News of the Center
News Archive — Fall 2019
Message From the Director
Holiday greetings to you, your family and friends, I hope 2019 was a good year.
Thanks to your support, we have been able to continue our work in underserved communities in Los Angeles—doing research, providing programs and education, and trying to reduce existing healthcare disparities for people with diabetes.
We have also been able to raise the bar for people on the Westside of Los Angeles, with new treatments and technologies that further enhance our ability to treat diabetes. I have never felt so confident in my ability to forestall and prevent the complication of diabetes, at least in patients who have access to high-quality healthcare. However, due to the ever-growing lack of healthcare professionals who are going into the field of diabetes, I feel increasingly compelled to educate primary care providers and to mentor young people in the field. I also believe in expanding the role for diabetes educators, like our own Mary Rose, who are capable of providing innovative care and support to people with diabetes.
I'm so proud of our teams in both the East and the Westside of the city. Please consider adding your support to our centers in your end-of-year charitable donations.
I am once again on the ADA Professional Practice Committee where we write the national guidelines for diabetes care. This time, I am the lead on the Technology Standards. It is one of the most intense, time-consuming volunteer jobs one can do, but it is also one of the most gratifying. It forces me to review everything in the field of diabetes and then work with the other committee members to interpret it and create a useful guide for other providers.
In other news, you may soon be seeing ads for Rybelus, a once-daily pill form of Ozempic (a once-weekly injection). This drug class is for people with type 2 diabetes and it is incredibly effective at controlling glucose levels while offering the added benefits of weight loss and protections against heart disease. Rybelus is a bit complicated to use—it needs to be taken daily on an empty stomach with no more than 4 oz of water and you have to wait 30 minutes before eating or taking another pill. I think some people will continue to take their once-weekly injection of Ozempic while others will prefer the new pill. I'm also hopeful that this oral medication will be something more readily used in primary care than the injectable form.
The second FDA-approved hybrid closed-loop insulin pump will be available in January. This is the Control-IQ version of the Tandem X-2 pump that works with a Dexcom G6 CGM to automatically prevent low glucose event and it will be updated with software to help with highs as well. We have many patients who have been waiting for the update while others are joining the #We’reNotWaiting movement, building their own iPhone Loop controllers to deliver insulin with hacked OmniPod devices. The web version of our summer newsletter article provides links to instructions on how to build the open-source version of Loop and will be updated with information on the new Tandem system.
As more patients are taking advantage of telemedicine visits, I am finding that I love this form of communication. I enjoy seeing people in their home settings and there are no complaints about how long the drive was into the clinic. I do not think it completely replaces an in-office visit, where I can often do more tasks, but I think it is terrific if interspersed with in-person trips to the clinic. And it is definitely useful for patients who live far away or have busy jobs or family responsibilities. Here is how you can connect.
The recent fires in California are a reminder that people with diabetes have an additional reason to be ready for fires, earthquakes and other emergencies and getting through the holidays with diabetes creates additional challenges in terms of managing weight and glucose control. Mary Rose has some great advice on how to manage the season.
As always, we appreciate any support you can offer for our clinical and research programs. Happy 2020!
Sincerely,
Anne
Telemedicine in the Time of COVID-19
We Love Our Patients — We Just Can't See You in Person Right Now
One attraction of taking care of people with a chronic condition is that we get to see you every three months and there are patients in our practice whom we have known for decades. We love the visits with you, catching up on your lives and helping with your diabetes care, however this can be done via telemedicine nearly as well as in person. Therefore, until the COVID-19 crisis has passed we will be doing essentially all visits via telemedicine, to reduce risk to you and to our staff.
Diabetes is the perfect condition for video and phone visits since many of you have long-term relationships with us already, and much of your visit revolves around reviewing your diabetes data. We started experimenting with telemedicine visits a year ago; we offered this option mostly to patients with long commutes. However, due to lack of consistent insurance coverage its utilization was limited. Now, with new reimbursement policies and the COVID-19 pandemic we ramped our telemedicine utilization so now nearly all of our visits are done this way.
Our office has recently been busy contacting patients to switch them to telemedicine. The biggest challenge is viewing your diabetes data. Some people already have data streaming into cloud-based services, and others are learning how to upload from home to share their data. Frankly, getting data from diabetes devices as people walk into the clinic has long been the weak link in providing care. It seems like every blood glucose meter, pump and CGM company has its own proprietary cable and software platform. Downloading to the software program or uploading the device to the cloud requires finding the cable, logging onto to the program and hoping that you are not blocked by the clinic's computer security team. With luck, it all works, but it is a high wire act that telemedicine could alleviate.
One common question we get when we contact a patient is, "What about my A1C?" There are two answers, the first option is doing a Home Access A1C test. test. It is a validated test that only requires a finger-stick and costs $40. The other option uses the data from a continuous glucose monitors (CGM) that provides what is called the glucose management indicator, or GMI, which is the CGM equivalent to an A1C for the time period displayed. More than numbers, however, we care about you, and helping you through this time of stress and uncertainty. We can help keep you healthy and we definitely want you to reach out to us!!!
The Telemedicine Technology
For our video visits we are using both the USC TeleCARE system and a HIPAA compliant (heath data secure) version of the Zoom video chat software. We are still experimenting with what system works best and we ask for your understanding as we make this shift to a new system.
USC TeleCARE visits can use either a computer or an iPhone, and Zoom requires a computer, with a video camera, an iPad or smartphone. Some of our older patients that we most want to keep out of the office due to the current health risks are tech savvy, but for others a simple voice or video phone call is also working.
Diabetes Device Data
This is where the fragmentation of the diabetes devices, including meters, pumps and CGM's, creates chaos. Some devices play well with others and are easy to share (Dexcom leads in this area), while others are locked into their own silos that complicate sharing (Abbott's LibreLink mobile system is a prime offender).
Whatever system you use, don't expect it to work the first time you try to share data. You are going to have to look for cables and try to remember passwords, and you will run into computer issues. Some of these steps are easy; others are much harder than they should be. Start early, do a test run and call tech support or your diabetes team for help at least a day before your visit. Our lives have enough added stress, so run the test and then add the last bit of data just before your visit. This also allows you to repeat the process to confirm that you know how the system works. Good luck!
Tidepool
Fortunately, the wonderful non-profit company Tidepool, started by Howard Look and supported by JDRF, was tailor-made for this crisis. This is the Swiss Army knife of diabetes data platforms, and it is our first choice for viewing data. It has the ability to accept data from multiple devices and display it together all on one timeline in a way that adds insight to your diabetes management. This data is available to both providers and patients, and we often encourage patients to review their data to improve their ability to make treatment decisions.
The main part of Tidepool is web based and runs on the Google Chrome browser. There is also a mobile app that can be used for creating notes and to transmit data collected in the
Apple Health app.
The website has a separate uploader application, which can be downloaded for Mac or Windows computers. Once downloaded, you select your device, plug it in and upload it to the cloud. When you have more than one device, it is important that the times and dates all match, as this allows the data to be properly synched.
Dexcom & Clarity
Dexcom is great at connecting its CGM with smartphones, pumps and its own receiver. There is a direct connection with Tidepool to your Dexcom account (the best way) or through the Apple Health bridge.
The Clarity app can also generate a sharing code that is easy to enter into its Clarity website. Patients can either share the code or download and email a pdf before their telemedicine session. For most patients using insulin pens, this is all that is needed before the visit. The receiver can also be uploaded to the Clarity website and shared as a pdf.
Companion Medical InPen
Patients using the InPen can also integrate their insulin dosing and Dexcom data into the InPen app. This paired CGM and insulin dose data creates a robust report similar to what we get from insulin pumps, and the report is easily generated in the app and emailed as a pdf.
Abbott Freestyle Libre
The Libre receiver can be uploaded to Tidepool, but if you want to use the LibreLink app on your smartphone to scan the sensor, that data needs to go to the LibreView website, where a pdf report can be generated. Alternatively, you can create a direct direct connection with your provider by entering a clinic code or by accepting an email invitation.
On the plus side, once the connection has been made, the data streams continuously, and we can look-up and view our patient's Libre data.
Tandem T:Connect
The best way to view data from the new Control-IQ system is through T:Connect, which is the only way that displays all of the new automated features. But Basal-IQ works in Tidepool as does most Control-IQ data. Create an account and download the uploading software that allows for uploading your paired pump/CGM data. Then create a pdf to email or make a connection with your health care team by sharing your username/email and password.
Loop
This could be the easiest solution because if you are tech savvy enough to build the DYI Loop hybrid closed-loop system, you should also know how to send your data to Apple Health and then stream into Tidepool. Once you make the connection, your data streams into Tidepool and your job is done.
Insulet OmniPod
OmniPod provides the Glooko software to use to upload your pump. You can generate a pdf and email a report or connect with your provider with a ProConnect Code. This software works with either the traditional PDM system or Dash system. It can also be uploaded to Tidepool.
Medtronic/MiniMed Carelink
Medtronic pumpers can either use their Contour Next meter or an uploader to serve as the communication bridge with the pump. Pumps can be uploaded to Tidepool or to CareLink. The wonderful news is there is finally a way to upload to CareLink without using JavaScript. To do this, you need to sign-up or log into your account and look for the new uploader. After you upload, you can generate a report and send a pdf, or you can share your username and password with your health care team. If you are using the Guardian sensor with the system, your CGM data is integrated with your pump data.
Meters
Try Tidepool to upload the meter or use the software from your meter company and send a pdf.
Once you master the diabetes data upload process, there is a learning curve on using your provider's telemedicine platform. Take a deep breath. The first time will be a challenge, but once you learn the system you will appreciate being safer and having no commute.
Vaccinations for Adults with Diabetes
Updated: March 10, 2020
With all of the attention on the novel coronavirus we thought that this could be a good time to revisit the list of vaccinations recommended for all people with diabetes. Number one on the list is getting the seasonal flu shot and if you don't yet have one this year it will still protect you from the virus that is still the greatest seasonal health risk.
We have them available in the office and they are easy to get at your local pharmacy, as well. This year already there have been up to 440,000 hospitalizations and perhaps as many as 36,000 deaths in the US alone from the seasonal flu.
The December wildfires in Los Angeles was fresh in our minds when we wrote our disaster preparation article and many of the tips to survive a wildfire or an earthquake can also apply to this outbreak of COVID-19. Be safe and stay healthy.
By Sharon Orrange, MD, MHS, FACP
We hear a lot about vaccination shots for children, but it turns out that adults also need immunizations. People with diabetes need to pay special attention to being up-to-date because they are more likely to be infected and get complications from the flu and pneumonia. The CDC recommends that adults with diabetes should be current with five different types of vaccinations.
The most important vaccination is the annual flu shot. Since the flu virus changes from year to year it is good to get into the ritual of getting a shot in September or October. Getting a bad case of the flu can lead to a lung infection called pneumonia.
To protect against the most common cause of bacterial pneumonia, you should receive the vaccines against the pneumococcal infection that causes pneumonia. You can do this based on age. Everyone with diabetes between 19 and 64 should have the PCV13/Prevnar 13 vaccination, those who are 65 and older should have both the PCV13 and the PPSV23/Pneumovax shots. The two type of vaccinations should be taken a year apart. If you are 65 and older and don't have the pneumococcal vaccination yet, start with the PCV13 and follow it a year later with the PPSV23.
Diabetes patients also have a higher risk of getting hepatitis B due to their exposure to needles and blood. Vaccination can prevent the potential liver disease and liver cancer that can result from contracting HEP B. Vaccination for HEP B is recommended for people with diabetes who are under age 60.
There is a new, highly effective vaccine against the painful shingles for people 50 and over. The brand name is Shingrix and it requires two doses 6-months apart. Lastly there is the Tdap (tetanus, diphtheria, and pertussis) shot to protect again whooping cough. This protects both the adult and prevents the transmission to younger children.
Taking these preventative steps can help prevent the complications dealing with your diabetes during sick days and it may seem like a lot of shots, but only the flu shot is needed every year and the other are spread out over your long adult life.
Many of these vaccinations are available in the clinic as well as your primary care office. The flu and other shots are also widely available at pharmacies. Not every primary care physician is current on the vaccination needs of people with diabetes and it is hard for your diabetes doc to cover all of your diabetes concerns is a normal visit, so it is good for patients to keep a vaccination record and ask for your recommended vaccinations.
For more information visit:
https://www.cdc.gov/vaccines/adults/rec-vac/health-conditions/diabetes.html
Preparing for the "Big One" and Other Natural Disasters
Simply by living in California, we need to be prepared for a variety of natural disasters—from recent wildfires and mudslide events that prompted split-second evacuations to the ever-present danger of a major earthquake.
You need to have your emergency diabetes survival kit ready because there isn’t always time to prepare during a disaster. This is especially important for seniors and people using insulin. We know from recent published studies on the impact of hurricanes Katrina and Rita that more seniors died in the first month after the storms and that the storms’ impacts lasted a year or more.
This is what a basic (not refrigerated) diabetes survival kit, ideally kept in a small backpack that is easily accessible, should contain:
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A small supply of all your prescription and nonprescription medications (like Tylenol/Advil/Benadryl—anything you might routinely take)
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A list of your medications
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A list of your medical conditions
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Copies of your health insurance card and driver’s license.
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A list of contact information for critical family members/friends/doctors, in case your cell phone dies
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A glucose meter, test strips, lancing device, and lancets if testing your blood sugar (this is true for patients on continuous glucose monitors as well, to have as a backup).
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An extra pair of glasses (if needed)
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Drinking water (available in emergency pouches) enough for at least 3 days.
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Food bars/other easily carried nonperishable snacks
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Glucose tablets or gels (if on insulin or other medication that can cause low blood sugar)
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Insulin pump/sensor supplies if needed.
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A change of underwear and socks.
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Cash
For patients taking insulin, a small insulated bag (such as a child’s lunch bag) should be kept in the refrigerator. I suggest a bit of redundancy with the backpack above. For patients requiring insulin, the insulin kit is life-sustaining, and if only one is grabbed, it must be this one. This should contain:
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Unopened insulin pens/vials for all types of insulin taken. For those on pumps, this must include long-acting insulin such as Lantus with instructions on what dose to take
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Syringes/pen needles
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Glucagon
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Glucose tablets/gel
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A food bar or two
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A few pouches of water
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Meter without battery in it/strips/lancing device/lancets (put here rather than in backpack if packing both—this way it always comes with the insulin)
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An extra battery for your meter should be taped to the outside of your refrigerator in case the one in your meter develops condensation. Be sure to grab it when you leave.
Make sure your refrigerator is strapped to the wall, so if it falls over your supplies won’t be trapped inside. Otherwise, put the insulin bag in a small refrigerator that you can easily pick up.
If, in an emergency, only regular and NPH insulin are available, reduce the doses by 20% compared to your usual doses of insulin. NPH (intermediate-acting insulin—peaks in 6-10 hours, is cloudy) and regular insulin (short-acting) are available at Walmart as ReliOn brand insulin. You can get them without a prescription for $25 apiece. Be sure to get syringes as well. See this guide for determining new doses: https://www.diabetes.org/sites/default/files/2019-08/switching-between-insulin.pdf
For exceedingly thorough preparers, it is helpful to have a portable solar charger panel and power bank (available at REI or other outdoor camping stores/Amazon).
Organizations to contact if you need help:
1. The American Diabetes Association: 1-800-DIABETES.
2. Diabetes Disaster Response Coalition
When emergencies occur in other areas, patients often ask how they can donate their insulin and other diabetes supplies. We recommend the Insulin For Life USA group—contact them to explore how you can help.
Navigating the Holidays with Diabetes
By Mary Rose Deraco RN, BSN, CDE
The holidays can be a time of great joy, but it can also pose a challenge for people with diabetes. The traditionally food-focused season can result in weight gain and difficulties maintaining glucose control. In addition to the high cost of managing diabetes, budgets can be stressed with the increased expense of gift shopping and holiday travel. Parties and social commitments can distract you from the healthy routines of exercise, meal planning,
sleep, and meditation that keep you centered and balanced.
When preparing for a more fulfilling holiday season, ask yourself what was difficult about last year so you can plan to overcome your barriers and pave new roads to success. Here are some of the tips I share with my clients to to create a more fulfilling holiday season.
Changing Routines
Changes in routine or activity can result in the need for adjustments in insulin or medications. If you are traveling overseas or taking a trip that requires a lot of exercise, you may want to meet with your health care provider to discuss how to adjust your medications and insulin when you travel. Most experts recommend that you monitor your blood sugar and weigh yourself more often over the holidays. One recent study found that the simple act of weighing yourself daily prevents the weight gain that many people experience over the holiday season.
Healthier Holiday Eating
Many traditional holiday foods are high in carbohydrates, so portion size is the key to success. Mashed potatoes, sweet potatoes, stuffing, dinner rolls, cranberry sauce, and desserts contain a lot of carbohydrates, sugar, and hidden fats, which can pack on the pounds. Don’t feel like you have to sample everything on the table. Have a reasonable “taste” of your favorite foods and, when filling your plate, use the plate method as your guide. Fill half of your plate with non-starchy vegetables and divide the other half of your plate into lean protein and complex carbohydrates (preferably grains, beans, or high-fiber starches.) Try to keep your total carbohydrate intake close to that of a regular day. If you plan on eating a big meal, make the other two meals low-carb and low-calorie. If you don’t have daily carbohydrate goals, see your diabetes educator or dietitian for guidance.
A great place to find diabetes friendly recipes for favorite holiday meals is the Diabetes Food Hub, a site created by the American Diabetes
Association: www.diabetesfoodhub.org.
The food hub offers a meal planner with a shopping list generator and additional holiday and year-round eating tips.
Parties & Drinking
While holiday parties can be fun, they can pose a challenge for people who are trying to maintain their weight and a healthy lifestyle. Avoid the temptation of high-calorie appetizers by eating a healthy snack before you leave. For potluck events, bring a platter of raw or blanched veggies or shrimp cocktail with your favorite low-calorie dip. You can also sit away from the buffet and appetizers and gravitate toward guests who are eating healthier foods.
Holiday spirits and beverages can be a huge calorie trap that can cause unwanted fluctuations in glucose. Stay hydrated with calorie-free fluids such as flat or carbonated water or unsweetened iced tea or coffee. Avoid drinking empty calories in juice, soda, lemonade, or traditional holiday drinks like eggnog. Avoid cocktails that are mixed with sugar and fruit juice and choose lower-carb alternative such as light beer, dry wine, or spirts served on the rocks or mixed with diet or club soda. If you are taking insulin or other medication than cause hypoglycemia, remember that drinking alcohol can cause low blood sugar, especially overnight.
Remember to Exercise
Strive to stay active over the holidays by walking first thing in the morning before you get busy or after big meals to lower your post-meal glucose levels. Exercising in the morning can improve your body’s ability to burn glucose more efficiently throughout the day. Physical activity improves your mental and physical fitness by improving metabolism and sleep as well as releasing hormones that help regulate stress and anxiety. Try to keep up with the American Diabetes Association’s recommendation of a minimum of 150 minutes of exercise per week and add it to your list of New Year's resolutions for next year. Have a healthy holiday season, and let me know if there is anything I can do to support you in 2020!
New Closed Loop Pump Options
By Mark Harmel, MPH, CDE
There are two new options for patients interested in moving to a hybrid closed-loop insulin pump system. Both new options use the Dexcom G6 continuous glucose monitor (CGM) to measure glucose. One version will be FDA approved and uses the Tandem X2 pump with the Control-IQ control system, the other option is an open-source Loop controller running on an iPhone that communicates to an OmniPod.
As a reminder, a hybrid closed-loop system is where an insulin pump communicates with a CGM and feeds information into a control algorithm that works to control glucose levels. The system largely does this by increasing and decreasing the basal insulin as glucose levels rise and fall. The user still needs to input carbohydrates and make adjustments for exercise, as well as make occasional corrections for high and low glucose levels.
We have been eagerly awaiting the second FDA-approved system from Tandem that uses their X-2 pump with an upgrade to their new Control-IQ software that pairs with a Dexcom G6 CGM to feed into the control algorithm (the first FDA approved system was the Medtronic 670G.) The system will be available to current Tandem X-2 pump users with a software update and will be installed on new pumps. This will be an upgrade from the Basal-IQ system that controlled the basal dose to help prevent glucose levels less than 70 mg/dl. We have a patient in the clinical trial using the Control-IQ system who is doing well, and we look forward to it being available to a wider audience.
Some of our other patients have joined the open-source community that that created the hybrid closed-loop system by hacking into the older OmniPod Eros pods. This allows uses to turn an iPhone into a pod controller when paired with a Dexcom G6 plus a communication bridge device called a Riley-link. This provides the option of using a current insulin delivery system instead of the previous option of using an out of warranty MiniMed pump. The older pumps can also be connected using an Android-based system create by the OpenAPS community. Each of these systems require some comfort with some basic computer coding and tinkering with devices.
The new options provide a choice between the FDA approved tubed pump solution from Tandem and the open-source community using the tubeless pods with Loop. Which one is right for you comes down to the personal choice of tubing (Tandem) or no tubing (OmniPod Loop) and how comfortable you might be with adopting an open-source solution. You might prefer a warranty and phone-based tech support that comes from Tandem, or you might be attracted to bypassing the FDA approved device companies to push the boundaries with Loop and be comfortable getting your tech support from a Facebook group.
We cannot officially prescribe the open-source solutions (the pod can be prescribed), but once a patient has built their system and is ready to turn it on, our team has had a lot of experience in helping patients use these devices. In all cases safety is the key. Expect continuing developments in this fast-moving field, we will do our best to keep up to date with the research, and we are available to help our patients decide what is right for them.
We have collected a set of links to the Tandem pump as well as to the instructions to build a Loop system and their Facebook support groups. There are also links to the OpenAPS system and a Tidepool initiative to win FDA approval for the Loop pod solution.
Tandem Diabetes
The Loop OmniPod
The Loop OmniPod Riley
Loop Facebook Group
So Cal Loopers Facebook Group
History of the OpenAPS
OpenAPS system
The Tidepool Initiative to get an open-source system approved by the FDA
