David Klonoff: 0:12

Welcome to Diabetes Technology Report. I'm Dr David Klonoff. I'm an endocrinologist at Mills Peninsula Medical Center in San Mateo, California. We have a special guest today from Europe my co-host.

David Kerr: 0:32

Dr David Kerr will introduce her. Hello everyone. Yes, this is David Kerr. I'm speaking to you from Santa Barbara, california, and it's a real pleasure to welcome the new managing editor of the Journal of Diabetes Science and Technology, dr Julia Mehta. Welcome, julia.

Julia Mader: 0:43

Hi, nice to meet you guys.

David Kerr: 0:45

And what we like to do with these is get a little bit of background. Try, you know, set the scene. So how did you end up being interested in diabetes and diabetes and technology? Specifically, what were the drivers of this?

Julia Mader: 1:02

Well, so interestingly, already quite early during my career, I ended up in diabetes technology. I have to admit so when I was finalizing my last year in medical school, I ended up in diabetes for doing my thesis there, diabetes for doing my thesis there. And my first project already brought me to the field of diabetes technology. That was about glucose sensing in the intensive care unit. At that time it was a bit of a how do you say awkward theme that no one was believing in. And that's been nearly 20 years ago and fortunately I managed to stay on the bloodstream.

David Kerr: 1:46

And what are you up to at the moment?

Julia Mader: 1:54

What sort of keeps you up at night thinking about diabetes and technology? So what really keeps me up at night is I want to make the lives of people living with diabetes more easy. So, for example, I just came back from a diabetes camp with kids with diabetes, and then you see all the hassle and all the difficulties that they still endure, even if they now have probably way much better therapies than we had 10 or 15 or 20 years back. It is still for them an ongoing challenge and I hope at some point in time we can make it so much easier that they don't notice that they have any chronic condition to pick out.

David Klonoff: 2:33

Julia, what would you say are the differences you see in the types of problems you have to address for type 1 people versus type 2 people?

Julia Mader: 2:42

So I think for type 1, it's still more complex.

Julia Mader: 2:47

Even if you're well trained and know what to do in different situations, you still have to take into account so much about exercise, so much about food, specifically, let's say, when you are on vacation.

Julia Mader: 3:01

So I was on vacation with a good friend of mine who has type 1 diabetes and he made kind of a challenge out of it to go for the food that all of us had and we were doing a report for the Austrian society there and he took pictures of the food and then how we ended up needing glucose and he said, even if he was trying his very, very best, he ended up either in hype or hypoglycemia because he never was sure about what in that group.

Julia Mader: 3:27

Specifically, he was not familiar with the kind of food in the workplace. And so type 1 is probably way more challenging if you compare it to xenocorpus tutoribus and I think for type 2 tutoribus the advances have been really ongoing. We have observed a lot of new medication, drugs that make light and walk in the air, so that people with type 2 diabetes nowadays don't need to go for complex count counting, for complex monitoring or advice by us, but with all the new drugs that we have available. In many countries, insulin is the last line of defense. It's not complex, it's just some new stuff.

David Klonoff: 4:20

Julia, you live in Austria. Is the Austrian government interested in helping people with diabetes? Do they have any programs that you work with?

Julia Mader: 4:31

So it's not so much the government that defines the programs, it's more the societies and also the hospital center people caring for people with diabetes who enable that. But what we have to definitely admit is that in many of the European countries, including Austria, access to medication is very good, so that people really pay a low amount of money compared to what I've heard at least people in other places of the world need to put in terms of money on the table. So, for example, in my country, if you have no special other insurance, usually you pay seven euros per package of medication. You're respective of what the costs are if you have it approved for your condition, but otherwise you pay seven euros a bed for whatever the cost of the medication is itself.

David Kerr: 5:30

Julia, I'm just interested in comparing the US with Europe. What do you think is the rate of type 1 diabetes? The proportion of people using closed-loop or artificial pancreas systems? How much penetration is there?

Julia Mader: 5:46

That's a very good question. I think that depends a little bit on the age of the people, so it's fully covered for everyone who wants to go for it. The obstacle is more into who wants to go for it. So I guess in the pediatric field we are at 70% to 80% to 90%, depending on the clinic that people are taking care of. In the adult population I guess it's roughly around 60 percent, 50 to 60 percent again, depending a lot where you are in uh in care. So it might be that the gp takes care of you and that they are not familiar with that technology and then you don't end up using it. But in general the uptake is increasing with better systems becoming available. Only drawback that we still have in my country we only have two systems available and none of that includes a patch plant.

David Kerr: 6:44

Interesting. I mean our own data here in California suggests that the use of AP is actually a lot lower than that. So we're very jealous. What about the use of wearable technologies such as CGM in people who are not on insulin? Is that becoming a big deal in Europe?

Julia Mader: 7:02

Not yet because that's not reimbursed and, in contrast to the US, people are not really used to pay out of the pocket for any healthcare-related expenses. Well, nearly not so for people without insulin. They might be really a minority in the one-digit area. So I don't even have one single patient who is using CGM without insulin at present. You see a slight uptake, even if it's not funded, in terms of those double agonists regarding obesity. So that's maybe something new that they did not have in the past before, because there they truly have the need on their own perspective. But for CGM in those without insulin, I don't see really a big uptake.

Julia Mader: 7:59

The only group that uses it but those are keeping without diabetes are people in training in the sense that who are training maybe, let's say, for marathon or long-distance runs or cycling, because they want to understand better their refueling procedures during exercise. But for type 2 and oral agents I would not see that. There is maybe a small niche where how I can still request reimbursement for people without basal bolus therapy If I indicate okay, people are using basal insulin with bolus on demand and the insurance companies don't ask how much the demand of bolus insulin is. So that's kind of a little way how to get around the reimbursement. Slotted genes, but only for those who are insulin-model.

David Klonoff: 8:53

Julie, you mentioned these new GLP-1 receptor agonists. In the US they're becoming very popular. Some people think that that's going to become first-line treatment, even ahead of metformin. These drugs are very effective. Are they used much where you are, and what do you think about them for type 2?

Julia Mader: 9:14

I think they are becoming more and more wide and loose and they will become for sure a game changer. If they will end up before metformin I do not yet know, but I think they are at a very strong position at least in coming in a second in those I do not yet know, but I think they are at a very strong position at least in coming in a second in those who do not meet the targets. Before it was only people who had either HbA1c above 8.5%, preferentially in those who had also a BMI above 30. But the insurance companies nowadays at least recognize advantages and allow us to use them in a broader clinical cycle so that meta-OR should be present and even in type 1 diabetes they are becoming reimbursed nowadays consensus panel that advocated the use of making GLP-1 RAs available for T1D patients using automated insulin delivery systems.

David Klonoff: 10:13

We worked on that together, and David Kerr is as well aware of that. So, Julia, what types of technologies do you see now that look very promising?

Julia Mader: 10:25

So I think for people who are not wanting to go for an AID system, connected pens and more of that, even smart pens, are becoming really important because they help people to really not only track better their insulin doses but also to help them to calculate, because calculation is a big deal Hopefully also with some technology included that tells them, as according to the glucose rise, how much insulin they should inject, because that's still the largest burden.

Julia Mader: 10:59

I also think that glucose monitors, even if they are not combined with the ID system, as soon as they give better insights and deeper understandings of how to re-inject to glucose values, will become important. I'm not so sure how soon we're going to see ketone meters or combined meters on the market, but I guess that will also facilitate some of the diabetes management, because sometimes you just simply don't know is it the meeting of the eating room, the fat content of the meal, because it's not going down, or is it the catheter cooling? In that sense we could do the benefit also of a combined and PCOS monitoring approach and we also observe in some people and some research that's ongoing, some technology to track other conditions like that. But it took disease, but that's still something very young, so I've been involved in one project, but it's not so sure how easily that's going to be realized on one side and we'll get the better treatment that we have. Maybe we also see deep decline in those complications that we don't need to monitor those conditions anymore.

David Kerr: 12:18

but I mean that would be another three the other thing I would like to ask all of our contributors is about artificial intelligence, because every time you open social media or the news, there's something about artificial intelligence. What's your thoughts on how it's going to influence what we do on a day-to-day basis in the near future and in the longer term?

Julia Mader: 12:47

That's a very good one.

Julia Mader: 12:48

So I think artificial intelligence will help us, at least with data interpretation a nd musicas. But it's maybe not as marked as all of us had thought it already is, because it's just learning from what is known in many places. So I think you can get something out of it, but you need to be very sure that the model is underlying it. You need to find the face, otherwise you don't get suggestions out of it. If you just simply test and go and try to write up some simple article, you might get very fun facts out of that, and the same is happening, of course, for certainly medical care, if the underlying database is not good. But on the other hand, we've seen that clinical interpretation of state or by machine can be better than by genome because they are not so much influenced by the individual sitting in front of them. So because each person has either dark or light errors in my immune smart or not smart I might have different approaches to them and the computer would be probably more neutral and not taking into account my personal observations.

David Klonoff: 14:11

Julie, I have one last question for you. Now you're managing editor of the Diabetes Technology Society Journal, which is the Journal of Diabetes Science and Technology. What's it like? How do you plan to handle that new position?

Julia Mader: 14:27

It's a really important position position and thanks again, david, for having me and for asking me for that one, so I had very, very positive responses to that. A lot of people approached me to it, so obviously this is something that doesn't go unnoticed. That's one thing. On the other hand side, of course, I hope that we can together further develop the journal and really keep it as successful as it is. So it's really on a very, very good track in my opinion, and that's all your longstanding, sustained work in this trial that's put into it and I think it's becoming, or it is, the leading trial for novelty colleges. Also, when I see the articles that are submitted, they are of high quality and people really want their data to be published here.

David Klonoff: 15:32

Well, with you at the helm, we'll reach even higher heights. So, Julia, thank you for being interviewed today. David, thank you for interviewing.

David Kerr: 15:41

Pleasure. Really welcome aboard.

Julia Mader: 15:44

Thank you so much.

David Klonoff: 15:46

This completes the podcast. This podcast is available on Spotify, Apple Store and the Diabetes Technology Society website. We look forward to seeing everyone at our next podcast and, until then, have a good day. Bye-bye.