Bringing Greater Context to Precision Monitoring in Patients With Diabetes

Growing evidence suggests the existence of connections among self-care behaviors, mental health, and maintenance of glucose levels among those with diabetes, according to a recent review article in the journal Diabetologia on achieving better precision monitoring of blood glucose.

According to the authors, automated integration of these characteristics and possibly others could lead to better precision therapeutics and precision diagnosis.

Precision monitoring of glucose levels has improved in the last 5 years, the authors wrote, thanks to advances in continuous glucose monitoring (CGM). However, the authors noted that little progress has been made in identifying subgroups of people with diabetes based on CGM data and tailoring treatment accordingly.

The integration of CGM with other monitoring technologies such as devices, apps, and trackers that collect information on individuals’ moods, sleep patterns, eating habits, and psychological variables may allow for more intelligent processing and interpretation of glucose data, by putting CGM information in context, according to the authors.

“By combining CGM data with the monitoring of these contextual variables, precision monitoring in diabetes can be achieved. This is in line with the current [American Diabetes Association] and [European Association for the Study of Diabetes] consensus statement that calls for precision monitoring. Based on the consensus statement, precision monitoring is defined as the multimodal assessment of glucose, behaviors, diet, sleep and psychophysiological stress,” said researchers.

The authors of this narrative review offered 5 key areas needed in precision monitoring for diabetic patients.

• Ability to measure performance and data integration
• Ability to analyze and associate identification of different subgroups of patients
• Develop interventions based on precision monitoring
• Measure outcome trials to evaluate precision monitoring
• Acceptability of precision monitoring in the real world

People with diabetes must manage more than just their glucose levels. They may also need to administer their own insulin injections, take medications, track their eating habits and exercise, schedule foot care and maintain a generally healthy lifestyle.

The need to actively manage so many important aspects of one’s life may consequently present itself as a burden, causing elevated stress, mental health problems, and an overall lower quality of life.

Several studies included in the review found that rising rates of postprandial glucose excursions directly correlated to negative moods, such as depression and anxiety. However, correlation between glycemic variables and positive moods was not found.

These studies support growing evidence that negative mood is correlated with high or low glucose levels, while positive mood and normal glucose levels are coincidental.

Further studies that measure both Ecological Momentary Assessment (EMA) and CGM may help identify different subgroups of diabetic patients. The authors describe EMA as “a methodology that allows the repeated daily sampling of participants’ experiences and behaviours in their everyday lives.”

The authors specify 2 levels of interventions that could occur based on subgroups identified in precision monitoring:

“From the point of view of ‘precision therapeutics,’ different therapy strategies might be offered to the 2 subgroups: for the first subgroup interventions to improve mental health could be more effective when including the diabetes context; and for the latter subgroup improvement of glycemic control and mental health could be addressed independently,” the authors said.

Behavior and Glycemic Control Studies

• A study by Wagner et al found an association between greater self-care behavior and less of a glucose level variability
• A study by Shapira et al demonstrated stronger negative effects were associated with less optimal self-care
• An analysis of binge-eating in patients with type 1 diabetes found that a higher effect of guilt, frustration, and diabetes distress put people at higher risk of binge-eating, leading to higher postprandial glucose excursions
• A study focused on digitally phenotyping self-care behavior in patients with type 2 diabetes (T2D) found that being in a low and waning engagement group was associated with younger age, female sex, non-White race, lower income, and higher baseline blood sugar levels

Sleep and Glycemic Control Studies

Observational data suggest impaired sleep quality to be more prevalent in people with diabetes, and related to the occurrence of T2D, inflammation, insulin resistance, and appetite and weight gain.

The authors called for additional studies to address knowledge gaps in order to achieve precision monitoring.

• More information is needed to measure the accuracy and performance of sensor data, such as EMA compared with traditional questionnaires.
• The stability and directionality of associations among glucose, behavior and mental health are unknown. More information is also needed to determine whether all 3 areas should be weighed equally or differently.
• Methods of change that can be used in interventions need to be tested and evaluated.
• Newly developed interventions should go through testing that proves to be cost-effective.
• Medical, demographic, and social variables may provide better insight as to which subgroups of people will benefit the most from precision monitoring.

“While precision monitoring is not yet established, it is a next step towards giving people with diabetes and healthcare professionals the tools to better understand the intricacies of diabetes therapy and help inform appropriate management,” said researchers.

Reference

Hermanns N, Ehrmann D, Shapira A, Kulzer B, Schmitt A, Laffel L. Coordination of glucose monitoring, self-care behaviour and mental health: achieving precision monitoring in diabetes. Diabetologia. 2022;65(11):1883-1894. doi:10.1007/s00125-022-05685-7