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Harrison Professor of Medicine
Division of Endocrinology
Department of Medicine
University of Virginia
Ananda Basu, MD, FRCP, has no relevant conflicts of interest to report.
Despite the advent of smart technology to help monitor and control diabetes, barriers to access and uptake of these important tools persist. In this commentary, I highlight a recent publication that investigated disparities in diabetes technology use and make the case that endocrinologists need to improve familiarity with these options and approach our patients with patience and empathy.
Diabetes Technology Use Among Vulnerable Populations
A recent study from Walker and colleagues highlights the barriers to diabetes technology use and care for underserved populations. It was a well-done study in a sizeable population of people with type 1 diabetes from 2 big centers of diabetes in Florida and California. The study intentionally aimed to include a population of adults with type 1 diabetes who had low socioeconomic status, were racially diverse, and were, therefore, often underrepresented in research studies. Using a series of focus groups, the investigators collected information from participants about their diabetes care, including barriers to endocrinology care and technology, and needs of communities with type 1 diabetes.
What was most striking was that the main barrier to using continuous glucose monitoring (CGM) was not financial; it was not the insurance coverage. The study revealed that the main barrier to technology use was at the provider level. Participants mentioned experiencing instances of bias in which the provider would not allow them to pursue CGM or an insulin pump until their diabetes was better “under control.” Participants mentioned feeling chastised or belittled by their endocrinologists. It was revealing that even in this day and age, patients were experiencing disparate treatment from their providers due to the stigma of type 1 diabetes, especially among people of lower socioeconomic status and among ethnic minorities and Black patients. I think we clearly need to do more work in this area. The more training and education that endocrinologists receive (1) in the use of CGM and its interpretation and application and (2) in disparities in healthcare delivery, the sooner these barriers will recede.
Training in the Use of CGM
I think all endocrinologists and diabetes educators should have a good working knowledge of state-of-the-art care of patients with diabetes. Application of diabetes technology, especially the continuous glucose monitors and a knowledge of how to use and interpret them, should become common practice. They may not need to know every detail of insulin pump use, which is currently used primarily in people with type 1 diabetes. However, endocrinologists and diabetes educators should recognize that CGM can also benefit people with type 2 diabetes regardless of whether or not they are receiving insulin.
Advice on Managing Diabetes
Empathy, optimism, and encouragement are very important when managing care for persons with diabetes. Providers need to remember that diabetes is a chronic disease. It involves the entire lifestyle—what we are eating, what we are not eating, what we are doing, and what we are not doing. It is a 24/7 disease, and it involves many day-to-day behavioral aspects, including food selection and calorie limitation. Let’s be honest—food is one of the pleasures in life and trying to control that is challenging.
Diabetes permeates every aspect of a person’s life and we, as endocrinologists, should have a huge element of empathy and sympathy for our patients. We should listen to them and we should highlight the positives, however minimal they are, so that they are encouraged to make further changes, however small and incremental those steps may be. We would not expect A1C to fall from 14% to 7% in 3 months or 6 months or even a year, but if our patients are showing steady progress over time, that is fantastic. Introduce changes gradually. For example, if you find that glucose values are elevated after every meal, focus on one meal at a time. First manage the postbreakfast blood sugar, and then deal with the rest.
Overall, we need to empathize with our patients and use CGM as a behavior‑modifying tool from time to time. Endocrinologists need to accept this tool and learn about it while recognizing the reality of disparities in diabetes care delivery so that we can better help our patients who are most in need.
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