June 4, 2013

ADA Relies On Faulty Studies, Not Good Advice

I wish I could copy all of the reasoning in this one file, but that would make for a long file. Dr. William H. Polonsky and Dr. Lawrence Fisher have some excellent points about self-monitoring of blood glucose (SMBG). The points run counter to the entrenched position of the ADA “experts” which rely on what I believe are faulty studies. I refer you to this blog from April 9, 2012. To read both sides of the point-counterpoint, you will need to download this file using Adobe Reader or a PDF compatible reader.  If you have one, clicking on the link should download it for you.

Yes, I am writing many blogs on self-monitoring of blood glucose (SMBG) and diabetes self-management education (DSME) because of the lack of support for this from the American Diabetes Association (ADA) and the American Association of Diabetes Educators (AADE). They both are using “feel good” hype, but doing nothing to turn words into actions. The AADE and ADA both participated in the development of National Standards, but do not have the personnel to make it a reality. In other words, they are ideal intentions, but no actions are taken to make it a reality.

The AADE is wrapped up in their own importance to the point they can't bare to see lay people even trained to assist in DSME. Yes, lay people (or better yet lay people with diabetes) could be trained to be able to give DSME as peer mentors or peer-to- peer workers with supervision, but this beyond the desires of AADE. They have to protect their position in the diabetes hierarchy. They are afraid that like the few studies have shown, people respond to fellow people with diabetes better than people that issue mandates and their only diabetes knowledge is what they have learned in books.

People with diabetes are generally open to listening to other people with diabetes that can speak to them at their level and not at the lowest common level that CDEs are prone to do. Every time I hear this from people that have met with CDEs, I know that they did not do the assessment they are supposed to do. They were only interested in making a few points and getting out rather than do what is required by their own policies and procedures. This says there is a disconnect between the upper levels of the AADE and the CDEs working in the field. This disconnect is almost large enough to say that there are two organizations, the AADE and CDE and each highly disregards the other.

This makes what Drs. Polonsky and Fisher even more important as they can see the value of SMBG and what the education would mean to people with type 2 diabetes. Yet, they see what the studies are doing that the ADA relies on and can see how they are set up to give predetermined results by asking the wrong questions. You don't have to rig the results if you carefully ask the wrong questions. You know that insurance has something to do with this and the National Institute of Medicine has to be involved.

Yes, I can see the USDA and their experts being involved in some of this because they don't want people to be testing and finding out how bad the nutritional information is that they are promoting through the ADA. In almost 100 percent of what we read about nutrition or food plans for people with diabetes, no mention is ever made of using our blood glucose meters to test what the different foods do to our blood glucose. This means that someone has a vested interest in not mentioning this as then there would be more available education for people with type 2 diabetes and more reason to have testing done.

Drs. Polonsky and Fisher state the following and discuss each.
  1. Recommended frequency and timing of SMBG must be adequate
  1. Patients need to be knowledgeable about SMBG and have the necessary skills to use SMBG data
  1. Clinicians need to be knowledgeable about SMBG, actually see the SMBG data that patients collect, and have the necessary skills to use the SMBG data
  1. SMBG data must be collected and recorded in a manner that permits blood glucose patterns to be readily observable and easily intelligible for clinicians and patients
  1. Further concerns about study design

  2. Conclusions
In the conclusions, Drs. Polonsky and Fisher clearly state how easy it is to arrive at the consensus the ADA arrived at by asking the wrong questions. A number of studies that Malanda et al. Explicitly excluded from their review have explored innovative ways of using structured and targeted SMBG testing for this patient population effectively, and have shown significantly reduced A1C, depression, and distress, and enhanced diabetes self-efficacy. The doctors feel that rephrasing the research question and retargeting studies to evaluate the specifics of effective use of structured SMBG are warranted.

Drs. Polonsky and Fisher clearly feel that asking the right questions and doing the studies properly would yield different results.

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