It's Complicated: How Diabetes Technology Can Help – Or Hurt
Key takeaways:
- People with diabetes-related complications can benefit significantly from incorporating technology to improve and reduce time spent managing blood sugar levels.
- Tools like voice assistants and AI can help reduce the burden of some complications.
- Technology can also be a burden, and one size does not fit all.
Anyone who has had problems with their smartphone or has spent time on hold for tech support knows that technology can be a blessing and a curse.
Likewise, when diabetes technology works as intended, it can automate manual and repetitive tasks, save time, and lead to better health outcomes. When that same technology fails, it can cause delays and frustration, which makes diabetes care more difficult.
Research presented at the 2024 EASD scientific conference in Madrid showed how technology can assist people with diabetes who have chronic complications like retinopathy and kidney disease. Also discussed was the stress diabetes technology can introduce, as well as the dangers associated with moving too quickly when adopting new tech, which in some instances can worsen chronic complications.
Two researchers – Dr. Tomas Griffin, a diabetologist from the University of Galway in Ireland, and Dr. Sufyan Hussain, a diabetes physician at Guy’s and St Thomas’ Hospital in London and honorary reader at King’s College London – shared their views on diabetes technology, based on research as well as their own experiences.
Benefits of technology for kidney disease
Griffin highlighted findings from several studies that show how technology such as continuous glucose monitoring (CGM) and automated insulin delivery (AID) can help people with diabetes who are also managing complications like kidney disease and retinopathy. Significantly improving time in range and A1C can allow people to feel better and reduce stress.
Griffin, who serves as the clinical lead for insulin pump and diabetes technology services at Galway University Hospitals, conducted a study that showed people on dialysis due to diabetes-related kidney disease experienced higher than average glucose levels, among other difficulties that can lead to burnout.
"There are limited medication options and impaired awareness of hypoglycemia, which can complicate diabetes management and contribute to unpredictable glucose levels and increased cardiovascular risk,” he said.
In one study of people with diabetes on dialysis, introducing CGM use decreased A1C significantly from 8.4 to 7.6% with no reports of severe low blood sugar. In another study, people on dialysis who began using AID devices had a nearly 38% increase in time in range.
Yet another study showed a boost of 13% (43.7 to 56.6) in time in range for those on an AID device vs. standard insulin therapy on days when the participants were on dialysis. And time in range went from 36% to 60% in 20 days. In one case, a patient on dialysis saw time in range increase from 20% to 80%, simply by switching from a Medtronic pump without automated features to closing the loop with the Medtronic 780G.
"This person was bolusing up to nine times a day, working really hard to get that A1C down, but just needed a little bit of extra help," Griffin said. "And that's where hybrid closed loop comes in. These results suggest that closed loop insulin delivery provides an effective method for achieving safe glucose control in this very vulnerable population."
Study participants using hybrid closed-loop systems reported benefits including less finger pricks to check blood sugar levels and less time required for diabetes care.
"This resulted in more personal time and a greater sense of freedom along with enhanced peace of mind and reassurance," Griffin said.
Technology pros and cons for vision
The presenters raised a somewhat ironic issue seen in people using AID systems or other therapies who experience a sudden, dramatic improvement in blood sugar control. Research has shown some people with diabetes-related retinopathy may see the condition worsen when their A1C quickly improves. Griffin urged a slow and steady approach in these situations.
"It's important to be very cautious," he said. "We're very fortunate that we engage with our ophthalmology colleagues for each person with end stage renal disease starting hybrid-closed loop and optimize their diabetic eye disease in advance."
Griffin also highlighted the benefits of tools that are designed to help those with vision loss and blindness who struggle with diabetes care and related technology.
He showed a clip-on magnifier that doubles the view of an insulin syringe as well as an app for Android phones that can magnify the screen up to eight times the normal view. These tools are designed to help with apps for diabetes care like those bundled with CGM, pump, and AID devices.
Existing screen reader apps that are built into Android (TalkBack) and iOS (VoiceOver) can help by speaking aloud glucose readings and trends. And voice technology combined with artificial intelligence, like ChatGPT, he said, offers tremendous promise for assisting people with diabetes-related complications. For example, AI can analyze a photo taken with a smartphone, count carbs and identify other nutrient content, or review and read aloud CGM readings and trend data.
If employed in CGM, glucometers, and insulin pens, Griffin suggested that voice assistant technology could improve diabetes care for those with vision loss by helping with dosing and reading blood sugar levels. Voice tech would also benefit those who use blood glucose meters, preserving the touch sensitivity that's crucial for those who read using braille.
Limitations of diabetes tech
Hussain, an honorary reader at King's College London, diabetes and technology specialist, and advocate who has lived with type 1 diabetes for more than three decades, said that he was familiar with some of the frustrations that diabetes technology can introduce. He addressed some of those limitations – and what could be done to help address those challenges.
In the U.K., Hussain said, 60-70% of people with type 1 diabetes are able to access hybrid closed loop systems for insulin dosing. Within that population, he said, a number of issues appear, which aren't necessarily reflected in the results of clinical trials.
For example, CGM sensors lose signal at times, he said, which can lead to frequent gaps in blood sugar monitoring. An effect of this disconnect is that AID systems can't operate as intended until the problem is resolved.
Hussain also addressed the idea that one size does not fit all when using diabetes tech.
Skin issues like lipohypertrophy – where tissue in one spot under the skin becomes hard because of frequent injections – cause insulin to be absorbed in an unpredictable way. This can affect the assumptions an AID system makes, which can then lead to high blood sugar and ketosis. Delayed boluses, which can occur in those with gastroparesis, a condition of delayed stomach emptying, can lead to too much insulin being delivered.
"You end up having the system-generated insulin and your own bolus, causing issues," he said. "And adaptations in the basal insulin, which usually takes into consideration insulin needs over the last few days, isn't quick enough for rapid changes in insulin sensitivity."
These are just a few examples of the day-to-day issues that cause frustrations for people with diabetes and can lead to stress and burnout, Hussain said.
"One particular theme in people with extensive complications is psychological challenges and anxiety from tech alarms," he said. "And as someone with lived experience, I can tell you, there's a lot of nuisances that you have to put up with. And if you've already got a number of other conditions, the number of visits, economic issues, and psychological issues – it does add to your burden of using tech effectively."
Access is also an ongoing issue.
"There is a higher representation of lower socio-economic groups and from minority ethnic groups amongst people with complications," Hussain said. "How do we ensure we don't exclude those who can benefit from tech, but equally ensure that they are looked after?
Both clinicians voiced the same concern: People with advanced complications must be included in research studies to identify and address their needs, including the difficulty they face using technology as well as a lack of access.
The bottom line
Considering the pros, diabetes technology can significantly improve care for people who are experiencing chronic complications by increasing time in range and lowering A1C. Researchers also addressed some of the cons that technology can introduce, like risks for retinopathy if A1C quickly and significantly improves, and frustrations when tech fails.
While technology can reduce the burden of diabetes, presenters highlighted the need for modifying and adapting technology to help people manage advanced complications like vision loss.
Read more about diabetes technology and disabilities here:
- Living with Diabetes and Hearing Loss
- People With Vision and Hearing Loss Call for Better Access to Diabetes Tech
- New Tech and the Psychological Toll of Diabetes Management
Photo credits: iStock (top); EASD – European Association for the Study of Diabetes e.V (bottom).