2016 Summer Vol 55

MY

NEWSLETTER

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

Summer 2016 DR EDELMAN’S CORNER

Are You a “Non-Compliant” Patient?

Inside

I have never met a person with diabetes who doesn’t

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want to live a long and healthy life. However, people with

Do You Count Carbs?

diabetes (PWD) who don’t have perfect glucose control or

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don’t follow the exact instructions given to them by their

The Hodson Corner PA G E 5

Case of the Month PA G E 6

Ask Your Doctor PA G E 8

Giving Back PA G E 9

Product Theater PA G E 1 0

Living Well PA G E 1 1

Eating Well

healthcare providers (HCP) are often labeled as “non-compliant”. I see this all the time in our hospital with the medical students, residents, endocrine fellows, dieticians, CDEs and other faculty and staff.

Once a PWD is labeled as non-compliant in the medical records, anyone who reads the note in preparation for a future meeting or consultation has already developed a preconceived notion that this person is a “bad” patient and doesn’t follow the rules. It is a common situation that is pervasive among healthcare professionals in the community and is proven difficult to change or reverse. It also poisons the “doctor-patient” relationship, which I feel is extremely important for long-term success and satisfaction on both sides of the aisle!

Why is it that so many PWD have less than ideal diabetes control and are labeled non-compliant? There are many diverse reasons, ranging from emotional, financial and physical barriers for the patient to uninformed and ignorant healthcare providers and, also, limited access to the best therapies currently available for many, many patients.

The non-compliant label also stems from recent information that has emerged from very large databases (administrative claims and pharmacy refill records from large healthcare institutions) that people with type 2 diabetes apparently are not taking or refilling their medications regularly. According to these very accurate sources of prescription and refill information, a PWD is labeled “non-adC 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 Steven V. Edelman, MD Stephen Ku, MD Sonnet Lauberth Chef Robert Lewis Jeremy Pettus, MD Lauren Ziminsky 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 Breann Robinson Administrative Assistant MyTCOYD Newsletter Robyn Sembera Editor in Chief Sarah Severance, Jennifer Braidwood, 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 services of 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

herent” if they do not have medication in their possession at least 80% of the time. This information is based on when an individual requests a refill on his/her medications.

The data on adherence with type 2 medication is shocking! For example, only 50% of people with type 2 diabetes (PWT2D) are still taking their oral diabetes medications one year after it was prescribed and only 20% are still taking injectable therapies, such as insulin, after one year. There was one recent publication that reported 30% of PWT2D never even filled their prescription for a new diabetes medication in the first place! It turns out that non-adherent patients cost the system tons of bucks in terms of higher rates of complications, hospitalizations, lost days from work, disability claims, etc.

The list goes on and on and this is not to mention the human suffering that affects the entire family when an individual is not under control and develops complications. What is happening? Are they talking about you?

Sometimes I think living with type 2 diabetes is tougher than living with type 1. This condition requires major lifestyle changes over the long term and it is associated with being overweight and having hypertension and cholesterol problems. Type 2 diabetes is a poly-pharmacy condition requiring a truckload of medications to keep these important

medical problems under control. In addition, these problems are often silent, which means you feel no different whether your blood pressure, cholesterol or glucose levels are well-controlled or not. The lack of symptoms, even when they are poorly controlled, results in many people feeling no sense of urgency to take their medications. It takes a lot of motivation to take a handful of prescription medications and/or injections a couple of times every day for conditions with no symptoms, not to mention the high cost for some of these drugs.

Whether you have type 1 or type 2 diabetes, the answer to improving diabetes control in this country is partly in developing new drugs and devices, but the most impactful remedy will be changing the attitudes of caregivers toward their patients and educating, motivating and supporting PWD by addressing their individual physical and emotional fears, needs and concerns. This takes time and, ideally, a multidisciplinary approach. HCPs must be empathetic with their patients who have diabetes and help them to understand why it is important for their good health to take their medications as they are prescribed. Additionally, those living with diabetes must become engaged and activated in their own self-care. It is the rare HCP who went into the field of medicine for any reason except to help people and I have never met a PWD who doesn’t want to live a long and healthy life.

The lack of symptoms, even when they are poorly controlled, results in many people feeling no sense of urgency to take their medications. It takes a lot of motivation to take a handful of prescription medications and/or injections a couple of times every day for conditions with no symptoms, not to mention the high cost for some of these drugs.

TCOYD IN MOTION

Do You Count Carbs…or NOT? T Y P E 1 C O R N E R BY S T E V E N V. E D E L M A N , M D, A N D J E R E M Y H . P E T T U S , M D

Carb counting seems to be the standard of care for how people with type 1 diabetes calculate how much insulin to take before meals. I think most folks would agree it is not a perfect method and often does not seem to work.

Of course, some would say to simply not eat carbs and, while we agree that strategy can work for some, the majority of us DO eat carbs (GASP!).

Steve’s Take: I DO NOT CARB COUNT! I was brought up on the exchange system, which was the fad back in 1970 when I was diagnosed. It is my personal feeling that carb counting is seriously flawed. Most folks, including experienced dietitians, cannot count carbs accurately.

If THEY can’t do it accurately, how do the rest of us mortals do it? Also, neither fat or protein is “free”. They both contain calories and will raise your blood sugar level, but just slower. I think people that just dose on carbs but also eat protein and fat in their meal tend to under dose themselves. I look at my total calories and try to get a sense if the food I am eating is caloric dense (has a lot of carbs in it) and then give my best estimate based on past experience. I also have a CGM that helps me with follow-on doses if needed. In the best of all worlds, we would have a phone app that scans our plate and can recognize the type and amount of nutrient on the plate and give a suggested dose base on past experiences, insulin sensitivity (insulin to carb, fat and protein ratios), and the CGM trend arrow. That would reduce the frustration many of us have in guestimating our doses.

Jeremy’s Take: My take is actually pretty similar to Steve’s. When I was diagnosed, the exchange system was being used, so I never really learned how to properly carb count. So, no, I do not “officially” carb count in that I never look at a plate, say in

my head “that has X carbs” and then make some calculation. I also don’t enter carbs into a pump. I do, however, take insulin based on how many carbs I am eating, but that is more qualitative rather than quantitative, and based on past experience. In other words, I use my type 1 SWAG (sophisticated-wild-ass-guess). Do I always get it “right”? Of course not, but I do pretty well.

I disagree with Steve a bit in his assessment of what would happen in a “perfect world”. In my perfect world, we wouldn’t have to do any of this crap! What we demand of type 1s is, in my opinion, absurd. We ask patients to carefully measure all their food, take their insulin according to that, oh, and don’t forget to account for your current BG, your BG trend, if you have just exercised, how quickly your insulin will work, what time of day it is, if your basal rate is right, what the macronutrient breakdown of the food is (protein, fat, etc.), what day of the week it is, what street you grew up on, the name of your first pet, and what phase the moon is in. It’s ridiculous! Can you think of any other medical condition that is this way?

The solution is not to have patients do better, it’s for the scientific and T1D community to come up with better treatment options. Maybe the answer is an artificial pancreas. I love how the Boston AP group uses meal announcement

based on YOUR typical size. It asks if you are eating a typical meal, a slightly bigger than usual meal, or a snack. Isn’t that so much easier? Or maybe the answer is in other therapeutics or islet replacement strategy, or maybe some combination of all of these. While Steve’s idea of scanning the food would be pretty sweet, I think we can do better. More than that, I think we WILL do better and very soon. I see an AP system coming to market in the next 2-3 years, I see islet cell encapsulation becoming a reality, I see an expansion of alternative therapies (SGLT-2i), and more.

In the meantime, it’s back to, “Hmmm…. let’s adjust your carb ratio from 1:10 to 1:8.

That oughta fix things.”

TCOYD IN MOTION

The Hodson Corner Highlights from the American Diabetes Association Scientific Sessions, New Orleans, Summer 2016 JEREMY HODSON PETTUS, MD

Let’s talk about what I thought was interesting at this important annual meeting. It’s a little long, so I recommend cracking open a bottle of bourbon and getting the bubble bath going before reading.

Or read it in your office. Whatever. But here it goes…

did at baseline to during the study. Key findings showed: Artificial Pancreas Developments The big splash in this department was made by Medtronic’s presentation on the results of their new 670g system. This pump is a hybrid closed loop device that modulates basal rates but still requires boluses for meals. So not a fully closed loop, but the next step in their line of products from their current low glucose suspend pump, to their predictive low glucose suspend, then to this model. This study took 124 type 1s and compared how they 4

MY TCOYD NEWSLETTER, VOL 55

• •

•

•

Reduction of A1c from 7.4 to 6.9 Slightly improved time in range (few highs and lows) Reduction of time < 70 and < 50mg/dl.

Both cut almost in half Slightly more insulin use and weight gain

My take on this study? To be honest, it’s pretty impressive that a group of already well-controlled type 1s (baseline A1c again was 7.4) was able to lower their A1c by 0.5% AND reduce their rates of hypoglycemia. The 670g uses a new Enlite

sensor with accuracy of ~10% which still isn’t as good as the current Dexcom (~9%) but is getting close. Also, the pump is updated and looks more like a 21st century electronic device instead of the pager my parents made me carry around in high school (true story).

The really cool thing is that Medtronic is submitting this to the FDA now and is on track to have it on the market by April 2017.

While Medtronic continues on this plan of slowly improving their pumps in their stepwise manner, others continue on working on fully closed loop systems.

The debate continues on whether these devices will require insulin only or insulin with glucagon. The current plan is that the Boston group will be doing a study comparing an insulin only model with a dual-hormonal one that will help to see what the added value of glucagon in an AP system is. Tandem also just announced that they are joining forces with Type Zero to accelerate their AP technology. This brings me to my next point….

CASE OF THE MONTH Faster acting insulins for type 1 and type 2 diabetes This is something we have all been begging for forever. We now have about 37 basal insulins to choose from that actually work really well, but our rapid-acting insulins are still painfully slow.

Nothing worse than staring at your CGM with a high number that constantly reminds you of how worthless you are and your rage bolus won’t touch it for like an hour. With that in mind, I was excited to hear more on this front. Steve and I had the pleasure of chairing a session on new therapeutics for type 1 diabetes that did feature rapid acting insulin developments. The two that were highlighted were Novo’s faster acting Aspart (Novolog) and Adocia’s modifications to Humalog to make it work faster.

I was disappointed with the Aspart data showing that the difference in the 2hr postprandial glucose was only about 12mg/dl. Awesome…so instead of being 284 after my Cinnabon, I will be 272. That doesn’t get me very fired up.

The Adocia insulin, though, showed some more meaningful results with 1hr and 2hr improvements of 42mg/ dl and 27mg/dl. Results like that might actually make an insulin only treatment in an artificial pancreas meaningful. In other words, if we really could have a rapid-acting insulin that could get in the system quickly and then get out, we may not need glucagon. There are rumors of different AP systems looking to use these different insulins in their devices. Don’t forget that MannKind is now marketing Afrezza and this inhaled insulin does work extremely well at limiting post meal highs and delayed hypos.

SGLT-2s for type 1s and type 2s This class of agents has been very positive for the folks with type 2 diabetes but there have also been some benefits observed in type 1 diabetes. These are meds approved for type 2s like Invokana, Jardiance, and Farxiga that some type 1s are also taking. The data in people with both types of diabetes from

all three companies shows a consistent trend that these medications lower A1c, improve time in range, cause weight loss, lower blood pressure slightly; however, they have a very low but concerning increase in the rates of ketoacidosis (a condition that could put you in the hospital). People are really split on this issue with many STILL saying that type 1s need insulin and only insulin to control their blood sugars. I wish this were the case, but the fact remains that most type 1s are not at A1c goal, even with the best pumps, CGMs, doctors (other than Steve and I) etc. We could use a med like this for sure, but the side effects need to be teased out. My advice again to any type 1 using these meds is to use the lowest dose possible, never miss or omit insulin doses, and think about investing in Abbott’s ketone meter to see what your ketones, which are high if you are developing ketoacidosis, are running. A baseline value is good, especially if you are sick. The real, almost unspoken benefit of these meds, however, is the improvement in quality of life. Yeah, your A1c might get a little better, but they definitely improve your time in range with less work. That means less chaos and a little more freedom to get your insulin doses wrong and not always pay for it.

What I mean is that if you should have bolused 5 units, but only took 4, these meds seem to pick up the slack. If you have type 2 diabetes, this class has been an awesome addition to the toolbox and can be used with any other oral or injectable type 2 medication.

More big news from the type 2 world, is that one of these drugs (Jardiance) was shown this year to lower cardiovascular outcomes AND kidney issues. Specifically, patients who took this medication were, to be blunt, less likely to die from heart issues (heart attacks, heart failure, etc.) as well as less likely to have new or worsening kidney disease.

Similar benefits were also shown at the meeting with liraglutide (Victoza),

TESTING YOUR BASAL INSULIN RATE

BY S T E V E N V. E D E L M A N , M D

Q:

I am a 48-year-old male with type 2 diabetes.

I’m treated with Tresiba, the new long-acting basal insulin that I take every morning, and Novolog, the insulin I take with my meals. As my diabetes doctor suggested, I had nothing to eat after dinner and made sure when I went to bed at 11pm that my Dexcom G5 CGM value was between 140 and 180 with a horizontal trend arrow indicating that my sugar was not rising or dropping. You can see my 24-hour profile here. I want to know if my basal insulin dose is correct and also why I have to confirm my CGM value with a fingerstick from my meter when I dose the insulin? The numbers are uniformly very close.

Comment: Getting your basal insulin dose adjusted correctly is very important whether you are a type 1 or type 2 on a multiple daily injection (MDI) regimen or an insulin pump. You performed a perfect test. Your doctor must have been to one of my lectures! To test your basal dose during the day, you should skip breakfast if you can and then not eat until dinnertime. Since you have a CGM it is very easy! If you don’t have a CGM, then pricking your finger every 2-4 hours will be important to give you the information needed to assess your basal dose of insulin. It looks like your typical upward excursions are due to meals and not your basal dose. A perfect basal insulin dose, or rate if you are using a pump, is the amount or rate that keeps your glucose values perfectly flat when you are fasting (not eating) but still doing your normal daily activities.

Your last question is timely since the FDA just had a panel meeting to give Dexcom approval for non-adjunctive use, meaning that you do not need to double check your Dexcom value with a fingerstick for day-to-day diabetes decision making. The final approval will come sometime in the 4th quarter of this year. I have been using my CGM values to dose my insulin because I have a lot of trust in my Dexcom.

C O N T I N U E D O N PA G E 1 2

TA K I N G CO N T R O L O F YO U R D I A B E T E S

5

ASK YOUR DOCTOR

Update:

BY STEPHEN KU, MD

turned against glucose-lowering medications in recent years when the drug rosiglitazone was implicated in leading to an increase in heart attacks and death from cardiovascular causes, even though it was later cleared of all charges! These concerns culminated in new guidelines issued by the United States FDA (Food and Drug Administration) in 2008, essentially shifting the burden of proof onto pharmaceutical companies to demonstrate that novel therapies for type 2 diabetes are safe from a cardiovascular standpoint.

O

ne of the most important long term consequences of living with type 2 diabetes is an increased risk of cardiovascular disease, including heart attacks and strokes. Unfortunately, the hope that improved control of blood glucose levels would decrease this risk has not been borne out, despite several large and high-quality studies. In fact, the tide

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Since 2008, six trials have been completed and reported, in large part supporting the cardiovascular safety of the drugs of interest: saxagliptin (Onglyza), alogliptin (Nesina), sitagliptin (Januvia), lixisenatide (Lyxumia), liraglutide (Victoza), and empagliflozin (Jardiance). Most exciting is that in the last year, the results of the empagliflozin trial and liraglutide trial were published and unexpectedly demonstrated beneficial cardiovascular effects in type 2 diabetes patients who had high pre-existing cardiovascular risk.

Empagliflozin is an oral pill that lowers blood sugars by encouraging the transport of glucose out of the body via the kidneys and urine, while liraglutide is an injectable medication that modulates the

How the New Medications for Type 2 Diabetes Affect the Heart release of naturally-produced insulin and glucagon. During approximately three years of study, empagliflozin showed a reduced risk of heart attack, stroke, or cardiovascular death (10.5% risk with drug versus 12.1% risk without drug). Similarly, during almost four years of study, liraglutide also showed a reduced risk of heart attack, stroke, or cardiovascular death (13.0% risk with drug versus 14.9% risk without drug). These differences may not seem large, but there were a ton of participants in these studies , which makes small changes quite significant. The importance of these findings is that for the first time, specific glucose-lowering therapies have been found to reduce cardiovascular disease in high-risk patients with type 2 diabetes. Certainly, a great deal of attention is now focused on these medications, and more work is underway to determine how empagliflozin and liraglutide might be producing these benefits and whether related drugs will have similar effects. There is little doubt that these studies mark a new stage in our understanding of the prevention of cardiovascular disease in type 2 diabetes. It is also important to note that the other completed studies showed no adverse effects and were basically the same as placebo. The ways these studies were conducted were quite different which also affects the results.

The importance of these findings is that for the first time, specific glucose-lowering therapies have been found to reduce cardiovascular disease in high-risk patients with type 2 diabetes.

TA K I N G CO N T R O L O F YO U R D I A B E T E S

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GIVING BACK

Have you been denied coverage for a Continuous Glucose Monitor (CGM)

by Medicare? If you have, TCOYD may be able to help!

We have received a grant from The Leona M. & Harry B. Helmsley Charitable Trust to enable TCOYD to assist in the appeals process of low-income Medicare beneficiaries with diabetes who require multiple daily injections or insulin pump therapy, and suffer from hypoglycemia unawareness (the inability to recognize when your blood sugar is too low).

We are thrilled to be able to offer this opportunity and hope that – with enough successful appeals – we can ultimately affect Medicare policy by demonstrating that Continuous Glucose Monitoring devices can be life saving.

For more information, and to apply for assistance in appealing your denial, please visit the TCOYD website at tcoyd.org.

A Big “Thank You” to Dexcom!

BY S T E V E N V. E D E L M A N , M D

Our friends at Dexcom are celebrating the 10-Year Anniversary of the launch of their first continuous glucose monitor. In honor of this truly momentous event, they have conducted a charitable campaign, asking their customers to choose their favorite nonprofit organization to be the recipient of a $10 donation from Dexcom.

TCOYD is thrilled to have received several thousand dollars from hundreds of Dexcom customers. These gifts will help to fuel all of the work we are doing in and for the diabetes community. Dexcom is an awesome supporter of patient education and our TCOYD conferences are stronger because of their support.

I also want to say congratulations to Dexcom for their successful

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panel meeting with the FDA on July 21st regarding the “non-adjunctive” use of their G5 Mobile CGM device. When this new use is formally approved, it will mean that users like myself will not be required to double check our glucose values by pricking our fingers and testing with a glucose meter before we dose our insulin and make other important diabetes treatment decisions. Many of us who use the

Dexcom CGM already rely solely on the glucose values generated by our CGM device, but it is important that the company have this claim on their product labeling so that they will be allowed to educate health care professionals and people with diabetes about when it is safe and when it isn’t safe to trust the CGM value alone.

This will be a very important and helpful advance in the use of CGM.

P RO D U C T T H E AT E R

Let the Countdown Begin to Simplified Blood Glucose Monitoring Simplify Your Diabetes Needs with the POGOÂŽ Automaticâ&#x201E;˘ Blood Glucose Monitoring System by Intuity Medical, Inc. The POGO System is the first blood glucose meter and multi-test cartridge to provide automatic testing with lancing, blood collection and analysis in one easy step. By combining all of the necessary blood glucose testing supplies into a convenient, self-contained 10-test cartridge, POGO provides ease of use and discretion for millions of patients who need to regularly test their blood glucose in the management of their diabetes. POGO eliminated the need to carry and use separate test supplies, including a lancing device, lancets and test strips. This means patients can perform a quick and discreet glucose test, while on the go!

automatically lances the finger, collects a blood sample and displays a result after a four-second countdown. The meter only requires a tiny blood sample of .25 microliters to analyze the glucose value. After all ten tests are complete, the patient disposes of the self-contained cartridge, eliminating the need to handle used test strips or lancets since they remain inside the cartridge. This reduces the biohazards of used lancets and used test strips in public areas. For more information about Intuity Medical and the POGO Automatic, please visit www. presspogo.com

To perform a test, a patient simply presses the POGO test port, and POGO

Taking Control Of Your Diabetes is Generously Supported By: Platinum Sponsors

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TA K I N G CO N T R O L O F YO U R D I A B E T E S

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LIVING WELL

Diabetes Fashion:

MYABETIC STYLE

BY LAUREN ZIMINSKY

M

yabetic, a company transforming the diabetes image, joined the TCOYD tour back in 2015. The diabetes fashion brand was established after founder Kyrra Richards battled with her type 1 diagnosis at 24 years old.

The professional dancer and model had returned home to Los Angeles from a tour in Afghanistan dancing for the troops when she decided to schedule a doctor’s appointment due to her insatiable thirst.

After guzzling down 24 water bottles in one night, she entered her doctor’s office proclaiming her suspicion that she had “broken her bladder” and left with a life-altering diabetes diagnosis.

As a performing artist, she considered her physicality her livelihood. She was terrified that a negative appearance would cause damage to her career and social life. “I hate to admit it, but I was embarrassed. I didn’t want people to judge me. I didn’t want them to associate me with a disease, so my health suffered.”

Richards explained that she would avoid

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MY TCOYD NEWSLETTER, VOL 55

testing her blood sugar or injecting insulin in public. “That lousy, tattered meter case made me feel like a medical patient and reflected my insecurity, so I hid it.”

She realized her attitude was harmful and began to think of ways to change her outlook.

“Art has always been my way of coping with tearful frustration, so one day I began sketching medical fantasies. I tried to envision what diabetes would look like if it were chic and beautiful.” And so Myabetic was born.

The company creates fashionable products to promote style, not shame. Their premium diabetes wallets, handbags and cases are specially designed for diabetes supplies, and their fashionable clothing encourages confidence for men, women, and children living with type 1 and type 2 diabetes. Myabetic also creates custom accessories for Tandem Diabetes Care insulin pumps and Dexcom continuous glucose monitors.

This year, Myabetic proudly announced their nationwide launch in Target stores. Their fashionable diabetes supply cases can now be found in the diabetes section of Target pharmacies.

Myabetic has joined the exhibit floor of many TCOYD health fairs, and Richards has been a featured speaker at conference discussions. “We love the community and support TCOYD provides. It’s an accepting, understanding environment, and we’re honored to be part of it.”

TCOYD members can now enjoy 15% off when using discount code TCOYD at check out: www.myabetic.com

This year, Myabetic proudly announced their nationwide launch in Target stores. Their fashionable diabetes supply cases can now be found in the diabetes section of Target pharmacies.

E AT I N G W E L L

Summertime’s Here!

Enjoy What’s Fresh Zucchini Boat Pizzas These “pizzas” are perfect for this time of year, zucchini, tomatoes, and basil are all in season! Adapt the recipe by adding toppings of choice! Spice it up with some turkey sausage or seasoned feta cheese.

Now that you see how easy it is, there’s no excuse not to enjoy this oh-so-delicious and healthy version of your favorite comfort food! Original recipe found at: insonnetskitchen.com/zucchinipizza-boats/

Servings 2 4 medium zucchini ½ cup marinara or pizza sauce ¼ red onion, sliced ¼ cup kalmata olives, chopped ½ cup cherry tomatoes, sliced 2 tablespoons fresh basil chiffonade

Preheat oven to 400 F. Cut the zucchini in half lengthwise and scoop out the inside seeds. To help them lay flat on the pan, you can also cut a piece off the bottom of the “boat” to create a flat surface.

Mix tomato sauce and nutritional yeast (if using).

Spread a light layer of sauce (about 1 tablespoon) inside each zucchini. Top with onions, olives, and tomatoes. Bake for 20-25 minutes, until zucchini is tender (but not mushy). Top with basil and serve.

2 servings: Depending on the type of marinara or pizza sauce used, the nutritional facts may slightly change. 280 calories 8.4g fat 46g carb 11.5g fiber 22.75g sugar 11.25g protein

FROM CHEF ROBER T, THE HAPPY DIABE TIC

Simple Grilled Peaches of LOVE

Salmon Skewers of LOVE Serves 4

Peaches

2 medium-size (about 4oz)

Canola oil

fresh salmon filets

First, preheat the grill for medium heat.

Next, clean and lightly oil the grates with canola and cut the peaches in half, and remove the pit. Brush fruit with oil (canola oil works well), and grill, cut sides down, until grill marks appear.

Turn, and continue grilling peaches until the fruit is softened. Total grilling time is about 6 - 8 minutes.

2 green peppers

Skin salmon and cut it into 1-inch pieces. Mix garlic, oil, basil and lemon juice in a bowl. Combine with salmon and refrigerate for 2 hours. Place skewers in cold water for 10 minutes before building them.

(This will keep them from burning.) Cut veggies into 1-inch pieces. Alternate peppers, onions, mushrooms, and salmon on skewers. Place on a hot grill for 8 to 10 minutes, turning often, or place on a baking sheet in a 375-degree oven for 10 to 12 minutes.

1 red onion

Per serving: 226 calories 26.5g fat 9.3 g carb 40g protein

2 tablespoons fresh garlic 3 tablespoons extra virgin olive oil 2-3 large leaves of fresh basil 2 tablespoons fresh lemon juice 1 red pepper

1 large Portobello mushroom 4 bamboo skewers T A K I N G C O N T R O L O F Y O U R D I A B E T E S 11

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T H E H O D S O N C O R N E R F R O M PA G E 5

however it took longer to see the CV benefits.

Now, these results were shown in type 2s who already had some type of heart issues, but it makes you wonder if the same thing would apply to type 1s. It certainly would shift the risk/benefit ratio of this class of medications.

If they made life better AND prevented these major health issues, well, now you’re cooking.

Unfortunately, I doubt we will ever get this type of study in type 1s, but you never know.

CGM stuff Dexcom presented the results from their “DIAMOND” study. Diamond is some ridiculous acronym for this study that basically took type 1s on injections (NOT on pumps) and randomized them to get either “usual care” or a Dexcom CGM. Not surprisingly, the CGM arm lowered their A1c by 0.9% (vs 0.4% in the usual care arm) and significantly reduced hypoglycemia. Now, if you are like me, the first time I heard these results, my initial reaction was “no

sh*t!” It’s pretty obvious to me that CGM helps nearly everyone with diabetes, but I think this study was important for several reasons: A. We haven’t had a study like this for years, and the best study we had previously was back when we were using the older CGM (seven plus) models that were much less accurate. So it’s nice to see that with improved accuracy we can get really good results.

B. This really sets the message that you don’t need a pump to get the benefit of a CGM, and basically, that CGM should be the FIRST piece of technology for insulin users. In other words, changing the current standard of care where patients are commonly pushed toward pump therapy but CGM is viewed as a “if you really want it” kind of thing. I’m hoping this data will change providers to realizing that patients can get insulin through pumps or shots,

but CGM provides data that you CAN NOT get from fingersticks alone.

C. The next piece of this study will be to take the patients who are on CGM and randomize them to pump therapy or not. That way we will be able to see the added benefit of pump therapy AFTER CGM. My guess is that pumps will maybe have a very slight edge in terms of A1c and maybe hypoglycemia. But who knows, there may be NO additional benefit. Wouldn’t that be something?

Lastly, Dexcom, in collaboration with Google, is developing a small, easy to apply, disposable and inexpensive CGM for people with type 2 diabetes at all stages from pre-diabetes to oral agents only to insulin therapy. Just think….no more pricking your fingers!

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