Diabetes Technology and Waste: A Complex Story

Abstract

Medical products are used increasingly by patients with diabetes as they make diabetes therapy more safe and efficient; subsequently such products are produced and used millions of times each day. This in turn means that the products themselves and the packaging adds up to a huge amount of waste, mainly plastic waste. Not only patients are well aware of this and start to complain about this, in view of the climate change the political pressure to change the situation is high and will increase further. A better balance between performance of the products and their environmental impact has to be found; however, diabetes technology and waste is a complex story with many different aspects.

Introduction

The climate change that all of us are experiencing will have many consequences for the way we live. Besides from aspects like energy spending, production, handling and avoidance of waste are topics that are addressed with increasing focus by societies, politicians, and governmental agencies around the globe. In Europe clear guidelines were issued that aim to reduce waste production to a large extent to achieve climate targets, such aspects are also mentioned in the new Medical Device Regulation that will become active in May 2021. ¹ This will also have an impact on manufacturing, packing, shipping etc. of medical products, also of products used for diabetes therapy. Also in the United States some states (eg, in California ² ) as well as the Federal Government ³ are identifying waste reduction as a relevant issue and respective laws have or will be issued. Industry has started to react to such pressure by initiating a number of activities to reduce waste production and improve recycling (eg, Novo Nordisk in Denmark ⁴ ).

Medical waste is regulated by many stakeholders, that is, countries/states, counties, and even cities can differ in their requirements and alignment would help to avoid adverse environmental impact. It is of interest to note that medical waste is a topic seen around the globe. Even authors of an editorial published in India about this topic have expressed an interest in diabetes treatment by stating the need for “Green Diabetology”. ⁵ The Diabetes Technology Society also regard more appropriate handling of the waste topic as an important topic and has therefore published a respective editorial in its journal and started the “Diabetes Technology Society Green Diabetes Initiative”.^6,7 Soon a first meeting dealing with this topic will be organized that shall initiate some kind of cooperation between all parties involved in the care of patients with diabetes.

The focus of this commentary is not on safe disposition of “Bio-medical waste,” that is, disposition of any potentially dangerous material (eg, contaminated needles) in appropriate boxes or safe disposal of drugs like insulin, nor on electronic components (incl. battery) disposition (=electronic waste), but on packing and recycling of the plastic waste. The aim of this commentary is to sensitize diabetes care professionals to their responsibility toward the physical environment, while reinforcing the urgent need for interdisciplinary cooperation between all stakeholders including manufacturers of medical products, national authorities, and relevant worldwide environmental organizations.

The current coronavirus pandemic is also associated with the generation of thousands of metric tons of plastic waste, much of it as hazardous waste, because there is a risk of infection with medical waste containing the coronavirus.

Waste and Diabetes Technology

We live in a world which is full of products which consist mainly of plastic and are also packed in plastic material; this also holds true for medical products used by patients with diabetes. CGM systems, test strips, syringes, insulin pens, insulin pumps, tubes, and so on. all are made from many different plastic materials and are packed to display and protect the products. So, modern diabetes management by means of diabetes technology products places a considerable burden upon the environment: Hundreds of millions of patients living with diabetes consume such products each day and discharge them after (single) usage into the waste stream. Most probably this issue will increase further in the near future with more widespread use of CGM systems and systems for automated insulin delivery (AID) by an ever-increasing number of patients. The waste shows up in the home of patients and is usually discarded in municipal solid waste or (at least partly) in the recycling stream. Multiplying the weight of such products and the packing amounts to hundreds of thousand tons of mainly plastic material each year. Here is just one example: if an inserter for a glucose sensor contain 80 grams of plastic, if millions of patients are using this respective CGM system and need to replace the sensor every 10 or 14 days, this means millions of pound of plastic waste annually. Handling of this waste is complicated by the fact that many diabetes technology products are not only made of plastic, but also of electronic components, and contaminated cannulas that pose biohazard risks, and possibly also contain residual insulin.

Patient’s Views and Perception

In order to visualize the amount of waste generated with diabetes therapy, ask your patients to collect all waste related to their treatment for example, 1 month: After unpacking a CGM system, a patch pump or an insulin infusion set, the patient has the actual product in their hands; however, the amount of waste generated is impressive.^8,9 The product may only be 10% of the total weight and volume that was delivered. The remaining 90% consists of cardboard/fiberboard/diverse plastic materials/bubble wrap/paper, and so on. All this goes to waste or - hopefully - to recycling. Patients are increasingly aware of the waste issue and they will ask more often in the future about this topic. They might start to discuss this with their diabetes team; however, this might also initiate a change in their behavior, that is, they might select a diabetes technology product in part based on the waste generated by using it. Such a chance in patient behavior will be seen by the market and might encourage appropriate reactions by the manufacturers.

Products

The Diabetes Forecast Consumer Guide lists various products for people with diabetes including blood glucose monitors, continuous glucose monitors, insulin pumps, insulin pens, insulin infusion sets, insulin injection aids, glucose-containing products, and medications. ¹⁰ Several of these types of products are discussed below.

• - Systems for self-monitoring of blood glucose (SMBG): glucose meter itself, batteries, test solution, test strips, box for test strips

• - Systems for continuous glucose monitoring (CGM): glucose sensors, inserter, handheld. Single-use insertion devices are used by many patients for easy and nearly painless placement of the glucose sensors (or the cannulas of insulin infusion sets). Each inserter comes with the need to dispose of various amounts of plastic for each inserter (70-80 g) which go directly into the waste.

• - Insulin syringes: these are made of plastic (=poly-propylene (PP)); also dimeticone or silicon emulsion is added to the rubber plunger to ease injection.

• - Disposable insulin pens: are also made of PP. Some companies provide more detailed information about the types of plastic used to make them. A simple composition makes it easier to separate the plastic waste. The plastic waste can subsequently be sorted in specific fractions. If this is of high quality, then it can be sold for recycling in other industrial products.

• - Reusable pens: In view of the sheer volume of dis-posable pens that are manufactured and eliminated each year (hundreds of millions of such pens), one wonders why reusable pens are not used more often. Clearly these are also made out of plastic and contain other materials and electronics that are difficult to sort out. This mixture of materials can hamper recycling to a large extent.

• - Insulin pumps (including patch pumps): pump itself, cartridge (with insulin), filler for cartridges, batteries, infusion sets.

Design and Manufacturing

Most probably topics like waste reduction and recycling may not have been highly relevant when designing a new medical product for diabetes therapy; however, it is crucial to keep these in mind, otherwise it might be difficult or even impossible to recycle, for example, an insulin pump. By taking such aspects more in consideration during the designing process it should be possible to reduce the waste issue to a large extent. For companies the costs associated with manufacturing a certain product and the efforts required to do so are of high relevance. If a given company invest a lot in attempts to be more “green” with their products in all aspects of manufacturing, transporting, selling, and so on, then it can be a problem if competitors ignore these considerations and produce for lower costs of goods.

Packaging

Packaging of medical products must fulfill a number of tasks. A primary task is to protect the product during transport and storage, which is also important for the safety of the users, for example, to maintain the sterility of needles. In hospital and clinic settings, protection from plastic enclosures after use of lancets and syringes is essential for health care personnel. A number of regulations and guidelines exist that are supposed to make sure that such aspects are covered adequately.

From a marketing point of view, the use of plastics visibly improves the presentation and appeal of a given diabetes technology product. Like with any product, such aspects are of high relevance for the manufacturer, because they have an impact on sales. However, in this age - the age which is so often referred to as the Age of Technology, where patients are turning to the internet to receive information and order specific products - one might ask about the relevance of such considerations.

Packaging is in the truest sense of the word a multi-layered issue, complicated by the wide range of plastics (and other materials) used and the highly complex ways in which they are combined. Plastics such as polyethylene, polypropylene, polyethylene terephthalate, polystyrene, polyamide, and others are used for packaging (and also for the plastic housings which support and present the products). Furthermore, the plastics are often mixed with additives prior to processing. These can be paints, but also flame-retardants or processing aids. Exactly what is used is often hidden from the public as a trade secret. This makes it extremely difficult or even impossible to separate them by type for recycling.

The question is, does this packaging effort have to be so great and can it not be otherwise? In practice many aspects are involved in this topic as well, that is, there are a number of hurdles to reduce the amount of packaging:

• Can product safety and performance be ensured without wasting 90% of the shipped product as packaging?

• Can manufacturers choose different materials and pack the products differently?

• Will patients be willing to pick up supplies instead of receiving one-box shipments to home address?

• Will insurance systems allow for patients to receive greater quantities at one time to reducing packaging material?

Research for Other Materials

The plastic used in the manufacture of many disposable pens and infusion sets is biodegradable. However, the time frame for bio-degradation is quite long.

The selection of materials used for medical products up to now has been a topic that is very much a guarded secret within companies and most companies will not reveal details. However, environmental aspects might have to be taken more into account in the future. The question is, can “plastics” be produced from bio-materials not derived from oil that can be used for packaging, as well as the products themselves? These materials are probably more expensive than the plastics used so far, which are produced comparatively cheaply in huge quantities, while ignoring their environmental costs. Bioplastic material might become an important topic in the future. ¹¹

Instructions for Use

In some cases, the booklet with the instructions for use (most often provided in a number of different languages) is more heavy and larger than the product itself. Most probably, such booklets are discarded directly (hopefully with paper waste) in nearly 100% of the cases. Nowadays patients watch short instructional video clips, but do not read. However, it would not only require a change of respective laws in many countries to avoid all the paper waste associated with instructions for use, they are also relevant from a legal point of view. Currently, manufacture must provide patients with all relevant information for a safe use of their products. So, today’s paper-based instructions are required depending on medical product risk classification, not taking specific therapy areas into consideration - a one-fit-all model. Also, not all patients have the connectivity to look up instructions electronically. Political pressure might be needed to induce such a change in regulatory thinking that would enable manufacturers to prevent/avoid unnecessary waste.

Recycling

When the first ready-made insulin pen came onto the market from Novo in the 1990s, a return campaign was launched to avoid waste. The pens were initially allegedly recycled to produce park benches. Today, pens are manufactured and used in much higher quantities; however, the subject of recycling pens (and other diabetes technology products) is not a hot topic to our knowledge. It is not clear how much of the product and its packaging (if any) are recycled in practice. Recycling can require that patients are provided with collection sites and specific return campaigns for given diabetes technology products.

Recycling requires by law adequate disinfection of all materials. It must be emphasized that recycling; which is an acceptable approach to plastic disposal, is completely different from re-use, which is absolutely contraindicated for medical waste; however, this is something many patients try to do, not only to save money, but also for environmental reasons.

Plastic waste can be recycled, used for co-processing in cement plants, or blended with bitumen and used to construct roads. Any of these allow recycling, promote conservation and efficiency, and help in revenue generation for waste disposal sites. Such conventional technologies are more reliable than an unproven method such as plastic pyrolysis and liquid fuel generation. Incineration and land filling with plastic should be avoided.

Summary and Outlook

Probably the first necessary change for improved waste disposal is to change our own mindset. In view of the importance of the climate change, our approach and way of thinking when it comes to developing and designing any new medical product for the treatment of patients with diabetes must be different in the future: Minimizing waste and designing recyclable parts must be a major aspect of product design.

Ideally plastic materials used for products and packing would be used again (ie, upcycling); this goal would require that the different materials can be easily separated. One has to find a balance between environmentally friendly packing and fulfilling all the rules that exist for medical products. A revision of such regulations having environmental aspects in mind will be key to able to make such initiatives possible and successful.

It appears as if until now reduction of waste and recycling was not a major topic for (most) manufacturers. Clearly they will be reluctant to redesign products and change packing of existing products because this is associated with considerable costs; however, it might very well be that the strongest power player in this business will push respective changes ahead. This player is the patients. If patients start to change their shopping behavior taking environmental aspects into account, then the reaction speed and creativity of the manufacturer might be pushed a lot. This might also push ahead a green diabetology movement, which addresses safe and environment-friendly disposal of diabetes technology products. Additionally, the political pressure to reduce the waste issue would then surely increase. Finally, one element of this article is clear: the topic of waste will not go away any time soon.