The role of blood glucose monitoring in non-insulin treated type 2 diabetes: what is the evidence?

A systematic bibliometric analysis on the clinical practice of CGM in diabetes mellitus from 2012 to 2022

Background

Continuous glucose monitoring (CGM) has revolutionized diabetes management, but a comprehensive analysis of its clinical implementation is lacking. This study aims to explore CGM in diabetes practice over the past decade using bibliometric analysis. It will identify trends, research focal points, and provide a framework for future investigations.

Materials and methods

The Web of Science Core Collection (WOSCC) was utilized to acquire literature pertaining to the employment of continuous glucose monitoring (CGM) in diabetes that was published between the years 2012 and 2022, and to conduct a comprehensive analysis of the associated citation data. To achieve bibliometric visualization and analysis of the collated data, the bibliography package in the Rstudio(v.4.2.2), Citespace 6.2.R4, and VOS viewer were employed.

Results

A total of 3024 eligible publications were extracted from 91 countries, with the United States being the leading country in terms of the number of issued articles. Furthermore, the annual publication rate has shown a gradual increase during the past decade. Among the various journals in this field, DIABETES TECHNOLOGY & THERAPEUTICS was identified as the most highly cited one. Keyword clustering analysis of the extracted publications indicates that the research hotspots in the past decade have primarily focused on "continuous glucose monitoring", "glycemic variability", "type 1 diabetes", "hypoglycemia", and "glycemic control". Moreover, the analysis of keyword emergence reveals that "Time In Range" and "Young Adult" represent the current research frontiers for the years 2012-2022.

Conclusion

The concept of Time in Range (TIR) has garnered considerable attention as a significant area of inquiry and an emerging research trend in the clinical practice of Continuous Glucose Monitoring (CGM) for Diabetes Mellitus. Moreover, recent investigations have demonstrated a growing focus on young adults with type 1 diabetes as the research population of interest. In the foreseeable future, research endeavors will persist in the pursuit of improving glycemic management among young adults through the utilization of continuous glucose monitoring (CGM) technology, while also delving into the examination of the Time in Range metric via supplementary clinical investigations.

Identifying the unmet needs of individuals with Type 2 diabetes: an international web-based survey

Aim: To identify and understand the main unmet needs of individuals with Type 2 diabetes (T2D). Materials & methods: An online survey was conducted in Brazil, China and Russia of individuals with recently diagnosed T2D. Results: The survey, involving 300 individuals with T2D, identified a need for more information regarding food/diet and for increased awareness of T2D symptoms. While most participants (94%) had experienced symptoms prior to their diagnosis, only 55% of symptomatic individuals sought medical attention. Conclusion: Novel strategies to increase awareness of diabetes should be developed and tested, and may enable earlier diagnosis and improve patients' quality of life.

Enhanced self-monitoring blood glucose in non-insulin-requiring Type 2 diabetes: A qualitative study in primary care

AIMS AND OBJECTIVES

To contribute to both theoretical and practical understanding of the role of self-monitoring blood glucose for self-management by describing the experience of people with non-insulin-requiring Type 2 diabetes in an enhanced structured self-monitoring blood glucose intervention.

BACKGROUND

The complex context of self-monitoring blood glucose in Type 2 diabetes requires a deeper understanding of the clients' illness experience with structured self-monitoring of blood glucose. Clients' numeracy skills contribute to their response to blood glucose readings. Nurses' use of motivational interviewing to increase clients' regulatory self-efficacy is important to the theoretical perspective of the study.

DESIGN

A qualitative descriptive study.

METHODS

A purposive sample of eleven adults recently (<2 years) diagnosed with non-insulin-requiring Type 2 diabetes who had experienced a structured self-monitoring blood glucose intervention participated in this study. Audio recordings of semi-structured interviews and photographs of logbooks were analysed for themes using constant comparison and member checking.

RESULTS

The illness experience states of Type 2 diabetes include 'Diagnosis,' 'Behavior change,' and 'Routine checking.' People check blood glucose to confirm their Type 2 diabetes diagnosis, to console their diabetes-related fears, to create personal explanations of health behaviour's impact on blood glucose, to activate behaviour change and to congratulate their diabetes self-management efforts.

CONCLUSIONS

These findings support the Transtheoretical model's stages of change and change processes. Blood glucose checking strengthens the relationships between theoretical concepts found in Diabetes Self-management Education-Support including the following: engagement, information sharing and behavioural support.

RELEVANCE TO CLINICAL PRACTICE

Tailoring diabetes care specifically to clients' stage of their illness experience with use of self-monitoring blood glucose contributes to engagement in self-management. Motivational interviewing and collaborative decision-making using blood glucose checking increase regulatory self-efficacy for people living with non-insulin-requiring Type 2 diabetes.

Three approaches to glucose monitoring in non-insulin treated diabetes: a pragmatic randomized clinical trial protocol

Background

For the nearly 75% of patients living with type 2 diabetes (T2DM) that do not use insulin, decisions regarding self-monitoring of blood glucose (SMBG) can be especially problematic. While in theory SMBG holds great promise for sparking favorable behavior change, it is a resource intensive activity without firmly established patient benefits. This study describes our study protocol to assess the impact of three different SMBG testing approaches on patient-centered outcomes in patients with non-insulin treated T2DM within a community-based, clinic setting.

Methods/Design

Using stakeholder engagement approach, we developed and implemented a pragmatic trial of patient with non-insulin treated T2DM patients from five primary care practices randomized to one of three SMBG regimens: 1) no testing; 2) once daily testing with standard feedback consisting of glucose values being immediately reported to the patient through the glucose meter; and 3) once daily testing with enhanced patient feedback consisting of glucose values being immediately reported to the patient PLUS automated, tailored feedback messaging delivered to the patient through the glucose meter following each testing. Main outcomes assessed at 52 weeks include quality of life and glycemic control.

Discussion

This pragmatic trial seeks to better understand the value of SMBG in non-insulin treated patients with T2DM. This paper outlines the protocol used to implement this study in fifteen community-based primary care practices and highlights the impact of stakeholder involvement from the earliest stages of project conception and implementation. Plans for stakeholder involvement for result dissemination are also discussed.

Trial registration

ClinicalTrials.gov NCT02033499, January 9, 2014.

Self-monitoring of Blood Glucose in Non-Insulin Treated Type 2 Diabetes (The SMBG Study): study protocol for a randomised controlled trial

BACKGROUND

The benefit of Self-monitoring of Blood Glucose (SMBG) in people with non-insulin treated type 2 diabetes remains unclear with inconsistent evidence from randomised controlled trials fuelling the continued debate. Lack of a consistent finding has been attributed to variations in study population and design, including the SMBG intervention. There is a growing consensus that structured SMBG, whereby the person with diabetes and health care provider are educated to detect patterns of glycaemic abnormality and take appropriate action according to the blood glucose profiles, can prove beneficial in terms of lowering HbA1c and improving overall well-being. Despite this, many national health agencies continue to issue guidelines restricting the use of SMBG in non-insulin treated type 2 diabetes.

METHODS

The SMBG Study is a 12 month, multi-centre, randomised controlled trial in people with type 2 diabetes not on insulin therapy who have poor glycaemic control (HbA1c ≥58 mmol/mol / 7.5%). The participants will be randomised into three comparative groups: Group 1 will act as a control group and receive their usual diabetes care; Group 2 will undertake structured SMBG with clinical review every 3 months; Group 3 will undertake structured SMBG with additional monthly telecare support from a trained study nurse. A total of 450 participants will be recruited from 16 primary and secondary care sites across Wales and England. The primary outcome measure will be HbA1c at 12 months with secondary measures to include weight, BMI, total cholesterol and HbA1c levels at 3, 6, 9 and 12 months. Participant well-being and attitude towards SMBG will be monitored throughout the course of the study. Recruitment began in December 2012 with the last participant visit due in September 2016.

DISCUSSION

This study will attempt to answer the question of whether structured SMBG provides any benefits to people with poorly controlled type 2 diabetes who are not being treated with insulin. The data will also clarify whether the telecare support provides additional value. The overall acceptability of SMBG as a tool for self-management will be assessed.

TRIAL REGISTRATION

UKCRN 12038 (Registered March 2012). ISRCTN21390608 (Retrospectively registered 15^th May 2014).

A Culturally Appropriate Self-Management Program for Hispanic Adults With Type 2 Diabetes and Low Health Literacy Skills

PURPOSE

This study assessed the feasibility of adapting a patient-centered educational intervention for type 2 diabetes (T2D) self-management for a Hispanic population with low health literacy skills.

DESIGN

A descriptive qualitative study design and phenomenological analyses were used. Nine Hispanic adults with T2D recruited from a rural community health center participated in an educational program that instructed on low glycemic food choices, meaningful glucose self-monitoring, and physical activity to decrease blood glucose spikes. Participants' feedback was recorded during four 2-hour focus group sessions. Findings/Results: Participants' feedback clustered around four themes: information and knowledge, motivation and barriers to change, experiences with new behaviors, and personal responsibility.

DISCUSSION/CONCLUSIONS

Data support the feasibility of adapting an established health-enhancing approach for promoting self-management of T2D to a low health literacy Spanish-speaking population.

IMPLICATIONS FOR PRACTICE

The findings may help in further development of tools and strategies for improved T2D self-management in the study population.

Frequency of self-monitoring blood glucose and attainment of HbA1c target values

AIMS

Test strips for self-monitoring of blood glucose (SMBG) represent in Argentina, around 50 % of diabetes treatment cost; the frequency of their use is closely associated with hyperglycemia treatment. However, the favorable impact of SMBG on attainment of HbA1c goal in different treatment conditions remains controversial. We therefore attempted to estimate the relationship between use of SMBG test strips and degree of attainment of metabolic control in an institution of our social security subsector (SSS) in which provision is fully covered and submitted to a regular audit system.

METHODS

Observational retrospective study using information of 657 patients with T2DM (period 2009-2010) from the database of the Diabetes and Other Cardiovascular Risk Factors Program (DICARO) of one institution of our SSS. DICARO provides-with an audit system-100 % coverage for all drugs and keeps records of clinical, metabolic and treatment data from every patient.

RESULTS

The average monthly test strips/patient used for SMBG increased as a function of treatment intensification: Monotherapy with oral antidiabetic drugs (OAD) < combined OAD therapy < insulin treatment. In every condition, the number was larger in people with target HbA1c levels. Test strips represented the larger percentage of total prescription cost.

CONCLUSIONS

In our population, the type of hyperglycemia treatment was the main driver of test strip use for SMBG; in every condition tested, targeted HbA1c values were associated with greater strip use. Patient education and prescription audit may optimize its use and treatment outcomes.

Once Daily Self-Monitoring of Blood Glucose (SMBG) Improves Glycemic Control in Oral Hypoglycemic Agents (OHA)-Treated Diabetes: SMBG-OHA Follow-Up Study

BACKGROUND

The aim of this study was to compare glycemic control between SMBG-continued and -discontinued subjects with type 2 diabetes in the SMBG-OHA study.

METHOD

Of the 96 subjects from the SMBG-OHA study, 59 were recruited for the 24-week, comparison follow-up study. The study outcomes were the differences in change in HbA1c levels at 24 weeks between the 2 groups, and change in SMBG frequency in SMBG-continued subjects.

RESULTS

Although health insurance does not cover the cost of SMBG, 22.0% of subjects continued SMBG of their own will after the SMBG-OHA study was completed. HbA1c levels were maintained from 6.81 ± 0.55% to 6.64 ± 0.53% in SMBG-continued subjects. Conversely, HbA1c levels were increased from 7.18 ± 0.63% to 7.48 ± 0.84% in SMBG-discontinued subjects. HbA1c levels were significantly different by 0.83 ± 0.25% (95% CI: -1.33 to -0.36). The difference in change in HbA1c between the groups was -0.46% (95% CI: -0.78 to -0.15). SMBG frequency was decreased from 2.02 ± 1.06 to 1.53 ± 0.86 times a day.

CONCLUSIONS

HbA1c levels were maintained in SMBG-continued subjects but increased in SMBG-discontinued subjects. The study implied that almost once daily SMBG is helpful to maintain glycemic control in non-insulin-treated type 2 diabetes.

Acute effect of fast walking on postprandial blood glucose control in type 2 diabetes

Purpose

Several guidelines have recently recommended exercise for prevention and treatment of type 2 diabetes. However, determining the optimum exercise conditions, e.g., the intensity, amount, frequency, and type of exercise, is difficult, particularly by patients themselves. We have investigated the acute effect of fast walking on postprandial blood glucose levels among patients with type 2 diabetes.

Methods

Fourteen patients diagnosed with type 2 diabetes at least 1 year previously were eligible for inclusion in this study during educational hospitalization. Three walking programs, natural walking (walking at a natural speed), 10 % fast walking, and 20 % fast walking, were performed 1 h after lunch in a randomized sequence with a washout period of 1 day. Walking time was 30 min in all the programs. Primary outcome was determined by self-monitoring of blood glucose. Blood glucose levels were measured before walking, after walking for 15 min, and at the end of walking. Heart rate and systolic and diastolic pressure were also measured for safety reasons.

Results

All the participants completed the study with no adverse effects. Compared with natural walking, fast walking markedly improved postprandial glucose excursion in an intensity-dependent manner without any adverse effects.

Conclusion

Fast walking acutely reduced postprandial blood glucose levels among patients with type 2 diabetes. Our method has major implications for the practice of diabetes education in clinical rehabilitation.

Self-monitoring of blood glucose: use, frequency drivers, and cost in Argentina

Although test strips for self-monitoring of blood glucose (SMBG) represent around 50% of diabetes treatment cost in Argentina, little is known about their current use and relationship with different types of treatment. We therefore aimed to estimate the current use of test strips and identify the major use drivers and the percentage they represent of total prescription costs in 2 entities of the social security system (SSS) of Argentina. Observational retrospective study measuring test strip prescriptions delivered by pharmacies from the province of Buenos Aires (8115 records collected during 3 months provided by the Colegio de Farmacéuticos de la Provincia de Buenos Aires) of affiliates with type 2 diabetes (T2DM) from 2 large entities of the SSS system. The average monthly test strips/patient used for SMBG was 97.5 ± 70.1. This number varied according to treatment: monotherapy with oral antidiabetic drugs (OAD) < combined OAD therapy < insulin treatment. Test strips represented a higher percentage of the total prescription cost in people under OAD monotherapy (84.6%) and lower in those with insulin analogs (46.9%). In our population, the type of hyperglycemia treatment was the main driver of test strip use for SMBG and its impact on the total prescription cost depends on the kind of such treatment. Since it has been shown that patients' education and prescription audit can optimize test strip use and treatment outcomes, implementation of such strategies could appropriately support, optimize, and reduce ineffective test strip use in people with T2DM.