• Recommend self- monitoring of blood glucose to anyone using insulin. B
• Consider self-monitoring of blood glucose in non-insulin-treated diabetes, but recognize that its effect on glycemic control is limited. B
• Consider self-management programs to promote patient involvement, but keep in mind that there is insufficient evidence to recommend for or against them. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE Donna M is a 53-year-old woman with type 2 diabetes mellitus, who maintains fair glycemic control with metformin and glipizide. Her HbA1c level is 8.7%, but she has mixed feelings about initiating insulin treatment. Many of her family members also struggle with diabetes, and they frequently accompany Ms. M on her office visits. Ms. M is motivated to do whatever she can—in addition to taking her medications—to improve her diabetes. Her family asks if there is anything they can do to help. If you were Ms. M’s physician, what would you recommend?
The Centers for Disease Control and Prevention (CDC) estimates that diabetes affects 25.8 million people (or 8.3% of the population) in the United States, and that 7 million of them are undiagnosed.1 Based on the known prevalence of prediabetes, the CDC estimates that 79 million Americans ≥20 years of age are at risk for diabetes. Approximately 5.7 million people with diabetes take insulin, with or without oral medications.2
As the spotlight shines brighter on efforts to promote patient-centeredness in health care—especially with respect to chronic illness—attention to the role of self-management has also grown. And family physicians have begun to reconsider how best to engage and motivate patients to manage their illness.
In this article, we review “what else” patients can do—and perhaps need not do—based on the evidence.
What is self-management anyway?
The concept of self-management is not foreign to most family physicians, yet they and their patients probably do not share a common understanding of what it entails. The American Diabetes Association (ADA) defines diabetes self-management as “the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. Self-management should incorporate the needs, goals, and life experiences of the person with diabetes and should be guided by evidence-based standards. The overall objectives of DSME (diabetes self-management education) are to support informed decision-making, self-care behaviors, problem solving, and active collaboration with the health care team and improve clinical outcomes, health status, and quality of life.”3
Few family physicians would disagree that self-management is a good thing for patients, but many would be surprised to find that the evidence for self-management is not as convincing as one might expect. The CDC reports that 57.4% of patients with diabetes have attended a self-management class for diabetes, and 63.6% perform daily self-monitoring of blood glucose (SMBG).4 Yet, there is only indirect evidence that self-management programs are associated with modest improvements in HbA1c.5 SMBG has long been considered a mainstay of diabetes self-care, yet a growing body of evidence has shown that this practice is not universally beneficial.6 Although self-management education may reduce HbA1c levels in the short term, the long-term clinical effectiveness of SMBG has not been established.7-11
Know when to recommend SMBG
With clinical interventions, we want to give priority to those that significantly improve patient outcomes. Checking blood glucose makes good sense for insulin-treated patients to monitor for and prevent asymptomatic hypoglycemia or hyperglycemia, especially when the risk for these complications is high. In a large database study of almost 27,000 children and adolescents with type 1 diabetes, increased daily frequency of SMBG, after adjustment for multiple confounders, was significantly associated with lower HbA1c levels (–0.2% per additional test per day, leveling off at 5 tests per day) and fewer acute complications.12
Although it has been suggested that more frequent SMBG improves long-term glycemic control among patients with insulin-treated type 1 and type 2 diabetes, the benefits are modest.13 The ADA recommends SMBG 3 or more times daily for patients using multiple insulin injections or insulin pump therapy.14
In patients with type 2 diabetes who are not taking insulin, the benefits of SMBG are less clear. A meta-analysis of SMBG in non-insulin-treated patients with type 2 diabetes showed that it was associated with a reduction of HbA1c of –0.4%.15 A Cochrane review added that SMBG leads to small but significant decreases after 6 months, but that these improvements are not sustained at 12 months. The same review noted no improvements in patient satisfaction or general health-related quality of life resulting from SMBG.6 But many of the studies in this analysis included other interventions, making it difficult to isolate the impact of SMBG on glycemic control. Other studies show that SMBG does not improve glycemic control at all.16