UK Study Under Review Finds People With Type 1 Diabetes More at Risk to Die of COVID-19 Than People With Type 2 Diabetes

There’s a large UK study (2 million people) under peer review that’s gaining traction on social media. Why? Because it defies our – already overtaxed mental states – of what’s possible.

Covid-19: people with type 1 diabetes more likely to die than those with type 2.” This is how The Guardian, among other publications, headlined it.

NHS (United Kingdom National Health Service) research reports that people with type 1 diabetes are at 3.5x higher risk for death if they get COVID-19 than people without diabetes. In contrast, people with type 2 diabetes are twice as likely to die as people without diabetes.

Surprised? I was. And even though the research is currently being reviewed, and nothing’s yet been proven, the data has a strong statistical basis.

If you’re curious what all this means, I can share with you information I’m privileged to have access to. I am part of a team of global diabetes experts – MDs, researchers, scientists, heads of the university, and hospital departments. The group was formed a few months ago under the leadership of Professor Itamar Raz, diabetologist and former head of Israel’s national diabetes health policies and Guang Ning, Head of Shanghai Clinical Center for Endocrine and Metabolic Disease.

The team is digesting a barrage of information, sharing their expertise and experiences and brainstorming prevention and treatment guidelines that they can safely, and quickly, recommend to health professionals and the public.

Unnerved by The Guardian article, I reached out to the group immediately. Philip Home, Emeritus Professor at Newcastle University, UK responded within an hour. It was 10:30 PM in the UK.

Here’s what I can tell you with the proviso, as Home emphasizes, that currently this research presents an interpretation of the data, which is dependent on a rapidly changing situation in the UK. This means its application to other people, in other circumstances, is not easy – medicine is as much art as it is science. And, it’s hard to know whether there have been any population and/or calculation errors. For instance, some people with type 2 diabetes on insulin may have been incorrectly counted as type 1s.

Below (in italics) is a summary from my email exchange with Professor Home.

Those Not Necessarily at Higher Risk:

This comment is currently a hypothesis, but we do think people who have no evidence of vascular damage, no retinopathy, no albuminuria (including microalbuminuria) and no cardiovascular disease, are likely not at greater risk to be hospitalized or die if they get COVID-19 than people without diabetes.

Further, if one’s blood sugar is also well managed, A1c under 7.5%, they are probably at no greater risk of getting COVID-19 in the first place than someone without diabetes.

Those at Higher Risk for Poorer Outcomes:

People who have type 1 diabetes who show evidence of vascular damage, should they get COVID-19, would be at higher risk of severe outcomes including hospitalization and death. The risk for vascular damage is higher the longer you’ve had diabetes, particularly if glucose levels have been high.

Further, if you have poor glucose management you may be at greater risk to contract the virus.

People can check with their health professionals whether their markers that indicate vascular damage are in range, that includes CRP, HDL cholesterol, triglycerides, and liver enzymes (ALT). They can also check if they have any albumin leakage through the kidney. Also, they can check with their eye professional whether they have any retinal damage.

Understanding that this is a vascular issue and that vascular damage increases risk for comorbidities such as cardiovascular disease, I better understand why it’s possible someone with longer duration type 1 diabetes, who gets COVID-19, may be at higher risk for worse outcomes than someone with type 2 diabetes.

What else can you do now to protect yourself should you get COVID-19? First, don’t panic. As Home says, the data is not yet in. Second, use this time to build your nutritional and metabolic health. In other words, follow the common recommendations:

  1. Do your best to keep your blood sugar in target range
  2. Eat as healthily as you can – vegetables, whole, not processed foods, some fruit, dairy if you can tolerate it, beans, seeds, nuts, healthy fats
  3. Be active, even if you’re in lockdown

Like everyone, diabetes or no diabetes, wear a mask when out in public, stay six feet away from others and wash, wash, wash your hands. My personal prescription includes using those clean hands to then pour a glass of antioxidant-rich red wine.

Note: I wish to gratefully acknowledge Professor Home who responded to my query immediately, answered my questions, lowered my stress level and helped me interpret the medical data.

Source: diabetesdaily.com

Big Changes! Centers for Medicare & Medicaid Services (CMS) Loosen Requirements for Obtaining a Continuous Glucose Monitor (CGM) During COVID-19

This content originally appeared on diaTribe. Republished with permission.

By Karena Yan and Kelly Close

In-person visits, lab tests, and finger stick documentation are no longer required at present to get a CGM

Editor’s note: This article was updated on May 21, 2020 to reflect that lab testing is still required for an insulin pump and pump supplies.

High blood sugar levels leave the body vulnerable to infections, meaning those individuals with poorly controlled diabetes are at greater risk of contracting COVID-19. To properly monitor and respond to glucose levels and to strengthen the immune system to fight off infections, a continuous glucose monitor (CGM) can be very helpful.

If you are on Medicare, obtaining a CGM through your healthcare professional is a relatively involved process, requiring an in-person clinic visit, lab tests, documentation of frequent finger sticks (four or more times a day), and a lot of paperwork. At present, only those on insulin have an opportunity for approval. However, due to COVID-19 and the increased risks it poses for people with diabetes, the Centers for Medicare & Medicaid Services (CMS) announced that it will not enforce the following criteria for receiving a CGM:

  • In-person clinic visits
  • “Clinical criteria,” including lab tests for C-peptide or auto-antibodies, or demonstration of frequent finger sticks

This means that people with diabetes do not have to go to the doctor’s office or undergo lab tests to receive a CGM. Importantly, these loosened restrictions also reduce the amount of paperwork and bureaucracy for healthcare providers and give them greater flexibility in providing CGMs. Lab testing is still required for insulin pumps and pump supplies.

This increased access to CGMs is a huge win for the many people with diabetes on insulin who would not otherwise be able to get a CGM. Because CGMs provide real-time data for blood sugar levels, users are able to monitor their glucose and proactively adjust their insulin doses. Not only do CGMs help increase time in range, and thus have the opportunity to increase productivity and quality of life, but they can also improve overall diabetes management and can help keep patients out of the hospital.

We hope that in the future, at least those on SFUs will be able to get CGM, as SFUs can prompt hypoglycemia, which is especially dangerous right now, given the importance of staying out of the hospital.

Every person with diabetes can benefit from either a professional CGM used regularly (at least yearly) or a 24/7 CGM. While these new CMS guidelines are temporary in response to COVID-19, we are hoping and advocating for making the changes permanent. With the rise of the Beyond A1C movement and increased awareness of time in range, CGM (24/7 or professional) is an essential tool for people with diabetes to live happy and healthy lives, both during and after COVID-19.

This article is part of a series on time in range maybe possible by support from the Time in Range Coalition. The diaTribe Foundation retains strict editorial independence for all content.

Source: diabetesdaily.com

David’s Journey to Becoming a Certified Diabetes Educator

We spoke to someone with type 1 diabetes who is working on earning their Certified Diabetes Care and Education Specialist (CDCES) credential, formerly known as Certified Diabetes Educator (CDE). David shares some of his journey and explains more about this educational process. 

Hi David, thank you so much for taking the time to speak with me. So many people living with diabetes are passionate about our cause and choose a profession related to our condition. I am always seeing questions within the community about how to become a Certified Diabetes Care and Education Specialist (CDCES) and I thought it would be helpful for our readers to have someone walk us through their journey on becoming a CDCES.

When were you diagnosed with type 1?

I was diagnosed with type 1 diabetes on October 13, 2008 when I was 11 years old.

How did you handle it growing up?

I didn’t know how to handle it as a kid, honestly. I hadn’t fully accepted my disease until I turned about 14 years old when I began to take this disease into my own hands in a more responsible fashion. Once I fully accepted this disease, I handled it very well, in a positive light!

Have you always wanted to become a CDE or did you start down a different path?

No! I actually didn’t want to be a certified diabetes educator until my junior year of college. I was choosing to go on several different routes. I started out majoring in biomedical sciences/pre-med to become an endocrinologist, then changed to pre-dentistry, and then I lastly switched to graphic design. I was convinced I wanted to be a graphic designer, up until I was in my third year of college, I realized my calling to become a diabetes educator, as I realized my passion for educating others on diabetes and tackling some of the common misconceptions behind it.

I then dedicated all my design work to becoming centered around diabetes education and stereotypes and then graduated with my BFA in graphic design, emphasis in photography and digital illustrations, creating a final Senior Gallery Exhibition where I was able to hold a display in a gallery of design work 100% related to type 1 diabetes. Now, a year later, I am getting my master’s in public health, majoring in health education and wellness coaching to eventually become a Certified Diabetes Educator, all with a designer’s twist to it!

Did you have any mentors (like a diabetes educator) who helped you with diabetes management? 

I would say first and foremost, my very first (pediatric) endocrinologist who diagnosed me as a type 1 diabetic and was very encouraging to me that I could lead a normal life with type 1 diabetes. I also have been inspired by several active members and leaders in the diabetes community who have truly shaped my passion and experience in this diabetes space.

Photo credit: David Mina

Did you have any positive or negative experiences with educators that shaped your perspective of how to best approach helping others with the condition?  

Yes! Absolutely. When I was about 13 years old and began caring for my diabetes on my own terms, I wasn’t caring for my diabetes in a responsible way, which led my hemoglobin A1c to skyrocket and be at the highest it had ever been. Once I went in for my 3-month check-up with my endocrinologist and diabetes educator, my diabetes educator sat me down and gave me a very mean and stern lecture as to how I was not caring for my diabetes and if I kept that up, I would be facing some very serious consequences, such as amputations, heart problems, and vision loss.

After that appointment, as scared and depressed as I was, I took that anger and frustration and proved not only my diabetes educator wrong, but I also proved to myself that I could reach a certain level of peace and stability over my own diabetes management. Though my diabetes educator hurt me with the words she used and her strict demeanor, I thank her for instilling that drive in me to fight against my diabetes and create a world where diabetes does not have to be the “worst case” for anyone! That is when I chose to start up my social media brand, @type1livabetic, where I try to encourage others to view their diabetes with positivity, rather than negativity!

What was the first step you took in order to get closer to your goal of becoming a CDE?

The very first step I took in order to get closer to my goal of becoming a CDE was to finish my undergraduate degree in graphic design, create a full body of work related to type 1 diabetes, then apply into a masters program that would grant me a Masters in Public Health (MPH). Once I finish my master’s program in December of 2020, I will be one step closer to earning my title as a Certified Diabetes Educator (CDE).

I understand you are more than halfway through the Health Education & Wellness Coaching Program through the School of Public Health. Congratulations! How has that been? I know you mentioned you liked to incorporate type 1 into class discussions and assignments, can you give us an example of something you did?

So far, my program has been pretty enjoyable for the most part. My biggest challenge thus far has been transitioning from design school and being a graphic design major, where I was so used to projects, rather than studying for tests and doing assignments. So now, being in a more health-related field, I am having to adjust my whole mentality in terms of how to go about studying and applying real-life health situations into my program.

When I get the chance, I always make sure to incorporate type 1 diabetes into any class discussion and/or assignment. At certain points in my program, we would have an assignment for class discussion and the topic would be diabetes that week. I chose to share my experiences with diabetes and try to educate my classmates at the same time, as I am aware that many still have some ideas about diabetes that may not be true, so I find as we all make it our mission to become health care professionals, I am able to help them gain a better understanding on what diabetes actually is, both type 1 and type 2, through simple lectures, class discussions, and assignments.

Photo credit: David Mina

What type of schooling do you need to have before you can go on to become a CDE? And are there different options?

The traditional route, from what I have heard, is that most CDEs have a background in nursing, nutrition, and/or dietetics, however, the type of schooling I need, based on the unique path I am going towards, is that I will need to gain my MPH degree, then obtain a certain amount of internship hours in the field of diabetes afterwards. After that, I will take the CDE exam and hope to become an official CDE finally!

Have you found other people living with diabetes going through your program?

I honestly have not, as my path is very unique, however, in sharing my own journey and experiences with this program, I have found a handful of my type 1 friends and followers showing interest in going through my program, which is amazing!

What have you found to be, or think will be, the most challenging part of becoming a CDE?

I believe that given I am a type 1 diabetic myself, I will be able to have a stronger impact on my patients as a CDE, making it easier for myself and for others, however, I believe the hardest or most challenging part will be having to learn how to work with others from a variety of different backgrounds and be able to still help them and connect with them on a very personal level.

I understand you need a certain amount of hours interning, how many exactly and where do you hope you can spend that time learning? In a hospital setting? Private office on-line coaching, etc?

Yes, I am not entirely sure of the exact amount of intern hours needed, however, I do know it is somewhere between 1,000-1,600. I feel as though it can vary depending on which program I go towards. I plan to somehow connect with a diabetes-based company or organization, whether a medical device company or a certain organization, and help in interning as a designer, educator, or any outreach/marketing professional in their space, as a way to practice my educating degree, as well as my degree and strong passion of design.

Now, more than ever, providers are making use of telemedicine as much as possible? How do you feel this affects patient care? Are there pros and cons to an online educational setting? 

I personally have had a few medical (diabetes-related) appointments through a telehealth system and have found them to actually be very nice and convenient, from a variety of different perspectives. For the most part, it is nice to be able to see a doctor from the comfort of my own home and still be provided with the exact same patient care I know I need. I believe that this can affect some patients in a way that some may feel they receive better care in person with a doctor and are able to gain more from that face-to-face interaction. In this case, I would say that the pros and cons to an online educational setting truly depend on the patient as everyone is different and may require or desire a different degree of medical attention.

How has this education impacted you financially? Is it manageable, do they have any special programs or resources you can recommend to anyone who is interested but may not feel like they can afford it?

This form of health education has not impacted me financially, only in the sense that my insurance at the moment has been great and has helped me in receiving the care I desire. However, many organizations or medical offices have been great, especially these days, in providing a discounted program for patients who need to see their doctors regularly, but cannot afford it these days, given the current state we are all living in. I think it is always worth it to ask a doctor for any recommendations they may have for patients who may not be able to afford certain online care, such as a savings card, insurance coverage, or any local telehealth programs that allow a patient to receive the same type of care they normally would have, only online now.

What advice would you give someone just starting on their road to becoming a CDE?

Stick with it. I know it may seem a bit discouraging now, but think of the big picture. You are needed in this field to change the way we discuss and manage diabetes as a society. Think of yourself when you were newly-diagnosed with type 1 diabetes (if you have diabetes), and how you could have benefitted from having a certified diabetes educator, just like you! Do it for yourself and do it for others as well!

Source: diabetesdaily.com

A Diabetes Educator Walks Us Through a TeleHealth Endo Appointment

With our country slowly heading back to our “new normal,” we will likely have to go back to our regularly scheduled lives, which includes being diligent about keeping up with all our routine doctor visits. It is even more important when living with diabetes to have annual eye appointments, physicals, dental appointments, and of course, our endo and diabetes educator appointments.

Since many are apprehensive about this new set up and wondering how exactly it will work, I thought it would be great to talk to Dawn, a nurse practitioner and certified diabetes educator who works in an endocrinologist office and have her walk us through the process and what we can expect.

Thank you, Dawn, for taking the time to talk to me today! How long have you been living with type 1 diabetes? 

24 years at the end of this month. 

Did living with diabetes play into your decision to become a CDE?

I had a great CDE in 1995 in a rural town which was unheard of. Then in college, I had a great nurse practitioner (NP) that I still look up to as a mentor for my practice. She talked to me like a person. She talked to me without pressure, shame, guilt, accusations and disappointment. She helped me come to terms with my diabetes and I will forever be in debt to her. I want to pass on that experience to other people living with diabetes.

How has your endocrinologist office responded to COVID-19? Have you closed down? How did you prepare for seeing your patients virtually?

We stopped seeing patients in the office at the end of March. We do still need labs so our lab is open but that significantly reduces foot traffic. We are only ordering labs that are necessary and will dictate current decisions. If they are not needed right now, then they can wait. We have two practice locations and staff are staying at one location. This way, if one office is quarantined we still have the other office to ensure patients have medical support.

We transitioned to virtual visits using the telehealth visit option within our EMR (electronic medical record) and we are using doxy.me as well. We are calling patients ahead of time to let them know about the change in the appointment and encouraging them to try to log in and make sure it works prior to their appointment. This would give you the chance to troubleshoot technical issues prior to your appointment.  We have had a few patients who still needed to be seen in person but almost all of our visits can be completed via telehealth.

I know many patients are curious about how an appointment like this will work. Is there anything the patient needs to do prior to the appointment? I know my son has an upcoming telehealth appointment and we had to download a certain app.

I would recommend as listed above making sure your means of communication works. Do a trial run at the location you plan to be at. If you will be at work during the call, make sure it works at work. If you are at home, then make sure it works at home. Will you use a computer or a smartphone? Do you know how to troubleshoot the speakers, video and microphone? Do you have a pump, continuous glucose monitor, or meter to download ahead of time? If you do, then get these downloaded at home prior to your appointment. Do a practice run a week ahead of time so if you need to call for help you have time to do so.

Having blood sugar readings and pump downloads ahead of time has streamlined my practice. I can view them prior to the appointment and focus on key items to make the appointment more productive. We are encouraging all patients to download at home, but we have made the exception for a few (elderly) to come and download at the office.

Can you walk us through what to expect during the appointment?

My wonderful medical assistants (Ariel, Tonya, and Whitney) have been calling patients to go over medications, any new changes to medical history just before the appointment and checking to make sure the telehealth app or doxy.me is working. Hopefully, I have already reviewed blood glucose logs and pump downloads ahead of time. If not, I will encourage the patient to get that for me.

What are some of the drawbacks of a telehealth appointment? I know my endocrinologist usually examines my thyroid, heart, etc. How will the doctor be able to check vitals as well as other routine measures? 

Yes, not being able to physically assess a patient sometimes is tough. However, if I am concerned enough that we need an in-person assessment ASAP, then they likely should have an urgent appointment with their primary care provider. If someone is complaining of an enlarged thyroid, with a keen eye, we can visualize that in most people via video. However, nothing replaces a hands-on assessment. We will see a patient in the office urgently if needed.

Do you find that overall providers have more or less time to spend with their patients this way?

When we have data (CGM/BG/Pump/labs) there is more time for providers to spend having meaningful conversations with patients. This streamlines appointments.

As a medical professional, how are you finding the telehealth appointments? What do you find most challenging?

  • When I have the data prior to an appointment, I love telehealth. I also love that I can go over reports with the patient and educate them on what I am seeing.
  • The most challenging part is obtaining data prior to the appointment. My medical assistant makes 2-3 calls prior to an appointment trying to prepare each patient. If I don’t have data, then essentially we are making an educated guess about what medications need to change.
  • For example, a patient can complain of afternoon hypoglycemia. However, it could be a reduction in basal insulin needs, overcorrection of pre-lunch blood glucose, or a too aggressive carb ratio. If we do not have data (CGM/BG/Pump) information, there is no way to tell for sure. So we ask questions around and around to try to figure out the most likely scenario but if we are wrong, you may have less hypoglycemia but BG will run higher. I know I do not want my provider to essentially guess at what needs to change.
  • Another example is a high A1c and the provider increasing the long-lasting insulin (basal) or basal rates unnecessarily causing low blood sugar in the middle of the night. I see this often when providers are grasping at straws trying to improve blood sugar control. When the real reason may be significant after-meal blood sugar spikes.

For someone who is unfamiliar with Zoom and other related apps, it may present a novel challenge. Have you found patients are having trouble with the new set up? Do you provide explicit directions on how to get set up for the appointment?

Most patients who have reliable internet access and have a smartphone or computer with a camera the platforms we use work beautifully. Doxy.me just requires the patient to click on the link we provide in an email. Click and then wait for me to start the appointment.

What do you think the patients will find the most pleasant about the virtual appointment? And what about the worst aspect?

The best part is that you can sign on from anywhere with cellular service or Wi-Fi. So your time away from work or other commitments is minimal. The worst part is that you are still at work or home and there are often other distractions. For example, if children or a dog are disrupting the appointment, this can be distracting and cause the appointment to take longer. It is also not a good idea to have an appointment while driving.

What can you tell us about privacy compliance? How can patients be sure their information is safe?

When using the Healow app or Doxy.me, the voice and video access is encrypted, keeping the visit private. The actual video does not access the patient chart in any way.

Looking forward, what do you think our medical system will look like after COVID-19? What about in 10 years?

I have no idea. I have learned to never assume anything in medicine because just when we think something will happen, the opposite occurs. I am hoping this opens doors allowing more rural telemedicine. This will provide medical care, especially those with chronic diseases, living in rural areas that travel 1, 2, or sometimes 3 hours for appointments. Historically, telehealth is not covered by insurance and the cost falls onto the patient. This hopefully will allow for proper insurance billing of these appointments to be more cost-effective and convenient.

Thank you so much, Dawn, for taking the time to walk us through what a telehealth appointment will look like. I have had two so far and they both went successfully! Best of luck and thank you for what you do!

Source: diabetesdaily.com

Working with Your Healthcare Team to Achieve Your Time in Range Goals: An Interview with Cleveland Clinic’s Dr. Diana Isaacs

This content originally appeared on diaTribe. Republished with permission.

By Frida Velcani

Dr. Diana Isaacs on improving time in range, making the most of your data, and the barriers facing people with diabetes and their healthcare teams

Dr. Diana Isaacs is a Clinical Pharmacist and Diabetes Care and Education Specialist at the Cleveland Clinic. She works with people with diabetes on a range of issues, including medications, technology, and lifestyle changes. She also educates people every day about the benefits of time in range.

In addition, Dr. Isaacs is the coordinator for the Cleveland Clinic’s continuous glucose monitor (CGM) program. You can find more information on how to choose a CGM here. We continue to think that CGM is of the utmost importance for helping people keep their blood glucose levels in-range, assuming they have access. Dr. Isaacs meets with 200 people every month, through individual appointments, classes, phone follow-ups, and virtual visits. She also works with other healthcare providers, including nurses, nurse practitioners, dietitians, and physicians.

For this article, we spoke with her to better understand her views on the importance of time in range for people with diabetes. Here are her insights on how we can shift away from using A1C and move everyone toward better health.

Dr. Isaacs on Ways to Improve Time in Range, Setting Target Goals, and Celebrating the “Wins” 

We asked Dr. Isaacs to pinpoint the most important things that people can do to improve their time in range. “Work with your diabetes care and education specialist and healthcare team to interpret CGM data, understand patterns, and optimize medication doses,” she said. When reviewing data, it’s important to keep a positive attitude and focus on the successes. Repeat what worked well on the days when your time in range was the highest. Figure out what is causing the lows (which often lead to rebound highs) and work to prevent them.

Dr. Isaacs wants people to know that having high glucose variability is completely normal. Many people have the misconception that they should be spending 100% time in range. In reality, time-in-range goals are different for each individual depending on factors such as medication, age, and type of diabetes. Experts recommend that people with type 1 and type 2 diabetes aim to spend at least 70% of the day within 70 to 180 mg/dl, less than 4% of the day below 70 mg/dl, and less than 25% above 180 mg/dl. However, experts emphasize that even a 5% change in time in range – for example, going from 60% to 65% – is meaningful, as that translates to one more hour per day spent in-range.

“I’ve seen everything from 0% to 100% time in range,” she said. “There are differences when comparing someone who is new to our clinic compared to someone working with us for a year. It’s so individualized, and people have different challenges. The goal is to improve your personal time in range, and any increase in time in range is a win.”

Measuring Time in Range using Blood Glucose Meters, CGM, and Professional CGM

If you are using a blood glucose meter (BGM) or CGM, talk with your healthcare team about your glucose targets. The data will be more meaningful if you are working toward a specific goal.

For BGM users, paired testing can help you see the direct impact of food on your blood glucose – all you have to do is check your glucose before a meal and again two hours after the meal. To check that your basal insulin is working well, check your glucose levels before bed and first thing in the morning.

At the Cleveland Clinic, people are required to attend a two-part shared appointment to get access to professional CGM. The classes are usually two diabetes care and education specialists (pharmacist and dietitian or nurse) and 4-6 people with diabetes.

In part one, you go over glucose targets, time in range, and how to treat high and low blood sugars. In part two, you download the data and review it with your diabetes care and education specialists. You discuss what it means, find patterns, and make medication adjustments as needed. This class is offered five times per month. Dr. Isaacs says that this program has helped many people improve their A1C (an average 0.8% reduction) and diabetes self-management.

How can we make time in range accessible to people with diabetes and their healthcare teams?

Dr. Isaacs believes that everyone should have access to affordable medications, affordable technology, and a great support system. She says, “I’ve seen so much rationing of insulin and medications, especially in the Medicare and uninsured populations.” There are many people that have diabetes and haven’t connected with their healthcare team in years. We need to do a better job to help these people.

According to Dr. Isaacs, the average healthcare professional is not prepared to talk about time in range. A1C has been and continues to be widely used by most healthcare teams. While she is excited about the growing use of CGM, there are “still some hurdles to get all practices up to speed with how to download the devices and interpret the data.”

Her advice is to tackle these barriers from multiple angles:

  • In research, we need to make sure that time in range is an outcome in all clinical trials that measure glycemic management, so that we can directly measure the effect of time in range on clinical outcomes.
  • We need targeted education for busy healthcare professionals, including podcasts, webinars, and continuing education.
  • We need targeted education for people with diabetes who are often the ones bringing information to their healthcare team.
  • In practice, healthcare professionals should discuss time in range with every person with diabetes that is using CGM.
  • People with diabetes using CGM should be encouraged to bring their reports to their healthcare provider and discuss time in range.
  • Instead of only marketing CGM as a convenient way to reduce finger sticks (which is true), the real benefit is that it lets the person with diabetes be the driver, and time in range is their roadmap.

Dr. Isaacs recently spoke on a panel at the ADA post-graduate sessions about the power of time in range and CGM for all people with diabetes. She was joined by diaTribe’s medical advisory board member, Dr. Irl Hirsch, our editor-in-chief, Kelly Close, and Jane Kadohiro as the moderator, who herself has had diabetes for over 50 years. If you or your healthcare provider are interested in learning more about time in range and downloading CGM data, you can make an account and watch the session here!

Source: diabetesdaily.com

“Inverse Vaccine” to Treat Type 1 Diabetes Passes Phase I Clinical Trial

In people with type 1 diabetes (T1D), the immune system destroys the insulin-producing cells in the pancreas, leading to high blood glucose levels, which are deadly if left untreated. All people with type 1 diabetes rely on insulin injections or infusions to regulate their blood glucose levels. Individual insulin requirements are affected by many factors and tailoring the dosing regimen around the clock requires a lot of mental effort, with many patients finding it difficult to consistently achieve their target ranges.

The search for better clinical approaches for type 1 diabetes is ongoing, with many labs around the world focusing on better treatments and the ever-elusive “diabetes cure”. Most recently, researchers at the City of Hope described the first-ever human phase I clinical trial of a “inverse vaccine” to treat type 1 diabetes patients.

We previously reported on this novel potential treatment approach when it was still in its pre-clinical stages at the ADA Scientific Sessions last June. Now, we have reconnected with the lead researcher, Dr. Bart Roep, Ph.D., the Chan Soon-Shiong Shapiro Distinguished Chair in Diabetes at City of Hope and director of The Wanek Family Project for Type 1 Diabetes, to learn about the outcomes of the first-ever human trial.

What Is an “Inverse Vaccine”?

When we think of a vaccine in a traditional sense, we are usually referring to the stimulation of the immune system to develop an immunity and prevent illness from a particular microbe. An “inverse vaccine”, on the other hand, is designed to stop a specific immune response (e.g., the unwanted autoimmune response that destroys beta cells in patients with type 1 diabetes).

How Does the Treatment Work?

This treatment aims to retrain the patient’s immune system to self-tolerate the insulin-producing beta cells in the pancreas. First, specific immune cells (called dendritic cells, DCs) are collected from the patient’s blood and are specifically treated, in particular, with pro-insulin peptide and vitamin D. When the stimulated cells are injected back into the patients, in a series of “vaccinations”, they can elicit a specific subset of the patient’s T cells (regulatory T cells, or Tregs), which should, in turn, act to regulate the unwanted autoimmune response seen in type 1 diabetes.

Dr. Roep explained more:

“We want to negotiate with the immune system rather than bombard it into submission, because the latter may affect your chances of fighting off cancer and infections, including coronavirus.”

First Clinical Trial Results Show Promise

The novel vaccine was recently tested to assess safety and tolerability in nine patients with type 1 diabetes of long duration (at baseline, only three patients had detectable C-peptide levels, indicating some degree of insulin production). The results of the study were just published last week.

The treatment “passed the test” with respect to serious adverse events. The researchers describe that,

“Most importantly, there were no signs of systemic immune suppression, no induction of allergy to insulin, no interference with insulin therapy, and no accelerated loss in beta-cell function in patients with the remaining C-peptide. In conclusion, generation and intradermal administration of [the treatment] appears feasible and safe.”

Clinicians monitored various other health parameters throughout the trial, including glycemic management, which remained stable for all participants. Notably, Dr. Roep stated that,

“With regard to the unexpected clinical benefits: while we told the participating patients that it was a safety and feasibility trial, they have all-time low HbA1c years after our therapy (long after the trial ended) and on average, 13 years after their diagnosis. This is bizarre, and could point to beta-cell regeneration (perhaps once you stop the immune attack) or possibly waking up hibernating beta cells that came out of hiding after the immune system got back in check. Speculation, of course, but tantalizing observation nonetheless, in the preferred direction.”

Why were patients with long-standing diabetes selected for this initial investigation? Dr. Roep explained:

“There are two reasons why we involved patients with long-term disease.

First, to build-in extra safety precautions in this first in-human trial, we selected patients with long-term disease whose condition is less likely to worsen. After all, we injected a vaccine built on their pancreatic islets, so in theory, this could aggravate islet autoimmunity.

The other reason is a frustration that I share with my stakeholders, the diabetes patients: all efforts to intervene in the disease are biased toward a short period after diagnosis. We just learned that most patients keep beta cells for most of their lives, so it is worth protecting those beta cells and serving patients with longstanding T1D at the same time. Our novel strategy is also perfectly suited to do so: perhaps it is even smarter to negotiate with the immune system once the medical emergency is over and remaining beta cells (and the immune system) get some rest. All other strategies so far bombarded the immune system into submission; this big hammer is probably better justified early on.”

You can read even more about the study, including the patient selection process and the specific treatment protocol here.

What’s Next?

Based on the success of the phase I trial that evaluated the safety and tolerability, the research group expect to conduct more human testing:

“Our results warrant subsequent clinical testing in patients with a shorter diagnosis of type 1 diabetes and with preserved C-peptide production, to assess whether this novel immune intervention strategy is able to delay or halt progressive loss of beta-cell function. Further testing would tell whether [the treatment] protects beta cells from autoimmune destruction and can act as curative therapy for type 1 diabetes.”

Dr.  Roep and colleagues are optimistic about the future:

“Our research brings us one step closer to finding a vaccine against type 1 diabetes, an ambitious quest at City of Hope, and the hope of many patients with this disease.”

Of course, there is a long road ahead before we can know for sure whether this type of therapy will be truly effective. Moreover, the way that type 1 diabetes develops differs between patients, and it is likely that immunotherapies will have to be tailored to different patient subsets, as we previously discussed with Dr. Roep.

Nevertheless, such a tailored approach constitutes a previously unexplored form of treatment for type 1 diabetes patients, which could lead to effective therapies, and perhaps even a cure. We will continue to follow this research and provide updates as more research is conducted.

Read the official press release about this clinical trial from the City of Hope here.

Source: diabetesdaily.com

Research Trends with Dr. Maria: Beta Cells, Botox, and More

Dr. Maria Muccioli holds degrees in Biochemistry and Molecular and Cell Biology and has over ten years of research experience in the immunology field. She is currently a professor of biology at Stratford University and a science writer at Diabetes Daily. Dr. Maria has been living well with type 1 diabetes since 2008 and is passionate about diabetes research and outreach.

In this recurring article series, Dr. Maria will present some snapshots of recent diabetes research, and especially exciting studies than may fly under the mainstream media radar.

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Even Very Slightly Elevated Blood Glucose May Impact Beta Cells

When diabetes first develops, a reduction in insulin production initially results in just a slight elevation of blood glucose. A just-published study by researchers at the Joslin Diabetes Center employed cell culture and mouse models to assess how very slight elevations in blood glucose levels might affect the beta cells. Interestingly, the scientists discovered that even slight perturbations in glycemia (*as little as “being only 11 mg/dL higher than controls) could result in gene expression changes in the beta cells. The major conclusion of the investigation was that “mild glucose elevations in the early stages of diabetes lead to phenotypic changes that adversely affect beta cell function, growth, and vulnerability.” Continuing to investigate exactly how the early stages of diabetes may affect disease progression may aid in the development of treatments aimed at slowing or halting disease progression by preserving or improving beta cell function. This study also underscores the importance of early diabetes detection and treatment.

Different Subtypes of Type 1 Diabetes Classed by Age at Diagnosis

The pathophysiology of type 1 diabetes is complex, although it is generally accepted that in most cases, a genetic predisposition and an environmental trigger result in disease onset. A research study that was recently published in the journal Diabetologia aimed to investigate different subsets (endotypes) of type 1 diabetes by evaluating the level of insulin production from recently-diagnosed patients. Interestingly, the authors report that in patients who were diagnosed prior to age 30, “there are distinct endotypes that correlate with age at diagnosis”. Specifically, the new research showed that those who were diagnosed at a very young age (before seven years old) exhibited more defective insulin processing as compared to those diagnosed at age 13 and older. The scientists believe that stratifying type 1 diabetes cases by endotype will prove useful in the most appropriate design of immunotherapies to treat the condition.

Male and Female Offspring May Be Differently Affected by Maternal Diabetes

Hyperglycemia during pregnancy can negatively affect the offspring. A study published in April 2020 in the journal Brain, Behavior, & Immunity – Health indicates that the effects of hyperglycemia on central nervous system development may affect male and female offspring differently. Notably, the authors concluded that while hyperglycemia could cause developmental defects in males in females, when it came to “impairments in recognition memory,” specifically, it was found that only the females were negatively affected. Although this research was performed in rodents, it offers valuable insights into how maternal diabetes may affect offspring development in a sex-specific way. Notably, it was also demonstrated that insulin administration to achieve strict glycemic control mitigated the negative effects, once again highlighting the importance of optimal glycemic management before and during pregnancy.

Botox Injection Plus High-Protein Diet for Obesity Treatment

Interestingly, the injection of botulinum toxin (Botox) has been shown effective in the treatment of obesity. A research study recently published in the journal Obesity Surgery evaluated the efficacy of botulinum toxin injections alongside a calorie-restricted, high-protein diet for weight loss. Participants were assigned to one of three groups: 1) botulinum toxin treatment only; 2) botulinum toxin treatment + calorie-restricted/high-protein diet; or 3) calorie-restricted/high-protein diet alone. Excitingly, the results showed that patients who received botulinum toxin treatment prior to initiating the diet protocol achieved faster weight loss and experienced more positive effects in improving comorbidities. The authors theorize that botulinum toxin treatment may help “facilitate adaptation to the new diet style”.

“Kitchen Intervention” in Type 2 Diabetes Education Helps Improve Outcomes

Several educational intervention programs aimed at improving glycemic management in patients with type 2 diabetes were compared in a recent initiative by the Milwaukie Family Medicine center in Oregon. A traditional diabetes education class was implemented for one group of patients, while a second group was assigned to the traditional education program, along with a “health-focused, budget-friendly cooking class” provided by the Providence Milwaukie Community Teaching Kitchen. Hemoglobin A1c measurements were acquired at baseline, and at several months post-intervention. The recently published results demonstrated that patients who participated in the cooking class intervention, lowered their A1c levels more, on average, than those who attended the traditional education program alone. Although this initiative was a small one and yields very preliminary results, the outcomes suggest that intervention programs focused on real-life applications (like budgeting and cooking) may afford better patient outcomes.

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Please share your thoughts with us and stay tuned for more recent research updates!

Source: diabetesdaily.com

Diabetes and Divorce: Getting Through the Process

Diabetes can wreak havoc not only on one’s physical health, but on one’s mental and emotional health as well, and oftentimes the toll that diabetes takes will affect the entire family. If you’ve faced or are currently facing a divorce and live with diabetes, you know all too well that it adds a complicated layer that can cause additional stress, heartache, and pain. Here are some ways to protect yourself (and your diabetes!) should divorce come your way:

Court Can Be Ugly

While sometimes divorce can be civil and amicable, going to family court, especially when child custody arrangements are being negotiated or when child support is in the picture, can get ugly. Be prepared for your spouse’s attorney to bring up your diabetes management, and to propose that as a liability against your ability to care for your children. Work with your attorney around this expectation. By providing your attorney your medical records (including HbA1c results), you can defend any argument against you regarding poor diabetes management.

Leaving a Marriage Can Mean Losing Insurance

Leaving any marriage is hard, but this is especially true for people living with diabetes who rely on their spouse’s health insurance, which equals access to insulin, pump supplies, and the ability to see an endocrinologist. Divorce can be a long, brutal process, but knowing that you will lose health insurance gives you time to stock up on supplies, make much-needed appointments, and line up ways to secure health insurance before you have a significant lapse in coverage.

If you were previously unemployed, you may be eligible for Medicaid coverage in your state, or since divorce is a qualifying life event, you can buy a health plan on a state or federal exchange. Check out our resources for securing insurance if you learn that you’ll lose coverage as a result of divorce.

Vulnerabilities Are Laid Bare

As a person with diabetes, we rely heavily on our spouses for everything from helping us take a shot in an unreachable place, to grabbing us a juice for a 3 a.m. low. Losing a spouse means losing part of our support system for managing our diabetes.

If you’re experiencing this sudden loss of support (especially if you struggle with hypo unawareness), try and prepare yourself by getting a continuous glucose monitor (CGM) that can alert you if you go low during the night. Many CGMs now have a “share” option that lets people “follow” your trend lines, and also receive alerts when your blood sugar goes too high or too low. This is an excellent feature for people who live alone and want additional assurance that they’ll be safe when they go to sleep at night.

Additionally, getting a diabetes alert dog can help not only with managing highs and lows, but also with the loneliness that can come with suddenly finding yourself on your own.

Know You’re Not Alone

You may be losing a spouse, but you have a lot to gain in terms of support, if you know where to look. For community encouragement, joining a diabetes support group, volunteering with a diabetes organization, or reaching out to family and friends and letting them know you need some more support around your diabetes can be greatly beneficial. Even becoming more involved in the diabetes online community (on Facebook, Instagram, or Twitter) is an excellent way to stay connected to people from the comfort of your own home.

Go Inward

Divorce is one of the most stressful times in one’s life. Seeking professional counseling can help you return inward, and to start to heal so you can eventually move forward. Counseling can also prepare you to deal with the stressors of moving out, perhaps finding new employment and new health insurance, and dealing with diabetes on your own for the first time in a long time.

Although it can be hard, divorce can also be a truly freeing and necessary step in one’s life, and can lead to beautiful new beginnings. It’s important to take care of yourself and protect your mental health throughout this time. It’s never too early or too late to start (or continue) work with a licensed counselor.

Have you recently gone through the heartbreak of a divorce, while living with diabetes? What aspects of the divorce were the scariest for you, as a person living with diabetes? What tactics and coping strategies helped you the most? Share this post and comment below; we love hearing your stories!

Source: diabetesdaily.com

Feeling Helpless? Here’s What You Can Do

This content originally appeared on Beyond Type 1. Republished with permission.

By Beyond Type 1 Editorial Team

Feeling helpless in the midst of COVID-19? You’re not alone. There’s a lot we still don’t know about the virus and the situation is changing by the hour. One important thing to think about is separating what you can do from the things you cannot control. We’ve compiled a list of specific actions you can take to have a real positive impact for yourself, your family, and your community.

People with diabetes may be at higher risk should they contract COVID-19, so please take all of the personal precautions you need to at this time. Not everyone’s risk is the same, so be mindful of yourself and others. Take what works for you from this list and leave the rest.

Take Basic Precautions

Wash your hands often for a minimum of 20 seconds with soap and water. Practice social distancing, limiting travel, working from home, and rethink big events – these precautions are not solely for you but for those around you who may be susceptible.

Stay up-to-date with your local health department about COVID-19 in your area.

Connect With Family

Stay in touch with friends and family virtually. Up the frequency that you communicate, and be clear about how you’d like to stay in touch. FaceTime or video chatting can be an awesome tool to feel close to those who are far away – without adding any risk for you or your loved one. Other ideas for staying in touch: start a family or friend group text, find games you can play together remotely, or set a regularly scheduled phone call.

Talk to the children in your life about what’s going on. Tell them we’re washing our hands and keeping to ourselves to protect ourselves and others to help them understand that this is about all of us, not just one of us. Ask if they have any questions and explain as best you can. For older kids and adolescents, asking “what are your friends saying about the coronavirus?” might be a good jumping-off point for starting a conversation to help clear up any misinformation.

Make a list of projects for children to help you with around the house, and teach them how to cook with your extra time at home – you’d be amazed at what they want to help with and how good they will feel knowing they are contributing.

Reach out to People Who Are Most Vulnerable

Think about the people you know, and be mindful of how the current situation might be impacting their specific circumstances. Elderly neighbors, grandparents, older relatives, friends with health conditions, anyone going through chemotherapy or the many, many, other circumstances that might contribute to the current level of anxiety. Reach out and ask how they are. Offer to listen or lend a hand — helping with simple tasks like grocery shopping and limiting the time they spend in public could make a huge difference. If you’re limiting your time in public, too, even just lending an ear at this time can help keep anxiety and loneliness at bay.

Don’t tolerate or perpetuate racism, particularly towards those of Asian or Chinese descent. Referring to COVID-19 as the “Wuhan” or “Chinese” virus may perpetuate racism and xenophobia. If you hear or read others referring to COVID-19 using those terms, please correct them. The importance and impact of being kind to one another cannot be overlooked.

Support Your Local Community

Follow local public health departments and support local news. Journalists everywhere are working hard to keep the public informed about this rapidly-evolving situation. Now is a great time to purchase a subscription to your local news source if it is in your budget. Please also think about the sources of information you read, and try to verify their trustworthiness before you repeat it – the CDC and WHO are good for receiving global updates you can trust.

Donate to your local food bank (find one here). Donating money might be more helpful than donating goods, as food banks often get their items at wholesale cost (in many cases, a $1 donation is equivalent to 5 meals). If you’re well, experiencing no symptoms, and have low risk, ask what volunteer opportunities are available to assist with food distribution.

Support local businesses. If you are fortunate to have uninterrupted income during this time (i.e. can do their jobs from home) and have it to spare, consider transitioning purchases from chains to local businesses, buying groceries from local stores rather than large online retailers.

Consider purchasing gift cards now for use later at a gift store, book store, or local restaurant. Call and ask what they need, or if they’ll accept the transaction over the phone. Ask if they deliver or ship.

If you’re out and about, tip your waiters and waitresses, Uber and taxi drivers, stylists, barbers, and other service industry workers as generously as you can afford. 

Offer support in other creative ways, like buying yourself or others a gift card online to use later, and shopping local businesses online if they have the capability. Reach out and ask what support these businesses need that you might be able to offer (i.e. even just sharing online about what they do).

Support the Diabetes Community

Help drive research + innovation. Sign up for the T1D Exchange Registry, a research study that pulls from your personal experiences and data to help accelerate the development of new treatments. Previous T1D Exchange research efforts have led to things like insurance coverage for test strips and changes in guidelines for A1C goals – your input has the power to make a difference.

Donate your data + impact others. Join the Tidepool Big Data Donation Project, helping further the reach of our collective knowledge about diabetes. Your data gets anonymized and Tidepool will also give back 10% of proceeds to the nonprofit organization(s) of your choice.

Share your voice. Talk to your network about the importance of social distancing and other steps you’re taking to minimize contact and stop the spread of this virus.

Connect with the Beyond Type 1 Community. Download the the Beyond Type 1 App and chat with others living with diabetes. We need connection with others now more than ever.

If You’re Facing Challenges Around Work + Income

If your work hours were cut, file an unemployment claim.

Contact your creditors, electric, phone, and cable companies to see if any accommodations or payment arrangements can be made to make up for lost hours or pay shortages at work.

Worried about homelessness or evictions? Reach out to organizations dedicated to fighting homelessness and their plans to deal with the pandemic. Also, stay informed on if your city’s policies on halting evictions due to COVID-19.

What You Can Do to Support Mental Health

Look into telehealth options for mental and physical care. Check your insurance to see if there is a telehealth service offered, contact your doctor to find out if they have an option for remote visits, or check out services like DoctorOnDemandBetterHelp, or TalkSpace.

Find a new daily routine. Keep getting up early, making coffee, eating breakfast, getting ready for the day and choosing a space to work. Going about your day to day as regularly as you can will only do you and your family good.

Volunteer with animals. Dogs and cats appear to not be susceptible to the virus*, so if you are able to walk dogs at your local shelter or visit the cats, consider it. Animals can help reduce stress, and you might even end up with a new friend to take home.

*the virus may be able to survive on the animal if it has been touched by an infected individual, so know the risks here 

Volunteer your time remotely to help others experiencing distress. You can take the training to become a Crisis Counselor with Crisis Text Line from home, and work to support those in crisis.

Source: diabetesdaily.com

Celebrating a Diaversary in Quarantine

The whole world has seemingly halted operations, due to the novel coronavirus. With over 1/3 of the world’s population on lockdown, shops, restaurants, coffee shops, tattoo parlors, bars, and gyms (any non-essential business) are closed, it’s almost impossible to find something (anything!?) to celebrate these days.

But as we all know, diabetes doesn’t stop, not even for a global pandemic. Those of us with diabetes are still counting, measuring, and injecting multiple times every day, and with that, come diaversaries, or celebrating the anniversary of our diagnosis date. For some people, this can be very emotional, and I’ve previously talked about celebrating my diaversary here. So, how exactly do you celebrate a diaversary while in quarantine? Whether you’re celebrating for yourself or a loved one, check out our top ideas:

Still Mark the Occasion

You may be wondering if celebrating your diaversary is even worth it during this time of international grief and suffering, and I say, if you feel like celebrating, then by all means, celebrate! There is a heaviness in the air, and many people are suffering, but if you can acknowledge the hard work, time, and dedication you’ve given yourself to be healthy this past year, it’s good not only for your self-esteem but also for your mental health.

Treat Yourself

You may not be able to take a lavish vacation, or go out to a fancy dinner, but you can still treat yourself by baking a cake, creating an elaborate meal at home, or toasting to good health in your backyard. Make the evening special by lighting candles, dressing up, and playing some music while you take in the occasion.

Involve Friends and Family

You can zoom or video chat with your closest friends and family who may live far away, for a party without all the clean up! Touching base with those close to you on such a momentous day to reminisce, laugh (or cry!), and connecting will be totally worth it.

Set Goals

A diaversary is an excellent time to look back on your year with diabetes, review what worked for you and what hasn’t (maybe ice cream for breakfast three times a week wasn’t such a good idea?), and set some goals for your upcoming year with diabetes. Maybe you want to try out a new kind of CGM, or get your HbA1c to a lower (or even higher) level. Maybe you’re trying to take a pump break or give insulin pens a try. Set some goals to get your year started off right!

Indulge

Whether that’s by skipping dish-duty for a long, leisurely walk around your neighborhood, or having an extra piece of cake, or even by ordering a fun diabetes bag, make sure you enjoy a no-guilt treat on this day- after all, you deserve it!

Celebrating your diaversary during quarantine and shelter-in-place rules is definitely different, but it doesn’t have to be sad or lonely. Have you celebrated your diaversary during the COVID quarantine, or are you planning to? What strategies or ideas have you used or do you plan on using in order to celebrate? Share this post and share your stories below; we love hearing from our readers!

Source: diabetesdaily.com

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