As Diabetes Technology Use Increases, A1C Levels Drop for Patients With Type 1 Diabetes
In this video, Viral Shah, MD, talks about his research team's study that analyzed the association between diabetes technology use and mean clinic hemoglobin A1C among adults with type 1 diabetes.
Additional Resource: Karakus KE, Akturk HK, Alonso GT, Snell-Bergeon JK, Shah VN. Association Between Diabetes Technology Use and Glycemic Outcomes in Adults With Type 1 Diabetes Over a Decade. Diabetes Care. 2023;46(9):1646-1651. doi:10.2337/dc23-0495
TRANSCRIPTION:
Viral Shah, MD: My name is Viral Shah. I’m an Associate Professor and Physician Scientist at the Barbara Davis Center For Diabetes, which is a part of the University of Colorado here in Denver, Colorado.
Consultant360: What prompted this study?
Dr Shah: The background is we know that there are so many randomized control trials and single arm, clinical trials suggesting that the automated insulin delivery system improves glycemic outcomes in people with type 1 diabetes. Now, we also know that from a past learning that, clinical trials are a completely separate world, and do they really translate in real life? And also, what if we are offering the automated insulin delivery system or CGM to most people with type 1 diabetes - would that change the overall outcome at our clinic, which is kind of looking at it as a population health outcome rather than just the individual outcome? So that's why we did this study.
Consultant360: How does this study fill a current gap in our knowledge about diabetes technology and type 1 diabetes?
Dr Shah: Yeah. To my knowledge, no one has looked at the last decade, of the technology used. Again, it's only a single center study, so take that with a little bit of a grain of salt, but at least, it suggests that this concept can be replicated to the others If they do the same model. So in our study, if you think about 2014 where we did not have a lot of technologies available. Technology use was defined as either the use of a CGM or the CGM and pump therapy, which is an automated insulin delivery system. We did not count, let's say, for example, just the pump user without CGM as a technology users because we know that without CGM, the pump therapy is not something that is best. So in 2014, overall in our clinic, which is about roughly 1800 individuals, for adults with type 1 diabetes, 27% were using CGM. And 2014, we didn't have any AID system at the time because Medtronic's 670 g was the 1st AID system got approved in 2016. So all these users were CGM users. And at the time, our clinic A1C, mean A1C, was 7.7% And about 30% of individuals were meeting the goal, which is less than 7%.
Now if you fast forward 2021, where we have a lot of options available. The technology use increased to 83%. And that leads to a change in A1C to 7.5%. And again, that's a clinic A1C. And if you look at the people who met that glycemic goal of less than 7%, it improved from that 33% to 42% during that time. So there was a significant improvement In overall glycemic outcomes in the entire clinic. So the bottom line is that, I think this technology helps people, to do better.
Consultant360: Why did your study only look at patients with Type 1 diabetes?
Dr Shah: That's a great question. And so there are two main reasons for that. Number 1 is that the Barbara Davis Center For Diabetes is predominantly a Type 1 diabetes center. And number 2 is that, unfortunately, none of the AID systems are currently approved in people with type 2 diabetes. Also, the CGM approval in type 2 diabetes is only limited to the people who are on multiple daily injections or not meeting the goal on two injections or so. And so it's a very limited population that we have an approval for, and so the utilization has not been as much as in patients with Type 1 diabetes.
Consultant360: If this were to be a multicenter study from different regions, do you think the study results would be dramatically different or in line with your study results?
Dr Shah: Yeah. Great question. And, not so now hypothesis, but I will tell you that the T1D Exchange Quality Improvement Collaborative just published a paper, which showed that 38,000 individuals with type 1 diabetes in this QI collaborative. (Editor’s note: the total number of patients in the Collaborative exceeded 48,000 patients). I may be wrong with a couple of numbers here, but the overall thing was they showed the same improvement across the lifespan, as we noticed here. Now think about that. A lot of people think that 7.7% to 7.5% is nothing. But this is not an individual change in A1C. This is a change in the entire population. So, when you look at the population mean, this 0.2% is huge. And that's what this T1D Exchange Quality Improvement Collaborative paper that just got published showed recently showed. So I think it gives me a confidence to say that, this finding should be replicable across the US or different clinics.
Consultant360: After the results of your study, what gaps in diabetes technology remain?
Dr Shah: Yeah. No. That's a great question, and thanks for asking that, question again. So If you again dive deep into the manuscript where we looked into how many people, with type one diabetes would be able to achieve an AIC of less than 7% if they are not using any technology versus CGM versus AID. An AID is kind of a like the final product or the best product that's available in a market, because it's an automation of insulin delivery based on sensor glucose, in the management of type one. And 51% of our population, were able to achieve less than 7%, despite that they were using AID. Right? So, if you ask me, this class is half full and half empty, I'm proud that, yes, it's half full. But then now next question is that why is that half empty? And so that's the thing is that why someone is able to achieve the outcome with AID, but someone is not. So, one of the factors that are kind of hindering, you know, good glycemic outcomes on AID use, and how can we make it better?
Consultant360: What are you planning on working on in the future regarding diabetes technology and type 1 diabetes?
Dr Shah: Yeah. Great question again. And I think, there are a couple of areas that we are working on. So number 1 is that we didn't show the data here, but if you think about the overall outlook, or again, look at the T1D Exchange Quality Improvement Collaborative, you know, the study data, you find that despite offering these technologies to people with type 1 diabetes, the outcomes are much better in whites than non-Whites, right? So, let's say, for example, the test supposed to work the way that it's supposed to work, but then why are the outcomes are different? So that's one area of research, that some of my team members are working on is trying to understand why non-White population and, specifically, Black and Latino population are somehow not able to utilize the full benefits of this system. Is it something related to culture? Is it related to a fear of using this technology? Something else? I don't know. But that's the one area.
The second is that we know that the prevalence of overweight and obesity is increasing in type 1 diabetes. That insulin resistance because of that overweight, leads to requiring more insulin, making it difficult to to achieve that A1C of less than 7%. And also most of the AID system does a really good job at nighttime, but daytime, it's not the best, right? So, it's because it's a unihormonal system. It's only insulin. And your physiology, your pancreas, produces a lot of other hormones beyond just the insulin.
So we have another trial going on right now that is funded by JDRF. It's a double-blind, randomized controlled trial where we are looking at the effect of GLP one analogs in people with the GLP System and not able to achieve the, A1C of less than 7%. So whether that adding a GLP as an adjunct therapy would probably improve this outcome further. So that's the second area that we are working on. Of course, there are a lot of other researchers are working a lot of different dimensions and area and trying to see how we improve those outcomes.
Consultant360: What is the take home message from your study?
Dr Shah: I think I want to just have one message here, that in the past we used to have a lot of criteria about when should we start insulin pump? You should be compliant. Using this word “compliant”, which now supposed to be more of an “adherence”, but anyway, there are criteria and guidelines. You must be checking four times a day. Your A1C must be this to start on a pump. And I just feel like those are old criteria that are not applicable for AIDs. So, my message to whoever is hearing this is that technology helps, and I think it's a time to offer technologies to more people with type 1 diabetes. And then off label, I'm sure a lot of people with type 2 diabetes will also help as well. So I think, providers and the supporting staff need to be more tech friendly and helping over people to achieve better outcomes.