Scott Webb (Host): This is Pediatric Insights, Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. I'm your host, Scott Webb, and today we'll discuss some exciting new technologies that help control Type 1 and Type 2 diabetes. With us today is Dr. Huay-Lin Lo, Pediatric Endocrinologist at Children's Health and Assistant Professor at UT Southwestern. Doctor, thanks for joining me.

Huay-Lin Lo, MD: Thank you for having me today.

Host: Yeah, it's nice to have you here and nice to learn some more about diabetes tech, if you will, today. And I know a recent article published by the New England Journal of Medicine discusses state of the art digital technology for diabetes. Maybe you could tell us about this technology and how it helps control Type 1 and Type 2 diabetes.

Huay-Lin Lo, MD: Starting with the basics of managing diabetes, obviously, there's a need to monitor blood glucose levels, as well as for all Type 1 diabetes patients and many Type 2 diabetes patients, a need to regulate and control how much insulin is administered.

And there's been lots of progress both in our ability to gather blood glucose data, as well as our ability to give insulin through devices, as well as in recent years, the ability to automatically make adjustments in how much insulin is being administered.

Host: Yeah.

Huay-Lin Lo, MD: So, in the old days, actually, in the really old days, we didn't even have any blood tests. It was just testing sugar levels in the urine, which is obviously, you know, grossly inaccurate and not ideal. Eventually, blood glucometers were developed, which involved using a small needle to poke your finger to get a drop of blood, and then you hold the blood against a test strip, and which goes into the blood glucose meter and then gives you a blood glucose value.

The more advanced, more recent developments are what we call continuous glucose monitors. These devices are actually worn continuously, hence the word continuous in the name, on the body. And the device doesn't exactly measure the blood glucose, it's actually measuring the glucose value in the interstitial fluid, which you can think of as just the kind of the fluid that's around your cells.

So it's not exactly the same as the blood glucose, but in most situations is pretty close. There can be some variability, particularly in times if your blood glucose level is changing rapidly, like if you just ate a big meal, or if there was any sort of, you know, cause for a rapid change, but in general, the CGM devices give you much, much more information than just a single blood glucose value. Because if you imagine, you know, on average, or I would say at a minimum, we hope that our patients with Type 1 diabetes are checking their blood glucose values at least four times a day. We start with a real breakfast, lunch, dinner, and at bedtime.

So that's four readings in a day, but you can think of it as well over a 24 hour period, that's actually not very much information. Again, it's only, you know, four snapshots at four specific times of day.

Host: Right.

Huay-Lin Lo, MD: With the continuous glucose monitors, because they're worn continuously, it actually checks the glucose levels in the interstitial fluid every 5 minutes and provides you a continuous reading.

So you can see, not just where your sugar is at this specific point in time, but also what it's been doing over the past several hours, and can also provide a little bit of prediction for what direction the blood sugar is heading towards, meaning it can tell you has it been fairly stable over the past you know, 30 to 60 minutes?

Is it dropping rapidly or is it increasing rapidly? I think the big benefit of that is it allows patients to oftentimes be a little bit more proactive with trying to manage their diabetes, as opposed to reactive, meaning if you don't have a CGM, let's say you have a low blood sugar; you know, there are some typical symptoms that develop with low blood sugars. People often become a little bit shaky, a little sweaty. You might feel a little kind of fuzzy and confused because your brain's not getting enough glucose, and then they would go get their meter, they check, say, oh my gosh, my sugar's low, and then go, you know, drink some juice or get some sugar into their bodies.

With the CGMs, because it's giving you continuous data, you can say, before my sugar gets to the point where I'm actually low enough to feel it, it can tell me, hey, while my sugar is still normal, but if I'm going down rapidly, I can proactively drink to get some carbs in my body before my sugar gets to the point where I feel the low.

And same thing for the highs, too. Before getting to the point where you, feel like you're having a high blood sugar, if it tells you, hey, you're going up really quickly, maybe we can get some insulin in you before you get to the point where you don't feel well. So I think that is definitely something that even without the other devices, the CGMs just provide an enormous amount of additional blood glucose data, which also makes as physicians, our ability to provide helpful advice and see the patterns of what their blood sugar levels are doing.

It makes us much more able to give useful advice in how, what sort of changes we might make to either your medications or diet plans or any other factors that we think could be causing you to have sugars out of the range where we want them to be.

Host: I wanted to just jump in here. I want to know, you know, specifically at Children's Health, how are you using this technology to inform patient treatments?

Huay-Lin Lo, MD: We really, really have made pushes and attempts to get all of our patients on continuous glucose monitors. There of course, are always various barriers, sometimes from the patient end, sometimes from a you know, cost and insurance standpoint. Some people just don't like wearing an additional thing on their body, even though it's not very big, and it's, over the years, each generation has gotten smaller and smaller and slightly more accurate, but there definitely are people who just I don't want to wear this thing on my body.

 You do have to deal with, if you're an athlete, or if you're getting sweaty a lot, or if you bang it against something, you know, that can be uncomfortable. Um, some people really just don't want to wear it, which that's a little harder to just, you know, hopefully with convincing and talking about the pros and the cons, you know, we hope that they'll agree to at least try it.

Other people have tried it and either sometimes there can be occasional issues with accuracy or some people just feel like it falls off too early and the convenience or inconvenience of that outweighs the benefits of it. And then of course, there are always people where depending on what insurance they have, or even just if it is covered, there still can be additional costs related to getting the supplies, those kinds of things are potential barriers.

But really our division has made it a bit of a focal point to try and at least make sure that every patient who wants or is interested in these devices and technology has the chance to get them whenever possible. Both the CGMs, the continuous glucose monitors, and insulin pumps that I haven't talked about yet.

Host: Yeah. Yeah. I was going to get to sort of thinking about the ease of use. So whichever ones, whether we're talking about the, the CGMs or the pumps, specifically, is there a learning curve for patients and their families?

Huay-Lin Lo, MD: Yes, yes, there definitely is. I would say probably more so for the pumps. Because those are giving you insulin, so a little bit more actively doing things, as opposed to the CGMs, which are just gathering data, if you will, you know, it doesn't give you any treatment. But, all of them are, do require, a few downloading a few apps and getting or some additional devices to use with the like a remote control or a receiver that youuse with the either the CGM or the pump. But we also have, here at Children's, we have established processes for helping families both figure out what they want and then once they know what they want, teaching them how to use those things.

The CGM devices, again, generally simpler is, just if you download an app and kind of go through the steps, it's fairly self explanatory. I would say the learning curve for that is relatively minimal for most families. The pumps are definitely more complicated and we have, multiple classes and sort of steps that we have before transitioning a family towards using that device and doing our best to make sure they know how to use it, they feel comfortable using it, and definitely don't want them to just blindly, you know, put on a device and not have any clue what it's actually doing for them.

Host: Right. Send them out the door, you know, good luck. Right. Yeah. Yeah. You mentioned some of the barriers or maybe that some folks, it keeps falling off or they just don't want to wear things, even though the wearables is such a, you know, a great advancement, especially when it comes to diabetes; but you also mentioned insurance.

Now let's talk about that just a little bit anyway. What are the barriers with insurance? It would seem to me that, you know, this is life saving technology. Sure. We're happy to pay for everything, but maybe not. So from your perspective in dealing with patients and families, what are some of the barriers with insurance?

Huay-Lin Lo, MD: Yeah, in a perfect world, yes, everything that we think we hope would be covered gets covered 100%. That would be my ideal scenario, but of course that's not always how it is. But generally speaking, you know, a lot of the insurance companies will cover devices and we spend, I don't know how many, in a single day I sign, you know, dozens of authorizations and saying things, saying, yes, this patient has diabetes. This is why they need the device. Please cover the device. So, you know, our nurses work very hard to make sure that as infrequently as possible, that that's not a barrier towards people getting the devices and care that we think would really benefit them. But they're definitely, even with insurance, there are still situations where you may not be able to afford the additional kind of ancillary supplies that come with using it because it's not just the one time you buy it and then you have it and you're done. So, you know, for both the CGMs and both the pumps, you do have to change them every two to three days, you have to put a new pump site, not a brand new pump, but you know, the place where it attaches to the body needs to be changed every two to three days.

So you're having to buy a 15, roughly of those sites every month, if you're changing it every 2 3 days. The CGM has to be changed every 10 to 14 days, depending on which one you're using. So there's a couple, 2 to 3 of those a month that you'd have to buy. You, oftentimes, additional supplies, like I talked about is, you know, if it's falling off a lot, we do have some tips to try to help with that.

There's different kind of adhesives and things you can possibly wrap around the device to help it stick on the body. But again, all of these things can add up over time in terms of additional costs and additional barriers. So I think in general, we of course do our very best to make sure that anyone who wants it can be on it.

But, depending on other factors that are sometimes not in our control; you know, cost is definitely still a barrier of course, to varying degrees for different people. And there are also times where we feel like a person should be on a pump and it's still not covered. And then insurance companies also uh, often have rules, but you also can't keep changing devices frequently either. But I think for the most part, Type 1 diabetes is usually pretty good at getting covered. Type 2 can be a little trickier at times, partially because, as you may know, the treatment for Type 2 is much broader. Not everyone takes insulin.

Some people just take oral medications. Other people, if they exercise, lose weight, may come off medications entirely. So that can be a little trickier than Type 1, but because Type 1 is a condition where you have to take insulin, there's no alternative to that. You know, like there's less pushback from insurance, but still can be other barriers.

Host: Yeah, it could be some, sure. I'm wondering from your perspective, you know, as a physician, there at Children's Health, talk about these digital advancements and how they've impacted you and your clinical practice. And what would be some takeaways that you'd want to share with other physicians?

Huay-Lin Lo, MD: Because a lot of the technology is still relatively new, there's a lot of movement and there has been a lot of thinking in the background of how can we better utilize the enormous amount of data that comes from having these technologies to provide better care and better management of our patients who have diabetes.

We have a few things that we're trying to work on without getting too much into the details, but, you know, in a general sense, if you think of it as, like I said, in a perfect world, I wish all of our patients could be on these devices and at the very least have a CGM so that we could see what their blood glucose values are at any given point.

And, they have ways of sharing that data with us through, you know, various websites and apps related to the device itself. And I think in a ideal scenario, is again, we would have ways of trying to sift through that data in a reasonably time efficient and cost efficient manner to identify, especially, I think most urgently, is the kids or patients who are struggling with their diabetes.

You know, if you look at all of our entire patient population, the kids who struggle the most oftentimes make up the highest percentage of patients who are admitted for their diabetes or get quite sick from it in what we call diabetic ketoacidosis. We have, you know, a lot of patients who never get admitted to the hospital again after their initial diagnosis.

But then on the other end of the spectrum, we do have some kids who get admitted multiple times a year, you know, maybe even every one to two months. Because, for various reasons, their blood sugars are much higher than we'd like them to be at home. And, obviously, we would want to focus more of our attention on the patients who are struggling, as opposed to the patients who do a great job of managing their diabetes at home, which we have plenty of as well.

But, we are moving and looking into ways and have some kind of plans trying to get established about how could we like I said, in a time efficient and cost efficient manner of really focusing on the patients who struggle, if we can get them to wear a CGM, we have lots of staff, our educators, our nurses, could we try and reach out sooner?

Could we have a little bit more contact with them or their families, whether it's through emails or phone calls or the MyChart system, messaging system, which, I would hope would reduce the frequency that they get admitted for their diabetes and even more so hope that it would also improve their glycemic control with their diabetes.

Host: Right.

Huay-Lin Lo, MD: And I think the struggle is just that, like I said, if you imagine, it's a, an enormous mountain of data, if you're saying, you know, the thousands of patients we have with Type 1, every single one of them, if every single one had a CGM rating of looking at hundreds of glucose values throughout the day, it's impossible unless you have a team of, you know, thousands of people, each one looking at one kid, to track every single person.

Scott Webb (Host): Yeah. It

Host: doesn't seem realistic. Thousands of folks working there, you know, scanning their screens, you know, looking for anomalies or whatever, right.

Huay-Lin Lo, MD: Right. So, but, like I said, in a perfect world, we could identify, particularly, again, focusing on the kids who are struggling the most, to help with their control and provide more support because they're the ones who need it more as opposed to the ones who are already doing a great job taking care of their diabetes at home.

Host: Yeah. I was thinking back to that New England Journal of Medicine piece that I read and wondering, were there any other findings? You know, we're talking about the pumps, we're talking about the CGMs and how far technology has come. Anything else in there, that you want to share with folks?

Huay-Lin Lo, MD: I think if you think about sort of the next possible step.

Host: Yeah, like what's on the horizon. What's coming, right?

Huay-Lin Lo, MD: I'm not gonna, don't quote me on any sort of actual timelines or timeframes,

Host: Sure.

Huay-Lin Lo, MD: One of the newest pumps that just came out is actually called the ILET, uh, I-L-E-T, come from, Beta Bionics. Without delving into the specifics, you know, all the pumps do have slightly different details in how they work and they have different algorithms, but it's another example of sort of the newest generation of pumps which have what we call a closed loop technology. This is probably just within the past not even 10 years, but the idea is if you have a pump that gives you insulin, you have the CGM that monitors your glucose; well, it would be fantastic if they could communicate with each other and then the pump could automatically make adjustments to how much insulin it's giving you, depending on what the CGM reading is predicting your sugar to be.

So if it's saying you're going to go high, it can ramp up how much insulin it gives. If your sugar is dropping, it can go down on how much insulin it gives. That's a simplified version. And again, everything has specific details that are a little different, but that's the general principle. With the ILET, it actually was originally, I think, the long term plan is the hopes to have dual hormone therapy, meaning all the pumps have insulin right now, but as you know, insulin lowers your blood sugar.

There are several hormones that help raise your blood sugar if your sugar gets too low, but sort of the one that's commonly thought of as the opposite of insulin, if you will, is glucagon. It's main job is to increase blood sugar, increase kind of secretion of glucose from the liver and sugar stores there and to kind of steal a metaphor from Dr. Adhikari; he kind of equates it to as okay, if we have insulin which lowers your blood sugar But knowing that you know we don't want to give too much because low blood sugars can also cause problems. Like I was saying is shakiness and sweaty and you're not getting enough sugar to your brain. In severe, severe cases can even cause seizures, possibly even death and coma, which obviously we try to avoid completely.

But it unfortunately does happen, and if you imagine insulin by itself, are somewhat limited by how aggressive we can be with how much we give because we don't always have a way of, you know, immediately fixing the low blood sugar, sorry. We do give families kind of emergency glucagons, which used to primarily be available as a shot, now there's actually a nasal spray, which is much more convenient.

But, if your child is having an emergent low blood sugar where they're unconscious, you can go ahead and give them that, which hopefully will bring their sugars back up. But imagine if you had a pump that had both insulin and glucagon. Dr. Adhikari's metaphor was, it's like having a car that only has a gas pedal. So you can go faster, but the only way to slow down is to release the gas pedal, but you still take some time to actually stop. If you add the glucagon, it's like adding a brake where we could be more aggressive with the insulin, because we have the capability of giving the glucagon in case we overshoot and now the sugar's going low. I think one of the hurdles that had to be overcome was finding a form of glucagon that could be kind of stable in a liquid form because you have to be able to keep it in the pump and so that it's ready to be given.

You know, the old school glucagon shots that we had for patients was something where it was a kind of a medicine tablet and you had to mix it in with saline solution as soon as you're about to use like you didn't sit there in a liquid form which I think recently they have developed some more kind of long term stable liquid glucagons and I believe that that was the sort of future vision for the ILET is having both insulin and glucagon as a dual hormone therapy.

So I would say the closed loop pumps over the past decade was sort of the most recent kind of big step forward. And the glucagon could be the next kind of big step forward after that.

Host: Yeah, you see how in that analogy, you know, even for lay people like me, you know, well, you have a gas pedal and a brake pedal, right? And you really see the benefits of having both, right?

Huay-Lin Lo, MD: right, obviously for anything that's new, there's lots of trials and it takes, you know, FDA approval and time, so it's not gonna come out next month or anything. I would say probably maybe not even in the next five years, but it's something that I think, you know, is more realistic and is looming on the horizon more so than, you know, five or ten years ago.

Host: Yeah, certainly, uh, very encouraging. And, this has been really informational and educational today. Always great to learn more about new tech and what's on the horizon and, you know, not holding you to any timeline, but just for folks that are being diagnosed now or been diagnosed recently, the thought of some of this technology coming through and coming to pass and you getting approval and all of that is certainly exciting.

Just give me a chance here as we wrap up and final thoughts and takeaways.

Huay-Lin Lo, MD: Yeah, I think one thing I will say is, a very common or frequent question we sometimes will get is, people do ask about, is when is the cure, right? Uh, and it's almost, it's

Host: Yeah.

Huay-Lin Lo, MD: It's almost a running joke in the diabetes community that people are like, oh, you know, they've been saying it's five years away, five years away for the past 50 years.

And when I get asked that, I often kind of counter with a question of okay well what do you think what do you define as a quote unquote cure? If you're saying you know you take a shot or one treatment and then the Type 1 diabetes or Type 2 diabetes is just completely gone; I'm skeptical to think that's ever going to be realistically on the horizon, like, I'm skeptical that's ever going to really happen that simply.

You know, even a hundred years ago, before the invention of insulin, there was no even treatment and they probably thought of insulin as the quote unquote cure at the time.

Host: Right.

Huay-Lin Lo, MD: And I try to reflect on, you know, looking over the years, the medicines have gotten significantly better in terms of their profiles and ease of use. We have long acting insulins, we have ultra rapid short acting insulins. The medicines we have are better, the technology is better. And things are only continuing to improve, but it takes a lot of time, and I try to focus on what we can do now. You know, the ultimate goal of all of these things is to make life easier and better for our patients who do have diabetes.

And, some of the patients who have been doing their own research may also ask about, you know, some higher level things like stem cell transplants and those kind of things, which I am by no means an expert and I really don't have time to delve into, but, you know, they pose their own sorts of problems with immunoregulation and immune suppression and those kinds of things.

But there are lots of different avenues for research, and, you know, every once in a while an article will pop up of oh, like this person was quote unquote cured of their diabetes, and I do think taking those with a little bit of a grain of salt, but also recognizing that there are things being worked on and looked into is hopeful and encouraging that at some point in the future there may be other options, but we're still slowly moving towards that.

Host: Yeah. I mean, it's one of those things, as you say, you know, an actual cure for diabetes, doesn't seem possible or realistic right now, but the way science and technology and medicine and all these brilliant minds and research and the way things are trending in so many areas of medicine, you never know, right?

Huay-Lin Lo, MD: Right, right. I think it's good to remain optimistic and hopeful, but also grounded in realism that you know, while we have made lots of advancements and strides, there's still a lot of work to be done.

Host: Definitely. Well, I appreciate your time today. You know, anytime we're talking about tech, especially with diabetes, it feels like we could probably have you back in three months or six months and talk about, you know, the latest advancements and things like that. And we'll probably do that. But for now, thanks so much.

Huay-Lin Lo, MD: No, you're very welcome. Thank you again for having me.

Host: That's Dr. Huay-Lin Lo, Pediatric Endocrinologist at Children's Health and Assistant Professor at UT Southwestern. And to learn more, visit childrens.com/endocrinology. And if you found this podcast helpful, please rate, review, and share this episode, and please follow Children's Health on your social channels.

I'm Scott Webb, and thanks for listening to this episode of Pediatric Insights, Advances, and Innovations with Children's Health, where we explore the latest in pediatric care and research.