Hello, and welcome to today's webinar. I'm Paige Johnson, RN, CDCES. I will be your moderator for today's presentation. Now for a few housekeeping details. These are my disclosures, and this is today's agenda. So, we have a couple of requests when it comes to the Q&A and the chat box. If you will please take time to put your questions in during the presentation and not at the end, because we would love for you to put the questions in the Q&A box instead of the chat box, because the chat box is something we're going to use to share links with you during the presentation. If you haven't registered, we strongly encourage you to sign up for the Diabetes is Primary Continuing Education Program. This program is an essential resource for primary care professionals committed to improving patient outcomes in the primary care setting. Register today and take the next step in mastering diabetes management in primary care. The link is in the chat box. I would like to provide you with a little background as to how we arrived at today's presentation. This webinar series was created after polling participants that took part in the Diabetes is Primary Care Continuing Education Program, and these topics are the interests and concerns as it relates to caring for patients with diabetes. We want to address these topics in a way that is interactive and fun, and in this series, you will have a chance to engage directly with the panelists as they dissect real-life studies, highlighting more efficient ways to care for patients with diabetes, and most importantly, to improve your outcomes. Each session provides practical strategies to help you implement the latest standards of care in diabetes into your practice without adding a lot to an already full plate. These are our learning objectives, and these are our presenters. This is a great group of people, I might add. The next slide talks about the, it actually represents the patient's journey in this case study, and I want to spend a little time and give you the ability to kind of absorb some stuff on this slide. I don't want to rush this slide because there are things that kind of jump out for most people in our profession. So, while you're looking at the slide, I want to just say this. This presentation is not about right and wrong. It's more about collaboration, sharing perspective and experiences, and actually really bringing the voice of the patient with diabetes to the forefront. I can honestly say that each one of these presenters have a passion for their patients with diabetes. They work for the patient and not merely the institution they are employed by. We have had great fun putting this project together, and it is our hope that you will have an enjoyable learning experience. Without further ado, I'd like to introduce our first speaker, Dr. Christopher Jones. My name is Chris Jones. I'm an internal medicine physician. I've been working at Intermountain Healthcare for over 20 years now, and I've been particularly focusing on diabetes, and I'm very pleased to visit with you today. My disclosures you can see here. There we go. All right. So, you can see my disclosures here. Let's start talking about a patient. This patient is a female, Jane Doe in this situation. She is 51 years old. She has a BMI of 31, and she has a particular family history that I would like to focus on not every detail that's on the slide, but to particularly point out the Wegener's granulomatosis. That is an autoimmune disease in her family. She is negative for hypo and hypothyroidism and for thyroid cancer, and she reported negative on her family history of diabetes. Interestingly, you'll see later on in the presentation that she did actually have some extended family with diabetes because she happened to find a glucometer, but she was negative for family history of diabetes. Her past medical history, her personal history does include hyperthyroidism, which was diagnosed as Graves' disease. Graves' disease is an autoimmune thyroid condition, along with a number of things that you can see here on the slide. Important to notice that she also has a lower extremity vasculitis, another autoimmune condition, and she has colitis, which seemed to impact her quite a bit, and impacted her also on this journey that she's on right now. You saw in the first presentation from Paige Johnson about the patient journey. There was a long journey of slides, and I loved how we were able to color coordinate it. If you didn't notice the color coordination, it's really important in this journey because the patient ends up being quite an advocate for themselves. The patient part of this journey is highlighted in yellow. The primary care physician is highlighted in blue, and so that's where I get to make this connection between the patient and their primary care physician in this first part of the journey. In this journey, the patient had had some connections with her primary care physician and with her endocrinologist, particularly around her Graves' disease. The patient, independent of those physician visits, felt poorly at one time, actually in June of 2023, and with a family member's glucometer, got a random glucose of 392. Well, the patient wasn't feeling well. At the time, the weight was recorded at 177 pounds, which was in the slide about her history with a BMI of 31. She called her primary care physician and was able to get an appointment in August. The primary care physician did note the weight and some nondescript symptoms and did appropriate blood work. The A1C was found to be 8.0. Let me go to the next slide and give a couple of more details here. The primary care physician's office did a full workup and appropriate vitals and history, and they found to have fairly normal vital signs, and the laboratory work, however, did reveal some abnormalities. The fasting glucose level was 142, and this was done on a lab value. The A1C was also done in the lab, and it was 8.0. This gives the primary care physician some distinct guidance as to why this patient's not feeling well, for sure, and also how to talk to their patient about the finger stick glucose. Now, interesting, the finger stick glucose of 392 may or may not have been perfectly accurate in this situation, but the fasting glucose level tells us quite a bit, and being obtained by the lab means it's accurate and we can trust it. So the diagnosis of diabetes is something that I think most people on this call will be quite familiar with. It's in the ADA standards of care, and the diagnosis of diabetes can be made on any of the four following values, and to highlight quickly, the A1C would be equal to or greater than 6.5. The two-hour oral glucose tolerance test would be greater than or equal to 200. Fasting plasma glucose greater than or equal to 126, and a random glucose with symptoms of hyperglycemia, such as polyuria, polydipsia, polyphasia, weight loss, or a hyperglycemic crisis. If a random glucose greater than or equal to 200 is found, then that would also be diagnostic. It is important to recognize that if there's any question, if it's a borderline, or if there's any question at all, then a repeat of one of these tests would be appropriate. So two tests would be the best way to diagnose diabetes. This patient did have two different tests that indicated diabetes, and so we now have the definitive diagnosis of diabetes, but honestly, it's really diabetes mellitus, and we don't have a type of diabetes with this laboratory value. It simply doesn't come as labeled with type 1 or type 2. It is diabetes mellitus. So that's where a diagnosing physician, or nurse practitioner, or physician's assistant needs to stop and think, okay, so I know we have diabetes. We've met the criteria. What kind of diabetes is this? How do I proceed now? And that's something I'd like to ask all of you in the poll question that I'm going to introduce now. What clinical indicators does this patient present? So this is a survey for you. Okay, so older age at diagnosis, 58 of you said that would be helpful in making the diagnosis of which type of diabetes. 59% said the higher BMI. 41% said having no DKA or more mild presentation of numbers is helpful. 75% said the personal and family history of autoimmune disease, and 22% said no family history of diabetes is helpful. And then ultimately 53% said type 2 diabetes, 7% said type 1 diabetes, and 40% said another type of diabetes. Excellent. So thank you for your input there. And hopefully it gets you thinking, as you would, every time you make a diagnosis, what type of diagnosis would you choose? So for me, as I was thinking through this case, there's a few things that look like type 2 diabetes, particularly their age, being a little bit older at 51, and not old, but older at 51. BMI also above 25 gives us some benefit that maybe there's some obesity or some insulin resistance. And the fact that there's no DKA, often people with type 1 diabetes will present with a higher A1c and a DKA event or more severe presentation. So these things lend toward type 2 diabetes, but there's also some things that lend toward type 1 diabetes, like the autoimmune disease found in herself and in her family. Also the fact that there's no family history of diabetes. Now we need to be careful. Type 1 diabetes does have a 15% inheritance rate, and type 2 diabetes does not have a 100% inheritance rate. It's much more in the mid-range of 50s and 60s, but still a little bit more type 2 diabetes lends toward a family history. And so with this conglomeration, we're kind of stuck thinking type 1, type 2, it's kind of a mixed picture, and that kind of leads us toward thinking, maybe this is another type of diabetes, because I've got a little bit of a mixed picture, nothing's super clear. Well, it's important to recognize that LADA is the name, latent autoimmune diabetes of the adult. And so latent means that it's somewhat hidden from the beginning. It's somewhat difficult to tell. In the very name, we acknowledge it is hard to recognize LADA from the very early outset. And so we will say, though, that there's autoimmunity associated with it. That's the first A here. And the second A refers again to age. And so the fact that it's difficult to tell, but it's an older-ish person, and yet there's some autoimmunity, even the very name blends type 1 and type 2 to some degree. So let's learn some facts about LADA. First of all, LADA is 2 to 12% of all diabetes patients. Now, this is assuming that all of the diagnoses were to be made correctly. LADA is often misdiagnosed, which is the purpose of our study today. The second fact I'd like you to remember is that it shares features with type 1 and type 2. And it's not just my little chart that I made of a few clinical features, but when we dig into the pathophysiology, there's some genetic similarities. There's immunologic and metabolic similarities. So it truly is a blending of different features of type 1 and type 2 diabetes. The diagnosis is not 100% clear. There's not unity amongst all of the organizations and all of the professionals about what the diagnostic criteria are. However, it probably, with the autoimmunity, lends itself toward having some type 1 similarities that should not be ignored. If everything looks exactly like type 2, then it probably is type 2. If it looks like a strange type 1, it's probably the type 1, which is LADA. Some of the strangeness though, one of the diagnostic criteria is seen on the reference that's given at the bottom here, is age greater than 30 years, positive autoantibodies that Dr. Walsh is going to talk about later, and then insulin independence for at least six months after the initial diagnosis. This is one of the ones that's a little controversial because everybody treats things a little differently and recognizes LADA a little bit more quickly, but it's a nice guideline for us to begin with on thinking about the diagnosis. So this case study timeline is that the patient did not, the patient was given Amaril, glimipride, on the initial visit after those diagnostic criteria were met. First at 2 milligrams and then doubled to 2 milligrams BID, but the patient did not feel well, didn't get the best response from their primary care physician, and it was time for them to find a new PCP. So in this new PCP visit that they had in December, the weight was found to be decreased, the vital signs still okay, but the polyuria and polydipsia became even more clear that it was diabetic related and she wasn't feeling well. So LANTUS was initiated along with some guidelines for eating healthier, exercising regularly, and then of course the monitoring was a consideration and Libre 14-day was started. And so with these, the patient did try to eat a little bit better and do a little bit better, but it was noted that the diabetes education would have been a beautiful thing to do here. That was not ordered in this situation, but at least the primary care doctor did give some education around diet and exercise. Also the follow-up wasn't really excellent with this second primary care physician. A CGM was done, but there was not a great follow-up to use that information. We were able to obtain that CGM information here, and so I want to go through this quite briefly. The purpose today is not to learn to read a CGM, but to see how our case of LADA is rolling out. So we can see on this CGM, you know, very briefly that you'll have up in the top left corner the average glucose of 228, and then in the top right corner you'll have some time in ranges. You can see the time in range, which is the green zone, is only 20%. The goal is to get above 70%, and this patient spends 80% of their time above goal range. The graph shows that. We can see on the graph that in the early parts of the day where the patient's probably sleeping, that the glucose is trending down, and then as the patient wakes up, you can see that the glucose starts trending up, and if you look really closely on the summary graph, you can kind of see a breakfast, lunch, and dinner, but at least when you go to the daily graph, you can see distinct four-hour elevations, which are related to meals. So the question then is, what further clues do we have to help us to understand what diagnosis is present? And I will run down a few bullet points here. First is the CGM reading. That helps us to understand the patient is not well controlled, even on this basal insulin of Lantus, but I will say that the fact that the insulin is, or the nighttime insulin is dropping through the night suggests maybe the amount of Lantus of 30 units might be too much because we call that over basalization, and so even the smaller-ish dose of 30 units might be too much for this patient, suggesting less insulin resistance. The glucose levels are higher than anticipated on two therapies, starts to give us an idea of what we might be dealing with, and then the mealtime glucose, the fact that there are four-hour glucose elevations often when there's insulin deficiency, those meal elevations will be more distinct and last four hours and then recover, and when there's insulin resistance, the sugars go up and just kind of stay up. That's not, you know, a perfect guideline, but a guideline. And then lastly, the weight continued to decrease even after the treatment, and so the individual, very quickly after this, has a normal BMI and continues to have, you know, higher, to have needs for insulin around mealtime. So with all of these different clues, the primary care physician needs to start thinking, if this, if I had diagnosed type 2 first, something's not going quite right. This doesn't look like a typical type 2 patient, or if they had to diagnose type 1 first, or were thinking of type 1, they think, yeah, I'm starting to see that those meals need some insulin. Maybe I'm thinking more about the insulin deficiency that's present in this patient. At least the primary care physician needs to always be aware that as they diagnose diabetes, it does take time to get the diagnosis firm and correct, and we need to be thinking of diagnoses, not just type 1 and type 2, but also LADA and MODY and pancreatic associated and other types of diabetes. So with that, I'd like to turn my portion over then to Dr. Welch. Thank you very much, Chris. My name is Andrew Welch. I'm an endocrinologist at the University of Cincinnati. I treat adults, but I have a special interest in transitions of care, mostly from pediatric to adult, but I think there's a lot of opportunities to study other types of transitions of care here in this case. So as time goes on, in March of 2024, the patient calls their endocrinologist, and we should emphasize this patient has an endocrinologist that they see for their post-ablative hypothyroidism. So you think this would have gone a little bit better than it did. The patient reaches out and requests an appointment. Some of the additional details around this are, you know, despite the patient stopping drinking all sodas and sugary beverages, they're still losing weight, and they're continuing to have high blood sugars. Somewhere around 200 is very common for this patient, as we saw in the CGM tracing. The message was directed to the triage nurse at the endocrinology office. The triage nurse forwarded this to the endocrinologist, and the endocrinologist advised to schedule a visit with diabetes education. I can imagine a very busy endocrinologist just wanting to gather more information before trying to make a conclusion about what the next steps are going to be. However, no formal referral was placed, and the triage nurse sent a message to the diabetes education scheduler, who called the patient that same day, but there was no answer, and a message was left for the patient on voicemail, but they never called back. So unfortunately, there was a real missed opportunity at this point. They continue to follow up with their other specialists, a cardiologist, and their weight continues to decrease at this point. Finally, in June of 2024, this patient is able to sit down face-to-face with their endocrinologist. The endocrinologist recognizes quickly that something isn't adding up with this diagnosis of type 2 diabetes and is able to order a few specific labs. I'll share those with you now. A non-fasting glucose was 213 with a concurrent C-peptide level of 0.8 nanograms per milliliter. I'm going to say that again because the C-peptide level is going to come up a lot in my subsequent slides. It was 0.8 nanograms per milliliter with a glucose of 213. The glutamic acid decarboxylase or GAD-65 antibody assay was positive at a level of 25.3 nanomolars per liter. And with that, the endocrinologist said that this is LADA and adjusted the insulin by adding frandial insulin and discontinuing the Amaryl. They were referred to diabetes education successfully at that point. So, my next few slides involve some questions to highlight principles of LADA. The cases that we'll see are not this case particular. These are cases that I kind of made up that could highlight different principles. So, in this first one, a 56-year-old patient with a three-year history of type 2 diabetes, an A1c of 7.2% on metformin and glipizide, and a BMI of 37 kilograms per meter squared, recently found to be GAD antibody positive, asks you when he will need to start insulin. So, excellent. The most chosen answer was B, by measuring fasting C-peptide levels every six months. Insulin can be started when levels reach less than 0.7 nanomolars per liter or if glucose control deteriorates. So, a few points to hit home here. The natural history of LADA is very heterogeneous. It's very difficult to predict the progression and timing of when something like insulin is going to be needed. There are some factors that have shown up on different studies, but factors that increase the risk of needing insulin include high levels of GAD antibodies, multiple positive autoantibodies, low BMI, and younger age at diagnosis. LADA is defined as initially not needing insulin, but patients may eventually require it. Even if a patient has some predictive factors, such as the patient in this case, as well as the patient in my question, it's not a guarantee that they will need insulin in the future. So, this is some of the difficulty around the diagnosis of LADA is sometimes it's hard to say sometimes it's hard to say exactly what it will mean for your patient. And again, it depends a lot on when the glucose is being checked. Somebody may have started out with LADA five years ago, but by the time something is detected as being wrong with their glucose, they've already progressed to a point where they're insulin requiring. So, yeah, there was a 2020 international consensus statement, partially sponsored by the ADA that suggested monitoring C-peptide levels in LADA patients, meaning GAD positive and considering insulin based on results and deterioration of glucose. I have a little flow sheet here that I think is helpful. So, at the time of diagnosis of diabetes, when if there's uncertainty to screen with GAD antibodies, and then if positive to measure the serum plasma, C-peptide and glucose based on the levels, you know, if the C-peptide level is high, it can be treated. They can be treated as more in the pathway of classic type two diabetes versus if there's kind of a high classic type two diabetes versus if there's kind of low or low normal C-peptide levels, they can be proceeded to be treated more within the lines of LADA or type one diabetes. And this can be what their suggestion was, it could be C-peptide could be repeated every six months to help you make decisions about diagnosis, the starting of insulin, et cetera. So, it's important to order appropriate labs to diagnose LADA and Chris already mentioned this. If you have to pick probably two, it would be the GAD and the C-peptide levels. I am okay using random C-peptide levels, but a lot of these guidelines refer to fasting C-peptide levels. You just need to know which one you're ordering when you're looking at these guidelines, but either one can help you get a sense of insulin deficiency. There are other autoantibodies associated with type one diabetes and LADA, but 90% of patients with LADA are GAD positive. So, you can do this in a stepwise process if you still have suspicion for autoimmunity influencing diabetes and order some of these other antibodies that I've listed below. So, these are some of my personal approaches and maybe helpful tips and pearls that you could take away. One is I have a dot phrase that's included in all of my diabetes notes that automatically displays the last time that the C-peptide level was checked and any of the autoantibodies that are associated with type one diabetes or LADA. So, every time I'm looking at a patient's note, I'm kind of confronted with this question, you know, is this somebody that we need to check? Has this already been checked? And that makes it part of my conversation with the patients. Promptly check autoantibodies whenever a patient's therapy does not yield the expected results, such as in this case, like A1C remaining elevated despite weight loss. And I mentioned this, but most studies focus on using fasting C-peptide, but I'm comfortable with random C-peptide just because it's, if there's a lot of convenience to it, patients can go right out and get this done. And even if an antibody tests are negative and C-peptide levels are normal, I remain vigilant for signs of insulin deficiency and am prepared to recommend insulin therapy when necessary. One more question on my part about the treatment of LADA, you were saying a 50-year-old male patient with newly diagnosed LADA, GAD-positive, fasting C-peptide is exactly 0.7, I think it was actually greater than 0.7 nanomolars per liter. A1C is 7.3%, BMI is 44, no weight loss, no polydipsia or polyuria. He has a past medical history of coronary artery disease and benign prostatic hyperplasia. Previously, he had severe GI symptoms while taking metformin. Which antidiabetic medications would you recommend? A is daily insulin injection, B is impagliflozin, C is glipizide, and D is semaglutide subcutaneous injections weekly. We'll take about 10 seconds to think about that. All right, the most selected answer was semaglutide subcutaneous injections weekly, but the second most chosen answer being daily insulin injections. So some of the rationale around this, the correct answer was the weekly semaglutide, and that's because this patient has sufficient C-peptide levels, they have obesity and no signs of insulin deficiency, and with the history of coronary artery disease, it just makes sense to use GLP-1 receptor agonists in this case. There's no current evidence of insulin deficiency, but it should be thought about in the future if there's any signs of deficiency or if glucose control worsens. Regarding the SGLT2 inhibitor, the patient lacks the history of chronic kidney disease or heart failure and might exacerbate BPH, and you know, they're in these, this consensus statement, there's potential concern around the risk of DKA in a patient who has the beginning stages of LADA, and maybe as that diabetes progresses, there would be risk of that in the presence of SGLT2 inhibitors, but this can be part of your plan is to monitor the C-peptide levels and to advise the patient about the risk of euglycemic DKA, and I believe that it can be used safely, but it may not be the first line if you know that this patient has LADA or borderline C-peptide levels. The one that there was a lot of agreement about not choosing was the sulfonylurea. There have been studies where the use of sulfonylureas in LADA have led to poorer diabetes control and lower C-peptide levels compared to other conventional treatments like metformin and DPP4 inhibitors, so there's uncertainty if sulfonylureas could promote the progression of LADA over time, so it's not recommended by this international consensus statement. This is another algorithm again showing based on C-peptide levels potential therapeutic pathways. Low C-peptide obviously will lead to insulin. Intermediate levels will lead to treatments that are very similar to the type 2 diabetes pathway, and I won't go through that, but I will mention in the SGLT2 inhibitor in the middle it says consider potential insulin requirement and risk of future deterioration and ketoacidosis. I made a really brief slide just because there's so many different ways to think about LADA, and one term that I might introduce is something called adult-onset type 1 diabetes, and the definition here revolves around the insulin requirements, you know, are usually very immediate. You know, this is somebody who's coming in with DKA, one or more autoantibody, but keep in mind that 5 to 10 percent of patients with type 1 diabetes may be negative. You might have to screen for MODY if there's uncertainty. This compared to the LADA that we've been talking about, insulin requirements can be delayed but may be progressive, and as we talked about earlier, six months to requiring insulin may be kind of a minimum requirement, but there's so much variability. In the UK prospective diabetes study, there was a subgroup of patients who were GAD antibody positive, and the average time it took for them to require insulin was actually six years, so a lot of variability, and then the tempo of progression is important. In LADA, it's slower than in type 1 diabetes, and in type 2 diabetes, there's going to be no autoantibodies. C-peptide is high but can decrease over time, and insulin requirements are variable. Just some summary thoughts before I pass it on. I wouldn't get too hung up on, you know, the diagnosis. Is this type 1 diabetes? Is this LADA? Really what you're looking for is insulin deficiency and risk of insulin deficiency. This is my proposal of maybe a different way that you can think about it, or what you could call it in your mind. This is not guideline at all. This is just Dr. Welch speaking out loud, but you could think of it as autoimmune diabetes with rapid progression is type 1 diabetes, and autoimmune diabetes with variable progression is going to be more consistent with LADA. This just highlights the autoimmunity is the key feature, and the timing is the variable part. If you focus on and treat signs of insulin deficiency, you will always be right and safe, and please refer to endocrinology if uncertainty about diagnosis or treatment if available, and looking back on this case, you know, the patient may have benefited from a little bit of support and advocacy from their primary care provider, maybe communicating to the endocrinologist themselves and saying, I'm concerned about this patient and their progression of diabetes. Is there anything that we can do right now? And I think that can go a long way, at least in my experience in my practice. Thank you very much. Great. Thank you so much, Dr. Welch and Dr. Jones. That was very informative. So, my name is Emily Matney. I'm a certified diabetes care and education specialist and a quality program coordinator, which basically means that I oversee diabetes education services at some different locations that include endocrinology, primary care, and maternal fetal medicine as well. So, one thing that I want to address as we kind of dive into diabetes education and its role here is, in your profession, what do you find to be the biggest barrier in referring to diabetes education? Some different feedback that I've gotten or different things that I've heard can include some scheduling issues, like there's a long delay in patients getting an appointment or being contacted. Maybe there's no programs close to your area. Maybe you've gotten feedback from your patients before that they went, but they maybe didn't find it helpful, or you don't see much change from it. It could be something else. I was thinking about, we recently changed charting systems, and the way that you place the referral has now become a lot more cumbersome. So, it can also be something that's not identified here or no barriers that referring to diabetes education and getting them in works pretty seamlessly. So, I'll give everyone a few seconds to respond. Let's see what we have. Okay. So, it's a little bit of a mix of, and I would love to hear if you fall into that other category, kind of what your feedback is, but it does seem a bit of a mix of some scheduling issues, maybe access to diabetes education, and I'm happy to see that there's some that have no barriers. That's always good to see, but I can definitely assure you that if it's a program that's accredited by the ADA or the ADCES, there is always a quality coordinator, and they would be happy to get back any feedback you have on barriers for getting them into diabetes education. So, on this case study, we've got diabetes education highlighted in purple. It was about a year after diagnosis when they had their first diabetes education visit, and in that appointment, so by this point, the patient had been diagnosed with LADA. They had several medication changes, but this was kind of a loaded appointment because that patient is learning, like, what is the difference between LADA and type 2? What does that mean moving forward? Being able to look at that CGM data and understand it. Insulin instruction goes a long way, and by that, I mean understanding the timing of insulin, when to give it in relation to your meals, injection sites, rotation, understanding your dosing, how do you treat lows? How do you treat highs? Checking for ketones, if appropriate. All of that is kind of covered in that initial wave of diabetes education, as well as some nutritional considerations, too, and then this August of 24, so they came back four weeks later to see the diabetes educator again, and at that time, mealtime insulin was increased. They looked at the CGM, but I also want to point out that what's not shown here is that there were several phone calls after that visit in July between the educator and the patient to answer questions, to look at the CGM, to really follow up and provide this kind of point of contact and consistency moving forward. This is just a look at the CGM data. This was prior to that first education visit, and at their first endocrinology visit is when this data was reviewed, but the CDCES did recommend changing from the 14-day Libre to the Libre 3 to allow for continuous data to make sure there's no gaps in that data related to not scanning, to receive alarms for low and high blood sugars, but now that we have so much ability to remotely view data, whether it's from a CGM or from an insulin pump, that also provides this closer follow-up in between appointments where changes can be made and work towards those treatment targets. But what does a CDCES do? And this is something else I've heard is just not not knowing what is covered at that visit. First off, it's not a one-and-done visit. Diabetes education is an ongoing service, and insurance is very different, and it varies on how many visits that patient can have, and we'll talk a little bit more about that, but it's not a one-and-done visit. We often require multiple visits and, again, like to have that kind of bone contact in between. The circle image on the right is showing what we call the seven self-care behaviors, so we are working off of a curriculum to make sure that nothing gets missed or lost, but we're going over, again, medication management, making sure they understand what their medications do in their body, how to take them appropriately, monitoring whether that be with a CGM, whether it be with finger sticks, how to treat highs, how to treat lows, problem solving. When we say DSMES, that stands for diabetes self-management education and support, so our goal is to really empower the patient in understanding their own diabetes and being able to troubleshoot when things maybe are not going the way that they thought they should. Healthy eating, of course, those lifestyle changes are so crucial. Being active, how does all of that play into blood sugar management, but I also want to note this healthy coping skills here, and I think with this patient in particular, as well as other patients that maybe are initially diagnosed with type 2 and come to find out it's LADA, oftentimes there's kind of this period of frustration where the patient really feels like they're trying so hard and they are taking their medications as prescribed, they're coming to their follow-up visits, they're calling in between, and they're still not getting to goal, and I think that it can often be very defeating and kind of impair that motivation to continue doing things if it's not going the way they want it to, so that educator is there to really reassure them to make sure that motivation stays. Diabetes is incredibly hard to manage, so in addition to that curriculum that we're following, we are, again, that kind of consistent point of contact. I certainly think that everybody on the team has a role to play in patient advocacy, but I do, I like that the educator is able to navigate different areas, so whether that be like calling the pharmacy to find out why they can't pick up their Dexcom or their Libre, maybe it needs a PA, being able to communicate back to the provider that some red flags are happening, that they're reviewing that CGM in between, and despite insulin adjustments, they're not meeting those treatment goals, and I think Paige said this at the beginning, but really working as like a collaborative team to make sure that that patient gets full support. Troubleshooting for both the patient and the provider. Again, a lot of pharmacy issues tend to arise, but also really being an expert in the field of technology. So we spend a lot of time being trained on CGMs to both place professional CGMs, but is also personal training and making sure that those apps get set up appropriately and linked to clinic portals if that's something that your clinic has. This patient is now being referred for insulin pump management, so that's kind of the next wave that's not shown here is that the patient is now considering starting an insulin pump. And in that goes this point of like shared decision making for what pump to start, as well as the training and the ongoing management. CDCS has also come from various professions, so RNs, RDs, PharmDs can all have this certification. We all can provide that DSMES service, but RDs can also provide medical nutrition therapy, which is so valuable and we'll hear about later on. Okay, so what is critical in utilizing diabetes education services is that per CMS guidelines, the referral does have to come from the provider that is managing the patient's diabetes. So if the patient is seen by a podiatrist who's consulting and that provider recognizes that they have not seen diabetes education, they certainly can communicate that back to the provider that's managing it, but they cannot be the one that places the referral. Same goes for hospitalization. If they're seen in the hospital, that just needs to be communicated back to the provider that that referral needs to be made. But it can be APP, MDDO, it can be any profession as long as they're managing the diabetes. Again, if there's concerns related to how diabetes education is going in your area, would strongly encourage you to reach out to the quality coordinator. We see that very few patients are referred to diabetes within the first year of diagnosis, and I want diabetes education to be viewed more as a preventative service. Like even if that A1C at diagnosis is 6.6, they still need to be referred so that they can get all of that upfront education on what diabetes is, how to manage, understanding the terminology, understanding the lab values. So we would like to see that number go up. Medicare covers 10 hours of diabetes education the first year of being referred. So that definitely means at diagnosis, but it also means if you see a patient who has had diabetes for 20 years, but they have never gone to diabetes education and they have Medicare, they still get that 10 hours. So it doesn't necessarily have to be within the first year of diagnosis, just within the first year of receiving those services. Also in that first year, they can get three hours of MNT. So that's 13 hours of total education within the first year that they can get. But it is a use it or lose it benefit, meaning that if they don't take advantage of it the following year, they only get two hours ongoing. So when do we refer to diabetes education? These are what we call the five critical times to refer. So at diagnosis, or again, if they have never seen diabetes education before, annually. When complicating factors arise, and by this I mean maybe like financial issues or food insecurity, this could be onset of new health complications like chronic kidney disease, starting new medications that may impact their blood sugar control, life transitions. So kind of as Dr. Welch had stated too, that pediatric to adult transition is very much a time that we want them to come to diabetes education. But this could mean going to college, it could be getting married and having a baby, it could be for our older population, it could be if they have to move into a nursing home, maybe the loss of a spouse. Those life transitions are absolutely times that they need to see diabetes education. And then of course, when not meeting treatment targets. So if you are not sure if there is a diabetes education program close to your area, these are just some different resources that you can use to search in your area and find out if there are any programs close by. Okay, so I just want to pull this continuous case study back up to kind of show this patient's journey. I think I would have liked to have seen that referral to diabetes education happen at diagnosis. The first step is to refer to get them in and back to the scheduling issues. I think a lot of programs are really dependent on that referral, because oftentimes we do need to contact the patient multiple times before we make contact and get them in for an appointment. But I think in this case study, the educator really could have been bridging that communication between the patient and the provider as well as from primary care to endocrinology, and to be that advocate and kind of filling in the gaps between visits. Again, once you establish that rapport and that relationship with the patient, I think being able to view their CGM data in between appointments and make medication recommendations, sometimes according to the program, there's policies and protocols in place where the diabetes educators can make changes within 10 to 20 percent based on how the data looks, and that is very dependent on the organization. Again, monitoring, so helping with those professional CGM placements or personal trainings and being able to get them connected so that the provider can see those results. That emotional support is so, I think there's a lot to be said for validating what the patient is going through. Oftentimes the educator has a lot longer duration to spend with the patient. In our clinic, we get about an hour with each patient, and that really opens the door for that conversation and to hear what they're going through from a coping perspective and how can we offer support and strategies for coping. And then, of course, medical nutrition therapy. I think so highly of when the primary care provider at that diagnosis is able to educate them on going ahead and getting those lifestyle changes going, like eliminating those sugary drinks and high-carb foods, but there's so much to be said for getting that official medical nutrition therapy, especially if they are going to need to transition from carb counting over to eventually insulin to carb ratio. So with that, I would like to pass it on to Maureen. Hi, my name is Maureen Chamko. I am a dietician and diabetes educator out in Seattle, Washington. I've worked in primary care for the past 12 years. The last eight of those has been in a federally qualified health center. So today I am going to talk to you about tools that the dietician, nutritionist, diabetes educator uses in their visits, but also some tools that the primary care provider can use in their abbreviated visits where you have five chief complaints and 15 to 20 minutes to address them. And so in a visit with a dietician or a diabetes educator, we are able to do an extended nutrition assessment. We can take up to 20 minutes as part of our 60 minute visit with the patient, really figuring out what the concerns are from the patient, what the issues we might see are in a nutrition plan. If you have time in your primary care visit, it would be fantastic to do a dietary recall very briefly, getting information on breakfast, lunch, dinner, really important to ask about drinks and snacks and practicing this so that you can do it in a nonjudgmental way. So the patient may be more likely to reveal information that they worry they might be judged about if they reveal. If you do not have time for that, which is kind of the standard in a primary care office, you can ask anywhere from one to three quick questions and we'll be diving into these in a little bit. But if you don't have time for that recall, these are three powerful questions that can get information from the patient and can help you guide the plan moving forward and hopefully get the patient to be motivated, such as the picture that's included here. So in our case study, we were fortunate enough to get a dietary recall in our diabetes education visit. And so excuse the arrows, they kind of got a little bit out of, out of order, but for our CGM report, we can clearly hear, see that there's these rises for breakfast, lunch, and dinner. We can't clearly see the dinner rise because it is already off the chart, unfortunately. So we get a recall, we find that for breakfast, our patient has her Dr. Pepper to get her day going good, some ounces of cheese and some crackers. And her lunch is also fast on the go. She's got a hot ham and cheese on a bun from Hardee's. And if you're wondering what that drink is in the back, it is of course Dr. Pepper. And then her dinner is a bit more well-balanced. It has pinto beans, cornbread, greens, fried potatoes, and a Dr. Pepper to close out the day. And we also ask her more about what she's drinking outside of the Dr. Pepper. And we see that she is drinking water in between meals. So I've been told by patients, you know, soda just makes the meal taste better. And this patient, I think would agree with that. So if I was more tech savvy, I would include a poll here. But my question to you, just thinking aloud to yourself, where would you focus with this patient? I feel like some folks might say, wow, there's a lot. We could focus on the soda. We could focus on how every meal there's carbs. We could focus on she's having fast food. What type of breakfast is that? Of course we wouldn't say it like that, but maybe that's what we are thinking. And so luckily we have the answer in the standards of care from the ADA. And so in chapter five, which includes the nutrition component, we can look up the term individualize, and it appears no less than 22 times in this one chapter alone. So even if we wanted to focus on the soda, or we wanted to focus on the quality of what she's choosing, or if we wanted to focus on how many carbs she's eating throughout the day, it kind of doesn't matter what we want to focus on. It matters what the patient is actually going to do, what she wants to focus on. So in a dietician visit or a diabetes education visit, we can take that time. We have, you know, my initial assessments are 60 minutes. We can talk about her personal preferences. If there are cultural preferences, we can assess for health literacy and numeracy, her access to food, her ability to make changes. And of course the barriers to those changes that she has. This is not something I expect a primary care provider to be able to accomplish in the brief visit. So this is something that certainly would be referred, could be referred out to really dive in. But in a primary care visit, we just want to make sure we're individualizing for the patient that's sitting in front of us. And I want to talk today about the tools that we have to individualize. We're going to talk about five different levels of strategies that we can use in our primary care visits. We want to choose one per patient per visit. I don't want you to do all of these in one visit. And as we go up the pyramid, the complexity starts to increase. So we're going to start with level one, which are those nutrition basics. We're going to return to those one to three questions we can ask our patients. If we just want to get a baseline assessment of what they know about nutrition for diabetes, what they know about what makes their blood sugar go up. So our first question is going to be, what do you drink throughout the day? This patient, of course, we learned drinks a lot of Dr. Pepper, regular Dr. Pepper and calorie king.com is a free tool. I'm not being paid by them. It's just a really easy website to navigate. You can enter in Dr. Pepper with the patient right in front of you. And it's very easy to change the size. So whether she's drinking out of bottles or cans, it's very easy to change the quantity. So what we can bring up is that for three 20 ounces bottles of Dr. Pepper in one day, it's about 200 grams of carb, which for us, we might say, wow, that is a lot of carb. But for a lot of people, they don't know if that's a lot of carb. Is that appropriate? Are we supposed to have 500 grams of carbs a day? We don't know. So what is a more useful tool is taking that total carbohydrate and dividing it by four. And that gives us 50 spoonfuls of sugar. And for most people, that is a very quantifiable amount that they can say, wow, that's a lot of sugar actually that I'm consuming. If that is not a super effective, we can also use the same tool on Calorie King, which it tells us how long it would take to burn off those calories. So the 750 calories of Dr. Pepper would take almost three hours of walking to burn off. So if the patient is agreeable that she can do three hours of walking while she's drinking the Dr. Pepper, that might give us a chance to control her glucose levels. But if she's not able to do that, which I certainly am not, it's going to be a little bit more difficult to control her blood sugar if we are drinking that much sugar in the day. So then we're moving up to level two. We can figure out a patient's knowledge about plate method, different types of foods, asking, you know, do you know what our source is of carbohydrate? And the patient might not even know what a carbohydrate is and what the difference is between a carb, a protein, a fat. And while we're talking this through with a patient, we can just be drawing a really quick circle with the patient and labeling out, okay, what carbs do you know about? And what carbs do you think make your sugar go up? We can talk about what foods are proteins, what foods are proteins that you like, and that proteins don't really have that much of an effect on our blood sugar. And then of course our vegetables, we can talk about, you know, which vegetables a patient like, and as you're talking about these things, you can be building a sort of a meal or brainstorming a meal together of something that they could eat. And the idea should be coming from the patient so that it's the foods that they are accustomed to and they can recognize easily. And I find that it's very easy. You don't have to have any measuring tools. The, these basic levels of nutrition education that you can do in primary care would, you can just use a person's hands. So the amount of carbohydrate they should eat at one time is about the size of their fist. If you're really focused or they're really focused on weight loss, you can try to say less than the size of your fist, or if someone's having, you know, an entire plate full, you could also individualize this by saying, you're just going to have half the plate full of carbohydrate. Again, it's always individualizing the plan for the patient based on what they've been doing and based on what they feel they're capable of doing. And then our third level up. So this is still something we can be doing in a primary care visit is having some awareness of carbohydrate and trying to start tracking that carbohydrate. And that can be introduced by asking what foods make your blood sugar go up. This will give us an idea of if the patient even is aware. So is the patient ever checking postprandially? We have these beautiful tools of CGM, which are getting this information available to the patient right then and there. But it's not available for everybody. We still, I'm sure out there, we have a lot of people who are still using just finger stick blood sugar measurements. Many patients are checking a fasting blood sugar, which is very helpful when we're titrating medications or changing medications. But past that, it loses a little bit of utility versus the immediate feedback a patient can get after trying different foods, trying different quantities and seeing what happens to their blood sugar. So this can be some homework that we can give to the patient for the next time of either doing hard copies like we looked at in that, I mean, my first slide or using apps, which we'll talk about later to track those carbohydrates. And then we move into level four on that pyramid of complexity. When we start talking about carbohydrate counting, this is something that I don't expect a primary care provider to be able to do in a brief visit. This is something that you would want to refer to a dietician or a diabetes educator for. It is quite complicated when we break it down. So first of course, we need to know which foods contain carbs. It's difficult to count carbs if we don't know exactly which foods we need to be counting. Then we need to kind of learn this language of carb counting, which is we measure things in carb choices, this 15 gram unit that we use to measure one carb choice. And then we get into the math behind this. And some people have strong math skills and some people math is not their favorite subject. So for example, a carb choice of rice is a third of a cup. If a patient has one cup, that is now three carb choices or 45 grams of carbs. This can be challenging for many people, as you can imagine. Then they have to learn the carb choices in the foods that they commonly eat. So building that library of foods that they're consuming. Most people consume about a hundred foods as far as variety of foods. Not all of those are carbohydrate foods, but we need to work through with them. Which of the foods that you consume are carbs? What are the portions you usually consume? Is that in the range of carbohydrates that we want to have per meal? So if you prescribe, you know, a, we're going to try to hit 45 to 60 grams per meal, or we're going to try to hit less than that or more than that. They need to know what they're eating and the quantity of carb in those foods. As I've been mentioning, it, it requires more health literacy and more health numeracy. So if your patient is not strong in those areas, that either would be a referral to education to figure out the easiest way this could be accomplished. If it's very important for the patient to get their sugars in a, in a target range or the provider of diabetes education or medical nutrition therapy would figure out the best way for this patient with limited numeracy skills. And then once we have that strong base and carbohydrate counting is when we can move into the gold standard, highest complexity of insulin to carb ratios. Again, this is something that we want to do a diabetes education or nutrition therapy referral, because this is also more, more layers of complexity. So we need to have our patient know how to locate a nutrition facts panel, find it online, figure out how many carbohydrates are in a food. And then also know that they just, they don't just have to look at the carbohydrates, but also the portion on that label. And this is where the complexity really increases. We need, they need to figure out, okay, the portion on the label, say it's a bag of family size bag of chips. The portion is about an ounce. So how does my portion of chips compare to the portion of chips that is listed on the bag? Is it more than that? Is it less than that? Spoiler, it's usually going to be more than an ounce of chips, but it's, they still have to understand what is an ounce and how many ounces is my serving. And then if we have given them a guide of, you have to have 30 grams of carb per snack or less, they have to change their portion size based on that. And then they have to use that ratio, which is again, more math by dividing the units of insulin into the grams of carbohydrate that they have calculated for that meal. So this is absolutely the gold standard intensive insulin therapy is when we're using carbohydrate counting and we're using a correction factor before meal. It is it reduces hypoglycemia. It improves overall glycemia. It is certainly recommended in patients that can do it. But again, this is requiring multiple sessions often with a diabetes educator in order to become really good at this. And it also needs to be refreshed. We, when we look at data of people who have been doing this for five, 10, 20 years, we find frequent miscalculations. So this is something that as Emily was mentioning, we need to keep referring over time, even if a patient has been doing this for a long time. And then, as I mentioned, there are individuals who will not be able to do the gold standard of carbohydrate counting. They will not be able to do a sliding scale and scale of insulin necessarily. So they might need fixed daily doses. And by that, I mean, a patient is taking five units with breakfast, 10 units with dinner, 20 units of mealtime insulin. I'm sorry, 10 units with lunch, 20 units of mealtime insulin with dinner. And so for those patients, if we are not able to do that intensive carbohydrate counting, the most important thing is that they're having carbohydrate intake that's consistent at breakfast. So at breakfast, there's about a range of carbohydrates that they're consuming. It's not like one day they consume 15 grams of carb at breakfast. The next day they consume 70 grams of carb. That's going to make, of course, as you can see the insulin dose, very difficult to predict and difficult to manage. And so in our case study, how do we wrap this up? How did our patient decide she wanted to improve her blood sugars? She did say she was going to minimize her sugary sodas that she consumes every day on her CGM. She can see it makes a big difference. She's talked to the educator about alternatives. And, um, we know she drinks water. So some patients, they say, I hate the taste of diet drinks. I'm just going to drink water instead. Um, for other patients, they have a lot of questions about diet drinks. And the, um, the answer we can give them is it's very clear, um, for insulin deficiency or people who need mealtime insulin, um, people who have fulminant diabetes, that sugary drinks are not good. We know they increase glycemia and, um, diet drinks do not. Um, but the evidence is a little bit more murky on diabetes prevention and weight management in, in patients. But we know for sure if a patient's on insulin, insulin cannot compete with the rapid spike that, uh, regular sugary beverages provide. So a diet beverage would be the better alternative. She also decided that she'd like to try portion control. She's lost that weight. She wants to keep it off. So we need to make sure that if she's trying to aim for 30 to 45 grams per meal, does she know what that even means? So what tools do we need to work with her, um, to give her that she makes sure she knows what is a carb and how much carb it has. And because she's going to start counting these carbs, she's going to enter those carbs into the events in her CGM, as well as the amount of insulins that she's taking at those times. And this will absolutely help the educator or the provider in the future to see the carbohydrates she's eating at meals to see the insulin she's taking. And it eventually will definitely help when she starts that, um, journey to get on a pump, because those are the skills she needs in order to get on a pump. And so these are some popular apps that can help, um, with counting carbs. Um, but there's so many out there. Um, so you can, you know, get recommendations from your patients on their favorite apps as well. Um, but this is something that can, um, help our patients succeed. So not just setting the goals, but making sure they have the right tools for that. And as a dietician and diabetes educator, um, our goals for all adults with diabetes, no matter the type, we want to just make sure that they are consuming a variety of nutrient dense foods. We talked to patients about appropriate portion sizes. A lot of patients do know that they need to eat less, but the most difficult part is how they actually can do that. We know that portion control is incredibly difficult and difficult to sustain. So working with a patient ongoing to make sure they're successful in that. And we want to maintain the pleasure of eating. We don't want to push a patient closer to diabetes burnout by limiting foods unnecessarily. We want to limit it only when it's indicated by evidence. And then as I was talking about in that previous slide, we want to make sure they have the tools for their meal planning. My guess is she's not eating crackers and cheese because she thinks that's the best breakfast for her. She's not grabbing a meal at Hardee's because she thinks that's the healthiest thing she can get. Um, but she might not have the tools or the knowledge of how to move forward with what choices would be better for her blood sugars. With that, I'm going to turn it back over to Paige for questions for all of us. Great presentation. Um, thanks for all the great information and all the hard work to the presenters. I want to also take an opportunity to thank the ADA for the opportunity to do this great work. The activity is partly funded by the Helmsley Charitable Trust, and we'd like to thank them. We look to our next webinar on October 1st, and that is the management of pediatric type 2 diabetes. Now we will get down to the Q&A. So, um, I think we answered the first question, how long did she go before antibody testing was done? Um, I have a question for Dr. Jones. How many primary care physicians do you think feel really comfortable ordering that test? The peptide and anti-GAD antibodies to look into the autoimmune nature of diabetes is everybody's heard of it. No, not that many people are comfortable with it. And, and honestly speaking, I think it doesn't enter minds very quickly. Often when we get into, to the patient profiles that we have, type 2 diabetes, of course, we know is so much more common, particularly in the primary care world. It sometimes reaches a hundred percent as we refer all of our type 1 diabetes patients to endocrinologists. And so we naturally just think of type 2 diabetes and forget to ask the question, could this be something besides run-of-the-mill classic type 2? So while we've heard about it, thinking about it at the right time is the, is really the difficult thing. If we think about it, I think we'll have the courage to order it knowing we've got endocrinology backup. If we find those tests to be abnormal, we just need to think about it. Good. We just had a question pop up in the chat. And we, and the, the participant said we have a referral to our clinic last week. She was diagnosed with type 2, but patient is only 27 years old, and she didn't even have a C-peptide or antibody ordered. Should I refer her to an endo or to have more testing done to really get the correct diagnosis? That's for me again. That's a primary care question right there at the point of diagnosis. And I hope this webinar that we're in right now empowers you to say, I'm able to order that test and decide, do they need to move on or not? I will, I will point out that it's not you that will take time to diagnose the right type of diabetes. It's the disease process that takes time to diagnose the right diabetes, right? And, and so sometimes it looks exactly like two and many years later, you're like, hold on. Now it's not looking like type 2. It's time for me to ask the question again, is this type 2? And, and you have the power. I hope you're field empowered to order those two tests. And if they're abnormal, then you can do that referral and say, what additional things need to be done? How do we proceed from here? But I would encourage primary care doctors to feel comfortable ordering those, ordering a C-peptide and an antigen antibody along with, of course, a glucose. You don't order C-peptide by itself. It has to be a C-peptide with a glucose because we all know that endocrinology involves feedback loops. And so you have to have the other part of that, that loop. So C-peptide, a glucose and an antigen antibody. And when you do that, if you find that it's distinctly not present, you know, C-peptide is high, antigen is negative, you can feel confident in proceeding. But, but please do set in your minds that that's something clearly within the role of a primary care physician or, or APP. And you know, it comes to my mind that you're really doing a patient the greatest justice, because the overall goal is to shorten this journey, resolve a diagnosis that can actually get them the quickest time and range and, and, you know, reduce their risk and complications later down the road. We have a question. Andrew, this may be for you. Would TZI be indicated in a patient with GAD positive antibodies without a low C-peptide in LADA? Currently, there is not an indication to use immune therapies like TZL, teplizumab in LADA. The very specific indication is you have to have stage two type one diabetes, which actually requires two positive autoantibodies and evidence of dysglycemia without overt diabetes range glucose discontrol. So, that's a very narrow range of people. And by the time somebody's coming to see you for their diabetes, and if they only have one antibody positive, there's not a current indication for that. But I think it's an exciting field. And I think we will see more and more coming from that in the future, since it makes sense to treat an autoimmune disease with an immune directed therapy. This is an autoimmune disease, though very slow. There may be a role for immune therapies in the future, but not yet. So, what is the downside of using low dose basal insulin because of the progressive nature of islet cell deficiency? Does this physiologically benefit patients so they understand the eventual long term need for insulin? Yeah, so I think the question is, why not use insulin for anybody who has a positive antibody? You know, anybody who has LADA, maybe they should just start on insulin. There's not enough evidence right now to say that with confidence. I think it makes sense, logically, that that's a good option. And it will depend a lot on the patient and their circumstances. Some patients really embrace this diagnosis. And they say, finally, it makes sense why my diabetes has been so challenging to control. And I'm ready to embrace, you know, subcutaneous insulin, maybe a low dose basal insulin is fine. But what I think there's value in also looking at the level of C-peptide, right? If a patient comes to me and the C-peptide is actually very high, I think there's a lot of endogenous insulin production reserve here, even if they have an autoantibody positive, we don't need to rush immediately to insulin. There's just not data to say that it makes a huge difference. So this is for you, Dr. Jones. So I'm pretty sure this person asked the question early on. She was saying the A1c was high. Why would you not start insulin immediately? Now, I work in one day a week in a primary care, very busy primary care practice. And one of the things that was problematic when I first started there about four years ago was there was a very big therapeutic inertia caused by fear of hypoglycemia. And, you know, it was almost like the last resort to start a patient on insulin. And they would just hit that referral to the endocrinologist. And, you know, I was trying to explain to them, okay, in our little part of the world may not be like this, the rest of the world, but I'm pretty sure it's very similar. You know, there's a long way to get in to see an endocrinologist. So let's start some CGM technology in this clinic and get you more comfortable and keep our patients safer. So there's a lot in that question. Let's say it is type two versus LADA or uncertain, right? Where do we go from there? And I'd love to think through the history very, very briefly with you of how treatment has changed based on the scientific knowledge that we have. We used to think that, you know, insulin is last resort. And it was always, the patient said, as soon as they put my grandma on insulin, she died, you know, and that was always the thing going around. So everyone had this fear of insulin. We spent the first half of, you know, the 2000s, 2010, to really understand that insulin is not something to be scared of. It is a great therapy. Starting insulin earlier seems to protect beta cell longevity to some degree. You know, there's some really nice benefits of using insulin when it's appropriate and not being scared of it. What's happened though, in the last number of years, a decade or so, is we've recognized that we now have therapies for patients who don't require insulin from severe insulin deficiency. We have secondary benefits from therapies that are available to us, namely the SGLT-2 and GLP-1, GIP medications, have cardiovascular benefits, have renal benefits and heart failure benefits. And with these additional benefits, it does now push us to the area of saying, we aren't scared of insulin. We're comfortable using it. It's a great medication, but it doesn't have the secondary benefits of cardiovascular protection and renal protection. So if we think we're dealing with someone with type 2 or even LADA, but they still have a significant insulin production, you know, endogenous insulin production, we do like those risk modifiers that come with those other medications. So unpacking that history is very interesting. It leaves us with the sense that insulin is a great medicine and we'd like to use it. It's not scary. It doesn't have to be last resort. But very quickly, let me say your CDCES is somebody that you need to have a great connection with. They help patients start insulin safely. They help talk about hypoglycemia and teach them symptoms and signs and what to do. If you don't have time or you have nervousness about insulin and the endocrinologist is, you know, months away, your CDCES is absolutely invaluable. And that's where I'd hand the baton off to that great colleague that we have. Thank you. It's a good point. Do you confirm every new diabetes diagnosis with GAD and a C-peptide test? So let me say two lines and then ask Dr. Welsh to cover that. No, I look for cases that are a little unusual or that have some features of both. And I'm quicker to use those tests, but I don't do it on everyone. I don't think it's efficient or appropriate. Yeah, I agree with you. I don't think that everybody needs to be screened in that way, particularly somebody who's followed kind of the script of type 2 diabetes, right? Many years of pre-diabetes as obesity worsens, diabetes worsens. Like I'm just not getting very many hints of autoimmunity there, but where I definitely think about autoimmunity is change, you know, sudden changes in A1C when it just doesn't add up. When you get that discrepancy of weight loss and glucose stays high or gets higher, these are all opportunities to think about autoimmunity and you should have a low threshold to screen in those situations. Great. All right, ladies, you're on deck next. Someone asked regarding the 10 hours of non-MNT, who must do the billing for that? Either one of you can jump in. So, that would fall back on the CDC, yes, whether it be the RN, the RD, if they are billing for DSME hours as long as they're functioning within that diabetes educator role, then they're billing for that service. They wanted to know, and you may have just answered it, how do you bill between these visits for all the RDCS's time between visits to adjust insulin, like titration? Oh, that's the, yes, that is the question of the time. I think that we are definitely learning more about how to bill in a telehealth capacity, but we have to be very clear with the patient. Is this just a quick phone call that we're reviewing and we're putting in like a documentation encounter or are we having a telehealth visit that we can bill for within 30-minute increments for DSME or 15-minute increments for MNT services? And I think that that falls back on the organization and their policies as to how they want to handle that. And yes, it can be challenging based on the payer. There was another question I answered by typing about non-Medicare coverage of this. And unfortunately, it depends on the type of commercial plan. Medicaid, at least in my state of Washington, does cover diabetes education services. And as Emily mentioned, if there's a barrier to group education, as in you don't offer it in a language that they speak, or they have a learning disability that they need a little bit more assistance, then they would qualify for a one-on- one diabetes education visit. If Medicaid does not pay for that regularly, they only pay for group. But if you have, you can look into your 10 most common payers, and I would encourage you to look at their coverage for these services, because both diabetes education and medical nutrition therapy might not be covered in all cases. Great. If there are any questions in the chat, because there's some things coming in the chat that you all can answer independently, I'm going to continue with a couple of questions that are directed at these two gentlemen here. Do you leave patients on metformin as they transition to MDI therapy, if they were on it initially, and when do you consider discontinuing it? I can take that question. This is a very individualized question. A lot will depend on the clinical course of the diabetes. Personally, I see metformin as a really great starter medication for type 2 diabetes. I think it shows a lot of benefits in pre-diabetes, early stages of diabetes. I don't know if it's necessarily your best medication in advanced diabetes. Once you're starting to use dozens and dozens of units of insulin, and the patient's been on metformin for years and years, sometimes we just do a little test. I say, how about you stop taking the metformin and tell me what happens? Sometimes they come back and say nothing. Sometimes they come back and they say, hey, I had to use more insulin to get the same results. That's very helpful for me. It's very individualized. I don't think I have a rule necessarily that I'm following. Some of it depends on the patient's comfort taking metformin, their willingness to take medications, so much variability around that. They were talking about, one person was talking about a patient, he was recently had his c-peptide and GAD 65 tested, which were both low and positive, respectfully. Should he be changed to basal bolus insulin? I guess he's 65 years old and low c-peptide, positive GAD. Yeah, I would say, assuming that c-peptide was taken while the concurrent glucose was elevated, not while they're hypoglycemic by any means, then yes, I think everything points to they're going to need insulin. The degree of insulin needs to be determined. You know, maybe you start with basal insulin, you're watching carefully with maybe a continuous glucose monitor, like we saw in this case for evidence that cranial insulin is required. But you know, if somebody has very elevated A1C and all that combination of things, low threshold to start basal bolus insulin, I think that's a good way to go. So, this is a good question, maybe a little bit, a little premature. What do you think about the new over-the-counter CGM stello released yesterday? You know, I'm, I'm all for it. I think with the proper understanding of the tool and, and what the proper understanding of the tool and what information you're getting, I think it can be helpful for a number of people, particularly patients who may have had trouble affording specific CGMs may have more access. But I mean, I'll just tell you once a week, I have someone come in with, you know, a long history of hypoglycemia that started when they put on a CGM for the first time, and now they're going crazy and gaining weight because they have to drink apple juice all day. So, that's, that's my concern. There needs to be a lot of education around this, and I'll just tell you, it's not going to be there. So, get ready. Hopefully, we will be able to reach out to people that we were not able to answer these questions for, because I was just told we were out of time. So, thank you all for attending, and I appreciate everyone.

diabetes management

primary care

continuing education

LADA

GAD-65 antibody

C-peptide levels

diabetes education

nutrition assessment

patient outcomes

interactive approach

case study

autoimmune diseases