Glycaemic control, glucose variability and the Triangle of Diabetes Care

Abstract

The discovery of insulin turned a diagnosis of type 1 diabetes from a terminal condition to one that can be managed in a way that allows a full and fulfilling life. Optimal management of glycaemia plays a key role within the long-term management of diabetes. Indeed, the Diabetes Control and Complications Trial and the UK Prospective Diabetes Study established beyond doubt that intensive management of blood glucose (HbA1c) reduced the risk of long-term (especially microvascular) complications of the disease in type 1 and type 2 diabetes, respectively. Long-term observational follow up years or decades beyond these trials revealed a longer-term macrovascular benefit from these interventions. There is more to glycaemic control than the prevailing level of HbA1c, however. Variability of blood glucose within and between days promotes hypoglycaemic and hyperglycaemic episodes that may increase the risk of diabetes complications or adverse clinical outcomes and which certainly impair patients' quality of life and confidence in managing their insulin regimen. The Triangle of Diabetes Care has emerged as a useful concept here, bringing together the need to improve glucose levels, but also to avoid hypoglycaemia and to reduce glucose variability. Continuous glucose monitoring is a particularly valuable tool for addressing glycaemic variability, but patients and healthcare professionals can be swamped by the large amount of data that it generates. Advanced glucose profiling provides a means of producing a straightforward, visual representation of daily glucose profiles over a number of days that can help to pinpoint the changes in the insulin regimen needed to optimise blood glucose control.