Welcome, everybody, to take two of the misdiagnosing LADA as type 2 diabetes webinar. We are very grateful to our panelists this afternoon to take their Friday afternoon and be willing to come up with a sequel to our first video. We had a lot of questions from you all, and we really wanted to do the right thing and answer all the questions that you submitted, so it necessitated a take two. So what we're going to do is we're going to go through the questions. We're going to have a nice collaboration and discussion. Hopefully, we give you all the information that you were seeking. Please do not forget this is part of a bundle webinar series. So we've got a really dynamic second webinar planned. It's going to be very fascinating, and we got a third one that's in the works, and I think it'll be as nice as this one was. So here we go. We're going to go to Dr. Chris Jones first. One of the questions, Chris, in the Q&A was they noted that the A1c was high, and why would you not start insulin immediately instead of Amiril? So it's a great question to understand where to go first. That's such a critical decision on the treatments and therapies, and I love in my head to think about what are the evidence-based guidelines of medication effectiveness for A1c lowering, and then try and tailor based on that. Now, that doesn't always work, but a lot of times it does. So for instance, this patient had an A1c of 8.0. My goal for the patient is to be under 7, so I want to get 0.1 or more reduction of insulin. So in my mind, I'm thinking what will do that? Well, I actually know that referring to a diabetes educator will lower the A1c significantly. Sometimes the range is pretty variable from 0.5 up to like 1.2 or something, but that would be a great way to get that A1c coming down. And then as far as medical therapy goes, I think I could reach less than 7 with a single oral agent because most of the oral agents will reduce the insulin by 0.4 up to like 0.8. And so probably any oral agent is going to be able to get me to the goal of less than 7. That's the way my brain kind of works. And so when I think of that, I would have gone to metformin myself personally rather than Amaril. And I think the metformin is a pretty standard first-line medication for somebody whose A1c is near but not at goal. So that's the way I would look at it. Let me add one more thing, though, and that is if the A1c is quite high, 10, 11, 12, I think insulin to start is a great idea regardless of the type of diabetes that they have. Okay. Would metformin for this particular individual patient with a history of colitis, do you think that would have bothered her? We know that metformin does not trigger colitis. However, metformin's side effect is the same as the colitis effect, and so that's something to be cautious with for sure. I would usually do it dependent on the patient's current symptoms. And of course, we know how you prescribe metformin makes a difference in side effects. If you prescribe a low dose to be taken with meals and especially the extended release formulation, your risk of having diarrhea and colonic or GI side effects is significantly less than if you do the opposite, like high doses at different times of day and not the extended form. So I would, in my own personal practice, I would have started really slow and said any signs of GI side effect, we'll get rid of this, but I think that the metformin was a good option. Right. Do you find that the ADA standard of care mobile app is helpful in kind of guiding your decisions at all? There's so much in the app. I think it should always be remembered. The decision of which medication to initiate is right there in the app. There's also decisions about many other things, including what we're talking about, right, is how to make the right diagnosis. So there's all sorts of things and people should be familiar with that. And directly, it would be helpful. And I think what I would point out is one of the things I mentioned in my portion of this webinar is that the very first thing you do is make the diagnosis of diabetes and that initial treatment of medication, you know, for diabetes, sometimes it's not usually obvious what kind of diabetes they have from the very outset, minus maybe a young person with DKA or something. And so nobody's going to fault you for doing what's best in the moment. And I think that the guidelines that are given by the ADA in that app that's on the thing is a really good guide and is functional most of the time. So that kind of leads me to the second question the participants had. Do you confirm every new diagnosis of diabetes with a GAD and a C-peptide? So I do not. That would be a lot of use of those tests. However, I'm probably a lot more ready to use that than many other people. And it's because I think personally that there's been a real blending of the type one and type two, the, you know, clinical characteristics that we used to see some 20 years ago or 30 years ago have blended quite a bit. You know, we have a lot of discussion about our young people with type two diabetes and sometimes we'll elbow somebody and, you know, how old is the oldest type one person you've ever diagnosed? There's just such a blending that I would say we should be more free to use the GAD and the C-peptide, but it's still not for everybody. If it's a pretty clear-cut case and everything's moving along over the first months and years, you won't need to do that. You know clinically what the diagnosis is. So one of the participants said, made a statement, they said a hesitation maybe in not ordering a GAD is that the lab may or may not be covered if a primary care orders it, may not be covered by insurance. Can you speak to that? Yeah, so there's, let me say that I've looked with a number of different insurances and there's way too many for me to like go after all of them, but the standard is that it's not one of those prior auth or have a requirement on the GAD antibodies screening test. So it should not need to be endo-ordered, it can be primary care ordered. And if there's an exception to that, I would actually promote that you write a letter to that insurance company and say, why are you different than the rest? And let's talk this through. But as best I know, feel free to order it unless you run into a barrier there. Gotcha. Another question is, do you leave patients on metformin as they transition to MBI if they were on that initially? And when would you ever discontinue metformin? Metformin continues to be a drug that's looked on favorably by the medical community, despite there being a whole lot of metformin naysayers in blogs and other sites. It continues to be looked on favorably. It has, I think, being aware of metformin as a medication, meaning its side effects and its benefits, its limitations and contraindications, really allows us to make that choice and yet not everyone's going to do it the same because one of the things to consider that's not in any package insert or prescribing guidelines is what is the desire of the patient or the wish of the patient, right? So clearly, if they've got a lot of side effects, it would be great to get off as quickly as you can. If a patient is super anxious to get off medications, I feel so sick, I'm taking these giant horse pills every day, perhaps that alone is enough to say let's cut back or get down off the metformin. But with those exceptions where you have contraindications like creatinine clearance that is reduced down to the point that their metformin dose needs to be reduced, you know, without those exceptions that you kind of know just because you know your pharmacology, the general statement is to leave metformin on if you see the benefit from it. And one of the things about metformin is that the MDI works better when you're on metformin, at least theoretically, and to keep a lower dose of insulin while still having the same A1C goals is really quite nice. Metformin doesn't cause hypoglycemia. Obviously, with insulin, hypoglycemia is still possible, but it seems to me that the benefits generally outweigh the risks or the negatives. And so I generally do leave on metformin when I transition to MDI or any insulin. And is this the same for a type 2 patient and a LADA patient, or would the answer differ based on LADA versus type 2? Yeah, I'd love to have Dr. Welch go in on that. But for me, again, patient discussion would be such a critical piece here. And to say, you know, this is something we do use with type 1 sometimes and type 2. Again, that blending of type 1 and type 2, we often have people with type 1 diabetes or LADA diabetes that also have a lot of insulin resistance and get on higher doses of insulin. So that might not be exactly package insert FDA approved, but it's something that I found useful to keep that dose of insulin to an appropriate or a level that's a little bit closer to non-insulin resistant. So Dr. Welch, any thoughts? When I think of metformin, I think this is a really great beginner diabetes medication. You know, there's probably a clear use in even pre-diabetes for preventing the progression of diabetes. So I see it as, you know, when somebody has been on insulin for years and years, and clearly they don't have beginner, early stages of diabetes anymore, and particularly LADA where probably the C-peptide has dropped and they're not making very much insulin. I think it's fair to always ask, is it time to discontinue metformin? And the way that I frame it for my patients is, you know, it's hard to know exactly what the benefit is of metformin right now. Let's do a little break. So they stop taking the metformin, they measure what their blood sugars do. Some patients come back and they say, you know, when I stopped metformin, my blood sugars went up quite a bit, you know, and then others come back and say I didn't notice any difference. And I think that answers my question very quickly. Other kind of special circumstances are, you know, somebody who may also be struggling with PCOS, you can get some kind of secondary benefits from metformin around insulin resistance. People who clearly are experiencing insulin resistance with very high amounts of insulin requirements, there may be more benefits than someone who's using kind of typical type 1 diabetes amounts of insulin each day and not showing any outward evidences of insulin resistance. Great. Dr. Jones, you've already given a shout out to the diabetes educators. So how hard is it for you to refer to diabetes education? And is it harder if you are not in a like a academic setting or a larger institution versus someone that is in a rural community? So I'm a super advocate for all of our colleagues, our CDCES colleagues, our nutritionists, and I'm so fond of the work that they do and the help that they give and the team that we can form that I have found the benefits and the work that they do is so immensely beneficial that I would strongly recommend doing all the work that it takes to make preliminarily to make it so that it's not hard to do in the moment. Right? So that's a lot of work because that means particularly if you're in a rural location or you're in a location that does not have a CDCES like affiliated with your clinic, you need to go out and find someone who serves that role. You need to have a set up a little relationship with them. How do I send people to you? What are your hours? What insurance do you take? You know, all that kind of stuff that allows you to have that connection and then use that connection regularly. And the more you use it, the more it will be, you know, this this pathway that rather than like, I don't know if I should do that, it's such a burden and all the paperwork and it never seems to work out. I would recommend. So for me, that's that's what I've done. I actually have the the advantage of having a CDCES associated with my clinic, and we have the CDCES who kind of goes out to different clinics like one day a week. And we've done that as a health system, right? You can't do that if you're private practice or single practice. But to to make those relationships in advance is well worth the effort so that when you're in the moment with your patient, that referral is clear and easy to do or easier to do. Excellent. We appreciate your support in that. Would in this particular case for this particular patient, would a professional CGM benefited you at all? I will say, I will say that for me personally, I have found that patients watching their own data has been powerful enough that my use of professional CGMs has gone down dramatically. It's been quite a while since I've used one. The the professional CGM allows me to make decisions for them. A personal CGM allows me to make decisions for my patients. Allows them to make decisions before they even come back to me. And then I still get to make the decisions. So there is a role for professional CGMs in in places. But whenever I need a patient to make decisions and participate, I like to go straight to the personal CGM. Right. And for instance, this patient was not immediately put on personal CGM, mainly because I was assuming that she was on just oral medications and most insurance require at least one injection a day. So at at the point she was placed on a personal CGM, in your experience or maybe, you know, share with us how your practice handles CGM technology. We like the data. And so we also think I've found so many times that with diabetes, communication is a critical, critical piece. And so we set up a communication plan from the minute that the CGM is ordered or if we have a sample, which sometimes happens, but not very often when it's placed. Then we set up a communication plan and that communication plan is generally a phone call within a week or two to say, is it on? Are you using it? Does it make sense, et cetera? And, you know, kind of troubleshoot, because everybody knows that when a patient tries something and it doesn't work right off the bat, you're just done. I just I'm not going to worry about this. I was such a hassle. And you don't find about it out about it for three, three months or something. All of that time is lost. So we set up just a simple phone call a week or two later. The second thing that is great to do, but again, becomes burdensome. And I don't want to put this on everybody who's listening because it might not be the right thing for your clinic. It's it's a burden, but it is a great thing to do if you do a higher volume of CGMs, and that is get the CGM data from the patient connected to your clinic. So, Libre, you can look in LibreView and Dexcom. You can look in, you know, Clarity and for the other the other CGMs. There are ways to look at the data even when the patient isn't there. If we're hooked up, then we can actually look at the data a week or two, see the data and then not just call them and say, how's it working for you? But say, and we can see your data. And boy, it looks like you're doing great. We can tell that you're and then give them a compliment. And so instead of I'm frustrated, I gave up. It became I'm connected with my doctor. He sees that I'm working hard and doing well. I like this scenario. This is working out great for me. And it just changes that tide to have that communication. Strongly recommend some kind of communication if you're setting up a CGM initially. Perfect. What would you say would be a motivator to overcoming therapeutic inertia for caring for diabetes patients in a in a primary care? Because to me, that working with primary care, a lot of them view it is so it's such a task. They require so much time. And, you know, it's true. It's true. Diabetes is a time consuming disease process. And the reason is, it's not just prescribing medication, at least when it's done best. It's not just prescribing medication, right? It's patient education. It's habit formation. It's change of lifestyle. And it's multiple medications often. And we will often understand that most disease processes we treat include oral medications. But this includes technology, injections, you know, so many different things. So in absolute nod when people think, yeah, but it's so heavy. It's so hard. It's so burdensome. It's so long. All of that is true. The best answer to that is team. You know, have a team. Right. And we could we could do a whole nother webinar about the team and how to form the team and who's on your team and how you use them to accomplish this. But that is the best answer. So let's go to the idea that you don't have a team set up. You want to do better tomorrow than you do today just because you're listening to this webinar. You know, how do how do we decrease the inertia in with diabetes? My best answer would be the patient has to have a goal and you need to work with that patient on their goal. OK, so instead of I'm the doctor or the the nurse practitioner or the PA who's now going to prescribe you one more in a long line of medications, it's how are we going to get to that goal of yours? Remind me what your goal is. How are we going to get there? What are you going to do? What am I going to do? And that that inertia seems to melt away in large part because now the patient is engaged and you're helping the patient to meet their own goals. If you keep that in mind, boy, that that it just seems to move things forward in a way that the patient is grateful for rather than seeming like a burden. Gotcha. OK, Andrew, you're next. What is the downside of using low dose basal insulin because of the progressive nature of islet cell deficiency? Does this psychologically benefit patients so they understand the eventual long term need for insulin? Yeah, so I think the question is getting at, you know, why wouldn't you just start all of the patients that you diagnose with LADA on basal insulin? Right. It makes a little bit of sense physiologically. That's sort of where we anticipate they'll go eventually. So is there maybe a psychological benefit to just saying, OK, you know, today we can start you on long acting or short acting insulin? So I think you should consider it. And I think there will be situations where patients will benefit from starting on insulin. I do find that when patients understand why they have diabetes, you know, maybe they've been blamed a long time for something in their lifestyle, for why they have diabetes. But then you tell them, hey, there's an autoimmune component and this isn't just going to get better only because you change your lifestyle. People tend to be a little bit more accepting of the diagnosis and a little bit more accepting of the treatment. You know, some people are going to be ready to jump in and say, give me the insulin. Some people are going to say, I, you know, I'm not ready for that. And if you are following and looking for signs of insulin deficiency, you'll know who immediately needs to start on basal or short acting insulin. But I don't think that it's always necessary at the time of diagnosis. And I think you can give patients time to process this diagnosis. And, you know, if you are, you can track the C-peptide level and say, you know, two years ago, your C-peptide was a lot higher and now it's low. I think it's time that we really start using the insulin to treat. And I think people will be more accepting of it. It's part of the diagnostic criteria of LADA that you don't immediately require insulin. So I would try and think outside of that if you can. But some patients will need insulin more immediately. One of the participants said we received a recall notice for Freestyle Libre 3, is that true? Yes, Abbott released a lot of statements about there were three lot numbers that had affected sensors, which read inaccurately high, you know, and this could put patients at risk. So these lot numbers are readily available on the Internet. And I'm sure pharmacists are looking for this, but if you have any concerns, patients should look and compare their lot numbers to make sure they don't have these. Perfect. Would T-ZILD be indicated in a patient with GAD-positive antibodies without a low C-peptide in Lana? The answer is no, because the indication for T-ZILD is for stage two type one diabetes. And very specifically, this is two or more antibodies positive. So if you only have one antibody and you're in an early phase of LADA, you really wouldn't be qualifying based on my understanding of T-ZILD. So anyone who's a LADA patient is also probably diagnosed with diabetes at that point, which puts them in a stage three of diabetes, which would also exclude them. I think it remains an exciting field of future research, and I'm excited to see what happens next. A patient recently has his C-peptide and GAD tested, which was both low and positive respectively. Should he be changed to basal bolus insulin? I think this connects a little bit with my previous question, when is it the right time to start insulin? I think if you're seeing signs of insulin deficiency and you're measuring low C-peptide levels, you should definitely be considering insulin. I often will favor using once a day long-acting insulin instead of jumping all the way to basal bolus insulin, as long as the control is reasonable at the time. So, you need to assess for modifiable factors and degree of hyperglycemia. If there is significant hyperglycemia, a basal and bolus insulin regimen should be started versus basal insulin only. What are things that make an A1C unreliable? Like for instance, on this patient, she had a long history of colitis, she had a history of pernicious anemia, apparently so severe that she had to have injections. So, how reliable was an A1C on this particular patient or in general, what makes them unreliable? Wow, the answer to this question is long. I'll give a brief answer. I think it's important to understand exactly what you're measuring when you measure an A1C. It's a hemoglobin A1C. This is measuring the degree of glycation of glucose onto molecules of hemoglobin. So, the longer a red blood cell is in circulation, the more time there is for this glycation to occur and the higher an A1C will appear. So, any process that affects hemoglobin turnover and lifespan is going to influence A1C. And so, pernicious anemia, anemia being a key word here, will influence the A1C. Things like chronic kidney disease, some patients have hemoglobinopathies, patients who receive blood transfusions, all of these things are gonna influence the A1C and make it less reliable. There's also evidence that some patients are just what they call a high glycator. They just have higher A1Cs or lower glycators, lower A1C for no really clear measurable reason. And some of this can even vary by race. So, I think it makes me an advocate for continuous glucose monitoring is an excellent way to test the A1C accuracy. There's also other labs like frutoxamine, which can give you a ballpark of accuracy of A1C. I think it's always reasonable to stop and think, does this A1C make sense? And should we consider doing further testing to prove it? So, that leads me to the next question. How accurate would you say the GMI is on CGM reports? And in comparison to the A1C? You know, there's probably more science to this than what I'm immediately aware of, but I think you need to recognize that there are also imperfections in GMI. You know, a CGM will have things like gaps, right? If something fails early and it's hard to start a new one a few days later. There are warmup periods. There's interfering substances that you can take that make the sensor read inaccurately. There's also a degree of inaccuracy at the beginning of a sensor's life. And sometimes there's artifact that occurs during and near the end of the sensor life. So, I think you need to understand all of those things before you say, you know, this is the more correct one. Personally, I really enjoy having the GMI and I often will lean on that if there is a discrepancy between A1C and GMI. Gotcha. So, talking about CGM therapy, you know, there are multiple reports involved in a CGM report. And for this particular person, there were some daily reports. When is it a pretty good idea to maybe do a deeper dive? Now, this lady started on Libre2. She had some issues with scanning because when you did a deeper dive into the daily reports on her, she had some gaps in her data. Can you address that? Sure. And it's probably not fair that I'd be the only person that answered this question. So, I might ask Chris to pipe in. But, because as an endocrinologist, when I'm seeing someone for diabetes, that's my main focus. And I will spend some time in the daily reports with all of my patients who are using a CGM. But to make it more efficient, because there's so much data there, my personal practice is, I look at the last 24 hours much more than all of the other data. I examine exactly what's happening overnight. Are there trends up or down overnight with glucose? I will ask patients if they had breakfast and what they ate for breakfast, because I'm usually seeing the effects of that in my office. And then I ask what they had for dinner the night before and seeing what the effects of that are. I'll say, honestly, just asking those questions and focusing on the last 24 hours will give you a pretty clear window into what is happening in this patient's life with diabetes. And then I do a really quick scroll through the rest of it to look for outliers. Very high numbers, very low numbers, and any unusual patterns that might show up. But I'd be interested to hear from a primary care perspective, how feasible it is to go and how deep it is, how deep they should go with some of the time limits that they have focusing on other things. Yeah, so time limits is a great point. And as I mentioned before, the hope is that patients with diabetes do a lot of their own learning. But if not, I always try and pull out one learning moment. Most times I can pull out one learning moment fairly quickly. And so let me give an example. And one includes not using a deep dive and the other one does include a deep dive. And so I look at the AGP, right? Which is the simplest one page. And I see there that they have a lot of low sugars. Well, I can go down to the graph and the graph is pretty clear about when most of the low sugars happen. So I don't really need to go into, was it 3 a.m. or 4 a.m. or 2 a.m. I can look down and say, you know what? Through the night is when your low sugars are happening and let's talk about that. And so we have a learning moment and they leave with a single plan or a single habit change. Or maybe it's an insulin change or something like that, right? So, okay, we're gonna address the hypoglycemia you have at night. I don't need to do a deep dive if it's pretty clear on the numbers in the graph on that AGP. But sometimes I look at it, their sugars are all high and the graph is just this wacky bunch of ups and downs and there's no real pattern to it. I'll go back and look for the one learning moment. And sometimes it ends up being in that first 24 hours. And I agree completely with Dr. Welsh. It's a great place to look because it's the only time patients actually remember. Nobody remembers what happens last Wednesday ever. So, well, not ever, but you know. So I like that. But every once in a while, taking that deep dive will give me that one learning moment. And sometimes it's something like, hey, I see that you're going high all over the afternoon. Like every day is different. Tell me what you're doing for lunch. Oh, I don't eat lunch. I just snack all afternoon. Okay, well, there's my learning moment. And it came by looking at the dailies or the deep dives because I recognize they don't have a lunch that happens on a day. And so then my learning moment is, hey, I know for this next few months until you see me back, let's work on eating one lunch and have it contain, you know, carbs and proteins and give your insulin before if it's insulin. And if it's not an insulin patient, that's fine. Just, you know, adjust that. And so that's when I try not to do a deep dive because it takes a lot of time, but I want that one learning moment for the patients. And sometimes a deep dive gives it to me. Perfect. And I would say if you're getting a little overwhelmed as the PCP looking at a report and there's just too much to focus on, right? The patient's drinking sodas or not taking their medications correctly and you feel overwhelmed, I think that's a great time to refer to a diabetes educator who does have the time to sit down with a patient for an hour and do exactly what you're talking about, a very deep dive with what they're doing with their medications, when they're eating, what they're drinking, when they're checking their blood sugar. So that is just another plug for us. I have a feeling sometimes they tell us more than they do the providers. They don't want to look bad in front of you guys. It's okay with us. You're safe. So Andrew, I know that one of your wheelhouses is CGM technology. Can you just touch really quickly how the technology is that you utilize that technology as far and address how you utilize it as far as CGM interpretation, charging for those interpretations? How is it, how have you worked it out where it's very efficient, easy and streamlined? Happy to share my personal experience. There are probably better ways to do this, but this is what I've found that has worked well in my past year and few months of practice as an endocrinologist. It starts as soon as, even before the patient comes in, patients who have had experiences and been able to go and sit down with diabetes education or other professionals and have the CGM set up right, that usually involves connecting it to the clinic. So that way, when the patient walks into the clinic, we're already set up. And sometimes this happens the day before or the week before or the day of. Most of the time is what happens in my clinic. We're pulling CGM reports for every single patient that comes in with the CGM with a pretty high degree of efficiency and reliability. Then that is uploaded into the EMR into a place where I can refer to it. Sometimes if there are some delays, I will go in and start talking to the patient while one of the staff members that I work with is pulling the data themselves and putting it into the EMR. I open up the CGM report with the patient on a large screen in a way that we're both looking at the data together and we'll scroll through and look for patterns and try and have these learning moments that Chris is talking about. That's just a routine part, but there's also billing codes and I'll give you the specific number here. It is 95251, which you can use when you are interpreting 72 hours of CGM data, which is pretty much every single CGM that you look at. So I have a dot phrase that I use for the patients that I see with CGM, which pulls in a lot of the data automatically. I will include a snapshot of the AGP from their CGM download into my note and a lot of the documentation requirements are already met by having that snapshot available in the note. So my documentation becomes very simple and it's mostly me describing the things that I see on the CGM and any recommendations that I made around that and then I bill for it. And so just if anyone is curious, I average about 80 CGM interpretations per month in my practice, and this is worth 0.98 RVU in my institution. So it significantly increases my productivity and compensation. Excellent. Thank you for that ticket. So one last question for you, does every patient with diabetes need an endocrinologist? No, the answer is no. But so I think it's a good question to ask is when should you consider referring to an endocrinologist? I think it's most helpful when there are significant challenges in the diagnosis, identifying the type of diabetes when typical treatments aren't working. Also, I believe that patients with type one diabetes in general should be connected to an endocrinologist just because there's so many changes that happen so rapidly in the world of diabetes technology that it may be hard to be aware of all of the options to be able to offer it to patients. Though I do know many primary care providers who do an excellent job managing type one diabetes independently and I think that's fine. I do think that, I think it should be a partnership with primary care. I don't think it's necessarily this patient isn't listening to me or this patient is hard. So now you're gonna, the endocrinologist is just gonna take care of it. I think it's more productive when you work as a team and you're both providing these touch points at your visits and reinforcing principles of good diabetes care each time that you're in the room. Good diabetes care each time that you're seeing the patient. So I think there's, you should consider it if things aren't adding up, but truthfully, probably most patients with type two diabetes will be served just fine by working with a primary care provider who knows the basics of type two diabetes management. Perfect. Okay, we're gonna move on to Ms. Emily. So Emily, the first question is on the ADA Standards of Care app, there's a section for directories and finders for education recognition program and mental health. Have you found this useful and reliable in reviewing it? Yes, absolutely. I think that in the app under the directory section, you can just put in your zip code and then have like a certain mile radius around that. And it comes up with a full list of accredited programs that are close to your area. So yes, I think that is a great resource to use. And then in addition to that, that app has so much to offer as far as resources and diagnostic tools and articles and podcasts. And like, I don't know that ADA Standards of Care app has so much in it and I think it's so useful. So yes, the directory is reliable and it works great. Great. What about, and this was a question from a participant, what about patients who do not have Medicare? Is there a uniform amount of DSMES allowed in that first year? That's a great question. I know we talked a lot about Medicare and the 10 hours within that first year. Private or commercial insurance does not necessarily mimic that. So there is no uniform or set amount of hours of diabetes education. Some programs will do like insurance verification. The patient can also call their insurance company at any point to ask what the coverage is for diabetes services or diabetes education services. I will say that the billing will be applied to their deductible and their co-pay. Typically though, I feel like just in my general practice, I haven't had too many complaints about the cost of diabetes education. Every once in a while in January, when deductibles reset, we'll have some higher co-pays for people, but outside of that, it seems to be cost-effective. Who does the billing for the 10 DSMT hours? Okay, so as far as who does the billing, let's start with the fact that it needs to be a program that's accredited by the ADA or ADCES. Those programs will do an annual status report where they submit their data each year, and then they go through a four-year renewal cycle. Within that program, and when they're reporting back, they have a list of diabetes educators within their program. So it doesn't necessarily have to be a certified diabetes care and education specialist, but they do have to be listed within that program. That could mean they're an RN, an RD, a PharmD. If they do not have their certification, then they are required to complete 15 hours of continuing ed in addition to their practice. But this is all something that the program coordinator can help with and make sure that it's meeting the standards. How do you bill between visits for the RD, CDC? Is this time between visits to adjust insulin? So I'm assuming that's in a titration clinic setting. Yeah, that's a tricky question. I, in the practice here, we typically do not bill for that time that is spent on the phone or reviewing that remote CGM data in between visits. If you do spend at least 30 minutes with the patient and the patient consents to having a telehealth visit, then that's fine to do to use your 95 modifier when you're putting in the billing code. And this might be a question for Dr. Welch too. I hear a lot about the 95251 CPT code, which it can only be billed by the provider. So this is not a code that the educator would drop, but is that something that the provider can put an interpretation charge to if it's not associated with a visit? I will speak on my personal opinion, knowing that there's probably variations on this. I do, and a lot of it is, it just can't be within one month of the last time that you use that code. But a lot of times this comes up, somebody is having a hard time with their glucose, they provide the CGM data for you, and I'll review it and make recommendations on it. So I will use those encounters and bill for the time that I spent doing the CGM interpretation, as long as it's been enough time since the last time that I have. I've been trying to clarify this with the powers that be to make sure that's okay. So please verify before you do that. But so far I haven't heard anyone say that that's not allowed unless Chris has more information. Yeah, could I add? So in my clinic, we do enough CGMs that we thought that that would be something that would really be an appropriate thing to do because we were spending a lot of time in between actual visits. And so we, for the period of about six months, we figured everybody would come in within six months, put something up front or a little sign or handed it out. I can't remember, my staff did the best job and I can't remember exactly how they did it. But we informed all patients that if you're using a CGM and we call you in between visits, that there might be a charge. And I think we even put something on there like the amount you'll be billed is X, which is less than amount if it was a visit, we hope you recognize that this is still beneficial or something, so we didn't have angry patients. But yeah, we do also bill for a CGM read in between visits having informed the patients that we were gonna do that. Yeah, I think that's really helpful. And so like as the educator, you would speak with that patient, gather all the information about their meal planning, their timing of their insulin, any other factors that may be involved, type up your telephone encounter and then route it to the physician and they can enter that code. So I think that's probably the best answer I have as far as billing in between visits goes, the educators don't typically drop charges for that time. It seems like that's a nice way of increasing your REU's guys without adding five patients to your schedule, is that right? Yes, and helpful to the patients. I mean, it's both, right? It's a win-win. Cool. I do wanna add on billing and I'm sorry, Paige, I do want to add a note on billing just in general that keep in mind, you cannot drop a DSMT charge and an MNT charge in the same day. And so if a patient is coming to the clinic, maybe they're driving from a long ways away, they want to see diabetes education, but they also want to have a medical nutrition therapy appointment. Those those cannot be billed on the same day. Sure. Um, this we had a multiple questions about this, so I just kind of put it all in to one discuss barriers in providers referring to diabetes education. Also, what are some of the barriers that prevent patients from going to diabetes education if they get the referral from the primary care? So in the initial webinar, we had talked about some barriers, including the time that it takes to get an appointment or the time it takes for the patient to be contacted, maybe not knowing about programs that are close by or in your area. I think in addition to that, a lot of it is just providers knowing that this is a service that's offered. You know, here we have several clinics within Atrium Health Wake Forest Baptist, but then outside of that, making sure that the surrounding health departments know that they can refer to our program, making sure that that even if you're not part of a larger medical system, that you can still refer to those places. And I think, again, just making sure that you have a contact in place like Dr. Jones was talking about earlier to make sure that you know of a place of a coordinator of a program that you can refer to is very important. Alongside with that is just making sure that providers are aware of what diabetes educators do and the benefit that we can offer both to the patient, but also to the provider and be a resource for them and a touch point for the patient and really be part of that collaborative effort. As far as as barriers with the patient, you know, one thing I do think is the time it takes to contact them. If the provider sees that patient, they diagnose diabetes, they immediately put in the referral and they're conducted two days later for an appointment. I think that's wonderful. And you've you've caught that patient while you have their attention. If they place the referral at diagnosis and then it's 45 days until they get a phone call, I feel like you've lost that kind of window of time. And so I do think that that plays a really strong role in the barrier for the patient. The other thing is how it's how is diabetes education presented to the patient? I had a scenario in my clinic where with a pediatric patient, the provider had said, hey, I think you need to go to diabetes education. And the feedback from the patient was kind of like, why? Because I failed my my diabetes management. And now you're you're like sending me to the educator. And they said they almost felt like they were being sent to the principal's office was kind of how they compared it, that they had they had essentially failed or like they weren't doing well. And so now they had to go see an educator. And and that's not what we want. But I think, too, that goes back to making sure that education is in place early on, you know, at diagnosis and being able to follow that patient through and not waiting until they're not meeting treatment targets before referring. Can I add on to that? This is our own kind of practice, and this wouldn't be feasible in a lot of locations. But since we have on site diabetes education, and a little bit of flexibility in some of their schedules, whenever I'm referring somebody to diabetes education, I will physically bring the educator into the room and I will introduce them in a warm handoff to the patient. And I'll explain to the patient, you know, this is so and so and they are an important member of our diabetes team and somebody that can be a very helpful resource for you. And when you talk to one of us, you know, it's communicated essentially to the other if there's a problem going on. And then, you know, they kind of leave with like one of the cards. They have a face and a name. And now when you schedule that appointment, it's it just means something different than kind of a stranger. It might be hard to do that everywhere, but I've really enjoyed it at the practice where I'm at. Yeah, I think that's great. And we just recently created some like rack cards that have a QR code to our website. And so if you don't have an educator that's in the office, being able to hand something to the patient that has the contact number so that if they don't hear then they can contact the scheduler. Just making sure that there's some follow up and follow through there. I agree. It's so often you hear the patient say, you know, well, I didn't know you did all this. You will. I just thought you told me what I can't eat. No, that's not what we do. We're here for the entire journey. There was a question that says, is there someone with whom I can connect with to help educate on a large scale in the primary care setting, state or region? I work in population health and would love some support in initiatives. I think the best thing I can say there is to find a program near your area and contact a program coordinator and that person may be willing to speak in some sort of initiative or they may have a contact to pull together. I think it's a great idea because the more education there is widespread, then the more knowledge base there is about diabetes education and how to access it. I think here we've done lots of education with population health, with primary care providers, with school nurses in the state. So I think that there's always opportunities to increase that knowledge base of diabetes education. I think, too, collaboration is great there. I mean, like, for instance, we just had a situation in our system where actually the population health division at the on-campus hospital, main campus, actually asked for our assistance in problem solving. They had been tasked with reducing readmission rates. So they turned to the diabetes educators, which I thought was great. I'm so glad you said that, too, because I've got the 2023 National Benchmark for Diabetes Education from the ADA is 63.8% of participants had decreased in hospital admissions that were referred to education, which is a great, great number. Great. Reign, you're up next. Were you going to say something? Yeah. I have a very specific idea for reaching out for someone through the Academy of Nutrition and Dietetics Diabetes Practice Group. They likely have a speakers bureau that lists people's specialties and likely all the people in that group will be diabetes educators as well. Perfect. So this was from one of the RDs that we're attending. Where can I learn more information to help and support patients? I've noticed the standard diabetes education can be limited in addressing cultural diversity, which can make it difficult for both. Yeah, I would love to share my screen, if you don't mind, because I have some visuals on that. And Paige, I've actually got two of the different questions here from the participants. So the question was similar to this other question about ADA plates related to ethnicity, which I also thought was, I think, also recognizing the cultural diversity. And so I have a few resources. The ADA plate method actually has a fantastic pack of many different cultures. And so I'm going to show you exactly how many there are. So it's clearly not everybody, but they do have a large variety. And I have all these in my office. If a patient's not really sure, we look at all of them. We say, OK, what looks most familiar or what looks like something you might eat? And then we talk about it from there. But as you can see, all the pictures on the sides, it has lots of different varieties of, OK, what are carbohydrates, what are proteins? And so you can get to lots of different cultures and lots of different foods through these placemats. And then additionally, something that Seattle has, but it's available to the entire country is EthnoMed.org. One of the University of Washington hospitals created this website, and it has lots of different topics. Specifically, there's an endocrine slash diabetes section that has the cultures that are common in this area in Seattle, Washington, but they're also common in many other areas in the country. So you can go to this website, go to clinical topics, endocrine diabetes, and you can filter by the culture that you're looking for and looking at things for patients. And they have both in the language that that person would speak and English. And most of the education is presented through pictures and visuals. So it's incredibly helpful whether the patient is literate in English or literate in their language or if they're not literate in either language. It's really helpful just because it has these big, beautiful pictures. And then lastly, to address that question, I have noticed the standard diabetes education can be limiting in addressing cultural diversity. And the amazing thing about this country is we have a tremendous variety of cultural diversity, but it does make it difficult to provide education specifically on food. And so unfortunately, sometimes you might have to make the education yourself. So, for example, I have a Lada patient who is from Ethiopia. He speaks Amharic and he would always complain, you know, I can't find anything on my carbohydrate counting for people who eat Ethiopian food. And he is right. Unfortunately, there's great resources for carb counting, but not always in Amharic or for Ethiopian people. So sometimes you have to just look if you have a lot of patients from Ethiopia or that speak a specific language or from a specific culture, kind of compiling something on your own can be helpful and worth it. I did this at the beginning of my time in my federally qualified health center, and now I have all the different cultures that come in and the things I can use over and over and over again. And Paige, I think that's it for those that first question. Yes, and it actually the next one was, where do you get the your carb counting handouts? Exactly. I am trying to be as prepared as possible. So that's at shopdiabetes.org. That is similar to those diabetes placemats that I was just showing you, except it is under the choose your foods handouts. And so that's going to be where you can find the food lists for not just diabetes, but also they have it for weight management. If someone is looking to use this type of counting for fats and carbohydrates as well. Perfect. How does fasting, a time window to eat 12p to 8p, affect glucose numbers for type 1, 2 and LADA? Is fasting for people with diabetes? And I wish we had great data on all those populations. Unfortunately, we do not have tons of data on type 1 or on LADA. You'll just you won't find dietary intervention studies on a large scale done with a lot of patients with type 1 and also LADA it's even less. So what we do have, we can look for the standards of care. So time restricted eating is the new way of describing intermittent fasting, because many people are eating in a specific window of time during the day. And so it has been shown to be safe for adults, not just with type 2, but also for type 1. Of course, if they're on insulin or if they're on sulfonylureas, they should kind of be aware of what happens to their sugars and if they need to reduce doses during those fasting times or adjust doses, which can be difficult if you're on like a basal insulin. It can operate differently when you're eating throughout that window or when you're not eating. So that just might be either talking with a diabetes educator or a dietician that can help adapt those medications for the different quantities of foods that people are eating. We do know that the later fasting period is much more popular, so most people do about 12 p.m. to 8 p.m., but unfortunately, it's worse for our glycemic management. So 8 a.m. to 4 p.m. is a great window for glycemic management, but unfortunately, no one wants to do it. So we do find that the later fasting periods, it still helps people lose weight. It's about the same amount of weight as people who are just continuously reducing their calories. It's not necessarily better, but it's also not necessarily worse. So some people find it a lot easier to do. Just I stop eating at 8 p.m. and I don't count anything. I don't do anything else different throughout the rest of the day. And then for the kind of specific studies that we've seen, they are all over the map. It's not just that time-restricted eating because intermittent fasting was more popular earlier, so we have more studies on that. So eating 500 calories on this many days of the week or two days of the week, I eat this many calories. It can result in weight loss. It can improve A1C, but as I mentioned earlier, it's not any different. Than just any other dietary intervention, any eating plan can work. So it is a tool. If a patient is interested in it, it's safe. It can help weight. It can help A1C, but it's not necessarily more superior than any other plan unless the patient really follows it. And then, of course, it is superior for that specific patient. What is your opinion of mindfulness in nutrition counseling? And they refer to a Yale study, Mind over Milkshakes. Have you heard of that? Yes. So let me quick jump ahead. So for those who are not super aware of what mindful eating or intuitive eating is, it is based on these 10 concepts. Probably the most important ones are number two, honoring your hunger. So eating when you are hungry, that diet mentality that they're talking about in that number one is based on if you're hungry, starve yourself, it's better not to eat. And so in this mode of meal planning or mode of managing weight, managing diabetes, saying you do eat when you're hungry. And then number six is another big piece of when you're full, feel it, recognize it in your body and stop eating at that time. Again, this is a good tool for a lot of people, but it can be very difficult. I think in the perfect world, all of us could do these all the time, but none of us live in that perfect world. And particularly people with diabetes do not live in this perfect world because they have a lot more demands on their time, a lot more demands on their emotions. So it can be difficult for everybody. And I think especially, you know, when we think of social determinants of health, it's really hard to say honor your hunger and fill your fullness when food security is an issue. So if you're not sure where your next meal is coming from or if you have a history of food deprivation, this is a really difficult concept. So I wouldn't necessarily use this for everybody, but it's a tool and it can be very helpful. And then I looked into the Mind Over Milkshake study, I had not heard of this study, and it is interesting. So kind of the general take home is that they told individuals that they were going to have a very indulgent high calorie milkshake. And then they told other groups that they were going to have like a sensible, essentially diet milkshake. And what they found was actually they found increases in ghrelin, which is like this hunger fullness hormone. So they did find a difference with the psychology, but I will caution the results of the study. So this is N of 46 and it hasn't really been reproduced. And the tricky part about this is the main outcome that they found was it produced a steeper decline. So it wasn't just these differences in, you know, like baseline levels or the end of the study. They were comparing specifically the decline was greater because the levels of ghrelin were larger before the indulgent shake versus the sensible shake. So until it's reproduced on a large scale, I wouldn't necessarily recommend it for everybody. The average BMI in this study was 22 and 78 percent of the participants were students at the college. So definitely not a randomized control trial. So I don't necessarily trust these results, but. I would say mindfulness is a great tool. How do you assist patients with the sugary soda struggle bus? Yeah, and so I did talk about this in my presentation, so the I think the most useful tools are in CalorieKing.com, completely free website, you can enter in the soda or the juice or what the Starbucks drink, whatever the person is consuming that has sugar in it and automatically adjust the amounts that they're consuming, the quantities that they're consuming, and then get the kind of end of day or end of week. I have never done that, but that might be even more impressive amount of sugar that they're consuming. That carbohydrate quantity, you can divide that by four to get spoonfuls of sugar, which is much more visual, much more useful than just that vague grams of carb. So that can be a helpful way of helping a patient understand how much that sugar is impacting their blood sugar. CGM, of course, is helpful with that as well. And then the same website also looks at how much time it would take to burn off those calories of sugar or to burn off that sugar in the bloodstream. So and this is specifically for type two patients. If it's a lot of patient, they need it's a lot of patient that relies on insulin. They're going to need insulin. They're not just going to necessarily get rid of all that sugar with a lot of jogging. Last question, how do fat and proteins affect blood glucose? So I looked specifically, I think with this is a higher level concept, I wouldn't necessarily recommend this for all people with diabetes. I wouldn't recommend this for a primary care provider to get into because it's very complicated. So again, this would be to a diabetes educator. And so this is specifically with people with type one or if they have a lot and they're using insulin. So. There is usefulness to getting a little bit more bolus if a person is having a high fat or a high protein meal, but there's no algorithm, it's not like it's X number of grams of fat, they need X number of bolus insulin. Same thing with protein, if it's that we don't have an idea of how much protein it is that is going to be across the board affecting somebody's glucose. So this is a great reason to get a CGM on a person and to figure out, OK, when you do eat, when you go out for Thursday night bowling and you eat four slices of pizza that one night a week, right, that would be a time where you could kind of do those little experiments with the patient and try to figure out, OK. For you specifically, what happens when you have this pizza or what happens when you you know, every month I have a 92 year old patient with type one and he goes out with his wife to a fancy steak dinner, right? So he's eating that huge steak. What happens those specific nights? So you can do experiments. And this was actually no, this is going to be coming out next year in the ADA guide for nutrition therapy for diabetes. We looked at a meta-analysis and everything's kind of all over the board, as I was saying. So it is recommended to give additional bolus insulin for fat and protein, but it's lots of different methods. So, again, it's important to individualize. You can use these as a starting point for your patients, but it would be really important not to just say everybody should follow these guidelines, particularly if they're not on insulin, you know, and we don't want to bring up having high fat meals, having high protein meals will affect your blood sugar in a different way. That is a much more advanced concept and mainly relevant for people who are bolusing insulin at meals. Excellent. So we will wrap this up. Thank you to all of our panelists that participated today. We greatly appreciate your time and for the participants. We hope this was helpful and we will see you at the next webinar in October, October 1st, Type 2 in Adolescents. Thank you for your attention and thank you for your participation, guys. Have a great evening. Thank you, Paige. Hey, I learned a ton. I don't know if no one else watches this. I think it was really great. I agree. I totally agree. And I did a presentation with my PCPs and I used your slides on C-peptide and we're going to change our practice. Usually they run a whole panel of like eight different things on a patient they suspect LADA. And now we're just doing 90 percent of the time. You're going to be right. Collaboration. There it is all over again in action. All right. Thanks, guys. See you all again. Good seeing you.

LADA misdiagnosis

Type 2 diabetes

A1c treatment

metformin

insulin therapy

GAD testing

C-peptide testing

diabetes education

continuous glucose monitoring

nutritional counseling