Filipe Fernandes | March 06, 2020

Do you really know diabetes?

Diabetes Worldwide

Diabetes has shaped my viewpoint of health from an early age because it is my mother's disease.

Diabetes is a serious, long-term condition with a major impact on the lives and well-being of individuals and families worldwide, leading to several complications if poorly managed. Simply speaking, it is a chronic disease that occurs when the body cannot produce, or correctly use insulin, leading to raised glucose levels in the blood (known as hyperglycemia). Insulin is a hormone synthesized by the pancreas, that allows for glucose ("sugar" from the food we ingest), to go from the bloodstream into the cells. In some people (like my mom), the immune system mistakenly destroyed clusters of cells in the pancreas, and they ceased to produce insulin. This is the onset of type 1 diabetes (insulin-dependent diabetes), and to this date, the cause is unknown. To mimic a functioning pancreas and achieve optimal control of their blood sugar levels they need to administer rapid-acting insulin every time they eat and once-daily basal insulin (long-acting), even if they are fasting.

The most prevalent form of diabetes (~90%) is Type 2, and people with it are said to have insulin resistance. At first, the pancreas makes more insulin to try to get glucose into the cells, but eventually, it can't keep up, and the sugar builds up in the blood instead (leading to hyperglycemia). People with type 2 diabetes may not require daily insulin treatment to survive and sometimes can be effectively managed by controlling weight and adopting a healthy lifestyle combined with medication when required.

Diabetes is a major health issue that has reached alarming levels as stated in a study published by the International Diabetes Federation. In 2019, nearly half a billion people (9.3% of adults 20–79 years) are living with diabetes worldwide. The estimated number of people (20–79 years) living with diabetes has increased by 62% during the past 10 years (from 285 million in 2009 to 463 million, today). Currently, half of the people with diabetes are undiagnosed.

Without urgent and sufficient actions, it is predicted that 578 million people will have diabetes in 2030 and the number will increase by 51% (700 million) in 2045.

IDF Diabetes Atlas 2019
IDF Diabetes Atlas 2019

Mom

My mother was diagnosed with type 1 diabetes when I was a child, so I followed her daily routine since I was a boy. The constant finger pricking for blood sugar test, insulin injection before every meal, the attention to diet and regular checkups at the hospital made me recognize the struggle many people with chronic disease suffer.

That's surely one of the reasons that got me interested in health research and innovation, influencing my decision to perform an MSc. in Biomedical Engineering. During the years I had the opportunity to experience some improvements in diabetes care through my mother's practice, though sometimes it seems slow. But still, some innovation has been made, like for example, thinner needles for insulin injection, new types of insulins for faster blood sugar correction, or the Freestyle Libre. This sensor changed my mother's routine because she no longer needs to prick the finger (at least regularly, since she pricks the finger when suspecting of hypoglycemia). As you can see by the image below, the sensor is attached to the person's arm (needs replacement after two weeks), offering continuous storage of glucose levels to 90 days. The user only needs to bring the monitor closer to the sensor (even over the clothes) to instantly get the most recent value of blood glucose and a trend arrow, informing him/her if the value is stable, rising or decreasing.

FreeStyle Libre sensor
FreeStyle Libre sensor

A project that I want to highlight is the Nightscout Foundation. Nightscout (also known as Continuous Glucose Monitor (GCM) in the Cloud) was created by a group of parents who needed tools to better manage the blood sugar of their T1 child. By identifying an existing technology provided by the Dexcom CGM, this group devised a way to view their child’s glucose level at a distance (while the child was at school, at daycare, playing sports, at a sleepover, or while traveling overseas). As you can imagine, it has given these parents - and their child with diabetes - a freedom that they had never experienced before.

The Nightscout Foundation exists to encourage and support the creation of open source technology projects that enhance the lives of people with Type 1 Diabetes and those who love them.

Checking blood glucose level using Nightscout - Amazing :)
Checking blood glucose level using Nightscout - Amazing :)

With the example of Nightscout, we can see some of the advantages of Continuous glucose monitoring (CGM) systems. Besides the impact of finger-tip prick (many people with diabetes have up to ten tests a day!), traditional monitoring provides a snapshot picture at one point in time. In contrast, CGM can record blood glucose levels every five minutes. A transmitter sends the readings to a smart device such as a mobile phone and can also sound an alarm if the glucose number is below or above a certain threshold.

Other developed approaches involve:

  • Smartpens - e.g. the InPen combines an innovative diabetes management app with a Bluetooth®-enabled pen injector to simplify the constant tracking, monitoring, and calculating required for insulin therapy.
  • Insulin inhaler - Insulin can't be taken with a pill, because it is digestible long before it reached the bloodstream. With an inhaler much like the ones people with asthma use, you breathe a fine insulin powder into your lungs. There, it enters your blood through tiny blood vessels. In June 2014, the FDA approved Afrezza. It's an inhaler with pre-measured, rapid-acting insulin you use before meals.
  • Bolus calculators (e.g. Roche mySugr mobile app) - software that calculates the rapid-insulin units a patient should administer, based on the grams/portions of carbohydrates he is going to ingest and the current glucose value. The algorithm uses some previously configured variables like the insulin sensitivity factor and the insulin-to-carbs ratios (provided by the clinician) and can be personalized for different insulin types and hours of the day.
  • Insulin pumps (e.g. Medtronic MiniMed Insulin pump) - small, digital devices that try to mimic a functional pancreas by continuously delivering small doses of insulin (basal rate) and variable amounts of insulin when eating (bolus). This sum depends on the quantification of the carbohydrate content of that meal. These devices allow for more advanced management of diabetes (to regulate the basal rate per hour or to regulate the bolus if the meal has a high-fat concentration.
  • Artificial pancreas - closely mimic the glucose-regulating function of a healthy pancreas and includes a CGM and an insulin infusion pump. In a recent study funded by the U.S National Institutes of Health, it was shown that an artificial pancreas system improved participants’ blood glucose control throughout the day and overnight. Good news!
Artificial pancreas system
Artificial pancreas system

Lifestyle

Besides future innovations, there is a fundamental aspect that it's still disregarded and full of misconceptions - Lifestyle

There is an obvious connection between sugar and diabetes, but you don't become diabetic from (just) eating candy. First of all, at present, type 1 diabetes cannot be prevented. The environmental triggers that are thought to destroy the body’s insulin-producing cells are still under investigation. On the other hand, the most influential factors for the development of type 2 diabetes are the consumption of unhealthy food and a sedentary lifestyle.

Adoption of a healthy lifestyle, as stated here, is associated with substantial risk reduction in diabetes and long-term adverse outcomes. Tackling multiple risk factors (including, but not limited to, smoking, alcohol drinking, physical activity or diet), instead of concentrating on one certain lifestyle factor, should be the cornerstone for reducing the global burden of diabetes.

Although Diabetes management is improving, as mentioned in this article, it is estimated that only one-third of people with diabetes can effectively control their disease, while more than half report significant distress related to their illness and its management.

To facilitate self-management in chronic diseases, the pattern of patient-provider relations must be more collaborative, resulting in greater patient satisfaction, adherence to treatment plans and improved health outcomes.

Education, support, and motivation are fundamental when caring for people with a chronic disease like diabetes, and should be customized to meet people’s needs, taking into account their experience and personal characteristics.

While there is no definite cure for diabetes, I am confident that many solutions will rise, encouraging people to best manage their condition. Empathy and deep knowledge of diabetics' daily routine and frustrations are vital for building better products and keep patients engaged in the process. I want to be part of this movement and empower people to a healthier life.