The T1Dialogues – Episode 11: David Ahn, Endocrinologist & Program Director of the Mary & Dick Allen Diabetes Center

In this month’s episode, we will have a captivating talk with Dr. David Ahn, Endocrinologist and Program Director of the Mary & Dick Allen Diabetes Center in Newport Beach, California. Dr. Ahn’s passion for Endocrinology and diabetes technology was first kindled after reviewing the first iPhone-compatible glucose meter as an editor for iMedicalApps.com. He is extremely optimistic about the future of digital therapeutics, continuous glucose monitoring, and smart insulin delivery systems. Join us and find out more about the impact of technology development, and the evolution of CGMs on the diabetic community, especially the Eversense CGM, and the similarities between T1D and T2D.

Watch the entire video down below:

Hi David. Welcome to the dialogues. 

Yeah, thanks for having me. 

Would you like to share with our listeners a bit about the background that where you’re at at the moment? 

Yeah. So I’m in Newport Beach, California. You might get that glimpse of a palm tree behind me, I think through the window. Basically, I’m an adult endocrinologist and I’m working as the program director for a Diabetes Center called the Marien Dick Allen Diabetes Center which is affiliated with Hogue Hospital at Newport Beach. 

Wow. Very nice. I’m curious to know about how you get here and how you ended up becoming an endocrinologist? 

Yeah, interesting question. It is actually a journey that there are a couple of different things I can point to. So growing up, my mom was diagnosed with type two diabetes when I was in junior high school. And that was a really impactful experience for me. I remember that my mom was really worked up about it and I didn’t really understand it. We all tried to learn more about diabetes.  I literally checked out the books from the library in 1995. Which seems really funny to look back on, by the way. But we would try to bake horribly tasted and sugar-free pies and stuff like that to cheer my mama, which was probably the exact opposite. So that was kind of my initial exposure to diabetes and then during my medical school. So my dad is a physician and I wanted to follow in his footsteps. 

In medical school, my ears would always perk up when I heard about diabetes. Or it was one of the topics because I knew my mom had it. But I didn’t really see it as part of my future career.

Internal medicine is like a general specialty that you have to do before you decide to do a sub-specialties and endocrinology is one of those subspecialties. So during my internal medicine residency, I still wasn’t sure what I wanted to do. However, I did a rotation through it just because of my mom. But once I did it, I really fell in love with it. I liked the technology and type one so it was something that was really fascinating to me because I’m always kind of a tech guy. 

Being able to use these technologies in such a way to affect health and improve people’s health was really fascinating to me. And the other thing I liked about it is that it involves a lot of personal components, right? Like a lot of times managing type one or diabetes, in general, involves patient coaching.  It’s like being a doctor but more like a coach and it’s not so much of prescribing the medication rather we spend a lot of time teaching people how to live their lives and make good decisions and analyze their numbers and stuff like that. This is something that really resonated with me and I really like dealing with different aged patients. So, you know, a lot of type ones are younger so we like having patients all across the spectrum and it’s been really fun, It’s kind of how I fell in love with it. 

That’s fantastic indeed!!  I’m interested in knowing the expectations or the perceptions that you had as a student once endocrinology became your specialty area that you’re interested in versus the realities of today, are they in line? Is it you doing what you thought of? Like, how do the realities match up versus the perception you had back then? 

Yeah, that’s a great question. I know this sounds really cheesy, but I feel like it’s even more fun than I was expecting. During my training as a doctor, I had always been a tech enthusiastic resident and I was kind of unique, right? I still remember I was going through my training when the iPhone got launched. I have always been interested in technology and stuff. 

As I’ve gone deeper into type one, I got to know about the emerging technologies for type one and in health care in general.  I think the fact that technology has taken such a prevalent figure and a footprint in the health care world. I think it is really exciting for me. It’s like a hipster when it comes to technology and healthcare. I’m kind of like “It is really cool”. It’s just exciting because there are so many cool technologies in all avenues of health care and that’s really exciting. 

In addition, it really surpassed my expectations. I think the more I’ve gotten to know and understand and help people with type one, I really feel happy. I think knowing and going beyond the numbers and understanding people’s quality of life. And that’s where technology can really help. Working with type one has just been super rewarding and it’s just been really awesome. I’m so happy about it. 

That’s awesome to hear and that’s partly how we connected to it, I suppose, given my interest and the business that we have with Not Just A Patch. The interest is around CGMs and certainly for me as a type one diabetic, the CGM technology is being a game-changer. I am really grateful to have access to these technologies because my HBA1C  has come down considerably to about 6.9 and now it’s 5.9 Nice. I can say that it has made a definite impact. And I tend to think of it a little bit like health Informatics, which is an area that I worked in. I have worked as a health information manager. And then I worked in some medical technology areas. I think trying to understand health informatics could be quite daunting because it’s such an ambiguous term “informatics”. 

Wearing a CGM is like having these micro informatics available that help you make these sorts of micro decisions. It’s almost like the power of health informatics in action that makes the information readily available to me. So you know, it’s so much easier to scare my reader than to prick my finger.  I used to probably prick my finger 4 to 6 times a day and now I’m scanning about 40 times a day or more and it’s that health information at my fingertips. This is ultimately what makes the difference for me totally. 

I always tell people that diabetes is like 10 years ahead of where the general public is like in terms of health technology, wearables, and things like that. Ten years ago, when Fitbit first went popular, everybody was talking about wearable sensors and CGM. At that point, I felt that people with type one diabetes are like the forerunners. I think eventually, as these sensors get better and better, they’re going to get smaller and smaller. I think it will expand. I wouldn’t be surprised to get to see an apple watch so that athletes and people trying to lose weight can regulate their blood sugar. I hope to see many technological advances for type one in the upcoming years.  

Yeah, I actually read in the last week about some wristwatch form of technology that is able to give glucose reading. I can’t remember where it originated, but they had some comparisons versus the libre. I think it is quite promising, right to think about the capability of having a device on your wrist that gives you information anytime when you need it. 

Yeah, it’s kind of the Holy Grail, you know, like a truly noninvasive, continuous glucose monitor. I think I am familiar with the product you’re talking about as it made a lot of headlines because they made a splash at the recent consumer electronics show. But I think the problem with a lot of these technologies is that they tend to be not like medical-grade, right? Like I don’t think they would ever get to that point. Or at least not in the next 3 to 5 years were, like someone with Type one diabetes can have automated insulin delivery but maybe it might be accurate enough to trend information that might reinforce healthy eating or lifestyle modifications. 

I also think that getting the accuracy is really challenging for that specific sensor. I believe they were compared to people without diabetes in the libre and the challenge is that if you don’t have diabetes, your blood sugar varies so narrowly. You know, it remains 80 to 140 all the time that it’s hard to differentiate between a good watch and a bad watch with that narrow of the normal range. 

A number of companies are starting to pop up in the metabolic space so we see a lot of crossover into the mainstream for this technology and value. In fact, it makes sense that, actually, if you want to improve your lifestyle, your diet, and your health in general, using a CGM and get information on your blood sugar level is a decent proxy for starting to improve your overall health care. 

Yeah, 100%. I think it’s just more of a cost and technology issue that’s getting better and better. For someone who does not personally have type one, I warn about it a few times, over the years because I test it for my patients, and I’m always fascinated by the information that I learn over time. It helps you see how different foods and exercise affects your blood sugar. I mean, these are all the things obviously type ones are quite familiar with, but It’s just so fascinating for anybody to learn from their body in that regard. 

Now the numbers aren’t as dramatic but it’s still very meaningful and helpful. And do you think that those businesses try to help people manage healthcare? Do you have a perspective on that as a doctor? I’m sure you’re aware of it. What’s the thinking in the medical field for this type of concept? 

There are a few ways to look at it, I think from a business perspective and putting on my fake investor hat, I think it’s really smart that these companies are doing that because it’s only going to become more and more prevalent, right? So these companies are basically establishing their name. They’re establishing data sets. They’re kind of iterating on the apps or whatever experience that they’re layering on top of the CGM’s. So I think from a business sense, it makes perfect sense for these companies. And definitely, health and wellness is a huge market, 

Now putting on my physician hat, there’s a little bit of skepticism in a sense that a lot of times when they ask me about this, I tell them yes it’s helpful to understand, to some degree, how your blood sugars’ pattern change when you take more carbs and when you are eating fewer carbs. However, It’s tough to really know what normal looks like and what exactly are they trying to achieve? What exactly are they identifying as problems? Because those patterns and data sets just don’t exist. Hence, it’s important to establish those data sets, and these companies are building that but it’s hard to know that Is it truly better or beneficial to have a blood sugar of 110 versus 125 for someone without diabetes? I think that’s where it becomes very gray and that’s where you worry that there might be a little bit of snake oil mixed in. Or at least you do not have that evidence-based medical care. So it’s an ideal health and wellness product. I guess the question is whether it’s a medical product, I would say it’s definitely more health and wellness product at this point. 

Yeah, and I think that we’re never really going to be out of a place. The role and the training that an endocrinologist has in terms of understanding of the mechanisms, underlying information, and patient experiences are really important in that context that helps you to be able to advise or coach. I’m curious about what you learned at medical school about diabetes and the endocrinology field versus what you have experienced now. I’m fascinated because medicine and science are always moving forward and getting innovative. Do you think that things have changed over time as compared to the past? 

Yeah, I think it has changed a lot, and unfortunately, this is why a lot of type ones, might not be satisfied with their health care experiences. I think the amount of exposure we have to type one diabetes in our medical schools, at least when I was training, is not very high. There is a large focus on type two diabetes so the type one gets drowned out a little bit and there’s not a huge emphasis on that. Obviously, one thing that’s sure changed a lot is the technology so now in medical school there might be some discussion of continuous glucose monitors but during my training, there was very little focus on that.  

There are so many differences between type one and type two diabetes that it is a disservice to bundle them together but unfortunately, even in medical training now they’re often bundled together. Did you know we had a sort of table differentiating the two that we look at on a page of our textbook? It’s definitely undersold but I was really blessed as I did my training at UC. San Diego for endocrinology and one mentor Steve Edelman who is one of the famous endocrinologists who has type one and one of my co-fellows had Type one. Both of them are very passionate about conveying the differences and how to type one is more of a lifestyle thing. So training under Steve Edelman made me get to know more type one.

As I’ve gotten more immersed in this world of diabetes, I have so much respect and admiration for the fact that it’s like a totally different disease process. But, unfortunately, many doctors and even some endocrinologists don’t fully appreciate the subtlety. 

Yeah, being a type one, it’s not necessarily something that frustrates me personally.  I believe that there is room for improvement in the field of medicine related to training in type one diabetes. I guess there are similarities in type one and type two. They’re both metabolic and they’re both glucose-related. What are the other similarities between the two?

Yeah, they’re both diseases of glucose regulation. Right? So the end result is similar in the sense that someone with type one and type two have glucose control issues, right? unless they do the right things or take the right medications, their blood sugars will be poorly controlled and the end result of poor sugar control. Whether it’s through type one or type two, you can have kidney complications, blindness, nerve pain, amputations, and so forth. Hence, the measurable outcome, which is blood sugar and complications, is similar. 

The underlying mechanism is different because type one is an insulin production problem and the immune system has attacked your pancreas so you no longer make insulin, whereas, with type two, it’s more of an insulin resistance problem, meaning your body can make enough insulin, at least initially but your body doesn’t respond to that insulin.  

Another similarity between the two is that insulin is a staple in type one management but it is the last resort of medications that we use for type twos. However, we do use insulin in both conditions. Another thing that you may or may not be familiar with is even though there are medications that are FDA approved for Type two diabetes, some of them actually have some benefit for type ones as well. So sometimes there are some pills, injections, or medications that are not insulin that is technically approved only for type two diabetes that might have some clinical benefit for type ones as well. So there’s a lot of overlap. 

Is metformin among these medicines?

I would not include metformin in that because you have type one doesn’t mean you can’t have type two diabetes right? So you can actually have both, unfortunately. It is that someone who is overweight and not physically active can end up with insulin resistance, which is the underlying process for type two diabetes. This same process can happen to someone with type one. So let’s say you were diagnosed at the age of five and your autoimmune system destroyed your ability to make insulin. But maybe you also have a family history of type two or maybe you put on weight in your thirties or forties, start being less active, and you might find that the amount of insulin you need in a day has increased from 30 units (that you needed previously) to 60 or 70 units to get the same results. In that situation, you’re starting to develop insulin resistance. And if that’s the case, metformin would help. However, if you are a true type one, metformin probably would not help. If you have features of type two layered on type one, then it can definitely be helpful. 

It’s really interesting. I have recently heard about metformin that it is a wonder drug and has applications for improving longevity, Like actually helping people to live longer and being like, the potentially wonder drug in that space. 

Yeah, every once in a while, you’ll see headlines pop up that says something like Silicon Valley CEO is taking metformin and it is true that some of these studies that look at large-scale data sets seemed to suggest that there might be a reduced incidence of cancer. Likewise, certain cancer studies have shown that maybe it reduces the incidence of dementia. Even independent of the blood sugar effect, there is some signal to that suspicion. but there hasn’t been any randomized control trial to confirm or deny the hypothesis. I agree, it is definitely something of interest and when I meet patients who are really reluctant to take metformin, sometimes I tell them to help make them feel a little bit better about starting it. 

I’m interested in knowing about the randomized control trials and  I think our listeners will also be interested in it so what kind of data exists or what plans are there that you might be aware of to generate some data comparing CGMs.

Yeah, that’s a very good question. It is true that most of the time the studies are sponsored by these device manufacturers. Right? So Dexcom sponsors Dexcom study, Abbott sponsors a Liber study and so on. Often they’re being compared against finger sticking and as far as I can tell, I can’t think of a head-to-head comparison of CGMs in terms of outcomes. I guess part of the question is who would pay for that study? So it’s hard to design something like that. Even companies are a bit reluctant or hesitant to do a head-to-head comparison against their competitors. A lot of times, they’re doing head-to-head comparisons to older medications etc. 

That stands true. In medicine, we tend to compare newer drugs to the older ones to see their effects and accuracy.  It’s really an interesting concept, right? Especially the information that’s out there and I believe that it would be nice to start to see that data where we could get a comparison of different CGMs on the basis of their impact and accuracy for example in terms of HBA1C or the time in range. So it’s the patients’ experiences that would probably be the most relevant like getting alerts and the general interaction from patient to device would be the area that might be of particular interest. 

Yeah, the differentiation is especially true for these algorithms and the automated insulin delivery systems. Taking the 50% time in range to 60%. is a lot easier than going from 80% to 90%. So once these algorithms are good enough to keep most people above the seventies and some in the eighties, I think that’s where the quality of life is going to improve and that’s what really matters to people, right? Because I think even now, when I look at CGMs’ tracings, I’ll tell patients like, Hey, this is awesome. Your time in range is 85%. And then they tell me Oh, but I’m eating all the time to avoid hypos. So their CGM looks great and those are the types of things that we have to get a better sense of assessment. 

So in terms of your day-to-day practice and your treatment for type one diabetics, what are the current issues, topics, or experiences that you and the patients observe, and what are the areas of focus right now? 

Yeah, good question. In California, COVID is currently a big deal and in the US, vaccines just got approved about a month ago so I think that’s a frequent topic of conversation. My patients keep on asking me when they can get the vaccine. At this point in time, the primary health care providers like frontline workers and elderly adults are prioritized for vaccines. A lot of my type ones are anxious to get on the vaccine. In fact, some of them are asking me if they should get it or not so this is something we are observing these days.  

Now in terms of innovation one of the exciting things for me is talking about continuous glucose monitoring, I prescribe and do these procedures for a different continuous glucose monitor called the Eversense which it’s an implantable continuous glucose monitor that is inserted under the skin. This is something that is really popular in certain portions of the population. For example, patients that have allergies to libre or Dexcom, so we have a solution for that as well. But some people just want a different type of paradigm for a continuous glucose monitor, and the Eversense is a good option.

The last thing that’s probably top of my mind is that some of my patients have growing enthusiasm and interest for automated insulin delivery and better-automated pumps so in the US right now, the tandem is a kind of the only true hybrid closed loop pump. They have something called Control IQ technology, which automatically adjusts the bolus rate of the pumps and it does a bit of auto-correction boluses and that’s been a big game-changer for my patients, However,  it’s still a tube pump like the Medtronic. Even an Omnipod also has some automation that will hopefully get FDA approval later this year. So those were the three main topics that are the focus of discussion these days. 

I’m keen to understand a bit more about Eversense and I would like to hear some of the patients’ stories, particularly around the pump to get some sense of patient experiences that you’ve seen whether it’s improvements or not but it will maybe give us more information about Eversense.  I have spent a lot of my time in CGM World so maybe my view is a bit skewed and certainly, I’ve found it really fascinating. Do you want to share with us some of the patient experiences or cases that you’ve seen with Eversense? 

Absolutely Yes, so Eversense is an implantable sensor. It’s about the size of a long tick-tock that would get inserted in the upper arm through a minor surgical procedure. We make a tiny incision and slide it in. You don’t need any stitches after and it could be worn for 90 days. In Europe, they have a 180 days version of it but in the US Hopefully, by mid-year or end of the year, we should have this 180-day version as well.  It’s important to note that you still have to wear a transmitter over the sensor to get a signal.

One of my patients who played water polo said that in water, Dexcom or libre used to get pretty dirty and violent so she wore that people would grab it and pull it off of her skin but now with Eversense she could just pop it off during a match and then after her match, she puts it back on. Obviously, you don’t get numbers during the match, but at least for those two hours, you could keep it aside. Similarly, I have patients who want to go to the beach or they want to go on a date, or they wanna wear a sleeveless dress like during a wedding they get so glad that they could just pop it off during the events and then put it back on afterward. 

So for example, if you are the water polo player, could you just put the scanner back on it at half time to get a quick reading to see where you’re at? 

Yeah, so it would reestablish a signal like it might not be instant and It wouldn’t be like a libre. I know they’re developing something like that, but say it was halftime and you had 15 minutes so you put it and get readings because it’s just whenever in the five-minute cycle. 

So if you only had 90 seconds or 30 seconds, then you might not get one depending on what the timing works out to be but if it’s like seven minutes, you’ll definitely get a reading. 

Yeah, that’s really cool. Actually, I think the idea of having an implantable to be on the skin would add another level of feature to it. That’s a product that they’re working on in research and development which I think your audience and you will really appreciate. And it sounds so stupid but going back to the whole concept of quality of life, the adhesive is a completely different experience. 

Even initially, I was a little bit skeptical about the Eversense. You know, in the US we use two calibration systems which means you still have to calibrate twice a day, which is obviously a big difference between the libre and the Dexcom.  The 180-day product in the US would have one calibration but we’re still waiting for that. 

It’s basically like a double-sided tape and one side is made to stick to the transmitter and the other side is a very gentle silicone adhesive. So it’s similar to an EKG lead, and it’s very gentle. Let’s say you wanted to go jump in the water so you just peel it off and you see it comes off very easily. In fact, you can also put it right back on. So that experience of just being able to pull it off and put it back on is very different as compared to the libre or the Dexcom. Some people sweat through their patches so their CGMs like Dexcom don’t last as long, and this is not a problem with Eversense, because it’s not hard to swap it out. 

That is fantastic, especially for people who have rashes or allergies. You said that calibration is necessary. Can you explain this part? The reason I ask this is that I wore a Dexcom and you know, the whole calibration thing didn’t necessarily seem to make it more accurate?

Yeah, so that is a great question and its a similar Dexcom scenario when you had to calibrate it. So one big difference is that with Dexcom you need to change the sensor every seven days. You’re still changing the sensor every seven days, and maybe up to 10 to 14 if you’re extending the life of the sensor. But in the end, you’re still getting a new sensor every 10 to 14 days, right?  whereas with the Eversense you’re getting one sensor for 90 days in a row. So if you don’t calibrate it at all over time, you’re kind of teaching it to be bad and that can lead to significant differences on day 30. So, you know, legally and medically, you’re supposed to calibrate twice a day. I wouldn’t I definitely not suggest anybody not to calibrate. 

I’m keen to understand what the future looks like for type one diabetics in terms of technological advances? Is there anything that you’re aware of what’s coming down the line? Whether it’s in the transplant space or any other inventions for type one diabetics that we can get excited about? 

I think that automated insulin delivery is going to continue to evolve and be kind of the gold standard over the next 35 years. I think maybe in the next 7 to 15 years stem cell therapy and transplant therapy will get more strengthened. Researchers are creating stem cells that can basically produce beta cells that make insulin. In theory, you could take these stem cells and put them into people with type one diabetes so that their body makes insulin again, which is the issue with type one diabetes. 

There’s been a lot of promising research in the creation of stem cells, and it’s really exciting. The challenge, however, is that when we take those stem cells and put them in humans the same process that destroyed your initial beta cells takes place with these new stem cell beta cells as well. So you know, your body basically rejects the new stem cells and kind of destroys them just like they destroyed the initial beta cells. A lot of the researchers and technologists are working on trying to find a way for those stem cells to be preserved in the type one patient without being destroyed or blocked off.  

You know that the artificial pancreas or bionic pancreas is already there and  It’s likely to get better over the next five years. Now, with stem cell therapy, I don’t necessarily feel like we’ve crossed that point where I could tell my patients like it’s coming rather we’re still working on this technology. We cannot predict when exactly it will come because I still think there are a few steps that need to be reached. 

Another big thing is smart insulin delivery. Scientists are basically working on smart insulin that might only be active when your blood sugar is high. So imagine you take Humalog or a Novolog, where it really kicks in and becomes activated when your blood sugar is high. But when your blood sugar is normal or low, it automatically gets inactive. That would be fantastic, because in a way, it is kind of autoregulation, right? So there’s a lot of enthusiasm about smart insulin as well, but I think that’s also still in the research and development phase. 

The last thing I would say is the use of some type two medications, which we briefly touched on. I think there has been some momentum on making that more mainstream. I think there’s a lot of exciting research being shown that you can maybe delay the progression of type one. If you know, you have a family member who tested positive on a screening test so maybe being able to delay type one for a year or two years to get more time for technology to advance.

That’s a fascinating concept, isn’t it? But so far we do not know why we get type one. We know it’s an immune response, but we don’t know the reason why people get it. We could talk about stress, virus, and genetics that led it but do you think we’ll actually get to the point where we can trace the reason behind it? 

I think that’s gonna be really challenging, but there’s kind of two layers to what you’re asking. It has been solved to some degree like we can identify people who are at risk of type one now.  For example, if you have a family member or if you have children, then you have the option to send the antibody tests for type one diabetes, and it’s not a slam dunk and It’s not an exact 1 to 1, but many patients that have antibodies to type one like if you have one of these antibodies, it’s about 85% risk of developing type one diabetes later in life. If you have two antibodies, it’s like 98% risk so we can identify people who are at risk of developing type one diabetes. So there is some degree of knowing who will get it now. 

You might be thinking of the reason behind it as did I eat something wrong? Did I get a virus? Did I get sick? Well. that is harder to tell because that might be difficult to tell what exactly triggered it Right? You know, the guy next to you might have eaten the same thing or had the same virus, but he didn’t get type one. We have solved the question of antibodies so we can identify people who are at risk but we can’t necessarily identify the insult that brings it out or activates it. 

What are those antibodies that you just talked about? 

Yeah, there are several. The most commonly discussed one is called glutamic acid decarboxylase 65 called GAD-65 and there are a couple of others as well like Zinc transporter 8 antibody and IA-2 antibodies. So it’s something that right now is largely limited to screening in family members because it’s not something that you can test everybody with, but interestingly enough,  JDRF is the US. Based fundraising body for type one. They actually launched a program in America called T1 Detect where they are basically making this antibody test screening affordable for everybody perhaps for $50 so anybody in the United States can order a kit and get these antibody tests done. This program was launched just a month ago so it’s popular among the presses. It’s called T1 detect and you can easily find it online by typing “JDRF” or  “T1 Detect”. 

Wow, that’s really interesting. So it means that we can detect the antibody and therefore we can predict the percentage of someone to be at risk of developing it but once we know that, what can we do? As you said, you could delay it for a year so what are the things that you’re doing to foster that delay? 

That’s like a huge body of research that is in progress right now. I think this is why you know, getting more widespread screening will help because providing certain medications can potentially delay it. However, the question is should we give it to everybody who has these antibodies? How long do we give it to them? When do we give it to them? I think these are all questions that don’t have answers and these medications or not benign and have side effects. So I think that’s the challenge and that has been a hotbed of research these days.  In fact, different people have postulated different things like does eating low carb can delay it but we don’t have clear evidence to support it so these are the types of questions that are being asked that scientists are trying to solve. 

Yeah, we have heard that type 1 diabetes is because of the immune reaction or response that takes place in the body therefore, you need to do something to avoid that immune reaction. The only way to do it is through immunosuppressant or immune therapy, right? Are we looking at ways to mediate those reactions? 

Well. a lot of research is going on in this area. There are people who believe that there might be a way to reactivate islet cells in people with type one diabetes for many years. Even I’ve heard scientists arguing that there’s a chance that we may be able to reverse that process in people with type one who has had it for a long time. So it’s kind of an unknown but exciting world that opened up because of a lot of people’s interest in it. When the first immunotherapy study came out, it showed a delay in the onset and progression of type one. So it was kind of a big groundbreaking change and  I think there’s a lot of excitement in this space as people try to better understand the processes. 

It’s good to see research and investment going into these areas and I think that we will see increased investment and the size of the potential market which will bring an impact and change in the future of healthcare delivery in the diabetes space. So I think it’s a great note to finish on. We really appreciate you for giving us your valuable time. Is there anything else you wanna sign off on before we end? 

Yeah, I think it’s an exciting time to have type one diabetes. That sounds kind of weird but it will always be exciting in terms of new innovative technologies and inventions that are being done in this space.  A lot of significant progress is going to be made.I would say there’s a lot of need for optimism and the next step in the upcoming five years is going to be improvement in quality of life.  I believe that our glycemic improvements have been reached. So now the bigger shift would be towards improving quality of life that is going to benefit people with type one more than anything. 

Yeah, the thing that I’ve always been fascinated by is this idea that if you are diagnosed as type one diabetic 50 years ago so  when we talk about morbidity and mortality for a type one,  we’re basing that information on patients who had diagnosed a long time ago. I got diagnosed as a 30 year old so the evidence that exists out there says that this is gonna be my outcome but  it actually isn’t necessarily going to be like that  because that evidence isn’t based on a 30 year old diagnosis. I hope that in future the type one doesn’t exist anymore.

Yeah I think you made a good point. Even if you diagnosed a five year old now that’s very different from being diagnosed as a five year old 30 years ago, right? Also, I hope the disparities in care get resolved whether it’s ethnic, financial etc. as this is  something that we haven’t solved yet at least in the US. We’re solving previous problems so there’s still a lot of ground to cover, and there are a lot of places where we fall short, but we’re getting better and better fast, 

So it’s pretty amazing discussion David, Thanks very much for your time!

Thank you for inviting me. Take care!