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MSN,RN,CDE
This Is Disconcerting
Section:  General Diabetes

 For people with type 2 diabetes who are not on insulin, monitoring their blood sugar does little to control blood sugar levels over time and may not be worth the effort or expense, according to a new evidence review.

"Uriëll L. Malanda of the VU University Medical Center in Amsterdam and his colleagues reviewed 12 studies, of more than 3,000 non-insulin-using diabetics. The review showed that self-monitoring of blood sugar by these patients had only a modest effect on a measure called HbA1c, a standard for assessing blood glucose control. Over a six-month period, patients who tested their own blood glucose levels reduced HbA1c by about 0.3 percent. This effect nearly completely dissipated after 12 months".

I don't know about your patients, but a few of mine were already affected by this review . Negatively. It took me a long time to convince them to stay on track, monitor their blood sugars, and problem-solve. They were seeing good results, too. And now this....

What do you think of this new evidence review?

How will you address your patients' concerns with regard to self-monitoring?

Thoughts?

Source: http://www.sciencedaily.com/releases/2012/01/120127162420.htm

MEMBER COMMENTS
Re: This Is Disconcerting

I think that this issue is something that has to be addressed with a lot of power. It is time for American Association of Diabetes Educators, American Diabetes Assn and Endocrine Society to promote the benefits of blood glucose monitoring. I know that physicians who so not want to be bothered with looking at glucose patterns would like to see the whole thing go away. 

 

 The use of blood glucose monitoring along with ongoing contact with a diabetes educator of choice would be the best. If that could somehow be reimbursed by blood glucose meter companies we would really be improving the health of people with diabetes.  What do you think?

Re: This Is Disconcerting

I am actually against blood glucose monitoring for its own sake.  But I am all for "actionable" blood glucose monitoring.  And that is the rub, patients are taught to take their readings, report them to their doctor and that is the entire purpose of monitoring.   In fact, most doctors could care less about meter readings, they won't take the time of day to look at them and identify any patterns.  All they care about is the A1c and average.  And that is a fatal flaw.  No wonder studies find self monitored blood glucose is useless.

Instead, patients should be taught how to make modifications based on their meter readings.  They should learn how foods affect their blood sugars and make appropriate adjustments their diets.  If they are high in the morning and find that their blood sugar is better during the day if they eat a good breakfast, they should eat a breakfast.  If they find their blood sugars in the mornings are better if they exercise the night before, then they should exercise some at night.

I am against the current regime of mindless patient monitoring.  I am all for "intentional" monitoring that leads to patient led actions.

Re: This Is Disconcerting

I agree with you Brian! Every week I see folks with T2 who dutifully test their fasting blood glucose levels but have no idea why they're doing this or what it means. When we talk about the value of using BG levels to help them manage their food choices, activity level, sleep patterns and stress levels - they become much more invested in BG testing. A1c is important, but it gives the big picture and folks with diabetes need to pay attention to the details.

Re: This Is Disconcerting

Yes, I totally agree.  We see patients fairly frequently who say that their doctor says that they don't need to monitor their blood sugar or that they only need to monitor once a week or so.  My answer to that is to ask them how they are going to know how they're doing if they don't monitor.  If they are putting forth the effort to make lifestyle changes, they need to be able to see how those changes are affecting their glycemic control.  I present monitoring as "information" and not a test (that they either pass or fail).  We talk about how they can use their meters to learn how different things affect them and also to tell them when they need to contact their doctor about their medications.  It's true that, if they are monitoring and doing nothing with the results, it isn't very helpful but patients need to be educated about how to evaluate their logbooks and what to do with the information.  Being proactive is the key--not just writing down numbers to show to their doctors.

Re: This Is Disconcerting

I recall a cardiologist speaking at one of Steve Edelman's TCOYD conferences in MPLS.  He started the talk with how lucky people with diabetes were.  With the use of their meters they could tell that moment where their blood sugar was.  His patients had to wait every 6-12 months to find out what their lipids were. 

I have a person with well controlled Type 2 who will jump on her bike for a couple minutes if her post meal numbers climb too high to suit her.  Empowered by her meter and years of a determined lifestyle.  With an A1c as low as hers, no insuror would think she needed to meter.

Re: This Is Disconcerting

Very Disconcerting for sure.

Analogous to telling graduate students not to bother spending the time or $$ doing field work to collect data,  unless they have at least a good idea of what questions they are trying to answer.

In our case (diabetics) unless we are proactively using the data to  manage our own BG levels as per Brian's comment, there is no use monitoring.

The danger is there however that by not monitoring at all the physicians, nurse practitioners, diabetes educators etc. will not know how their patients are doing at all other than an HbA1c every 6 months or possibly a year.

Having said that there are hoards of people who never check the oil on their vehicles until the red warning light comes on.  Many erroneously assume that it is an oil level indicator.  It is not, but indicates low oil pressure.  By the time the red light comes on some damage and wear has occurred to bearings.

Having said that, Brian et al. are correct that if many medical care professionals are only looking at averages and not trends, spikes etc. why bother testing?  No surprise that an average of say of 126 mg/dl is assumed to be OK by the medical care professional but patient is doing poorly by only looking at averages and they ignore or miss the many spikes above 140 where nerve damage occurs or many hypoglycemic events that may dip into the 50s there are serious issues.

As with diet and other medical issues when the mass media pick up on some study or another and the results are "dumbed down" it is very difficult to counter since it become conventional wisdom and nearly cast in stone. The plethora of examples include current climate change (not  hypothetical) issues, the facts supporting evolution all v.s. the media suggesting that varied belief systems refute actual facts and the supporting data etc. all make science based issues like medicine very difficult in many cases.

One acquaintance DX'd last year told me his physician said he would ONLY be concerned if his BG was > 200 mg/dl then he should use the insulin pen he was given and inject a "few" units.  When I asked how often he was testing he said usually only in the morning since he knew when he got up it would mostly be < 200 mg/dl and that way he did not need to use the pen or upset his physician.  When I asked if he ever tested after meals his reply was .. not really as the few times I did I was almost to 300 so I think it is best to test when I am low so the doc does not get pissed with me on the next visit when he looks at my meter.

Since we are moving back to the U.S. I hope I can start a diabetes support group in the community we are going to be.  Maybe I can make a difference to 1 or more people by just sharing my experience and the importance of testing.  I won't hold my breath as last year on fellow I met there sad he was now follow the vegetarian diet as he read somewhere that would cure diabetes.

OMG the popular press strikes again...
I guess one does not need to live in the Third World to have rampant ignorance...


Cheers from Belize

Bruce

-- 
Bruce W. Miller, Ph.D.
Conservation Ecologist
Neotropical Bat Project


office details
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Phone +501-220-9002

Re: This Is Disconcerting

 Thank you for the comments.

Bruce, I love your comment of "I guess one does not need to live in the Third World to have rampant ignorance..."

Jane, being proactive and teaching the patients to problem-solve is key to success indeed.

Patricia, the reason patients contact their CDEs is because they see the value of education and what this education enables them to achieve as far as their self-management activities go. And yet the market is rather slim for the CDEs. Go figure.

And now ..back to business.

“Regular self-monitoring of blood glucose in non-insulin treated patients has minimal impact on glycemic control, has no impact on general well-being or quality of life, and is rather expensive. Consequently, it does not add to a clinically relevant long-term benefit”.

I strongly disagree.

It just happens that I have many patients who are long-distance truck drivers , ComEd workers, and phone technicians on Meglitinides and Sulfonylureas. And we, as health professionals, are aware of the prolonged and dangerous hypos the sulfonylureas can cause. Thus, I instruct my patients to always carry their Side-kick glucose testers and emergency carbs on them and test before they set out to drive, an hour after driving, on breaks, and yes, on poles...if they are feeling "funny". Many of them do experience bg levels of 70mg/dl and lower due to the lack of food onboard, being too physically exerted, or staying on the pole far too long. Guess what? Many a time their meter(trusted friend) allowes them to problem-solve and get out of the danger zone... I will take this a step further. I know for a fact that long-distance truck-drivers can loose their special license to drive if their daily and quaterly bg levels are not up to par. For these people bg testing is a requirement that keeps them employed. Do I need to say more?

Why label something as useless when in reality it is so incredibly helpful/ important to at least some?

Thoughts?

Re: This Is Disconcerting

I was reminded of a comment that I heard from a Doctor that I used to work with at the Joslin Diabetes Center, when glucose monitoring started to become more of a treatment option rather than urine testing. Of course it was a few years ago, so I can't remember exactly but he stated but it went something like this: "Why would we want to bother asking the patient to inflict pain on themselves, when we have urine testing?  We know with urine testing we can get them to improve their control, that should be sufficient!".

Not all providers think alike, and I'm sure he was going against the flow.  There are studies that have been done that show that SMBG is a contributor to depression. YOUR THOUGHTS???

BMJ. 2008 May 24;336(7654):1174-7. Epub 2008 Apr 17.

Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial.

http://www.ncbi.nlm.nih.gov/pubmed/18420662

Re: This Is Disconcerting

Thank you for your comment, Joan.

I looked at the study you mentioned, and it was found that with newly diagnosed type 2 diabetes self monitoring of blood glucose concentration had no effect on glycaemic control but was associated with higher scores on a depression subscale.

I didn't find the results of this study surprising.

The key to understanding the results of the study are two important  words. And they are: "newly diagnosed". I can tell you (based on my clinical experience with newly diagnosed people with Type 2 DM) that these individuals are surprised, sometimes shocked and/or anxious, many are in denial at the time of dx and beyond. Add to this picture SMBG which will show uncontrolled DM for the first few months of adjusting to the different way of living, meds and etc.... Not very encouraging, is it? People react and state that their bg scores "depress them". As a matter of fact, I hear my newly diagnosed patients use this very same expression almost daily. You and I (and probably most of the health professionals in this forum) understand that it takes a significant amount of time (sometimes years) to learn how to succesfully self-manage one's diabetes, no?

Re: This Is Disconcerting

How true that a new dx of DM could potentially set the stage for depression.  And yes I'd say the folks I see are overwhelmed.

Of note: the 2012 Clinical Guidelines also say that SBGM can  be helpul for those with type 2 DM.

I'm not sure there are studies that look at depression and SBGM for those with long standing DM. 

As for using the "tool", there are other ways for us to determine their control, and if I can get them to focus on food records, I'd rather put my effort into that (OK, yes I am an RD), as that has been shown to improve a persons weight mangement efforts, which ultimately impact on control. 

We do have the a1c. 

Do any of you use fructosamine?

Re: This Is Disconcerting

This tool I created may be helpful when doing SMBG pattern management with a T2 or T1 PWD:

 

P.A.T.T.E.R.N. Management Action Plan  

Pinpoint FPG and PPG targets

 

Analyze logs for BG problems & also pattern(s) of >3 days. Act on priority problem & pattern first.

 

Target root causes of pattern(s)

 

Tap into insulin changes first

 

Execute insulin change for each pattern for 3-4 days

 

Review new logs to assess effectiveness of change

 

Navigate to additional insulin changes if BG not at target

 

Suggest lifestyle variables to change (1 at a time) to further optimize BG control, as needed

 

 

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much

 

Re: This Is Disconcerting

Thank you Joan and Mary Ann for your comments. Mary Ann, I like the tool .

 Joan ,we sometimes use the fructosamine test if we need to see the short-term progress of patients on a new therapy. We have used it for the patients with sickle cell disease as well.  Yes, we could use food diaries, A1C results to guide us, but it's not he same as using a glucose tester on a daily basis.

As far as the importance of SMBG  goes, I feel that Christine nailed it by quoting the cardiologist who said: "How lucky people with diabetes were. With the use of their meters they could tell that moment where their blood sugar was" .

I don't know about you, my dear colleagues, but I do consider SMBG a very important tool in DM management. Its usage enables me to empower my patients to change their eating habits and exercise. I once tested a patient before she went out for a 30 minute walk. I then retested her after 30 minutes and her bg level was 38 points lower. That's huge!! It's a cause-and-effect relationship that the patients can see for themselves. How can anyone beat that? Isn't seeing believing?

Thoughts?

Re: This Is Disconcerting

What are your thoughts on the ISO standards that FDA uses to regulate Blood Glucose Monitors for inpatients and outpatients?

Thanks Chuck T

Re: This Is Disconcerting

I don't know whether the new ISO standards are out or not. I am aware that due to complaints about glucose meter inaccuracy, the Food and Drug Administration  is currently developing a new standard for glucose meter accuracy.

The FDA plans to tighten their standard to the proposed 2012 ISO standard of having an accuracy within ±15% above 75 mg/dl. I don't know to what extent this improvement will reduce clinical error.

Re: This Is Disconcerting

It’s encouraging to see that this is a topic of concern in your community. As a type2 diabetic, I may be able to add insight into why they came to such a conclusion and what we may be able to learn from it.

First, we need to look at the context in which the study was designed. The National Health Service like any government agency in this economic climate is under tremendous pressure to cut costs. An editorial commenting on the study revealed that paying for self-monitoring in a rapidly expanding number of patients is not warranted since quite a few of these studies  suggest that blood glucose self monitoring has little or no effect on medium term blood glucose control in type 2 diabetes not treated by insulin. “The healthcare costs of self monitoring have been estimated comprehensively and, with diabetes now affecting some 3-4% of the population of the United Kingdom, the total healthcare cost of self monitoring may now exceed £100m each year in the UK.” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2394584/

Now, let’s look at the study itself. The endpoint goal was to assess the effect of self monitoring of blood glucose concentrations on glycemic control and psychological indices in patients with newly diagnosed type 2 diabetes mellitus. The treatment algorithm included a sulfolnurea which can have highly variable effects especially when used with other medicines or with the highs and lows associated with high carbohydrate meals. http://www.nature.com/clpt/journal/v74/n4/full/clpt2003489a.html and http://www.nhs.uk/LiveWell/Goodfood/Pages/Goodfoodhome.aspx  Although the education protocol wasn’t described, it is obvious that the education my CDE gave me is far better than theirs was: they required only four fasting and four postprandial readings a week! It’s obvious teaching that adapting carbohydrate and protein levels based on meter readings was not a part of their self management education. There was an obvious disconnect in support as well, since a third of the patients didn’t even follow this most basic request- “Of the 96 participants in the self monitoring group, 63 carried out more than 80% of the requested blood glucose monitoring (that is, four fasting and four postprandial readings a week).”

Even the NHS internal evaluation of their Diabetes structured educational program finds:  “Little robust evidence of the effectiveness of any particular educational approach for people with Type 2 diabetes was found.  In general, ‘interventions which were more frequent and extended over long periods appeared to improve outcomes more than less frequent, shorter duration interventions’.  Group education may be more advantageous due to peer support and more cost-effective.  Many studies were too short and of poor quality.  This review acknowledged that patient education programmes are complex interventions both in terms of the intervention itself and in the complex management of diabetes; consequently difficulties arise when assessing the effectiveness of structured education programmes.”  http://www.diabetes.nhs.uk/document.php?o=222

 This is what I think is happening- An HbA1C result of 6.9 equates to an average whole blood glucose level of over 150 mg/dl (for the past three months). So, as the patient, all you see are numbers in the monitor and they’re twice the numbers of a non-diabetic! What that means is, you're on the high end of borderline and for a whole year you are at a loss what to do about it. You know what the complications are of having numbers so high and if you are like most it’s even higher in the morning with no food at all overnight! If you don't make some very serious changes in your life style right now, you're going to have a tough time soon. But the advice is to follow the Eatwell Plate with plenty of, well, not much different from what US guidelines are. http://www.nhs.uk/LiveWell/Goodfood/Pages/Goodfoodhome.aspx So you see these numbers and decide the hell with it and 1/3 of you just stop taking the measurements. So the researcher decides to count that third in the final total using made-up numbers as “intent to treat” and everybody is happy to say oh it wasn’t cost-effective after all. Meanwhile the patient is at very high risk of complications because we all know 6.9 is a death/disability sentence years ahead of the general population.

So just look a little deeper into this or any study and remember the patient and what they desire: normal blood sugars or as close as we can get, a strategy to achieve that goal using meters and phone answering machine to my CDE weekly with readings upon awakening each morning, before and 2 hours after each meal (that’s right-7 a day), a nutrition website http://nutritiondata.self.com/tools/nutrient-search   to help me plan meals and see if recipes I make have the nutrients I need, a diabetes forum http://www.diabetes-book.com/cgi-bin/yabb2/YaBB.pl  to connect with others following the same strategy I am, and websites/books http://www.diabetes-book.com/readit.shtml  to try that keep our numbers normalized. Some like me follow the guidelines of Dr. Bernstein (6-12-12, and 12 more if strength training) or South Beach or Atkins/Paleo and some of us can use a little more carbs with exercise, meds, and weight loss. And most CDEs and Endos of really don’t mind working with us, because you can’t argue with the better test results. Empower the patient with knowledge and support, and they will feel better about themselves- I do each time I see my weight coming down and my HDL going up.

Re: This Is Disconcerting

Thank you for your thought-provoking post, Bonnie.

 You are corect.  What counts at the end of the day is how well we ( health professionals) educate people with DM on the skills and rationales of diabetes self-care activities and whether they are able and/or willing to problem-solve based on the education received.

 Empowerement of the patients is key and blood sugar testing (at least in my book) is a huge part of it!

Re: This Is Disconcerting

Bonnie:

You hit the nail on the head.  The last thing I would want to do is have a pt not return to see me, just because they didn't want to check their glucose.  If we work as a team in problem solving why the glucose levels are high and how you might use different techniques to lower them....then how can that be bad!

 

Carpe Diem!