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March 2019 -
Volume 17, Issue 2

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From the Editor

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Editorial

Dr. Abdulrazak Abyad
DOI: 10.5742/MEWFM.2019.93623

Original Contribution

Self-monitoring of Blood Glucose Among Type-2 Diabetic Patients: An Analytical Cross-Sectional Study
[pdf]
Ahmed S. Alzahrani, Rishi K. Bharti, Hassan M. Al-musa, Shweta Chaudhary
DOI: 10.5742/MEWFM.2019.93624

White coat hypertension may actually be an acute phase reactant in the body
[pdf]
Mehmet Rami Helvaci, Orhan Ayyildiz, Orhan Ekrem Muftuoglu, Mehmet Gundogdu, Abdulrazak Abyad, Lesley Pocock
DOI: 10.5742/MEWFM.2019.93625

Case Report

An Unusual Persistent Mullerian Duct Syndrome in a child in Abha city: A Case Report
[pdf]
Youssef Ali Mohamad Alqahtani, Abdulrazak Tamim Abdulrazak, Hessa Gilban, Rasha Mirdad, Ashwaq Y. Asiri, Rishi Kumar Bharti, Shweta Chaudhary
DOI: 10.5742/MEWFM.2019.93628

Population and Community Studies

Prevalence of abdominal obesity and its associated comorbid condition in adult Yemeni people of Sana’a City
[pdf]
Mohammed Ahmed Bamashmos
DOI: 10.5742/MEWFM.2019.93626

Smoking may even cause irritable bowel syndrome
[pdf]
Mehmet Rami Helvaci, Guner Dede, Yasin Yildirim, Semih Salaz, Abdulrazak Abyad, Lesley Pocock
DOI: 10.5742/MEWFM.2019.93629

Systematic literature review on early onset dementia
[pdf]
Wendy Eskine
DOI: 10.5742/MEWFM.2019.93627



Middle East Quality Improvement Program
(MEQUIP QI&CPD)

Chief Editor -
Abdulrazak Abyad MD, MPH, MBA, AGSF, AFCHSE

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Publisher -
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medi+WORLD International
AUSTRALIA
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March 2019 - Volume 17, Issue 3

Self-monitoring of Blood Glucose Among Type-2 Diabetic Patients: An Analytical Cross-Sectional Study

Ahmed S. Alzahrani (1)
Rishi K. Bharti (2)
Hassan M. Al-musa (3)
Shweta Chaudhary (4)

(1) Family Medicine specialist, Community medicine resident, Abha, King Khalid University Saudi Arabia
(2) Assistant Professor, Community medicine consultant, Faculty of Medicine, King Khalid University,
Saudi Arabia.
(3) Associate Professor, Family Medicine consultant, Family and Community medicine department,
Faculty of medicine, King Khalid University, Saudi Arabia.
(4) Assistant Professor, Department of Anatomy, Faculty of Medicine, King Khalid University, Saudi Arabia.

Corresponding author:
Dr. Ahmed Salem Al-zahrani,
Family Medicine specialist, Community Medicine resident
Abha, King Khalid University, Saudi Arabia

Email :
ahmedalzahrani122333@gmail.com

Abstract


Background: Diabetes mellitus (DM) is a public health disease needing urgent consideration; it has a great impact on human life in addition to being costly to manage. According to the current recommendations, self-monitoring of blood glucose (SMBG) is important in order to achieve and maintain glycemic control, prevent and identify hypoglycemia, prevent severe hyperglycemia and support lifestyle changes.

Methods: The objective of this study is to explore the effect of using SMBG on glycemic control among type 2 diabetic patients attending the primary health care centers in Abha city in the Kingdom of Saudi Arabia, by comparing those who are monitoring themselves and others who are not. The study design was analytical cross-sectional and conducted through an interviewing questionnaire.

Results: The age of participants was 30-82 years old, with a mean age distribution of 57.4 years old. The percentages of groups doing and not doing SMBG were 43% and 57% respectively. Chi square tests show that the relationship between glycemic control and SMBG is statistically significant according to frequency and time of doing SMBG, since almost all of the results for the participants who do SMBG are above the target for glycemic control (>=7%). The relationship between glycemic control and compliance according to SMBG shows there is a statistically significant relationship with appointment compliance among the group doing SMBG, and with drug compliance among the other group.

In both groups, almost all the participants were above the target for control (>=7%), which means that there is no relationship between doing SMBG and better glycemic control.

Conclusion: There is not sufficient evidence to show that the self-monitoring of blood glucose is associated with an improvement in glycemic control among type 2 diabetics and it is shown that glycemic control for both groups that are using and not using SMBG is above the target. It is recommended that more well conducted randomized controlled trials should be undertaken to evaluate the relationship between SMBG and glycemic control in type 2 diabetes, at the same time the current guidelines for the use of SMBG among patients with well controlled non-insulin treated type 2 diabetes need to be reviewed.

Key words: Self-monitoring, blood glucose (SMBG), glycemic control, type 2 diabetes, comorbidities.


INTRODUCTION

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia that results from defects in insulin secretion, action or both(1).

Diabetes can be classified into type 1 diabetes (B-cell destruction usually leading to absolute insulin deficiency), type 2 diabetes (ranging from being characterized predominantly by insulin resistance with relative insulin deficiency to predominantly an insulin secretory defect with insulin resistance) and other specific types of diabetes (1).

Diabetes and its complications are major causes of death in many countries. Type 2 is the most prevalent type occurring in up to 91% of adults with diabetes in high-income countries. It is estimated that 193 million people with diabetes are undiagnosed and they are more at risk of developing complications (2).

The prevalence of type 2 diabetes in Saudi Arabia is about 32.8%; the predicted prevalence will be 35.37% in 2020; 40.37% in 2025 and 45.36% in the year 2030. The coefficient on time factor indicates that the prevalence rate has increased from 1982-2015 (3).

Saudi Arabia should include preventive measures against diabetes on a war footing basis in its national health policy to minimise the burden of the disease (3).

In patients with type 2 diabetes, SMBG can help to achieve better glycemic control, although there is not sufficient evidence to confirm that strict monitoring in these patients is associated with an improved outcome (4).

The outcome of several clinical studies, especially amongst diabetics on insulin therapy, has shown that SMBG plays a key role in preventing complications in the short, medium and long term.

According to the American Diabetes Association (ADA) and the National Academy of Clinical Biochemistry (NACB), patients and healthcare personnel should be trained on the appropriate use of the device, as well as on the correct interpretation of data (5).

In type 2 diabetes, the efficacy of frequent glucose measurements remains uncertain. The results of studies suggest that SMBG can play an important role in improving metabolic control if it is an integral part of a wider educational strategy (6).

Higher SMBG testing rates were associated with lower HbA1c, only when stratifying the analyses to control for treatment intensification (4).

A significant reduction in HbA1c levels was associated with Asian populations, in a small sample size, and telecare, and with those patients with baseline HbA1c greater than 8.0% (7).

There was no convincing evidence to support a recommendation for routine self- monitoring of all patients and no evidence of improved glycemic control in predefined subgroups of patients(8).

SMBG indications can be used as a measure for acute correction ("primary adjustment"), if blood glucose levels are increased or decreased during intensive insulin therapy, when correction may be made with rapid-acting insulin or administration of carbohydrate (9).

The OneTouch® Select Simple™ glucose meter meets current regulatory expectations for glucose meter performance (10) and consideration of personal aspects of daily living that impact on an individual's ability to achieve their desired glycemic control(11).

Optimal glycemic control will improve long-term outcomes in many patients with diabetes. Tools such as new therapeutics and advanced technology, including highly accurate BGMSs, will help patients, working alongside their diabetes teams, to achieve the goal of improved glucose control (12).

The health burden due to DM in Saudi Arabia is predicted to rise to catastrophic levels, unless a wide-ranging epidemic control program is adopted, with great emphasis on healthy diet, including exercise and active lifestyles, and weight control. To properly manage DM in Saudi Arabia, a multidisciplinary approach is required (13).

SMBG is recommended as an essential part of daily DM management regardless of type and mode of treatment strategy of adjusting medication at monthly intervals based on intensified SMBG data can be adopted in conjunction with HbA1c results to achieve better glycemic control (14). According to one published study, 15.3% of people with type 2 diabetes practice SMBG (15).

Results of a Saudi study conclude that SMBG has a positive impact on glycemic control, expressed as decrease in HbA1c levels with time post referral(19). T2DM patients following SMBG have shown better lifestyle changes and compliance to drug therapy. It could be due to regular monitoring of blood glucose levels thereby patients became motivated and understood the importance of dietary changes, regular exercise and intake of antidiabetic pills in controlling the disease and its associated complications(19). Patients following SMBG have also shown a more positive attitude and awareness about diabetes and risk factors associated with it than patients without SMBG follow-up (19).

According to ADA, the glycemic targets are : HBA1c at target (defined as <7%) and not at target (defined as >7) (19).

FBS at target (defined as 80-130mg/dl) and not at target (defined as >130mg/dl) (20). RBG at target (defined as <180 mg/dl.) and not at target (defined as >180mg/dl) (20).

This study aimed to explore the effect of using SMBG on glycemic control among type 2 diabetic patients at Abha city's PHCCs.

MATERIALS AND METHODS

This research had an analytical cross-sectional study design to explore the effect of SMBG on glycemic control among type 2 diabetics in Abha city's PHCCs by comparing those who are doing it and others who are not doing it.

Type 2 diabetic patients attending governmental primary health care centres (PHCCs), excluding those with type 1 and gestational diabetes, made up the study population. There are about 10 primary health care centres in Abha city according to Abha sector of Aseer health affairs, serving about 5,000 diabetic patients. The study used STATCALC EPI software and the sample size was 314 calculated. The sample was recruited using systematic random sampling of patients attending the PHC.

The data were collected using a validated questionnaire which was distributed and initiated through an interview with participants. The study was approved by the ethical committee (institutional review board), and permission was granted by Aseer health affairs. Consent was obtained from participants verbally. Data were cleaned, coded, entered and analyzed using SPSS version 21.

RESULTS

Participants were aged between 30 and 82 years old with a mean age distribution of 57.4. Males constituted 47.8% of the sample and females made up 52.2%. The bio-demographic characteristics of type 2 diabetic patients according to their self-monitoring of blood glucose status are shown in Table 1.

Click here for Table 1: Bio-demographic characteristics of type 2 diabetic patients according to their self-monitoring of blood glucose status

Table 2 reveals complications of diabetes were present in about 43.9% of the participants (46.7% among the group doing SMBG) with 25.4% Retinopathy (14.3% were doing SMBG and 34.7 were not), Neuropathy is about 51.4% (23.8% were doing SMBG and about 74% were not). About 78.3 % of participants had diabetes for five years or more (87.4% among those doing SMBG), the majority of treatment received was by metformin in about 82.2% of participants: 69.6% were doing SMBG and 91.6% were not; the lowest is glimepiride by 5.1%. Comorbidities of diabetes were present in 51.3% of all participants: hypertension 50%, lipid disorders 26%, obesity 4% and others 20%.

Click here for Table 2: Diabetes data for patients according to their self-monitoring of blood glucose status

In the group doing SMBG: 46% had comorbidities and 54% had no comorbidities, while in the other group: 55% had comorbidities and 45% had no comorbidities.

Our result shows, causes of not doing SMBG were mainly because of unavailability of strips (36%) and no desire (about 24%).

Table 3 shows the number of people doing SMBG three times a day was lowest at 5.2%, and twice a day was highest at 45.9%, and moderately more than once a week by about 25%. Time of doing SMBG was before meals in 59.3%, feeling of hypoglycemic episode 35.6% and during episode of illness 5.2%.

The scale of was SMBG helpful shows extremely helpful in 28.9%, somewhat helpful in 40.7%, slightly helpful in 11.9% and not at all helpful in 0.7%. For reason for SMBG being helpful if scale was 7 or more it indicated the following: improved diabetes control (70.0%), help during episode of illness (12.7%), better to do physical activity (9.1%) and avoid hypoglycemia (8. Reason for SMBG being helpful if scale is 4 or less is because it is painful 100%. Good diet compliance constitutes about 28 %, fair 55% and poor 18 percent.

Good drug compliance constitutes about 54 percent, fair 45% and poor about 0.64%. Diet compliance among the group doing SMBG was fair (54.1%), good (40%) and poor (10%). Drug compliance among them was fair (29%), good (70%) and poor (1.5%), Physical activity compliance: fair in 63%, good in 24% and poor in 13% appointment compliance: fair in 38%, good in 61% and poor in 0.7%.

Click here for Table 3: Relationship between glycemic control and SMBG among type 2 diabetic patients

Table 4 shows the relationship between glycemic control and SMBG: In relation to glycemic control the frequency of SMBG once daily was in 26% at target, once a week in 46% while twice a day, three times a day and more than once a week all were not at target 100%. Time of doing before meals was at target in 14% while during episode of illness and feeling of hypoglycemic episode was not at target 100%. Not all scales of 'helpful' were at target except extremely helpful 15% and somewhat helpful 9% were at target.

Findings elicit the relationship between glycemic control and compliance according to SMBG: among the group of doing SMBG: diet compliance was good and at target in 9%, fair and at target in 8% and poor and at target 0% drug compliance: good and at target in 12%, fair, poor and at target in 0%. Physical activity compliance: good and at target in 16%, fair and at target in 7% and 0 in poor, Appointment compliance: good and at target 13%, fair, poor and at target 0%.

Click here for Table 4: Relation between glycemic control and compliance according to SMBG among type II diabetic patients

Findings show that about 57% are not doing SMBG in last 6 months and only 43% are not doing SMBG in last 6 months and only 43% are doing it.

DISCUSSION

The age of participants was from 30-82 years old with a mean age distribution of 57.4. Males constituted 47.8% of participants and females made up 52.2%, which is similar to some extent to the results of the Fremantle diabetes study (16).

There was a statistically significant difference (p <0.05) in all bio demographic characteristics according to SMBG, and only gender and marital status were insignificant (p >0.050), and these findings are in accordance with the Fremantle diabetes study(16). In terms of diabetic data, the duration of diabetes shows significant differences between the groups doing SMBG and those who were not (p<0.001) also in concordance with Fremantle diabetes study(16); all types of treatment received show significant differences except glibenclamide (p>0.05). The complications in general show an insignificant difference in terms of who had complications or those who were free of them, but among those who had complications, there is a significant difference with retinopathy and neuropathy groups rather than with nephropathy and cardiovascular complications.

Comorbidities with diabetes were present in 51.3% of all the participants; half of them had hypertension and of the other half, one third had a lipid disorder and