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A call for standardized self-monitoring blood glucose education
Standardization would build awareness that the patient goal for SMBG is to use the blood glucose results to improve patient health care.
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People with diabetes receive numerous recommendations for diabetes management, whether it’s what to eat, what medications to take, to be active, and/or, to check your blood glucose. All of these recommendations require that the individual adopt, adapt and adhere to a new lifestyle behavior. All of these recommendations also present choices; the patient can either follow or ignore some or all of them.
Adults tend to have a problem-centered orientation to learning. For the adult learner, there is a greater tendency to ignore recommendations that do not immediately apply to their current problems or situations.
There seems to be no appreciable difference in the recommendations to eat healthy, take medications as directed and to be physically active for people with type 1 or type 2 diabetes. When it comes to self-monitoring of blood glucose (SMBG) the difference is significant. Diabetes-related organizations such as the American Diabetes Association, the American Association of Clinical Endocrinologists, and the International Diabetes Federation all agree that people who are on multiple-daily insulin injections or insulin pumps should test their blood glucose three or more times per day. These individuals are taught what action needs to be taken based on their blood glucose results. They are applying the skill (when and how to properly test) and information (the blood glucose result) to solve a problem.
SMBG varies
What is significant in type 1 diabetes is that SMBG is used as a tool to provide answers to situation or “problem” (ie, hypoglycemia, hyperglycemia, correct amount of insulin to administer). From an adult learning perspective, performing SMBG has value and is useful for someone on insulin therapy.
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This relationship has not been as clear for people with type 2 diabetes, especially if they are not on insulin therapy. For the person with type 2 diabetes, SMBG recommendations vary from “at least once per day” (if not on insulin therapy), “may be useful as a guide to the success of therapy” to “postprandial SMBG may be appropriate to achieve postprandial glucose targets.”
From my clinical experience with type 2 patients, whether they are on insulin therapy or not, the majority of those who perform SMBG do so because they are asked to do so. They do not use the information to provide answers to situations or “problems.” It is not uncommon for many type 2 patients to stop blood glucose monitoring. Granted, there are many hypotheses for why people stop monitoring. But, from an adult-learning perspective, it is not surprising that if an individual does not see the value or usefulness of an activity, he/she stops the activity. More than a few type 2 patients, who tested once per day when fasting, have told me they stop monitoring because “the numbers are always the same.” Interestingly these are also the same patients whose HbA1c levels are rising.
Consistency is necessary
My observation has been that there is no consistency in how SMBG education, if at all, takes place. Individuals can obtain a blood glucose meter in a number of ways. For example, an individual can obtain a meter at the doctor’s office, in a pharmacy, at a durable medical goods storefront, shipped from a medical supply business, obtained free at a health fair, supplied by a diabetes educator, borrowed from a relative, purchased on the internet or even at garage sales.
At best, when SMBG education does occur, the “mechanics” of operating the meter, how often to test, and properly recording the results are emphasized. What to do with the blood glucose results, target blood glucose goals, and when to test to obtain the most useful information are not addressed. In this scenario, the adult learner is not given a reason to continue the SMBG behavior.
The American Association of Diabetes Educators’ position statement, Self-monitoring of Blood Glucose: Benefits and Utilization, states that, “Healthcare professionals providing diabetes care and education should encourage and support the use of SMBG in all individuals with diabetes. Safe and appropriate blood glucose monitoring methods need to be taught including self-management skills that incorporate and utilize the data obtained from blood glucose monitoring for an individualized program of self care.” The position statement also outlines the educational components of SMBG (see table 1). For the adult learner, especially type 2 patients, the most critical component is ensuring that the patient is able to apply the SMBG data to their own diabetes treatment regimen.
Table 1: Educational Components of SMBG |
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Perhaps it is time for the diabetes community to promote and adopt standardized SMBG education (see table 2). There are roles and responsibilities of the health care provider when teaching SMBG regardless of how and where a patient obtains their meter. This list could become the basis of standardized SMBG education. Standardization would build awareness that the patient goal for SMBG is to use the blood glucose results, not simply test “X” times per day. After all, SMBG is a diabetes self-management activity.
Table 2: Roles and Responsibilities of the Health Care Provider in Teaching SMBG |
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Mary M. Austin, MA, RD, CDE, is Owner and President of The Austin Group, LLC in Shelby Township, Mich., and is an Endocrine Today Editorial Board member.
For more information:
- ADA. Diabetes Care. 2009;1:s17-19.
- Austin MM. Diabetes Educator. 2006;32:835-847.