Are patients with type 2 diabetes testing blood sugar levels too often?

blood glucose test strips

If you have type 2 diabetes, but are not taking insulin, should you test your blood sugar?

Last week, a study published in JAMA looked at the costs of unnecessary blood sugar testing in patients with type 2 diabetes who are not at risk of hypoglycemia (dangerously low blood sugar levels). The researchers looked at two years of claims data and found that one in seven patients at low risk of hypoglycemia made three or more claims for glucose monitor test strips, at an average insurance cost of $325 per person per year. The authors conclude:

Despite a lack of clinical evidence and being identified as a low-value service by the Choosing Wisely initiative, a substantial percentage of patients with type 2 diabetes may still be inappropriately self-monitoring blood glucose.

The news coverage of this story was extensive:

NBC News: Many diabetics needlessly test blood sugar at home

The Atlanta Journal Constitution: Are you testing your blood sugar too much? You might be, study says

MedPage Today: Are T2D patients monitoring blood glucose needlessly?

This line of thinking, discouraging self-monitoring of blood sugar, is problematic but understandable.

It is problematic because the purpose of blood sugar testing isn’t necessarily just to guard against hypoglycemia. When patients with type 2 diabetes monitor their blood sugar, it can provide valuable information about how their body responds to different food. Knowledge is power, and knowing that your bowl of whole grain cereal caused a big spike in blood sugar whereas your bacon and eggs did not is valuable information. The point is that glucose strips can be used to monitor more than just dangerously low blood sugars… they can help people identify dangerously high blood sugar, too, and modify their eating patterns to avoid reoccurrence.

In fact, for this reason, many believe that continuous blood glucose monitoring, or CGM, will provide the kind of real-time feedback that is needed to affect the behavior of eaters, whether or not they have type 2 diabetes. (This Stanford study looked at CGM data in “healthy” individuals and noted that 80% of them experienced a diabetic-level spike after eating a bowl of cornflakes and milk.)

But the notion that blood sugar test strips are mostly to safeguard against hypoglycemia is understandable given the conventional advice most patients receive about diet and type 2 diabetes. Typically, patients are encouraged to consume 40 – 60 g of carbohydrate per meal, enough to cause a post-meal blood sugar spike, meal after meal. Patients with type 2 diabetes are not routinely counseled to use blood glucose strips to monitor their diets and eliminate foods that cause these spikes; if they were, most would end up on a low-carb diet simply by listening to their body’s blood sugar rhythms. Sadly, this is not how most patients are using blood sugar strips, so perhaps the usage is, for the most part, “low-value.”

It is troubling to see doctors discouraging the use of monitoring when high blood sugar levels have real consequences. Just last week, we saw this story, reporting that rates of amputations among patients with type 2 diabetes are rising:

Reuters: Diabetic amputations on the rise in the U.S.

[T]he results suggest that many U.S. diabetes patients need more support to keep their blood sugar controlled and more education about foot care, the authors conclude.

Blood glucose monitoring is a tool, but it must be used properly to be effective. It can support patients who are trained to use it to adjust their diets to achieve fewer blood sugar excursions. However, until this training is provided, it is not helping patients who are not at risk for hypoglycemia.

Earlier

Diabetes drugs are a juggling act – is there a better way?

New study: Exceptional blood-sugar control for type 1 diabetics on low carb

The American Diabetes Association misses the mark… again (sigh)

Guides

How to reverse your type 2 diabetes

A ketogenic diet for beginners

Diabetes

Low-carb basics

17 comments

  1. William
    Not now and never been diagnosed with diabetes, however I test BG at least once per day. My way of eating, exercising, relaxing, and living is informed by the records of those tests over the years. 50 test strips cost about $20 in my area of the USA. Well worth it to me.
  2. Don
    Pretty much a waste of time and money in my opinion. There is no need ro fixate on a reading wil vary continuously through out the day. The simplistic use of blood glucose monitoring based on a single food is also irrelevant since it will change based on what other foods are eaten and in what order the foods are eaten. Better to monitor HbA1c and 3 month average.
  3. Tanya
    Sorry Don, you are incorrect. There are ways to determine how food effects you. For a type 2 diabetic immediate knowledge is power and motivation. If you see rises in blood sugar two to 3 hours after eating can tell you more than a 3 month average which gives no detail to dawn effect, insulin effectiveness, and potential inability to metabolize different foods. As a gestational diabetic I found blood sugar instability over 2 to 3 days when I consumed certain foods including hidden sugars. An a1c will never give you that kind of instant information.
  4. John Konrath
    I have been using a continuous glucose monitoring system for more than 6 months. Based on those results I am absolutel convinced people are NOT getting enough blood glucose information using routine testing. “Fasting glucose” is a great example. My glucose the moment I awaken is usually ~100. One hour later BEFORE I eat breakfast it often is about 140. Still “fasting” but but elevating. Also, post meal glucose peaks can occur 1 to 3 hours after eating depending on what and how much was eaten. A single test gives you only a shot in the dark as to what your blood glucose level is. A single test does not give you any idea if your glucose is rising, peaked, or falling. If you want to understand your diet - blood glucose relationship I highly recommend more, not less, testing.
  5. tlclieske
    As a student nurse, let me explain to high of blood sugars effect your boxy to heal. Adding to neuropathy it's a recipe for wounds and injuries not healing leading to sepsis and amputation. In high school I had a very close friend whose father was very died about it and had went hiking got blisters honest feet, for the next year because they didn't know the role and to higher blood sugar playing on those wounds they slowly had to amputate him until he was nothing but a trunk and was begging just to let him go and die. Blood sugar being to high it affects your kidneys it affects your arteries. They are jagged and cause damage. It leads to damage. Higher risk of stroke, and heart issues. Person has to be willing to only to test their blood sugar but to do what it takes to stay healthy and that's up to the patients but discouraging them to do what's necessary to take care of themselves is the most irresponsible thing anybody in the medical field could suggest!
  6. jan
    I know too many people who are at least insulin resistant and probably diabetic (see the work of Dr. Joseph Kraft) who tell me they have "no problem with blood sugar" because fasting levels are still below 100 when checked by their doctors. Diabetes is well advanced by the time the morning fasting blood sugar starts to demonstrate metabolic disorder, but if these people could see their post prandial blood glucose readings for certain foods that they think are "healthy" they may have other thoughts.

    Sadly, we've abdicated our health care to what the insurer will pay for instead of what's best for us. A meter and test strips is a very modest cost out of pocket and will yield a wealth of information.

  7. Robin
    I can't even express how angry articles like those published in the news make me. It wasn't until I was well into neuropathy that my doctor even told me that I was pre-diabetic and that might be the cause and not the spinal compression I have. In April of 2017 he suggested that perhaps it was time for metformin. I suggested that I wanted to try controlling things with my diet first, I don't want to take medications I don't have to take. He said, well give it a try and let me know when you want to begin medication. Needless to say, I was a bit angry when I came home. I first went to the American Diabetes Association website and looked at their dietary information and knew that wasn't right because their recommended diet is exactly what I was eating, and getting heavier by the way. So I dug around and found dietdoctor.com and Jason Fung and did a lot of reading and began my Ketogenic diet journey. At the point I started my morning fasting glucose (b/s) was always between 175 and 200. I began testing my morning b/s reading every day, and I ate solo foods for 3 months - testing 2 hours after eating to see what the relationship was between what I ate and b/s levels, and also discovered the link between return hunger and foods that raised my b/s significantly. At six months, I had dropped 80 lbs and on the Ketogenic diet my HbA1c blood sugar dropped from 7 to 6.1; at nine months I was down 110 lbs and my HbA1c was down to 5.6, and my weight plateaued at 1 year and my HbA1c was down to 5.3 where it has remained - solely by diet without medication. After a lengthy plateau in my weight loss, I did further testing of my blood sugar after eating meat because I read that often times people with metabolic syndrome are as sensitive to protein as they are to carbohydrates because of gluconeogenesis and did in fact discover that lean proteins caused a significant blood sugar spike after eating so I have abandoned them in favor of fattier protein sources, and I am excited to see the scale slowly moving again and I am hopeful that my NAFLD will heal as I continue on this path.

    When I read articles like these I am outraged that it seems clear that BigPharma is behind the articles. I am ashamed that JAMA would even publish such a 'finding."

  8. Jerry
    I was diagnosed with type 2 a few years back. Though my doctor said that I only need to check my a1c once in three months I insisted on checking everyday. This has helped me a lot, I have a better understanding of how my body responds to different foods and exercises. Daily checking allows me to respond to spikes daily instead of waiting three months. I totally disagree with the notion that daily checking is too much. I am hoping that cgm becomes now affordable which would allow more insight and better management of diabetes,.
  9. Cathy
    Jerry, your A1C can only be checked by a lab sample that has to be ordered by your doctor. This gives you your overall BG for the last 3 months. I think your referring to your daily BG reading.
  10. Barbara Newsome
    I'm totally confused I'm eating what I'm supposed to so what is making my blood sugar go up to 2:55 every morning I called my doctor and she couldn't even tell me I'm taking 22 units of Humalog daily and I'm taking 40 units of a long a acting insulin every day rich like you what can I see next how to store
    Reply: #11
  11. Brigitte
    Barbara, have you heard of the Dawn effect? It is a physiological effect to get the body ready in the morning, unfortunately, it does not work correctly in diabetics.
    In addition, what you are supposed to eat depends on whose guidelines you are following. If you stick to ADA or NHS of any other official, government-endorsed guidelines, it will accelerate the disease process to the "inevitable" longterm damages. I suggest you check out Dr Fung instead and follow the low carb way of life. Not stuffing carbs in the mouth means less need for medication to make the blood sugar look pretty. In the long run, there will be less damage to your organs.
  12. Julia Parfitt
    Luckily we live in New Zealand where health care is largely free.Thank god some of you in the US have some degree of care through Obama Care.We have private care but our public health services are so good as we found out and are free so we don't probably need it.

    My view is you should do regular testing. My husband became very sick at the end of a European cruise. He became extremely ill and had to be induced in a coma in Belgium. Since recovery and return by stretcher to New Zealand and a brief period of hospitalisation he has been treated at home. He has occupational therapists , physiotherapists and nurses monitor him in our home . again for free. The progress he has made has been exceptional. The frequent testing he has done has shown that his insulin levels should be only a fifth of what he had prior to this event.

    Weight loss is a key but monitoring is also very important

  13. Mai
    I am new to self-monitoring of blood glucose. Just started at the end of October 2018. I became concerned about high blood sugars in early 2016 when my lab results showed a Hba1c of 6.6. I was called into the GP's office for aduscussion about my raised LDL. The GP wanted me to increase the dosage of Lipitor but I resisted. I took my copy of the report home and studied every line. I did not understand most of it but noticed the Hba1c of 6.6. I knew it was bad because it was flagged as high. I was so disturbed that my doctor had not even mentioned it. I did not trust myself to talk to her in case I might lose my cool talking about it. I wrote her a very civil letter, thanking her for seeing me and giving me a copy of the lab results. I mentioned my high Hba1c which was a concern to me and asked for a referral to Dr. Jason Fung's IDM program. Nine months later I was in the program. I learned about LCHF and Keto, and after a few weeks, some weight came down but that was not an issue because I am a TOFI. Hba1c came down to 5.9 but it remained stubbornly there. I was advised to get a blood glucose meter and test the foods I was eating. I resisted because basically, I am a very sqeamish person. After one year in the program I left with a Hba1c of 6.0 intact. Nothing I did after that could budge it. What the heck! I finally screwed up my courage and got a free meter with the purchase of 100 strips. So expensive! Asked my GP for a prescription for insursnce claims. She thought that I was being obssesive but gave me one anyway. I have been closely monitoring blood glucose before and after meals, and adding moderate exercise right after meals to see the effects. Very interesting! I can see why bio-hacking can be a very addictive activity.
  14. Mai
    Thank you, Robin, for your tip about lean proteins spiking BG. I was suspecting that, and had started adding more oil in my cooking. Would that help? Well, I will test and find out. If not, I will choose to eat more fatty meats.
  15. Vi
    My husband tests his BG every morning and has done so since diagnosed with Type 2 Diabetes in 2015. By doing this, he has seen the very direct results of switching from a SAD to a LC/Keto diet. His BG is now, without meds, in the normal range, and far lower than it was on the SAD with meds. When he does eat a high-carb item, he clearly sees the affect on his BG reading the next morning. I know that seeing his results each day help him stay LC without too much nagging on my part. Unfortunately, the folks that are wanting to stop regular BG monitoring are the same ones who said that women don't need regular mammograms and that men don't need regular PSA testing. All of these tests are tools in trying to stay as healthy as possible for as long as we can. No, we don't need to overreact or agonize over the results of any of them, but we ("we" meaning patients and physicians) can use them to help monitor how we're doing.
  16. Robin
    I strongly disagree with this study as a T2 diabetic. I was doing finger sticks up to 10 times a day to try to see patterns in how my blood sugar reacted to certain foods (eat to your meter). I insisted that my doctor prescribe the Freestyle Libre for me and now I can see at a glance how my blood sugar is all day. I lowered my A1C from 9 to 6.4 in the 3 months after getting my Libre and am trying to get it even lower. I try not to let my BS go over 140. I am not on insulin and I'd like to keep it that way. I consider my Libre and Dr Fung's books my most important tools for managing my diabetes. I cancelled my Weight Watchers membership and paid for a membership on Diet Doctor instead. It's been life changing.
  17. Bryan
    Another insurance company effort to reduce their cost. Daily testing of different foods is mandatory if you want to control your b/s. Trust me i am diabetic 2 and the daily monitoring is critical to know which foods kick it up. Also the keto diet keeps me at 6.0 A1C and that is the only plan in town if you dont want to be on the meds and control with diet. It is not hard as far as diets go you get plenty to eat just avoid
    all the whites = minimal if any carbs.

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