Data, Data Everywhere…
How to analyze, interpret and apply information from continuous glucose monitors.
By Gary Scheiner MS, CDE
A1c. HDL. LDL. Fasting
blood sugars. Postprandial CGM Basics
blood sugars. Grams of carb.
Insulin-to-carb ratios. We now have two systems
Correction factors. available that provide real-time
blood glucose estimations and
Ever feel like you’re drowning warning systems to guard
in your own numbers? against pending highs and
Diabetes care is chock-full of lows: The Dexcom Seven and
numerical data, all designed the Medtronic Guardian
(presumably) to help us System (and sensor-augmented
manage our blood glucose pump). A third system, the
levels, prevent complications, Navigator from Abbott
and live life to the fullest. Diabetes Care, is awaiting FDA The Medtronic Guardian
Judging by the problems approval. All three systems
diabetes still causes, perhaps utilize a thin metallic filament
we need to find a better way. inserted just below the skin to
detect glucose in the interstitial
Voila! Along comes fluid (fluid between the cells)
Continuous Glucose in the subcutaneous tissue.
Monitoring (CGM). When Spring-loaded insertion devices
working properly, CGM make sensor insertion quick
systems are supposed to and relatively painless.
generate the kind of
information that will allow us
to fine-tune our diabetes
management program and stay The Dexcom Seven
out of harm’s way. Trouble is,
even with the plethora of
charts, graphs and data points The information from the
(up to 288 per day) produced sensor is transmitted via radio
by CGMs, most people haven’t signals to a receiver/monitor,
got a clue as to what to do with which displays an estimate of
all that information. And that’s the current glucose
a shame, because even with The Medtronic Sensor Augmented Pump concentration. While the
their shortcomings, CGM transmitter and
systems can be an extremely receiver/monitor are “durable”,
valuable resource for guiding the life expectancy for the
daily decision-making. glucose sensors varies from 3
to about 14 days. In case
you’re wondering, the sensors
Diabetes Self-Management, April, 2008
© Copyright 2008, Gary Scheiner MS, CDE – Integrated Diabetes Services LLC Page 1
do not tend to cause skin of the nuances of the system Thus, if blood glucose levels
irritation the way pump before doing so. are rising quickly, the CGM
infusion sets can. data point can be significantly
For example, I find that my lower than a concurrent
The Dexcom and Medtronic CGM data tends to be fingerstick value. Likewise, if
receiver/monitors provide an unreliable during the first 12-24 the blood glucose level is
updated glucose reading every hours after a new sensor is dropping quickly, the CGM
5 minutes and can be set to inserted. It often takes time for data point can be significantly
alarm if the value goes above a sensor to become acclimated higher.
or below a target range set by to being below the skin, and for
the user. The Guardian system calibration readings to allow As a result, I only recommend
also has predictive capability, the sensor to “hone in” using the CGM’s blood glucose
which can warn the user of properly. Ironically, the CGM data for immediate dosing
pending highs or lows. Both data seems to become more purposes if:
systems require calibration by precise and reliable the longer a
way of fingerstick blood sensor has been in place. Until 1. the last couple of
glucose readings a minimum of I start to see a couple of sensor calibration (fingerstick)
twice daily, and both are values that are very close to values have matched the
generally accurate to within 15- simultaneous fingerstick sensor values closely
20% of most fingerstick readings, I just don’t trust the (within 10%).
readings. Both provide “line CGM for immediate decision-
graphs” depicting glucose making. 2. your current blood glucose
trends over the past several is not rising or dropping
hours, and software permits Likewise, the accuracy of rapidly (a quick look at the
detailed analysis over longer CGM values must be sensor trend graph can tell
time intervals. For a more questioned if there have been you if this is the case)
detailed look at CGM Basics, frequent or prolonged data gaps 3. the sensor has not generated
refer to the article in the on the monitor/display. Signal any error messages or
March/April issue of Diabetes interference or significant data gaps for at
Self Management. erratic/inconsistent signals may least the past hour.
cause erroneous and unreliable
information. Whether you use your CGM
Immediate Numbers data for dosing purposes or
There is also an issue known as verify the data with fingerstick
Go back to the paragraph “lag effect” that must be readings, the simple act of
above. See that “15-20%” considered. CGM systems take looking at your monitor has its
figure that we casually glossed multiple data points over a 5- rewards. Research has shown
over? That means that the data minute period and average that checking the monitor 10-
generated by the CGM is them to generate a single data 20 times per day and wearing
usually only a rough estimate. point. This means that, on the system most of the time
Too rough, in fact, to use in average, data is 2 ½ minutes (rather than intermittently)
making most insulin-dosing old. And because CGMs are tends to produce improvements
decisions. That’s not to say measuring interstitial fluid (and in HbA1c and reductions in
that CGM users never use their not blood), there is an inherent hypoglycemia.
data to determine insulin doses, 5-10 minute delay between
but it takes a sound knowledge fingerstick values and what
appears on the CGM display.
Diabetes Self-Management, April, 2008
© Copyright 2008, Gary Scheiner MS, CDE – Integrated Diabetes Services LLC Page 2
past three hours of data will not
Short-term trends help you to fix a prior problem,
they can provide you with
Perhaps more valuable than the information for preventing a
immediate blood glucose value recurrence.
is the direction it is headed. If
you checked your blood For example, checking the 3-
glucose at bedtime and found it hour trend graph a couple of
to be 95mg/dl, you would Dexcom CGM display indicating 1-hour hours after meals can reveal the
certainly react differently if you upward trend. postprandial effect of various
knew it was on the rise rather types of foods. When
than if it was dropping. For instance, If your blood downloading the Medtronic
Similarly, a value of 188 prior glucose is close to or slightly CGM to their Carelink website,
to exercise would mean more above normal but dropping the Sensor Overlay By Meal
to you if you knew whether it quickly, either take a snack or chart indicates these trends
was rising, falling or steady. be prepared to take a snack very clearly. Did your blood
soon. Similarly, if your blood glucose level spike very high
The Medtronic CGM systems glucose is near or slightly soon after the meal? If so,
display up or down arrows to below normal and dropping perhaps you need to give your
denote both the direction and gradually, take a snack and insulin earlier, get some
magnitude of blood sugar check again soon. physical activity after eating, or
changes over the past 20 choose foods that digest more
minutes. The Dexcom Seven With a rapidly rising blood slowly. Did your blood
system displays a 1-hour trend glucose level, you may choose glucose drop soon after the
graph that reveals similar to offset the rise with rapid- meal and then rise a few hours
information. USE THIS acting insulin (taking later? Perhaps you need to
INFORMATION TO YOUR active/unused insulin from delay your injection or extend
ADVANTAGE! The ability to previous doses into account), the delivery of your bolus (if
forecast where your blood and check the monitor often to using an insulin pump).
sugar will be over the next hour make sure you don’t wind up
or two can help to keep you dropping too much. If the
from straying too far out of blood glucose continues rising,
your desirable blood sugar a ketone check may be in order.
range. It is this type of frequent fine-
tuning that can keep you within
your target blood glucose range
more often.
Examples of postprandial “spikes”
Intermediate Trends
Medtronic CGM display with downward
For those who use Symlin or
trend arrow. Both the Dexcom and
Byetta, the 3-hour trendgraphs
Medtronic systems display 3-
can show whether or not the
hour trend graphs on-screen
medication is effective at
(the Medtronic Guardian also
minimizes postmeal spikes
displays a 6-hour trend screen).
without causing hypoglycemia
Although looking back at the
immediately post-meal. A
Diabetes Self-Management, April, 2008
© Copyright 2008, Gary Scheiner MS, CDE – Integrated Diabetes Services LLC Page 3
blood sugar drop soon after The 9-hour graph on the
eating, followed by a rise over Dexcom system and the 12 &
the next couple of hours, 24-hour graphs on the Guardian
indicates a need to either delay system (24-hr only on the
or extend delivery of the sensor-augmented pump) play
mealtime insulin. a role in the regulation of basal
insulin, particularly overnight.
The 3-hour trend graph can Whether you take insulin by
also reveal blood glucose way of injections or a pump,
patterns related to exercise. the basal aspect of your insulin
Checking the graph during and program is designed match
after exercise will show when your liver’s normal secretion of In the next example, taken from
and how much your blood glucose into the bloodstream. a person using Lantus as their
sugar rises or falls. Insulin and In other words, the basal basal insulin, the blood sugar
snack adjustments can be made insulin should hold your blood level is rising through the night
based on the patterns seen on- sugar steady in the absence of from 2am until 8am. This
screen. For competitive as well food, exercise, stress, and indicates the need for a higher
as casual athletes, these types rapid-acting insulin. dose of Lantus.
of adjustments can certainly
enhance performance. By looking at the CGM’s long-
term trend graphs starting
Stress is another concern for approximately 4 hours after a
many of us. In some instances, meal is eaten and rapid-acting
stress will cause an abrupt or insulin is taken, you can
prolonged blood sugar rise. At evaluate the effectiveness of
other times, it can make blood your basal insulin. If the blood
sugar drop. The very sugar level is gradually rising
inconsistency of the stress or falling after the food and
response can cause… well… mealtime insulin have worn
more stress. I have found that off, the basal insulin probably
the 3-hour trend graph provides needs adjustment.
a nice “inside look” at the
effects of various forms of In the example below taken In addition to helping fine-tune
stress on blood sugar levels. from an insulin pump user, basal insulin doses, long-term
Not only can you see if the with a meal eaten (and bolus trend graphs can be used to
stress is making you rise or fall given) at 11:30am, the blood determine the action curve for
(and thus requiring extra sugar level begins to take a your rapid-acting insulin. That
insulin or an immediate snack, downturn at around 4pm. This is, how long it takes for your
respectively), but it can also indicates that the basal insulin insulin to finish working (this
indicate how long the effects level is too high in the late is valuable in determining
last so that you’ll be better afternoon. “insulin-on-board” or
prepared at the next go-round. “active/unused insulin”.
Action curves can vary from
person to person, with times
Long-Term Trends ranging from 2½ to 5 hours.
To determine your action
curve, simply check to see how
Diabetes Self-Management, April, 2008
© Copyright 2008, Gary Scheiner MS, CDE – Integrated Diabetes Services LLC Page 4
long it takes for your blood blocks of time. Both systems “low alarm” makes it
sugar to stop dropping after can reveal overall peaks and considerably safer to work,
giving insulin for a meal or to valleys in blood sugar levels drive, exercise, and generally
correct a high blood sugar during the course of the day, as aim for tighter glycemic
level. Once the line graph well as patterns linked to off control. Likewise, the high
“flattens out”, the insulin has vs. work/school days, blood sugar alarms allow us to
pretty much run its course. For menstrual cycles, and other be more aggressive at
instance, in the example below, unique variables. managing after-meal blood
the insulin action curve is sugar spikes and preventing
approximately 3 hours. ketoacidosis.
Those Lovely Alarms High and low alarm thresholds
are not the same as your target
Perhaps the most valuable blood sugar levels. You don’t
aspect of CGM systems is their want to be experiencing alarms
ability to alert the user when for every mild excursion out of
blood sugar levels may be a normal range (we call these
approaching dangerously high “nuisance alarms”), but you
or low levels. To me, they act still want to be notified in time
sort of like “highway rumble to correct significant
strips” that keep us from excursions. When setting the
veering off the road and into a threshold levels for your alerts,
ditch. By allowing enough keep the “lag effect” in mind.
margin for error, the low blood When blood sugars are
sugar alarm in particular can dropping, the CGM value is
Long-term trend graphs are detect pending lows long likely to be a bit higher than
also useful for seeing the before any symptoms appear. your actual blood sugar. And
delayed effects of high-fat when they are rising, the CGM
foods and intense/prolonged Although they may not detect will probably read a bit lower.
exercise, as well as blood sugar every low, CGMs will provide For this reason, it is a good idea
patterns during illness. The an early warning for the vast to set the low alert threshold at
downloading programs that majority – and much earlier 80 or higher, and the high alert
can be used with CGM systems than most of us would detect in the 200-250 range. To
(Medtronic’s Carelink website; them on our own. In 2004, Dr. avoid nuisance alarms, many
Dexcom DM2 software) can be Bruce Bode, a reknowned people choose to set their high
used to examine long-term diabetes clinician and threshold a bit higher and their
trend graphs over multiple researcher, published one of the low threshold a bit lower
days. The Sensor Daily first studies on the during the night.
Overlay at effectiveness of CGM. He
www.carelink.minimed.com showed that using a CGM with Now get a good night’s sleep.
lets you see up to 7 days of 24- the low blood sugar alarm Tomorrow, you have a lot of
hour trend graphs turned on reduced the amount analyzing to do!
superimposed and color coded. of time spent in a
hypoglycemic range by nearly Editor’s note: Gary Scheiner is a
The Hourly Statistics report on Certified Diabetes Educator with a
Dexcom’s software provides 50%, compared to those who
private practice near Philadelphia.
statistical averages and graphic used the systems without the He provides diabetes self-
displays for virtually unlimited alarm option turned on. The management education and blood
Diabetes Self-Management, April, 2008
© Copyright 2008, Gary Scheiner MS, CDE – Integrated Diabetes Services LLC Page 5
glucose control consulting for
individuals throughout the U.S. and
abroad through his web site
(www.integrateddiabetes.com) and
toll-free hotline (877-735-3648). Feel
free to contact him by phone or e-mail
(
[email protected]) with
questions or for more information.
Diabetes Self-Management, April, 2008
© Copyright 2008, Gary Scheiner MS, CDE – Integrated Diabetes Services LLC Page 6
