Reviewed by: The ADCES Professional Practice Committee
Acknowledgements: Dolly (Rose) Noskowiak, RN, BSN, CDE; Marie Frazzitta, DNP, FNP-C, PNP, CDE, MBA; Dan Kent, PharmD, CDE; Marilyn Cox, MSN, RN, CDE; Sheila Mapes, MS, RN, ANP-BC, CDE; Melissa Max, PharmD, BC-ADM, CDE; Donna Funk, RN, MAEd, NP, CDE, BC-ADM; James Taylor, PharmD
Effective management of type 2 diabetes is contingent on numerous factors and behaviors. Among the AADE7 Self-Care Behaviors™, SMBG can be a key component of the treatment regimen.1 Large clinical trials have demonstrated that glycemic management, as assessed by hemoglobin A1C (A1C), reduces the microvascular changes that lead to severe diabetes-related complications.2-4 The reduction seen with microvascular, as well as macrovascular, complications was confirmed with the long-term follow-up of the UKPDS trial.5 Current evidence also suggests that post-prandial hyperglycemia can be a risk factor for the development of both microvascular and macrovascular disease leading to cardiovascular risk.6-8
Individualized approaches to lowering the risk of complications are especially important for the adult with type 2 diabetes.9 Although the self-monitoring market may be dominated by the trend towards continuous glucose monitoring, with more funding and research in that area, SMBG continues to be a tool used by many people with diabetes (PWD). In 2015, the CDC reported that 62% of PWD are self-monitoring their blood glucose at least once a day.10 SMBG is an important complement to the measurement of A1C levels because it provides the person with immediate feedback about their blood glucose levels. Unlike A1C monitoring, SMBG provides the person with diabetes a means to distinguish fasting, pre-prandial, and postprandial blood glucose levels, allowing them to monitor the immediate effects of food, physical activity, and medications on glycemic management.11 To be useful, SMBG must be integrated into the diabetes self-management plan in a personalized way so that results are meaningful to the individual.12-13
The diabetes care & education specialist has the skills and training required to ensure the person with diabetes understands the targets and techniques of SMBG, and more importantly, understands how to evaluate and use the data to improve blood glucose levels.
Self-monitoring of blood glucose (SMBG) is a critical component of diabetes management. SMBG, when combined with appropriate supplies, proper technique and education, provides individuals with the resources and information needed to make decisions regarding medication adjustments as well as lifestyle changes. Diabetes care & education specialists play a key role in assisting individuals with choosing a glucose meter that is appropriate for their needs and covered by insurance. Additionally, ensuring that individuals are using optimal technique can help improve the accuracy of results. Frequent monitoring, interpretation and application of SMBG values can help improve overall glycemic outcomes.
The purpose of this paper is to provide basic SMBG guidelines and groundwork so that future papers can focus on more advanced content.
The Role of the Diabetes Care & Education Specialist is to:
SMBG refers both to the act of checking blood glucose levels with a blood glucose meter and utilizing the results to make lifestyle and treatment regimen decisions. Results need to be used by the PWD to make necessary changes to self-care behaviors, to collaborate with their healthcare provider on a routine basis for feedback, and to analyze data and identify potential action plans.
Unfortunately, some people with diabetes may not understand how to utilize SMBG results in the above-described ways. Thus, there is a need to remedy this through diabetes self-management education and support. While the benefits of SMBG have been demonstrated in persons with type 1 diabetes and persons with type 2 diabetes who are treated with insulin, outcomes of studies assessing the effects of SMBG in persons with type 2 diabetes who are not treated with insulin have revealed inconsistent results.
A Cochrane review of randomized controlled trials published in 2012 concluded that there was no substantial evidence of a beneficial effect of SMBG in people with type 2 diabetes not treated with insulin.14 A subsequent review published in 2013 criticized the Cochrane review for excluding many studies and drawing conclusions from only a small number of studies; trials reviewed in the 2013 paper associated SMBG with major and significant decreases in A1C in persons with type 2 diabetes not treated with insulin.7
These inconsistent findings may be due to differing study design elements or other factors, e.g., the implementation of intensive treatment in both the SMBG and control groups. A limitation of some trials included in the Cochrane review analysis14 was the lack of information on modification of behavior or treatment in response to the blood glucose level readings.6-7,15 In a study published 2017 in JAMA, data supports that in subjects with non–insulin-treated type 2 diabetes there was no observed clinically or statistically significant differences in glycemic management or health related quality of life between subjects who performed SMBG compared with those who did not perform SMBG after 1 year.16
In contrast, a consensus report found that high quality efficacy data from randomized controlled trials which used a structured approach (a defined monitoring regimen where results were used to make pharmaceutical or lifestyle adjustments) demonstrated efficacy of SMBG in non-insulin treated type 2 diabetes.12
Similarly, in the Structured Testing Program study (N=483), appropriate use of structured SMBG significantly improved glycemic management and facilitated more timely/aggressive treatment changes in non-insulin treated type 2 diabetes without decreasing general well-being.
Beyond improving clinical outcomes, SMBG data can improve quality of life.16 Most people with diabetes believe that using SMBG has beneficial health outcomes, and those who received training in the interpretation of SMBG results experienced fewer negative feelings about SMBG compared to those who relied on providers to interpret their results.17-18
Interpretation of the blood glucose data. People with type 2 diabetes with proper training are able to use SMBG to predict future episodes of hypoglycemia.19 People with diabetes who inject insulin can be shown how to titrate their insulin dosage based on SMBG values to achieve improved glycemic management while minimizing acute episodes of hypoglycemia.20
Young children or their parents and adults may not recognize symptoms of hypoglycemia with hypoglycemia unawareness. SMBG is particularly valuable in these populations.21 Currently, there are no guidelines or standards for blood glucose monitoring in the growing type 2 pediatric population. In an article by Copeland22 the author recommended that monitoring be done fasting and post prandial at a minimum. This is an indication that more research is needed in this area.
SMBG also has an important place in the management of diabetes in pregnant women, i.e., gestational diabetes. The American Diabetes Association recommends SMBG fasting and after meals and, in some women, before meals to monitor treatment programs in pregnant women.23 Similarly, the National Institute for Health and Clinical Excellence clinical guidelines advise pregnant women with pre-existing diabetes to check fasting and one hour post-prandial blood glucose levels after every meal during pregnancy.
The Diabetes Care & Education Specialist must:
ADCES recommends the following practices:
Self-monitoring of blood glucose is an important aspect of diabetes self-management. The diabetes care & education specialist must be an integral member of the diabetes team in selecting the appropriate glucose meter, educating the individual on the use of the meter, the contribution of the results of checking, to diabetes self-management and the interpretation and application of the data, to changes in the diabetes care plan.
1. AADE 7TM Self-Care Behaviors. 2011. https://www.diabeteseducator.org/practice/aade7-system
2. Diabetes C, Complications Trial Research G, Nathan DM, et al. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977-986.
3. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352(9131):854-865.
4. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352(9131):837-853.
5. Stratton IM, Adler AI, Neil AW, Matthews DR, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000;321:405-12.
6. Parkin CG, Buskirk A, Hinnen DA, Axel-Schweitzer M. Results that matter: structured vs. unstructured self-monitoring of blood glucose in type 2 diabetes. Diabetes Res Clin Pract. 2012;97(1):6-15.
7. Schnell O, Alawi H, Battelino T, et al. Self-monitoring of blood glucose in type 2 diabetes: recent studies. J Diabetes Sci Technol. 2013;7(2):478-488.
8. Cavalot F, Pagliarino A, Valle M, et al. Postprandial blood glucose predicts cardiovascular events and all-cause mortality in type 2 diabetes in a 14-year follow-up: lessons from the San Luigi Gonzaga Diabetes Study. Diabetes Care. 2011;34(10):2237-2243.
9. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012;35(6):1364-1379.
11. Boutati EI, Raptis SA. Self-monitoring of blood glucose as part of the integral care of type 2 diabetes. Diabetes Care. 2009;32 Suppl 2:S205-210.
12. Klonoff DC, Blonde L, Cembrowski G, et al. Consensus report: the current role of self-monitoring of blood glucose in non-insulin-treated type 2 diabetes. J Diabetes Sci Technol. 2011;5(6):1529-1548.
13. Ceriello A, Barkai L, Christiansen JS, et al. Diabetes as a case study of chronic disease management with a personalized approach: The role of a structured feedback loop. Diabetes Research and Clinical Practice. 2012;98(1):5-10.
14. Malanda UL, Welschen LMC, Riphagen II, Dekker JM, Nijpels G, Bot SDM. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin. Cochrane Database of Systematic Reviews. 2012(1).
15. Polonsky WH, Fisher L, Schikman CH, et al. Structured Self-Monitoring of Blood Glucose Significantly Reduces A1C Levels in Poorly Controlled, Noninsulin-Treated Type 2 Diabetes: Results from the Structured Testing Program study. Diabetes Care. 2011;34(2):262-267.
16. Young LA, Buse JB, Weaver MA, et al. Glucose self-monitoring in non–insulin-treated patients with type 2 diabetes in primary care settings: A randomized trial. JAMA Internal Medicine. 2017;177(7):920-929.
17. Kempf K, Kruse J, Martin S. ROSSO-in-praxi: a self-monitoring of blood glucose-structured 12-week lifestyle intervention significantly improves glucometabolic control of patients with type 2 diabetes mellitus. Diabetes Technol Ther. 2010;12(7):547-553.
18. Hortensius J, Kars MC, Wierenga WS, Kleefstra N, Bilo HJ, van der Bijl JJ. Perspectives of patients with type 1 or insulin-treated type 2 diabetes on self-monitoring of blood glucose: a qualitative study. BMC Public Health. 2012;12:167.
19. Childs BP, Grothe JM, Greenleaf PJ. Strategies to Limit the Effect of Hypoglycemia on Diabetes Control: Identifying and Reducing the Risks. Clinical Diabetes. 2012;30(1):28-33.
20. McQueen R, Ellis S, Maahs D, Anderson H, Nair K, Campbell J. Frequency of Continuous Glucose Monitoring Use and Change in Hemoglobin A1C for Adults with Type 1 Diabetes in a Clinical Practice Setting. Endocrine Practice. 2014;20(10):1007-1015.
21. Gonder-Frederick L, Nyer M, Shepard JA, Vajda K, Clarke W. Assessing fear of hypoglycemia in children with Type 1 diabetes and their parents. Diabetes Manag (Lond). 2011;1(6):627-639.
22. Copeland KC, Silverstein J, Moore KR, et al. Management of newly diagnosed type 2 Diabetes Mellitus (T2DM) in children and adolescents. Pediatrics. 2013;131(2):364-382.
23. Standards of Medical Care in Diabetes--2018. Diabetes Care. Jan; 41(Supplement 1): S3-S3. https://doi.org/10.2337/dc18-Sppc01
24. Barry HG. Factors Affecting Blood Glucose Monitoring: Sources of Errors in Measurement. Journal of Diabetes Science and Technology. 2009;3(4):903-913.
25. Jing W, Janice Z, Judith TM, Denise C-P, Susan MS, Linda S. Self-Monitoring of Blood Glucose Is Associated With Problem-Solving Skills in Hyperglycemia and Hypoglycemia. The Diabetes Educator. 2012;38(2):207-218.
26. Cohen RM, Lindsell CJ. When the Blood Glucose and the HbA<sub>1c</sub> Don’t Match: Turning Uncertainty Into Opportunity. Diabetes Care. 2012;35(12):2421-2423.
27. Hirsch IB, Amiel SA, Blumer IR, et al. Using Multiple Measures of Glycemia to Support Individualized Diabetes Management: Recommendations for Clinicians, Patients, and Payers. Diabetes Technology & Therapeutics. 2012;14(11):973-983.
28. Tenderich A. Use of Blood Glucose Meters Among People With Type 2 Diabetes: Patient Perspectives. Diabetes Spectrum. 2013;26(2):67-70.
29. Cypress M, Tomky D. Using Self-Monitoring of Blood Glucose in Noninsulin-Treated Type 2 Diabetes. Diabetes Spectrum. 2013;26(2):102-106.
30. Grady M, Pineau M, Pynes MK, Katz LB, Ginsberg B. A Clinical Evaluation of Routine Blood Sampling Practices in Patients with Diabetes: Impact on Fingerstick Blood Volume and Pain. Journal of Diabetes Science and Technology. 2014;8(4):691-698.
31. Miller KM, Beck RW, Bergenstal RM, et al. Evidence of a strong association between frequency of selfmonitoring of blood glucose and hemoglobin A1c levels in T1D exchange clinic registry participants. Diabetes Care. 2013;36(7):2009-2014.
32. Poolsup N, Suksomboon N, Rattanasookchit S. Meta-analysis of the benefits of self-monitoring of blood glucose on glycemic control in type 2 diabetes patients: an update. Diabetes Technol Ther. 2009;11(12):775-784.
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34. Kitzmiller JL, Block JM, Brown FM, et al. Managing preexisting diabetes for pregnancy: summary of evidence and consensus recommendations for care. Diabetes Care. 2008;31(5):1060-1079.
ADCES provides additional resources in the practice section of www.diabeteseducator.org
Dolly (Rose) Noskowiak, RN, BSN, CDE; Marie Frazzitta, DNP, FNP-C, PNP, CDE, MBA;Dan Kent, PharmD, CDE; Marilyn Cox, MSN, RN, CDE; Sheila Mapes, MS, RN, ANP-BC, CDE; Melissa Max, PharmD, BC-ADM, CDE; Donna Funk, RN, MAEd, NP, CDE, BC-ADM; James Taylor, PharmD
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