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Diabetes Awareness
Shruti Dave, MD discusses how lifestyle management remains very basic to long term diabetes management and there is no one size fits all rules. He shares the technological advances that continue to make diabetes monitoring easier for patients and providers and the important considerations for other providers when choosing medications for diabetes patients, now that there are more options available.
Featuring:
Learn more about Shruti Dave, MD
Shruti Dave, MD
specialties include Cholesterol problems, Diabetes, Hormonal imbalance, Osteoporosis and Thyroid imbalance.Learn more about Shruti Dave, MD
Transcription:
Introduction: Expert Insights is an ongoing medical education podcast. The Carle division of continuing education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category one credit. To collect credit, please click on the link and complete the episodes post-test. This podcast forum is brought to you to share expertise and insights within our integrated delivery system. To help us improve the health of the people we serve and achieve world-class accessible care. This is Expert Insights. Here's your host. Melanie Cole.
Melanie Cole: Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and today we're discussing diabetes awareness. Joining me is Dr. Shluti Dave. She's an Endocrinologist at the Carle Foundation Hospital. Dr. Dave, thank you so much for joining us today. Let's talk a little bit about diabetes and what are you seeing in the trends right now?
Dr. Dave: We see that diabetes has been on the rise over the last decade, several years, probably two, three decades. The new diabetes incidents is not yet on the forum. We probably are seeing that just about the same number of patients are being diagnosed. Younger patients being diagnosed with diabetes is also a trend. And then there are a lot of advances happening in diabetes technology and also newer medications, especially for type two diabetes have become available and greater use of them is now encouraged because of expanded indications and establishing safety as we've had them on market for longer period of time.
Host: Well, so then let's get into a little bit of the technology. I'd like to start with self monitored blood glucose, as we're learning more about A1C and an estimated, and people are hearing these numbers being thrown around. They're not really sure, but those that have type one or type two that are monitoring their own, what are you seeing as far as timely, regular feedback and really any of the barriers or challenges or positivity’s to self-monitored blood glucose?
Dr. Dave: People, traditionally, at least for last couple of decades or so we have done the self-monitoring of glucose with what we would consider finger stick testing, or poking your finger, getting the capillary blood out, and then using one of the standard glucose meters to test your glucose levels. So, patients should get feedback from their providers about what their goals are for finger stick testing glucose levels when they are doing home monitoring. And general goals are for before meal timeframe, aiming to get all those numbers between 80 and 130. After meal, about two hours or so after eating, under 180, and then at bedtime, especially those with insulin therapy, we aim for a little higher goal between 100 to 160, just to reduce risk of hypoglycemia. What is new instead of relying just on those spot check measurements that patients have to do with finger poking, which obviously is not very pleasant and depending upon patient motivation, access, does not always get done.
So continuous glucose monitoring has come on the market and is getting refined almost every day. Lots of new devices coming along and also devices that are they're getting better and better. So the difference is a patient would wear one of these continuous glucose monitor. Some of them are called real-time, meaning they provide real-time feedback to the patient as to what their blood sugar is at any given time. What is the trend? Some are called intermittently scanned, continuous glucose monitors. And those are the ones where patients would swipe. And every time they swipe, they will be able to know what their glucose level is at that time. And then there have been blinded or professional continuous glucose monitors. These have been around for awhile and we used to use them more in office based setting, where we would put on one of these monitors on a patient, they will go out and about and live their life, and come back a few days later.
And then we will extract data from it and analyze it. So, they are not providing feedback in real-time, but it gives you still idea on a continuous level, how a person has done over the last so many days. That definitely does help figure out trends for a particular patient, rather than just having few spot check analysis of glucose levels. As far as limitations go, anytime new technology comes on, market cost and expense is an issue and that hopefully will continue to get better as we have more of these devices on market. Insurance coverage and cost of devices is the largest limitation factor, some of the times. Patient motivation can also be limiting. You can give them continuous glucose monitor, but if they don't scan them often enough, you're not going to get all the data that is being recorded.
Host: So interesting. How the technology is really advancing in diabetes. Now, Dr. Dave, What are some important considerations as you've given us some of the technology that's advancing, what about the medications available right now for diabetes patients, you have more options, we're hearing about more of them, they're working in different ways? Tell us a little bit about what's happening in medicational intervention?
Dr. Dave: Diabetes management, in terms of pharmacotherapy medication intervention is becoming more like many other chronic conditions where there are several different ways to approach diabetes. Like you eluded. Some medications working through your pancreas to make it release more insulin, some working on your liver and muscle to make the insulin being utilized more efficiently, some working to slow down your gut so that they have impact on hunger sense of satiety, and also how the nutrients flow through your gut, and how the interplay works with insulin. Those are broad medication, oral and injectable, how they work. And then there is insulin replacement therapy that has been available for several years now, but there are some advances, more longer lasting insulins on market. And there are some smart devices that also facilitate fine tuning treatment. So there are several factors that I like for all our healthcare providers to consider when they are deciding on medications, efficacy of medication, how much it is going to lower a patient's blood sugar is important.
Risk for hypoglycemia is something to keep in mind. Weight change is a very big factor nowadays. So medications that are encouraging weight loss, or at least are weight neutral are preferred over medications that encourage weight gain. There are things to look at in terms of complications. So patients with cardiovascular disease and heart failure, as well as patients with kidney disease benefit from certain medications like the SGLT two inhibitors and the GLP one receptor agonists, your flowscents, which are the SGLT two inhibitors, and then your gluetides are the GLP one receptor agonists. Then of course there is the cost that needs to be considered. And depending upon comorbidities, certain medications may hang around longer in a patient's bodies and may have some harmful effects. Kidney function is important in making these decisions. So for the majority of type two diabetes patients, Metformin is still considered first line medication. It is very effective in lowering glucose levels.
It does not have very many side effects besides some gastrointestinal side effects that in many patients settled down after two to three weeks of therapy and then some potential for vitamin B12 deficiency after long-term use. After Metformin. The choice largely depends upon these comorbidities that we talked about. For patients with cardiovascular disease, that includes atherosclerotic cardiovascular disease and also heart failure, as well as patients with kidney disease. The SGLT two inhibitors and GLP one agonist are preferred. For those patients who need to lose weight, which many type two diabetes patients do. These two classes are preferred also because they encourage weight loss. If a patient does not have any of those comorbidities and weight loss is not an important goal, then there are other oral classes of medications. The DPP four inhibitors have about intermediate efficacy in terms of lowering glucose levels.
And they have very little risk of side effects. Those are options certainly for patients to be considered. And those are your gliptins medications. There is one important thing I should mention for patients who have very high glucose levels, approximately over 300 or high A1C levels, approximately over 10, and especially ones who also have symptoms of high glucose, which is having basically polyuria polydipsia, or ones who are in catabolic state, losing weight. In those instances, starting out with insulin therapy is preferred, but then once you stabilize glucose levels, you can again go back to some of these other oral and non-insulin injectables.
Host: Oh, that certainly is a very comprehensive list. Doctor, thank you so much. And as we're wrapping up as lifestyle management remains very basic and you spoke about weight loss and how some type two diabetics, but not all. That is a main concern. We hear more about bariatrics as a way to help that. Tell us how there's no one size fits all obviously, but what are the latest recommendations for lifestyle management, behavior modification for diabetes?
Dr. Dave: What I find very useful is patient centered communication, motivational interviewing definitely the first visit and then almost every visit to figure out individualized plans for patients, personal beliefs, cultural beliefs, religion, tradition, health literacy, access to food, patient's willingness to change. And then of course you want to maintain pleasure of eating. So all of these factors are important. So trying to have an insight into all of these before you come up with suggestions and recommendations for patients is very helpful. The emphasis generally is on promoting helpful eating, with emphasis on non starchy vegetables, minimizing added sugars and refined grains. So whole foods that are rich in fiber are preferred over highly processed foods. Of course, then, as I said, the access to food, some of the healthier foods may be more expensive to access for certain patients. In those cases, you can always teach them other simple factors like changing over to artificial sweeteners in moderation, just placing emphasis on avoiding sugary beverages, also learning to combine different food groups. So eating a salad first to get a lot of your fiber and vegetables and then eating smaller helpings of maybe not so healthy carbohydrates, will also accomplish a lot for those patients who are not very willing to, or able to make dramatic changes. And then water. I cannot under-emphasize importance of hydration, when it comes to drinking, placing more and more emphasis on drinking more water and reducing sugar and even artificial sweeteners should only be consumed in moderation.
Host: Wow. That is great information. And so up to date, Doctor, thank you so much for joining us today. And that concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle provider's and to view Carle sponsored educational activities, please visit our website at carleconnect.com. For more information, we hope the information gained will be applicable to your work and life. If you found this podcast informative, please share on your social media and be sure to check out all the other interesting podcasts in our library. I'm Melanie Cole.
Introduction: Expert Insights is an ongoing medical education podcast. The Carle division of continuing education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category one credit. To collect credit, please click on the link and complete the episodes post-test. This podcast forum is brought to you to share expertise and insights within our integrated delivery system. To help us improve the health of the people we serve and achieve world-class accessible care. This is Expert Insights. Here's your host. Melanie Cole.
Melanie Cole: Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and today we're discussing diabetes awareness. Joining me is Dr. Shluti Dave. She's an Endocrinologist at the Carle Foundation Hospital. Dr. Dave, thank you so much for joining us today. Let's talk a little bit about diabetes and what are you seeing in the trends right now?
Dr. Dave: We see that diabetes has been on the rise over the last decade, several years, probably two, three decades. The new diabetes incidents is not yet on the forum. We probably are seeing that just about the same number of patients are being diagnosed. Younger patients being diagnosed with diabetes is also a trend. And then there are a lot of advances happening in diabetes technology and also newer medications, especially for type two diabetes have become available and greater use of them is now encouraged because of expanded indications and establishing safety as we've had them on market for longer period of time.
Host: Well, so then let's get into a little bit of the technology. I'd like to start with self monitored blood glucose, as we're learning more about A1C and an estimated, and people are hearing these numbers being thrown around. They're not really sure, but those that have type one or type two that are monitoring their own, what are you seeing as far as timely, regular feedback and really any of the barriers or challenges or positivity’s to self-monitored blood glucose?
Dr. Dave: People, traditionally, at least for last couple of decades or so we have done the self-monitoring of glucose with what we would consider finger stick testing, or poking your finger, getting the capillary blood out, and then using one of the standard glucose meters to test your glucose levels. So, patients should get feedback from their providers about what their goals are for finger stick testing glucose levels when they are doing home monitoring. And general goals are for before meal timeframe, aiming to get all those numbers between 80 and 130. After meal, about two hours or so after eating, under 180, and then at bedtime, especially those with insulin therapy, we aim for a little higher goal between 100 to 160, just to reduce risk of hypoglycemia. What is new instead of relying just on those spot check measurements that patients have to do with finger poking, which obviously is not very pleasant and depending upon patient motivation, access, does not always get done.
So continuous glucose monitoring has come on the market and is getting refined almost every day. Lots of new devices coming along and also devices that are they're getting better and better. So the difference is a patient would wear one of these continuous glucose monitor. Some of them are called real-time, meaning they provide real-time feedback to the patient as to what their blood sugar is at any given time. What is the trend? Some are called intermittently scanned, continuous glucose monitors. And those are the ones where patients would swipe. And every time they swipe, they will be able to know what their glucose level is at that time. And then there have been blinded or professional continuous glucose monitors. These have been around for awhile and we used to use them more in office based setting, where we would put on one of these monitors on a patient, they will go out and about and live their life, and come back a few days later.
And then we will extract data from it and analyze it. So, they are not providing feedback in real-time, but it gives you still idea on a continuous level, how a person has done over the last so many days. That definitely does help figure out trends for a particular patient, rather than just having few spot check analysis of glucose levels. As far as limitations go, anytime new technology comes on, market cost and expense is an issue and that hopefully will continue to get better as we have more of these devices on market. Insurance coverage and cost of devices is the largest limitation factor, some of the times. Patient motivation can also be limiting. You can give them continuous glucose monitor, but if they don't scan them often enough, you're not going to get all the data that is being recorded.
Host: So interesting. How the technology is really advancing in diabetes. Now, Dr. Dave, What are some important considerations as you've given us some of the technology that's advancing, what about the medications available right now for diabetes patients, you have more options, we're hearing about more of them, they're working in different ways? Tell us a little bit about what's happening in medicational intervention?
Dr. Dave: Diabetes management, in terms of pharmacotherapy medication intervention is becoming more like many other chronic conditions where there are several different ways to approach diabetes. Like you eluded. Some medications working through your pancreas to make it release more insulin, some working on your liver and muscle to make the insulin being utilized more efficiently, some working to slow down your gut so that they have impact on hunger sense of satiety, and also how the nutrients flow through your gut, and how the interplay works with insulin. Those are broad medication, oral and injectable, how they work. And then there is insulin replacement therapy that has been available for several years now, but there are some advances, more longer lasting insulins on market. And there are some smart devices that also facilitate fine tuning treatment. So there are several factors that I like for all our healthcare providers to consider when they are deciding on medications, efficacy of medication, how much it is going to lower a patient's blood sugar is important.
Risk for hypoglycemia is something to keep in mind. Weight change is a very big factor nowadays. So medications that are encouraging weight loss, or at least are weight neutral are preferred over medications that encourage weight gain. There are things to look at in terms of complications. So patients with cardiovascular disease and heart failure, as well as patients with kidney disease benefit from certain medications like the SGLT two inhibitors and the GLP one receptor agonists, your flowscents, which are the SGLT two inhibitors, and then your gluetides are the GLP one receptor agonists. Then of course there is the cost that needs to be considered. And depending upon comorbidities, certain medications may hang around longer in a patient's bodies and may have some harmful effects. Kidney function is important in making these decisions. So for the majority of type two diabetes patients, Metformin is still considered first line medication. It is very effective in lowering glucose levels.
It does not have very many side effects besides some gastrointestinal side effects that in many patients settled down after two to three weeks of therapy and then some potential for vitamin B12 deficiency after long-term use. After Metformin. The choice largely depends upon these comorbidities that we talked about. For patients with cardiovascular disease, that includes atherosclerotic cardiovascular disease and also heart failure, as well as patients with kidney disease. The SGLT two inhibitors and GLP one agonist are preferred. For those patients who need to lose weight, which many type two diabetes patients do. These two classes are preferred also because they encourage weight loss. If a patient does not have any of those comorbidities and weight loss is not an important goal, then there are other oral classes of medications. The DPP four inhibitors have about intermediate efficacy in terms of lowering glucose levels.
And they have very little risk of side effects. Those are options certainly for patients to be considered. And those are your gliptins medications. There is one important thing I should mention for patients who have very high glucose levels, approximately over 300 or high A1C levels, approximately over 10, and especially ones who also have symptoms of high glucose, which is having basically polyuria polydipsia, or ones who are in catabolic state, losing weight. In those instances, starting out with insulin therapy is preferred, but then once you stabilize glucose levels, you can again go back to some of these other oral and non-insulin injectables.
Host: Oh, that certainly is a very comprehensive list. Doctor, thank you so much. And as we're wrapping up as lifestyle management remains very basic and you spoke about weight loss and how some type two diabetics, but not all. That is a main concern. We hear more about bariatrics as a way to help that. Tell us how there's no one size fits all obviously, but what are the latest recommendations for lifestyle management, behavior modification for diabetes?
Dr. Dave: What I find very useful is patient centered communication, motivational interviewing definitely the first visit and then almost every visit to figure out individualized plans for patients, personal beliefs, cultural beliefs, religion, tradition, health literacy, access to food, patient's willingness to change. And then of course you want to maintain pleasure of eating. So all of these factors are important. So trying to have an insight into all of these before you come up with suggestions and recommendations for patients is very helpful. The emphasis generally is on promoting helpful eating, with emphasis on non starchy vegetables, minimizing added sugars and refined grains. So whole foods that are rich in fiber are preferred over highly processed foods. Of course, then, as I said, the access to food, some of the healthier foods may be more expensive to access for certain patients. In those cases, you can always teach them other simple factors like changing over to artificial sweeteners in moderation, just placing emphasis on avoiding sugary beverages, also learning to combine different food groups. So eating a salad first to get a lot of your fiber and vegetables and then eating smaller helpings of maybe not so healthy carbohydrates, will also accomplish a lot for those patients who are not very willing to, or able to make dramatic changes. And then water. I cannot under-emphasize importance of hydration, when it comes to drinking, placing more and more emphasis on drinking more water and reducing sugar and even artificial sweeteners should only be consumed in moderation.
Host: Wow. That is great information. And so up to date, Doctor, thank you so much for joining us today. And that concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle provider's and to view Carle sponsored educational activities, please visit our website at carleconnect.com. For more information, we hope the information gained will be applicable to your work and life. If you found this podcast informative, please share on your social media and be sure to check out all the other interesting podcasts in our library. I'm Melanie Cole.