Michael Hughes, MD (left), and Rayhan Lal, MD, at Camp De Los Ninos, a camp for children with diabetes in La Honda, California

When Michael Hughes, MD, was a student at Florida State University, he had no interest in becoming a doctor. His passion was music, and Hughes spent much of his time as an undergraduate studying music performance and touring in a band.

That was until he was diagnosed with type 1 diabetes, which can cause serious health complications such as heart disease, eye damage, and kidney damage. “It’s very intensive developing type 1 diabetes and learning about the medication management,” says Hughes. “It ultimately inspired me to switch my career trajectory from being a music professor to a physician.”

Specifically, he was interested in endocrinology and improving care for others with type 1 diabetes. Hughes worked as a research coordinator for a pediatric endocrinologist, which led him to medical school at McGovern Medical School in Houston and, eventually, the Stanford Medicine Endocrinology Fellowship. This was where he met Rayhan Lal, MD, an adult and pediatric endocrinologist who has lived with type 1 diabetes for more than 30 years and has dedicated his career to advancing care for people with diabetes.

Together, Hughes and Lal have worked to improve diabetes technology, including continuous glucose monitors (CGMs), which measure the amount of glucose in the interstitial space just below the skin surface, and insulin pumps, which deliver insulin into the body. The hope is that with better technology, they can make glucose monitoring and insulin administration easier for people with diabetes, both inside and outside of the hospital.

Gaps in Technology

If you are diagnosed with type 1 diabetes, the old way to monitor blood sugar involved pricking your finger and squeezing a small amount of blood onto a test strip before you ate a meal. Then, you would use that blood glucose number to calculate the correct amount of insulin to inject.

Rayhan Lal (left) and Michael Hughes live with type 1 diabetes and are dedicated to advancing care for people with diabetes.

This process can be painful, disruptive, and arduous, says Lal, who has used a variety of technologies over the years to manage his own diabetes.

CGMs are small temporary adhesive devices that insert under the skin to measure glucose levels every few minutes and transmit that information to a dedicated receiver, insulin pump, or smartphone. Insulin pumps deliver insulin through the skin and can be left on the body for days at a time, allowing for smaller, more frequent adjustments that take away the need for multiple daily injections.

But there are still gaps in this technology. Over the years, members of the Stanford Diabetes Research Center, including Lal and his mentor, pediatric endocrinologist Bruce Buckingham, MD, have developed algorithms that connect glucose readings from CGMs to an insulin pump. With this technology, the pump can automatically adjust insulin delivery based on predicted glucose levels — a process known as automated insulin delivery.

“We’re working on making these technologies easier and easier,” says Lal. “We’re trying to get to the point where patients can just put on the device, set it, and forget it. That’s the hope for the future.”

Our goal is to make diabetes technology the standard for management within the hospital.

— Michael Hughes, MD, instructor of endocrinology, gerontology, and metabolism

Keeping Technology in the Hospital

Another issue in diabetes care is the fact that hospital staff are frequently unfamiliar with how to operate patients’ CGMs and insulin pumps because diabetes technology is developing so quickly, says Hughes. Therefore, when a patient is admitted, these devices may be taken away.

There have also been questions about the precision of CGM glucose readings in a hospital setting. However, during the COVID-19 pandemic, data from inpatient CGM readings have suggested that CGMs are accurate.

Hughes, Lal, and other Stanford researchers also conducted a trial using automated insulin delivery systems to manage patients’ glucose levels in the hospital. They examined the accuracy of CGM readings by comparing the devices’ blood glucose values with those of a standard finger poke test. Additionally, they incorporated a system to monitor the accuracy of CGM readings into the hospital’s electronic health record. This work reaffirmed that CGMs are quite accurate at reading patients’ glucose levels.

Using this data, the team implemented a protocol at Stanford that supports diabetes patients who wish to continue using their CGMs while in the hospital. This helps reassure patients and allows them to continue using their automated insulin delivery systems, which data suggest may be superior to the current standard of care in managing high and low glucose levels.

The goal moving forward is to further integrate CGMs and automated insulin delivery systems into Stanford and other hospitals so that patients do not have to endure frequent painful finger poke tests. “Our goal is to make diabetes technology the standard for management within the hospital,” says Hughes.

Furthermore, Hughes and Lal hope to eventually see that diabetes patients at Stanford and beyond have access to easy, available diabetes technology. “I really want to help all of my brothers and sisters out there with diabetes,” says Lal.