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Self-monitoring of Blood GlucoseA CommentaryFrom the Michigan Diabetes Research & Training Center, Department of Medical Education, Ann Arbor, Michigan. Correspondence to Martha Mitchell Funnell, MS, RN, CDE, Michigan Diabetes Research & Training Center, 300 North Ingalls Street, 3D06, Box 0489, Ann Arbor, MI 48109-0400 (mfunnell{at}umich.edu). While widely accepted as a standard of care for patients with type 1 diabetes and patients with type 2 diabetes using insulin, the efficacy of self-monitoring of blood glucose (SMBG) for patients with type 2 diabetes not using insulin remains controversial. This comprehensive and cogent review examines the effects of SMBG on metabolic control but takes the review a step further by examining the data in light of the usefulness of SMBG as part of a complex system of self-regulation. The result is then to view SMBG in the broader context of self-management rather than as a single behavior.
The evidence for the benefits of SMBG for improving A1C levels among patients not using insulin is mixed. While some studies have shown improvements in A1C levels, others have demonstrated no effect or even a worsening of control. While the methods used in these studies explain some of the differences, the lack of clear-cut evidence makes the interpretation of these studies confusing for diabetes educators and their patients. While most educators continue to recommend SMBG for patients with type 2 diabetes who do not use insulin, many providers are hesitant to ask patients to take on this task without strong evidence of its benefit. This puts educators in the uncomfortable position of making recommendations to patients that may be counter to those from their provider, which not only is difficult for patients but also may jeopardize future referrals. Patients may give up on monitoring if their provider is not supportive of their efforts and does not pay attention to or even criticizes their results. Payors may also be reluctant to provide reimbursement for SMBG when the benefits are not firmly established. As the authors of this review point out, very few studies have examined SMBG as a component of self-regulation. Some studies have shown that teaching patients to use the data obtained for decision making increases the likelihood that SMBG will have a positive effect on A1C. This is particularly important for diabetes educators, who are often the health professionals who teach patients to make these decisions and adjustments. Thus, the evidence, while mixed, supports diabetes educators in recommending SMBG as part of self-management and for providing patients with the information to make appropriate modifications in their food intake, exercise, or medications.
While the evidence is supportive of viewing SMBG as part of self-regulation, very few studies have approached SMBG using this theoretical framework as described by the authors. This represents a major gap in the understanding of the effectiveness of SMBG. Diabetes educators are the most appropriate group to address this gap because they have the knowledge to develop interventions to test this approach and because the results could have a significant impact on their practices and the lives of their patients. In addition, diabetes educators have experience in identifying both the mediators and moderators of SMBG that need to be tested.
Because a definitive answer is not yet known, educators need to examine their practices to determine if they are truly assisting patients to appropriately use the results of their SMBG efforts. These strategies then need to be empirically tested to determine if they are effective. Based on the commonsense approach to self-regulation described in this article, strategies diabetes educators can implement to enhance the effectiveness of SMBG include the following:
In summary, while the evidence about the effectiveness of SMBG for patients with type 2 diabetes not using insulin is unclear, diabetes educators can potentially increase its effectiveness by implementing strategies that are consistent with self-regulation theory, in which SMBG is one component of a complex set of behaviors used by people with diabetes to manage their diabetes. In addition, diabetes educators should take the lead in developing and testing these interventions.
Work on this article was supported in part by grant NIH5P60 DK20572 and 1 R18 0K062323 from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health.
The Diabetes Educator, Vol. 33, No. 6,
1012-1013 (2007)
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