Diabetes could affect any of us, either directly or indirectly, since its prevalence continues to rise and one in three Singaporeans are at risk of developing the chronic disease.

Singapore began its war against diabetes more than four years ago but as Second Minister for Health Masagos Zulkifli said on World Diabetes Day last November, “we need to continue our fight against diabetes as a nation — as individuals, healthcare professionals, and the broader community”.

In Singapore, a third of people living with diabetes are not even aware they have the disease, while one in three of the remaining two-thirds have poor control over it. 

If left unchecked, the prevalence of diabetes could more than double from 440,000 in 2014 to one million by 2050, Singapore’s Saw Swee Hock School of Public Health projected.

Yet there are challenges in keeping diabetes in check.

THE COMPLEXITY OF MONITORING DIABETES 

Imagine driving every day on roads with a speed limit but you don’t have a speedometer in your car. 

What you do have is regularly scheduled notices from the traffic police, where you find out your average speed over three months and whether you’re going to be fined for going above the speed limit.

Driving under those conditions may prove challenging and can be filled with uncertainty.

For many living with diabetes, this scenario is similar to the way that the condition is managed today.

Many patients only have access to actionable information a few times a year, making it difficult for them to stay within the recommended range on a regular basis. 

Everyone with diabetes needs to know what their blood glucose level is because it’s crucial for effective diabetes management.

This is often done by pricking a finger to take a small sample of blood to understand glucose levels at a point in time.

A universally-accepted standard for diabetes is the Haemoglobin A1c (HbA1c) blood test, which measures the proportion of hemoglobin molecules in the blood that have bonded with glucose, or sugar.

Depending on the individual, a normal level is usually around 5.7 per cent. The American Diabetes Association recommends 7 per cent for adults with diabetes, a widely accepted target that is also followed in Singapore.

If it becomes very high, or very low, HbA1c value signals to a doctor that the diabetes isn’t being managed well.

The HbA1c measurement is an average over the past 90 days, which needs to be further validated by daily measurements.

However, a spot measurement on any given day could be influenced by everyday factors that include when patients eat meals, if they’re putting in a heavy gym session, or even the time of day a glucose reading is taken.

So individuals who have the same HbA1c level may clock in vastly different glucose ranges on different days.

Is there a better way to monitor HbA1c levels then?

Here’s where technology can help.

WHAT IS CONTINUOUS GLUCOSE MONITORING

Advancements in technology have enabled continuous glucose monitoring (CGM), a compact medical system which can help patients understand the impact of food intake and physical activity on their glucose levels — without having to routinely prick for blood.

Doctors can monitor remotely, observing real-time data, historical trends and predictive analysis around the clock to make recommendations on how to manage the condition.

Most CGM systems come with a wearable sensor which attaches to the body so that it can transmit blood glucose readings in real-time to a monitoring device, or smartphone app.

Patients can also set the parameters and notifications on how they would like to receive alerts when their blood sugar levels are too high or too low.

A US study presented at the American Diabetes Association sessions showed CGM technology can significantly reduce glucose levels in people living with diabetes.

Whilst most studies using CGM have involved people with Type 1 or Type 2 diabetes on intensive insulin therapy, this research was one of the first to focus on the more prevalent Type 2 diabetes, whether the patients were on insulin or not.

Researchers investigating the impact of one CGM system (Abbott’s FreeStyle Libre) reported an average HbA1c drop from 8.5 per cent to 7.7 per cent over six months, bringing levels closer to the recommended target of 7 per cent.

So how can this help people living with diabetes in Singapore?

It can help them make healthier choices. For example, a 40-year-old Singaporean man with Type 2 diabetes who normally eats white rice during dinner may observe a significant glucose spike.

With this in mind, he can change his diet, or take regular walks, while easily keeping track of his glucose levels in real-time to understand what works for him.

WEIGHING THE COST AGAINST POTENTIAL BENEFIT  

Continuous glucose monitoring for people living with diabetes has been available in Singapore for a number of years with several brands in the market.

CGM-based technologies usually cost a couple of thousand dollars for continued usage across the year, but the price varies, depending on the frequency of usage and the specific product used.

Blood glucose monitoring with finger sticks usually costs a few hundred dollars a year, but only provides a glucose value at a given point in time.

Continuous monitoring tracks glucose levels around the clock, providing comprehensive historical values that indicate the direction in which a patient’s glucose levels are trending.

Subsidies to patients in some parts of Asia Pacific such as Australia, Japan and South Korea have led to greater adoption of CGM technology by helping to cover the costs involved.

CGM monitoring is not subsidised in Singapore and the price remains a consideration for patients given their recurrent expenditures on medications and other essentials.

The application of the device is fairly easy, but it is very different from traditional glucose monitoring tools, so there’s a bit of training and familiarisation involved.

Another important factor is that the sheer amount of data that this technology provides can be overwhelming.

Doctors and healthcare staff can play a significant role in helping their patients set up, understand and operate the technology effectively.

The use of CGM technology is not intended to do away with the A1C test but to provide greater insights and actionable information on glucose movement on an everyday basis, as the HbA1C value is an average of 90 days.

CGM adds greater context and meaning around glucose readings, helping doctors analyse and customise diabetes management for each patient.

Diabetes can then be better managed with daily, updated information rather than depending entirely on one-time spot readings and a 90-day average.

CGM technology is an innovation which comes almost four decades after routine finger pricking. Every innovation has a price but can also bring value. 

What matters is the impact that this next generation technology can have on Singaporeans living with diabetes, by helping them to manage their condition more effectively.

About the authors:

Dr Eden Miller is an Oregon-based family doctor specialising in diabetes. Dr Wong Tien Hua, a family doctor at Mutual Healthcare, is a council member of the Singapore Medical Association (SMA) and a SMA representative in the National Diabetes Prevention and Care Taskforce.