Comments on: Re-evaluating Home Monitoring for Diabetes: Science-Based Medicine at Work http://www.sciencebasedmedicine.org/?p=487 Exploring issues and controversies in the relationship between science and medicine Fri, 10 Sep 2010 02:56:42 -0700 http://wordpress.org/?v=2.8.4 hourly 1 By: 21stCenturyRox http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-20094 21stCenturyRox Fri, 29 May 2009 20:01:55 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-20094 It's an interesting finding - but could the problem be not enough information? If patients are tracking diet, exercise and glucose, using a tool like Microsoft HealthVault (http://www.healthvault.com/Personal/index.html), and can see positive trends over time, maybe that could correct the emotional reaction and improve compliance with lifestyle changes. Of course, speculation w/o data is just a call for more research... It’s an interesting finding – but could the problem be not enough information? If patients are tracking diet, exercise and glucose, using a tool like Microsoft HealthVault (http://www.healthvault.com/Personal/index.html), and can see positive trends over time, maybe that could correct the emotional reaction and improve compliance with lifestyle changes. Of course, speculation w/o data is just a call for more research…

]]> By: beadle http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19419 beadle Sun, 17 May 2009 17:19:08 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19419 I agree with Michael Simpson concerning what it is this study really shows. I lean towards not having my DMII patients not test that often, because of the seeming cost/benefit mismatch shown in this study. Admittedly, this attitude has always been a "gut feeling" of mine more than anything. This study initially seems to validate that tack, but what is it really studying? Compliance? UK-brand BGM accuracy? The study’s stated end-points were "...group differences in HbA1c, psychological indices, use of oral hypoglycaemic drugs, body mass index (BMI), and reported hypoglycaemia rates" over a one year period. Fine. But DM is a life-long disease with some consequences of poor glycemic control not showing up for many years. It logically follows that no differences in a year (especially A1c levels and hypoglycemic events), multiplied by many years, equals no differences in many years. But that’s logic, not science. This study does not attempt to address long-term complications of DM between patients who monitor and those who don’t. Further research is needed. I agree with Michael Simpson concerning what it is this study really shows. I lean towards not having my DMII patients not test that often, because of the seeming cost/benefit mismatch shown in this study. Admittedly, this attitude has always been a “gut feeling” of mine more than anything. This study initially seems to validate that tack, but what is it really studying? Compliance? UK-brand BGM accuracy?

The study’s stated end-points were “…group differences in HbA1c, psychological indices, use of oral hypoglycaemic drugs, body mass index (BMI), and reported hypoglycaemia rates” over a one year period. Fine. But DM is a life-long disease with some consequences of poor glycemic control not showing up for many years.

It logically follows that no differences in a year (especially A1c levels and hypoglycemic events), multiplied by many years, equals no differences in many years. But that’s logic, not science. This study does not attempt to address long-term complications of DM between patients who monitor and those who don’t. Further research is needed.

]]> By: The Blind Watchmaker http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19414 The Blind Watchmaker Sun, 17 May 2009 13:50:36 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19414 I was happy to see this study published last month. I recommend all of my diabetic patients to see a dietitian. Most diabetic dietitians are still insisting on frequent glucose testing even in patients not on any meds, let alone insulin. It seems that some dietitians were trained with Type 1 diabetics in mind. It is time to focus on what is important in Type 2 diabetics: nutrition, exercise and reduction of abdominal fat. Many patients have been conditioned to check their sugars often and become upset when the doctor checks the "test <2 times a day" box on the prior authorization form for their diabetic supplies. I often feel frustrated that some people focus so much on testing, but focus so little on lifestyle changes. I was happy to see this study published last month. I recommend all of my diabetic patients to see a dietitian. Most diabetic dietitians are still insisting on frequent glucose testing even in patients not on any meds, let alone insulin. It seems that some dietitians were trained with Type 1 diabetics in mind. It is time to focus on what is important in Type 2 diabetics: nutrition, exercise and reduction of abdominal fat.

Many patients have been conditioned to check their sugars often and become upset when the doctor checks the “test <2 times a day” box on the prior authorization form for their diabetic supplies. I often feel frustrated that some people focus so much on testing, but focus so little on lifestyle changes.

]]> By: Harriet Hall http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19393 Harriet Hall Sat, 16 May 2009 15:37:31 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19393 ned perceives a psychological benefit from home monitoring, but the study suggests that the few like ned are outweighed by the many who get more depressed when monitoring. And ned can't really be sure he would have done worse without monitoring. Perhaps those who are diligent about monitoring are those who would naturally be more diligent about diet and life style changes. The AFP advice "Its use should be tailored to the needs of the individual patient." makes allowances for people like ned. ned perceives a psychological benefit from home monitoring, but the study suggests that the few like ned are outweighed by the many who get more depressed when monitoring. And ned can’t really be sure he would have done worse without monitoring. Perhaps those who are diligent about monitoring are those who would naturally be more diligent about diet and life style changes.

The AFP advice “Its use should be tailored to the needs of the individual patient.” makes allowances for people like ned.

]]> By: ned http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19381 ned Sat, 16 May 2009 01:32:16 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19381 I use a glucose monitor and I think it helps a lot. I use a notation method to keep track of my carbs daily, I write it all down with other comments-----how I feel both emotionally and physically. Sometimes I feel like eating something off diet I think of the morning number I will be facing. I gives me a little incentive to stay on the straight and narrow. People who diet find recording their food consumed to be helpful; I feel this is just an extension of that method. Been at this for 12 years, still controlling with diet and exercise. I use a glucose monitor and I think it helps a lot. I use a notation method to keep track of my carbs daily, I write it all down with other comments—–how I feel both emotionally and physically. Sometimes I feel like eating something off diet I think of the morning number I will be facing. I gives me a little incentive to stay on the straight and narrow.

People who diet find recording their food consumed to be helpful; I feel this is just an extension of that method. Been at this for 12 years, still controlling with diet and exercise.

]]> By: xwolp http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19362 xwolp Fri, 15 May 2009 13:49:01 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19362 In my experience as a type I diabetic, the difference between blood glucose levels of 160 and 110 should be very noticeable unless said person suffers from chronically higher levels (the perception changes a lot depending on your mean levels). But that is besides the point. Having a mother who suffers from chronic pancreatitis and thus periodically develops symptoms of diabetes I can attest to how much home monitoring can throw a therapy off course. A relatively minor hyperglycemia (170-190) can easily turn into more severe hypoglycemias since most type II medication is not very precise. In overall these are much more dangerous and a higher stress for the system overall. In my experience as a type I diabetic, the difference between blood glucose levels of 160 and 110 should be very noticeable unless said person suffers from chronically higher levels (the perception changes a lot depending on your mean levels).
But that is besides the point.
Having a mother who suffers from chronic pancreatitis and thus periodically develops symptoms of diabetes I can attest to how much home monitoring can throw a therapy off course.
A relatively minor hyperglycemia (170-190) can easily turn into more severe hypoglycemias since most type II medication is not very precise. In overall these are much more dangerous and a higher stress for the system overall.

]]> By: Michael Simpson http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19323 Michael Simpson Thu, 14 May 2009 18:14:05 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19323 I am really concerned about the conclusions given in both the paper and the review here. Is there a subset of patients who are compliant, find the monitoring to be a positive experience, or have managed their disease positively? Further, is there something about England's monitors or diabetes education that's different from say, the US (I'm going to say, maybe)? I'm not convinced that BGM is a complete waste of money. I am really concerned about the conclusions given in both the paper and the review here. Is there a subset of patients who are compliant, find the monitoring to be a positive experience, or have managed their disease positively? Further, is there something about England’s monitors or diabetes education that’s different from say, the US (I’m going to say, maybe)?

I’m not convinced that BGM is a complete waste of money.

]]> By: Sara http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19283 Sara Wed, 13 May 2009 20:19:29 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19283 I'd definitely like to know what kind of dietary advice was given to these patients. If, for instance, they were advised to eat something like the ADA suggested diet, which suggests 45-60g of carbohydrate per meal, and the suggested response to experiencing highs or lows was to try to stick more closely to that diet, then it's no wonder they didn't find metering helpful. If I ate like that, I'd find my glucose meter useless, distressing, and depressing, too. I'd like to see a version of this study where the participants were advised to limit carbs, and to test before and after meals to see how a particular meal affected them, and then see if they found the meters useless, or instead empowering. I’d definitely like to know what kind of dietary advice was given to these patients. If, for instance, they were advised to eat something like the ADA suggested diet, which suggests 45-60g of carbohydrate per meal, and the suggested response to experiencing highs or lows was to try to stick more closely to that diet, then it’s no wonder they didn’t find metering helpful. If I ate like that, I’d find my glucose meter useless, distressing, and depressing, too. I’d like to see a version of this study where the participants were advised to limit carbs, and to test before and after meals to see how a particular meal affected them, and then see if they found the meters useless, or instead empowering.

]]> By: Michael Simpson http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19271 Michael Simpson Wed, 13 May 2009 16:42:53 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19271 I want to amend my comments slightly. Is blood glucose monitoring for Type II diabetes useful? What I'm reading here is that there is a compliance issue, not a science issue. The studies did not indicate that blood glucose monitoring was useless in managing the disease, more that it's a waste of money because compliance is so low. Even though A1C testing is more accurate and gives better information for chronic levels of blood glucose, the information is a delayed effect. In other words, it may take a few months of lowering blood glucose to elicit a reduction in A1C levels. If you're trying to reduce your blood glucose from 160 to 110 (for example), I don't know if there's a way to observe that small of a reduction without a diagnostic test. You're probably not going to notice anything short-term in your health (maybe you'll urinate more glucose, but I'm not sure you can even tell that). So, blood glucose monitoring may be a waste of money, but is it useless? I can think of several cases where it isn't. A Type 2 diabetic who exercises heavily and frequently needs to know their pre and post-exercise glucose. Someone is truly trying to manage their diet (talk about positive feedback). I accept the fact that it's depressing for patients to be reminded of their diabetes. But, and since in my life I require no bedside manner, type 2 diabetes is almost always a consequence of poor lifestyle choices. Appropriate management of blood glucose can be the first step in changing that. I'm of two minds about blood glucose monitoring. It can be a valuable tool. But what a waste of money for our health care system. And the studies just show that it's a waste of money, not where it is a valuable tool. I want to amend my comments slightly. Is blood glucose monitoring for Type II diabetes useful? What I’m reading here is that there is a compliance issue, not a science issue. The studies did not indicate that blood glucose monitoring was useless in managing the disease, more that it’s a waste of money because compliance is so low.

Even though A1C testing is more accurate and gives better information for chronic levels of blood glucose, the information is a delayed effect. In other words, it may take a few months of lowering blood glucose to elicit a reduction in A1C levels.

If you’re trying to reduce your blood glucose from 160 to 110 (for example), I don’t know if there’s a way to observe that small of a reduction without a diagnostic test. You’re probably not going to notice anything short-term in your health (maybe you’ll urinate more glucose, but I’m not sure you can even tell that).

So, blood glucose monitoring may be a waste of money, but is it useless? I can think of several cases where it isn’t. A Type 2 diabetic who exercises heavily and frequently needs to know their pre and post-exercise glucose. Someone is truly trying to manage their diet (talk about positive feedback).

I accept the fact that it’s depressing for patients to be reminded of their diabetes. But, and since in my life I require no bedside manner, type 2 diabetes is almost always a consequence of poor lifestyle choices. Appropriate management of blood glucose can be the first step in changing that.

I’m of two minds about blood glucose monitoring. It can be a valuable tool. But what a waste of money for our health care system. And the studies just show that it’s a waste of money, not where it is a valuable tool.

]]> By: Michael Simpson http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19269 Michael Simpson Wed, 13 May 2009 16:16:12 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19269 Those with Type 1 diabetes tend to be obsessive about monitoring themselves, because it is a life or death situation. Those with Type 2 diabetes tend to be less obsessive (or even annoyed) about monitoring, because the effects tend to be more long-term. I also believe, with just a little bit of evidence, that most of the glucose monitors are just plain difficult to use, counterintuitive, and the lancets that are used to make the fingerstick are a bit medieval in design. I know many of you want to beat up on Big Pharma (or in this case Big Diagnostic), but maybe someone needs to send these results to managed care or third-party payors. They are authorizing and paying for the use of these devices by anyone who is diagnosed with Type 2 diabetes to manage this disease in the hope of reducing the risk from other diseases like CVD. Many of the managed care facilities are trying to teach patients how to use the devices. Anyways, I used to think there are lots of meters sitting in houses gathering dust. I guess now I'm convinced there are. What a waste of money. Those with Type 1 diabetes tend to be obsessive about monitoring themselves, because it is a life or death situation. Those with Type 2 diabetes tend to be less obsessive (or even annoyed) about monitoring, because the effects tend to be more long-term.

I also believe, with just a little bit of evidence, that most of the glucose monitors are just plain difficult to use, counterintuitive, and the lancets that are used to make the fingerstick are a bit medieval in design.

I know many of you want to beat up on Big Pharma (or in this case Big Diagnostic), but maybe someone needs to send these results to managed care or third-party payors. They are authorizing and paying for the use of these devices by anyone who is diagnosed with Type 2 diabetes to manage this disease in the hope of reducing the risk from other diseases like CVD. Many of the managed care facilities are trying to teach patients how to use the devices.

Anyways, I used to think there are lots of meters sitting in houses gathering dust. I guess now I’m convinced there are. What a waste of money.

]]> By: Newcoaster http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19238 Newcoaster Tue, 12 May 2009 21:15:21 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19238 As Daedalus pointed out, this kind of study shows the difference between EBM and sCAM. We actually test things that are common clinical practice, and adjust our practice accordingly if the evidence shows it doesn't work. Another recent study (I think in JAMA) also showed that tight glucose control in the ICU was counter-productive. As Daedalus pointed out, this kind of study shows the difference between EBM and sCAM. We actually test things that are common clinical practice, and adjust our practice accordingly if the evidence shows it doesn’t work.
Another recent study (I think in JAMA) also showed that tight glucose control in the ICU was counter-productive.

]]> By: mr. grieves http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19231 mr. grieves Tue, 12 May 2009 19:07:55 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19231 This is a very interesting study, thanks for posting it. I am curious if these results would continue beyond the 1 year mark. I would imagine (and have observed) that many patients (but not all!) are very motivated to take control of their disease early after diagnosis. However, as time goes on they become less and less interested in both monitoring and lifestyle management (diet and exercise). I wonder if continuing to monitor at home would reinforce the need for patients to lead a healthy lifestyle in these patients with a longer history of diabetes. On the other hand, I have also observed numerous patients who experience pain with home monitoring, difficulty utilizing glucose meters and those who face economic hardship due to the cost of lancets and strips. This is a very interesting study, thanks for posting it. I am curious if these results would continue beyond the 1 year mark. I would imagine (and have observed) that many patients (but not all!) are very motivated to take control of their disease early after diagnosis. However, as time goes on they become less and less interested in both monitoring and lifestyle management (diet and exercise). I wonder if continuing to monitor at home would reinforce the need for patients to lead a healthy lifestyle in these patients with a longer history of diabetes. On the other hand, I have also observed numerous patients who experience pain with home monitoring, difficulty utilizing glucose meters and those who face economic hardship due to the cost of lancets and strips.

]]> By: Calli Arcale http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19229 Calli Arcale Tue, 12 May 2009 18:59:33 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19229 Having had relatives who depended on home glucose monitoring (they were in the category of people where they really had problems if they didn't keep track of the glucose level), I can say that in addition to it being depressing and costly, it's *painful*. Not having to do it would be a mercy. Having had relatives who depended on home glucose monitoring (they were in the category of people where they really had problems if they didn’t keep track of the glucose level), I can say that in addition to it being depressing and costly, it’s *painful*. Not having to do it would be a mercy.

]]> By: Basiorana http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19225 Basiorana Tue, 12 May 2009 17:51:39 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19225 My dad monitors his Type 2 diabetes at home. He can't do anything if it's high except not eat any more sugar the rest of the day. It kind of is ridiculous for him-- he eats a big meal, checks his sugar, realizes it spiked, then eats salted peanuts all day to avoid sugars. Not exactly healthy. But then again, getting him to follow a diabetic diet completely flopped too... My dad monitors his Type 2 diabetes at home. He can’t do anything if it’s high except not eat any more sugar the rest of the day. It kind of is ridiculous for him– he eats a big meal, checks his sugar, realizes it spiked, then eats salted peanuts all day to avoid sugars. Not exactly healthy. But then again, getting him to follow a diabetic diet completely flopped too…

]]> By: DeanVenture http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19218 DeanVenture Tue, 12 May 2009 15:58:10 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19218 Couldn't help but think that studies like this show CAMmers that we're not in the corporations' pockets after all... Good review! Couldn’t help but think that studies like this show CAMmers that we’re not in the corporations’ pockets after all…

Good review!

]]> By: weing http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19214 weing Tue, 12 May 2009 14:23:25 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19214 I have not been telling my patients to monitor the glucose at home if it's well controlled based on glycohemoglobin measurements. It's good to have some backing for this. My approach has been to have the patients focus on living their lives and not have their lives revolve around a disease. There are some patients that get some kick out of monitoring their sugars and want to do it even though I don't see any need for it. So, it takes all kinds. I have not been telling my patients to monitor the glucose at home if it’s well controlled based on glycohemoglobin measurements. It’s good to have some backing for this. My approach has been to have the patients focus on living their lives and not have their lives revolve around a disease. There are some patients that get some kick out of monitoring their sugars and want to do it even though I don’t see any need for it. So, it takes all kinds.

]]> By: daedalus2u http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19212 daedalus2u Tue, 12 May 2009 11:49:03 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19212 Very nice article and analysis which shows very nicely the different approach to health that SBM and EBM take compared to CAM. The hypothesis that at home testing would help is quite reasonable, and intuitively makes sense. It turns out it was wrong. These are the most important kinds of studies to do, the ones where our intuition is wrong. They are also the most difficult to get funding to test. What is interesting is the rapid responses there were a number of complex ideas put forward as to why there was no effect, ideas which distorted what was actually done in the study. CAM wouldn’t even bother to test something like this. It also puts the lie to statements that SBM blindly favors interventions. Very nice article and analysis which shows very nicely the different approach to health that SBM and EBM take compared to CAM. The hypothesis that at home testing would help is quite reasonable, and intuitively makes sense. It turns out it was wrong. These are the most important kinds of studies to do, the ones where our intuition is wrong. They are also the most difficult to get funding to test.

What is interesting is the rapid responses there were a number of complex ideas put forward as to why there was no effect, ideas which distorted what was actually done in the study.

CAM wouldn’t even bother to test something like this.

It also puts the lie to statements that SBM blindly favors interventions.

]]> By: storkdok http://www.sciencebasedmedicine.org/?p=487&cpage=1#comment-19210 storkdok Tue, 12 May 2009 11:25:01 +0000 http://www.sciencebasedmedicine.org/?p=487#comment-19210 My mother, a type 2 diabetic, says that the monitoring at home is depressing. She is pretty well controlled. I am going to send her this study to discuss with her doctor. I hope there will be more studies to see if there is replication confirming this finding. It would be great if she could stop doing so much monitoring in the future. My mother, a type 2 diabetic, says that the monitoring at home is depressing. She is pretty well controlled. I am going to send her this study to discuss with her doctor. I hope there will be more studies to see if there is replication confirming this finding. It would be great if she could stop doing so much monitoring in the future.

]]>