I had a few quiet moments one day and decided to look at opportunities to contribute to the efforts of taking care of children with type 1 diabetes in Africa. A very short time later I was online making plans. Reference letters were sent, plans were made and poof…I was headed back to Africa as a volunteer – this time the east coast.
After 31 hours of airplanes and airports, I arrived in Dar es Salaam at 2300. Exhausted, but happy to be in country, I headed to my modest hotel and organized a few thoughts prior to going to sleep.
My main objectives were to help organize the type 1 registry for Tanzania and gain an understanding of how children in Africa with type 1 diabetes are provided with supplies and diabetes education. I also hoped do work with some educators there, but found them few and far between. I have long believed that the low incidence of type 1 in equatorial countries is largely due to the lack of diagnosis. Cerebral malaria and other common diseases are thought of and type 1, misdiagnosed. This appears to have been the case in Tanzania. A decade ago, the waiting room at the clinic had 3-5 children on diabetes day, now it is full. There are over 1,200 children in Tanzania that have been diagnosed with diabetes and great strides are being made in educating physicians and other health care providers to check blood glucose when a child comes in with weight loss, lethargy, frequent urination and excessive thirst. Often, however, there are no laboratory facilities or strips available for the glucometers to make the diagnosis.
Insulin is available to all children under the age of 25 at no cost thanks to the efforts of Life for a Child (Lilly sponsored insulin) and Changing Diabetes in Children (Novo Nordisk). NPH/Lente and regular insulin with syringes are the norm, with few children getting long or rapid acting insulin. Insulin doses are fixed rather than variable and few adults even adjust their own doses. Syringes are reused multiple times (20-30), and strips are allocated at 2 per day. The wonderful nurse I spent time with estimates that 50% of the children do not have refrigeration at home even in the city and the days are HOT! Insulin is stored in an earthenware jar with charcoal and water to keep it cool. Although there have been a number of excellent educational materials translated into Swahili, there are few trained nurses and dietitians that can work one on one with patients to enhance the family’s understanding of diabetes.
Many of the children have A1Cs over 14% (the highest the machine records). But a few children who have functional and devoted families resulting in attention to consistent insulin injections, exercise and overall healthy eating, are achieving A1Cs in the 7s. Amazing, isn’t it!
So as I head home, I think of lessons learned. Regardless of the way in which insulin is given, even the types of insulin that are injected, it is the carrying out of the tasks. Although the resources we are fortunate to have, the insulin pens, pumps, as many strips as we can muster, can contribute to the ease of insulin delivery; it really boils down to understanding what needs to be done, having a supportive team (families particularly), eating reasonably and in a timely fashion, exercising and most importantly, consistently injecting life giving insulin that leads to success regardless of which country the child resides.
By the time I boarded the plane for New Zealand, the battle to reach the other side of the world was nearly won. Like many passengers, I had to meet weight and size requirements for all of my luggage; however, my issues were a little different from everyone else's -- because I had to think about diabetes. Thankfully, diligent preparation kept my anxiety about traveling with diabetes at a minimum. I hope that sharing my experience can help others have pleasant travels, too!
3. Diabetes Jetlag
AADE members: What are your thoughts? Is there any other piece of advice you would give to your patients preparing to travel? Do you have alternative suggestions? I would be interested in hearing your thoughts!
Katie Doyle is a writer and traveler with Type 1 who is currently living in New Zealand. She has a few tips from her recent traveling experience to share to share with diabetes educators!
Fall is here – the air is crisp and according to the national weather reports, downright cold in many places. This is a sure sign the holiday season is starting. Not only will the feasting begin but the opportunity for outside exercise will be challenging. So we need to come up with ideas for our patients – as well as ourselves – to survive the season by planning ahead and doing some damage control. I want to share with you some ideas from my patients -
November is National Diabetes Month, which includes November 14th- World Diabetes Day, led by the International Diabetes Federation (IDF). This year’s message is Healthy Living and Diabetes.
Special AADE guest blog from Albert Terrillion, DrPH, Med, CPH
As we head into cold and flu season, it’s important to recognize that the flu, a respiratory infection, can be serious. For one person it might mean two weeks laid up on the couch. For another, it could be hospitalization, or even death, and there’s no way to know ahead of time how serious a bout with the flu might be. What is clear is that flu can be severe for people aged 65 and older and can make existing health conditions, like diabetes, worse.1 According to the Centers for Disease Control and Prevention, people who have diabetes are at higher risk for developing serious flu-related complications, like pneumonia.2
The National Council on Aging (NCOA), the nation’s leading nonprofit service and advocacy organization representing older adults, is spearheading a national education campaign, Flu + You, aimed at educating those 65 and older about the seriousness of flu, the importance of prevention and the available vaccine options. As part of this program, we are working with the AADE to ensure we educate people with diabetes, who are particularly vulnerable.
Consider these tips:
Don’t let the flu complicate your diabetes.
Know that the flu can be severe when you’re older.
Get an annual flu shot.
Talk to your doctor about vaccine options.
Please talk with your patients, particularly those 65 and older, about the dangers of the flu and the benefits of vaccination. Visit the Flu + You website at www.ncoa.org/Flu to learn more about the flu, download resources, share content, and watch a new public service announcement with award-winning actress Judith Light.
1 Centers for Disease Control and Prevention (CDC). People at High Risk of Developing Flu-Related Complications. http://www.cdc.gov/flu/about/disease/high_risk.htm. Accessed May 19, 2014.
This question is often one of the first I get asked when working with a person with diabetes (PWD). Let’s cut to the chase. What is going to give me the greatest return for my effort? Some people we work with like to exercise and want to know what should be done for the greatest benefit. Others don’t enjoy exercise and want to know what they can do to accomplish the most with the least amount of time and effort.
There are two main types of exercise that have been shown to be beneficial for a PWD: aerobic/cardiovascular endurance exercise and resistance/strength training. There are other categories of exercise, including flexibility/stretching and balance, which might help an individual but have not been shown to improve some key parameters of diabetes management (i.e., lowering blood glucose (BG), burning calories, improving lipids and blood pressure).
Aerobic/cardiovascular endurance exercise is defined by the CDC as “activity in which the body’s large muscles move in a rhythmic manner for a sustained period of time. Aerobic activity…improves cardiorespiratory fitness.” Common examples of aerobic exercise include walking, biking, running, swimming, water aerobics, dancing, sitting aerobics, and hiking to name a few. These exercises are not all equal when it comes to burning calories and lowering BG. In general, the more muscles used, the better the exercise. For example, walking, which uses all of the body’s major muscle groups, will burn more calories than an equal effort of bicycling where the upper body is less active or swimming where the lower body is less active. The harder any exercise is performed, the greater benefit. Brisk walking is more efficient than casual walking. While high intensity exercise may provide greater rewards, it may also increase the risk of injury or lead to a medical problem if a person is not healthy enough (refer to my last blog on intensity). But, the bottom line is the best exercise may be the one that an individual can and will do. Though brisk walking may be a great aerobic exercise, a person may prefer biking or can only do water aerobics due to painful conditions, making the best option the one that will be carried out routinely. If lowering BG or burning calories isn’t a priority, a person can choose the exercise they most enjoy.
Resistance/strength training was not often included in the exercise prescription for a PWD until the early 2000s when a couple of major studies were published that showed strong evidence supporting resistance training for most people with diabetes. The CDC defines “muscle strengthening activity (also called strength or resistance training)” as a “physical activity, including exercise that increases skeletal muscle strength, power, endurance, and mass.” Strengthening exercises have been shown to improve insulin action, BG control, fat metabolism and storage in muscles and muscle mass. Strength training can be especially important for aging individuals to improve the ability to do activities of daily living and maintain independence. Resistance training can be performed by using weight machines, free weights, elastic exercise bands or body weight (such as with pushups and wall slides). If someone has not performed resistance exercise, it may be helpful to work with an exercise professional to learn proper form and technique to avoid injury.
In summary, aerobic exercise and resistance training are the two main types of exercise that should be done by most people (including those with diabetes). In my next blog, I will review frequency and time of exercise to complete this series on the specifics of prescribing exercise for a PWD.
Investigational and emerging treatments are attempting to achieve certain outcomes in order to have a “place at the table” in the management of type 2 diabetes. Some of these desired characteristics include minimal to no risk of hypoglycemia and weight loss with an effective A1C reduction.
In August 2014, a new drug was approved for the management of type 2 diabetes. Empagliflozin, also known as JARDIANCE, is the third FDA-approved agent sodium glucose co-transporter 2 (SGLT2) inhibitors. In healthy individuals, approximately 90 percent of the filtered glucose is reabsorbed by SGLT2 in the proximal renal tubule. The kidney desires to excrete excessive, filtered glucose in order to restore normal levels of glucose in the blood. In a patient with type 2 diabetes, the kidney is dysfunctional and responds to hyperglycemia through glucose reabsorption. (Defronzo RA, Diabetes 2009)
Empagliflozin is a selective SGLT2 inhibitor, which will decrease blood glucose levels secondary to the process of glucosuria in which glucose is excreted in the urine. It is similar to the other SGLT2 inhibitors – INVOKANA (canagliflozin) and FARXIGA (dapagliflozin). Empagliflozin lowers A1C by 0.7 to 1%; reduces weight by 4 to 7 pounds; and lowers blood pressure by 3 to 5 mm Hg. However, it is expensive – estimated to be $10 per day. Other disadvantages include genital yeast infections and urinary tract infections. Empagliflozin should be started as a second or third agent with other oral agents. As a certified diabetes educator, you can educate patients to take the medication in the morning due to a possible diuretic effect.
To me, this agent provides another option in this therapeutic class. However, this class may become “me-too” class as there may be minimal differences between agents. In addition, there are several emerging SGLT2 inhibitors in clinical trials. These agents will not become a common first-line agent for type 2 diabetes, as metformin remains the superior agent. However, these agents could be used as combination therapy. Remember that diabetes management should be individualized and take into consideration the drug’s efficacy, safety, cost, as well as the patient’s preference and tolerance.
Many communities have support groups for patients with diabetes or type 2 diabetes, but few have the same opportunities for folks with type 1 diabetes to come together and share experiences or listen to type 1 focused presentations. Take Control of Your Diabetes had a track for those with type 1 this year which was very well attended in our area and patients and family members appeared to be very grateful.
I have many patients who feel isolated by type 1 diabetes, and I am surprised that so many have never met another soul with type 1. So teaming up a patient with an online support group seems to be a positive step towards increasing a feeling of belonging and encouraging sharing of tips for managing and coping with diabetes. If you have not worked closely with type 1 diabetes, it truly is a fellowship.
There are many options and here are a few to consider:
Listen to your patients, if they are asking for support, provide them with some options. Type 1 diabetes is a tedious but “do-able” disease. Having someone who understands the daily tasks and can offer support whether through a face to face contact, support groups in the community or online may provide that extra something that makes the tasks seem less burdensome. What support options have you found helpful for your patients?
I recently attended an interesting presentation given by one of our dietitians on the role of microbiota and its relationship to diabetes - A fascinating angle which sparked my interest to learn more. My dear friend Google helped me find a significant number of articles published in the past 2-3 years which address this fairly new topic.
Recent studies suggest gut bacteria play a fundamental role in diseases such as obesity, diabetes and cardiovascular disease. Most authors agree that intestinal bacteria may have a greater influence on us than was previously thought. More and more data, derived from animal and human studies, suggest obesity and type 2 diabetes are associated with a profound dysbiosis.
One article states the human body contains ten times more bacteria than our usual human cells. The majority of these bacteria make up the normal gut microbiota. These huge numbers of bacterial genes in addition to the genes in our own cells are collectively known as the metagenome. Swedish researchers compared the metagenome of 145 women with diabetes, impaired glucose tolerance and healthy controls, and showed that women with type 2 diabetes have an altered gut microbiota. Researchers concluded that by examining the patient's gut microbiota they could predict which patients are at risk of developing diabetes. In fact, researchers have had better predictive value using gut microbiota than the classical predictive markers used today, such as body-mass index and waist-hip ratio.
The next challenge is to examine whether the composition of the gut microbiota promotes the onset of type 2 diabetes. If studies show this to be true, this would indicate new opportunities to prevent the disease. That would add another layer of potential medications or perhaps modifying food choices to assist in the challenges we all face to prevent and treat T2D.
Interestingly, it has been found that certain drugs such as metformin also interfere with the intestinal microbiota. With so many of our patients using metformin, it would seem important to study this further – perhaps we are making things worse for our patients with the medications we think are helping. Changes in intestinal microbiota may also explain why gastric bypass surgery is more effective in correcting diabetes than gastric banding.
As more research develops and a ‘gut signature’ becomes more evident in T2D, a better understanding of the role of the microbiota in diabetes might provide new aspects regarding its pathophysiological relevance and pave the way for new therapeutic principles.
Fascinating information in an entirely new part of the human anatomy - it will be interesting to see where this leads.
Recently we had a well-loved diabetes educator, Patti Geil pass away. She was an author of 12 books and owned Geil Nutrition. I was so shocked to hear the news. She was a leader locally in Kentucky and nationally in the field. In her obituary, the family asked for donations to go to the AADE Education and Research Foundation. I thought it was very fitting that they chose the Foundation since Patti was so involved with AADE. It made me want to share so that other educators can let their families know about such a wonderful way to give to diabetes education.
It was AADE nationally and locally as well as the Annual Meeting that really inspired me as a diabetes educator and made me proud to be in the profession. The AADE Education and Research Foundation gives several scholarships allowing educators to help cover the cost of the Annual Meeting. This can be such an amazing experience especially for a new educator. They also offer recognition awards which really inspire educators and reward them for being leaders in their field.
There are also numerous research grants focusing on improving patient health outcomes through behavior change that are also funded by the AADE Education and Research Foundation.
It is so important for your family to know your preferences in such a challenging time. For Patti, it makes my heart smile to know that her passion for diabetes education will live on through contributions to the AADE Education and Research Foundation. You can learn more here .