Investigating Biosensor Adoption Among South Asians with Type 2 Diabetes

Diabetes mellitus is approaching epidemic proportions worldwide. Currently, there are 537 million adults, from ages 20-79, living with diabetes, predicted to rise to 643 million by 2030 and 783 million by 2045 (IDF diabetes atlas). Diabetes mellitus is a chronic medical condition characterized by elevated blood sugar levels; this occurs when the pancreas does not make enough or any insulin, a hormone that helps glucose get into one's cells for energy and regulate blood sugar. Furthermore, Type 2 diabetes mellitus (T2DM), where diminished insulin response classifies as insulin resistance, has grown into a serious health issue among South Asians, individuals in or with ancestry from the Indian subcontinent, as they hold one of the highest percentages of Type 2 diabetics around the world. 

There is a lack of care and attention around self-monitoring, shown by the complex medication regimen, problems with motivation, and stigma among families while battling type 2 diabetes. This problem has negatively impacted the Indian community of America, especially immigrants, by forcing a change in their dietary habits, furthering misconceptions, and creating a lack of resources attuned to their cultural practices in preventive care and self-management, becoming determinantal to their health (Sohal et al., 2015). A possible cause for this disparity is the lack of attention to barriers and a lack of an investigation into the attitudes and awareness of diabetic patients regarding how their daily lifestyle and culture are affected by living with type 2 diabetes as an Indian American. 

Furthermore, although there is a higher association between type 2 diabetes and the Asian Indian diaspora in comparison to other ethnic populations in the United States, there is a discrepancy in health literacy and T2DM knowledge about self-management and glycemic control, specifically with the different modes of monitoring such as glucose meters, electrochemical biosensors, and wearable devices, in the American South Asian community. A biological response transforms into a quantifiable signal using biosensors, analytical instruments integrating a biological element, and a physicochemical detector. The biological component, the bioreceptor, can be whole cells, nucleic acids, enzymes, or antibodies. By interacting with the target analyte, such as particular molecules or compounds, this bioreceptor produces a signal that can be detected. The physicochemical detector converts this biological response into a measurable output, typically thermal, optical, or electrical signals. Biosensors can potentially revolutionize diabetics' blood glucose monitoring in the future, thanks to current biotechnology advancements. Still, the interpersonal attitudes and opinions on these devices lack investigation.

Literature Review

Cultural Influences on T2DM Self-Care

In reviewing the present literature in the field, personal cultural beliefs are vital in actively shaping decision-making beyond the genetic pre-markers, external environment, and lifestyle choices that can be considered the basis for one's relationship with self-care for T2DM.

For example, the study by Misra & Khurana (2009) explored how the prevalence of obesity and metabolic syndrome is increasing within the South Asian population due to Type 2 Diabetes Mellitus (T2DM) and cardiovascular disease (CVD). The study explored how rapid urbanization, changing lifestyles, phenotypic features, correlations between determinants, subclinical inflammation, psychological stress, genetic and perinatal factors, migration, and socioeconomic factors contribute to preventing and controlling metabolic syndrome in South Asians. The results from this showed a high prevalence of metabolic syndrome and associated cardiovascular risk factors in economically disadvantaged people located in urban slums and rural areas due to nutrition, lifestyle, and socioeconomic transitions, which in turn increases affluence, urbanization, mechanization, and migration. More importantly, the psychological stressing factors of urban setting, genetic predisposition, the environment, and "catch-up" obesity, alongside physical traitors, are predominant in the South Asian community. The findings showed that increasing awareness of type 2 diabetes and the associated risk factors could help with prevention strategies in the South Asia community due to the high cardiometabolic risk associated with the Southeast Asian demographic (Misra & Khurana, 2009). 

Given the apparent awareness of one's health due to hereditary issues, personal perceptions, and evolving cultural attitudes shape one's relationship with one's health and how one approach self-care when treating chronic illnesses. Imran et al.'s study (2015) showcases this by exploring how South Asian perceptions and cultural views influence the self-management of type 2 diabetes in America. This study focused on perceptions, cultural factors, and practical constraints. The study found that the main barriers to healthy behaviors were regular physical exercise, consuming low-glycemic foods, attending physician's appointments, difficulty adapting to dietary changes, and poor understanding of disease severity and complications. The presence of cultural factors complicating self-care and adherence to traditional social roles also influences South Asian's management of diabetes and its associated complications. The most concerning responses in this qualitative study were the lack of knowledge and perceptions associated with diabetes, coupled with difficulties due to cultural practices and religious obligations (Imran et al., 2015).

Beyond oneself, interactions and relationships with family and caregivers actively shape one's case and reveal gaps in providing comprehensive T2DM support. Similarly, Sohal et al.'s 2015 study systematically reviews studies exploring South Asian diabetic patients' perspectives on barriers and facilitators to glucose management. Specifically, the study explored why diabetes management was so poor in South Asians, despite being a leading demographic in the diagnosis of type-2 diabetes mellitus, by investigating attitudes on interactions with health care workers, diet, exercise, and medication adherence, core components of diabetes management. The method used a literature search of over 208 abstracts using OVID, CINHAL, and EMBASE databases; 20 studies were evaluated based on qualitative synthesis for their interactions with health care providers, diet, exercise, and medication adherence. The sampling process for the 20 studies out of the 500 was the identification and assessment of the quality and risk of bias of qualitative studies using CASP (Critical Appraisal Skills Program). The studies identified language and communication discordance as a significant barrier, an inconsistency in wellness to following physicians' guidance in self-management, a lack of adaption to curate a South Asian diabetic diet, social responsibilities and stigma, and misconceptions. Moreover, the overarching theme was a lack of understanding and knowledge over diabetes medication management, which itself was not adapted to fit the needs of South Asians culturally (Sohal et al., 2015).

Present Solutions and Challenges  

Current T2DM treatments include glucometers, lifestyle changes such as a healthy diet and increased physical activity, and pharmacological interventions such as metformin, insulin, and other medications. However, any solution to living with a chronic illness will have its limitations and setbacks. 

The study by Chittem et al. (2022) significantly contributes to understanding the challenges faced by Type 2 diabetic Indian patients. It delves into the inhibiting factors to self-monitoring blood glucose (SMBG) and managing medication, comparing patients' experiences, their primary family members (PFMs), and physicians. The study identifies three main issues: confusion in the complex medication regimen, alternative therapies recommended by the family due to social stigma, and financial stress of the illness. The findings emphasize the importance of training physicians' emotional connectedness and communication, empowering patients to communicate concerns, and educating patients on managing Type 2 diabetes to reduce the negative implications. The study also sheds light on the shared ideals of the Indian immigrants in the United States with Type 2 diabetes, explaining their behavior and response in SMBG, which is furthered by discrepancies in the care presently available in the field, impacting the social stigma, cultural attitudes, and lifestyle choices (Chittem et al., 2022).

The discrepancies hurt improving the standard of one's health, as shown by Bhurji et al. (2016), who delved into the management intervention systems for Type 2 diabetes patients of South Asian origin from Pakistan, Bangladesh, and India in both the Western and Eastern realms. The study revealed a significant disparity in diabetes control within the South Asian population, a finding that should raise concern and prompt urgent action. The research also highlighted how lifestyle and knowledge influence this gap, drawing from a comparative analysis of randomized controlled trials (RCT), a systemic review of prospective pre-post-test observational studies, and differences in data collection of blood pressure, lipid levels, and anthropometric measures from the studies. Bhurji et al. (2016) found a disparity in the number of articles conducted in each hemisphere: only seven in the UK, while sixteen in India. The intervention studies included seven mixed, eight educational-based, and three exercise-based, which reflected themes of culturally specific educational practices and resources in the ones from the UK, while the Indian ones focused on yoga, resistance exercise, and dietary education. These findings expressed that diabetes management interventions for South Asian patients were varied because of the limited success in HbA1c reduction, which differed by region and intervention. Studies in India based on exercise interventions reduced HbA1c levels. In contrast, blood pressure, lipid levels, and knowledge levels were higher in European and Indian studies, yet BMI remained stagnant. The results highlighted the meta-analyses of RCTs to showcase that culturally adapted diabetes management significantly improves HbA1c, extending consideration to the surface (superficial characteristics of a population including people, language, places, and food) and deep (integration of the sociocultural concepts, historical context, and psychological factors unique to a population) structural, cultural adaptations (Bhurji et al., 2016).

Moreover, Saboo et al. 2019 explored the limitations of currently available glucose monitoring, glycosylated hemoglobin/self-monitoring of blood glucose, and glycemic variability, a predictor of poor glycemic control. Specifically, the study examined the Indian population, continuous glucose monitoring, and its potential benefits. It highlighted the importance of glucose variability and pathophysiology in diabetes complications, the role of software in glucose monitoring, and clinical applications of continuous glucose monitoring. The findings from this study not only recommend continuous glucose monitoring for type 2 diabetic patients on basal insulin therapy to address hyperglycemia in long-term treatment but also underline the transformative potential of continuous glucose monitoring in diabetes management. This revelation should inspire healthcare professionals and researchers, providing them with the knowledge to set target metrics, use data to analyze and adapt insulin dosage and meal plans, and deal with hyperglycemia and hypoglycemia effectively (Saboo et al., 2019). The prevalence of technology in transforming the performance of the present solutions is evolving into a necessary course of action according to the field.

Biosensors: Advantages and Setbacks

In exploring non-invasive blood glucose monitoring technologies, researchers have delved into various approaches and their potential impact on diabetes management. Bolla and Priefer (2020) explored how non-invasive devices and prospects perform in blood glucose monitoring. Specifically, the study looked into how blood glucose monitoring and its role in medication dosage adjustment can aid in managing burdens and adherence while checking glucose levels. The study compared the non-invasive blood glucose monitoring technology and devices such as urine, breathalyzer, finger detection, Metabolic heat conformation (MHC), Near-infrared spectroscopy (NIR), Mid-infrared spectroscopy (MIRS), earlobe, ultrasound, electromagnetic sensors, thermal emission spectroscopy (TES), hand, tears, optical polarimetry system, and retina pigmentation. The findings from the study showed that a significant amount of effort has been put into researching non-invasive technology. However, adherence to blood glucose monitoring can be accredited to the current methods that are considered painful, expensive, and a hassle. The market can be modified to accommodate the approaches to be more accessible, less expensive, and accurate to improve the quality of life for diabetic patients. 

Building upon this foundation, Bruen et al. (2017) explored the recent advances in glucose monitoring for people with diabetes using non-invasive methods utilizing other biological fluids rather than blood. More specifically, the study focused on interstitial fluid, sweat, breath, saliva, and ocular fluid within the context of creating a biosensor for daily use, personalized to each patient in monitoring. The study critically reviewed each of the options, assessing their various versions, growth within the field, prospects, and comparisons in effectiveness and usage; the findings from the study showed that as wearable biosensors play an essential role in continuous non-invasive monitoring for diabetes, among other diseases, the findings showed further clinical evaluation is needed for it to go big in the market. At the same time, the interest of significant companies attests to the marketability prospects of biomarkers. The findings recognize that the current options, such as fitness bands and smartwatches, are limited to a tangible impact on health and wellness, and there are no additional insights into clinical health practices that help promote a lifestyle that betters their state of day-to-day living. 

Shifting from technological advancements to practical considerations, the study by Johnsten et al. (2021) explored the factors needing improvement in user biosensing technologies. It specifically looked into the precision, repeatability, wearability, and accessibility to end-users, among other challenges that affect the perspectives on developing biosensors for glucose monitoring. The study identified general challenges and perspectives for biosensors, such as high costs that limit accessibility, development setbacks, biofouling, sensor lifetime, and calibration. It outlined the ideal design for a continuous glucose monitoring biosensor as having a long sensor life and being accurate, accessible, and affordable to the community. This underscores the community benefits of such a biosensor design, making the audience feel involved in the development process and its potential impact on the diabetic community.

These studies demonstrate the growing interest and investment in non-invasive blood glucose monitoring technologies and the challenges and opportunities of their development and implementation in clinical practice.

Gap

Since Type 2 Diabetes Mellitus (T2DM) is becoming more common in the South Asian community, especially in the US, it is urgently necessary to address gaps in health literacy, cultural perceptions, and self-management practices. Diabetes is a condition specific to each culture and individual, and exploring non-invasive biosensors is crucial to bridging this gap. There is a lack of culturally attuned monitoring and intervention practices that take into account the various factors such as the stress of "catch up" obesity, lack of awareness of their history, difficulty in adapting to dietary changes, poor understanding of disease severity and complications, the social stigma of having diabetes, and cultural practices and religious obligations as shown by Misra et al., Imran et al., and Sohal et al.'s studies. They are not tailored to the diverse cultural and ethnic groups of India; the disparity is furthered with immigration to Western nations, as shown by Bhurji et al. However, technological advances showcase how biosensors hold a promising alternative to current solutions, given the emerging technology's prospective efforts and advances in continuous glucose monitoring. The gap is that there is a lack of research or effort put into how biosensors can be culturally congruent to the American urban South Asian community as an emerging technology while being mindful of cultural perceptions, as the current research focuses on cultural congruency with intervention methods, medications, and lifestyle changes in areas that are in rural settings such as India.

Thesis

The combination of cultural perceptions, healthcare strategies, and evolving biosensor technologies significantly influences the monitoring preferences of South Asians regarding T2DM. These technologies can potentially enhance health literacy, self-management, and glycemic control among South Asians living with T2DM in the United States. Understanding these cultural nuances is crucial as it reveals an inclination for monitoring characterized by social acceptability, discretion, and minimal disruption to their daily routines rooted in tradition, culture, and religion. However, adopting biosensors may cause apprehension due to perceived costs, novelty, and reliance on technology, which contrasts with the familiarity of conventional glucometers and routine medical assessments. The aim of investigating these components is to develop a comprehensive understanding of the barriers hindering effective T2DM management within the South Asian community and to propose strategies for more culturally sensitive and technologically advanced approaches to enhance health outcomes.

Method

In order to assess the cultural perceptions and South Asian attitudes towards biosensors in T2DM blood glucose management, a mixed approach of analyzing quantitative and qualitative data, combining an ethnographic and needs assessment, was designed to target the lack of knowledge on diabetes management when it comes to newer alternatives, such as biosensors, within the South Asian community. The basis for the lack of awareness is investigated through ethnography, exploring cultural attitudes, religious beliefs, dietary customs, physical activities, and traditions to discover the causative factors of certain habits of the South Asian population and come up with accurate explanations for these behaviors. Moreover, a needs assessment will help address how the issues within self-care Diabetes Type 2 management can evolve and help to curate a solution for them based on their needs and habits by pinpointing areas that necessitate additional research, funding, and support; the needs assessment facilitates the formulation of targeted interventions aimed at enhancing diabetes management practices within the community.

Through a voluntary response survey published at churches, temples, and other religious establishments with a high South Asian population attending, the survey questions, answer choices, and sections in Appendix A was provided through either a link or a QR Code.

Access the full paper here.

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Written by Anagha Joby

References

Bhurji, N., Javer, J., Gasevic, D., & Khan, N. A. (2016). Improving management of type 2 diabetes in South Asian patients: A systematic review of intervention studies. BMJ Open, 6(4). https://doi.org/10.1136/bmjopen-2015-008986 

Bolla, A. S., & Priefer, R. (2020). Blood glucose monitoring- an overview of current and future non-invasive devices. Diabetes & Metabolic Syndrome, 14(5), 739–751. https://doi.org/10.1016/j.dsx.2020.05.016

Bruen, D., Delaney, C., Florea, L., & Diamond, D. (2017). Glucose sensing for diabetes monitoring: Recent developments. Sensors, 17(8), 1866. https://doi.org/10.3390/s17081866 

Chittem, M., Sridharan, S. G., Pongener, M., Maya, S., & Epton, T. (2022). Experiences of barriers to self-monitoring and medication-management among Indian patients with type 2 diabetes, their primary family-members and physicians. Chronic Illness, 18(3), 677–690.

IDF diabetes atlas. (n.d.). Retrieved from https://diabetesatlas.org/ 

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Johnston, L., Wang, G., Hu, K., Qian, C., & Liu, G. (2021). Advances in biosensors for continuous glucose monitoring towards wearables. Frontiers in Bioengineering and Biotechnology, 9. https://doi.org/10.3389/fbioe.2021.733810 

Misra, Anoop, & Khurana, L. (2009). The metabolic syndrome in South Asians: Epidemiology, determinants, and prevention. Metabolic Syndrome and Related Disorders, 7(6), 497–514. https://doi.org/10.1089/met.2009.0024 

Saboo, B., Chawla, M., Jha, S., Bhandari, S., Kumar, P., Kesavadev, J., Munjal, Y. P., Mohan, V., Unnikrishnan, R., Katswar, V., Arun, N., Sosale, B., Anjana, R. M., & Hasnani, D. (2019). Consensus and recommendations on continuous glucose monitoring. Journal of Diabetology, 10(1), 4–14. https://doi.org/10.4103/jod.jod_45_18 

Sohal, T., Sohal, P., King-Shier, K. M., & Khan, N. A. (2015). Barriers and facilitators for type-2 diabetes management in South Asians: A systematic review. PLOS ONE, 10(9). https://doi.org/10.1371/journal.pone.0136202