Glucose Pattern Management Teaches Glycemia-Related Problem-Solving Skills in a Diabetes Self-Management Education Program

GPM is the process of recognizing glucose patterns, analyzing what is causing out-of-target readings, and taking steps to bring readings back into the target range.⁶  Sometimes referred to as “pattern control” or “glucose pattern control,” this process provides patients with information to make decisions regarding their diabetes self-management. At the core of these decisions are glycemia-related problem-solving skills.

GPM is an integral component of patient-centered diabetes self-management because it:

• Educates patients about how well-controlled their glucose levels are

• Provides feedback on therapy and guides therapy changes

• Helps minimize the number of high and low glucose readings, thereby contributing to more stable glucose levels

GPM enables patients to understand how their day-to-day choices affect their glucose levels. Having this information empowers patients to make the decisions necessary to reach their goals.

Although quarterly or biannual A1C testing provides an overall average of glycemic control, it does not provide guidance on daily meal and activity decisions or medication adjustments. In addition, A1C levels may camouflage poor glycemic control because an optimum A1C level can be achieved even with wide glycemic fluctuations. In fact, such daily glycemic variability is a risk factor for hypoglycemia^7,8  and is being evaluated as a potential risk factor for other diabetes complications^9–12  and lower patient satisfaction/quality of life.¹³ 

The three essential components of DSME programs that integrate glucose testing and GPM are:

• A philosophical belief that glucose testing and GPM are necessary for understanding the impact of food, activity, and medications on daily glucose levels and, ultimately, on A1C levels

• Expert staff who can teach patients how to interpret their glucose data and how to integrate these data into food, activity, and medication therapies

• Materials that guide data collection and interpretation

Patients who review glucose data and use GPM have the ability to choose the best therapy to help them to achieve their glycemic targets. Many providers focus on adding or increasing medication to the treatment plan, but patients may choose, appropriately, to pursue healthy eating and increased activity instead. By using GPM, the success of meal planning and increased activity can be readily verified in the glucose readings. It can safely and optimally assist patients in achieving their A1C goal.

The diabetes care team at the International Diabetes Center (IDC) in Minneapolis, Minn., developed the Type 2 Diabetes BASICS curriculum to facilitate teaching GPM to newly diagnosed patients with type 2 diabetes or individuals previously diagnosed but in need of a review or update.^6,14–17  The primary teaching strategy is to have patients record their glucose levels in a food and activity log so that they can see the direct cause-and-effect relationships. This exercise empowers patients to make their own decisions regarding lifestyle and medication. The curriculum encompasses the three essential DSME program components listed above, which support patient self-efficacy in using pattern management to achieve glucose goals.

The BASICS curriculum has four core sessions. The first two sessions can be described as survival-level education and are team-taught by a nurse and a dietitian. These sessions promote the basic knowledge and skills necessary to provide a safety net for living with diabetes. They also establish a focus on glucose management and problem-solving.

Research has shown that the curriculum results in reduced A1C levels and is as effective in group settings as in individual settings.¹⁸  In a 6-month study, attendees in both settings significantly decreased their A1C levels—individuals by 1.7% (P < 0.01) and those in groups by 2.5% (P < 0.01). Body weight also significantly decreased—individuals by 10.4 lb (P < 0.01) and those in groups by 5.8 lb (P < 0.01). Improvements in health-related quality-of-life measures were similarly positive. A recently presented study using the curriculum in a U.S. Department of Veterans Affairs group setting showed decreases in A1C levels and weight compared to a control group receiving only medical follow-up.¹⁹ 

A guide for teaching glucose testing and GPM in a DSME program, based on the IDC experience, is provided below.

Teaching SMBG (including both glucose testing and GPM) is based on the core philosophy that the majority of patients will ultimately succeed at GPM and that the practice will result in improved glucose control. At the end of the initial education session, patients should know their target glucose goals and recommended testing times and have an initial food plan.

As with all learning situations, it is best if unique patient needs are addressed before the delivery of content. Instructors might use these discussions to guide the flow of information. In one-on-one sessions, instructors may let patients lead the learning process so that the content makes the most sense to them. In group settings, the facilitator (a certified diabetes educator) addresses individual needs while keeping in mind the group dynamic. For the most part, individuals' questions correspond with the content delivered during the initial session. Common questions include, “Why do I have diabetes?,” “Will I always have diabetes?,” and “How is diabetes treated?”

With the above caveats recognizing the need to individualize DSME to alleviate such concerns, the following describes how glucose testing and GPM are addressed in an initial DSME session. Because this session builds a foundation for successful GPM, the educator(s) should agree on the importance of GPM, understand how they can support it, and be comfortable problem-solving a variety of pattern management questions.

The initial goals are to ensure that patients understand what diabetes is and what treatments are available and to define individual treatment goals. Patients learn what glucose testing entails, including blood glucose and A1C targets, and how carbohydrate and physical activity affect glucose levels. To support discussion of these topics, it is helpful for patients to bring a 5- to 7-day food and activity record to the session.

Some DSME programs offer separate visits for teaching glucose testing and developing a food and activity plan. A prerequisite for teaching GPM is that patients must have a personalized food plan, so each program must decide how best to accomplish this. The IDC experience supports having a nurse/dietitian team co-teach an initial 2-hour session and blend glucose testing and GPM training throughout.

All educators need to have the same glycemic outcome goals and either use the same materials or be familiar with each others' materials. Education materials support the use of glucose data by highlighting the need for glucose control, listing target glucose goals, and providing logs for patients to record food, activity, and glucose data.

The IDC patient book begins with a definition of diabetes and how diabetes is diagnosed. It emphasizes the importance of glucose control, and, in so doing, sets the stage for introducing tools to manage glucose levels. Visual aids indicate that food and activity are always part of the treatment plan and that a variety of medications are available. The book states, “The best treatment plan is the one that keeps your glucose level in control.”¹⁷ 

The initial food plan is typically based on carbohydrate counting, with carbohydrate choices or grams distributed among each day's meals and snacks. As eating behaviors change, so, too, will the food plan. Because patients have much to learn about carbohydrate counting, food preparation, and portion sizes before applying this knowledge to everyday situations, some programs prefer to have patients go through the learning phase before implementing glucose testing and GPM. Regardless, patients need a food plan to interpret glucose data. In addition, glucose data are needed to evaluate the food plan as it is being adjusted to best fit each patient's eating patterns, health needs, and glycemic goals.

Many patients ask what their glucose level should be. Glucose target goals for fasting, premeal, and, in some cases, postmeal periods are discussed, and the patients' goals are written in their book. If a provider has not communicated A1C or prandial/postprandial glucose goals to patients, the educator discusses those and then communicates the goals to the provider. Primary care providers and their support team at Park Nicollet Clinic (the integrated health care system that includes IDC) use a patient handout, which is in the process of being integrated into the electronic health record as part of the post-visit summary. Called “My Diabetes Care Plan,” the handout reviews glucose and other diabetes-related goals. It is important for discussion with patients to have a shared care plan (Table 1). The educator emphasizes that patients' food, activity, and medication plans are aimed at keeping glucose levels in target and that the only way to receive immediate feedback on how well they are doing is through SMBG.

It is helpful for patients to understand that the glucose test is not a test in the sense that they will be graded. Rather, it is a test that alerts patients about what is helping them meet their target glucose goals and what is not. Glucose test results are labeled neither good nor bad but are provided as data for problem-solving and decision-making.

Patients learn that glucose levels will be out of target on occasion and that a reasonable goal is to have at least half of their glucose test results in their target range. Realizing that they are not expected to have every test result within range softens the nature of glucose testing as a “test” and eases patients' sense of perfectionism. Glycemic feedback is key to reaching long-term A1C goals (Table 2).

A typical testing routine after initial education is to have patients check their blood glucose three times a day: fasting and before and 2 hours after the start of their largest carbohydrate meal. The dietitian may recommend additional testing times based on patients' eating habits and activity patterns, and patients themselves may be interested in additional testing.

A consideration when recommending testing frequency is the number of glucose test strips a patient's insurance will reimburse. During the 2 weeks after the initial session and before the second session, patients will use 15–30 test strips, depending on the number of errors they have and any extra testing they perform.

A food record form that includes a place to record glucose data, such as the one used in the BASICS program, facilitates the integration of glucose data and GPM. This is a key aspect of learning GPM (Tables 3 and 4). For most clinicians, this makes sense because it allows them to easily review food intake (amount of carbohydrate and type of food) as well as activity levels and corresponding glucose values. Patients can see that their carbohydrate intake, activity level, and medication, if taken, all contribute to their glucose levels and, ultimately, their A1C.

As with all education sessions, it is important to end with a recap of the main points and personal goals. As part of the recap, it is helpful to review how to apply the information presented, what barriers might occur, how to deal with these barriers, and what support may be necessary to help patients reach their goals. Sample questions that focus on behavioral change include: What habits might be easy or difficult for me to change? What new behaviors would I like to start? What might get in my way of making these changes? What will facilitate change? Who will support me?

Activities between DSME sessions help patients focus on key aspects of diabetes management to reinforce what they can do to achieve glucose control. A checklist of activities might include:

• Test your glucose level every day at the recommended testing times.

• Record your glucose readings.

• Complete your food and activity record for at least 3 days.

• Stay active or become more active.

• Think about the new behaviors you have started and your goals for the future.

• Make notes about the challenges of taking care of your diabetes.

• List what has been helpful.

In the IDC's experience, two to four subsequent education sessions have been necessary to assess patients' knowledge, application of information, and resulting glucose levels to determine the appropriateness of therapy (nutrition, activity, and medication) and make changes, if needed. If patients are to successfully implement GPM, they should, by the end of the follow-up sessions, be able to assess their glucose data in relationship to their food, activity, and medication; know how to improve their glucose levels; and feel confident about making therapy changes or talking to their health care provider about changes to improve outcomes.

The first follow-up session is usually 2 weeks after patients begin to perform glucose testing and advances the interpretation of glucose values as patients begin to apply GPM. The goals of the session include reinforcing the content of the initial session(s) and discussing related questions, using glucose data to assess glycemic control, and evaluating patients' food plan, activity, and medication. Information may be provided on meter maintenance, obtaining accurate readings, high and low glucose levels, illness and stress, eating at a variety of places, alcohol, and physical activity.

After starting to implement their food plan and perform glucose testing, many patients begin to understand how glucose testing can give them useful feedback about their eating habits, activity level, and diabetes medications. Through GPM, they feel a sense of empowerment and confidence, which enables them to better engage and assist in the design of their diabetes care plan.

A three-step framework for interpreting glucose records is detailed in Table 3 and provides guidance to health care providers who are new to reviewing diabetes records. The three steps are 1) obtain sufficient, accurate data; 2) identify all possible interpretations; and 3) make individualized recommendations and plans.

The first follow-up session engages patients in a discussion about glucose levels both in and out of target. The importance of knowing this information is emphasized. As noted in the IDC patient education book, “Your glucose test numbers show how well your diabetes treatment plan is working.”¹⁷ 

Glucose records are reviewed for readings that are in target and above or below target. Patients are reminded that the goal is to have ~ 50% of their readings in the target range, and they or the educator performs this calculation. Specific glucose patterns are then examined. Patients are asked if they see any pattern that reflects when their glucose levels are in, above, or below target.

Patients can circle glucose numbers that are either low, high, or in target with different colored pens to more easily see their patterns. By reviewing numbers horizontally and vertically in their record books, they can identify glucose patterns of success and areas that need to be addressed.

Patients are reminded that glucose readings are not “good” or “bad,” but rather are data on which to make clinical decisions. Finding patterns is a discovery process for both patients and the educator and promotes an ongoing collaborative relationship. Patients see the everyday impact of food and activity because they have access to their glucose values. They know their target glucose values, and they know how to review their food, activity, and glucose records.

In the IDC Food and Activity Record, patients list the foods they eat, the amounts they eat, and either the number of carbohydrate choices or the grams of carbohydrate at each meal and snack. They also record their glucose data. This information is used to assess patient understanding and application of the food plan, and, together, patients and the educator discuss glucose patterns. Some patients may have increased their glucose testing times to determine the effect of additional meals. This demonstrates the power of glucose feedback and engaged patients.

Because there are many aspects to a food plan, one or two visits with a registered dietitian for medical nutrition therapy (MNT) are recommended for initial teaching and another one or two visits are needed to evaluate and adjust therapy. As mentioned above, the IDC program typically combines the nutrition visit with the DSME visit (and bills as DSME), whereas other centers provide these services separately. All educators need to support and reinforce the principles of GPM.

After the initial education session, most patients check their glucose levels when fasting and before and 2 hours after the start of their largest carbohydrate meal. The general guidelines for testing after subsequent sessions are:

• If ≥ 50% of their glucose tests are within the target range, glucose testing can decrease to three times a day on 2–3 days/week.

• If their glucose results are within target goals < 50% of the time, patients are advised to perform glucose testing three times a day, every day until therapy modifications result in ≥ 50% of their glucose tests within the target range.

• If a specific time of day yields an elevated glucose pattern, but the patient still achieves ≥ 50% of his or her glucose results within the target range, we address nutrition, activity, or medication modification for that time period, followed by additional testing to assess changes.

These recommendations may vary for patients who want to test more frequently; whose meal plan, activity level, or medication is changing; or who do not have enough test strips to perform SMBG as frequently as desired.

Some patients are surprised to discover that they have symptoms of hypoglycemia when their glucose is within target and not < 70 mg/dl. SMBG lets patients know whether their symptoms are the result of a low glucose level or the result of their body adjusting to better glycemic control. In this way, they avoid excess food intake based only on symptoms and know they are making an informed decision rather than a guess.

Patients must test often enough to attain the feedback they need to understand and refine their food and activity plan. SMBG should focus on times of day during which a recent pattern of high or low glucose levels has emerged.

Ongoing education continues to focus on GPM, problem-solving, and behaviors that positively influence glucose levels and address challenges. Typical content includes:

• How diabetes changes over time

• Staying healthy

• Diabetes complications

• Smoking cessation

• Food choices and heart health (fats and sodium) when glucose numbers are puzzling

• Strategies for creating life balance

• How to know if your treatment plan needs changing

• Stress and depression

• Staying motivated

• Staying active

Key to ongoing education is a continued focus on GPM and increasing patient confidence in diabetes self-care. Patients are encouraged to keep complete diabetes records (food, activity, and glucose results) for 3–7 days before each diabetes clinic visit. If patients do not bring a food record with them, they are asked to complete a 1-day food recall as a basis for discussion. It is important to determine what is working and where changes might be needed—both important components of GPM.

Downloading meters provides more data, sometimes enabling patients to make more informed decisions related to their diabetes management. Meter downloads, particularly the “modal day” or “standard day” graphs, provide a collapsed summary of glucose data that shows immediately which glucose values are in or out of the target range. Of course, reviewing food, activity, and medication therapies along with the glucose data is a key to GPM.

GPM can increase patient confidence in diabetes self-management. Confidence comes from understanding how their glucose data compare to their target goals and knowing if and when they should make changes in their food choices or physical activity. Some patients use the data for discussions about possible adjustments to their medication.

This article has provided a road-map for incorporating SMBG (glucose testing and GPM) into a DSME program based on the core principle that most patients benefit from knowing how to assess their care. The information patients' gain through GPM motivates them to take further steps to improve their self-care.

The authors thank the staff of the International Diabetes Center and the Park Nicollet primary care teams for their contributions to the development and implementation of the BASICS curriculum, diabetes support materials, and care processes.