Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and today, we're sharing the latest updates in diabetes management. Joining me is Dr. Liza Yambay. She's an Endocrinologist at the Carle BroMenn. Dr. Yambay, it's a pleasure to have you with us today. Tell us a little bit about the prevalence of diabetes today. What are you seeing and how have some of the treatment options evolved over the last decade or so? Why are we updating this podcast today?

Liza Yambay Valiente, MD (Guest): Hello. Thank you so much for having me. It's a pleasure to speak regarding diabetes. As we all know, November is diabetes awareness month and actually November 14th was the International Diabetes Day. We know that 10% of the population in the US has diabetes. And that's about 34 million people, 21% have been undiagnosed. This is the latest from 2020. Obviously the statistics may change because this was the last time I think the census was created. So this is information from then and it probably will get updated in the next couple of years. There's still one, one and a half million cases per year, a new diagnoses, obviously mostly people over 45 and mostly seniors over 65. And there's a pre-diabetes population that's about 34%. So, 88 million Americans have prediabetes.

Host: Wow. It's really staggering and it's, and it's turning into quite the epidemic. Right? So tell us what's new in screening and diagnosis, Dr. Yambay. Have the guidelines changed? What are some of the most recent guidelines for screening patients with suspected prediabetes or diabetes?

Dr. Yambay Valiente: Yes. So the actual screening methods have not changed much. It's still, you know, an eight hour fasting glucose or measurement of hemoglobin A1C or a two-hour glucose tolerance test measuring a load after two hours of the glucose. What has been updated most recently this year is there's been lowering of the cutoff of the age of the screening for patients who have a body mass index of over 25 and for over, overweight and obesity. And that's not, that's not surprising because that prevalence of obesity and overweight has increased as well. So the the US Preventative Taskforce has updated that. Traditionally patients over 45, that that would be the age of, or the screening would start unless there were risk factors that with family history and other and other co-morbidities that would make the physicians check for diabetes sooner. But again specifically in the, in the population who is overweight those the guidelines have have been updated to, to start screening at age 35.

Host: Well, thank you for sharing that. And as we're going to be talking about things that have changed and updating, we'd be remiss if we didn't mention technology that's available these days. How much does a health provider such as yourself rely on patient provided data when it comes to managing diabetes? Speak a little bit about some of the things that you've seen change in the last few years, as far as self-monitored blood glucose, technology, anything that you want to speak about?

Dr. Yambay Valiente: Yes, I will tell you that the endocrinologist community is very excited about the continuous glucose monitoring devices that are available currently. We actually have three in the market or three more common that we use in the market currently. And these are changing and evolving as we speak. So competition is good because it keeps us updated and, and the performance of these devices have improved over the last few years as a well. The, the indication for the continuous glucose monitors traditionally was just for the more for the Type 1 diabetic patients, because they were using insulin pumps.

They are still the category of patients who use it the most. But I will tell you personally, in my practice, I really like using this and I think patients have started to understand how to use technology. Even the older patients, they understand how to see their sugars, how to interpret their patterns.

And it has helped a lot of my patients control their sugars much better with less medications, with the continuous glucose monitoring. We have some guidelines regarding some targets that we want to look for, for the continuous glucose monitoring and the sugars. There's terms called time in range, time above range and time below range. And these actually have some meanings because every 5% increase in the time in range is clinically significant. And with every 10% of increase in time in range, it correlates with a decrease of anywhere from 0.5 to 0.8% in A1C reduction. So that's huge. And the patients can see it because there are other indicators on their summary that kind of give them an estimate of an A1C.

So as an endocrinologist, I like to look at numbers and we know that the continuous glucose monitoring are going to be the face of the future and the actual fingerstick glucose meters that we've used traditionally for decades are eventually going to fade away because these devices are replacing the traditional finger sticking, and just think about it. If you're a patient and you have an option of not pricking your finger even once a day and imagine four or more times a day to monitor your sugars, if you're using insulin or other medications that do affect your blood sugars and have to use a device, instead given the option to use a device that goes on your body for seven or 10 or 14 days, and you don't have to prick your fingers to look at your blood sugars.

Personally, I would prefer that. And so the information that comes from these devices are actually very, very useful. We have commercially available FreeStyle Libres, which are the easiest ones to use, and actually patients find it very convenient and very easy to use. So they're very user-friendly.

We have the Dexcom G6, which is also. They're, they're coming up with an update probably in the next year or so to a better model. And then Medtronic has its own standalone continuous glucose monitors called the Guardian sensor that pairs up with the phones. So some of these pair with phones most of these will pair up with phones if you don't want to carry an extra device and the other ones will pair up with something called a reader, which is a little machine that looks like a meter. But it's meant to read, to get the information from the blood show.

Host: Wow. That was such a comprehensive answer Dr. Yambay. What an exciting time to be in your field. Now tell us a little bit about, you've talked about the monitoring. Tell us a little bit about treatment options available today because those have certainly changed medicationally over the years and lifestyle hasn't really changed. And we'll talk about that, but tell us what's changed for medicational intervention.

Dr. Yambay Valiente: Yes, that is super important because over, even when I started my residency and my fellowship, and as I started practicing over a time, things have, have evolved. And traditionally, you know, when you found out that you had diabetes, the doctors would try to get your sugars down with essentially whatever medication would take to bring the blood sugars down that had evolved into guidelines that looked more into not only reducing the blood sugar, just looking through just using medications that will lower the blood sugars, but what would prevent complications, microvascular complications over time? What therapies would change that, then it evolved to, let's try to use the weight friendly diabetes medication so that we can also target the overweight and the obesity component, that's also a big risk factor. And then, the latest guidelines have also assessed additional co-morbidities, which are also other risk factors like cardiovascular assessment and renal benefits.

So our most current guidelines actually focus really on the patient as a whole, which is, which is really interesting because now we're looking at diabetes, not only as, you know, leveling the sugars, but also controlling other risk factors with medications that it was, that were created to treat just the sugars. So initially some of these medications were just designed to, you know, work by lowering the blood sugar in the patient's body. And with time as the clinical trials evolved because the FDA has granted, has, has actually required cardiovascular outcome trials, these extensions of these trials as have given us significant information of what else would be helpful with the, with the drug therapies that we have nowadays.

So this is really exciting. A conference a couple of years ago when I went the joke was, you know, the endocrinologists are playing cardiologists and the cardiologists are playing endocrinologists and the nephrologists as well. So everybody, the specialties that treat diabetes outside of endocrinology, meaning the cardiologist and the nephrologist who treat the complications and the risk factors are also starting to prescribe medications that are used to treat diabetes. So that is, that is great. So there's a lot of overlap between the specialties nowadays.

Host: I love that you said that because that's absolutely true. And as an exercise physiologist myself, I am seeing that as well because of the comorbidities and complications. They're all kind of melding in together. And that leads me very well to our next question about the multidisciplinary approach for these patients and why it is so important for primary care providers, Dr. Yambay please speak about how important this approach is so that everybody is working together and knows what each other are doing.

Dr. Yambay Valiente: Yes, that is super important. Because the, the mainstay of the treatment is, you know, focusing on the patient and the patient's characteristics. Every patient is different. And the main goal is to target, you know, their newly diagnosed diabetics. They need to get all the information that they can and digest it slowly because it's an overwhelming diagnosis, and an overwhelming condition and disease to have, and patients are scared of what they hear when they first meet their doctors.

So it's super important, if it works in the best, in the patient's best interest. So making sure that you make enough time to see your newly diagnosed diabetic patients starting by, you know, bringing little points of intervention, talking about the disease, talking about the potential medications, talking about who they're going to start seeing, because this may lead to complications. They will be seeing more than one doctor to manage their condition.

Some of these things have not changed, you know. We do have to send our patients to see their eye doctors on a routine, on a routine basis. So they have to just be encouraged if they haven't seen one, you know, explain why we have to send them to see the eye doc.. Why, it's important to keep up all those, those appointments. The other thing is making sure that, you know, at least they meet a few times with diabetes, certified diabetes educators, because they are the, our right hand actually for primary care providers, and also for endocrinologists, they kind of work hand in hand with us and they give that second wave of information to the patients. Patients think that they're just going to go there to talk about diet. And they also need to know that the educators focus on the, on the disease process itself. So they help the patients understand a little bit more about their condition. So it's another layer of information that kind of can sink in on a patient to better understand things. The number one comment that my patients, my new patients, when they come to see me is like, oh, you know, I've learned a lot on this visit because now, I can understand a little bit more amount my diabetes.

And I think that's super important because there is a lot of information that we're giving these patients and they just come up with, if it's too short of an appointment, they come up with this, like a deer in the headlights kind of face. So we don't want that to happen because we want them to be able to to feel comfortable and confident that they're going to do better and they will succeed, if the, if the doctor and the staff can approach them in a very easy way. The other thing that we like to do is obviously by the time that I personally see these patients, most of them already have, you know, a cardiologist or will be seeing a cardiologist. So, and, and some not all do see the nephrologist or the kidney doctor.

So, so make making sure that we touch base together when we're making adjustments in the medications, because a lot of things do affect the heart function or the kidney function. And you know, as one or the other starts medication, we want to make sure that we're monitoring for safety parameters, making sure that the filtration rate is not changing, making sure that their volume status is not changing.

And if we're making adjustment that would impact blood pressure or volume status, consult our colleagues who are seeing the patients so that they can, you know, that they can reassure the patients or see the patients in an interval after the patients have been seen by the endocrinologist or their primary care doctors that are managing the patients so that this kind of overlaps and there's not a big gap and confounders. And, and again, that medication adjustments doesn't impact you know, their their, their kidney function differently or, or their volume status differently because, you know, I don't manage water, you know, diuretics. So the cardiologist will be managing that.

But if I, if I give a medication that will make the patient have more diuresis, like the newer class SGLT 2 inhibitors, then I will touch base with my cardiologist to let them know, hey, I want you to, you know, back down a little bit on their furosimide or their torsemide or whatever hydroclorothiazide that you're using.

I tell my patients, I want you to monitor your blood pressure, and I want you to touch base with your primary and or your cardiologist if you're seeing that it's dropping, because you know, the medicine that I'm giving you will be affecting, will be affecting you. And I don't want that. You know too much for you and then you get sick and, you know, end up in the hospital because of a big change.

Host: Wow. It certainly is such an important part. What a great aspect that is also that you brought up the certified diabetes educators. They've, they've become quite the asset in this field in helping patients with diabetes. As we wrap up Dr. Yambay, as lifestyle management has remained very basic to long-term diabetes management, and there is certainly no one size fits all rules for this. What are you recommending to primary care physicians about using diabetes technology, about counseling lifestyle management, the multidisciplinary approach. I'm asking you to kind of wrap it up with your best advice and what you would like other providers to know.

Dr. Yambay Valiente: Yes. I would like everybody to be very proactive about diagnosing diabetes on the high risk population. If patients have symptoms and I want them to start their intervention early on. So if you find a pre-diabetic, talk to them, send them to the diabetes educators, the services will be covered under the correct diagnosis. And this is a super important step. If you are technology savvy and you like using these devices, make sure they're, there are a lot of webinars and resources of the ADA, even at the endocrine societies and even other places, including primary care resources where you can get updates on this.

And when you can get training. It's pretty easy. Train your staff to do it as well. Learn to interpret that data. And make sure that your refer your patients early on, if you're having trouble with them in particular. There are great guidelines under the ADA, which is the easiest one, they have this standard of care updates that they have annually or, you know, or when there are the updates and it's actually pretty easy to read, and it's very simple information that will give you a very detailed review of the approaches to take with your patients. And, and making sure that you, you know, then it when in doubt, reach out to the endocrinologist and say, hey, am I ready to send that patient to see you.

So just be proactive, learn your medications, learn your side effects. And then, like I said, learn that technology, if you're, if you're ready to, to use technology. And if your office is equipped to download technology, because, you know, knowing technology and not able to download it and interpret the data is, it's not useful and it doesn't really help the patients.

So that's, those are the important messages that I would like to, to pass on and making sure that you assess your patients for walking. We do now have additional resources that are part of technology as well, like counting steps. So set goals for your patients that are pretty easy for them to understand and to relate.

Host: What great information, what an excellent podcast this was Dr. Yambay. Thank you so much for joining us today and for more information, and to get connected with one of our providers, you can visit carle.org or for a listing of Carle providers and to view Carle sponsored educational activities, please visit our website at carleconnect.com.

That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole.