Having just accomplished the challenge of running 25 marathon-distance routes across the U.K & Ireland in the space of one month – an extreme mission which enhanced itself through coinciding with my daily challenge of managing type 1 diabetes – the evidence is there to reflect the exponential advantages that the use of technology brings to daily health management; particularly when you have a faulty pancreas unable to produce the natural “glucose coordinator,” the hormone known as insulin.
In this extreme endurance feat, I did not just run 25 marathons: I absolutely, rather freakishly, annihilated them. And what counted the most – after the crucial funds raised globally for this cause – was that my health remained in good-check throughout this gruelling schedule of fortitude, which was topped by tiresome travels: running marathons location after location with transportation via trains, ferries, airplanes – you name it – and the diva in oneself does not travel light! So whilst the demands of diabetes did bring its anticipated ups and downs on this adventure, what was interesting was how more often than not the glucose levels steadied in a good range – especially through the running durations!
“Your glucose levels appear better than mine, and I don’t even have diabetes!” quipped Adam Denton, a support driver on the Eastbourne to Brighton leg. Adam pointed out that on the MHealth Grand Tour – a cycling venture which included multiple type 1s riding from Brussels to Geneva in 2015 – he had placed a continuous glucose monitoring sensor on himself and found the beeping alerts of hypoglycaemic (hypo) & hyperglycaemic (hyper) levels occurring, such is the impact of continued endurance activities even on the ‘average body’ living without diabetes.
For this challenge “mobile health” was applied; the Dexcom G5. A continuous glucose monitoring system (CGM) which connects via an app to mobile devices – so as I ran, with a sensor and transmitter attached and communicating to my phone, my glucose levels were continuously accessible. Furthermore, not only the number of the level is displayed on screen (set in Mmol/ls) but a selection of arrows and alerts indicate whether the glucose levels are lowering, rising, rapidly lowering, rapidly rising… or remaining as steady as a rock! Further-furthermore, on the challenge I had a significant advantage in having a Dr Paula Chinchilla there (a recently graduated dietitian from Costa Rica, also living with type 1 diabetes herself) with access to view my glucose levels via the Dexcom app – therefore easily able to provide updates on what carbohydrates to consume and precisely when!
So… in light of the fact that whilst the body was under such stress of running not only a single marathon but 25 of them, with diabetes, and yet the daily glucose control remained arguably better than on an average day (not running marathons) the proposal has to be put forward: the benefits of funding a CGM long term vs short term. If the National Health Service (NHS) invested to provide patients living with diabetes with CGM technology, patient’s long term management on average would no doubt improve; however, short term on paper, this does mean additional costs to an apparently ‘stretched’ NHS budget.
The National Health Service themselves released: “Diabetes of all types can lead to complications in many parts of the body and in severe cases could lead to premature deaths if managed poorly or undiagnosed. There is also the economic impact of diabetes to consider: in the UK alone, the cost of diabetes to the National Health Service is over £1.5 million an hour or 10% of the overall NHS budget for England and Wales.”
Diabetes UK in 2017 furthermore released ‘the cost of diabetes report,’ which shared: “diabetes accounts for approximately 10% of the NHS Budget and about 80% of those costs are due to complications.”
Whilst this accounts for all types of diabetes in one statistic, the answer seems painstakingly obvious: do more to reduce complications!
Type 1 diabetes in young adult and adolescent age groups has one of the leading figures of all chronic illnesses connected to mental health related issues. Penny Robinson, a parent of a daughter living with type 1 diabetes and supporter of the marathons challenge during the Skipton to Leeds leg, shared that “one negative comment in a consultation can undo years of progress for a person adapting to diabetes.”
DiAthlete preaches that ‘type 1 diabetes education is essential but needs to come with the right balance of relatable understanding and encouragement.’ In DiAthlete’s article: ‘The Condition of Communication’ Shakira Chahal, a 23 year old patient and mother of a 5 year old boy, opened up about her diagnosis to a serious complication called diabetic gastroparesis – just 6 and a half years after being diagnosed with diabetes. Whilst sharing about how she had to consume her meals through a nasal Jedinal feeding tube, as she had lost so much weight and was unable to eat and take insulin, Shakira concluded: “all of this could have been avoided if people were educated more in their illness, instead of just being flung out of the door with set doses and no clue how to deal with problems that could occur. The way consultants speak and communicate with their patients has a big impact on the way people then deal with their health.”
Evoke Pharma in the US shared in 2017 on the costs of treating gastroparesis: ‘Hospital admissions for patients with gastroparesis as the secondary diagnosis increased 136%. The average length of stay for a patient is approximately six days at an estimated cost of approximately $22,000.’
‘Complications’ is a vague word to look into the mainstream costs and leading issues for people living with diabetes. A common threat for those living with diabetes is diabetic ketoacidosis (DKA) when glucose levels rise higher – which occurs when the body produces high levels of blood acids called ketones – and this often leads to hospital admissions. These admissions can be known to take 24 hours to stabilise the blood acids and glucose levels. The Diabetes Times revealed in their 2017 article Hospital DKA Treatment cost tops £2,000 that ‘by using the individual patient data and the Joint British Diabetes Societies Inpatient Care Group guidelines, the average cost for an episode of DKA was £2,064 per person.’
BMJ Open shared a Diabetes and Endocrinology Research Abstract on the incidence of DKA prevalence in 2017: ‘eleven studies reported prevalence (of DKA) with a range of 0-128 per 1000 people living with T1D.’ The abstract did also reflect on its results that ‘there was a higher prevalence of DKA reported in patients treated with insulin injections compared with patients using continuous subcutaneous insulin infusion pumps, respectively.’
As a patient on multiple daily insulin injections who has never, in 18.5 years living with type 1 diabetes, been admitted to hospital for DKA, there is an argument to say, HEY I’m okay… but the statistics are clearly there at the very least to show how the use of advanced technologies improve the average long term management of diabetes and can lower the risks of complications.
This brings us back to my example of using the Dexcom CGM whilst out running 25 marathons in a month. I do not have good hypoglycaemia awareness; the shaky and shivery implications deserted me long ago as a rebellious adolescent. Marathon or no marathon, it goes without saying that to be able to not only detect a hypo through the irritating alert sound of a ‘baby crying’ (as I have active on the Dexcom G5 settings for low glucose levels) but to be informed by alerts and the arrows on my phone app that my levels are lowering is advantageous. It allows me to act with time on my side to prevent a serious hypo – something I know personally how serious it can be, with the scars on my eyebrows to this day representing the evidence. An untreated serious hypo can even lead to a diabetic coma, something of which I was very fortunate to wake out of in 2008 after being unconscious for 3 hours.
Running continued marathons is extreme! And it is incredibly aerobic – maintaining a consistent pace whilst burning energy in exercise for many hours each day. The anticipated glucose level impact of this endurance is to decrease continuously during activity, and quite possibly again later on post activity. Despite such a challenge in conjunction with my diabetes, I only encountered 4 mild hypo levels throughout the entire month of running. The credit for this, alongside the valuable nutritional advice of Ms Chinchilla, goes to the use of mobile technology: being able to keep a step ahead of my diabetes in order to coordinate the best decisions from carbohydrates to insulin.
LeicestershireDiabetes.org.uk, supported by Diabetes Care UHL, East Midlands Ambulance Service & University of Leicester NHS, share that “hypoglycaemia is costly for patients and for the NHS. People with diabetes fear hypoglycaemia as highly as the risk of development of serious complications. The annual UK cost of hospital admissions and ambulance callouts is estimated to be £16.9 million.”
The threat of a serious hypoglycaemia can be life-threatening on a ‘short-term’ scale; whereas the threat of developing serious complications is a ‘long term’ issue, both of which can be greatly reduced by 2 crucial aspects: better forms of diabetes education and better access to advanced technologies – technologies which are out there and on the market, yet, in most cases self-funded. We have a great, social-healthcare system in the U.K – as a type 1 diabetic it does genuinely keep me alive by providing the resources I need – so I’m grateful to what we currently have; however, when you consider the day-to-day challenges which diabetes of all types brings, in particularly in type 1 diabetes where there’s a balance of the above short-term & long term risks apparent, the question has to be asked: why isn’t the best equipment to manage health – a continuous glucose monitoring system – available on the NHS??
The short-sighted answer will come down to costs…
On the contrary, you can understand an initial reaction to the higher costs there have been towards this new technology on the market, which keeps updating and evolving. Access to continuous glucose monitoring does need to be more cost effective, this is a diverse issue stretched location to location around the world – similar to the crucial resource of insulin! – A person’s health accessibility should not come down to a person’s postcode. The more the technology comes onto the market we start to see decreases on prices. Dexcom now share that their cost of a continuous glucose monitoring system is “on average GBP £160-£220 monthly, depending on how you use the product.” We have seen in recent times the Libre come more accessible onto the NHS budget – depending on the postcode still – and in some cases, CGMs such as the Dexcom occasionally do get funded, so the signs are positive there, but all round instead of a short-term look at the costs sheet, the long term picture needs to be considered towards the advantages for health. At present the majority of people can’t really afford to pay privately for such beneficial technologies for their health, especially young adults. Even the cost of an extra £50-£100 per month is too much for many in the present day, on top of the costs of rent, meals, phone bills etc – we didn’t purchase diabetes, people need more support.
There was a similar situation to when the insulin pumps first became funded by the NHS – those with “poorer” control would have the first opportunities to be on a pump. Whilst help is essential for those most in need, everybody requires as much support as they can get in living with a daily, demanding condition such as type 1 diabetes; reassessing the methods of education is a key for the former there, the latter requires more common sense: the common sense to say (from the NHS perspective) “wow 80% of the costs associated with diabetes are linked to complications, how about we give all patients the tools to best prevent complications from occurring and then we’ll slash that budget…” And a ‘good tool’ is the best you can bring in for someone’s health – such as a full continuous glucose monitoring system, like for example the G5 (or future developments to come on technologies), where I could see my HbA1c predictions; patterns of glucose levels daily, weekly, monthly; a downloadable app for Paula to be my ‘med professional / mother figure’ during this challenge and view my levels – something which can bring the reassuring guidelines for parents who have to become experts if their child is diagnosed; and to improve consultations with doctors viewing a more detailed insight.
The British health system has a great history of many breakthroughs in research, finding cures, to operating a fair system; but history is history, the only way to progress is to be the innovators of today and to lead the way for a better tomorrow. The statistics really do make this argument quite simple: provide funding in a more common sense solution today and you will save money long term concerning conditions such as diabetes. Over £2k on average per person for a DKA admission to hospital, with figures prevailing; nearly £17 million on ambulance callouts & hospital admissions, where diabetic comas and serious hypoglycaemias easily happen; the treatment of serious complications from diabetic gastroparesis to kidney failure, foot ulcers and laser eye-treatment can range anywhere from £15,000 to £100,000 per patient (or more!) – 80% of the diabetes costs in healthcare are associated with complications… why not do something that can help prevent these outcomes and minimise these costs?
Quite frankly I value health above any statistic: the best technology provides the best results. If I can be successful as a person with type 1 diabetes running 25 marathons on a CGM device, mobile health is a clear nucleus to a healthy present and prosperous future for daily self-management. The costs do need to lower – the companies have to negotiate more in this area – and there are some signs of this starting in the U.K with the continued growth of the market; the crucial education to go with it needs to improve, with more relatable, understanding methods of passing this on; and the NHS should invest much, much more into mobile health and CGM devices in diabetes should they wish to achieve a healthier future in this condition for patients, which is much more cost effective in the long term picture. Invest smartly today, improve tomorrow.