Photo by StevePB
Publish Date: 13.12.2021
Category: Our contribution to sustainable development goals
Sustainable development goals: 3 Good health and well-being, 4 Quality education (Indicators)
Modern approaches to glycaemic management in individuals with diabetes
The frequency of diabetes worldwide, and sadly also in Slovenia, is increasing steeply. In Slovenia, the estimated number of individuals with diabetes has already exceeded 100,000. This comprises both type 2 diabetes, which is present in 90 percent of people with diabetes and is associated with an unhealthy lifestyle, and type 1 diabetes, which is an autoimmune disease of unknown aetiology, affecting mostly children and young people. Both types are characterised by increased blood glucose levels, which damage blood vessels in many organs of the human body via various mechanisms associated with tissue inflammation and, if not properly managed, lead to chronic complications of diabetes, such as impaired vision, kidney function impairment, cardiovascular diseases and brain damage, including dementia. Unfortunately, an increase in the frequency of these chronic complications of diabetes has also been recorded.
On the other hand, the past decade has seen an extremely rapid development of new diabetes medications, as well as new technologies which enable continuous measurement of subcutaneous blood sugar levels (continuous glucose monitoring – CGM) and a closed loop insulin delivery systems with an artificial intelligence component. Since these new medications and technologies have opened entirely new avenues of treatment, new approaches to diabetes management also need to be developed and transferred into daily practice.
On this year's World Diabetes Day (14th of November), a review scientific paper on old and new approaches to blood glucose level control in individuals with diabetes, co-authored by Prof. Tadej Battelino, MD, PhD from the Medical Faculty, University of Ljubljana (UL MF), entitled Glycaemic management in diabetes: old and new approaches, was published in the prestigious medical journal The Lancet Diabetes & Endocrinology.
Glycated haemoglobin HbA1c is the most used parameter to evaluate blood glucose levels, as it approximately reflects average blood glucose levels over the past 70 to 100 days. However, new evidence has forced us to take a second look at the concept of increased blood glucose levels and highlighted various aspects that need to be considered. A modern approach to blood sugar level control in individuals with diabetes should focus not only on reaching and maintaining optimal glycated HbA1c values, which mainly indicate average blood glucose levels, but also on reducing high glucose levels after meals and glucose level variability, and to extend as much as possible the time in range around normal glucose levels. These goals need to be achieved, while at the same time avoiding too low blood glucose levels. Modern technologies for the continuous monitoring of subcutaneous glucose levels, along with new types of drug treatment (e.g. ultra-fast- and ultra-long-acting insulins, SGLT2 inhibitors and GLP-1 receptor agonists) and new types of artificial intelligence integrated into closed loop insulin delivery systems and automated algorithms to support the dose selection of medications, could help change many aspects of blood glucose control. The proposed changes favour a more holistic approach, which takes into account all of the various aspects of variable blood glucose control, this commonly oversimplified pathophysiological feature of diabetes.
Figure: Milestones in glycaemic control of diabetes – understanding its history (1975–2021) Source:
The above figure shows the timeline of official proposals for various approaches to glycaemic control (i.e. blood glucose level control). In 1975, occasional blood glucose level measurements were initiated, primarily in the mornings on an empty stomach and in the case of signs of low blood glucose levels (prior to that, only urinary glucose levels were measured). In 1980, monitoring of glycated haemoglobin HbA1c was introduced, which shows approximate average glucose levels over the past 70 to 100 days. Between the years 2008 and 2011, monitoring of blood glucose levels one or two hours after meals was initiated and in 2012 this was followed by monitoring of patients for a certain period after the occurrence of low blood glucose levels. Due to the increasingly widespread use of systems for continuous subcutaneous measurement of glucose levels (CGM), the variability of blood glucose levels began to be monitored after 2013. Most recently, in 2019, international guidelines were published, with which monitoring of the time in range was introduced. The lead author of these international guidelines was Prof. Tadej Battelino, PhD, from the UL MF.