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Newest Updates in Diabetes Care and Education from ADCES 2021

The Association of Diabetes Care and Education Specialists 2021 conference covered the impacts of diabetes stigma, smart MDI therapies, insulin delivery by means other than an insulin pump, the latest in diabetes tech, and more!

At the virtual Association of Diabetes Care and Education Specialists (ADCES) annual conference held from August 12-15th, diabetes care and education specialists and other expersts discussed some of the most important (and current) aspects of diabetes education and care. Read some of our top highlights below and stay tuned for more from the conference soon!

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Which Therapies Are Best for You? Breaking Down SGLT-2s and GLP-1s

There are many different brands of SGLT-2 inhibitors and GLP-1 receptor agonists that have proven to be effective in lowering glucose levels in people with type 2 diabetes. These therapies are especially helpful for people with diabetes who have kidney disease, heart disease, or heart failure but it can be difficult to figure out which therapy may be best for you.

At this year’s ADCES 2021 conference, Dr. Sam Grossman from the New York Harbor Healthcare System and Dr. Sara Reece from the Philadelphia College of Osteopathic Medicine outlined the benefits of SGLT-2 inhibitors and GLP-1 receptor agonists and discussed which therapies are most effective in treating and preventing heart and kidney disease in people with diabetes.

Click here to jump to the full article on this session.

Diabetes Stigma: Causes and Consequences

Dr. Lauren Beach from the Northwestern University Feinberg School of Medicine shared a fascinating presentation on diabetes stigma that explored the causes and impacts of stigma. This type of stigma – the shame and self-blame that a person might feel for having diabetes – can be a major stumbling block for people trying to manage this condition. Though both people with type 1 and type 2 diabetes can experience stigma, it often disproportionally affects people with type 2 diabetes due to the assumption that lifestyle choices led to their diabetes diagnsosis. Here are some of the highlights from her talk:

  • Diabetes is misunderstood and often misrepresented in popular media. Since diabetes is, for the most part, an “invisible trait,” it is often hard for people without diabetes to perceive the existence of diabetes stigma. However, research shows that those with diabetes do report feeling stigmatized, due in part to internet humor that frequently depicts diabetes as a result of poor diet and insufficient exercise. 

  • Some people with diabetes feel shame while others feel pride which may be a result of having access to a supportive community. Through a series of focus group conversations with people with diabetes, Dr. Beach collected qualitative and anecdotal data showing that people with diabetes have variety of experiences – from those who believed their poor diet resulted in their diabetes diagnosis to those who felt a sense of diabetes pride, not everyone experiences diabetes quite the same. For example, she recalled a conversation in which people described referring to the condition as “livabetes” since diabetes has the word “die” in it. 

  • Those with type 1 diabetes have more developed online support networks and might be contributing toward the stigma of type 2 diabetes. Dr. Beach found that the positive messaging and solidarity around the type 1 community led to increased resilience. Those with type 2 diabetes lack this source of resilience and are sometimes the target of stigma from those with type 1 who attempt to distinguish themselves from people with type 2 diabetes, by stating their condition is not the result of “poor decisions” – even though we know that both type 1 and type 2 diabetes involve genetic and other uncontrollable factors. 

  • To combat stigma, we have to build resilience for those with diabetes. At the individual level, this resilience manifests itself as pride; and at the interpersonal level, it is seen as social support. It’s important to build resilience through a sense of community and support in both these areas because higher levels of interpersonal stigma can lead to higher levels of self-stigma, which can then have impacts on medication adherence and other self-care behaviors. 

  • Diabetes stigma decreased people’s willingness to take their medication, while diabetes pride increased it. Dr. Beach’s team developed scales to measure diabetes stigma, diabetes pride, and medication adherence, and they conducted empirical research. Her research found that diabetes stigma influenced how they cared for themselves and whether they took their medication. This data help provide evidence that diabetes stigma is resulting in worse healthcare outcomes. 

  • Healthcare professionals should be encouraged to use language that is strengths-based, respectful, and imparts hope for people with diabetes. Dr. Beach concluded with language tips for healthcare providers. She called for greater use of language that is neutral, non-judgmental, and based on facts. As seen by her findings, a community of support can lead to better outcomes. Those with type 2 diabetes especially often lack this community of support, but a person’s healthcare team can help to fill this void. We encourage you to share our Stigma Resources with your healthcare team and loved ones to help encourage the use language that does not stigmatize people with diabetes.

Addressing diabetes stigma is an essential missing element of effective and compassionate diabetes care. To learn more about the work diaTribe is doing to combat diabetes stigma, check outr our resources on the subject:

InPen Helps Overcome Challenges in MDI Therapy

The InPen is a resuable smart insulin pen that is used to deliver basal and bolus insulin doses. The InPen app, called "Insights by InPen" allows the person with diabetes to access their diabetes care data and share it with their healthcare providers. Hope Warshaw, a Registered dietitian and Certified Diabetes Care And Education Specialist, presented recent data on the InPen that showed the device can help improve Time in Range (TIR). 

A study by Medtronic looked at 1,721 InPen users and showed that those who delivered more frequent bolus insulin doses had the most TIR. Ms. Warshaw explained that the ability to calculate insulin on board and integrate carbohydrate and continuous glucose monitor (CGM) data allows people with diabetes to “more safely and comfortably” deliver correction doses between their regular meal doses. Data shared in her talk included:

  • Users with more than six injections per day saw the highest average TIR (67%). These users were often delivering smaller bolus doses, reducing their risk for hypoglycemia and insulin stacking.

  • For those administering fewer doses, TIR range was lower. For those delivering only one injection per day, TIR was 54%.

Should You Use CBD or Medical Marijuana if You Have Diabetes?

You have might have heard that CBD (cannabidiol) or medical marijuana might help you manage conditions such as neuropathy that are associated with diabetes. But what do researchers actually know about these substances?

Dr. Kam Cappoccia, a clinical professor at West New England University, College of Pharmacy and Health Sciences, delivered a presentation on the use of medical marijuana or CBD in people with diabetes. Both CBD and medical marijuana are products of the cannabis plant, however CBD does not usually have the psychoactive effects on the brain that medical marijuana has. She began by establishing first and foremost that the use of marijuana is illegal on the federal level, though each state has different laws detailing whether or not marijuana is allowed (for medical reasons or recreationally). Alternatively, hemp, a version of cannabis that CBD comes from, is legal in the US as long as it meets certain requirements.

Dr. Cappoccia emphasized that CBD and medical marijuana should not be used by anyone with heart, liver, kidney, or immunological disease, or anyone who is pregnant or breastfeeding. In addition, she discussed the lack of clear evidence and data showing whether CBD or medical marijuana is beneficial for people with diabetes. The very few studies that have been done are small and inconclusive:

  • In a small, randomized trial of 29 people (62% had diabetes), the use of a topical (cream) CBD oil used over four weeks was found to reduce intense pain, sharp pain, and cold and itchy sensations compared to those using a placebo for people experiencing chronic, peripheral neuropathic pain (chronic pain in the participants’’ limbs). These results were identified by significantly reduced scores on the Neuropathic Pain Scale (NPS) that measures pain intensity on a scale from 1-10.

  • In another small, randomized trial of 62 people with type 2 diabetes (not on insulin), it was found that those taking THCV (a cannabis substance similar to CBD that does not have psychoactive effects) experienced decreased fasting plasma glucose (from 133.2 to 120.6 mg/dL in the THCV group compared to 136.8 to 144 mg/dL in the placebo group) and improved beta cell function. However, neither THCV or CBD had any effects on HDL or LDL cholesterol, cardiovascular function, bodyweight, appetite, or gut hormones.

Overall, Dr. Cappoccia said, there isn’t enough data to allow for informed recommendations on whether or not CBD or medical marijuana could help manage the associated complications that accompany diabetes.

If you are interested in trying one of these substances, talk to your healthcare team before starting them. CBD and medical marijuana are drugs, which mean they may interact with other medications you are taking or even the food you are eating. Dr. Cappoccia suggests journaling if you choose to try one of these substances to keep track of side effects and be able to talk to your healthcare team about them.

In addition, because these substances are not well regulated, you should always to research individual product quality in advance. This paper highlights questions you should ask when researching CBD products (including if it meets certain quality standards, is organic, and has been laboratory tested).

What Options Do You Have Beyond an Insulin Pump?

Insulin pumps are helpful devices that can give programmed basal doses of insulin and boluses to correct high glucose and match food intake, however insulin pumps are only used by a minority of people with diabetes who require it. Though insulin pumps can be very useful tools to manage your diabetes, they do have some limitations such as high costs, limited insurance coverage, and the need of being trained to use one.

Colleen Miller-Owen, a nurse practitioner and diabetes care and education specialist (DCES), reviewed the various alternatives to an insulin pump at this year’s conference. These alternatives may help overcome some of the limitations of an insulin pump.

Smart insulin pens with a bolus calculator 

  • Insulin pens, a limited number of which are now on the market with more in development, contain bolus dose calculators which help calculate how much rapid-acting insulin to deliver for a bolus at mealtime or for a correction bolus by taking into account carbohydrate ratios and your insulin on board from a previous bolus.

  • Smart insulin pens do well in managing large amounts of data. They can automatically record timing of a dose and the amount of insulin being delivered and integrate seamlessly with continuous glucose monitor (CGM) data. Smart Insulin pens can also help assess dosing behaviors, alert about missed doses, and track basal/bolus percentages. 

  • If you’re currently using meal-time insulin and are on MDI, smart pens may be a cost-effective alternative to an insulin pump. It is important to be trained by a DCES or healthcare professional and to share reports with your healthcare team to discuss adjustments.

Inhaled insulin

  • Ultra-rapid inhaled insulin has a very fast peak and shorter duration of action. It is not given by injection and can be given more discreetly.  

  • Inhaled insulin may be an option if you currently take mealtime insulin and you are looking for a way to reduce the number of injections of insulin you administer. 

  • Afrezza is currently the only approved inhaled insulin in the US. Training with a DCES or healthcare professional is important since the rapid onset and short duration of this type of insulin might make it challenging to get the dosing correct. 

Patch pumps

  • Patch pumps, mainly useful for type 2 diabetes, are disposable insulin delivery devices that can deliver basal and bolus doses or bolus only. While both use fast acting insulin, the basal/bolus device has to be changed every 24 hours while the bolus only device only has to be changed every 72 hours. 

  • The basal/bolus patch pump is ideal if you use both basal and bolus insulin and these patches often cost less than a durable insulin pump.

  • The bolus only patch pump is ideal if you can take basal insulin by injection but want to delivier bolus doses at mealtime discreetly.

  • When getting trained with a DCES be sure to ask how to calculate your starting dose based on a total daily dose or a weight-based approach.

It is important that all people with diabetes have a discussion with their healthcare team and receive training when starting a new insulin delivery device. Miller-Owen concluded by reiterating that people with diabetes all have unique needs and should be aware of the different options for insulin delivery. There is no “one size fits all” solution and it’s always an option to switch to another device if the one you are using is not helping you with your diabetes management.

Diabetes Technology: What’s New, What’s Hot!

Dr. Diana Isaacs, an endocrine clinical pharmacy specialist at Cleveland Clinic Diabetes Center, and Dr. Dhiren Patel, an endocrine clinical pharmacy specialist at VA Boston Healthcare System, discussed the latest advancements in diabetes technology, including exciting new and upcoming approvals for smart insulin caps and pens, continuous glucose monitoring systems (CGM) with advanced digital integration, and closed-loop insulin pumps. They also touched on the ways these technologies can be used on the personal level to improve outcomes for people with diabetes.

Dr. Patel kicked off the session stressing the ways in which new diabetes technology can be personalized to each individual, including identifying the right technology, designing a personalized treatment plan, and collaborating with healthcare providers on a regular basis. He then discussed the latest developments in smart insulin pens and caps, citing how many people with diabetes today struggle with improper dosing and inaccurate data logging, which can affect the ability of healthcare providers to respond to missing or incomplete data concerning treatment.

The newest and most advanced smart pens and caps have a few basic features in common. These pens are typically made up of a reusable insulin injector pen, or a disposable pen with a detachable cap that can be paired with a smartphone app. These devices – by pairing with a bolus calculator and a CGM, help calculate accurate dosing for meals and corrections, and they can alert the user to help remind them not to miss an insulin dose. Devices can be paired through a Bluetooth connection, allowing for quick transfer of data from your pen to your smartphone, and even to your healthcare provider. Some of these recently or soon-to-be approved pens include:

Following this, Dr. Isaacs discussed innovations in CGM technology. She explained the benefits of CGM in providing real-time glucose data and allowing people with diabetes to monitor their Time in Range (TIR), the time spent each day within a healthy glucose range of 70-180mg/dL.

Several options for CGM devices exist for people with diabetes. Professional CGMs are devices lent out directly by your healthcare provider, while personal CGMs are owned by the patient. Some of these devices require users to calibrate the device multiple times per day using a fingerstick while others have no fingerstick requirement. Devices awaiting FDA approval include:

Dr. Isaacs shared advancements in closed-loop insulin pump technology, which aim to mimic insulin delivery by the pancreas. The types of pumps available include patch pumps and open- and closed-loop pumps which have been shown to increase TIR and reduce the length of time and frequency of hypoglycemia.

Patch pumps cannot be paired with a smartphone but can be used for 1-3 days before needing a replacement. Closed-loop pumps, however, are paired to your CGM through a smart algorithm and can use this data to automatically adjust insulin delivery.

New technology in the pipeline seeks to enhance the algorithms these devices use to limit the need for fingerstick calibration, provide over the wire (OTW) updates to operating systems (avoiding the need to change systems entirely to receive a technology update), and have the device controlled by the smartphone develop a mechanism to control insulin dosing directly through the touch of a button on your smartphone.