From ADA Standards of Care 2017 – Page S12

The rate of progression is dependent on the age at first detection of antibody, number of antibodies, antibody specificity, and antibody titer.
Glucose and A1C levels rise well before the clinical onset of diabetes, making diagnosis feasible well before the onset of DKA.
Three distinct stages of type 1 diabetes can be identified (Table 2.1) and serve as a framework for future research and regulatory decision making (4,5).

iHealth Gluco Pro – A Real-Life Tool for CDCESs^®

iHealth Gluco Pro is a diabetes management application and clinical practice tool that helps Certified Diabetes Care and Education Specialists, (CDCESs®) maintain a real-connection with their patients between visits. It allows patients with diabetes to share their blood sugar levels, physical activity, nutrition intake, and medication with their educator.

“Now CDCESs^® can help their patients where they need it the most – in the real world. Our patients are using mobile phones more than ever. This iHealth Gluco Pro App is a great way to interact with patients and interject snippets of information and coaching when it means the most to them.”   Chuck Newcombe, MS, RD, CDCES –  Diabetes Expert and consultant with iHealth Labs

Pioneering CDCESs^® Needed – Stipend and Supplies included

Gluco Pro is looking for about 20 pioneering CDCESs^® that would like to evaluate the effectiveness of this innovative app in improving the patient – CDCES^® connection. The goal is to enroll 200 – 300 patients to evaluate the effectiveness of this innovative app.  That means, each CDCES^® would need to enroll 10-15 patients.

There is a stipend for CDCESs^® and a Bluetooth meter with test strips for their patients using only iOS devices. With feedback from patients and CDCESs^®, the Human Factor Study will help determine the effectiveness of the app in real life setting.

Yes, I want to help evaluate Gluco Pro >>

iHealth Gluco Pro Screen and Features

The cost of insulin continues to rise dramatically and steadily, especially in the past few years.

The American Diabetes Association just published the 2017 Standards of Care! Section 8 Reviews the average wholesale price per 1000 units of insulin as listed in the chart below.  Thank you ADA for sharing this incredibly useful and powerful information with the diabetes community.

Concentrated Insulin Update

There are currently 4 different concentrated Insulins as shown in the chart below. With the increasing BMI in the population of people with diabetes, daily doses of more than 100 units are more common. Concentrated insulins are particularly useful for people requiring these higher insulin doses.

Of all the concentrated insulins, only U-500 is still available in a vial. In July, 2016 the FDA approved  the first dedicated U-500 syringe. The U-500 syringe, manufactured by BD, will be available starting November 2016. 
The updated package insert for U-500 reflects this change and requires that only U-500 syringes be used with U-500 insulin.

FDA requires that all newly approved concentrated insulins have a matching delivery devices. As a result, all of the newer concentrated insulins are available only in a pen delivery device. U-500 is still available in a vial for use only with a dedicated U-500 syringe or in a U-500 pen.

Concentrated Insulin Chart from NEW PocketCards

Concentrated insulins deliver the same dose of insulin in less volume.

• U-200 = 2x’s the concentration of U-100 insulin
• U-300 = 3x’s the concentration of U-100 insulin
• U-500 = 5x’s the concentration of U-100 insulin

Clearing the confusion with Concentrated Pens – No conversion required!
The pens automatically deliver the correct dose (in less volume). No conversion, calculation or adjustments are required.  For example, if an order reads 10 units insulin, dial the concentrated pen to 10 units.  The pen will deliver the correct amount of insulin in less volume.

Warnings – Make sure to carefully read the label on the pen and look for the yellow or red boxed information that indicates the insulin is concentrated.
Also make sure patients know that they should never withdraw concentrated insulin from the pen using a syringe. This could lead to an overdose of insulin and hypoglycemia.

Want to learn more? 

• Purchase our Meds Management Update Webinar
• Download FREE Set of 4 Medication / Insulin PocketCards

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Want to keep on top of the latest medications?  Download our CDE Coach App.

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Treating type 2 diabetes is complicated. Supporting behavior change is the foundation of diabetes self-management. Medications are the next line of defense to prevent diabetes complications and get to the best health possible.

As providers and educators we are compelled be familiar with the wide range of medications that are currently available to treat diabetes. As patient advocates, we also perform a cost/benefit analysis to determine which medication would be the best match, considering cost, side effects and complexity.

There have been flurry of updates on existing medications. And many of the newly approved medications offer the hope of decreasing complexity, by combining 2 of different classes of medication in one shot. Plus, there are now four different concentrated insulins. Read on to learn more >>

Important Medication Updates

Metformin – new GFR renal threshold info approved by FDA.

• If GFR <30, do not use
• If GFR <45, don’t start metformin
• If pt on metformin and GFR falls to 30-45, eval risk vs. benefit and consider decreasing dose.

For dye study, if GFR <60, or with liver disease, alcoholism or heart failure, restart metformin after 48 hrs if renal function stable.

DPP-IV Inhibitors – New Warnings

• This class of med can cause disabling joint pain. Stop med, contact provider.
• Saxagliptin (Onglyza) and alogliptin (Nesina) can increase risk of heart failure. Notify provider if patient experiences shortness of breath, edema.

SGLT-2 Inhibitors – Considerations

• Can increase risk of ketoacidosis
• Empagliflozin (Jardiance) lowers all cause mortality 32%

To keep up with the latest medication updates, download our FREE Medication Pocket Cards

Our body responds to stress by releasing hormones that increase glucose levels to provide muscles with the fuel they need to engage in battle. This system works well if you don’t have diabetes. However, for people living with insulin deficiency and /or resistance, chronic stress can make glycemic control even more challenging. In addition, stress can cause a detour in the best laid plans to eat healthier and exercise more. Hence, the “Double Whammy” of diabetes and stress.

We asked our special guest contributor to share her expertise on stress and provide us with some coping strategies we can pass along to our patients. Thanks Cathy!

How does daily stress impact people?
Most adults experience some level of stress on a daily basis.  Everything from the minor annoyance of a traffic jam to the life-altering commitment of caring for a chronically ill family member can lead to the familiar feelings of uneasiness, muscle tension, difficulty concentrating, changes in sleep and appetite, irritability, headaches, gastrointestinal problems, increased heart rate, trembling, and even feeling faint.  Stress affects the physical functioning of the body as well as common behaviors, making it particularly challenging for people with diabetes.

How does stress increase blood glucose levels?

When faced with a stress or danger, the body initiates an immediate and well-coordinated fight or flight response that allows 
a person to fight the danger or flee it.  Stress hormones, like adrenaline and cortisol, are released causing an elevation in glucose levels. In people without diabetes, this glucose surge is beneficial; it provides energy for muscles to fight off the danger or to outrun it. The system is based on the assumption that the extra glucose will be spent while conquering the dangerous situation, allowing the body to return to a normal (baseline) state. For centuries this system has allowed humans to always be ready to handle threats to their survival.

How have the effects on stress impacted human’s overtime?

It’s rare for modern stressors to require physical fighting or fleeing.  Stressors are more often encountered while sitting still — paying bills, sitting in traffic, working at a desk, or having a difficult conversation. Unfortunately the fight or flight response is so ingrained and automatic that it does not allow for differentiation between stress that requires action and stress that requires other types of responses. If the stressor does not necessitate the use of muscles, glucose levels can climb in the bloodstream stimulating the pancreas to increase insulin release.

What is the impact of stress on people with diabetes?

Stress has a dual effect on diabetes. Life stressors can affect behavior by influencing decision-making abilities (such as snacking on unintended foods or skipping exercise). Plus, stress activates the body’s fight or flight response increasing glucose levels circulating in the blood. Recognition of the double impact of stress on individuals with diabetes highlights the need for effective stress management as an integral part of diabetes management programs. 

What are some tools that Diabetes Educators can share?

Several techniques can be employed to help alleviate stress. Perhaps the most important skill is to learn to identify stressors. Often individuals report feeling weighed down and stressed out.  It can be surprisingly difficult to pinpoint the causes of those feelings.  However, taking some time to discuss them with another person can be helpful in naming the stress-causing demands on their lives.  Once identified, one can work to lessen or eliminate the stress or to increase their ability to manage the stress.

There are numerous effective ways to reduce feelings of stress, making it possible to find a technique that fits into the lifestyle and values of the individual who will be using it. An active, energetic person might find that exercise is a great stress-reducer. Alternatively, a person who values calm and quiet may prefer taking several slow, deep breaths to encourage relaxation.

Several relaxation techniques, such as progressive muscle relaxation (PMR), meditation, journaling and guided imagery, have actually been shown to reduce glucose levels in people with diabetes in addition to reducing feelings of stress.  There are many books and internet resources available that can provide more detail or instruction on these techniques.  In some cases, individuals find it helpful to enlist the help of a therapist who is trained in ways to help reduce stress and change thought patterns.

While no one likes the feeling of stress, it’s clear that it is especially detrimental to those with diabetes.  Featuring stress management in diabetes management programs can bring about positive changes psychologically as well as physically.

Special thanks to our guest contributor, Cathy A. Bykowski, from Tampa, Florida. Her research and clinical interests revolve around the relationship between mental and physical health, and in particular, how psychological factors affect diabetes outcomes. She is actively recruiting participants for her FREE Stress and Mood Management Program to complete her PhD. Please share this valuable resource with your patients.

Here is a fact: oral health and blood sugars are inter-related and regular dental care for people living with diabetes is critical.

A close look at the 2015 ADA Standards of Care, reveal that referral to a “Dentist for comprehensive periodontal examination” is situated right under referral to a “RD for MNT,” and referral for “DSME/DSMS” within the “Components of the comprehensive diabetes evaluation,” on page s18.

As diabetes educators, we have an opportunity to learn more about the dynamic relationship between these two conditions and encourage patients to be active participants in their oral health.

Here are the questions we posed to our expert contributor, Jerry Brown, DMD, CDCES.  His responses appear below.

1)  What is the relationship between hyperglycemia and oral health?

Wow! That is normally a 60 – 90 minute presentation! Diabetes and periodontal disease have what we call a “bi-directional” relationship.

Simply put, in one direction, diabetes contributes to an inflammatory environment within the oral cavity and an exaggerated, destructive host response. In the other direction, the infectious process of periodontal disease, coupled with pervasive inflammation, can make glycemic control more difficult.

2) As diabetes educators, what questions can we ask the patient to find out about their oral health status? What should we include in our visual assessment?

The patient health history, or interview should include the following questions:

• When was the last time you visited the dental office for a cleaning?
• Do your gums generally bleed when you brush?
• Have you ever been told that you have “gingivitis”, or “gum disease?”
• Have you noticed any areas on your gums that get red, or swell?
• Do you notice, or have others noticed, that your breath has a consistently foul odor?
• Have you noticed any looseness or shifting of your teeth?
• Have you had dental extractions in the past?
• Have your parents or your siblings lost teeth because of gum disease?

    As part of a visual assessment, look for:

• Missing teeth, teeth with obvious tooth decay (disruption of the enamel surface with staining), dry mouth, raspberry-red tongue surface with yellowish-white patches, generalized exposed root surfaces of teeth, and mobile teeth. These findings indicate need for prompt dental referral.

3) What steps can patients take to maintain oral health?

Promote Preventive Oral Care/Maintenance includes:

• Professional Dental Hygiene visits with periodontal probing every 3 – 6 months.
• Brushing with soft toothbrush at least twice per day using a triclosan/copolymer-containing toothpaste (Colgate Total).
• Flossing- at least once daily.
• Antimicrobials, when necessary via sub gingival or systemic delivery.

4) If a patient has gum disease and diabetes, what steps can we take?

 As with any disease, the goal is to treat gum disease early, when gingivitis is first discovered.  More often than not gingivitis is reversible, with a dental cleaning, good oral hygiene instruction, and thorough homecare.

Periodontitis results when continued inflammation leads to detachment of the epithelial junction beneath the gum (pocketing) resulting in resorption of the alveolar bone supporting the teeth.

5). For patients who have no dental insurance, what are resources we can provide?

Unfortunately, for patients without dental insurance, resources are limited. Medicaid dental providers are rare and Medicaid coverage for necessary treatment is limited. State and local dental societies, as well as private dental providers, will generously offer free dental treatment for indigent patients in need of dental treatment. The Florida Dental Association for example, has an “Access To Care Resource Guide” on their website floridadental.org

6.  What is YOUR one take home message regarding diabetes and oral health that we can pass on to our patients and community?
Be diligent about your daily oral healthcare regimen and don’t underestimate the importance of visiting your dental healthcare professional, at minimum, every 6 months. A significant number of people with diabetes have moderately inflamed (or worse) gum tissue and will require visits every 3 months.
In addition, elevated blood sugars cause dry mouth and increase the amount of sugar in the saliva. Both of which can contribute to worsening gum disease, tooth decay and thrush.

The bi-directional relationship of periodontal disease and diabetes make regular and effective dental care absolutely essential.

Bottom line:  Glycemic control improves oral health and good oral health improves glycemic control.

7.   Any website resources you recommend?

• The American Dental Association has a patient information website: mouthhealthy.org
• The American Academy of Periodontology has a patient information page: perio.org
• State and local dental societies have patient information websites; i.e., The Florida Dental Association (floridadental.org).
• Diagnosing Diabetes at the Dentist – Medscape Article

Special thanks to our guest contributor, Jerry A. Brown DMD, CDCES who is the first, and currently, the only dentist who is a CDCES! Dr. Brown lives in Florida and spent nearly three years volunteering at the University of South Florida’s Diabetes Center. He is a member of the American Diabetes Association’s Advocacy Committee and Community Leadership Board. He’s lived with diabetes for 45 years.