver tends to produce more glucose) rather than in the middle of the night.  Note that all long-acting insulin in vials can be given with BD insulin syringes, and BD pen needles fit all types of insulin pens.

Fine-Tuning

Once you have started using basal insulin, the next step is to find the right dose.  Remember, the job of basal insulin is to control the amount of glucose produced by the liver during the night and early morning.  Our goal is to find a dose that holds blood glucose levels fairly steady during sleep.  It should also produce a wake-up blood glucose that is within the range designated by your physician.  A consistent or significant rise or drop during the night, or failure to wake up in your target range, means that your dosage probably needs to be adjusted.

Once the basal insulin dose is established, it is much easier to achieve normal blood sugars during the rest of the day.  Insulin and oral medications tend to work more effectively when blood glucose is close to normal, when you wake up. You may also be more likely to have the energy and discipline to follow your prescribed diet and exercise program when you start the day off right.

Is It Forever?

Once you start taking basal insulin to control your fasting blood glucose, is there no turning back?  Will you be on insulin for the rest of your life?

"It depends," says Dr. Hirsch.  “Type 2 diabetes is a progressive disease.  Treatments that work at first may not be successful later on.  Once insulin is added to, or replaces, oral agents, people generally remain on insulin indefinitely.  But there are always exceptions.”

For example, those who are started on basal insulin early in the treatment of their diabetes may experience a “recovery” of their insulin-producing cells several weeks or months later.  If they are able to produce sufficient amounts of insulin, they can sometimes stop the insulin injections for an extended period of time.  

With the development of new and more effective oral medications and injectable drugs (such as exenatide), the need for injected insulin may be delayed.  And of course, there are those who manage to reduce or eliminate their insulin requirements by adopting and maintaining healthier lifestyle habits.  Exercise and weight loss improve the body’s sensitivity to insulin, so there is potential to control those fasting blood sugars simply by living right!

About Gary Scheiner:
Gary Scheiner is a Certified Diabetes Educator with a Bachelor of Arts in Psychology from Washington University in St. Louis, a Master of Science in Exercise Physiology from Benedictine University, and diabetes training from the Joslin Diabetes Center. He operates a private practice near Philadelphia, specializing in intensive diabetes management for insulin users and providing consultations via phone and Internet.  Gary has had type 1 diabetes since 1985. 

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