Dispelling myths to overcome barriers around diabetes technology adoption

Automated insulin delivery systems (AID), usually consisting of a CGM and insulin pump, have revolutionized insulin delivery for people with diabetes. Yet why is it that adoption of these technologies remains low and most insulin-dependent people with type 1 diabetes do not achieve their glycemic targets?

Here are a few long-held beliefs that, as a pediatric endocrinologist, I have seen across a wide spectrum of clinical settings and have actively needed to train myself to dispel, if the evidence points otherwise.

1)????? It is not safe for people with poorly controlled diabetes to switch to technology; people with well-controlled diabetes are better candidates.

This sometimes stemmed from the notion that poor control had to be a result of poor compliance and individuals had to "prove" they took their diabetes seriously before qualifying for a CGM or pump. Many payers required evidence of an HbA1c in an “acceptable” range and/or proof of checking a fingerstick blood sugar 4 times daily to approve a pump or CGM.

Several AID trials have actually shown the most benefit (in terms of increased Time in Range-TIR and A1c reduction) in those participants with a higher A1c as opposed to an A1c at or slightly above target (which is not surprising!). This was found to be true in both children and adults accounting for all other variables.

2)????? Carbohydrate counting and "being good with numbers" is essential to utilizing the features of AID systems.

Living with diabetes (whether type 1 or type 2) comes with acquiring knowledge about nutrition, especially carbohydrates. However, advanced numeracy skills are not as crucial. It was shown that a basic understanding of carbs and knowledge about how many carbs were in one's plate of food (for a small, average or large serving) was enough to get to glycemic targets. With newer AID systems like the iLet, where meal announcements are made rather than inputting carbs, and with real-time learning and optimized BG control by its algorithms, this is evidence that lower numeracy skills should not be a reason to withhold AID systems\

3)????? Insulin pumps increase the risk of DKA, a feared complication of diabetes, especially type 1 diabetes.

This WAS true, to a certain extent in the past, when insulin pumps were not as sophisticated and safeguards against DKA were fewer. The underlying rationale was that people using multiple daily injections (MDI) were utilizing a long-acting insulin in addition to rapid-acting insulin. Even if they missed one or more doses of their rapid-acting insulin, the long-acting component would keep ketones at bay therefore avoiding DKA. In an insulin pump, only a rapid acting insulin is used, increasing the chance of ketone formation if there is pump malfunction that isn't corrected within a few hours.

Evidence shows, however, that people on pumps and CGMs actually have lower rates of DKA. The T1D Exchange found that participants using a pump had lower rates of DKA events than people using MDIs (2% vs. 4%;?P?=?0.002, adjusted for age, gender, race/ethnicity, diabetes duration, insurance status, CGM, blood glucose monitor [BGM], and A1c). Likewise, people using CGMs had fewer DKA events than participants not using CGMs (1% vs. 3%;?P?=?0.04 adjusted for the same variables)

4)????? Older people and minorities will have a harder time utilizing technology. This bias contributing to clinical inertia can sometimes relate to practical considerations such as language barriers, visual acuity, or reading literacy.

?It’s worth checking in at least a couple of times a year to see what new features address these barriers. Most CGMs have language support in English and Spanish. The Libre supports multiple different languages spoken in major parts of the world. Many insulin pumps now offer the ability to switch between several major languages as well. Font size and lighting can be adjusted on most screens for better visibility. Overall, these devices are also moving towards less text and more graphics to enable the interface to be as user-friendly as possible.

5)????? Relying on technology takes the control away from caregivers, especially parents of young children.

On the contrary, using diabetes technology allows even more oversight of blood sugar trends, dosing guidance and crucial alarms for families. Most CGMs and insulin pumps can transmit data wirelessly to parents and clinical teams. They have in-built alarms for impending low and high blood sugars, based on their algorithms, which provide extremely helpful guidance on how to adjust insulin dosing or modulate activity. Some insulin pumps provide remote bolus capabilities (within Bluetooth range), which makes dosing multiple times a day easier and less of a “process”. Data generated from pumps and CGMs in the form of a report provides invaluable information to care teams at or in-between appointments, leading to better clinical decision-making as well.