Diabetes Deconstructed

In Episode 54, Dr. Sarkar welcomes Dr. Jamie Hamilton, who will be talking with us about diabetes and metabolic dysfunction associated stenotic liver disease or MASLD. Dr. Hamilton is an associate professor of medicine in the division of gastroenterology and hepatology. He is the interim director of gastroenterology and hepatology and the director of hepatology for Johns Hopkins Medicine. Dr. Hamilton’s clinical specialties include Wilson’s Disease, cystic fibrosis related liver disease, liver transplantation, hepatocellular carcinoma, cirrhosis. Portal hypertension, acute and chronic viral non-alcoholic fatty liver disease, autoimmune,and cholestatic liver disease.  Dr. Hamilton is a recipient of the National Institutes of Health National Research Scholar Award for gastroenterology and hepatology.

Sudipah Sarkar: [00:00:00] Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Sudi Sarkar at Johns Hopkins. we developed this podcast as a companion to our Patient Guide to Diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkins diabetes info.org.

Today we’re excited to welcome Dr. Jamie Hamilton, who will be talking with us about diabetes and metabolic dysfunction associated stenotic liver disease or MASLD. Dr. Hamilton is an associate professor of medicine in the division of gastroenterology and hepatology. He is the interim director of gastroenterology and hepatology and the director of hepatology for Johns Hopkins Medicine.

Dr. Hamilton’s clinical specialties include Wilson’s Disease, cystic fibrosis related liver disease, liver transplantation, hepatocellular carcinoma, cirrhosis. Portal hypertension, acute and chronic viral non-alcoholic fatty liver disease, autoimmune, [00:01:00] and cholestatic liver disease. His research interests include copper homeostasis and its regulation of lipid metabolism and liver injury, fundamental mechanisms regulating liver fibrosis and the molecular genetics of hepatocellular carcinoma in early detection Biomarkers.

Dr. Hamilton is a recipient of the National Institutes of Health National Research Scholar Award for gastroenterology and hepatology. Welcome, Dr. Hamilton.

Jamie Hamilton: Thank you Dr. Sarkar.

Sudipah Sarkar: One question that we wanted to start off with today is, what exactly is metabolic dysfunction associated ketotic liver disease or MASLD? And could you tell us a little bit about what the name used to be and how did that shift and how does it better reflect how we understand the disease?

Jamie Hamilton: The disease used to be called “non-alcoholic fatty liver disease”. That was considered not to be a great name because it was a diagnosis of exclusion and many people didn’t really pay attention to the diagnosis because they just said the liver enzymes are mildly elevated [00:02:00] and it’s not that big of a deal. The reason for the name change was to really understand who was at risk for this disease, then make a diagnosis of the disease, and then who is at risk for developing serious liver problems from the disease? So there are five criteria, metabolic criteria that we use to determine who is at risk for the disease. And that’s having a obesity or overweight, so A BMI in Caucasians of over 25, and then E East Asians of over 23.

Or an an increased waist circumference of over 90 centimeters in men or 80 in women. Having a high triglyceride count over 150, having a low HDL less than 40, or on medicines to control lipids having high blood pressure or on medicines to control blood pressure or having most importantly type two diabetes and insulin resistance.

So people who have those problems are at risk for having fat in their liver. And we don’t like to use the word fatty liver ’cause fatty is not really a nice word. So we call it steatosis or st thetic liver. And that’s just a [00:03:00] doctor word for fat in the liver. There’s three main reasons why people get fat in the liver.

First one is alcohol. Second one are these metabolic problems. And then the third one. Is much more uncommon. It can be genetically caused or from medicines. But the main reason was take away the stigma of the word “fatty.” Take away the word “non-alcoholic” and really be more inclusive by saying, these are these in really important metabolic problems. Those people with those metabolic problems are at risk for having fat in their liver.

Sudipah Sarkar: Thank you. That’s very helpful. This is a podcast about diabetes and I know a lot of our listeners will be asking which comes first, is it that someone has diabetes and then they develop MASLD? Or do people usually have MASLD and then develop diabetes?

Jamie Hamilton: Usually they develop concomitantly or at the same time, usually at the time of a diagnosis of type two diabetes, the person, a patient will have some fat in their liver. It’s not as though it’s pretty, it would be pretty uncommon for someone to have fatty liver [00:04:00] first or steato liver first and then be diagnosed with diabetes later. But it is possible.

But they’re very tightly linked because. People who have type two diabetes have resistance to the insulin that they’re making, as and among other hormone problems they get. With this insulin resistance, you end up storing fat. In the liver inappropriately, and that’s what leads to the fatty liver.

And you mobilize fat from the your adipose tissues that goes to the liver. And then your liver continues to make its own fat and not checking that you or stopping that in the presence of having fat in the liver, but it can continues to make its own fat. And then of course you get fat from the diet.

Sudipah Sarkar: Another question that many listeners might have is how do you detect maced or how can a patient or their provider find out if they have MASLD?

Jamie Hamilton: The first thing obviously is just a routine checkup with either your diabetes specialist or primary care physician in which liver enzymes can be checked.

And they could be elevated, but that really shouldn’t be the [00:05:00] only test that are is done. There’re an ultrasound of the liver, which is a very non-invasive, easy test to be done should be done to measure fat in the liver. And so what is recommended now is someone who has these risk factors should be screened for fat in the liver, with liver enzymes and with an ultrasound.

And then there’s another simple test that you can use with existing blood tests. It’s called A Fib four, and it stands for Fibrosis four. And the four labs that we use or values that we use are the A ST, the A LT, which are liver enzymes, the platelet count, which is part of the complete blood count, and then the patient’s age.

And you put those numbers into a formula and it can put out a number. If that number is greater than 1.3, then the person could potentially have scar tissue in the liver. And if it’s greater than 2.6, the person, the patient likely has scar tissue in the liver and that should prompt further investigation as well.

So looking for fibrosis is really the most important thing in these [00:06:00] when you make these diagnoses, because that’s what really leads to liver damage is fibrosis in the liver.

Sudipah Sarkar: Based on the FIB four score, what further imaging tests could a general practitioner or endocrinologist order especially if it if it’s exceeds one of the cutoffs.

Jamie Hamilton: So what we generally recommend is something, there’s a thing called a FibroScan, which is an another non-invasive test. It requires a patient fasts for four hours prior to the exam, and then they put a probe on the abdomen over the liver and it measures the amount of fat in the liver and it measures the stiffness of the liver.

And from that, we can determine if there is scar tissue or not. There’s no IV needed. There’s no dye, there’s no biopsy needed in that situation. It’s it’s pretty non-invasive. There’s also a blood test called ELF or Elevated liver fibrosis, which is available at most commercial laboratories.

And that’s a really good blood test too, that can be used to estimate fibrosis. We don’t generally recommend something called the Nash fibro [00:07:00] brochure. That test is is pretty unreliable. And we don’t recommend that.

Sudipah Sarkar: At what point would you say that a patient should be referred to a liver specialist,

Jamie Hamilton: Anybody who has suspected fat in their liver and fibrosis.

Now, of course, if the problem is this is. This liver disease is the most common in the world, and about 30% of Americans probably have fat in their liver. So we can’t see all of them. So we do try and limit our evaluations to those who are just suspected to have fibrosis. One thing I will say too is patients that fib four test is not very reliable.

Once a patient gets over 65 or so. Then it starts to overestimate fibrosis. And so that can be more tricky. And in those patients you might want to go directly to a FibroScan to assess for fibrosis.

Sudipah Sarkar: In terms of treatment, what are treatments that are recommended to treat MASLD ?

Jamie Hamilton: The first thing we always recommend is trying to improve your metabolic risk factors and that we do that through dieting and exercise [00:08:00] because we know that weight loss can improve this condition markedly.

So we recommend generally what’s called a Mediterranean style diet, which is of course, rich in fruits and vegetables and lean proteins such as fish and chicken, and avoiding things like high carbohydrate diets, high fat containing diets, fatty meats like steak, And really portion control as many of your diabetic patients are aware of.

We also ask people to really reduce or avoid alcohol entirely because there really is no amount of alcohol that is safe for the liver. And then we also recommend routine exercise. Trying to exercise 30 minutes, five days a week, 30 days, 30 minutes a day, five days a week. Is ideal. If you do more than that’s even better.

And we studies have shown that if patients engage in that type of activity and are able to lose weight they do improve their metabolic risk factors and then they approve their fatty liver. But when someone has fibrosis, it’s a little bit more serious. And so in that case, there is one medicine that is [00:09:00] approved for this condition and it’s called Remeron.

And it was approved in March of 2024. And and it’s only approved in patients who have fat in their liver and stage two to three fibrosis. And so we determine that through a FibroScan. You can also do a liver biopsy In general, I don’t do liver biopsies for this condition too much unless there’s a competing diagnosis. And there’s also something called an MRI Elastography, which can also measure liver fibrosis, but of course that’s a more expensive test. But this drug rasmaderon. It was shown after a one the clinical trial was about one year long, and they enrolled patients many of whom had diabetes but all of whom had.

Fat in their liver in stage two to three fibrosis, and about 30% of patients at the end of that first year had a full one stage reduction or more in their liver fibrosis and in resolution of their steato hepatitis or their fatty liver. That is what we do for patients who have fibrosis.

I will say that really any strategy to reduce weight improves fatty liver. So many of the drugs that are used now [00:10:00] in diabetes also have the benefit of weight loss. So drugs like Mounjaro or ozempic or other types of what we call GLP one analogs they tend to help people lose weight and their fatty liver often improves.

And there been recently some clinical trials showing. Real benefit in patients with fatty liver disease and fibrosis in particular manjaro. Tirzepatide. It was published in the New England Journal of Medicine, a phase three trial showing about 50% of patients had a one or more stage reduction in their scar tissue.

So that’s an emerging indication for this condition, this fatty liver disease. But it’s not yet FDA approved it’s not a standalone drug just for this condition. Some people who have very significant obesity will also benefit from bariatric procedures. And in those patients, their metabolic risk factors rapidly improve after weight loss from those conditions.

So that’s always something to consider too. So things like endoscopic sleeve gastrectomy or surgical sleeve gastrectomy or gastric bypass can be of use.

Sudipah Sarkar: [00:11:00] Are there any exciting avenues of research and innovation that you could share with us in the field of MASLD and metabolic disease?

Jamie Hamilton: I think that the pharmaceutical industry is extraordinarily excited about this condition just because it really affects a third of the world’s population. So there’s something like 75 clinical trials that are ongoing right now at various different stages of development. And and all of these have very exciting preclinical data and e even some small, clinical trials showing benefit.

That’s really the major area of research is actually getting to the patient soon. Is are all these different meds that affect the way the liver handles fat and reduces inflammation and reduces fibrosis.

Sudipah Sarkar: In your experience, what would a coordinated care model look like for someone who has both MA and diabetes?

Jamie Hamilton: So I think a nice coordinated care model would be a team, a team that includes a liver specialist, an endocrine diabetes specialist and perhaps someone who specializes in medical weight loss [00:12:00] therapies. And sometimes in some cases, patient someone that specializes in lipid control lipid medicine sorry, lipid lowering therapies.

And sometimes that can be just a really good primary care doctor. And sometimes some cases it can be a specialist. But those are usually the general people that would be involved.

Sudipah Sarkar: Are there any over the counter medications that are used for treatment of MASLD?

Jamie Hamilton: I would not necessarily recommend over the counter supplements for the treatment of this condition. There are a lot of nutraceuticals or remedies that are out there in the lay media and in and in your health store that have been. Touted to help fatty liver disease. None of those have really been rigorously studied and have shown no benefits that we know of.

So I would be really cautious about using any of those. And many herbal preparations or holistic therapies can actually be liver toxic. So I would caution people against using those without the advice of a healthcare professional.

Sudipah Sarkar: Dr. Hamilton, are there any symptoms that a patient with diabetes [00:13:00] might see if they have MASLD.

Jamie Hamilton: That’s a really good question. So unfortunately, when maed in its early stages, it’s really asymptomatic.

You may have mild elevations of the liver enzymes. You may have some abdominal pain in the right side, that’s just vague and hard to describe. But in general, it doesn’t really cause a lot of symptoms. Unfortunately, by the time that. Liver disease really progresses towards cirrhosis.

You can have symptoms and that can be fatigue. It can be yellowing of the skin, it can be swelling of the legs. You can have bleeding problems, you can have confusion, but we really want to find people and treat people well before that happens.

So the answer to the question in the beginning stages, there’s really no symptoms. But as the disease progresses, it can have a lot of different symptoms and much of which can be vague. But fatigue, itching, yellowing of the skin would be really big things of concern.

Sudipah Sarkar: What complications is associated with both liver complications and heart complications.

Jamie Hamilton: [00:14:00] So the the most important liver complication is, is cirrhosis which is a scarring of the liver that can lead to liver failure and it can lead to liver cancer. So MASLD d is the second leading cause of liver transplantation in United States and North and and Western Europe. Oh. And it’s a fire alarm. The and then the heart complications of people with MASL D or fatty liver disease are things like coronary artery disease and heart attacks and arrhythmias and heart failure, all related to the same risk factors that cause the liver disease often cause heart disease as well.

Sudipah Sarkar: What resources do you recommend to your patients for more education about MASLD?

Jamie Hamilton: We try and give a lot of education in our clinics, but we also refer patients to the Hopkins website for information about the Mediterranean diet, for example. That, that is really the main resource we use. And we give out in our after visit summaries, we give out information on diet plans and exercise plans.

Sudipah Sarkar: Dr. Hamilton, thanks so much for your time. It’s been great talking with you and thanks for sharing your recommendations and experience.

Jamie Hamilton: Great. [00:15:00] Thank you so much.

In Episode 53, Dr. Sarkar welcomes Dr. Erin Michos, MD, MPH, who will speak with us about diabetes and preventive cardiology in women. Dr. Michos is a professor of medicine within the division of cardiology at Johns Hopkins School of Medicine with joint appointments in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health. She’s the director of Women’s Cardiovascular Health and the Associate Director of Preventive Cardiology within the Johns Hopkins Chicharone Center for the Prevention of Cardiovascular Disease. Dr. Michos is an internationally known expert in preventive cardiology in women’s health. Her research involves women’s cardiovascular health, lipids and lipid management, cardio, kidney metabolic, and obesity, disease management, coronary artery, calcium, inflammation, and biomarkers of cardiovascular risk. She was the recipient of the Nanette Wegner Award for Women’s Health Medical Leadership by the Women Heart Organization and the Donna Vogel Women’s Health Champion Award by Johns Hopkins University.

Sudipa Sarkar: [00:00:00] Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Sudi Sarkar at Johns Hopkins. We develop this podcast as a companion to our Patient Guide to Diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkins diabetes info.org.

Today we are excited to welcome Dr. Erin Mikos, who will speak with us about diabetes and preventive cardiology in women. Dr. Mikos is a professor of medicine within the division of cardiology at Johns Hopkins School of Medicine with joint appointments in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health.

She’s the director of Women’s Cardiovascular Health and the Associate Director of Preventive Cardiology within the Johns Hopkins Chicharone Center for the Prevention of Cardiovascular Disease. Dr. MicMikos is an internationally known expert in preventive cardiology in women’s health. Her research involves women’s [00:01:00] cardiovascular health, lipids and lipid management, cardio, kidney metabolic, and obesity, disease management, coronary artery, calcium, inflammation, and biomarkers of cardiovascular risk. She was the recipient of the Nanette Wegner Award for Women’s Health Medical Leadership by the Women Heart Organization and the Donna Vogel Women’s Health Champion Award by Johns Hopkins University. Welcome, Dr. Erin Mikos.

Erin Mikos: Thank you for having me be part of your program.

Sudipah Sarkar: I wanted to start off with asking you a general question. When we think of preventive cardiology for people with diabetes. What does this look like?

Erin Mikos: Unfortunately, cardiovascular disease, which includes both heart disease and stroke and peripheral artery disease, this still remains the leading cause of death in individuals with diabetes, both men and women.

And this is why attention to prevention and treatment of cardiovascular risk factors is just so [00:02:00] important. While in patients who do not have diabetes. There’s what we call a female advantage, where sometimes women get heart disease about 10 years after men do, but in the setting of diabetes, they, we don’t see this.

There is no female advantage and women with diabetes get this. Same earlier onset of cardiovascular disease as men do. If we don’t institute preventive therapies and while men have a greater prevalence of diabetes , in the setting of diabetes confers a greater relative risk of cardiovascular disease of heart attacks and strokes in women relative to men. So the impact of diabetes impacts women more than their male counterparts.

Sudipah Sarkar: That’s very helpful to know. In terms of cardiovascular outcomes that we see in people with diabetes could you highlight some outcomes that are different between men and women?

Erin Mikos: Yeah. So [00:03:00] as I mentioned, diabetes confers a greater relative risk of heart disease and cardiovascular disease and women compared to men. Women with diabetes can still get their traditional cardiovascular disease, the obstructive coronary disease that we see that can lead to needing stents or bypass.

But women are more likely than men to also get ischemia or cardiovascular disease without obstruction in their heart, arteries from microvascular dysfunction so they can have symptoms of angina, chest pain of their heart, indicating their heart’s not getting enough blood flow where there’s not a problem in the large arteries.

But there’s a problem in the small arteries. That is a more common phenotype in women than in men. But, cardiovascular disease still impacts women and unfortunately, despite the fact that this is the leading cause of death in women, in all women and women with diabetes, we know that women continually [00:04:00] get less treatments compared to their male counterparts.

For example, women with diabetes are less likely to be treated with a statin medication. Even though this is a class one indication, the strongest recommendation that everybody over the age of 40 with diabetes should be treated with a statin. Women are less likely to get this important preventive therapy.

Women with diabetes are less likely to have their blood pressure controlled. They’re less likely to have their LDL cholesterol control to their marital counterparts, and they’re less likely to be treated, with other preventive medicines. So there’s a lot of disparities, which may be why women have worse outcomes in the setting of diabetes as their male counterparts.

Sudipah Sarkar: Do we understand why there are differences in prescribing practices for men and women with diabetes when it comes to medications that can help prevent cardiovascular disease?

Erin Mikos: I think unfortunately there’s still a bias, a misperception that cardiovascular disease is a male disease, even though it’s [00:05:00] the leading health threat in women.

And this’s this presumption that women are lower risk. But as I just mentioned, there is no female advantage in the setting of diabetes. Women have just as equal risk as men do, so they’re presumed to be at lower risk. Both patients themselves female patients often don’t see, think of themselves as being at risk for heart disease.

But also clinicians unfortunately tend to undertreat women and some of the risk calculators may. Low ball women because some of the risk calculators we have for cardiovascular disease don’t include, female specific factors of such as gestational diabetes and preeclampsia and early menopause and polycystic ovary syndrome, which are all, these female specific risk factors, which not only increase the risk for diabetes, but they increase the risk for cardiovascular disease.

So women are underestimated in risk unfortunately, and this can lead to undertreatment.

Sudipah Sarkar: Could you tell [00:06:00] us a little bit more about these specific risk factors in women and how these risk factors impact the future risk of cardiovascular disease such as gestational diabetes in polycystic ovarian syndrome?

Erin Mikos: Traditional risk factors do confer a greater risk in women compared to men. Hypertension, diabetes, smoking, they’re bad for both men and women, but they confer a greater risk in women compared to men. And at the time of diabetes diagnosis, women tend to have higher body mass index and more cardiovascular risk factors at the time of diagnosis.

So that may be. Partly why they’re increased risk. But in addition, there are unique risk factors specific to women that increase their risk of both diabetes and cardiovascular disease throughout their lifetime that men do not experience. Specifically polycystic ovaries syndrome. This is the most common endocrine abnormality in women of reproductive [00:07:00] age. About 10% of women have PCOS. And although elevated body mass index is a feature, many women with PCOS, even lean women who have PCOS are more likely to have insulin resistance. So insulin resistance kind of underpins PCOS because there are more androgens, more male like hormones being made by the ovaries.

So we know that women with PCOS have a threefold increased risk of developing type two diabetes. And they’re also at increased risk of cardiovascular disease. Another major risk factor that’s female specific is having an adverse pregnancy outcome such as gestational diabetes or a history of preeclampsia, preterm delivery.

And the risk doesn’t end at delivery. This risk extends even, decades after their index pregnancy, which is why clinicians need to ask women about their reproductive history of ask about their pregnancies. Even if the women are years out of their childbearing years, this risk continues.

So we know that gestational [00:08:00] diabetes is a huge risk factor for developing type two diabetes. There’s about a tenfold risk that women with gestational diabetes will ultimately go on to have type two diabetes. They also have about a twofold risk of developing cardiovascular disease because. Pregnancy is like nature’s free stress test.

And so if this insulin resistance is unmasked during pregnancy, they’re often likely to get, develop diabetes, later in life, which is why after pregnancy with gestational diabetes, women need their A one Cs checked regularly, at least annually. Now we also know that early menopause is a risk factor for cardiovascular disease, and some studies suggest it’s a risk factor for diabetes too.

So we call menopause before the age of 45 is early and before the age of 40 as premature. And that is the loss of early estradiol is a risk factor for developing cardiovascular disease. But some studies suggest that early menopause may be a risk factor for diabetes. That in a [00:09:00] study called the Rotterdam study, women who had menopause between ages 40 to 45 were twofold, more likely developed Type two diabetes, and women with menopause before the age of 40 we’re threefold, more likely.

We also saw this in the Women’s Health Initiative, observational study. If you look at reproductive years between menarchy, the onset of menses and menopause women with short reproductive periods less than 30 years were 37% more likely to develop type two diabetes. And then also vasomotor symptoms is important flag that may highlight women that have increased sympathetic activity insulin resistance, hot flashes are not benign. Vasomotor symptoms, which are those hot flashes and night sweats are experienced by 75% of women transitioning through menopause. But women who have very severe vasomotor symptoms or persistent vasomotor symptoms that are lasting beyond five years, that’s a [00:10:00] hallmark of increased cardiovascular risk.

We know that in the Women’s Health Initiative, women with severe vasomotor symptoms were 48% more likely to develop type two diabetes. Those are all risk factors for diabetes as well as cardiovascular disease.

Sudipah Sarkar: Wow. Dr. Mikos, you mentioned for clinicians, we use risk calculators to help patients and ourselves under better understand a patient’s cardiovascular risk in the future.

Are there risk calculators that are. Built for women with diabetes, and if not would you suggest that more clinicians incorporate risk factors that are unique to women when they’re having that discussion about cardiovascular disease risk? For the individual patient?

Erin Mikos: Yeah, so in individuals who already have cardiovascular disease, we call that secondary prevention.

And they already had an event, like a heart attack or stroke, so they need very intensive treatment. We have very low LDL cholesterol targets. [00:11:00] So these risk calculators are meant to be applied to people who are ages 30 to 79 who, are not known to have cardiovascular disease. It’s a starting framework and the one that we’re currently using is something called the prevent score that came out from the American Heart Association.

It does include diabetes in that calculator. But I will note that we’re not doing in persons with diabetes, we don’t use that calculator to determine statin indication. If someone’s over the age of. 40 they’re indicated for a statin regardless of whatever that tenure calculator says. And if they have diabetes and another, major risk factor, we’re aiming for an LDL target less than 70 milligrams for deciliter in persons with diabetes, even if they haven’t had a prior heart attack.

So this tenure risk calculator, which can be used in persons with or without diabetes, is a starting framework and includes some basic things like diabetes. Smoking age, their, sex with their male or female their blood pressure. Some basic [00:12:00] lipids, whether they take medications for their lipids or their blood pressure.

But there are lots of things that we know increase risk that are not in that calculator. We call these risk enhancing factors like having these female specific factors of preeclampsia early menopause. Autoimmune disease like rheumatoid arthritis and lupus which are more prevalent in women.

This substantially increases cardiovascular risk because of inflammatory condition. There’s things like chronic kidney disease, having a family history of premature coronary disease metabolic syndrome and biomarkers like having an elevated lipoprotein little A or a OB having levels of inflammation with a high sensitivities.

CRP test that’s elevated. If any of these are present, we call them risk enhancers and they put individuals into a higher risk category than they might have been by the tenure calculator. But I will mention again, that just having diabetes already put someone into a much higher [00:13:00] risk where we’re being very intensive about primary prevention.

Sudipah Sarkar: This is a great, this is very helpful, Dr. Mikos. Can you tell us about what key prevention strategies might look like in women with diabetes who are motivated to decrease their risk of cardiovascular disease in the future?

Erin Mikos: Yes. Blood pressure control is important for everybody but persons with diabetes, we start anti-hypertensive therapy if the blood pressure’s above one 30 over 80.

And we try to target under that goal once we start treatment. Although lowers little even better. A normal blood pressure is less than 120 over 80, so they need blood pressure control. And if a person with diabetes, we wanna check to see if they have any, protein in their urine. We know that urine micro albuminuria is a major important risk marker, not only of risk of kidney disease, which diabetes is a leading cause of kidney disease, but also it’s a risk factor for cardiovascular disease.

If there’s any blood pressure elevation in this setting of having [00:14:00] protein in the urine. There’s a class of medicines ACE inhibitors or ARBs that we would use. So that’s blood pressure. Lipids, as I mentioned, you have diabetes, should be on a statin. And we have lower targets in someone who has diabetes plus other risk factors. We wanna get the LDL under 70. If someone’s had a prior heart attack, that’s a whole different story. We want the LDL even lower, less than 55. And we have a number of medicines, statins, but we have non-statin medicines. Statins are not the only game in town. We have a lot of medicines to treat lipids these days. We gotta treat lipids.

Of course, glucose control is important. Now there are some, a new I guess they’re not new anymore. They’ve been using them since 2016, but there are some class of medications used to treat diabetes that are actually cardiovascular prevention medicines that reduce the risk of cardiovascular disease.

And these are the GLP one receptor agonists and the SGL two inhibitor medications. So I’ve been prescribing these as a cardiologist since [00:15:00] 2016 when we had some pivotal trials called the leader trial and the sustained six trial looking at GLP one receptor agonists. And then the the EMPA reg trial looking at empagliflozin, which is an SGL two inhibitor. These medicines substantially reduce the risk of having cardiovascular events in patients with diabetes that were high cardiovascular risks. So these are prevention medications. So the guidelines have endorsed that persons with diabetes who are at elevated cardiovascular risks that have, several of these major cardiovascular risk factors or established cardiovascular disease, you really wanna prioritize medications that have organ protection that prevent heart attack and strokes and heart failure and kidney disease. And so you wanna prioritize these medications that have these cardio kidney benefits over some of the older medicines , like sulfonylurea. We wanna really prioritize those medications. Now the good news is that in these trials that I mentioned.

When they look at effects by sex [00:16:00] that women benefited just as much as men do with these therapies in terms of cardiovascular risk reduction and kidney disease risk reduction. When treated women benefit as much as men do.

In fact, some real world data that we have, outside of trials, looking at real world data from market scan showed that women with diabetes treated with this class of medicines called GLP one receptor agonists, they actually had even greater benefit from this class of medicines than men do.

So they benefit from therapy. We just need to make sure that we treat them. But unfortunately, we still have gaps where in clinical trials, which is where we figure out how, medicines are safe, do they work? Do they benefit patients? Clinical trials, shape guidelines. But we know that women continually are under es under -enrolled, underrepresented in clinical trials.

For lipid-lowering therapies and new diabetes drugs, et cetera, compared to their male counterparts. So we [00:17:00] need to make sure we have equity of representation in trials that we know that these, new drugs are safe and effective in both men and women.

 I could say the foundation for all preventive efforts is lifestyle, interventions. So generally the Mediterranean diet is one we recommend for patients.

There is evidence for cardiovascular benefit with the Mediterranean diet. So the diets that have beneficial for cardiovascular risk or diets low in saturated fat low in trans fats, but can have a modern intake of the healthier fats. The monounsaturated polyunsaturated fats that we see in fish like salmon, nuts olive oil, avocado want diets, rich in fruits and vegetables whole grains can lower LDL and we want to minimize processed foods as much as possible and try to minimize or limit, sugar sweetened beverages which can increase the risk of cardiovascular disease as well as type two [00:18:00] diabetes. We encourage physical activity. Individuals should get at least 30 minutes of moderate intensity activity most days of the week, at least five days a week, or 150 minutes a moderate activity per week.

Now, it doesn’t have to be vigorous someone’s trying to get more fit. Vigorous exercise may help with fitness, but in terms of cardiovascular benefit, we see most cardiovascular benefit at the moderate level. Brisk walking is a moderate intensity activity that most adults can do that as well as, more leisurely cycling, some easy jogging, a dance class, some moderate intensity gardening.

It doesn’t have to be vigorous, but we do want someone to do something active all day long and even light activity such as leisurely walking, has more benefit of over being sedentary. Getting those step counts in, we aim for. Trying to aim for 10,000 steps a day, but trying to go for at least 3000 more steps compared to where your baseline, where your starting is.

[00:19:00] So everybody benefits from exercise and lifestyle changes, both men and women. And interestingly although women are unfortunately are less active than men, when you look at physical activity. The cardiovascular risk reduction that we see the decreased risk that of heart disease we see with physical activity actually occurs at lower thresholds in women compared to men.

Women start getting heart benefit, cardiovascular benefit at lower amounts of exercise compared to their male counterparts. So if we can just get women patients moving more that, that can have significant benefit. But when you talk about diabetes, because the diabetes already places them at higher risk, they will need some often preventive medications such as statins, on top of lifestyle changes. Because if they’ve already developed diabetes, they’re now in a higher risk category. But it’s not in either or. It’s a both. We need lifestyle changes and preventive pharmacotherapies to decrease their risk.

Sudipah Sarkar: Awesome. Super. That’s really helpful

you mentioned early [00:20:00] menopause as a risk factor for cardiovascular disease. Could you talk to us a little bit about the role of hormone replacement therapy and cardiovascular disease risk?

Erin Mikos: Probably, age related midlife increases in adiposity and insulin resistance have the strongest relationship with diabetes from chronological aging, where hormonal changes that characterize menopause or perhaps not the strongest determinants of a diabetes risk.

But we do know that the menopause transition, there’s this very unfortunate change in body composition that women experience where there’s more adipose or fat deposition in the abdomen, the visceral cavity. So even if a woman’s weight doesn’t change on the scale, there’s a shifting of weight in unhealthy places in the abdomen, which increases the risk of insulin resistance.

Now I mentioned early menopause is a marker of increased risk of diabetes. But we’re not using [00:21:00] hormone therapy for the sole purposes of primary or secondary prevention of cardiovascular disease or diabetes prevention. In trials like the Women’s Health Initiative, there was a signal that menopausal hormone therapy was associated with a decreased risk of incident diabetes and estrogen may have some benefit on glucose homeostasis glucose metabolism, such as improving one’s sensitivity to insulin or insulin secretion. But we’re not using it for this purpose. Hormones can’t have a double edged sword. We did also know, in the Women’s Health Initiative, there’s an increased risk in blood clots deep vein thrombosis and pulmonary emboli.

And in older women, increased risk of cardiovascular events and stroke. But hormone therapy did seem to be relatively safe in lower risk. Women who are, were closer to the menopause transition. So our, the current indication for hormone therapy is for the treatment of symptomatic vasomotor [00:22:00] symptoms.

Hot flashes or night sweats, so that’s the role for hormone therapy. It’s not for diabetes prevention or cardiovascular disease prevention. And we think it’s relatively safe for women who were under the age of 60 or within 10 years of menopause who are not at very high cardiovascular risk, such as, who haven’t had a heart attack or a stroke, or haven’t had a blood clot event, we think it’s relatively safe in those individuals.

The keeps trial which enrolled women closer to the menopause transition there was no evidence of cardiovascular or metabolic. Benefits or harm within four years of use of both oral or transdermal form of hormone therapy. So again, we’re not using hormones to prevent diabetes but it’s still a good option to treat vasomotor symptoms in our symptomatic, patients who are closer to the menopause transition

Sudipah Sarkar: Dr. MicMikos, could you outline for us what the terms primary prevention and secondary prevention mean?

Erin Mikos: Yes. So for [00:23:00] secondary prevention, these are the highest risk patients who’ve already had an event. They’ve had a heart attack, they’ve had a stroke before, or they’ve had revascularization, a bypass or stents in other arteries, such as in their peripheral arteries of their legs. And so this is the highest risk patients ’cause they have disease. And our goals are trying to prevent, a second event or a third event. So we call secondary prevention. So we have very intensive recommendations. We try to have very aggressive LDL targets less than 55 milligrams per deciliter. And these diabetes medicines, particularly the GLP one receptor agonists and the SGL two inhibitors are, really indicated for most of these patients because they’re so high risk and we know those therapies can reduce a subsequent cardiovascular event. Secondary prevention patients often are taking anti-platelet therapy such as aspirin, because they’ve already had an event. Now, primary prevention is people at [00:24:00] risk for a cardiovascular disease event and just having diabetes places someone at elevated risk of cardiovascular disease and we’re trying to prevent that first event. We call it primary prevention, and this is where we try to treat risk factors very intensively and because persons with diabetes are already at increased risk, we may treat them more intensively for, and even in the primary prevention setting than individuals without diabetes, just because having diabetes already puts them in a higher risk category.

We also have a third risk group that we call high risk primary prevention or primary prevention and a half, and this is individuals who have evidence of. Subclinical disease of atherosclerosis, a plaque in their arteries that we can see on imaging. They may have had a CT scan that have shown calcifications in their heart, their coronary arteries, or calcifications in their aorta, or maybe they’ve had a carotid ultrasound that shows plaque in their carotid.

So we know their arteries have disease in [00:25:00] them. Fortunately they haven’t had an event, but they have disease, we call it subclinical disease. They also get more intensive prevention because we know they have disease. And when if they have a significant burden of disease, such as a calcium score above 300, their risk of a heart attack is the same as someone who’s had a prior heart attack.

So we often treat them like a secondary prevention patient if they have a lot of plaque in their arteries and when there’s some. Certainty about risk. Sometimes we do order some of these tests such as a coronary calcium score to see, how much plaque they have in the arteries.

But keep in mind that calcified plaque is late stage plaque, so people can still be at risk even if they have a calcium score of zero because they can still have noncalcified plaque. So we still treat individuals with diabetes with a statin, regardless of their calcium score. So really it’s about risk stratification.

We wanna apply the most intensive treatment, the most intensive goals to the highest risk patients

Sudipah Sarkar: [00:26:00] are women susceptible at all to more adverse effects of medications that we use to help lower the risk of heart disease such as gLP one receptor agonists or medications for blood pressure or statins that you’re aware of?

Erin Mikos: In terms of the benefit, women benefit just as much. There’s no increased safety signal. Women benefit just as much from statins, GLP one receptor agonists, SGL two inhibitors in terms of the heart and kidney benefit. But we do know that women tend to report more side effects. For example, women treated with statin therapy, even though they get that same cardiovascular benefit, they tend to report more statin associated muscle symptoms, at least for lipid lowering therapy, we have other lipid lowering options that we can offer patients. So it’s really important that we still treat lipids but women can have more side effects. With GLP one receptor agonists, all patients can [00:27:00] experience some GI side effects. Actually, the good news is women sometimes lose more weight with GLP one receptor agonists than male counterparts.

Although persons with diabetes lose less weight with those agents than persons without diabetes, but we’re using them in diabetes. Actually not really for the weight loss indication, but for the cardiovascular prevention indication with SGL two inhibitors they have significant benefit in reducing risk of being hospitalized for heart failure.

They have significant benefit in reducing the risk of kidney disease. They have a small absolute risk, although a greater relative risk, but a small absolute risk of yeast infections. Not urinary tract infections, but genital yeast infections because sgl two inhibitors can cause you to have more sugar in your urine.

But the cardio and kidney benefits are so important and so great. That is not a reason to, not use SGL two inhibitors In patients with diabetes. Most yeast infections can be treated [00:28:00] pretty easily with a single dose of a oral medicine called fluconazole. And so we wouldn’t wanna deprive patients from this really important class of medicines that have important, meaningful heart and kidney benefits.

Because of the concern about potential yeast infections, that it would only be a concern if somebody just had real, really recurrent refractory yeast infections that we would avoid that class of medications. So I think sometimes there is an overconcern about side effects and people put more emphasis on being worried about side effects, and they underestimate the tremendous benefit that they would get from these medicines.

So it’s really important that we treat women the same as men with the guideline directed medical therapy agents that we have.

Sudipah Sarkar: Could you touch on a little bit about the role of non-statin medications for lipid lowering and when those might be indicated?

Erin Mikos: Yeah, so we know there’s a proportional relationship between the lower the LDL cholesterol and the risk of cardiovascular disease.

For every approximate 40 [00:29:00] milligrams of deciliter or lower LDL one can reduce the major adverse cardiovascular events by 22%. It’s pretty consistent and lower is better. We see an benefit all the way down to 10. There’s no LDL that’s too low, so it really seems to be about LDL lowering and not necessarily, the agent that we use now, statins are still always the first line therapy because we have four decades of experience with them with safety and efficacy. Most statins are all generic and cheap, and so most guidelines say start with a statin. But if we I mentioned earlier that we have risk-based targets for LDL thresholds.

For higher risk patients, we wanna get to lower goals with LDL. And so if we’re not able to get there with maximally tolerated. Statin. Either someone’s already on the max dose or somebody’s having side effects and can’t go to the max dose. The good news is that statins are not the only game in town.

We have some other oral medicines, ezetimibe, MEPA, doic acid, and [00:30:00] we have really potent injectable medicines. These PCSK nine inhibitors. And alizarin that can substantially lower LDL. They can also have some modest effect on a particularly risky type of cholesterol called lipoprotein little a, that all patients should also have that measured at least once.

And so depending on where someone’s starting and where their goal LDL is based on their risk, we can use combination therapy. And I’ll mention in the racing trial, which was done in Korea some patients of Asian East Asian ethnicity tend to have more statin associated side effects. And in that trial they looked at a lower dose of statin Rosuvastatin 10 plus a non-statin ezetimibe 10 compared to a higher dose of statin Rosuvastatin 20.

And they showed that the combination. Had similar reduction in cardiovascular events and even better LDL control and less stopping of the medicine than pushing the statin to the highest dose. So I think we can, should use combination [00:31:00] therapy much more commonly in lipid management.

We’d use it. Very commonly in blood pressure. If someone’s blood pressure is above one 60 over 90, we’re thinking about two agents of blood pressure out the get go. Often in combination therapy. The same thing with lipids. If somebody is starting very high often we will need combination therapy to get to these lower LDL targets.

Sudipah Sarkar: Dr. Erin Mikos, thank you for joining us today and for such an informative discussion.

Erin Mikos: Oh, thank you so much for having me on your program. I enjoy talking with you today.

Sudipah Sarkar: I’m Dr. Sudi Sarkar, and you’ve been listening to Diabetes Deconstructed.

 We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.

For more information visit Hopkins diabetes info.org. We love to listen from our listeners. The email address is Hopkins diabetes [email protected]. Thanks for listening.

In Episode 52, Dr. Sarkar welcomes Dr. Michelle Ogunwole, MD, PhD, who will speak with us about gestational diabetes with a special focus on marginalized populations. Dr. Ogunwole is an assistant professor of medicine at the Johns Hopkins University School of Medicine and faculty member at the Johns Hopkins Center for Health Equity. She is a health disparities researcher, social epidemiologist, and general internal medicine physician who has additional board certification in obesity, medicine and lifestyle medicine.

She has advanced training and quality improvement in patient safety science. Dr. Ogunwole is research is focused on health disparities and maternal health outcomes among African American women specifically in the role of the general internist in optimizing chronic medical conditions in the preconception period, postpartum chronic disease and long-term health outcomes related to complications of pregnancy, African-American women’s experience with the healthcare system and barriers to primary care follow-up after pregnancy, and creating equitable community-driven quality improvement interventions around the transitions of care, from obstetrics to primary care for racial and ethnic minorities who experience medically complicated pregnancies.

Sudipa Sarkar:  Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Sudi Sarkar at Johns Hopkins. We develop this podcast as a companion to our Patient Guide to Diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkins diabetes info.org.

Today we are excited to welcome Dr. Michelle Ogunwole MD PhD, who will speak with us about gestational diabetes with a special focus on marginalized populations.

Dr. Ogunwole is an assistant professor of medicine at the Johns Hopkins University School of Medicine and faculty member at the Johns Hopkins Center for Health Equity.

She is a health disparities researcher, social epidemiologist, and general internal medicine physician who has additional board certification in obesity, medicine and lifestyle medicine.

She has advanced training and quality improvement in patient safety science. Dr. Ogunwole is research is focused on health disparities and maternal health outcomes among African American women specifically in the role of the general internist in optimizing chronic medical conditions in the preconception period, postpartum chronic disease and long-term health outcomes related to complications of pregnancy, African-American women’s experience with the healthcare system and barriers to primary care follow-up after pregnancy, and creating equitable community-driven quality improvement interventions around the transitions of care, from obstetrics to primary care for racial and ethnic minorities who experience medically complicated pregnancies.

Welcome, Dr. Michelle Ogunwole.

Michelle Ogunwole: Thank you so much for having me. I’m thrilled to be here.

Sudipa Sarkar: Thank you for joining us. So I wanted to start off with some general questions. So first I’d like to ask you to please give our audience a  general overview of what is gestational diabetes.

Michelle Ogunwole: Sure that’s a great way to start. Gestational diabetes is a special type of diabetes that develops during pregnancy. So it’s not the diabetes that people have before pregnancy, but the one that you only get during pregnancy. And it happens when the body really can’t handle the sugar. That’s in our bodies as well as usual.

It usually goes away after birth. But it’s also an important signal about women’s long-term health and if it’s useful, sometimes I think about a little bit of a metaphor about how, we can think about gestational diabetes. If it’s useful, then I sometimes share that with people.

I think about a drill sergeant, I was in drill team growing up, so I think about that. So during pregnancy, I’d say that your insulin is like a drill sergeant and its job is to tell the glucose where to go move it, get inside the cells. But when the : pregnancy hormone comes along, it acts like a bunch of new rebellious recruits who don’t really wanna listen.

And so you think that, trimester after trimester, as you grow in your pregnancy, you’re getting more and more of these recruits and they’re. Starting to ignore orders, they’re dragging their feet, they’re pushing back. And so the drill sergeant insulin is having a harder time managing them.

And so they’re having to yell more and louder and work harder. And, eventually the recruits stop responding. So that’s basically how I explain what insulin resistance is. And that can happen in pregnancy. And some people get gestational diabetes, right? And some people don’t. And I think there’s a lot of factors as to whether or not your drill sergeant and your pancreas, which supports like your insulin is able to handle those recruits as they grow. That’s one of the ways that I try to explain it to people.

Sudipa Sarkar: That’s very helpful. What risk factors might make someone more susceptible to : developing gestational diabetes?

Michelle Ogunwole: That’s also a great question. There are things like your medical history. We know that weight overweight and obesity, carrying kind of excess fat in our bodies definitely increases the risk. There’s other things like having a family history of diabetes. As well as, any prior pregnancy that you have with gestational diabetes definitely increases the risk in your next pregnancy.

And then we know that certain groups of people are more likely to get gestational diabetes. Black, Latinx, Asian and indigenous women are more likely to have the diagnosis or. To have less control of their glucose if they get gestational diabetes. But that is usually related to the social risk factors or social things that go along with being members of some of these communities.

The other one I would say too is just because diabetes is gestational diabetes and diabetes is so closely related to : nutrition as well. When you think about people who have limited access to healthy foods and have less resources and obtaining some of those healthy foods also, or higher risk.

Sudipa Sarkar: So it sounds there are risk factors that predispose people to gestational diabetes. So weight family history and then social factors and economic factors. Can you tell us a little bit more about these social and economic factors , that play a role in gestational diabetes, in including nutrition access?

Michelle Ogunwole: Yeah, that’s a, it’s a good point. I think that it’s. One of the things I like to say is a lot of these things are related to one another. In research we think of the root cause of all of these things. You think about, a tree and the roots that are in the ground and everything that spouts off the tree, then we can start to think about is structural kind of disinvestment in certain communities. We also refer to that as structural racism. Kind of the totality of all of the ways that : structures and systems are set up to make certain communities fail in certain communities thrive. Some of those dis investments that have happened along the course of history for certain communities.

I do a lot of work with black and African American population. Thinking about things, as far as chattel slavery and then Jim Crow and , even the GI Bill not being open to black people coming back and how redlining, which is when certain groups or black people were denied access to home ownership.

Because of discrimination, all of these things really set up communities to not be able to obtain generational wealth. Also it sets them up to be in cycles of poverty and then that poverty from that tree, if you think about going up and. The things that kind of bloom, the leaves that you see come off when you don’t have access to resources it’s really difficult for you to make great choices in terms of even things like : your nutrition. We talk a lot about as a doctor and trying to help people to make healthy choices, but in order to make a healthy choice, you have to have a healthy choice. And not everybody has access to healthy choices based on some of these factors.

Things like that really. Contribute to whether or not you can buy healthy foods when you’re supposed to, whether or not your neighborhoods are safe enough to walk and do the exercises that you need that support your overall health and your healthy weight. There’s other kind of contributors , in the environment that might make it more stressful to live in an environment.

Certainly anybody who’s had some of those experiences growing up when you have limited socioeconomic resources or just money, this is the point to say if you have limited means. it’s stressful. It’s stressful to be poor. It’s stressful not to be able to afford things.

And we know that kind of chronic stress also affects our health, our weight, and things like diabetes. So we have research that supports those ideas. Hopefully, I’m trying : to paint a picture of what the roots of this tree look like and how that tree grows.

And what we see on the outside is different risks for different communities of things like gestational diabetes based on this.

Sudipa Sarkar: Thank you. That really helps kinda build a very comprehensive picture of all of the factors and variables that can affect women’s health specifically when it comes to gestational diabetes.

Could you discuss a bit about why blood glucose control is so important. During pregnancy for someone who has gestational diabetes and what are the major types of treatment that are available for women with gestational diabetes?

Michelle Ogunwole: Yes. Blood sugar control in pregnancy is extremely important. I would say that. In terms of the baby’s outcomes, of course we know that how high your blood sugar is and how out of control it is really affects the complications that you have at birth. Whether your baby : is much bigger than they’re supposed to be, we call that large for gestational age, which can affect a lot of things related to your delivery outcomes and make it difficult with vaginal deliveries and for complications to occur.

And there’s other more serious complications in terms of the early pregnancy and the formation of the organs in the baby itself. We know that having poorly controlled blood sugar can affect that development of organs for the baby. It’s really critical. That we, have really tight glucose, there’s the forming of the baby and the complications , even the complications, the birth complications that can happen.

And then too for the mom, we know that, people who have worse control of their sugar during pregnancy also have an increased risk of having diabetes after pregnancy. So it’s a really big predictor of the people who will go on to have diabetes. And we also know now that there’s more data. It’s really fascinating that what happens in pregnancy, it can actually be a  predictor for your child’s future metabolic health. Whether or not they, your child has obesity, whether or not they may be at risk for diabetes can be determined by what happens during the pregnancy. And so that’s why the blood sugar is so important.

Going back to my metaphor about the unruly recruits. There are different levels of that unruliness, right? And so some people have only a few unruly recruits, and those are people who can maybe be managed with just diet.

They have gestational diabetes, but there are things that we can do to reduce their blood sugar. To the ranges that we would like during pregnancy, just through diet modification. That’s why working with a nutritionist is so critical because, you can really see it in real time. It’s incredible.

We have people who have more unruly recruits and sometimes they require more support to get them in order and that’s what I would call people who need insulin therapy to help  them manage their blood sugar and pregnancy. And so there’s other medications that people might be familiar with.

Metformin is a pill that we also can use in pregnancy to support this overall approach to improving our body’s ability to handle the glucose levels, the sugar in our bodies. So those are the main treatment modalities. And then along with the diet piece, I’ll go back to that.

There’s some interesting studies that, and we know this true, this is outside of pregnancy, but physical activity can also be supportive in this. So like sometimes we’ll have people after big meals going to take a walk and there’s really people who do very well with that and supporting like this plan to get their sugar into a better controlled range. And you may or may not ask me about this later, but it’s really fascinating because now we have more and more women wearing these continuous glucose monitors, which allows you to see the effects of your blood  sugar changing in real time. It’s a monitor that’s it’s painless and you attach it to your body and it’s continuously measuring your blood sugar all the time that you’re wearing it and you get alerts on your phone about what your blood sugar is in the moment. You can actually eat something and then see what happens to your blood sugar. You can take a walk and see what happens. I think that can be really empowering and helpful for people to really see the way that diet and activity can influence your blood sugar and how this is happening all throughout the day.

All of the things that you do really contribute to that, even the stress and the amount of sleep, all of those things come together to contribute to these rises and falls. So it’s nice for people to be able to really see that in real time.

Sudipa Sarkar: Are goals for women who are pregnant with gestational diabetes different , as opposed to someone who’s not pregnant but has diabetes and when would someone need medicationoutside of metformin more than diet and exercise intervention? Are the glucose goals different between those two groups of people?

Michelle Ogunwole: When we think about the way that we design our targets for glucose during pregnancy… because of everything that’s going on with the pregnancy, we have much tighter blood sugar parameters for pregnancy because of the baby’s organs forming and all of these things that are happening. And so yes, we do have slightly different targets in pregnancy.

Non-pregnant individuals, we are still looking at the same parameters. So when you wake up after you have slept and you haven’t eaten, we look at fasting blood sugar. We tend to look at our sugar right after we have meals one or two hours after that. And so we’re looking at the trends for all of these things.

I’m very interested in continuous glucose monitors, they’re really interesting because they can give us a little bit more information too. Even for that, when we set the parameters, we actually 1: set them differently for pregnant individuals to when they alarm, and we have goals for how often we want them to be in the ideal range for blood sugar for pregnant women. And that’s how we also guide our therapy. So it’s really interesting to see that too.

Obviously diet and exercise is one component. Then we sometimes add things like metformin which can help with our overall, sensitivity, to insulin and in our bodies.

And then we have insulin itself. We sometimes, despite our best efforts, especially with the pregnancy growing, we have this growing pregnancy every week, as that placenta grows, that baby grows, we just have more and more of those unruly recruits. That’s what I keep saying.

So it’s just. At some point, sometimes we cannot manage it and we actually have to give people insulin to help them manage their blood sugar. And particularly as the trimesters progress,we really see that increased need for insulin in the later trimesters, which makes sense. Because the baby’s growing as well.

Sudipa Sarkar: It sounds like there’s three phases that we think of for the woman with gestational diabetes kind of preconception period during the pregnancy and then post-delivery. And so in an ideal situation, what does the care of the woman who has had gestational diabetes look like after delivery in kind of 1, 5, 10, 20 years later in terms of, helping to prevent complications or the cardiometabolic diseases that we see that are associated with gestational diabetes.

Michelle Ogunwole: That’s a great question. Gestational diabetes, which is diabetes and pregnancy increases the risk of developing diabetes outside of pregnancy, and that is by seven to 10 times. So, it’s pretty significant. And we talked a little bit about the things that predict whether or not you will go on to get diabetes, so your blood sugar control in pregnancy, whether you needed insulin. These are the kinds of things that really predict whether you’ll go on to have diabetes in, after your pregnancy. But in addition to that we also know that gestational diabetes independently increases the risk of other diseases like cardiovascular disease. So, things like, stroke, high blood pressure having a heart attack. We know that this risk is like one and a half to two times higher for people who’ve had gestational diabetes.

It really is important I talk about pregnancy as a stress test, which kind of reveals some things to us. So when you get these diagnosis, it reveals something, but it’s also showing us that there is an important opportunity, I think to intervene to try to prevent these kind of long-term diseases from developing, and we can, and I think that’s what’s exciting about the work that I do, is that we can support people so that we could try to prevent progression to some of those outcomes that I talked about. Also, if they want to have another pregnancy right, that we can put them in the healthiest state that they can be to go into that next pregnancy and hopefully reduce the complications from happening again.

The other predictor after people have their babies, they also get another test of their insulin sensitivity or how well their body is managing glucose after they’ve had the gestational diabetes. Because this diagnosis usually goes away for a lot of people after the baby is delivered. So, we do another test about one to three months after delivery. It’s called an oral glucose tolerance test. We do another one to check to see if you still have some clues that your body is not managing your sugar as well as it should, even though the baby’s delivered.

Sometimes people have borderline or higher numbers, and that also predicts whether or not they end up getting diabetes in the long term as well. Some of the work that I have been doing is thinking about, what can we do in that or that postpartum period to reduce the risk of these chronic disease happening.

And one of the things I’ll say is that a lot of people don’t even come back for those follow up tests to check to see if they have that continued problem with their glucose. I’d say 50% of people don’t always show up for that test. That’s one thing that I think is really important that women who’ve had gestational diabetes recognize that the risk isn’t over just because the baby has been delivered. And so it’s really critical that we follow up with your primary care, your ob, your primary care team, just to continue to monitor that risk and see if there’s some things that we can do.

Then going back to diet and exercise and what we know is that, and maybe people have their own experiences with this, but we gain weight during pregnancy. That’s common. Some people gain more than the recommended amount as well, and those are kind of predictors of whether you get these chronic diseases too.

We often have weight gain during pregnancy. And then we have postpartum. And what we would like is for people to return to their pre-pregnancy weights within a year. But a lot of people retain that weight. So we call that postpartum weight retention. And that also predicts whether or not you go on to have diabetes.

It can become a cycle where you think about when you have multiple kids, if you never lose that weight from the first baby, and then you go into your your next pregnancy and you gain weight and you never lose the weight and you go into your next pregnancy. So it can happen that way for a lot of people. I will tell you that I have been very humbled myself, I, after having children that it’s not easy. To just go back to your pre-pregnancy weight in a year. I could share personally, I’ve gained 60 to 70 pounds with each of my pregnancies despite trying to eat the best that I could and be active.

It still happens that way, and it’s not an easy thing to tell people to just lose all of that weight in a year. And really the idea is how do we support  people to make small lifestyle changes, especially in the very early postpartum period when they’re already managing and dealing with so much.

Mostly everybody is sleep deprived and so it’s challenging to lose weight when you’re not getting rest. Some people are breastfeeding and they are really working towards making sure that they have enough calories and intake to support that and they’re just managing this kind of new normal of their life and dealing with kind of the hormonal changes that happen postpartum.

What it really is about is just having people make manageable changes. We start with things like trying not to drink soda trying to drink more water, trying to, get in a 10 or 15 minute walk once you’ve been cleared to exercise. Just small things that you can incorporate in that early phase that also make you feel more like yourself is really important. Then later on, discussing what other therapeutic options there are.

Sudipa Sarkar: It’s very insightful. I  wanted to ask, you mentioned the oral glucose test that’s done after pregnancy to see whether or not that person still is not responding to insulin in their own body. Are there other tests that are less cumbersome? The oral glucose tolerance test is a tough test, especially for someone who’s just given birth, a few weeks before.

Michelle Ogunwole: Outside of pregnancy we use a hemoglobin A1C, which is like a three month average of what your blood sugar has been doing in your body. We cannot use that in pregnancy just because that test relies on factors that change in pregnancy.

But after three months, we actually do use that test. So for people who haven’t had an oral glucose tolerance test, I will. Give them a hemoglobin A1C later. I do know that there are scientists working on this very issue right now. People don’t like doing the oral glucose tolerance test in pregnancy. It’s not a fun test. I know that there are some researchers that are working on a hemoglobin A1C that can be : during pregnancy. So that’s a grant funded study in Boston. I know that they’re working on that, so I think that’ll be very paradigm shifting. The other thing is, and I know that we do this sometimes in our high risk OB clinic because some people, let’s say if they have other complications like hyperemesis, which ratu, which means that you’re throwing up all of your pregnancy, and it’s just more than more than typical kind of morning sickness. It’s just excessive. It’s really difficult for people to handle the oral glucose tolerance test, which requires you to drink a very un tasty but sweet beverage. And some people really can’t tolerate that.

And so it’s been really interesting to think about, again, about continuous glucose monitoring and how some people we’ve been able to extrapolate for some people who are not in the range, that they may have some dysfunction in how they’re handling glucose from that test.

We know that those tests are the continuous glucose monitor. There was a big study on it actually to see, hey, if we use continuous glucose monitors in pregnancy versus having people  stick prick their fingers, do we have better birth outcomes? And there wasn’t really a difference in birth outcomes, but the thing is that the patients liked it better. It was less finger sticks and stuff. That’s also promising and that matters. I think it matters a lot about whether people are willing to accept a therapy because it helps us to get the data that we need. That’s something that I’ve seen used for people who really can’t tolerate the oral glucose tolerance test. And in my own work, we’ve been doing some postpartum measurements of the oral glu using continuous glucose monitoring. And there’s another huge study in Boston that’s looking at that. And I think in a couple years we’ll have enough data to say how we can, use the measures that we get from continuous glucose monitoring to actually diagnose people. I think all that’s in the pipeline.

One of the challenges with CGM, both inside of pregnancy and outside of pregnancy it’s not covered unless you’re on insulin. We have challenges getting it for people. Those people let’s say they don’t tolerate oral glucose tolerance test, but they’re not on insulin. Because we haven’t diagnosed them what happens is the : clinic has a sample or I have a sample, so they get to have it. We’re actually doing a policy brief on continuous glucose monitors for patients who are not on insulin in pregnancy, because I think that population is much more likely to get support because they still need tight glucose control, even if they’re not on insulin. It’s so important for the baby. It’s a easier narrative cell when you go to testify and say you can really paint a picture for people. I think that they’re using. It just depends. Like they have type two diabetes and they have poor control, and they’re seeing those numbers early. They’ll still slap it on there early because they already know that these people have type two. But for gestational diabetes, they have to have the diagnosis first, which typically happens around 8 weeks. Then it becomes this challenge of do they need insulin or not? Is it gonna be covered? So I think that’s what is tricky.

Sudipa Sarkar: Dr. Ogun Ole. How can we as clinicians incorporate a history of gestational diabetes when we’re seeing a patient in clinic who’s had gestational diabetes? How do we  incorporate that knowledge into helping the patient reduce their risk of cardiometabolic diseases in the future? And how can we better close the gap between different populations of patients, close the gap from someone who comes from a more marginalized population.

Michelle Ogunwole: I think number one, as non obstetric folks like primary care endocrine I think one of the important things is just making sure that we’re asking the questions because sometimes we feel like pregnancy is not necessarily our lane because we have our obstetric colleagues, but for providers that take care of women across their life course, so we see them, in other stages of their life when they’re trying to get pregnant, potentially when they’re postpartum. It’s really important to incorporate that in our history, all their complications from pregnancy. We can get a lot of clues from that. So I think number one is just asking the question. I think it would be surprised that how much it’s left off of our primary care  evaluations. So that’s one piece.

And then recognizing that if they have had certain complications. In this example we’re talking about gestational diabetes, then it does put them at risk for diabetes. So we should be more attentive in our screening for diabetes for those populations. That’s another piece.

We also wrote a perspective piece for, about this very topic and how we really should consider how these things that are showing up in pregnancy really are almost a warning or something that we should really take seriously as we think about our other therapeutic options, particularly with women in with obesity. And we have different medication approaches now, and whether or not considering gestational diabetes because we know obesity increases the risk.

We wrote a piece that said we should really take this into account when we’re considering whether or not to escalate therapies for managing obesity. So now we have a lot of different options for that. There’s a new class of medications that people are familiar with or may  have heard of the GLP-1s. So things that people might have heard of Ozempic or Wegovy. The way that we prescribe these, this is outside of pregnancy, usually has to do with obesity and then having, another disease that is related to obesity, that’s putting your health at risk.

And so we said, gestational diabetes is an indicator right of some other dysfunction. And for reproductive age women, we should really consider this as a reason to escalate and be more aggressive in our approaches to giving them options for weight management. And there’s other studies going on about postpartum populations, people who are struggling with obesity and the use of these medications, which right now, they’re not approved for use when you’re breastfeeding. But in people who aren’t breastfeeding, were there’s studies that are looking to see, do those medications reduce the risk of developing type two diabetes.

So we know things like metformin and certainly diet and exercise do.  There’s new kind of studies to seeing what else does. So I think just making sure that we’re really thoughtful in identifying these people and then making sure that we are creating plans that are aligned with their goals and offering them the full kind of array of options available to them.

To your point, I think that the same way I said, that kind of nutritious foods and all these things are not always available to certain groups. I would say the same thing is true about some of our newer medications and the the things that we have to treat obesity and potentially prevent and improve diabetes and its control.

Those things are not always available to certain populations based on their insurance status and some other things. The medications can be very pricey as well. I think there’s just a lot of work to do. The work that I’m have been really interested in is making sure that as we design therapies and options to support healthier lifestyles for people which ultimately improve  their risk of getting diabetes, that we also think about how our systems and structures can be accountable in helping to support that process. How should our hospital systems and how can government programs really support in giving resources for healthy food so that way when we prescribe them, people have a way to get them. That’s the work that I’ve been interested. I think that whatever things that we offer patients, particularly when we’re talking about dis health disparities or health equity, we have to ask ourselves, what is the structural and system solution that can support this recommendation that I’m giving? And work really hard to identify that, whether that’s with our social workers or through other programs or assistance programs that can support people in healthy eating as well.

Sudipa Sarkar: Dr. Ogun Ole, thank you so much for a wonderful conversation. This is very nice, very helpful.

Michelle Ogunwole: Thank you so much for having me. This has been delightful.

Sudipa Sarkar: I’m Dr. Sudi Sarkar and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.

For more information, visit Hopkins diabetes info.org. We love to listen from our listeners. The email address is Hopkins diabetes [email protected]. Thanks for listening and see you next time.

In Episode 51, Dr. Sarkar welcomes Dr. Tina Zhang, who will be talking with us about diabetes and menopause. She’s an assistant professor of medicine at Johns Hopkins University School of Medicine. She currently serves as co-director of the Johns Hopkins Women’s Wellness and Healthy Aging Program, the co-director of the Medical Education Pathway for the Johns Hopkins, Osler and Bayview Internal Medicine Residency Programs. She also serves as the director of the Academic Women’s Health Track of the Johns Hopkins General Internal Medicine Fellowship. Dr. Zhang has primarily focused her clinical work, research, and educational efforts on improving women’s health education and care with a special focus on menopause. She is a Menopause Society certified menopause practitioner, and has created a women’s health consultative practice within the Johns Hopkins Division of General Internal Medicine to support women through the menopause transition. Her research has focused on various women’s health topics including menopause, women’s health curricula, and HPV vaccination.

Dr. Sudipa Sarkar, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Sudi Sarkar, at Johns Hopkins University. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.

This podcast is included in our Women’s Health series, where we focus on how diabetes impacts the lives of women.

Today we’re excited to welcome Dr. Tina Zhang, who will be talking with us about diabetes and menopause. She’s an assistant professor of medicine at Johns Hopkins University School of Medicine. She currently serves as co-director of the Johns Hopkins Women’s Wellness and Healthy Aging Program, the co-director of the Medical Education Pathway for the Johns Hopkins Osler and Bayview Internal Medicine Residency Programs.

She also serves as the director of the Academic Women’s Health Track of the Johns Hopkins General Internal Medicine Fellowship. Dr. Zhang has primarily focused her clinical work, research, and educational efforts on improving women’s health, education and care with a special focus on menopause. She is a Menopause Society Certified Menopause Practitioner and has created a women’s health consultative practice within the Johns Hopkins Division of General Internal Medicine to support women through the menopause transition. Her research has focused on various women’s health topics including menopause, women’s health curricula, and HPV vaccination.

Welcome, Dr. Zhang.

Dr. Tina Zhang, MD: Thank you so much Dr. Sarkar. It is so wonderful to be here.

SS: Thank you for joining us. I wanted to start off and ask you to please explain the terms: perimenopause and menopause—if you could help us understand what they are and the differences between the two.

TZ: Absolutely, I think that’s a great place to start. Menopause is a clinical diagnosis and it’s a retrospective diagnosis. We define menopause as the point where a woman has gone 12 consecutive months without a menstrual period. In the United States, the average age (of onset) is around 51. After they hit that 12-month mark of no menstrual cycle, they are in menopause and then after that period, they’re considered post-menopausal.

Perimenopause—we like to use the term “the menopause transition”—is the transitional phase leading up to the point of menopause. This is where a woman’s body is producing less estrogen, less hormones. This period can last many years, and you are going to see a lot of symptoms like mood swings, hot flashes, sleep disturbances, et cetera. But all of that is part of the menopausal transition that can start as early as in your mid-to-late thirties and it can transition all the way until a woman hits menopause.

SS: Dr. Zhang, how does diabetes impact age of menopause or even the symptoms of menopause?

TZ: On average, diabetes by itself does not impact the age of menopause onset, as I mentioned earlier the average age (of onset) is about 51. What we do see is that women who have diabetes, who may have a higher BMI or more adiposity, they do have more severe and more frequent symptoms of menopause, in particular the hot flashes and the night sweats, what we call our vasomotor symptoms of menopause. Those seem to be more severe in the pre- and peri- menopause stage in patients who may have more central fat distribution, which is interestingly reversed in the post-menopause period.

There is some data (that suggests) that type 1 diabetes patients may experience earlier menopause. We are still not sure why, but we think there may be an autoimmune component to it.

In general, diabetes by itself doesn’t impact the onset, but it can make symptoms worse. It is important to know what the symptoms associated with menopause are, and unfortunately there are a lot of them.

The most common symptoms associated with menopause are what we call vasomotor symptoms of menopause — these are your night sweats, your hot flashes, and night sweats that are really just hot flashes at night.

We also have what we call the genitourinary syndrome of menopause (GSM), and that is symptoms like vaginal dryness, vaginal irritation, discomfort, burning, increased risk of developing urinary tract infections (UTIs), urinary incontinence, et cetera. Those symptoms worsen with time. In women, the majority of the other symptoms will get better, but genitourinary symptoms do worsen as patients get older.

A hallmark of menopause are the menstrual irregularities, sometimes that’s the first thing patients present with — they aren’t having any hot flashes, they’re not having any night sweats, but they’re starting to notice that their menstrual cycles are starting to space out or become more irregular or all of a sudden they got really heavy one month and super light the next month. That can be one of the defining symptoms of menopause that we see.

Other things to be aware of, I mentioned mood fluctuations just associated with the hormonal changes; mood swings are very prominent; sleep disturbances — we see a lot of issues with sleep in menopause; hair loss and; skin changes, those are things we’re going to see as well. It can really impact libido, so women can have lower libido. One thing I see all the time is brain fog — feeling like you’re starting to not remember words or just feeling like it’s hard to concentrate and feeling like the job that they were doing at work that initially wasn’t so hard, all of a sudden it’s just becoming harder. They feel like their brain is not functioning the way it usually does — that is something we see very often as well. There are estrogen receptors everywhere in the body, anywhere it’s in the body; you’re going to see it impacted. But those are some regular and common symptoms that we see associated with menopause.

 It’s not fair, it’s like everything. But I will say I do think it’s very important, as providers, to make sure we’re ruling out other causes and making sure that we are being thorough and proactive and clarifying that symptoms are due to the menopause transition and not something else as well.

SS: Can you tell us a little bit more about how perimenopause or menopause might impact women with diabetes? Specifically, in terms of areas like heart health, blood pressure, or cholesterol?

TZ: In younger, healthier patients, estrogen has a protective effect on cardiovascular health. What we see during menopause is that as estrogen declines, that can lead to changes in cholesterol. It leads to the “bad cholesterol” or what we call the Low-Density Lipoprotein (LDL) gets higher. The “good cholesterol”, which we call the High-Density Lipoprotein (HDL) gets lower and it can also elevate blood pressures as well. Those changes combined with the risks associated with diabetes can then lead to a higher risk of developing heart disease.

In patients who have diabetes, we want to really be careful of monitoring the eyes every year. Changes in menopause can impact vision. Estrogen levels can lead to dry eyes, which can impact your vision as well. That is just another thing that I think is important for patients who have diabetes to be aware of as they’re going into the menopausal transition, that sometimes dry eye can be associated with menopause.

Then bone health becomes really important as well. Especially our type 1 diabetics where we know there’s an increased risk of osteoporosis and increased risk of fractures; estrogen’s really protective of the bones. As you go through menopause and your levels are going down, what we can see is that menopause and diabetes can negatively impact bone density as well.

SS: That’s very helpful. How does weight gain during menopause impact diabetes management? And is there an increased risk of developing diabetes in women after menopause?

TZ: Many women gain weight during the menopause transition. We see that all the time in our consultative practices and during menopause consultations. I think weight gain is one of the top three complaints that we see in clinic. Most women are gaining weight during menopause, not because of menopause itself, but more related to aging and lifestyle changes rather than menopause. That is one thing that I did want to clarify, one thing that we chat with patients about a lot is that weight gain is maybe more related to the aging process than the hormonal fluctuations.

That being said, what we do know is that estrogen plays a big role in how fat is distributed in the body. With menopause, we see an increase in central fat distribution or central adiposity. That can lead to worsening insulin resistance and therefore that really impacts women with diabetes because if you’re more resistant to insulin, it can make glucose management more difficult.

I will say that because of the fluctuations in hormones associated with menopause, particularly the menopausal transition, the hormones while estrogen’s going down, it’s a rollercoaster ride of hormone fluctuations. Those fluctuations can sometimes impact blood sugars. That can be one of the things that patients can see that there are more fluctuations in blood sugars to be aware of during that menopausal transition.

SS: Great. Then Dr. Zhang, I think you answered this, but do you see that in women post menopause, are they more at risk of developing diabetes?

TZ: Yes, and the reason for that is more related to the fact that we do see weight gain associated with the menopausal transition and just aging. A result of the weight gain that is then associated with more insulin resistance and a higher risk of developing diabetes.

But I will say that it is just one potential risk factor. It’s usually that other potential risks are also playing a role here as well. If they have a history of gestational diabetes in the past or a history of Polycystic ovary syndrome (PCOS), things like that could also impact their overall risk for developing diabetes. So those are things that we do monitor for during our menopause consultations, we’ll ask about their obstetric history and see if they have a history of PCOS or things like that, which can also affect their risk of developing insulin resistance or diabetes for patients.

SS: You touched a little bit earlier about heart disease and bone health in women during menopause and after menopause. Do you find that for women with diabetes in menopause or after menopause, are they more likely to be diagnosed with heart disease and or low bone densities?

TZ: Absolutely. I think menopause, independently, can increase the risk of heart disease and osteoporosis, but then in combination with diabetes, I think these risks really magnify. I think patients who do have diabetes have a higher risk of developing heart disease because diabetes by itself is a risk factor for heart disease. Then you add the aspect of menopause to that, and both can definitely negatively impact bone density because, again, estrogen is protective of the bones. During the postmenopausal phase, where you’re losing estrogen, you end up losing bone mass. With type 1 diabetes, in particular, we see it associated with increased risk of osteoporosis and fractures.

SS: You talked a little bit about changes in estrogen in the perimenopausal period, then in menopause and then in post menopause and how they impact blood glucose in women with diabetes. Are the changes in blood glucose and those fluctuations similar in those three phases? Could you comment on that?

TZ: During the perimenopausal transition, like before they’ve hit menopause, there are very wide fluctuations in hormones. As a result it can impact blood sugars more. Once patients hit menopause and then are in the postmenopausal stage, some things tend to even out a little bit. But even within the post menopause phase, we have different stages. There’s early post menopause and late post menopause, we do still see some more fluctuations during the early post menopause phase and patients usually have still more menopausal symptoms. Whereas once they’re in that late post menopause phase symptoms really are very stable and those vasomotor symptoms like the hot flashes and the night sweats, by then, those symptoms are hopefully mostly gone.

As a result, blood sugars, typically the fluctuations that can be seen with that, you will stabilize a bit, but once you get into post menopause, then you have the risks associated with more insulin resistance, higher risk of weight gain, changes in your cholesterol, blood pressure, that can lead to higher risk of developing heart disease or metabolic syndrome.

SS: What options are out there for women, that are not medications, that might help manage blood glucose changes in the perimenopausal period during menopause and even after menopause?

TZ: Great question. In particular, for non-medication options, I think the most important thing that we counsel patients about almost every single day is about the importance of exercise. I think that’s something that we all know, I personally feel like I need to exercise more. I tell my patients to exercise more and I’m like, I need to exercise too. I think in this particular case, exercise is really important for menopause. There is data that shows that exercise can help to reduce the severity of menopausal symptoms. We know for a fact that aerobic activity is really important for heart health. We know for a fact that strength and weight training is really important for bone health. Exercise in general is not only going to help with menopausal symptoms, it’s going to protect your bones, it’s going to protect your heart, and it’s going to help with weight loss. Overall that is probably the most important non-medication strategy for managing menopause and blood, health,and diabetes, et cetera.

Then nutrition plays an important role here, obviously in diabetes, just being very careful about eating a balanced diet, not having too much sugar in the diet. Then thinking about limiting really refined carbohydrates, limiting added sugar, et cetera. But we also can see that sometimes spicy foods can cause worsening hot flashes or night sweats at night, there are certain foods that can trigger menopausal symptoms for some of those patients. Identifying what those triggers are can be really helpful.

SS: Can you discuss more about treatments for menopause and how this could impact glycemic management?

TZ: When it comes to menopause treatment, I like to bucket them into three categories. The first one we discussed already, more lifestyle modifications and mind-body techniques. Those things include exercise, a healthy diet, and things like cognitive behavioral therapy.

But in terms of medication specific I think about them in two buckets. The first one is hormone treatment options, and then the second bucket is our non-hormonal treatment options. Of the two, hormone therapy is going to be the most effective treatment for our menopausal symptoms, in particular, night sweats and hot flashes. When it comes to hormone therapy, there is a lot of controversy about it. There has been research in the past that have associated hormone therapy was with elevated risk of heart disease and breast cancer. It has led to a lot of women not being able to get hormone therapy. It has led to a lot of providers not feeling comfortable prescribing it or managing it. That has really impacted care for women who are going through the menopausal transition, unfortunately.

What we know now is that in patients who are less than the age of 60 or within 10 years of menopause onset who don’t have clear contraindications to being on hormone therapy, the benefits could outweigh risks in those patients who are having moderate to severe symptoms of night sweats and hot flashes. We have so many different options for hormone therapy. My preference is to choose the transdermal options because they are safer than the oral estrogen options. There are a lot of nuances that come with hormone therapy and management for menopause that could be a whole podcast in and of itself. I think the main takeaway is that hormone therapy is the most effective treatment for patients who are going to qualify for hormone therapy, and a lot more women do qualify than we think. This is where I think it’s equally important for us to educate providers about which patients would be the best candidates for hormone therapy, for menopausal symptoms, and we always use evidence behind everything we do here at Hopkins.

Then the other bucket is our non-hormonal treatment options. Actually there’s a whole toolkit, there are so many options out there. Many of the options are things that we use all the time as internists that we forget about. Things like our antidepressants, our Selective Serotonin Reuptake Inhibitors (SSRIs), which are antidepressants, can be very effective for helping manage symptoms. We have medications like gabapentin, which I know a lot of diabetics use because it can help with diabetic neuropathy, but it’s also very effective for helping with sleep disturbances associated with menopause. It helps to reduce both the frequency and the severity of night sweats associated with menopause. Gabapentin is an option that I use very often in menopause consultation clinics.

We also have some newer agents out there, like our neurokinin three receptor antagonists, those were FDA approved in 2023. It is a new medication to help manage hot flashes, but it’s really well tolerated, and patients do well on it. There are quite a few options out there that are non-hormonal as well.

That’s how I think about the two medication buckets, hormone therapy, and non-hormone therapy. Then, with regard to blood sugar in particular, hormone therapy is not going to really raise blood sugar. That is usually not something that we will be worried about. There is some newer evidence out there, I think there was a new meta-analysis that was published, that shows that it may improve insulin sensitivity. Again, it is not really going to impact blood sugar per se, in terms of concerns that it may make your blood sugar worse.

SS: How do diabetes and menopause intersect to impact mental health?

TZ: I think that mental health is really important during the menopausal transition, just because, number one, the symptoms of  menopause are just so uncomfortable that women are going through a lot, and I think that can really impact your quality of life; your relationships, at work, at home; your ability to focus; it can cause brain fog, et cetera. But the other thing to be aware of is there are so many hormonal fluctuations that are associated with the menopausal transition, and that leads to a lot of mood fluctuations. The hormone changes lead to mood changes, so the mood swings, we see that often. We see worsening anxiety; we see worsening depression. Then on top of that, in patients who have diabetes, that can be a really big psychological burden as well. The fear of complications, having to monitor your blood sugar all the time. The combination can feel quite overwhelming. Living with diabetes and then adding all the hormonal changes associated with menopause, that can lead to mood fluctuations as well. Thatis something that, number one, patients need to be aware of that, these mood changes we are going to see in menopause and that you are not alone. We expect this and we have ways to help manage it. I think open communication with their primary care practitioners (PCPs) or gynecologists or their menopause providers is going to be really important. Also knowing that there are ways to help manage their physical symptoms, but also their mental health as well. Especially because, as I mentioned earlier, our antidepressants can be used not only to help with mood, but can also be used to help alleviate menopausal symptoms. That is something that is going to help patients who may have issues with mental health and struggles.

Sometimes support groups can be really helpful, just whether it’s a diabetes support group or a menopause specific support group, just to help normalize the experience of what they’re going through, can provide some support and some guidance, and I think that can be really helpful as well.

Rita Kalyani, MD: It’s interesting for people with diabetes you think that the recent evidence doesn’t suggest they go through menopause earlier, but the symptoms could be worse, right?

TZ: Absolutely.

RK: Is that something you think we should be educating our patients with diabetes about, ahead of time?

TZ: I definitely think so. It is more related to insulin resistance and weight. The majority of the data that looks at severity and frequency of menopausal symptoms looks more associated with the weight side of things, and I think that goes hand in hand with diabetes. If you are overweight, that is definitely going to cause worsening symptoms in the pre- and peri- menopausal transition. Post menopause, interestingly, and I think it is because when you have more adiposity, there’s more peripheral conversion into estrone because you have more estrogen levels than someone who has a lower BMI, but post menopause, your symptoms actually lessen. It’s a little bit convoluted and confusing. But I do think regardless, I think women, even if they didn’t have diabetes, should be informed about menopause. But in our diabetic patients, in particular, knowing that they already have a risk factor for heart disease, now adding on the risks associated with menopause, that kind of compounds their risk — I think that is important to educate our patients about.

SS: Dr. Zhang, as we finish up our conversation, are there any thoughts that you’d like to share with our audience?

TZ: I think the main takeaway is that menopause is something that all women are going to go through. It’s a natural progression of aging, but unfortunately, I feel like a lot of women are not prepared for this transition. I don’t think we talk about it enough. I don’t think we were prepared to go through the menopausal transition enough, and I don’t think providers are educated enough to support women going through the transition and to be knowledgeable about what all of the options are to help them through this. I think the main thing I would say to the patients who are listening is that if you want to learn more or if you are going through menopause and having symptoms, just know that there are so many resources out there that are evidence-based that are really helpful, both here at Hopkins, but also at other places.

We’d be happy to help connect you with resources if needed.

SS: Dr. Tina Zhang, thank you so much. This has been a really informative discussion.

TZ: Thank you so much Dr. Sarkar.

SS: I am Dr. Sudi Sarkar, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.

For more information, visit hopkinsdiabetesinfo.org.

We love to hear from our listeners. The email address is [email protected].

Thanks for listening and see you next time.

In Episode 50, Dr. Kalyani welcomes Katie Lacy, who will be talking with us about diabetes distress and burnout. Katie is a registered nurse and certified diabetes care and education specialist at the Johns Hopkins School of Medicine Division of Endocrinology, diabetes and Metabolism. After earning a BS degree in psychology, she began working in the field of diabetes management in 2017 and graduated in 2022 from Johns Hopkins School of Nursing with an entry master’s into nursing. She’s currently pursuing her adult gerontology, primary care nurse practitioner doctorate at Johns Hopkins University School of Nursing, reflecting her commitment to expand her expertise and advance her practice, she currently practices in an outpatient clinical setting, focusing on education, optimization of diabetes technology, and promoting emotional wellbeing while navigating life with diabetes.

Dr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani, at Johns Hopkins. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.

Today we are thrilled to welcome Katie Lacy, who will be talking with us about diabetes distress and burnout. Katie is a Registered Nurse RN) and Certified Diabetes Care and Education Specialist (CDCES) at the Johns Hopkins School of Medicine Division of Endocrinology, Diabetes and Metabolism. After earning a Bachelor of Science (BS) degree in psychology, she began working in the field of diabetes management in 2017 and graduated in 2022 from Johns Hopkins School of Nursing with a Master of Science in Nursing (MSN).

She’s currently pursuing her Adult-Gerontological Primary Care Nurse Practitioner Doctorate at Johns Hopkins University School of Nursing, reflecting her commitment to expand her expertise and advance her practice. She currently practices in an outpatient clinical setting, focusing on education, optimization of diabetes technology, and promoting emotional wellbeing while navigating life with diabetes.

Welcome, Katie.

Katie Lacy, MSN, RN, CDCES: Thank you so much for having me.

RK: We are so thrilled to have you here to talk about this topic, which I think is so important to discuss, but probably is not addressed as much as it should be, and that is a topic of diabetes distress and diabetes burnout. Could you start off by telling us — What is diabetes distress and what is diabetes burnout?

KL: Diabetes distress refers to the emotional and psychosocial burden of living with and managing diabetes. It can involve feelings of stress, frustration, even fear. The fear could be related to, fear of complications or concern that maybe you will be judged in the medical setting based off what your diabetes looks like. It is really personalized to you, as to what is causing that stress in relation to your diagnosis.

Diabetes burnout is when you reach the state of exhaustion of either physical or emotional exhaustion from stress. You could feel powerless or hopeless to the point that you start to disengage from self-care activities. Maybe you miss appointments, start making unhealthy choices with eating or uncontrolled eating due to the state of exhaustion from the stress.

RK: Wow. It is a spectrum then between diabetes to stress, perhaps more common in people with diabetes to the point of diabetes burnout where there’s exhaustion and it sounds like impairment in activities of daily living. How common is diabetes distress?

Does everyone with diabetes experience this?

KL: It is pretty common, but not everyone experiences diabetes distress. If you look at statistics, they can vary. For someone with type 1, it could be anywhere from 22 to 42%, and then if you have type 2 some statistics show that it’s over 60%. So most likely while you are waiting for your appointment, somebody else in the waiting room has also experienced this type of stress.

It is definitely something that I see in varying levels every day in practice. It does not always have a label to it. I think that it is something we as providers can do a better job acknowledging that we are asking you to do a lot of things that can contribute to stress.

For example, if we asked you to check your blood sugar before each meal, there are multiple steps:

That is one thing that we are asking you to do, and we ask you to do it multiple times. Being stressed in relation to doing some of those tasks is perfectly reasonable. It is estimated that people with diabetes can spend upwards of four to five hours a day engaging in self-care activities. It is natural that it can be overwhelming. I think the numbers do not always reflect what everyone is experiencing, because we are not always screening for it. If we do not screen for it, you as a patient have to have the skill and the ability to say, this is a lot and this is stressful for me. 

RK: That is a lot of time for someone to spend managing a chronic disease such as diabetes at home, four to five hours a day. You can see how it can place stress or additional burden on the person living with the disease. As you were talking, I heard you talk about things such as stress, and it almost seemed like feeling overwhelmed as well. Is diabetes distress an umbrella term for having those feelings or, is what we are talking about here, really that feeling of being stressed and overwhelmed with having a disease such as diabetes? 

KL: It is specific to diabetes as a diagnosis. That feeling of stress and overwhelm is related to your diagnosis of diabetes, but it definitely encompasses varying levels. That is where we mentioned diabetes burnout — as that stress accumulates and maybe gets worse and is harder to manage, that is where you can see that burnout occur.

RK: It sounds like identifying diabetes distress is important to prevent it from eventually progressing to burnout. Is that right?

KL: Yes, I think it is a very important step because we can always get overwhelmed at times.  I also think that knowledge is power. Looking at how you are managing your diabetes, there may be ways that we can make it easier for you, to prevent that accumulation of stress related to the disease.

RK: While we are talking about that, I wonder if you could go into a little bit more detail and how would someone know if they are having diabetes distress? How would a healthcare provider screen for it? Are there certain signs or symptoms or ways that an individual with diabetes could know if they are experiencing this? 

KL: There are some validated scales that providers can use. One is called the Diabetes Distress Scale, and the Problem Areas In Diabetes (PAID) scale, and those both identify symptoms of diabetes as well as aiming to help identify what the root cause of the distress is. But it can also often be identified by reported symptoms. Some of these symptoms could be overwhelming thoughts about your food choices or worrying about having a low blood sugar. You might be disappointed that you are not getting the support from your provider or from your family members, and so those are some of the symptoms. You could also self-administer the scale online; it is available online for free. If you notice some of these symptoms or maybe there’s a change to your normal routine and you’re noticing high blood sugar, that could be an opportunity to step back and reflect if any of those emotions or experiences are applicable to how you’re feeling.

RK: That is great to hear about the different scales that might be available, but also the different symptoms and signs that someone could be aware of. Are there certain time-points in a lifetime of having diabetes that someone is more likely to experience diabetes distress. Is it more common when people are diagnosed, when there is a major life event or change in regimen? Or it just occurs anytime. What would you say?

KL: You are exactly right. You are more likely to experience signs of diabetes distress at diagnosis, and at times where maybe you have had a change in your regimen — something is new or maybe you were taking, one pill a day and now we have asked you to add insulin.

That creates a lot more steps and a lot more self-care tasks that we are asking you to engage in. Other times you may be more at risk for distress if you have had recent low blood sugar, as well as if you have any complications such as retinopathy or problems with your vision. A lack of family support can also be a risk factor that can contribute to more likely developing diabetes distress at that time.

RK: That is good to know, especially around times when we might have changes in therapeutic regimen, like you said, going from pills to insulin, for instance, or change in a support system that this could be a time when an individual could be more likely to experience distress. Just being aware of that and being educated about that seems like it is very important.

We talk a lot about these other psychosocial conditions associated with diabetes; depression and anxiety, which are also really important to identify, but we do not often talk about diabetes distress and burnout in that same conversation. Do you think we should be talking about it more? How are the conditions we are talking about today, distress and burnout, different from those medical conditions, anxiety and depression?

KL: I think that is a great question. First, yes, the symptoms can look similar between diabetes distress and depression or anxiety, some of the symptoms may overlap with diabetes distress. The emotional response varies. You may just experience one symptom, maybe lack of motivation towards diabetes tasks or fear of a complication versus depression and anxiety which have very specific criteria that need to be present for a certain period of time to meet a clinical diagnosis.

Now they can definitely coexist, you can have depression or anxiety as well as diabetes distress. Depending on what type of diabetes you have you can be anywhere from two to three times more likely to have a diagnosis of depression. I would say one, if you are not sure whether what you are experiencing is stress related to the illness specifically, or depression, that is when talking with your healthcare provider can be beneficial.

Then to the other question, yes, I think it is something that we should be screening for more and something that we should be having conversations with your patients. I personally like to start off my visits by asking, “What is your main goal for today? “and “What about diabetes right now is hard for you?” By asking those two questions, I think we get at what is making this stress build up and it helps us focus and identify what is important to you and what matters most. 

RK: That is so important to hear what you are describing. I really like how you approach that to ask, “What is really troublesome for you right now?” or “What challenges are you encountering?” Do you find in your practice that individuals are hesitant to share the difficulties they are experiencing? Is this in any way, a reflection of the ability to cope with the disease or what do you tell your patients who may feel like “I should have this under check. Why don’t I have a better feel on this? Is this normal to experience?”

KL: Yes, it is normal to have these feelings, and I often encounter patients that do put self-blame on themselves. I think it is an important point to take a step back and say, you are not responsible for your diagnosis of diabetes. There is a huge genetic component when it comes to diabetes. You can have lifestyle factors to help manage your diabetes, but there is no moral failing, there is no lack of care. When you have a chronic illness we know that you want to feel good — no one wants to feel bad, no one wants to have complications, no one wants to have bad glucose numbers, so we definitely acknowledge that. I think that is something that we can do a better job, as providers, of reminding patients that it is not your fault that you have diabetes, and it is not your fault that it is not going well. There are so many things that can influence your blood sugar and not all of that is in our control. You can do the same thing day to day and one day have a great blood sugar number, and then the next day, your blood sugar decides to be high or it decides to be low. You know it is really about building those tools to address that.

RK: Well thanks so much for bringing that up because I think that aspect of self-blame can sometimes underlie the hesitation that individuals might feel before bringing forth challenges they are facing or obstacles that they see ahead. I think one of the time points where sometimes I see this in my practice is at the time when people need insulin. One of the things that we remind individuals is that this is a natural part of the progression of the disease. It doesn’t reflect in any way that the management was not optimal or that there was anything that the person with diabetes did that led to this. But having to take injections is more a reflection of the natural history of the disease than a failure to manage it.

I think that in any chronic disease, particularly one such as diabetes, where there is such a large aspect of self-management. It is important to keep that in mind, so thank you for bringing that up.

Since we’ve talked about, different ways that diabetes distress can present and how people can identify whether they may be at risk or not? Once, once it is identified that someone may have diabetes distress or experiencing feelings that are consistent with distress or burnout, what can they do? What would you recommend and how effective are the approaches that you usually recommend to reduce distress?

KL: I think stress is managed by building resiliency and that resiliency is the ability to find strength and seek support. I tend to encourage patients to identify things that you’re doing well. Maybe you never monitored your blood sugar before, now you’re checking it once a week or twice a week and that in itself is a win. That is a strength and a sign of resiliency.

Focusing on those small wins is important because each win is going to help you manage your diabetes and feel better doing it. Different lifestyle factors like adequate sleep and nutrition, engaging in activities that you enjoy, such as yoga or music those can act as a buffer to stress and also build resiliency. I think another place to start is identifying what matters most to you as a person and as a person living with diabetes. Maybe one of your biggest hobbies is trying new restaurants or you want to play with your kids more. All of that is an important part of identifying what the next steps are in your management and what steps we need to take together as a team to accomplish that goal. It is important when we are creating those goals that they are unique to you and are realistically able to be achieved.

When I sit down with my patients, especially those who are going through stressful times, I like to use the acronym SMART (Specific, Measurable, Achievable, Relevant, and Time-bound). So, we work on SMART goals. We create something that is specific, something that we can measure so that we know that we are actually achieving it. Something that is attainable and something that is realistic, and then time bound. We will say, “In the next month, I want you to go from checking your blood sugar once a week to checking it twice a week,” and I am not going to ask you to go from once a week to three times a day because that is not attainable, it is not realistic. Also, maybe that doesn’t matter as much to you. I think that is a good way to approach the goals.

Once we have that goal, I ask you “How confident you are that you’re going to make this change on a scale of one to ten,” and if the number is low and you are not confident, that tells me that the goal is not right. We need to take a step back and then reevaluate what our goal is.                   Then the last thing I would say in relation to that, is looking into connecting with diabetes education group classes or support groups. That can be either online or local, and the chances are you are going to find someone that has a similar struggle to you, or maybe they have been through that before, and they have a solution that has worked for them that may also work for you.

RK: Those sound like great resources and I like the idea of small steps celebrating small wins because over time those can become huge wins. And not only the resources in the healthcare team, but the support group that you mentioned, learning from others who are experiencing similar challenges and may in some ways be able to offer even more support because they are experiencing what you are going through as at the same time.

For the caregiver who has a loved one who is experiencing diabetes distress or burnout, I can imagine it could be challenging at times to know what is the best way to help alleviate the feelings or the distress that the person with diabetes is going through. What would you suggest that caregivers do or need to be educated about to best support the person living with diabetes who might be at risk for undergoing distress?

KL: I think the first thing is looking out for signs — is your loved one disengaging in some of the behaviors that they usually do to manage their diabetes? Such as, skipping medications, not checking their blood sugar, missing appointments. Then really having an open conversation and listening to your loved one to see if they are expressing that they are stressed. Or do they usually share information about their diabetes journey, or how you can help them, and then now they are taking a step back and not willing to share as much information. That may be related to some shame or guilt that comes from the diagnosis of diabetes.

The biggest thing that you can do as a caregiver is offering to listen. Offering support in the way that’s important to your loved one. Asking a question about “How can I help you or will it be helpful if I do X?” You can start with an open-ended question and then you can move to something specific. If they identify that one of their stressors is ,for example, picking out what to eat for their blood sugar. Then offer, “Can I cook dinner?” or “Can I plan the meals for this week?” Allowing them to take a break from the diabetes relationship with food, maybe the relationship with counting carbohydrates, and allowing you to take some of that burden as a caregiver. 

RK: I appreciate you going over that because I think that sometimes it could be hard not only as a healthcare professional, but as a caregiver to know how best to support the individual who is experiencing the distress. Having those questions and having those ways to relieve, temporarily, some of the burden during times where there might be more stress could be immensely helpful, in terms of health outcomes and also just self-management.

KL: I think a good reminder to someone that’s trying to provide support is that support never has to be perfect. I think sometimes we get overwhelmed as a caregiver or as a provider saying, “I want to have the perfect answer.” We do not always have to have the perfect answer or the perfect solution to help you. Just by being present and offering, you as a person, to help can really be encouraging and helpful to the person that is going through this stress.

RK: Katie, thank you so much for talking about something we know it needs to be talked about more and really bringing attention to the importance of being educated on diabetes distress, knowing the signs, knowing the symptoms, knowing the resources that are available, and knowing what can be done both from a healthcare team and a caregiver perspective to help alleviate the distress that an individual with diabetes may experience in order to prevent burnout and prevent impairment in the ability to self-manage the disease at home for people.

For people who may be experiencing these symptoms, but have not had anyone ever ask them about it or pay attention to it, what would you say to them in terms of how they can go about seeking further counseling or further treatment or support for diabetes distress? 

KL: One thing I will say is the fact that you are actually listening to this podcast right now is a great sign. That is a sign of resiliency and that you are acknowledging that maybe you or someone that you love is going through this stress. I think first you have already taken a great step towards managing that. The next step with bringing it up with your healthcare provider, I think if you have a relationship with maybe the nurse, medical assistant or support staff it could be helpful to mention it at the beginning of your visit that this is something you want to discuss with the provider.

If you don’t have that relationship with them when you go into your visit, I would suggest saying, at the beginning of the visit, “I do want to acknowledge that, I have been feeling overwhelmed and stressed lately. I think it might be related to how I am managing my diabetes.” Or you can ask your provider if you can talk about some of the things about your diabetes that is frustrating — share specifics. Let them know that this is the most difficult part about diabetes — maybe it is not checking my blood sugar, but maybe it is actually coming to the appointments. It can also interfere with other things in your life. You could say, ”I’m having a hard time concentrating at work, and I think it is because I am focused on, what to choose for lunch or how to take my medication.”

Then ask directly for support or guidance. So “I would love to talk about ways to manage my stress around diabetes better. What resources do you recommend?” Then just to give you an idea of what resources are usually recommended — just because you have diabetes distress does not mean that you need to see a mental health professional. It is often managed through diabetes self-management training or DSMT. It has been shown to decrease diabetes related stress and improve quality of life. Another thing that has shown improvements in quality of life is using a continuous glucose monitor (CGM) because it takes away some 25 of the daily tasks that you have to do. If you do have a comorbid condition like depression, anxiety, or there’s concern that maybe you need additional skills or services, you may get a referral to a mental health professional. But initially, usually management is going to start with the diabetes education.

RK: Thank you so much, Katie, for sharing all your great experience and expertise and for really bringing to light the aspects of diabetes distress and burnout that we should all pay attention to. This has been such an informative podcast and I’m sure our listeners have learned a lot as well. Thank you so much for being here.

KL: Thank you so much for having me. I appreciate it.

RK: I am Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.

For more information, visit hopkinsdiabetesinfo.org.

We love to hear from our listeners. The email address is [email protected].

Thanks for listening. Be well and see you next time.

In Episode 49, Dr. Kalyani welcomes Dr. Scott Pilla, who will speak with us about diabetes and aging. Dr. Pilla is an assistant professor of medicine in the division of General Internal Medicine at Johns Hopkins. He completed his MD at Records Robert Wood Johnson Medical School, and his residency at Johns Hopkins Bayview. He also completed his clinical investigation fellowship in general internal medicine at the Johns Hopkins Hospital. Dr. Pilla is a practicing general internist with research on the management of type two diabetes and aging with a focus on individualizing diabetes treatment to account for the preferences and needs of older adults.

Podcast 49: Diabetes and Aging

Dr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani, at Johns Hopkins. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.

Today we are thrilled to welcome Dr. Scott Pilla, who will speak with us about diabetes and aging. Dr. Pilla is an assistant professor of medicine in the division of General Internal Medicine at Johns Hopkins. He completed his Doctor of Medicine (MD) degree at Rutgers Robert Wood Johnson Medical School, and his residency at Johns Hopkins Bayview.

He also completed his clinical investigation fellowship in general internal medicine at the Johns Hopkins Hospital. Dr. Pilla is a practicing general internist with research on the management of type 2 diabetes and aging with a focus on individualizing diabetes treatment to account for the preferences and needs of older adults.

Welcome Dr. Pilla.

Scott Pilla, MD, MHS: Great to be here.

RK: We are so glad to have you here. This is a topic, diabetes in older adults, that we know will become increasingly more important as the population ages both in the United States and around the world. I was wondering if you could, first off, talk to us about why it is important to talk about diabetes and aging. What is it that makes this population unique that we need to address today?

SP: That is a great place to start. The first thing I think about is just how common diabetes is in older people. It is up to about one-third of older adults in the United States who have diabetes, so the prevalence of it is very high.

But what makes it both interesting and challenging is how heterogeneous it is, by which I mean how different people with diabetes are, who are aging, and how it impacts their lives differently. One of the things that we are still trying to understand about diabetes and aging is why some people get diabetes as older adults and are able to control it very well, and it doesn’t impact their life very much, while other people go on to have a lot of serious complications from diabetes, and it affects them quite dramatically. Those differences are an important place to start and an important thing to understand, both as a doctor treating older adults with diabetes and as a patient.

RK: It is really interesting. A few of the things that you mentioned are the heterogeneity of the population, which I think we’ll get to probably later in our discussion. You also mentioned that diabetes is more common in older adults. I wonder if you could maybe share with us some of the epidemiology and maybe give us some insights into why that might be.

SP: Diabetes really is a disease of aging because it gets more and more common the older that you get. It is unusual to have diabetes, type 2 diabetes at least, as a younger person—although we are seeing that because of issues with the obesity epidemic becoming more prevalent, younger people are getting diabetes as well.

But there’s something about the physiology of how your body regulates blood sugar: you just lose the ability to keep it under as good control the older that you get. As I was mentioning before, a lot of the time this manifests as a very slow progression from normal blood sugar to mildly elevated blood sugar that we call pre-diabetes to diabetes. This slow process is something that is often picked up by doctors and taken good care of, but occasionally, we get people who progress to diabetes very quickly. We are still trying to understand how that works.

 In general, the epidemiology of diabetes is that the older you are, the higher your risk of diabetes. As I mentioned, up to about one third of older people actually have diabetes—this is part of the way that diabetes manifests with age.

RK: Wow, one-third—so one in three older adults. We did not define what we mean by older adults here, but what would you consider it? I know there are multiple ages you could use; when we are talking about these statistics, what is the age that is usually used?

SP: For these statistics, it is usually a cutoff of about age 65. Again, that is a very important point of complexity because we know when you turn 65, your body does not just suddenly change. Someone who is 65 may be very different from someone else who’s 65. If you are very active and you have good function and you are keeping up with your health, you can be as healthy as you were back in your fifties. That does not apply to everybody, unfortunately.

RK: I agree it is a nuanced discussion, but commonly it sounds like 65 and over. So one in three adults are living with diabetes over the age of 65. What about pre-diabetes? Is that also more common in the older adult population?

SP: Yeah, it really is as well. We see the whole spectrum of blood sugar get shifted up as you get older. So pre-diabetes is mildly elevated blood sugar. We define it typically based on this measure called the hemoglobin A1C level, which I know all of our diabetes researchers are very familiar with. But for people listening to the podcast who aren’t familiar with that level:

5.7 to 6.4 means you have pre-diabetes.

6.5 and higher means you have diabetes.

That level, 5.7 to 6.4, is a very complicated discussion of exactly what that means when older adults go into that pre-diabetes range. The epidemiology of it is that it is extremely common. If we combine diabetes and pre-diabetes together, the majority of older adults have one or the other.

RK: It sounds like if you put pre-diabetes and diabetes together, it is something like three out of four older adults have some form of glucose abnormality. That’s huge; that’s a high number.

SP: When you think about it that way, it is the minority of people who have normal glucose when they are older.

RK: That’s right. We have talked a little bit in the past about insulin resistance, and not to go into too much detail here, but I was just curious: since we do see so much pre-diabetes and diabetes in older adults, with this idea of insulin resistance, is this related to having more insulin resistance as people get older?

SP: I am going to be honest; I don’t know exactly how that physiology changes between when younger adults get diabetes and when older adults get diabetes. Generally, when we think about how diabetes develops, the first thing that happens is insulin resistance. The first change you could measure from normal is that the body needs to release more insulin to keep the blood sugar normal. Then as it progresses, the body is not able to release enough insulin to keep up with that resistance, and then the blood sugar starts to rise. That usually occurs over a period of years to decades. But I’m not sure whether that transition happens differently in older people versus younger people.

RK: Yeah, I think with the progression from pre-diabetes to diabetes, there have been various studies suggesting that that progression might be different in older adults; perhaps they can flip back to normal glucose status. I know in some of the work that we have come across that insulin resistance does seem to be more common in older adults, whether that’s with inflammation or just the body composition changes and hormonal changes that occur with aging. It is an interesting topic for another time, but there do seem potentially to be physiological reasons, perhaps with aging, why individuals might be more likely to have pre-diabetes or diabetes.

You talked about the age of diagnosis, and I thought it was an important point you made that we are seeing more type 2 diabetes in younger adults, but really diabetes is a disease of aging. That heterogeneity you talked about—the age by which people get diagnosed—is there a difference when people get diagnosed, let’s say in midlife versus in older age, in terms of their complication risk? Why the difference? Why the heterogeneity?

SP: There are some important points there. When I’m seeing people with diabetes, I put people into a much higher risk category when they have diabetes at a younger age because, for one, they are going to be living with high blood sugar for much longer. We know the way that blood sugar damages your blood vessels and your heart and your kidneys is—year after year—causing slowly accumulating damage. So when you are diagnosed with diabetes earlier, there is much more time for that to happen, and, at the same time, there is much more of an opportunity to prevent those complications because you have a longer time to intervene. I think the other thing about people who get diabetes at an earlier age is that I do worry. We do see a lot of people who have more severe diabetes related to other severe metabolic problems. Being overweight or obese, having really high cholesterol, or having other things that are related to your metabolic risk and your risk of outcomes like heart disease. If we look epidemiologically, people who get diabetes at an earlier age are much more likely to develop complications of diabetes. Whereas people who get diabetes when they’re older, especially those who have pre-diabetes or early stages of diabetes, their risk of complications can be almost as low as people who don’t have diabetes. That reflects the physiology that we understand.

RK: That is so interesting and it makes sense that the longer you have the disease, the higher the risk of complications and this just reemphasizes the importance of prevention, which I know we’ll talk about later too. Since we are talking about complications, could you talk to us a little bit about the complications that we see with diabetes and what are some of the unique considerations or other conditions that can occur with diabetes and aging?

SP: When we think about complications of diabetes, think about the different organ systems that high blood sugar can start to damage. We usually break it down into 2 categories. The first is macrovascular, meaning damage to large blood vessels; here we see the large blood vessels are feeding things like the heart muscle. So, you can get the risk of heart disease, heart attacks and heart failure, which is a weakening of the heart muscle. You could also get damage to large blood vessels in the legs, causing decreased blood flow in the legs or feet which sometimes, in severe cases, can result in foot damage and lead to amputations and those very severe complications of diabetes.

Then the other category is microvascular damage; there is damage to small blood vessels. Small blood vessels are in a lot of different places, but the organs that diabetes affects the most often are the eyes where you can get diabetic retinopathy — damage to the retina of the eye from decreased blood flow there, and that in the most severe cases, can lead to blindness. Then we have nephropathy, which is damage to the blood vessels in the kidneys. Again, this usually starts slowly, but if it is untreated it can progress to needing dialysis or end stage renal disease. Then the last is the nerves, the nerves in the body are also fed by small blood vessels. If diabetes starts to affect them it can cause neuropathy, meaning people start having changes in their sensation, usually in their hands or feet; pins and needles. That can also predispose people to having more damage to your hands or feet because of inability to feel when that damage is happening.

Those are the general complications of diabetes and how they arise. You asked about differences between younger people and older people in those complications? When I think about those, I think about what the challenges are that old people face in terms of their physical and cognitive functions. I think diabetes feeds into that because all of those changes that can happen as a result of high blood sugar can interact with the functional changes that are also happening as people get older. If, for example, someone is having difficulty walking because of arthritis and then, on top of that, they get changes in their sensation in their feet because of diabetes, it can worsen their function. We know that diabetes can be a major source of disability in older people. I try and put all of these potential complications of diabetes into the context of what is already happening with aging that is affecting someone’s health and function. There are so many different ways that can interact there.

RK: It certainly seems like there are many different things to think about. You mentioned the microvascular and macrovascular complications; the complications we think of for people of any age are heart disease, stroke, eye disease, nerve disease, and kidney disease. It sounds like with a longer duration of disease, people might be more likely without optimal management to have those complications. Are those complications more common in older adults? Is there a higher prevalence of those complications among older adults?

SP: Yes, they are more common in older adults, both with and without diabetes. Your blood vessels aren’t as strong as you get older, and they get narrowed from a lot of reasons, like high cholesterol and high blood pressure, and just living with them for decades and decades. However, people with diabetes have, higher rates of these complications. Although, as we talked about earlier, when you get diabetes, especially early diabetes as an older adult, your rates of these complications don’t go up by that much. Especially compared to people who got diabetes when they’re younger who really are, at the highest risk of these. So the people who’ve been, who are older adults who’ve been living with diabetes already for decades, they are the people who are at the highest risk.

RK: That makes sense—that if they have had the disease for longer periods of time, they would be at greater risk as an older adult. You also mentioned, which I think is an important point for us to talk more about, these other conditions that can occur more commonly in people with diabetes as they age—what might be called geriatric syndromes. I wonder if you could talk a little bit more about those and how common they are in people with diabetes and why it is important to recognize them.

SP: What we call geriatric syndromes are basically issues and health conditions that kind of frequently impact older adults and are common sources of disability in older adults. Diabetes, I would say, affects the vast majority of them (geriatric syndromes) and makes the vast majority of them more likely to happen. Again, every older adult is very different, so which of these syndromes affects different people is variable. Some of the ones that I think of commonly are changes in thinking and cognition—as your brain ages, often people develop decreased memory or dementia—and diabetes does make that more common.

One of the things that I research is hypoglycemia (low blood sugar), and diabetes treatments, which cause low blood sugar, can also make people have issues with their thinking. That can be another way that it is not just the diabetes itself impacting how people think and function as they get older; it is the effects of the treatment.

A lot of the other geriatric syndromes are different ways that the body is no longer functioning at its full capacity and causing limitations in what people can do. I know one area of your research, Dr. Kalyani, is about frailty and loss of physical function and strength as people get older. We could see that definitely impacts diabetes, in that diabetes makes that happen more often. It could also, I think, have a bidirectional effect where frailty makes people be able to exercise less and get around less, and then they are really not able to keep their blood sugar as well controlled because they are not moving as much.

Then another one that I will mention with geriatric syndromes is musculoskeletal issues like arthritis in the hands, where, on one hand, diabetes does not necessarily cause this, but when it happens, it can make people have difficulty taking care of their diabetes because they have difficulty checking their own blood sugar or administering insulin or doing the kind of fine motor skills that are required for a lot of these diabetes self-management efforts.

RK: I think that there are just so many different types of syndromes that are conditions that can occur more commonly in older adults. Part of the challenge is that there are so many of them, and I appreciate that you highlighted perhaps some of the ones that we may be more familiar with or may have a greater impact on day-to-day quality of life for older adults. I think that as people age, something that becomes more and more important is the ability to do tasks at home, to have mobility, to have intact cognition, and to be able to self-manage. I appreciate you going through all those different syndromes.

One of the ones you talked about was cognitive impairment, and I think that we are hearing more and more about that in the general population, but perhaps it would be worth talking about why cognitive impairment and dementia are so important to keep in mind for people with diabetes. What is the connection there?

SP: One question is how does diabetes contribute to cognitive impairment? That is a complicated physiologic question that I think people are still trying to figure out. One of the complexities, as I mentioned, is that diabetes itself can increase your risk rate of developing cognitive impairment, probably through its effects on the blood vessels in the brain, but also having cognitive impairment makes it more difficult to control your diabetes and to treat your diabetes safely. So that is something that we see also very commonly: that people who have cognitive impairment or dementia have more risks from diabetes treatment, like more side effects and more issues with hypoglycemia, or low blood sugar. It can be more difficult to get their blood sugar under control safely. That is one of the reasons why I assess cognitive impairment very frequently in people with diabetes, and I really think about, “Is the treatment that I’m giving them safe, and can they manage it?” When I think about managing it, not just them, but their whole system of care partners and care structure, I know everybody around them who is helping them take care of their diabetes—do they have the support that they need to do it safely?

RK: Yeah, I do think that’s where it becomes important, especially for our older adults who may not have that support, whether it be family support or caregiver support, that having some of these geriatric syndromes, particularly cognitive impairment or dementia, can make self-management more difficult. Isn’t that true?

SP: Yes, this is so true. There are ways of trying to get around that, but for the most part, it is just going to be altogether more difficult. This is something that people with diabetes and their care partners just struggle with. Unfortunately, there is no great way of making it easier.

RK: You also mentioned muscle loss, or sarcopenia, and this is an area that I have dedicated a lot of time to understanding more. This is something that we see with our older adults as well as in the general population: that they can lose muscle as they age, but in people with diabetes they can lose muscle faster than their counterparts. As you mentioned, the implications on mobility and being able to move around and the other body composition changes that occur with aging as well; people tend to retain more fat tissue, and that might also relate to some more of the insulin resistance we see with aging.

It is complicated with all of these different conditions that we can see, but it is important to recognize because of the impact it can have on self-management and quality of life. Just to summarize some of the other ones, urinary incontinence is something we talk about as well. We will talk a little bit about hypoglycemia in a little bit too. But there are things that can occur more commonly, like frailty, as well in older adults with diabetes.

As an internist yourself, how often do you screen for these syndromes in your older adults with diabetes, or how should someone who might have a loved one who’s older with diabetes or might be over the age of 65 themselves find out more if they might be at risk for these geriatric syndromes?

SP: It is a good question, and I think it is something that internists struggle with because there are just so many ways that your body changes as you get older and so many ways that diabetes could impact that. It is hard to know; you obviously cannot ask for every single one in every visit. I think what it comes down to is, as an internist, knowing your patients well, and as a patient, being able to bring issues that develop to your doctor’s attention openly. I always encourage patients that if they are having changes that they notice, we should talk about it early because it might be an effect of diabetes, and it might be something that we could address if we know about it early.

I will mention hypoglycemia again, but one of my studies about hypoglycemia, which is a complication of diabetes treatment, shows that only about a third of people who should be discussing hypoglycemia have actually discussed it in their visit with their doctors. Sometimes people may feel these things are either like a fault of their own or something they maybe do not want to burden their doctor with, but I think it is important to really bring these things up.

In terms of what doctors can do, I think there are certain things that, if caught early, are obviously very important and should be regularly screened for in visits or asked about whether or not the patient brings them up. One of those things is cognitive impairment. We should know when our patients are having changes in their thinking, and there are tools that we can use in clinic to do that efficiently. Then for people who are on these higher-risk medications for diabetes, I think we really should be screening for their side effects to make sure that we understand the risks that the medications are having.

RK: I agree; I think it is important for healthcare providers to keep this at the top of their mind. Also, as an individual who might have diabetes, to be aware that this can happen, to be aware of symptoms, and then to talk to your healthcare provider about whether you should be screened for these conditions.

We talked about hypoglycemia, and I think this is a good place perhaps for us to talk a little bit more about that because it is one of those conditions that can occur as a side effect or complication, or however you want to describe it. But when it does occur in people with diabetes, it can be potentially serious depending on how quickly it is treated and how severe it is. It is worth it for us to talk a little bit more about how we define hypoglycemia and what the symptoms are, if you could share some insights.

SP: Hypoglycemia has pretty specific definitions. The general definition of hypoglycemia is having a blood sugar level that is less than 70 milligrams per deciliter (mg/dL). That would be on a finger-stick reading of blood sugar. If you are less than 70 mg/dL, you are considered to have hypoglycemia, but within that there is really a wide spectrum. We categorize it according to levels.

Level one hypoglycemia is having a blood sugar in the 54 to 70 mg/dL range, which is low, but usually not so low that it can cause really serious harm. But then less than 54 mg/dL, we call level two hypoglycemia, and this is when you know people really can suffer a lot of serious consequences, which we will talk about in a second. Level three hypoglycemia is any low blood sugar level that actually changes your thinking and consciousness and sometimes can wind people up in the emergency room or needing assistance from somebody else. If you need help to manage a hypoglycemic episode, that is considered level three hypoglycemia, the most severe stage.

You mentioned symptoms, and symptoms of hypoglycemia are tricky because they are fairly varied and can occur due to other conditions outside of hypoglycemia. The most common symptoms that people feel are this sense of getting revved up; it is an adrenergic reaction, people can have like rapid heartbeat and sweating, sometimes it comes with headache and anxiety. Those are what we call the adrenergic symptoms of hypoglycemia.

But then as it gets more severe, there is another category called neurocognitive symptoms of hypoglycemia, meaning that it is affecting how you are thinking and feeling. Those can be symptoms like feeling drowsy or confused or changes in your emotions and acting strange. The most severe, cases could be decreased arousal or coma. That is the natural progression of hypoglycemia symptoms. In that area not everybody experiences the symptoms equally.

People who have had diabetes for a long time or who have a lot of hypoglycemia can get something called impaired hypoglycemia awareness. This means that they do not experience the typical symptoms of hypoglycemia when their blood sugar is low. On one hand that sounds like it could be good because, “Oh, I’m not having as many symptoms,” but the problem with that is you do not get the early warning signs. These early symptoms that you have when your blood sugar is just starting to get low, they just sail right through that, and then the first thing that hits them is more severe symptoms. Because they do not have this warning, it could cause really serious hypoglycemia more often.

RK: Thanks so much for going into detail and sharing that really important point, that older adults may not have these early symptoms of hypoglycemia, or low blood glucose, just as part of the process of aging. They might not have that racing heart rate or sweatiness until it becomes more severe. It does behoove us to talk about monitoring for low blood sugar even more for older adults. Would you say that it’s even more important in older adults, or what do you tell your patients with diabetes?

SP: I definitely think it is more important, both for the reason you mentioned that some people will not have those early warning symptoms and that we know that the risk of having more severe hypoglycemia goes up as you get older. The thing that we did not mention yet is that most diabetes medications do not cause hypoglycemia, at least by themselves; really, the most risky medication for hypoglycemia is insulin, especially like multiple daily insulin or the rapid-acting insulin that people sometimes need. Then there is another class of medications called sulfonylureas that are an older class of medications but are still very commonly used in older people. They also cause hypoglycemia without needing to be on insulin. The other diabetes medications, if you’re just on a medication like metformin or one of the newer medications by themselves, would not be expected to cause any significant hypoglycemia. When we talk about monitoring, it really depends on what your risk is and what medications you’re on.

RK: That is a great segue into talking about medications for diabetes and those that might have a higher risk for hypoglycemia versus those that might be relatively safer to use with older adults who have diabetes. I guess one of the questions that I often get, and I think it would be great for you to address, is, “Is insulin safe for older adults with diabetes?” We know that insulin has a side effect of hypoglycemia. We know, unfortunately, that it’s one of the reasons that people come to the emergency room. It’s one of the top three reasons, in fact, for having hypoglycemia and using insulin. We know that there are safe ways to use it as well. I wonder if you could talk to us about what medications, if any, people who have diabetes and are older should avoid and how safe it is to use medication such as insulin.

SP: Medication selection with aging is a very important topic and very complex. I will say, my general thought about it is, all of these medications have their place, and they may be the right medication for someone in certain circumstances. I try and use the medication that has the lowest risk but the greatest benefit for any particular person. Insulin for older people with type 2 diabetes is often used in two circumstances: one is where they cannot use other medications because of side effects or because of contraindications like low kidney function. We just do not have a lot of medication options, so insulin can sometimes be the only one that will work. Then insulin is often used when people have had diabetes for a long time and their pancreas just is not making enough insulin on its own anymore. Sometimes insulin is the only way to keep the blood sugar under control at that point. I think insulin has its place and is an important medication for older people. That being said, if those two circumstances are not happening, I try to use insulin as little as possible because I am very aware that it is the most risky medication for an older person to be on, bar none. If you really do not need it, I do not want you to be on it, and I want us to explore other medication choices.

RK: I think it is important that it depends on what it is being used for, and for many individuals with type 2 diabetes, they will need insulin eventually just because they cannot produce any on their own—in that case, we really do not have any other choices. In situations such as you mentioned, where there might be other choices, and increasingly we are seeing other medications used that have lower hypoglycemia risk, those might be preferred for older adults who are more likely to have symptoms of low glucose or not have symptoms of low glucose as well.

In terms of types of insulin that can minimize hypoglycemia, I wonder if you want to talk a little bit about that too. Not all insulin is the same, and we do have options for insulin that can lower that risk too.

SP: Yes, that’s true. The most risky forms of insulin are the rapid-acting insulins, especially when people are using them on what is called a sliding scale—they are adjusting their insulin based on numbers. People have to be very careful with giving themselves the right amount of insulin. Sometimes it is hard to estimate exactly how much insulin you need. Sliding scale insulin is the most risky form, but it is also sometimes necessary if you need closer control of your carbohydrate intake.

The longer-acting insulins are less likely to cause hypoglycemia, and now there are newer formulations of these longer-acting insulins that act in the body very slowly and at a very steady state that have the lowest risk of hypoglycemia of any insulins that have come before them. I think that those are definitely options, those ultra-long-acting insulins that are being developed.

That being said, I think as much as the type of insulin, it is having it being dosed appropriately and also being aware of when that dosing needs to be changed. For example, a lot of people get in trouble with insulin when they get sick and they are not eating as well, and they do not know exactly what to do with their insulin because their blood sugar might be high, but their intake is low, and how do we manage that? We all know as you get older, you are more likely to get sick and have things happen—when those things happen, you need to be in close contact with your doctors to know exactly how to manage your insulin so that you do not get into trouble.

RK: It is exciting to have so many newer insulins, those longer-acting insulins, on the market that can reduce hypoglycemia. As you mentioned, those rapid-acting mealtime insulins really are designed to be used when you are eating. If they are not matched appropriately in dose or if you eat less, you could be at greater risk for hypoglycemia, or if you exercise more. All those lifestyle patterns also contribute, as you mentioned, to the risk of hypoglycemia. We have not yet talked about perhaps another class that we should briefly talk about, sulfonylureas, and their effects on lowering blood glucose. I wonder if you could just briefly talk about what that class is, maybe some common names people would be familiar with, and how those can be used safely in older adults.

SP: Sulfonylureas are oral medications, and the three most common ones have the generic names of glipizide, glyburide, and glimepiride. If you have been on one of those medications, that is a sulfonylurea. I think oftentimes people think of sulfonylureas as fairly benign because they don’t cause severe hypoglycemia that often and they work fairly reliably. When people take them, I think they have a very expected effect on lowering your blood sugar.

That being said, I wanted to tell a story about a patient I took care of when I was a resident that had a really bad complication from sulfonylureas that just really stuck with me. This patient was on glyburide, an older woman who had early stages of dementia and was taken care of by her daughter. She developed symptoms of a urinary tract infection and was brought to an urgent care center to get that treated. They, the urgent care, put the patient on Bactrim (trimethoprim/sulfamethoxazole), which is a common antibiotic that we use to treat urinary tract infections. The daughter left the home to do a few errands, and she came back, and she found her mother on the floor unconscious. The Emergency Medical Services (EMS) showed up, and her blood sugar was 40 mg/dl. They brought her to the hospital, and that is when I met her—I did her intake when she came into the hospital. We realized that what happened was that this medication, Bactrim (trimethoprim/sulfamethoxazole), interacts with sulfonylureas and actually causes their dose to be at least three times as high as it would be otherwise. That was enough to cause this person to have profound hypoglycemia, and she was treated quickly, and she recovered somewhat, but she was in the hospital for almost a week and was not back to her baseline by the time she went home. Her thinking was not nearly as good as it was before this happened; it was a very bad thing for this person.

So even though these medications are generally not considered to be that risky, there are certain circumstances where they can be very high risk. These interactions between sulfonylureas and antibiotics are something that I always like to talk about because doctors do not seem to be aware of this, and it is a very common problem.

RK: Thanks for sharing that story. It highlights the importance of educating people who are taking these medications on the risks that can occur, particularly with infection or not eating as much as usual. Also knowing when to reach out to your healthcare provider—when you might need to reduce a dose or stop a dose of medications at higher risk of hypoglycemia. I think that knowing that with these caveats, there are medications in the sulfonylurea class that might be longer acting and reduce the risk of hypoglycemia. Even extended-release versions of these can lower the risk of hypoglycemia. Knowing that they are inexpensive and really effective at lowering A1C means that we do use these, but we should be using these cautiously, especially in those at higher risk of hypoglycemia, as you mentioned.

SP: The patient education part of it is really important because if you prepare people and they know what the risks are and they know when they should be cautious, you can really improve how safe these medications are. As you mentioned, they are still used very commonly because they are effective and are quite cheap. It is not that they do not have a place; they might be the right medication for some people.

RK: So, we have not really talked about A1C or what glucose level people should aim for when they are older; part of that is because of this idea of individualized care. I wonder if you could talk a little bit about what patient-centered or individualized care looks like for older adults with diabetes. What are the A1C targets that are usually recommended for older adults?

SP: When I think about individualized care of diabetes, the first thing I think about is that every aspect of diabetes care should be individualized and should be targeted to what a person needs. One area of individualized care that has had a lot of discussion over the last two decades is: What should your blood sugar goals be? The reason that this is so important is that the lower you push your blood sugar down, the more you can lower complications of diabetes, but you also increase the risks of the medications and the risks of treatment. How to balance those benefits and risks changes as you get older. There is a very nice figure in the American Diabetes Association Standards of Care, which kind of shows how we should select those blood sugar goals for different people and different age ranges.

The general principle is that people who have a better chance to benefit from lower blood sugar should get lower goals, as in more aggressive goals. Then people who have a higher risk of having side effects from medications should have less aggressive goals. It is about balancing those things. Some of the specifics we think about are your age and function. For healthy, older adults who have good function and are generally doing well, we say your blood sugar target should basically be the same as for anyone of any age, which is a blood sugar range of an A1C around 7 to 7.5%.

This is where we set blood sugar targets generally and sometimes even lower targets for people who are very healthy or who have not had diabetes for very long. Then as you get older and have accumulated health problems or decreases in your function or your thinking, you really have less of a chance to benefit from having a lower blood sugar; you have more of a chance to get harmed. So as we mentioned earlier, having dementia, for example, really poses a higher risk of side effects from diabetes medications. For people who are in those categories, the A1C goal could be 8%, or it could be even higher than 8%, depending on where their health and function fall. But the key thing to think about is that doctors should not just set a goal of 7 to 7.5% for everybody. They really should think about “What is the goal that my patient needs, and how risky is it to get there?”

RK: That is really helpful to hear about how the A1C target really can slide or be individualized based on the individual’s health function, life expectancy, and other considerations. It sounds like it is a conversation that really needs to be had between the person with diabetes and their healthcare provider to determine what’s the best target for them.

We also have not yet talked about technology, and we know that there is a lot of new diabetes technology, which is really exciting. People of any age should be eligible and get coverage for these exciting new technologies. Are there considerations unique to older adults that we should keep in mind?

SP: I think the big new technology that everyone is talking about is continuous glucose monitoring (CGM), and that is what most people are thinking about when they think about diabetes technology. Technology is advancing in a lot of areas of diabetes, especially type 1 diabetes care when people have to be on insulin. Every year there are better automated insulin delivery systems and these smart devices that can match your insulin needs to your carbohydrate intake very closely. When we talk about older people, mainly with type 2 diabetes, continuous glucose monitoring has been gaining use and gaining evidence that it is really helpful.

The people who it is most helpful for are the people who are on insulin because we know that they need closer monitoring of their blood sugar to prevent hypoglycemia. Their blood sugar fluctuates more when they need insulin; being able to capture those fluctuations in real time on a CGM device can show you exactly what is happening in your body and allow you to react more quickly to changes. They also let you and your doctor learn more about what the patterns are in your blood sugar. You can see what you are doing and what makes highs, or when you have a hypoglycemia episode, what precipitated that, and what time of day they are occurring so that you could change your treatment and your strategies so that you could match your insulin to your needs very precisely.

I will mention that CGMs are a pretty complicated technology. They are getting easier and easier to use; most of the time you need to be able to connect a device to a smartphone, be able to navigate apps, and understand the numbers that go along with it. There is definitely a learning curve, and there are definitely technology portions of it that a lot of older people will not be as comfortable with. The devices are getting better and better every year, and they are getting easier to navigate and understand. I think they are becoming more and more accessible to older people.

RK: Yes, and it is so great to have these technologies available. I think there are so many aspects that can make it easier to facilitate day-to-day care, but perhaps for those who have cognitive impairment or physical limitations or dexterity limitations, there are continuous glucose monitors that might be voice activated, for instance, or have big screens that might make it easier for people with those limitations. Overall, it is a really exciting time for people of all ages.

SP: There are monitors that you can have a care partner or someone else have the data go to them too. If someone needs help with managing the data, someone else can be there to do it too.

RK: One aspect that I thought would be important for us to talk about is the role of the caregiver. This would be a great time to talk about that. For an older adult with diabetes, what is the role of the caregiver, and how could they be supportive to the individual with diabetes?

SP: I have seen my older people, especially those who are struggling with issues with cognition or with mobility, having somebody who can come with them to appointments and help in the management of the diabetes can be just so valuable. There is just so much to do and so much to keep track of that I think a lot of older people need help. Having more than one person involved in these management decisions can make everything go smoother and easier. What the roles are varies so much by individual and what they need. I will mention there are very specific ways that caregivers can get involved and help. One that I am very interested in is prevention of hypoglycemia. Hypoglycemia can be a burden to not just the person with diabetes but their caregivers as well, because it can be really stressful, especially if they are having these severe episodes that find them unconscious or confused and the caregiver has to be the one to address that. One of the ways that can improve the safety is having a caregiver be trained in the use of something called glucagon. Glucagon is a medication that is given either nasally or as a shot that can rapidly reverse hypoglycemia. Having that in the home and having a caregiver know how to use it can be a way of improving safety and taking the power back from these really severe issues that can wind people up in the Emergency Room (ER).

Aside from hypoglycemia and medication management. I think caregivers’ roles can be so varied. It could just be about getting people to appointments and helping them navigate the health system, to helping administer their medication safely, and/or helping them keep track of their blood sugar. There can be so many things a caregiver can do. As a doctor, I also think about the fact that caregivers have a lot of burdens on them too. They often have their own health problems and sometimes feel the need to sacrifice their own health to help their partners. I think doctors need to also be aware of what the care partners and caregivers are going through and what they are dealing with and not just say, “Oh, you have to do this and do this,” and just keep harping on it. You have to try and make it practical and easy and something that they can accomplish without overburdening themself.

RK: That’s so important, what you mentioned about not only the physical support but also the emotional support that caregivers can give. The education that is important for caregivers for hypoglycemia treatment, like you mentioned, is knowing what to do in cases of an emergency. I always enjoy having the caregiver when they come to patient visits. Having a caregiver or a family member who has an active role in the care plan, is just so critical, especially as individuals age and have greater needs. Thank you for going over that.

We have covered a lot today, and I really appreciate you talking about the different ways that an older adult with diabetes may be affected by complications and geriatric syndromes and also the unique considerations that we have to think about in management.

Just some parting words that you might have for our audience, for anyone who has, let’s say, a parent or a loved one or maybe even themselves who falls into this category of having diabetes in older age and maybe struggling to find a healthcare provider who understands their needs or really to understand why things may not be working for them the way they work for their younger individuals—what would you say to them in terms of things that they can do or next steps?

SP: What I would say about taking care of a relative or loved one with diabetes who is struggling is I would start by thinking and talking amongst yourselves about what the goals for diabetes are and what their priorities are because knowing what you want to get out of the medical visit is extremely important. Telling your doctor that it is extremely important so that you are all on the same page at the start of the visit and that the doctor understands what you are hoping to gain. Priorities are important too because you cannot always address everything in one visit with your doctor. So, you should think, “Okay, what is the most important thing, the most important problem to focus on today?” If you come to your doctor with that in an ordered list, it can be really helpful to set the expectations for the visit and make sure something is accomplished. I would also try and bring in the worries and fears that you or the person with diabetes have so that the doctors know what they’re worried about and if there’s a way to alleviate that, because I think doctors often don’t know when their patients are suffering emotionally or struggling emotionally with the disease. And understanding that can just really help frame what the doctor can do for you and help them understand you as a person.

I think those three things—talking about goals, setting priorities, and then bringing up your worries and concerns in a visit—will really help things move forward.

RK: Thanks so much, Dr. Pilla, for sharing those last words. Goal setting is so important, especially in the older adult population. I really appreciate you highlighting that and for all of the expertise and clinical insights you shared today—giving some insights on things for older adults with diabetes to be aware of, to ask their healthcare providers more about, and really to be prepared for so that they don’t run into issues and can live a long, healthy life with this condition. Thank you so much for being here. We really appreciate it.

SP: Great. Thank you for having me. It’s great talking about it.

RK: I am Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.

For more information, visit hopkinsdiabetesinfo.org.

We love to hear from our listeners. The email address is [email protected].

Thanks for listening. Be well and see you next time.

In Episode 48, Dr. Kalyani welcomes Dr. Mihail “Misha” Zilbermint, who will speak with us about diabetes technologies in the hospital. Dr. Zilbermint is an associate professor of clinical medicine in the division of Endocrinology, diabetes and Metabolism at Johns Hopkins University School of Medicine. He is the Director of Endocrine Hospitalists at the Johns Hopkins Community Physicians Chief and Director of the Division of Endocrinology, diabetes and Metabolism at Suburban Hospital in Bethesda, and has pioneered the Endocrine Hospitalist Program at Johns Hopkins Medicine following the completion of his endocrine fellowship at the National Institutes of Health. His commitment to innovation has earned his specialized diabetes team, the Johns Hopkins Innovations and Clinical Care Award. Along with Dr. Zilbermint, we also welcome Jordan Spivak, who is the inpatient diabetes educator at Johns Hopkins, Sibley Memorial Hospital and Suburban Hospital. Jordan has seven years of experience as a registered dietician with clinical experience at Northwestern Medicine in Chicago, and now two and a half years at Johns Hopkins. She most recently graduated with her Master’s of Science in Clinical Nutrition from the University of Wisconsin Madison.

Dr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani, at Johns Hopkins. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.

Today we are thrilled to welcome Mihail, also known as “Misha,” Zilbermint, who will speak with us about diabetes technologies in the hospital. Misha is an associate professor of clinical medicine in the division of Endocrinology, Diabetes, and Metabolism at Johns Hopkins University School of Medicine. He is the director of Endocrine Hospitalists at the Johns Hopkins Community Physicians; chief and director of the Division of Endocrinology, Diabetes, and Metabolism at Suburban Hospital in Bethesda; and has pioneered the Endocrine Hospitalist Program at Johns Hopkins Medicine following the completion of his endocrine fellowship at the National Institutes of Health. His commitment to innovation has earned his specialized diabetes team the Johns Hopkins Innovations and Clinical Care Award.

Along with Dr. Zilbermint, we also welcome Jordan Spivak, who is the inpatient diabetes educator at Johns Hopkins, Sibley Memorial Hospital, and Suburban Hospital. Jordan has seven years of experience as a registered dietician with clinical experience at Northwestern Medicine in Chicago and now two and a half years at Johns Hopkins. She most recently graduated with her Masters of Science in Clinical Nutrition from the University of Wisconsin–Madison.

Welcome, Misha and Jordan.

Mihail Zilbermint, MD: Thank you.

Jordan Spivak, RD, LDN: Thanks for having us.

RK: We are so excited to learn from you both today about the use of technology in the hospital setting. This may be something that people don’t think too much about, but as technology becomes more and more common to use at home, this becomes increasingly a question that I know I hear from my patients: “What do I do with my continuous glucose monitor or insulin pump in the hospital?” We are looking forward to having you both shed some light on that. I wonder if you could start by telling us: why is it important to discuss the use of technology in the hospital in the first place? How common is it?

MZ: Thank you, Rita. First of all, we have to acknowledge that diabetes is extremely common in hospitalized patients; about one in four hospital patients have diabetes. Managing blood sugar in a hospital is absolutely critical to prevent complications, to speed up recovery, and, of course, to improve our outcomes. The diabetes technologies transform diabetes care, but hospitals have been slower to adopt these tools compared to some of our outpatient colleagues.

In 2025, the American Diabetes Association standard of care now supported the continued use of continuous glucose monitors and insulin pumps in the hospital when it’s clinically appropriate. Of course, there is proper training, proper protocols, and confirmatory blood glucose checks.

JS: As you mentioned, Rita, so many patients that are hospitalized now are already using these continuous glucose monitors and insulin pumps at home. It really does make sense to explore whether they can be used safely in the hospital with where we’re at with technology.

I had a patient just a few days ago with type 1 diabetes that was on a CGM at home and had it removed right on admission. It makes sense to explore whether we can replace the sensor for the patient so that they can continue to be involved in their care and have that autonomy. Then furthermore, have it re-set up for them once they get home.

The pandemic also accelerated a lot of interest in remote glucose monitoring. Having nurses cluster their care in a room and being able to see the patient’s blood sugars without even having to go into the room. Now more hospitals are integrating those continuous glucose monitors into inpatient care.

RK: That is so interesting to hear you both talk about how much this has become a topic to address. You mentioned, Misha, that it has now entered our clinical practice guidelines, the use of technology in the hospital. I think that really does highlight the importance of the topic that we are talking about today.

Jordan, you mentioned the remote monitoring, and it does seem like the hospital setting would lend itself particularly well to the medical staff or the nursing staff being able to remotely monitor blood glucose metrics or other metrics from the technology patients are using in their hospital room. Exciting possibilities for ways that we can really improve and facilitate optimal patient care. When we talk about technology, what kinds of technology are we talking about? And can these be used safely in the hospital?

MZ: We know that, as I mentioned previously, the American Diabetes Association now supports the continued use of personal continuous glucose monitors, or CGMs, and also insulin pumps in the hospitals. But what is important here is we clearly need institutional protocols and point-of-care blood glucose confirmations, like finger sticks for insulin dosing and for hypoglycemia detection.

         We know that insulin pumps are little tiny machines which can deliver insulin to a human, mostly to people who have diabetes. We call them automated insulin delivery systems—they can also be continued in the hospital when clinically appropriate, but it really depends on the staff training, availability of supplies, and the patient’s ability to manage the device.

That’s why here at Johns Hopkins, we spend a lot of time meeting with each other; all of the endocrinologists and the diabetes educators from all of the hospitals in Maryland and DC got together to put together a detailed policy in the training documents for the nursing staff to make sure that everyone knows what to do when the person walks into the hospital with either a continuous glucose monitor or an insulin pump.

JS: Just to piggyback off of what Misha said, so in our hospital we do allow patients to use their continuous glucose monitors when they’re admitted, as long as the traditional finger sticks are still being done by the nurses per our protocol. The continuous glucose monitors are not yet FDA approved for hospital-initiated use, meaning that hospitals can continue their personal continuous glucose monitors. We’re not putting on continuous glucose monitors and saying we’re using them by our hospital policy, but if the patient has one when they’re admitted, they can continue to use it. We do educate our nurses on that a lot when they’re oriented to the hospital and through my education on the units.

We do have a special program here where we can initiate a continuous glucose monitor at the time of discharge as long as the patient meets the predefined criteria. As long as the patient is alert and oriented, we double-check with their insurance coverage for continuous glucose monitors at the time of discharge. That is really just to set them up for success at that time when they get home and educate their family and things like that.

Hybrid monitoring protocols that combine the continuous glucose monitor readings and then those blood sugar checks done by the nurses is really, I think we are finding that is probably the safest approach.

MZ: I totally agree with Jordan. For example, we had a patient a few days ago who approached us saying that there is a clear discrepancy between a glucose reading on his personal monitor, his insulin pump, and the finger stick, which nurses are performing. We told him that sensor glucose levels and blood glucose levels are different; they are almost never identical. They are almost never the same because we are measuring slightly different things. I’m sure you discussed in your previous podcast the difference between blood glucose and sensor glucose levels. But what we do encourage all the time—every time a nurse comes in, if your sensor allows a calibration, which means that the patient has to manually enter the glucose number, we definitely encourage you to do it.

RK: Those are some really important points that you both brought up in terms of how we can, in practical terms, integrate technology into the management of a patient with diabetes in the hospital. I thought what you mentioned about nursing education really could not be overemphasized. While the person with diabetes has been using this technology, now that they’re in the hospital, it’s equally as important for the medical team to be familiar with the technology as well.

         So much of what happens—and Jordan, I know you do a lot of it in the hospital—is diabetes education. All the technologies are different; all the continuous glucose monitors are different in terms of their features. It’s really important to understand how they’re used.

I just wanted to clarify a point that you made as well. It sounds like what you’re saying is that when people have continuous glucose monitors and if they’re able to continue them per hospital policy in the hospital, these don’t substitute for the glucose monitoring that the nursing staff would do. It would be a compliment. Is that right?

MZ: That is correct.

RK: It’s giving additional information that might otherwise be missed—how often would you say, otherwise, people get finger sticks in the hospital?

MZ: On average, most of the people get at least five finger sticks in the hospital. Some of them get six finger sticks in the hospital. If patients are very ill and they have to be admitted to the intensive care unit, when we have to get insulin directly for their IV line, sometimes we have to do it every hour. In the future, when CGM will be FDA approved to use in the hospital setting, I think we are looking forward to the time when we do not have to finger prick patients so often.

RK: That’s a really important point. What do you see as the benefit of continuing these technologies in the hospital? If we could just touch upon that briefly.

MZ: I believe that even though we don’t have an FDA approval, per se, to use them for insulin decision-making. But what I have found is that patients who use CGM, for example, patients who use CGM in the hospital, are becoming a little bit more aware of their glucose levels—they’re a little bit more aware of trends in their glucose levels.

Let’s say someone was admitted for a heart attack and now they’re waiting for open heart surgery, and we have to receive medication, which is blood thinners such as heparin, which is mixed in dextrose or sugar. While receiving this medication, their glucose starts trending up, and they can alert them or say, “Hey, I feel that my sugar is trending up. Do you mind double-checking or triple-checking the sugar to make sure that we are trending in the right or wrong direction?” That may alert me as an endocrine hospitalist to maybe order a little bit more insulin or just some of another diabetes medication.

RK: That is one of the unique features, isn’t it, of the continuous glucose monitors—those trend arrows and the ability to see what direction the sugars are going, which you may not get from just a few data points throughout the day. Also, the ability of the patient to be involved in their care, to really have an understanding of what’s going on, and perhaps to give a heads-up for instances that may need to be addressed before they become bigger instances. For those who might be listening that are contemplating, why even consider this if it’s a hospital setting that does not yet have a policy? I think that’s a particularly important point: even as a complementary monitoring to what’s standardly done with the finger pricks, it can have value.

We talked about continuing use of continuous glucose monitors upon admission. I wonder if we wanted to talk a little bit about continuing insulin pumps as well upon admission. Are those technologies that are usually continued in the hospital setting? Is it approved to be continued? What do we know about that?

MZ: Yes. If clinically appropriate, and hospitals have proper protocols and staff have appropriate training, then, of course, we have to perform confirmatory blood glucose checks. We are strongly encouraging people to use their insulin pumps in the hospital setting. Sometimes patients may need to stop their insulin pumps, for example, if they’re critically ill or if they’re intubated and have to be admitted to the critical care unit and we are receiving some medications and vasopressors to keep people alive. Obviously, people cannot monitor their own insulin pump, and in those situations, we sometimes discontinue—temporarily—insulin pump use until patients get better. Also, sometimes we know that devices malfunction or if people run out of their supplies, as insulin pumps have to be changed every couple of days. Also, with CGMs, it depends on the type of CGM you have to update it or change it.

If they don’t have any supplies, which is frequently the case because, obviously, nobody comes to the hospital because they know they’re going to come to the hospital and spend a week here, right? Something emergent happens; a person gets a stroke, and they’re being rushed by EMS or 911 to the hospital. To bring additional pump supplies is not the first thing on people’s minds. What I usually do, for example, is I had a patient who had a foot infection the other day, and he came to the hospital just for a quick checkup; he was not feeling well. He had no idea that he had a severe foot infection, so he did not bring any pump supplies, and his insulin pump was running low. My first question to the person was, “Is there anyone in your family who can bring the supplies?” And he said, “You know what? My wife is going to be here in a few hours. Let me call her. She’s going to bring supplies.” In that case, given that his insulin pump still had enough insulin, I allowed him to continue it. But if the answer would be, “You know what? I live alone. There is nobody to bring the insulin pump supplies, and my insulin pump is going to run out in the next few hours,” we would advise him to transition to subcutaneous insulin shots.

JS: Yes, and I agree. Just to chime in with Dr. Z, I think the main key here is for the patient to let the staff know early that they have an insulin pump or for the staff to find out as soon as possible from a nursing skin check on admission. Just making sure, because I think, as evidenced by what Dr. Z says, that interdisciplinary teamwork is so important for the nurse to notice the insulin pump on the patient. If the patient isn’t alert and oriented to tell the nurse that there’s an insulin pump. The nurse finding out on the skin check, letting the doctor know and the doctor consulting from endocrinology to come and get the pump setting. It’s that whole interdisciplinary teamwork that can help these patients to safely continue to use their technologies on admission when it’s appropriate.

MZ: I want to add that in our electronic medical records, which we use here at Johns Hopkins, if doctors document the presence of the insulin pump, let’s say in their history or on the problem list, then there is a little line that appears on the left side of the chart that says “insulin pump in place.” Every single team member, whether it’s a nurse, a consultant doctor, or a patient care technologist, will be alerted that this particular person is using the insulin pump.

RK: As we’re discussing this, I think one of the things to point out is the differentiation from continuing your medications in the hospital. I don’t think there is really ever a situation where we say, “Bring your medicine from home, and we’ll let you take it in the hospital.” Unless it’s really a very specialized drug. But even that is a very rare instance.

What we’re talking about is a little atypical, what we’re saying is that you have a technology you use at home, but you can continue it in the hospital. Part of the reason that this has become more and more of a topic of discussion is because of how good these technologies are in the outpatient setting in helping patients self-manage their diabetes at home.

What would you say is the greatest push to continue these technologies in the hospital? We talked about them briefly with the CGM. What about the insulin pump? Why not just transition to subcutaneous insulin?

JS: I would say because the pumps, especially nowadays with the automated insulin delivery systems, know the patient so well that I think the patient oftentimes needs to receive less insulin overall than they may need if we transition them to our own basal bolus protocols.

MZ: I want to share one more observation. I’ve been volunteering at a camp for children with type 1 diabetes, Camp Possibilities, in Darlington, Maryland, since 2013. Many people who live with type 1 diabetes develop an emotional attachment to their devices, including insulin pumps. It is very important for me as a clinician and a physician to recognize these emotional attachments and preserve this relationship between the person who lives with type 1 diabetes or type 2 diabetes and the use of an insulin pump. Therefore, I strongly encourage people who come to the hospital with their insulin pumps to go above and beyond to secure additional supplies, but I strongly encourage them to continue using the insulin pump in the hospital setting.

RK: That’s an interesting observation that you shared, Misha, and one that makes a lot of sense. You have something that supported your management; it is working well—why rock the boat? I think that’s really what this comes down to, that it’s facilitated the management as an outpatient; it has flexibility to change settings if needed in the inpatient setting too. I think, Jordan, you mentioned in a more granular way perhaps what we can do in some instances depending on the patient with subcutaneous insulin and may allow us to give doses that more closely match the need for the patient as well.

MZ: Yes. At the same time, some people who live with type 1 diabetes or type 2 diabetes or an insulin pump actually want to take a break—and it’s okay. We all know about diabetes fatigue or diabetes burnout. People come to the hospital and say, “You know what? I want to take a break.” I had a patient who was on an insulin pump for quite a while, and she said, “I think I would like to be managed on insulin shots. I’m going to stop the insulin pump. I trust you, take care of me,” and I think it has to be respected as well.

RK: That is exactly true. Thank you for bringing that up. It really is a matter of individual preference, and I think that’s what we’re talking about here today: allowing the person with diabetes to have the option of continuing the technology if they’d like or taking a break if they’d like—really having that option that best meets the needs of the situation at hand.

We talked briefly about guidelines for diabetes technology use in the hospital. I wonder if there was any other information that you both wanted to share regarding current guidelines for the use of both CGMs and insulin pumps in the hospital, both for type 1 and type 2 diabetes.

MZ: We know that the latest research shows the use of continuous glucose monitors in the hospital can improve detection of nighttime hypoglycemia, which is low blood sugar, and can also help reduce recurrent low blood sugars.

The American Diabetes Association 2025 Standard of Care guidelines say that CGMs, or continuous glucose monitors, should be continued in the hospital if clinically appropriate and if blood glucose checks are done for confirmation.

The same thing goes for the insulin pump and automated insulin delivery system, which can be continued as long as the patient can manage them. There are situations where patients cannot manage them—they’re not well enough, but there is a family member who is by the bedside who can help them out with some of the management.

But the key to success is not just the person who is feeling comfortable with his or her insulin pump or continuous glucose monitor; it is to have trained personnel, trained nursing staff, and clear protocols in place that can safely integrate that use of diabetes technology into patient care.

JS: Yes, that’s exactly right, Misha. One of my goals is to really get into our nursing orientations, which we’ve already done, and the nurses have a whole hour with me to talk about our insulin protocols. But we’ve also recently added a section on CGMs, just so that the nurses can get comfortable with knowing what these devices look like, what brands there are, and just getting comfortable with how to manage them—not for the patient, but if the patient has it, just knowing what to do with that CGM.

We want to have these structured policies for continuous glucose monitors and insulin pumps that will help us see better glucose control, do fewer finger sticks, and, of course, have that patient-centered care and satisfaction that we were talking about so that they can keep their devices on.

I think our goal is to have the nurses so comfortable with them that they know, “Oh yeah, this is the policy, this is what we do when we see that type of device.” To help the patient as best they can to keep those devices on them, if that’s what they desire.

MZ: Last year, in 2024, our hospital got a grant from one of the companies where we received 70 sensors, and we trained a group of leader nurses from most of the unit and pharmacists and some of the dieticians as well on how to use the CGM. But what’s most important, we did not just train them; we created an opportunity where nurses and pharmacists were able to wear a continuous glucose monitor for a week, 10 days, or 14 days. However long they wanted to wear one, so they can not just understand what it’s like to wear a continuous glucose monitor. We can also experience it as well, and I strongly encourage other hospitals around the country to participate in those trainings and hands-on experiences as well.

JS: I can say as a person not living with diabetes, I feel like I learned the most about continuous glucose monitors when I wore them. That’s when you realize how many alerts go off overnight, and you get a sense of how a person living with diabetes might feel—being woken up during the night, having an alarm go off during your meeting because your blood sugar’s low, and all those things that you might not think about just taking someone through a tutorial of how to use them. I think having the nurses wear them and live with them, like Misha said, for 10 days to 2 weeks, you can learn a lot about what someone living with diabetes would go through.

RK: If the medical condition allows that this is something that could really benefit the patient, that with the nursing staff. It’s interesting to hear about the pilot program you had where the nursing and medical staff were able to wear it themselves so that they too could understand more about this technology.

I’m just curious; part of the hesitation perhaps about continuing these technologies in the hospital may be due to the patient’s reason for admission—that it may be unpredictable and that it may lead to challenges in management if the patient’s condition is not stable. I’m just curious, what situations, if you could give us examples, might lend themselves well to continuing these technologies in the hospital or, conversely, such as the ICU setting, I would imagine it might be more challenging to continue an insulin pump if someone’s intubated. I wonder if you might be able to give a brief insight into situations when these could be considered or not considered.

MZ: Most commonly patients ask me, “Can I wear an insulin pump during the surgery?” My answer is I quickly often get a phone call from a pre-op (pre-op stands for preoperative evaluation) department, which consists of excellent nurses who evaluate the patients prior to their scheduled surgeries. My answer for the nursing staff is, “It depends.” If a person with diabetes who is wearing an insulin pump is under anesthesia and unable to self-manage, and the procedure lasts a long time, let’s say it’s open heart surgery, they should probably discontinue the insulin pump. Remember that the surgical stress and some of the medications that are administered during the big surgery can impact blood sugars in quite unpredictable ways.

Sometimes patients require vasopressors or medication, which supports their blood pressures, and in those cases intravenous insulin, which is the insulin administered directly into their vein, is probably the safest method to provide good glucose control during those procedures. And Jordan, do you want to talk about some of the minor procedures?

JS: For a lot of the minor procedures, where patients might be awake or asleep for a short period of time, some hospitals may allow for their insulin pumps to continue to be on them and working. Our hospital is one of those. But we do recommend that patients talk to their surgical team in advance to discuss the options for whatever equipment they might have. I have meetings with our pre-surgical staff all the time just to talk about their pre-op management of the blood sugars, and so it’s really best to communicate with them so they can tailor the specific recommendations for the patient based off of the surgery they’re going to get.

RK: It sounds like it is a discussion between the patient and the team to understand the needs of the surgery, how long the surgery will be, and whether it’ll be more beneficial or not as beneficial to continue it during that aspect.

MZ: Sometimes surgeons may not have an answer to this because it’s really the anesthesiologists who are making the decision whether the insulin pump should be continuing during a particular surgery. Kindly ask the surgeon to connect with the anesthesiologist and quickly discuss it. Of course, if you’re admitted to one of the Johns Hopkins Hospitals, there is also, usually, an endocrinologist who is involved in the care. I ask our pre-op team, “Hey, send me a quick message.” And if there is a person, and they have a question about whether to continue or not, I’ll come and help out.

RK: That’s an important point. Thank you for bringing it up. It is definitely important to have coordinated care among everyone on the team: the surgeon, the anesthesiologist, the endocrinologist, the primary team, the nursing staff, and, of course, at the center, the patient. We’ve talked a lot about people who’ve been on these technologies before they came into the hospital and continuing them. But what about patients who might have heard of these technologies? Perhaps they hadn’t really had a chance to talk about it with their provider, or maybe they just weren’t familiar with them. This seems to be an opportunity in the hospital setting to provide education and also to discuss the opportunity or possibility of starting technologies, particularly continuous glucose monitors, I think is what we’re talking about here. Insulin pumps might need a more intricate discussion to start as an outpatient, but for those who might want to consider the continuous glucose monitor in the hospital, can this occur? Would it be something that, in your experience, you recommend, and how can we have success for those that do start it in the hospital once they leave?

MZ: I want to say absolutely. Whenever possible and whenever I suspect that a person’s health insurance is going to cover a continuous glucose monitor, I try to allow people who live with diabetes to at least experience a continuous glucose monitor at the time of discharge. What we do is we participate in the CGM on discharge program where, when we know the patient is ready to be discharged in the next 24 to 48 hours and they fit a particular criteria, what usually happens is I ask the patient, “Hey, would you like to try a continuous glucose monitor? I think it really can help you to control your sugars in outpatient.” Then I call Jordan.

JS: Yes, that’s where I come in, or any diabetes educator. It’s a unique opportunity, I think, in that 24 to 48 hours before they go home, for what our hospital does. You can bring in demonstration sensors for the patient to feel and touch and say, “This is what it’ll look like when it’s on your arm.” Then download the app—“Let’s set it up. Let’s create an account for you.” Then once it’s downloaded, we can walk them through and say, “This is where your logbook is going to be.” You can really do a step-by-step tutorial with them, not only putting their first sensor on for them but then setting up the entire app, which for a lot of patients, once they get home from the hospital, they might not want to do on their own, which is totally understandable—they just got home from a long hospital stay, and they’re exhausted. The last thing they probably want to think about is what to do with their new CGM.

Rather than just giving them the box and saying, “Okay, here it is, best of luck. Pick it up at your pharmacy.” Really going through that step-by-step process with them and showing them how it works, I think, is beneficial to give the patient that autonomy. I see patients all the time with family members at the bedside who are there to help them, and we can help them set up. With the apps that have been created, the patient has their alerts on, but then the family members also get notified when the patient’s blood sugar is low or high. It creates a safer environment for patients, and I think it really just tees them up for success when they leave.

MZ: I’ll share an anecdote. We had a patient last week who came to the hospital because of nausea and vomiting, and he was found to have a hyperglycemic crisis. We hydrated him. He was feeling better, but because his diabetes was so uncontrolled, we were essentially forced to suggest starting insulin, even though it’s not our first-line therapy, but we started insulin. The person was quite anxious; he had never checked his glucose before. I suspected, and I checked his insurance; we ran his insurance, and it sounded like it would be covering the continuous glucose monitors. I called Jordan, and she came and set it up. The patient was very happy, and then a few days later, we were able to schedule him for the diabetes health management training program with an outpatient diabetes educator. She, the outpatient diabetes educator, was already able to download the data from the previous few days and insert it into the chart and shared it with other practitioners in our practice, which was absolutely terrific.

RK: That’s a wonderful story and highlights the importance of having data in order to make management decisions. As we mentioned before, even the alerts for someone who’s at risk for some of these really severe complications, such as hyperosmolar hyperglycemic syndrome or even DKA, to be alerted to high blood glucose numbers before they enter the hospital could have tremendous value. I think it’s important to emphasize that we really are talking about giving patients options here. When we talk about the use of technology, some people may prefer not to use the technology.

But we know for those that do choose to use them, particularly those with type 1 diabetes, there has been a lot of evidence to support their potential benefits even in people with type 2 diabetes on insulin and now emerging evidence for people even not on insulin. I think this is an ongoing conversation, but an individualized conversation, as we talked about, might depend on the preferences of the patient and their particular situation.

Moving a little bit now to a separate but related topic, we talked about diabetes technology and really from the perspective of the person living with diabetes or admitted to the hospital. But what about from a population level or a health system level? How can the use of diabetes technology impact quality of care in the hospital setting?

MZ: I think it’s a wonderful question, and I’m looking forward to learning more as more research comes on this particular topic. The way I envision that is that CMS (which is the Centers for Medicare and Medicaid Services) announced a few years ago that they’re going to track severe hyperglycemia, which is high blood sugar (more than 300), and severe insulin-induced hypoglycemia (glucose less than 40) and just keep an eye on that. The hospitals that are not reporting by 2026 are going to be penalized. I suspect that in the next few years hospitals that are really the outliers, hospitals that, let’s say, have too much of the severe hyperglycemia, may even be penalized by Medicare for not performing well, and that’s where the technology is going to come into place.

         Just think about it: if you can get FDA approval for the use of CGMs in the hospital, we can maybe reduce the need for the finger sticks. We can get a more real-time glucose trend. Maybe we’ll be able to detect more “silent low blood sugars.” Quite often people go to sleep at night with a glucose which is 150, which is normal in a hospital setting. Then we may develop low blood sugar, but unless you check it, nobody knows about it. Some people may have a lot of glucose variability when patients’ sugars go up and down, and of course you will never know about this unless you have the trend; you have the data.

         Finally, a lot of people think about the quality of care from the perspective of “sugar number this, sugar number that, numbers…” I don’t believe that the quality of care lies in an actual number. It’s all about improving the patient’s comfort and enhancing the patient’s experience while they’re in the hospital.

RK: That’s so important, and I think you’re absolutely right. It’s not just the numbers, the A1C or the sugar number. It’s really the quality of the experience, the patient care experience. It sounds like having more data; detecting these otherwise silent or missed episodes of hypoglycemia, that could be asymptomatic, especially in people with longstanding diabetes; this gives us more information in terms of how the interventions we’re using in the hospital are impacting the medical care of the person with diabetes. It’s an emerging area. I’m sure we’ll learn more in the time to come, but one where I think we will see technology marry quite closely with quality of care goals in the hospital.

We talked a little bit about the importance of education, especially for healthcare providers and nursing staff in the hospital, to ensure the safe use of diabetes technologies and also education for patients. I wonder if we could just briefly talk about what we mean when we say “education.” Are there certain aspects that Jordan, you especially, I’m imagining, spend your time educating individuals about?

JS: Absolutely. Within the American Diabetes Association and the Association of Diabetes Care and Education Specialists, there’s what we call the seven diabetes self-care behaviors, which I think is really what our education focuses on in the hospital. Whether it’s monitoring your blood sugar, healthy eating, or medication adjustments, these are all things that someone living with diabetes often experiences changes with when they’re in the hospital, especially medications. If they’re admitted and their A1C has gone up since the last time they were seen by a doctor, and now we’re changing all their medications and the nurses are busy and the doctors are busy. The educator is there to sit down with the patient and say, “Hey, this is what’s going to change once you get home. This is how you’re going to give yourself the medication, how many times a week,” all those specific details that can be a lot to manage. As Misha mentioned, diabetes distress is a real thing—I think a lot of patients that we see in the hospital are extremely overwhelmed, whether they’re newly diagnosed or they’ve had diabetes for 20 years.

         To get back to the question, I think diabetes education really is focused on so many different areas, but the educator is really there to help break it down and figure out what the patient needs to focus on. Like we talked about before, it’s very individualized. A patient might be really comfortable with their nutrition plan and checking their blood sugar with finger sticks, but maybe medication compliance is difficult for them. The educator can focus on those individual facets of diabetes education with them.

RK: There’s so much that could be potentially covered; it could take a long time. But I think those priority areas, the seven topics that we emphasize in diabetes self-management education and support programs, or DSMES, are particularly valuable.

         It’s an ongoing process, and it’s just the start in the hospital, but it does lay a nice framework for integrating the use of these technologies and making sure everyone feels comfortable and familiar with them.

         Just a parting word: we cannot talk about technology for diabetes without talking about the technologies that we use for our patients in general, which are electronic medical records. I know that in the outpatient setting, in the clinic setting, we can often download data from continuous glucose monitors or insulin pumps, for instance, into our electronic medical records. What about in the hospital setting? How straightforward or easy is it in that setting?

MZ: That’s an amazing question because we are not there yet, but we are working on this. The Johns Hopkins Health System is in the final stages of integrating our electronic medical records with the data that accumulated from the continuous glucose monitor. A provider or a physician would be able to send a quick electronic message through the MyChart app to the person who is wearing a continuous glucose monitor and sign a consent form, and the data will flow into our electronic medical records, but we are not there yet. It’s coming, but we are not there yet.

RK: How neat would that be, you imagine seeing these screens in the hospital with the vital signs, the cardiac monitor, the oxygen monitor, to see the glucose patterns superimposed or overlaid on that? I think we’re just talking about more data, more information, and more ways for us to better understand how the patient’s medical condition is evolving and responding to the treatments that we give in the hospital setting. More to come, but very exciting.

MZ: My dream would be to have CGM telemetry in our hospital where nurses would just have to have a glance, and we’ll have all the patients connected to continuous glucose monitors and to see where the trends are.

RK: Wow, wouldn’t that be so neat? I can’t wait for the future. That sounds so exciting. I just wonder, Misha and Jordan, we’ve covered so much ground today, and it has been so great to hear about all the different ways that diabetes technology, particularly continuous glucose monitors and insulin pumps, for those who are already wearing them at home, can be safely integrated into the hospital setting. But with the caveat that it depends on the individual, it depends on the condition, and it depends on the hospital setting and familiarity of the nursing staff. Then also the opportunity to start continuous glucose monitors for the first time for those who may be considered good candidates or are interested in the hospital setting.

For our listeners who may be interested in learning more about how they can continue to use these technologies in the hospital or whether their hospitals even allow this, what would you recommend?

MZ: At the time of that admission, when we’re coming to the emergency room, please check in to see if they have an endocrinologist on staff who would be able to help out and be consulted. We are always happy to talk to people and help them with diabetes technology.

RK: Thank you again Dr. Misha Zilbermint, and Jordan Spivak. It’s been such a pleasure to have you both in our podcast, and we truly appreciate all your expertise and input today.

MZ: Thank you

JS: Thank you.

RK: I am Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.

For more information, visit hopkinsdiabetesinfo.org.

We love to hear from our listeners. The email address is [email protected].

Thanks for listening. Be well and see you next time.

In Episode 47, Dr. Kalyani welcomes Anika Alvanzo, MD, MS, FACP, DFASAM. Dr. Alvanzo graduated from George Washington University School of Medicine and Health Sciences, has a master’s in biostatistics from Virginia Commonwealth University, and is board certified in Internal Medicine and Addiction Medicine. She is a Principal at Health Management Associates, where her consulting has focused on supporting state and local jurisdictions in community needs assessment and strategic planning for behavioral health service delivery; provision of training, technical assistance, and coaching to behavioral health providers; training on and implementation of the ASAM Criteria; and advancing cultural humility and health equity in addiction treatment. As a national leader in addiction medicine, Dr. Alvanzo has served as a subject matter expert on national panels, including the National Institutes of Health, Substance Abuse and Mental Health Services Administration, National Quality Forum, and PEW Research Center on topics such as opioids and chronic pain, quality metric development and medication for opioid use disorder (MOUD) integration. Her publications span topics including gender, race, and ethnicity differences in the trajectory of and service utilization for substance use disorders and the association between psychological trauma, post-traumatic stress, and substance use, particularly in women. Dr. Alvanzo is a Distinguished Fellow of ASAM, currently chairs the ASAM Annual Conference Program Planning Committee and is Secretary of the ASAM Board of Directors.

Dr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani at Johns Hopkins. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.

Today we are thrilled to welcome Dr. Anika Alvanzo, who will speak with us about diabetes and substance use. Dr. Alvanzo graduated from George Washington University School of Medicine and Health Sciences, has a master’s in biostatistics from Virginia Commonwealth University, and is board certified in internal medicine and addiction medicine. She is a former faculty member at Johns Hopkins University and currently a principal at Health Management Associates, where her consulting is focused on supporting state and local jurisdictions in community needs assessment and strategic planning for behavioral health service delivery, provision of training, technical assistance, and coaching to behavioral health providers, training on an implementation of the ASAM criteria and advancing cultural humility and health equity in addiction treatment.

Dr. Alvonzo’s publications span topics including gender, race, and ethnic differences in the trajectory of and service utilization for substance use disorders and the association between psychological trauma, post-traumatic stress, and substance use, particularly in women.

         Welcome, Dr. Alvonzo.

Dr. Anika Alvanzo, MD, MS: Thank you, Dr. Kalyani, it’s great to be here.

RK: We are so excited to hear from you today about the intersection between substance use and diabetes. This may not be something that people immediately think about as being connected, so I wonder if you could first start by telling us: what is a substance use disorder, and is that even the right term that we should be using?

AA: Yes, substance use disorder is the right term. Substance use disorder is actually the diagnostic term that we use to characterize the disease of addiction. The American Society of Addiction Medicine, or ASAM, defines addiction as “a treatable, chronic medical disease involving the complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences.” When we talk about substance use disorders, substance use disorder is the compulsive use of substances despite adverse consequences, and those consequences ultimately lead to either physical and/or psychosocial functional impairment.

When we’re discussing substance use disorders, there are 11 criteria that we use to define substance use disorder or make the diagnosis. I typically like to group them into three categories: physiology; criteria that are indicative of loss of control over one’s use of substances; and then criteria that are indicative of the associated consequences of use.

         Examples of physiology would be tolerance, meaning that somebody needs to use more and more of a substance to get the same effect. Another [example of] physiology is withdrawal. If somebody stops using a substance abruptly or dramatically reduces the amount of substance that they’re using, they may have symptoms or a withdrawal syndrome. Those are the two criteria that fall under the category of physiology.

Then things that may be indicative of loss of control—so inability to cut down or control use, using more than originally intended, giving up important activities in order to use a substance, craving, spending a great deal of time either obtaining a substance, using the substance, or recovering from the effects of the substance.

Then, criteria that reflect associated consequences of use. That would be things like the development of physical or psychiatric problems associated with use and continued use despite those problems or exacerbation of those problems; role failure—not meeting obligations at home, at school, or in the family; interpersonal problems, either again with loved ones or with others; and use in hazardous situations.

So those are examples of the 11 criteria that we use. And then once we make the diagnosis, we stratify it based on severity—mild, moderate, or severe—with mild being two to three, moderate being four to five, and anything six or more being associated with a severe substance use disorder.

The only other thing I’d say is that substance use disorders are chronic diseases. Just like other chronic diseases, they are characterized by periods of remission and periods of recurrence. I think it is important to know that prevention efforts and treatment approaches for substance use disorders are generally as effective as those for other chronic diseases. While many times people with substance use disorders are stigmatized, we know that substance use disorders, like other chronic diseases, with effective treatment respond as well as other chronic diseases like diabetes, for example.

RK: Thanks so much for breaking that down for us. That was quite a bit of information, and it’s good to know about how this might be different than substance use in general. I think many of us could understand what substance use is. Could we clarify when we talk about substance abuse, what substances are we talking about?

AA: It varies; it can include what are considered legalized substances: that’s alcohol, tobacco, or nicotine (which is the active ingredient in tobacco). In our state and many others, cannabis is now a legal substance, and then there are opioids, which can be obtained either legally via prescription or illegally on the street, and stimulants like cocaine, methamphetamine, and hallucinogens. Any substance that has the potential to be addictive. Caffeine is another substance that we often don’t think about but that can be associated with disordered use.

RK: Thanks for going through all of those because, like you mentioned, some are more common, like caffeine. I think many of us can relate to that, whether it’s coffee, tea, sodas, or other products versus others that might be legal in some states versus others—you mentioned cannabis being legal here in the state of Maryland, but that might differ across the country. Then those [substances] that tend to be restricted or illegal across the United States.

When we talk about substance use, it sounds like there’s a spectrum of what we’re talking about. When we talk about substance use versus substance use disorder, you had outlined for us those criteria of what makes it a disorder. It sounds like things that impact daily life, things where you may become addicted or really need it more for the high or the effects that it has, or having used it so much that it interferes with your usual functional activities. Is that right?

AA: I think it’s important to know that there are a range of ways that people use substances. Some people never use substances, and then some people may engage in what we call experimental use or social use, and then some people are on the continuum where they are using substances chronically, and their use of substances has subsequently resulted in consequences that then lead to functional impairment.

When we talk about substance use disorder, we’re talking about the compulsive use of substances in the setting of continued consequences. You mentioned that there are different substances. I think again, there’s a lot of stigma related to the disease of substance use disorder, or people with a substance use disorder. But I think we also recognize that, whether the substance is considered a legal substance or illegal, the process of what’s happening in the course of a substance use disorder is the same. Somebody who has a nicotine use disorder and somebody who has an opiate use disorder—while the receptor systems in the brain may be different, the neurobiological changes that are occurring in the brain with chronic substance use are very similar. Hopefully, that will help reduce some of the stigma associated with substance use for patients and people who are listening.

RK: I was struck by what you said: it is using these substances, whatever ones they are, despite the consequences, despite knowing how they’re affecting someone’s daily life or affecting others around them. You mentioned the stigma, the fact that this is a disease that can be treated, and then really addressing the stigma that might otherwise be there, that this is due to neurobiology—this addictive potential—and it can be treated. When we talk now about substance use in diabetes, are people with diabetes at higher risk of using substances? Or, what is the interaction of these two conditions?

AA: I am not aware of data that suggests that people with diabetes are significantly more at risk of using substances. What we do know is that when somebody has a substance use disorder, particularly an active substance use disorder, it is not uncommon for them to have poor outcomes for other co-occurring diseases that they may have, including diabetes. Often in the midst of an active substance use disorder, people are not attending to their health, to their medical appointments, to the monitoring of their blood glucose, or to taking their medications to treat their diabetes.

I do want to say, though, that there are some substances that may be associated with a higher risk of developing diabetes. So not looking at people with diabetes who may be more likely to use substances, but looking at people with a substance use disorder who, because of their substance use, may be at greater risk for developing diabetes.

There is data that suggests that chronic use of nicotine may be associated with higher rates of diabetes. Specifically, nicotine may have some role in increasing insulin resistance. Then there’s data with respect to alcohol. In terms of the mechanism for alcohol, we know that chronic heavy drinking can result in pancreatitis. The pancreas is the organ that produces insulin to monitor or regulate our blood sugar. Particularly in the setting of chronic pancreatitis, you can get damage to the beta cells in the pancreas, which are the insulin-producing cells. With long-term damage, what ultimately happens is people get enough damage to those beta cells that they can’t produce insulin. Then they develop diabetes associated with the pancreatitis that they developed as a result of their alcohol use disorder.

RK: You mentioned nicotine or smoking. We know that smoking is a risk factor for cardiovascular disease, or heart disease, and that people with diabetes, especially, are at higher risk for developing cardiovascular disease. Clearly, having both is not a good combination. Then you also mentioned that nicotine can contribute to insulin resistance in some situations, which is very interesting, that there could be an underlying mechanism by which it could contribute to the development of diabetes.

AA: There is some data to suggest that this year ASAM released the seventh edition of his text with the principles of addiction medicine (2024), and in there, there is a chapter that looks at the endocrinologic effects of substance use. They talked about how, for people with chronic nicotine use, there does appear to be an increased risk of the development of diabetes. There appears to be a sex-related effect, such that men who are current smokers have greater risk than women. As you said, we know that nicotine use, particularly cigarette smoking in and of itself, can lead to a number of consequences that look similar to long-term diabetes and cardiovascular consequences. It is difficult to say in this instance if this is a result of nicotine itself or, more likely, the byproducts of cigarette smoking. But yes, if you’ve got somebody who has both diabetes and is smoking cigarettes, then you are looking at an exacerbation or increase in their risk for developing these cardiovascular complications.

RK: Yet another reason to cut down on nicotine use, isn’t that right? Now you mentioned alcohol and the relationship of pancreatitis, which, as described, you could get alcohol pancreatitis, and that could be related to diabetes development too. I have always been struck by what seems to be at times conflicting data about alcohol use and diabetes risk. I seem to recall that there has been literature suggesting that maybe one or two drinks a day can be protective. Can you talk about that?

AA: There is some literature that suggests that lower amounts of alcohol may be protective or may result in a decreased risk. But when we’re talking about alcohol-associated pancreatitis, that occurs in people with chronic, heavy drinking. So drinking that exceeds the recommended limits chronically (for an extended period of time). So yes, at times there does appear to be almost this U-shaped or dichotomous risk for alcohol based upon whether it’s low-level drinking within the guidelines or when we have people who engage in chronic, heavy drinking.

RK: It does seem like with that mild to moderate use, there has been mixed literature. But what we’re talking about here today is the heavier use, the substance use disorder that could be associated with alcohol, and the adverse outcomes that could be related to that in addition to the development of diabetes.

Some of the other substances that I know have been described in relationship to diabetic ketoacidosis and that I have seen during my medical training are the use of cocaine, and one of the things that I have wondered is whether the use of these substances, such as cocaine, and the relationship to the development of ketoacidosis, especially with type one diabetes, is more related to the effects that the substance has on the person, so they can’t manage their diabetes as well, or whether there’s an effect of the substance itself that puts people at greater risk of developing these hyperglycemic complications. I wonder if you might have any comments about that.

AA: I am less familiar with data on cocaine in terms of its impact on the metabolism of glucose. I would venture to guess that in those instances, it is more likely to be associated with someone’s use being so disruptive or, again, when we talk about that functional impairment, that it’s impairing their ability to successfully manage their diabetes.

RK: So it sounds like it is both, depending on the substance—either a direct potential mechanistic effect or effect on the insulin signaling in the body, like in the case of nicotine that could put someone at higher risk for diabetes or higher blood sugars in general, or probably more generally with these substance use disorders, the disruption of the daily routine and the management.  We know that self-management at home is so important for diabetes, and so having a substance use disorder on top of that just makes it much more challenging. I wonder if, in an individual who has both these conditions—who has diabetes and a substance use disorder—it is like a chicken and the egg question: which came first or which to address first. I am sure it is a multipronged approach, but I was just wondering if you could outline for us some general strategies or approaches that you might recommend for a person with diabetes who is challenged by these substance use disorders and how to address them in practice.

AA: We often have this conversation, particularly because we know patients with substance use disorders can have a number of co-occurring conditions, whether it’s a co-occurring biomedical condition or psychiatric condition. Traditionally, we used to have this co-occurring psychiatric condition. Do we treat the psychiatric condition first, or do we treat the substance use disorder first? Inevitably, what research has shown us is that an integrated approach where you are addressing both things concurrently is the most effective treatment. We know that with somebody who has diabetes that is poorly controlled, we need to help them in terms of the management of their blood sugar. But if they’ve got an active substance use disorder, their ability to successfully manage and gain control of their blood sugar is limited.

Ideally, you want to address both at the same time. Ideally, in an integrated setting, we know that is not always possible, but if somebody is being treated for their diabetes in a primary care setting, if the primary care setting is able to integrate behavioral health treatment focused on managing one’s addiction or at least screening to identify the presence of a substance use disorder and then appropriately linking to treatment, assuming patients are willing to go, that is the most effective approach to try to address both at the same time.

RK: It seems like it should be an integrated approach to addressing both conditions. For our audience: an individual who may have diabetes who is wondering, “I use substances; is it too much, or is it okay?” How would someone know whether they may have a substance use disorder? What symptoms might they see in themselves? Or how could they get a better insight into whether their own behavior is disruptive?

AA: I think one of the things is, again, looking at how they’re using substances; what are the substances doing for them, and then what is the impact of their use of those substances? If somebody is having a drink every now and then, or smoking cannabis every now and then, but not having any consequences associated with that use or any functional impairment associated with that use. Then it is less likely that they have a substance use disorder. It is when somebody is starting to have consequences associated with that use, and they’re continuing to use or find that they are not able to stop or cut down on their use despite those continued consequences. In terms of how to identify that; one is having a conversation with their medical provider, and there are a number of different screening tools that you could find online as well that they could search. The ASSIST is an acronym for the Alcohol, Smoking and Substance Involvement Screening Test. The ASSIST covers all substances. There’s the AUDIT or AUDIT C, which is the Alcohol Use Disorders Identification Test. There’s a full audit and then there’s also the audit C, which is the first three items, specific to alcohol. But again, those are some publicly available tools that can be used either in a clinical setting or if somebody wanted to search those tools online. But I would say if somebody had concerns, my encouragement to them would be to have a conversation with their medical provider.

RK: Those are great tools to know about. I agree; with any level of concern bring it up: bring it up to your healthcare provider or bring it up to a family member. Speaking of which, what if you are a caregiver of someone with diabetes and you’re concerned they may have a substance use disorder? How do you think a caregiver should gently approach it? I can imagine you mentioned the stigma attached to it. I can imagine that even the person who has the disorder might also have strong feelings about it.

AA: Yes. What I think is important for caregivers and for others to know is that chronic use of substances causes changes in the brain and changes in the brain in a number of areas, including the reward center. So that it hijacks the reward center of the brain. Initially, when people are using substances, they get a spike in the release of dopamine, which is the primary reward neurotransmitter. But over time with chronic use, that reward center essentially down-regulates itself so that it becomes even more difficult for somebody to have a release of dopamine with an activity that would normally have provided a reward—spending good time with family and friends, a great workout, or something that would normally provide a natural reward; that reward system gets downregulated. It becomes more and more difficult for people to experience pleasurable events. There were many times in my treatment career where I have had patients say, “At this point, I’m not using to get high. I’m using to feel normal.” So you have that and changes in the stress response system, and then you’ve got changes in the stress response system—that fight or freeze system. So you get changes in that system such that particularly when people are going through withdrawal, they have an increased response, a stress response that then motivates the behavior to continue using, particularly in the setting of substance withdrawal.

Then there are chronic changes that occur in the air of the brain that deal with what we call executive function. So that’s things like decision-making, impulsivity, and judgment. Sometimes initially, it can be difficult for an individual to recognize in themselves that they are having a problem with substances. So again, I think as a caregiver, one thing I would encourage is to not give up on your loved one or the person for whom you are caring. Try to involve as many people as possible; so again, if the caregiver has a concern, bring that concern to the attention of the medical provider.

I think it may be helpful for the caregiver to identify resources in the community that may help support them in their caregiving journey. Whether that is Alina or there are support groups that are specific for people who are loved ones or who are caring for those who have a substance use disorder, getting support for themselves.

But I would just encourage them to recognize that it is their loved one; the behaviors that they may be seeing in a loved one who has diabetes but may also have a substance use disorder are not a reflection of a moral failing or a personal choice. There are chronic changes that are happening in the brain. I think helping family members and even clinicians who don’t work in the addiction space be aware of that, hopefully, will allow people to have more patience and grace as they are working with individuals who may have a substance use disorder.

I can tell you; I did some caregiving for both of my parents before they passed away—caregiving is hard. As much support as you can get, just caregiving alone is hard, let alone adding caregiving for somebody who has a substance use disorder. Get as much support and resources as possible. Then again, bring it to the attention of the medical providers so that they can provide additional support.

RK: It’s great to hear about the importance of a good support system, as you mentioned, even support for the caregiver, which can be challenging. I appreciate you sharing your own experiences as well. When we talk about treatment, then, at the point where someone is ready for treatment, as you mentioned, it might just not be to get high anymore but really could be that they have a reset in their brain, that this is their new normal. So it would be understandable that it takes time to reset the brain again. Then also the withdrawal effects that I know some of these substances can have when you stop taking them and your body’s used to them. I wonder if you could talk just a little bit about the withdrawal strategies in general and treatments that are available for people having withdrawal symptoms. Are these the kinds of things that require being in a preserved program, or can people get treated for these substance uses at home?

AA: That’s a great question. I think it depends, so it is going to be individualized. When we think about withdrawal syndromes, all substances actually have a withdrawal syndrome. Some of them may be a little shorter or maybe less severe than others. The withdrawal syndromes that we are most familiar with, particularly when somebody may need to come in contact with medical treatment for them, include alcohol withdrawal, benzodiazepine withdrawal, and opiate withdrawal. 

Starting with alcohol and benzodiazepine withdrawal, those depending upon the severity of the withdrawal can require inpatient medical treatment for management of that withdrawal. Again, this is why when we are talking about caregivers or family members who may be working, it’s so important to involve the medical professionals. Make sure the medical team is aware because some of these withdrawal syndromes may require inpatient management depending upon the severity of the symptoms. For opiate withdrawal, there are some instances where it may require inpatient management, but it often can be managed in an ambulatory setting with the initiation of medication.

For those three withdrawal syndromes in particular—alcohol, benzodiazepine, and opioid use—there are medications that are available to manage that withdraw. For alcohol and opiate withdrawal, some of those medications can also be used for ongoing treatment. I think it’s important to know that there are medication treatments available for some substance use disorders, not all, but for some of the substance use disorders, we have medication treatments available.

Then for others, for all substance use disorders, there are behavioral or psychosocial treatments that are available. Again, figuring out what’s available in your community, and again, hopefully your medical professionals can assist you in accessing what is available in the community.

RK: I think it’s so important to emphasize what you just said—knowing what the resources are in your community and then knowing that there are medications out there to help with these three withdrawals, especially mentioning the benzodiazepines, alcohol, and opiates. And that a host of behavioral and psycho-social interventions are available for any of these substance uses. It is important to emphasize that there are many different treatment options, and it sounds like the first step is acknowledging and diagnosing or identifying the substance use disorder.

AA: Yes, absolutely. You have to be able to identify it in order to treat it and recognize that again, there are potentially multiple paths to treatment and, for each individual, that path may look different. There is no right or wrong path to recovery. While some people may use medication in the treatment of their substance use disorders, others may not; whether you use medication, behavioral treatment, or both—it is an individualized decision.

RK: When we talk now about people with diabetes specifically, and we think about the communities that are affected by diabetes and the communities that are affected by substance use disorders—are there overlaps, or can this really impact anyone of any background?

AA: Yes, I think it’s important to know that substance use disorders can affect anyone in terms of any demographic, any race, or ethnicity; there’s no respect of socioeconomic status, geographic location, sex, gender, or sexual orientation.

Anybody can be affected by substance use disorder. However, we do know that there are disparities with respect to race and ethnicity in terms of who is more likely to die from their substance use disorder, particularly when we’re talking about the current overdose epidemic that we are in.

There is clear data that Black people, particularly older Black men and Indigenous people, often younger Indigenous women, are at increased risk for dying from their substance use disorder or dying in the setting of overdose. There is also clear data on disparities with respect to access to treatment, both racial and ethnic disparities.

There are disparities by disability. So people with physical and medical disabilities who have a substance use disorder, particularly an opiate use disorder for which we know there are effective medications, are less likely to be prescribed medication than people without a medical or physical disability.

There are differences in risk based upon sexual orientation or gender. So there are disparities and inequities in substance use disorder. We also know that some of the same populations that are disproportionately affected by diabetes may also be disproportionately affected—not disproportionately affected in terms of the rate of substance use; there is no data to suggest (with the exception of some communities) that the rates of substance use are higher. We do find that the rates of consequences associated with substance use tend to be higher for racial and ethnic minorities and some of the other groups.

RK: Thank you for pointing out those disparities in consequences, resources, and outcomes that can occur among different populations, especially ethnic minority populations or other minority populations as well. We know that diabetes in general has health disparities and inequities that may also contribute to part of that outcome that you’re describing with substance use disorders. Addressing the availability of resources and making sure that people have equitable access to care is very important.

I thought that we could touch base on the opioid epidemic; you mentioned it briefly. We have not talked about it in the context of diabetes. There has been some literature to suggest that because people with diabetes might be more likely to have chronic pain due to peripheral neuropathy, vascular disease, or other complications related to diabetes, they might be more likely to be prescribed opiates as well.

I wonder if you are familiar with or have some insights into the use of opiates and those with chronic diseases in general and what you might say in terms of the use of these pain medications versus non-opiate therapies, for instance, in these populations.

AA: One thing I will say is at this point I no longer refer to it as an opioid epidemic; that is where it started. At this point, I call it an overdose epidemic because we are seeing an increase in deaths from multiple substances, in addition to opiates, often in combination with opioids. Yes, the current epidemic did start with—admittedly, it started with the medical and pharmaceutical industries and our prescribing practices with respect to pain and utilization of opioids for pain.

What we have seen is that over the years those prescribing practices have changed. Sometimes you wonder if the pendulum swings too far because there are some people who do have chronic pain, whose chronic pain may best be managed with opiates, who saw a sometimes-inappropriate reduction in their opioid use from it or their opiate prescribing to manage their pain.

I want to be cautious about this; certainly we need to be more judicious in terms of our prescribing of opioids—while making sure that we do not go too far in the other direction, where people who are in chronic pain who are benefiting from their opioids and not having evidence of an active substance use disorder to their opiates are being removed from opioids.

So that being said, yes, it did start with the prescribing of opioids. Many people then subsequently developed a substance use disorder to the opioid to which they were prescribed. That started in the early 1990s. When we talk about the epidemic, we often talk about it in waves. The late 1990s to early 2000s is the first wave associated with the prescribing of opioids. Then in 2010, approximately, is when we started to see a rise in heroin-associated deaths. As people who had developed an addiction or an opiate use disorder to the prescribed opiates were no longer able to access them, then they may have transitioned to heroin.

Also, financially, heroin was significantly less expensive. If you were relegated to having to purchase something on the street, heroin was less expensive than buying a pill of oxycodone, so many people transitioned. Then, probably about 2013 is when we started to see the rise of these illicitly manufactured fentanyl, specifically, or now people are referring to them as “highly potent synthetic opioids,” which is illicitly manufactured fentanyl.

You started to see a rise in deaths associated with fentanyl and its analogues in about 2013. In truth, even today, that’s what’s driving the majority of the epidemic: this high-potency synthetic fentanyl that is on the street. Fentanyl and its analogs that are on the street are what’s driving the current overdose epidemic.

Then many people will talk about a fourth wave of the epidemic where, around 2014-2015, we started to see a rise in stimulant deaths. Again, more likely in the setting of concomitant opioid use. Many times people purchased what they thought was a stimulant, and it was either fentanyl or laced with fentanyl.  Then you see people dying, increased deaths associated with stimulants.

That being said, when we are looking at substance use disorder, we certainly need to focus on opioids, but we need to focus on the larger substance use in general. But as physicians and other medical practitioners who are prescribing, we do need to be more judicious about opioids and our prescribing of opioids and recognition of non-opioid approaches to management of pain. There is a lot of data on non-opioids, whether it is acetaminophen or ibuprofen, in terms of adjuvant medications for the treatment of pain. We do need to look at that as part of our practice as well.

RK: It is so interesting to hear about these different waves and the provider role in some of this—the accessibility and how that has impacted what drugs people are accessing to numb their pain. Then there are these synthetic versions that might be laced in other products that people don’t realize. It is something that all of us have heard about, and in the context of diabetes care, anyone who is at risk for pain or could have pain-related complications, such as neuropathic pain, whether we can see what diabetes or other kinds of pain could be at risk for this. I appreciate you going through all the history and then also the different forms that are out there for our listeners to be aware of as well. We have covered a lot today. Did you have some other comments that you wanted?

AA: Yes, I am just going to say one thing: I would say, for people who are prescribing, if you are prescribing an opioid for management of pain, you should also be prescribing an opioid reversal agent. Whether it is naloxone or nalmefene, you should be educating your patients and their families on how to use that reversal agent, should it be needed.

 RK: It sounds like that is also good for patients and their families to know about too. If their provider does not talk about that reversing agent, they should ask about it.

AA: Yes.

RK: We do that, for instance, with people who are at risk for hypoglycemia, who might be on insulin—we give them glucagon as an emergency rescue. It is different than the reversal that you’re talking about, but it sounds like they go hand in hand. Thank you for bringing that up.

As we wrap up our podcast today, might you have some parting words for people who are listening with diabetes, family members of people with diabetes who are concerned that they or their loved one might have a substance use disorder but might be afraid to step forward or might be afraid to seek resources? I wonder what you would say to them and also what other helplines or anonymous resources or anonymous call centers there might be for them to even just start getting information if they’re not ready to make that step.

AA: Things that I want to say in terms of leaving people with something.

One, addiction is not solely based on one’s personal choice or moral failing; it is a chronic disease, and there are chronic changes that occur in the brain. But like any other chronic disease, it is treatable, and there are resources and support available.

I think it is important to know that there are medications for treatment for at least some of the substance use disorders and that the evidence shows that they, at least particularly for opiate use disorder, are often first-line treatment for the substance use disorder.

Recognizing that there are multiple paths to recovery and whether somebody is taking a medication to treat their substance use disorder, whether they’re using exclusively behavioral and other psychosocial supports for treatment and of the substance use disorder, all paths can lead to recovery in terms of resources available.

The Substance Abuse and Mental Health Services Administration, typically, that acronym is SAMHSA, has resources. SAMHSA has resources related to getting assistance with treatment for substance use disorders.

The National Institute on Drug Abuse, which is the NIH Institute, has a lot of resources and education. If people are looking for more information, it has a lot of information about, particularly drug use disorders.

There is the National Institute on Alcohol Abuse and Alcoholism (NIAAA), which is the corresponding institute in the National Institutes of Health related to alcohol use disorder. They have a lot of information and education and some resource materials as well.

If somebody is in crisis, 988 is the new number for crisis. If you’ve got a family member who is in crisis associated with their substance use or potentially co-occurring mental health disorder, 988 is where you can call to get information in a crisis; information, and assistance.

RK: Dr. Alvanzo, you talked about. So many great resources. I wonder if there are any other resources that you’d like to highlight for our audience today.

AA: Yes, there is one additional resource that I’d like to highlight. The American Society of Addiction Medicine (ASAM) is the professional organization for people who are treating those with substance use disorders. In addition to being the organization or the professional society for those who are working in the area of addiction or substance use disorders, there is a lot of information and education, particularly as it relates to policy and advocacy related to substance use disorder and the treatment of substance use disorder. That is just one additional resource I would like to highlight.

RK: That sounds like a great resource; thank you for highlighting it.

Dr. Alvanzo, thank you so much for sharing your expertise today, for talking to us about substance use and substance use disorders, the different types of substances, the types of treatments and treatments for withdrawal symptoms that might be available, the importance of resource availability for people of all populations, and then really, the stigma that some might still feel or hear about and resources that people have to make that first step to seeking treatment and having treatment for this treatable disease.

We appreciate your expertise today, so thank you for being here.

AA: Thank you. Thank you for this opportunity to talk about this; it is an important issue. I am so happy to have the opportunity to come on and speak about this with you and your listeners.

RK: I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.

For more information, visit hopkinsdiabetesinfo.org.

We love to hear from our listeners. The email address is [email protected].

Thanks for listening. Be well and see you next time.

In Episode 46, Dr. Kalyani welcomes Adena Goldstein, who will speak with us about diabetes technologies, specifically insulin pumps. Adena graduated from Villanova University with her Bachelor of Science in Nursing. She is currently a clinical diabetes nurse and certified diabetes care and education specialist at the Johns Hopkins Outpatient Diabetes Center in Baltimore.

Dr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani, at Johns Hopkins. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org. 

Today we are thrilled to welcome back Adena Goldstein, who will speak with us today about insulin pumps. Welcome back, Adena.

Adena Goldstein, RN, BSN, CDCES: Thank you.

RK: I thought that for today we could focus on insulin pump technologies. These have changed, haven’t they? A lot over time, in terms of the capabilities and functionalities that insulin pump devices can offer.

I thought before we dive into what these technologies are, if we could briefly talk about who might need an insulin pump and when they might be recommended by the healthcare provider for a person with diabetes.

AG: An insulin pump is an alternative way to give insulin. As opposed to multiple daily injections where you have a shot of long-acting insulin and then short-acting insulin for your meals or for correction. In the insulin pump there is just fast acting insulin and it’s just a different way to give insulin. Someone who is on multiple shots of insulin a day would be a candidate for an insulin pump.

The pumps, as you said, have changed a lot over the years. They’ve become very sophisticated. I tell my patients at every follow-up visit, “There’s something new on the market” or “Some new feature’s available.”

Generally, people who are dependent on insulin to manage their diabetes might be a good candidate for an insulin pump.

RK: It is good to know about because these have changed a lot over time, and they can offer an option that may be an attractive option for patients who are used to injecting insulin multiple times a day — four or five times a day. This is an alternative that might facilitate diabetes care and, in some ways, make it easier for the patient as well. It’s a personal choice; it may not be for everyone. As you mentioned it’s often recommended for people who are on multiple daily injections, usually a long-acting insulin and mealtime or short-acting insulin or fast-acting insulin as well. It could be type 1 diabetes, where I think we often see this discussed as an option and type 2 diabetes for those later in the stage of their disease who are on multiple daily insulin injections as well. Do you see patients with both type 1 and type 2 diabetes in your clinical practice that use insulin pumps?

AG: The majority we see are type 1, but we do have some type 2 patients as well, who just prefer that method of giving insulin. Aside from a practical, different way of giving it, there are a lot of advantages to insulin pumps.

Some of the advantages [include that] they have been shown to lower A1C levels, especially the hybrid closed-loop pumps, which I’m sure we’ll touch on later; less low blood sugar [levels]—more time in range; it helps with the dosing because it takes the insulin that they already have working in their body into consideration when they do give more insulin. The tiny increments at which you can give the insulin are so helpful because in pens you can’t go less than half a unit, and in pumps, you can be very precise. It also allows more flexibility for meals and dosing for snacks; instead of giving so many more shots, you’re just able to program the pump and tell it how much to give. Pumps can be programmed to different rates at different times of the day.

They are integrated with sensors now, based on where it predicts your blood sugar is going to be, it is going to adjust the insulin based on that. This is very sophisticated and has really helped a lot with preventing the lows and the highs. Some of the pumps also can give automatic correction doses if you are running high. It really takes a lot of the mental burden actually off of patients.

RK: Wow. It’s so amazing to hear about all the functionalities that insulin pumps can now offer. You are right, it is not just a different route of administration, but it has so many potential benefits, both clinical benefits and practical benefits.

As you mentioned—making the day-to-day management a little less burdensome for people with diabetes who take a preference to this modality of receiving insulin.

I thought the point that you mentioned was an important one to emphasize was that in an insulin pump, it is the fast-acting insulin. Only one type of insulin is given and hat can be a little confusing for patients who are used to having a long-acting insulin and a fast-acting or mealtime insulin injection. At this time, primarily insulin aspart (Novolog) and insulin lispro (Humalog) are given through the pump.

You mentioned so many different types of functionalities of the pump. Can you describe for us, for someone who hasn’t seen an insulin pump, what does it look like? What can people expect when we’re talking about insulin pumps?

AG: There are different types of pumps. The basic idea is that there is a little catheter that is placed under the skin, and it’s connected to the insulin pump. Some have tubes that connect to the actual pump, and some are tubeless, which are connected more to a pod. Insulin is fed through the catheter and then given to the patient that way, under the skin. It’s given continuously; it drips little bits of fast acting insulin all the time, which mimics that shot of long-acting [insulin] and it also mimics what a normal pancreas would do—a little bit all the time.

Then when you go to eat or correct a blood sugar, you enter that into the pump and it gives what we call a bolus of insulin through that cannula under your skin. That cannula is changed out every few days. There are some that can be changed every seven days, but typically it’s every few days. To give the area [a break], you need to move it around just so you have good absorption of insulin.

RK: In terms of the size of an insulin pump and the size of the catheter, could you give us a sense of how big we’re talking about here or how small?

AG: There are different sizes of the catheters. They are as small as 6 millimeters. There are some that are angled, so those are longer, those can be 13 millimeters. There are steel cannulas that you leave in — you don’t remove it. That is a different type, but those are about 6 millimeters as well. The pumps, vary in terms of sizes. They’re about the size of a deck of cards, maybe a little smaller.

RK: That gives us a good sense to visualize what we’re talking about. They’re really not that big at all; 6 millimeters for the catheter, the size of a deck of cards — maybe even a thin deck of cards, if you will, for some of the newer pumps. I think it’s important to recognize that these are not huge devices as they might have been when they first came out on the market, many decades ago.

But [these are] really portable devices that have a cartridge for the insulin that is infused continuously. An insulin pump usually infuses the catheter into the area right beneath the skin, the subcutaneous tissue. So it’s pretty remarkable when we think about this technology, isn’t it?

AG: If you see pictures of the first insulin pump, it’s a big backpack, and now they’re so small, they’re very discreet. Some of them can be managed through a smartphone. A lot has changed over the years.

RK: I can’t imagine the backpack pumps now that we know how small they’ve become. But technology evolves so rapidly over time. It’s important to recognize how far we’ve come.

You mentioned different components of the pump. The actual pump, which could be the size of a deck of cards or thinner, the catheter through which the insulin can be infused. Then you also mentioned using a phone. Can you talk about when that might be used? Is that for the CGM part of it, the continuous glucose monitor part of it? Or can that actually control the insulin pump?

AG: There are a couple pumps on the market right now that you can actually control the pump from the phone — you can give your boluses from the phone. There are times, [when] you have to deal with the pump; when you refill it and to cancel alarms sometimes. But a lot of the day-to-day functionality you can do directly from the phone. There are some pumps that are only managed from a phone. That’s a big component of that type of pump.

RK: Wow. That is just so amazing to have these different devices communicating with each other and that so much can be done even from the phone. This makes it, in some ways, less noticeable for someone who might be at work or in a professional setting who might need to give themself a bolus before they eat or change their rates for any reason. That they could do that from the phone, is pretty remarkable to hear about. Where do people wear the insulin pumps? Where on the body do people wear those?

AG: The insulin pumps are generally in areas where you would give insulin — same spots. The tubed pumps are generally in the midsection of a patient’s abdomen, lower back, upper part of the buttocks. Because that tube or the pump does need to clip onto something, in a pocket or, something like that. It can be worn [on] other places, but generally those are the more typical places we see.      Then there’s also tubeless pumps, which offer a little bit more in terms of flexibility of where you wear it because it doesn’t have that tube or that clip that needs to be clipped on somewhere. People wear those on the back of the arm, on their legs, also their stomach. Again, any place where you give insulin.

RK: It sounds like there’s really a lot of options in terms of where a pump can be worn and also in terms of the types of pumps. I wonder if we can now shift a little bit to talking about the different kinds of pumps that are available on the market and how an individual who’s considering this technology might try and decide which pump is best for them.

Clearly what’s covered by their insurance is an important factor. But assuming that there are options for coverage, how could they best decide what pump is best for them?

AG: Every pump has different features, and I always tell patients “It’s like buying a car. Which feature is the most important to you when you’re looking at a purchase like this?”

We can go through the different pumps and talk about some of the key differences between them. Again, for some people one factor is like number one priority and for other people it is not so important. It really is so individual.

We can start with the tandem pumps. There are currently two pumps on the market. The Tandem, t:slim X2 pump; it’s a touchscreen rechargeable pump that is updateable. As new technology comes out, you can just plug it in and get the updates. That’s pretty common nowadays, but years ago, as soon as you got the pump it was basically outdated because new technology was coming out so quickly. It’s updateable, which is great for new algorithms, new sensor compatibility, different things like that.

This pump is currently compatible with the Dexcom G6 and Dexcom G7, as well as the Freestyle Libre 2 Plus. It adjusts the basal rates and gives auto corrections based on where the blood sugars are predicted to be with the sensor integration.

This pump does allow you to bolus from your phone. It doesn’t allow you to manage the whole pump from your phone, but it does allow you to bolus from your phone. If you’re at work and you’re at a meeting, you don’t want to take out your whole pump. You could just do it directly from your phone.

The other newer tandem pump that is available is called the Tandem Mobi. This pump is about one third of the size of the regular t:slim X2, and it is completely controlled from an iPhone. It can be worn with a traditional long tube, or it can be worn with a 5-inch tube and a little pocket that it can sit in. This pump holds 200 units as opposed to the traditional t:slim X2 that holds 300 units.

For some patients who go through a lot of insulin, that might be an important factor. For some people, they really like the idea of doing everything from the phone. Other people don’t like to use their phone at all. It gives different options for different types of people and what they like. The Mobi has the same algorithm as the t:slim X2, it is just a different form factor.

RK: There are so many exciting developments, as you’ve mentioned with these newer models. I was wondering if you could talk a little bit more about how this automated insulin infusion works and how does the pump predict what’s going to happen. I’ve heard about pumps automatically shutting off infusions at times too, if you could talk a little bit about that as well.

AG: The tandem pump, for example, will look 30 minutes ahead based on, the Dexcom or the Libre reading, the sensor reading and based on how much insulin is already working in your body. It makes a decision every five minutes how much insulin to give you. I described the basal rate, like a dimmer switch, it goes up and it goes down based on where those blood sugars are trending. It could also, like you said, shut off so that pump, the tandem specifically, tries to keep you between 112.5 and 160 mg/dL, but it’s looking 30 minutes ahead. If it thinks you’re going to be above 160 mg/dL in 30 minutes, it’s going to dial that basal rate up. If it thinks you’re going to be below 112.5 mg/dL, it’s going to dial it down. If it thinks you’re going to be above 180 mg/dL, it’s actually going to give you an auto correction, if you haven’t had a bolus in an hour, automatically about 60% of what a correction dose would be. If it thinks you’re going to hit 70 mg/dL in 30 minutes, it’s going to just shut it off.

But it’s making that decision every five minutes. You might be shut off for 10 minutes and then it goes right back on — all automatically. We see these pumps really shine particularly overnight when people are sleeping because they need different amounts of insulin, night to night, and that’s when they’re sleeping and not paying attention to their diabetes. We really see a significant benefit, and one third of a patient’s day is sleeping. We do see a lot of improvement in the A1C because of that. Patients really enjoy waking up in a good range every morning.

RK: The automated basal setting really does have so many advantages like you talked about, and I know we’ll talk about other pumps that have a similar feature as well.

There are limitations though, aren’t there, which is why patients still need to bolus their insulin before meals. Could you talk about times where the automated setting may not be able to keep up with changes in glucose?

AG: During times of illness sometimes we would put someone out of the automated system and back into manual mode, depending on the pump. Or maybe we would create another profile for them with more aggressive rates, if they needed more insulin during a time of illness. Or if they were on steroids for whatever reason, you have that option. Also, during pregnancy sometimes we will take patients out of automated; for some patients we keep them on; in some patients we do half and half. Again, it’s very dependent on the patient.

RK: I agree. Especially when glucose levels are changing rapidly, for instance, after meals or those kinds of situations, that can take a while for the automated setting to catch up and for some patients who may need to be reminded that getting that mealtime insulin is just as important because the automated rate can’t keep up with the changing glucose levels. It still does require some effort from the patient as well.

AG: Yes, the, patients do need to input good information in order for the pump to work well. People hear automated and sometimes just stop — hands off. But really you do need to input all that. Your meal information, the blood sugars will pull in and give you appropriate doses based on that information.

RK: That’s an important point to keep in mind for all of these pumps. We talked about the Tandem pumps. What other pumps are out there on the market?

AG: There is the Medtronic pump. Medtronic has been around for a long time. Their current pump on the market is the 780G. This pump does have adjustable targets down to 100 mg/d. It is updateable, just like the other Tandem pump I mentioned before. This pump does use real batteries.

It’s integrated with their Guardian sensor. It does require one calibration to go into the automated smart guard — what they call it. This typically is done about once a week for most patients. This pump has a seven-day infusion set option, which is unique. The other infusion sets are supposed to be changed every two to three days, but this one can stay in for seven days.

This pump also has what they call meal detection technology where it detects the rising rate of change in the glucose after a meal, and then we will deliver more aggressive correction doses up to every five minutes to deal with that rise post-meal.

RK: That’s really interesting. We haven’t yet talked about the different pump settings that an individual with diabetes should be aware of. I wonder if we could just pause here to talk about the settings that a person with diabetes should be aware of. You mentioned correctional insulin, but I realized we hadn’t talked about the different components. Can you just briefly talk about those Adena?

AG: Yes. So, there is a basal rate, which is a little bit that’s given every few minutes, and that can be programmed for different times of the day. All of the settings really can be programmed for different times of day.

There is an insulin to carbohydrate ratio — how much one unit of insulin covers how many carbohydrates that will be programmed in.

As well as the correction factor where one unit will lower your blood sugar, a certain number, that is also programmed.

The target is also a number that we can program into the pump.  For some pump there’s a correct-above number as well.

Then there’s active insulin time. Active insulin time is a setting that we can sometimes change a little bit. It’s not necessarily what the actual scientific studies, in terms of how long insulin will last in a person’s body, but it’s how the algorithm uses that number and that will guide how often a correction dose can be given and how soon a full correction dose can be given.

RK: Usually, what is a number range for that?

AG: That’s typically three to four hours for most people. Some pumps are programmed at five hours for that. It just depends on the patient, and depends on the pump.

RK: And how about the carbohydrate ratio you mentioned? What are some examples of a range that people might be in for that?

AG: That could be something like one unit for 10 grams. Again, very dependent on the patient, and their insulin sensitivity. One unit for 15 grams, someone who’s very resistant might be on, one unit for five grams, or four grams.

RK: Yes, there’s a broad range, but I think that does give a sense of what we’re talking about here in terms of carbohydrate ratio.

Then you mentioned a correctional scale. What are some examples of a correctional scale that might be given to a person on a pump?

AG: A correction factor could be, let’s say 50 units. One unit will bring down a patient’s blood sugar by 50 or is expected to bring it down by 50. It uses that number as well as the target to figure out how much to give if a person’s blood sugar’s high.

The pumps also do all of the math for you. It’s good to know how to do it, the manual way in case something happens. And everyone always needs to have a backup plan in case — it is a device, things happen. You always need to have your backup plan of how you’re doing it currently, or back to injections.

RK: You mentioned quite a few pump settings and also that now the pumps can do a lot of calculations for the individual, even though it doesn’t replace the need to be educated about it and to know about it. Once the basal rates are programmed and these other rates are programmed into the pump, with the newer technologies, what do the individuals with diabetes have to do? What do they have to input in the pump?

AG: They input their carbohydrates that they’re eating. For some of the pumps they just announce when they are eating, which we’ll talk about soon, but they still need to input their carbohydrate intake to let the pump know this is what I’m eating. The pumps will automatically pull in that blood sugar to add the correction dose along with their mealtime dose.

RK: Then once that’s calculated, does a user have to do anything to actually give that, what we call, bolus dose?

AG: Yes, there’s usually a couple confirmations because we want to make sure that they really want to give the right amount. I always tell people, especially once you get used to it, “You go really quick, really fast, and it’s easy to press, an extra button, or skip the decimal point — always double check when it has that, you double check to make sure you’re giving the right amount that you intend to be giving.”

RK: It’s pretty remarkable that now that we have the integration with many of these newer pumps and a continuous glucose monitor that feeds the glucose levels. As you mentioned [with] the older pumps, often patients had to input two things — the carbohydrates they’re eating and the number before a meal.  But now that second part has been largely relieved by the integration of pumps with CGMs. While patients still have to input the carbohydrates they’re eating, much of that additional information is already fed into the pump, which is pretty amazing.

AG: Yes, it really is.

RK: We digressed a little bit to talk about the different types of pump settings that an individual should know about — just broad categories. But going back now to the Medtronic pump that you had talked about, were there any other features or any other models that you thought would be important to talk about?

AG: That was the Medtronic one. The next pump I’d like to introduce is the Omnipod 5.The Omnipod 5 is a tubeless pump. That is integrated with the [Dexcom] G6 and the G7 sensors. It takes the blood sugar readings and adjusts the basal rate only. This pump doesn’t give auto corrections, but it does adjust that basal — like that dimmer switch, we talked about earlier.

ecause it’s tubeless, it has a controller, a separate controller. But it is also integrated with Android apps and recently the Apple app came out.

The algorithm on this pump is adaptive, so as your insulin needs change and your total daily dose changes, it will change the rates as well. With this pump, the user can’t adjust basal rates during automation.

If you make an adjustment to the basal rate, it won’t affect any changes in automation. This pump is also unique because it is a pharmacy benefit. So, I don’t think I mentioned earlier, but [with] the traditional tube pumps, you’re locked into your warranty for four years for commercial insurance and five years for Medicare (in the United States). Meaning the insurance will pay for a new one every four or five years. But if it’s a pharmacy benefit, patients can go on that at any point regardless of their warranty status on a traditional pump.

RK: That’s really interesting. How is that determined? Whether it’s a pharmacy benefit or not? Does that vary by the type of pump or the type of insurer?

AG: The Omnipod 5 is marketed exclusively as a pharmacy benefit. This pump will only be available at the local pharmacy or mail order pharmacy. Occasionally some of the other pumps, or parts of it, the supplies, can be put through pharmacy, but the actual device is put through as medical typically.

RK: That is interesting, and it has implications when patients are looking at upgrades or looking at newer models and deciding what kind of benefit makes sense for them. I appreciate you pointing that out. You mentioned that it was tubeless. How does the insulin get infused if it’s tubeless?

AG: There’s the small catheter that comes out of the little pod, and that’s what goes under the skin. It sits directly on the skin. You can’t give insulin from the pod. Again, it needs to be done either from the controller, which is like a remote — it looks like a phone or from an actual app on your phone.

RK: That is really interesting and a different type of pump route of administration. That’s important to point out as well. What other pumps are there out there?

AG: The last pump I wanted to introduce is called the iLet. This is a different type of concept pump. This pump works with the Dexcom G6 and  G7, and the Libre 3 Plus.

This pump is different because, you know all the settings we were talking about before — this pump does not have those settings. The only setting you program into the pump is the patient’s weight.

For this pump, you don’t need to enter the precise carbohydrates that we talked about before — you’re just announcing your meals. You do need to be carbohydrate aware, so you need to be able to identify a carbohydrate and be aware of if you’re eating more than your usual amount, less than your usual amount or your usual amount. That is what you tell the pump and it will figure out exactly how much to give you. It takes the numbers out of diabetes management, which is a novel approach.

This pump has no real backup plan. If you’re not wearing the sensor, there’s no manual mode like we talked about before, because there are no settings that were input initially. Patients need to be very conscientious to always have their sensor on with this pump.

This pump is good for people who may not necessarily want to micromanage their diabetes — just announce what they need to announce and let it be, you can’t give corrections at other times.

This pump holds 180 units, so it’s a little bit less, but they do have some prefilled cartridges that we will [or] can sometimes get authorized for people to put in there, so it’s easier to bill and just replace the insulin. But it is the smallest amount of volume that’s in a pump.

RK: That’s so interesting that this model of pump doesn’t require carbohydrate counting the way the other pumps do. I know for some patients it can be hard to count the carbohydrates. Especially if meals are unpredictable or not being prepared at home, or even if they are being prepared at home, if there are ingredients that are not as familiar. So I can understand how this could be an option, particularly for people who may not be as well versed in exactly counting the amount of carbs or have challenges in doing that on a consistent basis. But it seems this is more qualitative, isn’t it? If it’s more than you usually eat, less than you usually eat or the usual amount. Given that it doesn’t seem to be as quantitative (in terms of numbers), how effective is it at really keeping the blood sugars in check?

AG: The algorithm is very strong and works really well if you don’t try to outsmart it. If you try to, give meals that don’t exist or if you forget to announce your meal — those are things that could mess up the learning and the algorithm. But if you do what you’re supposed to do with it and you’re pretty consistent, then it is a very effective way at managing blood sugars.

RK: Thanks so much, Adena, for going through those different types of pumps. Particularly the newer models within each manufacturer that are currently available. Given that there are so many great options out there, how do people decide which pump is best for them?

AG: Some people, the tube versus tubeless is a factor. Some people, the size is a factor. Some people, the phone compatibility with the apps, like we talked about, is a big factor. For some people it’s the algorithm, which algorithm is, more aggressive and will help them with their blood sugar. Particularly with their management habits and eating habits.

It really is so individualized. Your provider might have some suggestions and may guide you to one based on where they think you would do well. But ultimately it really is a patient preference as to which type of model they would like to move forward with.

RK: You mentioned not only the practical benefits of relieving some of that mental calculation and mental burden compared to being on the multiple daily insulin injections, but also some of the clinical benefits as well, not only in helping to manage the high blood sugars, but also the lows — I’ve definitely seen that as a benefit with some of the newer technology you’re talking about, the infusion rates can stop automatically to prevent lows, especially overnight when people are sleeping.

However, we know that insulin pumps aren’t for everyone. So, I wonder if you could just talk briefly about who might decide not to wear a pump and what other factors might contribute to that.

AG: There are some people who don’t want to wear anything on them or have a physical sign of their diabetes that’s visible. But again, a lot of them have become so much smaller and more discreet that I don’t hear that as often. Generally, the clinical benefits are so profound that a lot of people can move past that, to at least to try it. A lot of the different pumps, they allow you, even the ones that get processed through your medical, they do have a return policy. If you really are not satisfied with it, they will take it back and refund your insurance. I really encourage patients to try it and, see if it’s something that they can get used to.

Other patients who may not be a good candidate are patients who use a lot more insulin than, if they’re using 300 or more units a day, they would be changing out the pump so frequently. They also might not be a great candidate for a pump.

RK: It’s definitely an individual, personal decision regarding these pumps, but a discussion that’s important to have at some stage of management regarding the options that are out there.

Are there any activities to avoid while wearing a pump? How does it impact daily life at all? For instance, showering or exercising. What do people do with their pump?

AG: The tubeless pump, the pod, is always on. You don’t take that off. You swim with it, you shower with it, you exercise with it — it’s always on.

The traditional tube pumps while they’re water resistant and watertight; we typically don’t recommend swimming with it, because you never know when there’s a little crack in it and you know it’ll break if you go in the water. I tell people “it’s okay if you get wet outside in the rain or you get sprinkled by a hose, that’s fine.” But we don’t generally recommend wearing it in the water.

There is a little connector piece where you can disconnect it for showering and going in the pool, for short periods of time. Without the pumping connected you’re not getting that fast acting insulin. You don’t have any long acting insulin in the background. Your blood sugars can go very high without any insulin in the background. Your basal rate is stopped if you remove the pump for those activities. You have to be mindful, if you do swim all day to go back and forth with your pump to reconnect, give yourself some insulin and then go back out. But generally, it’s something you sleep with, you figure out how to get it to work for your lifestyle.

RK: I think that’s the key is that you figure out how to make it work for your lifestyle. But it’s great to know that showering, water resistant technology, is not a problem. And then different kinds of activity, like you mentioned, swimming clearly is an exceptional example where you might have to take it off and appreciate you mentioning that.

It’s important that if you’re ever disconnected from your insulin pump or if there’s a pump malfunction that a person with type 1 diabetes particularly and in person with type 2 diabetes, who was previously on multiple daily injections, may not or probably does not produce insulin on their own. They may need to take some insulin injections until the pump, or device is restored.

Then exercise in general. I think one of the great features about these pumps is you can have an exercise setting where you can maybe reduce your infusion rate by a set percentage, let’s say 50%. I know I have some patients who do disconnect the pump during times of exercise because they know their sugars go lower during some kinds of exercise.

It is just important to have that discussion, as you mentioned with your healthcare provider to know if there’s any other precautions that are needed, such as snacks, taking snacks, or injecting the insulin as well. But again, it’s about adapting to it, as you mentioned, which I think is the key.

Given that technology is changing so rapidly, how do people with pumps keep up with updates? Do, how do they find out about them? Does the manufacturer tell them when there are updates? Do they have to update the software every now and then? How does that work?

AG: They will be notified by the manufacturer if there’s any sort of update they need to do to keep their pump in good, healthy working order and as new technologies come out, so they can update their pump.

RK: We’ve talked about a lot of different types of functionalities of the pumps. We’ve talked about how far the technology has really come over the last few decades from backpacks to really now just a deck of cards, in size. What is on the horizon? What do people mean when they talk about closed loop systems and artificial pancreas? Could you just talk about that briefly? Where are we going?

AG: In the future the goal would be less patient integration or less patient interaction with the pumps. Right now, the insulin will bring the blood sugar down, but in the future if pumps could also have glucagon, for example, in the pump that would treat the low blood sugars.

The idea is, with iLet, having no carb number inputs takes more of that patient effort out of the insulin pump management. More announcements or like the Medtronic [system] can detect the meals; to have more sophisticated algorithms to manage.

Ideally if a patient could just wear a pump and not have to bolus, that would be, the best. It’s exciting, the things on the horizon. Some parts move quickly, and some parts move slower. We’ll see how the next few years play out.

RK: It certainly is an exciting time. And as you mentioned, a true closed loop system would require no effort from the patient. They wouldn’t have to press a button to give themselves additional insulin and a bolus for meals. They wouldn’t have to pay attention to the numbers, although we would hope that would still happen. But really it would be like having your own pancreas. You don’t think about it on a day to day or minute to minute basis. Really that’s where the technology is heading. It will be exciting to see as we get closer and closer to that the developments to come.

In parting Adena, I wonder for our listeners out there who might want to talk about the option of an insulin pump with their healthcare provider, or maybe they’ve had that conversation already with their healthcare provider and they’re reluctant to proceed with trying the insulin pump. What would you say to them?

AG: I really recommend them to just try it. I know people are very comfortable with the way they’ve been doing things and it’s always scary and nerve wracking to try something new and to shake things up. I always tell people if they are willing to try it, to do it at a good time in their life and not when they’re moving or starting a new job, at a good time when they could, invest into it and invest in learning it. Because there is a learning curve. It’s a different way of doing it, but after a while, like with injections, you do get used to it—it becomes second nature.

I think patients really do see a huge benefit, clinically. Their blood sugars just — when I see before and after pictures of patients, they go from injections to automated closed loop pumps, it gives me chills. You just see a lot less variability, a lot less lows, and smoother blood sugars. Very often patients just feel better with that smoother blood sugar range.

RK: That certainly is something to have chills about, to think about how much these technologies can impact the person with diabetes. Particularly the population that we talked about, who could really benefit from these — really having that conversation with the healthcare provider about whether it could be an option for you.

Thank you Adena so much for being here and educating us about all the different types of insulin pump devices out there. I’m sure there are going to be many more developments in the months to come, and we look forward to hearing about those too in coming episodes. Thank you so much.

AG: Thanks for having me.

RK: I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.

For more information, visit hopkinsdiabetesinfo.org.

We love to hear from our listeners. The email address is [email protected].

Thanks for listening. Be well and see you next time.

In Episode 45, Dr. Kalyani welcomes Adena Goldstein, who will speak with us about diabetes technologies. Adena graduated from Villanova University with her Bachelor of Science in Nursing. She is currently a clinical diabetes nurse and certified diabetes care and education specialist at the Johns Hopkins Outpatient Diabetes Center in Baltimore.

Dr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani, at Johns Hopkins. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.

Today, we are thrilled to welcome Adena Goldstein, who will speak with us about diabetes technologies. Adena graduated from Villanova University with her Bachelor of Science in Nursing. She is currently a clinical diabetes nurse and Certified Diabetes Care and Education Specialist (CDCES) at the Johns Hopkins Outpatient Diabetes Center in Baltimore.

Welcome, Adena.

Adena Goldstein, RN, BSN, CDCES: Thank you for having me. I’m excited to be here.

RK: We are thrilled to learn from you today about the latest in diabetes technologies. This is increasingly getting attention as we have more and more technologies available for people with diabetes.

While it has been life-changing for so many people, it can also make the management seemingly more complicated. We’re hoping you can break it down for us, in terms of what people with diabetes may want to consider as they’re thinking about these technologies and how to facilitate the smooth integration of these technologies into their diabetes care.

Perhaps we could start with continuous glucose monitors, could you tell us, what are continuous glucose monitors?

AG: Continuous glucose monitors, also known as CGMs, are a little device that is worn on a patient, and it has a little filament that goes just beneath the skin and measures the glucose in the interstitial fluid every few minutes. Then there is a transmitter that sends the readings to a device: it can be a phone; it can be a separate receiver; it can be a smartwatch; it can be an insulin pump. There are a lot of different ways that it can be used. That provides data every few minutes regarding blood sugars.

I always tell patients who are transitioning to them that it’s like treating diabetes with your eyes open versus your eyes closed.

When you use a glucometer, you’re pricking your finger, and it is really a surprise whenever you get that number—you don’t know if it’s going to be in the good range, a little high, or a little low—but with a sensor, because you’re getting so many readings, you have a sense for where the blood sugars are going. In addition to the number that you get from the CGM, you also will get a direction arrow showing where your blood sugar is going. It helps you plan what you’re doing next, how you’re going to give your insulin or treat with food based on where that arrow is going.

RK: Sounds like the CGMs just really have changed the day-to-day management for so many people with diabetes. You mentioned some of the functions—the trend arrows and the alarms—that we see with CGMs. In your experience, having worked with so many people with diabetes in implementing these into their day-to-day care, how do most people feel after using these continuous glucose monitors? Especially those who’ve been pricking their fingers for a long period of time?

AG: There are very few people who actually like to prick their fingers. Most people are very happy to put their meter aside and use it very sporadically. People still need to have a meter because things can happen with the sensor, or sometimes there can be an issue with the prescription. So, we are not getting rid of meters completely at this point, but patients usually really welcome having that data without having to prick their finger. The sensors have become so much more accurate, smaller and more comfortable over the years that people really wear CGMs all the time. Years ago, people wore them sporadically; they’d be on and then off of them. Now people have become so reliant on CGMs for their day-to-day management of their diabetes.

RK: Technology is great—we know it’s not for everyone, and it really is an individual or personal decision on whether you want to use them. But it sounds like the CGM technology itself has become not only smaller but also smoother to use. Have you been finding that people have difficulty keeping the sensors on? Or are there some people who just aren’t interested in it? What has your experience been?

AG: You have to get used to having so much data in your face all the time. I usually tell people, at the beginning, for the first few days, to just watch it like a movie. You are seeing numbers that have been happening; you’re just unaware of them when you are pricking your finger two, three, four, five, or six times a day. You don’t see all the numbers that you see with the sensor.

For some people, that’s okay; they can get past that. But for other people, there is a small portion of the population that just so many numbers, all the time, can make them anxious. They’re worried about them, or they may react to them prematurely, the numbers and the alerts. We also don’t want to set the alarms tightly because we don’t want them to be going off all the time.

We want it to alert the patient when there’s something that needs to happen. If it’s going off more than it needs to, some patients will just not like it because of all the alerts.

RK: It is great to have all the functions, but they need to be used within the appropriate context, and having a device go off every few minutes. If the alerts for high glucose, for instance, are set at a value that’s within a range where the sugar might vary, it is probably not as helpful as really setting an alert for a number where we would be very concerned.

The educational component of it is so important. What you were saying is that we don’t want to make people more anxious with more data. If you have well-managed diabetes, perhaps you’re on just one pill for type 2 diabetes, and you’re otherwise doing great; perhaps having all those numbers might be more overwhelming than is needed. Really, the individual context is so important in terms of the goals of care. What are the continuous glucose monitors really being used for? What are some of the reasons you’ve seen them being used in people with type 1 or type 2 diabetes?

AG: Sometimes we’ll prescribe it for patients if they let’s say, [have] type 2 [diabetes] and are on multiple medications, still not at goal. Sometimes we will prescribe a CGM, and it teaches them a lot about their lifestyle, their food choices, and their exercise. If someone knows their blood sugar is high going into lunch, they might make different food choices than someone just not knowing what their blood sugar is and just going with how they feel.

It teaches people a lot about their diet. I’ve had patients who think their daily breakfasts of oatmeal, or whatever it is for them, is really good for them, but then they put a sensor on, and they see that their blood sugars don’t react well to that. Then they make adjustments—here’s a non-medication intervention that sometimes really impacts the A1c and the overall blood sugar control.

RK: It certainly can be insightful for people to see how their foods and their activity patterns impact blood glucose during the day. I know, even people who are healthcare providers who have worn CGMs just to understand themselves how these patterns can vary throughout the day so that they can also educate patients about it too.

We do have these professional CGMs that even if you don’t wear one at home, you can wear it for—let’s say, a week or two—to get some insight into daily patterns. What we’re really talking about here today is those continuous glucose monitors that are worn every day by the person at home, the personal CGM. You mentioned with type 2 diabetes, it could be someone on multiple diabetes medications who’s having wide fluctuations in their blood sugars, highs and lows. I found them very effective for people who might have lows overnight, for instance, or are fearful of lows and really benefit from having the alarm go off when the sugar is too low. What has your experience been?

AG: That’s really where the sensors shine, having the alerts for patients. Someone who has had diabetes for a very long time, type 1 specifically, sometimes they lose their sense of feeling lows and they can just not have them. Without a sensor alerting them, particularly people who live alone, they wouldn’t necessarily know they were low until it was too late, and they were having a severe reaction. Having those alerts is so helpful. There’s also now an alert that goes off before they get low, so they can prevent lows. We don’t want them to just get low and know they’re low. We want them to prevent the lows and treat them early with a little bit, just so they can be in a safe range.

RK: I agree. Thanks for mentioning that unawareness. With the hypoglycemia unawareness, it’s especially helpful in people who might not feel symptoms anymore of lows. When we’re talking about lows, we’re usually talking about numbers below 70. So, for our audience who’s wondering what we’re talking about, when do you usually set the alerts for the lows? What number do you usually set alarms for?

AG: It depends on the patient. So that’s very individual, which is what we were talking about before, setting them not too tightly, but it depends on the patient and what their normal blood sugars are at the time that we start. I always tell them they could always adjust it to be notified at different numbers, but you want to be notified at a point where you would need to treat or do something.

It does depend on the patient; some older patients want to be notified at 80; some younger patients just want to be notified at 70. Again, there’s a low alert soon, which looks 20-30 minutes ahead and says, “Hey, you’re going to be low soon.” That could happen at any number—that could happen at 100. It’s just looking ahead at what it thinks the blood sugar is going to do.

RK: That’s such a great technological function that it can do this predictive algorithm to anticipate the low before it happens. We know that CGMs also have a little bit of a time lag, don’t they, compared to blood levels? Can you talk a little bit about that too?

AG: The sensors measure the glucose and the interstitial fluid. Compared to the blood glucose, it can lag about 5–15 minutes behind where the blood is. What I always teach patients when I train them on their CGM is that they need to keep that lag time under consideration when they’re treating their lows, for instance.

If someone has a low blood sugar [reading] on their glucometer and they eat some glucose, it takes about 15 minutes for the meter and for their blood to catch up to that. If the CGM is 5–15 minutes behind that, it may take a full 25–30 minutes before they see that arrow start changing.

Sometimes patients will just keep eating because they see their number’s low on their monitor, but we really have to tell them, “As soon as you take enough and you start feeling better, just let the sensor catch up.” There’s a learning curve with that, but they do get used to how to use that number.

RK: That’s a really important point. Also, another reason—even though we’re talking about the continuous glucose monitor and the sensor today — to have that finger-prick glucose meter to get an even more immediate number. Even though there’s still a little bit of a 15– minute lag there too for the sugar to bounce up. But with the sensor and the CGM, that’s also another 15–20 minute lag compared to the blood value. That’s a hugely important point that it’s based on symptoms. When you’re feeling better from your low and also starting to see the numbers go up on the glucose meter too.

AG: We see that lag mostly when the blood sugar is moving quickly. When the blood sugar is steady, there shouldn’t be that much of a difference in terms of the discrepancy of the numbers. But if you just ate, your blood sugar is going to be leading, and then the sensor is going to catch up to that afterwards. That’s where we see the biggest discrepancy.

RK: That makes a lot of sense. Since we’re talking about discrepancy, one of the questions that I often get is how accurate is a continuous glucose monitor compared to blood readings? What do we know about how accurate continuous glucose monitors are, especially at extremes of blood sugar, such as very low or very high?

AG: In the regular ranges, they’re very accurate. The FDA has said you can dose insulin based off of these numbers. So they are very accurate. At the extreme lows and highs, there’s a bit more of a margin of error. Those are some times where you may want to take out your meter just to double-check what it is. We always tell people, “If the number doesn’t match what you think it’s going to be, also test with your blood.” Or sometimes the monitor will give you a number, but no arrow, or no number. If it just says high or low, those are times that you also would want to verify with your glucometer.

RK: What about sensor wear? Some of the sensors last 10 days; some last 14 days. Are they just as accurate near the end of their lifetime as they are at the beginning?

AG: The first 24 hours of a sensor are generally the least accurate out of all the subsequent days. So, as you wear it, the longer you wear it, the more accurate it does get. On that first day, if the numbers don’t quite seem right, that might be an opportunity to prick your finger to check. But in general, even that first day, it’s still pretty accurate.

RK: I’ve heard of some studies where not all sensors necessarily read to the full 10 to 14 days. Have you seen that in your clinical experience in terms of the accuracy near the tail end of that time period?

AG: I think it depends on the patient. I have some patients that have no problems ever; they’ll last the whole time without any issues. Some people will say it doesn’t quite last the full amount of time for them. I’m not sure if that’s related to their activity level, to how it was placed originally, or to the location where it’s worn. I’m not sure.

RK: I think it’s an interesting question because, like you said, it depends on the individual. I think the main point to keep in mind is that it’s a tool—the CGM is a tool. If there’s any suggestion of a discrepancy or that the accuracy might not be as you would expect, check the numbers with a finger stick just to make sure or to change the sensor if needed.

AG: I also tell people that “people may feel very comfortable with their meter, and there are discrepancies within meters.” If you take different meters or test on different fingers, you’re going to get lots of different numbers. So, you’re really looking for patterns when you’re getting these alerts.

There is a margin of error with the meters, but there’s a similar margin of error with the sensors. The meters also have the user input: Are the patient’s hands clean when they take the blood sugar reading? Are they dry? Have the strips expired? Were the strips left in the car?

There are these other human factors that could affect the blood sugar reading. So people feel very comfortable with their meter—it is a great too— but the sensors also are very accurate as well.

RK: That’s great; since we are talking about the continuous glucose monitor and the sensor, perhaps you could just break down the anatomy for us. What are the components of a continuous glucose monitor? You mentioned the sensor; what is a sensor? What is a transmitter? When can a mobile device or cell phone be used? I wonder if you could just talk about the different components that make up the system.

AG: The sensor is inserted with an applicator. Some of the sensors are as small as two pennies stacked on top of each other; they’re each a little bit different. You wear the sensor on your skin; it has an adhesive patch that it sticks to. There’s a small filament that goes right beneath the skin; it looks like a thick eyelash, and that is what measures the glucose. Part of the sensor has a transmitter, which then sends the data to a device.

RK: I really like the way that you described the thickness of the sensor and then also the filaments, the tubing that goes underneath to read the glucose in the interstitial space. As you mentioned, that sensor also has a transmitter that transmits that glucose number to a receiver, which could be either its own receiver or it could be on a cell phone. Where do people usually wear the sensors? Where do you tell people to wear them?    

AG: Sensors can be worn in a variety of places. Some are FDA approved; some are not. Common places are the back of the arm, abdomen, and thighs.

RK: Yes and it is personal preference, where people decide to place a sensor.

AG: Generally, people will start with an area that’s FDA approved. Then if there’s any issue, they’ll talk to their health care provider about trying alternate sites.

RK: Then how often do the sensors need to be changed?

AG: Depending on the sensor, some get changed every 7 days, every 10 days, every 14 days, or every 15 days. There’s even an implanted sensor that gets replaced every year now. There are a lot of different options.

Going back to the placement of the sensor, I always try to guide people away from placing it directly where they sleep. There’s something called a compression low that can happen if you sleep directly on the sensor. It will look like your blood sugar is fine, and then all of a sudden, you’re at an urgent low. It’s because that fluid beneath the skin is getting compressed where you’re sleeping, and it looks like you’re low when you’re not actually low. I try to tell people to just avoid placing it if they sleep in one specific spot to just avoid that area.

RK: That’s a good tip and important to consider when people are thinking about where to place the sensor. Especially if it’s in the arm, when people are side sleepers, that might be something to think about when you’re placing it there. Especially if you’re worried about nocturnal lows, it may be hard to know if it’s because the sensor is being compressed or if it’s a true low. That’s a great tip. Given that these sensors are changed anywhere between 10 to 14 or 15 days, how easy is it for someone to change their own sensor at home?

AG: The applicators for the insertion have become so much easier over the years. Most patients don’t even feel it going in. It’s just quick; the little needle inserts the sensor, and then the needle is retracted, and you’re just left with the sensor. So, it’s really easy; they’re generally one-handed button pressing. Occasionally people will have a loved one or caregiver help them with it if they want to wear it somewhere they can’t reach. But generally, most of our patients can apply them by themselves.

RK: It’s fantastic that it’s become so much easier to do at home, with some instruction initially. It makes it so nice for the person with diabetes and their caregiver to just be able to do this at home.

Can you talk a little bit about the receiver and the fact that some continuous glucose monitors allow you to see the numbers on your phone? This is pretty amazing; you don’t have to carry a separate receiver though some people might still prefer a receiver, which is just a separate device where they see the numbers. Can you talk about that difference?

AG: The receivers came to the market first. Some of the advantages of the receiver are that you don’t have to use your phone. Some people don’t want to drain their battery. Some people don’t want to sleep with their phone next to their bed. So they just have their monitor to alert them to the blood sugars without having their phone with them. It’s simpler; that’s all it does is just monitor the blood sugar; some people like that.

The advantage is when you use the phone as opposed to the receiver, you can connect to the clinic portals, and then we can monitor the blood sugars remotely. You can do that with the receiver as well, but the patient needs to physically plug it into the computer to upload it for us to see the data. When you use the phone, the data is updated all the time and can go straight to the portal without the patient having to do anything else once they’re connected to the clinic.

Using the phone also allows loved ones to follow the patient’s blood sugars as well. You can invite followers to see the blood sugar in real time, which is extremely helpful for a variety of cases. To have that ability to follow sometimes gives patients comfort, if they live alone, to have a child monitoring their blood sugar or a parent monitoring the child’s blood sugar or spouses, a spouse that travels; they want to make sure their blood sugars are okay. There are a lot of different varieties of cases where that can be very helpful when using the phone.

RK: I find that as long as the phone is compatible, some older phones may not be; patients appreciate having the same technological device that they use to talk to people to be able to also monitor their blood sugar. It’s amazing that those have become integrated.

Now, we’re talking a lot about the anatomy, and I hope we will get into the different kinds of CGMs, but I think it’s important to break down what people can expect if they’re thinking about placing a CGM and how much easier it has become to do this at home. Those are sometimes the types of obstacles that people might see to starting something new, but it’s reassuring to hear from you about how much more straightforward it has become how people can use the phone also as the receiver. What about downloading the data? You can see it on your phone. You can see it on the receiver, the numbers as you need them in real time. But when your healthcare provider wants to know what your numbers were like, with a glucose meter we used to have the old-school written logs of blood sugars, or they would be stored in the glucose meter where individuals could see their trends over time. How does it work for a continuous glucose monitor? How easy is it to extract the data from that so you can share it with your healthcare provider?

AG: It is straightforward. The receiver would be plugged in physically to a computer to upload to the portal. The phones, we just put a code in, and it automatically syncs with our portal. It gives us as providers so much information to look at and so many different factors to consider, as opposed to just glucometers again being just like pinpoints in time.

Here you’re getting the full picture of what’s going on with the patient. You can really pinpoint patterns much more easily with the sensor. It gives us different metrics to look at. In the past we just looked at A1C, and that’s all we had to assess a patient’s blood sugar control.

Now with the sensors, in addition to the A1C, we also look at something called time and range, which is really the time you spend between 70 and 180. For most patients with type 1 and type 2, we want that to be about 70% of the time. That’s important because you can have an average A1C of 7%, which is about a 154-blood sugar, but have wide fluctuating blood sugars—extremes.

With the sensors, you can see that you have an A1C of 7, but your time in range is above 70%. We know that most of those blood sugars are in a good range. These reports really show us a lot of information aside from just the pattern.

RK: I love the ambulatory glucose profiles that we get from the CGM as a healthcare provider: you can see patterns, you can see time in range, you can see the mean, the 50th percentile, you can see the percent of the time that you’re low, and when you’re low over the day too. It’s a standardized 24-hour profile of your average sugars in the ranges over time, usually during a two-week period, but sometimes longer. They are so helpful.

You talked about how they can easily be plugged in; the receiver can be plugged into a computer. Do patients usually do that on their own, or is that usually done at their healthcare provider’s office?

AG: It depends on the provider, but most clinics have the ability to download all the devices. If a patient needs to be monitored remotely—they had a virtual visit or something like that—that would be a time that they would want to upload their data remotely from home.

RK: I think that’s one of the things that has made it a little bit easier for us in diabetes care.[The ability] to do virtual visits or telemedicine visits, that capability. If the person with diabetes is able to download their numbers remotely, we can read them from anywhere. Then otherwise, coming into clinic and the clinic can easily download it. At every point from the insertion of the CGM to seeing the numbers on your phone or your receiver to downloading the data, I would say that more and more we have seen these processes become more efficient and smoother. Wouldn’t you say, overtime?

AG: Definitely. More patients are using them. A very large percentage of our population is using them because they’re so easy. They’re so accessible, a lot of insurances cover them well, and patients just find them so useful for their care. It takes a lot of the guesswork out of their diabetes.

RK: It doesn’t have to be a mystery. We have numbers now, and we can get lots of them. That has been really helpful. We’ve talked about the basic anatomy of a continuous glucose monitor. Now moving towards the categories of continuous glucose monitors. We know that these devices monitor blood glucose continuously, but the way that those numbers are displayed and available to the user may differ. I wonder if you could talk a little bit about real-time continuous glucose monitors versus intermittent continuous glucose monitors. Then if you want to touch a little bit about implantable continuous glucose monitors, that’d be great too.

AG: The intermittent, continuous glucose monitor, the one that’s on the market right now, is the Libre 2. Or the old Libre 14-day, which required the user to physically take their receiver or their phone and place it up against the sensor to scan it for the number. You can do that continuously; you could do it every few minutes, so you get a lot of data that way, but it won’t show you the number on the monitor unless you scan it. It will show you the patterns, though. If you scan at least every eight hours, it will fill in the data and show you what happened.

For instance, if you tested when you woke up in the morning and then scanned it and got your reading with the intermittent monitor and then scanned again at lunchtime, you would see what your blood sugar did from breakfast to lunch.

The disadvantage of that is if you only test twice a day, once in the morning and once at night, for instance, you might get gaps in your data, but some patients like that model because you don’t necessarily have it in your face all the time—you monitor it when you want to know what your blood sugar is.

The continuous glucose monitors send numbers every 1-5 minutes straight to the device, to the receiver, or the phone, or the pump, or the watch without having to do anything. You just look at it. So, a lot of patients find that more discreet. They don’t have to be in public and scan themselves, although it’s become so popular that it’s socially accepted to do that too. Some people just like having the discreet data. They could be in a meeting and just look at their watch and know what their blood sugar is—which is very valuable.

The implanted CGM, which is the Eversense, is very unique. It’s a little sensor that is surgically implanted under the skin. It just got approval for wearing it for a whole year, which is really exciting. On top of that, you wear the transmitter, which also sends the blood sugars to the phone. As opposed to the other sensors, if you take it off, you can’t put it back on that specific sensor. This one, you could take off the adhesive patch with the transmitter and then your sensor is still good, and you could just replace the transmitter when you need to.

RK: So that’s really helpful. You talked about the intermittent or flash CGMs, which currently sounds like we just have the Libre 2 or the 14-day Libre before. I like to think of those as the on-demand, CGMs. You get the numbers when you want them, but you really do have to wave that receiver over the transmitter to get the numbers.

Then you talked about the real-time CGMs, which are probably the most common type that we’ve had for a while. What are some examples of real-time CGMs that people might be familiar with on the marketplace?

AG: That would be the Dexcom G6, Dexcom G7, the Libre 3, and the Guardian sensor. Those are all sensors that send the data directly to the device without having to scan.

RK: The Guardian sensor, that’s the one that’s in Medtronic devices, is that right?

AG: That’s a Medtronic sensor. They have a specific sensor that can be worn as a standalone, and they also have a sensor that is worn just specifically with their pumps.

RK: So some of these CGMs, like we talked about, are standalone. You just use them on your own. Some of them, like the Guardian, can be part of a pump itself integrated into the pump and can transmit numbers to the pump to help with dose adjustments. Some are two different devices that communicate with each other. Isn’t that right? The pump and the continuous glucose monitor.

There are so many different variations. I think that the compatibility of these different technologies with each other is also remarkable, especially as we start thinking about an artificial pancreas or something like that in the future, and we could touch upon that later. But it is really remarkable all the different ways that these CGMs can communicate also with the insulin pump and other devices.

You lastly talked about the implantable sensor. Who usually places that sensor for the patient?

AG: There are some endocrinologists who do this in their office. Not all of them, not every office, but there are some providers that have been doing a lot of these. You’d reach out to the company to find a doctor in your area that is very comfortable with placing and removing these sensors.

RK: It is not something that a patient can do on their own—they have to go in. It is a minor procedure that they get done within a few minutes, I think.

AG: The sensor is really small. The Eversense also, the way it’s designed, to give on-body vibrations; if you’re low, the actual transmitter vibrates. Even if you didn’t have your phone with you, you still would know you were low because it would vibrate. That’s a different feature that some of the other sensors don’t have.

RK: That’s interesting—so you’d be shaken awake. Are there any new models on the horizon? Is there a Libre 4?

AG: No, there’s a Libre 3 Plus. I think where the future is going with these sensors is, like you touched upon before, more integration with more devices. The idea is we want to give patients a full range of choices. Eventually, you can pick your pump, you can pick your sensor, and hopefully they’ll all combine with each other. All the sensors are trying to get the most wear time to get that 2-week to 15-day wear time.

Recently there have been a couple of over-the-counter CGMs, which are new and unique. Dexcom now has one called Stelo, which is designed for people who have diabetes but are not on insulin and not on any medications that could cause low blood sugars. But they still, like we talked about before, really find it valuable to learn about their lifestyle and have that feedback. That’s an over-the-counter sensor that is not available at local pharmacies at this point. It is purchased online from their website. It is essentially a G7 sensor; it looks like a G7 sensor, but it doesn’t have the alerts in the app. The app is different; it gives a lot of lifestyle coaching, feedback, and education—it really guides patients and gives them feedback regarding their blood sugars. It is not intended for people who have the potential for low blood sugars.

Abbott also has one; it’s called the Lingo, which is essentially the form of a Libre 2. That’s actually not even for people with diabetes. That’s just for people that want to monitor their metabolic health and to get feedback that way. That’s also over the counter. It is not going to have alerts but just gives people blood sugar feedback.

RK: These over-the-counter continuous glucose monitors are really interesting. I think we’re learning more about them; they’re relatively new. I do think an important consideration that I share with patients or family members who are interested in using this or even friends is the accuracy, especially in people without diabetes, as we had talked about, particularly in the extremes of readings, if they are as accurate. The accuracy has been validated because they are on the market. But it’s always something to think about with any of these devices. If there is any discrepancy with what you’re expecting, consider the finger sticks or even a lab draw.

The availability is important because we know that not everyone who wants to use CGMs necessarily has access to them. I wonder if we could talk briefly about who CGMs are usually covered for; type 1 diabetes versus type 2 diabetes, and some of the challenges that you’ve seen in getting access or coverage for CGMs for patients that you have seen with diabetes.

AG: With anything related to insurance, obviously it varies widely regarding coverage and access. In general, patients with type 1 or anyone on insulin can access a sensor. Medicare requires at least one shot of insulin a day or a history of severe hypoglycemia, defined as needing assistance to treat. Sometimes the sensors are ordered through the local pharmacy, and some insurances require you to use medical equipment companies. So sometimes navigating that can be a little confusing for patients, which way it will be covered for them. For someone with type 1 or a patient with type 2 on insulin, it really should be covered (by insurance), and they should have access to it.

Some patients who may not be on insulin, who have type 2, some insurances will cover it. They just will cover it regardless of what medication they’re on. If there is a patient who, let’s say, doesn’t have coverage, that’s where something like the Stelo is helpful because they can purchase it at a more reasonable price and still have that benefit of seeing their data.

RK: Like you mentioned, anyone on insulin, with type 1 diabetes, whether they’re on an insulin pump or even insulin injections, or type 2 diabetes, one insulin injection or more a day coverage – while it differs by insurance company usually we can get coverage. Usually it is recommended to check your glucose readings multiple times a day if you’re on multiple injections a day of insulin, or at least once a day if you’re on basal insulin. So having the CGM can be helpful. I’ve seen, as you mentioned, people with type 2 diabetes who are on oral treatments; sometimes it can be more challenging if they don’t have private insurance to get coverage for a CGM because of what you mentioned with the Medicare specifications. For those patients, I do think that these over-the-counter CGMs could offer, hopefully, a cost alternative that might be more accessible. Wouldn’t you think?

AG: They’re still not cheap. They’re about $90 to $100 a month. For someone, though, who may be just wanting to monitor their patterns and food intake and things like that, it could be they may not need to wear it for a whole month straight, or it could be they can wear it for two weeks out of each month to just get a snapshot of what’s going on with their diabetes. They’re still not really cheap, but they are more accessible.

RK: Thank you for pointing that out. Do you know how much, non over the counter CGMs cost, with a prescription?

AG: I think it differs a little bit. Libre used to have a coupon that would get it to $75 a month with a prescription. But some insurances are starting to not, or the coupon may not work so well with everyone now. Then it could be, for Dexcom, about $170 per month for it. There is a bit of a cost saving.

RK: Needless to say, these devices are not cheap. Having coverage is incredibly important for those who could benefit from it, and having it be accessible to people with diabetes, not only in the United States but around the world, that really could benefit from them, is also important.

I think as we think about technology and diabetes, it’s an exciting time, but it does need to be an exciting time for everyone who can benefit from them.

We talked about the different categories of CGMs and you talked about a few models within each of those categories. I wonder if you could just broadly talk about some different features that continuous glucose monitors can offer.

We talked about the trend arrows telling you if you’re going high or low. You talked about the functionality of being able to predict almost in 15-20 minutes if you’re going to go low or not. Are there other features that might be interesting for our listeners to hear about?

AG: he share feature, I think I mentioned before, is one of my favorite features. It’s not for everybody, but it is a nice feature for a lot of people to have that ability to share their data. Other features—what devices they’re integrated with…

RK: How about calibration? Do all of these continuous glucose monitors require finger sticks to confirm values that might be too high or too low, or do they replace the need for finger sticks altogether?

AG: We talked a little bit about when you might want to take out your meter to test. With some of the monitors, you can’t calibrate. The Libre is a sensor that you can’t calibrate. The Dexcom, while we don’t recommend it often, you do have the ability to calibrate if you want to, but you don’t need to. The Guardian and the Eversense, you do need to calibrate. They do differ in that way.

RK: What does that mean? What does calibration mean?

AG: Calibration means [that] at the same time you prick your finger with your glucometer and input that number into the monitor, and then it matches up the sensor and the blood sugar number together.

RK: In terms of using the numbers from a sensor for treatment decisions, from what I understand and what I’ve seen with my patients, some of the sensors, you don’t need to do anything more than that. They replace the need for finger sticks, as long as they’re not too low or not too high. Could you talk a little bit more about that and what devices those might be?

AG: All of the available sensors right now are approved to dose that your insulin off of. As long as you have a number and an arrow on the monitor, you can dose off of it. Sometimes if there’s no arrow or if the monitor is telling you to prick your finger, that may be a time where you wouldn’t trust the sensor necessarily—you would take out your glucometer. In general, most patients don’t need to do that, and they’re testing their blood infrequently and relying mostly on the sensor.

RK: I have patients who’ve been finger-pricking four times a day for decades and then finally now are at a place where they have a sensor, where they almost never need to do that anymore. It’s pretty remarkable. These have been game changers, haven’t they?

AG: Yes, definitely.

RK: So we covered a lot of ground today, and we really appreciate you, Adena, breaking down the types of CGMs, their functionalities, who usually can benefit from them, and the over-the-counter options as well. In this rapidly changing time, it just seems like there are so many new updates to the technologies. How do you recommend your patients keep up with them? To know the newer models, I’m sure there are software updates that need to be done at times too. How can they keep up with the changing technology to make sure that they’re getting the most up-to-date versions that are out there? 

AG: In terms of technology in general, I think when you come in for your office visit with your doctor, I think that’s a great time to revisit what’s happened, because the technology does change every 3, 6, or 12 months. I think, from a bigger picture, checking in with your doctor’s office is important, and there are lots of other resources online. The Johns Hopkins Patient Guide to Diabetes has a very good reference for technology and updates and comparison charts between the different devices because they’re all so nuanced.

We talked generally today, but they’re all very specific and a little bit different from each other. In terms of making sure your device is up to date, if you register your device, which you typically do when you get it, you should get a notification if you do need to update something. Generally, when there’s phone integration with the sensors, we tell patients to turn their automatic updates off on their phones because sometimes the latest version of the operating system may not be tested yet with the sensor. So, leave that off, and then when you get the go-ahead and you find out that it’s okay to use, you can go ahead and update your phone with that latest operating system.

RK: That’s important to emphasize registering your device so you can get those communications. Thanks for pointing out the resources out there to continue to learn more about new technologies and new devices that might be coming out on the horizon.

Adena, it’s been so great to talk to you today and to hear in a practical way the things that people with diabetes should be aware of as they consider these technologies, the exciting developments we’ve seen with continuous glucose monitors, who might be suitable for them and for whom, perhaps the glucose meter or less frequent glucose checks might be more appropriate, and then also, what are some of the functionalities that have really facilitated the day-to-day management for people with diabetes.

In parting, I wonder if you might have a few words for people out there that are listening who might still be a little reluctant to try these new technologies out. Maybe they’re used to their day-to-day management. Maybe they don’t want to complicate things anymore. What would you say to them about considering these technologies and integrating them into their day-to-day management?

AG: I have so many patients who tell me that the CGM has been the one most life-changing thing for them in the course of their diabetes management. It is a lot of information, and you do have to get used to that. For most people, there’s really a comfort to it, and it really takes a lot of the mental burden and worry out of their diabetes. You’re not worrying [about] what your blood sugar is because you know what it is. If you’re not feeling well, you can confirm, “Am I just not feeling well, or is my blood sugar abnormal?” It really gives people a big comfort. It’s much smaller, much more comfortable to wear—most people forget they’re even wearing it.

I would really encourage people to just talk to your provider about trying it. It’s not a big commitment. You could try it for a few days, a week, or two weeks; see if you like it; see if it helps you. For the majority of our patients, it is really life-changing and such a helpful tool to help them thrive with their diabetes.

RK: Definitely, talking to the healthcare provider, seeing if this might be for you, and seeing what the options are, especially if these numbers can give some reassurance and also some insights into behavioral patterns that can ultimately lead to improved outcomes. That’s ultimately what we want for everyone.

Adena, thank you so much for being here on our podcast. We really appreciated all your expert insights and your input today.

AG: Thank you for having me.

RK: I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.

For more information, visit hopkinsdiabetesinfo.org.

We love to hear from our listeners. The email address is [email protected].

Thanks for listening. Be well and see you next time.