Blood, sweat, tears and big data: The new wave of innovation in managing diabetes
Almost one in every 10 people has diabetes, and the number of diabetics has nearly doubled over the past 20 years. Despite that increase, development of new technology to help diabetics to manage their condition has been limited. Many diabetics still test and retest their blood sugar manually and inject insulin accordingly, just as they did decades ago.
Now, however, a wave of new technologies are emerging that could one day offer new tools to help people with diabetes manage their condition.
What is digital health?
Diabetes is caused by problems with insulin, a hormone that allows glucose to enter the body's cells where it can be used for energy. In type 1 diabetes, the body doesn't make enough insulin. In type 2 diabetes, the body has become resistant to insulin's effects. In both cases, those with the condition can find themselves with higher than average levels of glucose in their blood, which can lead to complications including sight loss, kidney failure, and even amputations. And it's a condition for which there is no cure.
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For many type 1 diabetics, their day is punctuated by regularly pricking their finger with a small needle called a lancet, squeezing out a drop of blood, and then using a handheld monitor to measure the glucose level in their blood.
Finding ways of measuring blood glucose reliably without the need for these regular 'fingersticks' has been a goal of researchers for decades and a number of alternatives to fingersticks have been investigated over the years.
Among the highest profile efforts was a project led by Verily, the life sciences arm of Google's parent company Alphabet. After four years of work on the project, which aimed to create contact lenses that could measure the levels of glucose in tears, the effort was abandoned, with Verily saying "there was insufficient consistency in our measurements of the correlation between tear glucose and blood glucose concentrations to support the requirements of a medical device".
While tears may not offer a successful way to monitor glucose just yet, the idea of using contact lenses to track diabetics' sugar levels hasn't been entirely abandoned. A team out of Pohang University of Science and Technology (POSTECH) has developed a contact lens that can uses LEDs and photodetectors to measure light in the near infrared spectrum, and so deduce the levels of glucose from the way light travels through the blood vessels on the outer section of the eyeball. "Smart photonic contact lenses thus hold promise for real-time blood glucose monitoring in diabetes," the researchers wrote.
As well as blood and tears, other efforts have concentrated on using sweat as a potential way to measure glucose. Researchers, for example, have created proof of concept smartwatches that can sample the sweat of the wearer to give them regular updates on their glucose level. However, sweat-monitoring hasn't really taken off due to the delay between a change in glucose levels and how soon it shows in the sweat -- meaning diabetics could be adjusting their insulin based on a reading that's out of date.
Other researchers are turning their attention to finding methods of measuring blood sugar that don't use body fluids at all. In order to develop non-invasive ways to test blood sugar, researchers are hoping to harness the ways that glucose behaves under the influence of different sound and light waves. Proposed alternatives to drawing blood typically involve one of three techniques: optical (using light to work out glucose concentration), transdermal (measuring glucose levels through the skin) or thermal (how glucose affects heat energy levels) methods.
However, it's hard to know when these projects will pay off. "Finding a real-time way to sample a small molecule like glucose in this continuous manner is still just very, very difficult… pretty much everything you look at falls short in one of the four areas of accuracy, reliability, time dependence, and safety," says James Hayward, principal technology analyst at IDTechEx.
Big Data
Research into non-invasive glucose monitoring has been ongoing for the last 30 years or more, he says, but such efforts are perpetually two or three years away from being approved. "Obviously, it is getting closer all the time, people are learning from different failures and the cumulative sum of all the work that's going on. But still, it's difficult to really commit to an understanding about when these are likely to be commercialised," IDTechEx's Hayward says.
But that doesn't mean that the end of fingersticks couldn't still happen, however -- the advent of continuous glucose monitoring (CGM) looks set to put paid, for some at least, to manual blood sugar checks done with a lancet and handheld glucose monitor.
CGM systems measure the body's glucose levels by means of a small plastic tube inserted under the skin, sampling the glucose in the wearer's interstitial fluid.
While the tech has been around for a while, it's currently only used by a very small proportion of people with diabetes around the world, mainly due to its suitability for certain use cases -- type 1 diabetics and insulin-dependent type 2 diabetics -- as well as the high cost of the units compared to manual blood sugar checking.
While hardware costs will fall eventually, as they do with any given technology that becomes more widespread over time, that's not the only reason that the uptake of CGM devices will grow: they give diabetics valuable information on how the rhythms of their lifestyle and medical use can affect their blood glucose. With a near real-time view of how decisions about, for example, what to eat, affects their blood sugar, diabetics can get a better control of their condition and keep their glucose in safe limits. Equally, it gives health insurers a reason to reimburse the cost of the devices: those diabetics with better glucose control are less likely to develop severe complications in future, like retinal damage that can cause sight loss or nerve degeneration that can lead to amputations.
For most of the diabetic population, where CGMs aren't considered suitable or are too expensive, the fingerstick looks to be around for some time to come. However, even here innovative new technology is being worked on.
"Diabetes is one disease that really requires a lot of data to manage it completely. If you think about it, why do we require CGM devices which take your blood glucose every five minutes?" asks Siddharth Shah, program manager of Frost and Sullivan's Transformational Health practice.
"It should be so much more powerful for you to have that knowledge at your hand, and you will definitely be better prepared to manage the disease," he added.
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OneDrop is one example of the new crop of companies that has learned the importance of bringing information from diverse data sources and sensors to help diabetics manage their condition. However, rather than using CGMs, OneDrop and others like it are looking to bring tech-smarts to the much cheaper and much more widely used world of fingerstick monitoring.
OneDrop sells a subscription service offering a sleek-looking glucose monitor, test strips, individualised online coaching and a mobile app that tracks glucose, medications, activities and food and offers predications on how users' glucose could change. All the data can also be shared with doctors and other clinical staff involved in the users' medical care.
OneDrop isn't alone in targeting the non-CGM market with packages that use data to nudge users into better glucose control: Livongo, Glooko, and mySugr offer similar functionality. These all-in-one diabetes tech companies can help overcome one of the biggest challenges with diabetes management: the issue of adherence (in non-medical speak, remembering to test glucose as frequently as a doctor recommends).
Interestingly, OneDrop recently acquired Sano, a company working on creating a sensor that gathers information on various biometrics, including glucose. The Sano patch isn't marketed yet, but uses microneedles that penetrate the skin to measure glucose in the body's interstitial fluid. Sano's glucose sensing patches were originally set to hit the market in 2016, but have yet to be commercialised.
It looks like the next wave of diabetic technology will involve fingersticks, research into innovative new ways of measuring glucose without using blood, and a sprinkle of data analysis. Perhaps when it comes to the next wave of glucose-monitoring technology, the industry's future is shaping up to look a lot like its past.