For Diabetics Not on Insulin, Self-Monitoring Blood Sugar Has No Benefit
Release Date: January 19, 2012 |
- In patients with diabetes who don’t require insulin, self-monitoring of blood glucose had a modest effect on HbA1c levels at six-months, which subsided after 12 months.
- Self-monitoring of blood glucose in non-insulin treated diabetics had no effect on satisfaction, general well-being or general health-related quality of life.
- Supplies required for self-monitoring of blood glucose are more expensive than for urine testing, a common alternative for non-insulin treated diabetics.
For type 2 diabetics 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.
Self-monitoring blood sugar levels for type 1 diabetics and type 2 diabetics who require insulin is recognized as a critical part of self-care. For these insulin taking diabetics, keeping track of blood sugar levels helps them attempt to keep glucose levels within an acceptable range. However, it has been unclear if self-monitoring of blood sugar has the same value for type 2 diabetics who are not on insulin.
To answer this question, 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.
Additionally, the review showed that blood sugar self-monitoring had no effect on patients’ satisfaction, general well being, or general health-related quality of life. One study, which compared the cost of the first year of monitoring blood for glucose versus urine testing, found that monitoring blood glucose was 12 times more expensive.
The review appears in the latest issue of The Cochrane Library, a publication of The Cochrane Collection, an international organization that evaluates medical research.
Mayer Davidson, M.D., a professor of medicine at Charles Drew University in Los Angeles who authored one of the studies included in the review, notes that many endocrinologists recommend blood glucose self-monitoring as part of efforts to educate patients on the effect of lifestyle habits—for example, how eating an apple affects their blood glucose compared to drinking a glass of apple juice. However, knowing their blood sugar numbers doesn’t appear to change patients’ behavior.
“Patients aren’t using these numbers to do anything clinically significant,” he says.
With the cost of blood glucose test strips for home monitoring equipment hovering around 1 dollar apiece, he adds, there doesn’t appear to be enough “bang for the buck” to recommend that form of self-monitoring for most patients.
Authors of the review agree. “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,” Malanda says.
For More Information:
Reach the Health Behavior News Service, part of the Center for Advancing Health, at firstname.lastname@example.org or (202) 387-2829.
The Cochrane Library (http://www.thecochranelibrary.com) contains high quality health care information, including systematic reviews from The Cochrane Collaboration. These reviews bring together research on the effects of health care and are considered the gold standard for determining the relative effectiveness of different interventions.
Malanda, U.L., et al. (2012). Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin. The Cochrane Library, issue 1.
Comments on this article
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|Pamela Tetro FNP, CDE says|
January 23, 2012 at 11:57 AM
I have found that unless the patient is taught and clearly understands what the glucometer numbers represent and learns how to evaluate and troubleshoot high and low glucose values, the self-monitoring feels somewhat useless or frustrating to the patient. A well educated diabetic patient learns how to be their own "detective" re their dm control when they understand the various aspects of their disease and self monitor blood glucoses.
|William Toth, Ph.D. says|
January 23, 2012 at 1:46 PM
What is lacking for users (I am one) are good references as to what is normal response of blood sugar levels to foods. A curve showing normal body responses of glucose levels with time would be good. A family of curves for different A1c levels showing the resultant overshoots with time, allows one to understand better where there body is in responding and what our individual efforts are doing to help our situation. Otherwise, we are measuring, collecting data, recording, and saving data that seems to mean nothing. Doctors don't collect it and analyze it for the patients and only the A1c is used. So I personally understand why patients get weary of pricking their fingers and taking data that no one seems to be interested in. Perhaps even a meter that averages over the last week might help so that patients at least try to lower the average number.
|Allen Clason says|
January 23, 2012 at 2:09 PM
I, for one, do not inject insulin. I have been using self monitoring for 5+ years. That daily act, along with many other self determined actions, especial physical activity and life style changes [some will call it diet], have made a significant difference in my health. The daily monitoring helps keep my ON TRACK. The value? Lower health care costs for near term and anticipated long-term. It is NECESSARY to continue monitoring. It is irresponsible research to think otherwise.
|Faye Wendland, RN says|
January 23, 2012 at 2:41 PM
I coach individuals with Type 2 Diabetes and in fact, just completed an appt. with an individual who started checking his BS's approximately 1 year ago. He has found this to be some of the best feedback for changing his lifestyle, including what he eats and how much he exercises. He feels it has helped him stay on track and actually improve his A1c. It needs to be mentioned, that in my telephonic coaching sessions with him, we have broken down how to monitor BS's, what the goals are and what impacts the BS levels. Without this, I have worked with many patients who found BS monitoring worthless because there was no problem solving occurring with them. This would be an important part to assess in reviewing the studies that have been done on this topic. Did the individual understand what the BS goals were; what impacted them and began to problem solve as a result of the results.
|Robert Miles says|
January 23, 2012 at 4:41 PM
These studies often exclude those with the best control of their blood gluccose, and include many who have never been told what to do with the results of their monitoring. I've seen many people on the diabetes newsgroups, TuDiabetes, the ADA forums, and so on, who needed many measurements to get started with controlling their type 2 well, but were then able to control it with fewer measurements. I needed many measurements to get started with good control of my type 2, but now seldom take measurements. After over 10 years, I still don't need insulin.
|Bharti Sheth says|
January 23, 2012 at 5:31 PM
I have been Type 2 Diabetic for over 20 years and have maintained HbA1C under 7 for most of time. I do self monitoring not daily, but 2-3 times a week at varying time. This process allows me to be alert when my blood glucose levels start creeping up (normally every 2 years or so) and may need a review and adjustment of my oral medication and dosage. For me, this works- I work in Health care and believe in taking charge of my health.
|Stephen Wilkins says|
January 23, 2012 at 6:30 PM
I have to wonder if the value of A1C self monitoring would be greeter, in terms of blood glucose reduction and patient satisfaction, if doctors actually looked at the results patients brought in during their office visit and use the data as a teachable moment for patients.
|Robert Suizu says|
January 23, 2012 at 10:43 PM
It appears that the review failed to differentiate between people are willing and able to use the blood sugar measurements to assess the effectiveness of lifestyle modifications and those who are not. As a diabetic, I find the measurements invaluable to assess the effects of changes in diet, exercise, sleep, stress levels, etc. The diabetics that I have known that do not seem to benefit from self-monitoring blood sugars do not seem to be motivated to make the changes necessary for tight control or poorly understand the relationship between lifestyle and blood sugar levels. Each diabetic needs to finds what works for them as people respond differently to foods, exercise, etc. and blood sugar measurements are a valuable tool. It really bugs me when the someone says that a tool has no value when the problem is patient behavior.
|Dr.Mansoor ul Haq says|
January 24, 2012 at 12:54 AM
I am a practicing Physician for the last 33 years. Most of the patients in my practice are type 2 Diabetics. These include newly diagnosed patients as well as patients with lonstanding Diabetes and its various complications. Practically what I have found is that self blood glucose monitoring atleast twice a week benefits patients who are not using insulin therapy. How the patients utilize the information gained by SBGM depends on the educational level of the patient about his disease as well as his motivation to take control of his disease.HbA1c is ordered after three to six months, but before that SBGM gives a feedback to modify diet,level of exercise, and medication.
January 24, 2012 at 8:19 AM
What continues to shock me about these sorts of studies is that SMBG was never about taking tests and not doing anything with the results, it was always about acting on the result. Dr. Richard Bernstein first bought a blood glucose meter after seeing an advertisement in Oct 1969 and promptly discovered that the foods that he ate affected his blood sugar (duh). He started adjusting his diet to reduce the surges in his blood sugar. His primary observation, carbs raise blood sugar (double duh).
And so we sit here, more than fourty years later. The ADA and medical establishment entrenched. What do patients get taught from this fundamental observation made all that long time ago? Test your blood sugar, then ignore it and eat a high carb diet. This study while done to a rigorous methodology is truly an example of garbage in garbage out.
It is high time that patients get taught that they need to "Eat to their Meter." I call on the ADA, the AADE and other organizations establishing education criteria to climb out of their rut and start teaching a responsible curriculum.
January 24, 2012 at 10:06 AM
What hogwash! If not for self-metering, I would never have been able to take control of - and correct - my high blood sugar. I am not on insulin (although given the nature of the disease, I probably will be one day) and the fact that I have reduced my HgA1c from almost 12 to under 6 in less than a year is totally attributable to my little home glucose meter. There's clearly something wrong with your study.
|Sam McNamee says|
January 24, 2012 at 11:00 AM
The testing protocols that these studies are based on are inappropriate for the patients being studied. This give invalid study results which are then generalized into areas that were not actually studied.
Testing before meals is important for folks on insulin so they can adjust their dosage. Since this is what the CDEs and physicians know, folks with Type 2 diabetes are still told to test before meals when it is the AFTER meal test that is important for them. Everyone's response to food is different, by testing 1.5 - 2 hours after eating, you can see the impact a particular meal has on your blood glucose. This allows one to make informed decisions about what they do and do not want to eat. Often, small changes in one's diet can make significant changes in the control of their disease. This is true of everyone with diabetes, whether on insulin or not.
For some 20 years, the HbA1C has been the holy grail of diabetes control. But this is a rather gross average of the bg level over the last 2-3 months and it is often only checked every six months. While this is like driving a car by looking in the rear view mirror, it also ignores potentially major spikes (and possibly dangerous dips) in one's bg.
Using the HbA1C gives the medical professionals a good tool to help their patients at a gross level. But ignoring spikes still leaves those patients exposed to the progression of the disease and its side effects. Personal bg meters give the patients a tool to personalize their treatment and a chance at much tighter control - if they are properly educated and if they are motivated to take action.
By finding the foods that most effect my bg and by adjusting my diet, I am able to maintain an HbA1C of 6% with bg spikes rarly above 130 mg/dl. Others I know are able to keep theirs in the low 5% range. I was there at one time but decided that I didn't want to expend that much effort. Still, I was able to make and INFORMED decision about my health. An inexpensive (often free) meter and $15 worth of test strips a week seem like a small price to pay for that sort of control.
I would like to see the ADA, the AADE and the medical profession in general open their minds to the possibility that folks with diabetes really can help themselves if they are provided the proper tools and education. Once they do, the insurance companies could be convinced to get on board and with the higher volumes the cost of supplies would come down drastically.
|Ellen M says|
January 24, 2012 at 11:20 AM
I was dx in early April 2011, A1C 7.7. Have been taking 500 mg Metformin once a day and eating to my meter, learning
what foods I can and cannot eat. Yesterday, 1/23/12, my A1C was 5.7. This would not have been possible if I had followed the ADA dietary guidelines, just too many carbs.
|Steve Yarbrough MLT (ASCP) says|
January 24, 2012 at 11:48 AM
As a T2 diabetic for 10 years, a Laboratory Technologist of 27 years and co-facilitator of a large community group of T2's. I found that while I was Not insulin dependent and Was taking oral meds, that frequent checking of my BS level was not providing me with any information that was clinically useful. I was not changing my meds, diet or exercise based on pre-prandial readings and I was able to maintain a HgbA1c level in the low to mid 5 range. Once oral meds were no longer effective and I had to take insulin to maintain control, I now take both Lantus and Novalog, I have test up to five times a day and inject myself 4-5 times daily to maintain a HgbA1c in the mid to high sixes. My conclusion has been while dealing with this group of T2 diabetics that number about 3500, that while frequent BS testing provides them with psychological and moral support it is of little clinical relevance and is wasteful of limited Healthcare resources and money. There is considerable difference of opinion and discussion on this subject which is very good as it helps maintain awareness and communication within the group. Over all I agree with the study results and am of the opinion that frequent testing by oral med patients is wasteful.
|Red Hen says|
January 24, 2012 at 12:11 PM
How many patients were included in this study and who sponsored it?
If it was sponsored by an Insurance company or large HMO, I'd have to think the conclusions were meant to save them money.
I've found that self-testing daily gives me enough feedback to keep me on the straight and narrow in terms of diet and exercise.
|Tom's Mom says|
January 24, 2012 at 2:05 PM
I have type 2 and have controlled it now for 18 months by diet that would never have been possible without the aid of my meter. I tested every morning and 2 hours after every meal until I figured out what/when I could eat without spiking my glucose. I'm on no meds and appalled to read that doctors have the opinion we don't need meters unless we are on insulin. There is so little understanding of those of us who want to take our condition seriously and be in charge of it ourselves.
|Robert Gillis says|
January 24, 2012 at 5:14 PM
I agree with Sam MacNamee. I test twice a day. AM Fasting and evening PP. My AM reading gives me an idea as to what I can eat for breakfast and the PM how much more I need to eat to raise my BGs to around 150 so that my following AM readings will not be in the 50s.
Answer to Willam Toth's question. Dr Bernstein in Diabetes Solution page 325 has a table of the effect of one gram of glucose by body weight. 1 gram glucose is circa 1 gram carbs
i will try to to find a file with the table and post tomorrow
|Anni Macht Gibson says|
January 24, 2012 at 7:37 PM
It is dangerous to draw such definitive conclusions from a "meta-analysis" - in effect - a piece of secondary research, which by its own admission was unable to do any analysis of subgroups and thus did not control for: how sick subjects were, efficacy of treatments they were on, adherence to BG and UG testing regimens, education regarding BG testing methods, interpretation and how to respond to results by adjusting therapies - just to name a few variables.
To then make a sweeping statement that the cost of meters and strips is not justified is unconscionable! Especially when insurance companies are just looking for an excuse to eliminate benefits. Imagine their glee at the thought of eliminating the cost of all those strips and meters!
There is a plethora of anecdotal evidence on the internet - one testimonial after another --- in fact, possibly in numbers that would constitute a statistical sample for a quantitative study . . . attesting to the enormous benefits of utilizing self-monitoring of blood glucose to manage non-insulin dependent diabetes.
Certainly true in my case where self monitoring led to early diagnosis when my Internist did not believe I was diabetic or had much of an issue, but eventually referred me to and Endocrinologist to get me off her back - and the Endo took one look at my meter readings (many initial readings over 220) and pronounced me diabetic on the spot.
It is my belief that education about glucose monitoring is inadequate. I have personally educated friends, both T1 and T2 and they have come to a significantly improved understanding of how to use their meters, the importance of their glucose readings and what to do with the information. My best friend is a long time Type 1 who had been quite complacent about her A1C - led to believe that around 7.0 was "just fine" for a Type 1. I informed her that I had read that Type 1's could do better than that - especially on a pump. She has now lowered her A1C to 6.7 using her meter.
To summarize, I believe that this analysis does a disservice to diabetics and I felt obligated to speak out.
I just hope you have not done too much damage.
Personally, I hope to share your summary and my opinion about it as broadly as possible, starting with my endocrinologist and with my insurer, United Health Care.
Anni Macht Gibson
|Chrissie Hobson says|
January 25, 2012 at 4:42 AM
The best motivator for life style changes is my meter. What to eat, how to exercise (how long, how intensive) - anybody who does not know the before and after numbers because they don't have a meter, is left in the dark. They have no idea how to take charge of their diabetes. I have to buy my own strips and cannot test as much as I would like, but fortunately I can afford some testing. I feel that testing is a very necessary part of my medication. Without it I would not have achieved a drop in A1C from over 11 at diagnosis to 6.9 four months later! Everybody should have access to testing, it makes all the difference.
|Robert Gillis says|
January 25, 2012 at 8:27 AM
Yesterday I said I was going to post an answer to the post by William Toth, Ph.D. 1/23/2012 1:46 PM
In Dr. Bernstein's Diabetes Solution on p. 325 he has a table of the effect of one gram of glucose by body weight.
Glucose and Dextrose are identical.
|John Pasztor says|
January 26, 2012 at 8:50 AM
Dr. Toth's idea of looking at blood glucose averges is also on target. The new standardized A1C testing and the relationship between A1C and average blood glucose have been described so that patients who monitor their BGs can access in their glucometers a 7-day, 14-day, 30-day ...etc. blood glucose average numbers which can closely correlate to actual A1C. According to ADA, the desired level of A1C is <7% which loosely equates to an average blood glucose level of <155 mg/dL. Tables describing this relatinship at numerous levels of A1C have been published. Look for A1C (%) compared to eAG (mg/dL).
|Teresa McFarland, MSN, FNP-C, CDE says|
January 30, 2012 at 8:39 PM
There is too little information provided in this brief abstract of the meta analysis, and reading the article in the Cochrane database provided little to convince me that the findings may be generalized to the patients in my practice setting. The second-hand data compiled from 12 studies is over 10 years old, does not indicate if participants tested before or after meals, or received education and support to ACT on the smbg numbers. Glucometer technology has improved dramatically, CGM is readily available now, urine testing is obsolete - Please give us information that is helpful! There are too many unanswered questions for me or any other critically thinking person who will read beyond the fallacious headline.
|AmyT of www.diabetesmine.com says|
February 26, 2013 at 6:54 PM
I'd have to agree this is irresponsible and misleading. I have an editorial coming out in the American Diabetes Association's Spectrum journal that looks at just this issue from a patient perspective. Very. Different. Story.
The question to ask is WHY aren't patients putting the numbers to good use and feeling satisfied about these amazing tools?! Lack of education & training, mainly, along with limited access and all sorts of negative experiences surrounding use of glucose meters that could easily be rectified... aaaarrrgh!
|james snell says|
October 29, 2013 at 2:07 PM
As a 30 year+ type 2 who finally got mess under control; took 30 strips a day, cgms and finally drugs-metformin, diet and exercise. I am offended by all this crap that testing has no benefit.
I am now testing 3 to 5 times a day checking at wakeup 5:00am; 2.5 hours after dinner and midnight.
I use these numbers specifically to:
a: I check wakeup and 12:00 midnight numbers to keep eye on dawn phen and to adjust eveing insulin.
b) post meal numbers at 2.5 hours I am checking my meals and portion size and if numbers too high I walk and exercise an extra mile.
c) metformin was key in arresting excess liver glucose release when liver was supposed to be fasting and for evening/am dawm phen.
d) diet of 1200 calories, 21.5 to 2 miles daily exercise were extremely critical to getting and keeping numbers down. Monitoring blood glucose numbers were never a useless exercise and were critical for:
diet and exercise adjustments and proper control. Dosing of humalog lispro as a boost to my pancreas of 1 to 2 units was key to pulling numbers in tighter.
I am one who is fed up with this stone henge anti-science approach to diabetes and the godless goal of trying to get to one strip a day for type 2. As a electronics engineer rational, consistent testing and data are crucial to control a complex system. To suggest otherwise is folly and stupidity!
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