Would You Restrict Carbs to Ease Diabetes Management? (ADA 2020)

Children and adolescents with type 1 diabetes are currently living at a time of a big diabetes technology boom. Continuous glucose monitors (CGMs) and insulin pumps are becoming more popular and offer the promise of better glycemic management and more freedom and peace of mind. As research and clinical trials on automated insulin delivery systems are in full-swing, clinicians from The Joslin Diabetes Center, Yale University, and Harvard University were interested in understanding various patient preferences. In one study, they posed the following question:

Would young people with type 1 diabetes be willing to limit their carbohydrate intake to a maximum of 50 g per meal if this meant they wouldn’t have to administer a manual bolus using an artificial pancreas (AP) system? 

The outcomes of this research were recently presented at the American Diabetes Association (ADA) 80th Scientific Sessions.

To help understand patient perspectives and preferences on this subject,  39 participants (average age 17 +/- 4.7 years) were recruited at two study centers. These patients had an average diabetes duration of 9.4 +/- 4.9 years and an average HbA1c of 8.4 +/- 1.1 %. Interviews were conducted with each participant and parents to gauge their views on the willingness to “limit carb intake to 50 g per meal/snack if this would eliminate the need to manually bolus for food when using the AP system.”

Based on their analysis, the study authors derived the following major insights:

  1. The majority of participants (and their parents) would prefer to have the option of eating more than 50 g per meal/snack and were willing to manually bolus for the excess carbs.
  2. Most believed that 50 g per meal or snack was too restrictive.
  3. Young people generally agreed that automation would “reduce self-care burden.”

The researchers concluded,

“An aversion to food restrictions overpowers the desire for an AP system that can independently manage glucose levels though limited carbohydrate intake. Carbohydrate limitations appear to increase self-care burden more than the time and effort expended on carb counting and bolusing. Future AP systems should consider options that enable users to choose to bolus manually for large meals and to forego bolusing for smaller ones.”

Here are a few notable quotes from the participants, which were highlighted in the poster presentation:

“I think that, if I had to choose between bolusing or limiting my carb intake, I think I would rather bolus, just because nobody really wants to be told what to do.” (25-year-old female)

“Every once in a while she wants to have an ice cream. You know, I think she should be allowed to have these things sometimes when she wants them. I don’t want her to be too restricted.” (Mother of a 16-year-old.)

Sadly, despite continuing advances in technology, the glycemic management for youth with type 1 diabetes has been stagnant or worsening, depending on the age group, for decades. As per the most recent available data, the average HbA1c for young people with type 1 is about 8.7%, similar to what was observed in this cohort. Automated insulin delivery could offer an important solution to so many young people who do not meet the ADA-set glycemic targets (currently, the organization recommends individualizing the A1c goals, from as low as <6.5% all the way up to <8% for some patients).

This study provides an interesting snapshot into what many young people with type 1 diabetes appear to consider very important — the freedom to eat whatever they want and bolus for it. 

There has been a long-standing debate, often in the diabetes online community, and sometimes among healthcare providers, about a low-carbohydrate approach for young people. Many have highlighted the benefits, and exceptional success stories. They are not just anecdotes, either. At least one study has demonstrated exceptional outcomes of carbohydrate lowering for youth with type 1 diabetes, with excellent adherence and reported quality of life, a normal average A1c of ~5.7%, and a very low rate of adverse events.

Nevertheless, some question difficulty of maintaining a lower-carbohydrate diet, and concerns have been cited over the potential for the development of eating disorders as a result of “restricted eating”.

When it comes to developing AP systems, this study suggests that many young patients would prefer more flexibility in the upper threshold of their carbohydrate intake and are willing to put in the work to manually bolus for and accept the outcomes, whatever they may be, of higher carbohydrate eating patterns, in lieu of sticking to a recommended carb limit and not having to manually deliver their insulin dose. Of  course, this is just a small study, and the results may be skewed towards this perspective due to the predominance of teenagers in this cohort. Also, it may be interesting to evaluate a shift in this perspective, if any, following a formal diabetes education program to explain to patients and parents, in detail, the benefits of lowering carbohydrate intake for diabetes management in general, and in the context of AP technology.

What are your thoughts on the subject? We love hearing from our readers.

Source: diabetesdaily.com

Is Healthcare Provider Knowledge of Diabetes Lacking?

People’s experiences with healthcare providers can vary widely. When it comes to living with diabetes, many people expect that their healthcare providers, even if they’re not specialists, will be at least somewhat knowledgeable about their health condition. Many have found however, that while endocrinologists and diabetes education specialists tend to be more attuned to the ins and outs of diabetes management, even their knowledge can be outdated, while the knowledge of other providers, is sometimes starkly lacking.

Meanwhile, two informal polls in two separate diabetes social media groups, highlighted that over 85% of people with diabetes expect any healthcare provider (even if not a diabetes specialist) to have a basic working understanding of diabetes, at the very least the two major types and general treatment options.

Nevertheless, when the asked to share their own experiences, many reported a lot of confusion and uneducated statements about diabetes from various healthcare providers. The consensus during the crowdsourcing research tended to be “while we expect it, we do not routinely see it.”

We asked people to share some of the comments that they received about diabetes from healthcare providers. Here are some surprising responses and stories to ponder:

“When did you have your insulin pump surgery?”

“Type 1 diabetes develops over 2-3 days, not months.”

“He was a big baby so clearly he’s was a diabetic when he came out.”

“You will kill your child with this low carb nonsense… I will not stand by and watch you do that… I’m sure one of the other doctors will call CPS with this.”

“Diabetics like you are only allowed 4 eggs a week. Period.”

“You should eat more carbs, it’ll stabilize your blood sugars.”

“Do not correct under 13 mmol/L [~234 mg/dL].”

“You need to eat a minimum of 45 g carbs per meal.”

“If you don’t like seeing high fasting blood sugar numbers in the morning, don’t test your blood sugar then.”

“You will likely be dead from diabetes by age 30. If by some miracle you are still alive, you will be blind, on kidney dialysis, and in a wheelchair due to amputations.”

“Are you sure you have type 1?”

“It’s probably best if you stop sports and strenuous exercise.”

“If you go low-carb, you’re going to kill yourself.”

“An A1c below 6.5 is dangerous.”

“You don’t have to bolus for corn or peas, they are freebies.”

“Your insides are destroyed from having diabetes so long.”

One woman shared the following story:

“When my daughter was diagnosed at age 2 (I had diagnosed her and had to fight with her pediatrician to test her blood, because her urine test was normal. We already ate low-carb, so I had to feed her a high-carb meal and take her back and storm the pediatrician’s office and force them to give her a test, which came back at around 500, at which point they finally sent us to the ER). After diagnosis, the endo told us she needed at least 100 g carbs for each meal (at age 2!!!), plus 30–50 g snacks in between meals. Insanity! They had her on massive amounts of Lantus, NPH, and Novolog. They told me to feed her lots of ice cream before bed every night to hold her steady at around 200, which was a great night-time number for a kid that age! I swear I still have PTSD from that whole experience! Nightmare! I had to fight with them every step of the way!”

Such stories amassed very quickly, with many nodding their heads at having similar experiences. Is there perhaps a gap in basic diabetes education, in particular for non-specialists?

Image credit: Haidee Merritt. Republished with permission. Please visit her Etsy store for more original work and gifts. 

Almost all will likely agree – while we cannot expect every healthcare provider to be fully attuned to the latest developments in diabetes diagnostics and treatment, an accurate knowledge of the basics should be a requirement – especially with the high number of diabetes diagnoses, and undiagnosed or misdiagnosed patients.

Moreover, ensuring better understanding of diabetes and its management across the board, for all providers, is highly likely to improve patient outcomes in various situations, including recovery from illness and surgery, and more effective prevention of numerous diabetes-associated complications.

***

What are your thoughts on this issue? Have you ever had a surprising conversation about diabetes with a healthcare provider?

Source: diabetesdaily.com

What Does a Low Blood Sugar Feel Like?

Despite so many advances in both medicine and technology, people living with type 1 diabetes still have a higher premature mortality rate than the general population. Severe hypoglycemia can be fatal and accounts for up to 10% of deaths among young people with type 1 diabetes. Being able to detect the symptoms of a low blood sugar is crucial to taking action and bringing your blood sugar back into the normal range before it becomes an emergency, life-threatening situation

Low blood sugar, also called hypoglycemia, means that your body does not have enough sugar in the bloodstream to fuel all of your body’s cells. Typically a low blood sugar is defined as anything below 70 mg/dL (3.8 mmol/L). The ill-effects of low blood sugar can be scary and some can be permanent. They range from confusion to seizure, to coma, and can even result in death. 

One of the most popular questions I get asked personally and see circulating in the diabetes online community is parents asking those living with diabetes–what does a blood sugar feel like? For a parent, this information can be so helpful in avoiding a very dangerous situation. It is also important for those of us living with diabetes to be attuned to our bodies and recognize the symptoms before they become more pronounced and severe. The quicker we can act and treat our low the less of an interruption this will also be on our, or our child’s,  daily lives. 

I asked our friends in the diabetes online community if they could do their best to describe how they feel when having a low blood sugar. Remember, everyone’s experience is different and how you may react can depend on how fast or slow you are dropping. It can also vary each time so make sure to stay on your toes and stay vigilant!

“I feel like I’m in the Matrix, everything is slowed down. I feel super floaty as if I am drunk and all I can think about is how sweaty and hot I am.”- Jesse, 28, NY

“Mostly I don’t feel them but when I do it’s like having run a marathon while having a panic attack followed by exhaustion.” – Jessica, age 32, PA

“Normally when I’m low I get the chills and cold sweats. I will be drenched in sweat. People around me notice I get a little hyper, especially with my talking. I was having bad lows in my sleep for a while and would wake up to someone putting juice or soda down my throat. My wife could tell I was low due to the massive amount of sweat.” – Bradley, 34, TX

“Weak. Fatigue. Dry mouth. Sweaty. Grumpy. Hungry.” – Briana, 26, UT

“It feels like someone is deflating your energy like a pool float.” – Matt, 25, NC

“I honestly feel drunk. Not the ‘fun’ drunk but the confused and dizzy kind. Plus, it’s like I’m having a hot flash. And sometimes I get that ‘sense of impending doom’ where it’s like ‘omg I think I might actually die this time’.”- Abby, 27, OH 

“If it isn’t a terrible low, I just feel a little off, woozy and shaky. A bad low will make me sweaty and tingly and then confusion sets in. Once I realize I am low, all my symptoms get magnified. I can feel my heart race and the drops of sweat build upon every inch of my skin. Sometimes this comes along with mild panic attack symptoms.” – Vonda, 21, NZ

“It makes my knees go weak. Also, my depth perception gets distorted.”- Maria, 38, TN

“It is like my whole equilibrium gets thrown off and it feels like I am on the very top of a rollercoaster right before you come down. Other than that, I feel sweaty, shaky, disoriented, and sometimes numb around my lips and tongue. I am also irritable, emotional and a little bit snippy.” – Allison, 35, TX

“I always compare it to being outside all day, without eating anything, and trying to walk home uphill.” – Jim, 35, PA

“Every low is a little different, but overall it feels like circuits in my brain are breaking, the lower I drop the more broken circuits there are. Hypoglycemia starves your brain, so you’re bound to feel weird!” – Paige, 29, CO

“Rapid drops cause sensory overload. Light, sound, touch become overwhelming inputs. Panic sets in, inability to form coherent thoughts, cold sweats then rage. By this time fight or flight has kicked in and I usually remove myself from other people and prefer to stay in the dark with earphones in but no sound playing until my blood sugar returns to baseline.” – Rodney, age 37, TX

“I have too much energy and craziness when I’m low. I feel invincible and have no shame.” – Jeroen, 24, Belgium

“Like those music videos where the singer is in regular motion when everyone around them is in super fast speed. Brain fog, illogical and irrational thoughts. Like my limbs weigh 100 lbs. each and moving them causes me to sweat.” – Nicole, 40, NC

“My first symptom is always that feeling when you’re on a plane that has taken off and it drops a bit and feels like the bottom has dropped out of your skull. I don’t know how else to describe it.” – Cat, 35, NZ

“Feeling like your body is shutting down.”- Lauren, 22, WY

“When I am just slightly low I feel mostly shaky. As I go lower I get sweaty, irritable, lose my vision and can’t make decisions. Bad lows feel like your brain is melting and then it hits that impending doom feeling where it’s like ‘eat to stay alive’.” – Nicole, 31, DE

“A bad low feels like donating blood then running a marathon.” – Eustacia, 42, CO

“I start feeling hungry and tired if it’s a slow approaching low. I feel sweaty, zonked out, and if I start seeing spots, it’s a fast dropping one.” – Cally, 39, CA

“It feels like I’ve spun around really fast (like little kids do) and then suddenly stopped.” – Lela, 41, NY

Knowing how your body and brain react to low blood sugars can help you to correct them quickly and avoid a scary situation. For parents of children living with type one diabetes, it is so important to know what signs to look for and asking your child to describe how they feel will be helpful in detecting lows. 

While we can do our best to identify and treat low blood sugars, there can be circumstances out of our control. Making sure we are always prepared for these events is key in managing our own or our loved one’s diabetes. There are several glucagon formulations on the market right now and everyone should have one on hand, just in case.

Source: diabetesdaily.com

Research Shows High Blood Sugar Can Cause Brain Damage (ADA 2020)

New research presented at the American Diabetes Association (ADA) 80th Scientific Sessions last month revealed some startling potential consequences of hyperglycemia on brain function. Scientists from the University of California, Los Angeles, applied brain imaging and specialized analysis techniques to discern differences in the brain structure of patients with type 2 diabetes at different levels of HbA1c, along with nondiabetic control subjects. The work was funded by the National Institutes of Health/ National Institute of Nursing Research.

Study Design

A total of 49 patients with type 2 diabetes were enrolled in the study (12 controls, 22 with A1c>7%, and 15 with A1c<7%). The demographic information is summarized below.

For all subjects, magnetic resonance imaging (MRI) was used to gather images of the brain, and the “whole-brain mean diffusivity (MD)”, a measure related to certain brain functions, was assessed and compared between the three groups.

Study Outcomes

The main outcome of the study was as follows:

“Uncontrolled T2DM patients showed increased MD values in multiple brain areas, including the cingulate, insula, para-hippocampal, hippocampus, cerebellum, basal-forebrain, prefrontal, frontal, and temporal cortices over controlled T2DM patients and healthy controls.”

The study authors went on to explain that the brain regions that showed significant tissue damage are known to involve various aspects of cognition, including mood.

Conclusions

The main implications of this study are as follows:

  • Higher A1c levels are associated with higher likelihood of brain damage
  • The areas of the brain that are likely to be affected serve to regulate various cognitive aspects, including mood

Furthermore, the study authors noted that the brain injury incurred due to hyperglycemia may further hinder the patients’ ability to manage their blood glucose levels effectively. In the clinical implications discussed in their poster, the researchers concluded,

“Poor glycemic control is associated with increased brain injury. Brain injury is located in regions which can impair diabetes self-care. Patient education which require these brain regions may not be effective. If confirmed, brain protection should be considered as a benefit of good glycemic control in clinical discussions with T2DM patients”

While this work provides important insights into how persistent hyperglycemia may negatively affect cognitive function, it will need to be further validated through additional research. Also, as this study was performed on a cohort of patients with type 2 diabetes only, it is not clear at this time whether these findings may be relevant for those with type 1 diabetes, although it is logical to postulate that glycemia is the primary determining factor in these findings.

Source: diabetesdaily.com

The Benefits of Working from Home with Diabetes

COVID-19 has officially changed the way the world runs. More than ever, people are staying home (whether by choice or mandate), spending more time with their families, avoiding public events, and yes, working from home. Essential employees, such as frontline healthcare workers, grocery store clerks, sanitation crews and workers rendering city services, are still having to report in person, but COVID-19 has made a third of Americans (over 100 million people) switch to home work.

This can be extremely beneficial if you live with a disability or chronic disease, and can be helpful if you live with diabetes. And while Americans still work more than anyone else in the industrialized world, working from home can help balance the stress of diabetes management. Here are some of the benefits of working from home if you live with diabetes.

No Commute

Let’s face it, commuting is not fun. The average American working full-time (8 hours a day, 5 days a week) commutes an average of 4.35 hours a week and over 200 hours (nearly nine days) per year. That is a lot of wasted time. With rising costs of living and stagnant wages, more people live farther and farther from their jobs, and have longer commutes than ever, which can cut into both one’s sleep and time for exercise. “Commuting” from your bedroom to your home-office leaves more time for quality sleep, morning exercise, and a healthy breakfast, which can set your blood sugars up for an excellent day, which can increase work productivity as well.

Not commuting will also save lots of money that would normally be spent on parking, car maintenance, tolls, and gasoline. Even if you normally take public transit to work, metro and bus tickets add up quickly! Working from home is also much better for the environment; transportation accounts for one-third of all greenhouse gases produced in the United States. Staying at home for cleaner air is an easy and simple way to help the planet.

Healthier Meals

Takeaway Chinese food or pizza at lunchtime can be a blood sugar nightmare. Working from home affords people the ability to cook easy, healthy meals in their kitchens, which is not only a healthier option, but saves money, too. It’s easy to cook lentils or beans in a slow cooker, or wash and chop up fruits and veggies for a quick grab and go snack if you get the afternoon munchies. Additionally, check out these easy, low-carb recipes that you can quickly make from the comfort of your own home!

Fewer Sick Days

People who work from home both take fewer sick days and get sick less often (no sharing germs in a communal setting or on the train en route to work!). Also, going into an office with a mild cold or flu can be miserable, but doing some work from home is almost always accessible. Plus, diabetes can mean dawn phenomenon, a kinked pump site midday, or a bad low that would previously require coming in late or leaving early- none of which would be necessary with a work from home schedule. It’s healthier for everyone!

No Judgement

Ever take a correction dose during a meeting, and get the side-eye from a nosey coworker? Ever have someone compare your diabetes to their distant relative who died of horrible complications from diabetes (when you never asked for the story?). Are people always questioning what you’re eating (or not eating), or how much you exercise (or how much you don’t)? Working from home prevents judgement and prodding questions, and you can go about your day and take the best care of yourself without intervention from others.

A Flexible Schedule

This can depend on your organization or company, but many offering work from home will grant their employees some flexibility in their schedules. If you have an endocrinologist appointment in the morning, shifting your work schedule back an hour or two can prevent the need to take personal leave for the entire day. Likewise, a flexible schedule can allow for a lunchtime run, which can counteract high blood sugars in the afternoon. Need to change your pump site or CGM midday? Working from home can let you do all that while still getting you work done. Flexibility is key to excellent diabetes management, and working from home makes it much easier.

Have you been working from home since the COVID-19 pandemic hit? How has it benefited you and your diabetes management? Is there anything that you particularly like or dislike about working from home? Share your story in the comments below; we love hearing from our readers!

Source: diabetesdaily.com

Be Prepared and Know Your Rights: Your Guide to Protesting With Diabetes

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

Editor’s Note: It is an extremely personal decision to protest, and Beyond Type 1 neither endorses nor opposes any person living with diabetes’ participation. This guide is to help those who choose to protest do so as safely as possible.

Protesting is one of many ways to create change and is a right of all Americans under the First Amendment. But if you have diabetes, there are extra things to consider, particularly amidst COVID-19.

Having diabetes – type 1 or type 2 – presents challenges in daily life already; adding a challenging environment with risk of exposure to a virus makes things more complicated. Because of that, you may choose to lend your voice to the things you care about from home, which is also impactful.

However, if you are heading out to protest, here’s what you need to know.

Be Prepared

Step 1: Make sure you are healthy enough and prepared to participate.

Consider the state of your health over the last few days and weeks. The best circumstances under which to attend a protest are when your blood sugars have been stable, you have been eating hearty and nutritious meals, you are well-hydrated, your immune system is strong, and your mental health is fortified.

Step 2: Pack a bag.

In addition to the standard items suggested for all protesters, like extra masks/face coverings, cash, your health insurance card, permanent markers, water, and snacks, there are extra things to consider if you have diabetes. Remember that you may get stuck away from home for a longer period of time than planned.

  • Double down on water. While heavy, staying hydrated can keep your blood sugar levels more manageable and can prevent other health issues. When volunteers or street medics offer more water, accept their offer.
  • Bring a variety of snacks, with a combination of carbohydrates and protein, and glucagon (nasal or injectable kit). It is helpful to have both fast-acting glucose, like glucose tabs or gels, to raise your blood sugar quickly if you experience a low, as well as more substantial snacks to consume periodically to keep your blood sugar stable. Ensure that the people you’re going with know how to use glucagon, including what personal signs of a low blood sugar you experience that they can look out for.
  • Pack extra blood sugar monitoring supplies. Even if you have a continuous glucose monitor (CGM), it is possible for your sensor to fail or become inaccurate due to heat causing your adhesive to loosen or jostling from being in a crowd. With either your CGM or glucose monitor, make sure you are checking your levels often. If you have a closed-loop system and can utilize an ‘exercise’ setting to keep your blood sugar levels slightly higher (typically around 160 mg/dL), do so.
  • Include a back-up insulin delivery method. If you wear an insulin pump, bring insulin pens (with extra pen needles) or vials and syringes. If you utilize injections, make sure you have more supplies than you typically need. Consider packing in a small cooler system/insulated bag to keep your insulin cool.
  • Write down your medical information on index cards kept in the outer pocket of your bag. This should include your medical background information (all medical issues you live with), your medications, and the contact information for your healthcare provider and emergency contact.
  • We are still living in a pandemic, so pack extra face masks, hand sanitizer, and disinfecting wipes. If you accept water or snacks from volunteers, ensure you sanitize surfaces, like the opening of a water bottle. COVID-19 is challenging, but made more challenging by diabetes management. Minimize your risks to stay safe. 

Step 3: Wear protective articles of clothing + a medical alert item. 

Wear a mask or face covering, long pants, comfortable closed-toed shoes, a long sleeve shirt, a hat and/or sunglasses, plus a medical alert item, like a bracelet or necklace.

  • If you do not have a medical alert item, write your alerts on your arm using permanent marker. This could something like “insulin-dependent, type 1 diabetes.” Your alerts should be as clear as possible, helping a person completely unfamiliar with diabetes be more aware of your health background.
  • Protective clothing – long sleeves, sunglasses, hat, etc. – shields you from the sun, and will also provide a barrier for your skin in case tear gas is deployed. A primary component of tear gas is capsaicin, a chemical compound derived from chili peppers. As tear gas (made from fine particles) is absorbed by your skin, it can produce extensive amounts of inflammation. This can lead to health issues in anyone, but can lead to issues with blood sugar, extra pain response, and dehydration for people with diabetes.

Step 4: Have a buddy and communicate.

No one should go to a protest alone if possible, but particularly no one with an underlying health condition. Ensure you attend a protest with someone you trust, who knows you have diabetes, and can help look out for the signs of low or high blood sugar. Ask them to remind you to drink water and eat. Create a plan for where and when to meet if you get separated. Be clear about your limits and make sure you are in agreement about your boundaries. For example, if you are attending with someone who is willing to be arrested and you are not, you will no longer have your buddy system intact, which could lead to a safety issue.

Step 5: Take care of yourself when you get home.

Chances are you just walked a long distance and tensions were high. Hydrate and eat once you get back home or to a safe place. Your blood sugar may drop or rise in unexpected ways due to stress and exertion. Keep an eye on your blood sugar levels as much as possible. If you have a CGM with follow capabilities, ask a friend or family member to make sure their alerts are loud, particularly while you sleep.

Know Your Rights

Attending a protest carries the risk of being detained or arrested. Because of this, ensure you know your rights before you attend. Be aware that while everyone in the US has the same rights theoretically, being undocumented, a person of color, or belonging to any marginalized group – including living with diabetes – alters how you may need to approach interactions with members of law enforcement.

The following is summarized from the American Diabetes Association’s Inappropriate Law Enforcement Response to Individuals with Diabetes.

  1. If you get arrested, clearly and calmly state to the police officer that you have diabetes. If you are concerned about or nearing a medical episode – such as a low or high blood sugar event – while detained, communicate the circumstances to the officer. By law, if an officer has visible cues (such as clear signs of a low or high blood sugar) or has been given notice of a person’s medical condition, they must abide by the resulting rights that provides.
  2. You have a right to be able to take care of your health and receive medical assistance if and as needed. The Fourteenth Amendment grants the right of pretrial detainees (anyone who has been detained, arrested, or jailed) to adequate medical care.
  3. Under the Fourth Amendment, a police officer is not allowed to search or confiscate your belongings without a warrant or without probable cause. If a police officer believes they have probable cause, they must inform you of what they are searching, as well as what they are seizing. Consensual seizures are not prohibited by the Fourth Amendment, so you must state that you do not consent for your belongings to be seized. This all becomes more murky if the police officer can make a case that a severe crime was being committed, an immediate threat is being posed to the officer or public, or if you are resisting or otherwise evading arrest. Stay calm, be clear, and follow directions as much as possible.

Overall, if you are considering or attending a protest, safety comes first. Be prepared. Be careful. Know your rights.

Source: diabetesdaily.com

Improving the Transition from Pediatric to Adult Care for Patients with Diabetes (ADA 2020)

At the American Diabetes Association (ADA) 80th scientific sessions, Dr. Robert Zimmerman MD, Vice-Chairman of Endocrinology and Director of Diabetes Center Cleveland Clinic, and his team discussed the importance of creating a smooth and seamless transition from pediatric to adult care.

This time of transition is considered a high-risk time for patients living with diabetes. Diabetes aside, these patients are dealing with other life stressors that often emerge at this point in their life. Coming off their parent’s health insurance, going off to college or out in the workforce, and having to pay their own bills can create a lot of stress. Because of this, patients often neglect their diabetes care. Having a transition plan in place from pediatric to adult care can help these patients feel empowered and equipped to handle their own diabetes care as they become young adults.

Key Takeaways

  • Each year, thousands of adolescents with both type 1 and type 2 transition to young adults and also from pediatric to adult care.
  • The developmental stage between ages 18-30 is defined as the period of emerging adulthood.
  • Due to life stressors, this is a period where many are distracted from their diabetes care.
  • During the first phase of transition, around age 18-24, many patients feel overwhelmed and have a tendency to reject parental control.
  • During the second phase of transition, at about age 25-30, the young adult tends to take on more responsibilities in life and usually starts to place more importance on diabetes management.
  • The period of emerging young adulthood is considered a high-risk time for patients with type 1 or type 2 diabetes.

Differences Between Pediatric and Adult Care

  • Pediatric Approach
    • Family-oriented
    • Holistic
    • Visits are with both child and parents
  • Adult Approach
    • The patient is autonomous in their care
    • Individualized counseling
    • The patient makes their own decisions regarding care

Major Risks During Transition

  • Suboptimal Glycemic Control
    • Only 32% of patients between 13-18 years old met ADA goals
    • 18% of children under 18 achieved the ADA recommendation for A1c
    • 56% of adults achieve an A1c of 7%
  • Neglect of Diabetes Care
    • Older teens and young adults tend to disengage from health care
    • Both short-term and long-term complications can occur as a result of neglecting care

Factors That Increase the Risk of Hypoglycemia and DKA

  • The loss of parental guidance
  • Less frequent doctor visits
  • Work/school stressors that take precedence over diabetes care
  • Consumption of alcohol
  • Change in physical activity
  • Different dietary patterns than once had under parental care
  • Lack of motivation to stay on top of health

Patients Face Many New Challenges During This Period

  • Psychosocial challenges include worrying about the future, lack of a plan or goal in place for managing their diabetes, feeling anxiety, or being overwhelmed with care, handling uncomfortable social situations regarding diabetes.
  • Psychological issues are prevalent during this time, although these can occur at any time while managing a chronic condition. Feelings of depression, anxiety, eating disorders and suicide are all concerns that need to be addressed during this time.
  • Pregnancy is another issue that arises during this period of emerging adulthood.
    • Contraception use is lower for adults with diabetes from the age of 20-44
    • 39% of adults with diabetes do not use contraception compared to 27% of adults who don’t have diabetes
    • An increasing number of women with pre-existing diabetes are becoming pregnant and having children
    • Only 1 in 4 women with diabetes age 16-20 were aware of the risks involved with getting pregnant with diabetes and the importance of optimizing glycemic control before and during pregnancy in order to maximize the odds of conceiving and delivering a healthy baby.
  • Other health risks that can happen at any age for people with diabetes seem to be most prevalent during these years: alcohol use, illegal drugs, smoking, driving and hypoglycemia.

Current ADA Recommendations for the Transition

  • Pediatric health care provider works with the patient and parent planning for transitioning starting up to 1 year prior
  • Preparation focusing on self-management for emerging teen
  • Preparation should include the differences between pediatric and adult care and should help guide the patient on major decisions such as health insurance, etc.
  • The provider should prepare and provide a list for the patient and new adult doctor summarizing the patient’s medications, assessment of skills, history, etc.
  • Healthcare providers need to recognize all the changes during this period can lead patients to neglect care.
  • The transferring provider should provide patients with specific referrals to adult physicians that would best fit the patient’s needs.
  • The transferring physician should empower patients and provide them with any educational materials and resources that can help them to stay on top of their diabetes care.
  • Care must be specific to the patient and strive to avoid both short term and long term complications.
  • The provider must evaluate and treat emerging teens with any disordered eating behaviors or affected disorders.
  • On-going appointments should take place every 3 months for patients on insulin and every 3-6 months for patients with type 2 who are not taking insulin.
  • Screening guidelines should be followed for both microvascular and macrovascular issues as well as the management of lipids and hypertension.
  • Birth control, drug use, driving, STDs, etc. should all be discussed with the teen and their parents by both the transitioning and adult physician.
  • Both providers should make sure the patient is getting primary and preventative health care and feels comfortable with the care and support they are receiving.

Transition Options Available at The Cleveland Clinic Foundation

  • Transition clinic: here, adolescents are taught how to manage their diabetes on their own. They are then introduced to the adult care endocrinologist who oversees the patient’s care after this first visit. The follow-up with the adult endocrinologist can happen on the transition floor or at Adult Endocrinology at the diabetes center.
  • Transition shared medical visit: In this instance, a shared medical appointment takes place instead of their traditional appointment and the goal is to make the transition as smooth as possible for the patient.
  • Adult endocrinology office visit: patient goes directly to the referred adult endocrinologist.

Cleveland came up with an Autonomy Checklist which helps patients to learn necessary information that they should have while transitioning to more autonomous care.

Group Visits

Cleveland Clinic put into place group visits that take place approximately every 3 months where they have an educational speaker, review A1cs, glucose readings and insulin adjustments to engage the adolescents as well as give individual exams.

Cleveland Clinic’s Transition Recommendations Moving Forward

  • Creating flexible appointments: nights, weekends and special availability while young adults are home from college are important. Virtual appointments and classes will likely be the main way of interacting for this group. Dr. Zimmerman stated that their office went from “1% virtual visits to 75% in approximately one week’s time”.
  • Building relationships: community support groups led by a provider, monthly events and taking advantage of organizations and apps like College Diabetes Network (CDN), where they can connect with others living with diabetes is useful.
  • Transition simulation nights where young adults going off to college can go through possible scenarios and problem-solve together as a group. Questions like “my insulin fell and cracked open, where can I get insulin in the middle of the night?” or “My blood sugar suddenly is dropping, but I am in the middle of taking an exam, what should I do?” would be addressed.

Conclusion

Young adults transitioning from pediatric to adult care are a high-risk group that needs a supportive and comprehensive system in place, where caretakers understand the unique complexities of this life stage. Creating a seamless and specific transition plan will help guide these patients to achieve optimal health during these years.

Source: diabetesdaily.com

Debate: Can Technology Eliminate Hypoglycemia? (ADA 2020)

Advances in diabetes technology have brought forth a lot of new and valuable tools to people living with diabetes. From continuous glucose monitors (CGMs), to insulin pumps, to integrated systems that can automatically adjust insulin delivery based on CGM reading to safeguard against hypoglycemia, diabetes tech is rapidly evolving. For all insulin users, low blood glucose is of particular concern; too much insulin on board can quickly result in an emergency situation, if not promptly addressed.

At the American Diabetes Association (ADA) 80th Scientific Sessions, experts debated the following important question:

Can technology alone solve the problem of hypoglycemia in diabetes?

Dr. Richard M Bergenstal, MD from the International Diabetes Center at Park Nicollet argued “for”, while Dr. Emma G. Wilmot, MD from the University Hospitals of Derby and Burton present her case “against” this notion. Here is the synopsis from this exciting debate. Notably, both presenters disclosed numerous relationships with technology companies and pharmaceutical companies.

Yes, Technology Alone Can Solve the Issue of Hypoglycemia

Dr. Bergenstal began by defining four specific “problems” of hypoglycemia:

  1. “Dangerous levels and ripple effects of hypoglycemia”—low blood glucose levels can cause mental turmoil and may prevent patients from striving for optimal glycemia
  2. Defining hypoglycemia
  3. Detecting hypoglycemia
  4. Preventing hypoglycemia

We have been pretty unsuccessful at preventing hypoglycemia; that is, until technology was introduced,” he stated.

Strikingly, the presenter mentioned that after over 20 years of improvements to the average a1C levels, they are now increasing across the board. Dr. Bergenstal attributed this largely to people’s fear of hypoglycemia. He also mentioned a recent paper that indicates that, sadly, we are also experiencing a “resurgence in diabetes-related complications.”

Next, the presenter addressed the importance of consistently defining hypoglycemia. He explained that the official definitions of hypoglycemia (as defined for clinical trials reporting) have been evolving in recent years, now often defined by levels.

Then, the speaker moved forward to discuss that CGM technology was critical to the most thorough detection of hypoglycemia, noting that self-monitoring of blood glucose (SMBG, or finger-sticks) did not present the whole picture of blood glucose trends, making it more likely that low blood glucose could go unnoticed. Moreover, he argued that the accuracy of today’s CGM devices are on par with many blood glucose meters.

As far as the capability of technology in preventing hypoglycemia, Dr. Bergestal presented data from a very large international study showing that CGM use resulted in a tremendous decrease in both hyperglycemia and hypoglycemia, across a large patient population, across the board. He also presented data from several other studies that demonstrated the benefits of CGM technology as related to the incidence of hypoglycemia.

Next, he also addressed the role of “smart insulin pumps” that communicate with CGMs in helping to further reduce hypoglycemia. Strikingly, the results from one study using an “automated basal/hybrid closed loop system (closed loop at all times with meal-time manual assist bolusing)” resulted in a 100% reduction in hypoglycemia. The presenter also showed some case reports that suggested more technology (CGM + Pump vs. CGM + MDI) may yield better glycemic management. Furthermore, he touched upon several other advancements, ranging from faster-acting insulin formulations on the market and in development to smart insulin pens, and their relevance in improving outcomes (see below).

Dr. Bergenstal had this to say in conclusion:

“Technology can address [all four problems of hypoglycemia]… We’re going now from just good clinical care, to really ethics and just morality, I think. This journal of HealthCare Ethics Committee Forum, they looked at and postulated that continuous glucose monitoring is really a matter of justice. I know that sounds a little extreme, but if it can do what I’m showing you it can do, and people are struggling every day, maybe they really do have a right to use this technology… I think we better rely on technology to prevent the highs and the lows of diabetes.”  

No, Technology Alone Cannot Solve the Issue of Hypoglycemia

Dr. Emma Wilmot began by sharing that she loves diabetes technology, and that it plays an important role in reducing hypoglycemia. “However, technology ALONE can solve the problem of hypoglycemia? If only it were that simple,” she stated.

The speaker went on to present data showing that despite CGM use, as many as 25% of users are still experiencing severe hypoglycemia. She argued that “structured education” in diabetes management plays a more central role in reducing hypoglycemia, pointing to numerous research studies showing significantly improved outcomes following a formal diabetes education program.

Moreover, Dr. Wilmot commented on the role of hypoglycemia unawareness, and how reducing the incidence of low blood glucose levels via educational programs, also helped to mitigate hypoglycemia unawareness, in turn likely reducing severe hypoglycemia even more.   In contrast, she stated that there is no research to show that technology use can help to mitigate hypoglycemia unawareness. Furthermore, the presenter discussed several studies that showed “no additional benefit” of technology use (CGM and/or insulin pumps).

Technology is not for all,” Dr. Wilmot noted, citing issues like various technical problems, alarm fatigue, and site skin reactions. Strikingly, according to data from T1 Exchange, “41% had stopped using CGM in the past year.” Similarly, she noted, “30% of youth discontinued the hybrid closed-loop system”. Access and affordability is another paramount issue, she noted.

Rebuttals

While Dr. Bergenstal remarked that he understood and appreciated the role of patient education programs, he noted in his rebuttal, that the glycemic outcomes are not optimal in these patient populations, stating he believes technology can give us better control, reducing both hypo- and hyperglycemia.

Dr. Wilmot concurred that the levels of glycemia currently being achieve are “nowhere near good enough” and also agreed that several established educational programs are now incorporating technology education as well. However, she maintained that technology alone was not the sole solution.

Dr. Bergestal concurred with this, but also stated that technology is “outpacing everything else we’ve thrown at hypoglycemia so far.”

Conclusions

While most will agree that technology use can help to reduce hypoglycemia, whether it can be altogether (or even mostly) overcome with technology use alone remains a point of debate. Undoubtedly, the role of education in diabetes management plays a pivotal role. There is no “set-it-and-forget-it” in diabetes management today, not quite yet, anyway, and certainly not across the board for patients. Perhaps, as smart technology evolves further and becomes more mainstream, it may eventually overtake patient education in importance when it comes to preventing adverse events.

What are your thoughts on this subject?

Source: diabetesdaily.com

Creative Bolus Strategies Result in Better Glycemic Control (ADA 2020)

At the American Diabetes Association (ADA) 80th scientific sessions on Friday afternoon, Margaret Pellizzarri, RN, MS, MBA, CDE along with the Integrated Diabetes Services team, including Gary Scheiner, MS, CDE delivered a unique presentation on clever insulin bolusing techniques for people living with diabetes who use a pump or multiple daily injections, when dosing for high-protein and high-fat meals.

Bolus Options

  • Normal bolusing–delivers insulin all at once and is used for most meals
  • Square bolusing–delivers insulin over a period of time. This is especially useful in situations where there is a buffet or you are eating over a longer period of time. Patients with gastroparesis also can benefit from square bolusing since their digestion is slowed down.
  • Combination or dual-wave bolus–delivers a portion of the insulin as a normal bolus and the rest as an extended or square bolus. This can be particularly helpful with meals that are high in fat, high in both fat and carbs, as well as for high-protein meals.

Insulin Dosing for Protein and Fat: Studies and Strategies

Studies conducted in both people living with type 1 and type 2 diabetes indicate that fat slows down gastric emptying and slows down glucose absorption. This can result in hypoglycemia for patients after a fat-laden meal. Several studies demonstrate that both high-fat and high-protein meals require more insulin to achieve target postprandial blood glucose levels. Furthermore, glycemic responses vary depending on the specific macronutrient profile of the meal, with higher-protein meals tending to cause prolonged hyperglycemia (if not accounted for). Altogether, this indicates that the insulin delivery strategy must be optimized in dose and timing to achieve the most optimal results when consuming such meals. 

Here are the highlights from the presentation:

  • One study showed that high-protein, high-fat meals required 30% more insulin over 6 hours and suggested using a glucose meter or continuous glucose monitor (CGM) to adjust as needed.
  • Another investigation demonstrated that consuming a mixed protein mixed meal (36 g protein, 30 g carbs, 5 g fat) when dosing only for the carb content, resulted in higher postprandial glucose values. By using a protein-fat insulin dosing algorithm, they suggested that adding 66% more insulin delivered in a combination bolus over three hours resulted in improved glucose levels. The impact of a meal that was higher in protein and fat, showed to be additive to postprandial glucose levels.
  • One study showed that mealtime doses for individuals with type 1 diabetes need to be individualized. For high-fat meals (more than 40 g), patients should consider additional mealtime insulin, around 30-35% of the initial dose. For individuals using pumps, it is recommended to try a combination bolus with half the dose before eating and half delivered over 2-2.5 hours after eating.
  • One investigation suggested that high-protein and high-fat meals require a >60% ICR (insulin-carb ratio) as a standard bolus before the meal with an additional ICR up to 70% in an extended bolus starting at 1.5-5 hours after the meal.

Conclusions

  • Experts suggest altering your insulin dosing and changing the timing of insulin delivery can help better navigate tricky meals that are high in fat and/or protein.
  • Using the bolus techniques presented above, those on an insulin pump can experiment to achieve what works best (Note: If low blood glucose occurs, it is recommended to extend the duration of the remainder of the extended dose.)
  • Those using multiple daily injections can also vary the timing and dose of their insulin according to the specific meal (although this may be more tedious). You could also consider different insulin based on their activity profiles (make sure to discuss any changes with your healthcare provider!).
  • Despite the manufacturer’s recommendations of dosing insulin within 15 minutes of meal consumption or immediately after, research shows that best postprandial glycemic results are achieved when taking the specific macronutrient distribution of the meal into account and adjusting both insulin amounts and timing to best match that food profile.
  • Recent research shows that injecting 15-20 minutes before meals is safe, and results in 30% lower glucose levels and less post-meal hyperglycemia when premeal glucose levels were in range.

Whether you use a pump and can take advantage of the special bolusing features or are on multiple daily injections, there are strategies to try when consuming high-protein, high-fat meals. With some trial and error, we can all benefit these creative tactics to strive for improved postprandial glucose levels when it comes to the always challenging high-protein, high-fat meals. Be sure to always consult your healthcare provider before making any changes to your insulin dosing regimen.

***

What are your thoughts on the subject? Do you use any of these strategies? How do you navigate complex meals?

Stay tuned for more from the ADA 80th scientific sessions!

Source: diabetesdaily.com

Study Shows the Need for Intensive Telehealth Intervention in Rural Areas (ADA 2020)

Access to specialty care and intensive self-management programs can be beneficial to patients living with diabetes and can help them improve their overall diabetes management. Unfortunately, these programs are lacking in rural areas and can lead to poor diabetes outcomes for those patients. With telehealth emerging as our new normal, this gives rural areas the opportunity to have better-specialized diabetes care.

This week at the American Diabetes Association 80th Scientific Sessions, the results of a study that examined the implementation of an intensive telehealth intervention in a rural area were presented. The researchers used the infrastructure of already existing Veterans Health Administration (VHA) and Home Telehealth (HT). This study took into account that the services provided would be in addition to already receiving in-person care.

Study Methods

Elizabeth A. Kobe led the 6-month telehealth intervention for patients with “poor glycemic control” (typically an A1c>8.5%), which was earlier found to be effective in a randomized trial.

The Advanced Comprehensive Diabetes Care (ACDC) combined telemonitoring, self-support management and medication management guided by a clinician. From 2017-2019,  the ACDC was implemented in five rural VHA sites with guidance from the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework.

Key Findings

  • A1c improved from an average of 9.25% at baseline to 7.89% at six months
  • Implementation at each site was well-received with an average of 8-10 of 12 scheduled ACDC calls complete
  • ACDC improved patient engagement and awareness of their diabetes management

Conclusions

There is no question that intensive telehealth interventions, when properly designed using already existing infrastructure, is a much-needed addition to standard care for many and can lead to improved and sustainable glycemic control improvements, especially for people living with diabetes in rural areas, who may have less access to traditional care and diabetes education approaches.

Source: diabetesdaily.com

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