Even though I don’t work with insulin pumps on a daily basis, I have always been amazed by their advancing technology. This weekend I was talking to a high school student with type 1 who wore a pump without tubing. It just made me think of what a big deal it is especially for a high school student to have a tube-free pump for social reasons. He is a senior this year and about to go away to college. That is usually a trust test to see how a freshman in college handles all the newness and stress of their first year and also works every day to manage his blood glucose and insulin.
A statement from the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group was just published in the “Online Ahead of Print” section in Diabetes Care describing their efforts. As diabetes educators we know all the benefits of a pump and how life changing it can be. We also know with any type of insulin therapy, there are major life threatening risks. This group asserts that we need to be doing a better job looking at the safety of pumps from a clinical perspective. The “adverse events” (AE) reports on the US Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database is not being used to its potential and the European Databank on Medical Devices (EUDAMED) is not publicly available. They want more real life usage data and AEs to be public so that public observational studies and clinical trials can be ongoing reviewing the safety of a particular pump.
Based on their assessment of current standards, they recommend:
1. The regulators (EU/FDA) should:
2. Pump manufacturing companies should be required to provide with transparency to the regulators:
3. International and national professional societies should:
4. International and national research funding bodies should:
5. Healthcare teams should:
How do you feel the industry is doing to continually review their pumps and provide education to users and healthcare professionals? If you have given feedback to a pump company, was action taken? Again, I am truly in awe of the advances in technology from pump companies and am excited about the future, but equal effort needs to be given to ensure safety and training for current pump users.
When you think diabetes, do you think osteoporosis or fracture? Maybe not. Unfortunately, there is an association between type 1 and 2 diabetes and fracture.
We have known for a long time that there is a relationship with type 1 diabetes and osteoporosis. Now, we also know there is an increased risk of fracture with type 2 diabetes, even with average or better than average bone density.
Osteoporosis, or porous bone, is a disease where the bone is not thick and/or strong enough leading to increased risk of fracture, especially in the hip, spine and wrist. It is estimated that 10 million people in the US have osteoporosis and another 43 million have low bone density putting them at risk for osteoporosis and fracture. About 1 in 2 women and 1 in 5 men will have a fracture related to osteoporosis! A fracture can cause many problems including risk of decreased mobility, admission to a nursing home, and even death.
There are some steps that can be taken to decrease the risk of osteoporosis, low bone density, and fracture. It is important to start early, during childhood and the teenage years, to build bone. During adulthood, we can work to modestly increase bone density and strength. Later in life, we can work to maintain density and strength but the main focus it to decrease the risk of falls to avoid a fracture.
Let’s look at the steps to protect bones with specifics for a person with diabetes (PWD):
• Do regular exercise/physical activity: This is important for all of us! The recommendations for exercise are basically the same to prevent osteoporosis and fracture and for a PWD. We should aim for about 30 minutes per day, most days of the week, of moderate exercise. To help build or maintain bone density, try for impact activities (brisk walking, hiking, stair-climbing, dancing, jogging or jumping rope). If a person has pain or other problems that would be increased with impact, try activities with less impact (elliptical, water exercise, bicycling). Strength training is also helpful for a PWD and to improve bone density. If a person hasn’t done strength training, it is best to work with a trainer who can help with best form for safe exercise.
• Eat healthy: A well-balanced diet will provide most of the important nutrients for bone health. This includes fruits and vegetables and healthy proteins (the building blocks for strong bones). When a PWD follows a healthy meal plan for diabetes, bones will be healthy, too!
• Get enough calcium and vitamin D: The recommended allowances vary by age. For vitamin D, children need 400 to 600 international units (IU) and adults need 600 to 800 IU per day. For calcium, children need from 200 to 1300 mg, increasing with age, and adults need 1000 to 1200 mg. It is good to have calcium-rich foods/beverage options with low, moderate, and high carbohydrate content to fit an individual’s diabetes meal plan. It is also helpful to know dairy-free and gluten-free options for individuals with lactose intolerance and gluten sensitivity or celiac disease. A PWD can work with a dietitian to include these nutrients in his/her meal plan.
• Limit alcohol: Generally, we should limit alcohol intake to 1-2 drinks per day. Taking in more can get in the way of healthy nutrition and increase the chance of a fall/fracture.
• Don’t smoke: Smoking is harmful to the bones and increases the risk of complications of diabetes. If a person does smoke, this is one more reason to stop. It is never too late!
• Don’t fall/work on balance: As the years go on, many people notice balance isn’t what it used to be. Many people don’t know they can improve balance but it can get better by doing challenging balance exercises. This has been proven specifically in people with diabetes. If a person has fallen in the last year or loses balance easily, she/he is at high risk of falls so should see a physical therapist (PT) or participate in a community balance program. Over 90% of hip fractures and nearly half of spine fractures are due to a fall; almost all fractures in the wrist, shoulder and pelvis are due to a fall. So, if a person doesn’t fall, the risk of fracture is greatly decreased! A PWD might have many risks for falls including vision problems, lack of sensory input from the feet due to neuropathy, taking more than 4 medications, and variable blood pressure to name a few. A complete balance assessment should be performed by a healthcare provider for a person at high risk of falls.
• Stand tall: Many spine fractures can be prevented by keeping the spine in a good position without forward flexing. This means using the legs to lift so the back can stay straight and avoiding flexing movements such abdominal curl sit ups and toe touches. If a person has slouched posture and struggles to be in a good position, he/she can work with a physical or occupational therapist to improve it.
Diabetes educators can raise awareness of the possibility of osteoporosis and fracture in a PWD and can help with steps to decrease this risk through adjustments to the diabetes self-management plan and referrals to specialists as needed.
As a practicing optometrist I realized the connection between diabetes and what I do, and decided to enroll in the online Master of Science in Diabetes Education and Management program at Teachers College. During my interactions with classmates, I have learned that diabetes educators in all clinical backgrounds can help people with diabetes take care of their eyes and protect their vision.
Eyesight vs. Eye Health
The eye provides a unique opportunity to monitor microvascular changes. An annual dilated vision exam by an ophthalmologist or optometrist can screen for the occurrence of retinopathy. Early changes are usually reversible with lifestyle (nutrition and activity) and medication interventions. Even in advanced cases (usually treated by laser for retinopathy, intravitreal injections for macular edema or vitreoretinal surgery for more advanced conditions) timely intervention and treatment can prevent further vision loss or blindness. However it has been my experience that many patients (with or without diabetes) correlate eyesight with eye health. The two terms are not equal. A patient may mistakenly carry a false sense of security about eye health. Patients with proliferative retinopathy or macular edema can have excellent acuity (20/20 vision). Undiagnosed these underlying conditions will continue to worsen and by the time a patient notices vision changes fewer treatment options remain. Additionally the risk of vision loss and blindness increases due to the condition itself and/or the treatment required to stop its progression.
Images that compare the different stages of retinopathy to that of a normal retina can be informative. One study indicated that showing the patient their retinal images had a positive impact on patient attitudes toward eye care. However, discretion should be exercised. An educational intervention that uses fear as a motivator for change (in this case continuity of eye care) has been shown to have the opposite effect.
Another helpful tool that can educate your patients on the importance of regular eye care is the web-based Retina Risk calculator (www.retinarisk.com). This tool uses blood pressure (BP), A1C, and diabetes duration to calculate future risk of retinopathy for a specified number of years in the future. It is easy to use on office computers or tablets. The BP and A1C numbers can be adjusted to demonstrate the positive affect of improved self-management skills. This resource is free for the first month, and then has a charge.
Another option might be for your institution, health center or clinic to invest in a retinal camera. This works well in instances where patients are reluctant or unable to engage in yearly comprehensive eye exams due to lack of transportation, age/cognitive change and time constraints. Digital photos without dilation can be taken by non-eye specialists for later review by a qualified clinician/physician.
Loss of vision and blindness are devastating to the individual with diabetes. The few minutes a diabetes educator invests in communicating the importance of regular comprehensive exams may provide a patient with a lifetime of vision and improved quality of life.
Guest blog post by Dr. John McDonald, OD
First, I know I have written several blogs about current or recently approved medications. I have always been fascinated with the chemistry of medications, but more importantly how and why do we use certain medications for a specific disease state? On a regular basis, I am having a discussion with my providers at a rural health family medicine clinic – “Which one is better an ACE-inhibitor or ARB?” “Which one should I use among patients with diabetes who need additional blood pressure control?” As a pharmacist, I have looked for key factors for why a patient may be prescribed an ARB, such as documented allergy (i.e. cough), documented angioedema, or insurance. Either option – ACE-inhibitor or ARB – has become the standard of care for patients with diabetes.
When talking about the latest blood pressure guidelines – JNC VIII – calcium channel blockers (i.e. amlodipine), thiazide-type diuretic (i.e. hydrochlorothiazide) are recommended at the same level of ACE-inhibitors and ARBs as there is no superior evidence among these classes. However, patients with diabetes may benefit from either an ACE-inhibitor or ARB due to risk of cardiovascular events. A patient with diabetes is at a higher risk of heart failure, myocardial infarction, and stroke. Therefore, the benefit would definitely be gained with an ACE-inhibitor or ARB for these conditions. It is okay for patients with diabetes to be prescribed amlodipine or hydrochlorothiazide, but it would be better for a patient with diabetes who also has chronic kidney disease, albuminuria, heart failure, myocardial infarction and/or stroke. No matter what, it will take several agents to lower the patient’s blood pressure. I think about all the available combination products – small doses of several agents can lower a patient’s blood pressure. It is important to strive for a desired blood pressure goal (i.e. for diabetes, less than 140/90 mm Hg per the JNC VIII and ADA guidelines) rather than maximize doses, which could increase the risk of adverse events.
While writing about blood pressure management, it is important to counsel patients about:
For everyone’s review, here is a list of current ACE-inhibitors and ARB with brand names (combination products are not provided):
Every year I look at all the educational offerings for diabetes professionals throughout the country. There are more and more options to choose from with excellent speakers, locations, and continuing education hours. So why choose the AADE Annual Meeting?
Continuing education: For the individual new to a career in diabetes management and education, there are multiple educational sessions that will help to guide you. For those in the field for many years – Master Classes will update you on the newest medications, research progress on prevention, and updates on the newest technology to enhance the your ability to help education and provide management skills to patients with diabetes. Product Theaters are available to bring you up to date on the newest products on the market to not only help guide our patients but to also share the information with fellow providers at home.
In the very early days of my nursing training, one of our classes was on “holistic” concepts of healing. We had just experienced the Love, Peace and Freedom movement of the 1960s and ‘70s – a lot of my instructors were what we would now call “old hippies.” Back in those days, we did a lot of “touchy feely” things – one of which was the benefits of therapeutic touch (TT). There were variety of research studies validating the practice of TT in nursing published in the late 1970s – early ’80s. Several of my colleagues during that time worked with the healing energy effects of touch for patients going to surgery or in pain – primarily in an effort to decrease the use of pain meds and/or to quicken the healing process.
With the advent of computers and more “hard” science, the practice of TT has been withering away. Recent studies from the early 2000s were unable to substantiate any hard scientific facts for diagnosing or healing using therapeutic touch. We now have much more sophisticated means of caring for patients – MRIs, CAT and PET scans to look into the human body; computer based algorithms to help us with determining patient risk of disease; guidelines on how to manage patient care; and agencies providing oversight to the healthcare professional as to how, when and what to do in the most cost effective manner.
As I write, I’m been home bound for 2 days now under 10 inches of snow. I live in Kentucky and we only get this much snow once decade. It’s times like these that make me think of those patients who cannot get to dialysis or just ran out of insulin the night before the snow storm. Are your patients prepared for times like these? It happens so infrequent that we can just get caught up in our usual curriculum or teaching points that we may not remember to engage in dialogue about the “what ifs”. What if you lost power for a few days? What if you were snowed in for several days? What if you had to evacuate your home?
We care so deeply about our patients that I would hate for you to have to be bundled up at home worrying if Mrs. Smith has enough medication or if Mr. Stevens has anyone to check on him.
The Kentucky Diabetes Prevention and Control Program has a section of their main page if you scroll all the way down called “Being Prepared for a Disaster”. I believe it was around the hurricane Katrina time that several of my colleagues put these resources together. Several of the items pertain to winter emergencies as well. There is even a PowerPoint that you are welcome to download and use in teaching.
For winter related challenges, talk with your patients and have a pen in hand to help them write up a plan in case they are snowed in:
-Do you have enough medication and supplies? For example: blood glucose monitoring supplies, insulin syringes, or an extra battery for your pump and monitor.
-Who can you contact in case of emergency? Several of our elderly patients may not have family nearby. When they know something like an ice storm is coming their way, have them call someone and tell them to check in on them every day.
-Do you have enough water and non-perishable food items that could last you for up to 2 weeks?
-Do you have a glucagon emergency kit?
-Do you have non-perishable foods to treat hypoglycemia?
In our county, we have a “Winter Care Program” that was activated where you can call and have the Sheriff’s office take patients to critical medical appointments, provide transportation for hospital and nursing home workers, and also have them check on elderly relatives or loved ones living alone.
What other tips do you have for discussing winter storm preparedness with your patients?
How much do we talk about international diabetes education? As a travel lover and person with type 1, I'm always interested in (and often surprised by) finding new opportunities for connection and discovery provided by this unusual aspect of my life.
Finland has the highest incidence of type 1 diabetes in the world, with a yearly rate of 57.4 cases per every 100,000 children aged 0-14 (by contrast, the United States experiences a rate of 16 cases/100,000 children 0-14 years old). While every country has its own ways of connecting with the adolescent type 1 population, there are also similarities to the strategies employed to coach those challenged with managing what can be an incredibly frustrating chronic disease.
Such was the topic of discussion when I recently talked with Ms. Sari Koski via email. Sari is the Project Manager for One Life: Diabetes, developed by the Diabetes Centre in Tampere, Finland. One Life: Diabetes offers a unique resource for teenagers with type 1 diabetes: a group called Club One. Here's some interesting information about Club One that sheds some light on how diabetes professionals in Finland offer support to adolescents with type 1:
Community is important. Sara says, "Teenagers don’t often know many other people with type 1 so they might feel different to others. That’s why they might not want to treat themselves properly. In Club One they meet others with type 1 and also a young adult who knows what it is to be a teenager with type 1 diabetes."
A peer atmosphere and a mentor to look up to for advice? Sign my teen self up! From my experience, I can see how this structure helps eliminate feelings of being ostracized and cultivates a sense of belonging in an accepting environment, ideally leading to better self-care among the teens with type 1.
Life isn't all about diabetes. Sari says the project stands out among other resources due to Club One's multifaceted approach to its programming.
"We have combined peer support, information (education) and having fun in the same package. There are resources from health care available as well. Groups have the activity (sic) that teenagers like to do."
I know that I could have used all of these elements when dealing with diabetes as a teenager!
I know from working with AADE on various projects that diabetes professionals around the world can share insight and offer ideas to one another. Learning about diabetes is a constant process for everyone involved.
Sari recommends incorporating activity when counseling teenagers about taking care of themselves and being responsible for their health.
"It is a good idea to listen to the teenagers themselves and to seek possibilities that teenagers have something to do together (sic). Education can be fun and it can be performed by doing things instead of talking and listening."
Most importantly, Club One is a place where teens feel that they belong. "Every teenager deserves to feel “normal” in some group in his / her life. In this group it is normal to measure blood sugar and to get insulin. In some other groups it might not be." It's such a powerful message, and one that's important to remember for diabetes educators around the world.
We know how important it is to participate in the care of an individual with diabetes. Yet, we are underutilized. Sure, we have a shortage of diabetes educators, if everyone with diabetes receives education. But they don’t. We, as DEs, can all help to increase awareness of our profession and what we offer.
Who needs to know about us? People with diabetes (PWD) and those affected by diabetes, referring providers, other non-referring healthcare professionals, the Diabetes Online Community (DOC), politicians at the state and national level, those in government agencies that can impact diabetes care, insurance companies (including Centers for Medicare & Medicaid Services), industries that deal with diabetes products, and the general public. Who did I forget?
Let’s look at each of these. It is a two way street for PWD, those affected by diabetes, the DOC, and the general public. People in these groups can benefit from interactions with a DE. And, DEs can also benefit when these individuals spread the word about what we can offer. I think about how pharmaceutical advertising has changed prescribing of medications. Many more people go to a healthcare provider’s visit with knowledge about medications and initiate the conversation about prescribing the medication based on advertising. Wouldn’t it be wonderful if more PWD went to their provider asking to be referred for diabetes education?
We all know that diabetes education can take more time than is practical for most healthcare providers. DEs can help primary care providers and specialists by spending the necessary time, and using our expertise, when working with a PWD. During my time with patients, I often suggest referral to other providers. There are many professionals that should know about DEs to suggest referral to diabetes education.
How about politicians? We have legislation we want to move forward. State and national politicians need to hear about DEs and the great work we do! When we make a visit or call or email or tweet, we want those involved in the legislative process to say, “Oh, yes, I know how helpful diabetes educators can be for an individual, for my constituents.”
Those that are involved with reimbursement should know how DEs can improve the life of a PWD and that we are quite cost-effective. And, we should be part of the conversation when those in the diabetes products industry are making decisions.
How can we get the word out? Do you have interactions that can promote our profession? Let’s get into the conversation, at the table, in the minds of all PWD, providers, and those who can impact diabetes care and reimbursement.
What a great start to the beginning of a new year!
Every year in late December, I look forward to the American Diabetes Association (ADA) guidelines for diabetes. The standards were released and there were several updates. However, there was one update that I was not expecting, which was the updated ADA and European Association for the Study of Diabetes (EASD) position statement on the management of hyperglycemia. I wanted to provide a brief review of the position statement.
The ADA/EASD have typically provided an update in the position statement every three years. The position statements have evolved based on new evidence, particularly newly approved antihyperglycemic agents. In the 2012 position statement, the document listed Step 1 as lifestyle modifications plus metformin for an adequate period of time (i.e. three months). Lifestyle modifications are recommended in conjunction with any pharmacologic agent. Following Step 1, additional glycemic control may be needed if desired glycemic goals have not been achieved. If so, there were five options: sulfonylureas, TZD, DPP-IV inhibitors, GLP-1 agonists or basal insulin. It should be noted that if the person's A1C is above 9%, then dual therapy is the direct option. Now, these organizations have updated the standards to include SGLT2 inhibitors as a sixth option for dual therapy.
In comparison, the American Association of Clinical Endocrinology (AACE) published an algorithm in April 2013. This organization has similarities, such as lifestyle modification plus metformin as first-line therapy. However, AACE recommends a hierarchy of medications for dual or triple therapy. The hierarchy is based on the clinical evidence; within this algorithm, if a patient’s A1C remains above 7.5% after three months, then the hierarchy can be followed in this specific order: GLP-1 agonists, DPP-IV inhibitors, TZD, SGLT2 inhibitors, basal insulin, colesevelam, bromocriptine, alpha-glucosidase inhibitors, and sulfonylureas.
Both of these guidelines recommend certain factors that should be considered for the medication options; these factors include degree of hyperglycemia, the risk of hypoglycemia, cost, effects on weight, and patient preference.
There are other updates in the ADA/EASD 2015 position statement, which include less stringent prescribing of metformin (based on glomerular filtration rate) and additional details on insulin initiation and titration.
If you have not had a chance to read the position statement, you can get a free electronic copy of the document from Diabetes Care. However, if you have read and reviewed the position statement, what are your thoughts?