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McLean A, Maple-Brown L, Murphy HR. Technology advances in diabetes pregnancy: right technology, right person, right time. Diabetologia 2024:10.1007/s00125-024-06216-2. [PMID: 38967667 DOI: 10.1007/s00125-024-06216-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/20/2024] [Indexed: 07/06/2024]
Abstract
This review outlines some of the extraordinary recent advances in diabetes technology, which are transforming the management of type 1 diabetes before, during and after pregnancy. It highlights recent improvements associated with use of continuous glucose monitoring (CGM) but acknowledges that neither CGM nor insulin pump therapy are adequate for achieving the pregnancy glucose targets. Furthermore, even hybrid closed-loop (HCL) systems that are clinically effective outside of pregnancy may not confer additional benefits throughout pregnancy. To date, there is only one HCL system, the CamAPS FX, with a strong evidence base for use during pregnancy, suggesting that the pregnancy benefits are HCL system specific. This is in stark contrast to HCL system use outside of pregnancy, where benefits are HCL category specific. The CamAPS FX HCL system has a rapidly adaptive algorithm and lower glucose targets with benefits across all maternal glucose categories, meaning that it is applicable for all women with type 1 diabetes, before and during pregnancy. For women of reproductive years living with type 2 diabetes, the relative merits of using non-insulin pharmacotherapies vs diabetes technology (dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors) are unknown. Despite the urgent unmet need and potential benefits, studies of pharmacotherapy and technology use are extremely limited in pregnant women with type 2 diabetes.
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Affiliation(s)
- Anna McLean
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- Endocrinology Department, Cairns Hospital, Cairns, Queensland, Australia
| | - Louise Maple-Brown
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- Endocrinology Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Helen R Murphy
- Norwich Medical School, University of East Anglia, Norwich, UK.
- Norfolk and Norwich NHS Foundation Trust, Diabetes and Antenatal Care, Norwich, UK.
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Been RA, Lameijer A, Gans ROB, van Beek AP, Kingsnorth AP, Choudhary P, van Dijk PR. The impact of socioeconomic factors, social determinants, and ethnicity on the utilization of glucose sensor technology among persons with diabetes mellitus: a narrative review. Ther Adv Endocrinol Metab 2024; 15:20420188241236289. [PMID: 38476216 PMCID: PMC10929059 DOI: 10.1177/20420188241236289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 02/08/2024] [Indexed: 03/14/2024] Open
Abstract
Continuous glucose monitoring (CGM) usage has been shown to improve disease outcomes in people living with diabetes by facilitating better glycemic management. However, previous research has suggested that access to these devices can be influenced by nonmedical factors such as socioeconomic status and ethnicity. It is critical that equitable access to CGM devices is ensured as people from those groups experience poorer diabetes-related health outcomes. In this narrative review, we provide an overview of the various healthcare systems worldwide and how socioeconomic status, social context, and ethnicity shape device usage and the associated health outcomes. In general, we found that having a lower socioeconomic status and belonging to an ethnic minority group negatively impact CGM usage. While financial means proved to be an important mediator in this process, it was not the sole driver as disparities persisted even after adjustment for factors such as income and insurance status. Recommendations to increase CGM usage for people of a lower socioeconomic status and ethnic minorities include increasing the availability of financial, administrative, and educational support, for both patients and healthcare providers. However, recommendations will vary due to local country-specific circumstances, such as reimbursement criteria and healthcare ecosystems.
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Affiliation(s)
- Riemer A. Been
- University of Groningen, University Medical Center Groningen, Department of Endocrinology, Groningen, The Netherlands
| | - Annel Lameijer
- University of Groningen, University Medical Center Groningen, Department of Endocrinology, Groningen, The Netherlands
| | - Reinold O. B. Gans
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine, Groningen, The Netherlands
| | - André P. van Beek
- University of Groningen, University Medical Center Groningen, Department of Endocrinology, Groningen, The Netherlands
| | - Andrew P. Kingsnorth
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Pratik Choudhary
- University of Leicester, Leicester General Hospital, Leicester, Leicester Diabetes Centre – Bloom, UK
| | - Peter R. van Dijk
- University of Groningen, University Medical Center Groningen, Department of Endocrinology, Hanzeplein 1, Groningen, 9713 GZ, The Netherlands
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Yamamoto JM, Murphy HR. Technology and Pregnancy. Diabetes Technol Ther 2024; 26:S108-S116. [PMID: 38441447 DOI: 10.1089/dia.2024.2507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Affiliation(s)
- Jennifer M Yamamoto
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Helen R Murphy
- Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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Murphy HR. A Diabetes Pregnancy Technology Roadmap: The 2023 Norbert Freinkel Award Lecture. Diabetes Care 2024; 47:324-330. [PMID: 38394634 DOI: 10.2337/dci23-0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Norbert Freinkel emphasized the need for "more aggressive therapy with exogenous insulin" during type 1 diabetes (T1D) pregnancy. Recent advances in diabetes technology, continuous glucose monitoring (CGM), and hybrid closed-loop (HCL) insulin delivery systems allow us to revisit Freinkel's observations from a contemporary perspective. The Continuous Glucose Monitoring in Women With Type 1 Diabetes in Pregnancy Trial (CONCEPTT) led to international recommendations that CGM be offered to all pregnant women with T1D to help them meet their pregnancy glucose targets and improve neonatal outcomes. However, despite CGM use, only 35% of trial participants reached the pregnancy glucose targets by 35 weeks' gestation, which is too late for optimal obstetric and neonatal outcomes. The constant vigilance to CGM data and insulin dose adjustment, with perpetual worry about the impact of hyperglycemia on the developing fetal structures, leave many pregnant women feeling overwhelmed. HCL systems that can adapt to marked gestational changes in insulin sensitivity and pharmacokinetics may help to bridge the gap between the nonpregnant time in range glycemic targets (70-180 mg/dL) and the substantially more stringent pregnancy-specific targets (TIRp) (63-140 mg/dL) required for optimal obstetric and neonatal outcomes. Use of HCL (CamAPS FX system) was associated with a 10.5% higher TIRp, 10.2% less hyperglycemia, and 12.3% higher overnight TIRp. Clinical benefits were accompanied by 3.7 kg (8 lb) less gestational weight gain and consistently achieved across a representative patient population of insulin pump or injection users, across trial sites, and across maternal HbA1c categories. Working collaboratively, women, HCL technology, and health care teams achieved improved glycemia with less worry, less work, and more positive pregnancy experiences.
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Affiliation(s)
- Helen R Murphy
- Norwich Medical School, University of East Anglia, and Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, U.K
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Ebekozien O, Fantasia K, Farrokhi F, Sabharwal A, Kerr D. Technology and health inequities in diabetes care: How do we widen access to underserved populations and utilize technology to improve outcomes for all? Diabetes Obes Metab 2024; 26 Suppl 1:3-13. [PMID: 38291977 PMCID: PMC11040507 DOI: 10.1111/dom.15470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/04/2024] [Accepted: 01/12/2024] [Indexed: 02/01/2024]
Abstract
Digital health technologies are being utilized increasingly in the modern management of diabetes. These include tools such as continuous glucose monitoring systems, connected blood glucose monitoring devices, hybrid closed-loop systems, smart insulin pens, telehealth, and smartphone applications (apps). Although many of these technologies have a solid evidence base, from the perspective of a person living with diabetes, there remain multiple barriers preventing their optimal use, creating a digital divide. In this article, we describe many of the origins of these barriers and offer recommendations on widening access to digital health technologies for underserved populations living with diabetes to improve their health outcomes.
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Affiliation(s)
- Osagie Ebekozien
- T1D Exchange, Boston, Massachusetts, USA
- Department of Population Health, University of Mississippi, Jackson, Mississippi, USA
| | - Kathryn Fantasia
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Farnoosh Farrokhi
- Alta Bates Summit Medical Centre, Sutter East Bay Medical Foundation, Oakland, California, USA
| | - Ashutosh Sabharwal
- Department of Electrical and Computer Engineering, Rice University, Houston, Texas, USA
| | - David Kerr
- Centre for Health System Research, Sutter Health, Santa Barbara, California, USA
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Sibiak R, Mantaj U, Gutaj P, Richard Law G, Wender-Ozegowska E. Functional analysis of daily glycemic profiles and excessive fetal growth in pregnant patients with well-controlled type 1 diabetes: Retrospective cohort. Diabetes Res Clin Pract 2024; 207:111088. [PMID: 38195042 DOI: 10.1016/j.diabres.2024.111088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/26/2023] [Accepted: 01/02/2024] [Indexed: 01/11/2024]
Abstract
AIMS The study objective was to compare daily glycemic profiles throughout gestation between the mothers of large-for-gestational-age (LGA) and non-LGA newborns in patients with type 1 diabetes (T1D). METHODS We selected 102 eligible pregnant women who were treated with sensor-augmented pumps in our single-center retrospective cohort study. We used functional data analysis to compare glycemic control across gestation. RESULTS Median HbA1c values in the first, second, and third trimester were 6.23 %, 5.49 %, and 5.75 % respectively. Median time-in-range (TIR) exceeded 70 % in each trimester (72.4 %, 72.5 %, and 75.9 %, respectively). From 59 % up to 77 % of women met the criteria for well-controlled T1D defined by the mean HbA1c and TIR in each trimester. Despite that, 27 % (28/102) of pregnancies were complicated by LGA. Mothers of LGA infants had significantly increased HbA1c levels and decreased TIR values in the second and third trimesters. The most significant differences in daily mean glucose values between LGA and non-LGA newborns' mothers occurred between 26 and 32 weeks of pregnancy. These discrepancies were noted in daytime glucose values rather than nocturnal and fasting glucose levels. CONCLUSIONS Mothers of LGA newborns present significantly worse glycemic control. Our findings may emphasize the need for more rigorous daytime glycemic control.
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Affiliation(s)
- Rafal Sibiak
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland; Department of Histology and Embryology, Poznan University of Medical Sciences, Poznan, Poland; Doctoral School, Poznan University of Medical Sciences, Poznan, Poland.
| | - Urszula Mantaj
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
| | - Pawel Gutaj
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Ewa Wender-Ozegowska
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
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