The history - and future - of blood glucose monitoring

In 1983, when Roche Diabetes Care’s predecessor Boehringer Mannheim brings its first self-monitoring blood glucose metre to market, life would never be the same again for people with diabetes.  Self-monitoring means they can measure their blood glucose levels by themselves – at home, in the office or wherever they are – and then make their own therapy decisions based on these values.  

This is only the beginning of making diabetes management more personal. Over the next few decades, metres become smaller and smarter, automatically saving entries and even connecting to apps, and people with diabetes become increasingly empowered to take control of their therapy. 

But no revolution happens overnight. Find out about all the firsts that came before this big home-testing breakthrough.

“Diabetes is a remarkable affliction,” writes Aretaeus of Cappadocia in the late Hellenistic Age, “not very frequent among men. The course is the common one, namely, the kidneys and the bladder; for the patients never stop making water, but the flow is incessant, as if from the opening of aqueducts.”  Aretaeus’ vivid and accurate description of the progression of diabetes is unparalleled in Antiquity, and he famously chronicles how diabetes got its name, which is the Greek word for “siphon,” explaining it’s because “the fluid does not remain in the body.” 

Oxford University’s Thomas Willis re-discovers that the urine of people with diabetes tastes sweet. This has already been observed in ancient texts from Egypt, India and China. However, as the first European to draw this conclusion, Willis is credited with adding mellitus (Greek for “like honey”) to the medical term, and it becomes known as diabetes mellitus. It remains unclear at this point why the urine is sweet, and there’s no way of determining whether or not it’s because there’s actually glucose present. Over the next few centuries, the only method for detecting diabetes is with a glance at the colour and a sip of the patient’s urine.

Matthew Dobson distills the urine of a person with diabetes and is left with a powdery sugar residue, confirming that excess sugar can be found in the urine. When he observes that the blood also tastes sweet, he’s the first to acknowledge that hyperglycaemia, high blood sugar, is common among people with diabetes.

The end of taste testing urine is near. Chemist Karl August Trommer lays the foundation for a lab-based diagnostic test to determine sugar levels in urine.

German medical student Paul Langerhans discovers the clusters of cells in the pancreas responsible for producing the hormone that will later be called insulin. The function of these “islets,” however, remains unknown until 1893, when Gustave-Édouard Laguesse, a French pathologist, hypothesises that the “islets of Langerhans” – as he’s the first to call them – are essential for hormone production.

While researching the role of the pancreas in fat metabolism, physicians Oskar Minkowski and Josef von Mering at the University of Strasbourg accidentally discover that the organ is involved in regulating blood sugar levels. They’re able to make this connection because, when they remove a dog’s pancreas, they notice the animal develops symptoms of diabetes.

In 1911, with the help of Swiss-based pharmaceutical company Roche, Georg Zülzer sets up an experimental laboratory and applies for a patent for acomatol, a pancreatic “extract” that the German physician believes can treat diabetes. For close to a decade, with mixed results, he’s been experimenting with the extract from cattle pancreases on animals and humans. In 1914, its effectiveness at lowering blood sugar is shown to last only a few hours and the intravenous dose needs frequent readministration. Since Zülzer’s superiors consider it unlikely that anyone would inject themselves several times a day for the rest of their lives, the decision is made to cease research into this extract – it’s not yet known that it’s the insulin within the extract that’s having the effect – and instead focus on developing an oral drug. No antidiabetic oral medication is available until 1955.

English physiologist Sir Edward Sharpney-Schafer concludes that diabetes results from a lack of insulin – a hormone developed in the pancreas – and is considered the founder of endocrinology.

There are still no effective diabetes treatments. Emaciation and diabetic comas are inescapable, and most people are dead within a year of their diabetes diagnosis. Patients have no choice but to live on the strict low-carbohydrate diet of 400 to 500 calories daily popularised in 1919 by Dr. Frederick Allen’s treatise, Total Dietary Regulation in the Treatment of Diabetes. Although patients on this “starvation diet” could live with their diabetes a little longer than most, they would eventually succumb to malnourishment.

In 1921, for the first time, Canadian scientists Frederick Grant Banting and Charles Herbert Best succeed in isolating insulin, a hormone formed in the pancreatic islets (also known as the islets of Langerhans). Following in the footsteps of their scientific forebears, Minkowski and von Mering [see entry for 1889], they artificially induce diabetes in dogs by removing the pancreas, but then go on to reverse the dogs’ diabetes by lowering the blood sugar with insulin extracted from cattle. With the active support of biochemist James Bertram Collip, they finally manage to obtain insulin from ox pancreases in sufficient purity and quantity to begin clinical testing for the treatment of humans. The following year, a 14-year-old boy is the first person to be successfully treated with the life-saving medication.

Danish pharmacologist Hans Christian Hagedorn ushers in the era of modern diagnostics with a new way to test for high levels of glucose. For years, the standard has been to mix urine with a chemical in a test tube, and then heat it to look for the discoloration that indicates a high glucose level. However, this only gives a window into the patient’s condition at the time the bladder was emptied. With the help of the chemical ferrocyanide, Hagedorn develops a way to measure blood sugar levels, helping to understand what’s happening in the patient’s body in the moment. This is an incredible first step towards empowering patients with self-monitoring of blood sugar, though it’ll still take decades before test strips for home use are developed.

Roche launches an animal insulin product named Iloglandol. It’ll be more than half a century before insulin can be synthesised (see our entry for 1978).

A differentiation between types I and II diabetes is made by Sir Harold Percival Himsworth based on the degree of insulin sensitivity. This is the first step to understanding that not everyone’s diabetes is the same. It’ll still take several decades before diabetes management technology can support people with diabetes in understanding their individual needs.

Boehringer Mannheim launches Glukotest urine test strips under licence from Eli Lilly in 1956. Since the colour of the strip changes depending on how much glucose the urine contains, it’s possible for people with diabetes to determine sugar levels by matching the strip against a colour scale. Self-testing of this kind is so well received that the company decides to actively develop its own version of the technology in the early 1960s.

The company scores its first success in the form of the Combur test strip, using urine for determining pH, glucose and protein in 1964. Urine tests, however, provide results only when blood sugar levels are very high, so the next goal is to create a strip that could test sugar in the blood for a more accurate reading. The more accurate the information, the easier it is for patients and doctors to find the right solution at the right time.

When a flask of chemical colour indicator accidentally bursts while being heated, spraying the laboratory walls and leaving a light-coloured patch on the latex paint, researchers at Boehringer Mannheim are inspired to try out the glucose test enzymes on the stain. In combination with the paint, the test promptly turns violet, indicating that there’s a reaction: A new technology for blood glucose tests is found. By 1968, the newly launched latex-coated Haemo-Glucotest strips are the gold standard for visual blood glucose determination. The only disadvantage is that having to match colours to read blood sugar levels requires a bit of guesswork, and people aren’t always 100% confident they’re doing it right.

Weighing in at 1.1 kg, the somewhat cumbersome Reflomat, an automated system for reading test strips to determine blood sugar values, is developed in 1974. Gone are the days of matching colours and values; designed for healthcare practitioners, the automation removes any guesswork. With this first generation of blood glucose metres, Reflomat marks the beginning of Roche’s efforts to bring the laboratory to the patient, kicking off the mission to develop faster, smaller and cheaper models for home use.

In the early hours of August 21, 1978, Dave Goeddel at Genentech  – a small San Francisco-based biotech company with only 12 employees – succeeds in reconstituting two amino acid chains into one molecule and becomes the first person to clone human insulin. The subsequent clinical trials  find that not only is synthetic insulin as effective as its chemically identical human twin, but it also eliminates the allergies from animal-derived insulin suffered by many people with diabetes. Discovering how to synthesise insulin is the first step towards creating a future where there’s greater availability of the life-saving treatment and no animals are harmed in its production.

By 1983, the blood sugar metre technology makes its way into the homes of people with diabetes. The much smaller and more convenient Reflolux metre makes self-testing possible, changing diabetes management forever. In making it easier and more convenient to monitor their own blood sugar levels, this technology helps people with diabetes have the confidence they need to take control of their daily diabetes care.

The Reflotron measuring device makes the leap into space in 1989. At the Soviet MIR space station, the Reflotron is used for rapid blood analysis, including blood glucose, to regularly check the health of the crew.

A visit to the final frontier isn’t the last adventure for blood glucose monitoring. Devices keep getting more accurate and comfortable to use, not to mention smaller, faster and lighter (from 60 seconds and 1.1 kg for the Reflomat to just about 4 seconds and 40 grams for today’s devices), making it easier for people with diabetes to keep their diabetes management on hand, wherever they are. With the new century come further evolutions: Digitalisation brings the next push for innovation and the development of a more integrated and personalised care. New systems for data tracking  - something that’s always been the foundation of therapy decisions - open up a world where this important part of daily life with diabetes doesn’t need to be so cumbersome. Software solutions that support healthcare professionals in the analysis of their patients’ glucose values also make their way into the doctor’s office. With the big step of connectivity, where metres send the measured values automatically to a diabetes management app, the blood glucose metre from 1983 has come a long way to support and empower people with diabetes.

The diabetes care landscape is always evolving to make life better for people with diabetes. New technologies with fresh approaches to the daily grind of diabetes management – like the continuous glucose monitoring (CGM) systems that automatically measure glucose levels – have the power to change lives. Roche Diabetes Care keeps working towards offering the most innovative and differentiated solutions to bring true relief to people with diabetes everywhere.

But it’s about more than just the latest tech. Diabetes is one of the most expensive chronic conditions in the world.  As the number of people living with diabetes keeps growing – surpassing all predictions – cost-effective therapy management is more important than ever before.

BGM offers a simple solution to this complex challenge: The technology that can be accessed in most regions of the world remains an affordable diabetes care solution for individuals who pay out of pocket and for healthcare systems.

BGM, however, doesn’t rest on its laurels; we keep improving BGM technology to meet people’s needs. We’ve added the power of digital connectivity, and now the tried-and-true metres are integrated with digital solutions so that diabetes management can be even more personal. With a clear overview of therapy information and the possibility of connecting with healthcare professionals from even the remotest areas, BGM continues to support better access to care.

Whether it’s to help counteract rising healthcare costs in developed countries, or to ensure high-quality solutions remain available and affordable in low- to middle-income countries, BGM will continue to play an important role in the daily diabetes care for millions of people and for decades to come.