Spring 2021 Newsnotes - Childrens Diabetes Foundation

CHILDREN’S DIABETES FOUNDATION — SPRING 2021

CAROUSEL OF HOPE 2020

COVID-19 & Vaccinations

WHAT YOU NEED TO KNOW AS A CAREGIVER OF OR A PERSON WITH T1D PAGE 18

PAGE 4

NEWSNOTES FEATURES

Children’s Diabetes Foundation Board Members EXECUTIVE BOARD: Mrs. Barbara Davis, Chairman Dana Davis, Executive Director

4 USE YOUR BLOOD GLUCOSE METER TO HELP YOU IMPROVE YOUR HEALTH

Mr. Cameron van Orman, Vice Chairman Richard S. Abrams, M.D., Treasurer Mrs. Arlene Hirschfeld, Secretary

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TELEMEDICINE AT THE BDC IN 2020 & BEYOND

Stephen Daniels, M.D., Ph.D. Chairman of Pediatrics The Children’s Hospital, Denver

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BDC STAFF HIGHLIGHT

Daniel Feiten, M.D.

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RESEARCH UPDATES AT THE BDC

Mrs. Nancy Davis Rickel Mr. Wayne Forman Mr. Robert Garelick Mrs. Deidre Hunter

PAT MACALISTER'S “DIABETES NEWS & EVENTS” PUBLISHES ITS LAST NEWSLETTER

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COVID-19 & VACCINATIONS - WHAT YOU NEED TO KNOW AS A CAREGIVER OF OR A PERSON WITH T1D

Mr. Shawn Hunter Mr. Steve Lucas Mrs. Marcela de la Mar John J. Reilly, Jr., M.D. Vice Chancellor for Health Affairs & Dean, School of Medicine, University of Colorado Denver Mr. Ken Rickel Mrs. Stacy Mendelson Robinson

23 MY FIRST COVID-19 VACCINATION DOSE 24 I WAS A 40-POUND KID WHEN DIAGNOSED

Marian Rewers, M.D., Ph.D. Ex-Officio Member Mr. Joseph Smolen Mrs. Tracy van Orman

WITH T1D: IF I CAN THRIVE, YOU CAN TOO!

Mark Atkinson, Ph.D. Professor of Pathology & Pediatrics, Director, University of Florida Diabetes Institute Ezio Bonifacio, Ph.D. Professor for Preclinical Approaches to Stem Cell Therapy, Center for Regenerative Therapies, Dresden, Germany Robert Eckel, MD Professor of Medicine, Physiology and Biophysics, University of Colorado School of Medicine

Mr. Shane Hendryson

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SCIENTIFIC ADVISORY BOARD: Richard S. Abrams, M.D. Director, Colorado Preventive Medicine, Rose Medical Center; Clinical Professor of Medicine UCD

Matthias Hebrok, Ph.D. Professor in Residence and Director, Diabetes Center, University of California, San Francisco Steven Kahn, MB, Ch.B. Professor of Medicine, Director of the Diabetes Research Center, University of Washington Rudolph Leibel, MD Professor of Pediatrics and Medicine, Co-Director, Naomi Berrie Diabetes Center, Columbia University Alvin Powers, MD Professor of Medicine, Molecular Physiology/Biophysics, Division Director, Vanderbilt University William Tamborlane, MD Professor of Pediatrics, Yale University School of Medicine

NewsNotes is published quarterly by the Children’s Diabetes Foundation. If you would like to submit an article or a letter to NewsNotes, send information to Raleigh@ChildrensDiabetesFoundation.org.

Raleigh Cooper, Editor Zachary Reece, Graphic Designer

Facebook.com/ ChildrensDiabetesFoundation

@CDFdiabetes

@CDFdiabetes

WWW.CHILDRENSDIABETESFOUNDATION.ORG CDFcares@ChildrensDiabetesFoundation.org • 303-863-1200 NEW ADDRESS AS OF DEC. 30 - 3025 South Parker Road, Suite 110, Aurora, CO 80014

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Spring Brass Ring Virtual Fundraiser & Silent Auction

April 8, 2021 at 6PM MDT Honorary Chair Event Co-Chairs Mrs. Barbara Davis

Dave Barnes & Scottie Taylor Iverson

Fashion Preview by Featured Designer

Get Your Virtual Ticket Online!

Register at

www.ChildrensDiabetesFoundation.org

Benefiting The Guild of the Children’s Diabetes Foundation & the Barbara Davis Center for Diabetes

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DIABETES NEWS

USE YOUR BLOOD GLUCOSE METER

TO HELP YOU IMPROVE YOUR HEALTH

BY ASHLEE ERNST AND BETSY OTTEN

This article was published by diaTribe and has been licensed for reproduction by Children’s Diabetes Foundation for NewsNotes.

While many people with diabetes use a blood glucose

meter to check our blood sugar levels, you may not be using your meter often enough to help you feel better.

Ashlee Ernst and Betsy Otten, two diabetes nurse educators, share tips on how to get the most out of your glucose checks, how to read data reports, and how to find a meter that’s right for you.

As diabetes nurse educators at the Barbara Davis Center for Diabetes at the University of Colorado – one of the largest type 1 diabetes clinics in the world – we see A LOT of blood glucose data. And as people who personally live with diabetes, we also understand how tedious it is to perform blood glucose checks. In this article we talk about ways to maximize your blood glucose testing, both in recommended frequency and in how to understand your data.

There are two big reasons why blood glucose checks are important. The first is the most obvious: you do it to make sure your glucose levels are safe throughout the day and over time. The second reason is the focus of this article: analyzing patterns in your glucose levels can help you and your diabetes care team make insulin dose adjustments and figure out ways to increase time spent in a healthy glucose range (70-180 mg/dl), often referred to as Time in Range, or TIR. While you may only work with your care team at visits every three to six months, you can learn to use blood glucose data on your own to make daily habit changes and insulin dosing changes.

The key is learning how to maximize the data that you get from your blood glucose meter.

Betsy Otten and Ashlee Ernst

ABOUT ASHLEE AND BETSY Ashlee Ernst is a registered nurse and diabetes educator at the Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO. Ashlee was diagnosed with type 1 diabetes at the age of nine in Lincoln, Nebraska.

From a young age she saw the impact that the diabetes community had on her life and knew that she wanted to integrate her future career into this community. Now 16 years later, she is working in the Pediatric Clinic at the Barbara Davis Center, supporting patients and families throughout their journeys with diabetes. Ashlee enjoys giving back to the community through planning and volunteering at camps for children with type 1 diabetes.

Betsy Otten is a registered nurse and certified diabetes educator at the Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO. Betsy has lived with type 1 diabetes since 1997. After many years attending and volunteering at diabetes camp with many awesome diabetes educators, Betsy decided to become a nurse and pursue a career in diabetes education. Betsy works in the Barbara Davis Center Pediatric Clinic educating people who are newly diagnosed and their care-partners, as well as people living with diabetes during routine clinic visits. She enjoys leading projects and opportunities to improve clinical care and life for children and adolescents living with type 1 diabetes.

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First, it is important to have at least one week of data (and more is better!) for you and your care team to review at appointments. The best way to evaluate diabetes management is to review blood sugar and activity data and then to identify patterns. For blood glucose data, people are often told to check four times a day – but is that enough?

If we only check blood glucose levels before meals, we miss the opportunity to look for variability throughout the day. The more data we have to work with, the better. As diabetes educators, we recommend checking six to ten times a day, including before meals, snacks, physical activity, and bedtime, along with the occasional postprandial checks (in the three hours after a meal) and overnight checks. If for whatever reason it is not realistic to check your blood sugar this frequently, it can still be very helpful to do this for one week at a time every month or two. These “data collection” weeks can provide invaluable data for insulin dosing and for assessing habits, and they can provide insight on your ongoing diabetes management.

ADDING CONTEXT TO YOUR BLOOD GLUCOSE CHECKS In addition to blood glucose checks, meters also have the ability to log other key variables that can affect your blood glucose levels. This includes information such as carbohydrate intake, insulin doses, exercise, and even other variables like menstrual cycles. This information paired with your blood glucose levels provides a fuller picture of daily life with diabetes. Consistency is key when logging data. This is why we recommend trying to include as much information as you can for a week at a time. The logging process can feel tedious, but the payoff is worth the effort.

DIABETES NEWS

THE MORE DATA THE BETTER: COLLECTING YOUR DATA

When you have at least six blood glucose checks available each day, you and your diabetes team can analyze key glucose metrics that are typically only available to people with continuous glucose monitors (CGM). These metrics include Time in Range (TIR, 70-180 mg/dl), and time spent below range (less than 70 mg/dl) or above range (greater than 180 mg/dl). With TIR you do not have to wait for a quarterly or bi-annual A1C to understand how your diabetes management is going – you can calculate these direct measures of glucose management for any time period you wish, though we recommend reviewing at least two weeks of data at a time. TIR empowers you to set clear goals for improvement: a goal of increasing time spent in range from one week to the next is more manageable than a goal of dropping your A1C by some percent in the next three to six months. By setting smaller goals, you create a path of stepping stones that will help achieve your big goals.

UNDERSTANDING YOUR DATA REPORTS How should you look at data on your glucose reports? We recommend starting with one piece at a time. Download your report and then begin by highlighting areas where you see patterns of hyperglycemia (high glucose, greater than 180 mg/dl) and hypoglycemia (low glucose, less than 70 mg/dl) – this will allow you and your care team to identify where adjustments need to be made.

When we review a person’s glucose information, we begin with hypoglycemia and assess the percentage of time spent below 70 mg/dl. Our goal is for people to spend less than 4% of their day (or less than one hour) in this low range.

The next area we focus on is TIR, with a goal of spending over 70% of the day (almost 17 hours) with glucose levels between 70-180 mg/dl. This will directly correlate with an A1C of 7% or less. Many data reports also give you an estimated A1C, based on the average blood glucose during a period of time.

Often you will see standard deviation next to the average blood glucose. The standard deviation can be best explained as how far the blood glucose “swings” either high or low. If your standard deviation is large, then you may experience lots of variability in your blood glucose. By making your glucose levels more consistent throughout the day, you’ll reduce this number and, typically, you’ll feel better. Some fluctuation in blood glucose is expected, though; to calculate your target standard deviation, take your average blood glucose and multiply it by 0.33. Once you’ve calculated your target, compare this number to the standard deviation on your report to see how close you are.

All said, don’t get overwhelmed. Many times, focusing on one area of your diabetes management will have a positive effect on other areas, and small adjustments can have big impacts.

Continued on page 6

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DIABETES NEWS

FINDING A METER + LOGGING SYSTEM THAT WORK FOR YOU The moral of the story is that it’s important to collect – and track – as much blood glucose data as possible. While there is no “perfect” glucose meter for everyone, there are meters that make data logging easier, and others that have easy-to-read data reports. The table on page 6 shows our personal assessments and key details of blood glucose meters that have a Bluetooth-connected app and data reports, to guide you in choosing how to access and review your data.

Bluetooth-connected meters and smartphone apps are not for everyone. The list below includes other options for logging, in order of what we consider the easiest to the most labor-intensive way to access and interpret data (not considering initial set up).

• Meter + data upload to a computer o Most meters + Tidepool software o FreeStyle meters + FreeStyle Auto-Assist software or LibreView

• Meter + manual entry into an app o mySugr o Sugarmate o OneDrop

• Meter + manual entry into an Excel Spreadsheet, with functions to calculate averages, standard deviation, etc.

You’ll have to develop this spreadsheet on your own.

However you choose to review your data, we hope that these tips help you understand what data is important, how to access that data, and how to translate the data into meaningful changes in your daily diabetes management.

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Meter + App

Ease of Use

Accu-Chek Guide, Guide Me + AccuChek Connect App (US)

Medium

Accu-Chek Guide, Guide Me + mySugr

High

Comments App quickly displays 7-day TIR summary

Report Readability Low

Able to email or text reports from the app

Clearly displays estimated A1C & summary of current day including: average blood glucose, standard deviation, number of hyper/hypo events, carbs, bolus events, and activity

High

Comments Report generated directly from app lacks visual tools such as graphs and color coding as well as logbook view of data (Logbook Report from Accu-Chek Connect Online included clear summary and logbook, but was not easy to access) Visually appealing and concise with the use of color coding and a clear layout of information Includes summaries of overall, weekly, and daily data

Visuals are clear, pleasant, and intuitive

Contour Next One + Contour Diabetes App

Medium

Highly customizable tags to track events Can easily access TIR on the app home screen

Medium

Shows 14, 30, and 90-day averages

Daily summary included in logbook view

Some app visuals not optimized for specific phones/operating systems

One Drop + One Drop: Transform Your Life App

High

OneTouch Verio Flex, Reflect, Sync + OneTouch Reveal App

High

True Metrix Air + True Manager Air App

Medium

Allows you to easily view your average glucose, total carbs, exercise, and insulin doses for the day Provides you the opportunity to log other medications besides insulin Easy to enter daily events

Readings less than 2 hours apart overlap, making days with multiple checks more difficult to interpret

High

Daily log maximizes analysis of patterns via color coding and including carbs, insulin, blood glucose, and exercise together Daily and weekly summary data included in logbook report

High

Provides easy access to total daily dose of insulin, average blood glucose, and TIR

Low

Provides a daily list layout that may be appealing to users

Can send reports directly from the app via email App provides summary data and analysis of patterns Clear display of average blood glucose and TIR

Weekly summary with key information included at top of the report

Very simple graphics

No logbook view of data

Some weird app visuals probably not optimized for specific phones/operating systems

Summary data useful Graphs are not easy to interpret or utilize in meaningful ways when making dose adjustments

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2021-2022 CHARLOTTE TUCKER

SCHOLARSHIP QUALIFICATONS • Patient at the Barbara Davis Center seen in the last 12 months • Have type 1 diabetes • Have a minimum of a 2.0 GPA • High school senior who is planning to attend a 2 or 4 year college or trade school OR college undergraduate taking a minimum of 12 credits per semester

“As a type 1 diabetic, I am aware of the technological advances in the treatment for type 1 diabetes, and I am hoping that I can use my education to further help the way diabetes is cared for and make life for all those with type 1 diabetes easier in the future.” -Charlotte Tucker Scholarship Recipient

Applications must be received no later than

April 26, 2021

apply at www.ChildrensDiabetesFoundation.org/charlotte-tucker-scholarship/ 8

CDF Support Groups You are not alone with type 1 diabetes!

• • •

• • •

All support groups will be held virtually until further notice Denver Metro Area – all ages & • Southeastern Colorado (Pueblo, relationships to diabetes Cañon City, Lamar, etc.): New! – All Colorado Springs, CO – all ages & ages & relationships to diabetes • Rifle, CO (Grand Junction, Glenwood relationships to diabetes Springs, Delta, Grand Mesa) – all ages Northeastern Colorado (Sterling, Iliff, & relationships to diabetes Merino, Hatxun, Crook, Fleming) – all • Cheyenne, WY – all ages & ages and relationships to diabetes – relationships to diabetes meets every 2 months “The Keepers” in Denver – parents & • Douglas County, CO – all ages & caregivers of teens with type 1 relationships to diabetes Fort Collins, CO – for kids 18 & under • Digital – Virtual meetings for anyone with type 1 diabetes & their caregivers regardless of location, age, & Central Rockies (Lake County, connection to diabetes • Teen Connection Community: New! Leadville, Summit County, Eagle (Virtual)- For those with type 1 County, and Chaffee County) – all diabetes between the ages of 13 & 18 ages & relationships to diabetes

Sign up to receive notifications about the specific time, date, & location of each meeting by visiting

www.ChildrensDiabetesFoundation.org/support-groups/

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BARBARA DAVIS CENTER

TELEMEDICINE AT THE BDC IN 2020 AND BEYOND

BY DR. PAUL WADWA

THE HISTORY OF TELEMEDICINE While most people were not using videoconferencing for

healthcare before 2020, telemedicine has been used at the Barbara Davis Center (BDC) and other clinical settings long before the COVID-19 pandemic. Telemedicine falls under the umbrella of telehealth, which is the delivery of health-related services and information via electronic and telecommunications technologies to improve a patient’s health status. Categories of telemedicine include store and forward, remote monitoring, and real-time interactive services. Store and forward, the process of capturing an image or data, storing it to then be forwarded for review by medical specialists has long been used in radiology, cardiology, pathology, and dermatology. In diabetes, remote monitoring can be done with continuous glucose monitoring (CGM) or artificial pancreas (AP) systems. Though the COVID-19 pandemic has led to a rapid expansion in the use of real-time interactive services like direct patient care through videoconferencing, healthcare providers were already implementing the use of telemedicine prior to the pandemic.

By 2015, 90% of health care providers reported that their organization had already begun developing or implementing telemedicine programs. The Veterans Health Administration, another early adopter, saw a 20.4% decrease in days of hospital stays for diabetes patients.2 Though telehealth showed promising outcomes, barriers to implementation hampered widespread utilization. These included limited insurance coverage and reimbursement, licensure to use telemedicine across state borders, privacy and security concerns (HIPAA compliant software), and the challenge of convincing stakeholders of the value of telemedicine visits.

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TELEMEDICINE FOR DIABETES CARE Telemedicine works well in diabetes care in part because of the way diabetes care differs from other fields of medicine.

A provider gives recommendations for a management plan and patients and families implement the plan in their daily life. Once a plan is implemented, insulin doses are adjusted based on information from the family as well as data from glucose meters, insulin pumps, and CGMs. The BDC provides clinical care for patients from a sixstate region and serves over 80% of pediatric patients with type 1 diabetes in Colorado and Wyoming. The pediatric clinic conducts 11,000 to 12,000 outpatient visits in any given year. For those who are not in or near the Denver metro area, however, in-person visits can be a challenge.

Barriers to care for patients in rural Colorado and Wyoming include travel time and expense, weather barriers, and now a global pandemic.

Telemedicine can bridge the gap in caring for these patients by improving their access to care, supporting local providers in rural communities, reducing travel expenses for families, and reducing travel burnout.

In May 2012 the BDC began its telemedicine program for youth with type 1 diabetes in rural Colorado and Wyoming. Patients and their families visit local diabetes centers or pediatric offices to meet with their BDC providers via videoconferencing. Upon arrival to their local center, patients have data from their meter, pump, or CGM uploaded. Their provider at the BDC is then sent reports via fax or secure email. The local medical staff measures height, weight, blood pressure, HbA1C, and blood glucose. From there the patient and family are taken into a room with video conferencing equipment where the BDC provider conducts a routine visit, just as they would in a BDC patient room. The BDC provider adjusts insulin doses and identifies topics of review with the local diabetes educator, such as sick-day management, hypoglycemia, and injection techniques. The family then receives a packet of their after-visit summary (AVS) with recommendations from the visit. If needed, prescriptions are e-prescribed

to a local pharmacy and routine labs are drawn at a local lab. Since the inception of the program there has been a dramatic increase in patients seen through telemedicine, with responses from families and partner facilities being overwhelmingly positive. Current sites are located in Durango, Grand Junction, Rifle, and Wray, Colorado, as well as in Casper and Cheyenne, Wyoming, and are served by five BDC pediatric endocrinologists.

Shortly after the BDC pediatric telemedicine program was implemented, a study of patients living in Wyoming was conducted to compare telemedicine with in-person visits.

Participants also completed a questionnaire regarding their experience with telemedicine and their child’s diabetes control over the previous year. The study suggested that glycemic control was equivalent to in-person care received prior to telemedicine visits. Other findings included increased visits per year and decreased time taken off from work and school when using telemedicine. Satisfaction with the experience was also ranked high amongst participants.3

COVID-19 AND TELEMEDICINE In 2020 the significance of telemedicine changed dramatically. On March 11, 2020, COVID-19 was declared a global pandemic, with the US declaring a national emergency on March 13.4 On March 16, 2020, the Anschutz Medical Campus closed for non-essential activity, with pediatric clinic visits decreasing by 46% and adult clinic visits decreasing by 83% that week. Many diabetes clinics across the country closed for non-emergent visits. Providers at the Barbara Davis Center quicky trained on workflow for telemedicine to set up “at-home” clinics, where providers could see patients by videoconference with families in their homes while in-person visits were

restricted. Such “at-home” telemedicine clinics were initiated on March 23, 2020. Luckily the BDC telemedicine team had years of experience that was easily applied to these new “athome” clinics to aid with an easier transition for providers and patients alike.

Prior to an “at-home” visit, patients are scheduled, have their insurance verified, demographic information is collected, they give consent to receiving care via telemedicine, and have their 3-month follow-up scheduled. Patients or their families then upload data via diabetes management applications such as Clarity, t:connect, Carelink, glooko, and Tidepool with the assistance of the BDC telemedicine team prior to the visit. Their provider is then sent the data and the patient receives a Zoom link for their appointment.

The visit itself happens over an encrypted and HIPAA compliant Zoom connection while the provider documents it in the same Electronic Medical Record (EMR) that is used in a traditional, in-person visit. After the visit, the patient or family is provided with an after-visit summary (AVS).

Prescriptions are then sent electronically to the patient’s pharmacy with lab orders sent to the patient or listed in a note for later. Lastly, the 3-month appointment (or sooner when clinically indicated) is confirmed with the patient and their provider.

While the BDC was permitted to reopen for in-person clinic at a limited capacity beginning May 11, “at-home” telemedicine still accounted for about one third of followup visits from May-December of 2020. Last year, BDC providers conducted over 5,600 telehealth visits, with 4,000 happening after March 23. To put this into perspective, 2020 saw 17 times more telehealth visits than 2019, and 4 times more than all visits between 2012 and 2019.

BARBARA DAVIS CENTER

BDC TELEMEDICINE SITES

Though telemedicine has proven an effective and useful tool for providers and patients alike, it is not without its challenges. These include the identification of good partners, contract concerns, billing and reimbursement, the connectivity and bandwidth of equipment, HIPAA and security, interstate licensure, credentialling and hospital privileges, as well as meter, pump, and CGM download issues.

Continued on page 12

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BARBARA DAVIS CENTER

THE FUTURE OF TELEMEDICINE The impact of the COVID-19 crisis on the delivery of diabetes care is still unclear, but telemedicine will continue be a part of patient care for the foreseeable future. Patient care will likely include a mix of inperson and videoconference visits, with the ratio of such visits being individualized for each patient.

Telemedicine could allow more frequent interactions for some patients in need of support and may help to overcome some hurdles for delivering diabetes care. It is important to remember that a patient and their family’s access to telemedicine is dependent on their access to technology, including internet access, hardware such as a computer, tablet, or smartphone, and software for uploading devices and videoconferencing.

The long-term impact of changes made due to the COVID-19 pandemic on state and federal telemedicine laws are also unclear, though permanent changes are under consideration. Reimbursement for models of care integrating in-person visits and use of videoconferencing, however, will be an important issue for the future of telemedicine. If this issue can be resolved, telemedicine has the potential for making major improvements for the delivery of diabetes care and removing barriers for patients and their families.

1 Specialty Healthcare Management Group.

Telemedicine is top priority. 13 November 2014.

Available at http://specialtyhmg.com/telemedicine-istop-priority%EF%BB%BF/. Accessed March 11, 2015.

2 Broderick A, Lindeman D. Scaling telehealth programs: lessons from early adopters. Commonwealth Fund. 2013; 1654-1: 1-10.

Broderick A, Steinmetz V. Centura health at home: home telehealth as the standard of care. Commonwealth Fund. 2013; 1655-2: 1-12.

3 Wood CL, Clements SA, McFann K, Slover R, Thomas JF, Wadwa RP. Use of Telemedicine to Improve Adherence to American Diabetes Association Standards in Pediatric Type 1 Diabetes. Diabetes Technol Ther.

2016 Jan;18(1):7-14. doi: 10.1089/dia.2015.0123. Epub 2015 Aug 21. PMID: 26295939.

4 www.ncbi.nlm.nih.gov/pmc/articles/PMC7095418 https://en.wikipedia.org/wiki/Severe_acute_ respiratory_syndrome_coronavirus_2

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BDC STAFF SPOTLIGHT

DR. LORI SUSSEL & GAIL SPIEGEL The Barbara Davis Center is proud to announce Dr. Lori Sussel as the new Associate Vice Chancellor for Basic Science Research (AVCBSR).

Dr. Lori Sussel, BDC Director of Basic and Translational Research, has recently taken on the additional position of Associate Vice Chancellor for Basic Science Research (AVCBSR) at the University of Colorado. This newly created position is dedicated to the needs and perspectives of basic science researchers, including facilitating the coordination of collaborative research across the University of Colorado Anschutz and Denver campuses. Dr. Sussel will work closely with Office of the Vice Chancellor for Research (OVCR) to fully align basic research with the overall missions of the two campuses. Dr. Sussel will also represent the OVCR on inter-campus committees in which expertise in the basic sciences is needed. This is a newly created position that is critical to promoting and strengthening the already outstanding basic research activities at the CU Denver and CU Anschutz campuses. The ability to help facilitate outstanding research efforts at CU, as well as fostering team science, cross campus collaborations, and graduate and post-graduate training will contribute to the ongoing T1D research efforts at the BDC. Advocating for diversity and inclusion is also integral to each of these efforts.

GAIL SPIEGEL CELEBRATES 25 YEARS WITH THE BDC! Senior Instructor of Pediatrics Gail Spiegel, MS, RD, CDE, is a Registered Dietitian and Certified Diabetes Educator with over 25 years of experience educating and counseling pediatric patients and their families at the Barbara Davis Center for Diabetes. Gail also serves as the manager of the pediatric nutrition program and has conducted research on carbohydrate counting accuracy in adolescents with type 1 diabetes. She enjoys sharing her expertise in T1D with other professionals and is an experienced public speaker and author for professional and lay audiences. She received her BA in Psychology from SUNY Binghamton and a MS in Nutrition from Pennsylvania State University. The BDC and CDF thank Gail for her decades of devotion education and those with type 1 diabetes!

The Barbara Davis Center & Children’s Diabetes Foundation Present

focusing on C O N N E C T I V I T Y for 2021

Virtual Conference Saturday, May 22, 2021 8:30 a.m. - 2:45 p.m. proudly supported by

Keynote Address: Connecting Scientific Advancements to Patient Care

with Kellee Miller, PhD, MPH, Senior Epidemiologist at the Jaeb Center for Health Research

Session Topics Include

• COVID-19 & Diabetes • Supporters & Caregivers • Remote Monitoring • Online Decision Support • Pediatric & Adult Mental & Emotional Health • Community Connections for Children & Adolescents • Diabetes’ Connection to Other Health Disorders • Diabetes Advice & Resources

$5 per person | $20 per family of 4+ Scan the QR code to register or visit

www.EPICconferences.org 13

BARBARA DAVIS CENTER

RESEARCH UPDATES Although 2020 was a challenging time for all of us, the scientists at the BDC research

Dr. Richard Benninger

division continued to work diligently and creatively to keep the T1D research going.

The BDC continues to be leader in the T1D research arena, continually receiving international recognition for their groundbreaking scientific discoveries toward predicting and preventing T1D.

In 2020, BDC basic and translational investigators were authors on ~40 peer reviewed publications. Notably, Dr. Richard Benninger and his group published a preclinical study in Nature Communications showing sub-micron ultrasound contrast agents can non-invasively detect insulitis prior to T1D onset. In addition, one of the newest members of the BDC faculty – Dr. Jordan Jacobelli – published his exciting discovery of a protein that promotes immune cell entry into pancreatic islet; the absence of this protein impairs the ability of immune cells to induce T1D. Dr. Maki Nakayama published a methods paper describing a new assay that measures immune cells (T lymphocytes). She has provided reagents for this assay to the global research community and in only 6 months these reagents have been distributed to over 15 different labs around the country, facilitating T1D research. Finally, due to their acknowledged expertise in the diabetes field, the New England Journal of Medicine invited Drs. Aaron Michels and Peter Gottlieb to write an editorial entitled “Advances in Diabetes Treatment - Once-Weekly Insulin” and invited Dr. Lori Sussel to author a Clinical Implications of Basic Research manuscript.

There were several additional research advances towards detecting and treating T1D, many which are ongoing. Dr. Liping Yu’s group has successfully developed and validated a highly sensitive islet autoantibody multiplex assay that allows them to combine all four major islet autoantibody assays in a single well. This allows them to test for all the islet antibodies in a single small patient sample. They are also continuing to identify and study new islet autoantibodies on the beta cell surface to open new avenues of investigation into autoantibody-mediated T1D etiology and progression. Dr. Benninger’s lab continues to explore novel ultrasound technologies to non-invasively monitor T1D disease progression and potentially deliver therapeutics directly to the pancreas. Dr. Rachel Friedman’s lab has begun to identify how the immune populations communicate during the progression of T1D; interfering with such communication has the potential to block or attenuate the autoimmune response.

Finally, Dr. Sussel’s lab has identified that misregulation of mRNA processing in beta cells in response to an autoimmune attack leads to beta cell dysfunction and death.

The ability to correct these processing errors would promote beta cell survival, even in the context of autoimmunity. Dr. Holger Russ also continues to make progress in his efforts to model human T1D in a dish.

Dr. Yu has also used his expertise to tackle COVID-19. He has developed a highly sensitive COVID-19 antibody assay that is >99% effective for detecting whether an individual has previously been exposed to the virus.

It has also been a strong funding year for the faculty and trainees, with many of them successfully competing for NIH and JDRF grants and Helmsley funding. The University of Colorado was also awarded the prestigious NIH Diabetes Research Center grant to provide support ($880K annually for 5 yrs) for diabetes research at the BDC and across the campus. Dr. Sussel is lead investigator on the award.

Dr. Jordan Jacobelli

Dr. Maki Nakayama

Dr. Aaron Michels

Dr. Peter Gottlieb

Dr. Lori Sussel

Dr. Liping Yu

Dr. Rachel Friedman

Of particular note, the Clinical Laboratory at the Barbara Davis Center that assays for the presence autoantibodies from patient samples in the US and around the world attained College of American Pathology (CAP) Accreditation. Accredited laboratories meet the CAP's rigorous standards and requirements for highest quality testing.

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Dr. Holger Russ

DIABETES NEWS

PAT MACALISTER’S “DIABETES NEWS & EVENTS”

PUBLISHES ITS LAST NEWSLETTER “Diabetes News & Events”, a decade’s long labor of love created by Pat MacAlister, has published its last newsletter.

For those unfamiliar with the publication, “Diabetes News & Events” has provided the community with medical news, dates for upcoming events, advice on maintaining your health with type 1 diabetes, yummy recipes, and inspirational, first-hand stories written by those living with T1D. This newsletter with personality and heart will be sorely missed.

Pat MacAlister, its creator, is a humble woman who has rightly been called a hero, legend, and inspiration. She was born and raised in Cut Bank, Montana, a small, rural community nestled between the edge of the plains along the Canadian border and Glacier National Park. As a young child Pat suddenly and mysteriously fell ill. Her mother took her to multiple doctors until one diagnosed her with type 1 diabetes. In her early years, no one trained Pat how to manage her T1D. Her father gave her a daily shot and her mother weighed and measured her food.

Everyone she knew was strictly forbidden to give her anything sweet. That was the extent of her knowledge in maintaining her health in her youth. It wasn’t until she went into a coma at age 15 that she was brought to see an endocrinologist that taught her how to take care of herself.

While the experience seems harrowing to those that hear it, Pat counts herself fortunate that, as she sees it, she’s never been challenged by living with type 1 diabetes.

“Diabetes News & Events” began when Pat retired from Metro State University, where one of the courses of study she taught was newsletters. After joining a diabetics optimism club, the president, knowing her background, asked her if she could start a newsletter. And while she moved on from the club, the newsletter continued, bringing information, community, and hope to all who read it. “Diabetes News & Events” helped thousands of readers around the world in its more than a decade in publication.

When asked what advice she’d give to someone recently diagnosed, Pat says to “realize what you have, live with it, and have a good life.” Pat had two dreams: to become a teacher and to one day have a daughter named Beth. She was told she could never have those things - so she did them both. Pat wants everyone out there to know that type 1 diabetes should not stop you from living your best life.

She’s been living with T1D for 73 years, and if she can have a good life then so can you! And while “Diabetes News & Events” may have published its last newsletter, Pat will continue to be an inspiration to us for years to come.

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THE NEW 14TH EDITION OF UNDERSTANDING DIABETES, 50TH ANNIVERSARY EDITION! The latest edition of Understanding Diabetes is here! Our new 14th edition of everyone’s favorite handbook for people living with diabetes features the most up-to-date information on diabetes care and technology.

THE ENTIRE PINK PANTHER BOOK HAS BEEN REVISED! Some of the changes include: • Words such as “control” (virtually impossible to completely achieve) and “prevent” (no guarantee of prevention) are no longer used.

• Chapter 6, on hypoglycemia, includes the use of intranasal glucagon (Baqsimi) in treating moderate or severe low blood sugar.

• Chapter 8 introduces new insulins (including new generic insulins) • Chapter 13, on exercise, emphasizes methods and measures to reduce the likelihood of hypoglycemia brought on by exercise.

• The new monitoring index, “Time in Range,” and other indices are reviewed in Chapters 14 and 29.

• The school chapter (Chapter 25) is entirely revised to make it usable as a “Standard of Care” for the school. New tables for insulin adjustments for high and low blood sugars and for exercise have been added.

• The three continuous glucose monitors (CGMs) currently available in the U.S. are reviewed in Chapter 29.

• Chapter 30, on the artificial pancreas, discusses systems currently available, as well as systems now in development.

Orders can be placed online at www.ChildrensDiabetesFoundation.org/books or over the phone at 303-628-5119 For any questions, please contact Ben@ChildrensDiabetesFoundation.org 16

Save The Date!

saturday, August 7, 2021 www.childrensdiabetesfoundation.org/2021rftr

Thanks for helping us raise nearly $90,000 on Colorado Gives Day!

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COVID-19 & VACCINATIONS

WHAT YOU NEED TO KNOW AS A CAREGIVER OF OR A PERSON WITH T1D

BY DR. KIMBER SIMMONS

Coronavirus disease 2019, or COVID-19, is the contagious disease first identified in Wuhan, China in 2019 that is caused by the virus severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2.1 SARS-CoV, or SARS-CoV-1, was a similar acute respiratory syndrome first reported in November of 2002 in the Guangdong province of Southern China that did not reach pandemic scale.2 The Centers for Disease Control and Prevention (CDC) confirmed the first case in the United States (US) on January 21, 2020.3 Because we did not yet fully understand how and to what extent the disease was spreading, people traveled, gathered, and went on in a way that quickly spread the virus around the world. We all remember how one day the virus seemed like a problem only in distant hotspots, and the next day our lives changed dramatically. After the World Health Organization (WHO) declared COVID-19 a global pandemic on March 11, 2020, and our president declared a national emergency on March 13, 2020, cities and states began imposing stay at home orders. As we sheltered in place, the new normal of social distancing, restrictions, masks, and other risk mitigations began.

COVID-19 most commonly spreads between people who are in close contact with one another through respiratory droplets or small particles, such as those produced when an infected person coughs, sneezes, sings, talks, or breathes.

These particles can be inhaled into the nose or mouth, then travel into the airways and lungs, causing infection. They can also enter through the eyes. The further away a person is from these droplets, the less likely they are to be infected. This is why social distancing guidelines suggest maintaining at least 6 feet of distance. While this is thought to be the main way the virus spreads, droplets can also land on surfaces or objects and be transferred by touch. A person may contract COVID-19 by touching a surface or object that has the virus on it and then touch their own mouth, nose, or eyes. Spread from touching surfaces is not thought to be the main way the virus spreads.

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When viewed under a microscope, each coronavirus virion is surrounded by a halo or “corona” of what are called “spike proteins.”4 Infection occurs when these spike proteins attach to our cells that have ACE2 receptors. These receptors are most common in the nose, tongue, oral mucosa, heart, lungs and colon, but are also present on other tissues including beta cells in the pancreas. Common symptoms include cough, fatigue, loss of taste or smell, and fever, while less common symptoms include sore throat, headache, aches and pains, diarrhea, skin rash, discoloration of fingers or toes, and red or irritated eyes.

While most illness is mild to moderate, serious COVID-19 symptoms that require immediate medical attention include shortness of breath or difficulty of breathing, loss of speech or mobility, confusion, and chest pain. There is a litany of confirmed and possible risk factors that increase risk for severe COVID-19 illness. The CDC currently states that there is limited evidence that T1D increases a person’s risk for severe COVID-19 illness. The biggest risk factor for severe illness is increased age. Interestingly, it is believed that 30-50% of people infected with SARS-CoV2 have no symptoms but can likely still infect others.

In the US, most states imposed stay at home orders between mid to late March 2020 until as late as May 2020, preventing a spike in new cases nationwide. While easing of restrictions in late spring and early summer 2020 resulted in a slight rise in new cases nationwide (with severe spikes in some sunbelt states), it was the onset of the fall and winter that the US saw its biggest increase in new cases. Positive cases of COVID-19 in patients at the Barbara Davis Center mirrored fall and winter spikes seen in Colorado.

Prior to the pandemic, we knew that people with T1D, especially those with poor glycemic control, were already at risk for certain infections. Adults with T1D are more likely than those without to have infections of the urinary tract, skin, lower respiratory tract, and serious bacterial infections. While adults see a higher risk, children and adolescents do not appear to have an increased risk of infections, including COVID-19. Although having type 1 diabetes doesn’t seem to be a risk factor for having a severe COVID-19 illness, we do know that people with T1D who have a hemoglobin A1c above target range or are a member of a minority race or ethnicity are at higher risk for diabetic ketoacidosis during COVID-19 illness.5

WHAT IS KNOWN ABOUT COVID-19 OUTCOMES IN PEOPLE WITH TYPE 1 DIABETES? While there have been multiple studies identifying type 2 diabetes as a significant risk factor for hospitalization and death, the same risk has not been seen overall for patients with COVID-19 and T1D. The healthcare system in England reported in May 2020 that patients with T1D were 3.5 times more at risk for in-hospital COVID-19 related death than those without diabetes, while those were type 2 diabetes were 2 times more at risk. This sounds scary, but it is important to know that severe illness and death rates were greatly impacted by people having other risk factors. Of the people with T1D who died from COVID-19 illness, 62.3% had a history of cardiovascular disease or renal impairment. When taking this into account, the risk for COVID-19 related death in people with T1D is not very different than the risk of COVID-19 death in individuals without T1D. Importantly, the majority of people in this analysis were over 50 years of age, and the risk of COVID-19 related death is related to age as well non-white ethnicity, socioeconomic deprivation, and previous stroke and heart failure. Other risk factors that likely played a role such as obesity and hypertension could not be examined within this data set.6 In December 2020, another report was published in Diabetes Care stating that COVID-19 severity was tripled in the diabetes community. Again, this report did not clarify which additional risk factors were present in people with diabetes who had severe COVID-19 illness.7 Although risk for hospitalization is not likely different in people with T1D and no other risk factors when compared to healthy people in the community, maintaining glycemic control is an important tool for improving your chances of a better outcome in the event that you become hospitalized with COVID-19. One study saw better outcomes in those whose blood glucose levels were between 70 and 180 mg/dl more than 60% of the time, protecting them from diabetic ketoacidosis (DKA) and potentially negative outcomes with COVID-19.8 In the data from England, patients with a hemoglobin A1C >10% were 2.6 times more likely to have a COVID-19 related death compared to people with hemoglobin A1C at goal.

Those with T1D who are hospitalized with COVID-19 do require special care. Hyperglycemia, hypoglycemia, and high glycemic variability are independently associated with increased hospital morbidity and mortality. Some treatments can actually cause complications for people with T1D. Steroids are included in some COVID-19 management protocols and can increase blood glucose, which may necessitate the use of insulin drips. This can be complicated during isolation protocols that attempt to limit patient interaction and spread of the disease. Remdesivir, a nucleotide analog RNA polymerase inhibitor which has been shown to shorten the time to recovery in adults who were hospitalized with Covid-19 and had evidence of lower respiratory tract infection, can cause liver injury and the inability to store and release glucose normally, complicating diabetes management. Because the disease and treatment options may impact blood glucose levels, patients with T1D need to be closely monitored and may require more frequent adjustments in insulin dosing and/or insulin drips.

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Overall, the rate of new diagnoses of T1D in the US remains similar to prior years. Prevalence of DKA upon new diagnoses of T1D, however, significantly increased during and after the stay at home orders. This is most likely due to fears of accessing healthcare during the beginning of the pandemic. It appears that people with T1D in the US in adequately resourced areas have been better able to maintain glycemic control since the pandemic began due to a more regularly scheduled lifestyle, reproducible meals, and more time for self-care.

HOW DO YOU AVOID CONTRACTING COVID-19?

Here are some simple practices: • Maintain a distance of 6 feet apart from individuals who are not in your household, more when indoors, and the further the better!

The CDC recently stated that individuals who are fully vaccinated (>2 weeks from last dose of vaccine) may visit with other fully vaccinated people indoors without wearing masks or staying 6 feet apart. Fully vaccinated people may also visit with unvaccinated people from one other household indoors without wearing masks or staying 6 feet apart if everyone in the other household is at low risk for severe disease.

• Wear a mask!

• Do not use a wet, dirty, or damaged mask.

• Do not share your mask.

• Do not use valved masks. You may be protecting yourself, but with a valve you are not protecting those around you.

• Wear your mask so that it completely covers your mouth, nose, and chin, and so that is it fits tightly against your face.

• Avoid the 3 C’s: spaces that are Closed, Crowded, or involve Close Contact.

• Keep rooms well ventilated. When possible, open a window to increase the amount of natural ventilation indoors.

• Wash your hands for 20 seconds – sing one round of “Happy Birthday” or the chorus to Dolly Parton’s “Jolene”! 9

NEXT QUESTION: SHOULD YOU GET A COVID-19 VACCINATION WHEN THEY’RE AVAILABLE TO YOU? YES! There are currently three COVID-19 vaccinations authorized by the FDA for emergency use in the US: the Pfizer-BioNTech COVID-19 vaccine (authorized 12/11/2020), Moderna COVID-19 vaccine (authorized 12/18/2020) and Janssen COVID-19 vaccine (2/27/2021).

All of these vaccines were authorized for emergency use after phase 3 clinic trials showed that the vaccines are highly effective at preventing severe COVID-19 illness and are safe. People with T1D participated in these trials. There is no reason to believe that people with T1D or other autoimmune diseases would be at increased risk for adverse effects from the vaccine – the health risks of COVID-19 illness are known and are far worse than any reported side effects from the COVID-19 vaccine. There have been anecdotal reports of both high and low blood glucose in those with T1D for a few days after receiving the vaccine. We would actually expect that when a person’s immune system is reacting to the vaccine; the resulting inflammation would result in temporary insulin resistance and higher glucose levels for a few days in someone with T1D. You might wonder how the vaccines work. It is helpful to review information from biology class first. DNA is a long molecule that contains your unique genetic code for making all the proteins in your body. In order to make proteins, messenger RNA (mRNA) makes a blueprint of the DNA “genes” and carries this into cells in your body.

Inside your cells, ribosomes read the mRNA and make proteins. Proteins are essential for all of the cells in your body to function.

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Both the Pfizer-BioNTech and Moderna vaccines are COVID-19 mRNA vaccines. The mRNA instructs your own body to make a spike protein, which is harmless by itself.

The Janssen vaccine uses a modified Adenovirus to carry spike protein DNA into cells in your body, which is made into mRNA, then spike protein. Adenoviruses are common viruses that typically cause colds or flu-like illnesses. The Janssen vaccine modified adenovirus so that it can enter your cells but cannot replicate inside your cells or cause illness. So, with any of the authorized vaccines, once the vaccine is injected into the muscle in your upper arm, your cells will make the SARS-COV2 spike protein. The mRNA or adenovirus vector is rapidly broken down by your body and is completely gone within days.

Soon after the spike protein is made, your body will recognize that the protein doesn’t belong in your body and your immune cells will start getting rid of the protein and making antibodies to tag the protein for destruction. At the end of the process, your body will have

gotten rid of all adenovirus vector/ DNA, mRNA and spike proteins.

Your body will have learned how to protect against future infection, similar to if you had been infected with COVID-19. The benefit of these vaccines, like all vaccines, is that you gain disease protection without ever risking the serious consequences of getting sick with COVID-19.10 All three vaccines are highly effective in preventing severe COVID-19 illness. PfizerBioNTech performed a double blind, randomized, placebocontrolled study in individuals 16 years of age and older. Participants received two vaccine doses, 21 days apart. Of the 43,548 participants, 21,720 received the vaccine and 21,728 a placebo. Only 8 cases of COVID-19 were diagnosed with onset at least 7 days after the second dose of the vaccine while 162 cases were diagnosed among the placebo group. The vaccine was thus 95% effective at preventing COVID-19 over the 2-month study and no one in the vaccine group had a severe COVID-19 illness causing hospitalization or death.11 Moderna also performed a double blind, randomized, placebo-controlled study, but in individuals 18 years of age and older. Participants received two vaccine doses, 28 days apart. Of the 30,420 participants studied, 15,210 received the vaccine and 15,210 received the placebo. Only 11 cases of COVID-19 were diagnosed with onset at least 14 days after the second dose of the vaccine and 185 cases were diagnosed among the placebo group. The vaccine was thus 94.1% effective at preventing COVID-19 illness and also did not allow for any severe COVID-19 illnesses or deaths in the vaccine group.12 Johnson & Johnson’s (Janssen vaccine) study (ENSEMBLE) was a randomized, double-blind, placebo-controlled clinical trial in 43,783 individuals 18 years of age and older where 21,895 received the vaccine and 21,888 received saline placebo. The trial was conducted in eight countries across three continents and included a diverse and broad population including 34% of participants over age 60 years old. In the US, the vaccine was 72% effective in preventing COVID-19 illness 28 days after the vaccine. The vaccine was 85% effective overall in preventing severe disease and showed protection against COVID-19 related hospitalization and death, beginning 28 days after vaccination.13 Clinical trials are currently being completed in children 12 years of age and older with plans to expand trials down to 1 year of age. We expect that there may be a vaccine available to children ages 12 and older by fall.

Side effects were similar with all vaccines, with the most common complaint being pain at the injection site. Other common side effects include headache, fatigue, chills, and muscle pain. Side effects were more common after the second dose in the Pfizer-BioNTech and Moderna vaccines. Fever was rarely reported and generally only after the second dose with the Pfizer-BioNTech and Moderna vaccines.

WHEN WILL YOU BE ELIGIBLE TO RECEIVE THE VACCINE? Because vaccine distribution varies by state, it depends on where you live. Colorado has parsed out vaccine distribution into phases and multiple subphases. Phases 1A, 1B.1 and 1B.2 concentrated on healthcare workers, first responders, skilled nursing facilities, child-care facilities, preK-12 educators, and those over age 65 years. Phase 1B.3 opened March 5, 2021, and people age 16-64 with two or more high risk conditions, INCLUDING T1D, are eligible for vaccination! If you have T1D and also have one of the following risk factors, you are eligible for vaccination: cancer, chronic kidney disease, COPD, heart conditions, obesity, pregnancy, sickle cell disease, solid organ transplant, and/or a developmental disability that prevents you from wearing a mask. The next phase (Phase 1B.4) will open on March 19, 2021, and will allow for those 16-64 years of age with only one high risk condition, such as T1D, to be eligible for vaccination before the general public is vaccinated in phase 2. If you live in Colorado you can learn more about vaccine distribution phases by visiting www.covid19.colorado.gov/for-coloradans/vaccine/vaccine-for-coloradans. If you do not live in Colorado and want to learn more about vaccination timelines in your state, visit www.cdc.gov/vaccines/covid-19/covid19-vaccination-guidance.html.

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HOW DO YOU ACCESS THE VACCINE? If you live in Colorado you can learn more about where to get it by visiting covid19.colorado.gov/vaccine-providers. Are you a patient at the Barbara Davis Center who is 16 or older? Then make sure that you are signed up for MyChart! Because your chart already lists that you have T1D, you should be notified via email when you are eligible to schedule an appointment for vaccination. Don’t have MyChart? Sign up! You can sign up even if you’re not a patient by visiting mychart.uchealth.org/mhcweb/registration. If you are outside of Colorado or your healthcare system does not use MyChart, find your system’s electronic medical record and sign up. Most have a lottery system and will contact you when you become eligible. Visit covid.cdc.gov/covid-data-tracker/#vaccinations to view an interactive map with links to each state health department for more information on vaccine access outside of Colorado.

An important thing to remember is that just because we can see a light at the end of the tunnel does not signal an end to the pandemic.

It is still all of our responsibility to mask up, wash our hands, and maintain six feet of distance when advised by the CDC to protect those who are not yet vaccinated and to reduce the spread of COVID-19 variants. These continued measures and increased vaccination will help ensure that in the near future our lives will look much like they used to before COVID-19.

VACCINATION CENTERS IN COLORADO

1www.cdc.gov/coronavirus/2019-ncov/cdcresponse/about-COVID-19. html#:~:text=The%20new%20name%20of%20this,D%27%20for%20disease 2www.cdc.gov/about/history/sars/timeline.htm 3www.ajmc.com/view/a-timeline-of-covid19-developments-in-2020 4www.cdc.gov/coronavirus/mers/photos.html#:~:text=Coronaviruses%20 derive%20their%20name%20from,%2C%E2%80%9D%20or%20halo.

5Muller et al., Clin Infect Dis, 2005 Shah BR et al., Diabetes Care, 2003 Laffel LM et al., Pediatric Diabetes, 2018 Cengiz E et al., Pediatric Diabetes, 2013 Kahkoska AR et al., JAMA New Open, 2018

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6Barron E, et al., Lancet, 2020

7Gregory et al, Diabetes Care, 2021 8Holman N, et al., Lancet, 2020 9www.npr.org/sections/goatsandsoda/2020/03/17/814221111/my-hand-washing-songreaders-offer-lyrics-for-a-20-second-scrub www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/mrna.html

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www.nejm.org/doi/full/10.1056/NEJMoa2034577

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www.nejm.org/doi/full/10.1056/NEJMoa2035389

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www.fda.gov/media/146217/download

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MY FIRST COVID-19 VACCINATION DOSE

BY PAIGE LINDBLOOM

When Governor Polis announced those with two or more high-risk conditions (including type 1 diabetes) would be in the next COVID-19 vaccination phase, I did not expect it to affect me. To my knowledge, I only have type 1 diabetes and have been lucky enough to avoid other chronic diseases. So it came as a surprise when on Tuesday, March 8, 2021 I received a message on the Barbara Davis Center tool “MyChart” that I was being permitted to receive the COVID-19 vaccine. Thanks to type 1 diabetes as well as my- in my opinion widely inaccurate- high BMI that indicates obesity, I was approved for the newest phase of vaccines. As the potential for being vaccinated has been on my mind for weeks, I knew I wanted to get the shot when presented the opportunity. I did not hesitate to look for an open timeslot to get my vaccine.

I was lucky enough to find a time at 9:10 a.m. the next day for my vaccine at Children’s Hospital on the Anschutz Campus in Aurora, Colorado. That morning I was nervous and honestly wondering if I was making a mistake. For me, my type 1 diabetes isn’t a big enough reason to get put ahead of others with more potentially catastrophic diseases than mine. Yes, there is some evidence that says COVID-19 may cause more serious consequences for those with T1D than others, but I still hesitated to get into my car that morning to drive to get my shot. It took me a second to breathe, remember that there is order and due process to vaccine eligibility, and that I needed to take the opportunity presented to me before it was gone.

When I arrived at Children’s, all I knew was that I needed to find the vaccine clinic. I had only been to the hospital one time prior to this visit, so I really had no idea where to go. I ended up parking in a garage and walked towards the front entrance. There, a gentleman was clearly directing people on where to go: to the left for general hospital visits and to the right for the vaccine clinic (Easy enough!).

Once in the doors I joined a short and masked line with a variety of different individuals all waiting for their COVID-19 screening.

After being asked the typical symptom questions, they gave me a “COVID screening” sticker and directed me upstairs to receive my vaccine.

Again, I had no idea where I was going. I opted for the stairs as I only needed to go up one floor. By the time I arrived at the next level, I felt lost. Luckily for me bright posters indicated where to go for the vaccine, and I followed these signs to a table outside of a ballroom.

At this table they verified I was there for the vaccine and handed me paperwork to fill out as well as informational sheets. I then hopped in another line with clearly marked places to stand and filled out my forms. I was asked if I had any questions and then directed to intake personnel who would verify my name and birthdate on the forms. Not once was I asked to pullout my official identification which, looking back, was probably because I had a set appointment and verified my information three separate times. I then waited to be called forward and, a minute later, I was directed to one of many vaccination round tables set up in the ballroom.

At the vaccine table was a smiling woman surrounded by papers, a laptop, and medical supplies. This is also when I noticed the videos playing a loop of bulldog puppies on big screens throughout the room – such a cute and smart touch which made my experience a little more enjoyable. She again verified my name and asked if I have had any allergic reactions to a couple of different things I couldn’t even pronounce. She then asked which arm I would prefer for the vaccine. Because I had my CGM in my left bicep, I elected for my right and dominant arm. Turns out the dominant arm is preferred as it helps you disperse the vaccine more efficiently due to extra movement that your non-dominant arm wouldn’t do – so go me! The nurse then cleaned my upper arm muscle with an alcohol swab, uncapped the shot, and gave me the impossibly painless vaccine. Even as a diabetic, the only time I have ever had a shot feel that way is when I find the perfect fatty-tissue, use emela cream, and don’t look. I was then directed to head to the theater outside of the ballroom as they needed to make sure I was okay for at least 15 minutes post vaccine. I of course stopped at the free snack table on the way out and headed to the supervision area to wait for my 15 minutes to be over. Again, the bulldog video was playing, but otherwise it was pretty boring! I hung out for a while, said thank you to the attending nurse, and walked back out of the hospital to head home.

Post-vaccine, which was my first Pfizer dose, the only symptoms I had were immediately after when I had a metallic taste in my mouth – which is very common – and some pain in my right arm. I had muscle aches in both the injection site and my elbow, which was interesting, that went away roughly 24 hours later. My blood sugars remained incredibly level, with no hyper or hypoglycemic events, and I over all felt good!

The biggest hurdle I had to get over with the vaccination process was the feeling that I shouldn’t have been vaccinated yet. In my eyes, I am not disabled and I have never felt at risk of dying from COVID-19. When I stood in line with others at Children’s Hospital I saw families and kids with breathing tubes, Down Syndrome, mobility complications, and so much more. Even now, the guilt of getting the vaccine before others in that line digs at me. Granted, there is a steady flow of vaccines in Colorado and there have been many more high-risk patients before me who have been able to get their vaccination. I don’t know if I will ever get over the guilt of getting my vaccine before others, but I do consider myself lucky for the opportunity to be considered for defense against COVID-19.

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I WAS A 40-POUND KID WHEN DIAGNOSED WITH T1D IF I CAN THRIVE, YOU CAN TOO!

BY DJ SMITH

My diagnosis was a lot calmer than most. No hospital visit, no extremely high blood sugar, and no attempt to get me back on this earth. I know a lot of diabetics did not have the same fortune as me. Although my diagnosis lacked an ambulance or helicopter ride to a hospital, there were things that my seven-year-old head could not understand. I was already someone who had always been skinnier than most and started to lose weight. I lacked energy.

I was drinking close to a gallon of water every two hours and never seemed to satisfy my thirst. I couldn't understand why these things were happening to me so abruptly. My parents noticed these changes and booked a doctor’s appointment on October 24, 2011, which led to a very drastic change in how I live my life. In a matter of 8 hours I was put on insulin. I did not understand how this drug worked or what it did. All I knew was once every morning I would get two shots, one for breakfast and one to get me through the rest of the day. While I could tolerate this, the change I did not like was that I could no longer eat whenever I wanted. I had to tell my mom or dad when and what I was eating so they could put this mystery drug in me. With time I have learned what that mystery drug does and the technology that goes with it. Now that I am 16, I don't have to tell my parents what and when I eat since I can just use my insulin pump and do it myself. I know how scary it can be when people are first diagnosed with diabetes, but it gets better. If a little kid that weighed 40 pounds when diagnosed can manage and live with T1D then you can too.

HEALTHCARE PROVIDERS

REGISTER FOR THE PRACTICAL WAYS TO ACHIEVE TARGETS IN DIABETES CARE July 15-18, 2021

It’s time to register for our annual, continuing education

conference designed for healthcare providers caring for adolescents and adults with diabetes. The conference will be held virtually this year.

This conference is for: certified diabetes educators, internists, pediatricians, family physicians, physician assistants, nurse practitioners, nurses, dietitians and all healthcare providers interested in receiving the most up-to-date type 1 and type 2 diabetes information from world-renowned diabetes experts.

Register at: www.atdcconference.com/registration View program details at: www.atdcconference.com RATES INCREASE APRIL 1, 2021 Questions? Contact Lisa Steele at lisa@childrensdiabetesfoundation.org or 303-628-5108

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Children’s Diabetes Advisory Board Members and Guild Presidents THE GUILD PRESIDENTS:

ADVISORY BOARD:

Founding President, Amy Davis Mrs. Gina Abou-Jaoude Mrs. Christy Alberts Mrs. Jamie Angelich Mrs. Karen Aylsworth Mrs. Linda Broughton Mrs. Tangy Buchanan Mrs. Joy Burns Dr. Bonita Carson Mrs. Lisa Corley Mrs. Nancy Cowee Mrs. Dalyla Creaghe Mrs. Norma D’Amico Ms. Donna Douglas Mrs. Margy Epke Mrs. Chris Foster Mrs. Helenn Franzgrote Mrs. Sally Frerichs Mrs. Debbie Gradishar Mrs. Helen Hanks Mrs. Georgia Imhoff Mrs. Marty Jensen Mrs. Gail Johnson Mrs. Sharon Kamen Mrs. Janet Knisely Mrs. Cheryl Lebsock Mrs. Shelley Lucas Mrs. Suzy Love Mrs. Judy McNeil Mrs. Sally Newcomb Mrs. Barb Oberfeld Mrs. Gretchen Pope Mrs. Carol Roger Mrs. Kay Stewart Mrs. Diane Sweat Ms. Charlotte Tucker Mrs. Loretta Tucker Mrs. Melissa Tucker Mrs. Jane Weingarten

Sir Michael Caine Mr. and Mrs. Robert A. Daly The Honorable Diana DeGette, U.S. House of Representatives, Colorado Mr. Neil Diamond Mr. Placido Domingo Mr. John Elway Mr. David Foster Mr. Kenny G Mr. David Geffen Mr. Magic Johnson Mr. Quincy Jones Ms. Sherry Lansing Mr. Jay Leno Mr. Paul Marciano Mr. Mo Ostin Sir Sidney Poitier Mr. Lionel Richie Mrs. Adrienne Ruston Fitzgibbons Mr. George Schlatter Ms. Maria Shriver Ms. Brenda Richie Ms. Barbera Thornhill Miss Joan van Ark Mr. Gary L. Wilson Mr. Stevie Wonder See complete list at ChildrensDiabetesFoundation.org

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Children’s Diabetes Foundation 3025 South Parker Road, Suite 110 Aurora, CO 80014 www.childrensdiabetesfoundation.org

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