It's been said that you can't change what you can't measure. Yet, self-monitoring of blood glucose (SMBG) can both help and hinder patients and us in our mutual quest to gauge glycemic control, as well as optimize outcomes and quality of life. Here are some common objections and barriers to testing that patients have shared with me. I'm sure you can hear echoes of the familiar in these.
1. "I don't test because I can tell what my sugars will be."
I'll ask the patient, "What about having home readings, so you and we have feedback on how your sugars are?" Or, "if you need to test if you feel you may be having a hypoglycemic episode?" I tell patients that they do not need to test daily if their glucose levels have been stable. I also gently remind patients that they may not be that accurate in predicting how low or high their levels have been.
2. "All I need is the A1c."
This remark launches a discussion about the distinction between the hemoglobin A1c and SMBG. I'll compare an A1c to the 10,000-foot view of glycemic control, but note that we can't see the details without SMBG.
These details include: if a patient's glucose levels are elevated, what times of day are they running high? Or low? We can then target our strategy-a kind of personalized medicine.
Patients can also see what effect a piece of pie-or their exercise-has on their SMBG readings. If glucose levels are high, I encourage my patients not to become discouraged, or be critical of themselves. Instead, I ask them to reframe this as feedback. These readings are a call to action, a signal to tweak, to fine-tune: whether it's titrating their metformin dose, adding another medication, increasing exercise, or decreasing a portion. These data help me and my colleagues on the team-whether our registered dietitian or our registered nurse-make recommendations on just what those adjustments may be.
What if the readings are consistently stable? My response: "Congratulate yourself; pat yourself on the back, and use this feedback as encouragement to sustain this positive path."
3. "I used to check my sugars regularly, but when I brought them in, my doctor didn't really look at them. So, I stopped testing and logging them."
I start by acknowledging that diabetes self-management can be as demanding as it is challenging. We're asking patients to keep track of multiple items: taking medications, checking their feet, obtaining lab tests, having their eyes checked, scheduling and keeping 3- or 6-month follow-up appointments, and SMBG. All of this in the name of reducing the risk of complications that may show up decades down the road, if ever.
It's so easy to let the urgency of now, the hustle and bustle and noise of daily demands-work, school, children, bills-crowd out the just as essential, though quieter, bigger picture: the potential for developing irreversible complications. In a way, we're asking patients to go against human nature. I also let the patient know that he or she may not feel any different, even with a glucose level of 300 mg/dL.
I then gently remind patients that they're ultimately doing all of this not for their spouse, caregiver, CDE, health coach, or me, but for themselves. It's about investing small amounts of time and effort, consistently, to reduce the risk of diabetes exacting a much greater, more painful toll: a hospitalization for a stroke or heart attack, or thrice-weekly treks to a dialysis center. It's having them feel that diabetes is not in control of them. It's for the pride and satisfaction of taking on what may have seemed at one point a gargantuan task, a seemingly insurmountable mountain, and proving to themselves, and others, that they can control their diabetes and live well.
What are your views, or tips you've gleaned from working with patients with diabetes? Let's start, and continue, a dialogue of best practices. I'm eager to hear from you!
Next month I'll discuss other SMBG challenges:
• The fear and discomfort that accompany finger pricking
• Forgetting to log readings and/or bring them to each visit