Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB Medcast. I'm Melanie Cole. And today, we're highlighting advances in diabetes technology. Joining me is Dr. Ananda Basu. He's a Professor in the Division of Endocrinology, Diabetes and Metabolism, and he's the Director of the UAB Diabetes Technology Program.

Dr. Basu, it's a pleasure to have you with us today. And before we get in to our topic, which is such an exciting topic and so many advances, can you just tell us a little bit-- you're new to UAB, please tell us a little bit about yourself and how you came to UAB Medicine.

Dr Ananda Basu: Thank you, Melanie. Thank you for inviting me. I'm glad to be here. So, I did my basic medical education and training in India, then spent about five or six years in the United Kingdom learning about diabetes. And then from there, in 1993, moved to Mayo Clinic in Rochester, Minnesota, where I did further training in endocrinology and became faculty at Mayo Clinic and was in Mayo Clinic for about 26 years before I moved to the University of Virginia and set up a diabetes technology program there in Charlottesville and then, was recruited here to UAB about six weeks ago as part of a strategic hiring initiative in diabetes. And I aim to replicate and improve upon what I did at Mayo Clinic where I also help set up a diabetes technology program, and then subsequently at UVA in Virginia and then now, here at UAB in Birmingham. And I'm glad to be here.

Melanie Cole, MS: Well, thank you so much for telling us that, and we're glad you're here as well. Now, how are you seeing recent advances in diabetes technology improve the lives of patients with diabetes? Tell us a little bit, as you're forming this program, how much does a healthcare provider rely on patient provided data when it comes to managing their condition. Tell us a little bit about what you're seeing going on in the field today.

Dr Ananda Basu: So, thank you for the question, Melanie. I think that's such an important question. Technology has really progressed in diabetes by leaps and bounds, even within the last decade with the advent of these continuous glucose monitors. I still remember, you know, years ago when I was in medical school in India and subsequently in the United Kingdom, that patients used to manage their diabetes using urine tests. And that is a far cry from now where patients have within their hands, literally, their glucose data every 5 to 10 to 15 minutes that are on real time. So really, continuous glucose monitoring has shifted the paradigm for diabetes care, especially for type 1 diabetes and also for patients with type 2 diabetes.

So, I would think that the vast majority of patients with diabetes can now avail of this technology wherever possible and available to monitor their diabetes and that would really help improve diabetes care throughout this nation and also around the world. And there have been several studies, research studies and clinical trials that have clearly shown the benefit of using this technology In patients with diabetes, both type 1 diabetes and type 2 diabetes. So really, continuous glucose monitoring technology has revolutionized diabetes care on this planet, all across the world.

Melanie Cole, MS: Well, it certainly can help with managing this condition, which as we know, has really turned into an epidemic and we're seeing kids coming up with type 2. So Dr. Basu, tell us some of the barriers or challenges. As you're starting programs and you've told us how many you've started, what are some of those major barriers that prevent widespread adoption of this kind of technology? Some of the challenges, because as I see it, patients and self-monitored blood glucose, sometimes maybe inconvenience or timely and regular feedback, data issues, technology, you know, if they're not so good with technology. What do you see as some of the barriers?

Dr Ananda Basu: That's probably the most important question regarding the adaptation of diabetes technology across this country, is that there are so many barriers starting at every level.

Let's start from the level of the provider. As an endocrinologist myself and a practicing endocrinologist, I am unpleasantly surprised sometimes by the number of my colleagues in endocrinology who do not know how to use and interpret readings from continuous glucose monitors. So clearly, there are barriers at the level of the provider itself, even within the subspecialty of endocrinology and diabetes.

Subsequently, you take into account also the barriers that are there amongst primary care providers within this country and within our community. So many primary care providers do not understand how to use and interpret the data from continuous glucose monitors. So clearly, a lot of education is needed both for endocrinologists within my subspecialty, as well as primary care providers, nurse practitioners that are out there in the community that manage patients with diabetes from day to day. And many education programs are needed. We have, myself, used educational programs and webcasts from grants from the American Diabetes Association and other areas and other NGOs that have helped disseminate this information amongst providers. So clearly, there are barriers within the providers.

Then, of course, there are barriers within the community, socioeconomic status, healthcare disparities that are major barriers for implementation of these state-of-the-art technologies to patients. And there have been many good research studies that have shown across this country that socioeconomic barriers and healthcare disparities have been tremendously impeding the growth and implementation of this technology in our patients. So certainly, Alabama is no stranger to this given the healthcare disparities that occur in minority communities within the state. And I hope to help improve that over the years by developing this diabetes technology program here at UAB.

Subsequently, also, there are the other barriers, the technological barriers. For example, as you mentioned, that many patients that live in the outreach areas and the rural areas of the state and this country do not have access to internet and cloud-based services. So again, those are barriers to developing and implementation and dissemination of this technology.

There are other practical barriers, including insurance coverage, although that is gradually improving over the years since many insurers including Medicare and Medicaid have realized the importance and the benefits of continuous glucose monitoring technology. So, they are getting more aware. But clearly, more work needs to be done in that area because these technologies are expensive for the patients who do not have insurance coverage. So, they cannot afford it, they will not use it. So certainly, you know, these are just some of the barriers that are currently present that impede the dissemination and use of this technology widespread across the country.

Melanie Cole, MS: So interesting. And Dr. Basu, as you were mentioning that even for other providers not really being familiar with insulin pump data and continuous glucose monitoring data, do you have the ability and indeed encourage that to download and share it? And as we're talking about technology and during the pandemic, we saw televisits. And especially for patients with diabetes, this was such an important aspect of managing their condition. And for patients in rural areas, it made that even easier. Are you finding that sharing this data remotely can make things like those televisits for rural patients more meaningful and that providers can understand the data that's coming in and use it so that it goes both ways? Is that shared decision-making?

Dr Ananda Basu: Absolutely. You've hit the nail on the head, Melanie. During the pandemic, one of the benefits was that using Zoom technologies, et cetera, we were able to reach our patients at their homes. They did not have to travel to the medical center to see us. So certainly, that was a huge benefit and that has really revolutionized telemedicine care in a chronic disease like diabetes. And that helps save a lot of money and time for the patients and they can access these technologies within their homes, wherever internet and cloud-based services are available, or they can go to their local clinic or local primary care center where such services would be available, and we can do expert consultation while they are there at the primary health center or the primary care clinic or with the primary doctors.

One of the barriers though that still continue to exist that we have tried to overcome is to directly download their CGM and pump data directly into the electronic medical records. We have made some strides and progresses in that area, but much more work needs to be done such that these data that are in the cloud, that can be uploaded into the cloud by the patient can directly and seamlessly transfer electronically directly into the medical records, whether it's Epic or Cerner or whatever system that the institution uses. That has been one of the barriers, but that is also improving over time, and I hope to do that while I'm here at UAB, to directly transport that data into the EMR without having to print it with a printer in black and white paper and then have the provider see it, because having it directly into the EMR saves time, and time is money. So, I think it's important that all of those aspects are smooth and seamless as we improve use of diabetes technology in our patients.

Melanie Cole, MS: And not only that, Dr. Basu, besides continuous glucose monitors and insulin pumps, there's so many technology devices available to patients for their own self-monitoring and management of their condition, free phone apps and activity tracking devices and nutrition apps. And if all of that could come into one place so that their physician can see how much exercise they're getting and how much exercise they're doing, that would really be so amazing.

Now, do you feel that there's an opportunity for the integration of artificial intelligence or machine learning to enhance the effectiveness and accuracy of this technology we're discussing?

Dr Ananda Basu: No question. In fact, when you talk about machine learning, you know, I've been involved over the last about 10 years doing clinical research into the artificial pancreas for patients with type 1 diabetes. And we did some early physiology studies to inform the next generation of the artificial pancreas. And at the University of Virginia, which is a leader in this particular area, we incorporated a lot of these, including machine learning, into the artificial pancreas algorithm so that, for example, you know, one of the things that we want to work on is that when a patient with type 1 diabetes, for example, is using the closed loop system, many of which are already approved within the United States by the FDA, is that, for example, we have GPS incorporated into the artificial pancreas system. And again, this is work in development. This is not available currently. That when a patient with type one diabetes, for example, goes to a burger shop, McDonald's or somewhere where patient is likely going to have high fat food, then that information can go into the artificial pancreas algorithm such that the insulin dosages can be perhaps dialed up while the patient has probably a relatively unhealthy meal, versus when a patient, say, goes into a local gymnasium or a Y, going to exercise, then that intelligence or that information can be dialed in to the artificial pancreas so that they can make accommodations or dial back on the insulin dosing while the patient is exercising.

So, the possibilities are infinite. There's no question about that, that a lot of information can be available through the internet and through these applications that you mentioned that can guide the patient and their provider to better manage their diabetes long term. Because let's face it, diabetes is representative of a chronic disorder, of a chronic disease, and diabetes is probably the only chronic disease that we have so much data from insulin pumps, which is almost minute to minute data from continuous glucose monitors, which gathers blood glucose levels every 3 to 5 to 15 minutes. So, diabetes is the star chronic disease that we have so much data from, day to day and minute to minute. And we should take advantage of that with help from our control engineers and the IT specialists so that we can integrate this data to help these patients with diabetes and also provide us help manage their diabetes better.

Melanie Cole, MS: It's so fascinating, your field, Dr. Basu. It really is, isn't it? It's incredible how fast it's moving. It's incredible the technology. And as you say, when we think of chronic diseases, this is one that we have so much information on minute to minute. And as we look to the future, what's your perspective on the future of this kind of technology for diabetes? How do you envision it evolving in the next five to 10 years and beyond? What do you see happening that you feel is really exciting?

Dr Ananda Basu: The current status is with the artificial pancreas, for example, for type 1 diabetes and insulin-taking patients and the future for type 2 diabetes. But that is a device, as you know, which these insulin pumps are getting smaller and smaller. There's no question about it. They are like little pagers and the continuous glucose sensors are also getting smaller and smaller and more user-friendly.

But really, I think, looking ahead into the future, there are various innovations that are currently being thought of, including a project in Europe which is called FORGETDIABETES, which basically involves ingestion of a pill that takes insulin into the intestine, and then there are gadgets that are placed within the abdomen that delivers this insulin into the portal system that is much more physiological than the insulin that is currently being used in the artificial pancreas that is present under the skin.

Because one of the things that we realize with the current technology in artificial pancreas system that are available here in the US, is that the insulin is delivered under the skin. And by the time this insulin gets to act on glucose metabolism, it takes some time. There is a physiological delay. While normally when a person secretes insulin, that is when a person does not have diabetes, insulin is secreted by the pancreas, which is present in the abdomen, that directly delivers the insulin into the venous system within your abdomen that goes to the liver where the main machinery of glucose metabolism occurs. So, there are efforts, especially in Europe, that hopefully will be available or will be researched here in the US, is to deliver the insulin directly into the abdomen through various gadgets and means. So, that is one advance.

The second advance that I think that will help in the future is to have nanotechnology available for delivery of insulin, again, directly into the abdomen. And perhaps looking further ahead, the use of genetic technology, the use of germ cells and Islet cell transplantation that would help not only treat but prevent diabetes in patients who may be predisposed to diabetes. So, the future of technology from where we are now may be entirely different, even 10 to 15 to 20 years from now as these state-of-the-art technology gets developed after clinical trials and research, appropriate safety research, feasibility research, so that even in some of our lifetimes, the management of diabetes will change drastically from what I remember when I used to do in medical school as a medical student, check patient's urine to measure their diabetes. Even in my lifetime, we have come a huge way and I'm sure in our children's and grandchildren's lifetime, the whole diabetes field will be revolutionized by the next generation of scientists and researchers.

Melanie Cole, MS: Well, I couldn't agree more. That was beautifully said, Dr. Basu. And thank you so much for joining us and sharing your incredible expertise for other providers today. And for more information, you can visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. For updates on the latest medical advancements, breakthroughs and research, follow us on your social channels. I'm Melanie Cole. Thanks so much for joining us today.