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1. Critique your 2 clinical practice guidelines using the AGREE 11 tool 

2. Discuss (using evidence) why you believe one of these policies, or procedures, or protocols is better than the other
3. Focussing on the differences; suggest possible reasons why this might be the case – eg: cultural differences , a new organisation as opposed to an old one, size of the
organisation, relevance of the policy to the organisations client base, resources available to the organisation , etc

Overview of SMBG and CGM guidelines

The two clinical practice guidelines for Diabetes Monitoring are Self-Monitoring of Blood Glucose (SMBG) and Continuous Glucose Monitoring Systems (CGM). SMBG applies Flash devices to check for the glucose levels in a diabetic individual (Parsons et al., 2017). The patient wears the flash device for fourteen days to monitor the diabetic condition. The diabetic client flashes the sensor on the device to get the glucose readings. The device records the levels of glucose at the intervals of fifteen minutes (Overland et al., 2014). Specialists recommend that the patients wear the device for twenty-four hours to monitor their diabetic states. The method is useful for both type one and two diabetes mellitus.

CGM gauges the concentration of glucose in the fluids at the interstitial space (Bell et al., 2015). The real-time CGM device displays time-to-time glucose levels. Additionally, the method provides an alarm notification if the levels of glucose shoot above or below the normal concentrations. However, a blinded CGM device records the glucose concentrations but fails to display the readings. The caregiver has to download the readings from the blinded device to view and analyze the results from a computer (Boom et al., 2014). This paper will critique the two guidelines for diabetes monitoring using the AGREE II tool. The write-up will also explain why CGM is better than SMBG and explain the differences between the two directions.

The score sheet for the SMBG guidelines is found in the first appendix. The authors of the guidelines have described the objectives of the protocols. Additionally, the health question is specific to the target population who are diabetic patients. The individuals who developed the guidelines are distinguished doctors and professors in the medical field. The investigators requested the preference and views of the diabetic patients before writing the procedures. The protocols patients with type one and two diabetes. The authors used information in the COCHRANE library, and Pub MED sources to develop an evidence-based write-up.

The researchers used sources from the year 2010 to 2013 with information on the clinical guidelines for diabetes monitoring. The paper also describes the strengths and limitation of the study. One of the advantages is that it covers both the disadvantages and disadvantages of SMBG. However, the boundaries of the research include the fact that the number of participants is few; hence limiting its scope. The authors are also evident in the recommendations, benefits, and disadvantages of the research. The document is peer-reviewed and indicates the procedures of updating the content. The above qualifications allow caregivers to apply the report in caring for diabetic patients. However, the authors fail to record competing interests. Therefore, the guideline is of high quality and I would recommend caregivers to use it.

Critique of SMBG and CGM guidelines using the AGREE II tool

The score sheet for CGM is found in the second appendix. The authors of the protocol have indicated its scope and purpose, as they have recorded the objectives, health questions, and target population. The authors have relevant academic qualifications, and they also consider the views of diabetic patients. The development of the procedures is thorough as the investigators indicate relevant details of a research paper.

The researchers are clear on their recommendations. They also offer different options for diabetes management. The evidence from the guidelines is applicable as it indicates the barriers and facilitators of the protocols among other details. The CGM guideline advices the diabetic patients on how to apply the recommendations in real life; however, it does not indicate auditing criteria. Additionally, there is no indication on whether the funding body has influenced the contents of the protocol or otherwise. The write-up had a recorder and addressed the competing interests. Therefore, I highly recommend the application of the CGM guidelines.

The CGM devices like the real-time equipment detect and record the glucose levels after every five minutes. Therefore, the system indicates the current trends in the fluctuation of diabetes status in the patient (Rodbard, 2016). However, the SMBG devices like the flash indicator do not display a continuous reading of the sugar levels. The patient can take appropriate measures at each reading time. The CGM devices provide the high and low glucose alarms, a parameter that is absent in the SMBG guidelines. The diabetic client stays updated of the readings throughout the day as opposed to SMBG that provides intermittent data. Furthermore, CGM guidelines are appropriate for individuals who are eager to study the trends of blood sugar fluctuations (Taylor, Thompson, and Brinkworth, 2018). The patient ties the device around the arm as opposed to SMBG that requires the clients to prick their fingers before taking the readings.

Patients find it easy to monitor their blood sugar levels during the day using the CGM guidelines. However, clients using the SMBG can only check the standards of their blood sugar when they flash the sensor (Ancona et al., 2017). The SMBG protocol makes it difficult to monitor glucose levels; since it involves numerous finger-stick examinations. The built-in alarm in the CGM systems enables the users to have tight control over their levels of blood glucose. Recent research has indicated that CGM decreases the levels of A1C in children and adults (Liberman et al., 2016). The protocol is also ideal with individuals who lack CSII but have type diabetes type one. The Real-time CGM measurement saves the time for hypoglycemic examinations. The protocol also suits pregnant women who are having either type two or one diabetes. Diabetes patients should wear the CGM devices for an extended period to ensure credible, accurate, and useful results.

Advantages of CGM over SMBG

CGM protocols enable users to study both short and long-term parameters in their blood sugar levels. However, the intermittent nature of the SMBG disrupts the investigation of such trends (Cheng et al., 2018). Diabetic patients should wear the CGM devices at all times including when they are asleep. On the other hand, patients can only monitor their diabetic status using the flash device when they are awake. Therefore, patients using real-time detectors can study blood glucose fluctuations when they are at rest. During meal times, the CGM devices remain around the arms or wrists of the diabetic clients. However, patients who are conducting a self-monitoring process cannot eat and at the same time measure their levels of blood glucose (Holmes-Truscott et al., 2016). Therefore, CGM enables users to study their diabetic status between meals. The continuous glucose monitoring devices also allow for patients to monitor their blood sugar levels when conducting and after various activities.

During physical exercise, a diabetic patient is likely to experience many lows in the blood sugar levels. The CGM guidelines enable the patient to detect the point at which the lows begin (Furler et al., 2018). Additionally, the system records the time that the blood sugar remains at the low levels. However, The SMBG devices cannot record and maintain such essential data. The knowledge from the continuous glucose monitoring prepares the patient for any changes during physical exercise (Gray, 2017). The patient can then take an appropriate action to prevent the drop at the time of activity. An example of the remedies towards the blood glucose low is adjusting the insulin injections. The patient can also change the snack after, during, or before the exercise. Diabetic patients always record low sugar levels; since the muscles convert glycogen into energy during strenuous activities. After physical exercise, the sugar levels drop even further thereby calling for a remedy.

Another advantage of the CGM over the SMBG is that the former can monitor and recorder the blood sugar fluctuations during meals. Diabetic patients usually record an elevated amount of glucose after meals (Carolan, Holman, and Ferrari, 2015). The CGM machine allows the patient to check the severity and timing of post-meal sugar spikes. The valuable data assist patients in preparing and managing the alterations before and after meals. The patient can evaluate and find out which meals result in a high shot in blood glucose than the others. Examples of foods that raise the readings of the continuous glucose monitoring devices are carbohydrate-rich meals. Therefore, the data from the CGM enables the diabetic patient to monitor the diet and reduce the uptake of carbohydrates. The patient can also take insulin after meals to bring the sugar levels to be normal after meals (Evert et al., 2017). Still, on insulin intake, the patent can adjust the bolus dose to match the CGM data.

Limitations of CGM compared to SMBG

There is a lack of sufficient evidence on the relationship between SMBG and the levels of A1C in blood circulation. However, studies conducted on CGM indicate that the system reduces the amounts of A1C (Martyn-Nemeth et al., 2016). The real-time device imposes a desirable effect on the glucose in circulation. A recent study examined a hundred diabetic patients using the continuous glucose monitoring device to explore the impact of the method on blood glucose. The patients that underwent the examination had type II diabetes. The investigators also gathered a hundred patients using SMBG to act as a control to the experiment. After the investigation, CGM users recorded lower A1C levels than their self-monitoring blood glucose counterparts (IHSG, 2015). The investigators set a similar analysis to gauge the impact of the two clinical guidelines on the levels of blood glucose. After the investigations, CGM users had lower blood sugar than the individuals who used SMBG.

Certain cultures may prefer the SMBG over the CGM; since the latter requires the user to tie the device around the arm. However, people who have no problem having the real-time CGM device on their body can use it. A new organization may prefer SMBG due to its high level of accuracy. An old firm can adopt both guidelines since the organization can manage the inaccuracy that accompanies the CGM machines on a few occasions. Small organizations may prefer the SMBG due to low budget, but a big organization can comfortably use both techniques.

The client base is also a determinant of the diabetes monitoring guideline that a health facility can adapt. A youthful clientele who are eager to know their sugar levels regularly can request the hospital to use the CGM method. On the other hand, clients that prefer accuracy over regular blood glucose results can ask for the SMBG machines. The high activity levels of CGM require multiple resources like trainers and electricity. However, using SMBG is simple and requires little to no training. Therefore, a facility that cannot recruit a suitable trainer will prefer CGM to the SMBG.


CGM guidelines allow patients to monitor their blood sugar levels continuously. On the other hand, SMBG enables the diabetic clients to take intermittent readings through the flash device. The authors of both guidelines have clear objectives, health questions, and the target population. The investigators intend to monitor the diabetic levels in patients with the two types of complications. The publications containing the guidelines are also peer-reviewed and provide tangible evidence. The authors of SMBG fail to recognize the competing interests in their directions. The inventors of the CGM fail to include the updating criteria for the contents of the guidelines.

Impact of SMBG and CGM on A1C levels

The CGM has several advantages over the SMBG. The former technique takes the readings of blood sugar after every five minutes while SMBG takes intermittent results. Patients also find continuous glucose monitoring devices to be easy to use than the self-monitoring machines. CGM also enables the patients to study their short and long-term glucose parameters over an extended period. The real-time devices can also monitor the fluctuations in blood sugar levels during meal times and physical exercise. The SMBG cannot accomplish the two tasks. The difference in the two guidelines makes their applications to differ from one organization to the other. Additionally, different diabetic patients prefer one technique over the other.


Ancona, P., Eastwood, G.M., Lucchetta, L., Ekinci, E.I., Bellomo, R. and Mårtensson, J., 2017. The performance of flash glucose monitoring in critically ill patients with diabetes. Crit Care Resusc, 19, pp.167-174.

Bell, K.J., Smart, C.E., Steil, G.M., Brand-Miller, J.C., King, B. and Wolpert, H.A., 2015. Impact of fat, protein, and glycemic index on postprandial glucose control in type 1 diabetes: implications for intensive diabetes management in the continuous glucose monitoring era. Diabetes Care, 38(6), pp.1008-1015.

Boom, D.T., Sechterberger, M.K., Rijkenberg, S., Kreder, S., Bosman, R.J., Wester, J.P., van Stijn, I., DeVries, J.H. and van der Voort, P.H., 2014. Insulin treatment guided by subcutaneous continuous glucose monitoring compared to various point-of-care measurement in critically ill patients: a randomized controlled trial. Critical Care, 18(4), p.453. 

Cheng, L., Sit, J.W., Choi, K.C., Chair, S.Y., Li, X., Wu, Y., Long, J. and Tao, M., 2018. The effectiveness of a patient-centered, empowerment-based intervention programme among patients with poorly controlled type 2 diabetes: A randomized controlled trial. International journal of nursing studies, 79, pp.43-51.

Carolan, M., Holman, J., and Ferrari, M., 2015. Experiences of diabetes self?management: a focus group study among A Australians with type 2 diabetes. Journal of clinical nursing, 24(7-8), pp.1011-1023.

Evert, A.B., Boucher, J.L., Cypress, M., Dunbar, S.A., Franz, M.J., Mayer-Davis, E.J., Neumiller, J.J., Nwankwo, R., Verdi, C.L., Urbanski, P. and Yancy, W.S., 2014. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care, 37(Supplement 1), pp.S120-S143.

Furler, J., O'Neal, D.N., Speight, J., Blackberry, I., Manski-Nankervis, J.A., Thuraisingam, S., de La Rue, K., Ginnivan, L., Browne, J.L., Holmes-Truscott, E. and Khunti, K., 2018. GP-OSMOTIC trial protocol: an individually randomized controlled trial to determine the effect of retrospective continuous glucose monitoring (r-CGM) on HbA1c in adults with type 2 diabetes in general practice. BMJ Open, 8(7), p.e021435.

Gray, S., 2017. Practice update: Continuous blood glucose monitoring. AJP: The Australian Journal of Pharmacy, 98(1165), p.70.

Holmes-Truscott, E., Blackberry, I., O’Neal, D.N., Furler, J.S. and Speight, J., 2016. Willingness to initiate insulin among adults with type 2 diabetes in Australian primary care: results from the Stepping Up Study. Diabetes research and clinical practice, 114, pp.126-135.

International Hypoglycaemia Study Group, 2015. Minimizing hypoglycemia in diabetes. Diabetes Care, 38(8), pp.1583-1591.

Liberman, A., Buckingham, B., Barnard, K.D., Venkat, M.V., Close, K., Heinemann, L., Weissberg-Benchall, J., Hood, K.K., Kubiak, T., Kowalski, A.J. and Laffel, L., 2016. Diabetes technology and the human factor. Diabetes Technology & Therapeutics, 18(S1), pp.S-101.

Martyn-Nemeth, P., Farabi, S.S., Mihailescu, D., Nemeth, J. and Quinn, L., 2016. Fear of hypoglycemia in adults with type 1 diabetes: impact of therapeutic advances and strategies for prevention-a review. Journal of Diabetes and its Complications, 30(1), pp.167-177.

Overland, J., Abousleiman, J., Chronopoulos, A., Leader, N., Molyneaux, L. and Gilfillan, C., 2014. Improving self-monitoring of blood glucose among adults with type 1 diabetes: results of the Mobile™ study. Diabetes Therapy, 5(2), pp.557-565.

Parsons, S., Luzio, S., Bain, S., Harvey, J., McKenna, J., Khan, A., Rice, S., Watkins, A. and Owens, D.R., 2017. Self-monitoring of Blood Glucose in Non-Insulin Treated Type 2 Diabetes (The SMBG Study): study protocol for a randomized controlled trial. BMC endocrine disorders, 17(1), p.4.

Rodbard, D., 2016. Continuous glucose monitoring: a review of successes, challenges, and opportunities. Diabetes Technology & Therapeutics, 18(S2), pp.S2-3.

Taylor, P.J., Thompson, C.H. and Brinkworth, G.D., 2018. Effectiveness and acceptability of continuous glucose monitoring for type 2 Diabetes management: a narrative review. Journal of diabetes investigation. 15(6) 787-801

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