David Klonoff: 0:14

Welcome to Diabetes Technology Report. I'm David Klonoff, I'm an endocrinologist and I'm going to be co-hosting this interview today with a special guest. Co-host is Dr David Kerr.

David Kerr: 0:29

Thanks, david, and hello to everyone. I'm David Kerr. I'm speaking to you from Santa Barbara, california. I work as a researcher at Sutter Health. Today we have, I think, our first pediatrician on the reports. So, ida Senge, it's great to see you Looking forward to the conversation, and one of the things that we like to do to set the scene is to really ask you a very simple question, but it's usually quite complicated how did you end up where you are and why are you interested in diabetes in children?

Eda Cengiz: 1:08

Hi, david, and both Davids. Actually we have Dr David Klonoff and Dr David Kerr. Thank you for inviting me and yes, indeed, it's a simple question. However, it could be a bit complicated question. However, it could be a bit complicated. So I've been trained as a pediatrician and I wanted to do pediatric subspecialty and during my pediatric training I was involved in some diabetes research. I was taking care of kids with diabetes and since then I've been interested in becoming a diabetologist. So that's why I went to training in diabetes, pediatric endocrinology, metabolism and diabetes.

Eda Cengiz: 1:57

There's also a little background story. One of my childhood friends she was diagnosed with diabetes. So I was six or seven when my friend was diagnosed and that was the first time I was introduced to like insulin syringes and vials and there were no sensors, pumps were not as common. So I observed her going through like the diagnosis treatment challenges. She was a little kid, she didn't understand what was going on and I was a close friend. So you know, I kind of had the first hand experience in a way, like how diabetes is. So that's the story about my pediatric diabetes training and then I got involved in diabetes technology research and I love technology. I'm like my family background. I have family of engineers. I'm the only physician, the black sheep in the family, so I had that technology connection too, I guess. Yeah, all the stars aligned, and here I am.

David Kerr: 3:10

Excellent. I mean just thinking about your friend. Clearly, what's available for children with type 1 diabetes has changed dramatically. Where do you think we still need to go? What's the next frontier in the area that you're interested in?

Eda Cengiz: 3:29

Well, diabetes technology has made significant strides in improving lives of children with diabetes. As you're aware, diabetes is not an easy disease and it's even more challenging for children with diabetes adolescents. More challenging for children with diabetes adolescents. Back when I started diabetes technology research, we had pumps, we didn't have sensors. So most of the parents of my patients, they used to sleep in the same bedroom, their kid's bedroom, right next to their bed, because they were afraid of missing low blood sugars in the middle of the night and those kids were not going to camps, you know, field trips they were not going to sleepovers. So now, with, you know, continuous glucose monitors, they can monitor their kids' blood sugars from their phone and, you know, those kids now can go to school trips, field trips. It's easier to be molded in sports because they're not nervous about, you know, low blood sugars while they are at a game or practice. So that's why it made diabetes technology. Continuous glucose sensors and now AID systems made things easy for them. However, there's still room for improvement. So what's next? We want precision medicine. We want treatments that are tailored for children, for adolescents.

Eda Cengiz: 5:03

I do research in women's health. We're working on designing algorithms, insulin delivery algorithms for women with diabetes. We've done some research in that field. We need smaller devices, more accurate devices, and our dream has been a fully automated insulin delivery system, and we actually tested the first version in February. Now we're doing a follow-on study in September, so that would be the ultimate dream, but you know, sky's the limit. There's a lot more we need to do in that field. I've also done some work in ultra-fast acting insulins. I've also done some work in ultra fast acting insulins we're using, you know, still first generation, or maybe we can call it second generation, but we need like third, fourth, fifth generation insulins that work near future that will be incorporated into AID systems to improve those systems.

David Klonoff: 6:12

At UCSF. We're very fortunate that you came out and joined us. How did you end up deciding to come to UCSF?

Eda Cengiz: 6:23

It was an easy decision. In a way, ucsf is a very progressive place and I'm an endowed chair from Baniyov Children's Hospital and that gives me many opportunities to advance the field for improving diabetes care. So I was actually collaborating with people from the Bay Area because I do diabetes technology work and then, given that UCSF is an amazing center, I said, okay, why not, let's go there and do more diabetes technology studies. Another advantage is I'm the program director for pediatric diabetes program for UCSF and it's cross-bay, meaning we have clinics on the San Francisco side. We also have clinics in the Oakland side and patient population is significantly different.

Eda Cengiz: 7:20

We have people with disadvantaged backgrounds on the Oakland side and one of the first things we tried to do after we built our Center of Excellence for Diabetes Technology at UCSF was to broaden our patient population that are treated with diabetes technology devices, because it's not easy to get approvals for diabetes technology devices and you need a lot of handholding, especially if you're coming from disadvantaged backgrounds.

Eda Cengiz: 7:56

So we were able to reach out to that population and started them on automated insulin delivery devices and we are now seeing amazing outcomes. Their A1Cs are better, we reduce the burden and we're actually reducing diabetes, diabetic ketoacidosis or other diabetes-related inpatient admissions. So it's been an amazing experience for me and I'm so close to all the technology. You know software engineers best software engineers in the United States so it's so exciting to collaborate with them and it's easier to you know, set up meetings, just meet for coffee and brainstorm ideas. Set up meetings, just meet for coffee and brainstorm ideas. And, on top of it, san Francisco is a beautiful city. That's another big factor, I guess. And I'm so happy that I'm close to Diabetes Technology Society too. We've collaborated in so many areas when I was in Connecticut and now it's easier to connect Same time zone and we're just 20 minutes away from each other.

David Klonoff: 9:06

Ed, speaking of collaborations, you and I are collaborating on a project now involving occlusions of insulin pumps. Could you explain what is an occlusion and what's wrong with having an occlusion?

Eda Cengiz: 9:22

You know, for insulin pumps they inject infused insulin from. It starts from the you know the cartridge, then you have the tubing and then there is the catheter, so it's insulin is infused in the subcutaneous tissue and then it goes into your circulation. So you know, we have these amazing algorithms, we have the sensor talking to the pump. However, if your insulin is not delivered into your circulation, none of that is going to work. So that's one of the crucial steps delivering insulin without interruption. And it has to be accurate to the circulation so that you can regulate blood sugars, to the circulation, so that you can regulate blood sugars.

Eda Cengiz: 10:11

So occlusion can occur at many steps. I mean it can be even at the cartridge level. What's going on in insulin in the cartridge? Is there a bubble there? What's going on with the infusion tube? Is there a you know blockage there? And what's happening at the site of infusion? What's going on right underneath the skin and interstitial area? Is there a reaction that's, you know, or like some sort of a clot that's causing the occlusion? Of course, another thing is there could be a pump issue. Maybe the pump is not delivering enough, so that can cause an occlusion too. So that's why that's one of the crucial steps we need to. That's why that's one of the crucial steps we need to prevent. If we can prevent occlusion, then we know that we can keep blood sugars in range and we can prevent ketosis. So it's an important factor to keep our patients safe and to keep blood sugars in range to keep our patients safe and to keep blood sugars in range.

David Kerr: 11:13

Ida, just to change subject, when I go on social media and the news, there's a lot of talk about prevention of type 1 diabetes in children and adults, and what's your sense of where we are with that and what still needs to be done?

Eda Cengiz: 11:28

What's your sense of where we are with that and what still needs to be done? Obviously, our ultimate goal is to cure diabetes and to prevent diabetes. I've been doing diabetes technology work to actually keep people with diabetes safe and healthy until we find a cure and prevention. I've done some prevention work. I was part of like this was 15 years ago. I was part of the, you know, teplizumab treatment group and we back then we were infusing teplizumab within the first 90 days of diagnosis. And now we have an indication it's T-Zil, that's teplizumab, but we're using it in stage two diabetes to, in a way, prolong honeymoon phase. So it's not a cure yet, but at least that's one of the first steps. So we were able to achieve that.

Eda Cengiz: 12:26

And now there's so much ongoing work regarding, you know, immune modulation treatment to prevent diabetes. Also, there's stem cell research. I wish I can say, hey, you know, we're going to have a cure within the next couple of years. We're not there yet. Having said that, there's significant progress. So there's still ongoing research. I believe in the cure. I know we'll get there. I believe in the prevention. I know we'll get there. It's just it's going to take a while and it's going to take a lot of work.

David Kerr: 12:59

Yeah, so it's early stages, early days in that particular journey. The other question I always like to ask our guests on Diabetes Technology Reports is how is artificial intelligence going to change what you do on a day-to-day basis? Have you got any thoughts on that? I mean perhaps now and maybe in a few years time.

Eda Cengiz: 13:21

Oh yeah, it started already changing things for us. You know we have been using insulin delivery algorithms and now the next step is using AI. How can we make these systems smarter? I've been doing insulin action studies for again over a decade now and what I know for sure is one size does not fit all. There's so much variability when it comes to insulin action, so you need smarter systems that will account for that. And AI is going to be again like a game changer for diabetes management. And CHAT-GPT is a block away from me. That's super exciting is a block away from me. That's super exciting.

Eda Cengiz: 14:10

And UCSF is already actually collaborating with CHATGPT for improving medicine. We haven't collaborated with them yet for any type of diabetes research yet, but AI is going to be a big part of diabetes technology automated insulin delivery devices and it's the future for precision medicine to improve diabetes care and we are already collaborating with some of the algorithm experts to incorporate AI into our medical decision system. I'm collaborating with University of Virginia to design algorithms to improve again you know insulin delivery system for women with diabetes. So AI is going to be a huge part of it. Another thing we've been doing was to use e-learning AI both for patients, people with diabetes and for providers, and I'm collaborating with Children's Hospital of Philadelphia, dr Marks. She's been working on e-learning and her actually training modules for providers. They already use some sort of AI so that, if you need to, if there are like certain gaps in knowledge, that AI detects that and sends you questions, more questions, regarding that field.

David Klonoff: 15:35

So we're doing little bits and pieces, but I think the future is going to be bright and exciting for AI for diabetes care, for diabetes care and you have some amazing tools to offer your patients, but we know that there are many patients who cannot, will not, are not using them. What do you see as a way of increasing the reach of these tools, products, AIDs, so that everyone will benefit from them?

Eda Cengiz: 16:06

Excellent question. We have been working to broaden our reach for a while now. One key issue has been insurance coverage and we're trying to make the case to insurance companies so that we have insurance coverage for diabetes technology devices. They just see the cost of a CGM or pump, but they forget to see the big cost of one admission to hospital. You know, if you can prevent one diabetic ketoacidosis, you are, you know. One, it's improving patient safety. Two, you are saving, you know, safety too. You are saving, you know, 40, 50,000, maybe a hundred thousand dollars per admission just by spending like minuscule amount of money, little amount of money for sensor and pump. Now we're going to have hopefully soon, you know, ketone sensors so we can prevent ketosis with that. We have sensors that alert you for, you know, for potential low blood sugars, so you don't have to again. It's number one is patient safety. But the other thing is you're preventing an admission to the hospital for severe hypoglycemic reaction or an emergency room admission for severe hypoglycemic reaction. So one key issue is um is insurance coverage. The other thing is obviously um broadening provider care for diabetes, for like provider, like educating people with diabetes, and also providers for diabetes technology devices.

Eda Cengiz: 17:49

I give talks to primary care physicians, pediatricians, pediatric endocrinologists in the country and we had some resistance even from pediatric endocrinologists to prescribe diabetes technology devices because they didn't know how to use it. They didn't know how to insert, they didn't know how to troubleshoot. It was quite challenging to interpret those reports. But now, if we make it easy for people with diabetes, for providers, I think that way we'll have more and more people using these devices, benefiting from these devices.

Eda Cengiz: 18:31

And look what happened during COVID Many people, many providers, were not able to see their patients, were not able to provide care to their patients because clinics shut down. But for our people, for our people with diabetes who were using diabetes technology, their care was not interrupted during that period of time because they were using diabetes technology devices. So we need again you know, so many other things to reach out to people, especially, you know, people from disadvantaged populations. As I noted before, they need more hand-holding. We need multilingual guides, online resources, better education and more people to kind of help them, at least at the beginning, and remote monitoring support.

David Klonoff: 19:34

I have one last question for you. In adults, we're seeing CGMs being used by people who don't have diabetes to see if they have prediabetes or they're actually developing type 2 diabetes. My question for you is do you think we're going to see this in children wearing CGMs to see if they're going to be developing type 1 diabetes going?

Eda Cengiz: 19:48

to be developing type 1 diabetes. That's an excellent question and I think it kind of, you know, it's also relevant for your question about prevention studies, david. We now we're seeing more and more kids. They were diagnosed with, like you know, some high blood sugars here and there at the clinic, you know, during like sports physical, and then you know, families are, you know, they don't know what to do, and in the past we were like, hey, we don't have anything, any prevention method, treatment for you.

Eda Cengiz: 20:25

So sometimes we're thinking like what's the point in you know, checking, like monitoring those kids? To be honest with you, there is a point actually, because you know we still have 30% of kids diagnosed in diabetic ketoacidosis. They're coming in a coma to the hospital when they're newly diagnosed. So if there's any suspicion, I still see the value, significant value, of monitoring them with a CGM. But on the other hand, now we have this prevention drugs TZL and if we can diagnose them sooner with stage two diabetes and, you know, start the treatment, this gives them a huge opportunity and we can, you know, prolong their beta cell life, reduce complications of diabetes. So I see CGM as a very important tool to monitor those kids too. But we need to make it easier for them. We need to have you know, we need to reduce the burden. So if we're going to do CGM monitoring for those kids, it shouldn't add any burden or stress to the kid or the family.

David Klonoff: 21:31

Edda, thank you for answering these questions. You know so much about diabetes. I've learned a lot talking with you today. So I want to say, on behalf of Dr David Kerr and myself, thank you for appearing on Diabetes Technology Report. This podcast is available at the Apple Store and Spotify and the Diabetes Technology Society website. So we will see you again at the next Diabetes Technology Report podcast. Goodbye everybody, thank you.

Eda Cengiz: 22:02

Thank you.