The Psychological Implications of Automated Insulin Delivery Systems in Type 1 Diabetes Care

Removing Barriers, Bridging the Gap, and the Changing Role of the Health Care Professional with Automated Insulin Delivery Systems

As all people with type 1 diabetes (T1D) and some with type 2 diabetes (T2D) require insulin, there is a need to develop management methods that not only achieve glycemic targets but also reduce the burden of living with diabetes. After insulin pumps and continuous glucose monitors, the next step in the evolution of diabetes technology is automated insulin delivery (AID) systems, which have transformed intensive insulin management over the past decade, as these systems address the shortcomings of previous management options. However, AID use remains fairly limited, and access represents a major barrier to use for many people with diabetes, despite these systems being standard of care. Therefore, the future of AID will necessitate addressing barriers related to social determinants of health, finances, and an expansion of the number and type of health care professionals (HCPs) prescribing AID systems. These crucial steps will be essential to ensure that everyone with intensively managed diabetes can use AID systems. The impact of implementing these changes will create a shift in the future of diabetes care that will result in achievement of more targeted glycemia and psychosocial outcomes for all people with diabetes and an expansion of the role of all HCPs in AID-related diabetes care. Even more importantly, by addressing social determinants of health and clinical inertia related to AID, the field can address disparities in outcomes across countries, race, gender, socioeconomic status, and insurance status. Furthermore, the increased use of AID system will provide more time during appointments for a shift in the discussion away from fine tuning insulin dosing and toward a focus on more topics related to behavior and conversations about general health. This will include psychosocial outcomes, and quality of life. In addition, these changes can hopefully allow for time to discuss more general issues, such as cardiovascular health, obesity prevention, diabetes-related complications, and other health-related concerns.

Exercising Safely with the MiniMed™ 780G Automated Insulin Delivery System

The physical and psychological benefits of exercise are particularly pertinent to people with type 1 diabetes (T1D). The variability in subcutaneous insulin absorption and the delay in offset and onset in glucose lowering action impose limitations, given the rapidly varying insulin requirements with exercise. Simultaneously, there are challenges to glucose monitoring. Consequently, those with T1D are less likely to exercise because of concerns regarding glucose instability. While glucose control with exercise can be enhanced using automated insulin delivery (AID), all commercially available AID systems remain limited by the pharmacokinetics of subcutaneous insulin delivery. Although glycemic responses may vary with exercises of differing intensities and durations, the principles providing the foundation for guidelines include minimization of insulin on board before exercise commencement, judicious and timely carbohydrate supplementation, and when possible, a reduction in insulin delivered in anticipation of planned exercise. There is an increasing body of evidence in support of superior glucose control with AID over manual insulin dosing in people in T1D who wish to exercise. The MiniMed™ 780G AID system varies basal insulin delivery with superimposed automated correction boluses. It incorporates a temporary (elevated glucose) target of 8.3 mmol/L (150 mg/dL) and when it is functioning, the autocorrection boluses are stopped. As the device has recently become commercially available, there are limited data assessing glucose control with the MiniMed™ 780G under exercise conditions. Importantly, when exercise was planned and implemented within consensus guidelines, %time in range and %time below range targets were met. A practical approach to exercising with the device is provided with illustrative case studies. While there are limitations to spontaneity imposed on any AID device due to the pharmacokinetics associated with the subcutaneous delivery of current insulin formulations, the MiniMed™ 780G system provides people with T1D an excellent option for exercising safely if the appropriate strategies are implemented.

The impact of real-time sensor technology on quality of life for adults with type 1 diabetes: A Dutch national survey

AIMS

To examine the impact of real-time continuous glucose monitoring (RT-CGM) on quality of life in Dutch adults with type 1 diabetes, inside/outside automated insulin delivery (AID) systems.

METHODS

In this cross-sectional retrospective observational study, RT-CGM users completed an online survey including (adapted) validated questionnaires, study-specific items and open-ended questions.

RESULTS

Of 893 participating adults, 69% used the RT-CGM as part of AID. The overall sample reported improvements in quality of life related to RT-CGM use (irrespective of initial indication), particularly with respect to physical health, emotional wellbeing and energy. Merits for sleep, intimacy and cognitive diabetes load lagged somewhat behind, mostly when RT-CGM was not integrated in AID. Users of AID had significantly larger improvements in overall quality of life, fatigue and diabetes-specific distress than users of sensor-augmented pump or Open Loop treatment. In regression analyses, user evaluations were associated with perceptions of benefit and burden. In qualitative content analysis, benefits (e.g. life 'normalization', increased perceptions of control) outweighed burdens (e.g. technology frustrations, confrontation with diabetes).

CONCLUSIONS

RT-CGM positively impacted the quality of life of adults with type 1 diabetes. This justifies a (re-)consideration of broader access. Increased support to maximize device benefits and minimize burdens is also warranted.

Prolonged Use of an Automated Insulin Delivery System Improves Sleep in Long-Standing Type 1 Diabetes Complicated by Impaired Awareness of Hypoglycemia

BACKGROUND

This study assessed changes in actigraphy-estimated sleep and glycemic outcomes after initiating automated insulin delivery (AID).

METHODS

Ten adults with long-standing type 1 diabetes and impaired awareness of hypoglycemia (IAH) participated in an 18-month clinical trial assessing an AID intervention on hypoglycemia and counter-regulatory mechanisms. Data from eight participants (median age = 58 years) with concurrent wrist actigraph and continuous glucose monitoring (CGM) data were used in the present analyses. Actigraphs and CGM measured sleep and glycemic control at baseline (one week) and months 3, 6, 9, 12, 15, and 18 (three weeks) following AID initiation. HypoCount software integrated actigraphy with CGM data to separate wake and sleep-associated glycemic measures. Paired sample t-tests and Cohen's d effect sizes modeled changes and their magnitude in sleep, glycemic control, IAH (Clarke score), hypoglycemia severity (HYPO score), hypoglycemia exposure (CGM), and glycemic variability (lability index [LI]; CGM coefficient-of-variation [CV]) from baseline to 18 months.

RESULTS

Sleep improved from baseline to 18 months (shorter sleep latency [P < .05, d = 1.74], later sleep offset [P < .05, d = 0.90], less wake after sleep onset [P < .01, d = 1.43]). Later sleep onset (d = 0.74) and sleep midpoint (d = 0.77) showed medium effect sizes. Sleep improvements were evident from 12 to 15 months after AID initiation and were preceded by improved hypoglycemia awareness (Clarke score [d = 1.18]), reduced hypoglycemia severity (HYPO score [d = 2.13]), reduced sleep-associated hypoglycemia (percent time glucose was < 54 mg/dL, < 60 mg/dL,< 70 mg/dL; d = 0.66-0.81), and reduced glucose variability (LI, d = 0.86; CV, d = 0.62).

CONCLUSION

AID improved sleep initiation and maintenance. Improved awareness of hypoglycemia, reduced hypoglycemia severity, hypoglycemia exposure, and glucose variability preceded sleep improvements.This trial is registered with ClinicalTrials.gov NCT03215914 https://clinicaltrials.gov/ct2/show/NCT03215914.

Sleep and Circadian Rhythm Disturbances in Diabetes: A Narrative Review

Sleep and circadian rhythm disturbances are less-known risk factors for the development and suboptimal outcomes of diabetes. The goal of this narrative review is to highlight the importance of sleep and circadian rhythm disturbances in the development and outcomes of type 1 diabetes (T1D) and type 2 diabetes (T2D), assess current treatment options and the possible mediating mechanisms. We performed a literature search using PubMed and selected relevant English and Dutch papers. Disturbances of sleep and circadian rhythm are common in people with diabetes. They are associated with an increased risk of developing T2D as well as with suboptimal diabetes outcomes (including higher HbA1c levels and reduced quality of life) for T1D and T2D. Preliminary data suggest that treatment of sleep and circadian rhythm disturbances could improve diabetes outcomes in people with T1D and T2D. Finally, the association with medical parameters appears to be mediated by disturbance in hormones, and by suboptimal self-care including forgetting or postponing glucose monitoring or medication use as well as higher consumption of high fat/high sugary foods. Diabetes may also disturb sleep, for example through nocturnal hypoglycemia and nocturia. We concluded that sleep and circadian rhythm disturbances are closely linked with diabetes. More attention to sleep in regular diabetes care is warranted, while further research is needed on treatment of sleep and circadian rhythm disturbances in the prevention of diabetes and its suboptimal outcomes.

Are nocturnal hypoglycemia prevention strategies influenced by diabetes technology usage? A BETTER registry analysis

AIM

To assess the association of nocturnal hypoglycemia prevention strategies (NH-PS) and diabetes technology usage (insulin pump and/or continuous glucose monitors [CGM]) in people with type 1 diabetes (PWT1D).

METHODS

Logistic regression models were used to describe associations between self-reported NH-PS and diabetes technology (pump with intermittently-scanned or real-time CGM (isCGM or rtCGM), or automated insulin delivery (AID)), hypoglycemia history, and fear of hypoglycemia (FOH).

RESULTS

Among 831 adults (65 % female, aged 44 ± 15 years, T1D duration 26 ± 15 years), 32 % reported HbA1c ≤ 7.0 %, 88 % used ≥ 1 diabetes technology, 66 % reported ≥ 1 symptomatic NH in the past month, and 64 % used ≥ 2 NH-PS. Compared to multiple daily injections (MDI) + capillary blood glucose (CBG), bedtime snack consumption was less likely among pump + isCGM (OR [95 %CI]: 0.55 [0.31, 0.98]), pump + rtCGM (0.40 [0.20, 0.81]), and AID (0.34 [0.17, 0.66]) users, while evening insulin basal reduction was associated with CSII + CBG (3.15 [1.25, 7.99]), pump + isCGM 4.00 [1.99, 8.01]), and pump + rtCGM 2.89 [1.28, 6.50] use. Elevated FOH was associated with snack consumption (1.37 [1.00, 1.89]), evening bolus insulin avoidance (1.77 [1.11, 2.83]), limiting exercise (2.50 [1.30, 4.82]), and limiting alcohol consumption (2.33 [1.15, 4.70]) as NH-PS.

CONCLUSION

Technology use and elevated FOH might influence PWT1D' choice of NH-PS.