Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Very old news
- David Kerr (18 April 2008)
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For heavens' sake, not again...
- Nicola Moxey (19 April 2008)
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The DiabeticOptiCarbDiet (DOCD) almost eliminates testing, and the remaining testing is meaningful
- Roger L Grant (21 April 2008)
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Empowering the patient
- Kum Chung Fok (21 April 2008)
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Motivating diabetics
- Devon M Herrick, PhD (23 April 2008)
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Imagine you were diagnosed with Type 2 Diabetes tomorrow...
- Laila T King (23 April 2008)
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Allowing diabetics to keep running to stay in the same place
- Lexley M. Pinto Pereira, Cecil K DaSilva, Hackenthorpe Medical Center Sheffield (23 April 2008)
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Misleading title for editorial
- Jonathan Webber (23 April 2008)
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Type 2 Diabetes: Is Self Monitoring of Plasma Glucose Necessary?
- Dr.Basavaraj Shivayogi Hadapad (26 April 2008)
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The Tragedy of BG Self-Monitoring
- Michael P. Blinston Jones (1 May 2008)
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Blood glucose monitoring needs adequate support
- Buddhike Mendis, George A Thomson (1 May 2008)
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Self Monitoring - a personal view
- George B Alcorn (24 May 2008)
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NICE quick reference and self testing
- Owen A Thurtle (3 June 2008)
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David Kerr, Consultant Physician Bournemouth Diabetes and Endocrine Centre
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Dear Sir, I would feel much safer driving to work if I knew that anyone swallowing glucose lowering medicines (sulphonylureas and insulin)had tested their blood sugar level before getting into their car. Competing interests: I have participated in advisory boards for the manufacturers of blood glucose strips and glucose sensors |
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Nicola Moxey, IT professional IP9 2DD
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You know, for those of us who use SMBG to inform diet, exercise, and medication choices, NOT testing is about as depressing as it gets. Competing interests: Type 2 diabetic, BMI 25, last A1c 5.5% |
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Roger L Grant, Diabetic Diet Researcher and Educator Campion House, Standen Street, Benenden, Cranbrook, Kent TN17 4LB
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This comment is based on the Abstract alone, but I have followed this on-going debate for nearly a decade. My comment relates to control by diet plus exercise alone, and not more broadly to those “who do not use insulin”. However extension of DOCD to metformin has started. The main reason for the self-monitoring of blood glucose being wasteful is the absence of a structured testing approach that can be meaningfully interpreted by the patient. Thus their despondency. When diagnosed Type 2 nearly 10 years ago, I used my background as a career-long multidisciplinary industrial consultant, and the help of my GP wife, to find a means of making diet plus exercise control last as long as possible. It was soon clear that while the qualitative side was fairly well understood (i.e. ‘good’ versus ‘bad’ fats, etc), handling of the equally important quantitative side (eg: carb weights to eat) was cursory (e.g. exchanges, divided pyramids and plates). After 5 years of structured testing on myself, I found an approach that told me the maximum weight of any healthy food (or mixture of foods) I could eat without my blood glucose going up to levels where macro- and micro-vascular damage and postprandial dysmetabolism occur. This meant the postprandial peak generally coming at 9 mmol/l or below, and very seldom rising above 10.0 mmol/l. Nearly 3 years of piloting this DiabeticOptiCarbDiet (DOCD), among medical professionals and independent users, showed that each individual has their own personal scale of such maximum food weights - according to their diabetic severity, etc. DOCD determines this scale for them. It indicates that I have quite a high degree of beta-cell exhaustion, but I’m in my 10th year of freedom from complications and medication, with no deterioration in sight. DOCD is essentially just eating ordinary healthy food and following Diabetes UK’s recommended daily nutrient intakes, plus some little-known (maybe unknown) procedural refinements. Coming back to the article, DOCD has done the ‘leg work’ for DOCD users, so that postprandial testing is almost eliminated. Once the user has settled into DOCD, other testing can be reduced to one test a week - and the outcome of that is meaningful. They may also need to do some structured research for optimizing DOCD to their lifestyle, and troubleshooting. Far from being depressed by the outcome of these tests, they are elated by good values, and needing few but meaningful tests. The disadvantage of DOCD is that, being quantitative, it requires greater assimilation of detail and numeracy that only a minority commands. For all medical professionals DOCD is important, because it shows the direction they should be taking their patients. I believe DOCD is a ‘world first’, although it is impossible to ascertain that. This is partly because I’ve never read or heard anything like it mentioned. Also, if one takes O’Keefe et al’s “Dietary strategies for improving post-prandial glucose, lipids, inflammation, and cardiovascular health” (J Am Coll Cardiol. 2008;51(3). In the press) as summarising the current state of knowledge on the quantitative side of diet control, DOCD was well ahead of these findings when it first became available in 2004, and it also included the individual maximum food weights, etc, information. There is more about DOCD on http://www.dietcontroldiabetes.com Roger L. Grant MA (Oxon), Ddel’U (Grenoble), Phd (Manchester), CChem, MRSC, Professional Member of Diabetes UK. Competing interests: The DiabeticOptiCarbDiet (DOCD) is sold for £24 per copy on the Web. This is the only contributor to the creator’s personal outlay for bringing DOCD to the profession’s and public’s attention - apart from a small grant towards the cost of presenting a poster at the Diabetes UK Annual Professional Conference at Glasgow in March 2008. |
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Kum Chung Fok, Med Reg Sydney, Australia
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The editorial summerises succintly why Type 2 diabetics not on insulin should not have to monitor their own glucose control. But this is beyond words & figures; it is about the patient as well & in my firm belief, self monitoring of blood sugars in a Type 2 diabetic would empower them towards better health. It is not just the fuddy doctor sitting in a corner telling them what to do; self monitoring would be allowing the patient to be proactive in the management on his own health. Motivation in the management of a chronic disease like diabetes could be the key to current & future compliance with medications; especially so with the younger diabetics in our communities. Competing interests: None declared |
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Devon M Herrick, PhD, health economist National Center for Polich Anaysis, Dallas Texas 75251
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The potential for diabetics to self-monitor their blood glucose should be self-evident. However, the reality is that people often find excuses for not adhering to the diet and treatment regimens that should be a part of any self-testing routine. It doesn’t have to be that way. I recently met with the CEO of a disease management firm that relies on self -testing. The diabetic's blood glucose monitor is Bluetooth enabled to automatically send readings through a computer or PDA to the physician’s office. If the diabetic fails to test on schedule – or if blood sugar has spiked – a diabetic nurse educator calls on the phone to inquire why the test was not done or which foods recently eaten may have caused a spike in blood sugar. It’s not the self-testing that controls diabetes. Rather it’s using the information to adjust and adhere to treatment goals. I cannot imagine how any program to successfully manage chronic diabetes would not include some type of self-testing between office visits. Competing interests: None declared |
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Laila T King, Senior Diabetes Specialist Nurse Educator Medical School, University of Warwick
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Dear Sir, Many of us in the diabetes care profession have encountered this same old argument over and over again, almost ad nauseam. I wonder what the authors of the current two papers expected to discover when they chose this topic for their study. But with even greater wonder and curiosity, I would like to ask them the question I often pose to my colleagues,'If you were given the diagnosis of Type 2 Diabetes tomorrow, what would YOU want to do: test to know how high your glucose levels were at different times? request the most effective treatment options available? OR: just sit and wait for Godot?' 'Physician, heal yourself!' Let's be honest - we would want to know, we would want to be given the best therapies with a level of guarantee of doing the least harm. I would. Competing interests: None declared |
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Lexley M. Pinto Pereira, Professor of Pharmacology The University of the West Indies, Faculty of Medical Sciences, St Augustine, Trinidad and Tobago, Cecil K DaSilva, Hackenthorpe Medical Center Sheffield
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Simon et al1 used data from the DiGEM2 study done on 453 patients with non-insulin treated type 2 diabetes and a mean haemoglobin A1c of 7.5%. The ESMON study utilized 184 newly diagnosed diabetics3. Diabetes is more often than not associated with partners of the metabolic syndrome such as hypertension, dyslipidaemia, obesity, hyperuricaemia and renal function insufficiency, none of which were described in the O’Kane and Simon study populations. Diabetics in the community commonly have HbA1c levels over the 8.8 reported in the O’Kane study. Self monitoring of blood glucose (SMBG) allows patients to monitor and quantify their disease progression. As with asthma, objective assessments which patients can see avoids over-rating disease control and encourages them to take responsibility for and control of their disease. In Trinidad, patients proudly present their SMBG records with explanations for deviations and positive results after initiating corrective measures. Rather than being a drain on the purse or the psyche, SMBG avoids complications of co-morbid diabetes, and enables patients who may not be able to travel to do an HbA1c estimation, to call their health care provider and seek assistance to correct SMBG values. The expense to the health exchequer for SMBG would be expected to be more economical than the burden of hyper and or hypoglycaemia which urine testing cannot offer. The wisdom of extending these findings to diabetics in general must be viewed with sobriety. Controlled diabetics doing SMBG will keep running to stay in the same place. 1. Simon J, Gray A, Clarke P, Wade A, Neil A, Farmer A. Cost effectiveness of self monitoring of blood glucose in patients with non- insulin treated type 2 diabetes: economic evaluation of data from the DiGEM trial. BMJ 2008 0: 39526.674873 2. Farmer A, Wade A, Goyder E, Yudkin P, French D, Craven A, et al. Impact of self-monitoring of blood glucose in the management of patients with non -insulin treated diabetes: open parallel group randomised trial. BMJ 2007;335:132-9. 3. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial Maurice J O’Kane, Brendan Bunting, Margaret Copeland, Vivien E Coates on behalf of the ESMON study group. BMJ 2008 0: 395345716 Competing interests: None declared |
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Jonathan Webber, Consultant Diabetologist University Hospital Birmingham NHS Foundation Trust, B29 6JD
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The message that many rushed readers will take away from this editorial is the headline that the BMJ has given to it. This contains the statment that self monitoring of blood glucose in patients with type 2 diabetes may not be clinically beneficial or cost effective. A more appropriate title for this editorial would be self monitoring of blood glucose in type 2 diabetes: May not be beneficial in many patients whose diabetes is reasonably controlled on diet and/or oral agents. There are now large numbers of patients with insulin treated type 2 diabetes who may benefit from glucose monitoring. Other scenarios where glucose monitoring is helpful in type 2 diabetes include before and during pregnancy even when patients are not on insulin. No doubt your readers will add a number of other scenarios where monitoring can be useful. The BMJ is widely read and influential. It has a responsibility to send out accurate messages when its opinions may impact significantly on healthcare provision. My concern is that the simplistic title of this editorial may lead to many patients experiencing difficulties in obtaining monitoring strips from their healthcare providers, even where monitoring may be indicated. Competing interests: None declared |
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Dr.Basavaraj Shivayogi Hadapad, Associate Professor of Ayurveda Manipal University, Manipal, India - 576104
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Dear Editor, thanks a million. On the surface every thing looks good. How good is good? How good is plasma glucose screening? Statistical medicine, sold all over as very scientific originates from scandal of poor research says Douglas G Altman, head of the medical statistics, London. Plasma glucose screening was recently proved to be disease mongering and selling sickness. Many studies have consistently demonstrated that history taking and physical examinations are the most important factors in arriving at correct diagnosis, whereas lab tests play only minor role and too often palpably illogical laboratory findings are accepted without question. The quotation from a Cardiologist Mimi Guarneri “Beyond the power of most sophisticated medical equipment is a physician’s humanity – the listening ear, the healing touch, the devices of healers throughout time”, holds good at this juncture Health Care Providers from traditional system of medicines including Majority of Ayurvedic physicians, having a great influence of poor research based western medicine gradually are going away from clinical symptoms of diseases in general and T2DM in particular based on laboratory results / self monitoring blood glucose. If laboratory reports are abnormal, asymptomatic healthy person is “medicalised and drugged or operated upon”, irrespective of truth whether he or she is suffering or not. It is unfortunate that such a great Science Ayurveda which has existed for “Times out of mind” in India is also slowly deviating to follow the Modern Medical System of Laboratory Diagnosis even in the “Well” segment of the population. Even in the Western Medicine treatment of asymptomatic Hyperglycemia has been shown to be futile, if not dangerous. Even the newly invented disease in Western Medicine IGT or Impaired glucose Tolerance has been shown to benefit more by life style changes rather than modern medicine like Rosiglitasof in a large study. “Euboxic” Ayurvedic doctors have been neglecting the definition of disease defined in different classics of Ayurveda , as a “state in which both the body and mind are subjected to pain and misery”. Chambers Dictionary also defines disease which is similar to Ayurvedic definition as “an unhealthy state of body or mind; a disorder, illness or ailment with distinctive symptoms. The laboratory diagnostic criteria of Diabetes Mellitus of western medical science which is flourishing with unscientific practice should not be followed for diagnosis of Madhumeha, because "The medical profession is being bought by the pharmaceutical industry, not only in terms of the practice of medicine, but also in terms of teaching and research," says Arnold Relman, a Harvard professor and former editor of the New England Journal of Medicine. Random glucose more than 200 mg/dl and Plasma glucose of 126 mg/dl or higher after an overnight fast, documented more than one occasion with associated symptoms are the essentials of Type 1 diabetes mellitus diagnosis. The essentials of diagnosis of Type 2 diabetes are plasma glucose of 126 mg/dl or higher after an overnight fast on more than one occasion and after 75 gm oral glucose, diagnostic values are 200 mg/dl or more 2 hours after the oral glucose. Polyuria, polydipsia. ketonuria and weight loss generally are uncommon at time of diagnosis. Candidal vaginitis in women and Belanophosthitis in men may be an associated initial manifestation .Many patients have few or no symptoms. This so called international diagnostic criterion with no symptoms takes liberty of life and puts healthy individual into bottom less pit till last respiration Total body scan (TBS) including plasma glucose for T2DM has become a routine among educated, economically rich people and national program in developed countries. Whole body scanning is currently marketed in the medical field to make healthy individual ill and who will rarely become healthy as Professor Isan burg says. A study reported in Journal of the National Cancer Institute says that routine screening for prostate cancer using the prostate specific antigen (PSA) leads to over diagnosis. In Netherland, in 1982 around 1000 children were referred to pediatrician after a positive screening result which was shown to be false for congenital hypothyroidism. More test, more false- positive result. This type new born and children screening programs with false positive results create potential parental stress The Pap smear screening program for cervical cancer in Bristol to prevent cancer, where in 13000 women needed to be screened over 20 years to prevent one death. To prevent one cardiac event per year about 1000 patients needed to treat with newly introduced Polypill which is nothing but old wine in new bottle. This is the use of screening which could damage public health and nation treasure. The plasma glucose scanning will show natural normalcy in asymptomatic person as abnormal and encourages physicians with linear thinking to drug healthy mind and body by creating ghost fear. Epidemiologists to cause epidemics predicted that Diabetes affects one in 20 adults world wide and 333 million cases are predicted world wide by 2025 and to sell drugs to increase mortality rate which has been proved by recent clinical trail. Statistical science is one of the leading causes of death in United States of America. To prevent and stop disease mongering The Pew Charitable trust has given US$ 6 million campaign by name ‘prescription project’ to reduce the influence of pharmaceutical industry marketing on US physicians and doctors-in –training Professor B.M. Hegde Sir in his classic “What Doctors Don’t Get to Study in the Medical School” says “The problems lie in medicine’s difficulties in defining normality, the devil of “false positives”, and our limited understanding of the natural history of disease. The most common way of defining normal is that the measure lies within two standard deviations of the mean”. So defining normal and abnormal plasma glucose level in a dynamic non- linear human body which has the natural super power to manage altered internal environment to great extent is impossible by linear science. Twentieth century great physician, Lord Platt a great teacher of medicine at the university, in 1949 wrote that “If you listen to your patient long enough, s/he will tell you what is wrong with her/him”. Later his students did prove that with a very well executed prospective, double blind, randomized, hi-tech based (even PET scanner) study of the role of history taking, physical examination, and investigations in medical diagnosis. The study showed that 80% of the final accurate diagnosis and 100% of the future management strategies could be arrived at the end of listening to the patient and reading the GP‘s referral letter. This is refined slightly by examination and investigations! Diabetic Medicine 1999 published a revolutionary study report on the effect of insulin on symptomatic and asymptomatic hyperglycemic patients. Quality of life and plasma glucose in insulin treated diabetics clearly showed real relief only in those patients who were symptomatic before treatment. Asymptomatic hyperglycemic patients experienced more problems with social functioning and pain with treatment. This is the proof for efficacy of drugs in symptomatic hyperglycemia and adverse effect of medicalisation. T2DM needs a good Physician to understand T2DM, not a machine. In other words of Sir William Osler, “It is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patient himself” References: Douglas G Altman. The scandal of poor medical research. BMJ 1994; 308:283- 28, Sushruta Samhita of Sushrita with Nibandhasangraha Commentary of Sri Dallnacharya edited by Vaidhya Jadavji Trikamji Acharya and Narayanaram Acharya,Sixth Edition 1997, 6-1/23, Richard Smith. Unscientific practice flourishes in science. BMJ 1998; 316:1036, Elizabeth A, Gurian, Danial D. Exapanded Newborn screening for biochemical disorders: The effect of a False- Positive Result. Pediatrics 2006; 117:1915-1921, M Thompson, R Perera. Prevention of diabetes. BMJ 2006; 333:764-765 Competing interests: None declared |
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Michael P. Blinston Jones, GP New Lyminge Surgery Folkestone Kent CT18 8NS
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Patient empowerment and disease self-management have become such all- pervading mantras at the Department of Health and at Primary Care Trusts that questioning them is tantamount to criticising Mother Theresa or Princess Diana. Yet in terms of non-insulin managed type2 DM the question must be asked: does regular self-monitoring empower a patient and does it allow disease self-management? I contend that the answer to both is no. The point of any investigation is that the result should inform management. In what way is this true of BG self-testing in this group of patients? Are they supposed to double or halve their dose of-say-metformin on the basis of their measurement? Do they only stick to their diet if their single measurement is raised? Should they not drive if the reading is below 6mmol/L? Self-testing & self-management can be very effective in some diseases; daily weighing in cardiac failure can be used to fine-tune diuretic dosage as can PEFR in asthmatics and sputum appearance in COPD. It would be ridiculous to oppose the concepts of empowerment & self-management. It's just that self-testing BG in non-insulin dependent diabetics represents neither. The tragedy is that the genie is now out of the bottle. Testing-strip manufacturers cleverly adopted the methods of the razor & computer printer companies. Sell the device cheaply, even give it away, and then reap the profits by selling the strips ( or razorblades or refill cartridges )over the years. £100million could be spent so much more wisely Competing interests: None declared |
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Buddhike Mendis, SpR Diabetes and Endocrinology Sherwood Forest Hospitals NHS Trust,NG17 4JL,, George A Thomson
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Letter to the Editor Dear Sir, We would like to make a few points in response to the two recent articles regarding the usage of self blood glucose monitoring in Type 2 diabetes. Opinion on this subject has always been divided. Patients in the DiGEM (ref. 1) study had initial education and 1-3 monthly follow up appointments to discuss their results. None of these patients had 24 hour decision support available to them. O’Kane et al (ref. 2) had 78 out of the 98 patients at 1 year on none or only one drug. Given their treatment algorithm we would thus expect that the majority of these newly diagnosed people with diabetes on just one drug would be on Metformin, hence the incidence of hypoglycaemia would be minimal in these patients. Hypoglycaemia has major implications in patients who drive patients in certain professions and those who undertake exercise. SBGM plays a valuable part in the daily management of their diabetes and their safety. We would expect that up to 50% of the patients with type 2 diabetes will progress to insulin therapy in 6 years ( ref 3) and by introducing the culture of SBGM monitoring and its implications will surely only serve to benefit both the patient and HCP. If we were to advocate the cessation of HBGM where is the evidence of non- maleficience? Is it possible that patients may come to harm if they do not test? For example, the Sulfonylurea or insulin treated patient may run higher glucose levels to avoid hypoglycaemia if they lacked the assurance of HBGM results and thus be at increased risk of long term complications. By contrast might rates of severe hypoglycaemic episodes increase in this group of patients. There is evidence that linking HBGM to decision support is beneficial in Type 2 Diabetes (refs.4,5) There are also existing Health informatics solutions that offer a cost effective link between decision support and HBGM (refs 6,7). In some systems, access to data is supported by online structured patient education with assessment of educational outcomes and further targeting of additional education as appropriate (refs 8,9) The point of evidence based medicine is to advance the quality of clinical care and outcomes until non-maleficience is demonstrated it may be premature to withdraw HBGM in type 2 diabetes. We would encourage RCT’s in health informatics decision support systems. Conflict of interests- none Prof G A Thomson, Consultant Diabetologist Sherwood Forest Hospitals Foundation NHS Trust Email: george.Thomson@sfh-tr.nhs.uk Buddhike Mendis, Specialist Registrar Sherwood Forest Hospitals Foundation NHS Trust Email: buddmen@yahoo.com References 1. Cost effectiveness of self monitoring of blood glucose in patients with non- insulin treated type 2 diabetes: economic evaluation of data from the DiGEM trial. Simon J, Gray A, Clarke P, Wade A, Neil A, Farmer A. BMJ 2008 0: 39526.674873 2. .Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial Maurice J O’Kane, Brendan Bunting, Margaret Copeland, Vivien E Coates on behalf of the ESMON study group. BMJ 2008 0: 395345716 3. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood- glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837-53 4. M-healthcare for patient self-management: a case for diabetics CocosilaM, Cousaris C, Yuan Y Int J Electronic Healthcare 2004;1(2):221-41 5. Home blood glucose prediction: validation, safety, and efficacy testing in clinical diabetes Albisser AM, Baidal, Alejandro R, Ricordi C 6. A graphical user interface for diabetes management that integrates glucose prediction and decision support Diabetes Technol Ther. 2005 Apr;7(2):264-73 Albisser AM 7. Task delegation and computerized decision support reduce coronary heart disease risk factors in type 2 diabetes patients in primary care Diabetes Technol Ther. 2007 Oct;9(5):473-81. Cleveringa FG, Gorter KJ, van den Donk M, Pijman PL, Rutten GE. 8. Defining a comprehensive, streaming, e-education engine for chronic diseases: The development of a Virtual Diabetes Centre L Telemed Telecare 2006; 12:48-50 Thomson GA, Fernando DJS, Bushby P et al 9. Future patient management enhancements: Developing the virtual health provider Hosp Healthcare Eur 2008 Thomson GA Competing interests: None declared |
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George B Alcorn, Rural GP 5731
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I have been a Type 2 diabetic for five years now. Apart from testing for the first three months when I found that my morning BSL was between 6 and 7mmol/L and below 6 for the rest of the day, I have not monitored my BSL at all. I use a three monthly HbA1c to ensure that I remain within a safe range and in the five years, my readings have fallen from 6.4 to 5.8 and have remained there for the past three years. I have changed my diet, lost 3 Kg in weight and increased my exercise and remain well with no symptoms of end organ damage. I found self monitoring to be a painful irritation in my daily routine and would not willingly use it again unless my HbA1c started to climb. I support the findings that self monitoring does not improve the health of the majority of type 2 diabetics as I have yet to find a reasonable patient who finds the process enjoyable and informative. Competing interests: None declared |
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Owen A Thurtle, GP Woodbridge Rd Surgery IP4 2PE
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The editorial is doubtful about the value of self testing in Type 2 diabetes. This doubt does not seem to be shared by NICE in their recent guideline which seems to assume that self monitoring of plasma glucose "should be available" to those on insulin and those on oral hypoglycaemics to give information about hypoglycaemia and to assess changes in glucose control and to monitor changes in intercurrent illness and to ensure safety in driving. I think that includes most people with Type 2 diabetes. Competing interests: None declared |
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