I spent last week in Berlin at #ATTD2023, a major global conference on advanced technology and treatments in diabetes. This article is a breakdown of my personal top 10 takeaways based on what I saw and heard with links to further information and a curated set of live tweets from the event. I’ve included a couple of extra bonus topics at the end for those keen to read more - I'd love to hear what you think.
My top 10 takeaways at a glance
Why was I at #ATTD2023?
Before I start, for those who don't know me. I’ve had type 1 diabetes for 16 years and I’ve been writing about it since 2018. I’ve been using an insulin pump for 13 years and a commercial hybrid closed loop (the Medtronic 780G) for the last 2 years. I went to #ATTD2023 thanks to the #dedoc organisation which facilitates people with diabetes from all around the world attending diabetes conferences so there can be #NothingAboutUsWithoutUs.
Let's dive in.
1. Evidence supports "DIY" artificial pancreas systems
I kicked off my ATTD week at the Closing Conference of the OPEN Project.
The “OPEN” project brings together an international and intersectoral consortium of patient innovators, clinicians, social scientists, computer scientists, and patient advocacy organizations in order to investigate various aspects of Do-it-Yourself Artificial Pancreas Systems (DIYAPS) that are used by an increasing number of people with diabetes.
The project has been running for the last few years and this session brought together the conclusions of each of the project work packages.
How do people find DIY APS?
Bryan Cleal reported on the work on patient reported outcomes from using DIY APS (AKA Open APS or Android APS or AID), looking at emotional well-being, quality of life and lived experience. The evidence demonstrates a clear and positive impact on quality of life.
Does it work?
Yes! Katarina Braune presented positive data findings on blood glucose with improved HbA1C and Time in Range.
What does the future hold?
Dana Lewis talked about the potential for much more personalisation of Open APS systems and the ability to focus on what matters to each person. This could lead to the same great outcomes with less effort (YES!).
The #WeAreNotWaiting movement is leading the way on fully closing the loop (more on that in 8. below).
They are also working on how to get the algorithms to deal with the menstrual cycle (more on that in 7. below).
Industry is following, albeit slowly.
2. Ultra cheap insulin pumps are coming
With hybrid closed loop systems, the clever part is the algorithm that tells the pump how much insulin we need (or don’t need) at any given time.
To do this, we need two things: a CGM and an insulin pump. We need accurate and reliable CGMs so the algorithms are working with the right inputs (this isn’t a given – as an aside, see the post from Diabetes UK last week about approval standards for CGMs).
The pump, however, is “just” an insulin delivery tool. It doesn't need to be fancy.
But insulin pumps are still really expensive. And we’re committed to them for 4 year cycles. Martin de Bock gave a brilliant presentation on the work he and his team are doing to design an ultra cheap pump that can be made using 3D printers and other cheap components. They are aiming for these pumps to cost less than NZ$500 (about US$300). All the CAD designs for these pumps in development are freely available to view online and more research is underway.
There were questions!
Does this mean we’re all going to be 3D printing our own insulin pumps, cottage industry style?
Isn’t that a bit scary?
Martin was clear that this isn’t the model they have in mind. Ideally, once successfully tried and tested, this idea needs to be picked up by a low cost manufacturer and produced at scale so we can widen access to insulin pumps globally, and particularly lower income countries.
3. Big challenges for PWD in lower income countries
If we can make a cheap pump, that will be great for lower income countries, right?
Well, it’s not that simple.
It was raised in the Q&A discussion that in Africa and India, there is still a lot of social stigma around having diabetes. Wearing diabetes technology devices is not necessarily something that PWD in these parts of the world will be open to.
We were starkly reminded that in some places, access to diabetes technology means having a fridge to store insulin. Electricity supply is sporadic. There might not be money for food. Clinics may be far away and transport may not be available. Access to insulin and glucose testing strips is a challenge. People may not be able to read and write. We can’t get ahead of ourselves talking about new technology when basic needs aren't being met.
ATTD gave a platform to advocates from India and Africa
It's very easy to moan about things when you live in a G7 country with universal healthcare. We really don’t have any idea of the day to day challenges that people with diabetes face in other places, unless we create platforms to get their messages out and pay attention when they do. Thanks to the #dedoc organisation for connecting us with #dedoc voices representing Zimbabwe, Uganda, India and Latin America so we can learn from their experiences. It’s vital that we have local connections to understand what the real and immediate problems are in caring for PWD in those locations, and learning from THEM what is needed.
Fellow #dedoc voice Hamidah Nabakka presented at the #dedoc symposium on the challenges of having diabetes in Africa. The Sonia Nabeta Foundation is working hard to make a difference.
Leading diabetes advocate from India, Jazz Sethi, highlighted the common challenges.
Later in the week, Jazz took to the stage with Partha Kar to talk about Fighting Disparities.
4. Not much new tech on show from the big players
The exhibition stands were lovely, coffee was flowing freely from branded cups, but when it came to diabetes technology hardware there wasn't a lot of new tech on show.
Nonetheless, as a person with diabetes, it was a great opportunity to touch and feel the different pumps and CGMs on offer. We don’t get enough of a chance to do that in real life but choosing a pump is a big decision as it is something we have to wear 24/7 for the next 4 years.
Insulin pumps
I’ve been using the Medtronic 780G set up for nearly 2 years and that was the latest offering Medtronic had on display (there was an innovation booth too but entry was strictly controlled). The Dana, Ypsomed and Tandem pumps all looked like the same versions I’ve seen online for a while and they all continue to be very popular pumps. It was fun to look at the Omnipod too - I'd never held one in real life before and but I’ve brought an experience kit home with me to try. Of all of these, the Ypsomed looks like it ticks my boxes. Small, remote controllable (so you can wear a dress), loopable, easy set changes. Good feedback from the other #dedoc voices using it. I’m bookmarking that one for 2 years’ time when I need to shop for my next pump.
CGMs
Now I use the Guardian 4 which I have to use because it’s the only thing that works with the Medtronic 780G system. When it comes to other CGMs, the Dexcom G7 is a lot smaller than the previous model. If size matters to you though, the most exciting new device I saw was the Freestyle Libre 3. I used the original Freestyle Libre for a few years and really loved it. The Freestyle Libre 3 is the tiniest, loveliest CGM I have ever seen. For reference, here it is with my wedding ring.
It lasts 2 weeks. There's no overtape. It’s going to be compatible with looping set ups. It looks like it is proposing to me and I think I might say yes.
5. Some exciting start ups addressing unmet needs
In the back corner of the exhibition hall there was a Tech Fair section. There were stands from over 30 start ups and throughout the conference they each got a slot to present their pitch. I didn’t watch them all but some of the ones I saw were VERY cool, and seeking to meet genuine unmet needs.
Here are just a few highlights:
Problem: no independent platform to compare diabetes devices.
Solution: Created an algorithm to personalise recommendations. There's also a Diabetes Wise Pro site. US focused but helpful for all
Problem: Carb counting is hard to get right
Solution: the SNAQ app can do it for you!
Problem: too long between HCP appointments
Solution: New app links to CGM/pump data and gives clinical behaviour recommendations any time
Problem: Infusion set failures are frequent and hard to detect
Solution: "Smartfusion" tech can detect them quickly and can be integrated with all pumps
A full list of all companies exhibiting at the tech fair can be found at this link along with short company bios for each.
6. Interoperability really matters for user choice
Interoperability was raised at the Closing Conference of the OPEN Project. Choices are quite limited at the moment in terms of commercially available loop setups.
Pick and mix to personalise your set up
If you want to use a hybrid closed loop, you need a pump, a CGM and an algorithm that all work together. Some apps only work on certain smartphones. Things are available in some countries and not others.
People with diabetes are different and have different preferences when it comes to this stuff.
For those of us still choosing to use commercially available options (for now at least), the ideal scenario is that we can "pick and mix" so we can choose each element that best suits our needs and preferences. That would give us the most permutations and combinations of set ups but for that to happen, diabetes technology companies need to play nicely with each other. The people who go down the DIY route probably have the best set of options of all.
I think diabetes technology companies are acknowledging this, and they are making a big thing about their ability to connect their devices or apps with other diabetes technology companies. More of this please.
Or use one provider for everything
The notable exception here is Medtronic which is the only technology company currently offering a fully vertically integrated system with the pump, algorithm and CGM all offered under one roof. There are practical and convenience benefits to using one provider – everything works seamlessly together straight out of the box and all of your contact is with one company. The downside is – if you don’t like one of the elements in the system you can’t swap it out for something you like better.
I don’t see Medtronic moving away from its vertically integrated strategy though and I expect they will always have a captive audience of long time Medtronic users and people who simply prefer a one stop shop for their diabetes technology.
I spent a couple of hours with the Medtronic team at the conference. I've been very honest about my experience with the 780G system and the Medtronic team have taken it on board - the good and the bad. It was good to talk about what is in the pipeline and they were all lovely, generous with their time and open to hearing my feedback.
7. Diabetes is not sex/gender neutral - take notice!
Women and girls with diabetes have different challenges to males throughout all stages of life and we just haven't had the research or tools to support us. A lot of these issues have been ignored by the mainstream research community and its funders, even though we’ve known about them for decades. They haven’t attracted the money or the attention. It’s pretty rubbish.
THANKFULLY the ATTD gave a platform to women looking at these issues. I was delighted that there was a session focused on the specific issues women and girls with diabetes face. All the presenters were women, they were all EXCEPTIONAL and more than once I wanted to get out of my seat and cheer.
The sessions were on Saturday, last day of the conference. The conference hall started off pretty empty, and was mainly an audience of women but it did eventually start to fill up. Kudos to the men in the audience. You are the people we need to listen!
Side note to the ATTD organisers: the “women’s issues” and “disparities” sessions were at the same time right at the end of the conference – these are important issues and shouldn’t have to compete with each other in the graveyard slot at the conference.
I tweeted throughout the talks. The first is a thread on the presentation Technological Gadgets: What is available to women and girls with diabetes?
This thread is from the talk “Insulin dosing in women with T1D" – is there a need for tailored solutions.”
The conclusion was yes! During the menstrual cycle, insulin sensitivity changes and looping algorithms CAN successfully take this into account and improve time in range.
There are also different things to consider for women with diabetes when it comes to exercise (tweet thread here) and cardiovascular risks (tweet thread here).
Separately during the conference, #dedoc voice Laura Burlando presented her talk on diabetes and the menstrual cycle.
Dawn Adams also spoke about diabetes and the menopause and highlighted the research needed to help women with diabetes at that stage of life.
What’s next?
Tidepool is working on something called the Period Project.
Work is also going on to refine closed loop algorithms specifically for use in pregnancy.
Femtech startups are taking off around the world but none are (yet) focused on women with diabetes. Watch this space!
PLEASE amplify the work of these women. More money and support is needed to keep this important work going and to find answers to questions that women and girls badly need.
8. Bolusing for carbs will be a thing of the past
I said in the heading “will be” but it is already a reality for some of the DIYers out there. I met people at the conference who are on Android APS through the #dedoc events who say they are doing “absolutely nothing” each day to manage their diabetes and getting TIRs of over 90%. This is life changing stuff.
One of the oral presentations was given by Tim Street about removing "the onus to bolus". The #WeAreNotWaiting community is on the case!
The commercial players have also been talking openly for some time about the work they are doing to incorporate "unannounced meals" into their algorithms.
Diabeloop announced last week that it is conducting a clinical study with adolescents and young adults to validate their system for unannounced meals - read more here.
Medtronic announced last week some further positive results from its 780G system and talked about the Next Frontier in Therapy Management, including "the goal of eliminating manual meal announcements." Early results are promising - read more here.
Dexcom talked about "minimal user interaction" in one of their slides at the conference - this would be the ultimate goal. As fellow #dedoc voice Minou says, the #WeAreNotWaiting movement has led the way for industry to follow.
Is that the end of carb counting?
Does this mean the likes of SNAQ and other software companies helping PWD to count carbs are going to go out of business? Well, no, not any time soon. Remember that the vast majority of people who use insulin to treat their diabetes are using insulin injections so counting carbs and bolusing is going to be a continuing need for the foreseeable future for a lot of people.
9. Diabetes affects longevity - need to close the gap
The opening talk of the conference by Prof. Chantal Mathieu looked at the changing face of diabetes over the years – we've developed a better understanding of the complexity of diabetes, its incidence and prevalence and we've seen huge advances in treatments. Despite these advances there is still a longevity gap.
If you want to see the data on life years lost, I tweeted this slide (with a trigger warning) and it was one of the most viewed tweets I posted last week. Some people really didn’t like it, and that’s understandable. It’s upsetting if you or a loved one have diabetes (type 1 in the case of the data Chantal shared). But it has been talked about multiple times throughout the conference and as much as I personally would like to think that is about other people and I will beat the odds and live to 100, that’s not really very helpful. Instead now I want to know:
Why is there a longevity gap?
What are the risk factors I can modify?
What behavioural changes can I make?
How can technology help me?
What do I need to think about specifically because I am a woman?
In the women focused session I talked about above, some of this was addressed. I left that session feeling slightly scared but also more empowered. When you are confronted with the facts, you have to accept that some things you can’t change (like age at diagnosis) but some things you absolutely can. I am going home thinking a lot more seriously about how I can give myself the best chance of living a long and health life with this “shi**y disease”.
10. HCPs: be an enabler not a gatekeeper of tech
The evidence has demonstrated countless times that uptake of diabetes technology leads to improved clinical outcomes. We need to get it to people who can benefit from it.
Too often, bias, prejudice and hurdles get in the way.
This person is not focused enough on their diabetes to be a good candidate for a pump.
They aren’t checking their blood sugars often enough.
They won’t get the full benefit.
We need them to attend an education course first.
Often the prospect of moving onto a pump isn’t even raised.
They are all barriers to access. Obviously we aren’t talking about all HCPs. There are system issues that constrain what people can offer in their clinics. But PLEASE be open. Tell people what their options are. Don’t prejudge their preferences.
Supporting DIY APS
There is also still a difficult dynamic in some camps around the acceptance and support of people with diabetes using DIY APS. There was an interesting exchange in one Q&A session where an HCP said (and I paraphrase) “DIY APS is causing us problems, how are you [PWD] going to fix that?”. There were also stories from the other end of the spectrum of “off the record” HCP appointments in coffee shops to allow them to talk openly about the DIY APS system that the PWD is using and offer advice and guidance. Starting from a place of “lets learn about this together” is probably a good way forward. DIY APS is here and it can’t be ignored.
Education for HCPs needs to keep up with these rapidly changing times.
It seems fitting to end with the voice of Partha Kar. Be a guide.
Bonus topics
These didn’t make it into my personal top 10 but they are deserving of a mention:
11. Use of technology in people with T2D
There were discussions about the use of CGMs in people with Type 2 diabetes (both insulin users and non insulin users). More research is needed on this.
12. Healthy ageing with diabetes
In her conference opening speech, Prof. Chantal Mathieu urged people not to dismiss technology for older people with diabetes.
In a dedicated session, the topic of healthy ageing with diabetes was explored further. Check out this thread for some take home messages:
Acknowledgements
Thank you to the #dedoc organisation for providing me with a scholarship to attend the conference. They paid for my flights, accommodation and my entry to the conference.
These are all my personal views.
I hope this helped! Please feel free to reach out to discuss any of this further.