An interview on the psychology of diabetes technology with William Polonsky, Associate Clinical Professor in Psychiatry at UC San Diego and president of the Behavioral Diabetes Institute.
An interview on the psychology of diabetes technology with William Polonsky, Associate Clinical Professor in Psychiatry at UC San Diego and president of the Behavioral Diabetes Institute.
Welcome to Diabetes Technology Report. I'm David Klonoff. I'm an endocrinologist at Mills Peninsula Medical Center and UCSF and I'm going to turn this over to fellow endocrinologist, david Kerr.
David Kerr:Hello everyone. I'm David Kerr. I'm speaking to you from Sutter Health in Santa Barbara, california. Today we have probably the most famous diabetes psychologist on the planet. It's a really warm welcome to Bill Polonski. Bill, I'm sure most of our listeners know you have heard from you, have listened to you, but I'm kind of wondering, as a first question how did you get into diabetes and psychology in the first place? What persuaded you to go down that route?
William Polonsky:Well, first of all, thanks. I'm really glad to be here and to join you guys. So I've been a diabetes psychologist for about 35 years and my journey was fairly accidental. I'm by training what's called a clinical health psychologist and in 1988, I think it was I almost accidentally stumbled into a place called the Jocelyn Diabetes Center and they had I can't remember exactly even how I ended up there, but for a variety of reasons they said oh, maybe you should come work here for a while. They weren't quite sure they needed a psychologist there actually, and I wasn't. Of course I had no idea what I was doing either. But they said why don't you come work here for six months and let's just see what happens?
William Polonsky:And I was very lucky because the very first day I walked in, luckily the Jocelyn at that point being the largest diabetes center in the world had a very large waiting room and I just started walking up to people and I would introduce myself and say, excuse me, I don't know if I'd like to ask you a question just could you tell me what's living with diabetes like for you? I figured that was my only way I'm going to figure out if I could have a job here and what I needed to do. And I'll never forget the very first person I asked that question to said looked at me in shock actually, and said, to my surprise, thank you. And I went thank you, what are you talking about? She says, well, I've had diabetes a long time.
William Polonsky:No one's ever asked me that question before. And I went wow, that's really unfortunate. But she did tell me. And then I kept walking around the waiting room and kept asking that one question what's living with diabetes like for you? And I just got more and more fascinated and honored. People be willing to share their stories with me and didn't take long to realize we uncovered an incredibly important problem that hadn't been addressed or even noticed before, and I have just felt lucky every day since then to be involved in this field and feel like I'm able to make a difference with folks, both as a clinician and a researcher. So nice.
David Kerr:it was accidental. Accidental it's worked. Now we're today going to talk about diabetes technology, just in general terms, but what's your view of where we are with this? I mean, how much benefit have people with diabetes globally seen with the application of technologies in your view, and what are some of the things that still need to be done?
William Polonsky:I'd like to be neutral and stay calm about this, but I can't and just say it is a freaking miracle how things are right now and, in terms of what I've certainly I've seen in the 35 years I've been in this field, it is absolutely extraordinary the degree to which we've helped people have a sense of control over their own fate, sense of hope for their future, sense of self-efficacy. So much has happened, so much gained. I'm quite sure you both feel the exact same way. It has really been amazing. Do we have a long way to go? Yeah, because we know this is at least here in the United States.
William Polonsky:This is still technology that is not as affordable as it could be for somebody folks. We still know there's other advances that we need in terms of well, who am I talking to? You guys know more of this than I do In terms of making the data meaningful for folks, in terms of miniaturizing things even more. I mean making things even more reliable than they already are. Although we've seen such enormous advances over the past few years, I couldn't be more excited about what we've seen or what's happened with diabetes technology. What an enormous difference it's made for folks, especially in my own tiny universe of my field, in terms of its impact on diabetes distress, in terms of people's fears of hypoglycemia and so much more. It's been beyond revolutionary, and I think we're very lucky to live in this time.
David Klonoff:Bill, one of the most widely used technologies these days is continuous glucose monitoring. What's been your observation about whether people like using it or whether they feel they're tethered to a machine? What's it been like?
William Polonsky:It's been extraordinary. I can't help smiling just thinking about it. I can only remember one person who came to see me. In fact, I just saw her again after about seven or eight years, I think, since I first met her. I remember telling her I said you're someone who's having a tough time. I think you would really benefit from getting on one of the early continuous glucose monitoring systems.
William Polonsky:She had such an interesting type of reluctance that I never heard of. She said I really don't want to do this. The concern she had was if I start using it, then I won't be able to stop. I went well, no, you could stop anytime you want. She goes. Oh, well, then, yeah, I guess I should give it a try. But there was this sense of this is going to be permanent, it's going to be glued on, I'll never be able to quit using it. And once she realized it was in her control, it changed everything for her. So she was literally the only person I can think of who was, at least initially, rather that reluctant, and for I'm probably overstating it I could probably think of others.
William Polonsky:But again, we've seen, for I mean, how many people have you seen that I've seen? You said it's like using CGM, it's like someone's turned the light off. It's like, oh, that's what's going on. And yes, it's true, there are people who I meet who need a break from it. I just saw some of a few weeks ago like that who needs a break every once in a while because she was losing a sense of perspective on who's controlling who. It was sort of this sense that this CGM was sort of watching me and judging me as opposed to being my information. I can do with it what I wanted, and she really needed to put it aside for a while so that she could take time with me actually to rethink what's her relationship with this device and is it working for me or am I working for it? So that sometimes is a challenge that we see, but I'm glad to hear that I don't think that's so common. It's not as common as we saw it originally.
David Klonoff:You were first author on the famous step study, which showed benefits from blood glucose monitoring. Do many of your patients do blood glucose monitoring these days? Not, if I can help it.
William Polonsky:No, we don't see that too. I mean I feel very lucky. At least here in sunny San Diego and given their really extraordinary and a chronologist community we have here in town and PCPs, we see people very rapidly moving from using traditional all-strip blood glucose monitoring to CGM. Especially, it's become more affordable and covered by insurance. We see that even in the newly diagnosed patients as well, and newly diagnosed type 2 patients even and of course I think we're all we can all agree this becomes more affordable. We're going to see regular strip monitoring probably go away. I mean, it's hard to believe it will stick around.
David Kerr:Well, let's look into the future. The hottest topic in technology at the moment is artificial intelligence, and I don't know what's the right or the wrong thoughts about this. What are your thoughts about the application of AI in diabetes care? Who's going to benefit, who's going to suffer, is it affordable? And all the usual philosophical questions.
William Polonsky:You know I have a funny feeling. You two may know a lot more about this than I do. I'm not sure at all what we are talking about and what we're seeing. I mean, I've played with this technology a bit but as we see how I guess the promise of AI is going to make you know whether it's pumps and whether it's CGMs simply make it easier for people so that they need to make fewer decisions. Right, as we move that much closer to a truly closed loop system, I think we're going to see people uncomfortable and reluctant about such systems until they can feel that they can trust it right.
William Polonsky:So one of the things that we've seen in all of our studies over the course of years is what drives people to be willing to take and use technology, to start it and to continue to use it and to use it well, is trust. You know, can I trust that this device is reliable? Can I trust that this device isn't going to mess things up for me? It's that trust issue that is so gigantic. I'm sure you've both seen that as well.
David Klonoff:Bill, have your patients been using mobile apps that either give them advice or reminders or nudges? What's been your experience with that type of technology?
William Polonsky:You know, I've seen some. I tend to downplay it so much. If they have, they probably don't even talk about it to me anymore. So you know, to me, what we see is the people who benefit from apps are the people who like apps, right? It's people who are already engaged with their diabetes to such a degree that they find this to be an extra benefit that can help them make better use of their engagement, and I preface that just because of what I do for a living. We tend to see people who aren't that engaged, right? So you know, we tend to see people who are again wearing my clinical hat who are really disengaged from their diabetes. Maybe they have one foot in, one foot out, but they're far away from thinking about what are the most advanced technologies to use. We're still trying to convince them that it might be worth their effort to even give their diabetes as much attention as it probably needs. But the apps are not something we touch on much.
David Kerr:Bill, just taking that further, I still remember your fantastic presentation at the American Diabetes Association a few years ago about diabetes education. You had some fairly provocative things to say in those days and they stuck with me. So I mean the bottom line diabetes education doesn't have people refer, it's boring, I think you said so. What can technology do to turn that on its head and get people access to and participate in and benefit from diabetes education? What do we need to do?
William Polonsky:Bill, I'm so glad you asked. We published a small pilot study last year. In fact, we're just getting ready to start a randomized control version of this where we really want to reinvent diabetes education, especially diabetes education for people with type 2 diabetes, because it has been for so many people so boring and so demotivating. And so it's what we call the AHA project and the idea of saying why should anyone ever, ever have to be given another boring lecture about how to eat, right, about diabetes? We could just give them a CGM, send them on their way and have regular conversations about whether it's in a structured way, like we did in the step study, where we're using just strip monitoring, or whether it's more free form. But to say, let's, you know, people are going to be way more interested in their glucose values than, broadly speaking, what a glucose value is or what an A1C test is.
William Polonsky:And so when you set people free and let them have you know, give them a CGM and say, let's find out how food affects you, let's see how exercise affects you. It's extraordinary and so funny actually. People often come back and say I had no idea. Why didn't anybody ever tell me that? You know, exercise can have such a positive effect on my blood sugars. Well, I'm pretty sure people did tell you that, but what's important is that you've discovered that on your own with your own data, because it just makes it a whole lot more real and a lot more meaningful. So we couldn't be more excited about how the future the CGM is going to completely transform what diabetes education really is for people in this country and hopefully around the world.
David Klonoff:Bill, I have a question for you that's not about technology. What do you think about the widespread use of Inquitins these days? These are drugs like Osempic, Monjaro, Trulicity. Will these replace all the other treatments for diabetes and we won't need to do anything else except prescribe these drugs?
William Polonsky:That's a really good point. I mean, certainly we have seen extraordinary outcomes, right, Not just in our large RCTs that we're all familiar with, but in our own clinical practices, whether we're talking about Osempic, whether we're talking about Wacovi Monjaro. It really has been, although not universal, but it really has been extraordinary in terms of what we've seen. You know, I have to say clinically something that's really been niggling at me, that I'm just starting to wonder whether people, we should co-brand Inquitins with CGM, Because we're starting to see patients who are more likely to stick with, say, Osempic through some of those difficult early weeks and months when they're also provided with and can look at their own data and see that it's making a difference and they kind of reinforce each other and help people stay enthused. And we're seeing that clinically and I wonder if that's going to end up becoming a bigger thing.
William Polonsky:Because I do think just Inquitins on their own aren't going to be just enough for everybody. I don't know. I think we're going to see that many people need support, very specialized and personalized support, and I'm going to be fascinated to see how technology, especially CGM and use of mobile apps, can make a difference for some of these folks. Obviously, we're just at the fourth, we're at the beginning of this in so many ways, so I'm intrigued, but I don't think it's going to replace everything.
David Klonoff:Bill, thank you for speaking to us today at Diabetes Technology Report. This podcast is available at Spotify, the Apple Store, Diabetes Technology Society website and Salud Diabetes. We will catch you at the next Diabetes Technology Report. On behalf of Dr David Kerr and myself, we appreciate your time with us today. Bye-bye.
David Kerr:Bill, thank you very much.
William Polonsky:My pleasure. It's great to be with you guys. I'm very happy. Thank you for inviting me.