I am here in Indianapolis with 3000 other Certified Diabetes Educators. It has been amazing. I am energized to bring back the best of what I have seen to Saipan and the rest of the CNMI. In the following paragraphs, I will go through some of the highlights.
Continuous Glucose Monitoring
We are proud to be bringing continuous glucose monitoring (CGM) to Saipan. CGM has been widely used throughout the US for years to help in the care of type 1 diabetes, and in difficult to control cases of type 2. Unfortunately, it has never been available in the CNMI. With CGM a sensor is placed on the arm and is worn for up to two weeks. I had a sensor placed on my arm, it was about the size of three quarters and completely painless.
After the sensor is worn, it will be removed in our office and connected to our computer. We will than have a complete 24 hour reading of the blood sugar variations over the last two weeks. Our current tests only give brief snapshots. See here a review of the Abbott Libre sensor we will be using.
The American Academy of Endocrinology calls for continue glucose monitoring for the following:
- Any diabetes patient on intensive insulin therapy
2. Patients at high risk of hypoglycemia (low blood sugar)
3. Patients on insulin or insulin secretagogues (Glyburide, Glynase, Amaryl) who manifest
4. In severe diabetic kidney disease
Continuous glucose monitoring has been called the EKG of diabetes. It brings a great deal of additional information so that both doctors and people with diabetes can make better treatment decisions.
Helping our patients afford their diabetes medications
So many of my patients on Saipan, have great difficulty affording their medications. Even when they have insurance, they often have large deductibles. This has especially been a problem for those who require insulin, or other very expensive diabetes medications like Victoza. Every major medication manufacturer has so called “patient assistance programs”. In the past, the companies have not provided this assistance to people in the CNMI. I have been working on this for the last few years. In Indianapolis, I met with high level executives from several companies producing diabetes medications. One has committed to establishing this program for the CNMI. We will see, but I am optimistic. This potentially could be a big deal for improving our overall health and avoiding the worst complications like blindness.
There is a lot of work being done on the national and local level to prevent diabetes from starting. The leaders from the Centers for Disease Control (CDC) were very active at this conference. The CDC is the federal agency tasked which conducting and supporting health promotion and prevention in the United States. They just updated their 2017 diabetes statistics showing that 30.3 million Americans have diabetes, and that 84 million have prediabetes (studies show that most people with prediabetes will go onto full diabetes within 5-7 years).
The best evidence for how to prevent diabetes came from the Diabetes Prevention Program (DPP). It was a large study which demonstrated that lifestyle changes were much more effective than medication in preventing the progression to diabetes. I will be writing much more fully on this in a future post. There is currently a strong effort to scale up the DPP and bring it out on a national level to help more people. We are planning to implement the DPP in our office on Saipan as well as in Rota next year, and hopefully soon after in Tinian.
Metformin has for many years been the most commonly prescribed medication for diabetes. The American Diabetes Association has called for nearly every type 2 diabetes patient to be on Metformin for life. It has until recently, been the only major medication to significantly lower the rate of cardiovascular (heart) disease in diabetes. Also, late last year the FDA changed their guidelines, and now call for most patients with diabetic kidney disease to remain on Metformin. At this conference, some new studies were presented. It has now been established that people with diabetes who take Metformin, get less cancer than those taking other diabetes medication. It also seems to have an anti-inflammatory effect, as well as having positive effects on our microbiome. I will write more explaining these findings in a future post.
Reframing our thought processes for better diabetes control
Dr. Alison Ledgerwood, a behavioral scientist from UC Davis, presented a series of studies, some her own, showing how the human mind tends to focus on the negative. There are specific studies showing people with diabetes often get caught up in a negative cycle of thoughts which make sticking to lifestyle changes much more difficult. She presented a plethora of evidence based strategies. I will be using these in my own personal life (like so many of you, I also struggle with maintaining a healthy weight). I will also be sharing these with my patients as well. I plan to write on this topic in more detail in the future.
My favorite nutrition writer, Dr. David Katz, gave a thought provoking presentation. I have read all of his books, and most of his columns, so I was aware of most of what he said from my previous reading. Hearing it in person still made quite an impression on me. He talks about feet, forks, and fingers. How using these things correctly can benefit our health. In other words, using our feet to walk, our forks to eat healthy food, our fingers, not to smoke. He presented a series of studies demonstrating that over 80% of all chronic disease, of course including diabetes, could be prevented. This prevention is in all of our control, again, by using our feet, forks and fingers correctly. I encourage you to see his much more articulate writing here.
Dr. Katz also spoke about Blue Zones. These are areas of the world, such as Okinawa, where people live long healthy lives. The blue zones project is attempting to bring what works in these blue zones to other areas. My friend Lisa Hacskaylo from Northern Mariana College has been working diligently to have the blue zone project started here. Dr. Katz spoke passionately on how this could help.
Cardiovascular disease and diabetes
I discussed earlier how Metformin has been proven to lower the risk of cardiovascular disease (heart attacks and strokes). Treating diabetes with other medication has for many years been proven effective for preventing complications like blindness from diabetic retinopathy, amputation, and kidney failure. Only over the last two years several new medications have come out which are also proven to lower the risk for cardiovascular disease. There was a great deal of talk about these new findings.
The first study called EMPA-REG was released less than two years ago. It showed that in patients at high risk, taking the medication Jardiance for about three years, lowered a persons risk of dying from cardiovascular disease by 38%. Now similar findings have been shown for other medications, like Invokana in the CANVAS trial, and Victoza in the LEADER trial. These findings have shaken up the diabetes treatment world. The above medications are now often used as second line therapy after Metformin. I will be writing about these studies further in a future post.
In the United States over one third of patients with type 1 diabetes (childhood onset) wear an insulin pump. Even though we have hundreds of people with type 1, there has never been an insulin pump prescribed in the CNMI. We are trying to change this, and hope to bring insulin pumps to Saipan by next year. There have been some amazing advances in the technology.
Insulin pumps deliver a small amount of insulin constantly throughout the day, with larger quantities after each meal. Medical studies show fewer complications, and much less severe hypoglycemia than is seen with insulin injections. There is some new technology’s in pumps that I will write about further in the future. My two favorite pumps at this time are from Medtronic and Omnipod.
-New Blood glucose meters. There are several new blood glucose meters out this year. I am most intrigued with the Accu-Chek Guide. We have long used the earlier Accu-chek Aviva, as it is highly accurate and very easy to use. Several studies were presented showing the new meter is even more accurate. It also has blue-tooth technology to connect automatically to apps on smart phones.
-New inhaled insulin, called Afrezza. It lowers blood sugar more quickly than other insulin. In addition it gives us another option for people who are afraid of needles.