The Latest News in Diabetes Technology – More from ATTD 2021

By Matthew Garza, Eliza Skoler, Cherise Shockley, Frida Velcani, Julia Kenney, Arvind Sommi, Hanna Gutow, Katie Mahoney, and Albert Cai

From automated insulin delivery to therapeutic advances to glucose management during COVID-19, read our full coverage of one of the biggest international virtual diabetes conferences this year.

The diaTribe team brings you the most exciting and inspiring updates in diabetes technology from the 14th annual Advanced Technologies and Treatments in Diabetes (ATTD) international conference. After four days packed with real-world data, new results, and cutting-edge technology, here are our top highlights from the conference – and check out our breaking news coverage from day one.

Click to jump to a section:

• Real-world data from Control-IQ shows more Time in Range, better sleep, and improved quality of life
• RocketAP automated insulin delivery algorithm shows impressive detection of unannounced meals for better Time in Range
• CGM use shows major effect among people with type 2 diabetes on intermediate or long-acting insulin
• Omnipod DASH users benefit from major A1C reductions in first 90 days
• Barriers to diabetes technology in specific populations
• Advances in type 2 diabetes management
• T1D exchange database shows lower A1C, less DKA and hypoglycemia, and better COVID outcomes
• SWEET pediatric diabetes registry reveals long-term A1C trends and the impact of COVID-19
• How healthcare professionals can strengthen the diabetes online community

Real-world data from Control-IQ shows more Time in Range, better sleep, and improved quality of life

Dr. Steph Habib presented interim results from the ongoing real-world Control-IQ Observational (CLIO) Study. Control-IQ is an automated insulin delivery (AID) system that combines Tandem’s t:slim X2 pump, Dexcom’s G6 continuous glucose monitor (CGM), and an insulin adjustment algorithm; it launched in the US in January 2020. The study included data from 700 people with type 1 diabetes on Control-IQ (59% female, 87% White, median age of 39). At the start of the trial, 89% of participants were CGM users and 80% were pump users. After three months, participants:

• Had an average Time in Range (TIR) of 71% (that’s 17 hours per day in range).

• Spent only 1.6% of time with glucose levels below 70 mg/dL and 27% of time with glucose levels above 180 mg/dL – both were improvements over baseline.

These results are similar to the one-year real-world data published in April 2021.

The CLIO Study also shows significant improvements in participants’ quality of life after three months on Control-IQ. Participants reported greater satisfaction with their insulin delivery device and its impact on their diabetes management, as well as a significant reduction in the perceived negative impact of diabetes. Likewise, nearly all participants (96%) reported improved sleep quality after three months of Control-IQ use – about 55% of them reported good or very good sleep, up from about 20% at the start of the trial.

Dr. Marc Breton presented additional real-world data from more than 70,000 Control-IQ users showing that the algorithm helped improve sleep. When using the sleep activity function, people experienced:

• A 7% increase in TIR (that’s 100 minutes more spent in range each night).

• Less time in hyperglycemia (glucose levels above 180 mg/dL).

• Less variability in glucose levels overnight.

To learn more about the personal experience of using Control-IQ read Cherise Shockley’s “Considering Control-IQ? Why I Made the Switch.”

RocketAP automated insulin delivery algorithm shows impressive detection of unannounced meals for better Time in Range

A small but exciting study showed that a brand-new automated insulin delivery (AID) algorithm called RocketAP helped adolescents with type 1 diabetes spend more time in range after meals even when they didn’t take mealtime (bolus) insulin. RocketAP is similar to Control-IQ but with one major difference – a new system feature that can detect unannounced meals and quickly deliver bolus insulin to avoid post-meal high blood sugar levels (hyperglycemia).

Dr. Garcia-Tirado and his team at University of Virginia tested the RocketAP system in a small clinical trial of 18 adolescents with type 1 diabetes. Participants used Tandem insulin pumps and Dexcom G6 CGMs and were randomly assigned to either the RocketAP or Control-IQ algorithms. They used the systems for two days; on the first day all participants bloused insulin and ate identical meals. On the second day, the meals were repeated, but participants did not bolus for these meals. Participants then switched to the opposite system and repeated the process.

The results were impressive and could indicate the first steps toward a fully closed loop algorithm (an AID system that doesn’t require the user to announce or self-bolus any meals):

• Time in Range (TIR) during the post-dinner period (6 pm to midnight) for the unannounced meals was 83% for RocketAP compared to 53% for Control-IQ.

• On average, RocketAP was able to detect an unannounced meal about 10-15 minutes after the user began eating. In this small study, no meals were incorrectly identified and no accidental boluses were delivered.

• The two systems performed comparably when meals were announced and bolused for. The Rocket AP system reported 100% TIR  in the post-dinner period while Control-IQ reported 93% TIR.

• Overall TIR for RocketAP was 87% and overnight TIR was 99%. Overall TIR for the Control-IQ was 80% and overnight TIR was 92%.

CGM use shows major effect among people with type 2 diabetes on intermediate or long-acting insulin

In our day one coverage of ATTD we shared Dr. Tom Martens’ exciting presentation on the results from the MOBILE study, which looked at the effects of continuous glucose monitoring (CGM) in adults with type 2 diabetes on basal insulin. At the start of the trial, the 175 participants had an average A1C of 9.1%, were being treated mainly in a primary care setting, took one to two injections of basal insulin per day, and had never used a CGM before. Participants were randomly assigned to use either a Dexcom G6 CGM or a One Touch Verio Flex blood glucose meter (BGM) for eight months, meeting with healthcare professionals throughout this period both in person and virtually.

After eight months, those using the CGM:

• Spent on average 3.8 more hours per day in range, compared to those using the BGM (59% versus 43% TIR, respectively).

• Spent on average 3.6 fewer hours per day with glucose values above 250 mg/dL (11% compared to 27% in the BGM group).

• Reduced A1C by 1.1% on average, compared to a 0.6% reduction in the BGM group.

• Used the CGM frequently over the eight-month period and reported high satisfaction with the system.

Especially impressive about this trial was the appropriate enrollment of a diverse population – the majority of the participants were people of color and didn’t have a college degree or private health insurance. Given the prevalence of diabetes in these communities, the enrollment by this trial was particularly noteworthy.

"All in all, this represents a huge step forward and the entire group of investigators and staff should be commended. In my mind CGM is a must for all people on insulin, from basal insulin through MDI and insulin pumps, for people with type 1 and type 2 diabetes. Now we have to figure out how to use CGM even more effectively. And make sure all our patients with diabetes have access to the resources they need," said Dr. Anne Peters, Director of the USC Clinical Diabetes Programs.

A few days later, we received even more data from MOBILE: a sneak peek at the results from a six-month extension study. During this extension phase, half of the people from the CGM group continued to wear CGM for six more months while the other half went back to using a BGM. From the BGM group, 55 participants continued using BGM for the extension study. Preliminary results show that when the participants discontinued CGM use, their TIR decreased and their A1C increased – highlighting that the benefits of using a CGM disappear when the device is taken away.

• After four months, the group that discontinued CGM saw TIR fall from 62% at the end of the initial study to 50%. The group that continued using CGM maintained their TIR, and TIR even increased slightly at four months.

• At four months, the group that discontinued CGM saw their A1C rise from 7.9% at the end of the initial study to 8.2%. The groups that continued using CGM and BGM were able to maintain their A1C level (8.2% to 8.1% for CGM and 8.4% to 8.5% for BGM).

Omnipod DASH users benefit from major A1C reductions in first 90 days

Dr. Grazia Aleppo shared exciting real-world data from 3,436 Omnipod DASH users (both adults and children with type 1 diabetes). Omnipod DASH is an insulin patch pump and connected diabetes management system.

Users saw major reductions in A1C:

Of note, participants on MDI prior to starting Omnipod DASH saw greater A1C reductions than those who were previously using an insulin pump.

Click here to learn more about Omnipod DASH.

Barriers to diabetes technology in specific populations

Several short presentations discussed important research on the awareness and adoption of diabetes technology in specific groups of people with diabetes. Though the use of diabetes technology like CGMs, insulin pumps, and automated insulin delivery (AID) systems often has major benefits and can help people manage their diabetes with greater ease and success, it is important to remember that there are unique challenges to the use of diabetes technology in certain populations. Healthcare professionals should do their best to recognize and work with people with diabetes who may face additional challenges to accessing and adopting these tools.

Dr. Shana Mencher presented on the significant racial disparities in the adoption of diabetes technology evident among African American youth. To better understand this important health equity issue, researchers analyzed how African American youth with type 1 diabetes and their caregivers approach decisions about using diabetes technology to help understand why these disparities occur and how they can be addressed.

• Significant barriers to using diabetes technology included stigma, feelings of fear, and a mistrust of the medical community.

• Cultural and family traditions – such as culturally-specific diets or sports – can either facilitate or interfere with technology use.

• Participants in the study believe that more culturally tailored education, peer support, and follow-up from their healthcare team would make it easier to use diabetes technology.

Dr. Lilli Priesterroth presented on the benefits and barriers of using diabetes technology in people with type 1 diabetes and dysfunctional and disordered eating. Though research on this topic is limited, studies found that:

• Insulin pumps and automated insulin delivery systems (AID) are able to give people with type 1 diabetes more flexibility in their diet which could help improve dysfunctional and disordered eating.

• CGMs may help healthcare professionals identify patterns of dysfunctional and disordered eating (though currently CGMs are not used to diagnose or treat people with disordered eating).

Advances in type 2 diabetes management

Dr. Steven Nissen presented the latest clinical trial results on tirzepatide, a new glucose-lowering combination drug (a “dual GIP and GLP-1 agonist”) for people with type 2 diabetes. Tirzepatide combines two types of drugs into a once-weekly injectable medication. Dr. Nissen discussed several recent trials (SURPASS-1, SURPASS-2, SURPASS-3, and SURPASS-5) that investigated 5 mg, 10 mg, and 15 mg doses of tirzepatide over 40 or 52 weeks. Collectively, the results showed that tirzepatide reduced A1C by 1.8 to 2.5 percentage points and led to weight loss between 15 and 25 pounds. Though there were some side effects such as nausea and diarrhea, Dr. Nissen explained how slowly adjusting the dose could help reduce these adverse effects. While there is not enough data to confirm this, based on his clinical experience Dr. Nissen believes there is a high likelihood that tirzepatide also supports heart health.

On the technology front, Dr. Richard Bergenstal described the benefits of remote and connected care in type 2 diabetes management. He presented results from the MOBILE study, which compared CGM and BGM use among people with type 2 diabetes – read coverage of the exciting results above.

In addition to increasing the adoption of CGM, Dr. Bergenstal called for efforts to collect and store diabetes data in one centralized location. According to Dr. Bergenstal, only 71% of people with diabetes at the International Diabetes Center are reaching their A1C targets. He believes that one solution is to have people’s data automatically uploaded to their electronic health record and reported in a standardized way. The Ambulatory Glucose Profile (AGP) report, which helped standardize CGM reporting, is being widely used by people with diabetes and healthcare teams. Dr. Bergenstal concluded his presentation by describing the future of Artificial Intelligence (AI) in guiding food and therapeutic decision-making. By analyzing previous glucose data and trends, AI could potentially provide people with personalized food and treatment recommendations.

T1D Exchange database shows lower A1C, less DKA and hypoglycemia, and better COVID outcomes

Dr. Nudrat Noor from T1D Exchange presented encouraging real-world results from an analysis of 11,472 people with type 1 diabetes spread across eight different endocrinology clinics. Data showed that 48% of people were using real-time continuous glucose monitoring (CGM) while 52% were self-monitoring their blood glucose (SMBG). However, while 49% of white people with type 1 diabetes were using CGM, only 38% of Hispanics and 18% of non-Hispanic Black people were using CGM – highlighting key disparities in access to diabetes technology. Those on private insurance were also more likely to be using CGM (57% compared to 33% of people with type 1 diabetes on public insurance).

CGM use was associated with much better diabetes management. The data also seem to confirm findings from the COMISAIR study, which suggest that CGM drives the benefits of advanced technology in diabetes management.

• The average A1C of those using CGM was 8.1% compared to 8.7% for those using SMBG.

• 2% of people using CGM experienced diabetic ketoacidosis (DKA) incidents compared to 7% of those using SMBG.

• 8% of people using CGM experienced incidents of severe hypoglycemia compared to 10% of those using SMBG.

• CGM users were twice as likely to be using an insulin pump than those using SMBG (68% of those on CGM versus 32% using SMBG). For those on SMBG with an insulin pump, average A1C was 8.3%

In related news, Dr. Osagie Ebekozien presented an analysis of 794 people with type 1 diabetes in the T1D Exchange COVID-19 registry. Of the group, 63% were using a CGM and 47% were using an insulin pump. The average A1C of those using a CGM was 7.9% (compared to 9.5% for those not using a CGM) and for those using an insulin pump, it was 7.8% (compared to 9.1% for those who were not). The majority of individuals using these devices were privately insured (67% of CGM users and 72% of pump users).

The analysis revealed drastic differences in COVID-19 outcomes between those using diabetes technology and those who were not.

• Among people with type 1 diabetes who tested positive for COVID-19, 10% of CGM users ended up in the hospital or ICU compared to 42% of those not using CGM.

• While 10% of insulin pump users who tested positive for COVID-19 ended up in the hospital or ICU, that rate increased to 33% in the non-insulin pump user population.

Concerning racial disparities were also evident. Non-Hispanic Black non-pump users were more likely to be hospitalized or admitted to the ICU (27%) than their pump-using counterparts (3%). Likewise, Hispanic non-pump users were also more likely to be hospitalized or admitted to the ICU (20%) than Hispanic pump users (3%).

SWEET pediatric diabetes registry reveals long-term A1C trends and the impact of COVID-19

Prof. Thomas Danne presented ten years of data from the SWEET project to illuminate new understandings in pediatric diabetes. The data were collected from 2008 to 2018 and included 13,654 youth with type 1 diabetes.

• A1C levels declined for all age cohorts. This may be explained by greater use of insulin pumps and continuous glucose monitors (CGM) among study participants. Prof. Danne supported this theory by presenting a recent publication in Diabetes Care that found a strong correlation between use of a pump or CGM with lower A1C levels.

  • While glycemic targets vary for children – the ADA recommends an A1C below 7.5% and ISPAD guidelines suggest a target below 7% – the study found that even lower A1C targets were associated with better glucose management.

• In 2020, the median A1C for SWEET study participants was 7.7% – much lower than the average of 9% among youth with type 1 diabetes in the US. The size of the clinic was not associated with A1C outcomes.

• CGM use increased among SWEET study participants during the first wave of COVID-19 in countries with higher COVID mortality. This likely occurred due to a need for remote data monitoring during the pandemic. However, similar increases were not observed for insulin pump use.

How healthcare professionals can strengthen the diabetes online community

The diabetes online community (DOC) started as a place where people with diabetes could communicate with one another. As the DOC has grown over the last 30 years, healthcare professionals and industry leaders have also found ways to connect with others in the diabetes space. Companies create community forums to build awareness of products, while researchers share data and findings with the world. At an engaging session this year at ATTD, several leaders in diabetes shared insights on social media support, building community, and the role of healthcare professionals in the DOC:

• People with diabetes spend more time managing diabetes on their own than with their healthcare team, which is why peer support through social media can be so helpful. Dr. Partha Kar explained that, thanks to social media, clinicians can have a front-row seat to a sea of patient voices. Healthcare professionals can also serve as a source of information and a lighthouse in this sea of DOC voices. 

• COVID taught us the importance and power of connecting via technology. diaTribe founder Kelly Close urged healthcare professionals to consider participating in social media and encouraged people with diabetes to connect online or in person. Since we have the tools, it’s crucial to provide people with support for navigating their diabetes so that they don’t have to go at it alone.

• There are few diabetes online communities focused specifically on type 2 diabetes information and emotional support. Simon O'Neill (Diabetes UK) pointed out that many people with type 2 diabetes are treated by a primary care physician (rather than an endocrinologist or another diabetes-focused healthcare professional) and don’t necessarily receive the diabetes management support they may need. As online forums grow for this population, it’s essential to answer questions without judgement or contributing to the stigma that surrounds diabetes.