The fifth annual Clinical Diabetes Technology Meeting was held in Long Beach, California on April 3rd and 4th, 2009. In attendance were hundreds of clinicians, scientists, and engineers from government, industry, academia, and clinical practice. During the two days of sessions, speakers shared information on a variety of topics, including issues affecting accuracy in home blood glucose monitoring, many aspects of continuous glucose monitoring, glycemic variability, reimbursement issues, and various telemedicine options just to name a few. Here is a summary of some of the sessions:
- Dan Streja, MD, presented Postprandial Hyperglycemia: Detection and Treatment. In his talk, he stressed that postprandial hyperglycemia is an important part of the glycemic burden and that there is potential cardiovascular benefit by detecting and targeting it. Dr. Streja also noted that changes in postprandial glucose may precede a deterioration of glycemic control and there is potential benefit in monitoring post prandial blood sugars in this instance also.
- David Sacks, MD, presented Estimated Average Glucose (eAG): What Clinicians Need to Know. Dr. Sacks in his talk prepared clinicians for upcoming changes in how patients will be presented with average blood sugar control. Currently most patients receive a HbA1c at clinic visits. With the kickoff of the eAG (estimated average glucose) at the 2009 ADA Scientific Sessions, a new report will be available to patients and clinicians. A linear relationship between HbA1c and average glucose has been shown in studies. Labs will use a regression equation to convert HbA1c to eAG. Most likely both measurements will be included with lab measurements in the near future. It is hoped that this new measurement (with similar units to home blood glucose measurements) will be less confusing for the patient with diabetes.
- Jorge Cuadros, OD, in a very inspiring presentation, Adding Teleophthamology to Your Practice, told about EyePACS (an adaptable telemedicine system for diabetic retinopathy screening). EyePACS is a license free system funded in part by the California Healthcare Foundation and was developed to lower barriers to access to diabetic retinopathy screening in diabetes care. An evaluation of the pilot project showed a significant impact. Over the two-year grant period, the EyePACS system was used to screen over 12,000 patients, half of whom were diagnosed with some level of retinopathy. Only 15% of the cases, however, were advanced enough to require referrals (10% for sight-threatening retinopathy and 5% for other eye conditions). In addition to the Central Valley clinics, EyePACS has been used by 25 other safety-net organizations in California and Mexico.
- Richard Rubin, PhD, CDE, presented Factors Affecting Use of Insulin Pens. Dr. Rubin presented interesting statistics that the US lags significantly in insulin pen usage compared to other countries such as the U.K., Germany, or France where the usage of insulin pens is close to 100% for patients on insulin. Dr. Rubin in his studies has also shown that physician behavior strongly influences patient pen use and that physician belief that the pen facilitates diabetes self-care is strongly associated with the proportion of patients who adopt pen usage.
- Stuart Weinzimer, MD, FAAP, presented Insulin Pump Therapy, which was a thorough review of current insulin pump choices, basic and advanced features of each insulin pump, evidence supporting use of pumps to improve diabetes control, and methods for initiating insulin pump therapy in clinical practices. Dr. Weinzimer also reviewed realistic and unrealistic expectations for people with diabetes initiating insulin pump therapy.
- Howard Wolpert, MD, presented Sensor Augmented Pump Therapy, in which he stressed that frequently for patients using continuous glucose monitoring systems (CGMS) there exists a trade-off between increased detection of hypoglycemia and the increased risk for hypoglycemia from overbolusing for post meal hyperglycemia. Dr. Wolpert reviewed ways to avoid cgms burnout during initial learning with the devices by strategically setting high and low blood glucose alarms higher and lower at first until the learner becomes familiar with the device.
- David Klonoff, MD, FACP, presented Self-Monitoring of Blood Glucose: What Does the Literature Say? Dr. Klonoff reviewed nine SMBG studies highlighting the positive and negative outcomes of self monitoring. Appropriately debunking the negative outcome trials he focused on the benefits of the positive SMBG studies for both Type 1 and Type 2 insulin requiring diabetes. SMBG requires proper training of the healthcare provider and the patient to appropriately perform, interpret and act upon the information. Most notably he described the necessary skills needed by healthcare providers of interpretation to appropriate target levels, knowledge to make therapy adjustments, evaluation in a non judgmental manner, creation of an action plan for the patient, addressing both fasting and postprandial glucose levels and acting to prevent hypoglycemia. He reported the optimal diabetes control comes from a true partnership of the patient and provider.
- Bruce Buckingham MD, presented Continuous Glucose Monitoring: What does the Literature Say? Several CGM studies were reviewed including the JDRF multicenter clinical trial which used all three commercially available devices. Adults had a significant decrease in their A1c levels, the children had a smaller improvement and the adolescents show no improvement at all. CGM proved effective in all groups that used the sensor more than six days per week. The predictors for patient success was age, SMBG testing > 6 times a day, supportive provider team and positive attitude. For more information about CGM, visit the Continuous Glucose Monitoring School website developed by the JDRF working group that conducted the study. Another study showed that CGM/pump users enjoyed a reduction in hypoglycemic events and lower HgA1c that may have benefits extending 12 months past the study phase.
- Jennifer Block RN, CDE presented Getting Started with Continuous Glucose Monitoring in your Practice, elegantly explaining the features of all the commercially available CGM devices. Using CGM means thinking more about your diabetes, not less says Block. Patient success includes setting realistic goals, underestimating the benefits of this therapy at the beginning so you can be surprised at the results and knowing that the desire to use the technology can be a powerful indicator of success. Real time data is of great use to most patients and retrospective data while not used as frequently provides for meaningful interactions with patients and their healthcare providers. Even patients in good control can benefit from less hypoglycemia and reduced glycemic variability. And remember diabetes is a family disease where you must work with families to utilize this technology for the greatest benefit. Block and Irina Nayberg RN, BSN, CDE facilitated an interactive patient panel later that day. Participants shared their personal experiences with CGM. Dr. Klonoff reported in his wrap up of the meeting on Saturday that this panel discussion was the session where he always learns the most valuable information for his practice. Most memorable panel quote was from a self professed patient with ODD (Overactive Dexcom Disorder) who said, "I love it when I straight line, it's not at all like a straight line with a heart attack." Another panelist mused, "My condition is so improved, my doctor and I aren't talking about diabetes anymore."
- Linda Siminerio RN, PhD, CDE asked the question, Telemedicine – Are we Ready? Technology and web related learning has increased 20% in the US population in the last 20 years and increased over 70% in people with diabetes age 30 to 39. Chronic disease management lends itself well to this environment as it is detail oriented, requiring information such as dietary lists, SMBG records and 525,600 minutes of self management per year. The Diabetes Wishes and Needs study showed diabetes team care and case management were the best indicators for improved glycemia. Siminerio reminded everyone that people with diabetes provide 98% of their own care with physicians involved in only 2% of management. She discussed a number of patient portals that promote collaborative care with information systems, decision support and improve patient satisfaction. Studies with My Health Track and the Diabetes Prevention Support System revealed that while patients value the coaching and follow up of these electronic visits they were not willing to pay for the service. More outcome data needs to be generated to convince insurance providers the value of reimbursement for these services.
- Stuart Phillips Phd, FACN and Shane Boley NASM-CPT finished up the conference with sessions on the Benefits of Exercise Therapy and The Five Elements of Fitness. Dr. Phillips relayed that the effects of exercise on improved glycemic control and lower HgA1c are similar to pharmacological therapies in both Type 1 and Type 2 diabetes. Insulin sensitivity improves with exercise. The most beneficial physical routine includes endurance training coupled with 3.5 hours of aerobic activity per week of moderate intensity equal to 15 miles per week at a rate of 14 minutes per mile. Any continuous activity at this rate was effective and included walking, running, swimming or cycling. Boley shared the 5 elements of Fitness; Proper Nutrition, Resistance Training, Cardiovascular training, flexibility training and Personal Assistance/Motivation.
Mike Schurig, MS, RD, LD, CDE
Conferences and Content Manager
Children With Diabetes
Heather Speer MPH, CDE
Diabetes Research and Education Coordinator
CHOC Children's
Orange, California
For Additional Information
April 12, 2009
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