What Technology is Right for Your Patient With Diabetes?
In this podcast, Jennifer Smith, RD, LD, CDCES, discusses technology options for patients with diabetes based on the patient's needs, lifestyle, and goals, including their use, benefits, optimization, and data analysis.
- Diabetes Wise. Accessed September 17, 2023. https://diabeteswise.org/
For more diabetes technology content, visit the Excellence Forum.
Hello everyone and welcome to another installment of Podcast 360, your go-to resource for medical education and clinical updates. I'm your moderator, Jessica Bard, with Consultant360, a multidisciplinary medical information network.
What technology is right for your patient with diabetes? There are a lot of options on the market today and they're evolving rapidly. Jennifer Smith helps us break down options for patients based on use, benefits, optimization and data analysis.
My name is Jennifer Smith and I'm a registered dietician and a certified diabetes care and education specialist. I work with Gary Scheiner at Integrated Diabetes Services. We have a really intensive management clinical practice, that really affords us the ability to work with people all over the world for diabetes navigation. We see a lot of people who mostly are Type 1.
We've got a handful of people with Type 2 diabetes. I've been a, gosh, diabetes educator for a long time already. I also have type 1 myself for more than 35 years now, so both personal as well as the load of clinical experience as well, go into the practice I bring to all the people that I have the opportunity to work with.
Excellent. Well, we're really looking forward to speaking to you today. The first topic that we'll talk about is diabetes technology. Let's start with just a general introduction to diabetes technology.
I know it's been evolving over the years and there are lots of different options. What kinds of technologies are available to patients and if you want to talk a little bit about the evolution?
Absolutely. Years ago, my diagnosis, we had a glucometer thankfully. In the '80s, that was the piece of technology that was the newest and the coolest on the market. Obviously, we still have glucose monitors today to do a fingerstick and get an actual, real-time blood glucose value, but we have gone beyond that thankfully. Technology in the past five to 10 years has really bloomed. We've got continuous glucose monitors that have really great accuracy at this point, very comparable to a fingerstick value.
We also have beyond that, insulin pumps, which they've been around for a while, but have continued to evolve in what they can deliver and how they can deliver insulin. Today's insulin pumps now actually work along with the continuous glucose monitors, which really means that we have an advantage of using something called an algorithm. Glucose values come in, the pump sees them, and the algorithm drives the insulin delivery through the pump device.
All the different really FDA-approved systems that are on the market, do have an algorithm-driven, technology-based pump, which is fantastic. We've changed a lot in a really short amount of time recently. I waited and waited and waited years for this kind of technology that we have now.
What are general principles that clinicians should be keeping in mind when prescribing a device to a patient?
That's a great consideration. There are so many things to consider. One, you have to consider the point of where the person that you're working with actually is, newly diagnosed versus years of information already. Are they interested in using newer technology? Again, considering where are they, what are their goals? That's a really important piece to knowing when you're going to prescribe something.
Does this align with the goals that you have, as well as what the person with diabetes can manage? I think that's a piece to consider before discussing a device. Then when prescribing them, make sure of so many things. One, do they have a baseline of understanding? Do they really understand things like a bolus, basal insulin, and how the insulin pump actually works?
There are many wonderful classes that people with diabetes should have access, in order to actually use the technology that you want to prescribe. Then the other consideration is really do they have the right coverage so that they can afford this type of technology? Because it's not inexpensive if you're considering paying out of pocket. Insurances have gotten better with coverage, but not each and every plan will cover each and every part of or piece of technology.
That's another piece that does need to be considered when you're discussing moving into technology or moving into a different type of technology, that you feel could be of benefit. Also, understanding things like numeracy, and literacy are really important pieces to consider in any technology, be it a pump, a smart insulin delivery injection device, or even continuous monitors.
We've got smart glucose meters now that also communicate with the different app-based technologies. But if somebody doesn't know how to use it, then it's not going to go far in reaching anyone's goals.
That really goes into my next question about barriers. Now we've mentioned several, patient interest and knowledge, insurance coverage, et cetera.
Maybe even we can talk about care team knowledge, but can we talk about ways to overcome some of these barriers as well?
Yeah, absolutely. In terms of care team knowledge, again, you as the prescriber or the person who may bring to the person with diabetes some information of, "Hey, we could try this and this may reach the goals that we're both trying to get to." Your knowledge about this technology needs to be there so that you can answer the questions that are very likely to come from the person you're trying to help.
What that means is you really need to play with these devices. If you know one particular insulin pump, for example, but you really don't know the others that are on the market, or what the button pushing feels like or looks like, or what it's like to wear it, then it's your job as a clinician to get that done. You've got lots and lots and lots of different product reps that are very happy to come to your office space and give you education.
Thankfully, we also have online tutorials, and simulated types of devices that you can play with the device online. You can see what it does. You can even see how insertion for some of the pumps and the infusion sets. For some of the different continuous monitors, you can get a visual of how that actually looks. But I always think I'm a very visual, hands-on learner myself, and so I'm a show me. Show it to me, let me put it on.
Let me push the buttons. I think a lot of people are like that too when it comes to devices like this. Because what it translates into is then how you, as a clinician, may be able to share that experience and explanation in a way that your patient is going to better understand because you've had the actual, personal experience. You've not just watched something get done, you've done it.
You've pushed the button, you've put the infusion set under your skin. You've popped the sensor on. You know what it feels like and when those questions come, it's not a guess. It's an answer that you can give because you know. I think barriers often are that the clinician may know the baseline, the tip of the iceberg about products, and what studies have shown that they can provide in terms of outcome.
But the real-time is to cross a barrier of use and be able to explain it from a personal standpoint. I think that's what many people with diabetes really want, is not just the baseline information.
As a diabetes care and education specialist, what resources are available for education and training? We can even talk about both for the care team and then also for the patient.
Absolutely. I know a lot of different practices, both in hospital as well as clinical, endocrine types of practices for people with diabetes. They do have really good education, like a Saturday or a Sunday, or a weeknight or something to come in if you're considering a pump or whatnot, to actually get the training process completed. So that all of those checks that you want to make sure somebody has an understanding of, they're already checked off then.
As far as a clinician, again, meeting with your reps is really, really important, because they're the ones who are going to be able to bring that product to you, and explain it from a very personal level. In fact, many of the reps actually have diabetes and have worn the products. They can give you some of that personalized explanation from a higher level of the questions that you might, as a clinician, be asking.
DiabetesWise.org also has a professional, I think it's DiabetesWise.org is the website, that is a fantastic resource for people with diabetes, in terms of discovering what type of device fits your needs, fits your lifestyle, fits where your goals are going. From a clinician standpoint though, the professional site gives a lot of that on a higher level.
The nice thing about it, it also gives some understanding of coverage and insurance, how to put claims through, and how to write prescriptions the right way. How to write a statement of medical necessity based on this, this, and this coming from a person who actually needs this type of technology, to facilitate them getting the device that both you and they would like. That's a fantastic resource that I always recommend.
We'll put a link to that in our show notes on the website landing page as well.
Let's take a deeper dive now into different types of diabetes technology.
If we could go through a couple of different types of technology and talk about maybe their use, benefits, optimization, and data analysis. Does that sound good to you?
Yeah, of course.
Okay. Let's start maybe with blood glucose meters, self-monitoring, and blood glucose meters. Can you talk a little bit about that?
Sure. Blood glucose meters themselves are the ones where you will do a fingerstick. You'll apply a drop of blood on the test strip and then the meter will give you a glucose result. There are many that are on the market today. The good majority of them actually have, from a technologically advanced standpoint, they upload automatically almost Bluetooth right to an app on the phone, which is fantastic.
Because then you can get a collective of your data, in a way that some of the apps put together to provide you with some feedback. Some of the apps or devices will actually tell you messages after a week or two of glucose monitoring around lunchtime. They'll say, "Well, you're always high or you're always having a lower blood sugar at lunchtime."
Then as a person with diabetes, it's a little bit easier to go back to your clinician and say, "Hey, I've noticed this trend and I'd like to do something about it." On the upload of it or the download to the clinician's connected site, many of these devices connect with a clinical database, which allows the clinician to get a notification of recently, uploaded data from each of their patients.
It will clue them in on how many people have had hyperglycemia or high blood sugar levels above a certain range, or how many have lower blood sugars above a certain percent. As a clinician, you then have a way to see, "Who are the people I really need to check in with sooner than later?" Because they're sending their data to you.
From blood glucose monitors eons ago when I was first diagnosed, everything was handwritten up like a log book. You brought it in and you gave it to your clinician to look at. But these new blood glucose meters even have event markers, which you can say whether it was pre-meal if it was fasting in the morning or if it was around exercise. If it was post-meal if you have a stress like an illness or a menstrual cycle or something.
Those event markers can not only help the person with diabetes if they're using them, but it can also help the clinician when they're looking at their data, to be able to make more sense of that information. Rather than randomly looking at information from three weeks ago and hoping that the person with diabetes can reflect what happened there.
Right. Next on my list here, do we want to talk about insulin pumps?
Oh, insulin pumps have come a long way in a really short amount of time. Like I said earlier, they really have. When I was first diagnosed, pumps were available, but they were nothing. They weren't anything really for a number of years after I was diagnosed where they started to look a little bit smaller. They started to actually look like something that could be beneficial in terms of insulin dose adjustment.
Our pumps today can adjust doses down to really, really tiny, deliverable bolus like .025 of a unit of insulin. For those who are very insulin sensitive or just need really microdosing adjustments, that can be a huge advantage over bolusing with an insulin, a syringe, or even an insulin pen, which the smallest you can get is half a unit. Today's pumps especially have what I said before might be algorithms.
Algorithms are something that allows both continuous glucose monitors, not blood glucose monitors, but a continuous monitor, a sensing device that sends that sensed glucose value right to the pump. The pump has an algorithm, which is essentially a fancy math equation. Takes all the information along with that sensor glucose value, and it baseline adjusts the delivery of insulin throughout the course of the day, to accommodate for the fluctuations in blood sugars.
Our pumps today are really, they're so much smarter. They're not yet AI. They don't make decisions. They're still definitely based on settings and well-known insulin use parameters that as a clinician, you really have to be good about helping the people with diabetes find their right doses before we start on this fancy equipment. Because the technology is only as good as the smart person who put the information in to set it up.
If you have stinky settings to begin with, you're not going to have very good results, even with an algorithm that is technically smart. I think technology is advancing so quickly that things continually change. Even on a year-to-year basis, there's something different, there's something new. There's something coming out that's upped the algorithm and how it adjusts things a little bit better.
But we still are the smartest piece in the use of that technology. As a human brain, we still have to know what we're doing.
I imagine it's difficult for the patients and also for the care team to keep up with how quickly things are changing.
You even mentioned an AI piece there, which maybe we'll have to circle back to. I'm sure we could talk a lot about that as well.
But next, let's talk about CGMs.
Yeah. CGMs are, as a person with diabetes as well as a clinician working with the many, many people that I do, if you asked me right now to give up one of my pieces of technology, I wouldn't be happy about it, but I would give up my pump before I would give up my CGM. Continuous glucose monitors are by far one of the best step forwards in technology that we have with diabetes today because they give real-time at least direction to what's happening to your glucose values.
Eons ago when CGMs first really became popular, there was a really cool graphic that actually it set up a 24-hour graph, that put pinpoint fingersticks about six times through the course of the day. Behind it then the next screen, filled in all of the missing fluctuations in blood sugar, when CGM is mirrored on top of just those fingersticks. You can see what ends up happening then in the three hours between a meal bolus and the meal, and going for a three-mile run.
You can see what ended up happening compared to just a fingerstick here and a fingerstick three hours later. CGMs have brought forward a way to have safety, that's a really important thing in all of the discussions about technology. Is it safe? Is it accurate? Does it provide more of a sense of handholding for the person, the person with diabetes? Is it something that helps them have more confidence moving through their day and whatever life choices they have to make?
If I can look down at my watch, that's another piece of CGMs. Now they Bluetooth to everything. Not only can you see the information on your phone, but if you have a CGM and you're a child, the parents or the caregivers can follow the CGM trends. Parents can see what's happening to their child's blood sugar when they're away at school or they're off on vacation, and there's a caregiver taking care of them.
I, as a person with diabetes, can quickly look at my watch and I can see where my glucose value is, rather than having to open my phone all the time to see it. The CGM world certainly has opened up. I think there's a comfort level to having a CGM. CGMs also provide alerts. It's not just a visual to your glucose, but you can set high and low alerts that are within a parameter that you specify.
And/or specify along with a discussion with your clinician, to be able to say, "You know what? I want to be able to stay under this number. I want to get an alert when I'm above this number so that I can do something about it. Or that I want to get an alert if I'm going too low, especially overnight when I'm sleeping." Before having a CGM, I had a 2:00 AM alarm that I set every single night.
I got up and checked my blood sugar overnight because while I had good doses of my basal insulin, the variables of the day going into a night, could change what happened to my blood sugar overnight and so I just wanted to know where I was. With a CGM, I was like, "Oh my gosh, I can sleep through the night. This is fantastic." Something is going to alert me if I actually need to get up and address a high or low blood sugar.
But otherwise, I get to sleep, which is fantastic. I think CGMs by far are the most beneficial technology of anything that's really come out. It really is.
I think of peace of mind for you. I also think of peace of mind if someone is a parent with a child with diabetes.
I can't imagine being responsible for that child and always wondering what's going on. I'm sure with new technology, it really gives a lot of peace of mind.
Next, insulin pens and smartphone apps, do we want to go over that?
Absolutely. There are a lot of people who just really prefer MDI or multiple daily injections, and thankfully for them, there are smarter ways to calculate and follow insulin doses. Years ago, taking an insulin dose right now with an injection, meant that you had to mentally keep track of when did I take it? How much of this insulin might be left if I want another snack or something an hour or two from now? But I did dose, so I know there's leftover insulin there.
Our smart pens today, interact again via Bluetooth with an app on a phone or a smart device. The apps actually will allow some of the calculation. This means that if you plug in using an insulin-to-carb ratio and you say, "Okay, I'm going to have 20 grams of carb right now." The algorithm that does the calculation within the app communicates with the insulin pen or the insulin delivery device. It allows the calculation, and now that keeps track of your insulin on board.
I consider insulin pens today, the smart insulin pens, they're like pumping without a pump, because all of your calculations reside in that app. Insulin-to-carb ratios, your correction factors. Many of the apps will even allow you to essentially have a notification for your basal insulin injection, as a reminder, "Hey, it's eight o'clock at night, take it. Or it's seven o'clock in the morning, take it." You can mark your dose.
Again, from a cumulative of data or event marking, these apps can translate into a PDF that you can print out, you can bring it to your clinician and there's no more paper logging. Even if you're not using a smart pump, the smarter pens make a big difference in terms of what you have to keep track of. They can also dose a little bit more reliably based on your settings. Again, insulin-to-carb ratio, correction factors, and overlapping doses.
I know there's one in Europe, it's no longer in use here in the United States, but there's one that even takes activity into consideration. If you're bolusing at a mealtime, you can tell it that you're going to be moderately active after this meal. It would actually do a dose adjustment based on activity factor, which is really fantastic. These are some apps that essentially work with smarter insulin delivery injection devices.
They're a fantastic tool. I know the nice thing about at least one of them, the InPen allows you to also use multiple different types of rapid-acting insulin. You're not locked into just using one of the brands of rapid insulin, which makes it really nice because some people can't use one brand or another. Those are things as a consideration to think about.
I feel like we can talk about these all day long, but as we start to close here, do we want to talk about the future?
What the future looks like or could look like for diabetes technology? I know you mentioned maybe potentially incorporating AI into it. What do you anticipate could be in the future?
I think that's really the direction, I would say many people with diabetes and maybe even clinicians, are really hoping that the advancements in diabetes technology, I think that we're hoping that's the direction things are going. To something that truly is a little bit more closed thinking, taking much of that consideration that's still there for the person with diabetes out of the picture. Having us do a little bit less input into the device in order for it to navigate.
In my perfect world, my pump would just learn. Learning is really a piece of AI. None of the systems available today learn. That learning piece would be able to anticipate a shift, for example, in women's hormones that time of the month. The algorithm can look back a month ago and say, "Yep, this is about the time. I need to ramp up delivery here." It takes a piece of that management down a considerable level for the person living with diabetes.
Those are the hopes. There are so many people working on improving technology and improving these already pretty smart devices that we're using. We'll have to see where it goes, honestly.
Absolutely. Time will tell. Well, Jennifer Smith, thank you so much for joining us. Is there anything else that you'd like to add before we wrap up today?
I think the biggest thing really around technology, is that there is so much technology that's hard technology, the pumps and the insulin pens and the CGMs, but there are also more of the technology that can work with that. There are diabetes apps and there are a lot of diabetes apps that are available. I think the last count was like 2,000 some apps that are available within the realm, and that's just like diabetes, not even all the healthcare kinds of things.
Again, as a clinician, you can't know everything. I certainly don't know all the apps that are out there. I have a handful that I really use. But those are some of the try, look, keep up with some of the things that people with diabetes are bringing in as questions because that is a piece of this technology. As we talk more about AI, I think that's where a lot of this is also going. Apps that talk to each other and can gather data from here and from here and bring it together in a decision-making way.
So look forward to apps that are also a piece of all of this. Remember to individualize and look at what the person with diabetes is really coming in with, in terms of their goals and how to move them there at the pace that's right for them.
Absolutely. Well, thank you so much for joining us on the podcast today.
We sincerely appreciate your time and for everything that you do for your patients with diabetes.
Well, that's wonderful. Thank you for having me