I have patients that consider their CGM the best addition to diabetes management since the discovery of insulin. I also have patients who have been disappointed, and one who even needed to see a psychologist after following every trend and pattern and literally ending up in tears.
Many studies support the effectiveness of CGM, particularly when used consistently. Trends and patterns can be spotted, acute hypoglycemia averted. The newest system (Enlite-Medtronic) will respond to a low BG value when communicating with their insulin pump utilizing an automatic suspend. What a blessing to parents and caregivers!
Given the upside of CGM, why doesn’t everyone want one?
As we all know, type 1 diabetes is a chronic disease requiring due diligence to achieve the strict guidelines that are set for preventing long term complications. We ask patients to check BG a minimum of 4-5 times per day, to wear a device that resembles a cell phone but that can never be removed for more than an hour at a time. We ask them to count carbohydrates and when ill and hyperglycemia results, to pee on a strip and check ketones. We coach them on adjustments for exercise, realizing that the adjustments do not always work from one exercise session to the next. We ask them to refrain from carbohydrates for meals to determine accurate basal rates, realizing that it is a helpful tool, but not always providing a consistent answer. For 24 hours a day, 7 days per week, type 1 diabetes can never really be set aside for a break.
Now enters CGM. A movie picture so to speak. It generally follows BG trending, and can provide a great retrospective look to determine what could have been managed in a different and perhaps better way. It can be set to predict a low or high BG as it follows glucose trending. However, it is not always accurate and can provide false alarms and false readings adding to frustration in an already unpredictable disease. It is also another piece of equipment that must be worn consistently and it is financially an added cost – and for some – a huge cost due to lack of insurance coverage.
So how do we help our patients decide if it is the step they want to take?
I believe almost every patient on multiple daily injections or insulin pumps should be educated on the option to choose a sensor; to understand both the benefits and the drawbacks and to realize it will take time to learn the ins and outs of utilizing a CGM. Using a professional CGM first, and reviewing the data with a patient, may help them see how they could use the information to promote better management of their diabetes. Freedom to choose, assessing the benefits, drawbacks and costs, and allowing the patient to decide if it is something they want to pursue is part of our job as educators.
How successful have you been at embracing this great optional technology with your patients? And if they choose to use it, what educational steps do you use to make the experience a positive one?
“All my bags are packed, I’m ready to go…” This John Denver song reminds me that AADE14 in sunny Orlando, Florida is less than 30 days away!
Last Friday the FDA (US Food and Drug Administration) approved the latest inhaled insulin, Afrezza. I can remember a few years back the inhaled insulin Exubera was approved and then later pulled from the market due to safety concerns regarding lung tissue. I can remember my patients being so excited and then bummed when it was discontinued.
Afrezza is an ultra-rapid acting mealtime insulin approved for adults with type 1 and type 2 diabetes. It comes with a cartridge of the inhalation powder and then a very tiny inhaler. I can remember the Exubera inhalers were large chambers that would draw some attention if pulled out in a restaurant. This little inhaler looks a little smaller than the size of an asthma inhaler. Afrezza dissolves immediately after inhaling and then peaks at 12-15 minutes after being absorbed into the bloodstream.
The MannKind Corporation page for Afrezza reports that there have been clinical trials with over 6,500 patients, and the results have found reductions in hemoglobin A1cs, hypoglycemia and weight gain in comparison to rapid-acting insulin. They found that there were some small changes in lung function and did not continue with Afrezza was stopped. The most common side effect was a cough.
According to the FDA, studies have been done to compare Afrezza to insulin aspart and found that the HbA1c reductions were lower in aspart than Afrezza. They also of course caution that Afrezza is not a substitute for long-acting insulin and is not recommended for the treatment of DKA or in patients who smoke, have chronic lung diseases like COPD or asthma. The FDA also notes other common side effects of hypoglycemia and throat irritation. Studies are being conducted now to evaluate Afrezza in children and to see if using Afrezza increases cardiovascular risks and lung cancer.
When new products come out like this, it’s great to be the first ones to tell our patients so we can educate them on the pros and cons and how to correctly use products. I’m sure we will be hearing a lot more about this soon!
We all know of the possible negative outcomes of high blood glucose (BG) including micro- and macrovascular complications. A large part of what we do as diabetes educators is to work with people to help manage BG, aiming for goal ranges. I now share a sad story about another negative outcome involving high BG that describes several missed opportunities with very bad consequences.
On May 20th, I received a call from my cousin. Her father, my uncle and godfather, had cancer. We knew this already. He had various treatments over the past couple of years. As part of his cancer treatment, he was on steroids and recently developed diabetes. His scans were now negative but blood work suggested there was still cancer somewhere. His current problem was pain and numbness in his lower extremities and incontinence. He had started using a cane. It was determined that he had degenerative changes in his spine and was going to undergo neck surgery the next day. Within a couple of hours, the surgery was cancelled. They found where the cancer was, in the covering of the spinal cord.
The plan was set: 13 radiation treatments and then start chemotherapy. He underwent a radiation treatment the next day and was discharged home to continue. He was on insulin in the hospital but placed on one dose of one oral medication for home; no insulin, no diabetes education. When he arrived home, he was weaker than when he left a few days earlier so he borrowed a rolling walker.
Within a day of getting home, his BG went up to 450. My cousin knew this was too high so tried to control it with very low carbohydrate meals until his next appointment with his PCP. Off to radiation each day, BG checks during the night, avoidance of carbs.
I stopped by on May 24th to help with strategies on how to get up from the chair and go to the bathroom due to rapidly increasing weakness. His BG that morning was in the 200s but had been in the 300s. I talked to my cousin about this and encouraged her to contact his PCP. Monday, May 26th, Memorial Day, our family had a get-together but I worked the holiday so didn’t see my uncle. My mom said he looked very weak. I checked with my cousin the next day to see how things were going. BG was still very high; they were doing the best they could with monitoring, watching carbs, taking the one oral medication and were going to the PCP soon.
Later that week, I called to check on how things were going. My cousin sounded so tired since she had been staying bedside to monitor BG during the night. They generally remained in the high 200s, an occasional spike to 350.
On June 2nd, BG was 450 again and my uncle reported a fruity taste in his mouth. It was determined at the PCP office that insulin should be started so they would get a call to be scheduled with the person who comes in to do insulin starts. Radiation continued daily, other physician’s appointment mixed in, my uncle kept getting weaker, so they got a wheelchair, BG still in the 200s to 300s.
Now, things start to change quickly.
My uncle had terminal cancer. We all knew he was going to die. But, did it have to happen this way? Could the UTI have been avoided? Could he have been started on insulin for home? Could he have received diabetes education? High BG can cause so many problems. There were many missed opportunities that might have changed this course. What can we do to help others appreciate the horrible consequences of hyperglycemia? Thank you for listening to my story. I hope we can increase our influence so others don’t have to go through something similar.
Recently, I was exploring the AADE website and seeing if there was any new information for myself and/or my patients. As I was reviewing the website, I got an email from AADE about the latest news. One of the recent updates included the AADE 2013 Annual Report, titled “Steering a New Course.” The annual report is a quick summary of AADE’s accomplishments during 2013. I would encourage every AADE member to read this report. The first half of the report aligns with the organization’s 2013-2015 strategic plan, but here are some highlights:
Investing in Diabetes Educators
Advancing Diabetes Population Health Management
Empowering People with Diabetes
AADE also created and launched a mobile app for use among members and patients. The Diabetes Goal Tracker is a free app for iPhone and Android mobile phones. This app is specially designed for patients to learn about the seven self-care behaviors, but to also set SMART goals for each behavior. Check out the app yourself!
Expanding AADE’s Capacity
Check out the year-in-review by reading the AADE Annual Report. You may find another recourse for yourself or patients. Along the way, you may recognize some colleagues on the leadership team – give them a shout out!
More than a decade ago, it seemed like every magazine and newspaper I picked up was featuring a new herbal supplement for some chronic disease prevention and treatment. Interest appeared to wane for a few years, but there is a documented resurgence. I feel almost overwhelmed with advertisements and articles touting the benefits of new supplements. I’m in awe at the number of products lining store shelves.
As I prepared to write this blog today, there was an advertisement for a new supplement for diabetes prevention and treatment in my mailbox and a new journal article on dietary weight loss supplements on my desk. It appears to be time to revisit this topic and recognize how many of our patients are reportedly taking supplements.
According to the National Center for Complementary and Alternative Medicine, nearly 40 percent of Americans use health care approaches that are not considered mainstream medicine http://nccam.nih.gov/health/whatiscam . More than 50 percent of people with diabetes have been reported to take nutritional supplements, and persons with type 2 diabetes more than twice as likely than those with type 1 diabetes.
When questioning my diabetes patients about supplement use, alpha lipoic acid, cinnamon, chromium, ginkgo biloba and garlic are frequently mentioned. My challenge is to help determine if the product is appropriate or potentially dangerous.
When trying to find answers, it is a challenge to find consistent evidence based on research, particularly within the gold standard of a double-blinded randomized control trial.
So where to go for help?
It’s important to recognize that all products that change the way our body works are drugs, whether they come from “natural” or synthetic sources. Herbal products and supplements have little production and marketing oversight and must be proven to be detrimental prior to being removed from the market place – they do not have to prove that they actually work. Let’s help our patients understand if their herbal and supplemental products have the potential to augment a healthy diet, be neutral or have the potential for harm especially when combined with other medication they may be taking.
Are you asking your patients which supplements they are taking and why? Are you assessing whether they are healthful, harmful or just extra money many patients can ill afford?
If this is a topic you are interested in, stay tuned. AADE will sponsor a webinar on herbal supplements and type 2 diabetes in August! Click here for more information.
I was reading a brochure last week trying to figure out how I could attend a major conference in Boston when one of the presentation topics caught my eye – “Is Alzheimer’s Type 3 Diabetes?” Whoa…Did I read that right? Since my budget made it very doubtful I could attend and listen to the presentation in person, I decided to do more investigation.
The American Diabetes Association states that 27% of American people over the age of 65 have diabetes and about half (that would be 50% - which is a LOT) have prediabetes. I interpret that as – for every couple, one of them will have pre-diabetes after age 65. That is scary.
There are a number of studies showing that people with diabetes, particularly Type 2 diabetes (T2D), have a lower level of cognitive function and are at an increased risk of dementia than those without diabetes.
We know that one of the biggest risk factors for Alzheimer’s is having T2D. But to say that Alzheimer’s IS Type 3 – that is a new one for me. As I found out in researching the topic, a number of studies are closing the connection between Alzheimer’s and diabetes.
In one example, a study published in 2005 out of Brown University, they identified the reason they think people with diabetes have a higher risk of developing Alzheimer’s. Their study showed that in this type of dementia, the part of the brain which is involved in learning and memory seemed to be insensitive to insulin. (That sounds familiar). They found that not only are your liver, muscle and fat cells resistant to insulin but it seemed, so is your brain. When they fed animals a diet designed to give them T2D it left the animal’s brains riddled with a protein called beta-amyloid. These beta-amyloid plaques are one of the key findings in Alzheimer’s. It is also noted that insulin plays a key role in memory. This study suggests that when you consider these 2 items, perhaps Alzheimer’s may be caused by a form of brain diabetes.
It is estimated that the number of people with diabetes is expected to rise from 382 million currently to 592 million over the next 25 years. An article in New Scientist from 2012 reports that if the above is true, we should see an associated increase in Alzheimer’s over the same period. If the beta-amyloid build-up can be stopped in people with T2D and their cognitive impairment reversed or delayed, perhaps many of them will not progress to Alzheimer’s.
There is discussion that perhaps we should be looking for diabetes medications that work on the brain. Researchers at UT Dallas are contemplating looking for a vaccine to prevent Alzheimer’s. Past studies looking at using antibodies to treat Alzheimer’s all looked at those patients in the advanced stages. UT Dallas reports that perhaps it would be better to inoculate those at high risk, which they now think are most likely people with T2D.
If you want to learn more, go to www.alz.org and search for diabetes. There is much more information supporting these theories.
I’ve always seen California as a cutting edge state to lead the nation in heath advocacy. Have you heard about SB 1000? It is the “Sugar-Sweetened Beverages Safety Warning Act” requiring all sweetened non-alcoholic drinks (over 75 calories per 12 oz serving) to have a warning like the one below on all bottles, cans, vending machines, dispensers, and restaurants:
This is a very similar approach to the tobacco legislation that requires labels on all nicotine-containing products stating that it can cause cancer. Even if you don’t smoke, you have seen this warning. It is public health education that spurs conversation and could potentially make people question why they are drinking something with a health warning. A label also still allows for personal choice. It is similar to the legislation that requires nutrition facts on food items or the legislation in some cities to add calories to menus.
Though some of my diabetes patients understand that sugary beverages are not the best choice for them, others are very confused and think a couple a day is fine because it is “much better” than their family members who drink 7 or more per day. The media message of beautiful healthy celebrities drinking sugary beverages and the excessive availability of sugary beverages give them the green light in our culture. Surely if the majority of choices in a hospital waiting room vending machine are sugar sweetened beverages, it can’t be that bad, right?
Just a label isn’t necessarily going to reverse the obesity epidemic, but it is a harmless piece of education that may spur some to question their decision and slowly shift the perception of sweetened beverages.
This is a great summary video of the SB 1000 legislation and co-sponsors:
Here is a link to a fact sheet to discuss with legislators of your state: