Conversations About Diabetes Research: Diabetes, Digital and Devices - How technology is advancing care in diabetes

Digital technology is making it easier for people living with diabetes to self-manage their condition. This episode explores the cutting-edge research that has led to the advancement of these technologies, and what the future holds.

Joining Dr Neil Hill and Reuben Lewis is Professor Nick Oliver - a Diabetes Consultant at Imperial College Healthcare NHS Trust, and Professor of Human Metabolism at Imperial College London. He is also a Clinical Divisional Lead at the NIHR Clinical Research Network North West London.

Professor Oliver discusses the research he is working on, the challenges of developing technology, and what’s on the horizon for people living with diabetes.

Find out more online about diabetes research at Imperial College London.
Anyone interested in taking part in research can search for studies on the Be Part of Research website.
People living in North West London can join the Discover register to be kept informed of local opportunities to get involved.

Conversations About Diabetes Research - episode 3 transcript.

Transcript

Dr Neil Hill  0:06 
Welcome to the podcast of the National Institute for Health Research - the NIHR. This is an episode in the series Conversations About Diabetes Research. Digital technology is making it easier for people living with diabetes to self manage their condition. This episode explores the cutting edge research that has led to advancement of these technologies and what the future holds. My name is Dr Neil Hill, and I'm a consultant in Diabetes and Endocrinology at Imperial College Healthcare NHS Trust, as well as the speciality lead for diabetes for the NIHR Clinical Research Network North West London.

Reuben Lewis  0:43 
And I'm Ruben Lewis, a Research Delivery Manager at the NIHR Clinical Research Network North West London. It's a pleasure to have you with us.

Dr Neil Hill  0:54 
So I'm really pleased to welcome Professor Nick Oliver. He is a diabetes consultant at Imperial College Healthcare NHS Trust, and also professor of human metabolism at Imperial College London, and an expert in diabetes technology. And well, I'll let you talk a bit further. Nick, can you tell us a bit about yourself?

Professor Nick Oliver  1:16 
Sure, many thanks for inviting me. So my name is Nick Oliver. I work at Imperial. That's both the College and the Trust in West London. And I'm also Division Two lead for the NIHR local research network in North West London.

Professor Nick Oliver  1:30 
So my interest clinically is looking after people, mostly adults with type one diabetes, and helping them to self manage effectively and safely. And my research intersects with that very nicely in that we've looked at how people can use new technologies, and how we can design new technologies to help people to self manage more safely and effectively, and hopefully to make their lives with type one diabetes less burdensome, and to reduce the later risk of complications.

Reuben Lewis  1:56 
Thanks, Nick. We've actually called this podcast Diabetes, Digital and Devices. And obviously, you can choose your research area and you could have chosen sort of any area in in diabetes. Why do you have a particular interest in the in technology.

Professor Nick Oliver  2:13 
So I ended up doing diabetes because I worked at Hillingdon Hospital in the early 2000s. And I worked for a consultant called Rowan Hillson, who later became National Clinical Director for Diabetes. And she was inspiring in how she supported people living with diabetes. Was a fantastic physician and sure still is although she's now retired, and encouraged and supported me to be a dermatologist. And that was how I got into doing diabetes.

Professor Nick Oliver  2:40 
I've always been a nerd. I've always liked technology and gadgets. And then I never, I don't think, envisaged that they would intersect. But when I was a registrar at St. Mary's Hospital, in the middle of the 2000s, the Institute of Biomedical Engineering at Imperial College was set up by a guy called Chris Toumazou, who's now Regius engineering professor. So he is the Queen's engineer.

Professor Nick Oliver  3:05 
So he set up this institute and he was looking for a clinician to work on some technologies that happened to be diabetes focused and I and I was in the right firing line at the right at the right time. And he asked me to come and work with him. And it enabled me to really develop skills with technologies, working with engineers and to develop some new technologies. So it was really serendipity and being in the right place at the right time. And it intersected with pre existing interests and being a bit of a geek.

Dr Neil Hill  3:32 
It's interesting how serendipity plays a role in people's research careers, isn't it? So what do you think? What research in the past has really advanced the utility of technology for people that they might be using today, for example, Nick?

Professor Nick Oliver  3:48 
So there are a few landmark studies. So one of the nice things about working in technology in diabetes is that really, there wasn't very much before 1999 or so when the first continuous glucose sensor started to become available. And most of the technology that we use and develop now hinges around that, that glucose information as a as a part of the system. And there were there were a few things in there before then. But in some ways, you might argue that diabetes has always been technology based. People have always used novel syringes and insulin delivery devices, in the 1980s were the first paper glucose monitors.

Professor Nick Oliver  4:27 
So there's always been new technologies, but the things that that people are using now, and that that people are really seeing benefit from things like continuous glucose sensors. And one of the landmark studies was in 2008, shortly after I'd got into diabetes technology, and that was the JDRF study and that that has changed access and and technology for people living with type one diabetes. And really importantly, in that study, they recruited children, young adults, adolescents and older adults and they were really agnostic and really supported. Getting an evidence based technology across the lifecycle of type one diabetes. And that was one of those really, landmark moments. And then after that we had a few landmark studies in artificial intelligence and in artificial pancreas technologies. And again, those have been really important in getting those technologies into people's hands. And we now have three commercially available, automated insulin delivery devices in the UK, that wouldn't have happened were not for studies over the last five years or so.

Reuben Lewis  5:27 
So it's really interesting that you mentioned access. I often when I think about technology, I think about cost. And I think about whether actually people can access these technologies. Do you think, you know, the, you mentioned how research enabled better access to these technologies? Can you just explain a little bit about that? Do you think there any barriers for people who might be listening on the podcast too, you know, accessing these current technologies today for diabetes care?

Professor Nick Oliver  6:00 
Yeah, sure. So I mean, we're very lucky in some ways in the UK, for lots of reasons. But but most importantly, because we have an NHS and the NHS enables equitable access, hopefully, to novel technologies in a way that doesn't discriminate based based on socioeconomic background or, or age or any other characteristic. And that's enabled by NICE guidance, and by by guidelines that we follow. So we're very fortunate to have that.

Professor Nick Oliver  6:27 
There is still of course, some some variants and some some issues around accessibility that are difficult to address. But I suppose one of the one of the real challenges at the moment is that technology moves very quickly. And these conventional ways of assessing clinical and really importantly, cost effectiveness for technologies aren't necessarily as responsive as the evidence base. So it used to be said that drugs take over a decade to get from preclinical into into final marketing. Devices can go through much more quickly. And we see nice guidance for type one diabetes that was written in 2015, is being revised this year. But already, you can see that some of the technology components of that of that guideline are out of date. So one of the challenges is how do we keep guidance and the evidence base together? And how do we keep doing it in a way that's coordinated? So I think that's one of the challenges.

Professor Nick Oliver  7:22 
But in terms of barriers, one of the barriers is that we don't have the right evidence base always. So I say I said earlier that the 2008 CGM study was landmark in showing us continuous glucose monitoring was effective. But it took many years after that, for us to actually have support from NICE guidance. And that's because we used to select participants for studies who often already were doing very well with their diabetes. And actually, what we need to do is to say, who's finding this really difficult? Who finds that type one diabetes really challenging? And how do we help them the most?

Professor Nick Oliver  7:55 
So actually, I think some of this is about how we generate an evidence base. And how do we select participants who studies in a way that shows a benefit in people who stand to benefit the most. But it's also then about how do we translate that rapidly into guidance and guidelines, and how do we ensure that that accessibility is communicated on the ground. Because you've got commissioning structures and general practitioners and provider trusts and lots of other people who are involved in this and it can be challenging sometimes to disseminate that equally across a large population. Though, if COVID has shown us anything, it's that change can happen rapidly, even in the NHS, we can deliver vaccines in a stratified risk associated way to millions of people very quickly when there's a will. So these things are possible. It's just about how we do it on the ground and how we do it effectively and rapidly.

Dr Neil Hill  8:45 
That ties in nicely to my next question, which is, what current research are you working on at the moment in this area? And how would interested people get involved with that, please?

Professor Nick Oliver  8:57 
So our research has been hit a little bit by Coronavirus pandemic. And we've had some of our studies that have been delayed but at the moment are recruiting and active studies are looking at severe hypoglycemia of people in London who have a visit from the London Ambulance Service. And we're just about to restart recruitment to that. We're looking at the accuracy of continuous glucose sensor devices in people with diabetes who have hemodialysis for kidney failure. We're looking at how we support people to make decisions. As you know, Neil, people with type one diabetes make multiple decisions every day about carbohydrate and insulin and activity and food and alcohol and stress and a million other things. And how do we support the people to make decisions that are that are the best at the time. So we have some some devices and some ways hopefully to support that that we're looking at in a randomised control trial. And we've got some studies hopefully opening up later this year, looking at novel ways to use automated insulin delivery. So that's continuous glucose monitors and pumps, and we've got studies more widely in the group. Neil you're running studies in people with stroke and in people doing exercise, and we've got other studies looking at continuous glucose monitoring in young young adults with diabetes who are finding self management challenging.

Professor Nick Oliver  10:12 
Very happy for people to contact us to discuss those, we have a webpage on the Imperial College London website that lists most of our recruiting studies. And a quick Google will find me or the group and you're very welcome to contact me, or indeed you.

Dr Neil Hill  10:29 
Absolutely. Absolutely. Thanks, Nick.

Reuben Lewis  10:31 
Yeah, so we will ensure if you're listening to this, and you didn't get all that information, we will ensure the appropriate links are under the podcast that you clicked. So it's clear, NIck, that that there's there's just there's lots and lots going on. And actually in the next, you've mentioned the next six months, things happening. I wondered if you could dust off your digital crystal ball and just sort of look into the next sort of 20 years, and almost sort of outline what what kind of exciting technological developments there might be for diabetes care. And then obviously, while you're at it, check out if there are any future pandemics, because then I would probably just stock up on loo roll in advance. But yeah, just you know, just tell me a little bit about where diabetes care is going and what it might look like in 20 years, if you can.

Professor Nick Oliver  11:29 
I think 20 years is really hard, isn't it? George Alberti, who we work with and who is one of those very senior, hugely, highly respected researchers in diabetes, always tells a story about how when he did the first artificial pancreas studies in 1978, when he was at Southampton, and he presented it at a meeting. And somebody said, Professor Alberti, when do you think patients will be able to use this and he said, five years, and that was in 1978. We've only just really had them more recently.

Professor Nick Oliver  11:59 
So I think we're very bad at seeing beyond five years, I think it's a sort of horizon that we can just about conceive of. In 20 years, I'll have retired by then, Reuben. And so you know, who knows what could possibly happen? I think broadly, we're going to have, technology is not going away is it so I mean, technology is my interest. But actually more broadly, across diabetes, we've got new classes of drugs that have become available in the last few years, and we're going to get better at using them. So drugs are the same as technologies that they get released. And they're initially for a smallish group of people. And then we work out who really benefits and where they're most clinically and cost effective. And they find their home and their niche. So it'll be interesting to see how the new drugs that we've had recently find that find their way. And there are some new drugs coming down the track, there are new classes of drugs in there and new drugs within existing classes, that will, again hopefully help us to support people to self manage more effectively.

Professor Nick Oliver  12:56 
And one of the really interesting things that there's a an oral version, so a tablet version of semaglutide, which is a GLP-1 receptor agonist for people with type two diabetes. And normally that up until now that has been an injection, but we now have an oral version of that. So that'll be very interesting. We're going to see more technologies, they're going to be smaller, they're going to be lower power, they're going to be more intelligent, and they're going to be able to support people to do more, and then hopefully be more accurate and precise, both of monitoring and delivering insulin. And we might see some newer insulins that are faster acting, and even some urinses that are much slower acting.

Professor Nick Oliver  13:33 
So we're going to push those boundaries of duration of action of insulin so people with basal insulin needs can happen that last longer. And we're getting closer to physiology and what body normally does with the faster acting insulins. So it's exciting and it never stops moving. So the only thing I can guarantee about that, Reuben is that it will all be wrong. Because who knows what's around the corner. It's all exciting.

Reuben Lewis  13:56 
Well, if the if the last year hasn't hasn't indicated that then nothing will. But I suppose I just have a little point about that. Because I suppose what you mentioned about self management is probably going to look like it will be a key theme, I would imagine, in diabetes care. Where once you know, 10, 15 years ago, people would have to go to their local hospital. Now they largely, especially in type two diabetes, would go to their GP and maybe it is being pushed more and more into the fact that actually you could probably manage a lot of stuff at home with very little face to face time possibly. Do you think that's that's likely?

Professor Nick Oliver  14:35 
Yeah I think that's absolutely right. We've changed our model of care in within the last year but what we don't know is what is the most effective way to deliver remote care to support people living with diabetes. And we've got a whole evidence base of things being delivered face to face, but we've got no idea how to convert those things to virtual and remote consultation models. So it's opened a whole new theme of research. I don't I don't think anyone even necessarily knows how best to do the research, let alone how best to answer the questions. So it's a real watch this space, isn't it, and it'll be really exciting to see what comes out.

Professor Nick Oliver  15:11 
We're never going to go back, I don't think, to how we delivered care 18 months ago. So we will see in the next year or two, how we deliver care for the future. And whether that is as clinically effective and acceptable to people with diabetes. And I suppose the other thing is that we need to be careful that we don't create a new group of people that find it hard to engage with clinical services. So there are new concepts around digital inclusion, that we need to really think about consultation that we've never thought about a year or two ago.

Dr Neil Hill  15:42 
Yeah, well, thank you, Nick. I mean, that's, that's been a real tour de force in explaining where we've been, where we're at and where we're going to in terms of diabetes, and some of the technological advances that have happened and are on the way.

Dr Neil Hill  16:02 
This was an episode of the NIHR podcast, part of our Conversations About Diabetes Research series. I'm Dr. Neil Hill.

Reuben Lewis  16:10 
And I'm Reuben Lewis. Thank you for listening.

Dr Neil Hill  16:13 
For more information about the NIHR you can visit our website www.nihr.ac.uk, or find us on Twitter @NIHRResearch.