THE prevalence of type 2 diabetes mellitus continues to rise inexorably in many high and low income countries. The International Diabetes Foundation estimated in 2019 that 463 million adults (aged 20–79 years) were living with diabetes and by 2045 this will rise to 700 million. Furthermore, the proportion of people with type 2 diabetes is increasing in most countries and 79% of adults with diabetes are living in low and middle income countries. One in five of the people aged over 65 years have diabetes and one in two people with diabetes (232 million) are undiagnosed.

The economic impact is enormous, and the health burden of diabetes manifests as premature microvascular and macrovascular complications. Diabetes caused 4.2 million deaths and accounted for at least USD 760 billion dollars in health expenditure in 2019 – 10% of total spending on adults globally. In Australia, it remains the leading cause of blindness and premature end-stage renal failure.

The rising incidence of T2DM is related to the intersection of genetics and environment. T2DM is a variable disorder that runs in families and exhibits strong genetic penetrance. The environmental factors are largely driven by the rising incidence of obesity and reduced physical activity in our communities. The Australian Institute of Health and Welfare estimates that the prevalence of adults with obesity is one in three, whereas two out three adults are either overweight or obese (2017–2018).

Auspiciously, diabetes practice has always been at the forefront of innovation. Over the past 40 years, it has evolved through a series of stepwise changes depicted in Table 1.

Table 1

Traditional (Generation 1) Patient-centred (Generation 2) Chronic disease self-management (Generation 3) Integrated care (Generation 4) Personalised medicine (Generation 5)
1. Doctor–patient relationship 1. Ambulatory care


1. Patient empowerment


1. Formalised linkages to primary care 1. Information-driven
2. Patient education



1. Primary care and GP engagement 2. Guidelines 2. Mobility
3. Self-monitoring 3. Service frameworks 3. Social media
4. Practice incentives 4. Cloud-based
5. Predictive analytics
6. Genomics

These changes have in part been driven by practitioner attitude and behaviour and in part by technological developments that have permitted new ways of working to address the needs of the patient with diabetes.

The field of diabetes was probably the first to introduce patient education and, subsequently, diabetes nurse educators as early as 1981. The first service was established as early as 1974 at the Royal Newcastle Hospital. This change allowed the specialty of diabetes to move from an inpatient service to an ambulatory model of care. It introduced new concepts of patient empowerment and patient home monitoring that challenged the orthodoxy of the traditional doctor–patient relationship. There have many assessments of the effectiveness of diabetes education. The model was rapidly adopted by all institutions. Individual and group programs were established, some as long as 5 days, but as teaching methodology improved, programs were shortened to meet the needs of busier lifestyles. Diabetes education delivered either face-to-face or more recently using web-based tools is the keystone of all future developments.

The 1990s saw the introduction of personal computing, the internet and mobile phone technology. These developments were paralleled by advances in glucose monitoring and miniaturisation of testing devices. Each one of these developments spearheaded the evolution of chronic disease management (Generation 3). Standards of care as guidelines were developed for patients and practitioners. National service improvement frameworks were developed to improve the processes and outcomes of diabetes care. The first integrated care program was developed in 1995 to enhance skills and competencies in primary care. The latter were further refined in the 2000s and progressed to the delivery of specialty care in the GP environment (Generation 4).

As of 2020, we can confidently state we are now entering the fifth generation of personalised diabetes care. In addition to the previous elements, this current generation of care is highlighted by the nexus of digital technologies bringing together mobility, cloud, information and social media platforms. Blood glucose meters are smaller, faster and more accurate. Continuous glucose monitoring is now a reality and has been commodified. Information from these devices can be uploaded to personal phone apps or cloud-based desktop tools that look for patterns and advise changes to doses and timing of medication. This information can be rapidly communicated with practitioners or other interested parties. Other apps can assist with nutrition and physical activity monitoring.

Diabetes education is now available online using platforms such as KNOWDIABETES to provide personalised and timely access to information in a safe and secure environment. Recent changes to telehealth Medicare provider numbers, in part because of the coronavirus disease 2019 (COVID-19) pandemic, will necessitate a greater use of this technology. Gartner has identified that tailored or personalised messaging in health care will provide a key strategic advantage to practitioners and organisations.

We are on the cusp of further innovation. Gartner has identified 10 strategic technology trends that will disrupt the way we traditionally work. Paramount among these will be artificial intelligence, which will be a foundational catalyst for advanced process automation and human augmentation and engagement. Furthermore, genomics and linkage to other medical informatics will drive personalised medicine. These developments will facilitate improved patient and provider experience as well improved patient outcomes and better value for money invested in health.

These technologies may initially appear confronting and complex but for those of us who have worked through each of the last five generations, I am reassured that they will find their appropriate niche. Over the years, what I have learned is that, although technology may change, the fundamentals of good patient care remain constant. Parenthetically, these technologies will be absolutely necessary to address the ever-increasing demand for services and to mitigate the potential complications of the disorder.

Steven C Boyages is Clinical Professor with the Sydney Medical School at the University of Sydney, and Westmead Clinical School.



The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.

2 thoughts on “Fifth-generation diabetes care: evolutionary change

  1. Anonymous says:

    great article

  2. Anonymous says:

    I find the evolution of diabetes care of the years and Dr Boyages “generation” table very interesting. Exciting times ahead.

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