Self monitoring of blood glucose in type 2 diabetes: longitudinal qualitative study of patients' perspectives
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39302.444572.DE (Published 06 September 2007) Cite this as: BMJ 2007;335:493
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In his editorial, Snoek identifies the need more efforts to capture
the patient’s perspective of the self-management of Type 2 diabetes. Peel,
Douglas and Lawton go some way to addressing this. Their findings accord
with my own experience but they appear to have omitted one significant
reason for decreases in self-monitoring – tedium.
Diagnosed with Type 2 diabetes four years ago, and in the absence of
much detailed, practical guidance from the NHS, I have sought to self-
manage the condition effectively. My diet is guided by the information
provided initially by the NHS dietician and by the excellent information
available from Diabetes UK. I take frequent and regular exercise. And I take my
metformin as bidden (500 mgs thrice daily). That
this combination works is evidenced by an HbA1c, at the last reading on 15
August, of 5.7.
For the first year after diagnosis, I self-monitored assiduously,
twice daily three times a week – not to identify the need for short-term
fixes but to identify dietary or other events that caused ‘spikes’ with a
view to avoiding them in future. The readings became remarkably
predictable, rarely below six or above eight, and the process became
tedious.
It was this, combined with evident lack of GP interest in the results
or even in whether I was self-monitoring or not, and with the absence of
any ‘continuation training’ in self management, that led to a gradual
reduction in the amount of self-monitoring I did.
If GPs and diabetic nurses believe self-monitoring is a valuable
component of self-management, they should make that clear in their
conversations with patients. And they should be prepared to discuss with
patients the possible causes of poor control the means of addressing them.
If they do not, there will be very little incentive for patients to
persist with so tedious a chore.
Competing interests:
PL is patient editor of
the BMJ
Competing interests: No competing interests
As both a GP and a sufferer of 'type 2 diabetes'I read this article
with some interest. As a doctor, in spite of the plethora of evidence
based medicine about this illness, I now feel generally that, as a
profession, we understand little about its day to day management and the
causes of the longterm risks. GPs and consultants who deal with this
illness often become frustrated by weight gain and poor control but tend
to give lip service to diet.
Regular monitoring of sugar levels both to set adequate fasting
levels and post prandial control requires patients to understand how
specific food types modify post prandial responses and how limited tablets
can be in helping to resolve the conflicts. Metformin is the most
effective drug in dealing with post prandial surge, and once the disease
if fully matured sulphonureas can only supply a baseline for those with a
genetic illness like myself.
It is very hard to live an active life with a fixed dosage regime
that fails to take into account varied energy consumption. Only when
monitoring is linked with understanding of these factors, and the changes
in diet and medication to achieve this, can the patient take control of
this illness and regularily monitor himself.Once monitoring becomes a tool
it becomes useful and an individual will be motivated to do it.My
monitoring soon showed up that all refined carbohydrates, particulrily the
starchy foods long used as a basis for diabetic diets, had a dramatic
effect on raising my sugar levels for a long time. As soon as I realised
this I moved my carbohydrate base to natural carbohydrates. Diabetics will
loose interest in monitoring if the advice doesn't produce solutions to
their endeavours. We have to ensure that the patients both have the
confidence to react to their findings and the authority to make their own
decisions.
Monitoring will become more relevant when patients are advised to
shift their energy base away from the carbohydrate axis so that more
energy is taken from fat/oils and the protein axis. They will then see a
greater influence of their dietary control over their sugar levels.It is
only by doing this that you can hope to control your weight if you have a
non reactive insulin output and no access to quick short acting insulins.
Long term agents like sulphonureas stimulate appetite and weight gain
by increasing the insulin level to blood sugar ratio. Low carbohydrate
diets based on natural carbohydrates reduce this, particularily if the
protein/fat axis has been increased to provide the energy base.Please note
I am absolutely in favour of 5 or more fruit and vegetable portions a day
to safely go with the large portion of stilton. Such a diet does not cause
weight gain or heart disease if rigorously applied, as fat cannot create
fat cells in the absence of refined carbohydrate because such a diet
produces comparatively low insulin levels.
We have ingrained into the entire psyche of the nation that fat
energy causes heart disease so diabetics, having been told that they have
a high heart disease risk, have a pschological barrier to pass to even
contemplate taking such steps. It took me some time to satify myself that,
by eating like my ancestors in the forest, I was safe.
Type 2 diabetes is not a homogeneous illness and neither is IHD. The
triad of illnesses and I supect chronic renal failure are linked to
obesity and require a treatment approach directed at obesity. Isolated
heart disease and isolated diabetes is, I am sure, a separate illness
which can also of course occur among the obese.
We should therefore stop analysing these illnesses with simple models
of care lumping them into one. Instead we should treat every patient as an
individual with an individual risk and medication profile.This will be
identified by the cholesterol profile, bp reading,and electrolytes with
eGFR.Weight gain in adult life will be very relevant to the formation of
these measurements.
When we apply these principles monitoring will be rewarded, but we
will also have to introduce the new fast acting lispro unsulins so that
isolated elevated sugar levels can be quickly rectified with a much
reduced risk of creating obesity. Then monitoring starts to have a
positive benefit it will be taken up by our patients who wish to remain
active fit and slim.
Now you will realise that I am adopting such an approach, but I have
no link with any drug company or research. Fast acting insulin has however
been a huge benefit to me and stimulated monitoring, simply because a low
output of background insulin enables weight control but reduces sugar
stability, so monitoring becomes vital as a simple mistake on diet
produces a large effect on sugar level requiring a fast resolution. The
alternative is a high sugar for up to 12 hours.
It is time we changed our rigid approach to this illness and provided
flexible solutions for our patients with clinical sophistication.
Statistics cannot successfully instruct us how to treat our patients.We
need to return to observation, wisdom, clincal judgement, and flexibilty
before we cease to become a profession.
David Field MBChB Bristol 1975
Competing interests:
None declared
Competing interests: No competing interests
I was diagnosed with type 2 diabetes a year ago, when I was
hospitalised. Since then, on medical advice, I had been self monitoring my
blood glucose, daily, as prescibed. On my last visit to the Diabetes Nurse
at my GP's surgery, on 26th July 2007, I was told that "N.I.C.E. will no
longer allow blood sugar test strip prescriptions for type 2 diabetes
patients to test their own blood sugar". I was utterly astounded to hear
this, as it means that my next blood glucose test (HbA1C) will not take
place for six months. In the mean time, I will have no way of knowing
whether my diabetes is still under control. I can only presume that this
as a short sighted cost-cutting measure.
I take the maximum recommended daily amount of Metformin tablets and
my recent HbA1C blood glucose reading was even higher than it was when I
was first diagnosed. In other words, my diabetes has worsened yet I am not
able to monitor my own condition! I am on an extremely low income and
cannot afford to buy the test strips privately; if I did buy them myself,
I have the impression that no-one but myself would have any interest in
the tests' results. It seems that only the HbA1C test matters and even the
results of this test do not lead to further intervention. What a farce!
Competing interests:
None declared
Competing interests: No competing interests
What an indictment this article provides of the health professionals dealing with these people! And it's not confined to people in the Lothian area; that kind of indifference to SMBG readings, and indifference to diabetes management techniques other than pharmaceutical responses, matches my experience in East Anglia. It's no wonder that conclusions like those reached by Farmer et al (BMJ 2007;335:132 (21 July), doi:10.1136/bmj.39247.447431.BE (published 25 June 2007)) are propagated.
It strikes me that the next step in the research chain would be to take DESMOND graduates, encourage and support them in SMBG, and do a longitudinal study on their outcomes.
Another interesting approach might be to model on success. Are there health professional teams out there who are achieving consistently good results - measured in healthy patients? What are they doing right? The communities on the Internet with conspicuous success are the Bernstein forum, and people on the diabetes newsgroups following this advice http://www.alt-support-diabetes.org/Newly%20Diagnosed.htm - both strong proponents of SMBG.
We hear all too often that the cost of test strips is too much for the NHS to bear, alongside figures showing rising costs for treatment of diabetic complications. The linkage between the two is clear in Dr Peel's report - ineffectual education and support leads to pointless SMBG and unnecessary progression. We need to find a way to break that cycle.
Competing interests:
None declared
Competing interests: No competing interests
Individual management
I am a retired GP and work part time for a PCT. I was diagnosed as
type 2 diabetes at the end of July this year, 1 week before leaving for
our one month's holiday in Italy. We decided that treatmnent would be by
diet. I decided that, as a bit of a scientist, I wanted to know what my
blood gluose was under various circumstances. I decided to self monitor
and will continue to do so for the forseeable future. If the reading is
raised I reflect and see where I might have gone wrong and alter
something.
I agree with the points David Field has made and I think the study by Peel
et al would have been enhanced if the attitudes of the patient's GPs and
consultants were also included.
I believe that any diabetic should have the fundamental right to know what
is going on with his or her body and that testing strips and apparatus
should be available on the NHS. I do not think there is an evidence base
strong enough to counter my belief. What do patients do to alter behaviour
if the HBA1C is raised? Often not a lot, in my experience as a GP who
worked in a deprived area.
Richard Sloan PhD, FRCGP
Competing interests:
None declared
Competing interests: No competing interests