BMJ  2007;335:458-459 (8 September), doi:10.1136/bmj.39315.443160.BE (published 30 August 2007)

Editorials

Self management of type 2 diabetes

More efforts are needed to capture the patients' perspective

The introduction of home blood glucose monitoring in the late 1970s was instrumental in shifting the focus of the management of diabetes from doctors to patients.¹ It is now a common view that patients are primarily responsible for the daily management of their diabetes, which includes self monitoring, at least in patients treated with insulin. The usefulness of self monitoring in patients with type 2 diabetes not treated with insulin is controversial, a debate that was recently fuelled by findings from the DIGEM trial.²

Two studies in this week's BMJ are related to optimising the treatment of type 2 diabetes.^{3 4} In the first, Peel and colleagues³ report the results from a longitudinal qualitative study of the views of patients with type 2 diabetes about self monitoring, using a repeat interview design. The authors rightly point out that the patient's view has been largely absent in discussions on self monitoring in type 2 diabetes. While self testing of blood glucose has the potential to empower patients, it is often viewed as complex and inconvenient. Finger pricks can be painful, and the repeated confrontation with unexpected outcomes and "bad" results can lead to frustration, guilt, and indeed "learned helplessness."^{5 6} These negative effects on patients' wellbeing are probably responsible to a large extent for the low adherence to self monitoring seen in patients with both type 1 and type 2 diabetes.⁷

Peel and colleagues previously reported from the same research project on patients views on self monitoring six months after diagnosis.⁸ Results suggested that patients with poorly controlled diabetes were more likely than those with good control to voice concerns and to have problems with self monitoring.

Three years after diagnosis, 18 of these patients (one on insulin) who had ever self monitored their blood glucose were contacted for a third interview round, to explore (changes in) their experiences and views of self monitoring.³ The relevance of a longitudinal approach is underscored by recent research showing that self monitoring practices change over time and may have different effects on glycaemic control in new and established users.⁹ Peel and colleagues found that fewer patients were self monitoring over time, and those who did continue monitoring did so less frequently. Some patients expressed uncertainty about the meaning of the test results and how to act on them, while others found self monitoring to be reassuring and did it routinely. Most participants voiced concerns about the value health professionals placed on their readings. Doctors generally appeared to show little interest in patients' test results after the initial phase, leading some patients to perceive self monitoring as not very important or even pointless. Interestingly, some patients continued to self monitor despite lack of guidance and the perceived health professionals' disinterest.

The generalisability of the findings from this small qualitative study remains uncertain, although the reported experiences and attitudes seem all too realistic and common. The study reminds us of the importance of demographic, social, and psychological variables in explaining the observed interindividual differences. The question of how useful self monitoring is in patients not being treated with insulin remains, but clearly Peel and colleagues' study confirms the need to develop educational strategies that can help patients effectively use blood glucose monitoring and manage negative feedback. As the authors point out, self monitoring is apparently still surrounded with feelings of personal failure and self blame, particularly in female patients. Experience has shown that simply providing patients with a manual on how to overcome common emotional and behavioural barriers to self testing can have significant beneficial effects on psychology and glycaemic control.¹⁰ The second study, a systematic review by Eurich and colleagues, assesses the optimum drug treatment for patients with type 2 diabetes and heart failure.⁴ The review used evidence from eight studies to look at the effects of various blood glucose lowering drugs, including oral drugs and insulin, on morbidity and mortality in patients with type 2 diabetes and heart failure. It found that metformin is the only antidiabetic drug that is not associated with any measurable harm in people with diabetes and heart failure. In fact, metformin was associated with reduced mortality.

A weakness of the review is that most of the data were observational and only one randomised trial was included. However, the review does complement a recently published systematic review on the effectiveness and safety of oral drugs for type 2 diabetes, which found that metformin and second generation sulphonylureas are similarly effective or even superior in terms of glycaemic effects to newer and more expensive agents.¹¹

Despite the new information provided by these reviews, more evidence is urgently needed on the benefits of newer antidiabetic drugs in different populations of patients. Future trials should not only include clinical end points, but also outcomes that are important to patients, in line with the draft guidance from the US Food and Drug Administration.¹² Patients are experts on their own quality of life. It would seem wise therefore for the medical industry and scientists to ask patients to join them in designing clinical trials and choosing the most relevant outcomes to be reported by patients.

Diabetes Psychology Research Group, VU University Medical Centre, 1081 BT Amsterdam, Netherlands

---

This article was posted on bmj.com on 31 August 2007.

Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. Saudek CD, Derr RL, Kalyani RR. Assessing glycemia in diabetes using self-monitoring blood glucose and hemoglobin A1c. JAMA 2006;293:1688-97.
2. Farmer A, Wade A, Goyder E, Yudkin P, French D, Craven A, et al. Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomized trial. BMJ 2007;335:132-6.[Abstract/Free Full Text]
3. Peel E, Douglas M, Lawton J. Self monitoring of blood glucose in type 2 diabetes: longitudinal qualitative study of patients' perspectives. BMJ 2007 doi: 10.1136/bmj.39302.444572.DE[Abstract/Free Full Text]
4. Eurich DT, McAlister FA, Blackburn DF, Majumdar SR, Tsuyuki RT, Varney J, et al. Benefits and harms of antidiabetic agents in patients with diabetes and heart failure: systematic review. BMJ 2007 doi: 10.1136/bmj.39314.620174.80[Abstract/Free Full Text]
5. Dunn SM. Psychological issues in diabetes management: blood glucose monitoring and learned helplessness. Pract Diabetes 1987;4:108-10.[CrossRef]
6. Wysocki T. Impact of blood glucose monitoring on diabetic control: obstacles and interventions. J Behav Med 1999;12:183-203.[CrossRef]
7. Vincze G, Barner JC, Lopze D. Factors associated with adherence to self-monitoring of blood glucose among persons with diabetes. Diabetes Educ 2004;30:112-25.[Free Full Text]
8. Peel E, Parry O, Douglas M, Lawton J. Blood glucose self-monitoring in non-insulin treated type 2 diabetes: a qualitative study of patients' perspectives. Br J Gen Pract 2004;54:183-8.[ISI][Medline]
9. Karter AJ, Parker MM, Moffet HH, Spence MM, Chan J, Ettner SL, et al. Longitudinal study of new and prevalent use of self-monitoring of blood glucose. Diabetes Care 2006;29:1757-63.[Abstract/Free Full Text]
10. Moreland EC, Volkering LK, Lawlor MT, Chalmers KA, Anderson BJ, Laffel LM. Use of a blood glucose monitoring manual to enhance monitoring adherence in adults with diabetes. A randomized controlled trial. Arch Intern Med 2006;166:689-95.[Abstract/Free Full Text]
11. Bolen S, Feldman L, Vassy J, Wilson J, Yeh HC, Marinopoulos S, et al. Systematic review: comparative effectiveness and safety of oral medications for type 2 diabetes mellitus. Ann Intern Med 2007;Jul 16; Epub ahead of print.
12. Food and Drug Administration. Guidance for industry: patient reported outcome measures. Use in medical product development to support label claims. Draft guidance. February 2006. www.fda.gov/cder/guidance/5460dft.pdf.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Relevant Articles

Self monitoring of blood glucose in type 2 diabetes: longitudinal qualitative study of patients' perspectives

Elizabeth Peel, Margaret Douglas, and Julia Lawton
BMJ 2007 335: 493. [Abstract] [Full Text] [PDF]

Benefits and harms of antidiabetic agents in patients with diabetes and heart failure: systematic review

Dean T Eurich, Finlay A McAlister, David F Blackburn, Sumit R Majumdar, Ross T Tsuyuki, Janice Varney, and Jeffrey A Johnson
BMJ 2007 335: 497. [Abstract] [Full Text] [PDF]

Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial

Andrew Farmer, Alisha Wade, Elizabeth Goyder, Patricia Yudkin, David French, Anthea Craven, Rury Holman, Ann-Louise Kinmonth, and Andrew Neil
BMJ 2007 335: 132. [Abstract] [Full Text] [PDF]