# How to stop doctors recommending self-monitoring ...



## Eddy Edson (Jul 31, 2018)

http://www.annfammed.org/content/16/4/349.full.pdf+html

_ABSTRACT This qualitative study examines to what extent and why physicans still prescribe self-monitoring of blood glucose (SMBG) in patients with non–insulin-treated type 2 diabetes (NITT2D) when the evidence shows it increases cost without improving hemoglobin A1c (HbA1c), general well being, or health-related quality of life. Semistructured phone interviews with 17 primary care physicians indicated that the majority continue to recommend routine self-monitoring of blood glucose due to a compelling belief in its ability to promote the lifestyle changes needed for glycemic control. Targeting physician beliefs about the effectiveness of self-monitoring of blood glucose, and designing robust interventions accordingly, may help reduce this practice._

Anyway, interesting for insight into rationales for why some health systems discourage it.


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## travellor (Jul 31, 2018)

It doesn't really say much to be honest.

I have been to a fair number of diabetic conferences when I was initially diagnosed, and I have met people who obsess about blood sugar though, and I mean to such a degree it has taken over their entire life, that has been worrying.

Generally, it helps, but remember, we are a very small percentage of the diabetic population, in that we have accepted we control the problem.


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## Eddy Edson (Jul 31, 2018)

travellor said:


> It doesn't really say much to be honest.
> 
> I have been to a fair number of diabetic conferences when I was initially diagnosed, and I have met people who obsess about blood sugar though, and I mean to such a degree it has taken over their entire life, that has been worrying.



I worry that I'm at risk of that, but hopefully I'll get bored & find something new to obsess about


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## Ruby/London (Jul 31, 2018)

I can relate to that, too and I am hoping that once I truly nailed down my dietary changes I can reduce testing to maybe twice a day ...


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## Eddy Edson (Jul 31, 2018)

Ruby/London said:


> I can relate to that, too and I am hoping that once I truly nailed down my dietary changes I can reduce testing to maybe twice a day ...



At the moment, I'm finding that getting kind of intellectually interested in D helps me to forget how annoying it is to have it.


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## Ruby/London (Jul 31, 2018)

Knowledge is power, Eddy


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## Martin Canty (Jul 31, 2018)

Well, I can wholeheartedly say that opposition to self-testing is utterly ridiculous.... Self-testing helps me manage my D on a day to day basis....

One has to recognize the purpose of the various tests: First the ,HbA1c test will measure the average BG over a time period (3 months) without regard to highs/lows which in themselves can be quite damaging to the body, Second, self monitoring will tell the picture now, at this moment in time, allowing us to take corrective action.

The real issue is that people are not educated in what to do with the data obtained from self-testing, I (like probably most of the forum) had to learn how to interpret the results myself. They offer classes on how to eat (forgive me for saying this) rather unhealthy meals for diabetics but I have not once seen anyone offered a course on how to interpret the results of self-testing.


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## Amigo (Jul 31, 2018)

Martin Canty said:


> Well, I can wholeheartedly say that opposition to self-testing is utterly ridiculous.... Self-testing helps me manage my D on a day to day basis....
> 
> One has to recognize the purpose of the various tests: First the ,HbA1c test will measure the average BG over a time period (3 months) without regard to highs/lows which in themselves can be quite damaging to the body, Second, self monitoring will tell the picture now, at this moment in time, allowing us to take corrective action.
> 
> The real issue is that people are not educated in what to do with the data obtained from self-testing, I (like probably most of the forum) had to learn how to interpret the results myself. They offer classes on how to eat (forgive me for saying this) rather unhealthy meals for diabetics but I have not once seen anyone offered a course on how to interpret the results of self-testing.



Absolutely and wholeheartedly agree with that Martin.

This ‘research’ seems to concentrate on physicians perspectives with no accompanying data on response levels/success levels in patients. Hard to see what use it is in view of this.  

There’s some incredible success stories on this site where type 2’s have turned their lives around and the common theme is self testing. Ok, not all patients will engage and not all want to self test. However, those who do should be allowed and funded to within reason. 

I’m prescribed test strips because glycaemic control is essential with my health issues and it’s a very accurate ‘barometer’ of impending infection. Having had sepsis twice, I can’t afford to let infection flourish and my bg’s are always first to elevate. 
I only have annual Hba1c’s and my GP never even mentions my diabetes because sadly it’s too far down the health pecking order in my case. Sad but true!


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## travellor (Jul 31, 2018)

Martin Canty said:


> Well, I can wholeheartedly say that opposition to self-testing is utterly ridiculous.... Self-testing helps me manage my D on a day to day basis....
> 
> One has to recognize the purpose of the various tests: First the ,HbA1c test will measure the average BG over a time period (3 months) without regard to highs/lows which in themselves can be quite damaging to the body, Second, self monitoring will tell the picture now, at this moment in time, allowing us to take corrective action.
> 
> The real issue is that people are not educated in what to do with the data obtained from self-testing, I (like probably most of the forum) had to learn how to interpret the results myself. They offer classes on how to eat (forgive me for saying this) rather unhealthy meals for diabetics but I have not once seen anyone offered a course on how to interpret the results of self-testing.



Are you strips free, or do you need to pay, either directly or through an insurance?


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## Martin Canty (Jul 31, 2018)

travellor said:


> Are you strips free, or do you need to pay, either directly or through an insurance?


I make a co-payment of about $10 for a pot of 50


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## Bubbsie (Jul 31, 2018)

Martin Canty said:


> I make a co-payment of about $10 for a pot of 50


We all pay for our strips one way or another Martin...nothing is free on the health service as you likely know...we're all taxed at source...anything we receive on the NHS is only free at source.


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## travellor (Jul 31, 2018)

Martin Canty said:


> I make a co-payment of about $10 for a pot of 50



Yes, that is a major difference. 

Freely prescribed in the States, and it's no cost the medical system, just a cost to patient or insurer.

Prescribed for all in the UK, and it's a cost directly to the NHS.

So, with an estimate of 4 million type twos - 
I had 100 strips a month prescribed, for 5years. So I cost the NHS (say £20 a pop) £1200.
So, if the UK prescribe 100 strips a month to all 4 million, that's £80,000,000 a year the NHS has to find to fund it.


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## Martin Canty (Jul 31, 2018)

travellor said:


> £80,000,000 a year the NHS has to find to fund it.


No mention the cost of medication & interventions due to complications for those who are not able to control their D because they don't have data to be able to control the disease.

BTW, because I have very good control, I only test once a day (usually) so a pot of 50 will last 7 weeks; many well controlled T2's (who test) don't test as frequently enough to warrant 100 strips a month, they sound like their testing pattern is much the same as mine.


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## Amigo (Jul 31, 2018)

A 2012 report from the London School of Economics, estimates that the cost of prescribing medication for complications of diabetes is around 3 to 4 times the cost of prescribing diabetes medication.


In total, an estimated £14 billion pounds is spent a year on treating diabetes and its complications, with the cost of treating complications representing the much higher cost.


As already said, we contribute to our health care through NI and taxes. It’s not a free service and a significant proportion of people would not want to test or feel unable to do so. My concern is for the committed patient, motivated to maintain control, who is still denied the means to do so.


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## travellor (Jul 31, 2018)

Martin Canty said:


> No mention the cost of medication & interventions due to complications for those who are not able to control their D because they don't have data to be able to control the disease.
> 
> BTW, because I have very good control, I only test once a day (usually) so a pot of 50 will last 7 weeks; many well controlled T2's (who test) don't test as frequently enough to warrant 100 strips a month, they sound like their testing pattern is much the same as mine.



My doctor was happy to prescribe, I was happy to test.
I tested every variation that I could test, it was very helpful to reverse my diabetes, so the cost was an excellent investment for the NHS.


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## Amigo (Jul 31, 2018)

travellor said:


> My doctor was happy to prescribe, I was happy to test.
> I tested every variation that I could test, it was very helpful to reverse my diabetes, so the cost was an excellent investment for the NHS.



Precisely travellor! Which is why I’m struggling to grasp your posts which seem to suggest others shouldn’t be given the same opportunity.


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## travellor (Jul 31, 2018)

Amigo said:


> A 2012 report from the London School of Economics, estimates that the cost of prescribing medication for complications of diabetes is around 3 to 4 times the cost of prescribing diabetes medication.
> 
> 
> In total, an estimated £14 billion pounds is spent a year on treating diabetes and its complications, with the cost of treating complications representing the much higher cost.
> ...




This is the issue with politics.
Today, we pay for the treatment of diabetes.
Tomorrow, our children pay for the cost of treating the complications. 

That's how tax, national debt, every aspect of life works.
We vote in a government that promises to mortgage our kids future, so we pay less now.
No one would vote in a party that offered to raise income tax by 5% today.

Not everyone contributes to the NHS through NI.
Poorly paid, elderly, unemployed, all are exempt.
The government are trying to exclude more and more from the benefits of the NHS, especially by removing millions of disabled from the system.

I wish I could tell you the answer.


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## travellor (Jul 31, 2018)

Amigo said:


> Precisely travellor! Which is why I’m struggling to grasp your posts which seem to suggest others shouldn’t be given the same opportunity.




I suspect you are reading your own opinion there, and not any words I've actually written?
Unless you can quote me on it?


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## Amigo (Jul 31, 2018)

travellor said:


> I suspect you are reading your own opinion there, and not any words I've actually written?
> Unless you can quote me on it?



In honesty it was the cynicism that was coming through from your posts on the previous thread on the subject where you seemed to dismiss many type 2’s as being unwilling to change, incapable or coping with testing or selling their supplies on eBay.


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## Martin Canty (Jul 31, 2018)

Amigo said:


> In honesty it was the cynicism that was coming through from your posts on the previous thread on the subject where you seemed to dismiss many type 2’s as being unwilling to change, incapable or coping with testing or selling their supplies on eBay.



Well said @Amigo .... I have seen that several times.

IMHO testing should be offered, not everyone would accept (I'm sure) but at least it's there on the table. I hear too often comments like "obsessive", "anxious", "wouldn't understand", testing is not rocket science, even without the help of this forum I was able to understand trends, spikes, hypo's & other useful data that self-testing provides.


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## travellor (Jul 31, 2018)

Amigo said:


> In honesty it was the cynicism that was coming through from your posts on the previous thread on the subject where you seemed to dismiss many type 2’s as being unwilling to change, incapable or coping with testing or selling their supplies on eBay.



I have been to many courses, many conferences, and sadly, I met many who didn't want to know.
I am also public facing, and I am not embarrassed to discuss the fact I am type 2, and have reversed it. 

Many out there don't want to test.

And all you need to do is look on ebay.
It's real, the NHS see it every day, in even greater numbers.

It's an unreal world on this forum.
We are dedicated to making a difference to ourselves, but, even this forum is a very small percentage of the rest of even the UK.

I believe the first thing to do it to convince people they matter, and that they have the power to change.
But that means seeing it from their point of view, and encouraging small changes, not straight in at the deep end, as then it is very easy to sink.

If I can get someone to switch from white bread to brown, (even though it is as bad) the switch is their head is now going to be "healthy", and from there, changes snowball.
I don't need to get them bread free, I need them to think they have the power to change.

And testing does have issues. 
I've had at least one diabetic, who thinks they failed, because they tested after a meal.
"I was at 4, and rose to 6.7, the internet says any rise over two is bad, and the NHS lie about it, what can I eat?"
That was at a conference.

Me, I'd love those figures, even as a none diabetic.


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## travellor (Jul 31, 2018)

Martin Canty said:


> Well said @Amigo .... I have seen that several times.
> 
> IMHO testing should be offered, not everyone would accept (I'm sure) but at least it's there on the table. I hear too often comments like "obsessive", "anxious", "wouldn't understand", testing is not rocket science, even without the help of this forum I was able to understand trends, spikes, hypo's & other useful data that self-testing provides.




Well, that's a simple answer.
Does every single diabetic in the states buy strips?
As it is offered to all there.
Or do some choose not to?

I can't comment at all on your system, indeed, I don't think I've ever met an American diabetic, so you have the advantage of me, if you know our system to be fair to me.


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## Amigo (Jul 31, 2018)

travellor said:


> I have been to many courses, many conferences, and sadly, I met many who didn't want to know.
> I am also public facing, and I am not embarrassed to discuss the fact I am type 2, and have reversed it.
> 
> Many out there don't want to test.
> ...



I certainly don’t live in any kind of ‘unreal world’ travellor and if you knew my background, you’d know why. 
The odd anecdotal case of a panicking type 2 freaking after testing doesn’t do it for me as argument I’m afraid.

I come across more people who are refused the right to test than those who refuse to test. 

You can’t ‘save’ everyone or get them to protect themselves but let’s at least give the ones who want to try a fighting chance!


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## travellor (Jul 31, 2018)

Amigo said:


> I certainly don’t live in any kind of ‘unreal world’ travellor and if you knew my background, you’d know why.
> The odd anecdotal case of a panicking type 2 freaking after testing doesn’t do it for me as argument I’m afraid.
> 
> I come across more people who are refused the right to test than those who refuse to test.
> ...



I seriously don't believe this forum represents the typical 4 million type 2 diabetics in the UK, so we will have to agree to differ there.
I like to think I put in an unreal amount of effort to reverse my diabetes, and I think this forum is probably populated by very committed diabetics, who invest a lot more time than the rest of the diabetic population.

However you are right, the rest deserve a chance.

What are we going to do about it for them?


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## Amigo (Jul 31, 2018)

travellor said:


> I seriously don't believe this forum represents the typical 4 million type 2 diabetics in the UK, so we will have to agree to differ there.
> I like to think I put in an unreal amount of effort to reverse my diabetes, and I think this forum is probably populated by very committed diabetics, who invest a lot more time than the rest of the diabetic population.
> 
> However you are right, the rest deserve a chance.
> ...



Give them the right to funded testing if only until they learn what foods they can tolerate. Provide health providers who actually understand diabetes and stop advisory agencies clinging to outdated nutritional advice that would spike most diabetics into the stratosphere!


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## travellor (Jul 31, 2018)

Amigo said:


> Give them the right to funded testing if only until they learn what foods they can tolerate. Provide health providers who actually understand diabetes and stop advisory agencies clinging to outdated nutritional advice that would spike most diabetics into the stratosphere!



I don't have an axe to grind over tieing testing to a diet.
It's an old chestnut, and I believe a diabetic should choose any type of diet that works for them personally.
It shouldn't be used as a stick to beat a diabetic with, if they don't follow a specific diet they lose the strips.
My NHS approved diet worked spectacularly. 

But, I invested my time in a massive Taguchi exercise, and worked hand in hand with the NHS dietitian for about a year.


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## Martin Canty (Jul 31, 2018)

travellor said:


> Well, that's a simple answer.
> Does every single diabetic in the states buy strips?
> As it is offered to all there.
> Or do some choose not to?
> ...



First, a bit of background, I'm a British Expat currently living in California so I am familiar with the NHS (though not as a diabetic)

I think it's safe to say that on DX all or most Diabetics are prescribed meters (even pre-D in some cases).

As for what is covered & what is not, that's governed by the insurance companies; if the Actuaries declared that testing was not a cost effective solution then they would make testing for us a lot more difficult. As it's a profit based system they would be weighing the cost of uncontrolled D vs testing. From my experience the medical system here (God knows it's got it's faults) places a large emphasis on preventative medicine.


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## travellor (Jul 31, 2018)

Martin Canty said:


> First, a bit of background, I'm a British Expat currently living in California so I am familiar with the NHS (though not as a diabetic)
> 
> I think it's safe to say that on DX all or most Diabetics are prescribed meters (even pre-D in some cases).
> 
> As for what is covered & what is not, that's governed by the insurance companies; if the Actuaries declared that testing was not a cost effective solution then they would make testing for us a lot more difficult. As it's a profit based system they would be weighing the cost of uncontrolled D vs testing. From my experience the medical system here (God knows it's got it's faults) places a large emphasis on preventative medicine.



Our system is the opposite.
We have a £1.78 billion national debt.
So the current government is mortgaging my kids future to pay that back.
The less they spend now, the better our taxes are.
And that's a vote winner today.

No strips are good, we pay less taxes today, and the complications are paid for tomorrow.

Although, from the first post in this thread, are things possibly changing there?
If insurers are leading your healthcare, are they suggesting strips are not cost effective?


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## Martin Canty (Jul 31, 2018)

travellor said:


> Although, from the first post in this thread, are things possibly changing there?
> If insurers are leading your healthcare, are they suggesting strips are not cost effective?


I don't think so but they do monitor the prescriptions..... My last prescription was for 4 strips/day but the insurance company reduced it to 2 strips/day (so 100 for a 25 day supply to 50)


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## Martin Canty (Jul 31, 2018)

travellor said:


> Although, from the first post in this thread, are things possibly changing there?
> If insurers are leading your healthcare, are they suggesting strips are not cost effective?


Also I advocate from the standpoint of being in a system that is working for diabetics rather than considering them a pest.... My other pet cause is dietary guidelines, I was eating pretty much within the ADA guidelines yet 3 years ago diagnosed with T2....


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## travellor (Jul 31, 2018)

Martin Canty said:


> I don't think so but they do monitor the prescriptions..... My last prescription was for 4 strips/day but the insurance company reduced it to 2 strips/day (so 100 for a 25 day supply to 50)



You still pay cost compared to  UK  products


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## travellor (Jul 31, 2018)

Martin Canty said:


> Also I advocate from the standpoint of being in a system that is working for diabetics rather than considering them a pest.... My other pet cause is dietary guidelines, I was eating pretty much within the ADA guidelines yet 3 years ago diagnosed with T2....



No idea on ADA, all I can state is how well the UK worked for me.
I'm not diabetic now, not on a restrictive diet, and I had the full support of the NHS on that resolution.

Thinking about it, why don't the insurers bring a class action against the ADA, if their recommendations are causing an issue the insurers have to pay out on?


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## Martin Canty (Jul 31, 2018)

travellor said:


> No idea on ADA, all I can state is how well the UK worked for me.


The ADA recommendations are much like Eatwell....


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## travellor (Jul 31, 2018)

Martin Canty said:


> The ADA recommendations are much like Eatwell....


Yet your insurers don't challenge them, if they are costing them money?

(sorry if this is boring other people, it's just interesting to get a view from a profit driven healthcare base)


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## Martin Canty (Jul 31, 2018)

It's all driven by money, big food & pharma have deeper pockets than the insurance companies so the FDA will look to them for guidelines


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## travellor (Jul 31, 2018)

Martin Canty said:


> It's all driven by money, big food & pharma have deeper pockets than the insurance companies so the FDA will look to them for guidelines



Insurers can pull the strings on any pharmaceutical company. 
Insurers underwrite every trial, every claim, every nod that any pharma makes. 
Big food trials are underwritten, so the conspiracy theory dies in the light to be fair.

Big food, big pharma is a myth that you propagate only if you believe it, and repeat the buzzwords that make the conspiracy theory happen.

The reality is it's just a company, making money for it's shareholders, like every other company out there.


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## travellor (Jul 31, 2018)

Martin Canty said:


> I make a co-payment of about $10 for a pot of 50



What do you reckon Trump will do to your costs?
You must be subsided by anything up to $20 a pot there, (depending on your strips)
Any chance they will drop pre existing conditions?


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## Amigo (Jul 31, 2018)

Seems to be veering well off subject now.


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## travellor (Jul 31, 2018)

Amigo said:


> Seems to be veering well off subject now.



An american paper, a completely different health care system, as @Martin Canty  has said, a completely different ethos, so it seems very relevant to get an understanding of the facts behind the paper surely?

Even more relevant with the changes in Obamacare that are happening at the moment, and Martin is ideally placed to report on the effects it has on diabetics?


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## trophywench (Aug 1, 2018)

I wish the elderly didn't have to pay income tax!!!  Admittedly it does depend on the level of pension you collect and as I don't qualify for a full state pension I'd be well below the income tax threshold, but there again I wouldn't be able to live on it anyway so it's a damn good job I was prudent enough to spend some of my employment income on my own pensions, wasn't it?


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## Eddy Edson (Aug 1, 2018)

travellor said:


> Yes, that is a major difference.
> 
> Freely prescribed in the States, and it's no cost the medical system, just a cost to patient or insurer.
> 
> ...



From one of the papers cited in the study from the original post:

*CONCLUSION:*
_This low-cost programme demonstrated a major reduction in unnecessary prescribing of SMBG, along with cost savings. If replicated nationally, this would avoid unnecessary testing in 340 000 people and prescribing costs that total £21.8 million._

https://www.ncbi.nlm.nih.gov/pubmed/25824186

(As of 2015.)

Obviously a major issue is that there are several reasonable-quality studies which demonstrate no significant (population) benefits from SMBG & apparently none that demonstrate otherwise - just the weight of "expert opinion" from specialist organisations like the ADA, DUK etc, which doesn't necessarily count as good "evidence".

So you get people like a friend of mine who is a University Dean of Medicine, in favour of scrapping SMBG and sticking with periodic HbA1c tests - because that's where the weight of academic evidence guides him.

I guess what would be useful is a good-quality study picking out population segments, categorised in clinically useful ways, for which SMBG does show meaningful evidence of increased utility over educational or whatever other efforts.

Personally, I can't imagine how I would have gotten whatever handle I now have on D without frequent testing - but that doesn't constitute "evidence" in this context.


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## Eddy Edson (Aug 1, 2018)

Anyway, just because I find it interesting ... Another paper cited in the study from the original post, from last year: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2630691

It seems to have been regarded as surprising & important in the D-research community.

_*Question* Is self-monitoring blood glucose levels effective for people with non–insulin-treated type 2 diabetes in terms of improving either hemoglobin A1c levels or health-related quality of life (HRQOL) in primary care practice?

*Findings* In this pragmatic randomized clinical trial that included 450 patients randomized to 1 of 3 groups: no self-monitoring of blood glucose (SMBG), once-daily SMBG, and once-daily SMBG with enhanced patient feedback. There were no significant differences in glycemic control across all groups, nor were there significant differences found in HRQOL.

*Meaning* Routine self-monitoring of blood glucose levels does not significantly improve hemoglobin A1c levels or HRQOL for most patients with non–insulin-treated type 2 diabetes; patients and clinicians should consider the specifics of each clinical situation as they decide whether to test or not to test.
_
For me, an evident structural weakness to the study is the "once-daily" thing.  I think I would have found a once-daily test pretty much useless for my D-handling, so far.

On the other hand, what would the cost/benefit balance look like for a health system contemplating funding say 6-8 daily tests?

This is obviously where the push for cheaper & more accurate CGM becomes very relevant, and it's interesting to see the study results presented at ADA in June relating to that (funded by Abbott et al mainly, but nevertheless ...).


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## Martin Canty (Aug 1, 2018)

Eddy Edson said:


> For me, an evident structural weakness to the study is the "once-daily" thing. I think I would have found a once-daily test pretty much useless for my D-handling, so far.


Fortunately, for me I'm prescribed 2 a day, most days I just test my FBG so that allows for me to stockpile strips enough for more intensive testing. However, while I was in the learning phase of my diet I was testing way more frequently and needed perhaps 5-7 a day.
I get the impression that the establishment don't really understand what the data from testing can really give us outside of whether we are hypo/hyper or not.


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## everydayupsanddowns (Aug 1, 2018)

Martin Canty said:


> Fortunately, for me I'm prescribed 2 a day, most days I just test my FBG so that allows for me to stockpile strips enough for more intensive testing. However, while I was in the learning phase of my diet I was testing way more frequently and needed perhaps 5-7 a day.
> I get the impression that the establishment don't really understand what the data from testing can really give us outside of whether we are hypo/hyper or not.



I found this article by Prof Jane Speight very interesting https://www.mja.com.au/journal/2015...sely-when-it-comes-monitoring-type-2-diabetes

Because along with mentioning the usual negativity regarding the general sum of research findings published in the scientific literature it actually pretty much says what we have all said all along... that research on occasional one-a-day random BG checks are unlikely to produce brilliant results... and that trials that are structured with more intense BG checking frequency but which require subjects to rigidly stick to their (high carb?) diet sheets rather than adjusting food on the basis of their individual results are going to lead to people seeing an unforgiving sequence of high numbers and get annoyed / frustrated / worried / depressed / give up.

But treating PWD with respect, as partners in their care, and showing them how to use BG results to personally tailor their own dietary choices *actually works*. It's not just BG monitoring that helps - it is **structured** BG monitoring.



> Structured SMBG is more than just 21 finger pricks. It involves meaningful (rather than random) glucose checks at set times (eg, pre-meal and 2 hours post-meal, and before bedtime) to generate a pattern over at least 3 consecutive days. The person with T2D also notes their meal sizes and energy levels to provide context for the readings.





> As with most behaviour, if individuals do not value it, or perceive more costs than benefits, they are unlikely to instigate or maintain the behaviour. This applies not only to people with non-insulin-treated T2D, but also to health professionals.





> Far from recommending against routine SMBG, which may unintentionally deter _any_ SMBG in people with non-insulin-treated T2D, we believe Choosing Wisely Australia should positively advocate structured SMBG for all people with T2D not using insulin or other hypoglycaemia-inducing medications.


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## Eddy Edson (Aug 1, 2018)

But then note the response from the anti-SMBG team, below. 

_The authors of this article, all of whom have industry associations [funding from Roche, Sanofi, Medtronic], argue against recommendations which emanate from independent systematic reviews and guidelines. Their arguments are based on 1 study (the STEP study ), which is also linked to the same industry sponsorship. This particular study was considered for Cochrane analysis but was rejected because of methodologic flaws.

If this SteP study was considered, “structured SMBG” based on an intention to treat basis resulted in a 0.3% reduction in HbA1c which the authors have already recognised as insignificant. Only the subgroup that had strict adherence to study protocol resulted in a 0.5% reduction in HbA1c results.

To achieve these insignificant reductions required increased clinical visits in the SMBG of almost 3 times the control group. This resulted in 75% of the SMBG having treatment changes, versus 28% in the control group, which included 18.5% of the SMBG group starting insulin, compared to 10% in the control group.

In the end, SMBG (as indicated in the Step Study) resulted in increased clinical visits, monitoring and drug intervention without significant clinical improvement. No cost-effective analysis was included in this study. 

Choosing Wisely is correct in its decision to include self monitoring of blood glucose in its recommendations as it currently stands.

Competing Interests: Chair - RACGP Expert Committee - Quality Care Clinical Editor - RACGP General Practice Management of Type 2 Diabetes Member - RACGP Choosing Wisely

Dr Evan Ackermann 
*RACGP*_


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## mikeyB (Aug 2, 2018)

There are always going to be problems with cherry picking evidence, but the case for current recommendations is well made. There’s no denying that.

You have to remember that we on this forum are a self selected group. We know what works for us. The trouble is, most PWD don’t, or won’t, or can’t be bothered, or know how to act on the information provided by testing. And it’s most people that these studies cover.

Mike is right to mention diet as an essential part of diabetes care, but it’s only on this and the other forum that appropriate dietary advice is promulgated. That needs fixing.


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## everydayupsanddowns (Aug 2, 2018)

Eddy Edson said:


> _If this SteP study was considered, “structured SMBG” based on an intention to treat basis resulted in a 0.3% reduction in HbA1c which the authors have already recognised as insignificant. Only the subgroup that had strict adherence to study protocol resulted in a 0.5% reduction in HbA1c results.
> 
> To achieve these insignificant reductions required increased clinical visits in the SMBG of almost 3 times the control group._



So you have people of opposing views digging their heels in. And industry sponsored trials seen to generally support whatever it is. Well blow me down. That IS shocking .

What I find interesting though is how relatively meagre those results are compared to years of forum experience (dare we consider that an ‘observational study’?).

0.5% A1c reduction is not to be sniffed at if you are in the 7s-8s, but less impressive if you are starting at 10, of course. In some contexts 0.5% would be seen as clinically significant, but folks on the forum generally see MUCH greater reductions (with no need for increased HCP time/appointments at all). So why is that.

The two most obvious reasons are:

1. It is a different, more self-motivated population, which is being supported to continue sticking at it. (Note results above were half as good again for people that actually stuck to what hey were supposed to be doing).

2. The advice/recommendations on the forum for how to react to the results provide better outcomes than the advice that was being offered (or the way it was offered?) in the study.

SMBG is only information. It doesn’t have any effect in itself. It is what people DO with the information that matters. The *way* they are told to consider changes and also the changes themselves.

It strikes me that many of the negative SMBG studies in the literature date from a time when officially dietary advise was even more focussed on ‘healthy wholegrains and starchy carbs’. When low carb was not even on the radar of the mainstream and was feltmto be deeply suspect. A time at which it was not unusual for newly Dx T2s to significantly *increase* their carbohydrate intake on the advice of their Practice Nurse or whoever.

Some recent SMBG studies for T2 have had to admit (seemingly reluctantly) that there are ‘certain subgroups’ for whom self monitoring on D&E /metformin has significant benefits.

There still seem to be very few robust studies that manage to replicate the amazing results we see on the forum all the time. Which is very odd, as what we do here is so very simple and is advice that’s been freely available for over a decade.

So perhaps it is true that some T2s really cannot be bothered and would find SMBG burdensome and ineffective - but that cannot be an excuse for denying self monitoring to motivators people who can significantly improve their diabetes management is given access to the information that BG strips provide.


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## Eddy Edson (Aug 2, 2018)

everydayupsanddowns said:


> There still seem to be very few robust studies that manage to replicate the amazing results we see on the forum all the time. Which is very odd, as what we do here is so very simple and is advice that’s been freely available for over a decade.



That's the rub, for getting thru the evidence barriers.  

A comprehensive-seeming review from 2016:

http://www.unisa.edu.au/PageFiles/13515/In Development/9. ADEA SMBG .pdf

One recommendation:

_Further research is required into the specific role of SMBG use within a DSME program. Further research evidence is also required to understand what sections of the T2DM patient community get stronger clinical effects from SMBG than others to allow targeted SMBG interventions._

So that defines a goal: Get evidence for the effectiveness of SMBG in a structured setting amongst clearly characterised T2D segments. (And methods for moving non-responders into these segments.)

I'm just a newbie, but I also find it odd that nobody seems to have done good trials along these lines.

Anyway, thanks for the interesting discussion!


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## travellor (Aug 2, 2018)

Testing will always be a debatable topic.
I was prescribed strips, I rarely did a fasting test.
I did a lot of structured testing, so see how I reacted to foods, to exercise, to heat, to cold, in some days I could use near enough a pot in a day.
However, I didn't worry about highs, it wasn't to try to drive into the lows.
I tested in the majority when I knew it would be the worst case scenario to be honest.

So, I know how my body reacts.

But, I wouldn't recommend others deliberately try to catch every spike they can on their meter, unless they are happy with what is pretty depressing reading.
It worked for me, as it was a purely scientific, data gathering exercise.

(It also required to ignore every diet out there, as I was purely using feedback from my own body, so I could develop my own particular route to reversing it.
I also have to say, the eatwell plate was a lot better than my pre diagnosis diet, my diet now is better than that)

Maybe what we should be as a group, is to start to put together how we used the benefits of knowing our BG to implement changes, and how that has benefited us?
(Not what changes we made, and how our measured BG came down as a result, as that is where the NHS is at, just without the actual day to day measurement)

Then if there is a common factor, that's what we need to be promoting.


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## everydayupsanddowns (Aug 2, 2018)

travellor said:


> Maybe what we should be as a group, is to start to put together how we used the benefits of knowing our BG to implement changes, and how that has benefited us?
> (Not what changes we made, and how our measured BG came down as a result, as that is where the NHS is at, just without the actual day to day measurement)
> 
> Then if there is a common factor, that's what we need to be promoting.



We often suggest this page on the forum to newly diagnosed folks who are interested in using SMBG to improve their own personal diet: http://loraldiabetes.blogspot.com/2006/10/test-review-adjust.html

It's more than 10 years old, and links to the famous 'Jennifer's Advice' which is another very helpful structured approach.

Both stress the importance of being systematic, methodical and finding your own way through the maze of possibilities.

To my mind there's no value in stating 'people with diabetes can't eat x' or 'people with diabetes must only eat x' when different foods (even different types of specific carbs) affect different people so differently, or the same people differently at different times of the day.

Perhaps that's why per-protocol research studies struggle so much. I'm not sure how you contruct a trial where the ultimate diet / system / monitoring frequency etc is as varied and unique as the cohort you recruit!


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## travellor (Aug 2, 2018)

That seems an excellent methodology.
I do think the issue with testing can be the  way it is used.
To me, it wasn't a way  to prove my diet was correct. Or to beat myself up if I "spiked" by over 2, or saw the more than 7.8. 
Any "diet" would  have been correct, and lowered  my BG compared to my previous life to be honest.

What I needed was a diet that was the best it could  be, but fitted my lifestyle, not one that I had to make my lifestyle fit.
How do I prove that's  what strips should be prescribed for?


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