If you have been to Washington, DC lately, you might have seen the Capitol dome covered with scaffolding as it gets a “facelift.” I was there recently and had a chance to snap this photo. Diabetes educators will be heading to DC in a couple of weeks as AADE goes to The Hill for our 2015 Public Policy Forum (PPF). Diabetes educators and diabetes education need a lift!
I have been able to attend several PPFs with AADE and am really looking forward to it. But, I do remember my first when I was more nervous than excited. The word “advocacy” was a bit intimidating to me as was the idea of going to our representatives’ offices. As diabetes educators, I think most of us are uncomfortable with the idea of advocacy. We are healthcare providers. But, I went through AADE’s PPF training and got comfortable. Armed with what I learned, within a couple of minutes in the first office, I was relaxed. This year, I will go to the visits with good data to support our requests, bringing along my passion for diabetes educators and people with diabetes who benefit from Diabetes Self-Management Training (DSMT).
Here are the facts:
I am surprised by how government works. Our representatives and their staff members “listen” to our emails and tweets. Gone are the days of hand-written letters. You will receive communications from AADE prior to, and on the day of, the Capitol Hill visits. Please act so we can flood representative’s offices with emails and tweets! The links will bring you right to your representatives. (If you don’t have a twitter account, consider getting one now to be ready to tweet your representatives.)
Remember, you are their constituents; they will take your communications seriously. Every voice counts!
There are several conditions associated with a high prevalence of low testosterone levels, such as chronic obstructive pulmonary disease, osteoporosis, and infertility. Men may be screened if specific symptoms or signs are reported, such as reduced libido, loss of body hair, breast discomfort, or hot flashes. However, there has been more published research about the link between low testosterone levels (i.e. hypogonadism) and type 2 diabetes mellitus. In this blog, I wanted to focus on testosterone replacement therapy as June is Men’s Health Month.
Testosterone replacement therapy is commonly used to restore testosterone level back to physiologic levels, in which can improve symptoms. Testosterone replacement therapy should be given to those with a diagnosis of hypogonadism, which is the presence of symptoms with low testosterone levels. Testosterone levels should be obtained between 7 and 11 am and also be confirmed with a second diagnostic test – similar to fasting glucose levels for diabetes diagnosis. There are several formulations for testosterone replacement therapy, such as intramuscular, transdermal (i.e. gel, patch, solution), buccal tablet, or subcutaneous pellets. Each project as its advantages and disadvantages and will be dosed differently. The appropriate product should be selected for the patient. Often, in clinical practice, the most commonly prescribed products are transdermal formulations. These specific projects are dosed once-daily and have flexible application instructions. However, a concern is risk of transfer to another individual based on the site of transdermal application. Among the transdermal products, the gel and solution would be the most convenient, as the patch can cause more skin irritation. Once a patient is prescribed testosterone replacement therapy, monitoring should be completed on a 3-6 months basis. Symptoms, adverse events, testosterone, and complete blood count should be monitored. Lipid panel should also be monitored based on the 2013 cholesterol guidelines. Bone mineral density tests can be completed as 1 to 2 years of therapy, especially among those with a diagnosis of osteopenia, osteoporosis, or fracture.
In addition to more evidence about testosterone and diabetes, there has been published data about testosterone replacement therapy and increased risk of cardiovascular event. In a retrospective cohort study, charts of patients with low testosterone levels who underwent coronary angiography were reviewed. Based on the information, there seemed to be a higher frequency of death and cardiovascular events among those receiving testosterone replacement therapy. In another retrospective trial, individuals younger or older than 65 years had a high risk of a myocardial infarction, based on relative risk of 2.07 and 1.90, respectively. It is important to consider these risks and warnings, especially among patients with type 2 diabetes, whether or not the patient has a documented history of heart disease.
Repeatedly I hear from older patients that medicine is just not what it used to be. Their care provider seems to spend more time looking at the computer, checking off “something” and not really listening to what they are saying. In a recent study, older patients repeatedly expressed frustration at the lack of time they spend with their doctor and feel they are not being heard (1).
Recent standards for treatment of older patients with diabetes (2) include more flexibility in setting goals for this population – including current health status (co-morbid conditions) and expected lifespan. Due to the many pathways to help monitor and control diabetes, along with the variable and ever changing goals, more individualized time is required to assess and set a disease management course during the patient’s visit to their health care provider. This one on one time, in reality, is shrinking.
Diabetes educators to the rescue. Diabetes educators are uniquely qualified to listen to the patient with diabetes, address their concerns, design programs that fit the lifestyle and goals of the patient, connect with their health care providers, and monitor the progress of the patient through telephone, e-mail or face to face visits. Educators can also review the costs of medication and the patient’s ability to pay and connect them with patient assistance programs. In an era of checked boxes and universal goals we, as educators, must keep the needs and desires of each patient our focus. We must be their advocates and help them problem solve to achieve their individual goals. The December 2013 AADE Practice Synopsis: Special Considerations in the Management and Education of Older Persons with Diabetes, is a helpful tool to review in delineating the role of the diabetes educator in the care of the older adult.
We as diabetes educators have such an important job. We can have a huge impact on the lives of the older person with diabetes and help to achieve the 2020 healthy goals for Americans which includes: “Reduce the disease and economic burden of diabetes mellitus (DM) and improve the quality of life for all persons who have, or are at risk for, DM”.
1. Beverly EA, Wray LA, Chiu CJ et al. Older adults’ perceived challenges with health care providers treating their type 2 diabetes and comorbid conditions. Clin Diabetes. 2014:32(1)12-17
This is the 2nd edition of my review of most of the literature and journals I receive. I try to scan them to keep informed on what is happening in the diabetes world – and there is a lot. Here are a few items I think you might want to know about.
• A new implantable device recently cleared by FDA blocks a major nerve in the body that controls appetite. The patient turns the device on and off during the day. Like a pacemaker, the device helps people lose weight by making them feel full. Typically an out-patient procedure, the device is surgically implanted into the stomach. It is indicated for adults who meet criteria for obesity which includes many patients with diabetes who have not been able to lose weight with traditional weight loss methods. Source: FDA, Jan 14, 2015
• This past weekend I attended the 3rd Annual Texas State Diabetes Conference. There were many great speakers but one of my favorites is always Stephen Ponder, MD, CDE a board certified pediatric endocrinologist who was discussing his new book, Sugar Surfing. Dr. Ponder has had type 1 diabetes, I believe he said for close to 50 years. He was sharing his experiences with CGMS and how he has, through trial and error, learned how to best “pivot” and steer his blood sugars in the right direction. He stresses that each person with diabetes is unique – that there is no magic formula for controlling a person’s diabetes - patients must be educated, engaged and empowered. To learn more, you can follow him at his website www.stephenpondermd.com or on his Facebook page, “The Power Within.”
• Monogenic neonatal diabetes – a rare genetic form of diabetes in children diagnosed at 6 months or younger most effectively treated with sulfonylureas. There are many forms of monogenic diabetes but all occur due to a mutation in one of more than 20 genes that control the body’s ability to make insulin. Maturity Onset Diabetes of the Young (MODY) falls into this category. Proper diagnosis is done through DNA testing. Depending on the specific genetic mutation, these children are often treatable with diet and/or sulfonylureas. Source: Diabetes Forecast May/June 2015. For more info: www.monogenicdiabetes.org.
• Anti-VEGF therapy – for years the standard treatment for diabetic macular edema has been laser therapy. A new therapy is showing great results. Anti-vascular endothelial growth factor is injected into the eye to stop the blood vessels from leaking. Anti-VEGF therapy not only stops further vision loss – it can improve the vision in affected patients. Even in patients who were diagnosed as being legally blind, treatment with anti-VEGF restores vision to the point where they can drive and return to work. There are currently three agents on the market which must be injected into the eye in a series of injections – every 4-6 weeks initially and then tapering off to once a year. Long acting anti-VEGF agents are also being developed and tested. Source: Dr. Victor Gonzalez ophthalmologist – presenting to the Texas Diabetes Council.
Don’t forget to register for AADE15 – August 5-8 in New Orleans. See you there!!
My husband came home from work excited about his new health incentive program with his health insurance. I was intrigued! He’s always been into sports but not necessarily into personal exercise. Our insurance is with Humana and they have a program called Humana Vitality. You first do an online questionnaire assessment about your lifestyle and you are assigned a virtual age based on your answers. Then the software integrates with mobile devices and apps to track all your activities and you can log your health appointments such as dentist appointments and blood work. For the first time since I’ve known him he is excited to get blood work done!
Every day at work he checks his iPhone app- Apple Health for the amount of steps he has for the day and he tries to get in his goal of 10,000 steps a day. The Apple Health app is integrated in his Humana Vitality app which gives him a daily point value. He also checks another screen where he can see how his daily points compare with his other coworkers. In the evening before bed I have even caught him pacing in circles around the house to polish off his last 50 steps to meet his goal! What a motivating tool! Isn’t technology amazing? Besides his competitive nature to “win” against his coworkers, he also is incentivized with prizes like Amazon gift cards. At the end of the year, we even save money on our health insurance if we have a certain number of points as a family. Integrating personal daily health tracking with insurance incentives is huge.
I see our role as diabetes educators to be familiar with all the health tracking software and insurance incentive integration so that in our one on one visits we can be a partner to the patient helping them reach their goals. I know not every patient is technology savvy just like not all educators are, but the apps are very user-friendly and I think it helps just spending some time to play around with them so we can help our patients use these tools to help motivate them. It would be nice if everyone was just intrinsically motivated but we not that’s not always the case. So having programs like this can help those who need an extra boost ;)
What apps and programs have helped your patients? Have you talked to patients where these incentive programs have helped them? Please share below-
A few weeks ago, I presented at a Weight Management & Chronic Disease Teaching Day on “Exercise Considerations for Diabetes and Obesity.” I talked about calories burned during certain exercises, noting those that burn few and others that burn many.
At that time, I was counting calories to lose my holiday weight gain. (Which holiday? From Halloween to New Year’s!) To do this, I was staying below 1500 calories/day as we encourage for females in our weight-management program (1800 for males). This was a bit of a challenge that day since I wasn’t home with my own foods; a real-life situation for many patients/clients that are trying to lose weight. I had a bagel for breakfast (calorie-dense), was careful at the lunch buffet (salad bar and soup), and then got in the car to drive home. I got hungry, looked in my bag, and found a granola bar; a healthy snack but this bar had 190 calories. This isn’t too bad but, for a snack, it was taking lots of calories toward my total; too calorie-dense.
I reflected on my talk, the snack, and exercise. In our work as diabetes educators, we guide people toward exercises that suit their goals. If weight loss is part of the goal, we should encourage exercise that is efficient at burning calories; those that use lots of muscles, preferably of the arms, legs and trunk. The idea of “calorie-dense exercise” came to mind. We talk about calorie-dense or energy-dense foods; those that contain high amounts of calories per serving and should be limited if trying to lose weight. The same notion fits when thinking about choosing the best exercise to lose weight but opposite; try to choose “calorie-dense exercise.” What do you think about the phrase “calorie-dense exercise?” Can you think of a better term?
For example, if that person says “I am trying to lose my belly weight so I am doing 10 sit ups each day” or “I do stretches 3 times a week but am not losing weight,” we should be providing accurate information about other options that might better help them reach their goal.
By doing a search on a phone app or the computer, we can help the individual find an exercise that they might enjoy, that suits them, and that is “calorie-dense.” There will be individual variability depending on the person’s ability, weight, and intensity of the activity. Any exercise done for longer or higher intensity will burn more calories than shorter duration, lower intensity.
Below are some examples of calories (estimated) that a person weighing 200 pounds will burn when doing one hour of some common exercises/physical activities, from high calorie-dense to low calorie-dense. (If a person weighs less, they will burn fewer calories and if a person weighs more, they will burn more calories per minute.) We can lead an individual who is trying to lose weight go to a good source, put in their weight, and determine which exercises best suit their interests and needs.
(Adapted from: Ainsworth BE, et al. 2011 compendium of physical activities: A second update of codes and MET values. Medicine & Science in Sports & Exercise. 2011;43:1575.
I recently attended a regional diabetes gathering to learn what has been happening with certified diabetes educators in upstate South Carolina. I also attended the gathering to refresh my memory on the 2015 American Diabetes Association (ADA) Standards of Medical Care. It was a great review by a medical science liaison. I will be honest – I spent most of the time reflecting on the new pneumococcal recommendations. The Centers of Disease Control (CDC) and Advisory Committee on Immunization Practices (ACIP) provides the annual schedule for childhood and adult immunizations. When thinking about the constant changes in immunizations, I wanted to write about the hepatitis B virus and its recommendations.
In 2011, the ACIP voted 12-2 to recommend the hepatitis B virus immunizations among patients with diabetes. The series is recommended for any patient 19 to 59 years of age with diabetes, whereas it is the physician’s choice to vaccinate a patient with diabetes and older than 60 years. For patients over the age of 60 years, the physician should determine the patient’s risk of contracting hepatitis B since the vaccination’s effectiveness decreases with age. In addition, patients living in nursing homes may be at higher risk of contracting hepatitis B virus, than someone living along at home. Some certified diabetes educators may have a difficult time with physicians accepting this recommendation. Patients may even look puzzled when mentioning the hepatitis B virus immunization as a preventative strategy against the disease. Explaining why patients with diabetes are at a high risk of hepatitis B may improve rates of immunizations among this special population.
First, blood or other bodily fluids is the common source of hepatitis B transmission. If an infected patient shares diabetic supplies, such as needles, pens, syringes, then she or he is putting other individuals at risk of transmission and infection. All patients should be educated on methods of transmission and strongly encouraged not to share any diabetes supply item. Second, people may think hepatitis is only an active infection of the liver. Yes – there is acute infection, but most often, people develop chronic hepatitis B infection, requiring indefinite treatment with anti-virals. Furthermore, liver complications can develop from hepatitis B. Third, the best method of prevention is the hepatitis B virus vaccination series. Patients should be educated about receiving the three injections over a 6 month period. According to the CDC, the injections can be given intramuscularly at 0, 1, and 6 month. Patients can be informed that this series is lifelong and will not require re-vaccination. Additional information can be found from the CDC.
I hope this information is helpful. Do not forget to speak with patients about hepatitis as May is Hepatitis Awareness Month.
For all of my adventuring around the world, I’m a fan of following tradition, even if it doesn’t always seem to make sense. St. Patrick's Day is a holiday laden with tradition, but for me, the green holiday holds a different kind of significance.
Over the last few years, I've developed a tradition of doing a fun and exciting thing (or just anything out of the ordinary) each year around my "diaversary"--the anniversary of when I was diagnosed with type 1, which falls on St. Patrick's Day (March 17th). Why does it often end up being something really dramatic? Because doing something challenging and fun that coincides with commemorating a diagnosis of something challenging and not always 100% fun makes the situation a little bit better, I think! Past diaversaries have involved celebrating St. Patrick's Day in Dublin, Ireland, celebrating St. Patrick's Day in Boston, and heliskiing in the Italian Alps.
We recently had a very undernourished gentleman admitted to the hospital with multiple problems, one of them, a new diagnosis of diabetes with no detectable c-peptide. He was started on basal bolus insulin appropriately and the blood glucose control was leveling off reasonably. I was at the nurses’ pod reviewing his notes, when I was tapped on the shoulder and a student nurse asked if I could help her figure out where to give his insulin injections. He was so thin that she was having difficulty finding any subcutaneous tissue. We discussed optional locations, the 45 degree angle for the injections and she went into the patient room to help with the shot. I decided to take a look at the one-use needles we were using, and noted they were 8 mm needles. I was surprised to find out it was all we stocked! In further investigation I learned some parents of the children bring in their own pen needles due to the child’s discomfort when injected with the hospital needles, not to mention their inappropriateness. Not exactly a good protocol in the hospital – but hats off to the parents finding a way to minimize the discomfort for their child.
In all the concern over the change in policy, nursing education, changing IV drip to subcutaneous insulin equations, writing insulin pump protocols, I have missed a simple change that could make a difference not only in comfort, but in the successful delivery of insulin in most patients.
So I am once again reminded of how important it is to remember the simple things in this complex and relentless disease. To review on a consistent basis the things we have learned about taking care of persons requiring insulin that may make a difference.
I pulled out an article I had cut and saved “Translating the Research in Insulin Injection Technique: Implications for Practice” in the October 2012 issue of The Diabetes Educator and reread it. Research that investigated injection technique, teaching insulin administration, and of length of the insulin needles and reviewed it for clarity.
So along with needle length – here are a few simple reminders when reviewing insulin administration with patients, nurses, and care providers:
1. Check needle length, 4-5 mm is enough – there are still some folks with 12 mm needles – in fact I was horrified last year to see some had been shipped to kids’ camp!
As we work with our patients, both inpatient and outpatient – it is often the little things we can forget. Appropriate needle length is just one of those details and an easy thing miss when there is so much work to be done to help take care of our patients. Needless to say, we are already working to resolve this issue!