SMBG not found useful for Oral drug treated Type 2 Diabetes patients

While the value of self-monitoring of blood glucose (SMBG) is well established in patients taking insulin (in both type 1 and type 2 diabetes), debate has continued as to its usefulness in type 2 patients not taking insulin.

It has been a working hypothesis that self-monitoring in these patients could prompt them to adjust their diet and lifestyle resulting in improved glycemic control.

A meta-analysis published in the Cochrane Library this year has concluded that this hypothesis is false.

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Comment by PatientX on April 19, 2012 at 7:57pm
The hypothesis seems false because doctors do not teach type 2 patients how to use testing to adjust meals based on the numbers they see. I think it's the medical community that has failed type 2 diabetics because they do not show that it's possible to reduce a1c with proper testing. I have never had a doctor or dietician tell me how to adjust carb intake based on a number from the meter. I had to apply what I learned on my own. When I was first diagnosed I was put on insulin. I was on a step scale. I had to adjust insulin intake based on a number. This is never taught for type 2 diabetics. So a scenario that i have encountered is that I test before eating a meal. I see a number of 186. Now if I would not have tested I could of easily eaten a carb heavy meal and drove my number even higher. Now if I see that number what I do is adjust my meal to a lower carb alternative. Now doc can you please explain to me how someone with type 2 would be able to adjust carb intake without test results? I have been practicing this method and have managed to drop my a1c a whole point level from 7.3 to 6.3. To me it seems these studies are done to not have to cover test strips for type 2 diabetics. I would like to see who commissioned these studies.

This seems like the mammogram issue, so that insurance does not have to cover a tool to prolong life. I think if doctors would try to solve problems like information technology people we would have better studies. I bring in more people to solve a problem than my doctors.

The use of the number from testing can be effective to type 2. I think doctors need to evaluate how to use information to adjust carb intake.
Comment by Dr. L.K. Shankhdhar on April 19, 2012 at 8:20pm

Dear Friend. I feel no need to make any comment on your observation since what I quoted is the outcome of a meta analysis by one of the most authentic body in Medicine.

Comment by Sam Iam on April 20, 2012 at 8:07am

Doctor, I think that you need to take a closer look at this meta-analysis.

Meta-analysis of studies including patients with a diabetes duration of one year or more showed a statistically significant SMBG induced decrease in HbA1c at up to six months follow-up (-0.3; 95% confidence interval (CI) -0.4 to -0.1; 2324 participants, nine trials), yet an overall statistically non-significant SMBG induced decrease was seen at 12 month follow-up (-0.1; 95% CI -0.3 to 0.04; 493 participants, two trials)

This does not prove the hypothesis false. Rather, it demonstrates that the subjects could have improved their glycemic control, but (as a whole) didn't.

Comment by Dr. L.K. Shankhdhar on April 20, 2012 at 9:54am

Dear Sam
SMBG has always been a disputed subject in OHA treated T2 Diabetes patients. If I add to this discussion, my own observations in Indian patients, I have even found it worse than those who do not monitor. In India, SMBG is a status symbol; since it is not available free, hardly 10-15% patients can afford it. There are many adverse things with SMBG in India e.g. 1. Those who undertake SMBG, they stop paying regular visits to their physicians and keep trying many funny things such as more srtingent dietary restrictions, too much exercise and resorting to indigeneous Tt with the result that their A1c even gets worse and they land up in serious hypo on mofre occasions. SMBG must be backed by regular physician support which is missing.

Comment by Brian (bsc) on April 20, 2012 at 1:15pm

Actually, I think the study is absolutely correct, but is is being portrayed wrong. It turns out that patients are not taught to do anything with their test results. I know it seems stupid, but that is what happens. So if patients are taught to take their tests and ignore the results, one would expect this ressult.

The proper interpretation of these studies is that patients are not being taught to take proper action based on their test results. When I undertook testing, I quickly found that carbs raised my blood sugar and I changed my diet significantly. My doctor(s) and educators were basically "useless" in learning to do this.

Comment by Dr. L.K. Shankhdhar on April 20, 2012 at 5:07pm

Dear BSC
Try to understand that it is only Insulin which can be used by patients for finer monitoring of glycemia, since Insulin can be administered in units but Oral drugs can not be broken in to many pieces for finer tuning of glycemia, so the only thing which can be safely conveyed to the patients is to focus on diet and exercise. So this allegation is wrong that patients on oral antidiabetic drugs are not being trained to improve glycemic control if SMBG reveals poor results.

Comment by PatientX on April 20, 2012 at 8:30pm

I have gone through several endocrinoligist and doctors and they have never taught the eat by the meter rule as some of us call it. We are just taught to check your numbers once or twice a day to verify your current number. After that method did not work for me I went back to the methods I was taught when I was on insulin. This ment testing everytime I put something in my mouth. I was never taught to check before eating but check after 2 hours of eating as a type 2.
What good is that going to do for me if I am starting at a high number before I put carbs in my mouth. Think outside of the box and think about a person if they knew that they were at 160 before eating. Why would they eat the same meal if they were at 100. I dont. If my meter says I am about 140 before eating I wont eat carbs. I stick with a salad. I am not saying this method would work for everyone. One thing that I throw into the mix is that I try to live a very active life. When you have an active life consistancy is out the window. Workouts can change your number dramatically throughout the day. I think a study should be done where someone adjust meals based on numbers and see the results.

Comment by Dr. L.K. Shankhdhar on April 20, 2012 at 10:24pm

Dear X
Kindly go through my comment offered just before your comment. I still paste it for you and that shall answer your present query:-
Try to understand that it is only Insulin which can be used by patients for finer monitoring of glycemia, since Insulin can be administered in small fractions called units but Oral drugs can not be broken in to many pieces for finer tuning of glycemia, so the only thing which can be safely conveyed to the patients is to focus on diet and exercise.
So this allegation is wrong that patients on oral antidiabetic drugs are not being trained to improve glycemic control if SMBG reveals poor results.

Comment by Sam Iam on April 21, 2012 at 2:05am

Very interesting about diabetes in India. You raise some good points.

Many years ago, the AMA had the same attitudes about SMBG for T1 diabetics in the US. Also, of course, doctors were making less money if people tested at home, rather than coming in to be tested in the office.

Cost of testing supplies is an issue here, as well. However, today, few would deny that SMBG has done much to extend and improve life for T1 diabetics (and to some extent T2). I maintain that 1 year's worth of (not entirely conclusive) data is not enough evidence on which to base patient care. Diabetes research is often problematic to begin with.

Couldn't T2 also gain and improve safety from using SMBG to adjust their diet and excercise?

Also, which oral medications do you prescribe?

Thank You.

Comment by Brian (bsc) on April 21, 2012 at 5:22am

"Dear BSC
Try to understand that it is only Insulin which can be used by patients for finer monitoring of glycemia, since Insulin can be administered in units but Oral drugs can not be broken in to many pieces for finer tuning of glycemia, so the only thing which can be safely conveyed to the patients is to focus on diet and exercise. So this allegation is wrong that patients on oral antidiabetic drugs are not being trained to improve glycemic control if SMBG reveals poor results.

This is unfortunately the attitude my doctors and educators had. I believe this is fundamentally wrong, and I ask that you please consider what I have to say. Patients can learn from testing what foods raise their blood sugar and by how much. Using this information, they can make very detailed choices about what foods to avoid and what foods they need to restrict protion sizes. Using this approach you can obtain very fine glycemic control change.

In the US (and presumably in India) patients are taught that they "must" eat enough carbs, 45-65% of their calories. In the US, patients are not educated to change what they eat based on their test results. I would bet India is the same way.

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