Pharmacists Adding Value: Glucose Monitoring In Type 2 Diabetes
Recent policy changes mean blood glucose strips are now restricted for people with non-insulin-treated type 2 diabetes – but that doesn’t mean monitoring is not valuable. Pharmacists can support structured monitoring to promote active self-management.
What is type 2 diabetes?
Type 2 diabetes (T2D) is a long-term condition characterised by elevated blood glucose levels. Over many years, this causes damage to vital organs, and increases the risk of long-term complications. Just over one million Australians are living with diagnosed T2D1.
Making the invisible visible
The symptoms of elevated blood glucose are typically silent in T2D and do not impact much on daily life in the short term. Around 75% of people with T2D use diet/lifestyle modifications or oral hypoglycaemic agents (OHAs) to manage their condition. Both clinicians and people with T2D are often reluctant to intensify treatment to improve outcomes. One of the reasons for this can be that people do not perceive the need to intensify their treatment (low severity) or that they can improve their outcomes (low self-efficacy)2.
Self-monitoring of blood glucose (SMBG) is an important addition to regular assessment of glycated haemoglobin (HbA1c; average blood glucose over the past 8-12 weeks). Unlike HbA1c, SMBG can reveal individual patterns of blood glucose changes, and help in planning meals, physical activity, and timing of medications. Importantly, SMBG helps people to realise that they are living with a serious condition that requires active self-management3.
Psychological barriers to SMBG
Investigation of SMBG using the Information-Motivation-Behavoural Skills model of behavioural change4 demonstrates that, to undertake and sustain SMBG in everyday life, people with T2D need but frequently lack:
- Information, e.g. When to check? How often to check? What do readings mean? What to do if the reading is high/low?
- Motivation, e.g. SMBG is a constant reminder that they have T2D, SMBG is expensive, SMBG is painful/inconvenient
- Behavioural skills, e.g. remembering to check, getting an adequate drop of blood, checking discretely when in public, dealing with other people’s reactions
Furthermore, one of the key psychological barriers to monitoring reported by people with non-insulin-treated T2D is lack of feedback or encouragement from health professionals3
Recent policy changes go against the principle of active self-management
With effect from July 2016, the Australian Government has delisted blood glucose strips from the Pharmaceutical Benefits Scheme (PBS). They remain available via the National Diabetes Services Scheme (NDSS) but there is now restricted access for people with non-insulin-treated T2D. This decision follows a two-year review by the Pharmaceutical Benefits Advisory Committee (PBAC)5 and is influenced by two systematic reviews6,7. Both reviews concluded that the ‘clinical benefit is limited’ for SMBG in this group. That conclusion has been critiqued in other published commentaries8,9, on the basis that the studies varied enormously in their methods (e.g. inclusion criteria, recommended SMBG frequency, education/feedback). A more nuanced conclusion is that unstructured SMBG is not effective as it precludes identification of glucose patterns, while structured SMBG is effective in reducing HbA1c and diabetes-specific distress10, increasing confidence in self-management11, and satisfaction with treatment and perceived control over diabetes12.
Check, change, and check again: a structured approach to SMBG
Random glucose checks are, indeed, unhelpful for the person with T2D: the numbers on the meter are often difficult to interpret, which is unproductive, frustrating and demoralising. Structured SMBG centres on asking a specific question, checking glucose levels at meaningful times and using the findings to answer the question. This is known as ‘experiential learning’ and it is a powerful tool. Not only does it make T2D visible to the person but it also demonstrates the ‘small wins’ that people can achieve with relatively small behavioural changes. Seeing the potentially dramatic effect of swapping raisin toast for wholemeal toast is much more powerful in creating behaviour change than being ‘told’ what to do by a health professional.
How pharmacists can assist people with type 2 diabetes
It is clear that there is an important role for pharmacists moving forward. The Government’s decision to restrict access to those with ‘clinical need’ can be interpreted as enabling access for all people who find it clinically useful. So, rather than advising people with non-insulin-treated T2D that they do not need to monitor at all, have a conversation about why and when to monitor for best effect. Remember, the effectiveness of structured SMBG lies not just in monitoring but also on taking action.
Finally, remember that language matters13. Many people with T2D experience feelings of guilt and anxiety when they get ‘off-track’ with their diabetes management. Pharmacists are in the community to assist people with T2D, to understand, respect and support them. Rather than discouraging people with non-insulin-treated T2D from monitoring, pharmacists can acknowledge their frustrations, and help them to use structured SMBG effectively to increase their engagement in active self-management, and to improve both their glucose levels and their well-being.
What you need to know:
1: Who is eligible for ongoing access to blood glucose strips from 1 July 2016?
People with non-insulin-treated type 2 diabetes are eligible for ongoing access to blood glucose strips, if they have:
- an inter-current illness that may affect blood glucose levels
- been prescribed a medication that may affect blood glucose levels, e.g. sulfonylureas, steroid or anti-psychotic
- unstable or above-target blood glucose levels
- a clinical need to check their blood glucose levels
- undergone a change in their diabetes management in the past 3 months
Whenever a person meets one of these criteria, they will be eligible for a 6-month supply of blood glucose strips. There is no limit to the number of extensions that may be obtained. If in doubt, refer the person to a medical practitioner or credentialled diabetes educator (CDE), who are both authorised to sign the NDSS form for continued access to glucose strips. CDEs have expertise in using structured monitoring and educational techniques to support people with T2D in active management of their condition.
NB. The restrictions do not apply to people with type 1 diabetes, women with gestational diabetes and people with type 2 diabetes who use insulin.
For further information, see www.ndss.com.au.
2: Experiential learning: an example of structured monitoring
- Start with a simple question, e.g. how does breakfast affect my blood glucose levels (BGLs)? How does activity affect my BGLs?
- Every day (e.g. for 3, 5 or 7 days), check your blood glucose level before and after the activity (e.g. 2 hours later). Make a note of the glucose levels and what the activity was.
- How did your blood glucose levels change following each activity? The more structured monitoring you do, the clearer the patterns will be.
- What did you discover? e.g. you might discover that what and how much you eat really matters.
What does this mean for your ongoing diabetes management? e.g. you might want to be more aware of portion size, or incorporate a daily walk after breakfast or lunch.
3: Language matters
Our language shapes the way we feel, think and behave. People are often curious about their blood glucose levels but may be discouraged by the idea of doing blood ‘tests’. The words ‘tests’ and ‘testing’ remind people of doing exams and being back at school; it makes them feel like they are going to be judged for ‘passing’ or ‘failing’ the test. Talking about ‘checking’ glucose is less judgmental and more empowering. ‘Checking’ glucose simply means the person is seeking information to guide what they do next (e.g. whether going for a walk might be useful, whether it is safe to drive) or feedback on what they have consumed (e.g. the impact of a large bowl of pasta or a glass of juice).
People tend to look at glucose readings and think of them as being ‘good’ or ‘bad’. Thinking or talking about glucose levels using emotive language has a tendency to lead to emotional reactions, e.g. getting upset, frustrated, thinking its all ‘too hard’. Sometimes, a person’s behaviour is then counteractive to their goals, e.g. they think catastrophically and decide that if their glucose is high they may as well finish the bar of chocolate or eat the rest of the biscuits. Thinking rationally – i.e. considering glucose readings as within, below or above target – means the person is more likely to act rationally to achieve their goals, e.g. to go for a walk to bring the glucose level down within target range. Remember, all readings are useful because they represent the person engaging actively engaged in self-managing their condition – but checking glucose at meaningful times of day will be most useful and least frustrating.
About Professor Speight
Prof Jane Speight1,2 MSc PhD CPsychol AFBPsS
- School of Psychology, Deakin University, Geelong
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne
Professor Speight is Foundation Director of The Australian Centre for Behavioural Research in Diabetes (ACBRD), a partnership for better health between Diabetes Victoria and Deakin University.
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