6 Lifestyle management/non-pharmacological management
6.1 Dietary advice
6.1.1 Clinical introduction
All people with Type 2 diabetes should be supported to:
_ try to achieve and maintain blood glucose levels and blood pressure in the normal range
or as close to normal as is safely possible
_ maintain a lipid and lipoprotein profile that reduces the risk of vascular disease.
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it can be argued that limited credence can be given to observational study associations between blood glucose control and self-monitoring as those patients and healthcare professionals who
advocate self-monitoring may be the same people who are motivated to achieve better control.
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8.1.3 Health economic methodological introduction
A cost analysis of implementing intensive control of blood glucose concentration in England
identified increased frequency of home glucose tests as a main contributor to the total costs of
intensive control.(52) It was estimated that the additional management costs of implementing
intensive control policies would be £132 million per year, of which £42.2 million would be on
home glucose tests. The sensitivity analysis results found that changes in the unit cost of home
blood glucose strips (baseline cost £0.27, range tested £0.16–£0.40) in the proportion of
patients already being managed intensively, and the costs of intensifying management, had the
largest impact on the cost of implementation.
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The study by Jansen also reported that interventions with SMBG were found to be more
effective in reducing HbA1c than interventions without self-monitoring. The reduction in
HbA1c was statistically significant and it was estimated to be around 0.4%. This effect was
increased when regular feedback was added to the SMBG and was shown in both an insulin treated Type 2 diabetes group, and in a group of Type 2 diabetes patients that included those
being treated with oral agents.
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Pros of self-monitoring:
_ provides a heightened awareness of, and evidence of, the condition
_ when readings are within advised guidelines and fluctuations are easily interpretable,
patients emphasise the positive role that monitoring has in their diabetes management. Low
readings are a high point giving personal gratification
_ cultivates independence from health services and enhances self-regulation.
Cons of self-monitoring:
_ potentially, self-monitoring can raise anxiety about readings
_ blood glucose parameters were found to be problematic by patients when they felt they
were receiving contradictory information about upper thresholds or no guidance about
ideal parameters
_ lack of awareness as to how to manage hyperglycaemia
_ increased self-responsibility accompanied by increased self-blame and negative emotional
reactions to high glucose readings
_ counter-intuitive readings could be sources of distress and anxiety, in some cases
adversely effecting adherence to diabetic regimens by promoting nihilistic attitudes
_ healthcare professionals were not interested in readings.(50)
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RECOMMENDATIONS
R22 Offer self-monitoring of plasma glucose to a person newly diagnosed with Type 2 diabetes only as an integral part of his or her self-management education. Discuss its purpose and agree how it should be interpreted and acted upon.
R23 Self-monitoring of plasma glucose should be available:
_ to those on insulin treatment
_ to those on oral glucose lowering medications to provide information on hypoglycaemia
_ to assess changes in glucose control resulting from medications and lifestyle changes
_ to monitor changes during intercurrent illness
_ to ensure safety during activities, including driving.
R24 Assess at least annually and in a structured way:
_ self-monitoring skills
_ the quality and appropriate frequency of testing
_ the use made of the results obtained
_ the impact on quality of life
_ the continued benefit
_ the equipment used.
R25 If self-monitoring is appropriate but blood glucose monitoring is unacceptable to the
individual, discuss the use of urine glucose monitoring.
The situation regarding blood glucose testing strips has arisen following the issue of guidelines from the National Institute for Health and Clinical Excellence (NICE) on the management of blood glucose in Type 2 diabetes. NICE advised that in Type 2 diabetes, self-monitoring of blood glucose has not been shown to have a significant impact on long term blood glucose control (HbA1c levels), decreased body weight, reduced incidence of hypoglycaemia or improved health-related quality of life. Some PCTs have taken this to mean that home blood glucose monitoring is not indicated, and have discouraged the prescription of the blood testing strips used in monitors.
However, the NICE guidelines go on to stress that there are benefits from self-monitoring programmes, particularly as part of an integrated self-help package and this is central to the National Service Framework for Diabetes. The ideal, exemplified in the Framework, is that people with diabetes have sufficient knowledge to take decisions in partnership with their healthcare professional about the best regime to manage their condition, including the benefits of home blood glucose monitoring. On the basis of this, Sue Roberts, the National Clinical Director for Diabetes, produced a factsheet for Strategic Health Authorities on home blood glucose monitoring. The factsheet reiterates the NICE advice, and suggests that PCTs may wish to link their strategy on self-monitoring to that on patient education.
Any PCT which is automatically discouraging the prescription of blood glucose testing strips is not acting in accordance with NICE’s advice that self-monitoring may prove useful to people in their overall approach to self-care.
If you have concerns about your own treatment, you should speak to your GP. You can also contact the Patient Advice and Liaison Service (PALS) at your local PCT. This can provide information and advice about NHS services, including information on how to make a complaint.
This seems to be at odds with the 3 or 6 months tests if we don't have strips."Information for Patients
Patients should be informed of the potential risks and benefits of Metformin hydrochloride tablets and of alternative modes of therapy. They should also be informed about the importance of adherence to dietary instructions, of a regular exercise program, and of regular testing of blood glucose, glycosylated hemoglobin, renal function, and hematologic parameters."
spitfire said:Thank you all very much for your informative replies they are very helpful im off back to the docs now to argue a few little points will let you know how it goes thank you all once again.
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