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Empower patients to use SMBG results to move HbA1c to target
Good pharmacotherapy and lifestyle decisions and utilizing SMBG benefits patients and practitioners.
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Achieving an HbA1c that is as near normal as possible, whether it is less than 7%, 6.5% or under 6%, is the accepted target for glycemic control for people with diabetes. The utilization of self-monitoring of blood glucose as a tool to help achieve this goal, or to at least improve HbA1c, has recently been the center of debate, especially for people with type 2 diabetes who are not using insulin.
A very disturbing clinical scenario that I have been witnessing lately is that patients are being told by their primary health care provider that it is not necessary for them to perform SMBG, because a quarterly HbA1c is sufficient enough to use in modifying glycemic therapy and track glycemic control. I would hate to think that this is so, but I have no reason to doubt my patients’ stories.
Variations in knowledge
Prior to the development of the HbA1c test, home blood glucose monitoring was the cutting-edge technology that provided “real-time” blood glucose values. People with diabetes could use the “real-time” blood glucose value to make decisions about how to respond to a documented hypoglycemic or hyperglycemic event. But, here is where the confusion began. Teaching someone how to properly operate a blood glucose monitor and when to test became the focus, but what to do with the blood glucose values (unless there was marked hypoglycemia), was not so clear for the patient or the health care provider.
 Mary M. Austin |
Early in my career in diabetes education, I worked for a regional endocrinology center. Many patients would come once a year and drive hours to see “the specialist” and also meet with the rest of the diabetes care team. A man that I will never forget brought completed blood glucose log books for an entire year. He faithfully tested four times per day — never missing a day (judging from the blood-splattered books, I am confident that the numbers entered represented actual tests). Unfortunately, every single blood glucose number was over 200! Trying not to appear too alarmed, I applauded him for his consistency in performing SMBG and asked him why he thought his blood glucose numbers were always over 200. His response was unforgettable, “Yeah, I don’t get it either, I was told by my doctor that if I tested my blood four times per day, my blood sugar would improve. It sure doesn’t look to me that checking my blood for sugar is making much of a difference.”
Unfortunately, I see versions of this scenario today as well. For example, what is the goal of telling patients to check their fasting blood sugar every morning (some have been doing this for years) when their fasting blood sugars do not vary more than 50 points, their HbA1c is over 8%, and pharmacotherapy is never advanced? Is testing their blood sugars going to improve their HbA1c? Not likely.
For the most part, adults start and continue a behavior if there is a benefit in doing the behavior. Improving HbA1c levels, by utilizing SMBG information, increases when patients and practitioners utilize the results of SMBG to make pharmacotherapy changes and lifestyle decisions. Once the patient is competent in operating a blood glucose meter, one of the goals of SMBG is to use the data to improve HbA1c levels. The following checklist might be helpful:
- Has the rationale for performing SMBG been explained to the patient?
- How does the practitioner plan on using the SMBG results?
- How does the patient use the SMBG results on a daily basis?
- Have target blood glucose goals and desired HbA1c level been established and discussed with the patient? This includes fasting, pre and post meal (specify if post is a one hour or two hour postmeal check) and bedtime blood glucose values.
- Are the target blood glucose goals and the HbA1c goal consistent? For example, “keep blood glucose levels under 200” and a target HbA1c under 6.5% are not consistent.
- Address pattern management: Does the patient know what to do when blood glucose values are not in target range?
- Have the factors that might cause hypoglycemia and hyperglycemia been discussed with the patient?
- Does the patient know what actions need to be taken when hypo- and/or hyperglycemia occur?
SMBG is a cornerstone of self-management for the person with diabetes, regardless of whether they have type 1, type 2 or gestational diabetes. Health care providers need to support the SMBG efforts of their patients if SMBG is to be utilized to improve glycemic control. Currently there is no standard for SMBG education. Patients receive their meters in a variety of ways with varying degrees of education in the meter’s operation and data utilization. Maybe the time has come to standardize SMBG education.
Mary M. Austin, MA, RD, CDE, is Past President of the American Association of Diabetes Educators, Owner, President of the Austin Group, LLC, and is a member of the Endocrine Today Editorial Board.