How AI and New Tech Are Revolutionizing Diabetes Care and Changing Lives

A large VA study found that people who started CGM had 31% reduction in hypoglycemia related emergencies and 11% reduction in all-cause hospitalizations. CGM and automated insulin delivery keep the glucose range more consistently, reducing the damage to the blood vessels. The GLP1 and STLT2 inverse, like I talked about, they reduce heart attacks, strokes, and heart failure. Technology reduces the burden of management. When somebody has to make a decision all the time, oh my blood sugar is 200. Now, and that leads them into anxiety or worry if all that is gone. Now they can be on its own pump and they don't have to make those decisions. So the burden of management is much better so that people can focus on living rather than constantly managing the disease.

Dr. Rengi, I know I've been reading a lot about these incredible advances that we've talked about some of them previously, but for example, continuous glucose monitors, artificial pancreas systems, AI that can actually predict blood sugar levels. It feels like we're really living in the future, right? So I really want to understand a little bit more about it and if it's actually changing outcomes for real people, or is it mostly just hype? So I'm excited to dive into this and learn more about it. So it's amazing to see you as always. How are you doing today?

I'm doing well, Leila. Glad to be here. And thank you for doing this topic. And it's very dear to me because I really enjoy doing technology and the latest and the greatest for my patients. And it's absolutely a game changer and it's changing outcomes. It's not just a hype. We have hard data showing that the technologies reduce hospitalizations, they prevent complications, they improve quality of life. This isn't hype. It's a genuine revolution happening right now in clinics around the world. And I hope more people will benefit from it.

Amazing. And let's start with the continuous glucose monitors. So CGMs. So I know a lot of people have heard of these, right? But I think that there's still a lot of confusion about what they actually do. And from my understanding, it's that instead of pricking your finger a few times a day, you have a sensor that tracks your glucose constantly. But what does it actually look like in practice? And is that correct also? But how does wearing a sensor 24-7 actually change somebody's relationship with their diabetes?

Yeah. Layla, it's like driving without GPS or managing heart without any kg. So you're literally trying to get a lot more snapshot or looking behind the scenes to understand how your body's behaving so we can guide you the right way. CGM gives you 288 readings per day. I roughly call it 300, compared to maybe even four finger pricks a day. In my earlier days when we were not doing CGM, and even now, sometimes when the insurance is fighting with me or when the patients don't know enough about CGM and they're trying to argue, why do I need to go on it? When can't I just do the finger prick? You don't know enough. Even the best patients who are checking four to six times a day are giving me point of care at certain time. And what the CGM containers glucose monitor does is it connects those dots. So, like for example, before breakfast, your blood sugar could be 120. And what I don't know is how high did you go? And then maybe you if you didn't check anything after breakfast and you check it again at three o'clock and you're 60. I have no idea where did you go between 120 and 60? Did you go too high or did you just keep going down? So it completes the picture, it gives me a lot more values. No matter how many times you can do finger prick, you cannot replace CGM with finger prick. And I think it's a matter of time. Finger prick is probably going to get obsolete at some point soon. And we're going to be pretty much doing CGM in most patients. You see your glucose on the phone in the real time, you get alerts before it's too high or too low. You can share the data with your doctor remotely, or you can share with their family. I have friends who have their kids who have diabetes and they constantly know what their children's numbers are. I have mom and daughter or multiple family members who are managing their numbers and their mom's numbers. So they can keep a real-time pattern in check, you know, where they are. And if they are it's time to eat, they can remind their loved ones, you know, that I see your numbers going down and let's take care of things. And when you see how the meal and how the walk and how the snack is affecting your glucose, you can immediately make a choice and change the trajectory and make sure next time you pivot and make a different choice so you don't go as high. So it's a feedback that no finger prick can provide.

And I think that makes sense intuitively, but what does the research actually show? And I imagine there's probably some skeptics might say or might think, okay, well, you have more data, but does more data actually translate into better health outcomes? So are people with CGMs actually healthier than people doing traditional finger stick monitoring? What's your take on that?

The evidence is remarkable. Multiple randomized control trials, which we consider as the gold standard of research. So multiple RCTs have shown that CGM reduces hemoglobin A1C while also reducing dangerous low blood sugars. So we are not just getting better control, but we are also skipping or avoiding the low blood sugars that was a big problem at one time. A large VA study found that people who started CGM had 31% reduction in hypoglycemia-related emergencies and 11% reduction in all-cause hospitalizations. These are real, measurable outcomes. So it's not just a hype. We see the research changing the outcomes.

And I always thought CGM was mainly for people with type 1 diabetes, the people who are really on insulin pumps and really need a tight control. But from what I'm hearing more about and learning more about, is people with type 2 diabetes are using them as well now. So is there actually evidence that CGM helps people with type 2 diabetes, or is that more of a lifestyle gadget for people who are curious about glucose?

Yeah, thanks for bringing that. And I think both the points are very well taken. Definitely it helps you with your lifestyle, but just thinking that it's only for type 1 diabetes is outdated for you now. There was a trial called the mobile trial that showed people with type 2 diabetes on just basal insulin. In the past, we used to think hemoglobin A1C was a standard of care. And now we consider time and range as standard of care. And we know the time and range, how much time you're spending in good control, not high, not low, is something that is very important for our body to function normal and for us not to get complications. So time and range is important.

And speaking about time and range, I've heard that term. I think that that's a term that's thrown out here and there, but can you explain what that means and why it really matters? And is replacing HBA1C as the main way we measure diabetes control, or is it something different?

Leila, time and range is the percentage of time your glucose stays between 70 and 180. The goal is more than 70%, about 17 hours per day. Most of the times when I download my data, or I can even remotely look at my patients, majority of my patients are on CGM. If they are in insulin, almost 99% of them are on CGM, or I should say 90% plus. But if they're not on insulin, then also I try to put them on CGM. But there are some who are not on it. So when they have a CGM, I can see them anywhere, anytime, remotely or in office, because the data is stored on the cloud and I can have access to that anytime. I always download that data and share it with the patient and show them how much the time they're spending in range and how much time they're spending in high blood sugar range and how much they're spending in low glucose range. The guidelines recommend that the time in range, which is between 70 and 80, should be at least 70% of the time. So it does multiple things for me. One is in real time, I'm so confident that the patient is spending time more than 70%. Two is I encourage them to look at the graph and understand how their lifestyle is affecting their or the timing of the insulin or so many other factors that could influence that time and range, and how can we optimize it even further? You know, 70% is just a guideline. That doesn't mean that's enough. I aim at 80%, 90%. There are patients who have 95% time and range, and that's what I would try to achieve if I had diabetes. So not only does it help me get to the goal of more than 70% time and range and less than 3% hypoglycemia. If I see someone with a hypoglycemia or low blood sugars, 5% or 10%, then my focus completely goes away from time in range to hypoglycemia because that is something that can kill people right away. So my goal is to adjust the medications, do whatever it takes to decrease the amount of hypoglycemia. And then, of course, simultaneously, as I cut down, make changes to lower the hypoglycemia, their time in range will get better. So that's what time in range is. It captures glucose variability and hypoglycemia risk that hemoglobin A1C misses. Studies show that time and range directly predicts eye and kidney disease risk. So it goes a long way.

Absolutely. And speaking a little bit about AI and new technologies, let's let's dive into that for a second and let's talk about something that sounds almost like science fiction, right? The artificial pancreas. So I've heard this term thrown around, I guess, for the past few years at least, but I remember when it seemed like it was something further away, maybe like five, 10 years away. But now I've been starting to hear that these systems are actually available and people are using them now. So what exactly is an artificial pancreas and how close is it to actually mimicking what a real pancreas does?

So Layla, it combines a continuous glucose monitor that we just talked about, insulin pump, and a smart algorithm that automatically adjusts insulin every five minutes based on the glucose readings. So most of my patients who are on insulin, and if they are a good candidate for insulin pump, I do offer them insulin pump and then various kinds of insulin pumps, and we can talk about that later. But I always tell them the benefit of being on insulin pump is most if you try to marry them both, the CGM and the pump, because what we get is something beautiful. If you have a CGM sending the data into the pump and the pump reading the data and adjusting the insulin based on the real-time CGM, it's a game changer. It's something that we never learned in our earlier years. And I'm using that everyday basis. The difference is when you have different kinds of pumps, they have different kinds of algorithms, how they adjust, how much they adjust. Do they just adjust basal? Do they help any predict highs and do they adjust at that time as well? So the science is really getting fascinating in this field. And because it can adjust, do micro adjustments, your risk of hypoglycemia goes down and then your time and range gets better. It increases a delivery when the glucose rises and decreases or stops when the glucose falls. So when you take a long-acting insulin and you take a shot, it's in your system. But if you have a pump, it microadjusts throughout the day. And whenever you're going low, it'll stop. So your risk of hypoglycemia will go down. It's like a tiny endocrinologist making hundreds of decisions per day for you. So if you're on insulin and you don't have an option of getting off of insulin, everybody should look into artificial pancreas.

That sounds incredible and life-changing, but I'm curious about the real world experience when we're talking about this. So I imagine there's a difference between how something works in a clinical trial with lots of support versus how it works when someone is just, you know, living their everyday life, going to work, traveling, exercising, dealing with stress even. So, how well do these systems actually perform when people are using them at home in everyday lives versus clinical trials?

The trials show that these systems increase time and range by 10 to 15% points while dramatically reducing hypoglycemia, especially in the dangerous overnight lows. A lot of my patients are afraid of getting hypoglycemia, so they will underdose themselves. You know, that's a big problem in our space or in our expert area that we cannot get better time in range because patients are afraid of getting low blood sugars in the middle of the night. So they're gonna let high ride overnight. So it's not a good feeling. And your heart is racing, you're sweating, you wake up scared, and then you have to get up and eat. That adds to the weight. There's so many factors that play a role. So decreasing the overnight hypoglycemia is a very big achievement, and that really helps us get better control for my patients. Yeah, so the dangerous overnight lows can be reduced, and people describe sleeping through the night for the first time in years. The ADA now recommends that these systems for all patients or people with type 1 diabetes who can use them safely. You know, I I think of an example of my patient who's an engineer, and his hemoglobin A1C used to be 5.6 before, and I put him on an insulin pump and his A1C is still 5.6. And I just happened to ask him, I said, what do you think is different? I don't feel like I have done much, you know, because your control was so good and you're still under good excellent control. And his answer was, you have no idea. So he said, I used to wake up every two hours to check my finger stick, and now I'm sleeping through the night. And that's a game changer. So it's not just numbers that we're looking at, we're also looking at quality of life. Absolutely.

No, that definitely sounds like such a game changer, like you said. And what systems are actually available right now? So if someone's listening to this podcast and wanted to talk to their doctor about getting an artificial pancreas, for example, what would they actually be asking for? And are these artificial pancreases something that's covered by insurance? Or are we talking about something that's only accessible to people who can really afford to pay for this out of pocket?

Oh, and Leila, thank you for asking me. I deal with this every day. And no, these are FTA-approved systems that are available in the US and we use them every day, and insurances cover them. You just have to prove them whatever they're asking for. For example, a lot of times they ask me to show C peptide or blood tests showing that the patient has very minimal amount of or no insulin that the body is capable of making. Once they get that, or sometimes they ask me to do antibody testing. And if I've done the antibody and the C peptide, and if that goes with the guidelines, then they don't fight it. Then they usually give the pump to the patients easily. It's possible their insurance might cover one pump versus the other, and that can be a challenge because to me, majority of the time, they're all good options, but patient choice should matter. For example, if somebody's trying to make their diabetes very discrete, then a patch pump is best for them. But that doesn't mean the patch pump has the best algorithm, so then something else can give them better control. Some people don't care if the tubing is showing and how they're wearing it. So I look at what the patient preferences, and the ones that they have available are Medtronic 780G, Tandem Control IQ, Omnipart 5, Eyelet Bionic Pancreas, and the latest one, the Twist. Most insurance covers them for people who qualify. A majority of insulin pumps sold in US and Europe now have automated insulin delivery technology, like we just talked about.

Wow. So what about people with type 2 diabetes? I know most of the artificial pancreas conversation has focused on type 1, but there are a lot of people with type 2 diabetes who are on insulin as well. So is it something that they can also benefit from with this technology, or is it really just designed specifically for type?

This is such an important question. And I hope people with type 2 diabetes are listening to this. A lot of times they're not given the option. A lot of times the providers don't know this, but absolutely they can benefit. And ADA now recommends automated insulin delivery systems for adults with type 2 diabetes on insulin therapy. Once your doctor has figured out whether you need to stay on insulin or not, whether that there's an option of other medications versus insulin, you may still be on GLP1 agonist and SGLT2 inhibitor and other options, but you need insulin. In that case, I prefer to put them on this kind of insulin therapy or the smart insulin pump, because the same technology that can be game changer for type 1 can benefit the type 2 as well in the same way. It helps them reduce the amount of insulin they need. Once they go on insulin pump, their amount of insulin that they need drops by about 20%. And that can help them with their struggle with weight gain from insulin, because that is a usual struggle with type 2 diabetes patients. It decreases the risk of hypoglycemia. So to me, if somebody needs to stay on insulin, regardless of type 1 or type 2, they should try to go on an insulin pump and close loop if possible.

And so wait, let's talk about inhaled insulin. Because I think that it's something that isn't talked about as much anymore. Is it something that's still available? And if so, why isn't it used more commonly or widely now? It seems like it should be appealing to most people, but especially if they don't like needles. So what's going on with that? I imagine a lot of people feel like that.

Layla of that is available and underutilized. That's the one word I can say. It's the fastest-acting insulin available, absorbed through the lungs. You just inhale it with a small device, you put the small cartridge of insulin in there, and all you do is inhale and it goes to your lungs and absorbs so quick. It starts working within 12 to 15 minutes and clears body system within three hours. No needles, less weight gain. In fact, this is weight neutral. And some studies have seen some weight loss on these rather than gaining the weight. And less hypoglycemia than injectable insulin. I'm a big fan of a fresa. I use it a lot in my practice, and I wish more doctors would offer it to their patients. I think of this as the latest technology. You know, when people are standing in line to get the latest Apple iPhone and whatnot, why would you not get the best insulin out there that can be fast in your system and fast out of your system? So if you need to be on a long acting insulin, take one shot at bedtime, and the short acting insulin could be for your meals. So that way instead of four shots a day, you're doing only one shot at bedtime and you're inhaling during the rest of the day, provided you can take it. If you have history of COPD, or if you're a smoker, if you have lung problems, or if you have lung transplant or asthma or any kind of lung problem. So the first thing I do is ask everyone if they have a lung problem, if they can be on it, forget it. I'm not going to give that option. But if they don't have it, they should be offered the option. Absolutely.

But that almost sounds too good to be true. Because if it's faster, causes less weight gain, doesn't require needles, which I would think is a huge plus. Why isn't everyone using it? There has to be some kind of downside or limitation that explains why it hasn't become more mainstream or even the standard of care for the situation.

I personally think if people don't have the knowledge and it's not been advertised heavily. That's my bias. The second bias I have is, or my understanding is it has a little bit different way of writing prescription and to teach the patients, it takes a little time. Most doctors are so overworked, they're so busy, they have no time to explain patients that this is a different way to do it and this is how you do it. The other thing is most insulins, when they're interchanged or between different kinds of insulins, it's unit for unit. And this one is not really the translation from an injectable to inhaled is a little different. It's usually you need twice the amount, and it comes in a specific cartridge. So you get four, eight, twelve units. So a lot of doctors are afraid if my patient is taking seven units, I may not be able to use it. I really think it boils down to lack of knowledge and lack of time to teach the patients. And then, of course, people with lung problems, you're not going to give it to them. But those are the some limitations that I think of. For the right patients, it is transformative and it's not for everyone. So patients should ask their doctors.

Absolutely. I think that should be more mainstream. I know it may not be for everyone, but I think everyone should inquire about it at least. So let's shift a little bit more to medications. I've been hearing a lot about drugs like OZEP, and we talked about this a little bit on our last episode, and everyone's been hearing about GLP1 medicines. But another thing that we haven't really talked about specifically is about how drugs like Ozempic and even Jardians, not just for blood sugar control, but for actually helping with heart and kidney protection. So this seems like a huge shift from how we used to think about diabetes medication. So can you explain what's changed? And are these drugs actually preventing heart attacks and kidney failure, or are they just improving numbers on lab tests, for example?

Yeah, I think that's a very important question. And I'm gonna go back a little bit. I think it was in 2008 or so, there was a meta-analysis that came out and they mentioned about one of the diabetes drugs that was causing harm to the heart. And that analysis or the publication really shook up the diabetes world. And after that, FDA started requiring all companies to prove that their drug is not only going to benefit diabetes, but it's not going to hurt the heart. So that was a really interesting time. And luckily, I've lived through those times. And then what we learned was oh, after that, when the company started looking into if their drug is not hurting the heart. They learned something unique. They learned that not only is it not hurting the heart, certain drugs are benefiting the heart. And that was a game changer. That's when the term cardioprotection came up. We always knew diabetes hurts the heart. We always knew diabetes leads to heart complications. We always knew diabetes can hurt kidneys and eyes and other complications. Well, we didn't know in the past that there are medications that can help you prevent that in addition to A1C. So not only do you control the blood sugars better, but the using the drug can help you protect your organs as well. So yeah, they're actually preventing events. The meta-analysis was done for 56,000 patients that showed GLP1 receptor agonist reduced heart attack, stroke, cardiovascular death by almost 12%. And that's huge. And SGLT2 inhibitor reduced heart failure, hospitalization by 30 to 40%. These benefits are largely independent of the glucose control. So yes, we have plenty of evidence.

So if I'm understanding this correctly, these medications are doing something beyond just lowering blood sugar. They're actually protecting organs in some direct way. So that seems like a fundamental shift in how we used to think about diabetes treatments. So should everyone with type 2 diabetes be on one of these medications, do you think, or are they reserved for people who already have heart or kidney problems?

The current guidelines say anyone with type 2 diabetes and established cardiovascular disease or at high risk for cardiovascular risk, heart failure, or chronic kidney disease should be on SGLT2 inhibitor andor GLP1 receptor agonist, regardless of the blood sugar control. And this is where I have a little bit of difficulty explaining to the patients when I'm trying to add these medications. The question is, but doctor, my sugars are already under excellent control. Why would you add another medication? Because I'm trying to give you protection above and beyond the blood sugar control only. We are no longer just treating glucose, we are preventing complications. And these complications are what kill people, not diabetes. It's a diabetes causing heart problem, diabetes causing heart attack, diabetes causing heart failure. That is what kills people. So we are trying to work on that end result as well.

And so what about using them both together? I've heard some doctors, for example, are prescribing both a GLP1 and a SGLT2 inhibitor at the same time. But is there evidence that combining them is actually better than using just one or the other? Or do you feel that that might be maybe overkill for some patients?

No, that's a great question. Layla, the benefits are additive. And I usually tell my patients that's my favorite cocktail. GLP1s are particularly very good in preventing etherosclerotic events like heart attacks and strokes. And SGLT2 inhibitors excel at preventing heart failure and protecting your kidneys. So when you use them in combination, using that both provides complementary protection. It's not an overkill, it's a comprehensive care.

Okay, so let's talk a little bit about artificial intelligence. Let's shift there. So AI seems to obviously be everywhere right now, right? But I'm curious how it's actually being used in diabetes care directly. Is AI already helping patients today, or is this still mostly in the research phase? So what can AI do now that doctors are current or current technology can't?

Layla, AI is already here. Okay, it's not the future anymore. But you can say that we are on 1.0 and we don't know how far it's going to go. It powers the automated insulin delivery system, like we just talked about, making hundreds of decisions for the patients. So every minute the AI is understanding the feed of glucose into the pump, and the pump is making those micro decisions of how much insulin to give at what point. So that's like taking multiple decisions off of patients so they are not overloaded with that. AI can analyze your retinal photos to detect diabetic eye disease with specialist level accuracy. You know, machine learning can predict hypoglycemia with 80% sensitivity and 92% specificity, warning people before the dangerous low can happen, something that we could never think of in the past. So I think the AI is here already and it's a game changer.

Yeah, we're definitely living in the future, and that's fascinating. Especially the idea of predicting hypoglycemia before it even happens. I could imagine that that would be a life changer for some people who have hypoglycemia unawareness. But I'm also curious about the bigger picture. So, can AI help doctors make better treatment decisions? Could AI look at all of someone's data and recommend the best medication or even the right insulin dose? Yeah.

Clinical decision support systems are emerging that analyze the complete medical records and they suggest personalized recommendations. AI can identify patterns in CGM data, flag the concerning trends, and alert the providers. The key is AI should augment the human decision making and not replace it. We should not think about doctors obsolete or not being needed. AI and doctors need to work together, and AI should enhance the decisions that I make, handling the data processing, while the clinicians focus on human aspects of care. I have a young couple that comes from a couple hours away, and we try to do more televisits with them. And the other day they were in the clinic and we thought, let's play with AI. So we decided to upload the insulin pump for his wife in the AI system that we have, HIPAA compliant. And we try to analyze if the suggestions that AI gives me to change the insulin pump settings matches with what I was going to do. And guess what? It exactly matched.

Wow.

And that was fascinating. And now we know that next time when we have to do things from this far, we can work at another level that can sometimes help us reduce that gap of care from being that far. AI is going to change things dramatically, and I'm excited about it.

Absolutely. And speaking about AI, another thing that is super common are apps and wearables. So what about smartphone apps and wearables? There seems to be thousands of diabetes apps out there, right? So are any of them actually proven to help, or is it mostly a wild situation where people are just using apps they haven't even been properly tested or may not be the best apps to really rely on? How do you feel about that?

The feeling is it's mixed here because I feel there's it's an overwhelming world out there, just like what you said. For type 2 patients, the apps supporting lifestyle modification can improve the outcomes. Apps embedded in comprehensive diabetes education programs have shown impact on the A1C and quality of life. The smartwatches are increasingly integrated with CGM systems. I have a lot of patients who will say, now I don't have to take a break to go in the bathroom or something at my office to check my fingertips. Just imagine what kind of lifestyle has changed for them because that was always in the back of their mind while they're making other decisions that I got to take a break and go check my blood sugars. But now they're wearing their smart watch and in the middle of the meeting, they can see their watch and know that their numbers are safe and they don't have to step outside. So the integration of multiple data streams into unified platforms is what is the future. Right now we're picking different apps, giving different things, but it'll be good if, you know, instead of just knowing where my blood sugar is, if it's high at that point, if it says take some insulin or get up and go for a walk. So the multiple streams, when they can come together, that'll be mind-blowing.

Absolutely. And along with AI and apps and all of these things, another thing that has accelerated is telehealth. So especially after the pandemic, I think that was one of the big factors that really accelerated telehealth adoption. And I'm curious, and I've worked for telehealth companies before, so I'm extremely interested in this. But specifically, I'm curious about whether virtual visits are actually as good as in-person visits for diabetes care, or whether we're sacrificing some quality for convenience. So, do you think a doctor can really manage someone's diabetes effectively without actually seeing them in person?

Leila, the cloud-based access to CGM and pump data made it possible to replace many in-person visits with virtual visits. And I just feel nowadays patients don't even need to come. We can totally do virtual care with 100% access to everything. We need to do foot exam once a year. We need to do other exams that we need to do. But if they have a problem with their feet, I can even look at it from that far. So you can talk about the technology has definitely replaced the in-person visits to the majority of the extent. For people in rural areas and with mobility challenges, it's been transformative. Let's talk about the money they're spending on the gas, especially in this day and age. They can save that and they're still home. And a lot of my elderly people, they're not driving anymore and they have a vision problem or they may have other issues, or could be time. I could have a busy CEO who has to sit in my waiting room for 30 minutes to see me. And I would rather have him sit at home and in his office and just hop on the computer when I need to see him. So I really think this is there to stay. And evidence clearly shows that telehealth is as effective as in-person care for many aspects of diabetes management. A doctor can review the data and adjust the treatment without you leaving your home or office.

No, that's great. I think cell health is something that's revolutionary, and I think it's been something that's so helpful. But it's good with all these wearables and apps and all these other things that we mentioned are able to help specifically diabetes care get addressed and taken care of virtually. But now let's talk about something that also sounds pretty revolutionary: stem cell therapies. So I've been hearing a lot about the possibility of growing new insulin-producing cells for quite some time now, but it's always seemed like something that was either perpetually in the future or may not really happen. So I'm hearing that there have actually been some real breakthroughs pretty recently. So are we actually close to being able to cure type 1 diabetes by replacing the cells that have been destroyed or not? What's your take on that?

I think that's a great question, Leila. We are literally witnessing history. A landmark 2025 trial in New England Journal of Medicine, which we consider as the best journal out there, showed that stem cells derived, eyelid cells, achieved insulin independence in 10 to 12 patients at year one. Their time and range of the glucose range improved from 49% to 93% with zero severe hypoglycemic events. This is closest we've ever come to cure. So stay tuned.

We're getting there. Absolutely. I think that's incredible. But I could imagine or suspect that there might be some catches because if not, why wouldn't this be front-page news everywhere? So, what are the limitations? Are there any limitations? Or if not, why can't we just start offering this to everyone with type 1 diabetes tomorrow or today?

I think that's a great question, Leila. The main challenge is immunosuppression. The patients still need drugs to prevent rejection, which carry real risks. Long-term duration is unknown. Long-term durability is unknown of these kinds of treatments. The manufacturing at scale is complex and very expensive. These are very small trials that they're doing in a handful of patients. But the next frontier is gene-edited hypoimmune eyelids that may survive without immunosuppression. If that works, we could have true functional cure within the next decade.

Wow, that's incredible. And you've talked a little bit about precision medicine. And I think most people understand the concept in cancer where you test the tumor and you choose drugs based on the genetics. But what does precision medicine mean for diabetes specifically? Isn't diabetes pretty straightforward? Either you make insulin or you don't, or am I thinking about that in the wrong way? Or if not, you know, how can we treat that accordingly? Yeah.

Layla, it's much more nuanced. You know, we use C peptide levels to measure insulin production and get antibodies to identify autoimmune diabetes often, which is misdiagnosed as type 2 diabetes, and advanced lipid testing to identify cardiovascular risk that standard cholesterol testing misses. So about 5 to 10% of people diagnosed as type 2 diabetes have slow-onset autoimmune diabetes requiring different treatment. So I just feel there's a lot that goes in. You can use precision medicine to enhance your care, provided you know what you're looking for.

How does knowing all of this actually change what treatment someone gets specifically? So, can you give me an example of how precision testing would lead to a different treatment decision versus maybe just a standard approach?

Yeah, Leila, again, something that we see in the clinic all the time. Like I mentioned earlier, there are people who have autoimmunity bodies and they have immune reaction against their own beta cells that make insulin. And in that case, the treatment for them is insulin and that too earlier in the disease, and we should not keep pushing other medications because that leads to beta cell exhaustion and that has other problems. So, in those patients, if you can use precision-based care, you are not going to use the medications that will be not appropriate for them. You're not going to use oral medications that won't work. I would rather do the right kind of insulin and maybe have a better plan for their future. Someone with severe insulin resistance needs medication that target the pathway. Someone with very high LP little A needs aggressive cardiovascular prevention, regardless of the LDL level. AI is helping integrate all this information to predict which treatment worked best for each individual. And it's fascinating. I use all of this in my practice every day. So to me, it seems like I'm ready for next now. You know, I've been doing this for a while. But what I find fascinating is if somebody's living with diabetes for 50 years, when they started with glass tubes to check their urine to see how much glucose is there, to automate an insulin pump and now doing further cardiovascular protection, these people are really benefiting a lot from that. And I think I'm using that literally every day. I can think of five patients from yesterday that we used all these things in our practice.

Wow. Wow, no, that that's incredible. But let's bring this all together, right? So the ultimate goal of all of this technology is presumably to help people with diabetes live longer and healthier lives. But historically, diabetes has been associated with shorter lifespan and a lot more complications. But is all this technology actually closing that gap, would you say? Or can someone diagnosed with diabetes today expect to live as long as someone who doesn't have diabetes?

Yeah, Layla, we're getting closer every day. CGM and automated insulin delivery keep the glucose range more consistently, reducing the damage to the blood vessels, the nerves, the eyes, and the kidneys. The GLP1 and the SGLT2 inhibitors, like I talked about, they reduce heart attacks, strokes, and heart failure. Technology reduces the burden of management. You know, when somebody has to make a decision all the time, well, my blood sugar is 300, what do I do now? And that leads them to anxiety or worry about it or make wrong decision or take multiple injections of insulin that is stacking, now they're getting low blood sugar, all that is gone. Now they can be on insulin pump and they don't have to make those decisions. So the burden of management is much better. So the people can focus on living rather than constantly managing their disease.

Absolutely. And for someone listening who has diabetes or maybe has a family member with diabetes, what should they actually do with all of this information? So, how do they access these technologies and what questions should they ask their doctors directly?

I would definitely ask about CGM if you're on insulin. That should be non-negotiable. Ask about automated insulin delivery if you're struggling with control. Make sure you're on a GLP1 and a SGLT2 inhibitor if you have any cardiovascular risk in the type 2 space. These are not yet approved in type 1. Embrace digital tools and telehealth and stay informed. What was experimental five years ago is standard of care today already.

That's a really good way to think about it too. And looking ahead, what excites you most about the future and where this is going? So if we're having this conversation again in let's say 10 years, what do you think will have changed?

I think a lot would have changed 10 years from now. Fully closed loop systems requiring zero user input where somebody does not have to do anything is what I'm gonna hoping to see. Once a weekly or once monthly insulin, we'll be seeing something that people are doing every night or twice a day. They will be taking, we already have once a week insulin. Hopefully, we'll see once a month insulin. Stem cell therapies providing functional cures without immunosuppression is something I'm looking forward to. And AI integrating all the data systems into truly personalized recommendations is something we'll be seeing. And future isn't coming, it's already here, like we just said. We just need to make sure everyone has access to that and everybody can have that discussion with their doctors to get the best care.

Absolutely, for sure. And like you said, we are living in the future now, and I think that this has been such an incredible conversation, lots of great informative information as always. And thank you for helping us really understand how technology is transforming diabetes care and how people can access it and really learning more about their health and whether it's for them or even a loved one. Thank you so much. I think it's been a great conversation.

Thank you, Layla. The goal is simple helping people with diabetes live as long as possible, as well as possible, and as independent as possible. And we are closer to the goal than ever before. So thank you.

Of course, absolutely. And for our listeners, Dr. Rangi's book, The Silent Decade, Reversal, Remission, and Protection, What's Your Diabetes Window, covers all of this and a lot more. And thank you for following the show. If this resonated with you, make sure to send it to someone who can also benefit from it. And make sure you subscribe and follow and share. And thank you so much again, Dr. Rangi. I can't wait to talk to you again soon.