S Garg, IB Hirsch. Self-monitoring of blood glucose. International Journal of Clinical Practice, 2010; 166:1-10.

Studies have shown that reducing A1c levels can delay and/or reduce the overall risk of microvascular and macrovascular complications associated with both type 1 and type 2 diabetes. Implementation of intensive diabetes management (using insulin pumps or multiple daily injections along with increased frequency of self-monitoring of blood glucose [SMBG]) is expensive, although there is a significant reduction in risk of long-term complications and cost. Although the benefits of optimal glucose control seem clear, the risk of severe hypoglycaemia can be a barrier to achieving this goal. In fact, there is nearly a threefold increase in hypoglycaemia with intensification of treatment in type 1 diabetes. This is further complicated by the results of recent clinical trials in type 2 diabetes (ACCORD, ADVANCE, and VADT). The results of these trials have shown conflicting outcomes in the intensively treated arm. This paradox has created a need for new technology that will facilitate optimal glucose control by recommending appropriate insulin doses while decreasing the risk of hypoglycaemia. There is no questioning the role of SMBG in insulin-requiring patients with diabetes as it helps guide patients and the providers to adjust their insulin dose on a daily basis. There is enough data documenting the beneficial effects of increased SMBG in such individuals. However, the story for patients with type 2 diabetes who are not on insulin therapy is different. There is no consensus on frequency and timing of SMBG, and its exact impact on glucose control in non-insulin-requiring individuals with type 2 diabetes is debatable. Part of the reason for this controversy may be related to increasing healthcare cost and thus payers finding ways not to reimburse SMBG, since there is conflicting data and the evidence of SMBG improving long-term outcomes in such individuals is not fully evaluated. The prevalence of diabetes is rising worldwide and there are more than 24 million people, with both diagnosed and undiagnosed type 1 and 2 diabetes, in the USA. With a limited number of endocrinologists or diabetes specialists available, tools to help patients adjust their insulin dose at home should help in improving their glucose control. Several technologies such as continuous glucose monitors (sensors) and glucometers (SMBG) are on the market and have been shown to help patients improve glucose excursions, reduce glucose variability, decrease time spent in hypoglycaemia and hyperglycaemia, and improve A1c levels. Other software available on insulin pumps can also guide patients with adjustment of insulin dose, especially mealtime boluses.

WHAT THE STUDY MAY MEAN TO YOU AS A HEALTH CARE PROVIDER: Garb and Hirsch concluded by hoping hope the future might see many such technologies being used on a regular basis to guide providers and patients for better long-term outcomes.

WHAT THE STUDY MAY MEAN TO YOU AS A HEALTH CARE CONSUMER:
Self-monitoring is key to the control of any chronic illness. Ways to improve the self-monitoring of diabetes should increase the effectiveness of the self-management of the disorder.

RE Glasgow et al. Outcomes of Minimal and Moderate Support Versions of an Internet-Based Diabetes Self-Management Support Program. Journal of General Internal Medicine, August 17, 2010.

Internet and other interactive technology-based programs offer great potential for practical, effective, and cost-efficient diabetes self-management (DSM) programs that are capable of reaching large numbers of patients. Russ Glasgow and his associates evaluated minimal and moderate support versions of an Internet-based diabetes self-management program, compared to an enhanced usual care condition. A three-arm practical randomized trial was conducted to evaluate minimal contact and moderate contact versions of an Internet-based diabetes self-management program, offered in English and Spanish, compared to enhanced usual care. A heterogeneous sample of 463 type 2 patients was randomized and 82.5% completed a 4-month follow-up. Primary outcomes were behavior changes in healthy eating, physical activity, and medication taking. Secondary outcomes included hemoglobin A1c, body mass index, lipids, and blood pressure. The Internet-based intervention produced significantly greater improvements than the enhanced usual care condition on three of four behavioral outcomes (effect sizes [d] for healthy eating = 0.32; fat intake = 0.28; physical activity= 0.19) in both intent-to-treat and complete-cases analyses. These changes did not translate into differential improvements in biological outcomes during the 4-month study period. Added contact did not further enhance outcomes beyond the minimal contact intervention.

WHAT THE STUDY MAY MEAN TO YOU AS A HEALTH CARE PROVIDER: The Internet intervention met several of the RE-AIM criteria for potential public health impact, including reaching a large number of persons. It was also practical, feasible, and engaging for participants, but with mixed effectiveness in improving outcomes, and consistent results across different subgroups.

WHAT THE STUDY MAY MEAN TO YOU AS A HEALTH CARE CONSUMER: The authors conclude that additional research is needed to evaluate longer-term outcomes, enhance effectiveness and cost-effectiveness, and understand the linkages between intervention processes and outcomes. This is a superb group of investigators, however, so better results can be expected from their investigations.