In the latest episode of The Hard Things About Healthcare, we sat down with Dr. Viral Shah, an endocrinologist and clinical researcher at Indiana University’s Center for Diabetes and Metabolic Diseases. With a career spanning pivotal research in continuous glucose monitoring (CGM), automated insulin delivery (AID) systems, and glycemic risk analysis, Dr. Shah brings both a scientific and clinical perspective to the ever-evolving world of diabetes care.
Why Diabetes? A Personal and Professional Mission
For many endocrinologists, diabetes care is more than just a field of study—it’s personal. For Dr. Shah, the connection to diabetes is deeply rooted in his background.
"Being an Indian, if people are not aware, South Asian Indians are at a pretty high risk of developing type 2 diabetes. And so I do have family members with both type 1 and type 2."
With over 15 years dedicated to diabetes research—predominantly type 1—Dr. Shah’s work has significantly influenced the development of CGM technology and AID systems, shaping how people with diabetes manage their condition today.
Revolutionizing CGM: The Fight to Eliminate Fingerstick Calibrations
One of the most impactful studies Dr. Shah contributed to was the Replace BG study, which ultimately led the FDA to remove the requirement for fingerstick confirmations before making insulin decisions. This was a game-changer for people with diabetes.
"At the time, the FDA was concerned that CGMs weren’t accurate enough. Our study showed that, nope, it doesn't matter. And so I think that's one of the beautiful studies...”
This shift in CGM technology has paved the way for more seamless, user-friendly devices, ultimately improving safety and quality of life for people with diabetes.
Glycemia Risk Index (GRI): The Next Step in Data-Driven Diabetes Care
With CGMs producing an overwhelming amount of data, the challenge has shifted from getting enough information to making sense of it all. Enter Glycemia Risk Index (GRI)—a concept spearheaded by Dr. David Klonoff and further developed by Dr. Shah and his colleagues.
"Think of it like an Amazon or Yelp rating for blood sugar control. A 5-star review tells you something is great, but it doesn’t explain why."
GRI condenses glucose data into a single number by analyzing both hyperglycemia and hypoglycemia, giving a clearer picture of glucose stability.
GRI has the potential to revolutionize both patient care and clinical research: ✔️ For clinicians: Helps prioritize patients who need intervention the most. ✔️ For researchers: Allows smaller, more efficient studies to test new diabetes technologies.
The Future of Diabetes Tech
When asked about the next big innovations in AID systems, Dr. Shah emphasized the need for full automation and seamless integration.
"All automated insulin delivery systems need to be completely automated. Right now, they still require some user input, but the goal is a system that functions on its own without manual adjustments."
Patients also want devices that are:
✔️ Smaller and more discreet
✔️ Easier to use
✔️ Integrated (pump and CGM in one device)
At the same time, AI-powered predictive tools could play a significant role in preventing complications before they happen.
"Sometimes I feel like the EMR or our electronic medical record houses so much of information. Yes, lot of things that can be junk, but I think there are a lot of different things that are really useful, but they're just never being utilized and it becomes a part of the junk. Rather than that, utilizing that information to develop those kinds of prediction tools and doing something before it's coming."
The Hidden Challenge: Standardization in Diabetes Tech
As technology advances, a lack of standardization is making it harder for both patients and providers to navigate the growing list of available devices.
"The industry needs to realize that I totally value innovation. Everybody wants to craft their brand differently. But at the same time, we need to try to think about commonalities. Try to make sure that there is some kind of a standardization, right?"
Dr. Shah compared the situation to something as simple as toothbrushes, which follow an ISO standard to ensure usability.
"Do we use like a different toothbrush? No, it was very interesting. You Google that. There is an ISO standard for your toothbrush. It cannot be this long, okay? It has to be certain length. I think it hasn't come that much into the diabetes space, and I would appreciate that."
Final Advice for Endocrinologists: Listen and Streamline
For endocrinologists looking to efficiently integrate diabetes technology into their practice, Dr. Shah offers two key pieces of advice:
1️⃣ Listen to Your Patients.
"Just listen to your patients. I do understand the science, and that's what 80 % of my time, as I said, it's research. People don't follow the textbook. And so just listen and validate what they think is the best."
2️⃣ Optimize Your Clinic’s Workflow.
✔️ Set up protocols for integrating CGMs, pumps, and AID systems.
✔️ Keep device demos on hand—patients should see and feel their options.
✔️ Build strong industry connections to ensure seamless device training and support.
"It took me two months to build my clinic’s workflow, but now, when I prescribe a pump, 99 % of the time my patient gets it within two weeks, with training and a follow-up visit scheduled. It runs seamlessly without my direct involvement because my team knows their roles."
Final Thoughts: A More Streamlined Future
With patient-driven research, AI-powered insights, and a push for standardization, the future of diabetes care is full of potential. But for real change to happen, we must bridge the gap between innovation and implementation—ensuring that new technologies actually make life easier for patients and providers alike.
For more insights into the evolving landscape of diabetes technology, tune into the full episode with Dr. Viral Shah, Matt Faustman, and Ginger Vieira.
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