Frequency and motives of blood glucose self-monitoring in type 1 diabetes

https://doi.org/10.1016/j.diabres.2009.04.022Get rights and content

Abstract

Aims

Recommendations for self-monitoring of blood glucose (SMBG) from the DCCT have not been implemented with the same rigour as recommendations for intensifying insulin therapy. We assessed the frequency of and motives for SMBG and compared SMBG behaviour with clinical, behavioural and demographic characteristics.

Methods

Cross-sectional Danish-British multicentre survey of 1076 consecutive patients with type 1 diabetes, who completed a detailed questionnaire on SMBG and related issues. The key variables were test frequency and motive.

Results

SMBG was performed daily by 39% of the patients and less than weekly by 24%. Sixty-seven percent reported to perform routine testing, while the remaining 33% only tested when hypo- or hyperglycaemia was suspected. Age, gender, and level of diabetes-related concern were associated with test pattern. Reported frequencies of mild and severe hypoglycaemia and awareness of hypoglycaemia were independently associated with testing behaviour, whereas the presence of late diabetic complications was not. Lower HbA1c was associated with more frequent testing.

Conclusion

Patient compliance regarding SMBG is limited. Thus, almost two thirds of the patients do not perform daily SMBG and one third do not perform routine tests.

Introduction

Achievement and maintenance of near normoglycaemia resulting in reduced incidence or progression of long-term complications are goals for the treatment of patients with type 1 diabetes. In the DCCT and the EDIC follow-up study, intensive therapy consisted of multiple injections or pump-based basal-bolus insulin therapy and self-monitoring of blood glucose (SMBG) ≥4 times per day [1], [2]. In contrast to basal-bolus insulin therapy, which is today the standard treatment of type 1 diabetes, the SMBG recommendations (measuring at least 4 times daily) from the DCCT have not been implemented with the same intensity. This may be due to the less clear documentation of the effect of SMBG. Two earlier studies have not shown a benefit from using SMBG as compared to urine glucose self-monitoring in type 1 diabetes [3], [4] and a systematic review [5] did not provide evidence to support the clinical effectiveness of SMBG in improvement of glycaemic control. However, current clinical practice recommendations from the American Diabetes Association [6] and the Global Consensus Conference on Glucose Monitoring [7] encourage the use of daily SMBG. For most patients with type 1 diabetes, SMBG is recommended three or more times daily, although the frequency and timing of SMBG should be adapted to the particular needs and goals of the individual patient [6], [8], [9]. Even though present recommendations are clear, adherence to blood glucose monitoring is suboptimal as number of patients who never practice SMBG vary from 6% to 21% [9], [10], [11], [12], [13], [14].

The aim of this cross-sectional study was to assess the frequency and the motives for measuring blood glucose in daily life in patients with type 1 diabetes and to identify patient characteristics that are associated with adherence to SMBG.

Section snippets

Subjects

In all four centres we consecutively included adult (>18 years of age) outpatients with clinical type 1 diabetes mellitus for more than 2 years. Data were collected between February 1999 and May 2000. Type 1 diabetes was defined by diagnosis before the age of 40 years and insulin treatment from the time of diagnosis. We only excluded those with end stage renal disease (haemodialysis), concomitant malignant disease, pregnancy or an inability to complete the questionnaire. The study was approved

Materials and methods

The study was a four-centre cross-sectional questionnaire survey including clinics at one Danish general hospital (Hillerød Hospital), one Danish university hospital (Steno Diabetes Center) and two British university teaching hospitals (Northern General Hospital, Sheffield and Radcliffe Infirmary, Oxford). An analysis of severe hypoglycaemia has been published previously [15].

Results

Of 1183 subjects asked to participate, 1076 patients (91%) completed the study (Table 1). Non-participants had a slightly higher prevalence of microvascular diabetic complications but their characteristics did not otherwise differ from those of the participants (Table 1 in Ref. [15]). A total of 96.6% reported to do SMBG and 3.4% did not. Test frequency was distributed in four groups: 24% tested less than weekly, 17% did single tests more than once a week, 20% did series one or more days per

Discussion

This study shows that patient compliance to guidelines regarding SMBG is suboptimal. Thus, 3% of patients do not perform SMBG at all, 33% do not perform routine tests, and 61% do not test on a daily basis. This is in accordance with earlier studies [10], [11], [12], [13], [14], [20], [21], [22], [23] suggesting that the self-monitoring recommendations from the DCCT have not been possible to implement in clinical practice.

Both the Danish Diabetes Association and Diabetes UK recommend daily

Conflict of interest

The authors state that they have no conflict of interest.

Acknowledgments

The authors are indebted to the research nurses Pernille Banck-Petersen (Hillerød Hospital), Susan Hudson (Northern General Hospital, Sheffield), and Victoria Wright (The Radcliffe Infirmary, Oxford) for thorough collection of data, and to Philip Hougaard (Lundbeck A/S, Copenhagen, Denmark) for statistical assistance. The study was funded by grants from The Foundation of Harald Jensen and Wife, The Foundation of Olga Bryde Nielsen, The Foundation of Region 3, and Novo Nordisk A/S.

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      Our study showed a 2 point decrease in mean A1C in patients with more frequent BGM to 3-4x/day when all patient were included. Patients with 3-4 x/day BGM had an A1C of 9.6 ± 2.24% vs. those with ≤2 x/day with A1C of 11.8 ± 1.95% (95% CI 0.2-3.7, p = 0.03) which support previous studies findings.21–24 Contrary to that reported in the study by Miller et al. wherein A1C consistently decreased with increase in the number of BS checks per day,22 our study showed no further improvement in A1C with BS checks >4x/day.

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