2016 Fall Vol 56 by Joe Rollinson

NEWSLETTER Fall 2016

TCOYD IS A 501(C)3 NONPROFIT CHARITABLE EDUCATIONAL ORGANIZATION

DR EDELMAN’S CORNER

Every Day Should Be World Diabetes Day Inside PA G E 3

The Hodson Corner PA G E S 4 & 5

Ask Your Doctor PA G E 6

Giving Back PA G E S 6, 7 & 10

Product Theater PA G E S 8 & 9

Taking Control PA G E 11

Case of the Month

November 14th was “World Diabetes Day”. The theme of the campaign this year was to highlight children and adolescents living with diabetes. There were celebrations in major cities around the globe including New York, Sydney, and Tokyo. 246 monuments worldwide, such as the Coit Tower in San Francisco, were lit up this day to commemorate the diabetes epidemic. The United Nations recognized World Diabetes Day for the first time since the International Diabetes Federation established it in 1991. Dignitaries, politicians, and diabetes professionals made speeches to highlight the growing and staggering diabetes epidemic—one of the most important health concerns facing millions of people around the globe. Many diabetes organizations brought attention to this day with email blasts, form letters, media alerts, and requests for donations, and their representatives showed up at events to bring attention to the cause. What a day it was! Yep… 24 hours of incredible festivities. There are over 245 million people living

with diabetes worldwide, and it is estimated that by the year 2027 there will be over 380 million. It is estimated that 200 children a day are diagnosed with type 1 diabetes and over 4,000 children and adults are diagnosed with type 2 diabetes each day in the United States alone. Type 2 diabetes, formerly called “adult onset diabetes” is growing at alarming rates in children and adolescents. In the United States, it is estimated that type 2 diabetes represents between 8% and 45% of new-onset diabetes cases in children, depending on geographic location, and an increasing trend is seen around the world. For example, over a 20-year period, type 2 diabetes has doubled in children in Japan, so that it is now more common than type 1. The prevalence in children of native and aboriginal decent in North C O N T I N U E D O N PA G E 2

Special Acknowledgements Board of Directors Steven V. Edelman, MD Founder and Director, TCOYD Sandra Bourdette Co-Founder and Executive Director, TCOYD Edward Beberman Christine Beebe Audrey Finkelstein Margery Perry Daniel Spinazzola Andrew Young Contributing Authors David Ahn, MD Cecilia E. Bonaduce Steven V. Edelman, MD Leslie Miranda, RD, CDE Jeremy H. Pettus, MD William Polonsky, PhD, CDE Tricia Santos, MD Lynne Scharf Robyn Sembera Amir Zarrinpar, MD, PhD TCOYD Team Steven V. Edelman, MD Founder and Director Sandra Bourdette Co-Founder and Executive Director Michelle Feinstein, CPA Chief Financial Officer Jennifer Braidwood Vice Executive Director Jill Yapo Director of Operations Michelle Day Director of Meeting Services Robyn Sembera Manager of Continuing Medical Education Sarah Severance Manager of Events and Fundraising Collin Stephens Manager of Health Fairs and Marketing Lynne Scharf Administrative Assistant MyTCOYD Newsletter Robyn Sembera Editor in Chief Sarah Severance, and Lynne Scharf Assistant Editors Leah Roschke Design MyTCOYD Newsletter is offered as a paid subscription of Taking Control Of Your Diabetes. All material is reviewed by a medical advisory board. The information offered is not intended to constitute medical advice or function as a substitute for the servicesof a personal physician. On the contrary, in all matters involving your health, TCOYD urges you to consult your caregiver. ©2016 All rights reserved.

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D R E D E L M A N ’ S C O R N E R F R O M PA G E 1

America and Australia is also growing at an alarming rate never before observed. In addition to the human suffering, the effects of which cannot be estimated, we will spend hundreds of billions of dollars caring for these afflicted people. Let’s not forget the men, women, and children in developing countries, suffering every day from the acute and chronic complications of diabetes. These unfortunate individuals suffer from malnutrition, infections, blindness, amputations, and kidney failure—and cannot even get the basics of care, such as oral medications or insulin. Some advances, such as newer insulins, insulin pumps, pens, home and continuous glucose monitoring, are totally out of reach. The difficult lives of these folks are the same every day throughout the year, including November 14 (World Diabetes Day). The main issue for me is this: What happens on November 15 and thereafter until the next volley of extravaganzas that will occur on World Diabetes Day 2017? Every healthcare organization focusing on diabetes, including TCOYD, needs to work together every day of the year with the

common goal of wiping out the devastating effects of diabetes. We have so many tools to help successfully control type 1 and type 2 diabetes, yet access to these new medications and devices, in addition to knowledgeable caregivers, is severely limited for the vast majority of people living with diabetes on this planet. Increased public and government awareness, ongoing meaningful patient and professional education, access to the basic oral pills, insulin, and glucose testing devices, advocacy and emotional support are all part of a long list of what is needed to make a dent in the amount of human suffering caused by diabetes worldwide. World Diabetes Day is important to re-ignite awareness of diabetes to the public as well as to governmental agencies and the private health care sector. However, it is also important that we do not ever lose sight of the fact that this disease is with every person affected by it every minute of every day, year after year. All of us at TCOYD feel that every day should be World Diabetes Day!

In the United States, it is estimated that type 2 diabetes represents between 8% and 45% of new-onset diabetes cases in children, depending on geographic location, and an increasing trend is seen around the world. For example, over a 20-year period, type 2 diabetes has doubled in children in Japan, so that it is now more common than type 1. In addition, the prevalence in children of native and aboriginal decent in North America and Australia is also growing at an alarming rate never before observed.

LIVING WELL

The Hodson Corner PEAK Program: Educating Providers and Type 1s on how to Exercise Safely and Well!

BY JEREMY H. PETTUS, MD

The idea of the the PEAK Program is to create presentations that can be given to either healthcare providers or patients on the topic of exercise. This is a super important topic, so kudos to JDRF for making the effort. I have to say, I am really happy to see a practical approach to exercise that can apply to people like me and most of the patients/friends I see.

don’t know about you guys, but I’m stoked for the type 1s out there climbing Everest and flying to the moon and what not, but that’s just not me. I just want to be able to teach my patients how to go to the gym without having to stuff their face pre, during, and post-exercise. Gosh, I hate getting low when I exercise. Nothing worse than trying to shed a few pounds but having to eat more just so you can exercise. For example, I have been known to pound a can of Coke on the treadmill! It just feels so wrong. Oh, and everybody in the gym gives you really weird looks. My response to their weird looks is always the same, “No, I will NOT put on clothes!” So, this event had the ‘who’s who in T1D exercise’. There were about 20 folks that literally flew in from around the world. There were exercise physiologists, endos, athletes, coaches, JDRF folks, and yours truly. My take home points? 1. Exercise tips The specific cases we talked about had to do mostly with 1) Avoiding hypos during and after exercise and 2) avoiding hyperglycemia after exercise (common with high intensity activities). For me, avoiding hypos is easier to address, where folks can reduce their bolus for the meal prior to eating (go into exercise a little high), reduce their basal by 50% or so 90 minutes prior to exercise, or just eating more carbs. Some combination of those usually

gets the job done. An important focus was also on delayed, or usually overnight lows, after exercise from increased insulin sensitivity. The post-exercise spike that I get after running is more troublesome, as it seems to come some of the time but not always. Some really good suggestions were for people to do about a 20 minute cool down jog after a high intensity workout to allow your body to continue to burn off the extra glucose made from all the adrenaline you get pumping during bursts. After that, if the BG is high, bolusing to bring it down might be needed, but definitely only about 50% of what you might usually do. At any rate, tips and talks around these types of issues are SO IMPORTANT, and obviously there are a lot more details and specifics I can’t go into here, but I left wanting to go run and try out some new stuff! 2. Nutrition recommendations It’s fascinating to me that with diet being such a key component of T1D life and treatment, that there is no clear consensus on what type 1s should be eating. One recommendation presented was a carb breakdown of about 50% of your total daily calories (higher for more active folks). So, for a 2,000 calorie day, that would be 1,000 calories from carbs or about 250 grams. This recommendation caused the biggest kerfuffle (underused word) as a lot of endos thought this a bit too

high. I spend about 95% of my time trying to convince other type 1s to eat fewer carbs. I’m not a zealot about low carb, but I do know for sure that eating fewer carbs makes staying in range a lot easier. On the other hand, if it isn’t broken don’t fix it. If your BGs are good, and you are happy with your weight, then don’t change a thing. In fact, YOU should be writing this post! 3. Ketone measurement I was really interested to see a dramatically different utilization in blood ketone measurement across the globe. Frequently checking blood ketones in Europe, Australia, and other countries is common practice, but here, not so much. In fact, I don’t think I personally have EVER checked a blood ketone (urine yes, but blood no). This is driven, in part, by cost – to test your ketones will run you about $5 per STRIP. That’s not the case in other parts of the world, so they routinely check ketones with high blood sugars around exercise, and they make recommendations to potentially avoid exercise if ketones are positive (over 1mmol/l). The irony is that we can get pumps and CGMs here in the states relatively easily, but they can’t in many parts of Europe. In fact, one of my major complaints about the exercise slides was the lack of a hard recommendation on CGMs. For me, if you want to exercise well with T1D, get a CGM!!!! The pushback was that they are simply not available in other countries, so there is no point talking about them. Kinda crazy. It does seem like a misuse of resources that ketone testing and strips C O N T I N U E D O N PA G E 1 2

TAKING CO NTRO L O F YO UR DI ABE TE S

ASK YOUR DOCTOR

The Gut Microbiome and Diabetes B Y C E C I L I A E . B O N A D U C E A N D A M I R Z A R R I N PA R , M D, P H D

Understanding and learning to alter our microbiome and its impact on our genes may be the missing link to treating many diseases and conditions that, until now, science has been unable to treat effectively.

Microbiota and the Microbiome The “microbiota” is “the collective community of bacteria present in a particular environment (skin, gut, etc.).” The “microbiome,” on the other hand, not only refers to the bacteria that are present but also to all of the genes they have available to them. The genes of the microorganisms turn on and off in response to what we do, what we eat, where we live, etc. The relationship between microbiota and our bodies is a two-way street. The genes of the microorganisms that reside in and on our bodies actually impact our own gene expression! It is important to remember that the gut microbiome is not only made up of bacteria, but also other organisms, such as fungi and viruses (that mostly target the bacteria). Recent studies show that we can actually identify which part of the body a sample comes from by looking at the types of microorganisms in the sample. For example, the microorganisms in the gut are distinct from those found on the skin, the eyes, or in the mouth. The gut microbiota serves many functions. These include protection from pathogens, development of a normal immune system, vitamin synthesis, fermenting complex fibers into easier to absorb sugars, and salvaging energy from the food we ingest. What medical researchers are finding now is that intestinal dysbiosis, or an imbalanced or impaired microbiota, is a risk factor for health problems like obesity, diabetes, atopic dermatitis, inflammatory bowel disease and, possibly, autism. Understanding and learning to alter our microbiome and its impact on our genes may be the missing link to treating many diseases and conditions that, until now, science has been unable to treat effectively. Microbiome and Health

The gut microbiota play an important role in human metabolism. For example, researchers have found that individuals with diabetes and obesity have a microbiome that is different from those without either condition. This particular composition is linked to decreased satiety, liver disease, increased inflammation and triglyceride composition in fat tissue, increased gut permeability, and altered hormone regulation. All MY TCOYD NEWSLETTER, VOL 56

PROBIOTICS BY L E S L I E M I R A N D A , R D, C D E of these factors can contribute to overall inflammation and increased resistance to weight loss (both linked to type 2 diabetes), and increasing the risk for developing autoimmunity (linked to type 1 diabetes). Given the many ways that we know of so far that the gut microbiome can influence the body, further research in this field will likely have a dramatic impact on the treatment of diabetes and obesity. Changing our microbiomes Many factors affect the gut microbiome including age, genetics, diet, and household/environment. Not long ago, scientists thought that the microbiome was stable and resistant to change. However, recent research shows that the gut microbiome is incredibly dynamic and adaptive – it can change in as little as 24 hours! Developing medical treatments that alter the microbiome may play a role in the future of diabetes treatment and management. For example, one study showed that transferring the intestinal microbiota from a lean donor to patients with metabolic syndrome led to improved insulin sensitivity in some of the recipients. This is just one example of how medical researchers may be able to leverage the microbiome to develop treatments for diabetic patients. The future Many were introduced to the concept of the microbiome by ads for probiotic yogurts and fermented drinks. Now the national dialogue on this topic is shifting to focus on the scientific potential of researching and understanding our microbiomes. We know that the microbiome impacts our gene expression and our risk for certain diseases. We also know that the microbiome is dynamic, adaptive, and can be altered by external factors. What is left to be discovered is how we can change and improve our microbiomes to achieve optimal health. Amir Zarrinpar, MD, PhD, is Assistant Professor, Division of Gastroenterology, University of California, San Diego. Cecilia Bonaduce, MD Candidate, 2019, UC San Diego School of Medicine.

Bacteria that are actually good for us? Chances are you have heard the terms “prebiotics” and “probiotics”, but many aren’t aware of what they are, what they do, or where to find them. These functional food components can support our gastrointestinal health and our overall health! Prebiotics are non-digestible food ingredients that help support the growth or activity for our good bacteria (food for your probiotics). They can also support gastrointestinal health. Another term you may hear in the bacteria world is synbiotics (a combination of preand probiotics). Foods containing prebiotics include: legumes, beans (including soy), peas, oats, berries, Jerusalem artichokes, asparagus, dandelion greens, tomatoes, garlic, leeks, onions, bananas and whole wheat foods. Probiotics are “live microorganisms which when administered in adequate amount confer a health benefit to the host”. Simply put, they are good bacteria that help optimize health and fight harmful bacteria. You may not realize it – but you already have good bacteria in your gut. We also can obtain these live active cultures in various foods, including: fermented foods (watch sodium intake), cultured dairy, and some fortified foods. Why are these bacteria important? The food you eat plays an important role in the balance of good and bad gut bacteria! Research has shown that high-sugar and high-fat diets influence the gut bacteria negatively, creating an imbalance in our microbiome and allowing harmful species to overgrow. High-fat, lower-fiber diets reduce microbial diversity and dietary sugar can also affect the “healthy” microbial colonies in your gut – altering digestion in a way that increases the risk of T2D. Probiotics are showing encouraging research in the areas of gastrointestinal disturbances (C-difficile, diarrhea, Irritable Bowel Syndrome [IBS]) and more research is being conducted in the areas of anxiety, prevention & treatment of certain skin conditions, promoting health in the urinary tract and vagina, preventing allergies, obesity, diabetes, and asthma. Should I take probiotics? Well, not necessarily… unless of course your physician or gastroenterologist is recommending it. Probiotics are generally recognized as safe (occasional gas or bloating); however, not all probiotics are the same, they can be costly (cost doesn’t equal quality), and they do not all show benefit for all diseases. In looking at the probiotic label, each brand may have different types of bacteria and that bacteria may not be effective in achieving your desired outcome. Also, to note in the diabetes population, some probiotic supplements have added sugar which can elevate your glucose reading. Consumption of probiotic supplements is not recommended for those with severely compromised immune systems or critically ill individuals. So what should I do? Eating a diet rich in pre-and probiotic foods can promote the most ideal balance between good and bad gut bacteria. Consider more of a plant-based diet (less fat, less processed foods and refined sugars) as we know a plant based diet supports gut health. Here are a few ideas: stir fry asparagus, tomatoes, onion, and garlic with tempeh; or have a plain, non-fat Greek yogurt with ½ banana and cinnamon. By adding pre- and probiotic food sources into our diet, we can help create a healthier you!

TAKING CO NTRO L O F YO UR DI ABE TE S

GIVING BACK

An Attitude of Gratitude T

BY ROBYN SEMBERA

COYD would like to send a tremendous “thank you” to the hundreds of donors who helped us meet our “$7,500 match challenge” at the TCOYD San Diego conference (the largest one of the year), in October. Three of our steadfast sponsors offered to match up to $7,500 in donations received at the conference. If one individual donated $5, it would turn into $20 from the match of the three companies! Dr. Edelman kicked off the campaign by donating $500 at the end of his morning presentation and throughout the rest of the day donations came pouring in. TCOYD would like to send a warm and special thank you to David and

Barbara Groce for also matching the $7,500; and to Ashley Kunz-Ali who donated in memory of her late father, Joseph Kunz, a long-time conference goer and close friend to Dr. Edelman and our TCOYD family. TCOYD would not be the organization it is today without YOUR support which helps to make the conferences possible. The donations received at our San Diego conference, or any event for that matter, go right back into the conferences, year after year. We are so humbled, here at TCOYD, by our gracious, giving and loving attendees and members. Thank you for allowing us to continue bringing you the best conferences for diabetes! See you in 2017!

Take the Guess I NT R O D U C I N G T H E The good news is that OneTouch® test strips have the lowest co-pay on the most health plans* and are always covered by Medicare Part B.†

AFREZZA Q&A

BY TRICIA SANTOS, MD Is inhaled insulin a better insulin?

Although it has been almost a century since insulin was discovered, inhaled insulin is relatively new. Many patients think that the only benefit to inhaled insulin is fewer injections, but inhaled insulin has some other benefits as well. What’s the deal with inhaled insulin? Normally insulin is injected under the skin. Afrezza is a man-made insulin powder made by MannKind Corporation that is inhaled into the lungs using an inhaler device. The inhaled insulin is absorbed into the blood stream more rapidly than insulin injected under the skin. Afrezza starts working in 12-15 minutes and is out of your system in about 3 hours! This means that Afrezza 6

MY TCOYD NEWSLETTER, VOL 55

works as a fast-acting insulin to be used at meal time or to quickly lower a high blood sugar. In fact, Afrezza inhaled insulin works even faster than our fastest injectable mealtime insulins such as humalog, novolog, or apidra. The rapid on/rapid off effects of Afrezza can help control blood sugar even better than traditional meal-time insulin and reduce the risk of hypoglycemia after meals because the insulin is out the body in a few short hours.

How do you use Afrezza inhaled insulin? Inhaled insulin is delivered to the body with an inhaler device instead of an insulin pen or syringes & vials that patients are used to with traditional insulin. Afrezza inhaled insulin comes in color-coded single dose cartridges containing either 4 units (blue), 8 units (green), or 12 units (yellow) of inhaled insulin. A single cartridge is loaded into the small, hand-held inhaler device, and is then inhaled by the patient.

PRODUCT THEATER

work Out of Your Blood Glucose Numbers … and live more colorfully! O N E TO U C H V E R I O F L E X ® M E T E R

he OneTouch Verio Flex® meter takes the guesswork out of your blood glucose with a simple 2-step test: just insert a test strip and apply blood to either side of the test strip. That’s all there is to it! Your results appear on the meter’s screen with an arrow that shows if your results are low, in range, or high. The meter features ColorSure™ technology, which instantly shows when your blood glucose results are in or out of range:

It should be noted that the units of inhaled insulin may not correlate exactly with the units of traditional injectable insulin. For example, if you would normally inject 6 units of insulin for a particular meal, you may find that you need 8 units of inhaled insulin. This does not necessarily mean that you are getting more insulin into your system since one cannot directly compare units of inhaled insulin and injectable insulin. If you are prescribed inhaled insulin, you should work closely with your doctor to determine which dose is right for you. Afrezza inhaled insulin should be taken immediately before a meal since it works very quickly (not 15-20 minutes before the meal as with injectable mealtime insulin.) Afrezza is approved for use in patients with both type 1 and type 2 diabetes. However, remember that type 1 diabetics will still need to take basal insulin while using Afrezza. Is inhaled insulin safe? The most common side effects associated with Afrezza are hypoglycemia and cough. However, the cough is usually mild and only occurs at the time of inhalation. Afrezza can also cause a very mild decrease in lung function. When this happens, the lung C O N T I N U E D O N PA G E 1 2

Blue — Lets you know you are low Green — Lets you know you are in range Red — Lets you know you are high Insurance coverage is another important factor to consider. The good news is that OneTouch® test strips have the lowest co-pay on the most health plans* and are always covered by Medicare Part B.† And if you’d like, you can even wirelessly sync your OneTouch Verio Flex® meter with the OneTouch Reveal® mobile app. The OneTouch Reveal® mobile app uses colorful, easy to understand visuals to highlight your patterns and helps to track your blood glucose, food and insulin over time. You can download the app at no cost from the Apple App Store or Google Play. * Some health plans may have more than one test strip covered at the lowest co-pay. † Not a guarantee of coverage and payment. Coverage and payment may be subject to co-insurance, deduct-

ible and patient eligibility requirements. Apple, the Apple logo, and iPhone are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc. Google Play is a trademark of Google Inc. The Bluetooth® word mark and logos are registered trademarks owned by Bluetooth SIG, Inc., and any use of such marks by LifeScan Scotland is under license. Other trademarks and trade names are those of their respective owners.

Get a OneTouch Verio Flex® meter at no charge! Ask your doctor for a OneTouch® prescription, then bring this coupon to your pharmacist to receive your OneTouch Verio Flex® meter at no charge! Attention Pharmacist: Please submit this claim to Patient Choice®. You will then receive your reimbursement plus a dispensing fee. For any questions regarding on¬line processing, please call the Help Desk at 1-800-422-5604. No claim can be submitted for reimbursement to Medicare, Medicaid, or any other payer for the OneTouch® meter received from this offer. This card is good for one fill only and cannot be combined with other offers. Patient may not receive a duplicate meter. Limit one meter per patient. Offer good while supplies last. Void where prohibited by law. Please re¬move identification number from patient profile after claim has been processed. This offer from LifeScan, Inc. is available to all patients and may be redeemed wherever OneTouch® products are sold. Offer only valid for legal residents of the United States. Void where prohibited or restricted by law. Available while supplies last. Limit one per patient. Qualifying conditions may apply. Bin: RxPCN: GroupID: ID#: 004682 CN LVARV472 NOCHARGEMETR OFFER EXPIRES 03/31/2017

TAKING CO NTRO L O F YO UR DI ABE TE S

TAKING CONTROL

Did Medicare Deny Coverage for Your CGM?

WE CHANGED THE PROGRAM CRITERIA—SEE IF YOU NOW

QUALIFY!

TCOYD Tackles Medicare Denials from a New Perspective! B Y LY N N E S C H A R F

t’s the start of a new day, and upon waking you realize you have the whole day free to do anything you’d like. You toss some ideas around in your head: Go to the beach? See a movie? Have lunch with friends? Eh, not quite in the mood. And then it hits you – spend hours on the phone with Medicare trying to understand your benefits? Yes! That’s it! You leap out of bed, dash into the office for a pad of paper and a calculator (fingers crossed there will be complicated math involved) and track down your glasses to start reading the inch-thick packet of benefit explanations to prep before the call. This is going to be FUN! Okay so chances are this is not the feeling you get when “Call Health Insurance” is on your to-do list.

Figuring out your benefits when you have diabetes can be complicated, and figuring them out once you transition to Medicare can be especially overwhelming. If you have insulin-dependent diabetes and require a continuous glucose monitor, it can be particularly frustrating because Medicare does not automatically cover CGMs. Without the help of a CGM, people often have a harder time recognizing when their blood sugars are too high or too low, leading to an increased risk of serious health complications. Medicare beneficiaries have the choice to either pay out of pocket for a CGM and sensors which can cost hundreds of dollars annually, or go through a lengthy appeals process that may or may not result in a favorable outcome. That’s where we come in to help.

TCOYD recently received a grant from the Leona M. and Harry B. Helmsley Charitable Trust to assist low-income seniors in the Medicare appeals process for CGMs. If you (or someone you know) is insulin dependent with hypoglycemia unawareness and has a denial letter for their CGM from Medicare, please check out our website at tcoyd.org to see if you qualify for the program. We’re thrilled to have the opportunity to work on this important issue and to assist in the appeals process for 50 applicants. We hope one day soon we can announce that Medicare will cover CGMs for everyone who needs one, and that WOULD be a great reason to leap out of bed indeed!

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What’s So Tough about Starting Insulin? B Y W I L L I A M P O L O N S K Y, P H D , C D E

f you have type 2 diabetes and are now taking insulin, then we need your help. As you may know, when first learning about the need to take insulin, many people are not so happy about it—to put it mildly! Several decades of good research tell us that more than one-third of people with type 2 diabetes are very reluctant to take insulin when their doctor first brings up the subject. They may refuse insulin outright (“look, doc, there is just no way I could take the needle”), bargain with their health care providers for more time (“please, I just need a few more months to see if I can drop this weight”), or even drop out of treatment altogether. Sadly, these personal decisions can lead to chronically elevated blood glucose levels, often for years and years, raising the risk for long-term complications. Over the past ten years, researchers have learned a lot about why so many people with type 2 diabetes are unhappy about the idea of starting insulin. First, starting insulin often makes people worry that they will somehow lose control over their lives. As one

PWD explained, “Taking insulin would mean no more spontaneous adventures for me. It would make it too hard to travel, or eat out, or even have a life!” Second, many people equate insulin with a sense of personal failure. As another PWD described it, “If I have to take insulin, it means that I have messed up, that I haven’t done a good enough job taking care of my diabetes.” Third, for many PWDs, starting insulin signifies that diabetes is now suddenly more serious, more dangerous and may cause long-term complications. (Reality check: it doesn’t). Fourth, many people are just scared about taking injections. And finally, a big issue for many PWDs is that they aren’t so sure that taking insulin will help them at all. In fact, in one large international survey, more than half of people with type 2 diabetes didn’t believe that taking insulin would help them achieve good glycemic control, improve their energy level, or improve their health. Given these widespread beliefs that insulin is such a negative and perhaps harmful intervention, it is no wonder that so many

people with type 2 diabetes are so reluctant to try it. But the funny thing is-- despite all these bad feelings about insulin-- most of these folks, even if they were deadset against insulin, eventually end up taking it. How does this happen? What helps that reluctant individual to finally say—“Ok, I’ll give insulin a try”? What happened to YOU? If we scientists and health care professionals can learn what helps the reluctant PWD to give insulin a try, then maybe we can be of greater service to those unwilling PWDs who are going thru years and years of high blood sugars unnecessarily. We will soon be starting a new research survey to answer this particular question, and we need your help. If you were reluctant to start insulin and finally decided to start it anyway, then we want to know what happened to you! If you would be willing to help us, please consider joining the TCOYD Online Research Registry today (if you haven’t already joined). It is simple, just go to www.tcoydregistry. com and answer a few simple questions. C O N T I N U E D O N PA G E 1 2

TAKING CO NTRO L O F YO UR DI ABE TE S

PRODUCT THEATER

Exciting Technology Updates Coming Your Way! BY DAVID AHN, MD

all has come with a flurry of new prod ucts, FDA approvals, and announcements from the major players in diabetes technology. Don’t miss out by checking out a quick recap of what matters: 1. Tandem Diabetes begins shipping the forward-thinking T:Slim X2 Thanks to an all-new Bluetooth transmitter and its FDA-approved ability to add new features with software updates, the T:Slim X2 unifies and replaces Tandem Diabetes’ outgoing models, the T:Slim and T:Slim G4. (The T:Flex will remain as the primary option for users requiring higher doses of insulin). While it currently closely resembles the outgoing T:Slim in form and function the T:Slim X2 will soon introduce (via free software update) the long-overdue ability to display data directly from the Dexcom G5 continuous glucose monitor (CGM). In addition to wirelessly receiving information from other devices like the G5, the T:Slim X2 can transmit data to other devices such as the iPhone. This two-way communication opens up the very likely possibility of smartphone apps to display information from (and possibly even control) insulin pumps and CGM’s. Years down the road, the future-proof X2 platform will be able to incorporate “artificial pancreas” features such as predictive low glucose suspend and eventually fully autonomous closed loop systems.

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2. FDA approves Medtronic 570G, the next step toward the Artificial Pancreas The same month that the (underwhelming) 630G systems began shipping, the FDA surprised the diabetes community by approving the eagerly anticipated Medtronic 670G Hybrid Closed Loop system, including their next-generation CGM sensor. The Medtronic 670G’s landmark feature is its SmartGuard HCL (Hybrid Closed Loop) technology, which automatically adjusts the pump’s insulin rate to target a blood sugar of 120. Much like a car with adaptive cruise control, the 670G will increase or decrease the basal rate of insulin delivery but will still require user intervention for notable events such as mealtime boluses. The 670G also comes with the updated design introduced in the 630G, and includes the new Guardian 3 sensor, featuring better accuracy and a 7 day wear period (up from 6 days). Although Medtronic won’t ship the 670G until April 2017, the 670G’s FDA approval represents a pivotal step forward toward achieving the goal of a true Artificial Pancreas.

3. FDA Approves Abbott Freestyle Libre Pro System for Short-Term CGM Usage Although the Abbott Freestyle Libre has been available for personal use in Europe for years, the hybrid-CGM comes stateside with limited functionality as a professional system (rather than for personal use). That means the Libre Pro System would be purchased by health care providers to be worn by their patients for a 14 day period (this 14 day period improves upon the Medtronic iPro’s 4 day and Dexcom Professional’s 7 day period). During that 14 day period, the patient will not have to do any calibrations, BUT they would also not have real-time access to their CGM readings. At the end of the period, the patient would review their CGM data with their provider to identify patterns. While we’re still hoping that the FDA will eventually approve the version of the Freestyle Libre for long-term, personal use found in Europe, the Libre Pro System can still benefit patients in the USA whose insurance only covers short-term CGM trials. Also, the Freestyle Libre Pro System’s 14 day wear period and freedom from calibrations makes it an obvious upgrade over the Medtronic iPro. 4. Medtronic adds Android compatibility

CASE OF THE MONTH

KEEPING AN EYE ON YOUR FEET B Y S T E V E N V. E D E L M A N , M D to Connect The Connect is Medtronic’s answer to Dexcom’s Share, and comes in the form of a separate device that must be carried along with the pump and phone. Also, like the Dexcom’s smartphone connectivity, Medtronic had been limited to the Apple iPhone. Until now. With the release of MiniMed Connect in the Android Play Store, the Connect finally allows data from the 530G to be viewed from your smartphone, Apple or Android. (Dexcom plans to release a G5 app into the app store very soon). Unfortunately, the Medtronic Connect platform is curiously not compatible with the aforementioned upcoming 670G and their current top-of-the-line 630G. Original article featured on blog.tcoyd.org

y patients ask me all the time, “Do I really have to inspect my feet every night?” This practice is what most of the beginning education classes teach but ‘one size does not fit all’ when it comes to diabetes recommendations. If you have absolutely no loss of sensation in your feet and you feel every thing you step on, including little pebbles, then you do not need to worry more than anyone else who is not a diabetic. But, if you have a loss of sensation (the medical term is insensate) you do need to be more careful since you may step on something that could cause an infection if not removed and the wound cleaned. I have had type 1 diabetes for 47 years now and I am partially insensate. I was in my back yard and broke a glass on the cement patio (thank GAWD I had finished my Old Fashioned already!). Like a dummy, I was barefoot when I swept it up with a broom and dustpan and did not realize I had stepped on a piece of glass because I did not feel it. The next day I did feel the pain of inflammation and I saw redness around the cut on the bottom of my foot. I put some antibiotic ointment on it and covered it with a Band-Aid. Well…it was not getting any better and my girlfriend reminded me to use the PuracynPlus wound care solution I had in my medicine cabinet that I had received at one of our TCOYD conferences. Puracyn is an over-the-counter solution for the care of wounds and sores. The folks at Innovacyn, INC., the makers of Puracyn, came to me a year ago and wanted to be a sponsor of TCOYD and give out samples in the health fair and, to be honest, I was skeptical at first as I have a pet peeve about the unregulated

supplement industry that can promote false claims and are not FDA approved. Well, after I investigated the product I learned it IS FDA approved for the cleansing, irrigating, moistening and debridement (getting off dead tissue) of wounds and that it is used heavily by veterinarians. After two days of use I was really shocked by how improved my cut was, especially since it was deeper than I had originally thought. I have used it three other times since then with similarly impressive rapid healing. The bottom line for all of you peeps with diabetes is that you really need to pay attention to the feet when you have peripheral neuropathy and are partially or fully insensate. For wounds or sores anywhere on your body, jump on them with local wound care and try PuracynPlus. I think you will be just as impressed as I was. If you would like more information you can find it at www.puracynplus.com.

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could potentially save episodes of DKA, yet we have very limited access to them. I think at the end of the day, we all agreed that it is hard to come up with universal guidelines for exercise since it varies so much depending on the activity/sport, the duration, the intensity, and about a zillion other factors. That really is a common theme for just about every aspect of type 1 diabetes care, actually. It doesn’t matter if you are talking about how to control highs after eating, adjusting your basal rate, or tackling exercise; the approach is generally the same. If you have some good basic knowledge and some tools in your toolbox to tackle the problems, you can figure out a safe place to start, and with time and a lot of trial and error, you can perfect it. It is extremely rare that I adjust an insulin dose for a patient or a carb ratio or whatever and they come back saying, “Dr. Pettus, you freaking nailed it. I’m all fixed!” Much more often, with time and understanding of the concepts at play, patients figure it out for themselves. Ironically, as I’m typing this, I’m eating a piece of pizza and thinking, “What the hell am I going to bolus for this?” Ah, the learning never ends…

function usually returns back to normal when Afrezza is stopped. Your doctor should order a baseline test called spirometry to check your lung function before you start this medication. The safety of Afrezza has not been well-studied in patients with chronic lung disease (such as asthma, emphysema, or COPD) or in smokers. Therefore, you should not use this medication if you have chronic lung disease, if you are an active smoker, or you recently quit smoking within the last 6 months.

Don’t worry, you won’t be signing your life away. By joining the Registry, you are just giving us permission to contact you when new research surveys begin; you then have the option to participate or not. We will be starting a number of research projects in January, and this particular one (about how people with type 2 diabetes get started on insulin) is one of the most important projects we’ve ever done. And, as with all of our research surveys, we will express our gratitude by providing a small gift certificate to Amazon.

MY TCOYD NEWSLETTER, VOL 56

Conclusion Although insulin is the oldest medication used in the treatment of diabetes, we will continue to see improvements in the insulins available to patients. Afrezza inhaled insulin offers an exciting new opportunity for a faster acting insulin with fewer injections. The rapid-on/rapid-off effects of Afrezza may be a better option to control high glucose spikes after meals while decreasing the risk of delayed hypoglycemia.

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