Traveling Abroad with Diabetes: Have Your Dolce and Eat It Too!

This content originally appeared on diaTribe. Republished with permission.

By Maria Horner

Maria shares her experiences and strategies for managing blood sugar levels while studying abroad

Like many young adults, I love to travel and will take any excuse to do so. Going into college, I knew that I wanted to study abroad; the moment I learned about my university’s semester program at their Rome campus, I was ready to go. However, traveling with diabetes isn’t always easy. The longer the trip, the more complicated it can be, and especially a trip to Italy, a country known for all of its carbohydrates!

What’s someone with diabetes to do about managing their diabetes while living in Italy?

Preparation is key!

One of the most important things I did to ensure my trip went well was put a lot of time into preparation. This means figuring out the quantity of diabetes supplies you’ll need, ordering them in advance, and finding space to pack it all. On my blog, I created a handy spreadsheet that helps you calculate exactly how much of each item you’ll need. You should start refilling your prescriptions as frequently as possible months before you travel, to make sure you stockpile enough supplies to last the whole trip. When I was preparing to go to Italy, my insurance only allowed me to order three months of supplies at one time, so I had to wait a few weeks before refilling my prescription. If you’re short on time, ask your healthcare professional if they can help you order extra supplies.

Preparation also means making back-up plans in case anything goes wrong, like talking through solutions to possible challenges. I have a great team of people that support me at home, including my parents, friends, and healthcare professionals, so before I left, I made sure I had several ways to contact them while abroad. Once I arrived in Rome, my host family, my friends, and the staff at my school became the people who could help me if I needed assistance.

Here are some things to talk about with your support team before you travel:

  • If I run out of a diabetes supply, what will I do? Can I get this supply abroad? Is having it shipped to me an option, considering what can be sent through the mail, what is allowed through customs, and the reliability of the mail system?
  • If I need to see a doctor or go to the hospital, can I find English-speaking doctors? Where is the closest hospital?
  • How does insurance work? Do I need to get special insurance while I am abroad?
  • How can I get in contact with my doctor? Can someone from my support team contact my doctor if I can’t?

Here’s a little story about how back-up supplies and my support team saved the day while I was in Rome:

About halfway through my semester, I was returning from Venice on an overnight trip and I arrived back in Rome early in the morning. I must have been sleep deprived, because I left my phone on the train! To anyone else, that would be very frustrating but manageable; most of the things people use their phones for, like email and messages, can be done on a computer. For me, it felt like a disaster, because my Dexcom G5 continuous glucose monitor (CGM) was tied to my phone. I love being able to check my blood sugar with just a glance at my phone, but without my phone, I couldn’t use my CGM. Because I’m used to constantly knowing my blood sugar, not having readings for an extended period of time was hard. Long story short, it was two days before I could get my phone back, and only with help from my support team in Rome. Thankfully, I had plenty of test strips and a blood glucose meter (BGM), so my back-up supplies came to the rescue.

Enjoy new foods, but do so in moderation.

After all my preparation, living in Rome still brought different challenges my way. Even though I wanted to experience all that Rome had to offer, I still had to keep blood sugar management in the back of my mind, especially during mealtime. Italian cuisine is full of carb-heavy foods, from pastries for breakfast to sandwiches, pizza, and pasta for lunch and dinner. Unfortunately, all these unknown carbs can make it hard to keep one’s blood sugar in range.

I didn’t want to deny myself all of the delicious, yet carb-rich, Italian foods. But I also didn’t want to drive my blood sugars out of my target range. I found that my best option was to eat these foods in moderation (just one or two bites), and fill myself up with delicious lower carb options, like vegetables and meat.

To prepare for a meal that may contain many carbs, make sure to dose extra insulin before the meal. If you end up eating more carbs than expected (which can easily happen with Italian food), the sooner you’re able to dose additional insulin – even if it means stopping in the middle of the meal to take insulin – the more quickly your blood sugars will respond.

Do some research and know what to order at restaurants.

When eating out at a restaurant, a good tactic is to order a meat, seafood, or vegetable-based dish as your main entree. Before you’re faced with ordering low-carb food in a foreign country, it’s helpful to know what you can expect from a local menu. Here’s what I learned in Italy:

  • Italian meals consist of several courses, including antipasto (appetizer), primi (the first course, typically pasta), secondi (the second course, usually meat or seafood), contorni (a side dish, usually a vegetable), and dolci (dessert).
  • Most people order either a primi or secondi as their main dish.
  • You can find the best low-carb options in the antipasti, secondi, or contorni sections of the menu.
  • If you have diabetes, ignore the primi section – it won’t be helpful for keeping your blood sugars in range.

One more tip: when you’re not sure what something is on the menu, it never hurts to ask the server or look up a picture online. This was important for me in Italy, since some of the meat dishes are breaded. I’ve included a list of my favorite low-carb Italian orders at the end of this article.

Share food with friends and family!

If you don’t want to miss out on experiencing all the pizza and pasta, get your friends to help you out. If they order a high-carb dish, ask if you can trade a few bites of your food for theirs – that way, you get to taste some pizza or pasta, while still keeping your meal low-carb. The same thing can apply to desserts, like gelato: ask a friend for a few bites, or offer to split one.

No matter what you decide to eat, just make sure you watch your blood sugars carefully, especially when trying new foods and guessing on insulin doses. Don’t let your diabetes stop you from exploring all the wonders of a new cuisine and culture, but also, don’t let impulsive food choices throw your blood sugars off. That balance can be hard to find, but do the best you can and enjoy the experience. Mangia bene (eat well)!

For more details, tips, and advice on studying abroad with diabetes, visit my blog, Winging It.

Here are some of my favorite low-carb Italian food orders, classified by course.

Antipasti (appetizers):

  • Insalata caprese (mozzarella, tomato, basil salad) – if you’re lucky, they’ll use fresh mozzarella di bufala, the most delicious cheese I’ve ever tasted!
  • Verdure grigliate misti (mixed grilled vegetables)
  • Affettato misto or salumi misti (mixed cold cuts)
  • Prosciutto (ham)

Secondi (entrees):

  • Tagliata/bistecca/filetto di manzo (beef)
  • Salsiccia (sausage)
  • Petto di pollo (chicken breast)
  • Vitella (veal)
  • Bollito alla picchiapo (beef stew in tomato sauce)

Contorni (side dishes):

  • Carciofo alla romana (roman artichoke)
  • Peperone (bell peppers)
  • Spinaci (spinach)
  • Insalata (salad)
maria horner

Image source: diaTribe

Maria Horner is a college student from Northern Virginia. She was diagnosed with type 1 diabetes at age seven, but she hasn’t let that hold her back! She had the incredible opportunity to study abroad in Rome during the fall of 2018, and recently started a blog about her experiences, to help and encourage other people with diabetes that are interested in studying abroad. When she’s not in class, you can find her taking a dance course or trying out a new recipe in the kitchen. She also loves travelling and going on adventures, one of her most recent adventures being skydiving!

Source: diabetesdaily.com

Advancements in Treatment: The Use of Adjunctive Therapies in Type 1 Diabetes

This content originally appeared on diaTribe. Republished with permission.

By Paresh Dandona and Megan Johnson

Read on to learn about the research around GLP-1, SGLT-2, and combination therapy use in type 1 diabetes. Dr. Paresh Dandona is a Distinguished Professor and Chief of Endocrinology at the University of Buffalo, and Megan Johnson is a fellow on his team

For people living with type 1 diabetes, new treatments are finally on the horizon. The University at Buffalo (UB) Endocrinology Research Center is helping to revolutionize the treatment of this condition. Among the most promising new therapies are two non-insulin medications currently used in type 2 diabetes, SGLT-2 inhibitors and GLP-1 receptor agonists.

SGLT-2 inhibitors, such as Farxiga, act the kidney to help the body excrete more glucose in the urine. Meanwhile, GLP-1 receptor agonists like Victoza work in several different ways: increasing the body’s natural insulin production, decreasing the release of the glucose-raising hormone glucagon, slowing the emptying of the stomach, and curbing excess appetite. Some people with type 1 diabetes take these medications as an addition to insulin treatment as an “off-label” drug. To learn more about off-label, check out the article: Can “Off Label” Drugs and Technology Help You? Ask Your Doctor.

Why consider these medications?

In people without diabetes, the body is constantly releasing more or less insulin to match the body’s energy needs.  People with type 1 diabetes do not make enough insulin on their own and have to try to mimic this process by taking insulin replacement – but it isn’t easy.

People with type 1 diabetes often have fluctuations in their blood sugars, putting them at risk for both low blood sugars (hypoglycemia) and high blood sugars (hyperglycemia). Many individuals are unable to manage their blood sugars in a healthy glucose range with insulin alone. In fact, less than 30% of people with type 1 diabetes currently have an A1C at the target of less than 7%.

Can GLP-1 agonists be safely used in type 1 diabetes?

Over the past decade, the endocrinologists at the University at Buffalo and other research groups have been conducting studies to see whether GLP-1-receptor agonists can safely be used in type 1 diabetes.

  • The first of these was published in 2011 and showed a decrease in A1C within just four weeks of GLP-1 agonist treatment. Importantly, people given GLP-1 agonists plus insulin also had much less variation in their blood sugars, as measured by continuous glucose monitors (CGM).
  • Another study involved 72 people with type 1 diabetes who took GLP-1 agonist or placebo (a “nothing” pil) in addition to insulin for 12 weeks. The GLP-1 group had decreases in A1C, insulin requirements, blood sugar fluctuations, and body weight. People in this group did report more nausea – a common side effect of GLP-1 agonists.
  • Since then, multiple studies, some involving over 1000 people and lasting up to 52 weeks, have shown that GLP-1 treatment in people with type 1 diabetes can reduce A1C and body weight, along with insulin dosages.

Many of these studies, but not all, have suggested that GLP-1 agonists can do this without increasing the risk for hypoglycemia or diabetic ketoacidosis (DKA). There is also some evidence that GLP-1 agonists can improve quality of life in type 1 diabetes.

Who should consider GLP-1’s?

The effects of GLP-1 agonists seem to be especially strong in individuals who are still able to make some insulin on their own, although it also works in people who do not.

In one notable study, researchers gave a GLP-1 agonist to 11 people with type 1 diabetes who were still able to produce some insulin. To get an estimate of insulin production, they measured levels of a molecule called C-peptide, which is produced at the same time as insulin. In these 11 individuals, C-peptide concentrations increased after GLP-1 treatment. By the 12-week mark, they had decreased their insulin dosage by over 60%. Incredibly, five people were not requiring any insulin at all. Even though the study was very small, the results were exciting, because it was the first study to suggest that some people with type 1 diabetes had sufficient insulin reserve and thus, could – at least temporarily – be treated without insulin.

Can SGLT-2 inhibitors be used in type 1 diabetes?

SGLT-2 inhibitors like Farxiga have also shown tremendous potential. In two large studies called DEPICT-1 and DEPICT-2, adults with type 1 diabetes were randomly assigned to take either placebo or SGLT-2 inhibitor in combination with insulin. Over 700 people from 17 different countries participated in DEPICT-1, and over 800 people with type 1 diabetes participated in DEPICT-2. At the end of 24 weeks, people taking dapaglifozin had a percent A1C that was lower, on average, by 0.4 compared to people who had received placebo, and it was still lower, by over 0.3, at 52 weeks. The number of hypoglycemic events was similar in both groups.

As with GLP-1 agonists, people taking SGLT-2 inhibitors had weight loss and decreased insulin requirements. People taking SGLT-2 inhibitor, however, did have an increased risk of diabetic ketoacidosis (DKA). If individuals consider this therapy, they should be cautious about not missing meals or insulin, and not drinking large amounts of alcohol, as these behaviors can lead to increased ketone production.

Several other research groups, in trials recruiting up to 1000 individuals, have seen similar results when using this class of medications.  Researchers have been conducting additional studies to try to determine how best to minimize the risks associated with them. Farxiga (called Forxiga in Europe) has now been approved as the first oral agent as an adjunct treatment for type 1 diabetes in Europe and Japan.

Promising Combination Therapy

Now, endocrinologists are also looking at whether GLP-1 agonist and SGLT-2 inhibitor combination therapy could increase the benefits of each of these treatments. A study conducted on a small number of people showed that GLP-1 agonists can help prevent ketone production, so it is theoretically possible that this medication could reduce the risk of DKA that was seen with SGLT-2 inhibitors.

In an early study involving 30 people with type 1 diabetes who were already on GLP-agonist and insulin were randomly assigned to take SGLT-2 inhibitor or placebo, as well. People who received both drugs saw an 0.7% reduction in A1C values after 12 weeks, without any additional hypoglycemia. People on the SGLT-2 inhibitor did make more ketones, though, and two individuals in the combination group experienced DKA. Larger studies are now being conducted to expand on these results and learn more about how to give these drugs safely. The hope is that non-insulin therapies will soon be approved for type 1 diabetes. By unlocking the potential of these therapies, we can do more than manage blood glucose levels – we can improve people’s lives.

Source: diabetesdaily.com

Prior Authorization: Getting Diabetes Supplies and Medications Covered by Insurance

This content originally appeared on diaTribe. Republished with permission.

By Divya Gopisetty

What is a prior authorization? Read on to learn more about why diabetes supplies or medications might require a prior authorization and how to go through the process

It can be frustrating to learn that you need a prior authorization when you already have a prescription. Insurance plans sometimes require a prior authorization to cover a diabetes supply, device, or medication, even if your doctor prescribed it to you.

Read on to learn about what a prior authorization is, and how you can make the submission process as smooth as possible.

In this article:

Click to jump to a specific section!

What is a prior authorization?

My pharmacist told me I need a prior authorization. What happens next?

How can I check if I need a prior authorization?

How long do prior authorizations last?

What happens if the prior authorization is denied?

What is a prior authorization?

A prior authorization, also known as a pre-authorization or pre-certification, means that your healthcare provider or device company has to get specific approval from your health insurance company (so that it will pay for it).  The requirements for prior authorization differ between and within insurance plans.

If you need a prior authorization, the pharmacist cannot process your prescription until your healthcare professional has contacted the insurance company. Similarly, a device company may not ship your diabetes device to you until it has prior authorization from the insurance company.

A prior authorization is designed to make sure certain prescription drugs or devices are used correctly and only when medically necessary. Before your insurance plan will cover a certain device or drug, you must show that you meet a set of criteria.

Prior authorizations are most often handled by your healthcare professional’s office, but sometimes are handled by the device company itself (e.g., for CGM).

If you want to see what a prior authorization request form looks like, check out this one for OptumRx.

My pharmacist told me I need a prior authorization. What happens next? 

  1. If your insurance company requires (and has not received prior authorization), your pharmacy will contact your healthcare professional.
  2. The healthcare professional will contact your insurance company and submit a formal authorization request.
  3. Your insurance plan may have you fill out and sign some forms.
  4. Your insurance plan will contact the pharmacy once it has approved or denied the request.

During this process, be sure to communicate with both your healthcare provider and your insurance company to see if they need any additional information. Prior authorizations usually take about a week to process – after that, check with your pharmacy to see if the request was approved. If the request was approved, you should be able to pick up your prescription from the pharmacy.

If it wasn’t approved, your pharmacy should be able to tell you why, and then you can decide to request an appeal.

As someone living with diabetes, you are your best advocate. Be prepared to track down the paperwork to make sure you receive the requested device or medication.

How can I check if I need a prior authorization?

Check your health plan’s policy and formulary (you can normally access these on the insurance company’s website) to see if any of your treatments require a prior authorization. Or, you can call the member services number found on the back of your insurance ID card to speak with someone directly.

How long do prior authorizations last?

Most approved prior authorizations last for a set period of time (usually one year). Once it expires, you’ll have to go through the prior authorization process again.

What happens if the prior authorization is denied?

  • You can request an appeal (which is often successful!)
  • You can pay the full cost for the medication or healthcare supply, without insurance coverage.

Want to learn more?

Check out this easy-to-read resource created by DiabetesSisters on prior authorizations, step therapy, and appeals.

What’s Worked for Other People with Diabetes? Hear from Them!

  • I was denied my first CGM in 2008 by a Blue plan and fought and won by knowing how to Google my payer’s medical policy and prove that I met coverage criteria. It helped that I was given the HCP line phone number by a nurse sympathetic to my cause, but I ended the call with an authorization code. – Melissa
  • My strategy has always been persistence pays (eventually the insurance company will give in, although they may have peculiarities to navigate. The doctor’s office is really key and many have specialists who only deal with insurance company issues [mine does]). I’ve been covered by 4 insurance companies over the past decade while at the same employer if that tells you anything about the evolving insurance market. My experience with Anthem was a hassle but predictable, United Healthcare was easiest to navigate, Aetna was straightforward but a pain and had some weird rules (Why does a precertification inexplicably expire at the end of a calendar year? My chronic illness did not expire at the end of the year.). – Scott
  • Do you have experiences with prior authorizations? Let us know!
diaTribe Series

Image source: diaTribe

This article is part of a series on access that was made possible by support from AstraZeneca. The diaTribe Foundation retains strict editorial independence for all content. 

Source: diabetesdaily.com

Benefits of Time in Range: New Study Shows Cost Savings

This content originally appeared on diaTribe. Republished with permission.

By Eliza Skoler and Albert Cai

A new paper suggests that as people with diabetes increase their time in range, healthcare costs decrease

IQVIA, a healthcare consulting firm, published a 22-page paper describing the limitations of A1C and the potential financial benefits of improving time in range, the time a person spends with blood glucose levels between 70-180 mg/dl. The paper was sponsored by Lilly Diabetes.

The paper predicts that if the average time in range for people with diabetes in the US increases to 70% or 80%, healthcare costs will be reduced. The savings could be up to $9.7 billion for the US healthcare system over ten years if the average time in range for people with diabetes is increased to 80%.

The graphic below shows how much money is saved over ten years just by reducing hypoglycemic (low blood sugar) events in people with type 1 diabetes. Other costs saving would likely come from a reduction in diabetes-related complications. Studies (Diabetes Care 2019, Diabetes Care 2018) have suggested that greater time in range is associated with a lower risk of health complications.

Stat

Image source: diaTribe

Unsurprisingly, the biggest reductions in healthcare costs were seen in people with high baseline A1C. While a 5% increase in time in range for a person with an A1C under 7% would save only $20 over ten years, the same 5% increase in time in range for a person with an A1C over 8% would lead to $1,470 in savings over ten years – mostly due to a greater reduction in the risk of diabetes-related complications. This means that to get the greatest health and cost benefits, it is essential to bring time in range practices to people who are most struggling to manage their blood glucose.

To calculate the effects of improving time in range, the study assumed an average time in range for people in the US of 58% (type 1 and type 2 diabetes). This 58% came from a 2019 review of four major CGM studies. However, these four studies were done at top diabetes centers and the participants had relatively low A1Cs (~7.5%). Additionally, the majority of people with type 1 diabetes and almost everyone with type 2 diabetes still don’t have access to CGMs. In other words, the actual population average is likely much lower than 58% time in range and the $9.7 billion calculated in cost savings would actually be much higher if the population’s time in range reached 80%.

IQVIA provides several reasons why CGM should be used to support blood glucose management in people with diabetes:

  • A person with diabetes can understand how variables like food, exercise, and sleep habits affect blood glucose and can use that information to improve decisions and outcomes.
  • Healthcare professionals can provide more individualized care to support people with diabetes.
  • The healthcare system will save money on diabetes care.

The illustration below outlines how CGM can be used to monitor blood glucose and guide shared decision making for a healthcare professional (HCP) and person with diabetes (PwD).

Stat

Image source: diaTribe

The last eight pages of the paper discuss how time in range can become more commonly used, asking policymakers, healthcare professionals, and people with diabetes to drive the time in range movement forward. IQVIA’s ideas include:

  • promoting CGM to help people measure and understand time in range;
  • educating healthcare professionals and people with diabetes about the health benefits of time in range; and,
  • tackling affordability and access issues to make sure all people with diabetes (or even prediabetes) can use CGM.

This paper not only emphasizes the importance of time in range for well-being but also highlights time in range as a public policy matter. While there is clearly much work to be done, this study is an important step in underscoring the need to bring CGM and time in range to more people.

Source: diabetesdaily.com

Traveling with Type 1 Diabetes: Marrakech, Morocco

Dr. Jody Stanislaw has had type 1 diabetes (T1D) for 39 years and is on an inspiring adventure of living in a new country every month until Sept 2020! She is on a mission to inspire T1Ds everywhere that living a healthy and adventurous life with T1D is 100% possible. This week she is in Morocco. Check out this video of her wandering through this crazy market in Marrakech, with her Dexcom by her side.



Source: diabetesdaily.com

World Diabetes Day 2019: The Most Important Issues We Face

Today is World Diabetes Day. What are the most important issues that you face as a person with diabetes? See what the online diabetes community had to say.
Source: diabetesdaily.com

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