Nolan Alexander (Host): A look at Diabetes on this episode of Curating Care, a podcast brought to you by St. Clair Health, expert care from people who care. I'm Nolan Alexander. And joining me is Tia Fragello, physician assistant with St. Clair Medical Group Endocrinology here at St. Clair Health. Tia, it's great to have you today.

Tia Fragello, PA-C: Thanks for having me.

Host: Can you tell us a little bit about your background? And what led you to become a physician assistant in endocrinology?

Tia Fragello, PA-C: So, I always wanted to be a doctor from the time I think I went to my first grade career day, dressed as a doctor. So, I always wanted to be a doctor my whole life, pediatrician to be specific. And as I got older, I started to realize that a physician assistant, the path of physician assistant was becoming more popular when I was in high school. And the path to that seemed a little bit better for the lifestyle that I wanted. I knew that I could have a family and raise children and be able to do that a little bit better, going to PA school versus medical school.

And once I started looking into what a PA did, it fit more with my personality and the fact that I really love people and love to take care of people, and it offered me a little bit more one-on-one time with patients than being a doctor and having twice as many patients to see and things like that. So, I had an older cousin who was going to PA school. And so, I followed in her footsteps. And I went to Duquesne University here in Pittsburgh, PA, and they had a five-year intensive master's degree program to be a PA. And I graduated with my Bachelor's in Health Sciences with a Minor in Biology. And then, a year and a half later, I graduated with my Master's Degree of Physician Assistant Studies.

So right away, after I took my boards, I was looking for jobs around, again, specifically pediatrics. And that's where I had my first job at Children's Hospital of Pittsburgh of UPMC, and it so happened just to be in endocrinology. I had always had a love for specialty care, not just making sure that kids' ear infections were treated or they had the flu or colds or well-child checks. But really, making sure that kids were able to have specific diseases or conditions and be able to prosper and live healthy lives with that.

 When I first started, I didn't know much about endocrinology, but I developed a quick love for endocrinology. So, I worked at Children's Hospital for about 14 years. And then, my own love of children caused me to have my own and need to be a little bit closer to where I was living and my children were growing up. So, I had known Dr. Evron who was the doctor that I work with now. I had known him personally, and he was looking for a PA and I was looking for a job. And I really loved endocrine and really wanted to continue my focus in endocrinology. So, that brought me to St. Clair and St. Clair Medical Services and Dr. Evron. And I've been here for about eight or nine years now.

Host: That's incredible. And as you get to live out your childhood dream of working in the medical field every single day, what does a typical day look like for you?

Tia Fragello, PA-C: So, my typical day is I have patients all day long. So, I am just seeing patients in the clinic every day. And as a PA, I have a little bit more time to focus with my patients. So, I see patients in the morning, a specific number every day. I see all kinds of different endocrinology issues. And then, the same in the afternoon. So, most of my day is direct patient care, which is what I love the most, which is why, again, I chose this field.

I work part-time so that I do have, you know, two younger children that I'm carting everywhere and being a mom too. So, the other times that I'm not working, I am doing other things such as this podcast. I've been a speaker for diabetes educator groups. And something that we'll touch on later, my true love, I'm the Medical Director of Camp Courage, which is a summer diabetes camp for children.

Host: I can't wait to talk about Camp Courage. Let's go on ahead and set the scene though and talk about diabetes. I just want to make sure, for those who may not know, can you explain the different types of diabetes you commonly treat?

Tia Fragello, PA-C: So, the two most common types of diabetes are type 1 and type 2 diabetes. So, type 1 diabetes is an autoimmune disease. And it is when your antibodies in your system attack the cells in your pancreas that make insulin. And so, you're insulin-deficient, your body does not make any insulin. And that often happens in childhood. It used to be called juvenile diabetes, but we don't call it that anymore. It often, like I said though, happens in childhood. But you can see it in adulthood as well where your body just stops making insulin, period. And you require insulin from an outside source, which is injections. Your body needs insulin in order to get sugar into your cells. Sugar is the energy that makes all of our cells work. So if we can't get the sugar into our cells for energy, what ends up happening is we excrete all of the sugar in our urine, and it stays in our blood. And the blood sugar continues to go higher, and we're trying to excrete it, like I said. And so, you need to have the exogenous insulin, the insulin given through an injection into your system so that you can get the sugar that's from your blood into the cells to work.

The other most common kind of diabetes is type 2 diabetes. So, the biggest difference between type 1 and type 2 is that type 1, like I said, is insulin deficiency, type 2 is insulin resistance. So, your body makes the insulin, but you become resistant to it. So where it might take a little bit of insulin to get that Sugar into the cells, it now will take more and more.

So, in the beginning, you can go with type 2 for a long time without necessarily noticing it. Type 1, once you start to not make any insulin or not make enough insulin, your blood sugars go really high, really fast, and you can get into a very dangerous situation. Type 2, we typically start with diet and exercise as our first form of treatment. And then, down the line, we have to move into oral medication and then, if need be, insulin later on.

As I said, type 1 is an autoimmune disease. Type 2 has a lot of outside factors. Genetics can be one of them. So, you can just be predisposed to having a type 2 diabetes in your family. Then, you get to kind of different kinds of diabetes that aren't as common. You can get gestational diabetes when women are pregnant. Sometimes that can lead to diabetes later on in life. You are definitely at a higher risk for diabetes later in life with that. And then, sometimes we also have this gray area. Sometimes we call it type 1.5 diabetes where your body's not making the insulin. But then, due to other issues, you can be resistant to the insulin that we're giving you. So then, it makes it a little bit more difficult to treat.

Host: With so many different forms that you went over there, what are some of the biggest misconceptions people have about diabetes?

Tia Fragello, PA-C: That you did it to yourself. " Did my child eat too much sugar? Is that why they got diabetes? Did they not follow a good diet?" That only obese people get diabetes. I would have to say that those are the biggest misconceptions, and that you basically "did something wrong to get this." And sometimes, when it comes to an autoimmune disease, autoimmune diseases in general can be hereditary. But when it comes to type 1 diabetes, your body doesn't work the way it should, because your body has attacked itself. And so, it's not making that insulin that you need.

In type 2 diabetes, sometimes it's just you can do all the right things, you can have a healthy weight, you can be the best eater in the world, you can exercise every day, and sometimes just genetically, you're just predispositioned to get it or predisposed to get it. I often tell my patients, you know, it's not that you did something wrong, it's just like the fact that I can't change that my eyes are brown based on the genes I got from my mom and dad. We can't change this either.

Host: We continue to benefit from technology, and there's technology like continuous glucose monitors, insulin pumps too, and that's changed diabetes management. How do you see these tools helping patients?

Tia Fragello, PA-C: In the grand scheme of things, I've been practicing medicine a little over 20 years, and the changes that I have seen in that time are just remarkable. When we look at things like insulin pumps, it's a way for people to get their insulin all the time, slowly get dripping into their system. And then, when they eat to take more and they can adjust it based on the hour, that makes controlling your diabetes much easier because you are able to work down to hourly increments of when you're getting insulin and how much insulin you're getting versus just taking one shot and having to deal with the side effects of that later, depending on what kind of insulin you're taking. So, that is a huge benefit that we've had in just diabetes treatment period.

And then, when you look at the continuous glucose monitors or the CGMs, that is just life-changing for a patient with diabetes to know what their blood sugar is literally every minute of the day. It can be a little overwhelming for sure. But a lot of times what we see happening and what I tell my patients all the time is you now can be proactive seeing that your blood sugar is going up or going down or staying steady versus being reactive and saying, "Oh, I'm really low. I need to treat my blood sugar," or "I'm really high. I need to take some insulin." So, it makes us proactive in how we handle our diabetes and how we handle treatment of diabetics.

When you think about what it used to be, it was a finger stick. Prior to that, people would dip their urine. If they had glucose in their urine, they knew to take more insulin. If they didn't, they knew to take a lower amount. Then, we moved to finger sticks, which was a great improvement. But the thing with the finger stick is you only know what your blood sugar is that second that you're pricking your finger. Now with these continuous glucose monitors, they're monitoring your interstitial fluid and they're able to tell you what that blood sugar is all hours of the day.

Host: Well, it's literally back in my day, this is what we had to do.

Tia Fragello, PA-C: Yeah. Yeah. It's crazy.

Host: Well, Tia, earlier in our conversation, you exuded a lot of passion when you brought up Camp Courage, and I want to talk about that. You're the Medical Director for Camp Courage. What's the camp all about and how did you become involved?

Tia Fragello, PA-C: When I started working at Children's Hospital, I want to say my first week, I was informed by the head of my department, her name was Dr. Dorothy Becker that, "By the way, you have to go to diabetes camp." And I stopped and I looked and I went, "I don't camp." And I think since that first year, I have never turned back.

Diabetes camp was started over 40 years ago by Dr. Dorothy Becker from Children's Hospital. It was started originally as a camp for children who had type 1 diabetes to go and live a week where diabetes was on the forefront, but it wasn't. They had plenty of staff there to take care of them and be able to live a regular life. I'm not sure how long ago it was now, the American Diabetes Association took over control of diabetes camp and they are now the backbone of diabetes camp. And that is when we decided that there were plenty of camps like this all across the country that the ADA was taking over. And we decided each camp needed its own name. One of our campers who had been a patient of mine since she was a little girl, she put in the name for Camp Courage. And that was what was picked because these kids are courageous on a daily basis.

And so, I have been doing Camp Courage every year. And the previous nursing director at the time was transitioning jobs and she wasn't able to continue as the head of camp. And she had been kind of grooming me for years, because she knew of my love of camp. And so, I would say maybe 10 or so years ago, I became the medical director. And I work very closely with the ADA camp director in setting up a week filled with fun and enjoyment for these campers.

I always say that Camp Courage Diabetes Camp is just like any camp, any other summer camp that any of these kids would go to with a side note that all these children have type 1 diabetes.

Host: Wow.

Tia Fragello, PA-C: Yeah.

Host: What sort of- transformation do you see in kids from the beginning camp to the end of camp, and how do they build their independence?

Tia Fragello, PA-C: It is so life-changing for these kids. And as you said, I mean, this is my true love, diabetes camp. I mean, my heart just explodes whenever I talk about it, whenever I'm at camp. I have seen kids go from coming to camp and saying that they hate camp on the first day. They're trying to send letters home to their mom and dads to pick me up. And I have seen those children-- I mean, there's one camper I'm thinking of specifically. I have seen him, he not only was a camper, then he became a counselor for the younger campers. He continues to be a diabetes counselor for these kids. And he's going to nursing school and he has asked, "Once I graduate, will you accept me back as medical staff?" So, I think that in and of itself tells you how life-changing this camp is for kids. I have watched children go and be scared of talking about the fact that they have diabetes to talking all the time about their diabetes, because it's just one other facet that makes them so unique of a human.

There's one little girl who is my youngest daughter's friend. One summer, whenever my daughter went back to school, she came home and she said, "Mom, guess who has diabetes? She's got a CGM on her arm." And I talked to this little girl about, "Why don't you come to camp?" And it took me a couple years, about two years to get her to come. And when she came this year, she had never given herself a shot. By day two or three, she was giving her own injections. I just talked to the school nurse the other day and she said, " She started at the beginning of this year not wanting to do it, and now she does every shot at every meal, every lunchtime by herself without my help." And it's just so amazing to watch these kids become so independent in their care and realize that they're not alone, that they have a full group of people behind them, that they have medical staff who adores them, who wants to see them flourish, and they have other people around them watching them who have the same condition that they have.

I always say, so I have two daughters. My oldest just turned 13 and my youngest will be 11 next week, and my daughters have been coming to diabetes camp since they were in utero. I've always come to diabetes camp, they have been. I've been pregnant with them. They've been newborn babies at camp. And my favorite thing about camp is watching that that's the one week where my daughters seem to be the outsider because they don't have diabetes thankfully. But they seem to be the outsider. And all of these kids, they are all together in all the things that they're doing to the point where my daughters are like, "Mom, can I check my blood sugar just to see?" Because everybody else is. So, it's just-- I mean I say it and I don't say it lightly, it is life-changing for these children.

Host: It is tough to put all that into words, Tia, and I can only imagine what it's like for parents too. How have you seen them respond after they see the impact that Camp Courage has had on their child?

Tia Fragello, PA-C: They are just beyond thankful. I have parents who it's a struggle for them to get to Camp courage every year. Financially, it can be a struggle. I have parents who have more than one child who are coming. And they will do whatever it takes to get their children there. Camp Courage, it affects these children so much. And like you said, it's hard to put into words unless you see it and are in it. And you just see the love that we all have for each other, the medical staff for each other. I love all my counselors, my kids. I mean, all these campers are my kids. I'm their mom for the week and I love it. These parents are so thankful.

And the other thing, it really provides these parents is it provides them a week of going, "Okay, I can take a step back. I know they're well taken care of and I can breathe," because having a child with diabetes is a full-time job and it can be very taxing on these parents. And so, Camp Courage, even though it sounds like it's just for a diabetic child and it is life-changing-- I know I've said that word so many times for this child-- it also is needed and life-changing for parents to have a week where they can not have to get up at night and make sure that their child's blood sugar is okay, not treat a kid with a low blood sugar or need insulin in the middle of the night, rest knowing that their child is safe In a place where there's medical staff. We're checking on these kids. These kids don't go more than two hours without somebody laying eyes on them. And overnight, it's even more frequently than that, we're checking these kids all night long, making sure they're okay.

So for the parents, it's a breath of fresh air because they know their kids are getting comradery with other children, and they're learning how to handle their diabetes better and it not be the elephant in the room, but these parents are also getting a week of breath. And it also is beneficial for the siblings of these kids. Sometimes it's really hard to be a sibling when everything has to stop because your brother or sister needs an apple juice. I have had parents who go on vacation for that week, the two parents, because they need a break. I've had them do fun things with their other child. They leave and they go and do something where they might have to stop and think about doing, like going for ice cream has to be kind of worked into the day when you have a child with diabetes. But they might drop their sibling off at camp and say, "Okay, let's go get ice cream because we can." So, it's just helpful for all aspects of the care team with a child with diabetes, it is the parents, the siblings, the doctors, the medical staff, and the child themselves.

Host: Well, Tia, I'll wrap it up with this. Is there something else that you feel like people understood more about diabetes or anything specific with their care and the timeliness of getting checked up on?

Tia Fragello, PA-C: I think the most important thing to know no matter your age, is that if you take a good care of yourself with your diabetes and you keep your regularly scheduled appointments with your endocrinologist, your pediatrician, or PCP, making sure your eyes are checked. And if you need further care for issues with your diabetes, that you can live a completely full, healthy, happy life, and a long life.

I just saw a patient the other day. I think he's had diabetes 50 some years. I have another patient, I think next week I'm seeing, who's had diabetes for over 60 years with minimal complications regarding that. So again, I think it's knowing that diabetes is a lifestyle change, whether it's type 1 diabetes, type 2 diabetes. But if you do what you need to do and you are a care team for your diabetes, that you can live a healthy, happy, long life and can do anything you want to do, you just have to take something else into consideration.

Host: Well, Tia, this was a wonderful conversation today. Thanks so much for joining us.

Tia Fragello, PA-C: Of course. Thank you so much.

Host: That was Tia Fragello sharing her invaluable insights on diabetes. To schedule an appointment with Tia, visit stclair.org or call 412-942-7295. If you enjoy this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you, I'm Nolan Alexander. And this is Curating Care. Thanks for listening.