Cheryl Martin (Host): Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. I'm Cheryl Martin. On this episode, learn how technology is changing diabetes care. Our guest, nurse practitioner and diabetes expert, Caitlin Nass. Caitlin is the Clinical Director of the Diabetes Transformation Program for the Primary Care and Population health Department at the UM Baltimore Washington Medical Center. Caitlin, glad to have you on.

Caitlin Nass: I'm so glad to be here. Thank you very much.

Host: To start, how has technology changed diabetes care in recent years?

Caitlin Nass: It has changed it so much for the better. So, diabetes is a uniquely challenging chronic illness to manage. And we are very data-dependent. So, we're always after patients to be testing their sugars at home to kind of guide their therapy and understand how they're doing. And technology's making easier to capture that information.

It also provides patient coaching or feedback information. There are apps now that help people capture a better understanding of how their food choices impact their diabetes care, coaching apps with education. So, there are a lot of great extra virtual support for patients that we haven't had in the past.

Host: So for someone who's new to this topic, what are the main diabetes tools—you mentioned apps—people should know about today?

Caitlin Nass: So really, the first one is the more challenging, but that is for many, many patients with diabetes, they need to be able to understand their blood sugar patterns at home. And historically, that's meant pricking their finger and getting a blood test. And then keeping track of that and remembering to bring it to appointments when they go to see their provider for things like glucose meters. There are apps on the phone that can make sharing those results easier with their care team and also seeing them in an organized fashion to make sense of them. We also have continuous glucose monitors, which can take the place of the fingerstick testing of blood and show people their blood sugar patterns continuously. And that has been a huge game-changer with the great expansion of that across patients with both type 1 and type 2 diabetes in the last 10 years.

Host: You mentioned glucose monitors—and there's been a lot that people have heard of them—or CGMs talk more about what they are and how they can help compared with traditional fingersticks.

Caitlin Nass: They're just one of the best things that has happened in diabetes care. For patients who are totally insulin-dependent, like people with type 1 diabetes, they're life-changing, and also lifesaving in some cases because they allow the patient to understand where their sugar is every moment in time, to see a continuous tracing of their sugar readings on their phone or on a handheld receiver. It tells them not only where they are and where they've been, but it can also give them information about where their sugar is projected to go over the next 15 to 20 minutes. So, that allows for learning and planning and anticipatory problem-solving. That is just not possible when you're just looking at individual fingerstick readings without that pre-/post- context that a sensor can give. They're easy to put on. They're not painful. They're just a fabulous tool and most patients find them really, really empowering and motivating.

Host: Caitlin, we also hear about insulin pumps and smart insulin pens. How do they work and who might benefit from them?

Caitlin Nass: So, the smart insulin pens. And then, there's another device that allows people to give insulin in small increments that's actually attached to them that's not a pump. A couple things about them that are really, really helpful is that they keep track of everything for the patient. And so, the patient has a record of how much insulin they took and when they took it. And if they're tracking also with a continuous glucose monitor or with their fingerstick readings, then they and their care provider can see how well their doses are working for them. It can be really clear when I'm looking at a report with a patient, if they're dosing for meal times after they've already started eating, if they have a sensor on, and I can see their sugars were already high, they may not meet a higher insulin dose, we may just need to work on getting the insulin dose taken before the meal actually starts.

So insulin therapy, managing insulin therapy is one of the hardest things that we ask people to do. So, these pens and other insulin administration devices can just make that part of the job more manageable for the patient, and also collect data that is really useful when analyzing how well their therapy is working for them.

Host: Talk more about these technologies that help people spot patterns in their blood sugar and make day-to-day decisions about food, exercise, sleep, or stress.

Caitlin Nass: The continuous glucose monitors that we were talking about, they now have options to help patients capture their images of their food, and also to record and comment on patterns in their blood sugars, "The last time you ate this meal, your sugars went higher." That is a level of functionality that really didn't exist a couple years ago, and it's one that I think both patients and providers are newer to. So, it's something I'm looking forward to learning more about with my patients.

But just having all that blood sugar and food and physical activity and illness, having that information all mapped out and organized is just so empowering and so helpful when a patient is talking to their provider and trying to figure out when something went wrong or being able to illustrate why things are going so well, it's because a patient with diabetes is making dozens and dozens and dozens of decisions in a given day about what to eat, when to eat, their medications, physical activity and trying to keep track of all that and recollect it when you're talking to your provider is overwhelming. So, any tool that helps patients capture and retain that information so it can be analyzed is very, very helpful.

Host: Now, technology. This sounds so helpful, but it can also sound intimidating for some. So, what would you say to someone who feels overwhelmed or worries these devices might be too hard to use?

Caitlin Nass: I think for the insulin administration devices, whether it's the insulin pens that have apps connected to them, or definitely insulin pumps are a huge step up in terms of what a patient is being asked to take on and to manage, getting somebody started on a continuous glucose monitor is a much easier sell.

Let's try it for 10 days, try it for two weeks. See what you learn. If you don't like it, that's fine. But I certainly want anybody who's taking insulin, anybody who's struggling with low blood sugars to have really strongly considered that option and whether it would help them. It's always the patients choice. But when it comes to continuous glucose monitors, I would say the response is almost universally positive as long as the patient has been prepared and educated and we kind of talk about scenarios in advance of them leaving the office wearing it for the first time.

Host: That's great. Now, affordability can be a big concern for some people. So, are these devices usually covered by insurance? And what can patients do if the cost seems out of reach?

Caitlin Nass: That is one of the things we struggle with every day with patients. Yes, for certain patients, we should anticipate that this technology would be covered by their insurance. So, for instance, in the state of Maryland, anybody with type 1 diabetes who's insured should be able to get an insulin pump and a continuous glucose monitor, which are standard of care for type 1 diabetes.

But the process of getting it, the copay that they might encounter can differ, and that can be a challenge for patients. And then, for people who are uninsured, people who have type 2 diabetes, they may have difficulty with affordability or their insurance plan may not choose to cover it for them. So, this is a conversation we're having throughout the day every day when we're working with people with diabetes to figure out the right choice for them.

Believe it or not, when it comes to continuous glucose monitors, patients value the freedom from the fingerstick testing so much and they value the data that they can give them. Patients are even willing to pay out of pocket sometimes for those devices. And, again, it's not because I want them to, but it's just a testament to how much they are valued. But no, we would like to see even broader access and lower prices for sure.

Host: How important is it to work with the diabetes care team when choosing or learning to use this technology and who might be part of that team?

Caitlin Nass: I am a huge proponent of diabetes education with a diabetes care and education specialist, and that's typically in an urban area like Baltimore, Washington, big cities, you should have access to diabetes care and education specialists within diabetes centers or endocrinology practices. We would love to have more of them. But as I alluded to, there are so many elements of diabetes self-care, medications, food stress, blood sugar testing, that having a real expert coach and clinician who can understand you, understand your challenges, and your learning needs is incredibly important.

For some people they get, they open up the box, they put it on themselves, and they're off to the races. With something like a continuous glucose monitor, I much prefer to have people have coaching from whoever their clinician is, wherever they're being seen. And certainly if someone's going to be using something like a insulin pen that has software attached to it or an insulin pump, I would absolutely want them to be working with an endocrinology practice, so an educator and a diabetes expert in a diabetes center.

Host: So, what should patients ask their doctor, diabetes educator or care team, if they think a device might help them?

Caitlin Nass: Just feel free to be the first one to bring it up. And certainly people, clinicians, in all settings, primary care providers are getting this question routinely. And don't hang back, don't hesitate if your provider hasn't mentioned it, It doesn't mean it's not appropriate for ., So, raise your hand and ask about it. They're very, widely available and in use. So if for whatever reason you have diabetes and you've been struggling with your care, or you'd like to make one part of the job easier, be the squeaky wheel.

Host: So, you find that most people with diabetes are already aware in a general sense of these technologies.

Caitlin Nass: I guess I would say that because of the direct-to-consumer advertising. That is really, really prevalent, just like with the different medications. So there is a fair amount of awareness of them, but what they entail, if they would work for me, "Do they hurt? Is it going into my vein?" You know, those kinds of practical, logistical questions, most people wouldn't know and they need to get information and trust the person they're getting the information from.

Host: So, the patient should be proactive in asking the medical advisor about the possibility of getting these.

Caitlin Nass: Yes. And I think it's our job to offer it and to suggest it and to advocate for it. But if that conversation hasn't happened for you as an individual, by all means, raise your hand and ask.

Host: Caitlin, if you could leave listeners with one message about technology and diabetes care, what would it be?

Caitlin Nass: Just that those of us who work with patients with diabetes, we really do have an appreciation for how challenging the job is, and I want you to think of technology as something that can help make it more manageable and with, good coaching and preparation, it can really take a huge burden off of things like the daily reality of fingerstick testing and insulin administration, and also give alerts if your sugar's going too high, your sugar's going too low, and that can be a huge relief both for the person with diabetes And for their family.

Host: Caitlin Nass, thanks for bringing us up-to-date on how technology is changing diabetes care. Great, helpful information. Thank you.

Caitlin Nass: Thank you so much.

Host: We invite you to listen to more episodes when you visit umms.org/podcast, YouTube, or your favorite podcast platform. Thank you for listening to Live Greater a Health and Wellness podcast, brought to you by the University of Maryland Medical System. We look forward to you joining us again, and please share this on your social media.