Not all diabetes conferences are the same. They range from being focused on technology, to those aimed at health care professionals (HCPs), through to the highly scientific ones. These days there are even ones just for the people living with diabetes (PWDs). You might think that the people living with the condition should be attending the other types of conferences, and in my opinion you would be absolutely right. However, the rules and laws around industry being able to talk to PWDs directly about their products vary between countries and are often very strict which puts challenges that (again in my opinion) should never become obstacles to them being able to attend.

Having been extremely fortunate in the past few years, I have attended several conferences either as a blogger or speaker, and they all have one thing in common. They are busy. REALLY busy! Industry and HCPs from around the globe descend on one location for 3 days to learn as much as possible about new technologies, therapies and research. They also use the opportunity to meet with colleagues and peers that they only see once or twice a year face to face. Industry symposia and scientific program sessions run in parallel and one after another for the entire event. On top of that, there are the exhibition and poster halls which are packed with additional research and supporting information about products and companies.

So, how does one Grumpy old bloke with diabetes cover all of these sessions on his own in order to report it back to those who are not able to go? Simple answer is that I can’t. So I’m about to try and summarise the main topics of discussion and provide an idea of my highlights.

I covered the exhibition in my post for Day 2 of the conference which can be found below this one, if you haven’t read it and are interested.

Posters are just that. Posters of information from things like research projects that summarise their findings. Usually there are vast numbers of them lined up in a hall, each with a number identifying them and they are listed in the Program Book. I’ve often found myself lost in the maze of posters wishing that I had Sat Nav to find my way out. This year at ATTD there were some e-Posters where they were displayed on large screens. I think this is a great idea and could be more widely used to save us losing our favourite HCP in the poster maze forever…

The industry symposia are often about new products that will be available soon, or the next generation of an existing one. Accuracy is always a main focus for any BG meter or CGM/Flash system, but I personally wonder whether there is a line of useful accuracy and if, or when, we will pass it. I guess my analogy for this would be, if the speedometer on my car reads accurately to 0.1 of a mile per hour but my accelerator pedal only lets me contain the cars speed by 1.0 mile per hour, what is the point in employing such an accurate speedometer? With my BG meter, CGM or Flash system being the speedometer and my insulin delivery system being my accelerator. I still believe accuracy is important, but I wonder also at what point the R&D budget should stop being spent on finessing the product and be used to develop it so that it is cheaper to manufacture, reducing the cost to PWDs. Is it better to have the perfect product for the few, or an extremely good one for the many?

I am starting to see a change in the industry symposia though. It feels that the advances in technology are slowing down a bit. There are fewer new and shiny devices coming out and this seems to be driving some of the discussions more towards how the technologies can actually be used to improve outcomes and quality of life for the PWDs that are using them.

Also, there is more discussion about how best to use the different technologies together and make sure they complement each other rather than one technology being there to replace another. For me this is hugely important. The majority of PWDs globally do not have access to a lot of this equipment and we should be looking to ensure that the management of their diabetes is not disadvantaged by the fact that they just happen to be born in a different country, district or postcode than someone more fortunate.

The subjects included in the Scientific Program are vary varied. They also have ridiculously long titles. Such as “Closing the Loop - NIH- Funded AP Research Efforts” but wait, I can beat that one! “Glyco-Metabolic Control, Inflammation Markers and Cardiovascular Outcomes in Diabetic Patients on Insulin Pump or Multiple Daily Injection”. I skipped that session by the way….

The really long and complicated titles cover a wide range of subjects and here is my summary of what they were discussing:

• Technology - There remains a lot of talk about closed loop and Artificial Pancreas systems. From what I was hearing there are still plenty of live/ongoing trials, all still proving that these systems would be great for a lot of PWDs that want them (keep in mind that not all of us will). The systems are still in development and not yet available. Yet there are PWDs who are already “Looping”. These are the increasing number of PWDs that are using “DIY AP” systems that they have put together themselves using industry devices and additional, programmable technologies. This is of course completely off-label, out of warranty and not approved by any regulatory bodies. However, they seem to work well and, to date, safely for those who are using them. It’s reassuring too they were discussed in some of the sessions at ATTD this year. There is no point hiding from the fact that this is happening and I don’t think anyone should be judging PWDs for doing this. It’s a difficult subject of course, as these are medical devices, but we can, and should, all learn from each other in the hope that it drives better outcomes for those living with this condition.

• Biotechnologies - So as I’m clearly not an expert, HCP or scientist, as far I could make out from these sessions, they are all about things like prevention, cure or fixing the bits of the pancreas that decided to give up the ghost when we developed diabetes and joined the club that nobody wanted to join. A cure is a long way off and it may never happen, certainly in my life time, but we should never stop looking for one. Every bit of research helps us to understand this condition which still poses multiple questions to medicine. And everything that is learnt can be used to try and help us PWDs to manage our diabetes in the way that we want to, in order to live and thrive with it. Work still goes on trying to find a vaccine to stop people developing diabetes, along with beta call encapsulation and transplants in an attempt to start our bodies producing insulin again and to protect the cells from being attacked and destroyed again. The encapsulation is important. I wasn’t overly pleased when I developed diabetes the first time, so you can imagine how Grumpy I’d be if they fixed it only for it to happen again!

• Other sessions covered subjects related to living with diabetes such as pregnancy, physiological impacts of living with this condition and the risks and complications that are associated with having diabetes. Great scientific sessions I’m sure (unfortunately I couldn’t attend any of these since I was in others). However, there is very often one thing that I think is missing from these. If you are going to talk about living with diabetes, who may you expect to hear from? Yep. The people that are living with diabetes. All too often, that most important voice is utterly absent from the conversation in these sessions. Science is great, but experience can often be different. Neither is wrong but each can learn from one another and improve the outcomes and quality of life for all of us living with this condition. After all, isn’t that what these conferences set out to do?

One final thing that stood out for me at this conference. There was a lot less talk about HbA1c and a lot more talk about “Time in Range”. I think that time in range is a better way to measure how my diabetes management is going compared to the way I want it to.

So that is my whirlwind attempt to describe what went on at ATTD and give you an idea of the kind of things that are discussed from the perspective of just one person that has lived with the condition for a few years now.

Given that this a technology conference, I thought it would be an idea to give an overview of what technologies are in the exhibition hall this year.

However I guess the first question is what is considered as “Diabetes Technology”?

Of course the first thing that springs to mind are pumps and CGM. Probably because they are the most recent and latest innovations, although they have been around for several years now.

My view is anything I use to manage my Diabetes is “Diabetes Tech” and at its highest level I need three things.

1. Insulin
2. An insulin delivery method
3. Blood Glucose (BG) data

That was the case when I was first diagnosed over 23 years ago and my Diabetes toolkit was made up of mixed insulin (delivered by twice daily injection via syringe) and BG data provided by a rather large BG meter that I did 4 finger stick checks a day with. This data was recorded manually in a diary (when I could be bothered).

About 4 years later I moved to Multiple Daily Injections (usually 4-6 per day). At this time I was taking two different insulins. Long acting at night and rapid acting for all other injections. The delivery method changed to an insulin pen, which was much easier to use as it was filled with insulin cartridges instead of drawing it up out of a vile. The BG meter was now smaller, needed a smaller drop of blood and gave faster results.

Fast forward to present day. Back to one type of insulin (rapid acting). The delivery system is now an insulin pump. BG data is via CGM, which is calibrated with BG readings from my BG meter. I also use my meter for pre meal checks and also to ensure I adhere to the UK driving laws.

So things have changed a lot with technology, but as you can see they still fall into the same three categories.

The exhibition can be summarised in the same categories.

There are still advancements in insulin and these should not be ignored. One of the issues is that insulin is slow. Even “rapid acting”. It can take around 20 minutes from injection (or delivery by pump) to start working. This gives those of us living with Diabetes the challenge of matching (as best we can) the start of our insulin acting (onset), with the eating and digestion of our food. If the food starts acting before the insulin, we risk high BG spikes. If the insulin acts first, we are likely to have low BG (hypo). So the faster acting insulins are always of interest to us living with this condition.

Insulin delivery technology is not just about pumps. I love my pump, but not everyone wants one and it would be wrong to assume that they did. I turned down the offer of a pump 12 months before I decided to try one because it went right for me at the time. And of course they are not available to all that want them. So technical developments in insulin pens are hugely Important. The ability to deliver half units of insulin is very important to a lot of PWDs since for some, half a unit too much can send their BG low. New developments in “smart pens” help to bring some of the advances we have seen with insulin pumps such as recording last injection and amount of insulin taken along with Bluetooth connectivity to start phone apps can be useful to those using these devices. The sad news here is that I did not see one single smart pen exhibitor at ATTD this year. This could possibly be because they are not considered as technology? Whatever the reason is a real shame in my opinion. For every health care professional (HCP) attending the conference, the vast majority of their patients are unlikely to be on pumps. So surely this is a missed opportunity?

With BG data we have seen the most recent and fast moving developments over the last 12 months. We have CGM that talks to our mobile devices and several new features of CGM devices have been shown at the conference this year, including a new easier insertion system for one of the latest generation devices. Flash Glucose Monitoring is being used more widely and a new app that allows scanning of the sensor directly from an iPhone 7 has just been revealed, complementing the existing Android app that was already available.

BG meters are more accurate, need less blood and can transfer the data to mobile apps or the cloud, so the days of carrying a log book and manually recording all the data required to manage Diabetes are gone for those who want to use this technology. As someone that tends to manage their Diabetes “on the go” it’s great to be able to just load the data from my meter to an app before I attend a clinic appointment.

As someone living with Diabetes I now have the Diabetes Tech that I need to make much more informed decision. However, all this technology will not improve my Diabetes Management. The way I use it will. 

I guess before I start this series of posts on ATTD 2018 I should introduce myself.

My real name is Chris Aldred and I’m from the UK.

I was diagnosed with Type 1 Diabetes in 1994 at the age of 25.

I blog and tweet about my life with Diabetes under the guise of The Grumpy Pumper.

I have seen many changes in Diabetes technology over my 23 years of living with the condition, from twice daily injections and a blood glucose (BG) meter that was steam powered and took an age to give you a reading, to now using an insulin pump, Continuous Glucose Monitor (CGM) alongside my battery powered, 5 second to result BG meter. So I’m always interested in hearing about advances in this field.

In the past I’ve always avoided industry symposia.

Why?

Well, I assumed the it would be combination of the industry telling me that their new product will make my life with Diabetes so much better or that they have a new intrusive way of sticking a hole in my finger to draw blood. A quick tip here. If it’s going to draw blood then its intrusive……

I also assumed that there will be a panel of health care professionals (HCP) telling me that I’m not using my kit right and that if I did, guess what?, my life would be better.

So today I broke that rule and attended the Ascensia symposium entitled “BGM and CGM, is there only one Future?”

The first speaker was Adam Brown. I’ve known this guy for a few years now. He also lives with Type 1 and I have to say it’s a refreshing change to see industry realise that they need to get the people with Diabetes (PWDs) that use their products to talk to them and to the HCPs that prescribe the products. Living with Diabetes can vastly vary from the text book.

Adam talked about the use of BG meters and number of blood checks that are done on average by each PWD. The numbers were surprisingly low and he highlighted that most PWDs have very few data readings per day to make informed dosing decisions if they just use a BG meter. He then moved onto CGM. CGM (including Flash Glucose Monitoring) is only used by 1-3% of PWDs worldwide. So whilst it gives much more data, and in real time in some cases, it is not accessible for the vast majority of PWDs.

You’d think that of that 1-3%, most would only use their BG meter to calibrate the CGM or for the legal requirements around driving, but no, something like 45% of these PWDs still use a BG meter more than 6 times a day. Personally I can back this up. I do less BG checks when using CGM, but I easily do 6 a day.

Why?

I think for me it’s because I trust my BG meter. At diagnosis it was one of the things I was given to help me. It’s been one of the only dependable things in my Diabetes tool kit. CGM gets more inaccurate over time through use (yes I use it longer than warranty) and it drifts at times in accuracy. My meter just keeps going. Its results are my reference point.

Discussion moved to meters that Bluetooth to smart phone apps. Statistics show that use of these meters is again low.

The next speaker, Dr Guido Freckmann, talked about the difference between BGM and CGM

Unsurprisingly BGM is just that. It checks your BG level from a drop of blood.

CGM? Well that’s a bit more complicated. It’s an estimation of the BG level based on a reading from interstitial fluid and a lot of complicated maths in an algorithm to work out that figure. Also, there is a time lag. Unlike BGM, which gives me my BG reading at that point in time, the CGM estimation is from effectively 6 minutes ago. However that lag depends on certain things and can vary from person to person (4-20 min). I can tell you from experience that it can vary on the same person. My CGM lag can be different each day at times. So you can probably see that whist I love my CGM, I will always trust my BG meter and will always depend on it whether I am wearing CGM or not.

Then it all got a bit mathematical with Dr Marc Breton looking at the numbers behind MARD. The stand out point for me was that I can have the most accurate meter in the world, but if I don’t change my lancet for every BG check (I don’t), If I don’t wash my hands properly (I don’t, as it is not always practical) or if my strips have not been stored correctly (I think I’m ok on that one) then my results may not be as accurate as they should be. It’s a balance of real life, convenience and the way things “should really be done”.

The final speaker was Dr Steven Russell talking about the importance of accuracy with the closed loop systems (Artificial Pancreas). He pointed out that any PWD whose BG is within range is never far away from dropping into a hypo (hypoglycaemia) and that any automated insulin delivery system needs accurate BG data to ensure that the right amounts of insulin are infused to walk this fine line. So this could need someone like me to change my behaviours, to ensure that I’m getting accurate BG results  and avoid the risk of making an accurate CGM sensor into a less accurate one through calibration.

The session wrapped up with a lively Q&A session led by chair, Professor Lutz Heinemann.

My personal view on BGM and CGM, is there only one future?

No.

At least not for a very long time. For me and my Diabetes management they complement each other with my BG meter being my safety net.