Test Your Knowledge #510: A 60-year-old female schoolteacher who was diagnosed with Type 2 diabetes two months ago....

She started neutral protamine Hagedorn (NPH) at bedtime and learned self-monitoring of blood glucose (SMBG) and how to measure daily fasting blood glucose and random preprandial and postprandial blood glucose several times weekly. The diagnosing physician's staff increased her NPH dosage two or three times during the first 2 weeks after diagnosis because of fasting hyperglycemia. Once her fasting blood glucose levels were consistently between 80 and 130 mg/dL (4.44–7.22 mmol/L), she was told she did not need to consult the diagnosing physician but should follow up with her primary care physician when she returned home at the end of summer.

She reports that she has been following the prescribed carbohydrate-counting meal plan and has been walking almost daily. She has been recording all of her SMBG values in a logbook. She says that her blood glucose readings are higher than she thinks they should be, but she is uncertain how to improve the readings. A review of her neatly written logbook indicates that most of her nonfasting blood glucose values are above 180 mg/dL (9.99 mmol/L). Her hemoglobin A1c value is now 8.3%.

Which of the following key components of diabetes self-management training is this patient missing that could have prevented her from experiencing nearly 2 months of persistent hyperglycemia?

A. Self-monitoring of blood glucose before each meal and at bedtime.

B. Keeping a detailed food record in addition to the self-monitoring of blood glucose records.

C. Using pattern management to adjust her regimen.

D. Increasing the intensity of her exercise program.

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