Glucose monitoring in diabetes – can more be done?
Written by Dr Niamh O’Reilly
National Diabetes Week from July 9th – 15th aims to raise awareness about diabetes, its management and prevention (1). Diabetes presents a huge disease burden with the prevalence of diabetes worldwide estimated at 422 million people, including 1.7 million Australians among whom 500,000 are undiagnosed (2, 3). Each day 280 Australians are diagnosed, which is one person every five minutes (3). The healthcare costs of diabetes in Australia are around $1.7 billion per year, yet when indirect costs such as lost productivity, work absenteeism, and early retirement are also considered, the total cost burden may be as high as $14.6 billion (3, 4).
Insulin is the hormone that regulates blood glucose levels in the body. Type 1 diabetes is an autoimmune disease whereby a person’s immune system destroys the insulin producing cells of the pancreas. In type 2 diabetes, which represents the majority of the disease and cost burden, the body becomes resistant to the normal effects of insulin and/or cannot produce enough insulin. Type 2 diabetes is generally lifestyle related and often associated with obesity/overweight and physical inactivity, yet it is preventable. Increasing the disease burden are a further 2 million Australians with pre-diabetes who are at risk of developing type 2 diabetes (5).
What is the impact of poor glucose control?
Poor control of glucose levels risks the development of micro- and macro-vascular damage, which can result in heart disease, stroke, blindness, kidney failure and lower limb amputation (3, 6). The extent of the burden of these complications is shown in Figure 1 (3). Of particular concern is that only around half of Australians with diabetes achieve the general HbA1c (glycated haemoglobin) glycaemic target of 7% or less (7). HbA1c is the average blood glucose level over 3 months, however it does not provide insights on the extreme high and low glucose levels that people with diabetes may experience on a daily basis. Therefore, even individuals with an acceptable HbA1c result may be at risk of developing diabetes related complications if there is considerable out of range variability in their daily glucose levels (8).
Figure 1. Poorly controlled diabetes leads to complications
It’s not only about glucose levels
Diabetes is a complex chronic and progressive condition affecting people not only physically, but often also their cognitive, psychological, emotional and social well-being (9-11). Poorly controlled glucose levels can negatively impact cognitive function and daily activities (9), while the burden of managing diabetes may lead to emotional distress for affected individuals and their family/carers (11). People with diabetes are also twice as likely to suffer from depression compared to those without diabetes (10). Remaining motivated to manage their diabetes without ever having a break becomes a relentless challenge that can leave affected people frustrated and overwhelmed (10, 11). This may result in “diabetes burnout”, which manifests as self-destructive behaviours such as eating unhealthy food and administering estimated insulin doses without prior glucose testing in an attempt to ‘free’ themselves from the confines of their condition (12).
How do available self-glucose monitoring methods measure up?
A key aim of glucose monitoring is to keep glucose levels within a specified target range and so avoid the extreme highs and lows that can lead to acute and long-term complications (7, 8). Glucose monitoring also shows those with diabetes the effects of food intake, exercise, medications and other factors (e.g. illness) on their glucose levels. However, available self-monitoring methods may not be fulfilling their needs. Indeed, one may argue that these methods, which are invasive, serve as a constant reminder to people about their diabetes.
The most widely used glucose monitoring method is self-monitoring blood glucose (SMBG) or “finger stick” testing. However, many individuals are not performing SMBG as recommended, typically because it is invasive, painful, inconvenient, time consuming and tends to undermine their daily activities (12, 13). Indeed, a comprehensive review identified that people with type 2 diabetes not prescribed insulin fail to regularly monitor their blood glucose levels (15). Alternative systems such as flash glucose monitoring (FGM) and continuous glucose monitoring (CGM), while providing individuals with a more complete picture of their glucose levels, are still invasive. These technologies are also not readily accessible to many people with diabetes due to their lack of suitability (e.g. requires technical competence) and high cost, while calibration with finger sticks is still needed.
Is non-invasive glucose monitoring the answer?
Maintaining good control of glucose levels is essential for people with diabetes to stay healthy and prevent or reduce the risk of complications. Moreover, these individuals want to be in control of their diabetes rather than the condition controlling them. This presents a real opportunity for a glucose self-monitoring system that is non-invasive, accurate, painless, convenient and discrete with the ability to transmit data to their family/carers and healthcare providers (16). Such a system also has the potential to considerably improve adherence to self-monitoring which, in turn, would help to reduce the diabetes burden and associated healthcare system costs (16).
To this end, a key emerging technology is saliva based glucose detection, which presents an attractive and potentially more accurate, sensitive and low-cost alternative to available methods for measuring glucose levels. This is because saliva based technology offers non-invasive, painless and convenient sample collection with the ability to detect glucose concentrations 100 times lower than identified in blood (17,18). Glucose detection in saliva is a simple, discreet process involving a small disposable test strip impregnated with glucose oxidase, which is placed in the mouth. The glucose oxidase reacts with the glucose in saliva to ultimately produce an electrochemical signal that is subsequently processed by a handheld reader or smart device to produce a glucose level reading.
To have a non-invasive, painless, convenient and discreet method for monitoring glucose levels, ideally with data connectivity to inform family members, carers and healthcare providers, would be the ‘Holy Grail’ in diabetes management and prevention.
Fortunately, an innovative, first in class, saliva-based technology for monitoring glucose levels, which has all these attributes and is likely to be low cost, is on the horizon. Called the glucose biosensor system, it is expected this technology will go a long way in helping address the growing diabetes burden across the globe. For further details see Glucose Biosensor.
Figure 2. Image of salivary glucose biosensor
Can more be done beyond available glucose monitoring methods to manage and even prevent diabetes? To help affected individuals gain control over their diabetes? Absolutely.
Diabetes is a therapeutic area about which CRC is passionate. Based on our team’s solid medical affairs and market access expertise in this and many other therapeutic areas, we welcome the opportunity to plan and implement a wide range of initiatives in contributing to the commercial success of our pharma, biotech, device and other healthcare industry clients.
- Diabetes Australia. 2017. National Diabetes Week. Available at: https://www.diabetesaustralia.com.au/itsabouttime. [Accessed 12 July 2017].
- World Health Organization. 2016. Global Report on Diabetes.
- Diabetes Australia. 2017. Diabetes in Australia. Available at: https://www.diabetesaustralia.com.au/diabetes-in-australia. [Accessed 12 July 2017].
- Australian Government Department of Health. 2016. Australian National Diabetes Strategy 2016-2020.
- Diabetes Australia. 2017. Pre-diabetes. Available at: https://www.diabetesaustralia.com.au/pre-diabetes. [Accessed 12 July 2017].
- Diabetes UK. 2016. Diabetes UK Key facts and stats.
- Shaw J, Tanamas S. Diabetes: the silent pandemic and its impact on Australia. Diabetes Aust. 2012. 1–52.
- Sun S, Kim J H. Glycemic Variability: How do we measure it and why is it important? Diabetes Metab J. 2015;39: 273-282.
- Kodl CT, Seaquist ER. Cognitive dysfunction and diabetes mellitus. Endocr Rev. 2008;29(4):494–511.
- Debono M, Cachia E. The impact of diabetes on psychological well-being and quality of life. The role of patient education. Psychol Health Med. 2007;12(5):545–55.
- SANE Australia. The SANE Guide to Good Mental Health for people affected by diabetes. 2008.
- Diabetes UK. Diabetes Burnout. 2017. Available from: http://www.diabetes.co.uk/emotions/diabetes-burnout.html [Accessed 12 July 2017].
- Diabetes Australia. Fact sheet “Your SAY Glucose Monitoring” Study.
- Moström P, Ahlén E, Imberg H, Hansson P-O, Lind M. Adherence of self-monitoring of blood glucose in persons with type 1 diabetes in Sweden. BMJ Open Diabetes Res Care. 2017;5(1).
- Post-Market Review of Products Used in the Management of Diabetes Part 1: Blood Glucose Test Strips. 2013;1–78.
- NHS National Institute for Health Research. Horizon Scanning Research & Intelligence Centre. New and emerging non-invasive glucose monitoring technologies. 2016.
- The Australian. New saliva test for blood sugar could help diabetics. 2015. Available from: http://www.theaustralian.com.au/business/technology/new-saliva-test-for-blood-sugar-could-help-diabetics/news-story/8c7501a2858de7cb44c734538b7d9077 [Accessed 12 July 2017].
- The iQ Group Global – Glucose Biosensor. 2017. Available from: https://youtu.be/ifLqii2efao [Accessed 12 July 2017].