Prevalence and Predictors of Home Use Blood Glucose Meters Among the People with Diabetes in Bangladesh and Relation with HbA1c: A Multicenter Cross- Sectional Study

Global Journal of Diabetes, Endocrinology & Metabolic Disorders

Volume 1, Issue 2, September 2022, Pages: 05-22
Received: June 30, 2022, Reviewed: July 27, 2022; Accepted: August 8th, 2022; Published: September 06, 2022

Unified Citation Journals, Diabetes 2022, 1(2) 05-22; https://doi.org/10.52402/Diabetes702
ISSN: 2752-6283

Authors: Kabir MA1, Ahmed S2, Abedin M3, Mallick S4, Dhar A5, Islam AS.6, Hannan MA7, Faruque MO8, Sultana T9, Hoque F10, Zarin N11, Hasan MM12,

1Dr. Md. Ahamedul Kabir, Assistant Registrar, Department of Endocrinology, Shaheed Ziaur Rahaman Medical College Hospital, Bogra, Bangladesh
2Dr. Shamim Ahmed, Former MPH student, Department of Epidemiology, State University of Bangladesh, Dhaka, Bangladesh
3Dr. Mohaiminul Abedin, Lecturer, Department of Anatomy, Abdul Malek Ukil Medical College, Noakhali, Bangladesh
4Dr. Satyajit Mallick, Assistant Professor, Department of Endocrinology, Chittagong Medical College, Chittagong, Bangladesh
5Dr. Ashim Dhar, Medical officer, Department of Endocrinology, Shaheed Shurawardy Medical College Hospital, Dhaka, Bangladesh
6Dr. AHM Shadequl Islam, Resident Physician, Department of Neurology, Shaheed Sheikh Abu Naser Specialized Hospital, Khulna, Bangladesh
7Dr. Muhammad Abdul Hannan, Consultant, Department of Medicine, 250 Bedded General Hospital, Sherpur, Bangladesh
8Dr. Md Omar faruque, Assistant Professor, Department of Endocrinology, Mugda Medical College, Dhaka, Bangladesh
9Dr. Tania Sultana, Resident Physician, Department of Medicine, Dhaka Dental College Hospital, Dhaka, Bangladesh
10Dr. Fazlul Hoque, Lecturer, Department of Community Medicine, Shaheed Syed Nazrul Islam Medical College, Kishoregonj, Bangladesh
11Dr. Nusrat Zarin, Assistatnt Professor, Department of Endocrinology, BIHS General Hospital, Dhaka, Bangladesh
12Md. Mehedi Hasan, Former Statistics student, Department of Statistics, University of Rajshahi, Bangladesh

Corresponding Author:  Dr. Md. Ahamedul Kabir, Department of Endocrinology, Shaheed Ziaur Rahman Medical College Hospital, Bogra, Bangladesh

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Introduction: The importance of self-monitoring blood glucose (SMBG) in the management of type 1 diabetes mellitus has been recognized and has its role in Type 2 diabetes mellitus as well. Despite the health benefits of SMBG, many diabetics do not practice it on a regular basis. Our study aimed at determining the proportion of people with diabetes who practiced SMBG with home use blood glucose meter and also to find out the factors that influence glucometer utilization.
Methods: Between September 2020 and March 2021, this multicenter cross-sectional study was conducted among Bangladeshi adults who had diabetes for more than 6 months and were recruited from the outpatient departments (OPD) of 10 hospitals and private clinics across the nation. For this study, patients who used a glucometer at least once a month were labeled as glucometer users, while the rest were labeled as non-users.
Result: Glucometer users accounted for 50.4 percent of the 1056 participants, while lack of awareness about glucometer use was the main reason for non-use among the non-users. Among the glucometer-users majority (40.7%) had checked their blood glucose weekly and mostly (39.6%) found the fasting state to be the most convenient time to monitor blood glucose. Age, gender, education status, occupation, monthly income status, having a first-degree relative with diabetes, experiencing hypoglycemia & hospitalizations in the previous six months, both physician consultation setting & consultation duration, treatment regimen, awareness of diabetic complications, a proper idea about diabetes control, and thinking of both whether glucometer use helps to manage diabetes or modifying medications were all found to be significantly associated with SMBG adhesion. Whereas marital status, smoking status, diabetes duration, and the existence of diabetic complications had no bearing on this study. In addition, this study found a significant association of glycemic control with glucometer usage (p<0.001).
Conclusion: The importance of SMBG in diabetes management is highlighted in this study.

Diabetes is a dangerous chronic condition that has a huge influence on people’s lives, families, and societies all over the world.[1] The International Diabetes Federation predicted that 465 million (9.3%) persons globally had diabetes in 2019, with that number expected to climb to 700 million by 2045. (10.9%).[2] Adult diabetic people of India, Bangladesh, and Sri Lanka account for 98.9% of the total adult population with diabetes in the south-East Asia region. The prevalence of diabetes in Bangladesh has been steadily rising, reaching 8.1 in 2019, and 63.4% of the people with diabetes suffer from diabetes-related macrovascular and microvascular complications.[3] It was one of the top ten causes of mortality in adults in 2017, with an estimated four million fatalities worldwide.[1]. In 2017, diabetes was the eighth most common cause of death and disability in Bangladesh, and it had a direct healthcare cost to the nation of almost US$ 5.3 billion in 2014.[3] Glycated hemoglobin (HbA1c) testing is still the gold standard for glycemic control monitoring; however, it has several drawbacks.
It can’t provide information about day-to-day and intra-day fluctuations because it’s only done once every three months.[4] Glycemic fluctuation, on the other hand, appears to raise the risk of endothelial dysfunction, cognitive impairment, vascular complications, and death independently.[5] In this situation, one of the most crucial components of diabetes therapy is self-monitoring of blood glucose (SMBG), which patients perform at home using portable glucometers.[4] SMBG is the term for monitoring and documenting blood glucose levels throughout the day, whether at home or in a medical facility, by the patient and/or caregiver.[6] SMBG is essential in the management of patients using insulin, and its importance for patients receiving non-insulin therapy has also been acknowledged.[6]-[11] Previous research have shown that greater blood glucose monitoring frequency is linked to reduced HbA1c and lower incidence of acute complications such as diabetic ketoacidosis in people of all ages.[12],[13] Regular personalized SMBG is universally recommended as a vital tool for the effective management of all patients with type 1 diabetes, according to clinical practice guidelines.[14] However, the evidence for SMBG in type-2 diabetes is ambiguous.[5],[6],[15] Randomized control trials DiGEM, DINAMIC, and ESMON found no difference in glycemic control between type 2 DM patients who practiced or did not practice SMBG. Other randomized control trials that used a research design that included structured SMBG testing, on the other hand, found that type 2 DM patients who practiced SMBG had a larger mean reduction in glycosylated hemoglobin.[16] Despite the health benefits of SMBG, many diabetics do not practice it on a regular basis.[17] In comparison to developing countries like Malaysia, India, and Pakistan, SMBG techniques are currently more extensively practiced in more developed economies like Germany or the United States of America (USA).[4] Age, obesity, sedentary behavior, housewife status, history of chronic respiratory disease, diabetes type, and duration, socioeconomic status, HbA1c level, frequency of HbA1c monitoring, medication regimen, number of oral hypoglycemic agents prescribed, health care provider recommendations, frequency of hospitalization, and availability of blood testing assistance have all been linked to SMBG adherence in studies conducted in the United States and Europe.[17] However, because cultural, economic, and healthcare facilities differ from those in the West, these findings may not be applicable to people in South Asia. To the best of our knowledge, there is virtually little information about this topic in Bangladesh. As a result, we conducted a multicenter study to identify the proportion of persons with diabetes who used a home blood glucose meter for SMBG and to learn more about the factors that influence glucometer use.

General Objective

  • To determine the proportion of people with diabetes practiced SMBG with home use blood glucose meter
  • To find out the factors that influence the glucometer utilization

This multicenter cross-sectional study was carried out among Bangladeshi people with diabetes. The diabetic population was selected from the outpatient department (OPD) of ten hospitals and private clinics across the country between September 2020 to March 2021. Adult people who have had diabetes for more than 6 months duration were considered as the study population and the samples were collected consecutively by purposive sampling technique. Patients with acute illnesses (sepsis, acute MI, severe heart failure, recent admission to the intensive care unit) were excluded from the study. Those who were pregnant or in the lactational phase, suffering from drug-induced diabetes (high dose steroids, pentamidine, diazoxide), or from other secondary causes of diabetes were also excluded. The patients who gave written informed consent were interviewed and necessary demographic information was collected along with types & duration of diabetes, diabetic complications if present if there was any history of hypoglycemia or hospitalizations within the last six months. The study subjects were also asked about their current treatment regimens, the interval of visiting their physicians for consultation, their idea about the control of diabetes, and whether they had any awareness about the factors leading to diabetic complications. Then, they were queried whether they use glucometer for their routine SMBG monitoring. Upon whom consultation they had started using it & how often they had practiced SMBG were asked further among the glucometer-users and the reasons for not using also been noted in the case of non-users. Study subjects who used glucometer at least once a month was considered as glucometer users for this study and the rest of the patients were labeled as non-user. Control of diabetes was defined according to the recommendation of the American diabetic association, 2020 (FBS: 4.4 – ≤ 7.2 mmol/l; PPBS/RBS: ≤ 10 mmol/l & HbA1c: ≤ 7%),[18] while patients were asked about their idea of diabetes control. When the patient answered correctly at least two among the three questions mentioned, his/her idea was considered satisfactory, and the idea was considered unsatisfactory if they answered correctly only one. In the case of those who gave all three answers wrong or couldn’t mention anything were labeled as having no idea. Hospitalizations due to any acute or chronic diabetic complication directly linked with but not for trauma, accident, or any surgical intervention which is not related to diabetes were defined as hospitalization for diabetes. However, documented both symptomatic & asymptomatic as well as probable hypoglycemia was marked as patients suffering from hypoglycemia. e (2007). Data entry was reviewed by Data Management Officer. We used frequencies to describe the study population. The relationship between chosen covariates and SMBG practice, HbA1c level were analyzed by performing a bivariate investigation. In the bivariate arrangement, Chi-Square and Fisher Exact tests were utilized to identify the relationship between response and explanatory variables in order to 5% level of significance. This data was analyzed using IBM SPSS version 20.

Out of the 1188 patients approached, 1059 completed the questionnaire fully while the rest of the 132 questionnaires were discarded due to incomplete and inadequate data, and 3 cases with type 1 DM were further excluded from the final analysis due to a very small number. The majority of the respondents were between 40-60 years (65.9%, n=696) where the female made up 58.8% (n=621) of the population. Most of the participants were housewives (52.6%, n=555) while the monthly income of 65.6% (n=497) of patients was above twenty thousand (Taka). Among the study subjects 90.4% (n=955) were married, 83%(n=876) had received secondary education or above and 76% (n=803) were reportedly non-smoker. Most of the people with diabetes in this study had received consultations in private clinics (49.2%, n=520) followed by affiliated centers of the Bangladesh diabetic association (37.9%, n=400) and government hospitals (12.9%, n=136). First-degree relatives were affected in the case of 71.3% (n=753) diabetic patients and 419 (39.7%) had the disease for 5-10 years duration. The majority of the patients (662, 62.7%) were taking oral medications and 28.8% (n=304) were on both insulin and oral drugs followed by diet & exercise (4.5%, n=48) and only insulin users were 4.0% (n=42). (Table-1) Those who had been hospitalized within the last six months were 65 (6.2%) and 221(n=20.9%) people had experienced some sort of hypoglycemia within that period of time. Only 37.4% (n=395) had taken their physician’s consultation every three months interval whereas most of them had no specific routine visit (51.7%, n=546). About 45.8% (n=484) of the study population had given satisfactory answers when they were asked about their idea about diabetes control and 59.7% (n=630) had awareness of the factors leading to diabetic complications. Nearly 73.7% (n=778) people with diabetes had diabetic complications while 58.7% (n=620) were suffering from peripheral neuropathy, 21.1% retinopathy, 16.3% CVD, 13.3% nephropathy and 17.3% of had erectile dysfunction. (Table:1) People who had been using glucometer was 50.4% and non-user was 49.6%. Lack of awareness about glucometer use was the leading cause for not using it among the non-users (65.5%, n=343) where most of the users had started using it upon consultation of their physicians and the majority (84%, n=447) had their own glucometers. Interestingly, about 62.1% (n=656) and 38.4% (n=406) of study subjects thought that using a glucometer doesn’t help them in modifying medications or managing diabetes respectively (Table:2).
Among the glucometer users, 40.7% of people had checked their blood glucose weekly, 26.4% every 15 days, 12.4% monthly, 8.5% at least once in every three days, 9.8% on-demand basis, and only 2.3% of them checked daily (Figure 1). The majority of the glucometer user (39.6%) had checked fasting blood glucose (FBS), followed by 2-hour after breakfast (30.2%) and random blood sugar (20%). Very few proportions of the patients monitor blood glucose at the rest of the period like only 0.4% of them had checked before lunchtime, 1.6% for 2 hours after lunch, 1.9% before dinner, 0.6% at 2-hour after dinner, and only 0.9% at bedtime. (Figure 2). Univariate analysis as shown in Table 3 represents that age, gender, education status, occupation, monthly income status, the suffering of a first-degree relative with diabetes, experiencing hypoglycemia & hospitalizations within the last six months, both physician consultation setting & consultation duration, treatment regimen, awareness about diabetic complications, a proper idea about diabetes control and thinking of both whether glucometer use helps to manage diabetes or modifying medications significantly associated with SMBG adherence. Whereas marital status, smoking status, duration of diabetes, and presence of diabetic complications showed no significance here. About 61.5% (n=650) of the patients with diabetes had HbA1c above 8%, 21.5% (n=227) had between 7% -7.9 % and only 17%(n=179) had within target (<7%) (Table:2). This study found significant association of glycemic control with the glucometer usage (HbA1c<7%: 24.8% vs 9%; p<0.001). Interval of glucose monitoring also significantly (p=0.040) affected glycemic control like people who had checked blood glucose weekly, 30.1% of them had good, 25.9% had poor and 44% people had very poor glycemic control followed by those who had checked every 15 days interval (24.3% good, 33.6% poor and 42.1% very poor), monthly (19.7% good, 30.3% poor and 50% very poor), once in every three days (15.6% good, 22.2% poor and 62.2% very poor), and on-demand basis (17.3% good, 19.2% poor and 63.5% very poor). Further, frequency of SMBG was associated with glycemic control as a proportion of very poor glycemic control (HBA1c ≥8%) successively had decreased with an increased count of glucose monitoring on the day of measurement (58.8% vs 44.3% vs 40.4% vs 38.9%; p=0.019) (Table-4). In this connection, the scatter plot shows a weak negative correlation between the frequency of glucose monitoring and HbA1c level. (Figure-3).

Table 1: Demographic and clinical characteristics of study population (n=1056)

Characteristics n (%)
≤ 40 Years 216 (20.5)
41-60 Years 657 (62.2)
> 60 Years 183 (17.3)
Male 435 (41.2)
Female 621 (58.8)
Unemployed 109 (10.3)
Housewife 555 (52.6)
Day labor 42 (4.0)
Business 145 (13.7)
Service 205 (19.4)
Educational level
Uneducated/ Primary education (grade 0-5) 180 (17.0)
Secondary/ Higher Education (grade 6-12/ graduate/ post graduate) 876 (83.0)
Marital Status
Married 955 (90.4)
Others 101 (9.6)
Smoking History
Current smoker 86 (8.1)
Ex-smoker 167 (15.8)
Never smoker 803 (76.0)
Monthly Income (taka)
 < 10000 29 (3.8)
10000 – 20000 232 (30.6)
>20000 497 (65.6)
Consultation setting
Government Hospital 136 (12.9)
Affiliated Centers of Bangladesh Diabetic Association 400 (37.9)
Others private clinics 520 (49.2)
Duration of Diabetes (years)
> 10 261 (24.7)
5-10 419 (39.7)
< 5 376 (35.6)
Any first degree relative affected
Yes 753 (71.3)
No 303 (28.7)
Presence of Diabetic Complications
Yes 778 (73.7)
No 278 (26.3)
Diabetic Complications
CVD 172 (16.3)
Retinopathy 223 (21.1)
Nephropathy 140 (13.3)
Peripheral. Neuropathy 620 (58.7)
Sexual dysfunctions 183 (17.3)
Hypoglycemia within last 6 months
Yes 221 (20.9)
No 835 (79.1)
Hospitalization for diabetic complications within last 6 months
Yes 65 (6.2)
No 991 (93.8)
Visit for consultation
Every 1-3 months 395 (37.4)
Every 6 months 115 (10.9)
No specific routine visit 546 (51.7)
Current Diabetes treatment regiment
Diet and Exercise 48 (4.5)
Oral AD drugs 662 (62.7)
Insulin and Oral drug 304 (28.8)
Only insulin 42 (4.0)
Awareness about the factors leading diabetic complications
Yes 630 (59.7)
No 426 (40.3)
Idea about diabetes control
Satisfactory 484 (45.8)
Unsatisfactory 358 (33.9)
No idea 214 (20.3)

Table 2: Characteristics of self-monitoring blood glucose (SMBG) usage (n=1056)

Characteristics n (%)
Glucometer user
Yes 532 (50.4)
No 524 (49.6)
Reason for not using glucometer
Painful/Discomfort 22 (4.2)
Expensive 41 (7.8)
Don’t have education about usage 74 (14.1)
No benefit as I can’t modify medication 10 (1.9)
I think they don’t provide correct result 34 (6.5)
I don’t know much about it (No awareness) 343 (65.5)
Whom consultation started using glucometer
Physician (MBBS) 335 (63.0)
From self-idea 103(19.3)
Others 94 (17.7)
From where they usually had Checked blood sugar
Own glucometer 447 (84.0)
Local pharmacy 78 (14.7)
From Neighbors 3 (0.6)
Hospital or Clinic 4 (0.8)
Whether Glucometer helps in managing diabetes
Yes 650 (61.6)
No 406 (38.4)
Whether Glucometer helps modifying drugs/ insulin
Yes 400 (37.9)
No 656 (62.1)
HbA1c level
Good glycemic control (<7%) 179 (17.0)
Poor glycemic control (7-7.9%) 227 (21.5)
Very Poor glycemic control (≥8%) 650 (61.5)

Figure 1 Interval of SMBG by the glucometer user

Figure 1: Interval of SMBG by the glucometer user

Table 3: Predictors of self-monitoring of blood glucose (SMBG) usage

Characteristics PARTICIPANTS (n (%)) p-value
Adherence Non-adherence
 Age (Years)
 < 40  89 (50.3)  88 (49.7)  0.008
 40-60  332 (47.7)  364 (52.3)
 > 60  111 (60.7)  72 (39.3)
Male  249 (57.2) 186 (42.8) < 0.001
Female 283 (45.6) 338 (54.4)
Marital status
Married 490 (51.3) 465 (48.7) 0.063
Others (Divorced/Widowed/Single) 42 (41.6) 59 (58.4)
Educational level
Uneducated/ Primary education (grade 0-5) 49 (27.2) 131 (72.8) < 0.001
Secondary/ Higher education (grade 6-12/ graduate/ post graduate) 483 (55.1) 393 (44.9)
Unemployed 67 (61.5) 42 (38.5) < 0.001
Housewife 242 (43.6) 313 (56.4)
Day laborer 10 (23.8) 32 (76.2)
Business 83 (57.2) 62 (42.8)
Service 130 (63.4) 75 (36.6)
Monthly income (taka)
<10000 9 (31.0) 20 (69.0) < 0.001
10000-20000 84 (36.2) 148 (63.8)
>20000 298 (60.0) 199 (40.0)
Smoking history
Current smoker 42 (48.8) 44 (51.2) 0.065
Ex-smoker 98 (58.7) 69 (41.3)
Never smoker 392 (48.8) 411 (51.2)
 Duration of diabetes (years)
> 10 144 (55.2) 117 (44.8) 0.098
10-May 196 (46.8) 223 (53.2)
< 5 192 (51.1) 184 (48.9)
First degree relative affected
Yes 409 (54.3) 344 (45.7) < 0.001
No 123 (40.6) 180 (59.4)
Presence of Diabetic Complications
Yes 382 (49.1) 396 (50.9) 0.164
No 150 (54.0) 128 (46.0)
Diabetic complications
Yes 105 (61.0) 67 (39.0) 0.002
No 427 (48.3) 457 (51.7)
Yes 115 (51.6) 108 (48.4) 0.689
No 417 (51.1) 416 (49.9)
Yes 84 (60.0) 56 (40.0) 0.014
No 448 (48.9) 468 (51.1)
Peripheral neuropathy
Yes 300 (48.4) 320 (51.6) 0.123
No 232 (53.2) 204 (46.8)
Sexual dysfunction
Yes 87 (47.5) 96 (52.5) 0.398
No 445 (51.0) 428 (49.0)
Hypoglycemia within last 6 months
Yes 137 (62.0) 84 (38.0) < 0.001
No 395 (47.3) 440 (52.7)
Hospitalization within last 6 months
Yes 45 (69.2) 20 (30.8) 0.002
No 487 (49.1) 504 (50.9)
Consultation setting
Government 53 (39.0) 83 (61.0) < 0.001
Affiliated Centers of Bangladesh Diabetic Association 173 (43.3) 227 (56.8)
Others private clinics 306 (58.8) 214 (41.2)
Visit for consultation
Every 1-3 months 271 (68.6) 124 (31.4) < 0.001
Every 6 months 65 (56.5) 50 (43.5)
No specific routine Visit 196 (35.9) 350 (64.1)
Current diabetes treatment regimen
Diet and exercise 17 (35.4) 31 (64.6) < 0.001
Oral AD drugs 308 (46.5) 354 (53.5)
Insulin and Oral drugs 183 (60.2) 121 (39.8)
Only insulin 24 (57.1) 18 (42.9)
Awareness about diabetic complications
Yes 409 (64.9) 221 (35.1) < 0.001
No 123 (28.9) 303 (71.1)
Idea about diabetes control
Satisfactory 320 (66.1) 164 (33.9) < 0.001
Unsatisfactory 176 (49.2) 182 (50.8)
No idea 36 (16.8) 178 (83.2)
Whether glucometer helps managing diabetes
Yes 492 (75.7) 158 (24.3) < 0.001
No 40 (9.9) 366 (90.1)
Whether glucometer helps modifying drugs/insulin
Yes 338 (84.5) 62 (15.5) < 0.001
No 194 (29.6) 462 (70.4)

Figure 2 Frequency of SMBG by the glucometer user

Figure 2: Frequency of SMBG by the glucometer user

Table 4: Glucometer use and glycemic control (HbA1c)

Characteristics Glycemic control (HbA1c) P-value
Good (<7%) Poor (7-7.9%) Very poor (≥8%)
n=179 n=227 n=650
Glucometer usages
User 132 (24.8) 145 (27.3) 255 (47.9) <0.001
Non-user 47 (9.0) 82 (15.6) 395 (75.4)
Interval of SMBG
Every 3 days 7 (15.6) 10 (22.2) 28 (62.2) 0.04
Weekly 65 (30.1) 56 (25.9) 95 (44.0)
Every 15 days 34 (24.3) 47 (33.6) 59 (42.1)
Monthly 13 (19.7) 20 (30.3) 33 (50.0)
Demand basis  9 (17.3) 10 (19.2) 33 (63.5)
Frequency of glucose monitoring on the day of measurement
1 time 32 (20.9) 31 (20.3) 90 (58.8) 0.019
2 times 86 (27.8) 86 (27.8) 137 (44.3)
3 times 10 (19.2) 21 (40.4) 21 (40.4)
More than 3 times 4 (22.2) 7 (38.9) 7 (38.9)

Figure 3 Scatterplot between frequency of glucometer use per day and HbA1c Level

Figure 3: Scatterplot between frequency of glucometer use per day and HbA1c Level

This study observed relatively high prevalence (50.4%) of glucometer usage among the people with type-2 diabetes which supports the study of Farhan SA et al. & Rafique G et al.[4],[19] whereas most of the previous studies found relatively low prevalence like 27.5% in China, 15.3% in Malaysia, 34% in western Kenya.[20]-[22] In this current study patients who had practiced SMBG at least once a month was considered as glucometer users while once weekly measurement was taken in consideration in most of the previous studies though consensus on frequency and timing of SMBG in case of type-2 DM individuals has not yet established.[4],[6],[19]-[22] If we count the participants only practiced SMBG at least once a week, then the figure of the glucometer users would be 25.9% which remains consistent with the earlier studies.[20]-[22] Our study found that lack of awareness about SMBG was the leading cause for not using it among the non-user (65%) and this finding is in accordance with previous studies.[4],[23] Though another study mentioned failure of SMBG in providing better glycemic control as the most important reason.[24] In this study, nearly 61.6 % people with diabetes thought that using glucometer is useful in diabetes management which supports the study by Farhan SA et al. (55.3%).[4] Majority of the respondents included in the current study had their own glucometers as like of the study of Kenya S, et. al.[25] We observed about 40.7% participants had checked blood glucose weekly which is consistent with earlier findings from China (38.7%) but higher than that of the Pakistani data (17.6%).[17],[19] Very low percentages (2.3%) of people had practiced SMBG on daily basis in our study and the same picture also found in Pakistan (7%) & in Malaysia (16.4%).[19],[21] This study describes the frequency of SMBG by the glucometer users where we found nearly 39.6% patients had checked before breakfast which is similar as of Pakistani data (40%) but slightly lower than in Malaysia (64.7%).[4],[21] This study specifically reported that about 30.2% people had checked blood glucose 2-hour after breakfast time but the proportion was very low at lunch & dinner times (1.6% & 0.6% respectively) where the earlier studies found relatively high percentages (21%in Pakistan & 30.6% in Malaysia) after main meals. [4],[21] On the other hand, in our study only 0.4% and 1.9% patients had checked blood glucose before lunch & before dinner times respectively while the proportion before main meal times was relatively higher in previous studies conducted by Farhan SA et.al. (9%) and Mastura I et.al. (37.6%).[4],[21] Further we noticed that around 20% patients had neither checked before nor after main meals rather they practiced randomly. Age of the participants found to be associated with SMBG adherence in the current study which is in accordance with a similar study,[26] but not supported by few other studies.[17],[20] In this study gender was also associated with SMBG practice. This finding is similar with a study of China,[20] but discordant with the other studies.[4],[17],[26] We observed degree of SMBG adherence was significantly related with the educational status, occupation and monthly income of the respondents. These findings are consistent with the earlier similar studies.[4],[17],[20],[26],[27] These findings might be due to fact that education status plays a vital role in operating the instrument as well as applying the data in diabetes management.  On the other hand, financial status is also important for better adherence as patients have to count extra penny to their daily cost. Suffering of other first-degree relatives with diabetes found to have positive impact with SMBG adherence in our study and it supports the earlier studies.[4],[20] Previous exposure to glucometer uses and their participation as well as earlier experiences in the management of diabetes might make the difference with the non- adherent group. Earlier study reported greater adherence with frequent hospitalizations.[20] We also observed that experiencing hypoglycemia and hospitalizations for diabetes within last six months were significantly associated with SMBG adherence. These findings probably due to fact that those who had been hospitalized for diabetes or suffered from hypoglycemia were adequately counselled by their physicians about the importance of SMBG. Better adherence was also linked to frequency of consultation visits in our study which matches one of the previous studies,[20] but not with another one,[4] and this contradiction might be due to selection bias. Moreover, we found consultation setting was also associated with SMBG adherence like patients who had taken consultations from private clinics were relatively better adherent than that of government hospitals and affiliated centers of Bangladesh diabetic association and this result is in accordance with earlier data.[4] Frequency of SMBG differs according to different treatment regimens.[4],[17],[20] Adherence rate was greater among the participants who used insulin only or in combination with oral drugs as compared to those on non-pharmacological agents which is consistent with the previous studies of Pakistan and USA.[4],[28] This result contrasts with the Chinese studies where SMBG adherence was much lower among the insulin users.[17],[20]. Definition of SMBG adherence differs across the studies and that might be the apparent paradox findings here. Studies from South India have shown that individuals who are educated and diligent with their diabetes mellitus self-care gain longer term control.[27] In this connection we found glucometer usage rate was significantly high among the patients who had proper idea about diabetes control, awareness about diabetic complications as well as who ever thought glucometer as a useful tool in diabetes management. Patients who are aware that intensive glycemic control can prevent diabetic complications should have a thorough understanding of the various levels of glycemic control, and if they are aware of the targets, they will be more cautious and adamant about checking their blood glucose levels. These factors are likely to have influenced the conclusions of the current investigation. This study observed only 17% (HbA1c < 7%) population had good glycemic control which is similar (18%) with the earlier Bangladeshi data of Afroz A et. Al.[29] Glycemic control status (HbA1c%) was significantly better among the glucometer users in our study and this result is in accordance with some previous studies,[17],[26] but contradicts some other studies.[4],[16],[25] The STeP study, a randomized control trial showed that structured SMBG was associated with improved glycemic control whereas SMBG adherence characteristics was also varied across the studies and these findings might for the apparent contradiction in glycemic control.[5] Furthermore, we observed interval of SMBG was associated improved HbA1c status where proportion of good glycemic control (HbA1c <7%) was greater among the patients who had practiced weekly and proportion went downwards with increased interval of checking. In our result, those who had checked every three days interval didn’t follow the chronological sequence and this might be due to very small sample size. Moreover, frequency of glucose monitoring on the day of measurement had impact upon glycemic status as we found proportion of very poor glycemic status (HbA1c>8%) went downwards with increased frequency of monitoring on that particular day. Peoples who practice SMBG more frequently find whether their glucose values within targets or not and in turn can take necessary steps for achieving good glycemic control, which could be the probable explanation of the above-mentioned findings.

Limitations of The Study
This study had some limitations that need to be mentioned. First, as it was a cross-sectional study, we could not draw any conclusion about cause-and-effect relationships of the demographic and clinical characteristics with SMBG adherence or frequency. Second, our SMBG frequency data might be affected by potential recall bias as they were self-reported. Third, we could not measure height & weight of the participants and failed to show the association of obesity with SMBG. Forth, as HbA1c status depends on many clinical factors, relationship between SMBG adherence and HbA1c shown in the study might be affected by some confounding variables. Fifth, baseline knowledge of the subjects regarding using glucometer as well as self-adjustment of medications with the provided data were not explored. Large scale studies need to be conducted in future to explore the remaining gaps of the study.

Our study observed increasing trend of glucometer use among Bangladeshi people with diabetes. Still about half of this population not practicing SMBG even once a month. In addition, we found higher financial & education status along with many other factors were associated with SMBG adherence while lack of awareness, education about glucometer use & cost were the leading cause for not using it among the non-users. Moreover, there was better glycemic status among the glucometer users. So, every physician dealing diabetic populations should render enough time to their patients for counseling about different aspects of SMBG in their management of the disease. On the other hand, government & other organizations who are working in this field should take necessary steps to create awareness about role of SMBG in diabetes management.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee


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To citation of this article: Kabir MA1, Ahmed S2, Abedin M3, Mallick S4, Dhar A5, Islam AS.6, Hannan MA7, Faruque MO8, Sultana T9, Hoque F10, Zarin N11, Hasan MM12, Prevalence and Predictors of Home Use Blood Glucose Meters Among the People with Diabetes in Bangladesh and Relation with HbA1c: A Multicenter Cross- sectional Study, Global Journal of Diabetes, Endocrinology & Metabolic Disorders

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