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doi: 10.1111/1753-0407.12307

Journal of Diabetes 7 (2015) 593–594

EDITORIAL

Self-monitoring of blood glucose for type 2 diabetes In the management of diabetes, clinicians and, even more, individuals with diabetes themselves need feedback to adjust a variety of treatment approaches, not least of which is lifestyle intervention itself. The commonly used measure of glycemia, HbA1c, has several drawbacks. It does not reflect variations in glycemia at different times of the day, or in response to different environmental stimuli. Furthermore, there is appreciable interindividual heterogeneity in the degree of hemoglobin glycation in both type 11,2 and type 2 diabetes (T2D),3 although, for a given person, the relationship between mean glycemia and HbA1c appears much tighter4 so that the concept that we can precisely assess average glucose from HbA1c is likely incorrect.5 Hemoglobin glycation decreases during pregnancy,6 increases with age, and shows substantial racial and ethnic differences for a given level of glycemia.7,8 Therefore, the use of self-monitoring of blood glucose (SMBG) becomes an important additional approach to achieving good glycemic control, especially for patients treated with antidiabetic medication. Although the benefits of SMBG are obvious, many factors influence adherence to the use of SMBG: for example, an individual’s socioeconomic status, age, gender, HbA1c level, education background, and diabetes duration.9 A recent multicenter survey in China on 5953 patients with T2D showed an increase in SMBG use to 65% of the group (from 35% reported 10 years previously) and that SMBG adherence was associated with better glycemic control.10 However, only 19% of patients met the Chinese Diabetic Society’s recommended treatment goals, showing the considerable gap between the ideal and reality.11 Similar results were observed in another Chinese survey in female patients with T2D.12 A striking study, which certainly needs replication, analyzed mortality and nonfatal endpoints, finding that these endpoints were less likely to occur among T2D people using versus not using SMBG,13 offering evidence of the benefit of such an approach. However, some investigators have expressed reservation as to whether SMBG is useful in the management of T2D. It is not surprising that a study that explicitly “used an identical treatment algorithm for dietary and pharmacological management of glycaemia for both groups based on HbA1c targets” would fail to show difference in glycemic outcome between T2D using and not using SMBG,14 particularly when these investigators failed to make use of meter downloads, given the important evidence that handwritten glucose logs tend to show

relatively low reliability.15,16 Certainly studies that fail to show a benefit of SMBG and fail to show a benefit of hbA1c monitoring should be questioned.17 We need to improve diabetic self-care education and health care support, as well as technological innovations to facilitate self-care, all of which could improve the usefulness of SMBG. Self-monitoring of blood glucose needs to be incorporated in a program of diabetes selfcare that offers a structure by which patients with T2D can understand how to use the information gained.18 This could simply be weekly telephone discussions of SMBG results, which would allow patients initiating insulin to more confidently increase insulin doses and achieve control of glycemia.19 Text messaging has been used in this setting, with evidence of greater improvement in HbA1c while reducing the likelihood of major and nocturnal hypoglycemia,20 so the development of hypoglycemia, particularly among patients treated with sulfonylureas, appears to be a specific indication for SMBG.21 Graphic display of SMBG results with color coding to help patients more easily identify trends and areas where intervention is needed has similarly been shown to improve HbA1c levels.22 Such approaches to SMBG are not only useful in insulin-treated T2D patients, but have also been shown to result in improved glycemic control in individuals with milder disease,23 and may, by improving motivation, lead to lifestyle improvement and weight loss.24 Similar improvement was shown in well-controlled patients who initiated post- rather than preprandial glucose-testing,25 presumably by allowing greater understanding of the effects of food choices. Not all patients with T2D need to perform SMBG, and it is reasonable to consider that its use may not be required with good control while endeavoring to identify those patients who will benefit from SMBG to improve motivation.26 We think that the use of mobile phone “apps” offers further potential to help patients use this approach and look forward to coming developments in the field. References 1. Rohlfing CL, Wiedmeyer HM, Little RR, England JD, Tennill A, Goldstein DE. Defining the relationship between plasma glucose and HbA(1c): Analysis of glucose profiles and HbA(1c) in the Diabetes Control and Complications Trial. Diabetes Care. 2002; 25: 275–8. 2. Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group. Hemoglobin A1c and

© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd

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mean glucose in patients with type 1 diabetes: Analysis of data from the Juvenile Diabetes Research Foundation continuous glucose monitoring randomized trial. Diabetes Care. 2011; 34: 540–4. Shrom D, Sarwat S, Ilag L, Bloomgarden ZT. Does A1c consistently reflect mean plasma glucose? J Diabetes. 2010; 2: 92–6. Hempe JM, Gomez R, McCarter RJ Jr, Chalew SA. High and low hemoglobin glycation phenotypes in type 1 diabetes: A challenge for interpretation of glycemic control. J Diabetes Complications. 2002; 16: 313–20. Bloomgarden ZT, Inzucchi SE, Karnieli E, Le Roith D. The proposed terminology “A(1c)-derived average glucose” is inherently imprecise and should not be adopted. Diabetologia. 2008; 51: 1111–14. Herranz L, Saez-de-Ibarra L, Grande C, Pallardo LF. Non-glycemic-dependent reduction of late pregnancy A1C levels in women with type 1 diabetes. Diabetes Care. 2007; 30: 1579–80. Selvin E, Zhu H, Brancati FL. Elevated A1C in adults without a history of diabetes in the US. Diabetes Care. 2009; 32: 828–33. Herman WH, Ma Y, Uwaifo G et al. Differences in A1C by race and ethnicity among patients with impaired glucose tolerance in the Diabetes Prevention Program. Diabetes Care. 2007; 30: 2453–7. Yuan L, Guo X, Xiong Z et al. Self-monitoring of blood glucose in type 2 diabetic patients in China: Current status and influential factors. Chin Med J (Engl). 2014; 127: 201–7. Franciosi M, Pellegrini F, De Berardis G et al. The impact of blood glucose self-monitoring on metabolic control and quality of life in type 2 diabetic patients: An urgent need for better educational strategies. Diabetes Care. 2001; 24: 1870–7. Pan L, Centers for Disease Control and Prevention (CDC). Self-monitoring of blood glucose among adults with diabetes: United States, 1997–2006. MMWR Morb Mortal Wkly Rep. 2007; 56: 1133–7. Lu J, Weng J, Gu W et al. Non-pharmaceutical factors for poor glycemic control in 13,970 Chinese women with drug-treated type 2 diabetes: A cross-sectional survey in 77 tertiary hospitals in four Chinese cities. Patient Prefer Adherence. 2014; 8: 1161–7. Martin S, Schneider B, Heinemann L et al. Selfmonitoring of blood glucose in type 2 diabetes and longterm outcome: An epidemiological cohort study. Diabetologia. 2006; 49: 271–8. O’Kane MJ, Bunting B, Copeland M, Coates VE, ESMON Study Group. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): Randomised controlled trial. BMJ. 2008; 336: 1174–7. Given JE, O’Kane MJ, Coates VE, Moore A, Bunting BP. Comparing patient generated blood glucose diary records with meter memory in type 2 diabetes. Diabetes Res Clin Pract. 2014; 104: 358–62. Mazze RS, Shamoon H, Pasmantier R et al. Reliability of blood glucose monitoring by patients with diabetes mellitus. Am J Med. 1984; 77: 211–17.

17. Nauck MA, Haastert B, Trautner C et al. A randomised, controlled trial of self-monitoring of blood glucose in patients with type 2 diabetes receiving conventional insulin treatment. Diabetologia. 2014; 57: 868–77. 18. Polonsky WH, Fisher L, Schikman CH et al. Structured self-monitoring of blood glucose significantly reduces A1C levels in poorly controlled, noninsulin-treated type 2 diabetes: Results from the Structured Testing Program study. Diabetes Care. 2011; 34: 262–7. 19. Chen HS, Wu TE, Jap TS, Lin SH, Hsiao LC, Lin HD. Improvement of glycaemia control in subjects with type 2 diabetes by self-monitoring of blood glucose: Comparison of two management programs adjusting bedtime insulin dosage. Diabetes Obes Metab. 2008; 10: 34–40. 20. Lim S, Kang SM, Shin H et al. Improved glycemic control without hypoglycemia in elderly diabetic patients using the ubiquitous healthcare service, a new medical information system. Diabetes Care. 2011; 34: 308–13. 21. Barnett AH, Krentz AJ, Strojek K et al. The efficacy of self-monitoring of blood glucose in the management of patients with type 2 diabetes treated with a gliclazide modified release-based regimen. A multicentre, randomized, parallel-group, 6-month evaluation (DINAMIC 1 study). Diabetes Obes Metab. 2008; 10: 1239–47. 22. Bosi E, Scavini M, Ceriello A et al. Intensive structured self-monitoring of blood glucose and glycemic control in noninsulin-treated type 2 diabetes: The PRISMA randomized trial. Diabetes Care. 2013; 36: 2887–94. 23. Durán A, Martín P, Runkle I et al. Benefits of selfmonitoring blood glucose in the management of newonset Type 2 diabetes mellitus: The St Carlos Study, a prospective randomized clinic-based interventional study with parallel groups. J Diabetes. 2010; 2: 203–11. 24. García de la Torre N, Durán A, Del Valle L et al. Early management of type 2 diabetes based on a SMBG strategy: The way to diabetes regression. The St Carlos study: A 3-year, prospective, randomized, clinic-based, interventional study with parallel groups. Acta Diabetol. 2013; 50: 607–14. 25. Zhang DA, Katznelson L, Li M. Postprandial glucose monitoring further improved glycemia, lipids, and weight in persons with type 2 diabetes mellitus who had already reached hemoglobin A1c goal. J Diabetes Sci Technol. 2012; 6: 289–93. 26. Farmer AJ, Wade AN, French DP et al. Blood glucose self-monitoring in type 2 diabetes: A randomised controlled trial. Health Technol Assess. 2009; 13: iii–iv, ix–xi, 1–50.

Zachary Bloomgarden Editor-in-Chief Mount Sinai School of Medicine, New York, New York, USA Email: [email protected] Guang Ning Editor-in-Chief Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China Email: [email protected]

© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd

Self-monitoring of blood glucose for type 2 diabetes 2.

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