A new study ignites a debate over the frequency of finger pricks and how blood sugar data should be used.
A recent study published in JAMA Internal Medicine concluded that 14 percent of patients with type 2 diabetes are testing their blood sugar levels too often.
That conclusion concerns many of the healthcare professionals who treat patients with diabetes on a daily basis.
It’s also at the center of a debate within the diabetes community about how often people with type 2 diabetes should measure their blood sugar.
Three of the largest diabetes-related medical associations in the country (the American Academy of Family Physicians, the Society of General Internal Medicine and the Endocrine Society) are now supportive of encouraging patients to test their blood sugar less rather than more.
This contradicts decades of patient education efforts.
At the same time, there’s concern this small study’s results could be misleading and harmful to many diabetes patients, leading them to believe they don’t need to test their blood sugar levels frequently.
Frequent blood sugar testing is still considered a critical part of saving limbs, eyesight, and kidney function in people with diabetes.
What the study uncovered
The report states that the participants in the study “who don’t require insulin” were buying enough test strips to test their blood sugar two or more times a day.
According to medical guidelines, this is unnecessary.
The report also encourages the assumption that just because a patient is on metformin, or doesn’t need insulin or other blood sugar-lowering medications upon diagnosis, means they don’t need other medications and that their blood sugar levels are still in a healthy range.
“Patients who only take metformin — the most commonly prescribed blood sugar lowering medication — don’t have this risk,” explained the study. “So most don’t need to test at all, much less multiple times daily.”
This conclusion assumes that every patient on metformin is achieving healthy blood sugar and HbA1c levels. Your A1c provides an average of where blood sugar levels have been over the prior three months.
However, blood sugar levels don’t simply sit in one place all day.
Instead, they fluctuate based on the balance of carbohydrates, fat, protein, activity, stress, diabetes-related medications that require regular adjustments, and other non-diabetes related medications such as cortisone injections that will raise blood sugar levels.
Without a glucometer, test strips, and a lancing device, patients have no way to assess on a daily basis whether the medication they’re taking to manage their blood sugar levels after each meal is working, if it needs to be adjusted, or if it should be swapped for a different treatment plan.
How often is enough?
“There are two sides to this,” said Lisa Harris, CDE, RN at Rush University Medical Center in Chicago, Illinois. “Sure, some patients test just to test because their doctor said to do it, but if no one is actually looking at the blood sugar logs, and the patients themselves don’t know how to interpret them, then yes, that’s a waste.”
But Harris says many patients with type 2 diabetes — and even those with prediabetes — would likely benefit from testing more frequently, not less.
Along with better diabetes education and support.
She also hopes to see continuous glucose monitors given to patients for a few days at a time shortly after a diagnosis of prediabetes or type 2 diabetes so they can see the fluctuations in their blood sugar levels for themselves.
“Testing your blood sugar can be extremely informative for people when they’re trying to prevent the need for further medication, like insulin,” Harris told Healthline. “Even if they’re only taking metformin, seeing for themselves how certain types of foods affect their blood sugar can have the biggest impact on motivating them to make changes in their diet.”
Harris says, on the other hand, if a patient is showing consistently healthy blood sugar levels over a period of a few months, it’s appropriate to take a break from frequent testing.
“I’d tell them, ‘Just keep doing what you’re doing, and periodically, we’ll spot-check, testing frequently for a few days just to see that things are still on track,’” she said.
“I wouldn’t want an 80-year-old woman taking metformin for type 2 diabetes whose A1c is in a healthy range to needlessly be poking her fingers every day,” Harris said.
But that’s not the case for many patients.
Instead, Harris says some patients keep testing and don’t report consistently high blood sugar levels to their doctors.
And since many doctors aren’t downloading and reviewing the patient’s blood sugar logs, things go easily unnoticed, even with quarterly HbA1c tests.
“It’s hard to adjust a medication dosage or add a new medication based just on A1c levels. You need more data showing when and why blood sugars are running higher,” explained Harris. “And the A1c doesn’t catch everything. People can wake up with high fasting blood sugars on a daily basis and an A1c result might not reveal that.”
An A1c result of 8 percent isn’t nearly as startling as seeing a 190 mg/dL on the screen of a glucose meter after eating a bowl of sugar-loaded cereal.
The A1c results are infrequent, vague, and easy to dismiss, whereas the daily results on a glucose meter provide specific results based on specific decisions around food, medication, and exercise.
Other experts in the diabetes field are equally frustrated with the idea of telling diabetes patients they don’t need to test blood sugar levels as frequently.
“It reflects the oft-repeated ignorance of the role of glucose monitoring in diabetes management. It has been often misunderstood by nonexperts,” Dr. George Grunberger, FACP, FACE told Healthline.
Grunberger founded the Grunberger Diabetes Institute in Bloomfield Hills, Michigan, in 2002 after years of establishing diabetes-focused programs in other medical institutions.
“Simply doing finger sticks without any guidance might be truly wasteful. As has been concluded in many studies and in conclusion of the first AACE national consensus conference on glucose monitoring,” explained Grunberger, who was chairman of the conference. “Glucose monitoring has to be actionable.”
Other recent research
This recent study only looked at two groups of patients.
Those who didn’t take any diabetes medications and those who took non-insulin diabetes medications.
These two groups are considered to see the least fluctuation in their blood sugar levels. However, another recently published study contradicts the idea that these patients don’t need to more closely monitor their levels.
It also concluded, similar to Grunberger’s statement, that patients are receiving the education and treatment options they need in order to improve their blood sugar levels.
“If one looks at studies which actually assessed outcomes of actionable results — in which patients are being educated, being given practical guidance on what to do, or change based on the glucose levels — the results are a bit different,” Grunberger said.
The financial side
The American Diabetes Association reports that diabetes costs the United States approximately $327 billion annually — with a 26 percent increase over the past five years — and only 15 percent of that cost is related to diabetes supplies such as test strips.
About 60 percent of that financial burden, on the other hand, is due to “hospital inpatient care” and “prescription medications used to treat diabetes.”
By providing patients with adequate tools to assess and manage their diabetes on a daily basis, it’s more logical to conclude that this would then reduce the rates of hospital visits.
The cost of prescription medications used to treat diabetes is also a heated issue in today’s current healthcare system.
A recent statement from the FDA Commissioner, Dr. Scott Gottlieb, said that upcoming changes in the overall system will force drug prices to come down in the next few years.
In fact, the higher rates of patients testing their blood sugar levels more often could be contributing to the decline in diabetes-related amputations in recent years.
“In 2010, 73,000 American adults who have diabetes and are over age 20 had amputations,” a Healthline article in 2016 explained. “That may sound like a lot, but amputations account for only a small percentage of the over 29 million people in the United States with diabetes. Better diabetes management and foot care have caused lower limb amputations to be reduced by half over the last 20 years.”
What other countries do
Countries such as Finland have found that more frequent blood sugar checks performed by patients resulted in lower costs, explained Gretchen Becker, author of The First Year: Type 2 Diabetes: An Essential Guide for the Newly Diagnosed.
Becker has covered the issue of telling patients to test less many times in her blog, Wildly Fluctuating, because it is a source of great frustration for both diabetes patients and diabetes specialists.
The struggle to get adequate diabetes testing supplies is significant enough that innovators such as OneDrop, Livongo, DiaThrive, and mSugr offer affordable test-strip subscription programs along with diabetes education that bypasses prescriptions and insurance approval.
Pharmaceutical giants such as Accu-Chek have tried to copy this model to keep up with patient interest in getting testing supplies for less.
Another study in the United Kingdom in 2016 found that SMBG (self-monitoring blood glucose) plays a critical role in improving blood sugar levels — but only when paired with proper guidance on what to do with those results.
“SMBG does little good if patients are given a meter and told to test once a day — usually fasting — or if they’re told to test more often — usually before meals but not after eating — but they’re not told what to do with the results,” explained Becker.
Motivated patients, on the other hand, have used their meters to determine which foods make their blood sugar levels rise the most, explained Becker. Which leads them to make different choices in the future for the sake of improved results.
“A friend of mine was diagnosed with type 2 diabetes recently,” Becker told Healthline. “His diabetes educator gave him a meter and said, ‘I don’t want you testing more than once a day.’ So he bought another meter, and he’s testing after meals with that one, and once a day with his ‘official’ meter.”