Wednesday, November 15, 2006

Blood Glucose Testing - Lost Opportunities

During the three day Institute of Health Economics conference, taking place this week in Edmonton, Canada, experts are debating the efficacy of daily testing of blood sugars for those with type II diabetes reports CBC News.

Canadian diabetes experts are revisiting the idea that people with Type 2 diabetes need to monitor their blood-sugar levels daily.

Such frequent testing is valuable for people with Type 1 who take insulin many times a day. But for people with Type 2, who aren't on insulin, the benefits are less clear and are contentious.


A six-month study by institute fellow Dr. Jeff Johnson concluded the test strips don't offer much benefit to Type 2 diabetics in the long run, and the money governments pay out may be better spent."

There's a number of research studies conducted in the last few years since the time that our guidelines were written that suggest that the long-term benefit of doing more frequent tests for people with Type 2 diabetes has very little impact on their blood-sugar control," Johnson told CBC News on Tuesday.

With my experience as a corporate strategist it boggles my mind how these experts miss the point so often.

In the corporate world, profits are driven by performance and strategists are employed to review business processes and find ways to improve performance to enhance productivity and profits. Folks, it always comes down to money!

And, that's not necessarily a bad thing - enhanced productivity can lead to growth that not only improves the bottomline for a company, but also enhances innovation, employment opportunities and even safety. But, as any strategist will tell you, you cannot make improvements without establishing performance measures, accountability, and ensure that return-on-investment data is being used to find where improvements will make a difference.

It is a continuous cycle of gathering data, learning, tweaking, implementation, testing, and analysis of outcome as you apply changes trying to enhance productivity and profits; and when the data for return-on-investment is impressive, you move forward to implement those process changes system wide that are found to have the best bang for the buck.

If I had a project under way and spent time and money to set up a review of process, then measured various potential changes with the influence of each and then did nothing with the results, it would be a waste of my time, corporate executives time and a lot of money.

Measuring and then not doing anything with the results is simply a waste of time.

Various studies investigating the efficacy of blood sugar testing continue to find that it does little to improve glycemic control in those with type II diabetes.

Now the burning question seems - is it worth all this money to provide meters and test strips when testing doesn't result in improvement in those with type II diabetes?; when the question should be - is there improvement to be made in how results are used to improve glycemic control in those with type II diabetes?

The problem isn't that testing does nothing to improve glycemic control; the problem is nothing is done with the data to effectively make changes that will result in improved glycemic control.

Those with diabetes are told to test; they're given a very powerful tool for data gathering that is reliable, real-time and specific to direct inputs/outputs; what they're not provided is the one thing they require - what to do with the data?

Measuring and then not doing anything with the results is simply a waste of time.

Testing blood sugar, in and of itself, does absolutely nothing to improve blood sugars. Instead testing is a "return on investment" proposition for a person with type II diabetes; if they are going to use the data, it is worth the investment; if they're not, it's a waste of time and money.

Measuring is knowing (as I learned, a saying from Holland - "meten is weten"); simply knowing however is only the very first step; knowing cannot make your blood sugars improve; knowing cannot make your blood sugars decline; but we all knowledge is power.

Power to do what?

Power to change the inputs to see what affect those inputs have on the outcome.

"Eat to your Meter" is a saying often expressed by those who, through trial-and-error, tweaking, testing, measuring, and modifying their diet along the way, have found their meter to be the single most important tool in their control over their disease. The don't just measure their blood sugars, they do something when they see less than desired results.

Measuring and then not doing anything with the results is simply a waste of time.

Those debating the issue of testing, testing supplies and usefulness of testing for the individual miss the point that it's not the testing that is a problem - it's that nothing is done to effectively use the data at hand to make improvements.

The problem is one of perspective not performance.

Rather than evaluate why daily testing is not leading to significant or sustained improvement, the thinking is testing is obviously a waste of time; and with nothing gained, then nothing is to be lost if testing is reduced or eliminated by the individual.

What is lost is opportunity.

Not only the opportunity to evaluate the current assumptions, but also opportunity to really understand how diet affects blood sugars; how changes impact glycemic control in the short and long-term; and how real-time feedback from the meter is invaluable in the decision making process as one learns how to improve glycemic control as they modify their diet.

Rather than ask why testing is not leading to improvement - asking the difficult question, what are we doing wrong here? The assumption is nothing is wrong, diabetes simply is progressive and there is little one can do, so with nothing wrong with the process, there's no benefit to gathering data, which really is what testing is - gathering data.

Measuring and then not doing anything with the results is simply a waste of time.

Until these experts step back from their assumption that the present guidelines are the best we have, testing will remain a useless endeavor for someone with diabetes who follows the guidelines.

For those who understand the concept of actually using their data - testing and re-testing with modifications to see what the result is - it is and will remain an invaluable tool to help make improvement not only possible, but a reality as their blood sugars improve and their HbA1c goes down.

Those individuals who "get it," that testing means having to make changes to see the results also "get it" that with each small improvement they can manage, they also make a parallel improvement to reduce the risk of complications.

That's because those with diabetes who measure and DO SOMETHING with their results know it is possible to achieve normal or near-normal blood sugars and HbA1c when they use the tool - the meter with daily testing is a tool - to do what it takes to gain control and thus reduce the risk of complications.

Just don't wait for the experts, the ADA or the IDF to jump on that bandwagon and promote the idea that daily testing is the single most effective way to gain control. That would mean having to tell the truth about carbohydrates in the diet of those with type II diabetes.

I don't expect that to happen any time soon - instead we'll keep seeing the advice move in the direction of medicating the problem away, and now, leave it all up to the healthcare team, don't inconvenience the patient - just take your medications and come in every few months for tests so we can adjust them.

Makes you wonder whose bottomline benefits most, doesn't it?


  1. Bottomline? Take the power of the data out of the hands of the patients, and you have organizations like the ADA retaining their power.

    Testing is what keeps my Type 1 mother alive (and she acts on the data, too!)with absolutely no diabetic-related complications for over 30 years.

  2. They can have my glucose meter when they pry it from my cold dead fingers. :)

    I even got my doctor to prescribe more test strips so I could test more frequently. That really helped me fine tune my diet as to what foods to avoid or limit.

    Another problem is that acting on the data usually requires deviating from the standard dietary advice to diabetics. Until most diabetics think they have "permission" to try something different, they will be reluctant to do so. As you have pointed out before, the standard dietary advice isn't working. Very few diabetics can brag about an A1C of 5.5% as I have, even though I want to get it lower. A good quality control effort would investigate to find out why it isn't working and make some adjustments.

  3. You are so right....they do nothing with the results, and it seems the docs are already telling patients to "not worry about" testing!!!

    My own sister, diabetic for about 15 yrs, takes Glyburide, 5 mg each tablet, 2 in the AM, one in the PM and Metformin HCL 500 mg tabletsan, 2 in AM, 2 in PM.

    She tells me that her last A1C was 6.2 or 6.3, not sure of the number, and that her last random "was good". Last summer when she visited her between meal sugars were running in the 160' this was over 3hrs after eating.

    But she tells me "Bottom Line--------------You don't have to give up sweets, but you certainly need to cut back, and its not just the cookies, pies, cakes , candy, its also the pasta, breads, ice cream........the key to the whole thing is MODERATION..............the other things is to be very careful with fruit juices, especially orange, loaded with sugar.............fruits, and learn to READ LABELS..................IF SUGARS AND OR CARBS TOO HIGH, DON'T BUY IT.........THEN YOU CAN OCCASSIONALLY SPLURGE WHEN OUT TO DINNER OR A HOLDIAY."

    I've tried over and over, sent her articles, tried to talk to her, but she believes what her doc tells her!!!

  4. In the context of the medical industry, the study and it’s conclusions are dead right. Unfortunately for their victims, dead is the operative term. Anyone who actually used the data would inevitably discover that the dietary advice they were given was actually killing them, hardly a desirable outcome. Better to deprive them of the data in the first place. Current practice doesn’t give the victim any information as to how to use the data anyway, and as long as they follow their “diabetes educator’s” dietary advise the result will inevitably conform to the study’s conclusion.

    The transformation of medicine from a profession into an industry has made the “bottomline” something measured by bean counters.

  5. Anonymous5:35 AM

    As the saying in Holland goes: meten is weten (measuring is knowing). We have to buy our own strips in Holland, so it's not a burden on the Health Care system, only our pockets.

    The standard practice is to follow the standard high carbohydrate diet and throw more medication at it if the blood sugars are out of control and so you end up on insulin. Is that the solution?

    I don't think so. By measuring each day I am not caught on the hop with sudden unexpected highs. If it is high, then I stick to my diet a bit more diligently to get it back in line. It is extemely difficult to do if you only measure once every six weeks or so and the highs have been going on for six weeks without you knowing it.

    The result is that I have been able to reduce my medication dramatically and so stave off the inevitable complications that plague diabetics. No one mentions what the cost to the Health Care system will be of all those amputations, blindness, etc. 100 times more than the cost of the strips.

    Who draws the short straw in this debate? The diabetic with his/her deteriorating health, not the ADA.

    Jo from Holland

  6. Anonymous7:35 AM

    I generally use my meter to tell me whether I need to do some extra exercise to bring the reading down. If I get anywhere near 7.8 (140) at the one-hour mark, I go for a walk (and think about how to modify the meal). I'm certain this reduces my complication risk, thereby saving the health service a ton of money - but getting test strips is astonishingly hard. Short-termism, doncha love it.

  7. Thank you, Regina, for so clearly stating what should be obvious but apparently isn't -- that testing alone isn't going to change anything. It's what the diabetic DOES with those numbers that lead to good control of BGs.

    This seem so obvious to me. Why don't docs (and the ADA) get it??
    Vicki LADA type 1 since 1997
    Testing 10x a day
    A1C under 6 for 8+ years.