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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
"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.
Dear Shankhdhar,
Last year I strongly suspected that one of the oral meds I was taking was causing my A1C to continually rise. I was on a very high dose of metformin and gliclazide. I was supposed to add Januvia to the mix. I stopped taking the gliclazide and did not take the Januvia. My A1C immediately decreased. By testing 8 to 10 times a day, I was also able to reduce the amount of metformin I was taking. I don't think I would have been able achieve the same results while taking the gliclazide as my numbers never ever went below 10 while I was taking it. My questions are: Why is the response to continually rising numbers following the introduction of an oral med always to simply increase the oral med. ? If the patient has no control, who is in control?
BTW my A1C is now 6.7 on the low dose of metformin. I test frequently. It has been 10 months.
Dear Peeti
Your situation is peculiar and paradoxical. Gliclazide can not increase A1c.
Dear Shankhdhar,
Well, this is just my theory based on my own experience. I am T2 of normal (not skinny) weight. I always tested even before I took the drugs. My problem has always been fasting ie I'm in trouble if I miss a snack. My fasting numbers are always higher than my postprandials. So my liver is the problem? When I was on the high dose of metformin I had GI issues so I often skipped the snack and regular meals because I felt too sick to eat. When I reduced it by cutting the tablets in half I was able to eat normally again. So if my problem is with the liver pumping out more sugar when I fast, perhaps the gliclazide by forcing my pancreas to produce more and more insulin, stimulated my liver to produce more and more sugar? Do you think this could possibly be what happened?
Dear Preeti
No Insulin is most effective in suppressing Hepatic glucose formation, So that is not correct.
Hi Shankhdhar,
So now I'm really confused. I thought the metformin was prescribed along with the gliclazide in order to prevent the liver from dumping sugar? I also understand that there are T1 diabetics who inject insulin and also take metformin to suppress hepatic glucose formation? I have also heard that gliclazide can cause one to experience lows and this was not my experience. Intestingly, I have seen many 4's and one 3 since I stopped taking the gliclazide and reduced the metformin.
So I would say that, based solely on my own experience, that I was unable to control my blood sugar through testing while taking the oral med gliclazide. Unlike my experience prior to taking the gliclazide, I found that the numbers did not change despite changes in diet and exercise. The numbers remained consistently high despite my best efforts. I also was unable to fully understand what the drug was doing in my body. So I would agree with you that the testing was useless while I was taking the gliclazide.
The metformin is different however. I have been able to cut the pills in half and use the meter to adjust the dose. During a period of high stress, my numbers increased and I was able to use the meter to determine the time of day when I needed to take an additional half pill. So my experience has been that I'm able to use testing to adjust the metformin.
Here in Canada, the government pays for my 3-month doctor's appointments and the A1C testing so I never skip it. I am not sure whether your patients are required to pay for their appointments in India. If they do, could this be the reason why those who test tend to skip their appointments?
That was my first question this time. My second question is: If it has been determined that patients are unable to control the action of the oral meds they are taking, why are oral meds prescribed instead of or along with injected insulin for those who are willing to test and eat accordingly?
Thank you for taking the time to respond to my posts. Joanne