Evolution of risk management in diabetes mellitus: from standardized restrictions to personalized technological solutions

Diabetes mellitus (DM) represents one of the most significant medico-social problems, characterized by a steady increase in morbidity and a high burden of complications. Historically, risk management was based on strict dietary restrictions and unified insulin therapy protocols, which often failed to ensure adequate compensation of the disease and a satisfactory quality of life for patients. In the context of the development of digital technologies and evidence-based medicine, the treatment paradigm is undergoing a fundamental change.

Systematic literature reviews published between 2009 and 2024 in PubMed, Scopus, Web of Science, and eLibrary, along with the results of meta-analyses, randomized controlled trials, and cohort studies, were analyzed to identify the key stages of the transition from unified approaches to the diagnosis and treatment of diabetes mellitus toward personalized technological solutions in diabetes management. This article established that the transition from the concept of “avoiding acute conditions” to the strategy of “preventing chronic complications” became possible due to the introduction of HbA1c (glycated hemoglobin) as a standard for monitoring the effectiveness of therapy. The technological revolution (development of insulin analogs, continuous glucose monitoring systems, insulin pumps) shifted the focus to glycemic variability and Time in Range (TIR) during the day. Treatment personalization now includes digital tools, pharmacogenetics, and psychosocial support.

1. International Diabetes Federation. IDF Diabetes Atlas, 10th edn. Brussels, Belgium: 2021. Available at: https://diabetesatlas.org

2. Patterson C.C., Dahlquist G.G., Gyurus E., et al. Incidence trends for childhood type 1 diabetes in Europe during 1989–2003 and predicted new cases 2005–20: a multicentre prospective registration study. Lancet. 2009;373(9680):2027-2033.

3. Министерство здравоохранения и социальной защиты населения Республики Таджикистан. Статистический сборник «Здравоохранение Республики Таджикистан». Душанбе, 2023.

4. Berger M. History of insulin therapy. In: Insulin Therapy. Berlin, Heidelberg: Springer; 2002;1-15.

5. Chance R.E., Hoffman J.A. The molecular engineering of insulin. The structure-activity relationships of monomeric and dimeric species. Adv Exp Med Biol. 1983;157:1-12.

6. Blatt A.J. The discovery of insulin: a medical miracle. J Med Biogr. 2011;19(3):146-151.

7. Skyler J.S. History of insulin therapy. Endocrinol Metab Clin North Am. 2009;38(4):703-713.

8. Ginsberg B.H. Factors affecting blood glucose monitoring: sources of errors in measurement. J Diabetes Sci Technol. 2009;3(4):903-913.

9. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977-986.

10. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352(9131):837-853.

11. American Diabetes Association. Standards of Medical Care in Diabetes—2023. Diabetes Care. 2023;46(1):1-S291.

12. Rodbard D. Interpretation of continuous glucose monitoring data: glycemic variability and quality of glycemic control. Diabetes Technol Ther. 2009;11(1):55-S67.

13. Zinman B., Wanner C., Lachin J.M., et al. Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. N Engl J Med. 2015;373(22):2117-2128.

14. Home P.D. The pharmacokinetics and pharmacodynamics of rapid-acting insulin analogues and their clinical consequences. Diabetes Obes Metab. 2012;14(9):780-788.

15. Heise T., Nosek L., Bøttcher S.G., et al. Ultra-long-acting insulin degludec has a flat and stable glucose-lowering effect in type 2 diabetes. Diabetes Obes Metab. 2012;14(10):944-950.

16. Bolinder J., Antuna R., Geelhoed-Duijvestijn P., et al. Novel glucose-sensing technology and hypoglycaemia in type 1 diabetes: a multicentre, non-masked, randomised controlled trial. Lancet. 2016;388(10057):2254-2263.

17. Battelino T., Danne T., Bergenstal R.M., et al. Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations From the International Consensus on Time in Range. Diabetes Care. 2019;42(8):1593-1603.

18. Brown S.A., Kovatchev B.P., Raghinaru D., et al. Six-Month Randomized, Multicenter Trial of Closed-Loop Control in Type 1 Diabetes. N Engl J Med. 2019;381(18):1707-1717.

19. Monnier L., Mas E., Ginet C., et al. Activation of oxidative stress by acute glucose fluctuations compared with sustained chronic hyperglycemia in patients with type 2 diabetes. JAMA. 2006;295(14):1681-1687.

20. Kasimova S. J., Saadullozoda T. S., Narzullaeva A. R. Trends in the prevalence of diabetes mellitus in the republic of Tajikistan 2024

21. Pearson E.R. Pharmacogenetics in diabetes. Diabet Med. 2013; 30(3): 288-295.

22. Herold K.C., Bundy B.N., Long S.A., et al. An Anti-CD3 Antibody, Teplizumab, in Relatives at Risk for Type 1 Diabetes. N Engl J Med. 2019;381(7):603-613.

23. Snoek F.J., Bremmer M.A., Hermanns N. Constructs of depression and distress in diabetes: time for an appraisal. Lancet Diabetes Endocrinol. 2015;3(6):450–460.

24. Rakhimov A. A., Nutritional characteristics of patients with diabetes mellitus in the condition of Tajikistan. Dushanbe: Irfon, 2021.

25. Agiostratidou G., Herrington H., Braddon F., et al. Standardizing Clinically Meaningful Outcome Measures Beyond HbA1c for Type 1 Diabetes: A Consensus Report of the American Association of Clinical Endocrinologists. Diabetes Care. 2023;46(5):1-15.

26. Beck R.W., Connor C.G., Mullen D.M., et al. The Fallacy of Average: How Using HbA1c Alone to Assess Glycemic Control Can Be Misleading. Diabetes Care. 2017;40(8):994-999.

27. Danne T., Nimri R., Battelino T., et al. International Consensus on Use of Continuous Glucose Monitoring. Diabetes Care. 2017;40(12):1631-1640.

28. Heinemann L., Freckmann G., Ehrmann D., et al. Real-time continuous glucose monitoring in adults with type 1 diabetes and impaired hypoglycaemia awareness or severe hypoglycaemia treated with multiple daily insulin injections (HypoDE): a multicentre, randomised controlled trial. Lancet. 2018;391(10128):1367-1377.

29. Holt R.I.G., DeVries J.H., Hess-Fischl A., et al. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2021;64(12):2609-2652.

30. Davies M.J., D’Alessio D.A., Fradkin J., et al. Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2018;41(12):2669-2701.

31. American Diabetes Association Professional Practice Committee. 6. Glycemic Targets: Standards of Medical Care in Diabetes—2023. Diabetes Care. 2023;46(1):97-S110.

32. International Hypoglycaemia Study Group. Glucose concentrations of less than 3.0 mmol/L (54 mg/dL) should be reported in clinical trials: a joint position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2017;40(1):155-157.

33. Klonoff D.C., Ahn D., Drincic A. Continuous Glucose Monitoring: A Review of the Technology and Clinical Use. Diabetes Res Clin Pract. 2017;133:178-192.

34. Fleming G.A., Petrie J.R., Bergenstal R.M., et al. Diabetes Digital App Technology: Benefits, Challenges, and Recommendations. A Consensus Report by the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) Diabetes Technology Working Group. Diabetes Care. 2020;43(1):250-260.

35. Quinn C.C., Shardell M.D., Terrin M.L., et al. Cluster-randomized trial of a mobile phone personalized behavioral intervention for blood glucose control. Diabetes Care. 2011;34(9):1934-1942.

36. Kruse C.S., Mileski M., Alaytsev V., et al. Utilization of Telemedicine in Diabetes Management: A Systematic Review. J Med Internet Res. 2019;21(1):e11633.

37. Nasirov N. G., Gafarov N. I. Epidemiology of diabetes mellitus in the Republic of Tajikistan. Medicine and Health.2020;(2):12-18

38. Rakhimov Z. R., Quality of life of the patient with diabetes mellitus in outpatient care setting. Dushanbe, 2019

39. Dedov I.I., Shestakova M.V., Galstyan G.R. Algorithms of specialized medical care for patients with diabetes mellitus. Diabetes Mellitus. 2021;24(3):1-112. (in Russian).

40. Mayorov A.Y., Surkova E.V. Self-monitoring of blood glucose in patients with diabetes mellitus. Diabetes Mellitus. 2018;21(1):5-15.