Addressing Advancements in Digital Health and Diabetes Technology

The prevalence of diabetes mellitus worldwide presents a significant public health challenge. In the United States alone, there are 34.2 million diagnosed cases of diabetes, a number expected to rise to 61 million by 2060. The growing diabetes population raises concerns about limited access to endocrinologists, particularly in rural areas, and a potential shortage of primary care physicians, who currently conduct the majority of diabetes care.¹

The traditional model for managing diabetes has proven insufficient, emphasizing the need for innovative solutions that can accommodate the growing number of patients while maintaining high-quality care. Recent advancements in diabetes technology have revolutionized healthcare: addressing prevention, management, and evaluation of complications. Digital health technologies offer specialized medical interventions, improved access to information, and support while enhancing medication adherence and facilitating evaluation and management of complications. These technologies have the potential to empower patients, enabling them to actively participate in their diabetes self-management and fostering continuous communication between patients and healthcare providers.¹

Online interventions based on the US Diabetes Prevention Program (DPP) show promise, with some even reimbursed by health insurance.² These interventions bridge gaps in education, providing accessible programs for patients. However, there are still additional program-based needs: strong clinical evidence, fair payment systems, and regulatory reform. As diabetes care transitions to digital-first care, it is vital to maintain the multifaceted nature of diabetes care and to guarantee access and equity to diverse care teams. By embracing advancements and prioritizing inclusivity, patient outcomes can be enhanced, and holistic diabetes management can be achieved.

George Grunberger, MD, FACP, MACE, is the chairman of the Grunberger Diabetes Institute in Bloomfield Hills, Michigan, which he founded in 2002. The institute provides comprehensive care to individuals with diabetes. He is also a clinical professor of Internal Medicine, and Molecular Medicine and Genetics at Wayne State University School of Medicine in Detroit, as well as a professor of Internal Medicine at Oakland University William Beaumont School of Medicine in Rochester, Michigan. With decades of experience, Dr Grunberger has an extensive publication record that includes over 150 peer-reviewed manuscripts, review articles, abstracts, and book chapters. In this article, Dr Grunberger delves into the latest advancements in diabetes technology and provides valuable insights on the transformative effects of digital health for individuals with diabetes.

Diabetes mellitus poses a significant worldwide public health challenge, with an estimated population of more than 463 million individuals affected currently. This number is expected to rise to 578 million by 2030 and reach 700 million by 2045.¹ How does increased connectivity between diabetes care teams contribute to efficient remote care of patients with diabetes, including analysis of glucose monitoring and subsequent medication adjustments?

The world has witnessed a significant rise in the prevalence of diabetes mellitus over the past few decades. As more people adopt a westernized lifestyle and life expectancy increases, this disease is anticipated to affect a larger portion of the global population. However, only a few societies have the means to implement the necessary lifestyle and medical management solutions that can effectively reduce the direct and indirect costs associated with diabetes mellitus.
 
The wider adoption of digital connectivity has the potential to alleviate the burden of this disease, but this potential remains largely untapped for the majority of individuals with diabetes. Remote digital care is only feasible for patients who possess the ability, resources, and motivation to participate, as well as access to the necessary wearables for data collection and analysis of glucose levels and medication usage.³
 
Conversely, for those diagnosed with types of diabetes that require intensive insulin management and have access to CGMs, insulin pumps (or connected pens), trackable devices, apps, and high-speed internet connection, increased connectivity could lead to improved glucose control. This, in turn, holds the promise of more significant long-term outcomes. Overall, addressing the growing prevalence of diabetes mellitus requires a comprehensive approach that combines lifestyle modifications, medical management, and the potential benefits offered by digital connectivity.

How have multidisciplinary treatment approaches in diabetes, facilitated by technology, addressed the limitations faced by patients living in rural or remote areas?

Implementing more frequent and concise multidisciplinary digital visits enables targeted and personalized diabetes care, even for individuals residing in remote areas.¹ Currently, these patients face challenges due to the expensive and time-consuming nature of long-distance trips, making them infrequent or impossible. However, there are various other obstacles to overcome for remote interactions. One significant obstacle is the limited access to technology, particularly for patients with type 2 diabetes who rely on noninsulin medication regimens that may not qualify for insurance coverage of CGMs and other advanced tools.⁴

Can you explain how digitally connected diabetes care can successfully augment face-to-face clinic visits, and what implications does this have for patients in terms of cost and convenience?

While in-person human interaction is unparalleled, access to digitally connected care can greatly enhance healthcare outcomes. By enabling physicians, dietitians, exercise physiologists, and other clinical professionals to have more frequent personalized visits, patients can accelerate their progress towards clinical targets.³ Additionally, there are clear advantages for patients, as they can eliminate the costs and time associated with traveling to a clinic for in-person visits.² Furthermore, if these digital visits are covered by the patient’s insurance plan, they can achieve better outcomes without any additional cost.

Initiation of CGM, continuous subcutaneous insulin infusion, and/or automated insulin delivery early in the treatment of diabetes may be beneficial, depending on patient preference.⁵ Can you discuss how to provide individualized device recommendations based on a patient’s specific requirements, preferences, and skill level? How do you provide ongoing patient education for CGM and device training, either in-person or remotely?

Currently, the use of CGM is primarily intended for patients with diabetes who require insulin and use continuous subcutaneous insulin devices (pumps) as part of intensive insulin regimens.⁵ I firmly believe that the choice of a specific CGM and insulin pump should be left to the patient. After all, they are the individuals who will be interacting with these devices around the clock, every day of the year. It is crucial for them to feel comfortable with their choice, taking into account their unique lifestyle, skills, preferences, and subjective factors.
 
Our role is to provide unbiased presentations of all available devices, highlight their features, and address any questions patients and their family members may have. This empowers them to make an informed decision. Once the decision is made and all necessary prescriptions and payer requirements are fulfilled, we can proceed with education. This can be done either in-person or remotely based on the patients’ preferences, skills, and scheduling constraints.
 
It is vital that the education process is interactive, allowing patients to demonstrate their understanding of the tasks involved in glucose monitoring and insulin delivery. Additionally, initially scheduling several shorter follow-up visits ensures that patients can successfully implement these tasks and have all their questions answered.

How do you optimize blood glucose monitoring in patients with diabetes requiring intensive insulin therapy? What role does real-time CGM play vs intermittently scanned CGM in these patients?

The advent of CGM has revolutionized diabetes care, benefiting both clinicians and patients. It provides unprecedented insights into glycemic excursions triggered by eating, physical activity, and various lifestyle events. Additionally, it enables the detection of asymptomatic nocturnal hypoglycemia.⁵ Armed with this valuable data, healthcare providers can make well-informed management decisions, relying on objective information rather than subjective patient reports. However, the effectiveness of CGM relies on proper and consistent usage by patients, who must wear and utilize the sensors diligently.
 
Traditional FreeStyle Libre devices required users to physically scan the sensors every 8 hours with a lifetime of 14 days, posing an inconvenience for those who would occasionally forget. Fortunately, the introduction of Libre 3 eliminates the need for these scans. Currently, there are 4 different manufacturers offering real-time sensors in the US market. The specific type of sensor is a personal decision, as patients should feel a sense of ownership in managing their diabetes care.⁶

What are some newer advances in insulin pumps, including functionality-related sensor-augmented pumps and AID systems?

The integration of CGM sensors and insulin delivering pumps through a central “brain,” starting with the MiniMed^TM 670G, has paved the way for several AID systems in the US market. These hybrid closed-loop systems have significantly enhanced glucose control, reduced hypoglycemia, and improved the overall quality of life for patients and their families, especially when it comes to sleep.⁷ Recent advancements include the introduction of the iLet by Beta Bionics, which only requires weight input to initiate AID; the Guardian 4^TM sensor (MiniMed^TM 780G) that eliminates the need for periodic fingerstick calibration; the availability of extended-wear (7-day) infusion sets; and the ability to deliver insulin boluses from a smartphone. All these features aim to alleviate the burden on patients who have to manage these wearable devices. Furthermore, the newer systems offer the flexibility of lower glucose targets, which can lead to improved overall glucose levels, such as lower glucose management indicator (GMI) and glycated hemoglobin (A1C). However, 2 significant challenges still persist: the slow onset of action of bolus insulin, which typically requires the patient to know their insulin requirement and administer the dose about 15 minutes before starting a meal, and the need to announce the meal beforehand.^8,9

What advancements do you foresee in diabetes technology that would make adoption among primary care providers more accessible and affordable?

This is a crucial question for which there are currently no easy answers. The adoption of diabetes technology in primary and specialty care practices depends on several factors. First, patients need access to, affordability of, and proficiency in using the technology. Second, primary care clinicians must be able to comprehend the data produced by these devices and provide informed management decisions to their patients. However, this requires additional time to learn how to analyze the information and deliver appropriate treatment decisions.
 
Practices also require resources, including trained staff, to download the data from devices. The staff needs the necessary hardware and software to connect the data to the practitioner’s electronic medical record (EMR). Some large health systems have successfully implemented direct downloads from CGM sensors into EMRs, which could significantly streamline the process if made available to all practitioners. Education is vital for all involved parties, including specialists, generalists, nurse practitioners, educators, dietitians, and patients. Programs like the national Innovating Decisions and Empowering Action in Diabetes Management (IDEA) program, launched by the American Association of Clinical Endocrinology in 2018, should focus on teaching basic interpretation of CGM ambulatory glucose profiles, glucometrics, and data trends to translate sensor-generated data into actionable clinical decisions.
 
Advocacy efforts are needed to ensure that all patients with diabetes, regardless of their medication, have affordable coverage for technology devices. Additionally, bureaucratic obstacles related to ordering technology supplies should be eliminated. Lastly, there’s no reason why CGM sensors cannot be made available over the counter, similar to glucose meters, strips, and accessories for blood glucose monitoring.
 
This Q&A was edited for clarity and length.

References

1. Al-Badri M, Hamdy O. Diabetes clinic reinvented: will technology change the future of diabetes care? Ther Adv Endocrinol Metab. 2021;12. doi:10.1177/2042018821995368
 
2. Rhee SY, Kim C, Shin DW, Steinhubl SR. Present and future of digital health in diabetes and metabolic disease. Diabetes Metab J. 2020;44(6):819-827. doi:10.4093/dmj.2020.0088
 
3. Kompala T, Neinstein A. Accelerating transformation to a digital-first diabetes care model. J Diabetes Sci Technol. 2020;14(4):743-744. doi:10.1177/1932296820930004
 
4. Alvarado MM, Kum HC, Gonzalez Coronado K, Foster MJ, Ortega P, Lawley MA. Barriers to remote health interventions for type 2 diabetes: a systematic review and proposed classification scheme. J Med Internet Res. 2017;19(2):e28. doi:10.2196/jmir.6382
 
5. ElSayed NA, Aleppo G, Aroda VR, et al. Diabetes technology: standards of care in diabetes — 2023. Diabetes Care. 2023;46(suppl 1):S111-S127. doi:10.2337/dc23-S007
 
6. Dovc K, Battelino T. Evolution of diabetes technology. Endocrinol Metab Clin North Am. 2020;49(1):1-18. doi:10.1016/j.ecl.2019.10.009
 
7. Cordero TL, Dai Z, Arrieta A, et al. Glycemic outcomes during early use of the MiniMed^TM 780G advanced hybrid closed-loop system with Guardian^TM 4 sensor. Diabetes Technol Ther. 2023;10.1089/dia.2023.0123.doi:10.1089/dia.2023.0123
 
8. Slattery D, Amiel SA, Choudhary P. Optimal prandial timing of bolus insulin in diabetes management: a review. Diabet Med. 2018;35(3):306-316. doi:10.1111/dme.13525
 
9. Norlander L, Anderson S, Levy C, et al. Late and missed meal boluses with multiple daily insulin injections. Diabetes. 2018;67(suppl 1):992-P. doi.org/10.2337/db18-992-P

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