by Mary M. Austin, MA, RD, CDE
People with diabetes receive numerous recommendations for diabetes
management, whether it’s what to eat, what medications to take, to be
active, and/or, to check your blood glucose. All of these recommendations
require that the individual adopt, adapt and adhere to a new lifestyle
behavior. All of these recommendations also present choices; the patient can
either follow or ignore some or all of them.
Adults tend to have a problem-centered orientation to learning. For the
adult learner, there is a greater tendency to ignore recommendations that do
not immediately apply to their current problems or situations.
There seems to be no appreciable difference in the recommendations to
eat healthy, take medications as directed and to be physically active for
people with type 1 or type 2 diabetes. When it comes to self-monitoring of
blood glucose (SMBG) the difference is significant. Diabetes-related
organizations such as the American Diabetes Association, the American
Association of Clinical Endocrinologists, and the International Diabetes
Federation all agree that people who are on multiple-daily insulin injections
or insulin pumps should test their blood glucose three or more times per day.
These individuals are taught what action needs to be taken based on their blood
glucose results. They are applying the skill (when and how to properly test)
and information (the blood glucose result) to solve a problem.
What is significant in type 1 diabetes is that SMBG is used as a tool to
provide answers to situation or “problem” (ie, hypoglycemia,
hyperglycemia, correct amount of insulin to administer). From an adult learning
perspective, performing SMBG has value and is useful for someone on insulin
therapy.
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Mary
M. Austin
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This relationship has not been as clear for people with type 2 diabetes,
especially if they are not on insulin therapy. For the person with type 2
diabetes, SMBG recommendations vary from “at least once per day” (if
not on insulin therapy), “may be useful as a guide to the success of
therapy” to “postprandial SMBG may be appropriate to achieve
postprandial glucose targets.”
From my clinical experience with type 2 patients, whether they are on
insulin therapy or not, the majority of those who perform SMBG do so because
they are asked to do so. They do not use the information to provide answers to
situations or “problems.” It is not uncommon for many type 2 patients
to stop blood glucose monitoring. Granted, there are many hypotheses for why
people stop monitoring. But, from an adult-learning perspective, it is not
surprising that if an individual does not see the value or usefulness of an
activity, he/she stops the activity. More than a few type 2 patients, who
tested once per day when fasting, have told me they stop monitoring because
“the numbers are always the same.” Interestingly these are also the
same patients whose HbA1c levels are rising.
My observation has been that there is no consistency in how SMBG
education, if at all, takes place. Individuals can obtain a blood glucose meter
in a number of ways. For example, an individual can obtain a meter at the
doctor’s office, in a pharmacy, at a durable medical goods storefront,
shipped from a medical supply business, obtained free at a health fair,
supplied by a diabetes educator, borrowed from a relative, purchased on the
internet or even at garage sales.
At best, when SMBG education does occur, the “mechanics” of
operating the meter, how often to test, and properly recording the results are
emphasized. What to do with the blood glucose results, target blood glucose
goals, and when to test to obtain the most useful information are not
addressed. In this scenario, the adult learner is not given a reason to
continue the SMBG behavior.
The American Association of Diabetes Educators’ position statement,
Self-monitoring of Blood Glucose: Benefits and Utilization, states that,
“Healthcare professionals providing diabetes care and education should
encourage and support the use of SMBG in all individuals with diabetes. Safe
and appropriate blood glucose monitoring methods need to be taught including
self-management skills that incorporate and utilize the data obtained from
blood glucose monitoring for an individualized program of self care.” The
position statement also outlines the educational components of SMBG (see table
1). For the adult learner, especially type 2 patients, the most critical
component is ensuring that the patient is able to apply the SMBG data to their
own diabetes treatment regimen.
Table 1: Educational Components of
SMBG |
| 1. Operation of the meter including calibration. |
| 2. Obtaining an adequate blood sample. |
| 3. Proper use of attendant supplies, such as control
solutions. |
| 4. Care and storage of device and supplies. |
| 5. Proper disposal of sharps. |
| 6. Documentation of results. |
| 7. Utilization of results. |
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Perhaps it is time for the diabetes community to promote and adopt
standardized SMBG education (see table 2). There are roles and responsibilities
of the health care provider when teaching SMBG regardless of how and where a
patient obtains their meter. This list could become the basis of standardized
SMBG education. Standardization would build awareness that the patient goal for
SMBG is to use the blood glucose results, not simply test “X” times
per day. After all, SMBG is a diabetes self-management activity.
Table 2: Roles and Responsibilities of the
Health Care Provider in Teaching SMBG |
| 1. Assist in selecting a glucose monitoring system best
suited to the patient’s needs. |
| 2. Discuss and determine, by mutual agreement, individualized
glycemic target goals. |
| 3. Provide instruction in accurately performing SMBG and
recording glucose values. |
| 4. Provide education in making appropriate therapy
adjustments utilizing the results. |
| 5. Provide periodic reassessment of user technique and data
utilization. |
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Mary M. Austin, MA, RD, CDE, is Owner and President of The Austin
Group, LLC in Shelby Township, Mich., and is an Endocrine Today Editorial Board
member.
For more information:
- ADA. Diabetes Care. 2009;1:s17-19.
- Austin MM. Diabetes Educator. 2006;32:835-847.
