Adolescence, Stigma, and Owning Diabetes

This content originally appeared on diaTribe. Republished with permission.

By Katie Bacon

Katie Bacon is a writer and editor based in Boston. Her daughter was diagnosed with type 1 diabetes in August, 2012, when she was six. Katie’s writing about diabetes has appeared on TheAtlantic.com and ASweetLife. Katie has also written for The New York Times, The Boston Globe, and other publications.

Adolescence can be a confusing time, and this is doubly true for teenagers with type 1 diabetes. At a stage when everyone is starting to figure out who they are, the teenager with type 1 must also decide how much they want diabetes to be a part of their identity. Katie Bacon, the mother of a teenager with type 1, spoke with a range of experts and peers who shared their expertise and experiences on this subject.

Our daughter was diagnosed with type 1 diabetes at six years old, just before she started first grade. At the time, it was important both from a safety perspective and from an emotional one that the people around her knew about her diagnosis. Along with her teachers and the school nurse, we let all her friends and their parents know, and they rallied around us to support her. She quickly owned having type 1. It became an important and immutable part of her identity, one she was proud to share with others.

Fast forward eight years to this past fall, when she was doing orientation for her new high school. After being surrounded by a group of familiar and supportive friends from kindergarten through eighth grade, here she knew almost no one. Not to mention that, in the era of COVID-19 – with masks, cohorts, and strict rules about socializing – it would be much harder to meet people.

During orientation she was asked to create a timeline of important moments in her life. While chatting about what she might write, I asked if she was going to include her diagnosis. Her response seemed to come completely out of left field: “Why would I put that down? I’m not planning on telling anyone unless I become really close friends with them.”

She made it clear that she was now much less willing to acknowledge having type 1 as she entered high school. Although she didn’t express it quite this way, it seemed that the reason stemmed from a desire to avoid being judged or stigmatized – she didn’t want to be known as the new girl with diabetes. So, we agreed that we would tell the school nurse, her teachers, and her sports coaches – for her health and safety, it was non-negotiable that they all know. We also agreed that it would be up to her to choose when (and if) she would tell her friends.

Still, it felt like my daughter was cutting away her safety net. I wanted to know if this shifting perspective on her condition was typical for teenagers, and I wanted some advice on how to help her through it. I reached out to Rachel Rifkin, a longtime friend who was diagnosed with type 1 at age ten; to Dr. Ananta Addala, a pediatric endocrinologist at Stanford Children’s Health; and to Dr. Persis Commissariat, a pediatric psychologist at Joslin Diabetes Center who also has type 1. Through their expertise and experiences, they helped answer my questions about disclosing teenage diabetes versus hiding it; about stigma, perceived stigma, and how to deal with it; and about how to let go a little bit while still giving our daughter support through this process.

One of the crucial parts of adolescence is identity development, when teenagers figure out who they are in relation to their family and their peers. At this developmental stage, people are particularly sensitive to being different in any way; and if they are different, they want it to be in ways that they’ve chosen. All of this is complicated, of course, by having a chronic disease that requires frequent visible action and identifiable devices to manage (insulin shots, continuous glucose monitors or CGM, insulin pumps, etc.).

Dr. Commissariat took on this topic as the lead author of a paper on identity and treatment adherence in teens and young adults with type 1 diabetes, which appeared in Pediatric Diabetes. She and her co-authors looked at the differences between those who “incorporated” their illness versus those who “contained” it or tried to keep it separate from the rest of their identity. “Those who incorporate their illness … take it into account in their daily life and are able to find ways to include the illness as part of their sense of self. Those who contain their illness may try to keep their illness hidden, worry about stigma, or try to … maintain a sense of self [that is] unburdened by illness, often ignoring daily self-management needs.”

What they found, Dr. Commissariat explained to me, was that people who tend to take a more “positive approach to making diabetes part of their sense of self – people who view it as ‘it’s my burden and I’m okay with it’ – tended to have lower A1C levels. They were a little more engaged in treatment.” In other words, those teenagers who managed to incorporate diabetes into their identity usually did better.

Because of this, Dr. Commissariat works with her patients to help them develop an identity that has “an appropriate degree of type 1 in it. I don’t think anyone needs to identify first and foremost as a person with diabetes. But the fact of the matter is that there are secondary issues that come up if we don’t take care of diabetes. So, you must identify with it to some extent. And I think what oftentimes becomes difficult for teenagers is finding that balance between being a ‘normal teenager’ and being a teenager with diabetes. Because on its face, they don’t really go hand-in-hand, but they should and they can.”

As I’ve witnessed firsthand with our daughter, adolescence can be a time when children want to move away from their identity as someone with type 1. When Rachel Rifkin was a teenager, she found herself transitioning from being relatively open about having type 1 to having it be something that she preferred to keep to herself. “I always did whatever I could to avoid people knowing about it. I always wore my pump in a back pocket. I never wanted to clip it onto the front of my pants or anything.”

In her practice, Dr. Addala has seen people go both ways. While she says that it’s more common for teenagers to “minimize the thing that makes them different, which is a very normal teenage developmental thing to do,” she’s also had patients who have embraced that difference. And in fact, in those individuals she sees a “further doubling down on the fact that diabetes is what makes them who they are; it’s a source of strength and pride and something that defines their character.”

But for those teenagers who aren’t willing to talk about or share that they have diabetes, both Dr. Commissariat and Dr. Addala try to understand the reasons behind the hesitancy. As Dr. Addala explains, “I try to see where the source of the apprehension comes from. Is it specifically that they don’t mind taking care of their diabetes or they don’t mind wearing technology, but they just don’t want other people to see?”

In these situations, Dr. Addala treads lightly and tries to respect the teenager’s feelings while gently encouraging them to open up. “I let them lead a bit when this topic comes up. They might say, well, I think I could probably tell my closest friend that I have diabetes. Or maybe they’re not willing to tell anyone, and I do my best to support them even in those cases. I’m trying to find out where their internalized stigma is originating from, and then see how far they’re willing to go in terms of who they share the information with. I generally use this approach because then they have some ownership.”

Dr. Commissariat points out that there’s an essential difference between being private about having diabetes and being secretive about it. As she tells her patients, “You don’t need to advertise it. But for safety purposes, it is important that at least a couple of your close friends know.”

She also talks about helping teenagers learn to communicate that they have type 1 in a way that feels manageable and builds confidence. She tells her patients: “I want to know exactly what you wish other people knew about diabetes. And then let’s find a way to teach people in a way that is not burdensome to you. Teenagers are trying so hard to not draw too much attention to themselves, so I often practice with them in our visits – how can we bring this up in a way that is not going to bite you in the back? That could mean having a serious discussion with your best friend, or that could mean something as easy as wearing short sleeves around people who don’t know you have diabetes, just so that they can see your CGM. Wait for people to comment on it. Use a passive disclosure strategy where you just pull out your pump and you take a bolus, and you don’t say anything unless somebody asks you.”

It’s especially helpful for teenagers to have a disclosure strategy when it comes to romantic or physical relationships. As Rifkin says, “With people you’re interested in, it’s a whole other web that you have to navigate in terms of what you tell people and when. And as I’m sure you can imagine, if you have a CGM or a pump, there are physical things on your body that may come up. It’s helpful to have a strategy for how you deal with that.”

Teenagers tend to be both self-centered and self-conscious, so when it comes to diabetes, it’s easy for them to assume that everyone is noticing it in a negative way. Rifkin remembers being in a movie theater one time when her pump started beeping. “I was so horrified. I was like, ‘Oh my God. Everyone must hate me right now. I’m ruining this experience for them.’ You don’t have a lot of perspective at that age. Diabetes seemed like such a big deal.”

Dr. Commissariat points out that all teenagers tend to think the focus is on themselves – even when it’s not. She tells her patients, “Your friends don’t care that you’ve had to go to the bathroom to take an injection. Your friends are like, ‘Okay, let’s go to the bathroom, then I can check how my hair looks.’” And she comments that those who do ask about it are probably asking because “they’re interested and they’re curious, and maybe those will be the people who will help you in the future.”

Another tip Dr. Commissariat gives her patients is to make sure that they talk about diabetes in the way they want others to see it. “If you don’t want it to be a big deal, don’t make it into a big deal because people are going to mirror you.”

For both Dr. Addala and Dr. Commissariat, part of the process is working with the parents on learning how to give their children the space to develop independence, as teenagers need to do. This can be a difficult transition, since diabetes requires so much oversight from both the parent and the child. As Dr. Commissariat says, “One of the major tasks of this developmental stage is to be independent and become less attached to your parents. But it’s really hard with diabetes to be less attached to your parents and be more like your friends when you’re managing something that takes so much responsibility.”

Dr. Addala focuses on helping parents try to see the situation from their child’s perspective. “So often part of the conversation is helping the family understand why a teenager might not want others to know they have diabetes. Where safety is concerned, it helps for the family to create boundaries around what is a true concern, and what’s just an added buffer in terms of safety.”

For both Rifkin and Dr. Commissariat, owning type 1 was a long process, one that continued into adulthood. Now, Rifkin says, “I’m a lot more open about it. I think it makes sense that those feelings that teenagers have of wanting to be private and not wanting to stick out at all fade over time, as people feel more confident in their own skin. These days I don’t feel like I have to explain it to anybody.”

Dr. Commissariat describes a long process of slowly pushing herself to make diabetes a more public part of her identity; she started by keeping her pump on display rather than keeping it in her pocket. Then she moved to bolusing and checking her blood sugar in front of people she knew and then also in front of people she didn’t know. Part of the change, for her, started when her nurse practitioner sat her down and said, “You’re not a diabetic, you’re a person with diabetes.” (Dr. Commissariat has since learned about research suggesting that this shift in labeling helps people become “more accepting of their identity with diabetes.”)

“When I look back on it now,” she says, “that statement suddenly clicks for me [in terms of] everything I went through. I thought diabetes was trying to define me, and that was my big mistake. I own it, it doesn’t hold me. When I allowed diabetes to be a part of my day and created my own definition of myself with diabetes as just a part of who I am and what I do, it wasn’t quite as burdensome anymore, but still annoying, no doubt.”

As for our daughter, after a year at her new school, my sense is that she’s still private about her diabetes, but she’s no longer secretive. A couple of her closest friends at her school now know, and that feels like a good start. At an event at the end of the year, after what felt like months where she hadn’t been willing to bolus in front of anyone, I finally saw her pull out her pump and give herself insulin right there in public – even if she was a bit off to the side. No one except me seemed to notice. I felt like she was beginning to establish that place for herself where she could feel like any other teenager. A teenager who just happens to have diabetes.

About Katie

Katie Bacon is a writer and editor based in Boston. Her daughter was diagnosed with type 1 diabetes in August, 2012, when she was six. Katie’s writing about diabetes has appeared on TheAtlantic.com and ASweetLife. Katie has also written for The New York Times, The Boston Globe, and other publications.

Note: Given the personal nature of this article, Bacon asked for and received her daughter’s permission to publish it.

Source: diabetesdaily.com

Getting Started with Insulin if You Have Type 2 Diabetes

This content originally appeared on diaTribe. Republished with permission.

By Frida Velcani

New to insulin? Learn about insulin dosing and timing and how often to test your blood sugar levels if you have type 2 diabetes.

If you have type 2 diabetes, it is likely that your treatment regimen will change over time as your needs change, and at some point, your healthcare professional may suggest that you start taking insulin. While this might feel scary, there are millions of others living with type 2 diabetes and taking insulin, so it’s definitely manageable.

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Why do some people with type 2 diabetes need to take insulin?

Type 2 diabetes can progress with time, which means that it gets more difficult for a person’s body to regulate glucose levels. The body’s many cells become less responsive to insulin (called increased insulin resistance), and the specific cells in the pancreas that produce insulin make less of it (called beta cell insufficiency). This is not necessarily related to a person’s diabetes management, and it is likely not possible to prevent.

For many people, adjusting lifestyle factors such as a reduced calorie diet and increased physical activity are key to keeping blood glucose levels stable and in a target range. Healthcare professionals may also recommend that people with type 2 diabetes take additional medications like metforminDPP-4 inhibitorsSGLT-2 inhibitors, or GLP-1 agonists to their treatment plan to improve glucose management, reduce A1C, lose weight, or support heart and kidney health.

When do people with type 2 diabetes start insulin?

After 10 to 20 years, many people with type 2 diabetes will begin insulin therapy, although every person’s journey with type 2 diabetes is different. This happens when lifestyle changes and medications aren’t keeping your glucose levels in your target range. It is important that you start treatment as early as possible to avoid persistent hyperglycemia (high blood sugar), which can lead to long-term health complications affecting your heart, kidneys, eyes, and other organs.

What are the different types of insulin?

The key to transitioning to insulin is knowing your options. Some people taking insulin need to use both a basal (long-acting) and a prandial (rapid-acting or “mealtime”) insulin each day, while others may only need to use basal insulin. Learn about your options here.

  • Basal (long-acting) insulins are designed to be injected once or twice daily to provide a constant background level of insulin throughout the day. Basal insulins help keep blood sugars at a consistent level when you are not eating and through the night but cannot cover carbohydrates (carbs) eaten for meals or snacks or glucose spikes after meals.
    • Some people use other medications, like GLP-1 agonists, to help cover mealtimes. GLP-1/basal combination treatments for people with type 2 diabetes combine basal insulin with GLP-1 agonist medication in one daily injection. This combination can effectively lower glucose levels while reducing weight gain and risk of hypoglycemia (low blood sugar). Learn more here.
  • Prandial (rapid-acting or “mealtime”) insulins are taken before mealtime and act quickly to cover carbohydrates eaten and bring down high sugar levels following meals. Ultra-rapid-acting prandial insulins can act even more rapidly in the body to bring down glucose levels. Rapid and ultra-rapid insulins are also taken to correct high glucose levels when they occur or are still persistent a few hours after a meal.
  • Basal and prandial insulins are both analog insulins, meaning they are slightly different in structure from the insulin naturally produced in the body. Analog insulins have certain characteristics that can be helpful for people with diabetes. Human insulins, on the other hand, were developed first and are identical to those produced by the human body. Human insulins are classified as regular (short-acting insulin) or NPH (intermediate-acting). These are generally cheaper than analog insulins and can be bought without a prescription at some pharmacies.

Although many people use both basal and prandial insulin – which is called multiple daily injections of insulin (MDI) and consists of one or two injections of basal insulin each day as well as prandial insulin at meals – people with type 2 diabetes who are beginning insulin therapy may only need basal insulin to manage their glucose levels. Basal insulin requires fewer injections and generally causes less hypoglycemia. For these reasons, many healthcare professionals recommend basal insulin when you first start insulin therapy.

How do I take and adjust my insulin doses?

It is important to learn the different methods of taking insulin and what kinds of insulin can be delivered through each method. There are several ways to take insulin – syringe, pen, pump, or inhalation – though injection with a syringe is currently the most common for people with type 2 diabetes. There are many apps that can help you calculate your insulin doses.

  • Insulin pens are considered easier and more convenient to use than a vial and syringe. There are different brands and models of insulin pens available. Smart pens are becoming increasingly common and can help people manage insulin dosing and tracking. They connect to your smartphone and help you remember when you took your last dose, how much insulin you took, and when to take your next one.
  • Insulin pumps are attached to your body and can be programmed to administer rapid-acting insulin throughout the day, to cover both basal and prandial insulin needs. When you need to take insulin for meals or to correct high glucose, calculators inside the pump can help determine the correct dosage after you’ve programmed them with your personal insulin pump settings.
  • Inhaled insulin is ultra-rapid acting insulin and can replace insulin used for mealtime and corrections of high glucose. It is taken through an inhaler and works similarly to injected prandial insulin. People with diabetes who do not want to inject prandial insulin might use this, but it’s not for people who only use basal insulin. The only approved inhaled insulin on the market is the ultra-rapid-acting mealtime insulin Afrezza.

Your insulin regimen should be tailored to fit your needs and lifestyle. Adjusting your basal insulin dosage and timing will require conversations and frequent follow-up with your healthcare team. When initiating insulin therapy, you may be advised to start with a low dose and increase the dose in small amounts once or twice a week, based on your fasting glucose levels. People with diabetes should aim to spend as much time as possible with glucose levels between 70-180 mg/dl. Insulin may be used alone or in combination with oral glucose-lowering medications, such as metformin, SGLT-2 inhibitors, or GLP-1 agonists.

One of the most important things to consider is the characteristics of different insulin types. To learn more, read “Introducing the Many Types of Insulin – Is There a Better Option for You?” and discuss with your healthcare team.

In order to dose insulin to cover meals or snacks, you have to take a few factors into consideration. Your healthcare team should help you determine what to consider when calculating an insulin dose. Prandial insulin doses will usually be adjusted based on:

  • Current blood sugar levels. You’ll aim for a “target” blood sugar, and you should know your “sensitivity” per unit of insulin to correct high blood sugar levels.
    • Insulin sensitivity factor (ISF) or correction factor:  how much one unit of insulin is expected to lower blood sugar. For example, if 1 unit of insulin will drop your blood sugar by 25 mg/dl, then your insulin sensitivity factor is 1:25. Your ISF may change throughout the day – for example, many people are more insulin resistant in the morning, which requires a stronger correction factor.
  • Carbohydrate intake. Insulin to carb ratios represent how many grams of carbohydrates are covered by one unit of insulin. You should calculate your carbohydrate consumptions for each meal.
    • Insulin to carbohydrate ratio:  the number of grams of carbs “covered” by one unit of insulin. For example, a 1:10 insulin to carbohydrate ratio means one unit of insulin will cover every 10 grams of carbohydrates that you eat. For a meal with 30 grams of carbohydrates, a bolus calculator will recommend three units of insulin.
  • Physical activity. Adjust insulin doses before, and possibly after, exercise – learn more about managing glucose levels during exercise here.

Learning to adjust your own insulin doses may be overwhelming at first, especially given the many factors that affect your glucose levels. Identifying patterns in your glucose levels throughout the day may help you optimize the timing and dosing of your insulin. Your healthcare professional, a certified diabetes care and education specialist, or insulin pump trainer (if you use a pump), can help guide you through this process. Do not adjust your insulin doses without first talking to your healthcare team.

How often should I test my blood sugar?

The frequency of testing will depend on your health status and activities during the day. Initially, you may be advised to check your blood glucose three to four times a day. As a starting point, check in with your healthcare team about how often to check your blood sugar. Many people test before meals, exercise, bedtime, and one to two hours after meals to ensure that they bolused their insulin correctly. Over time, your fasting, pre-meal, and post-meal blood glucose levels will help you figure out how to adjust your insulin doses.

Continuous glucose monitors (CGM) are particularly useful for tracking changes in glucose levels throughout the day. Some CGM devices also connect with an insulin pump to automatically adjust insulin delivery. After you start a treatment plan, the goal for most people is to spend as much time as possible in their target range. Talk with your healthcare professional about starting CGM and developing glucose targets.

What else do I need to know about taking insulin?

It’s common to experience minimal discomfort from needle injections or skin changes at the insulin injection site. You may also experience side effects of insulin therapy, which can include some weight gain and hypoglycemia. In some people, insulin increases appetite and stops the loss of glucose (and calories) in the urine, which can lead to weight gain. Hypoglycemia can occur if you are not taking the right amount of insulin to cover your carb intake, over-correcting high glucose levels, exercising, or consuming alcohol. Treating hypoglycemia also adds more calories to your daily intake and can further contribute to weight gain. Contact your healthcare professional to adjust your insulin dose if you are experiencing hypoglycemia, or call 911 if you experience more serious side effects, such as severe low blood sugar levels, serious allergic reactions, swelling, or shortness of breath.

Staying in contact with your healthcare team is the best way to make the transition to insulin therapy. Though the first few days or weeks will be challenging, with the right support, you’ll find a diabetes care plan that works for you.

If you were recently diagnosed with type 2 diabetes, check out more resources here.

Source: diabetesdaily.com

How to Advocate for Yourself: Making Employer-Sponsored Health Plans Work for Your Diabetes Care

This content originally appeared on diaTribe. Republished with permission.

By Julia Kenney

The therapies, devices, and care that people with diabetes need can be expensive without adequate insurance coverage. For those with employer-sponsored health insurance, there are steps you can take to improve your insurance options and advocate for yourself.

Over 45 percent of Americans have diabetes or prediabetes and roughly half of US adults receive health insurance through their employer. Unfortunately, not all employer-sponsored health plans meet the needs of people with diabetes. According to a study of 65,000 people with type 1 diabetes on employer-sponsored health insurance, the average annual out-of-pocket cost of diabetes care was $2,500. Eight percent of study participants had annual costs well over $5,000. Since diabetes is most prevalent in low- and middle-income households, these costs, in addition to paying for premiums and non-diabetes healthcare, are unaffordable for many people.

If your health insurance does not cover a component of your diabetes healthcare, or if your diabetes care is covered but still unaffordable, you can work with your employer to get better coverage. Here is an overview of the different types of health insurance, who to go to for help, and how to advocate for better diabetes health coverage.

What are the different types of health insurance?

You will have expenses no matter what health insurance you have, but some plans can be more affordable for diabetes care. These are the expenses you will typically encounter with your health insurance plan:

  • Premium – Similar to paying rent, a premium is a fixed amount that you pay every month to keep your health insurance active. It’s common for employers to pay about half of your monthly premium, and sometimes more. In 2019, people with employer-sponsored insurance paid an annual average of $1,242 for health insurance premiums.
  • Deductible – The deductible is the amount you pay out-of-pocket before your insurance provider covers expenses. For example, if you have a $1,000 deductible, your insurance coverage will not kick in until you’ve paid $1,000 in healthcare expenses for that year.
  • Copays – Copays are a fixed amount that you pay for a health service or medication, and your insurance provider covers the rest of the cost. Copays are a helpful way to pay for diabetes care because they are fixed, predictable costs that people can plan for.
  • Coinsurance – Unlike fixed-price copays, coinsurance costs are a percentage of the total price of a health service or medication. These expenses are less predictable because medication prices can fluctuate.

There are three main types of health insurance – health maintenance organizations (HMO), preferred provider organizations (PPO), and high deductible health plans (HDHP). Here is an overview of the different types of health plans and what they might cost:

  • HMO – Health maintenance organizations have high premiums and low deductibles. An HMO plan covers healthcare within a network of hospitals and healthcare professionals. Your providers must be in-network in order to get your diabetes care covered. If your diabetes care professionals are in-network, this is often the most cost-effective healthcare option for people with diabetes.
  • PPO – Preferred provider organizations also have high premiums and low deductibles than HDHPs. PPOs are more flexible than HMOs because you are able to see providers out-of-network and you can see specialists without a referral. Because of this, PPOs typically have higher premiums and out-of-pocket costs than HMO plans.
  • HDHP – High deductible health plans typically have low monthly premiums and high deductibles. In 2020, the IRS defined a HDHP as any plan with a deductible of at least $1,400 for an individual and $2,800 for a family. If you have a high deductible health plan, you can open a health savings account where you set aside money to pay for medical expenses tax-free. These health plans are good for people who don’t anticipate needing regular healthcare; paying for diabetes care can be difficult with this type of plan because you will have high out-of-pocket costs upfront before you meet your deductible.
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Keeping these different types of health insurance and related expenses in mind, here are some things people with diabetes should think about when reviewing an employer-sponsored health plan:

  • What are my diabetes-related costs? Make a list of your diabetes healthcare costs including medications, devices, supplies, healthcare visits, and lab tests.
  • What are the health insurance costs? Look at the premium, deductible, and whatever cost sharing method (copay or coinsurance) is used for the health plan.
  • Are my medications and devices covered? Refer to your health plan’s Summary of Benefits and Coverage to see what is included in your insurance coverage. If a therapy or device is not covered, you may have to switch to one that is or submit a request to get it covered. Getting a new medication or device covered under your health plan can be a challenging and time-consuming process.
  • Is insulin covered pre-deductible? Some health plans cover insulin before you reach your deductible because it is considered preventive medicine. This can make insulin considerably more affordable, especially for people on high deductible health plans.
  • Are my healthcare professionals in-network? Accessing in-network healthcare is more affordable than out-of-network care. You should choose a health plan where your current providers are in-network or one that has good in-network options.
  • Can I access a flexible spending account (FSA) or health savings account (HSA) to save money? FSAs and HSAs are used to put aside money that is not taxed to help pay for medical expenses. HSAs are paired with high deductible health plans. FSAs can be used for any kind of health insurance and all FSA funds must be used in the same calendar year. Learn more about FSAs and HSAs here.

If I have a problem with my insurance, who do I go to for help?

Your employer’s human resources (HR) department should be able to address many of your insurance-related questions, since it likely helped select the health plan(s) available to you. Your HR department is your first resource for health insurance questions. If you need help selecting an insurance plan, want to see if your diabetes care is covered, need to file a claim, or are having trouble navigating your plan and understanding the costs, the HR department will support you.

For further questions, your HR department can refer you to a representative with the health insurance company or to a third-party administrator. A third-party administrator will help you understand your health plan, file health insurance claims, and navigate the appeals process if your insurance company denies coverage for a diabetes treatment. You can also apply for an exception to get treatments, medications, and devices covered if recommended by your doctor. A third-party administrator will guide you through these steps for getting important diabetes treatments covered.

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How can I make my employer-sponsored health coverage better for people with diabetes?

People with diabetes typically require expensive medications, devices, and regular visits with healthcare professionals to stay healthy. Robust employer-sponsored health insurance plans should make these expenses affordable and predictable. If you are trying to make permanent changes to your employer-sponsored health plan, your HR department can help you advocate for future health plans that better support diabetes needs. Employers have the power to make changes to their health coverage options every year. Here are some changes you can advocate for:

  • Add insulin and other diabetes care to the preventive medicine list.

In 2019, the IRS ruled that expenses for chronic disease management can be covered before you meet your deductible under a high deductible health plan. HMOs and PPOs also have preventive medicine lists. Diabetes care such as insulin, A1C testing, blood glucose meters, and eye screening – which are all considered preventive medicine – can be added to the preventive medicine list to reduce the copay or coinsurance costs for diabetes care. This saves employees money instead of paying full price before meeting their deductible.

  • Request to get a medication or device covered under your health plan.

If a device or medication you currently use (or want to try) is not covered under your health plan, you can ask for coverage in next year’s health plan. Diabetes devices, such as continuous glucose monitors (CGM) and insulin pumps, can help people with diabetes manage their glucose levels and increase their Time in Range, but are expensive without insurance coverage. Employers can typically negotiate to cover essential diabetes care, so request coverage for your medications and devices. Your diabetes treatment should be determined by your healthcare professional, not by what’s included in your health plan.

  • Share discounts and rebates with employees.

While list prices for diabetes medications may be high, your employer’s pharmacy benefit manager (PBM) can negotiate discounts and rebates on drug prices on behalf of the insurance plan and employer. The list price minus the negotiated discounts is called the net price. Sometimes PBMs and employers will keep the money saved; however, employers can pass discounts on to their employees to lower their out-of-pocket costs.

  • Use copayments for cost sharing instead of unpredictable coinsurance.

Coinsurance costs are unpredictable because they fluctuate as a drug’s net price changes. You can advocate for your employer to choose health plans that use copayments for healthcare cost sharing, instead of coinsurance.

More resources for accessing diabetes healthcare with your employer-sponsored health plan:

Feel free to share this article with your employer or your HR department. All people with diabetes deserve access to affordable, high-quality care. To learn more about health insurance and affording diabetes treatment, visit diaTribe.org/access.

Diabetes Series

Image source: iStock Photo

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

Source: diabetesdaily.com

What if a Pump Could Deliver Both Insulin and Glucagon?

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

By Lala Jackson

Diabetes technology like insulin pumps and continuous glucose monitors (CGMs) have created less burdensome care routines for people living with diabetes who are able to get them. For some, this tech has also led to lower A1c, more time in range, and fewer hypoglycemic events. As we work to get better access to diabetes technology and medications for all who need them, we’re also looking forward to what’s next in diabetes tech – dual hormone artificial pancreas systems that keep blood sugar levels in a healthy range using both insulin and glucagon delivery.

Existing artificial pancreas (AP) systems, also known as hybrid closed loop systems, integrate insulin-only pumps and CGMs using a programmed algorithm that allows the insulin pump to “make decisions” in insulin dosing based on the blood sugar number provided by the CGM. In the current systems, the insulin pump can dose insulin in response to high blood sugars, but has no way to directly address a predicted low blood sugar other than lowering or stopping insulin delivery, or suggesting external actions (such as eating carbs) be taken. Even with this limitation, current AP systems are shown to significantly improve daily time in range, a key measure for safety and quality of life in those living with diabetes. But what if we could more closely mimic a fully functioning pancreas?

Enter, the Dual Hormone Artificial Pancreas

Also known as the bihormonal artificial pancreas (BHAP), several companies have been working on these systems over the last decade, but the last few years show promise toward a streamlined, effective, easy-to-use BHAP.

In late 2019, the FDA granted breakthrough device designation to the iLet™ pump system, made by Beta Bionics. Breakthrough device designations create an accelerated regulatory review process for a product or therapy that “has potential to address unmet medical needs.” Essentially, it shows priority for a solution that is believed able to create a large impact on people’s lives, beyond anything currently available.

Beta Bionics’ intentions for their iLet systems are ambitious – they aim to provide their system in insulin-only, glucagon-only, or bihormonal with both insulin and glucagon. Additionally, their algorithm is unique, in that the wearer must only enter their body weight, “with no need to count carbohydrates, set insulin delivery rates, or deliver bolus insulin for meals or corrections.

The iLet system was granted breakthrough designation with the use of insulin analogs that are currently approved for usage in an insulin pump, alongside Zealand Pharma’s dasiglucagon, recently approved by the FDA for use in an autoinjector and prefilled syringe. Dasiglucagon, a glucagon analog (i.e. a synthetic lab made version of the naturally occurring hormone), is stable as a liquid, versus old formats of glucagon in which a powder and liquid had to be mixed immediately before use.

Beta Bionics’ insulin-only AP system is currently in Phase 3 clinical trials, with its BHAP system slated to be one to two years behind, having completed a Phase 2 at-home use trial in 2019. Phase 3 trials of the BHAP system are expected in 2021.

Other insulin and glucagon BHAP systems are also in development, with additional companies looking into a dual-hormone format pump using insulin and pramlintide (commercial brand name Symlin), aimed at better mimicking natural absorption rates of food, leading to better time in range.

The Bottom Line

As we get closer to diabetes technology that more closely mimics a fully functioning pancreas, affordable access to both life-improving diabetes technologies and life-sustaining insulin remains key. Robust diabetes technology has the power to greatly improve quality of life, particularly when coupled with affordable, equitable healthcare.

Source: diabetesdaily.com

Zoning in on Sick Day Management: Practical Tips, Strategies, and Advice

By Dr. Francine Kaufman

Pediatric endocrinologist Dr. Fran Kaufman shares tips for managing illness and diabetes: make a sick day plan, have supplies on hand, log your data, modify your insulin doses, and call your healthcare team. 

Everyone with diabetes who takes insulin needs to have a sick day plan. This is something you develop with your healthcare professional to help you manage the high and low sugar levels that can be associated with an illness. The following advice applies to people with type 1 diabetes and people with type 2 diabetes who take insulin – the advice may be different if you have type 2 diabetes and do not take insulin.

Click to jump down to a section:

When you get sick, you are at risk of becoming dehydrated from poor intake or from excessive loss of fluids due to nausea, vomiting, diarrhea, and fever (your body may lose more water when you have a high temperature). In addition, dehydration is common in diabetes because high glucose levels (above 180-200 mg/dL) cause sugar to enter your urine, dragging an excess amount of fluid with it. Illness also puts you at risk of developing ketones, which when coupled with high glucose levels can lead to diabetic ketoacidosis (DKA), a very serious condition. How do you know if you have ketones? Good question, click here!

The purpose of your sick day plan is to try to keep your glucose levels in a safe range – to avoid dehydration and to prevent ketones from rising to a dangerous level. When you get sick, you should contact your healthcare team to describe your symptoms, determine if they want to evaluate you or send you to a lab (for testing), and most important, to share the numbers that you will collect as you fill in your sick day log (more on this below). It is possible that no matter what you do, you might need to go to an emergency department or be hospitalized – but acting quickly, obtaining the right data, and doing your best to manage your glucose and hydration will minimize risks.

So what illnesses are we talking about? It turns out just about any common bacterial or viral infection – such as the flu (influenza), a cold (upper respiratory virus), tonsillitis, strep throat, an ear infection, stomach flu (gastroenteritis), a bladder infection, and even a skin infection, such as an abscess – can interfere with your diabetes management. However, right now, the greatest concern is COVID-19. An infection with COVID-19 can lead to very high glucose and ketone levels, putting someone at risk for DKA. Acting quickly to start your sick day plan, even if you end up needing to be hospitalized, is important.

When you get sick, your body needs energy to fight the infection and repair damaged tissue. The infections listed above, particularly those that lead to vomiting, diarrhea, fever, and dehydration, cause your body to release certain hormones (called stress or counterregulatory hormones) that tell your liver to release stored glucose and tell your fat cells to release free fatty acids that form ketones. In someone without diabetes, the body releases more insulin to control the rise in glucose and ketones; because you have diabetes, you have to take additional insulin to manage the high glucose and ketone levels. You want to get your sugar levels between 100-180 mg/dL. Blood sugars below 180 mg/dL will prevent excess urination that can dehydrate your body. Staying above 100 mg/dL helps keep you from dipping too low and risking severe hypoglycemia.

If your glucose level is above 180 mg/dL, you need to consider increasing basal insulin doses, using an increase in basal insulin with the temp basal feature on your insulin pump, or giving repeated corrections of bolus insulin with a syringe, pen or pump. Usually, correction doses should not be given more often than every two to three hours to avoid “stacking” insulin, which could lead to low blood sugars. By having a plan for illnesses that starts your modified care early and by keeping in touch with your healthcare team, you are more likely to keep your glucose values in the 100-180 mg/dL range.

But you also have to be concerned about hypoglycemia. Low sugar occurs, particularly in children and the elderly, if the illness affects calorie and carbohydrate intake by decreasing appetite or by causing vomiting or diarrhea. Although low glucose is usually considered to be less than 70 mg/dL, during illness there is concern if glucose levels are below 100 mg/dL. If your infection or illness leads to low glucose levels, reducing basal insulin and not taking bolus insulin doses should be considered. If suspension of insulin is required, you should not suspend or delay taking the next dose of basal insulin for more than 60 minutes, because this increases your risk of developing ketones. Start sipping a sugar-containing drink, one tablespoon at a time. If hypoglycemia continues and you cannot make it better by ingesting sugar, consider the administration of low-dose glucagon. Low-dose glucagon can increase glucose level by 50-200 mg/dL in 30 minutes. To learn about whether low-dose glucagon is right for you, and at what dose, talk with your healthcare team.

To follow what is happening in your body, it helps to start a log of your glucose levels, ketones, fluid intake, and insulin doses. This sick log can be shared with your health care team. It should show improvement from one time period to the next (see below). Note: the biggest concern is vomiting; if you vomit more than twice in a time period or across two time periods, call your healthcare team.

The log shows only two days, because you should be better after 24 hours and completely on the mend after 48 hours. If you are not getting better, call your healthcare team.

Table

Image source: diaTribe

Here’s how to keep track (and why to keep track!) of these important numbers:

1. Glucose Levels: Check glucose levels every 1-2 hours. You may have to change this and check your glucose every 30 minutes if your levels are changing quickly. CGM trend data should be looked at every 10-15 minutes. Watch for rapid changes by looking at numbers and arrows. The goal is to keep your glucose between 100-180 mg/dL and without wide swings in values.

2. Ketone Levels: Urine ketones are often detected using a urine ketone strip. A small patch on the strip changes color depending on your level of ketones, representing negative, small, moderate, large and very large levels of ketones. Moderate, large, and very large levels are of concern. Ketones can also be measured with a fingerstick and a special ketone meter. The readings for blood ketones are more accurate and range from 0.0 to 3.0 mmol/L or greater. Blood ketone levels below 0.6 mmol/L are considered normal. Between 0.6 and 1.5 mmol/L ketones are high and show that your fat has broken down to form excess ketones. This puts you at risk of DKA if glucose levels are also elevated. Ketone levels above 1.5 mmol/L are serious, and you should contact your healthcare professional. Signs of elevated ketones:

  • Nausea and vomiting (which may also be present because of the infection)
  • Shortness of breath and labored breathing (your body is trying to eliminate the ketones through your breath so you can also smell them, they make your breath smell fruity)
  • Weakness
  • Altered level of consciousness and trouble staying awake (this is most concerning; call your healthcare professional immediately if this is happening)

Ketones should be tested at the onset of an illness and then every four hours.  If ketone and glucose levels are both elevated, your healthcare team might advise you to increase correction insulin doses further, by an additional 10-15%. If ketone levels are high and glucose levels are not high (less than 150 mg/dL), oral glucose and some insulin – reduced by about 50% – will help clear your ketones. Drinking water will also help reduce ketones as they are removed in the urine. To learn more about ketones, including what they are and how to measure them, click here.

3. Temperature: High fever can help show the severity of your illness, particularly if it is persistent.  We have learned that COVID-19 is associated with persistent high fever. Use the log sheet to document any medications you take to lower fever so that you can report this to your healthcare team.

4. Fluid Intake, with and without Sugar: Consuming liquids is critical if there is risk of dehydration. Fluids with sugar should be taken if glucose levels are between 100-150 mg/dL, and fluids without sugar should be taken if glucose levels are between 150-180 mg/dL. If you have vomited, wait 30-60 minutes before trying to drink, and then start with teaspoons of water or ice chips, progressing to tablespoons and ounces. The goal is to retain 4-6 ounces of fluids (or 2-4 ounces for young children) every 30-60 minutes until you can drink without risk of vomiting and as your thirst dictates. Food is much less important after vomiting; don’t try to eat food until you are on the mend.

5. Urination: Noting frequency and amount (small, medium, or large) is important to understand the ongoing risk of dehydration. As glucose levels reach the target of 100-180 mg/dL, you should see a decrease in both frequency and amount of urination, as well as less dehydration.

6. Vomiting, Diarrhea and Dehydration:  Vomiting and diarrhea can lead to dehydration. The signs of dehydration include dry mouth, sunken eyes, weakness, loose skin, rapid heart rate, and low blood pressure. Vomiting is also of great concern because it occurs not only from the illness, but as a result of DKA. That’s why vomiting that occurs throughout one time period or spans two time periods in your log means it is time to call your healthcare professional.  However, if you feel weak after vomiting only once or twice, it is always better to call earlier than later.

7.  Insulin, Amount and Time: One of the most important things to remember is that during an illness, you still need to take insulin. Even if you are not eating or drinking at the beginning, you need to have insulin in your body. Insulin allows sugar to enter your body’s cells to be used for energy, and you need more energy to fight off an illness. Insulin also reduces ketone formation and stops excess urination by lowering glucose levels. If you have high glucose, you might need 25-50% more insulin than you usually take, due to insulin resistance created by the extra stress or counterregulatory hormones in your body. If you have low glucose, you might need to take 25-50% less insulin than you usually take, but you still need some basal or background insulin on board.

8. Medications: At the beginning of an illness, you should consider calling your healthcare team to determine if you should avoid taking any of your routine medications while sick. This includes glucose-lowering pills or injections, such as SGLT-2 and GLP-1 drugs, or medications for blood pressure and cholesterol. In addition, it is important to write down any medications you take (name, dosage, time) to treat fever, vomiting, diarrhea, or other symptoms of your illness. Anti-vomiting medications may be helpful but should only be taken after discussing with your healthcare professional.

Key Messages:  

  • Know your sick day plan before you become sick.
  • Have supplies on hand. These include supplies to measure glucose, a way to measure ketones, a thermometer, sugar-containing fluids, glucagon, extra-rapid (or short) acting insulin, and medication to treat fever. Discuss with your healthcare team whether you should have medication for diarrhea and vomiting on hand.
  • Have all the contact information for your healthcare team available, and call them sooner rather than later.
  • Before you call your healthcare team, have the data listed on your log sheet written down, plus your symptoms.
  • Take insulin at modified doses to address both high and low glucose levels. You still need to have some insulin in your body, even if you are not eating.
  • Let someone help you while you are ill. It is too big a job to be done alone.

About Fran

Dr. Fran Kaufman is the Chief Medical Officer of Senseonics, Inc. She is a Distinguished Professor Emerita of Pediatrics and Communications at the Keck School of Medicine and the Annenberg School of Communications at the University of Southern California.

Source: diabetesdaily.com

Type 1 Diabetes: Advocacy 101

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

By Katie Doyle

If one of your resolutions for 2018 was to learn more about getting involved in advocacy, be a more effective advocate or support advocacy groups, we have a story that will get you motivated! Check out this profile for some advo inspo:

Advocacy

Image source: Beyond Type 1

Cameron Keighron, a student at National University of Ireland (NUI) Galway, is making strides in his community by standing up for his LGBT peers and people with disabilities. You may recognize Cameron’s name from our 2017 story about an NUI Galway research team’s D1 now study on the relationships young adults with type 1 have with their healthcare teams — Cameron is a member of the Young Adult Panel that advises the D1 now study. We recently picked his brain to find out what it takes for those of us looking to dive into a certain project or be a more active participant in our communities.

Become the Advocate You Need

“I was the first and only type 1 diabetic diagnosed in my family and was thrust into a world of complete confusion,” said Cameron, who was diagnosed when he was 16. “As is so common with my generation, I took to the internet to find some sort of support with this transition in my life. I found a group on a diabetes forum that would become my support group for the next number of years, juggling my diabetes with high school, university and much more.”

Cameron’s positive experience with the diabetes online community inspired him to give back when he found himself in a position to do so. “Before going to university, I asked to switch to insulin pump therapy. I became somewhat of a support for people I had met online for pump issues and transitioning from childhood to adulthood. I became the support that I so desperately needed when I was first diagnosed.”

Recognize When the Time Is Right

Cameron is currently a graduate student completing a master in Regenerative Medicine. After joining three student societies during his undergraduate years, Cameron became a disability advocate at NUI Galway and found a calling in administering to student societies as a grad student.

“I am heavily involved in LGBT and disability activism in Galway and the wider country,” he said. “When I finished up my degree it was a natural progression, really, to move from one side of societies to the other. I had been working on the development and governing committee of societies, working hard on implementing policy changes to the way societies ran themselves. With this, I found my home within my job of policy and training development. Currently, I mentor new and existing societies through their constitutions and through the training programs we design for them.”

Think Globally, Change Locally

Like many of us with type 1, Cameron has overcome other challenges through his work in the community. “I came out as a queer trans man at 19 and have been campaigning for equal rights ever since. NUI Galway strives to be inclusive of all LGBT+ students and staff. The biggest change that I have seen is the willingness to talk about these issues, to talk about what is going wrong and how can we fix it. We recently brought in gender-neutral bathrooms for all people across campus. We strive to educate both the student and staff population on LGBT+ issues and raise awareness of how people can get involved in the campaign for equality.”

He has seen broad impacts in his work in the diabetes sphere as well: “After becoming involved with the Young Adult panel, my passion for diabetes advocacy grew, especially in my age group. I saw what wasn’t working with my care and helped develop innovative solutions in the hopes of correcting this. We were given the opportunity to help write papers, present at conferences and influence the project in every aspect of its development. Right now, I have signed on to be a part of the second phase of the project where we are hopefully to be recognised as co-researchers.”

Appreciate Every Victory

“My relationship with my diabetes team was essentially non-existent before the Young Adult panel. After joining the panel I started to build up a rapport with key members of the team. Since engaging with the group, I have found it a lot easier to engage with the team and that my own diabetes care improved.”

Cameron notes that advances in his college setting have improved his overall experience there. “When I started in NUI Galway no one really knew what “transgender” meant, no one had a way of relating to me and how I felt. I found a group of people who worked with me and on my behalf, lobbying for change and recognition, a fight still on going in many universities. For me, NUI Galway became a home, it adapted to its ever-changing demographic with provisions in place for people to change their student records and ID cards if needed.”

Keep an Eye on the Long-Term

For Cameron, advocating for any cause takes a lot of energy and focus. “In all the areas that I am involved with, in the positions that I hold, you generally get asked some inappropriate questions and it’s tough to find the fine line between answering their question with respect and without getting angry.”

“It’s also tough, I think, because as humans we surround ourselves with like minded people, that’s just who we are attracted to. So when we leave those bubbles and see that actually people in the world still have the crappy views on people it can be tough to keep motivated.”

Despite challenges, Cameron is hopeful about the future. “People with disabilities are becoming more and more visible on campuses across Ireland. They are given a voice to talk about their experiences and where we can do better.”

Source: diabetesdaily.com

Time Flies! Don’t Wait to Use Your Year-End Insurance Benefits on a New Insulin Pump

Time for a new insulin pump? Regardless of the time of year, with the t:slim X2™ insulin pump, you won’t need to replace it when the next big features arrive. Stacey Simms shares how using your year-end insurance benefits can be your best option to pay less.
Source: diabetesdaily.com

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