Dr. Gloria Cánovas, an endocrinologist at the University Hospital of Fuenlabrada (Madrid), assures that there is much room for improvement in glycemic control in patients with diabetes in Spain, a fact that has important repercussions on the health of these patients and that for reversing it would be necessary to increase adherence to prescribed treatments.
QUESTION. What is the current situation of diabetes control in Spain?
RESPONSE. To begin with, we do not know exactly how many patients with type 1 diabetes (DM1) there are in our country, because there is no patient registry, although there are plans to create one. It is estimated that 0.2% of the population has diabetes, which represents regarding 90,000 patients. Regarding the degree of control of these patients, the SED1 study carried out by the Spanish Diabetes Society (SED) in which 647 patients from 75 hospitals in Spain participated, reveals that only around 30% of the patients had HbA1c below 7%. In other words, a situation that might be greatly improved, although it is similar to what is happening in other Western countries.
P. And this poor control that you mention exists, what implications can it have from a clinical point of view for these patients?
R. We have known for years that a person with poorly controlled DM1 will live less and will live worse, because chronic complications appear. And that is why it is so important that we all make an effort so that diabetes control and, therefore, the prevention of associated complications continue to improve.
P. What prevents us from getting better control?
R. Diabetes is a disease that involves a tremendous effort for the patient: every time he eats he has to measure the carbohydrates in the food, he must take physical exercise into account, calculate the dose of insulin he needs and administer it before each meal …there are many variables every day, several times a day. It is difficult to comply with all the instructions we give and learn everything you need to manage type 1 diabetes. Patients need a lot of education and we need to be able to give them all the possible tools to facilitate their control.
P. How important is adherence to treatment to achieve good control?
R. If there is no adequate adherence to treatment, there is no control because people with type 1 diabetes do not produce insulin. They must therefore administer insulin without forgetting the basal or bolus before each meal. They are, therefore, 4-5 injections of insulin on average per day. It is not uncommon for one of these doses to be missed or avoided for fear of hypoglycemia later.
P. Are there differences in forgetfulness between basal and bolus?
R. We know that they forget regarding the two types. Endocrinologists used to think that it was more common to forget boluses, but studies say that boluses are forgotten 1 time out of 4 but that the basal can be forgotten in up to 36%. In that same study by Munshi MN, et al. 2019 the difference in blood glucose is measured between those who forget the most and those who forget the least and the difference in HbA1c is 0.9%. Forgetting insulin is associated with more variability, less time in range (TIR), more and later hypoglycemia, and higher glycosylated hemoglobins.
P. What tools can we use to improve adherence to treatment?
R. Glucose sensors are very useful because they detect increases in blood glucose and allow you to assess with the patient if there was an oversight. But the tools we have now only serve to suspect that there has been oversight. Sometimes the patient prefers not to take a bolus that he has forgotten for fear of hypoglycemia and is hesitant to admit it, or he forgot an administration and does not remember in the consultation if it was really a mistake or not. We are missing a lot of information. We need a reliable record so that the patient can check if an insulin dose has been forgotten, become more aware, and have all the information for consultations. Right now that we do not have this technology, we are making decisions with information that is not entirely reliable.
Another fundamental piece of information is the moment in which the bolus is administered, and we don’t have that controlled right now either. It is not the same to administer it before meals, as we should do, than during or following the meal, because if the insulin bolus is administered during or following the meal, the patient will have more hyperglycemia and a greater risk of hypoglycemia.
In addition, being able to share this information with the patient would help show patients how their sugar level has behaved depending on the time of the dose so that they understand the importance of all this. Studies have also been conducted on this subject that concluded that administering boluses before meals increases the time in range per day by up to 2 hours and reduces the risk of hypoglycemia.
P. Taking all of the above into account, would you say that it takes you a long time to talk with the patient just to try to get the necessary information regarding their adherence and their treatment habits?
R. Effectively. It takes time to download the sensors and discuss with them what happened at each moment. Time that is deducted from other aspects that might be addressed in each visit
Sensors currently have the option for the patient to actively, manually note when and how much dose has been delivered. However, this is an additional effort to all the effort that the patient already has to make, and in practice we see that few patients do it, and those who do are the ones who are more aware and have better adherence. .