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ORLANDO -- Technologic advances aren't fulfilling their promise for improving diabetes or overall health outcomes in the U.S., argued FDA Commissioner Robert Califf, MD.

"We are wowing the world in technology -- much of it related to the field that you're interested in [diabetes]," he told attendees at the keynote opening session of the American Diabetes Association Scientific Sessions. "We are not succeeding in implementation of the things that we know. We need to bring these things together so that we harness technology, particularly digital technology and AI [artificial intelligence], to the benefit of the people that we care about."

He pointed to the dismal numbers: "The U.S. and almost every other high-income country had about the same life expectancy and spent about the same amount on healthcare," he said. But then as per-capita health expenditure rose over time, "all the countries rise up to have longer life expectancy for a reasonable cost, except for one outlying country -- that's the United States of America."

There was a "particularly precipitous decline" in the U.S.'s relative status at the time of the COVID-19 pandemic, "essentially putting us in last place compared with other high-income countries," Califf noted. The latest CDC data showed some improvement, but not relative to other countries.

High fasting glucose, poor diet, and high BMI are all in the behind death and loss of disability-adjusted life years in the U.S. And according to some sources, diabetes has now surpassed cancer as the leader in the economic cost of healthcare in the U.S., with some 34 million adults having some form of diabetes in 2020, he said. "This is an honor I'm not sure I'd want to have, but it does give you a lot of power to do things to make this better."

Technology has brought incredible advances in diabetes, notably continuous glucose monitoring and pumps that make life more manageable for patients.

However, Califf pointed to a truism Ed Yong wrote in : "Technological solutions tend to rise into society's penthouses, while epidemics seep into its cracks."

While those words were written about the pandemic, Califf said, "if you look at all the technology we developed in diabetes -- and I saw this very much when I was working at Google or Alphabet -- despite all the avenues, there was a great tendency for the best things to be taken up by people with PhDs and living in urban areas. Most of our people were left out and haven't caught on as much."

GLP-1 receptor agonists are highly effective but remain out of reach for many with type 2 diabetes due to high costs, insurance coverage, drug shortages, and clinical inertia. Continuous glucose monitors are also not uniformly covered, he noted. "So this is the thing that we really need to work on and figure out how to get effective technologies and interventions to people in rural areas that you under-serve. And it's not going to be easy," Califf said.

There just aren't enough endocrinologists to go around. In 2021, there were some 8,200 endocrinologists to care for 38.4 million Americans with diabetes, a ratio of about 1:4,660.

"A big part of [the solution to] this is going to have to be digital health tools," Califf argued. "We're living in a world now where new digital health tools are coming out on a daily basis, but analyses that have been done are not showing that they're delivering on the promises."

He pointed to a by the independent Peterson Health Technology Institute showing that eight widely used digital tools that people with type 2 diabetes use to track and manage blood glucose using a noncontinuous glucometer increase healthcare spending without delivering meaningful clinical benefits.

"Are these technologies reaching the majority of people who need them, and do we know what to do with all this information? I would say the answer to both is no at this point," Califf said. "It reminds me of a period in aviation when every time an engineer thought of a new thing to measure, it was stuck in the cockpit in random order. There were so many near-misses that they actually put a moratorium on new dials and gadgets in the cockpit and redesigned using different factors in the cockpit that enable pilots to have a standardized way so they know what to look at. We haven't done that in this field, and we think it's very much needed."

He also emphasized the need for pragmatic research embedded in the healthcare system, "so that it pertains to real life. Rural areas, community health centers all need to be involved in the research enterprise." The NIH is now kicking off a national primary care research network, he noted, "and I'm very hopeful that this is going to play a major role."

He also pointed to an effort to create a comprehensive home health docking station and dashboard that all these devices could plug into. "We hope this will help the industry gravitate to something like the cockpit of an airplane, which is reliable, that people can depend on and not be besieged by information from all kinds of different places, that they can put in context. ... We need to disrupt the system as it is. Digitization can do that."

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