Diabetes Technology: Choosing What’s Best for You

People with diabetes have broadly similar needs. If you have the condition, then your body can’t regulate blood sugar without help, so you need tools to track your levels and alter them when necessary. However, no two people with diabetes are the same, and the specific tools you choose to use may not be the right choice for someone else.

“What might work for an 8-year-old kid is not going to be the same thing that works for a busy mom or construction worker or an older adult,” said Dr. Robert Gabbay, an endocrinologist and former chief scientific and medical officer of the American Diabetes Association (ADA).

Fortunately, there have never been more options for people with diabetes. Gabbay led a discussion with a group of experts to give an overview of the current state of diabetes technology and to explore the factors that affect how people engage with medications and devices. The panel included:

• Dr. Viral Shah, professor of medicine at the Indiana University School of Medicine
• Dr. Jen McVean, pediatric endocrinologist at Hudson Physicians and senior director of medical affairs at MiniMed
• Amy Tenderich, founder of DiabetesMine

CGM: More data and an opportunity to learn

Using continuous glucose monitoring (CGM) – the small wearable devices that track glucose values in real-time – can revolutionize diabetes management. With a CGM, people with diabetes can get a sense of how their blood sugar changes throughout the day using options like the Abbott Freestyle Libre and Instinct (made for MiniMed), Dexcom G7 (or new G7 15-Day), Simplera Sync, or Guardian 4.

“Once you’ve started on it, it’s hard to imagine life without it,” said Tenderich, who also lives with type 1 diabetes. “Diabetes is kind of trial-and-error, so CGM has really helped me learn my own body and what foods and exercises do what to me.”

A fingerstick test tells you what your blood sugar is at the moment you test it, and an A1C check gives you a sense of how well you’ve been managing it over the past few months. But neither value is that helpful when you’re trying to pick a snack or deciding when to take your medicine.

In contrast, a CGM gives you updates every one to five minutes, so you can track your time in range and figure out which foods give you the biggest spikes and which exercises cause the biggest dips. And you can use them to anticipate potentially dangerous situations like hypoglycemia and take appropriate preventative measures.

“It’s kind of like your speedometer,” Shah said. “If you don’t have a speedometer, you don’t know the speed of your car, and sometimes that can cause a crash.”

Of course, all of that information can be overwhelming. 

“The beauty of it is that it’s so immediate, but that can also be the downside because it freaks people out,” Tenderich said.

She stressed that the goal is to learn from the CGM and not overreact to changes you see after a meal. It’s just an opportunity to see for yourself that, for example, rice causes your blood sugar to spike and to understand how long it takes your mealtime insulin to bring that spike back down.

Tips for wearing a CGM

Other than the potential for information overload, the main trouble people have with CGM is figuring out how to wear them comfortably. The devices have very thin wires that pierce the skin, but they generally rely on adhesives to stay attached. When they’re on you, CGM can irritate the skin, causing rashes and red spots. They’re also prone to detaching if you’re sweating a lot in a hot, humid environment.

The good news is that these are not new issues. Many people have already encountered these problems and figured out ways to deal with them. Healthcare providers, diabetes educators, and people in the diabetes community can all be great sources of information.

Tenderich noted that you can spray Flonase on your skin before attaching the CGM to limit irritation. As for keeping them on, McVean recommended placing them after bathing and with plenty of time before you’re planning to do something physical or get in the water. Barrier wipes and patches can also help them stick.

As for taking a CGM sensor off, McVean cautioned people not to treat the device like a Band-Aid. “You do not want to rip and tear. You want to peel it gently,” she said.

If people prefer not to wear a CGM, there’s an implantable option that lasts a whole year: the Eversense 365. It still requires a small transmitter on top of the skin to send information to a smartphone app, but the transmitter can be removed easily if you’re doing something physical, and it relies on a silicon adhesive that’s gentle on the skin.

Automated insulin: Cutting down on the number of daily decisions

McVean had been living with type 1 diabetes for nearly 30 years when she first tried an automated insulin delivery (AID) system. From the MiniMed 670G – the first FDA-approved AID system in 2017 – things have come a long way in the diabetes tech world. 

“It was the first peaceful night of sleep I’d ever had in my life with diabetes,” she said.

AID systems combine CGM with wearable insulin pumps, which can release a steady drip of insulin in much smaller increments than an injector pen. While you could wear the pump on its own, AID systems have algorithms that use information from the CGM to adjust insulin and even stop it if your blood sugar is going too low.

McVean found AID so beneficial in children with diabetes that she led a trial comparing the effectiveness of starting an AID system immediately after diagnosis versus the standard of care at the time: CGM and multiple daily insulin injections.

“We found that children who started AID within one month of diagnosis had much better glycemic control at one year – 78% time in range versus 64% in those on CGM alone,” she said.

Consequently, AID systems quickly became the standard of care for people with type 1 diabetes, and more recently, they have also become the standard of care for people with type 2 diabetes who use insulin as well.

“It’s pretty much for everybody who is on insulin therapy,” Shah said. “That’s the bottom line.”

Tenderich noted that some commercially available AID systems were actually preceded by open source systems, built mostly by tech-savvy individuals with a personal connection to diabetes. Today, people who decide that commercially available AID systems aren’t exactly what they want can continue to work on their own systems and algorithms and advise each other in online forums.

As for insulin pumps, people can also choose between tubed and tubeless. Tubed pumps are larger devices that are more likely to snag on things. In contrast, a tubeless pump is smaller and might be easier to use for some, but you can’t really take it off until it’s empty and needs to be replaced. Right now, the Omnipod 5 is the only tubeless AID system available.

If you’ve been managing diabetes with insulin injections, choosing between different pumps and algorithms may seem overwhelming at first, but Tenderich stressed that AID systems really do simplify things once you get used to them.

Navigating stigma around diabetes tech

Beyond skin irritation, CGM and insulin pumps make some people uncomfortable because they can make you stand out. As a pediatric endocrinologist, McVean has noticed that this often affects children with diabetes and their parents.

“The minute you put things on the child – CGM, pump, whatever – it’s accepting that the child is different, and that’s not easy,” she said.

But McVean said that having diabetes does mean that you have different needs, and accepting and embracing that fact is an important part of managing the condition. And wearable devices really do reduce the burden, which is what matters.

As for teens and young adults who are starting relationships and worrying about showing off their wearables, Tenderich said that it’s usually less of a big deal for the other person than the wearer of the technology thinks. For many people with diabetes, it can also be very exciting and validating when you see someone “out in the wild,” like at the grocery store or beach, wearing a CGM or AID device.

She added that people asking weird questions about diabetes tech is something that never really goes away. Sometimes she’s willing to engage, and other times she’s not, but she puts up with it because the technology works. Her wearables really make it much easier for her to navigate life with diabetes in a safe and healthy manner.

Connected pens and inhaled insulin

While AID systems are the standard of care for anyone who uses insulin, Shah said that healthcare providers recognize that some people do not want to use pumps for one reason or another. In these cases, he said that connected smart insulin pens like the MiniMed InPen – which sync with smartphone apps, allowing people to keep track of how much insulin they’ve injected and how it’s affected their CGM data – are a better option than standard injector pens.

People with diabetes can share this information with their healthcare providers, and it’s much more likely to produce actionable advice than if they go to their appointment with only hazy memories of when they think they took their insulin on that one day a month or two ago.

Aside from pens and pumps, people over 18 with type 1 and type 2 diabetes can also try out inhaled insulin (Afrezza). Shah said that inhaled insulin can theoretically serve as your main mealtime insulin, but your body processes it so quickly that using it (and only it) to manage post-meal spikes may require more doses than you’re comfortable taking. Instead, most of the people he knows use inhaled insulin together with a pump.

“Sometimes the blood sugars are high, not coming down. In those situations, you can literally just take this inhaled insulin, pretty quick-acting, and it can get the blood sugars down in literally 30 minutes or so, and then the pump will do the rest of the job,” Shah said.

Tenderich, who uses inhaled insulin, said it has made life easier because she’s now less likely to overshoot her insulin needs in situations where she exercised before she ate or isn’t sure about the exact carb count in a meal. If her blood sugar is higher than she was anticipating, she can correct it afterwards with a few puffs from the inhaler.

Accessing diabetes tech

In the U.S., most public and private health insurance plans provide coverage for diabetes technology. For those who don’t have insurance or still struggle to pay out-of-pocket costs, financial assistance may be available. Companies like MiniMed also offer support programs for people who buy their products.

However, she also noted that cost is just one part of the equation when it comes to access. Language and technological proficiency can also create barriers, so she thinks about how to disseminate information in other languages and train people to use digital tools.

“We keep working on access, and it’s always improving, but there’s always more work to be done,” McVean said.

Shah agreed, adding that it’s crucial to train and educate not just people with diabetes, but also healthcare providers, who are ultimately responsible for educating people with diabetes about the tools that could improve their lives. 

The bottom line

Wearable technology and new methods of insulin delivery have helped many people manage their diabetes better. Whether you’re starting an AID system, switching to a connected pen, or trying out inhaled insulin for the first time, figuring out what works for you may require some experimentation. But there is a community of healthcare providers, diabetes educators, and peers that can fill you in on what’s worked for other people and help guide you on your way.

Learn more about diabetes technology here:

• How To Start Using a CGM
• Fully Closed Loop: Automated Insulin Delivery Takes the Next Step
• 7 Common CGM Hang-Ups (and How to Get Around Them)