or more (depending on the nature of the insulin preparation used and individual patient reaction). in addition, the onset and duration of the effects of oral hypoglycemic agents vary from type to type and from patient to patient. personal (home) glucose monitoring control and outcomes of both types 1 and 2 diabetes may be improved by patients using home glucose meters to regularly measure their glucose levels. glucose monitoring is both expensive (largely due to the cost of the consumable test strips) and requires significant commitment on the part of the patient. lifestyle adjustments are generally made by the patients themselves following training by a clinician. regular blood testing, especially in type 1 diabetics, is helpful to keep adequate control of glucose levels and to reduce the chance of long term side effects of the disease. there are many (at least 20+) different types of blood monitoring devices available on the market today; not every meter suits all patients and it is a specific matter of choice for the patient, in consultation with a physician or other experienced professional, to find a meter that they personally find comfortable to use. the principle of the devices is virtually the same: a small blood sample is collected and measured. in one type of meter, the electrochemical, a small blood sample is produced by the patient using a lancet (a sterile pointed needle). the blood droplet is usually collected at the bottom of a test strip, while the other end is inserted in the glucose meter. this test strip contains various chemicals so that when the blood is applied, a small electrical charge is created between two contacts. this charge will vary depending on the glucose levels within the blood. in older glucose meters, the drop of blood is placed on top of a strip. a chemical reaction occurs and the strip changes color. the meter then measures the color of the strip optically. self-testing is clearly important in type i diabetes where the use of insulin therapy risks episodes of hypoglycemia and home-testing allows for adjustment of dosage on each administration. its benefit in type 2 diabetes has been more controversial, but recent studies have resulted in guidance that self-monitoring does not improve blood glucose or quality of life. benefits of control and reduced hospital admission have been reported. however, patients on oral medication who do not self-adjust their drug dosage will miss many of the benefits of self-testing, and so it is questionable in this group. this is particularly so for patients taking monotherapy with metformin who are not at risk of hypoglycaemia. regular 6 monthly laboratory testing of hba1c (glycated haemoglobin) provides some assurance of long-term effective control and allows the adjustment of the patient's routine medication dosages in such cases. high frequency of self-testing in type 2 diabetes has not been shown to be associated with improved control. the argument is made, though, that type 2 patients with poor long term control despite home blood glucose monitoring, either have not had this integrated into their overall management, or are long overdue for tighter control by a switch from oral medication to injected insulin. continuous glucose monitoring (cgm) cgm technology has been rapidly developing to give people living with diabetes an idea about the speed and direction of their glucose changes. while it still requires calibration from smbg and is not indicated for use in correction boluses, the accuracy of these monitors is increasing with every innovation. the libre blood sugar diet program utilizes the cgm and libre sensor and by collecting all the data through a smartphone and smartwatch experts analyze this data 24/7 in real time. the results are that certain foods can be identified as causing one's blood sugar levels to rise and other foods as safe foods- that do not make a person's blood sugar levels to rise. each individual absorbs sugar differently and this is why testing is a necessity. hba1c test a useful test that has usually been done in a laboratory is the measurement of blood hba1c levels. this is the ratio of glycated hemoglobin in relation to the total hemoglobin. persistent raised plasma glucose levels cause the proportion of these molecules to go up. this is a test that measures the average amount of diabetic control over a period originally thought to be about 3 months (the average red blood cell lifetime), but more recently thought to be more strongly weighted to the most recent 2 to 4 weeks. in the non-diabetic, the hba1c level ranges from 4.0 to 6.0%; patients with diabetes mellitus who manage to keep their hba1c level below 6.5% are considered to have good glycemic control. the hba1c test is not appropriate if there has been changes to diet or treatment within shorter time periods than 6 weeks or there is disturbance of red cell aging (e.g. recent bleeding or hemolytic anemia) or a hemoglobinopathy (e.g. sickle cell disease). in such cases, the alternative fructosamine test is used to indicate average control in the preceding 2 to 3 weeks. continuous glucose monitoring main article: blood glucose monitoring the first cgm device made available to consumers was the glucowatch biographer in 1999. this product is no longer sold. it was a retrospective device rather than live. several live monitoring devices have subsequently been manufactured which provide ongoing monitoring of glucose levels on an automated basis during the day. electronic health records sharing their electronic health records with people who have type 2 diabetes helps them to reduce their blood sugar levels. it is a way of helping people understand their own health condition and involving them actively in its management. m-health monitoring applications the widespread use of smartphones has turned mobile applications (apps) into a popular means of the usage of all forms of software. as a consequence, the use of mobile apps in managing people's health and supporting their chronic conditions is receiving popularity, especially among healthcare systems, which are showing a great tendency toward using these apps to integrate patient-generated data into electronic health records, and to modify and improve treatment plans accordingly. the number of health-related apps accessible in the app store and google play is approximately 100,000, and among these apps, the ones related to diabetes are the highest in number. conducting regular self-management tasks such as medication and insulin intake, blood sugar checkup, diet observance, and physical exercise are really demanding. this is why the use of diabetes-related apps for the purposes of recording diet and medication intake or blood glucose level is promising to improve the health condition for the patients. however, despite the high number of apps, the rate of their usage among the patients is not high. one of the reasons for this could be due to the design problems that affect their usability. in addition, a 2016 study of 65 diabetes apps for android revealed that sensitive data, such as insulin and blood glucose levels, "was routinely collected and shared with third parties". foot checking monitoring a person's feet can help in predicting the likelihood of developing diabetic foot ulcers. a common method for this is using a special thermometer to look for spots on the foot that have higher temperature which indicate the possibility of an ulcer developing. at the same time there is no strong scientific evidence supporting the effectiveness of at-home foot temperature monitoring. the current guideline in the united kingdom recommends collecting 8-10 pieces of information for predicting the development of foot ulcers. a simpler method proposed by researchers provides a more detailed risk score based on three pieces of information (insensitivity, foot pulse, previous history of ulcers or amputation). this method is not meant to replace people regularly checking their own feet but complement it. lifestyle modification the british national health service launched a programme targeting 100,000 people at risk of diabetes to lose weight and take more exercise in 2016. in 2019 it was announced that the programme was successful. the 17,000 people who attended most of the healthy living sessions had, collectively lost nearly 60,000 kg, and the programme was to be doubled in size. diet main article: diet in diabetes because high blood sugar caused by poorly controlled diabetes can lead to a plethora of immediate and long-term complications, it is critical to maintain blood sugars as close to normal as possible, and a diet that produces more controllable glycemic variability is an important factor in producing normal blood sugars. people with type 1 diabetes who use insulin can eat whatever they want, preferably a healthy diet with some carbohydrate content; in the long term it is helpful to eat a consistent amount of carbohydrate to make blood sugar management easier. there is a lack of evidence of the usefulness of low-carbohydrate dieting for people with type 1 diabetes. although for certain individuals it may be feasible to follow a low-carbohydrate regime combined with carefully managed insulin dosing, this is hard to maintain and there are concerns about potential adverse health effects caused by the diet. in general people with type 1 diabetes are advised to follow an individualized eating plan rather than a pre-decided one. computer assisted dietary history taking appears to just as applicable as oral or written dietary history taking, however there is lack of evidence showing effects on improving dietary habits, levels of hba1c and overall management of diabetes. exercise those who have type two diabetes are prone to having higher than normal blood sugar levels; one way to help manage these levels is through exercise. people diagnosed with type two diabetes can use exercise as a way to maintain their blood sugar and it has been shown to work just as well as medications. any physical activity can improve type two diabetes, whether that is walking, swimming, or dancing, any type of movement that burns calories. people living with type two diabetes go through many challenges, one of those challenges is keeping on top of blood glucose levels. exercise will not only improve blood sugar levels, but can also allow the body to be more sensitive to insulin, reduce the risk of heart disease and stroke which are common illnesses associated with diabetes. by exercising, the body becomes more sensitive to insulin allowing for better absorption of glucose by the muscle cells, not only during but up to 24 hours later as well. through many studies, it has been made clear that exercise helps with glycemic control and has shown to lower hba1c levels by approximately 4.2 mmol/mol (0.6%). studies show that exercise along with diet can slow the rate of impaired glucose tolerance in those with type two diabetes. with that, it is recommended people with type two diabetes take part in 150 minutes on average of exercise a week. there have not been studies that show how exercise can help manage blood glucose levels in those with type one diabetes. studies on youth and young adults with type one diabetes where the hba1c was monitored in both a controlled group and intervention group over a 1-3 month and even up to 5 month program showed no consistent effect on glycemic control. possible factors that may affect the impact of exercise on management of glucose levels in type one diabetes are that energy consumption increases near time of exercise to account for possible hypoglycaemic episodes; this may be the reason type one diabetics do not see the lowering of glucose levels during exercise. those with type one diabetes are also prone to nocturnal hypoglycaemic episodes due to exercise as the translocation and expression of glut4, which is an insulin-regulated glucose transporter that is used to give glucose to muscle and fat cells, are increased by exercise. those with type one diabetes may be more apprehensive of exercising out of fear of hypoglycaemia. although exercise may not offer any direct benefit to lower blood glucose levels in those with type one diabetes, there are still many benefits such as a decreased risk of cardiovascular diseases, including blood pressure, lipid profiles, endothelial function, body composition and insulin sensitivity. the two most effective forms of exercise for people with type two diabetes are aerobic and resistance training. aerobic exercise has been shown to largely improve hba1c, and contributes to weight loss and the enhanced metabolic regulation of