According to the French historian Jules Michelet, each century suffers a ‘great malady’, such as leprosy in the 13th century, plague in the 14th and syphilis in the 16th. Unless we take action, future medical historians could be designating diabetes as the 21st century’s great malady.
According to the National Audit Office there were 2.8 million adults in England with diagnosed diabetes in 2013-14 – and another 400,000 people undiagnosed. By 2030, 4.2 million adults could be diabetic.
Almost every presentation at the Diabetes Professional Care conference held in London last November began by highlighting the human, clinical and economic toll imposed by diabetes, such as the two-fold increase in cardiovascular disease, the 30-fold increase in amputations and the average six-year reduction in life expectancy.
Diabetes is the leading cause of end-stage kidney disease and blindness among people of working age and accounts for 10 per cent of the NHS budget for England and Wales.
In his keynote presentation, Professor Sir Bruce Keogh, the medical director at NHS England, said that, faced with growing demand and limited resources, the NHS needs to develop new models of care that make greater use of selfcare and technology.
The availability of information about health on the internet was welcomed by Professor Keogh because it aided the democratisation of “previously privileged knowledge”. In addition, he noted, healthcare’s increasing interconnectivity with apps, biosensors and diagnostic aids allows the collection of data to assess adherence and service effectiveness – all information that can be uploaded to electronic medical records.
Certainly, self-care seems to be the foundation of the NHS’s vision for diabetes management. The new NICE guidelines for adults with type 2 diabetes underline the importance of structured education to facilitate self-management and individualising care based on personal preferences, co-morbidities, polypharmacy, and the ability to benefit from long-term interventions.
LabStyle’s Dario system, launched in November, is just one example of the way in which technology can facilitate self-care. The Dario system allows people with diabetes to measure blood sugar using a monitor that plugs into the headphone socket of a smartphone or tablet. The Dario app logs blood sugar levels and can track carbohydrate intake, insulin use and physical activity.
A calculator helps users adjust their insulin dose based on their carbohydrate intake, blood sugar level and glycaemia target. Healthcare professionals, parents and other carers can access the data on a cloud.
Other advances may finally do away with the need to take blood samples. In 2014, Alcon licensed Google’s ‘smart lens’ “for all ocular medical uses”.
The smart lens has embedded non-invasive sensors, microchips and other miniaturised electronics. This means, for example, that the lens can continuously measure glucose levels in tear fluid and upload the results wirelessly to a mobile device.
The ultimate technological advance would probably be self-regulating or closed-loop insulin delivery devices (artificial pancreases), which mimic the natural variation in insulin secretion and glucagon secretion in the case of some devices. Researchers have devised several variations on the artificial pancreas theme but fundamentally they all use a sensor to measure blood glucose levels and release basal and bolus insulin in response.
Often the devices use pumps, microprocessors and sophisticated computer algorithms but a device developed by De Montfort University in Leicester uses a glucose-sensitive gel to control insulin release from a reservoir. When glucose levels rise, the gel barrier starts to liquefy releasing the insulin. As glucose levels fall, the gel re-hardens, reducing release. The device will probably be implanted peritoneally.
Uptake of insulin is rapid from the peritoneum, which allows real-time control of blood glucose levels. This helps to iron out peaks and troughs in blood glucose. Although still some way from widespread clinical use, artificial pancreases are highly promising.
That said, there’s no single answer to the problems posed by diabetes. We need the NHS Diabetes Prevention Programme to deliver on its promise, which could stop much of the expected increase in type 2 diabetes. We need therapeutic innovation and new models of integrated care. If all this happens, we may be able to prevent diabetes from becoming the great malady of the 21st century.
Although still some way from widespread clinical use, artificial pancreases are highly promising