November 14th was World Diabetes Day.i Today in the UK there are some 3.5 million people diagnosed with diabetes and 549,000 people living, unknowingly, with the condition. In 2015, diabetes cost the NHS some £10 billion, however, the real cost to the individual is the debilitating effect of the disease and the increased risk of developing life-threatening complications. People with diabetes are twice as likely to be admitted to hospital and, every day in the UK, some 65 people die prematurely from complications of diabetes. Improving the management of diabetes has significant implications for patient outcomes and reducing healthcare costs.ii This week's blog is a personal story of living with diabetes type 1 and the impact that health technology can have on improving diabetics' lives.
Earlier this summer I went shopping for a wedding dress with my best friend. What a special moment. Between lace, colour, and style, the most important selection criteria for my friend was:
"Will it accommodate my insulin pump and where will I place my continuous blood glucose sensor"?
Diabetes is a condition where the levels of glucose in the body become too high because the pancreas fails to produce any, or inadequate levels of, insulin. There are two types of the diabetes:
- Type 1 diabetes, a life-long condition affecting about 10 per cent of diabetes patients. It occurs as a result of the destruction of insulin-producing cells and, following diagnosis, is treated by daily insulin doses, either by injections or via an insulin pump. It usually develops before the age of 40, and most commonly in childhood.
- Type 2 diabetes, usually occurs in people over the age of 40. It is also becoming increasingly common in children and adolescents. It occurs when insulin-producing cells fail to produce enough insulin or the insulin produced is inadequate. It accounts for between 85 and 95 per cent of diabetics and is closely linked to life-style factors. If diagnosed early enough, it can be managed by losing weight, a healthy diet and increasing physical activity. Otherwise, treatment involves oral medication and eventually direct injection of insulin.iii
The inexorable increase in diabetes prevalence is largely due to the increase in type 2 diabetes. However, understanding what it means to live with life-long, type 1 diabetes can provide lessons and an incentive for better managing the 'slow epidemic' of preventable type 2 diabetes.
My friend was diagnosed with type 1 diabetes when we were teenagers in Germany. Our close friendship over the intervening years has given me the opportunity to see first-hand the impact diabetes can have but also share in the increased freedom that new technological developments have granted her. This includes travelling, a passion for rock-climbing and pursuing a career as a gynaecologist. Improvements in technology have also enabled my friend to reduce her risk of complications by optimising her average blood sugar levels.
From the outset, my friend's management of her diabetes involved the use of an insulin pump, allowing her to match the administration of long- and short-acting insulin to her lifestyle- rather than constraining her life to fixed daily insulin injections. Previously this would have required her to prick her fingers several times a day to self-monitor her blood sugar, while leaving gaps in monitoring that she called 'flying blind'. More recently, she has been able to avoid both by using a continuous blood glucose sensor which allows seamless monitoring and has resulted in improved management of her condition.
While she values the sensor highly, she had initially faced challenges obtaining funding for the device from her insurance company. She enjoys the flexibility of using an app on her phone for measuring and recording her blood sugar, however she does worry about data security and privacy. Meanwhile, her sights are set on upscaling to an 'artificial pancreas' system. This close-loop system consists of a sensor capable of continuously monitoring glucose levels and integrating with an insulin pump that autonomously calculates and administers the necessary treatment.iv
Unfortunately, many people living with diabetes today don't have access to these life-changing technologies. This is due to regulatory, cost and funding challenges, underpinned by a lack of understanding of the disease and limited awareness of technological developments, compounded by a reluctance among patients and staff to adopt new technology.
For others to enjoy the benefits that my friend now enjoys and at the same time alleviate some of the demand pressures on healthcare services, our UK health system needs to take the following steps.
Improving awareness of diabetes and its risks
Globally, as many as one in two of all patients with diabetes are undiagnosed (an estimated 193 million). Awareness campaigns and use of online questionnaires can help overcome the lack of knowledge about causes and risks of the disease.v On-line education and patient activation programmes can improve prevention, increase early diagnosis and reduce complications.vi
Enhancing early diagnosis and monitoring
New non-invasive screening to predict diabetes risks can speed up access to care. They also improve long-term management, enable tailored treatment and reduce the risk of life-threatening complications. One such tool uses visible light to assess skin biomarkers, whilst another uses tear drop or salivary assessments.vii These new technologies have yet to be widely adopted, rather, the focus has been on low cost, easy use diagnostic tools.viii
Reducing reluctance among patients and clinicians to engage with new technologies
Providing patients and clinicians with information on the growing evidence of the efficiency and effectiveness of digital technology and improving their education on its use, is a crucial first step to gaining trust and confidence. On-line learning, for example, can increase knowledge of treatment options and improve clinical and psychosocial outcomes.ix Evidence from the X-PERT Diabetes programme has demonstrated savings to the NHS, of some £367 million per year.x
Tackling accessibility and equality of access within the UK
To harness the full potential of technology, financial and regulatory barriers need to be addressed. Currently not all patients with type 1 diabetes are offered insulin pump therapy and fewer still are able to obtain continuous glucose monitoring, and then only after individual funding requests. NICE guidance in February 2016 concluded that routine adoption is not yet supported by sufficient evidence.xi
Diabetes is currently a chronic condition and there is as yet no cure. However, equitable access to technology is an important enabler for improving the monitoring and compliance of treatment while reducing healthcare costs and improving the quality of life for millions of people.
For my friend, it certainly makes all the difference. She did find a beautiful wedding dress. It was a marvellous day and the stains on the dress, were not the result of having to prick her finger repeatedly throughout the day, but rather told the story of a fabulous party.
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