Opinion

Diabetes progress: it’s finger-pricking good

November 8 2019

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Dr Erica Smyth with Royal Flying Doctor Service staff at Jandakot airport, WA. Photographer: Frances Andrijich

Erica Smyth - bio

Dr Erica Smyth

Fellow of the Academy in Western Australia

From blunt needles to Bluetooth glucose detection, Dr Erica Smyth has experienced the evolution of health technology the hard way.

“You have Type 1 diabetes.” I heard this for the first time 45 years ago, and what a shock.

I was five weeks into my first job as a geology graduate at Newman in the Pilbara in 1974, and I hadn’t wanted to admit that I was not my usual self. Yes, I had experienced all the classic symptoms – I was tired all the time, I was losing weight at a very rapid pace, I had to wee 20 or more times a day and my eyesight had deteriorated to a point where I couldn’t drive.

But my earlier visit to a doctor about my failing eyesight had been short and no real questions were asked. “Just see an ophthalmologist when you’re next in Perth.” So I just ignored the symptoms. I refused to believe there was anything else wrong with me: it was just the heat and a new job. Not long after that, I was comatose.

By the time the Royal Flying Doctor Service got me to Perth I was in a very bad way. During the next five weeks I was told about all the terrible complications that would probably happen to me if I did not control my blood glucose. The (as it turned out, temporary refractive index-related) failure of my eyesight was the one thing that scared the living daylights out of me. I learned that the real long-term risk was that retinopathy – the bleeding of vessels in the retina – is a major cause of blindness for diabetics.

Ever since, I have been focused on getting my blood glucose under control. This meant I had to learn about this chronic disease and take personal control. It’s been an enormous learning curve, and I’ve been a user of every advancing medical technology. From the 1970s to the 1990s this wasn’t easy, as researchers were still debating how the whole hormone system interacts.

First, some background on diabetes. Type 1 (or “juvenile”) and type 2 diabetes have different root causes, but the risk of severe complications is the same. It’s all about managing blood glucose.

When non-diabetic people digest food, carbohydrates turn into glucose, then enter the blood stream. High glucose in the blood triggers the beta cells in the pancreas to release insulin. Insulin then gives cells access to the glucose so they can convert it to energy.

With the help of other hormones in the pancreas and liver, and the cleaning action of the kidneys, a blood glucose balance is maintained in a range of around 5.5 mmol/l.

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Dr Erica Smyth with a selection of the technologies she’s used over the years to manage her diabetes.

My auto-immune system attacked my pancreatic beta cells, so I don’t produce any insulin and need to artificially add it. (Type 2 diabetics, on the other hand, have insulin resistance: their cells don’t respond effectively to insulin’s role in absorbing glucose.)

The big challenge is to balance my food and exercise with the injected insulin. Different types and intensities of exercise combine with the pre-injected insulin to have different short and longer-term effects on my blood glucose.

I need to keep making adjustments to stop my blood glucose getting too high or too low. My cells need a bit of insulin in my system all the time to help the transfer of glucose (even when I sleep), and the impact of exercise can last for hours after the exercise is finished.

In the “olden days” I used fast-acting injections at meal times and slower release insulin at night, but I didn’t understand all the chemistry. I had only one way of knowing about my blood glucose level: if it was too high, my kidneys would strip it out.

To see if excess glucose was leaving my body, I had to wee in a test tube and use a small dipstick to compare colours. This wasn’t very accurate or convenient, but it was the only method I had. The only way I knew I had low blood glucose was if I started to shake, perspire or get gruff and confused.

My insulin came from pancreases of slaughtered beef and had to be stored in the fridge in a very close temperature range. The glass syringes I used needed to be boiled every week and stored in methylated spirits. The needles themselves were very big and quickly became blunt.

But this “fly by the seat of my pants” world did not last too long, as diabetes was benefiting from excellent international research and major advances in technology. I was willing to try any new advances as soon as they became available.

The first big change was disposable syringes with small needles. This meant the injections – which by then were four times a day – were not nearly as traumatic or painful.

Next came portable blood glucose meters. Initially, these were quite heavy and cumbersome and not easy to use in a crowded place. But they were a step forward from weeing in the test tube. Of course, each new test required pricking one of my fingers. I’ve had more than 15,000 finger pricks over my lifetime.

The next step was a big one – cloned human insulin (I say thanks to “Dolly the sheep”). This agreed with my biology much better than insulin sourced from beef. It was also more stable from the temperature point of view, making it easier for me to travel.

At about the same time the insulin pen arrived. This is a more discrete method of carrying around an insulin supply and had even smaller needles.

Looking forward, the next pharma advance I would like to see is a faster acting insulin

But sometimes I still got it very wrong. Low blood glucose can leave me confused, uncoordinated and often aggressively saying “No” to whatever’s going on. This can happen very quickly. At times it scared my work colleagues when I could not string two words together or I had small fits. My handbag store of high-glucose jelly babies often saved me – and still does.

Almost 15 years ago I received an insulin pump, and my life really did start to change for the better. No more four injections a day – only one every three days to change the infusion site. Now I get a little bit of insulin every three minutes, and dial up an extra dose when I eat.

The insulin pump is with me 24/7 (except in the shower) and is a good, though not perfect, solution. My insulin still needs adjustment when I do something outside the normal routine that my pre-programming is designed for.

The latest technology I have taken up – just two years ago – is a method to measure my glucose levels whenever I want by just waving a Bluetooth detector over a patch on my arm. I change the patch every two weeks, and can get an interstitial fluid glucose reading whenever I want. This reading is a bit behind my blood glucose, but it’s pretty close.

I have gone from averaging maybe five finger prick tests a day with the old meter to 17 painless tests a day with the new one. Because I can tell whether my blood glucose levels are going up or down, I now have better knowledge of what’s going on in my body. I always test my levels before I get into a car to drive.

None of this technology is cheap. Pumps are now about $8000 every four years, and some health insurers will not fund them unless there is an “urgent medical need”.

The consumables for pumps, blood testing meters and insulin are partially subsidised on the National Diabetes Supply Scheme or the Pharmaceutical Benefits Scheme, but my pump and Bluetooth patches are not. The patches are $200 per month, which means they are out of the financial reach of many people.

These costs are covered by the Government for children under 18, but once you are an adult you are pretty much on your own.

So it might sound like my diabetes is now easy to control, but it can still spring surprises on me and the people around me. The key is for me to be open by explaining my disease and what to do if I “go a bit strange”.

Diabetes is like standing on an unstable four-legged stool. The legs of insulin, exercise and food are the normal focus for the balance but the fourth leg – my emotional state – can bring the whole stool tumbling down. Overlying all this is my general health, as infections or even getting the flu can also significantly change the balance.

Looking forward, the next pharma advance I would like to see is a faster acting insulin. After 45 years I don’t absorb my insulin as quickly as I used to and there is a significant time delay between delivery and effectiveness. I am testing a new insulin now and have great hope for it.

The next technology advance for me will probably be an automated combined intelligent pump and glucose meter. But first, I need to be sure about the faster acting insulin. The details from the pilot trials of these new automated pumps are still being published, and I am not willing to have one installed – yet. For now, I am sticking with my brain as the main controller.

I have no retinopathy in my eyes, my kidneys still work, I heal well and I can feel the tips of my fingers and toes. So I say thanks to all the wonderful researchers, educators, pharma companies, technologists and engineers that have made my extended life span liveable and enjoyable.

Erica Smyth - bio
Dr Erica Smyth AC FAICD FTSE

Chair of NOPSEMA

Erica Smyth is a professional Company Director with more than 20 years’ experience on minerals, energy, science and education/research boards.

She is immediate past Chair of the Diabetes Research Foundation WA, Chair of NOPSEMA and a Non-Executive Director of Lions Eye Institute, MinEx CRC, ICRAR and National Energy Resources Australia.