There’s no arguing that diabetes is an epidemic in the United States, and its impact will continue to grow until there is more effective control of the disease. Conventional methods of testing and monitoring blood sugar, such as a finger stick test, may work for some – but it doesn’t always provide the most accurate, timely insights into an individual’s condition.
Utilizing technology is the key to better diabetes control. Continuous glucose monitors (CGMs) and accounting for other metrics that assess glycemic risk, paired with remote patient monitoring (RPM), can provide clinicians with a better picture of their patient’s health and enable them to take proactive actions that result in more effective management of the disease and prevent serious, life-threatening complications.
Diabetes Management by the Numbers
More than 37 million Americans are living with diabetes, with more than 7 million people having diabetes serious enough to require daily insulin and close monitoring of their blood glucose levels.
But the impact of diabetes cuts even deeper. It’s estimated that another 96 million adults – one-third of the population – have prediabetes – and many people may not even be aware of their risk. Individuals with both diabetes and pre-diabetes are at risk of serious health complications, including cardiometabolic disorders such as heart disease, stroke, chronic kidney disease, end stage renal disease, blindness, challenges with wound healing and even amputation.
Treating diabetes and its comorbidities is estimated to cost $237 billion in the U.S. alone, with another $90 billion that can be attributed to reduced productivity related to diabetes. And those diagnosed with diabetes have 20.5% higher costs for inpatient services and 7.6% more for outpatient services.
The Problem with Finger Sticks and A1C Tests for Diabetes Management
Self-monitoring blood glucose has been the predominant recommendation for most patients with diabetes. This requires painful finger stick tests and expensive supplies to measure blood glucose throughout the day to ensure levels stay between 80 mg/dL and 130 mg/dL before meals and 80mg/dL and 180mg/dL after meals. Individuals are taught to track their results with the goal of having sufficient understanding of how to adjust their insulin or diet to ensure they do not go out of range. This approach can be frustrating for patients, and studies have shown that those who self-monitored had no clinically significant improvements in glycemic control after a year.
Guidelines also recommend that people with diabetes receive A1C tests quarterly, which provide information about blood glucose levels over the course of three months. Since this offers an average estimation of control, it does little to elucidate the difference between individuals whose blood glucose ranges from 50mg/dL to 300 mg/dL versus individuals whose glucose is more tightly controlled between 90 mg/dL and 150 mg/dL, yet the two individuals could have the same average blood glucose, and therefore, the same hemoglobin A1c.
Improving Patient Outcomes Through Continuous Glucose Monitoring
New technology – specifically CGMs – is being used more frequently to help people with diabetes and their doctors gain better control over the disease. Currently, about 2.4 million people use CGMs in the United States, and it’s expected that more than half of people with Type 2 diabetes may have them within the next few years.
Using a small filament inserted under the patient’s skin, a transmitter and a receiver (in many cases the receiver is the individual’s smartphone app), individuals are able to see their glucose data in real-time. CGMs automatically track blood glucose and can help drive insights into how food, medication, exercise, sleep patterns and other factors may impact glucose levels. The technology also enables this data to be shared with caregivers and family members so they can take action when urgent problems arise, as well as with clinical teams through RPM platforms to enable them to better understand the patient’s day-to-day condition.
Overall, CGMs provide a more complete picture of glucose levels than finger sticks, calculating changes in trends and real-time directionality of changing glucose levels. This information helps remove the guesswork and stress individuals face when trying to determine their insulin doses.
More importantly, perhaps, when it comes to staving off complications, CGMs can help individuals maximize their Time in Range (TIR), which is the amount of time they spend in their target glucose range, both by being able to respond to high or low glucose levels in real-time, as well as to better understand contributing factors that lead to high or low glucose levels. Of course, improved TIR will translate to improvements in hemoglobin A1C, but with the knowledge that both the individual’s values and the average are improving. TIR should be around 70% – 17 out of 24 hours in the day – and when that goal is met, A1C will be around 7%.
Emergence of Glycemic Risk Index as a Streamlined Measure for Managing Diabetes
While TIR is well-established and gaining clinical adoption for CGM management, there is a newer index – the glycemic risk index (GRI) – that combines categories of TIR data into a single number.
Instead of solely focusing on Time in Target Range (TTR) (70mg/dL – 180 mg/dL), GRI incorporates:
- Time Below Range54 (less than 54 mg/dL)
- Time Below Range70 (less than 70 mg/dL, greater than 54 mg/dL)
- Time Above Range180 (greater than 180 mg/dL, less than 250 mg/dL)
- Time Above Range250 (greater than 250 mg/dL)
These metrics are converted into a numeric score, which then enables the clinical team to quickly identify where adjustments should be made for more effective glucose management.
While still new, the GRI has the potential to be an important addition to daily measurements from CGM, TTR and quarterly A1C tests. GRI can potentially help both individuals and healthcare professionals gain better insights into glycemic levels through CGM and remote patient management, and support more proactive adjustments to factors that may not be noticed with traditional finger sticks, quarterly A1C or TTR data.
Lucienne Marie Ide, M.D., PH.D., is the Founder and Chief Executive Officer of Rimidi, a leading clinical management platform designed to optimize clinical workflows, enhance patient experiences and achieve quality objectives. She brings her diverse experiences in medicine, science, venture capital and technology to bear in leading Rimidi’s strategy and vision. Motivated by the belief that we can do so much better as individuals, in industry and society, Lucie left clinical medicine to join the ranks of healthcare entrepreneurs who are trying to revolutionize an industry.