I had this “convergence” moment tonight.

Here I am at the teen boys campout. A light, cool summer breeze blows across my face as I overlook a truly beautiful view of the sparkling lights of Texas hill country spanning over 25 miles. I’m micro-blogging about the campfire talk via my cell phone while actively engaged in discussion with 25 teen boys with diabetes, plus my 3 outstanding facilitators. The discussion ranges from every conceivable medical issue about diabetes in kids that you might imagine, to driving and diabetes, to girls, and everything else in-between.

I suddenly get an e-mail request from a mom in west Texas who’s family is part of my Diabetes HouseCall practice. In two minutes I’m able to review her son’s blood sugar trends via the GlucoDYNAMIX day over day plot collected by her son’s GlucoMON device, plus her son’s insulin pump settings, and reply via my phone with suggested changes to his management. I don’t miss a beat.

It then hits me: it doesn’t get any better than this!

Beyond the headlines:

- when walking alone
- at night
- in a dangerous neighborhood

A few weeks ago, headlines in the British newspaper The Daily Telegraph blared out that at home self testing of blood sugar levels could be detrimental to diabetics. The story went on to say that thousands of diabetics could be doing themselves more harm than good by testing their own blood sugar levels. The story was based on a 2008 study reported in the British Medical Journal which discovered a 6% higher score on self-reported measures of depression in adults with newly discovered type 2 diabetes (Additional details from a review by the National Health Service here).

 The purpose of this research was to investigate connections between self-monitoring of blood sugar, overall diabetes control, and a patient’s mental health. The researchers concluded that overall diabetes control over the one year after diagnosis of type 2 diabetes was not different between groups who checked their blood sugars and those who did not. Even though diabetics who checked blood sugar reported slightly higher feelings of depression, this was not associated with any higher levels of anxiety, lower energy levels, or reduced levels of well-being.

Another report released at the same time reported what many would consider a pretty obvious conclusion: that the costs of diabetes care are almost twice as high for diabetics who monitor their blood sugars frequently compared to those who don’t.

So what does this all mean and how should we react?

First, don’t go toss your lancet and meter device in the trash just yet. This study looked at a very narrow group of all patients with diabetes and the results shouldn’t be generalized to everyone.

Home Glucose Monitoring Is Only A Tool

And a fantastic tool at that. But like any tool, it is no better than the person who wields it. Self glucose monitoring is invaluable to type 1 diabetics who take insulin and are striving for the best possible diabetes control. Frankly, anyone who is on insulin therapy for any reason should be checking their blood sugar regularly. This study only targeted a specific group of patients: the newly diagnosed type 2 diabetic. There are some characteristics that you should understand about these individuals to better understand why they came to the conclusions they did.

At the time they’re diagnosed, most people with type 2 diabetes have permanently lost about half of their pancreas’ ability to make and release insulin (the hormone that controls blood sugar levels). That ability is never recovered. Losing the rest of that ability is what slowly happens over the rest of the life of the person with type 2 diabetes. Good control of the diabetes may slow down how fast the remaining 50% goes away.

After this story went out, it sent a mini shock wave through the diabetes world. Calls started coming in to doctor’s offices as to whether they should pitch their glucose meters or if checking blood sugar was now somehow hurtful. But like many headlines, they’re written to primarily grab attention more than to really inform the public.

Self monitoring of blood glucose (SMBG) was first made available in the 1970’s. Until then, diabetics could only indirectly check their sugar levels by measuring the amount that spilled over into the urine over time. While it’s helpful, this was a crude method to measure diabetes control. But ever since it was created in the early 1930’s urine testing was the best method we had. Urine sugar results were expressed as percents or colors on a chart. The goal was to allow the least amount of sugar to spill into the urine, preferably none. But blood sugar levels could be almost twice normal before any sugar showed up in a urine sample; this is hardly a way to keep someone in the best possible control of their blood sugar levels based on what we know today.

Early blood sugar meters required large amounts of blood compared to today’s devices. The measurement could take up to several minutes to perform, compared to the few seconds that today’s meters need. Meters lacked memory chips and required the user to write everything down, or the information would be lost forever. Because of the need for sugar levels to make smart insulin adjustments, the most enthusiastic adopters of glucose monitoring were those with type 1 diabetes.

Today’s glucose meters take extremely small amounts of blood (a fraction of a drop) and the samples can be collected from areas of the body other than the fingertips. Readings are available within 5 seconds and the results are stored in a memory chip to be downloaded later at the user’s convenience. Without a doubt, checking blood sugar levels at home has never been easier.

But measuring blood sugar readings is only half the job. For that information to be helpful to your control, it needs to be used to make better decisions about diabetes self care. The reason why so many studies have failed to show a direct benefit from blood sugar monitoring is that the information that is gathered by this process must be used in some constructive way if there is any expectation of these data helping better control the person who gathers them. If you are not the one who is responsible for this, then your doctor or diabetes team should be.

These days, many doctors may direct the patient to check their blood sugar several times a day; usually before meals and at bedtime. While most patients will do this for a while, others may struggle with this since they feel the act of blood sugar monitoring is uncomfortable, doesn’t seem to make any difference at all, or is even pointless.

Study Conclusions Were Wrong

Or, the real findings took a back seat to someone’s desire to grab headlines? Here is the reality check raised by that British study. It only focused on blood sugar checking in one group of people with diabetes, namely the newly diagnosed adult with type 2 diabetes. Persons with type 1 diabetes (where insulin is needed to survive) or persons with long standing type 2 diabetes requiring insulin treatment were excluded from this study. So, it’s wrong to apply these conclusions to all diabetics.

In all my years as a diabetes doctor and diabetes educator, I’ve found that when patients have a clear understanding of why I ask them to perform a self care behavior, they are far more likely to keep doing it. I also make a point to explain to my patients that I don’t take care of anyone’s diabetes (except my own, of course). Ultimately, it’s the person with diabetes who makes all the numerous choices and decisions every day that make up their overall diabetes control. I go on to explain that the doctor and diabetes team’s role is to educate and motivate patients to understand how to best take care of themselves. It truly is the sum of their choices each day that determines the overall quality of a person’s diabetes control.

The act of collecting a blood sugar reading will only help if someone (hopefully the patient) can use that information to make better self care choices. But choices based on training and diabetes education are far superior to choices based on ignorance or random guesses. Sadly, today many diabetic patients never get the necessary education and training to fully benefit from self blood sugar monitoring. And even when some do get that basic training, many choose not to apply it in their daily lives with diabetes.

If that extra work to check blood sugar doesn’t feed back to the patient in a positive way, then it is reasonable to question why it should be done.

Many diabetics have the wrong attitude about their blood sugar results. Many may tend to think of the readings as “good” or “bad”. Unfortunately, health care providers can fall into the same trap. A blood sugar result is simply a number; nothing more, nothing less. There really should be no place for value judgments. You can’t “study” for a blood test and you can’t “will” your blood sugar into submission.

Control of diabetes is more a pattern of behavior than what kind of equipment or medicines you use.

If patients are unable or unwilling to track their own readings and learn to analyze them, then glucose monitoring will not be very helpful to the patient. When the patient sees the doctor, only then might a change in management be made based on the doctor’s quick analysis of the results. If the doctor doesn’t encourage home sugar checking (and some do), then it’s not surprising that overall control is unlikely to improve or reach a mediocre level at best.

Managing your diabetes takes a lot of work. It can take less work however depending on which tools you use and how often you use them.

“Should I do shots or a pump?” Doesn’t matter if you are looking for ‘easier’. They both require a commitment although the tasks are different. Also, the typical person with diabetes doesn’t exist. Everyone is unique and therefore it requires the individual or at least someone with intimate 24×7 knowledge of the person with diabetes to have insight into care, actions, analysis of cause and effect, etc… No easy task even for the biggest egghead on the block. Unfortunately, there is no secret formula for one-size-fits-all blood sugar control either.

And don’t confuse collecting data with the act of analysis to understand and finally taking action followed up by further analysis to understand and take action in a never-ending cycle. This is called pattern management in the world of diabetes self-care.

So when it comes to looking at recent blood sugar numbers and potentially reams of other data like carbs, insulin and exercise to name a few, for patterns, very few people do it at all and even fewer do it right. There is more than one way to perform pattern management. And like everything else in life, you have hard ways and easier ways. If we look at the state of diabetes in this country alone, we quickly understand that nobody has solved the problem.
The average person using manual logbooks and PC-based or web upload software must spend 30 - 45 minutes given the complexity of these ‘free’ tools. So is it any wonder there is still a huge opportunity to improve on self-care? One way is to get more people to practice pattern management - on a frequent basis but how if it takes so much time and effort?

In a recent survey of both people with type 1 and type 2 diabetes, less than 10% of the respondents indicated that they performed review of blood sugars on their own. Most people will only review blood sugars during the office visit with their provider if they are lucky enough to even have a provider who practices pattern management.

In contrast, participants in Diabetech trials incorporating our ADMS (automated diabetes management system), over 90% of participants are able and willing to practice self-review of blood glucose patterns weekly or more often week in - week out. What’s the difference?

Simplicity. It’s no extra work via ADMS so why wouldn’t you sneak a peak at your trends and consider where you’ve been, where you’re going and how you might take a different tack to affect a more desirable blood sugar? The other key we’ve found out is that by doing this frequently, like every few days, most of the ‘other data’ behind the blood sugars is still in your mind. If you only look at patterns infrequently of course you would have to use a notebook with lots of other background data. Did I mention yet that nobody likes to keep a notebook?

Tracking insulin and carb data: why? Again, by performing frequent blood sugar reviews for trends, most of the background behind insulin, carb/fat, activity is top of mind. Ultimately, the patient is only going to address a trend at one time of day. Not all of the problems at the same time. As a real world example, one might spot a trend for high blood glucose at 10am and understand that this is cause to perform a 10% tightening of the insulin to carb ratio that got them to that 10am blood sugar trend. For example, that might mean adjusting the breakfast ratio. This scenario is made quick and painless for a person using our ADMS.

Frequent pattern management is key as it makes a simple version of the exercise possible by looking at only the system collected and formatted blood glucose data!

When I talk to patients through our work at clinics or while fielding calls with people in our trials and commercial programs, the most common concern I hear from people who aren’t already using a GlucoMON is that they know they should be reviewing their logbook(s) for patterns more frequently. Lots of guilt in the diabetes patient community. When we talk about how they might increase their practice of pattern management, they are often stuck in the mindset of brute force… “I’m just going to have to force myself to do it more often”, they say.

Another section of that road I was talking about just got paved.

Sadly, we all know too well that virtually nobody is going to brute force their way through this tedious task of assembling blood sugar data and markers to shed light on control. But what if patterns were an automated thing that just showed up in front of your eyes in a visually impactful way? Would that feel like cheating?

The point of this entry is to get more people to commit to regular and frequent pattern management. If you are performing weekly pattern management, is your current level of effort sustainable over the months, years and decades to come? If it’s too hard then consider that maybe you aren’t using the right tools for the job because others are doing it regularly and with success.