The threat of hypoglycemia remains one of the most dangerous facts of life with diabetes, both as an immediate and potentially fatal hazard and as a subtle influence that pushes patients towards the relative safety of hyperglycemia. In recent years there has been a great proliferation of new diabetes technology, notably continuous glucose monitors (CGMs) that sound low blood sugar alarms and closed loop insulin delivery systems that can automatically reduce or suspend insulin in anticipation of hypoglycemic events.
But are these new technologies enough to prevent hypoglycemia all by themselves? Or is education still essential? On the first day of the American Diabetes Association’s 80th Scientific Sessions, two experts argued each side of this coin.
Arguing for the importance of education, Dr. Emma Wilmot referred to several studies showing that education alone is able to reduce the incidence of severe hypos and improve hypo awareness, by percentages that were at least as impressive as those claimed by advocates of CGM use. Dr. Wilmot is a diabetologist and educator based in the United Kingdom.
Dr. Wilmot also pointed to a study that showed that about a quarter of CGM users, despite those useful low blood sugar alarms, had suffered a severe hypoglycemic event in the previous 6 months.
Dr Richard Bergenstal of the International Diabetes Center in Minneapolis insisted that knowledge was “not enough,” and that educational efforts to avoid hypos too often give short shrift to the issue of hyperglycemia (high blood sugar).
Dr. Bergenstal drew attention to what he called the “ripple effects” of hypoglycemia: that the fear of hypos can cause people with diabetes to loosen up their glycemic control and as a result to suffer more complications.
“After a couple of decades making steady improvement in our A1c’s across the United States, now the average A1c is starting to go up… I think this is a direct consequence of this ripple effect of hypoglycemia making us lighten up our goals.”
Dr. Bergenstal referred to a 2019 opinion (PDF) authored by Dr. Edward Gregg of the CDC that pointed to a recent “resurgence” in severe diabetic complications. In that paper, Dr. Gregg speculates that in recent years a welcome and appropriate loosening of blood sugar targets for older adults may have been accompanied “by an unintended relaxation of glycemic control targets for younger adults,” resulting in more negative outcomes, particularly in that population.
While it is easy to accept that technology can be very useful in improving hypo prevention, it is difficult to prove that technology can prevent hypos entirely and all by itself. For that, we need to turn to the great dream of diabetes technology: the perfected closed loop system (or the “artificial pancreas”), a linked combination of CGM and insulin pump that monitors glucose levels and administers insulin with little or no effort from the patient. While this technology is still more or less in its infancy, Dr. Bergenstal pointed to two early trials, one of the Medtronic MiniMed 670G, the other of the Tandem Control-IQ, both of which found that patients using the technology experienced zero severe hypoglycemic events.
However, as Dr. Wilmot pointed out, not everyone shares the dream of the artificial pancreas. A 2019 study found that 30% of youth that were given the new 670g closed loop system stopped using the system within 6 months. Distressingly, those with a higher baseline A1c – that is, the patients most likely to benefit from the revolutionary technology – were also the most likely to discontinue. Other studies have found a similar pattern in adult populations. A T1DExchange survey also found that some 40% of CGM users had ceased using the tech for a variety of reasons, chiefly discomfort. (A minority of users experience such awful skin reactions from CGM adhesives as to make the system basically a nonstarter.)
Technology is only good if people will use it, and if adherence rates are really so low, it seems clear that the latest devices are no panacea. Dr. Bergenstal mentioned the Dexcom outage of 2019 as an example of how important technology has become to the diabetes community, but one might also view the same event as a lesson on the fragility of electronic solutions.
For some of the debate, the elephant in the room was the question of access and affordability. The fact is that an overwhelming percentage of people with diabetes in the world (and a worryingly high percentage even in affluent nations) simply cannot afford or have no access to these technologies. As long as that remains true, the question of whether or not technology can entirely prevent hypos remains, for a great swath of the diabetes world, science fiction. While the blame for sure lies with politicians (or voters) more so than with scientists and diabetes technologists, it remains a truth to be reckoned with.
It seems that, until the latest diabetes tech is both universally available and universally adopted, there will remain a critical role for education in hypoglycemia prevention. And no matter what technology we have available in the future, whether distant or near, diet and lifestyle choices will undoubtedly remain extremely important to mitigate and prevent the worst outcomes of diabetes.