December 2012

Monitoring Sugar in Type 2 Diabetes

Self-monitoring of Blood Glucose or SMBG is considered to be an important part in diabetes management. While its utility in insulin-requiring diabetes is proven, the role of monitoring in non-insulin-requiring type 2 diabetes is highly debated. Nikita Apraj, ENN explores the subject

IDF Diabetes Atlas (Fifth Edition), 2011 estimates that India has more than 60 million people diagnosed with diabetes. The number is expected to grow more than double by 2030. With 63 million people diagnosed with diabetes and around 32 million with undiagnosed diabetes, India is a country with the largest diabetic population, second only to China. Effective management of the disease forms an integral part in diabetes care.

Self-monitoring helps
Self-monitoring of blood glucose allows patients to track the levels of blood glucose in their body, what particular foods affect them, and what happens after physical activity or taking medication. Self-monitoring is even more helpful if done in a structured way – by monitoring at the right times and in the right situations and right frequency. Structured self-monitoring can help patients see a pattern that they themselves as well as their healthcare professional can effectively use as a part of ongoing diabetes management.
Dr Roshani Sanghani, Consultant Endocrinologist at P D Hinduja National Hospital says, Monitoring at home is very important. Every diabetic needs to know their control on sugar frequently. It also helps doctors to adjust medications accordingly. Most importantly, it helps patients understand their own disease better. The best patient is the one who understands his disease.

Dr Roshani Sanghani
Consultant Endocrinologist, P D Hinduja National HosptialWe would like the blood glucose monitoring devices to directly send the numbers to doctors mobile device

SMBG gives a real-time record of blood sugars and tells you about excursions or variability in blood sugars. Patients and physician  can better understand about the blood sugar control and undertake Titrate Therapy accordingly to avoid hyperglycaemia and hypoglycaemic episodes, says Dr Vimal Pahuja, Consultant General Medicine at Dr L H Hiranandani Hospital.

Dr Vimal Pahuja
Consultant General Medicine, Dr L H Hiranandani HospitalWe still dont have the culture of specific diabetic health educators who will spread awareness

The 12-month data of the Structured Testing Protocol (STeP) Study shows that the use of a new diabetes management concept including structured SMBG, data visualisation, pattern analysis and derived therapy adjustments can significantly contribute to a  reduction of HbA1c values and improved glycemic control, Sidhartha Roy, Business Unit Head, Roche Diabetes Care explains.

SMBG is for all
Roy says people with diabetes need to monitor at regular intervals as suggested by their physicians. The monitoring throws out data points of hyperglycaemia and hypoglycaemia at different times like fasting, postprandial, before sleep. This data becomes useful for his physicians. There were school of thoughts about using SMBG in type 2 diabetes but studies are in strong favour of SMBG. There are recommendations from bodies like ADA (American Diabetes Association) and AACE (American Association of Clinical Endocrinology) in patients of type 2 diabetes for SMBG, he adds further.
Dr Pahuja asserts that frequent diabetes monitoring is not necessary for the individuals who are generally wellcontrolled and maintain HbA1C below 7 percent without any evidence of macrovascular or microvascular complications. However, people with longstanding
type 2 diabetes and with uncontrolled type 2 diabetes who are not on insulin and show evidence of some macrovascular or  microvascular complications should monitor blood sugar at home. The frequency of SMBG can be reduced for type 2 diabetes patients and still would generate enough data points for interventions for better quality of life, says Dr Pahuja.
Its mainly because individuals not on insulin are not as much prone to sugar dropping as those who are on insulin are. Their  (individuals not on insulin) sugar tends to be more stable through the day. However, if they are taking tablets for sugar-control and sugar goes out of control, they need to check. Monitoring gives a rough but fair estimate about whether sugar is going low or high,  explains Dr Roshani Sanghani.

Awareness level
Doctors and vendors agree that the level of SMBG awareness among patients is quite low. Sidhartha Roy attributes this to the fact that India being a self“pay market that also results in lower percentage of usage.
Dr Sanghani and Dr Pahuja both feel people are hesitant to pricking. Dr Sanghani says patients are very reluctant to prick themselves. They prefer their healthcare providers to perform tests. They are also afraid of results.
Importance of SMBG is being still underplayed by physician. We still dont have the culture of specific diabetic health educators who will spread the awareness, says Dr Pahuja.
Can SMBG Replace Diagnostic Tests?
Sidhartha Roy refuses any such possibility. SMBG is a structured way of monitoring your blood glucose. It will never replace laboratory diagnostics, says Roy.

Sidhartha Roy
Business Unit Head, Roche Diabetes CareThere are recommendations from bodies like ADA and AACE in patients of type 2 diabetes for SMBG

I dont think they will and should replace diagnostic tests which we have now. Any test which is used for diagnosis should give  consistent results and SMBG devices are still inconsistent in that sense, says Dr Pahuja.
SMBG devices cannot replace HBA1C or fructosamine. There are chances of errors which are either operator-dependant or instrument-dependant. It can under-estimate or over-estimate when sugars are extremely low or high, adds Dr Pahuja.
Dr Roshani Sanghani too rules out the idea, Both have different purposes. Diagnostic tests are for more precise testing. SMBG devices readings may show slight variations but these devices are very helpful to check sugar at home. A patient cannot every time rush to pathology to check his blood sugar. Its also helpful in monitoring sugar levels while travelling and at workplace.
We would like the blood glucose monitoring devices directly send the numbers to doctors mobile device. It will help us to plot graphs, find trends and learn more about diabetes, says Dr Sanghani while talking about the future development she wants to see in SMBG devices.
The decision of recommending SMBG for individuals in type 2 group may largely be determined by personal preferences, cost and individual and healthcare system resources. Priority lists may be needed to decide which individuals should be offered SMBG. These might include people recently diagnosed with diabetes, those with more erratic lifestyles, people having problems of hypoglycaemia  and those particularly keen to tighten their blood glucose control.

What studies say
As published in IDF Guideline for type 2 diabetes 2012, studies performed among insulin-treated individuals with type 2 diabetes suggest that SMBG is required to titrate the insulin dose while avoiding hypoglycaemia. SMBG may help type 2 diabetes patients who are on insulin or sulphonylurea drugs because the information about a patients glucose level is useful to refine and adjust insulin dosages, resulting in an improved glycemic control, says a study published in ADA Diabetes Care. The impact of monitoring on patient wellbeing must also be considered as some studies suggest adverse psychological effects. Given the large increase in the prence of type 2 diabetes, it will be important to define the role of SMBG so that resources can be used appropriately.

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