I just got a message from Ronald Tamler, MD, PhD, MBA, CNSP that ought to get your dander up. The October issue of the Journal of Family Practice contains a bold (literally) statement: “Self-monitoring blood glucose had no effect on HbA1c over the course of a year among patients who didn’t need insulin.”
British Group Detests Testing —
American Family Physicians Fall for It
Ronald Tamler, MD, PhD, MBA, CNSP
I just saw something that made me testy: The October issue of the Journal of Family Practice contains a bold (literally) statement: “Self-monitoring blood glucose had no effect on HbA1c over the course of a year among patients who didn’t need insulin.”
They were quoting a British study that had been sponsored by the British National Health Service (NHS) and published in the British Medical Journal (BMJ) in July. The study followed 453 patients (151 per group) with mild diabetes controlled by diet or oral medications. The patients were assigned to either no blood glucose self-monitoring (SMBG), “non-intensive SMBG” (i.e. they were given a machine but no instructions on what to do with the results) or “intensive SMBG”. After one year, the investigators found that the HbA1c had dropped by about 0.2% from the average of approximately 7.5% in the intervention groups. Since this difference was not statistically significant, the authors concluded that there was no benefit in recommending self-monitoring blood glucose levels to patients with orally controlled DM.
While I was pleased that the Journal of Family Practice took an interest in diabetes, I was stunned by their simplified conclusions and the fact that they awarded this study a grade Ib EBM rating, equating its quality to that of much larger and more influential randomized trials.
The British Medical followed the path that any good journalist would take and published the story of “man bites dog”. However, the editorial pointed out significant weaknesses like the fact that only 15% of eligible patients were included in the trial , that patients already testing more than twice a week were not eligible and, most importantly, that these patients already had pretty good glycemic control to begin with, leaving little room for the sweeping improvements one would expect at a higher HbA1c. What baffles me is that nobody thought to mention the benefits gleaned from decreased glucose variability not seen with HbA1c monitoring alone.
The ADA strongly recommends SMBG in all patients with diabetes, tailored sensibly to the individual patient’s clinical situation. strongly recommends SMBG in all patients with diabetes, tailored sensibly to the individual patient’s clinical situation and gives it a level “A” rating. I challenge my patients with Type 1 and Type 2 diabetes every day to test their blood glucose levels more often. Yes, it’s painful, yes, every test strip costs money, but the information gleaned is priceless: Patients can see how different behaviours and meals impact them and take ownership of their condition. They can bring me that data, and together, we can make good, motivated decisions about lifestyle and pharmacological regimens. The US department of Health and Human Services is planning to increase the number of patients with diabetes who monitor their blood glucose level at least once a day to >61%, but with American family physicians uncritically embracing research sponsored by an institution with an inherent interest in containing cost, that goal has just become so much harder to reach.
If you would like to discuss the usefulness of SMBG in diabetes, and this study in particular, please post your contribution in our forum and take this week’s poll regarding the authors of the British study.
Until next time,
Ronald Tamler, MD, PhD, MBA, CNSP
PRESENT Diabetes Associate Editor
Division of Endocrinology and Diabetes
Department of Medicine
Mount Sinai School of Medicine
This Week’s Lecture
“Type 2 Diabetes — overview“
by. Dr. Derek Leroith
Barbara Davis Center for Childhood Diabetes
University of colorado Denver Health Sciences Center
Click on image to view lecture