- Category: Knowledge
- Published on Thursday, 15 November 2012 14:52
Dr Shashank R Joshi, President, Indian Academy of Diabetes & Consultant Endocrinologist, Lilavati Hospital and Bhatia Hospital, Mumbai elaborates on the future trends in diabetes management and opines that frequent diabetes monitoring and intensive management is on the rise
|Dr Shashank R Joshi|
There has been a considerable rise in the prevalence of diabetes across the world. As per the World Health Statistics 2012, one in every 10 adults is diabetic, with the figure increasingly rising among the youth due to unhealthy lifestyle and lack of exercise in their daily routine. The rising trend of weight gain, coupled with lack of physical exercise and high level of mental stress in school-going children acts as a precursor of future diabetes in them at a younger age, particularly in those children who also have a family history of diabetes.
More than 346 million people worldwide are currently suffering from diabetes; and this malady is predicted to become the seventh leading cause of death in the world by the year 2030. Unfortunately, India has one of the largest number of diabetic patients in the world (62.4 million people live with diabetes in India and there are 77.2 million people with pre-diabetes). It is estimated that every fifth diabetic in the world would be an Indian. The disease is such that it cannot be cured, making it all the more important to actively manage it.
According to the World Health Organization, every year, 35 million people die because of diabetes. 80 per cent of these diabetes deaths worldwide occur in low- and middle-income countries with people aged between 35 and 64 years. While there is one person in the world dying of diabetes every ten seconds, two new diabetic cases in the world are being identified every ten seconds. Additionally, by the year 2025, there will be seven million new diabetic cases in the world.
Currently, India is facing an epidemic of diabetes, with a high prevalence in urban areas. Over the past 30 years, the prevalence of diabetes has increased to 12-18 per cent in urban India and three to six per cent in rural India, with significant regional variations. Moreover, impaired glucose tolerance (IGT) is a mounting problem in India and another 14 per cent of the Indian population has pre-diabetes in India, a harbinger of future diabetes.
The need to better manage and control the rapid rise of this disease has led to innovations in diabetes monitoring and management therapies to assist patients and physicians in tackling the chronic disease with more scientific and accurate results. People with Type 1 diabetes and many people with Type 2 disease require treatment with insulin to control blood sugar and reduce the risks of complications, including blindness, heart disease and nerve damage leading to amputations. The main aim of diabetes treatment is to achieve blood glucose in order to prevent acute and chronic complications, improve quality of life and avoid premature diabetes associated deaths.
Research in the field of diabetes has taken two main directions: innovations aimed at improving current management methods, and exploring radical new approaches. Improvements in current therapy include making glucose monitoring and insulin delivery less invasive and more patient-friendly, and many significant advances have been made in this context over the past two decades.
Among these have been the development of improved glucose monitoring techniques and minimally-invasive techniques for sampling blood. New, fast-acting forms of insulin have also been introduced along with novel, and more accurate, ways of insulin delivery through the use of insulin pumps. There has also been considerable research in non-injection dosage forms for insulin, such as inhalable insulin, although many products have not been granted approval and require more clinical data. Once approved, these could herald a new era in insulin therapy.
Recent trends in diabetes monitoring and diagnosis
Blood sugar of a person without diabetes is maintained by the body within a normal range irrespective of the amount of food that is consumed by a person. In patients having diabetes, blood sugar spikes within an hour after any meal. This process goes on throughout the day. So the blood sugar of a person with diabetes is continuously changing every minute of the day throughout the person’s life. Patients may use glucometers to check blood sugar, but this gives the value of blood sugar only at the particular time when the test is done. However, since blood sugar levels of a patient are changing from minute to minute, checking simply with blood glucose meters may not be sufficient.
However, a more effective way to monitor sugar levels and understand how the blood sugar is changing throughout the day is with the help of a technology called continuous glucose monitoring system (CGMS), which is now also available in India. CGMS is done with a monitor (like iPro 2 etc.) that is attached to the abdominal wall. It reads the sugar levels of the person every 10 seconds and keeps a record every five minutes so that we can get 288 readings per day during the CGMS study period. This data is uploaded on a computer and it is clearly visible in the form of a graph which anyone can understand.
The patient gets to see how his or her blood sugar has moved after each and every meal of the day. This gives the person a clear idea as to how much the blood sugar has risen after a particular meal. The patient can then take corrective measures regarding food intake. The doctor can make out how a particular patient’s blood sugar is changing throughout the day. There are plenty of patients who have high blood sugar at odd times of the day which is not detected by the routine tests like fasting blood sugar and PPBS (blood sugar after food) or who are unaware that they may be experiencing low blood sugars at night. With this information the doctor can modify the treatment to get better control of blood sugar throughout the day.
For patients who are suffering from gestational diabetes and patients with diabetes who are planning pregnancy, it is absolutely vital that the blood sugars are very tightly controlled throughout the pregnancy. The consequences of poor control can be grievous to the mother and foetus. So, in patients with diabetes who are planning pregnancy it is extremely useful to get a CGMS done and get a correct picture of the blood sugar pattern. Low blood sugar, especially at night, may go unnoticed and this is clearly picked up by a CGMS study.
Glycosylated haemoglobin (HbA1c) is a very useful test to detect how well blood sugar is controlled over the previous three months. However, HbA1c indicates the average blood sugar and so it does not give a correct picture of how much fluctuation occur. In fact, if a patient has frequent low blood sugar, it could result in low HbA1c (because HbA1c denotes an average value) and a false sense of security to the patient and doctor, even when the blood sugar is often high and is actually poorly controlled. CGMS is a useful tool to detect this disease.
Another new upcoming diabetes monitoring approach is the use of implantable chips. A microchip can detect the amount of glucose in a person’s blood and will then transmit this information to a wireless scanner where it can be easily read by the patient. All it will require are some basic instructions, and monitoring one’s own glucose level with this product will be simple and accurate. This innovative little device serves as an alternate for the aid of glucose monitoring.
Recent trends in diabetes management
Insulin therapy is one of the cornerstones of diabetes management, and its efficacy in early and late-stage diabetes is well-established. Yet, the first choice of doctors in India for most diabetics has so far been to attempt sugar control through oral anti-diabetics (OADs), diet control, exercise and lifestyle changes. One of the key reasons for delaying control through insulin is the resistance and fear in patients, of taking injections daily, particularly self-administering the same.
For Type 1 diabetes where insulin is required to manage the condition, the traditional diabetes management is done by delivering insulin through multiple daily injection (MDI) through devices such as insulin pens and insulin injections. These devices are also available in india and help in self-management of diabetes.
An excellent alternative to multiple daily injections is insulin pump therapy. By using an insulin pump, patients can match their insulin to their lifestyle rather than trying to adjust their lifestyle to their body's response to insulin injections. People of all ages,who require insulin to manage their diabetes, can get benefit from this novel therapy.
Insulin pumps are being more commonly used because of their unique ability to continuously infuse insulin, closely mimicking the behaviour of physiological secretion from a normal pancreas. Just as a healthy pancreas delivers insulin automatically, every seven to ten minutes throughout the day, an insulin pump matches the natural rhythm of a healthy pancreas, which is nearly impossible for people using traditional injection therapy. In brief, insulin pumps consist of: (a) the pump (computerised battery operated device); (b) a disposable reservoir to hold insulin; (c) a disposable infusion set, (including a soft plastic cannula to be inserted just below the skin). The insulin pump is a small mechanical device that is worn outside the body, often on a belt or in a pocket. The pump delivers insulin directly into the body through the soft, flexible cannula under the skin. Patients generally refill their pump with insulin every two to three days. Scientific evidences from published studies have also proven the added benefit of insulin pumps in improving quality of life, normalising sugars in recalcitrant diabetes, improving sexual function, and relieving the intractable pain of neuropathy.
Pump therapy allows people with diabetes to adjust insulin intake easily and maintain glucose levels within a near-normal range. An insulin pump is an excellent tool for helping improve glycemic control. Tight glycaemic control is central to good health, as proven by numerous studies, including the landmark diabetes control and complications trials (DCCT). In that study, patients who maintained near-normal glycaemic control significantly reduced their risk of long-term complications. The risk of diabetic eye disease decreased up to 76 per cent, nerve disease was reduced up to 60 per cent, and kidney complications were reduced up to 56 per cent. A pump can help patients avoid hyperglycaemia (high blood sugar), which can cause long-term complications and lead to ketoacidosis (causing coma or death if left untreated), and hypoglycaemia (low blood sugar), an acute condition that can be dangerous, particularly while sleeping.
With a pump, people can also be more flexible. Patients using longer-acting insulin with injection therapy must follow rigid schedules of insulin injections, meals and snacks, whereas patients using an insulin pump can program insulin delivery when they eat, and adjust or stop insulin delivery for exercise or other needs. Patients using pump therapy can eat what they want, when they want - something almost unheard of in patients treating their condition with traditional insulin injections.. Pumps are also beneficial for patients who are unable to manage their diabetes or related complications.
Currently, approximately 500,000 people worldwide are using insulin pumps to manage diabetes; however, despite India’s claim of educational achievement and economic progress, the benefits of insulin pump therapy have reached only a fraction of people with diabetes, who rightly deserve such innovative therapy. Advanced insulin pump technology like MiniMed VEO, is one of the new insulin pumps in the world that can automatically shut-off the supply of insulin, if the patient’s glucose levels drop too low, protecting against dangerous, and potentially life threatening, hypoglycaemia (low glucose suspend). The insulin pump, when used with an integrated glucose-sensing technology, monitors the patient’s glucose levels 24 hours a day and can actively protect the patient against the risk of a hypoglycaemic event becoming severe, even while the person is asleep. This new therapy also has a range of simple alerts to help patients act to keep their glucose level stable, providing the best possible chance of staying safe and avoiding highs and lows.
This new technology, which is now also available in India, gives greater freedom in eating and sleeping. At the same time it takes the stress and fear out of diabetes management for its capacity to protect against the dangers of hypoglycaemia.
The reasons for the poor utilisation of insulin pump therapy in India include lack of awareness among doctors and patients, affordability concerns, lack of proper diagnostic infrastructure, and lack of reimbursement. As a greater number of doctors in India begin to be more aware of such advance therapies, they will be able to educate more Indians on the causes, prevention and management of diabetes. The success of insulin pump therapy depends on selection of the right candidate, extensive education, motivation, and implementing the sophisticated programmes with skill.
So far, while diabetes does not have a cure, diabetes management with the help of education, correct diet and exercise, medication (oral hypoglycaemic agents and/or insulin), glucose monitoring, and modern technology have made managing diabetes better and simpler. However, finding a permanent cure for the disease will be one of the greatest breakthroughs in medical science. Some animal studies have shown promising results and there seems to be hope for curing diabetes in the future.