Diabetes treatment hasn’t changed much in 100 years, but I’m optimistic we are entering a new era of innovation

By Christine Chang, manager, Deloitte Center for Health Solutions, Deloitte Services LP

I was seven months pregnant when my two-year-old son was diagnosed with Type-1 diabetes. It was his first day of pre-school…and it also wound up being his first trip to the emergency room. Over the past year, our whole family has learned how challenging it can be to manage this chronic condition. However, we are optimistic that diabetes and other chronic diseases will become more manageable as we move closer to the Future of Health^TM.

About 60% of American adults have at least one chronic disease (e.g., heart disease, asthma, cancer, diabetes), and the number of people who have a chronic illness has been rising steadily for years.¹ As someone who has spent a career tracking health care issues, I was caught off guard when I realized how little I knew about managing diabetes. Blood-sugar levels, for example, have to be tracked throughout the day—and at night—through finger pricks (something little boys try hard to avoid). In addition, there is more than one type of insulin needed each day, and the doses vary based on blood-sugar levels and upcoming meals. All of this was overwhelming initially, but it is getting a little easier to manage.

The Future of Health and chronic disease

We are entering an era of innovation that could change the way people prevent, detect, and manage chronic illnesses. Artificial intelligence (AI), always-on sensors, and real-time micro-interventions are part of the Future of Health that we expect will emerge over the next 20 years. My son’s endocrinologist recently told me that now might be the “best time to be diabetic” in terms of emerging technologies. Here’s a look at how technology could change how we manage diabetes and other chronic diseases:

• New ways to deliver therapies: Insulin was discovered in 1921 and was used to treat diabetes a year later. Prior to this, people who had Type 1 diabetes typically lived no more than a year or two after developing the disease.² The treatment was ground-breaking, but it has changed surprisingly little over the past century. Many people who have Type 1 diabetes still need to inject insulin. And while there are more types of insulin available today, almost all of them need to be refrigerated. One type of insulin delivered through an inhaler was approved in 2016, but it didn’t catch on with patients.³ Researchers are now developing a concentrated insulin that does not need to be refrigerated.⁴ In addition, a recent advancement in formulating glucagon (the body’s antidote to insulin when blood sugar is too low) is being tested in a dual-chamber pump and could offer better and easier management.⁵
• Smart devices: My son was not initially able to get an insulin pump, but he is getting one soon. While pumps typically provide better results over manual injections, the technology still feels clunky, and we will need training to learn to use it. Moreover, most insulin pumps require upfront programing, and information needs to be entered manually multiple times a day. Pumps are NOT plug-and-play. More advanced pumps are able to automatically stop delivering insulin when blood-sugar levels get too low and deliver more insulin when levels are high. I expect these devices will get much smarter in the future by identifying weekly/daily patterns, incorporating different types of data like physical activity, imbedding continuous learning, and synching better with continuous glucose monitors (CGMs) so that insulin levels can be adjusted automatically.
• Always-on sensors: Before we were able to get a CGM for my son, we typically had to do five or six finger-sticks each day to monitor his blood sugar. A CGM can automatically generate hundreds of readings per day, and some devices are able to provide directional data, allowing the user to understand if glucose levels are likely to rise, fall, or remain steady. The alarm settings also help users catch blood sugars before they become too low or high. CGMs can be paired with insulin pumps to create a closed-loop system. This is sometimes referred to as an artificial pancreas, although it is not as effective as an actual pancreas. In addition, wearable devices such as fitness trackers and watches are being developed to continually track glucose levels through the skin.⁶
• Real-time data: Rather than relying on a handwritten glucose log-book, we have an app on our phones (and on our son’s phone) that allow us to see when blood-sugar levels are out of range. The app also lets us record what he eats and track his physical activity. Being able to see his real-time data from my phone gives me peace of mind when he is at school. The apps also make it possible for his care team to see the data that our phones collect. They typically review the data with us and can evaluate his activity over the past couple of days/weeks before we meet.
• Artificial intelligence: Medical devices that include AI will be able to learn from each meal, each day, and adjust insulin levels as needed. This will be important for my son given that growth hormones and stress hormones can wreak havoc on glucose levels. Glucose levels are also impacted by different types of food and exercise (e.g., playing in the snow vs swimming in a pool; soccer practice vs soccer games). What works for him now will likely not work for him in a year, and often there are day-to-day differences. AI that accounts for all of these changing factors could improve the accuracy of insulin-dose calculations.
• Virtual health: We are already doing virtual visits to some extent—like when we call the office between appointments with questions or concerns. Our pump training will be all virtual because of the pandemic. I hope that this option will continue to be offered (particularly for visits with nutritionists) and that clinicians become more proactive using this tool in the future. At this point, we are the ones initiating the calls, rather than having a care team that checks in when they notice dosing changes need to be made.  
• Early detection/prevention: While it might be impossible to prevent Type 1 diabetes, Type 2 is preventable. Smart watches and other non-invasive ways to test glucose could help detect diabetes earlier, avoiding a traumatic and costly trip to the ER. Education could also help parents recognize the symptoms of diabetes earlier. Our son didn’t have all the classic Type 1 symptoms, and I also didn’t realize how urgent the situation could become. It wasn’t until he was pretty far along that we finally went to the doctor. 

Type 1 diabetes is a do-it-yourself (DIY) disease. Everyone reacts differently to foods and insulin, which means diabetes management has to be personalized. People who have diabetes often learn how to manage their conditions from others who have the disease, in addition to their doctors and nurses. The lived experience is valuable, and the knowledge transfer—with the recognition that not all of it will apply to everyone—has been key for us. Patients should not have to figure this out on their own! Some useful tools have been created by patients and parents of patients. For example, the parent of a child with diabetes created a DIY pump/CGM loop called Riley’s loop. There is also an app called SugarMate that helps monitor blood-sugar levels.  

It has been 100 years since the discovery of insulin made it possible for people with diabetes to live long and healthy lives. While the treatment for this disease has changed little over the past century, I am optimistic about the future. There have been so many advancements over the past couple of years that it is hard to imagine what will happen in 10 years, 20 years. I just want it all to come out as soon as possible so my son can spend less time thinking about his diabetes, and more time being a kid.

Endnotes

^{1.        Chronic diseases in America, Centers for Disease Control and Prevention, January 12, 2021}

^{2.        The history of a wonderful thing we call insulin, American Diabetes Association, July 1, 2019}

^{3.        Why was inhaled insulin a failure in the market, American Diabetes Association, August 29, 2016}

^{4.        Thermalin is developing no-refrigeration insulin and a postage stamp-sized pump, healthline, February 15, 2021}

^{5.        How many hormones make an ideal ‘artificial pancreas?’, Medscape, July 1, 2020}

^{6.        New Fitbit app update will allow users to track their blood-sugar level, USA Today, February 8, 2021; Two lifesaving features could be coming to smartwatches, Forbes, January 29, 2021}

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