Expert Q&A

The Impact of Technology on the Management of Patients With Diabetes

Lisa Jones, MA, RDN, LND, FAND; Rachel Stahl Salzman, MS, RDN, CDN, CDCES

Diabetes technology has improved significantly in recent years, including the use of blood glucose meters, continuous glucose monitors (CGM), cutting-edge insulin pumps, and more. Lisa Jones, MA, RDN, LND, FAND, interviews Rachel Stahl Salzman, MS, RDN, CDN, CDCES, on episode 14 of Nutrition411:The Podcast to help clinicians find the best digital health devices for their patients.

Rachel is a registered dietician and Diabetes Care and Education Specialist in the Division of Endocrinology, Diabetes, and Metabolism at Weill Cornell Medicine in New York City. She is passionate about empowering individuals to make sustainable lifestyle changes and leveraging diabetes technology to improve their health and quality of life.

The following is an excerpted transcription of the podcast episode “Smart Solutions for Diabetes Care: Combining Nutrition, Dietitians, and Technology.”

Listen to the full podcast here.

Lisa Jones: What is diabetes technology for those who may not know or be familiar with it?

Rachel Stahl Salzman: Diabetes technology is broad in scope, so I am so glad you asked this question. It is considered the term that is used to describe the hardware, devices, and software that people with diabetes use to manage it. It includes everything from glucose monitoring where we use blood glucose monitoring systems and continuous glucose monitoring systems known as CGMs, which people might be hearing about. It includes various insulin delivery devices such as smart connected pens, insulin patches, automated insulin delivery systems, and digital health. Running the spectrum of various consumer wearables and diabetes apps, ultimately to help support the patient to live well with diabetes.

Lisa Jones: How can this technology be used to support individuals who have diabetes when they are trying to manage their nutrition management and more broadly to meet their overall health goals?

Rachel Stahl Salzman: Diabetes technology can offer an array of benefits and it is really such an exciting field. And as you said, it can absolutely be hard to keep up with this ever-evolving field. But it is an exciting one because it is making it easier to live with diabetes and manage all the complexities that come along with it.

To start, it has been shown to help improve clinical outcomes, such as improving A1C and really cardiometabolic care. More than just glucose lowering and glucose supportive, it is having effects on a variety of other health conditions for that person. It can also help reduce the risk of micro and macrovascular complications and ultimately help make it easier to improve their day-to-day living. It provides flexibility, it can help improve quality of life. And what has been exciting for me is seeing how it really empowers the person living with diabetes to take more of that important role to manage their condition, giving them the tools to do so.

Lisa Jones: What would you say would be the latest technological advancements in diabetes management? And more specifically, could you talk about current ones now and then what would you say is a futuristic forecast?

Rachel Stahl Salzman: Oh, wow. Such a great question. We could probably spend so much time talking about it, so I will do my best to cover what I can. As I have mentioned, this is such an exciting time to be in diabetes technology and it is so great for all the listeners out there to continue to learn and keep your ears open for all the latest advancements. It feels like every month there is a new FDA approval, something new in the news in diabetes care. So, it is always evolving, which again, as a dietician in this realm, it is really a great field. I think what we are seeing now and what we have seen are new features and functionalities from companies that already know and used. For example, we have seen tremendous advancements in continuous glucose monitors. In the past year alone, we see these systems getting smaller, more accurate, more comfortable, and for the first time, approved in pregnancy. So that is what is exciting in the CGM world.

If we were to also think about the insulin side, we have seen tremendous advancements in what we call automated insulin delivery systems. These are systems that combine continuous glucose monitoring data with insulin pump technology and algorithms that can automatically adjust insulin dosing in response to glucose levels. And this has been a tremendous support for patients. Again, giving them so much more of that hands-off approach. Again, still in the driver's seat, but tremendous support with this automation and they are just continuing to get smarter and better. I also want to add that for patients that are using insulin, we are seeing tremendous advancements in the use of other types of delivery systems. We are seeing patch pumps where patients could not use injections like they are doing with pens. They can just click and an example I am thinking of is CeQur.

They can have a little patch connected to their body for 2 to 3 days and they just click it to support their mealtime insulin dosing. So, with a simple click, they could provide their mealtime insulin dosing, keeping it very discreet and easy to use. We also now see inhaled insulin, and that is known as Afrezza. So, a world, again, without insulin injections. We are seeing such growth in that field. And with the pens, we are seeing more connected insulin pens. I have patients using InPen, which we really love in that it helps to integrate data. Not only are they getting their insulin dose, but it is tracking their doses. It is providing reminders through a Bluetooth-connected app on their phone. It is helping them with the calculations of doing their mealtime insulin injections. We know it is a lot of math for patients. They need to calculate their insulin-to-carb ratio to determine how many grams of carbs they are eating, what are their glucose levels before the meal, and how much insulin they need to reduce it. By having a system with a connected app that is doing the math for them, that is tremendous and a big help.

I also want to highlight diabetes apps and digital health. We have seen tremendous growth in these technologies to help support our patients living with diabetes. For example, these apps are combining data not only from diabetes devices and smart scales but also using artificial intelligence and machine learning to provide advanced insights for patients. So, it is an amazing opportunity and tool to get involved with. And I encourage any of the listeners out there who are thinking about apps or might want to recommend apps to their patients, but are not sure where to start, to try the app out themselves. It is such a great way to learn about it and find out more. And I will also put a plug for an article about apps that I just published in ADCES in Practice journal where you can go to learn more about diabetes apps.

Lisa Jones: How can registered dieticians keep up with all this and provide the best possible care for clients? What is your recommendation for that?

Rachel Stahl Salzman: Yes, I have a couple of ideas. I would say there are a lot of tools and resources out there, and that is the good thing. But it could be hard to know where to go when there is a wide variety of sources, and you are looking for evidence-based sources. If you are a member of the Academy of Nutrition and Dietetics, I strongly encourage you to become a member of the Diabetes Dietetic Practice Group. As you might be familiar, there are many dietetic practice groups known as DPG in our academy, and there is a diabetes-specific one. I'm the diabetes technology chair of this DPG where I work along with a committee to provide exciting educational content for all our members, including hot-off-the-press news. We provide webinars, and we have a regular column in our peer-reviewed publication called Newsflash.

I also want to encourage dieticians to look at leading diabetes organizations, including the Association of Diabetes Care and Education Specialists, known as ADCES, as well as the American Diabetes Association, ADA, which offer many resources to help keep you up-to-date, including consensus statements, patient education handouts and conferences. One of my favorite conferences I just went to last year was a diabetes technology-focused conference through ADCES.

ADCES puts on an amazing annual conference every year, and for the past 2 years, they have had a specific diabetes technology one. I encourage any of our readers out there to look for that. And not only was it, again, so focused on technology, but they had a hands-on training where participants could try out some of these devices, feel what it is like to wear a CGM, connect it with your phone, and review it. I feel like that has made me so much more confident in talking to patients about it. They ask me, "Is it painful? Does it hurt? How do you connect it?" And having that firsthand experience has made me feel so much more skilled in supporting them.

ADCES also offers a free resource for healthcare professionals called Danatech, and that is available at It is a site exclusively on diabetes technology where you can compare devices, find out the latest and greatest in technology, and there are free webinar certificate programs. There may be some costs associated with some of these, but in general, it is a great resource. I encourage all of you to check that out.

I also want to make a plug for dietitians who are looking to get more involved in diabetes care to consider going for the Certified Diabetes Care and Education Specialist credential. This is something that has helped me tremendously in my role, and I cannot speak more highly of it. To learn more, you can go to the National Certification Board for Diabetes Care and Education, you could look up eligibility, and you could look up details. And again, I really advocate for that credential.

Lisa Jones: How do you take yourself as a dietitian and other dietitians and work with other healthcare professionals, such as endocrinologists and diabetes educators, to then take this technology and work together for a more comprehensive diabetes management approach?

Rachel Stahl Salzman: It is a great question. The important takeaway that I have seen in my practice, and where we see success for our patients, is using a team-based approach and putting the person living with diabetes at the center of it. We know that with the complexities of diabetes, having a support team is so important so that on a first visit where a patient who may be newly diagnosed or may have been living with diabetes for many years and is looking to establish new care, we set an expectation from the beginning, working with an endocrinologist, a dietitian, and a Certified Diabetes Care and Education Specialist. We wish we could have behavioral health support and psychologists on board, but having the dietitian is a key factor. Just the example of continuous glucose monitors, we used to be lucky if we had patients checking their glucose once or twice a day, but now with CGMs, we can see glucose values 24-hours a day, 7 days a week, and seeing how food is affecting their glucose levels, we are a key to help unlock that data. We can help patients to understand it. We can help patients to interpret how their glucose levels might be fluctuating with certain meals. We can help them understand if they might need some support with carbohydrate counting, maybe taking into effect some protein and fat in their insulin dosing, and then making the decision about maybe intensifying their medication regimen. And that is where I will work with the endocrinologist to see what kind of changes we can make. So, it is amazing that we can provide this team-based approach and help kind of unlock the medication management with some of the more lifestyle components together.

We have already seen so many advances in these technologies. And one thing I want to mention is just in the past, probably like six weeks or so, We have seen that Medicare and CMS has expanded coverage for CGM. So this is only going to continue to grow as more patients get access to these technologies. So previously, CGMs with Medicare and Medicaid were only previously available to patients who are on at least three insulin injections a day. But this is now changed, which is opening the door to millions of patients to have access and coverage for these technologies. It is now available to people who might be on just one injection daily, for example, maybe a basal insulin, or also for patients who have had severe hypoglycemic episodes, who may not even be on insulin, but other medications that might contribute to it.

So, it is really opening the door. So we're going to see continued growth. And another thing I see, and I really heard this a lot at that technology conference I was at, was a growing effort for interoperability. And what this means is that more of these devices and systems are going to communicate and talk to each other. And with that unlocks more data and more integration to provide more insights, not only for the patient but helping inform that healthcare team, helping us to really see what's going on. And patients, it'll give them more choice. Maybe they want this insulin pump with this CGM, with this app and giving them that choice. I see that growing a lot in the field too.

Yes. Bring the cost down. I think that is been a big barrier for sure, is the cost of some of these technologies. But I do see, and I think in our future we'll continue to see these companies really making efforts to bring the cost down and give access to more people for it.

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