Self-management of type 2 diabetes: A good idea—or not?
The evidence supports the use of some measures but is questionable on others, including routine self-monitoring of blood glucose.
For patients using less-frequent insulin injections, non-insulin therapies, or medical nutrition therapy alone, the ADA suggests that SMBG may be useful as a guide to management. Continuous glucose monitoring for patients with type 2 diabetes might improve glycemic control, but the evidence for this is inconsistent.17
Why wouldn’t you want to recommend self-monitoring? Despite the fact that the benefits of SMBG are unclear in patients with type 2 diabetes not treated with insulin, it’s hard to imagine why this practice could be harmful to patients. After all, it’s natural to assume that more knowledge must be a good thing. Unfortunately, it is not that simple. Even in newly diagnosed patients with type 2 diabetes not taking insulin, self-monitoring does not improve glycemic control and may increase depression.16
It is also important to remember that self-monitoring comes at considerable cost, monetarily for the health care system and in impaired quality of life for patients.18 While there is scant evidence in the empiric literature about patient attitudes toward self-monitoring, the available evidence suggests that patients are ambivalent about it. One qualitative study concluded that patients tended not to act on the results of self-monitoring, in part because of a lack of education about the appropriate response to readings.19 With better knowledge, it is possible that patients might find more value in SMBG.
Self-management programs: Not all are created equal
The driving principle in patient-centered care is engaging patients to be active participants in the management of their chronic conditions. At face value, this would seem to be a good thing. But although individual trials of self-management are promising, the balance of evidence for self-management is limited and inconclusive. In a systematic review of 72 randomized trials of DSME in patients ≥18 years with type 2 diabetes, short-term improvements in diabetes knowledge, frequency and accuracy of glucose self-monitoring, self-reported dietary habits, and better glycemic control were possible, but long-term clinical effectiveness was not shown. In this analysis, there was no significant effect on cardiovascular events or mortality.20 In another systematic review and critique of the literature on self-management, investigators again found small to moderate effects, but with significant evidence of publication bias in the included trials.21
The uncertainty about self-management exists because not all self-management interventions have equal impact on patient outcomes. Motivational interviewing, collaborative problem solving, and negotiating individualized goals for each patient, for example, may have longer-standing benefit than those focused on education alone.22
A 2009 meta-analysis of DSME and its efficacy differentiated teaching, behavioral, psychological, and “mixed” or combination approaches. Most of the interventions were behaviorally oriented, sometimes combined with one other format. Psychological interventions targeting negative or self-defeating moods and social and emotional coping skills yielded moderate effects on metabolic control and self-care behaviors.23
Clinic-based self-management. One randomized prospective study compared intensive clinic-based education on complications of diabetes with standard care. After 4 years, patients exhibited significant reductions in HbA1c, blood pressure, and low-density lipoprotein cholesterol levels.24
A large meta-analysis examining a range of self-management programs for multiple chronic conditions showed a statistically and clinically significant improvement in glycemic control equivalent to a 0.81% reduction in HbA1c. Features of self-management addressed in this meta-analysis included various forms of nurse- and provider-driven education about medications, diet and exercise, motivational interviewing, and biofeedback.25
Nurse-led DSME has been associated with improvements in HbA1c and cardiovascular risk factors.26 Dietician-led DSME has been associated improvements in HbA1c when compared with routine care.26
Cognitive behavioral therapy. Overall, the most frequently reported and most widely used psychosocial intervention is cognitive behavioral therapy (CBT); it is often short term and skills based, targeting unhelpful negative thinking and increasing positive behavior, including problem solving and relaxation, which have been shown to be effective in treating depression.27 An older randomized control trial (RCT) specifically focused on type 2 diabetes explored the impact of CBT on both diabetes and depression among patients with diabetes and comorbid major depressive disorder (MDD). Improvements in depression seen at the end of the intervention were still evident 6 months later. And while there was no difference in HbA1c levels immediately following the intervention, after 6 months the mean HbA1c level was significantly better in the CBT group than in the control group (9.5% vs 10.9%; P=.03). There was no statistically significant difference in SMBG between the groups.28
