Roadmaps to Continuous Glucose Monitoring’s Role in Transforming Diabetes Management Free

We are experiencing a global pandemic of diabetes and its associated complications, costs, and effects on quality of life, challenging us to innovate and disrupt our current approaches to diabetes management (1–3). Over the past decade, there have been a series of innovations in diabetes research followed by positive clinical trial data leading to new drugs (e.g., glucagon-like peptide 1 [GLP-1] receptor agonists, dual GLP-1/GIP receptor agonists, possibly triple agonists, and sodium–glucose cotransporter 2 inhibitors) and a new approach to glucose monitoring (i.e., continuous glucose monitoring [CGM]), offering hope for a more comprehensive and personalized approach to diabetes care. If one adds the promise of advances in precision diabetes care (i.e., the “-omics”), digital health, and the recognition of the need to also address the social determinants of health, the elements are in place for a transformation in diabetes care within the next decade (4,5).

Transforming diabetes care is a step-by-step process from innovation to investigation to implementation (6). We need roadmaps for each component of diabetes care (i.e., drugs, devices, data, and equity) to keep the diabetes community, including people with diabetes and their families, clinicians, researchers, diabetes care and education specialists (DCESs), payers, industry stakeholders, regulators, funders, quality measurement organizations, psychologists, social workers, pharmacists, and others, focused on effectively translating research into practice (7). I would like to thank the American Diabetes Association and Diabetes Spectrum for giving us the opportunity to focus this From Research to Practice section on how CGM can address many of the unmet needs in diabetes management.

My partner in pulling this series together has been Diabetes Spectrum Associate Editor Anastasia Albanese-O’Neill, who exemplifies what it means to be both a leader and a collaborator dedicated to finding a way to help people live well with diabetes. We debated whether the communication vehicle for these insights should be roadmaps or toolkits because both embrace systematic approaches and are action-oriented. Roadmaps prevailed because this concept would allow each contributing author to map out recent advances in the use of CGM in their areas of expertise, discuss barriers remaining to be overcome, and highlight their expectations for the next frontiers in CGM innovation, investigation, and implementation.

The diabetes community is very broad and diverse, and while we did not have space in this article collection to learn from representatives of each group, we did ask respected leaders in five key diabetes care disciplines to create roadmaps outlining the opportunities and challenges for the effective use of CGM to transform diabetes care in their domain of expertise. These experts have been leaders in either innovation or landmark clinical trials moving diabetes care forward, but most important to this collection was each authors’ ability to outline practical implementation strategies to translate these advances into new models of more effective clinical care. I am excited to introduce the authors, whom readers will immediately recognize as leaders in the diabetes community. I am grateful for their willingness to educate, inspire, and guide us toward transforming diabetes care with their wisdom and their roadmaps to the effective use of CGM in diabetes self-management education and support, endocrinology, primary care, and pregnancy care for people with diabetes, as well as in our efforts to achieve care equity for all people with diabetes.

Our series starts by highlighting the crucial work of DCESs, the key technology champions on most diabetes care teams (p. 288) (8). These professionals serve as an essential communication link across all disciplines providing diabetes care, as they both educate and support people with diabetes and also facilitate professional education and skills-building for the clinical implementation of diabetes technology. There was no better person to ask to write this article than Dr. Albanese-O’Neill. She highlights how effective CGM can be in optimizing diabetes care and quality of life, and this message seems to be resonating, as evidenced by a steady uptake in CGM use in both endocrinology and primary care practices. Despite unanimous recognition among all of the major diabetes organizations that diabetes education and support services delivered by DCESs are an essential and effective component of comprehensive diabetes care, these services are still significantly underutilized. In her article for our collection, Dr. Albanese-O’Neill delivers a valuable real-world example of how to implement an effective diabetes care, education, and support service for the use of diabetes technology, outlining all of the strategies, materials, and workflow steps her team at the University of Florida’s Division of Pediatric Endocrinology has implemented. Their approach can serve as a model for other institutions.

Next, we turn to CGM use in diabetes specialty care—in this case, pediatric endocrinology, as represented by Priya Prahalad and David M. Maahs, two leaders who are doing groundbreaking diabetes technology research to determine the value of early intervention with advanced technology such as CGM in children and adolescents with type 1 diabetes (p. 299) (9). They review lessons from their influential and often-cited 4T (Teamwork, Targets, Technology, and Tight Control) study. We are fortunate that Drs. Prahalad and Maahs were willing to share not only their research but many key pearls of implementation, including their work to ensure care equity, the importance of having easy access to CGM data, and the value of developing a technology data dashboard, all of which make the Stanford Pediatric Endocrinology Clinic such a valuable model clinic for other endocrinologists who are seeking to transform diabetes care.

Most care for diabetes, particularly type 2 diabetes, is delivered in the primary care setting. Thus, if CGM is going to live up to its full potential in helping to transform diabetes care, we will need many primary care provider champions who are skilled in analyzing and acting on CGM data. Primary care clinics will need to figure out how best to implement CGM into their remarkably busy workflows and determine how and when to comanage people with diabetes with DCESs and endocrinologists. This topic is addressed in our series in an article by Thomas W. Martens (p. 306) (10). It has been my pleasure to work closely with Dr. Martens, who has an active internal medicine practice at Park Nicollet/HealthPartners and is also a medical director at the International Diabetes Center (IDC). He helped to lead the MOBILE study, which showed the value of CGM in optimizing the care of individuals with type 2 diabetes on basal insulin therapy (11). This work was incorporated into the American Diabetes Association’s (ADA’s) Standards of Medical Care in Diabetes (12), and basal insulin therapy was added to the growing list of indications for the use of CGM. This is a prime example of the first step in translating research to practice. Dr. Martens’ article in our series also takes us on an insightful exploration of additional opportunities and barriers encountered in implementing CGM in the real-world primary care setting.

All would agree that optimal glycemic management is essential and yet complicated when dealing with diabetes in pregnancy. We are fortunate that Helen R. Murphy, one of the world’s leading experts on the management of diabetes in pregnancy, was willing to share her insights on the value of CGM and other advanced technology systems in her article for our research section (p. 315) (13). Few people have spent as much time as Dr. Murphy thinking and writing about CGM metrics, profiles, target ranges, and management strategies to help ensure the well-being of both pregnant women with diabetes and their babies. Just reading Dr. Murphy’s closing paragraph on directions for future research will make you feel that it was worthwhile to open this issue of Diabetes Spectrum.

The preceding four articles all mention the particularly challenging goal of providing CGM-guided diabetes care in an equitable and affordable manner in each of the settings addressed. Our fifth article, by the inspiring chief medical officer of the T1D Exchange, Osagie Ebekozien, expands on this theme (p. 320) (14). Across the diabetes scientific literature, in the lay press today, and in Dr. Ebekozien’s article, you can find facts and references that elucidate the current state of inequity in the prescribing and use of CGM and other advanced technology systems in diabetes management. However, Dr. Ebekozien’s article is one of the few sources that focuses on the actual steps needed to move toward tangible solutions to this vexing and persistent problem. These suggestions for action are based on the findings from the CGM equity project of the dynamic and influential T1D Exchange Quality Improvement Collaborative, which Dr. Ebekozien so masterfully leads. No matter what discipline within the diabetes community you represent, you will fine recommendations that pertain to you in this comprehensive call to action toward the realization of CGM equity.

To close our From Research to Practice section, I was given the opportunity to reflect on the evolution, current impact, and future promise of CGM (p. 327) (15). I incorporated concepts from the other five articles and from what I have learned from my colleagues at the IDC throughout the past 40 years, including Don Etzwiler, Roger Mazze (who introduced us all to the concept of the ambulatory glucose profile), David Kendall, Bob Cuddihy, Mary Johnson, Gregg Simonson, Amy Criego, Anders Carlson, Dr. Martens, and others. I also drew on the knowledge I have gained from colleagues at other institutions, who I routinely call to ask, “What do you think of this idea?” or “How can I help with the amazing technology work you are doing?” These world-renowned diabetes technology experts include Roy Beck, Irl Hirsch, Anne Peters, Satish Garg, Bruce Buckingham, Grazia Aleppo, Davida Kruger, David Klonoff, Tadej Battelino, and Moshe Phillip, to name just a few.

My closing roadmap to CGM innovation, investigation, and implementation was formulated with Aaron J. Kowalski’s classic artificial pancreas roadmap in mind (16). I tried to summarize the 25-year history of CGM, outlining what the diabetes community has achieved, what we are still working on, and what we need to tackle next, including innovations we all hope will materialize before much longer. Others in this field may have laid out this roadmap in a different manner, but I imagine the destination for all such CGM roadmaps will be a place and time when all who can benefit from the use of CGM or other life-changing approaches to diabetes management have equal access to these transformative therapies.

Dr. Albanese-O’Neill and I thank our coauthors and the ADA Journals production team, including our skilled Managing Editor, Debbie Kendall. We hope you enjoy this insightful collection and welcome your comments.