DIABETES VIGNETTE

320 Pract Diab Int October 2008 Vol. 25 No. 8 Copyright © 2008 John Wiley & Sons

Diabetes Vignette

A routine day at the diabetes clinic waslivened up when a patient proffered hismonitoring sheet (Figure 1). He pulled itout of a well-maintained cardboard filewhich contained 13 years worth of rigor-ously recorded capillary glucose values.Extreme care had been taken to calli-graphically record three glucose valuesevery day, with notes on activities, thedate when a new test strip box wasopened, and even the correspondinglunar cycle. He was questioned about thefour-figure values jotted near the insulininjections and self-monitoring of bloodglucose (SMBG) values. Apparently, hehad been accounting for every insulininjection and lancet use that he had doneto date! As the monitoring sheet showed,he was on the 8025th finger prick and the8926th insulin injection of his life. Not sur-prisingly, he worked as an accountant.Surprisingly, his HbA1c was 9%!

Why then, this paradox of poor controlin the face of motivated self-monitoring?SMBG is an important aspect of diabetesself-care and is crucial in patients withpoor glycaemic control to help titrate ther-apy. It constitutes one aspect of ‘patientempowerment’ which features highly onthe list of desirables in the NationalService Framework standards for dia-betes.1 Yet, anyone involved in caring forthe diabetic patient is well aware of the dif-ficulty in getting patients to do regular ifnot intensive monitoring. Often it is theworried well who do monitoring with itsfinancial implications. Motivating factorsfor patients to monitor their capillary glucose vary. For some it may be the fearof complications, for some the need forbetter quality of life or the need to be incontrol, and for others a need to conformto standards expected by the treatingphysician or to avoid the berating sessionat the diabetes clinic. The neat andextremely methodical recording hints at anobsessive compulsive streak in ourpatient. The monitoring exercise seemedto be an end in itself, giving him a feelingof control and a false sense of security.Concern about the recorded high valuesmight have produced further anxieties,with or without self-blame, as well asattempts to improve glycaemic control

although studies show that this is notalways the case.2,3 Rigorous monitoringthat does not facilitate better controldespite all efforts can be exasperating forpatients. Thankfully, in our patient theobsessive monitoring was producing norecognisable detriment to mental health.He seemed to have a good understandingof target values, but no desire to achievethem. Motivation will not translate intoproductive changes unless all aspects ofempowerment are addressed. Many fac-tors may prevent a proactive approach torecorded values including patients’ healthbeliefs, false perceptions of current con-trol, prevailing state of asymptomaticity,an inability or unwillingness to prioritise,fear of hypoglycaemia or weight gain, fearof generating further anxiety, denial etc.

Often, even when intensive monitor-ing is done, lack of collateral data makesinterpretation impossible. Our patient’sdetailed charting had been offeringopportunities to improve control at everyvisit and perhaps even allow furtherresearch into glycaemic excursions andlunar cycles! On the one hand there is theguilt-ridden patient who is embarrassedat not having taken the effort to monitor,and on the other there is the beamingchap waiting expectantly for the pat onthe back for having monitored andrecorded diligently despite it not havingmade the slightest difference to hisHbA1c. It is perhaps more painful for the

health care worker to see the latter, withpoor glycaemic control despite excellentmonitoring rather than due to lack of it.Good intentions are a start but, unlessthey are followed through, the numbersjust won’t add up despite the best ofaccounting. A desire in the patient toachieve target values needs to be gener-ated to ensure translation of the monitor-ing effort into effective remedial action –which makes one wonder: shouldn’t webe paying our patients rather than GPs forvalues monitored and targets achieved?

Ayesha Ali, MB BS, Foundation Year1 DoctorLuxy J John, MB BS, MRCP(UK),Consultant Physician, Diabetes andEndocrinologyDiana Princess of Wales Hospital,Northern Lincolnshire and Goole NHSFoundation Trust, UK;e-mail: ayeshanasrullah@hotmail.com

References1. Improving Diabetes Services – The NSF Two

Years On. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4106716

2. Farmer A, Wade A, Goyder E, et al. Impact ofself monitoring of blood glucose in the man-agement of patients with non-insulin treateddiabetes: open parallel group randomised trial.BMJ 2007; 335(7611): 132.

3. McAndrew L, Schneider SH, Burns E, et al.Does patient blood glucose monitoring improvediabetes control? A systematic review of the lit-erature. Diabetes Educator 2007; 33: 991–1010.

Taxed by obsession or obsessed with taxation?

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Figure 1. The patient’s monitoring sheet

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