Did a Virus Trigger Your Type 1 Diabetes?

Type 1 diabetes is an autoimmune disease– that is, a disease resulting from the immune system attacking the body. In the case of type 1 diabetes, the immune system mistakenly attacks the beta cells in the pancreas that produce insulin, and without insulin-producing beta cell function, one develops type 1 diabetes, and quickly. Researchers still are not 100% sure what causes type 1 diabetes, but many believe that a virus can “trigger” the body into attacking itself, resulting in disease.

Why does this happen? When a virus invades the body, the immune system starts to produce a response to fight the infection. T-cells are central to recognizing and fighting off the virus. However, if the virus has some of the same antigens as the pancreatic beta cells (in the case of type 1 diabetes), the T cells sometimes actually start attacking the body’s own beta cells. Once all of the body’s beta cells have been destroyed, type 1 diabetes is developed and diagnosed.

It can take more than a year for the body’s T-cells to destroy the majority of the beta cells, but that original viral infection is hypothesized to be a trigger in the development of type 1 diabetes.

A recent study showed that kids exposed to enteroviruses are more likely to develop type 1 diabetes. Enteroviruses are a group of viruses that usually cause mild symptoms, similar to that of the common cold. Certain strains, such as the poliovirus or hand, foot, and mouth disease, can cause more serious complications.

Researchers in Finland tested more than 1,600 stool samples from 129 children who had recently developed type 1 diabetes and 282 children without diabetes for enterovirus RNA (a marker of previous exposure to infection). They found a significant difference: 60% of the control group showed signs of prior infection (without diabetes), versus 80% of the group with type 1 diabetes.

The results also showed that children who developed type 1 diabetes were exposed to the enterovirus more than a year before their diabetes diagnosis; taking this lag time into account, the researchers proved that children with diabetes are exposed to three times more enteroviruses than children without diabetes.

vaccine against enterovirus

A vaccine against enteroviruses may help prevent type 1 diabetes. | Photo credit: Adobe Stock

Researchers are hopeful about current trials, showing vaccines against enteroviruses could potentially prevent 30-50% of new cases of type 1 diabetes, but not all infections can be prevented.

Jessica Dunne, PhD, director of discovery research at JDRF, is excited by the current research. “Enteroviruses are not the only trigger for diabetes, so it’s important to note that even if we prevented all enterovirus infections we probably wouldn’t be able to prevent all cases of type 1 diabetes. I think it would go a long way,” Dunne said.

Clearly, other genetic and environmental facts are at play in the development of type 1 diabetes, but a growing amount of research is pointing to a virus as a common trigger. Other studies have shown that pregnant mothers with antibodies from enteroviruses go on to have children who develop type 1 diabetes.

Not every virus can trigger this reaction ending in disease. The virus must have antigens that are similar enough to the antigens in beta cells (and thus could easily be confused by the immune system); those viruses include:

  • B4 strain of the coxsackie B virus
  • German measles
  • Mumps
  • Rotavirus

There is even new, mounting evidence that the current COVID-19 (SARS-CoV-2 virus) pandemic could be triggering a new wave of type 1 diabetes diagnoses now and into the future.

There is still much debate in the medical community over the exact cause of type 1 diabetes, and most researchers believe it to be a mix of genetics and environmental factors, but the theory of enterovirus-triggered diabetes is gaining support from physicians and researchers alike. There is still much to be explored in the development of type 1 diabetes, but research like this is promising for the eventual development of a vaccine to help prevent new type 1 cases worldwide. Understanding viruses and their connection to the immune system can help unravel the medical mystery of type 1 diabetes without an apparent cause.

What was your experience when you were diagnosed with type 1 diabetes? Were you extremely sick with a viral illness, several months or even years before diagnosis? Do you think a virus could have triggered your diabetes? Share this post and comment with your story, below! We love hearing from our readers.

Source: diabetesdaily.com

The Biggest News in Diabetes Technology, Drugs, and Nutrition: Highlights from ADA 2020

This content originally appeared on diaTribe. Republished with permission.

By Eliza Skoler, Jimmy McDermott, Matthew Garza, Divya Gopisetty, Frida Velcani, Emily Fitts, Karena Yan, Joseph Bell, and Rosalind Lucier

The diaTribe team attended the 2020 ADA 80th Scientific Sessions to share several of the greatest highlights from the virtual conference!

The American Diabetes Association (ADA) 80th Scientific Sessions was full of exciting news on advances and studies in diabetes technology, treatments, and nutrition. Click on the links below to learn more!

Diabetes Technology

Diabetes Drugs

Nutrition, Exercise, and Mindset

Access to Care and Policy

Diabetes Technology

The Next Generation of Automated Insulin Delivery Systems for People with Type 1 Diabetes – Updates from Four New Clinical Trials

The first day of ADA featured data on four clinical trials of the newest automated insulin delivery (AID) systems. In what was a packed (virtual) room, the session began with three highly anticipated presentations of studies on Medtronic’s MiniMed 780G Advanced Hybrid Closed Loop System (AHCL). Dr. Bruce Bode, presented the US adult pivotal trial. Here are the main results:

  • Big news – nearly 80% of participants achieved a time in range of more than 70% without an increase in hypoglycemia.
    • On average, AHCL therapy increased time in range to nearly 75% from a baseline of 68.8%.
    • Among adolescents, time in range increased to over 72% from a baseline of 62.4%.
  • AHCL therapy improved average A1C from 7.5% to 7.0%. This is what is sometimes called a “high quality A1C” in the field – hypoglycemia is low, and therefore not contributing to a “better” number.
  • How were these results achieved? Experts said that the lower algorithm target of 100 mg/dl (vs. 120 mg/dl) helped, along with an active insulin time (AIT) setting of 2-3 hours. If you use a pump, check what you have for this setting and talk to your healthcare professional about it to see if you can make changes (regardless of whether your pump can deliver insulin automatically).

Following Dr. Bode, International Diabetes Center’s Dr. Rich Bergenstal shared data from FLAIR, a trial comparing MiniMed 780G Advanced Hybrid Closed Loop (AHCL) with the 670G Hybrid Closed Loop (HCL) in adolescents and youth with type 1 diabetes (ages 14-29). This is the first ever head-to-head comparison of an AID system with a commercially available AID system. The study also had broad entry criteria: at start, 20% of participants were on multiple daily injections of insulin (MDI), 38% were not using CGM, and 25% had a baseline A1C above 8.5%.

  • Time in range over 24 hours increased from 57% at baseline to 63% with the 670G and to 67% with the 780G. Notably, 6% greater time in range totals nearly an hour and a half more time in range per day.
  • Compared to baseline, the number of participants achieving the international time in range consensus target of more than 70% was nearly two times higher with the 670G and almost three times higher with the 780G (22% and 32% of participants, respectively, compared to a baseline of 12%; see slide below).
  • This was the first time that a study measured participants meeting the combined metric of both time in range greater than 70% and time below 54 mg/dL less than 1% (see slide below). This is important since all therapy – and particulary automated insulin delivery – aims to decrease hyperglycemia and hypoglycemia.

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Image source: diaTribe

  • From a baseline average of 7.9%, those on the 670G achieved an average A1C of 7.6%, and those on the 780G had A1Cs that fell to 7.4% on average.
  • Both the 670G and 780G were considered safe when evaluating severe hypoglycemia or diabetic ketoacidosis (DKA).
  • Participants satisfaction favored the 780G over the 670G.

Today’s MiniMed 780G data finished with Dr. Martin de Bock’s study, which served as the clinical trial supporting 780G’s CE-Mark submission (and today’s announced approval in Europe). In a study of 59 people (ages 7-80 years, with an average age of 23) who had never used an insulin pump:

  • Average time in range increased to over 70% from 58% (a change of 12.5%) when using the 780G compared to a sensor augmented pump.
  • Overnight time in range increased to 75% from 59% when using the 780G compared to the sensor augmented pump.
  • The improvement in time in range was primarily driven by a 12.1% decrease in time in hyperglycemia (high blood sugar) with the 780G.

It was warming on Twitter to see Dr. de Bock with his three small children while also engaging in Q&A/Chat from their breakfast table. If you’re on social media, follow Dr. De Bock here.

The session concluded with Stanford’s Dr. Bruce Buckingham who presented data on Insulet’s Omnipod 5 Automated Glucose Control System, powered by Horizon. What fantastic data! The study assessed the safety and effectiveness of the fully on-body system over 14 days of use before starting the three-month pivotal study. Interestingly, this study was conducted during the winter holiday season when some of the lowest time in range is observed (typically a three percent drop); the system performed remarkably well in both children and adults, even during this challenging time period.

  • In adults, time in range increased to 73% on the hybrid closed loop system, up from 65.6% using standard therapy – this is the same as nearly two hours more time in range per day.
  • In youth, time in range increased to 70% on the hybrid closed loop system, up from 51% using standard therapy – what an increase, nearly five hours more per day.

These reductions in time in range were mostly driven by a decrease in hyperglycemia. Hypoglycemia was also very low to start. Dr. Buckingham eloquently emphasized, “… this is so important for families and people at night to go to sleep and not worry about hypoglycemia … for a number of kids, they got to go on their first sleepover during this study. It was really decreasing a lot of the burden and a lot of the thinking about diabetes.”

Tandem’s Control-IQ Real-World Data: Time in Range Increases 2.4 Hours Per Day

Tandem presented two posters featuring very positive real-world data from early Control-IQ users. Control-IQ was cleared in December 2019 and officially launched in January 2020.

The first poster, Control-IQ Technology in the Real World: The First 30 daysincluded at least 30 days of pre- and post-Control-IQ data from 1,659 participants. During the first 30-days of Control-IQ use:

  • Time in range increased by 2.4 hours a day (compared to pre-Control-IQ data) to 78%
  • The time in range improvement was driven by a 9.5% decrease in time spent above 180 mg/dl (that’s 2.3 hours less per day in hyperglycemia – wow!).
  • Average glucose levels fell from 161 mg/dL to 148 mg/dL.
  • Glucose management indicator (or GMI, an estimate of A1C) fell from 7.2% to 6.9%.
  • Users spent 96% of time in closed loop!
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Image source: diaTribe

The second poster, Glycemic Outcomes for People with Type 1 and Type 2 Diabetes Using Control-IQ Technology: Real-World Data from Early Adopters, looked at 2,896 participants with type 1 diabetes and 144 participants with type 2 diabetes, using at least 14 days of pre- and post-Control-IQ data.

  • Time in range was improved by 2.1 hours per day in the type 1 group to 77%
  • Time in range was improved by 1.4 hours per day in the type 2 group 79%
  • Both groups spent 96% of time in closed loop.

We learned so much at ADA about improving time in range, and we were moved by the power of automated insulin delivery in doing so, since it shows much greater time in range with what sounds like so less work for people and their healthcare teams.

To learn more about Control-IQ, check out the following articles:

A1C vs. Time in Range – Which Should be Used for Children with Diabetes?

A panel discussion of leading experts, moderated by JDRF CEO Dr. Aaron Kowalski, focused on the pros and cons of using A1C and time in range as primary metrics in diabetes care and management for children. As they debated the best marker of glucose management, they attempted to define the ultimate “goal” of diabetes care: is it preventing complications, spending less time in hyperglycemia and hypoglycemia, or improving mental and emotional wellbeing?

Dr. William Winter presented extensive evidence that A1C can predict a person’s risk of developing complications (kidney disease, heart disease, retinopathy, and neuropathy). While lower time in range has been associated with microvascular complications, experts agree that more studies are needed to determine its predictive accuracy for long-term outcomes. Dr. Thomas Danne presented results from the SWEET project that furthered the case for A1C as a measure of population outcomes: setting ambitious targets based on A1C could lead to significant improvements in outcomes for children with type 1 diabetes.

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Experts discussed cases in which A1C can be misleading and time in range may emerge as a more reliable measure of glucose control. Dr. Winter explained that population A1cs differ among racial and ethnic groups, leading to misdiagnosis (for example, African Americans have a higher A1c on average compared to white people). Very importantly, as diaTribe has reported on for many years in Beyond A1C research, A1C also does not demonstrate hypoglycemia, hyperglycemia, or glucose variability. According to Dr. Danne, healthcare professionals find CGM reports more helpful in identifying daily highs and lows and in adjusting therapy. This technology allows them to better work alongside families to set individual and measurable goals based on time in range – it is terrific to hear about this continued teamwork.

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Though Dr. Danne acknowledged the issue of access and affordability, he believes CGM use will continue to increase among children who are tech savvy. Dr. Daniel DeSalvo presented data from the SENCE and CITY to further support use of CGM among children with type 1 diabetes.

CITY

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Young children (two to seven years old) enrolled in the SENCE study saw their hypoglycemia (blood glucose under 70 mg/dL) and time spent over 300 mg/dL reduce by 40 minutes per day – that’s nearly five hours a week. Teens and young adults (ages 14 to 24) in the CITY study saw a 7% increase in time in range, which is almost two more hours per day spent in range – 100 minutes, to be exact!

The Use of CGM in Type 2 Diabetes — Is There Value?

Continuous glucose monitoring (CGM) has been a revolutionary tool; it gives people real-time updates on their blood glucose levels that can help to increase time in range (TIR). For most providers in diabetes, the value of CGM is now nearly universally supported (either “real-time” or “professional CGM”) even if all people with diabetes can’t get it. Reimbursement throughout much of the world has reinforced the value of CGM in type 1 diabetes almost everywhere, though the value of CGM for people with type 2 diabetes is still being explored.

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Dr. Philis-Tsimikas argued for CGM for type 2 diabetes given the technology’s ability to offer remote solutions for care management, provide direct feedback of behavior modification, and allow evidence-based changes to drug therapies. Dr. Philis-Tsimikas shared data from several CGM studies in people with type 2 diabetes on a variety of therapies (basal insulin alone, and oral and other medications), highlighting the improvement in clinical and behavioral outcomes. In what could be the most exciting set of results, people with type 2 diabetes who used real-time CGM (RT-CGM) intermittently for 12 weeks showed an average A1C reduction of 1 percentage point at the end of 12 weeks (compared to a 0.5 percentage point reduction in the blood glucose meter control group). During the 40-week follow up period, A1C was still significantly lower in the RT-CGM group.

Dr. Elbert Huang gave what we felt was a less persuasive view. He argued that in most cases, CGM use is not valuable for people with type 2 diabetes, on the basis of cost. Howerver this is based on outdated data – just yesterday at ADA, there was striking Late-Breaker data presented that showed very meaningful reductions in A1c by Dr. Eden Miller and Dr. Gene Wright (he’ll be speaking at the TCOYD/diaTribe Forum Monday night!) The study showed very meaningful A1C reductions in thousands of people with diabetes – starting A1C was 8.5%, which fell to 7.6% to 7.9% depending on the population. Dr. Huang presented two studies that showed that the cost ratio of CGM was different depending on the assumptions of costs related to the quality and quantity of lives impacted by type 2 diabetes. A QALY, by the way, is a “quality adjusted life year” that measures both quantity and quality (based on disease burden) of life years. We also strongly believe that many people become more engaged in their diabetes management due to a variety of factors that reduce stigma (no fingerstick tests required, etc.) and enable them to focus on how data and technology can work together to improve their results.

Dr. Huang suggests that less costly treatments (such as the use of ACE inhibitors to avoid high blood pressure or to prevent kidney disease) might be better areas of focus and certainly all experts would agree that focus here is important as well. He also mentioned potential negative psychological effects of constantly checking blood glucose readings using CGM and the fact that this technology may only work if it is shared with a person’s healthcare team – we agree integration with healthcare teams where available is a valuable point and also emphasize our learnings from ADA 2020 from many providers that emphasize, as Dr. Diana Isaacs did on Saturday, that CGM enables greater interest in diabetes management by people. While the technology is extremely important, Dr. Huang also expressed that it could be more valuable if the price of CGM declines or if it is shown to improve glucose management while also reducing the need for costly medicines, among other factors – these factors of cost are extremely important. CGM is going down in price on average and global pricing of $109/month is already available from FreeStyle Libre all over the world. While no one should have to pay $3/day on their own, we believe many more health systems are interested in investing more here due to the positive results they are seeing. We’ll be back with more data from the ADA 2020 Scientific Sessions on this and related fronts!

Parent Perspectives on DIY Closed-Loop

An observational study on Loop, a do-it-yourself (DIY) automated insulin delivery system (AID), used focus groups to gather the attitudes and experiences of parents and children using Loop. The study followed people using an AID system, continuous glucose monitor (CGM) readings, and a communications bridge device, called “RileyLink.”

Overall, parents felt that Loop had a positive impact on their family’s lives. They reported the following outcomes:

  • Improvements in emotional health as a result of a greater sense of security and normalcy, increased quality of life, and decreased parental stress.
  • Improvements in other areas of life, including management of children’s diabetes at school, quality of sleep, confidence in caregivers, and children’s ability to explore extracurriculars without supervision.

Dr. Anastasia Albanese-O’Neill presented survey results on what parents expect of school and diabetes camp staff to help their children manage their DIY closed-loop system. School nurses were also surveyed on their opinions regarding DIY. Here are some highlights:

  • 29% of parents expect that school staff will assist children with delivering a bolus.
  • Expectations of diabetes camp staff were lower than school staff – 23% of parents expect school staff to assist with carbohydrate counting and timing of bolus, while only 13% of parents expect diabetes camp staff to do those things.
  • Though 46% of school nurses had never heard of DIY before participating in the survey, 33% of them agreed that school staff should help students using DIY who cannot manage it independently.

This suggests a need for training on DIY and diabetes technology for school and camp staff.

Is Technology the Solution to Hypoglycemia? Dr. Bergenstal and Dr. Wilmot Debate

Dr. Richard Bergenstal from the International Diabetes Center (IDC) emphasized the advantages of using continuous glucose monitoring (CGM) for reducing episodes of hypoglycemia (low blood sugar) and other health complications in this debate with Dr. Wilmot. Both doctors are highly regarded, and we took this as a big opportunity to learn lots more rather than land only on one size, though it’s certainly hard to avoid saying yes to this question, from diaTribe’s perspective. Dr. Bergenstal eloquently explained that, on average, hypoglycemia is the biggest barrier to optimal blood glucose management, pointing to the fact that A1C levels increase when people fear going low (what he called the “ripple effect of hypoglycemia”). Luckily, with CGM reports, people can finally detect patterns in hypoglycemia and understand exactly how much time they are spending with blood glucose levels under 70 mg/dL in a day.

Evidence shows that closed-loop technology can reduce and even prevent hypoglycemia. In a study of 124 people with diabetes that Dr. Bergenstal shared, the use of automated-insulin delivery systems (AID) completely eliminated hypoglycemia. This was a historic win – previous studies (see slide below) using low glucose suspend systems (LGS) reduced hypoglycemia by 38%, while predictive low glucose suspend systems (PLGS) reduced hypoglycemia by 59%.

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Dr. Emma Wilmot argued that while these findings are exciting, technology is only part of the solution. Technology does reduce the risk of hypoglycemia, but is not available to all (particularly those from underserved populations) and is not suited to all. She said that unless CGM is also paired with structured education, it will not provide the significant and lasting improvements in hypoglycemia awareness that the diabetes community needs. We know, of course, how important education is – and diaTribe will be coming back to discuss this in an upcoming piece about a new article just published in Diabetes Care earlier this week (Diabetes Sisters’ CEO Anna Norton was a key author in the new consensus report)!

Early CGM use can help kids and predict T1D progression

The use of CGM across different populations – including people of various ages and different stages of type 1 diabetes – shows that CGM can accurately predict the progression of type 1 diabetes for people at risk. For those transitioning from “stage 2” to “stage 3”, continuous monitoring can also help prevent DKA, which many people with type 1 have at diagnosis. While there are no clinical guidelines at the moment for how to manage “stage 2” type 1 diabetes, the TESS study is currently evaluating the benefits of CGM use in this population. “Staging” of type 1 diabetes is fairly new and we will be thinking about this more as we consider how to further improve education about type 1 diabetes.

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Experts all agreed that earlier use of CGM could result in better diabetes management later on. Dr. Jan Fairchild studied the start and continued use of CGM in a pediatric population with early “stage 3” type 1 diabetes. Kids who started CGM at diagnosis had slightly higher CGM wear at 24 months, compared to kids who started within the first two years of diagnosis (78% vs. 66%, respectively), though this result was not significant. All children using CGM ultimately benefitted – they demonstrated a median A1C of 7.7% at 24 months, which was less than the clinic median A1C of 8.1%. Dr. Fairchild also mentioned the educational role that early CGM use could play, especially with a focus on time in range.

Diabetes Drugs

VERTIS-CV Trial of Steglatro and Heart and Kidney Health

Dr. Samuel Dagogo-Jack and Dr. Christopher Cannon presented highly anticipated results from the VERTIS-CV trial, which studied the effects of Merck/Pfizer’s SGLT-2 inhibitor Steglatro (ertugliflozin) on over 8,000 participants with type 2 diabetes and cardiovascular disease (CVD). The trial found that treatment with Steglatro reduced average A1C by 0.5 percentage points, lowered average weight by nearly five pounds, and reduced blood pressure compared to standard diabetes treatment. Steglatro also improved kidney function, as measured by eGFR, and reduced the number of study participants with heart failure.

The researchers agreed that the VERTIS-CV results confirm the current guidance on the use of SGLT-2 inhibitors to prevent and treat heart failure and diabetes-related kidney disease. As a reminder, the current ADA Standards of Care advise using SGLT-2 inhibitors in people with type 2 diabetes for reducing hyperglycemia (high blood sugar), improving blood pressure, and facilitating weight loss. SGLT-2 inhibitors have also been shown to improve heart and kidney health in people with and without diabetes.

Read more about the trial in our full article here.

New Data Shows Teplizumab Delays Diagnosis of Type 1 Diabetes

At last year’s ADA, we were very excited to report on trial results that showed teplizumab (pronounced Tep-pli-ZU-mab!) delayed type 1 diabetes diagnosis by two years, compared to placebo. The study enrolled 76 participants (55 children and 21 adults) who were the relatives of people with type 1 diabetes and did not have diabetes, and were at high risk for developing the condition (they had unstable blood glucose levels and at least two diabetes-related antibodies). On average, time to diagnosis of type 1 diabetes for the teplizumab group was four years, compared to two years with placebo. At the end of the trial, 53% of the teplizumab-treated group did not have type 1 diabetes, compared to 28% of the placebo group.

New follow up data, presented by Dr. Emily Sims (Indiana University), showed sustained reduction in the onset of type 1 diabetes. Previously, teplizumab had been proven to delay clinical onset by only two years in high-risk people; however, these new data support a delay of as much as three years, compared to placebo.

Furthermore, people who were treated with teplizumab showed a “striking reversal” in C-peptide decline (this is a common measure of type 1 diabetes) in the six months following treatment, after which C-peptide levels seemed to stabilize. These data suggest that the treatment helped stabilize beta cell function (the cells in the pancreas that make insulin) and that repeated teplizumab treatment at key time points may be able to further extend, delay, or even prevent diagnosis of type 1 diabetes. While not a cure, three years of living without daily diabetes management is certainly a meaningful outcome.

When will teplizumab become available? With an estimated six-month review time if Priority Review is granted, an FDA decision could be expected as soon as mid-2021.

SGLT-2 Inhibitors and GLP-1 Agonists to Prevent Heart Disease

Dr. Mikhail Kosiborod (University of Missouri-Kansas City) and Dr. Darren McGuire (University of Texas Southwestern Medical Center) debated the use of SGLT-2 inhibitors and GLP-1 agonists in primary prevention of heart disease (called cardiovascular disease, or CVD).

As background, primary prevention is using medication in people who do not have CVD in order to prevent CVD. This is different from secondary prevention in which a person who is diagnosed with CVD uses a medication to prevent progression of the disease.

Dr. Kosiborod started the session with a strong “yes” – SGLT-2 inhibitors and GLP-1 agonists should be used for primary prevention. However, primary prevention is difficult to prove: larger and longer trials are needed. Dr. Kosiborod believes that we do have enough evidence.

  • A meta-analysis of SGLT-2 inhibitor trials suggests that:
    • SGLT-2 therapy works to prevent heart failure regardless of whether a person has established CVD (based on hospitalizations for heart failure).
    • SGLT-2 therapy protects kidney health regardless of whether a person has established CVD.
  • The FDA has approved SGLT-2 inhibitor Farxiga for people with type 2 diabetes and established CVD, and those with risk factors for CVD. That is primary prevention!
  • REWIND showed that GLP-1 agonist Trulicity prevents major adverse cardiovascular events (MACE, which includes stroke, heart attack, and cardiovascular death) in people with and without established CVD.
  • The FDA agrees again here – Trulicity is approved for people with type 2 diabetes with CVD and those with risk factors for CVD.
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Next, Dr. Kosiborod looked at the population level. Worldwide, primary prevention with SGLT-2s and GLP-1s will significantly reduce cardiovascular events (compared to secondary prevention alone) because there are many people who are not diagnosed with CVD.

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Dr. Kosiborod believes this primary prevention is cost-effective and essential, given the high risk to the population. And many SGLT-2s and GLP-1s will become generic in the future.

Dr. McGuire argued that we are not ready for SGLT-2s and GLP-1s to be used in primary prevention. He pointed to a meta-analysis that showed no benefit of SGLT-2 inhibitors and GLP-1 agonists in atherosclerotic cardiovascular disease (ASCVD) outcomes compared to placebo in people without established ASCVD. In his analysis of REWIND, Dr. McGuire pointed to an absolute risk difference of 0.3% in people without established CVD taking Trulicity versus placebo (1.7 events for every 100 patient years, vs. 2.0 events for every 100 patient years). This would mean that you would need to treat 333 people without CVD to prevent one MACE – which would be $3.4 million in drug costs.

Both speakers agreed that SGLT-2 inhibitors have shown strong effects in primary prevention for heart failure and kidney outcomes. There was no significant debate on this point, as the data speak for themselves regarding the profound effect of SGLT-2 treatment in reducing these outcomes.

Weekly Basal Insulin – The Wave of the Future?

New types of insulin – once-weekly basal insulin injections – are being tested in clinical trials and may bring major developments to how people take insulin. In this session, Professor Philip Home, Dr. J. Hans DeVries, and Dr. Stefano Del Prato discussed the pros and cons and recent results from clinical trials of weekly basal insulin.

Prof. Home explained that weekly insulin could reduce hurdles in starting or maintaining insulin therapy for people with diabetes, especially those who are:

  • Afraid of injections
  • Hesitant to start insulin due to the change in lifestyle or impact on quality of life
  • Wary about handling devices
  • Already on a weekly injectable GLP-1 agonist

Weekly insulin could help people adhere to their prescribed therapy – but it will likely make dose titration and adjustments more challenging. One of the major challenges of weekly insulin is that people can’t modify insulin doses according to life disruptions (for example, sick days or increased physical activity).

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Dr. DeVries and Dr. Del Prato reviewed the various weekly insulins that companies are studying to evaluate their safety and how they affect diabetes outcomes in comparison to existing insulins. Dr. Del Prato highlighted results from a recent study that compared Novo Nordisk’s weekly insulin (icodec) to Glargine U100 (Lantus) in people with type 2 diabetes:

  • Both insulins showed a similar reduction in A1c.
  • Icodec showed improved glucose profiles for self-monitored blood glucose (SMBG).
  • Rates of hypoglycemia were low for both insulins.
  • Weight gain, which is common when starting insulin, was the same for both insulins.
  • Icodec did not show any new safety issues.

Research is still to come on weekly basal insulin, but it looks promising.

Farxiga for Diabetes Prevention? New Analysis of DAPA-HF Trial

Yale’s Dr. Silvio Inzucchi presented an analysis of the landmark DAPA-HF trial, suggesting that along with the heart health benefits of SGLT-2 inhibitor Farxiga, an additional benefit of preventing type 2 diabetes also exists.

As background, DAPA-HF examined the heart health effects of Farxiga (spelled Forxiga in Europe) in people with and without type 2 diabetes. The trial showed that:

  • Farxiga reduced heart-related death or worsening heart failure by 26% compared to placebo (a “nothing” pill).
  • The heart benefits were the same in people with diabetes and without diabetes.

Dr. Inzucchi’s new analysis showed that for participants who did not have type 2 diabetes at the start of the trial, treatment with Farxiga reduced the risk of developing type 2 diabetes by a whopping 32% compared to placebo. After 18 months, 4.9% of the Farxiga group had been diagnosed with diabetes compared to 7.1% of the placebo group. This is a big deal and anyone you know at high risk of type 2 diabetes should learn about these results and talk to their doctor or healthcare team.

We’re glad to see this important benefit – type 2 diabetes prevention – may be conveyed to people with heart failure who can now take Farxiga regardless of whether or not they have type 2 diabetes. As a reminder, Farxiga is the first SGLT-2 inhibitor drug to be approved for a non-diabetes specific population.

Metformin, GLP-1 agonists, and SGLT-2 inhibitors in Type 1 Diabetes

UCSD’s Dr. Jeremy Pettus moderated a session with three expert presenters from across the world: Dr. Irene Hramiak (Western University), Dr. Tina Vilsboll (Steno Diabetes Center Copenhagen), and Dr. Chantal Mathieu (University Hospital Gasthuisberg Leuven).

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Dr. Hramiak kicked things off discussing the current challenges and risks of insulin therapy, including hypoglycemia, weight gain, glucose variability, and diabetic ketoacidosis (DKA). According to data from the T1D Exchange, average A1C levels have not improved in the last decade, and adolescents continue to be a difficult group for glycemic management, despite increased use of pumps and continuous glucose monitors (CGM). How can adjunctive therapies (added to insulin) help?

The REMOVAL study looked at the effects of metformin in people with type 1 diabetes (40 years of age or older). Over three years, participants taking metformin saw the following benefits compared to those taking a placebo:

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  • A decrease in A1C of 0.13 percentage points
  • A reduction in insulin dose by 1.2 units
  • No change in the rate of minor or severe hypoglycemia
  • From a baseline body weight of 193 lbs (87.7 kg), a weight loss of 2.6 lbs (1.17 kg)
  • A reduction in LDL (“bad”) cholesterol by 0.13 mmol/L (5 mg/dL)

These data suggest that metformin did not have a clinically meaningful impact on glycemic management but may improve cardiovascular health in adults with type 1 diabetes. That’s disappointing, but something we’ve all wondered for years – now we know!

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Dr. Vilsboll continued the conversation by discussing GLP-1 agonists for type 1 diabetes. She reminded that adjunctive therapy has several important goals but does not replace insulin – which is the main treatment for people with type 1 diabetes.

Dr. Vilsboll provided an overview of the effect of GLP-1 drugs in the pancreas (on insulin-producing beta cells), liver, brain, kidneys, and other organs before sharing data from a trial on GLP-1agonists in type 1 diabetes.

The LIRA-1 Study evaluated 24 weeks of GLP-1 agonist use in people with type 1 diabetes and excess weight and found that GLP-1 treatment:

  • Did not have a statistically significant (meaningful) reduction in A1C compared to placebo.
  • Reduced body weight by 13.4 lbs (6.1 kg) compared to placebo (from a baseline of about 205 lbs, or 93 kg).
  • Increased gastrointestinal side effects (nausea, diarrhea).
  • Did not decrease the amount of bolus insulin required but reduced basal insulin by about five to six units per day.

The ADJUNCT trial was the longest such trial, involving 1,400 people with type 1 diabetes with an A1C between 7%-10%. In this trial, participants taking GLP-1 agonists experienced:

  • A clinically significant reduction in A1C of 0.54 percentage points compared to a baseline of 8.2% after 52 weeks.
  • A reduction in body weight that correlated with the dose of GLP-1 agonist: 10.8 lbs (4.9 kg) of weight loss with a 1.8 mg dose of GLP-1 agonist; 7.9 lbs (3.6 kg) with a 1.2 mg dose; and 4.9 lbs (2.2 kg) with a 0.6 mg dose.
  • An increased rate of symptomatic hypoglycemia, but no increase in severe hypoglycemia or DKA.
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In a more recent trial, MAG1C, researchers examined the use of GLP-1 agonist exenatide (Byetta) over 26 weeks in adults with type 1 diabetes. Researchers found that compared to placebo, the GLP-1 agonist did not decrease A1C but did decrease insulin dose and body weight. Researchers concluded that the GLP-1 agonist does not have a future as an add-on treatment to insulin in type 1 diabetes. We are not certain this is the correct answer, because it seems like TIR would’ve been useful to measure – but, there’s no fighting city hall.

The session concluded with Dr. Chantal Mathieu discussing the role of SLGT-2 inhibitors in people with type 1 diabetes. She pointed to three main trials: DEPICT with Farxiga, InTANDEM with Zynquista, and EASE with Jardiance.

Compared to placebo, participants taking Farxiga (either 5mg or 10mg dose) experienced:

  • Approximately a 0.45 percentage point drop in A1C by 24 weeks, and 0.2 to 0.3 percentage point decrease in A1C after 52 weeks.​
  • time in range increase of about 10% – a gain of almost two more hours of time in range per day

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  • A 10% decrease in both basal and bolus insulin.
  • A decrease in body weight of about 5.5 lbs (2.5 kg) with a 5mg dose, and about 7.7 lbs (3.5 kg) with a 10mg dose (from a baseline of 179 lbs, or 81 kg).
  • An increased risk of genital infection and urinary tract infections.
  • No increase in hypoglycemia.
  • An increased risk of DKA that rises with a larger dose.

The inTandem trial also showed a drop in A1C: after 24 weeks, participants taking Zynquista experienced a 0.5 percentage point drop in A1C compared to those taking placebo. Time in range also increased with Zynquista. There was a 77-minute increase in time in range with the 200 mg dose, and almost a three-hour increase for people taking the 400mg dose. The increased risks of DKA and genital infections were also observed in this trial.

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The EASE trial provided evidence that supported the effects of SGLT-2 inhibitors on the reduction of A1C – about 0.3-0.4 percentage points after 52 weeks. This study also used a much lower dose of 2.5 mg, which offered an intermediate effect – lowering A1C by about 0.2 percentage points and reducing body weight by 4 lbs (1.8 kg). Interestingly, there was no difference in DKA with the 2.5 mg dose compared to placebo.

Dr. Mathieu concluded by sharing her “bottom line” on the use of SGLT-2 inhibitors in type 1 diabetes and preventing DKA.

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To learn more about off-label drugs in type 1 diabetes, check out this article from Kerri Sparling.

What Therapies Are Best for People with Type 2 Diabetes at Risk of Heart Disease?

The world of diabetes is now focusing more than ever on preventing diabetes-related health complications. Not only is the treatment of diabetes about blood sugar (measured by A1C or time in range), but it is also about heart health, kidney health, and so much more. In 2019, data from large trials showed that GLP-1 agonists and SGLT-2 inhibitors have heart and kidney protection benefits.

As such, experts strongly emphasized using GLP-1 or SGLT-2 drugs for individuals at high-risk for heart attack, stroke, heart failure, or chronic kidney disease. They also named that GLP-1 and SGLT-2 therapies should become more accessible and affordable to people living with diabetes.

Studies have not yet evaluated the heart and kidney health benefits of metformin, compared to those of GLP-1s and SGLT-2s. However, trials have shown that metformin helps lower blood glucose and body weight, comes with a low risk of hypoglycemia, and is cost-effective.

If your healthcare professional has not brought up additional therapy options for you, we recommend you ask them to read this article and discuss your options.

A Debate on the Use of Sulfonylureas in Type 2 Diabetes

Sulfonylureas, or SUs (drugs like glimepiride, glipizide, gliclazide), are a commonly prescribed low-cost drug for people with type 2 diabetes across the world. At ADA 2020, experts Dr. Sophia Zoungas and Dr. Carol Wysham debated the role of SUs in the treatment of type 2 diabetes. While the two endocrinologists differed on how to interpret data from various studies, we came away from the debate with several important take-aways.

Benefits of SUs:

  • Like many other compounds available today, SUs can help lower A1C, especially at the beginning of use in diabetes management.
  • SUs are low-cost and can be an economical method of managing diabetes, at least in the short term.
  • The CAROLINA study demonstrated that sulfonylurea glimepiride is safe for the heart in people with type 2 diabetes.

Challenges of SUs:

  • The CAROLINA study showed that SUs lead to a greater risk of hypoglycemia than other type 2 diabetes medications (not including insulin).
  • All SUs are associated with weight gain, which itself is associated with cardiovascular disease for many people with diabetes.
  • Not all SUs are created equally – each SU might have different health risks, so more research needs to be done on this front.
  • Preventing long-term complications is possible with GLP-1 agonists and SGLT-2 inhibitors – SUs confers no cardioprotective advantages.
  • Without the cost advantage in the short-term, no one would use SUs.
  • Clinical trial investigators are sometimes discouraged from using SUs in major trials, as we understand it.

If you do use an SU, and have experienced hypoglycemia or weight gain, we encourage you to ask your healthcare professional if there is an alternative. To increase safety, we encourage you to check blood sugar as often as you can (or start using a continuous glucose monitoring device, if you can get access – see here if you are on Medicare) to minimize the risk of hypoglycemia.

The Debate on Metformin and Insulin Use During Pregnancy Continues

Traditionally, healthcare professionals have been advised to use insulin to treat pregnant women who have type 2 diabetes or gestational diabetes (GDM). Now, there is debate about whether metformin or other medications are equally effective alternatives to insulin.

Dr. Denice Feig presented data showing that in pregnant women with GDM, metformin use resulted in less maternal weight gain, less preeclampsia (pregnancy-related high blood pressure), lower birth weight, and less neonatal hypoglycemia (low blood sugar). Additionally, there is no evidence that metformin causes any abnormalities in babies, and the drug may reduce insulin resistance in the fetus. During the first trimester of pregnancy, metformin may be a reasonable alternative, if not a first-line treatment equivalent, to insulin. It is also cheaper, easier to use, and poses less of a risk for hypoglycemia (low blood sugar) than insulin.

While the data are promising, both Dr. Feig and Dr. Linda Barbour pointed out that long-term effects on the baby due to exposure to metformin during pregnancy may include a greater risk of being overweight, developing obesity, and having a higher BMI. Unfortunately, the data did not include pregnant women with type 2 diabetes; an ongoing study, MiTy, is currently studying these effects. Both Dr. Feig and Dr. Barbour emphasized that we need more data to decide the best treatment for pregnant women with diabetes – that may well be, and we also hope that better screening is in the works, so that those at risk of gestational diabetes can learn about it earlier and work with their healthcare teams to live with it successfully, which is eminently possible. Learn more about gestational diabetes in our recent article by Cheryl Alkon.

Nutrition, Exercise, and Mindset

New Physical Activity Recommendations for Adults and Children

Dr. Katrina Piercy and Dr. Ronald Sigal presented the 2018 Physical Activity Guidelines for Americans, with updates to the age-specific guidelines and evidence of even more health benefits. These are the recommendations for each age group:

  • Children ages 3-5 should be physically active throughout the day to support their growth, development, and motor skills. Though the US guidelines do not include a specific amount of time, Australia, the United Kingdom, and Canada recommend three hours per day.
  • Children ages 6-17 should do at least 60 minutes a day of moderate or vigorous physical activity.
  • Adults (under age 55) should do at least 150 minutes (2.5 hours) to 300 minutes (5 hours) each week of moderate-intensity activity, or 75 minutes (1 hour and 15 minutes) to 150 minutes (2.5 hours) each week of vigorous-intensity aerobic physical activity. Adults should also do muscle-strengthening activities at least twice a week. We were slightly surprised not to see adults urged to exercise every day like former head of CMS/FDA Dr. David Kessler does in his recent acclaimed book, Fast Carbs, Slow Carbs.
  • Older adults (above age 55) should do the recommended aerobic and muscle-strengthening activities for adults. They should also incorporate balance and functional training, such as standing on one foot or ballroom dancing.

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How do you determine the intensity of exercise? Dr. Piercy recommends the “talk test”: someone doing moderate-intensity aerobic activity can talk, but not sing, during the activity, while a person doing vigorous-intensity activity cannot say more than a few words without pausing for breath.

The speakers noted that while the most health benefits come with at least 150-300 minutes of moderate physical activity per week, any activity is beneficial: any time spent sitting that is swapped out for exercise (even light activity,) can lead to short-term and long-term health benefits. Read more about the guidelines here.

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Diabetes Self-Management Education and Support (DSMES) 2020 Consensus Report Recommendations

A group of educators made a strong case for the greater use of diabetes self-management education and support (DSMES). The benefits are many, including improvements in clinical, behavioral, and psychosocial outcomes, and greater diabetes knowledge and self-care behaviors. Dr. Margaret Powers stressed that compared to other treatments prescribed by healthcare professionals, DSMES and medical nutrition therapy produce few to no negative side effects for people with diabetes and are low cost.

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The experts discussed low DSMES participation rates across the nation and the factors that reduce referrals to diabetes education. Evidence shows that less than 5% of people newly diagnosed with diabetes who have Medicare insurance, and 6.8% of privately insured people with diabetes, have used DSMES services. The 2020 DSMES Consensus Report was created to address these concerns by outlining steps healthcare professionals can take to help people access DSMES services. The report recommends that healthcare professionals make referrals and encourage participation in DSMES at four critical times in someone’s diabetes journey: (1) diagnosis, (2) annually or when not meeting treatment targets, (3) when complicating factors develop, and (4) when transitions in life and care occur. It also suggests that awareness of, and access to, DSMES must be expanded (culturally and geographically), and financial support should be provided for use of DSMES services.

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Food as Medicine! Geisinger’s Fresh Food Farmacy

Michelle Passaretti (Geisinger Health System) presented data on the success of the Fresh Food Farmacy initiative. Fresh Food Farmacy was developed to meet the health needs of people with diabetes in Pennsylvania who do not have access to healthy foods (also known as being food insecure). diaTribe interviewed two leaders from Geisinger in 2018, Dr. Andrea Feinberg and Allison Hess; now, Fresh Food Farmacy has provided 482,219 total meals.

The data speaks to the power of food as medicine! The program participants had a:

  • 2 percentage point reduction in A1C from a baseline of 9%
  • 27% reduction in fasting glucose
  • 13% reduction in cholesterol (including a 9.9% reduction in “bad” LDL cholesterol)
  • 15% reduction in triglycerides

Fresh Food Farmacy also led to increased use of preventive care: flu shots increased by 23%, annual eye exams increased by 17%, and annual foot exams increased by 33%.

Compared to eligible individuals who did not participate, Fresh Food Farmacy participants saw:

  • 49% lower hospital admissions rates
  • 13% decrease in emergency department visits
  • 27% more primary care visits
  • 14% more endocrinologist visits

Participant surveys show significant improvements in quality of life, with 31% of people in the program rating their overall health as very good, compared to just 6% before participation. Additionally, 44% of Fresh Food Farmacy participants now rate their emotional and mental health as very good, compared to just 9% before the program. Passaretti emphasized that Fresh Food Farmacy is not a diet, but a lifestyle change, and that support for the individual’s entire household is necessary for success.

A Sneak Peek into the Film Blood Sugar Rising

Blood Sugar Rising is a film that powerfully articulates the need for a war on diabetes. During this panel moderated by our own Kelly Close, we heard from ADA CEO Tracey Brown, Rise and Root urban farmer Karen Washington, social media influencer and film star Nicole Egerer, film director David Alvarado, and incoming ADA Chief Scientific & Medical Officer Dr. Robert Gabbay.

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Many myths exist in diabetes. One is that if you get diabetes, it is your fault. Blood Sugar Rising dismantles some of these false narratives by showing the complexity of the disease and amplifying diverse voices of people in the diabetes community. Watch the film here if you are in the US and here if you are outside the US.

Tracey Brown ended with a powerful call to action: “What will we do when the burning bush stops burning? We need to move from words into action. We get one point for saying and nine points for doing. Each of us can use our voice, our monetary power, and our ears, and reach across the aisle to collaborate. This is what we need to do to bring diabetes down. We can make it happen, but only together. I’m full up of hope and courage that tomorrow is going to be better than today.”

Lifestyle Interventions for Type 2 Diabetes Remission

In a fascinating session on type 2 diabetes remission, several leaders in the field introduced data on how specific lifestyle interventions (diet and exercise) may help put type 2 diabetes into remission.

Alison Barnes presented data from the DiRECT trial, which focused on low-calorie diets (LCD). The trial compared an intervention group on an LCD (between 800-900 calories per day) to a control group receiving typical diabetes care. Remission was defined as achieving an A1C below 6.5% and stopping all diabetes medications. Results from the DiRECT trial were promising:

  • At one year: 4% remission in control group and 46% remission in the intervention group.
  • At two years: 3% remission in control group and 36% remission in the intervention group.
  • 64% of participants who lost more than 22 lbs (10 kg) were in remission at two years.
  • The intervention group dropped from 75% of participants on diabetes medications at baseline to 40% at two years (compared to 77% at baseline and up to 84% in the control group).
  • Average A1C decreased by 0.6 percentage points in the intervention group at 2 years.
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We thoroughly recommend Dr. Roy Taylor’s book Life Without Diabetes: The Definitive Guide to Understanding and Reversing Type 2 Diabetes – he provides a major connection to the DiRECT trial.

Next Dr. William Yancy spoke on low-carbohydrate diets (classified as less than 130 g carbs per day, with no overall calorie restrictions). In an analysis that compared the effects of nine different diets on glycemic outcomes in type 2 diabetes, the low-carb diet was ranked as the most effective dietary approach for lowering A1C.

Finally, Dr. Kristian Karstoft presented the U-TURN study on how exercise alone, or exercise and diet, may play a role in type 2 diabetes remission. U-TURN had two groups, one receiving standard care and one receiving intensive lifestyle intervention, which included diet and exercise components.

  • After 12 months, 37% of participants in the intervention group stopped using glucose-lowering medication and maintained glucose levels below the criteria for type 2 diabetes (effectively achieving remission).
  • Of the participants who achieved remission, the majority of them came from the group that consistently exercised the most.

The Need for a Personalized Approach to Obesity Treatment

Experts shared the latest data on different treatments for obesity. They focused on three approaches:

1. Lifestyle interventions:

  • The Look AHEAD trial tested whether reducing calories and exercising regularly would lead to diabetes remission. After one year, 11.5% of participants achieved diabetes remission with an average weight loss of 19 pounds (8.6 kilos). After four years, 7.3% of participants were able to maintain remission with an average weight loss of 10 pounds (4.5 kilograms).
  • The Diabetes Remission Clinical Trial (DiRECT) tested whether calorie restriction alone had an effect on diabetes remission. After one year, 46% of people in this study with type 2 diabetes achieved remission; after two years, 70% of the people who had achieved remission were able to maintain remission.

Participants in Look AHEAD had more advanced diabetes than in DiRECT, leading to the big difference in remission rates. The speakers emphasized that the longer someone has been diagnosed with diabetes, the harder it is to achieve diabetes remission.

2. Obesity medication:

  • Just 2% of people living with obesity are managing the disease with medication. However, many obesity medications can lead to weight loss, prevention of diabetes, and diabetes remission.
  • Combination therapy has shown success for managing obesity and type 2 diabetes. A study testing tirzepatide (a dual GLP-1 and GIP receptor agonist) in people with type 2 diabetes found a 1.7-2% decrease in A1C and an average weight loss of 12 pounds in just 12 weeks.

3. Bariatric surgery:

  • Experts agreed that bariatric surgery should be considered as a treatment option for people with a BMI greater than 35. Bariatric surgery can also lead to sustained weight loss and a decrease in diseases associated with obesity, including sleep apnea and heart disease.
  • It’s clear that obesity treatments must be determined at individual levels – we know that so much more is possible for people with diabetes to reach healthier weights and will be returning to this topic. In the meantime, if changing your weight is of interest, talk to your doctor about how to do this in the best way for you.

How Might Type 1 Diabetes Affect the Gut Microbiome? How Can We Use the Gut Microbiome to Treat Type 1 Diabetes?

Though the science is not yet conclusive, research continues on the relationship between the gut microbiome (made up of all the bacteria that live in the human digestive tract) and type 1 diabetes autoimmunity. Dr. Eric Triplett reviewed studies of the gut microbiome in babies with high genetic risk for type 1 diabetes. Three of the studies (DIPP, Babydiet, and DIABIMMUNE) showed an association between the species of bacteria living in the gut and the onset of type 1 diabetes. He then presented a study using data from the general population in Sweden (ABIS), which compared the gut microbiome of children with low, neutral, or high genetic risk for type 1 diabetes. The study found that high genetic risk for type 1 diabetes is associated with changes in the gut microbiome early in life.

Dr. Emma Hamilton-Williams shared unpublished research on the effect of high-fiber dietary supplements on gut microbiome composition and diabetes management in 18 adults with type 1 diabetes. Fibrous food breaks down into short-chain fatty acids (SCFAs) when digested. SCFAs are known to support gut health and regulate the immune system. The study found that the high-fiber supplements affected the species of bacteria living in the gut as well as their function (though these returned to baseline after the diet ended). Participants with better-managed diabetes at baseline had a stronger response to the dietary change – and experienced changes in their glycemic management: A1C levels decreased and less daily insulin was required. Further research on short-chain fatty acid supplements could shed lead on diabetes treatment and prevention.

Real World Stories: Supporting People at Different Stages of Diabetes

Dr. Neesha Ramchandani presented her work on young adults living with diabetes (ages 18 to 30). Through interviews, she found four main challenges: finding a balance between diabetes and life, feeling in control of diabetes, navigating the hidden burden of diabetes within their social circles, and wanting a better connection with their diabetes healthcare professional. One participant said, “Diabetes is like having a full-time job… you can’t 100% turn off. It always has to be a part of your thought process.” diaTribe has resources for teens here.

We then heard from Dr. Della Connor and Dr. Gary Rothenberg on the need to care for people who are living with diabetes post-kidney transplants and post-amputations. In all three talks, the experts emphasized the need to:

  • Build trust and comfort between people with diabetes and healthcare professionals.
  • Incorporate perspectives based on gender, race, and ethnicity into care.
  • Recognize the importance of a team approach, including care-partners.

Access to Care and Policy 

Soda Taxes: Are They Working?

Dr. Lisa Powell (University of Illinois at Chicago) presented compelling evidence in support of sugar-sweetened beverage (SSB) taxes and their ability to reduce soda consumption. Evidence suggests that taxes do reduce the consumption of sugary beverages – a 38 percent reduction in Philadelphia, PA and 21 percent reduction in Seattle, WA, for example – and incentivize soda companies to decrease the amount of sugar in their products, especially when the tax is dependent on the drink’s sugar content. Research also shows that while some consumers replace sodas and sugary drinks with other forms of sugar, such as candy or chocolate milk, the most common substitute is water.

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Dr. Martin White (University of Cambridge) and Dr. Rafael Meza (University of Michigan) presented promising data on how SSB taxes are working in the United Kingdom and Mexico, respectively. UK consumers overall have been switching to drinks with less sugar and most companies have been reducing levels of sugar in their products; however, taxes have not had a dramatic negative impact on the sugary beverages industry’s revenues overall. Similarly, Dr. Meza showed that Mexico’s overall sugar consumption has decreased since the implementation of the SSB tax, having the largest influence on people who drink lots of sugary drinks, and he noted that the current tax, which is about 10% of the beverage price, would have a significantly larger impact if doubled.

Dr. Powell pointed out that the most effective taxes require careful design. To significantly curb consumption of sodas, the SSB tax should be added into the shelf price, rather than applied at the register, and the tax ought to apply to a broad base of sugary-drinks (including sodas, juices, sports drinks, etc.) to avoid substitutions. Moreover, researchers must be mindful of cross-border shopping – this is when consumers purchase their beverages in places where the SSB tax doesn’t apply. This tax avoidance can heavily impact the effectiveness of the tax: for example, in Philadelphia, PA, consumers buying SSBs outside of Philly reduced the the impact of the tax from a 51% reduction in SSB sales to a 38% reduction.

Effects of Health Policy on Diabetes Care

Professor Rebecca Myerson (from the University of Wisconsin) shared key findings of a study on the impact of Medicaid expansion for people with diabetes:

  • Medicaid prescriptions for insulin increased by about 40%, even with rising insulin prices, meaning that more people with diabetes are receiving treatment.
  • Prescriptions for metformin also increased, suggesting that more people are getting treatment for early-stage diabetes.
  • About one-third of the other prescriptions are for newer medicines (such as SGLT-2 inhibitors and GLP-1 agonists) – promising trends for preventing diabetes complications and saving significant costs down the road.

Dr. Kasia Lipska from Yale School of Medicine discussed the importance of coverage for essential medicines and pre-existing conditions – two health policy issues that are front of mind for many Americans as the November election approaches. In addition to Medicaid expansion, the Affordable Care Act (ACA, or Obamacare) provided coverage for “Essential Health Benefits,” which includes prescription drugs, mental health services, emergency services and hospital care, preventive services and chronic disease management, and more. Dr. Lipska shared a study that found the ACA reduced the percent of income spent on family medical costs for people ages 18-64 with diabetes. This reduction was especially true for people whose family income was in the lowest bracket ($0-34,999 per year).

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Importantly, ACA also prohibited health insurance companies from denying people coverage or charging higher costs to people who have “pre-existing conditions,” including diabetes. Given the significant improvements in coverage and care, Dr. Lipska emphasized that getting rid of the pre-existing conditions provisions would be “a disaster for people with diabetes” – presumably diaTribe readers in the US would agree! Over half of those surveyed were in favor of expanding Medicaid programs in their state – this doesn’t surprise us, since there are so many states that do not have favorable diabetes care programs (for example, see our article on CGM coverage for people on Medicaid; although this was not part of the ACA, many cite it as helping improve care quickly for those that are able to access the benefit). She shared results of a Kaiser Family Foundation survey that emphasized the need for ACA provisions:

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Whole-Population Interventions Aim to Prevent Type 2 Diabetes

As type 2 diabetes rises in the United States (and around the world), organizations are working to prevent new cases and improve the health and wellness of entire communities. Simon Neuwahl (RTI International) showed models of the benefits of proposed changes, which includied soda taxes, worksite health promotion, and bike lanes. The models suggest that the introduction of these three societal reforms can reduce the rate of type 2 diabetes by 17% over the next ten years. In 2018, 1.4 million people were diagnosed with type 2 diabetes in the, US so a 17% decrease would prevent 2.4 million cases over ten years.

There is still a long way to go. The CDC is aiming for the rate of type 2 diabetes to drop by 21% by 2025. The efficacy of some reforms, like the soda tax, are well proven. But, experts like Professor Nicholas Wareham (University of Cambridge, England) believe that no single intervention can make a difference. Decreasing rates of type 2 diabetes will require societal and individual lifestyle reforms.

Thankfully, diverse groups recognize the need for holistic approaches to diabetes prevention. The CDC’s National Diabetes Prevention Program coordinates with both public and private organizations to connect people with diabetes or prediabetes to lifestyle change resources and programs. Neuwahl’s cost-effective model is adaptable to national, state, and local communities hoping to implement whole-population interventions. Together, his three proposed population-level reforms could directly improve the lives of 2.4 million people.

Source: diabetesdaily.com

New COVID-19 Medicare Funding for Telehealth in Australia

By Rachael Baker

COVID-19 is proving to be an extreme and unparalleled time for healthcare services across the globe. Credentialled Diabetes Educators (CDEs) are not exempt from this rapidly changing landscape and multiple shifts are occurring in the way we now provide care. Changes to funding models are being welcomed by CDEs with open arms.

Telehealth is by no means a new concept for patients living with diabetes in Australia, and CDEs have been advocating to endorse telehealth to be an equitable means of service delivery for quite some time. Telehealth is often an integral component of care for a person’s diabetes management; however, never before have patients been able to claim Medicare rebates on these services, until now.

Easier Access, More Convenience

Prior to the COVID-19 funding, telehealth already enabled many Australian

s living with diabetes, especially in rural and remote areas, to have access to up-to-date, specialist education and diabetes technology provided by CDEs. Diabetes is a chronic condition that necessitates a person to attend frequent appointments to a range of healthcare professionals across the multidisciplinary team, including: General Practitioner (GP), CDE, Endocrinologist, Dietician, Podiatrist, Psychologist, Optometrist, along with other specialist clinicians. Juggling life, and diabetes and attending these appointments can prove difficult at the best of times.

Telehealth consults eradicate time spent on the sometimes long journeys traveling to a CDE appointment, time taken off work (especially if telehealth consults are provided outside of business hours), along with the difficulty of finding someone to mind the kids and the common struggle of parking. While face to face consults are still imperative, especially for new diagnosis and starting on insulin pump therapy, telehealth services have anecdotally proven to have high attendance rates and result in patients feeling well supported, leading to greater health outcomes, both short and long term.

Rebatable Telehealth Appointments

As we see ourselves voyaging through the uncharted waters of this pandemic, abiding by Australian Government guidelines in line with social distancing and essential interactions only, it is a relief that patients will be able to have critical access to CDEs via Medicare rebatable telehealth appointments. While we are navigating the finer details (see link for legislation), it looks like this will be equivalent to current face to face Medicare rebates, equating to $53.80 per consult for patients who have a shared care plan, or a GP Management Plan and Team Care Arrangements, or if they are a resident of an RACF and have a multidisciplinary care plan.

CDEs are the front line when it comes to providing education to patients with diabetes to safely and effectively manage their blood glucose levels (BGLs), optimize their health and wellbeing, but also assisting people with diabetes to safely navigate their blood glucose levels and ketones during sick days. Now more than ever, as our acute healthcare services become overwhelmed, it is vital that we support people living with diabetes to stay safe and well, avoiding preventable Emergency Department presentations and hospital admissions. We also need to come together to support tertiary diabetes services, as they redirect medical and nursing staff to emergency and acute inpatient areas to meet the demand of COVID-19 patients.

Telehealth: A Service Innovation

Living with type 1 diabetes myself, I strongly stand by the notion that patients find this innovative means of service delivery extremely beneficial. It focuses on the needs of an individual and discovers a way to make diabetes management fit into people’s lives with greater ease. With today’s technology, telehealth platforms are incredibly easy to use and patients are able to attend their telehealth appointment using their smart mobile phone.

Given the current climate, telehealth is quickly becoming the standard or the ‘norm’ for a lot of outpatient services. As I have already mentioned, face to face consultations with CDEs will always be essential, nevertheless, telehealth appointments certainly have a broad and practical range of opportunities for use. During this time, telehealth consults are not merely an option, but in fact, the only option to stay engaged with their regular CDE appointments and receive the imperative support and guidance they require.

This is a milestone worth celebrating, and as we are being forced to reflect upon what is really necessary in our individual lives, for those living with diabetes, CDEs certainly fit the bill, and the Australian Government thinks so too. CDEs have a significant impact on people living with diabetes; as a patient and a clinician, I have experienced this from both sides.

I would like to thank Diabetes Australia, the Juvenile Diabetes Research Foundation (JDRF), the Australia Diabetes Educators Association (ADEA), Diabetes QLD and NSW ACT, and most importantly our diabetes community whom are themselves, their loved ones or family members, living with diabetes. I am incredibly passionate about telehealth, and with this funding set to kick in on March 30, 2020, my next question will be whether the cease date on September 30, 2020 will be negotiable, as inevitably people with diabetes adapt to a new way of seeing their CDE.

Stay home and stay safe.

About the Author

Rachael Baker is Credentialled Diabetes Educator (CDE, BN) and Clinical Nurse Specialist at Macintyre Health. You can follow her or her company on Instagram for tips.

Source: diabetesdaily.com

What Should I Do If I Have Symptoms of COVID-19?

As the global viral outbreak continues, you may be wondering what special considerations there are for people with diabetes to keep in mind. In particular, what should you do if you begin to experience symptoms consistent with the infection? This article reviews the most common COVID-19 symptoms, discusses potential issues specific to people with diabetes, and provides a guideline of how to respond if you become sick.

Symptoms of COVID-19

Be on the lookout for the following most common symptoms of COVID-19:

  • Fever
  • Coughing (especially dry)
  • Shortness of breath

Other symptoms may include fatigue, body aches, and sore throat, among others.

Special Considerations for People with Diabetes

You may have heard that people with certain medical conditions, including those with diabetes, are considered to be in the high-risk group for developing more serious symptoms of the disease, and have been reported to have a significantly higher mortality rate than those without underlying conditions. While these statistics are both relevant and can be scary, it is also important to keep in mind that your individual risk will vary widely depending on your specific health status, regardless of your diabetes diagnosis. Your age, other related and unrelated health conditions, and blood glucose management profile, all play a role in determining your overall risk. So, while as a whole population, people with diabetes are at higher risk for complications, your individual risk could be much lower than that.

For instance, as per the JDRF, those who have type 1 diabetes are  “not necessarily at higher risk of developing serious complications from the disease. Those at greatest risk are those who have another, or second chronic disease (such as a compromised immune system, heart disease or renal failure).

Talk to your healthcare provider to better understand your individual risk level and recommendations.

Have a Plan of Action If Symptoms Arise

Being adequately prepared ahead of time can help you feel calmer and more empowered if you do get sick. Consider taking the following steps today, if you haven’t already:

  • Take preventative measures. Stay home. Practice social distancing (note: if you already have symptoms, self-isolate!)
  • Wash your hands. Avoid touching your face. Disinfect “high-touch” surfaces regularly.
  • Make sure that your medication refills are up-to-date so that you have the supply you need if you will stay in your home for a long period of time (e.g., at least several weeks). Make sure that you consider supplies used for diabetes management as well as any other medications that you use.
  • Check that you have medications on hand that you would typically use to treat a viral infection, such as a fever-reducing agent, like acetaminophen (Tylenol). Consult with your healthcare provider for advice about their specific recommendations.
  • Have enough food and water in your home in case you stay home for a prolonged period of time (e.g., several weeks).
  • Review the “Sick Day Rules” for people with diabetes. COVID-19 causes mild symptoms in most of the people who are infected. This means most likely, you will be treating your symptoms at home. However, any illness can make blood glucose levels more challenging to manage. It is important to be aware of how illness can affect your management plan and make adjustments as needed, with the help of your healthcare provider, to keep yourself safe during the illness. You can find the standard “Sick Day Rules” as described by the Joslin Diabetes Center here, but discuss your specific recommendations with your healthcare provider.

So, what should you actually do (and not do) if you develop symptoms of COVID-19?

  1. Don’t panic.
  2. Self-isolate. Don’t go to urgent care or the emergency room, unless instructed to do so or you experience serious symptoms (see below). Stay home.
  3. Call your doctor and follow their advice closely.
  4. Keep a close eye on blood sugar levels. Work with your healthcare provider to make adjustments to medications, if needed, to help stay in the target glycemic range as much as possible. Keeping blood glucose levels in check as much as possible can go a long way to helping you avoid complications during any illness.
  5. Manage your specific symptoms (e.g., fever). Ask your healthcare provider for specific at-home treatment advice.
  6. Stay hydrated. This can help you keep your blood sugar levels in the target range and avoid complications.
  7. Be on the lookout for serious symptoms, including those of diabetic ketoacidosis (DKA), as well as the following “COVID-19 emergency warning signs”:
  • Difficulty breathing
  • Chest pain
  • Confusion or difficulty waking
  • Blue tint to the skin (on the lips or face, in particular)

If you experience these any of these symptoms, promptly seek medical care. Wear a mask if out in public.

  1. Continue to wash your hands and clean surfaces regularly.
  2. Continue to avoid contact with others (humans and pets).
  3. Do not discontinue isolation until you get the “all clear” from your healthcare provider.

***

For even more detailed information on what to do if you are ill, read these guidelines from the CDC:

What to Do if You’re Sick

Guidelines for At-Risk Populations

Also, learn even more about COVID-19 illness with diabetes from the American Diabetes Association (ADA) here.

Source: diabetesdaily.com

Diabetic Ketoacidosis (DKA) at 30,000 Feet

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

By PK Hrezo

Twist of Fate?

It’s coincidental, if not oddly poetic, that type 1 diabetes presented itself to my family and me for the first time just two weeks before National Diabetes Awareness Month — a time we won’t soon forget.

Until that night, I thought type 1 diabetes (T1D) was something that kids were born with. I never thought it could be presented at any stage of life. I’d participated in JDRF walks before for friends and charity, so I knew the bare minimum. It had never been suggested to me by medical professionals that T1D was something all parents should keep an eye out for. Perhaps I hadn’t consulted the Parent Handbook regularly enough. But face-to-face with T1D for the first time, it was clear, I was on the brink of full-on parental guilt.

T1D did not run in our family, but that was the first question the ER doctor asked me while my thirteen-year-old daughter Abby was lying on the ER stretcher, nearly comatose, during a severe DKA episode in Halifax, Nova Scotia on October 19th, 2019.

DKA

Image source: Beyond Type 1

I was far from home, away from my husband, family and friends, and I was shell-shocked.

The Backstory

Abby and I had been planning a girl’s weekend to Paris for years, just the two of us, and it was to be the weekend of October 18th. Abby was beyond excited, which now, looking back, is probably what propelled her through the symptoms that we ignored as pre-DKA indicators. But we didn’t know. All we knew was that Abby had been under the weather for about a week – not herself, more tired than usual, and her ear had been bothering her just enough to prompt us to see the family doctor before getting on a plane.

We saw a nurse practitioner who checked Abby’s vitals and said her throat was red, but no ear fluid, and that she’d be okay for travel with some Mucinex. That night, Abby didn’t sleep at all. She woke up and stayed up for most of the night with indigestion. When she looked exhausted the next morning, we chalked it up to a bad night’s sleep.

Once we got to our connection at Chicago O’Hare, Abby seemed to be even more exhausted than before. Looking back, I realize the altitude from the plane ride from Tampa to Chicago had an adverse effect on her already gradual decline into DKA. She was uncomfortable in any position, and very thirsty for sweet, juicy-type drinks. She had an apple juice, a smoothie, a sweet tea with honey – all of these, unbeknownst to me, were contributing to the high sugars that would send her into DKA. I thought I was keeping her hydrated to flush out the virus, but sadly, all I was doing was shoveling more sugars into her bloodstream.

When Abby looked at me during our long layover and said she thought Paris would be a bad idea, I was both glad she’d owned up to it and puzzled by her sudden change. Of course, I wanted to do what was best for her. She mentioned one of our backup destinations — somewhere closer where we could still have our mother-daughter weekend but relax without the hustle and bustle of a busy city. We were already part of the way to another place, so we chose a pleasant B&B in Halifax, where it’d be autumn and beautiful. I made our arrangements and we headed to the next gate.

In Hindsight

If I could redo that day, I wouldn’t have put her on a plane to Canada, but that doesn’t mean I wouldn’t have made a different mistake. I might have booked a room in Chicago, so we could rest and she could sleep it off, which could have been fatal, since I still didn’t know she was in near-DKA.

I called my husband and told him how Abby was behaving, and that we’d changed plans. He was surprised, but agreed she likely just needed rest. That was also about the time doubt squirmed its way into my mind. People were beginning to stare at her. She was stumbling to the bathroom, and she just kept saying she was tired and needed to sleep. I was eager to get out of the airport and settle down somewhere so we could get back to normal. Little did I know, that normal had left us for good.

We pressed on and boarded the aircraft, and after about thirty minutes into the flight, my mommy senses went full-on haywire. What had I done? Something was wrong with Abby — I had no idea what, only that something wasn’t right, and it was too late for us to turn around. Tears welled in my eyes and I stared out the window wondering how I could’ve made such a big mistake.

Completely in the Dark

Abby could hardly hold her cup of ice she’d been munching on. She was dropping everything, and I was getting frustrated, because I’d never seen her that way, and I knew something was happening that she wasn’t telling me. “Talk to me,” I kept saying to her. “I don’t understand what’s going on.”

But Abby didn’t understand what was happening to her either. She complained that her lungs were hurting. Her lungs? I didn’t know if she was exaggerating or if she was having an allergy attack. How did all of those symptoms measure up to exhaustion and a virus? It didn’t make any sense.

Abby got up to use the bathroom again and was gone for quite a while — this is what I now know as T1D’s excessive peeing symptom. I was just about to go check on her, when she returned to our seat and laid over me. Her voice was barely audible when she complained again of her lungs hurting.

“Is there a doctor here?” she asked me in hardly a whisper.

“No,” I told her calmly. “But we’ll find one when we land.”

My nerves spiraled. I was, without a doubt, the worst mom ever. I decided that as soon as we landed, I’d call 911. We were halfway there. I held Abby as she laid over me in the row. And then she began to breathe heavily and rapidly.

I rubbed my hand up and down her arm. The stark difference between my hand temperature and hers was so alarming that I knew I couldn’t put it off any longer.

“Wait here,” I told her, and I beelined for the back of the plane where the two flight attendants stood in the galley.

“Can you see if there is a doctor onboard?” I asked. “I think there’s something wrong with my daughter.”

Team Work

Without hesitation, the flight attendants sprung into action and all the lights on the aircraft came on. While everything was moving in a blur for me, I returned to Abby and a passenger seated behind us, Nick Wasser, popped up as the announcement was made and identified himself as a nurse.

I explained Abby’s symptoms and everything up to that point, and a minute later, two more professionals appeared: Dr. Peter Laureijs and his wife, Beth, also a nurse. The flight attendants had oxygen and medical kits and they moved the passenger from the bulkhead row, so that Abby could be laid there on the floor. The doctor and nurses attended to her with great care, administering oxygen and checking her vitals.

I whispered a prayer and asked God for courage to get through whatever was to come, and that He might save my daughter. I remember very well, the moment when the woman in the adjacent row, Nick’s wife, Johanna, reached her hand over and lay it on mine, with tears in her eyes and said, “If you need anything, I’m right here.” The flight attendants checked on me throughout the remainder of the flight and made sure I was okay. They were in communication with the flight deck, and the pilots opted not to divert, but instead speed up the plane to get us to Halifax sooner, where IWK Health Centre would know how to care for whatever was wrong with Abby.

DKA

Image source: Beyond Type 1

They’d administered an IV by then, and that’s what saved Abby’s life, because unbeknownst to me she was dehydrating by the minute, as her bloodstream was filled with all that sugar that couldn’t be processed.

An ambulance waited on the tarmac when we landed. I could see their flashing lights out the window, and an announcement was made for no one to move until the EMTs had boarded and retrieved Abby. We started moving through the airport and Border Patrol gave me temporary paperwork and told me to call later after we knew what was going on. They wanted to make sure Abby wasn’t contagious, rightfully so, and that we weren’t bringing disease into Canada. At that point, we still had no idea what was happening.

On the ambulance, the EMT said her glucose level was 30 mmol/L (540 mg/DL). That didn’t mean anything to me. I said she’d had a lot of sweet drinks and nothing really to eat, so it was no surprise they were high. I was so naïve to the symptoms of T1D.

Learning the Ropes

The EMTs and ER staff that met us at IWK were all top-notch professionals with such warmth about them, that I never once felt alone, nor judged for my epic mom fail. While Abby was transferred to a bed and hooked up to all kinds of tubes, the ER doctor asked me a ton of questions, one of which was if diabetes was in the family.

“No,” I said informatively.

This is diabetes,” he said. “I can smell the ketones from here.”

“Ketones? What the heck are ketones?”

A word I’d later come to be acquainted with on a much deeper level. T1D had just blindsided me in a T-bone collision. Welcome to your new life. How had I not known? How had the doctor back home not identified it? Did this happen to other kids Abby’s age? Why did it wait so long to show up?

I stepped out and called my husband, and he, too, was in denial at first, insisting she’d probably just had a lot of sugar. Then I mentioned what the doctor said about smelling ketones, and it hit Nate like an anvil.

“Holy cow!” he said. “That’s what I smelled yesterday, remember? I said you need to brush your teeth because your breath smelled, and I thought it was you. I can’t believe I didn’t recognize it!”

Nate is a fire chief in Tarpon Springs and has thirteen years of experience in the EMT/first responder profession, and he has run across T1D patients a number of times.

Abby was admitted to PICU a few hours later where she was tended to by sweet, caring nurses for the next forty-eight hours, and where I would begin googling words and terms I’d never known before, in hopes of learning a lifetime worth of information within a couple of days.

Every time an ICU nurse would come in, I’d fire off questions, one of which being: “Does this type of thing happen very often?” One of the nurses said that in the last three months, they’d had eight cases of pediatric DKA where the parents had no idea that their child was T1D. After ICU, we moved to a room on the children’s ward, where we were introduced to managing T1D on our own. I was trained to use a glucometer and give insulin injections, and how to count carbs.

Making Sense of It All

I posted on Facebook when we finally returned home to Tampa. Sharing the signs of DKA with other parents seemed a priority, in hopes others could learn from my mistake. After my Facebook post went viral, I was contacted by so many other T1D parents and patients who have similar stories. So many of whom were turned away from doctors and ERs who also thought nothing was wrong.

I was an anxious ball of nerves when Abby and I finally received the okay to travel home to Tampa, because I’d be in charge of her insulin doses on my own for the first time. Since I learned dosages and glucose readings in Canadian measurements, I had to retrain my brain to switch over.

DKA

Image source: Beyond Type 1

The IWK nurses stayed in close contact with me throughout our journey home and advised me on what dosage to give after each blood reading. We had a doctor’s appointment the following morning with our new Tampa-based pediatric endocrinologist, and after one delayed flight to Newark, and another delayed flight to Tampa, we muddled through our insulin injections, and were able to get home and begin our new normal.

Together, our family is planning healthier food options with fewer carbs. We are making Abby’s lifestyle change our lifestyle change, we’re all watching our sugar intake. Once at home, I realized how fortunate we were to get help when we needed it, and I realized I didn’t know one of the nurse’s names from the flight. I also wanted to find out the flight crew of UA5596 so I could thank them. I made a Facebook post one morning asking others to help me find them, and I received an overwhelming response.

The post received almost 6K shares from people eager to pass on Abby’s story. The T1D community embraced me in a way I’ll forever be grateful for. Instead of feeling alone with this condition, I feel a part of something so much bigger than a crummy auto-immune disease, and I know a wealth of resources and support are waiting online should I need it.

While Abby and my weekend had not been the one of culture and mother-daughter bonding we’d hoped for, we found something else equally important. We learned that we are both stronger than we think, and that love and faith will get us through anything. We gained a new respect for life and its fragility, and humanity proved it’s still full of compassion. Since that fateful October night, Abby and I have been invited into a community of fellow T1Ds we never knew existed, and we’re reminded that there is strength in numbers, and that people truly are eager to help when given the chance. We are not alone.

Source: diabetesdaily.com

Onederland: Poems About a Childhood with Type 1 Diabetes

This content originally appeared on diaTribe. Republished with permission.

By Eliza Skoler and Kelly Close

Jamie Kurtzig, a high school student living with type 1 diabetes, just published a book of 100 poems that she has written over the last ten years

Onederland: My Childhood with Type 1 Diabetes is a book of 100 poems recently published by a 15-year-old diabetes advocate, Jamie Kurtzig. The book takes readers through Jamie’s childhood, touching on themes of growing up, navigating challenges, and finding hope. We attended the book launch yesterday and were so impressed by Jamie’s discussions about diabetes. We asked her if she could give one piece of advice to families that reflected the sentiments of her own family, and she answered eloquently with a single word “Hope.” She continued, “Never lose hope.”

Jamie was diagnosed with type 1 diabetes when she was one year old and has been writing poems since the age of five. Her book is now available from Book PassageBarnes & Noble, and Amazon. We sat down with Jamie to learn about her poems and her vision for this book.

Jamie: I’ve always liked writing poetry; I wrote my first poem when I was five, and it’s actually included in the book. Writing poetry helps me express myself and make sense of things and think about things, so it’s been a really fun process. I’m excited that Onederland is now published.

What did you learn about yourself during this process?

Jamie: Diabetes has really influenced who I am, and it has also given me a passion for finding a cure, something I want to do for the rest of my life. I realized this while writing my book.

What do you most want people to know about Onederland?

BookJamie: All of the proceeds are going to diabetes non-profits – including The diaTribe Foundation – to help find a cure, one of my main goals. I would love to experience just one day where I do not need to check my finger or bolus for a meal or have glucose tabs for low blood sugar. I’m so lucky to live in the Bay Area and have access to tools to help me manage diabetes; we need to find a cure not only for people like me, but for people everywhere.

How did you go from the poems you’ve written over the last ten years to this incredible, finished book?

Jamie: I had these poems but didn’t know what to do to get them on paper, so I talked with Book Passage, an awesome local bookstore. They introduced me to great mentors, who helped me create a story arc — my story — so that the book evolves along with my life. I start with an intro of me (“Where I’m From”), and then move into some of the challenges in my life and how I’m dealing with them and working with them, and then into more hope. I also wanted to include an index so people could see how old I was when I wrote each poem.

What was the hardest part of publishing a book?

Jamie: Getting all the details right! I had to order three proofs before I caught all the mistakes.

Who are your favorite poets?

Jamie: Mary Oliver – I have a giant quote of hers on my wall. And also Emily Dickinson.

How did your family respond to your choice to publish a book of poetry?

Jamie: My mom has been so supportive of me. In everything I do she always supports me and helps me get things done – which is awesome because sometimes it’s hard for me to get from ideas into… a book!

We asked Sara Kurtzig, Jamie’s mom, to tell us a bit more.

How do you feel about Jamie’s book of poems?

Sara: So, so proud. She’s so graceful to me, and I so appreciate her way and her spirit, and I think it comes through in her book. I had never read her book until she asked me to read her proof. I read the whole thing on the airplane and I was in tears. She had to do a lot of work to make this happen. She had to figure it out. She picked the paper, she picked the font, she picked the title. It’s a lot of thinking. I feel that she did not cut corners and took the time to do all of it. And I am so proud. She did this all in her own way. And she is donating every penny to various diabetes non-profits. We can get a lot of places with that power.

Find Onederland: My Childhood with Type 1 Diabetes at Book PassageBarnes & Noble, and Amazon.

Jamie was a Junior Summer Associate in 2019, working with college students and recent college grads at The diaTribe Foundation and Close Concerns. She is also now a writer for diaTribe – read about her experience with Loop and her advocacy work at the 2019 JDRF Children’s Congress.

Source: diabetesdaily.com

GivingTuesday: Donate for Diabetes

Have you heard of Giving Tuesday, a global generosity movement? Learn more and consider donating to a diabetes organization of your choice.
Source: diabetesdaily.com

From Dance to “American Ninja Warrior”: Talking to Christina Martin

This content originally appeared on Beyond Type 1. Republished with permission.Christina Martin has had type 1 diabetes since she was 13 years old. In high school, she started her own foundation – Type Zero – to help others know they were not alone. This year, Christina attended the JDRF Children’s Congress and participated in Season […]
Source: diabetesdaily.com

Editor’s Note: You Are Not Alone

May is Mental Health Awareness Month and here at Diabetes Daily, we take this issue very seriously. Managing an invisible disease, day in and day out, can create a lot of other issues for people with diabetes. It is important that everyone feels comfortable talking about their problems, reaching out for help and knows they […]
Source: diabetesdaily.com

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