Diabetes Self-Management Blog

Two just-published studies in BMJ, the British Medical Journal, suggest that people with Type 2 diabetes don’t need to monitor their blood glucose much, unless they’re on insulin. You heard it here first.

This is an old debate. I’m going to tell you what I think, but I’d really like to hear your experiences and opinions.

One article is called “Cost effectiveness of self monitoring of blood glucose in patients with non-insulin treated type 2 diabetes.”

This study followed three groups of people (a total of 453 participants) who had had diabetes for at least 12 months. All groups got standard care. One group did no blood glucose monitoring. Another was taught to check blood glucose levels, but not what to do about them. The third group learned self-monitoring and also received “additional training in incorporating the results into self-care.”

The study lasted one year and looked at two outcomes: expense and quality of life (called “Quality adjusted life years.”)

The results showed that self-monitoring cost approximately an extra 84 pounds ($164) a year. Interestingly, the group that had been taught what to do about their blood glucose results spent a bit less than the group that was just monitoring and writing the numbers down.

When it came to quality of life, “an initial negative impact of self monitoring on quality of life occurred,” moreso in the group that received the advanced training. This was not a huge effect (about 3% in one group and about 7% in the other), but it was a significant negative.

The researchers concluded that “self-monitoring of blood glucose with or without additional training in incorporating the results into self care was associated with higher costs and lower quality of life in patients with non-insulin treated type 2 diabetes. In light of this, and no clinically significant differences in other outcomes, self monitoring of blood glucose is unlikely to be cost effective in addition to standardised usual care.”

What about health outcomes?

The other study is called “Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes.”

In this trial, 184 non-insulin-using patients at hospital diabetes clinics, who had no experience in self-monitoring, were split into a blood-glucose-monitoring group and a no-monitoring group and followed for one year. Both groups received identical education programs. The self-monitoring group received additional education on how and when to check their blood glucose.

The participants were followed every three months for one year. Their HbA1c levels, use of oral diabetes drugs, body mass index (BMI), and psychological well-being were measured.

No Differences Found
There were no significant differences between groups at any time point in the study. HbA1c levels, BMIs, and oral medicine use were all about the same. Monitoring was associated with a 6% higher score on the depression subscale of the well-being questionnaire, a very significant result. The experimenters conclude that, “In patients with newly diagnosed type 2 diabetes, self monitoring of blood glucose concentration has no effect on glycemic control but is associated with higher scores on a depression subscale.”

My Take
In my practice and in my book Diabetes: Sugar-coated Crisis, I caution people against monitoring without a plan. Sticking yourself, obtaining numbers, writing them down, and showing them to the doctor twice a year will not do you much good.

Monitoring with a purpose can be valuable. You can learn how much different foods raise your blood sugar, or how much a certain amount of exercise lowers it. You might find out how certain stressful events or certain medications affect you.

But you don’t have to do those kind of tests every day. Just check when you’re trying to find specific information.

It’s different if you’re on insulin, of course. There, monitoring is a question of safety. Sick days might also call for monitoring, as blood sugar levels can go high very rapidly when you’re sick.

So I believe everyone with Type 2 diabetes should know how to check their blood glucose. But for most people, I don’t think you need to do it very often, if you’re feeling good. When you’re feeling poorly physically or emotionally, it’s probably a good idea to check.

For overall self-monitoring, knowing your HbA1c will give you a better idea. A random blood glucose check only gives you a snapshot of one moment in time. An HbA1c result gives you a picture of where you’ve been for the last four to eight weeks.

What Do You Think?
Well, that’s my view, supported by the BMJ studies. What do you think, people with Type 2 diabetes? Has self-monitoring your blood glucose helped you? How much of it do you do? Do you think you could cut back or stop? Or are these studies wrong in some way? Please comment here.

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Comments
  1. Without self-monitoring, I would not be where I am today. I started out on 3 diabetes meds, as well as a med for cholesterol and a med for blood pressure. I tested my glucose 3 times a day religously, sometimes more. Just to learn and figure the stuff out. It takes awhile. A year after diagnosis I am med free, 140 pounds lighter, with a 4.9 A1c. Could I have made that without testing my glucose? Perhaps, but I doubt it.

    Testing works for those willing to do the work. Testing doesn’t do the work for you. There is a difference.

    Posted by Pilbur |
  2. I am all for individualizing blood glucose monitoring schedules. I think we should check blood glucose when we need the information it supplies. And I think it’s silly to check blood glucose when you don’t need the information.

    I use an insulin pump and monitor regularly — but not at every meal, as is recommended. For the first few years that I had the pump, I was absolutely rigorous about monitoring on schedule all the time.

    A few years ago I realized that ordinarily, my lunch and supper time blood glucose levels are very predictable. If I have eaten my usual food, and feel OK, and have not had any unusual physical activity, I know my blood glucose will be in an acceptable range. If any of the above conditions are not met, then I must monitor, But if they are, I can safely simply bolus for my meal.

    This won’t work for everyone. But it works for me.

    Posted by Beth |
  3. I understand that most things in life are done for the greater good and I think that works well for most things, but not in health care. I am type 2 with my last A1c results of a 4.9. When I was first diagnosed a little over a year ago my A1c was 7.1. Before I even had an appointment with a CDE I bought a meter and started testing about 8 times a day. I used this information to see how different foods affected me. Since my diagnosis I have lost over 60lbs using the information I have gathered from frequent testing. I have now started using a CGMS to fine tune my control even more. My insurance company pays for my test strips and I have just started to work on getting the CGMS supplies paid for. If my insurance company were to take what you have said and apply it to how they will pay for supplies for type 2 diabetics it might be ok for most people but I don’t believe that it will get the end result that we, the patient and insurance company are looking for.

    Posted by Aubrey |
  4. Puh-leeze! When the results were sent to the press about a month ago, we learned that “testing” meant “one test per day”. That is hardly enough information for anyone to do anything with — and the groups tested were not told to do anything with the numbers, either.

    In addition, there were way too few subjects, and they were followed for way too short a period of time.

    IMO, the way to test the effectiveness of bg monitoring for NIDDM is to keep to the same “tight control” schedule as for insulin-dependent diabetes, with diet, exercise, and medication adjustments to bring the numbers into the desired range. A reasonable study would have something more like 5000-10000 subjects, minimum, and would follow fully-compliant versus not-fully-compliant patients versus the no-check control group for a minimum of five years, and preferrably longer (20-30 years). Endpoints for each subject would be (1) switch to insulin, (2) death. Measurements of effectiveness would include switch-to-insulin rates, complication types and rates, and mortality rates.

    Those of us who are in the “frequent testing/tight control” choir are already convinced that this sort of test would be unethical towards the “no test” subjects; unfortunately this might be the only way to get the rest of the congregation to at least pick up the hymnal, even if they can’t figure out what page we’re on.

    Posted by tmana |
  5. Yes It is Important
    ===================
    I was diagnosed with Type-2 Diabetes two years ago. The PP blood glucose was 225 at that time. Upon medication dan regular exercise it went down to 105 - 110 normal level. Since then I took bood glucose test every morning, every single morning until now. It helps me to know exactly the actually blood glucose level; it helps me to determine the type and amount of food I shall consume everyday. If it reaches higher than normal, I will consume less (less carbo, less starchy foods) to avoid any spikes;if the glucose level within normal range, I will adjust my diet accordingly to normal portion and or variation. So I feel that the regular daily control of blood glucose is very important as part of effort to deal and live with diabetes.

    Posted by Phillips Gunawan |
  6. I take my blood sugar every morning to see if I’m on track. When I’m not, I test before and after selected meals to see how I’m doing. Since I’m controlling my glucose by diet and exercise, and I eat a varied diet, I need this data to refine what I’m doing, and I do make changes based on the information. Otherwise I won’t find out that I’m off course until my A1C, which is only twice a year. That’s too long.
    On the other hand, my husband is perfectly happy to eat schleck and take medicines and only worry if the doctor doesn’t like his A1C. When he was testing, he didn’t make any changes based on the results anyway.
    If we were in a study like this, we’d cancel each other out.
    Deb

    Posted by delebra |
  7. Thanks for all these great stories, and keep them coming! I’m going to the ADA Scientific Sessions this weekend, and I’ll take your stories with me to the Behavior change/diabetes education workshops.

    You’re definitely giving me, for one, a lot to think about re: self-monitoring.
    David

    Posted by David Spero RN |
  8. When I was diagnosed, with an A1c of 10.3%, I checked my bg anywhere up to 12 times a day. It was essential to learn what various food and exercise patterns did to my body. With that kind of information, I rapidly got down to normal bg levels. These days, I might only test two or three times a week - but if I change something in my exercise routine, or try out a new food, I will certainly test, to see if it fits into my lifestyle. My doctor initially thought I was nuts - but now I’m 4 years down the line, with an A1c of 5.4% for the last 3 years, and having reversed some early neuropathy - he’s coming round to my point of view. There’s a very simple but powerful piece of advice on how to use SMBG here: http://www.alt-support-diabetes.org/NewlyDiagnosed.htm

    Posted by Nicky |
  9. I check several times a week, and try to check before eating and 2 hours after the start of a meal, to see how the food and quantity of food affects the numbers. This also with time gives me an average (stored in the meter) that I plug into the formula: A1c = (AvgMG/dl + 86) / 33.3 to get an approximation of what my A1c is running.
    I can’t imagine trying to control my numbers without seeing how the variables affect them!!

    Posted by Ron |
  10. I test 3 times minimum a day per my newest doctor and for myself. It helps me decide how much exercise, what to eat, and when to eat so that I keep control.

    I inherited diabetes, but because I was an active ‘older’ woman, ate heart healthy I was able to obviously keep tight control on diabetes for 9 years (from when my neuropathy began) without even knowing I had it. When I complained about certain aches, feelings, neuropathy in the feet, etc. doctors would only do an A1C test which was always under 7, then give me a pat on the shoulder and say ‘you’re healthy, just normal stuff, growing old”, and change my shoe style since maybe that was causing my neuropathy! (and they knew my family history with this disease)

    It finally progressed 2 years ago and my A1C was over 13 so that doctor was ‘fired’.

    I once was told diabetes is like a game show host and it changes the rules whenever it wants, and I won’t take chances with my life by not testing and knowing.

    Before meds I was having many highs and lows, which would average out to a good A1C, but extreme highs and lows I have discovered are not good either and I want to know where I stand, after all I am very lucky not to have eye damage, heart disease, high blood pressure and the neuropathy is even better and I intend to live a healthy ripe ole age even if it means being a human pin cushion.

    Posted by mzizgayle |
  11. I test anywhere 6 times a day. I use it to makechanges in diet and decisions about exercise, to check for lows, or when I do not feel right. Monitoring to me is a vital part of diabetes care and control. It is not just about learning to do a blood glucose check it is learning what to do with the number once you have that number. I also feel that monitoring lets us see if your numbers need additional help or what is happening.

    Posted by deafmack |
  12. I’ve been a type 2 for 7 yrs now. My A1C started at 6.8. I don’t take any meds or insulin. At first I tested 1 hour and 2 hours after each meal. Once I determined what foods I could eat without spiking my blood sugar, that went on my list of foods I could eat. I did that for a 6 months and lost 30 pounds. For me, I found low (net) carb foods worked the best. Since then I haven’t tested. I have blood work every 6 months to check my A1C, which has never been higher that 5.9. I feel fine and definitely enjoy NOT sticking myself all the time. I’d rather give up the “bad” food than stick myself. “Life is good”

    Posted by HT |
  13. I check my glucose level in the AM only. I gauge what I will eat from that. I am type 2 and have 6.4 A1C. I have neuropathy which is better with the lower A1C. I complained of painful new sensations in my feet to my doctor just before being diagnosed with diabetes. I was in his office for a bladder infection and he told me he couldn’t treat two things at once. I never went back to him.

    Posted by Margaret Pearce |
  14. Testing doesn’t do much. Even for the poster who lost all the weight, I find it hard to see how it was the testing that resulted in the weight loss. You can know you’re sugar is high, that’s one thing - it certainly doens’t mean you’ll do anything about it, hence the plan the doctor is talking about. The only useful thing about testing is that I discovered my numbers are always high in the morning, something to this day we haven’t been able to control. Any ideas????

    Posted by rememberthecoop |
  15. I think of testing as my “safety net”. It may be more of a mind game, but if I know I’m going to test myself, it keeps me from eating something that will spike my glucose. I brought all sorts of complusive overeating food issues with me when I was diagnosed almost 4 years ago and testing, writing it down, making charts, and good food tracking help me keep my 1AC numbers below the 7.0 range. When I have a high number in the morning, then I know that I overdid a bed time (binge) snack and that makes me stiffen my discipline and make better choices. All this news about it not helping has been hard for me. Because of my binging personality, I tell myself I don’t have to test daily because the studies say it isn’t important. That just gives me leeway to eat. Not all of us with diabetes can really stick with the program just because of the long-range risks of the disease. Food is a part of my every day and I eat better when I test frequently. All this news about it not being necessary scares me because I fear the insurance companies will stop paying for the strips!

    Posted by hcubedinoregon |
  16. Hi, I am a type 2 since 1999. Normally I test just once a week before and after meals and at bedtime. I can feel if my sugar is off (low). I am on the new drug Januvia since march and am now testing more often as I am playing (as I call it) with pills. I also take glucophage twice a day and have added at bedtime 1/2 of diamcron. This is all to lower that morning high after breakfast for which there seems to be no magic pill. I am afraid of insulin and will continue trying to lower the morning. I am fine the rest of the day and always in the normal range. Any help will be apreciated

    Posted by Lorraine |
  17. i think it is very inporton to check your bs
    each day, it’s the only way to know how you are doing for sure. to say us t-2 do not have to check that much, is just worry, for are hearth we need to know,where are ,level’s are at, just as much as the t-1
    do.

    snowgirl

    Posted by snowgirl |
  18. I have had type 2 diabetes (non-insulin) for 10 years and I test twice a day. I believe testing has helped me to stay focused. I believe if I had not learned to self monitor I would be a rubber-band diabetic. I have not once since diagnosis been in the hospital for any diabetic related reason. My A1c’s have gotten better, I am now 5.5. Testing is necessary.

    Posted by pjmier50 |
  19. It was only by monitoring four times a day that I was able to obtain the results documented here; specifically, it was the only way I learned the effectiveness of lowering fasting blood sugar by spreading my carb allowance out into progressively smaller portions as the day progressed.

    Recently I’ve taken to testing as many as six times a day when I test (see below), to see what else I can learn from postprandial readings.

    Since I manage my diabetes by being systematically habitual in my diet, at a certain point continuous testing stops giving me new information, because the results are the same. Also, I’m on the county health, and the pharmacist cross-examines me if she thinks I’m getting more strips than I’m entitled to. So now I do the intensive six-times-daily testing for a couple of weeks each quarter, or when I realize or suspect I’ve fallen off the dietary wagon: cross-checking results against behavior.

    Best to all,
    M.

    Posted by Michael.Massing |
  20. I totally disagree with not monitoring consistently. I find that myself, and my friends who are diabetic, do much worse if we don’t monitor ourselves regularly. It’s “out of sight, out of mind”, so we don’t watch what we eat. If the readings are right there, staring back at you, it makes you more health-conscious and wiser in your daily food choices and also gives me the impetous to get up and exercise. Keep monitoring! So what if it’s $164 a year? It’s worth it to have that extra year of LIFE later on.

    Posted by Leatherferret |
  21. I was diagnosed with Type 2 in 1992. I had poor bg control until the new insulin resistant drugs came out. I loved Rezulin because I had normal readings for the 1st time in 5 years. When it was taken off the market I went on Avandia for many years, until it got the black box warning. I switched to Actos just this year. I test only once or twice a day. If I get a reading that I think is high (150+) I will cut out carbs for a while. Every couple of months I will test 4 or 5 times a day for several days just to monitor what is happening. I recently read an article about 55% of Type 2’s possibily never having to take insulin. I hope I am in this catagory. After 16 years, I have no complications and am increasing my exercise since I retired. retired in Tucson

    Posted by retired in Tucson |
  22. I have been diabetic(type 2)for over 20 years and am in better control than ever since I have started checking my sugar before each meal.
    I only take insulin when I read over 150, which is not often. Knowing what I am reading helps me to decide what and how much I will eat each meal. At times I do resent having to do this but it helps, so I keep doing it.The endocrinologist who started me doing this had me to fax my readings to her every 2 weeks for months. That really kept me in check.

    Posted by naortego |
  23. rememberthecoop,

    In response to your comment about high morning blood glucose levels, you may want to read “Blood Glucose Monitoring: What Do the Numbers Tell You?” The article offers the following possible explanations for high blood glucose levels in the morning:

    * Your liver might be sending a lot of glucose into the bloodstream because the signals telling it to shut off aren’t working. The drug metformin may be prescribed, because its main action is to signal the liver to shut off.
    * Your dinner or bedtime snack choices might be raising your blood glucose the next morning. Try changing your food choices and portions to learn more about their effect on your blood glucose levels.
    * Your body may be unable to handle the effect of the hormones secreted at dawn that work against insulin. This early-morning release of hormones is called the dawn phenomenon. High blood glucose that results from it can be managed with oral medicines or insulin.
    * Your insulin or oral medicine dose may need to be adjusted.

    You may also want to read more about the dawn phenomenon and the Somogyi effect (which can also cause high morning glucose levels).

    Posted by Tara Dairman, Web Editor |
  24. I would very much like to see a research programme comparing *proper* testing, not just once or twice a day, as per

    This was the protocol I followed initially, until I had worked out what was going on and, more importantly, what I could DO about it.

    Now I have settled into somewhat of a routine I don’t bother to test nearly so much. I always test my postprandials when I’m eating out or otherwise consuming food of unknown provenance, when I’m feeling ill or off colour and when I’m doing large amounts of exertion, then every few weeks I will run a whole day to check for any long term changes.

    I suffer from Impaired Glucose Tolerance and Reactive Hypoglycemia and have done for maybe 50 years. My fasting and preprandial numbers are still good and my A1c has never been out of the fives, but my postprandials have been everywhere from 60 to 210, so until I got a good one doctors have always written off my symptoms as “hypochondria”, “neurosis” and even “personality disorder”. ONLY by doing my own testing was I able to discover this pattern, and to determine that by reducing my carb input to 1/4 - 1/3 of what the dietician recommended I can keep my BG in the 70 - 90 range with postprandials running under 120.

    The result has been that my blood pressure has dropped and my lipids have gone from the frightening to the spectacularly good. Peripheral neuropathy has mostly disappeared unless I spike my BG over 140 - 150, but I still have symptoms of autonomic neuropathy despite this level of control.

    I have always been a skinny bastard and quite fit and active, this is obviously a genetic problem considering others in the family also show symptoms of insulin resistance, including one who is an athlete.

    I am deeply disappointed in such “research” and the corollary that our NHS disallows testing for Type 2s in many areas. They are spending pounds in order to save pennies and causing a great deal of unneccesary suffering and disintegration.

    The majority of wild-type Type 2s have horrendous A1cs, whereas many people following the above protocol are members of the 5% Club. Of course testing and doing nothing with the results but follow the Standard High Carb Low Fat diet will prove that it is a waste of time and money. Of course following that diet will not improve anything. To make proactive changes you need data. Preventing patients from accessing such data “in case it makes them depressed” is horse apples, I for one have found it highly empowering to actually see in real time what is happening and how I can improve it.

    Posted by trinkwasser |
  25. Hi Trinkwasser,
    I’m glad the low-carb diet is working for you. From your history, I think you should look into the possibility that you have MODY (mature onset of diabetes of youth) or LADA (late-onset autoimmune diabetes), which are forms of Type 1 that come on in adulthood. We’ve done blogs about these.
    David

    Posted by DavidSperoRN |
  26. I’m going to disagree with you, David. MODY (Maturity Onset Diabetes of the Young, of which about six types have been found so far) is its own form of diabetes–neither type 1 nor type 2). And I don’t believe LADA (Latent Autoimmune Diabetes in Adults) takes 50 years to progress.

    Jan

    Posted by Jan Chait |

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