The issue of self-monitoring for people with type 2 diabetes is a topic I feel particularly strongly about.
I’ve seen the news reports saying that self-testing for type 2 diabetics is not cost effective and I’ve thought to myself, really?!
Also I’ve watched how many people with type 2 diabetes on the diabetes forum have made a huge amount of progress thanks to a bit of education and intelligent blood testing. So why should the research contradict this?
The DiGEM study
The most authoritative study on the subject of self-testing for people with type 2 diabetes is the DiGEM study.
The report here concludes that:
“This trial does not provide convincing evidence to support the routine use of SMBG for non-insulin-treated patients with reasonably well controlled type 2 diabetes.”
‘Reasonably well controlled’ here refers to the participants whose collective HbA1c numbers averaged 7.5%.
What did the DiGEM study involve?
The study involved three approximately equally-sized groups, of around 150 participants with type 2 diabetes and not using insulin. One group was a control group who were not encouraged to self test. A second performed self-testing with training from a clinician. The third performed self-testing and were given additional training to interpret results, apply changes and to aid motivation.
Over the 12 month period, both the intensively trained self-testers and less intensively trained testers were averaging 5 tests per week.
What were the results of the study?
The results were sadly disappointing. The group with less intensive education scored an average improvement in A1c results of 0.14% and the more intensively trained group achieved an average improvement of 0.17%.
Having read this, I start to question, so what might be causing the improvement in these groups to be small?
Who were excluded from taking part in the study?
The first clue is offered in the exclusion criteria –ie which people were excluded from taking part in the trial:
“Exclusion criteria were: the use of a blood glucose monitor twice a week or more often over the previous 3 months”
So it’s fair to say that the study excluded anyone who was already significantly pro-active in self-testing.
Average participant was aged 66 years old
It’s worth noting that the average participant’s age was 66 years old. Therefore, if I were say a 50 year old type 2 diabetic and I’d had my test strips withdrawn by my GP as a consequence (indirectly or otherwise) of this study, I’d feel disgruntled on this basis as well.
It stands to reason that participants aged 70 plus would be less likely to adapt and cope with a significantly new lifestyle change compared with those who are notably younger.
Was the intensive training any good?
The report of the study provides a wealth of anecdotal evidence about the study itself, featuring a number of interesting comments from the participants.
Based on the anecdotal comments featured in the report, it does seem as though the training received may have been of questionable quality.
As an example, one participant from the intensively trained group noted:
“my readings very, very rarely alter, they’re all between 7 and 10, depending which time of day I take them.”
So clearly this patient’s training failed to educate him that the difference between sugar levels of 10 mmols/l and 7 mmols/l over the long run is actually very significant.
Unwilling to learn
When you look at some of the attitudes of some of the patients, it just goes to show how significant a bearing the exclusion of pro-active testers may have been on the study outcomes:
“… a sort of reminder of the fact that you know that I’ve got something wrong with me…I don’t like to be reminded particularly.”
This response appears to be fairly typical of the attitude of the participants. It seems that for a proportion of these non-pro-active testers, denial is preferred to the truth.
Given that there was a significant amount of disaffection towards self-testing in the participants, it is therefore not so surprising that the improvements in HbA1c were as low as they were.
So what does the study show?
The study indicates that encouraging people with type 2 diabetes to self test as a matter of course may not be viewed as cost effective.
And what does the study not show?
The study excluded any testers who had recently shown a concerted commitment to self test. Therefore, the study cannot draw any conclusions about people with type 2 who are actively keen to self-test their blood sugar levels.