Patient Perspectives on the Benefits and Challenges of Diabetes and Digital Technology

BGM, in which blood glucose is intermittently measured by a fingerstick blood sample, was introduced in the early 1970s (15,22). Today, glucose meters are relatively compact and unobtrusive and provide results in a few seconds from a small blood volume (22). They are important tools that, when coupled with education, can help to guide clinical and self-management plans that aim to improve outcomes (12). Although their accuracy depends on the instrument and the user, the training is straightforward (15).

However, BGM only provides glucose measurements at intermittent time points and does not provide information about the direction of glucose trends (i.e., whether glucose is increasing or decreasing) (15,23). BGM can be difficult to perform discreetly, with the exception of one meter (the POGO Automatic). BGM can be inconvenient and painful, leading to poor adherence and impaired quality of life (22). In our experience, emotional and physical pain associated with finger pricking reduces the effectiveness of BGM and results in less patient engagement and adherence.

Smart meters are an advanced version of BGM meters, as they integrate directly with smartphones that allow for the tracking of blood glucose results (e.g., Livongo, MySugr, Accu-Chek, and All-in-One). Some smart meters can calculate how much insulin should be administered based on food consumption and how basal insulin should be titrated. They can also correct a high blood glucose and help to avoid underdosing, overdosing, and guesstimating insulin doses. Subscription-based programs offered by manufacturers that provide unlimited test strips in addition to a BGM meter are also available, making the use of these devices more affordable.

CGM systems were first introduced in 1999, and 24/7 use is now considered the standard of care for people with type 1 diabetes and for those with type 2 diabetes who require insulin (12,15). In contrast to BGM, CGM devices have an interstitial sensor (applied through the skin every 7, 10, or 14 days or implanted under the skin for up to 6 months) that allows glucose levels to be continuously monitored through the day and night, which gives a daily glycemic profile, including information on trends. These systems also sound alarms to warn users of impending high or low glucose levels (12,23–25). CGM devices can help to alleviate the burden of frequent BGM (12).

Continuous glucose readings from a CGM system offer a distinct advantage over BGM because they allow patients and PCPs to monitor the time when glucose is in range (70–180 mg/dL) and to assess glycemic variability and the rate of glycemic change over time (23–25). These data can be used to inform changes in lifestyle, eating habits, and medications (including insulin), both in real time and with retrospective review, leading to improved glycemic management with less time spent outside of the target glycemic range. This functionality ultimately reduces the risks of hyperglycemia and hypoglycemia and over the long term, can lead to better heart, liver, and kidney health by helping to prevent diabetes-related complications (23,25–27).

CGM devices fall into two main categories: personal CGM systems, which are owned by individuals who can access the data in real time, and professional CGM systems, which are owned by clinics (23). Professional CGM systems can be used by individual patients for a discrete period of time, usually 7–14 days, with real-time data either blinded or visible to users (12). Intermittent use of a professional CGM system, either quarterly or annually, can identify glycemic patterns over a set period of time when continuous use of a personal CGM system is not available, necessary, or desired (12). Professional CGM is typically used by either people with type 2 diabetes who do not need or do not have access to a personal CGM device or by those with type 1 diabetes who cannot afford a personal CGM system.

CGM devices can be enabled to share data with selected contacts (e.g., friends, family members, and HCPs) and to alert them to potential acute glycemic events (26,28). Some evidence suggests that data-sharing is associated with health and quality-of-life benefits, including improved sleep (28,29). However, there can also be interpersonal challenges, specifically with how the selected contacts respond to the shared data (28). PCPs are also able to view data directly from an individual’s CGM device, enabling the PCPs to provide treatment guidance based on documented data (26).

Several CGM systems are available, offering many different features (Table 1) (30–34). The most frequently used are the Dexcom G6 and G7, Eversense E3 180-day (implantable), FreeStyle Libre 2 and 3, and Guardian Connect.

In our experience, CGM systems have very few limitations compared with BGM. They are pivotal for giving people better management of their health and the reassurance of knowing what their glucose levels are and how they are trending (25). Importantly, CGM systems have alerts and alarms that can be adjusted and personalized, warning individuals and their chosen contacts in real time when glucose levels go out of range. Their use can affect immediate food choices and exercise, empowering individuals to improve glycemic management (22,23). CGM data can also increase the efficiency of clinic visits by pinpointing areas for discussion (26).

The key to successful management of diabetes in individuals using CGM is to have them engage with their data and to help them interpret the readings. In-depth practical guidance for PCPs on how to interpret and use CGM data has been reviewed in detail by Edelman et al. (26); therefore, only a brief overview is provided here.

CGM data are usually displayed as an ambulatory glucose profile (AGP) report, which shows trends that can be used as the basis of discussions between PCPs and individuals with diabetes (26,35). In our experience, individuals also log meals, medications, and activities, either on paper or via a mobile app. An international expert panel reached consensus in 2019, recommending that a useful CGM report is one that is understood by both PCPs and people with diabetes, through the use of common terminology. Those of most value are single-page reports that can be reviewed, filed, and shared as a decision-making tool (36). Too much CGM data can be overwhelming, but presentation has become more streamlined in recent years. In addition, CGM devices display important trend arrows that indicate the direction and rate of change of glucose, and this information can inform insulin dose calculations by users in real time (35,37). Alerts can be set to detect impending low and high glucose levels to manage hyperglycemia and hypoglycemia (37).

Experience suggests that, ideally, individuals should be educated on how to observe their glucose values before and after meals with different carbohydrate loads; observe the effects of meals, exercise, sleep, and stress on their glucose values; adjust insulin in response to trend arrows to avoid low glucose levels; set upper and lower glucose alerts and alarms; and share their glucose data with their chosen contacts and HCPs (37).

Figure 1 depicts an AGP report summarizing a 2-week data download from a CGM device that was used by a 63-year-old man with type 2 diabetes and active for 60% of the time during that period. The individual was receiving a glucagon-like peptide 1 receptor agonist, metformin, insulin glargine at bedtime, and a sodium–glucose cotransporter 2 inhibitor.

The man’s average glucose was 171 mg/dL (target <155 mg/dL), which reflects a glucose management indicator (GMI) of 7.4% (target <7.0%). GMI is an estimate of A1C based on the average of glucose data collected by the device sensor during the report period and may differ from the laboratory-measured A1C (24,38). For further in-depth practical guidance on how to interpret and use CGM data, readers are referred to a previously published review by Edelman et al. (26). The man’s glucose variability, defined as the percent coefficient of variation, was 36% (target <36%). His time in range was 63% (target ≥70%), and he had no hypoglycemia. The 24-hour view on the AGP report shows that his glucose levels went above range after his evening meals and that another peak typically occurred after lunch, with meaningful variability.

The man’s diabetes management plan was updated to add fast-acting insulin before the evening meal each day and to observe post-dinner glucose levels. Reducing carbohydrate intake at mealtimes was also discussed as a further management strategy.

In our experience, CGM offers a valuable opportunity for meaningful discussions and for developing effective partnerships between PCPs and individuals with diabetes focusing on the most important issues to optimize glycemic control and improve long-term outcomes, particularly cardiovascular and kidney health. PCPs must provide training not only on how to download data and use CGM mobile apps, but also on how to interpret the data. PCPs should use terminology that people with diabetes can understand, which ideally includes taking time to explain terms such as time in range, time below range, time above range, A1C, average glucose, and glycemic variability.

Although CGM is the standard of care for people with type 1 diabetes and those with type 2 diabetes who use insulin (12), its use is hardly widespread (23,39,40), and it is estimated to be used by <10 million people with diabetes worldwide (41). One reason for this lack of uptake cited in the literature is clinical inertia; the introduction of technology requires initiative, awareness of its benefits, and efforts to integrate its use into routine clinic workflows, all of which may be lacking (23,39). Other reasons cited in the literature include various constraints related to accessibility and real or perceived ease-of-use concerns. However, barriers to CGM adoption—primarily expense, inaccessibility, and lack of knowledge or awareness (39)—can all be addressed.

First, PCPs who may not be familiar with CGM or aware of the positive impact of CGM on long-term outcomes can gain more knowledge through education. Individuals with diabetes themselves may not be knowledgeable about the benefits of CGM because of a lack of awareness, education, interest, or access. It may also be difficult for PCPs to engage and educate patients in settings with limited resources. Education must therefore be a priority, both for PCPs, to further their own clinical expertise, and for people with diabetes, to enable them to take advantage of this beneficial technology. Such education is key to successful engagement and essential to facilitate shared decision-making (27,39). Approaches for integrating CGM into clinical practice have been reviewed in detail by Kruger et al. (27).

We believe that personal CGM should become more widely used for people with type 1 diabetes or those with type 2 diabetes who use insulin or who are at risk for severe hypoglycemia. In our experience, the introduction of CGM has extensive benefits, including accurate reports that can inform treatment recommendations, the ability to monitor individuals’ glucose levels throughout their everyday activities, and, in some cases, immediate access to glycemic data between clinic visits. CGM could also be integral in delaying the development of diabetes in people with prediabetes, but this use is rarely covered by insurance or prescribed. Randomized controlled trials are needed in this area.

Insulin pens combine an insulin cartridge and syringe in a single device for insulin delivery (15). Compared to traditional vials and syringes, they are more convenient, have good dosing accuracy, and are associated with improved adherence and less hypoglycemia risk, making them the most widely used insulin delivery devices (42). Examples include the Basaglar KwikPen, Lantus/Toujeo SoloStar, Levemir FlexTouch, Tresiba FlexTouch, NovoPen Echo Plus, and InPen Smart Insulin Pen.

Conventional insulin pens do not capture data, and individuals must manually record their insulin doses, timing of injections, and food intake, which is challenging and can lead to missing, incomplete, and/or inaccurate data (15,42).

Smart insulin pens record the amount and timing of insulin doses, transmitting the data to dedicated mobile apps, which allow users and their HCPs to access accurate information on insulin administration and injection patterns over time. The first U.S. Food and Drug Administration (FDA)-approved insulin smart pen was launched in 2017 (42). Smart pen apps can also calculate insulin doses and provide downloadable data— functions that are pivotal for assisting with individual diabetes management (15,42). Individuals who switch to smart pens experience less glucose variability, more time in range, and less time in both hyperglycemia and hypoglycemia (43). Smart pens may also help to reduce the number of missed bolus injections and help people properly adjust doses, leading to better glycemic management (43).

Another important established but evolving method of insulin delivery is insulin pump therapy, also known as continuous subcutaneous insulin infusion (CSII) (12). First introduced in the 1970s, CSII gained popularity in the 1990s as its benefits for glycemic management became apparent (44) and systems became easier to use. Insulin pump devices deliver rapid-acting basal and bolus insulin to manage glycemia (12,45). CSII is a highly efficient and flexible method of insulin delivery; studies have shown that it can improve glycemic management and reduce hypoglycemia (15,46). Most insulin pumps use tubing to deliver insulin via a cannula (e.g., t:slim ×2, MiniMed), but a few so-called patch pumps attach directly to the skin (e.g., Omnipod, V-Go) (12,47). The recently approved CeQur Simplicity 3-day patch pump, which delivers bolus insulin only, can benefit individuals on mealtime insulin by simplifying delivery (48).

In 2017, the FDA approved the first automated insulin delivery (AID) system, which connected an insulin pump and a CGM system with a control algorithm to automate insulin administration based on the continual automatic input of glucose data (12,15). At the time of writing, multiple hybrid closed-loop systems (i.e., that automate basal and/or correctional insulin delivery but require manual delivery of mealtime doses) were available, including the t:slim ×2 with Control IQ Technology, MiniMed 780G, Omnipod 5, and iLet systems; the latter requires users to input their body weight when initiating the pump and provide meal announcements (small, medium, or large), whereas the other hybrid closed-loop systems require manual input of carbohydrate intake (12,49,50). We anticipate that AID systems in the future will require no inputs from users.

Insulin pumps and AID systems allow targeted use of rapid-acting insulin in response to changes in glucose levels (15). Although our experience suggests that maintaining adherence can be difficult for some individuals, these systems have become easier to use, and we anticipate that they will continue to do so. PCPs should aim to ensure that users are engaged and informed about the long-term benefits of these devices. Ongoing education is important for everyone using an insulin pump or AID system, including discussion of site rotation, as is done for multiple daily injection (MDI) insulin regimens and troubleshooting of any technical issues. Although individuals may find the insertion location and size of the control unit uncomfortable or may feel self-conscious using devices when participating in activities, more devices are now incorporating methods to address these concerns. Failure to plan for appropriate use of these devices, including keeping reservoirs filled with adequate amounts of insulin, and failure to appropriately choose and/or rotate sites, can yield challenging outcomes. Therefore, it is important to assess individuals’ true acceptance of device usage beyond just the initial novelty of starting a new technology.

Some people modify their diabetes devices by efforts ranging from replacing CGM transmitter batteries to using do-it-yourself (DIY) remote monitoring software (i.e., Nightscout) (51). The impetus for these modifications arose from dissatisfaction with the slow pace of innovation with regard to AID systems and has resulted in people with diabetes and their families rallying behind the development of open-source systems for diabetes management. Open-source systems have software code (i.e., the instructions for the program) that is freely available online and can be redistributed and modified for personal use (52).

Some people, primarily technology-savvy individuals with type 1 diabetes, use DIY AID systems (12). Information on how to devise and use these systems is freely available online, and it is important for HCPs to understand that some of their patients might be using such systems (12). In early 2023, the Tidepool Loop became the first DIY system to receive FDA approval (53).

Another unconventional use of diabetes technology is known as the “untethered regimen,” first described by one of the authors (S.E.) in a 2004 Internet post and later discussed in his patient-oriented book, Taking Control of Your Diabetes (37,54,55). In this method, basal insulin delivery is split between CSII (at a reduced rate) and subcutaneous injections (54,55). Individuals can disconnect their insulin pump during physical activity such as when swimming and then inject a small dose of insulin (or use the pump to deliver a mini bolus before disconnection), which will provide an ongoing reduced rate of basal insulin (54). A study assessing whether this approach might result in reduced glycemic management and increased risk of hyperglycemia and ketogenesis showed that a hybrid regimen of injected basal insulin and CSII with pump removal during exercise appeared to be safe and effective in adults with type 1 diabetes who exercise regularly. The study concluded that this approach could offer improved glycemic management immediately after exercise (54).

Digital health software and apps have been developing rapidly, and a wide range of platforms are now available to help people manage their diabetes (15,56). A small study of 20 people with type 2 diabetes that assessed the use of mobile health technology to support diabetes self-management concluded that, although there was some hesitation about using these platforms, participants largely incorporated them or were open to incorporating them as a means of making medication-taking more automatic and less burdensome. Participants had individual preferences, indicating that customization of content is needed, and they preferred simple and positively framed communications (57). These findings are reflected in ADA guidelines, which state that digital health systems that bring together technology and online coaching can be beneficial for some people with diabetes (12).

Because of the large volume of available software and apps, people with diabetes may find choosing which ones to use overwhelming, and PCPs may also struggle to advise them. A consensus report by the European Association for the Study of Diabetes and the ADA Diabetes Technology Working Group states that HCPs play an important role in advancing the use of diabetes mobile health apps, which can significantly reinforce medical practice, if the apps chosen complement individuals’ lifestyles and needs (56). The statement emphasizes that PCPs need to be supported to stay updated about available diabetes apps, that they should be knowledgeable about apps’ strengths and weaknesses, and that they should support and inform people with diabetes about the use of digital health apps to augment diabetes management and lifestyle modifications (56).

People with diabetes increasingly look for apps and online programs for lifestyle counseling, data tracking, and coaching, among other tasks, but there is limited evidence on the efficacy and safety of these platforms (12,56). The challenges of using digital health technology include inadequate evidence on accuracy and clinical validity, lack of training, poor interoperability and standardization, and insufficient data security (56). Although some apps have limitations, it is possible to identify apps that have been clinically validated by the FDA and hence are called “digital therapeutics” (12). Online privacy and security are also key considerations when using digital health programs, and individuals should review data privacy and sharing policies carefully before using them (12).

It is estimated that 96 million people ≥18 years of age in the United States have prediabetes (6). Prediabetes is a high-risk metabolic state for development of diabetes and is associated with heightened cardiovascular risk (58–60). Early identification of prediabetes (A1C 5.7–6.4% [39–47 mmol/mol], impaired glucose tolerance, or impaired fasting glucose) allows for prevention of later progression to type 2 diabetes and development of its complications (59–61).

The ADA recommends that adults with overweight or obesity who are at high risk for type 2 diabetes be referred to an intensive lifestyle behavior change program consistent with that used in the Diabetes Prevention Program (DPP) (59,62). The large-scale DPP demonstrated a reduction in the incidence of diabetes by 58% with lifestyle intervention and by 31% with metformin administration versus placebo (62).

Depending on individuals’ preferences, technology-assisted programs may be used to deliver the DPP-style program via smartphone, web-based app, or telehealth (59). Indeed, ADA guidelines state that programs that bring together technology and online coaching can be beneficial for some people with prediabetes, as well as those with diabetes (12). There is also increasing interest in using technology to remotely monitor individuals’ clinical data (e.g., glucose levels, weight, and blood pressure), but further studies are needed to quantify the benefits of doing so (12).

One beneficial feature of diabetes devices is the ability they afford to generate reports using a smartphone app or computer. This functionality enables the viewing of data and trends, which is useful for making adjustments between clinic visits, particularly when data can be connected to the clinic remotely for review at any time. Device apps provide a wide range of options for viewing blood glucose trends over time. The reports summarize a vast amount of data and lend themselves to easy interpretation make timely decisions, especially when testing basal rates and insulin-to-carbohydrate ratios.

Numerous mobile apps are available offering various features that will appeal to different individuals. When assessing which mobile app to use, we recommend looking at the following parameters:

• Is it easy for the individual to use?

• Does it offer automatic data input?

• Does it produce a data summary for the user and provider that combines BGM and CGM data overlaid with insulin delivery and food intake?

When using digital health technology such as mobile apps, individuals will need support to learn how to read and interpret their own data. PCPs and endocrinologists are essential in educating people with diabetes about how to adjust their care between medical appointments based on technology-derived data (12).

Once technology is incorporated into clinical practice, its use can save time and make clinic visits more efficient and effective; it also has the potential to allow clinics to support larger populations of people with diabetes (63,–,65). The ADA has provided recommendations on the use of technology for people with diabetes, and key actions PCPs should take when incorporating technology were highlighted in a recent review (12,15). The guiding principle is that the choice of technology devices should be individualized based on people’s needs, desires, and skill level, as well as device availability (12). There is no one-size-fits-all approach to the device selection or use for people with diabetes (12).

Simply prescribing a diabetes device is not enough; individuals must be engaged with the technology to optimize its use and their outcomes. The ADA recommends that health care teams ensure that both individuals and caregivers receive ongoing education and training (either in person or remotely) to evaluate their technique, results, and ability to interpret data (12).

Individuals using CGM should be advised about the potential for dislodging a sensor and told that skin irritation from sensor adhesives may occur (15). Technical issues with software and connectivity may also arise (15). Data suggest that CGM training and support provided remotely via telephone are sufficient to improve outcomes (40). Psychosocial support for CGM may be required in addition to technical training, and CGM may not be suitable for some individuals (e.g., those with high levels of anxiety) (15).

Diabetes care and education specialists (DCESs) are in a unique position to provide expert advice on how to integrate technology into the clinic and to partner with people with diabetes to implement technology devices (65). In primary care practices where resources are limited, telehealth and remote monitoring can enable virtual visits with a DCES (65). The role of DCESs as technology champions, and recommendations for best practice, are discussed in more detail by Isaacs et al. (65). In addition, Danatech, powered by the Association of Diabetes Care & Education Specialists, supports PCPs with up-to-date production information, device training, and professional education about diabetes technology (66). DiabetesWise for Health Care Professionals is another resource offering technology support for PCPs (67).

We are mindful that PCPs face extreme time pressures and that managing the introduction of diabetes technology may add to this pressure. Many people with diabetes are treated by nonspecialists such as PCPs and internists, which creates a “cycle of need,” in which physicians need to be trained on the latest advances but do not have the time to access the resources available to specialists (i.e., major diabetes scientific congresses). Indeed, we have experienced situations in which patients are more knowledgeable about and have more experience with a given type of diabetes technology than their PCPs. It is our belief that a lack of education for HCPs around diabetes technology is a barrier to people with diabetes using these devices, but it is a barrier that can be overcome.

We advocate targeted, efficient education initiatives to teach PCPs how to optimize the use of diabetes technology in clinical practice (e.g., how to quickly analyze CGM data download reports to inform treatment decisions). Doing so will allow PCPs to consider the addition of dedicated DCESs to their practice. These professionals can focus on patients’ technology needs and directly interface between patients and PCPs, with reimbursable benefits to the practice. DCESs can also improve communication among clinical team members and between the team and individual patients. We recommend referring to the ADA’s annually published Standards of Care in Diabetes (16) for the latest evidence-based recommendations on diabetes technology.

Gaining access to diabetes technology can be a complex process and may involve navigating multiple coverage components of insurance plans. Limited insurance coverage can be a substantial barrier to technology use, with varying levels of coverage available to commercially insured people and even more limitations for individuals with fewer resources (40). There is some evidence that the use of insulin pumps is more common in individuals of higher socioeconomic status (i.e., those with private health insurance and higher annual household income) (68,69), but further in-depth studies are needed to gain a better understanding of barriers to accessing technology resulting from insurance and reimbursement disparities. PCPs may also have their own, sometimes incorrect, perceptions of what is or is not covered by insurance companies (70,71), and these perceptions may limit their prescribing behaviors.

For people in the United States who have commercial insurance, we recommend that HCPs and individuals themselves contact insurance providers to find out whether a given technology and/or a specific device may be covered and to find out the eligibility criteria that must be met for that coverage. Several organizations, charities, and patient advocacy groups also provide resources about insurance considerations that PCPs can share with patients (Table 2). Alternatively, some device manufacturers offer a free service to check whether individuals’ insurance plan covers their device. Depending on the type of insurance plan, diabetes technology devices may be covered as durable medical equipment and/or as a pharmacy benefit (40), but even then, out-of-pocket expenses may be too high for some individuals and should be discussed on a patient-by-patient basis (72). Some device manufacturers also offer patient assistance programs that may enable access to individuals with low resources or no insurance.

For Medicare recipients, we suggest referring to the Centers for Medicare & Medicaid Services Medicare Coverage Database for information about which devices may be covered and related eligibility requirements (73). Support for navigating Medicare coverage issues can also be accessed via State Health Insurance Assistance Programs, which are federally funded by the U.S. Administration for Community Living (74) and can provide counseling and assistance. CGM devices are now covered by Medicare for anyone who uses an insulin pump, an MDI insulin regimen, or a basal-only insulin regimen, as well as for anyone with “problematic” hypoglycemia. Medicaid covers CGM in a growing number of states (40).

The U.S. health care system is difficult to navigate for HCPs, individuals, and caregivers alike. Understanding whether people with diabetes are uninsured or the extent to which they may be underinsured is crucial. Once this is understood, a major challenge for PCPs is the time required to determine insurance requirements for reimbursement and to check authorizations. PCPs need to be knowledgeable about the availability of reimbursement for technology and the affordability of devices for their patients. In our experience, PCPs may not always know what specific insurance plans will reimburse. Thus, we encourage PCP clinics to ask their payers what technology devices they might reimburse and under what circumstances. We also recommend that clinical practices implement processes for handling authorizations and reimbursements that work for their team; there is no universal approach that will best serve every clinic. In our experience, it may help to have dedicated full-time staff to handle these matters alone.

Diabetes technology is evolving rapidly, with new devices and approaches introduced each year, making it difficult for clinicians to stay informed of the developments (12). Some examples of advances on the horizon include smaller CGM sensors with longer wear times, further integration of CGM and insulin pumps, and more advanced predictive insulin delivery devices to further reduce the frequency and duration of hypoglycemia and hyperglycemia events (15). We recommend that HCPs do their best to stay abreast of these changes by referring to the annual ADA Standards of Care in Diabetes guidelines (21), as well as periodic updates released online.

Diabetes technology devices have become essential for high-quality management of diabetes and anticipated advances have the potential to further enhance and streamline patient care and empower people with diabetes to more effectively manage their condition. If we can overcome the barriers to diabetes technology use while also gaining a better understanding of the potential benefits of these devices, we will be able to optimize their potential for individuals and reduce costs within the health care system. An infographic highlighting the benefits of and barriers to diabetes technology as well as solutions to facilitate its adoption is available in Supplementary Figure S1.

In our experience, because they live with their condition all of the time, people with diabetes must be the most active and knowledgeable members of their care team to achieve the best outcomes and highest quality of life. Optimal use of diabetes devices can help them achieve these goals. Family members, loved ones, and caregivers are also pivotal in supporting people with diabetes and can also benefit from education about how best to help with diabetes care. Further education of both people with diabetes and their caregivers is necessary to make technology more widely available, prescribed, and used.

The authors are all active members of the diabetes care, education, and advocacy community, as well as people with diabetes themselves. S.E. is an endocrinologist who was diagnosed with type 1 diabetes at the age of 15 years. W.W.C. is an endocrinologist who developed type 2 diabetes almost 25 years ago. A.N. led a nonprofit advocacy organization for women with diabetes for more than 8 years and was diagnosed with type 1 diabetes at the age of 18 years. K.L.C. is a writer and advocate and leads a diabetes news organization and an online education and support website for people with diabetes. She was diagnosed with type 1 diabetes at the age of 18 years.

Medical writing and editorial support for this article were provided by Beth Degg of OPEN Health Medical Communications Group Limited and Gemma Hall, a contract writer working on behalf of OPEN Health Medical Communications Group Limited. Their work was performed under the direction of the authors.

The authors thank James S. Hirsch and Charles M. Alexander of the diaTribe Foundation and Close Concerns, Inc., for their reviews and editorial support.

The preparation of this article was funded by Novo Nordisk, which also completed a medical accuracy review of the manuscript.

S.E. serves on medical advisory boards and speakers’ bureaus for AstraZeneca, Lilly, MannKind, Merck, and Sanofi-Aventis; is a member of a medical advisory board for BrightSight; and is a board member of Senseonics and TeamType1. K.L.C. reports subscription fees and nonprofit contributions from multiple organizations. A full listing is available online at closeconcerns.com and diaTribe.org. No other potential conflicts of interest relevant to this article were reported.

All of the authors contributed to the conception of this review article, directed the writing of the manuscript by paid medical writers, critically reviewed and revised the manuscript for important intellectual content, and approved the final version for submission. S.E. is the guarantor of this work, and as such, had full access to all of the information presented and takes responsibility for the overall integrity of the article.