Use it or lose it: the hidden cost of diabetes technologies

Stephen W. Ponder MD, FAAP, CDCES

2018 ADCES Diabetes Educator of the Year

Since the creation of insulin itself, there has been a growing dependency on technology in the day to day life of persons with diabetes. Diabetes technologies aim to make self-care tasks easier to perform, more accurate, and often faster to complete. Hopefully, the mental burden of diabetes decision making is lightened. But can things be lightened too much? Are persons with diabetes at risk for becoming so tech-dependent that their core competencies start to wither? Might a point be reached where the person will contribute almost no decision-making roles in their own insulin delivery process, aside from maintaining the hardware and infusion apparatus of a CGM enabled insulin pump?

Blood glucose and ketone monitoring were originally cumbersome and time consuming processes. These now require mere seconds to perform. Insulin dosing is largely automated in partial closed loop delivery systems. Documentation of self-care data has long ago been replaced by meter memory cards and/or wireless apps which track every aspect of patient care. We have handed over much of our daily lives to technology. After all, when was the last time anyone had to memorize a telephone number or use a paper map to navigate?

As technologies continue to marginalize the role of the person with diabetes, does this create an increasingly high level of dependency on these devices and systems? In the absence of a complete cure, how far can we safely separate ourselves (with technology) from the cognitive principles of diabetes self-management? Are persons who use high-tech diabetes management tools at risk for fragmentation of their foundational self-care skills and problem-solving abilities when their technologies are disabled or not accessible? Lastly, how can diabetes care and education specialists act to mitigate patient “de-skilling”? The term “de-skilling” has arisen to characterize the phenomenon of loss of core self-care skills through prolonged use or dependency on diabetes technologies.

Glimpses of this phenomenon have been evident for years regarding risk of diabetic ketoacidosis in type 1 diabetes due to a rapid decline in sick day care skills usually taught at the time of initial diagnosis. I often get quizzical looks from patients when I ask them to describe how they “manually” dose insulin for a meal or correction without using their insulin pump calculator. That information only resides in the pump itself and is rarely recalled though it is often used many times each day. Many patients make changes to their dosing regimens with at best a fragmented understanding of how insulin and/or pumps operate. There is a great reliance today on social media. Online peers often ‘coach’ and otherwise direct persons with diabetes in many of their core diabetes decision making skills.

When a muscle is flexed infrequently it atrophies. A parallel phenomenon also applies to the ‘cognitive muscles’ which comprise patient self-care abilities. It is estimated the average adult makes 35,000 conscious or minimally conscious choices daily. Choices in diabetes self-care determine whether metabolic control is achieved and maintained. Daily choices that are wise and insightful are most likely to improve metabolic control. If choices are reckless, lack insight, or cavalier, they invite calamity.

There now exists an expanding number of patients of all ages who only know a technology driven style of diabetes self-care. This is to be celebrated. Hopefully, patients of all economic backgrounds can benefit from these technologies in the future. But basic diabetes self-care skills must continue to be taught, mastered, and maintained especially with the use of advanced diabetes technologies. As these technologies increase in use, they encourage a form of ‘cognitive atrophy’ to settle in: they can and do act to de-skill many persons with diabetes.

A child who grows up with a hybrid closed loop pump receives enormous benefits. But do the skills of self-care grow over time? And since no technology is infallible, how prepared are high tech patients to manage “old school” when the need suddenly arises? Will the user feel somehow trapped by this technology, unable to take a break from it? In the last few years, I have heard some very experienced persons in the diabetes community eloquently describe their struggle to recall their basic decision-making skills when faced with a high-tech diabetes device or system malfunction or interruption.

Are there solutions we should develop and use to mitigate this de-skilling process? One solution is to take strategic “diabetes tech holidays”. Go back to basics. That might mean taking an insulin pump holiday if possible. Use pens or syringes. Or simply open the closed loop during the day to encourage greater cognitive independence in dosing decisions. Since continuous glucose monitoring (CGM) technologies are generally superior to standard blood glucose monitoring, this technology should be exempt from the holiday suggestion above. Yet it is a prime example of how dependent most CGM users are on this technology, me included.

I don’t expect too many patients to take such an extended ‘about-face’ in self-care, but I hope this commentary helps emphasize the point I’m trying to make: that we should not allow our diabetes technology to completely disable our basic self-care cognitive (thinking) and procedural skills.

Parents of children with type 1 diabetes welcome most diabetes technologies with open arms. I do not blame them one bit and prescribe these devices frequently. More sleep at night, less fear of extremes of glucose through the day, improved time in range, are all to be appreciated and welcomed. But how do we best prepare for those inevitable interruptions? Please reflect on how diabetes technology best fits into your life. Would a strategic break be beneficial? Or has a sense of diabetes technology dependency already been established?