Self-Monitoring of Blood Glucose in Type 2 Diabetes
Time for evidence of efficacy
- Laurence Kennedy, MD, FRCP
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, Florida
The second half of the 20th century saw a major shift away from the paternalistic “doctor knows best” philosophy, which characterized patients as passive unquestioning recipients of care at the hands of all-powerful, all-knowing medical practitioners. Most patients, given sufficient information, now wish to be active participants, fully involved (usually with a multidisciplinary health care team rather than a single autocratic doctor) in making decisions relating to their medical assessment and management. Because diabetes is a complex lifelong condition, the good sense of such an approach seems obviously self-evident. The development of glucose meters that combine technological sophistication with speed and ease of use has greatly enhanced the potential for all diabetic patients to monitor their blood glucose. Detection of subtle hypoglycemia, asymptomatic hyperglycemia, and unnaturally wide glycemic excursions should, in theory, empower patients to make appropriate changes in lifestyle and/or pharmacological treatment, which will lead to more physiological glucose profiles and lower HbA1c levels.
However, another late 20th century philosophical shift—toward the practice of evidence-based medicine and away from a combination of anecdote, personal bias, and instinct—renders “obviously self-evident,” as a verdict, “obviously insufficient.” For sure, self-monitoring of blood glucose (SMBG) was a key component, but not the only one, in landmark studies such as the Stockholm Diabetes Intervention Study, the Diabetes Control and Complications Trial, and the Kumamoto study, which proved beyond doubt that intensive insulin treatment of both type 1 and type 2 diabetes can result in lower HbA1c and less risk of microvascular complications. It is worth noting, however, that the U.K. Prospective Diabetes Study essentially achieved the same scientific goal of improved glycemic control (as reflected by …