Interview on diabetes technology and care in underserved patient populations with Anne Peters, MD, Professor of Medicine at the Keck School of Medicine of USC and Director of the USC Clinical Diabetes Programs
Interview on diabetes technology and care in underserved patient populations with Anne Peters, MD, Professor of Medicine at the Keck School of Medicine of USC and Director of the USC Clinical Diabetes Programs
Welcome to Diabetes Technology Report. This is the podcast that covers new technology and profiles leading doctors and scientists in the field of diabetes technology. I'm Dr David Klonoff. I'm an endocrinologist at UCSF and Sutter Health. My co-host for Diabetes Technology Report is Dr David Kerr. He will introduce himself and our guest today.
David Kerr:Thank you, david, and good morning to everyone, or good afternoon wherever you are. It's a real pleasure to welcome Dr Ann Peters from Los Angeles. Dr Peters is a world authority on diabetes. Ann, I'd just like to begin. Some people would suggest you have the dream job where on one day you're looking after the stars and the next day you're looking after I guess you could say the underdogs. Was this by design or how did you end up in this situation where you have a whole cross section of humanity with diabetes that you're caring for?
Anne Peters:Well, it was completely by design, but it started because I knew I wanted to be a doctor by the time I was five years old. When I was six years old, in first grade, my desk partner was a black young man who had trouble learning how to read. I realized his big trouble was that he was never in school because he was always sick. At that point I vowed that I would be a doctor who spent their time helping basically everybody. I realized that there was this huge need, which obviously was not that well-formed at the age of six, but I've always felt that people deserve medical care and that, whether they're well-served or underserved, there's something I can do to help. I've spent my life both doing volunteer work as well as doing my regular job.
David Kerr:The current situation. At the moment, you have an interest in diabetes technology. How excited have you been about the progress, as you say it, that we've made over recent years and going forward?
Anne Peters:My very first research with diabetes technology might have been 20 years ago.
Anne Peters:I tried to do it in my under-resourced population because I've always wanted them to have a voice in all of this I realized that I couldn't do research on technology with them because the protocols and the instruction manuals and everything else weren't written at a level that would work for them.
Anne Peters:Then I became really obsessed with trying to create tools and approaches to help people who don't have the same literacy and numeracy skills as my better-served patients. It's really worked because in the beginning I thought that the technology, the world of technology, was creating this divide that was getting greater and greater. Then the pandemic changed everything, because when the pandemic happened, I was able to get technology for my under-resourced patients Because I felt it was imperative to their lives to use technology in a helpful way. Because of telemedicine and access and everything else, I really was able to work with technology in a way that made a big difference. Ever since, I feel that I've been able to use technology in my under-resourced population almost as well as in my less-resourced population, with the one caveat is that a lot of technology requires that one have a certain smartphone, which my patients don't have. I even give them those smartphones to use because I want them to be able to use technology.
David Klonoff:And how do you feel that technology supplements or complements traditional diabetes treatments, which are lifestyle, healthy diet, in some cases, medication?
Anne Peters:Well for all patients that I have. It helps them be more aware of their glucose patterns, and becoming more aware, no matter what your skill level, is something that people understand. They can see that their glucose goes up after they eat and that maybe something should change. And so I've been doing work in my under-resourced population, where I just give everybody CGM I don't care what treatment they're on and we use it to help with diet, we use it to help with oral medications, we use it to help with insulin, and people respond. And I think the thing that I've learned the most is that I have to do a lot more education up front with my under-resourced patients than I do with my better-served patients, who are more familiar with technology. But it doesn't matter. I can get anybody to use technology as long as I have the right educators. And that's the most important thing I can say is technology plus education is everything.
David Klonoff:And you work in Los Angeles. Do you think that the problems with diabetes that people face in Los Angeles are different than in other parts of the country, for example rural areas or other regions of the United States?
Anne Peters:My sense is that every area requires their own solutions, so our population is largely Latino. I have to have educators and people who work with me who really understand that community and are from that community. I believe in using community-based help. So we started working with some of the people in New York and their population is similar but different, and so we're each finding our own solutions. And I'm very proud of Los Angeles County because we have a committee that works together and we now can get the technology because we've really advocated for it. But I think that we can teach each other. But then we do a lot of focus groups. We do a lot of things to help us understand the patients we're treating.
David Kerr:And just focusing in on continuous glucose monitoring. We're having conversations about trying to work out this is really in the type 2 in pre-diabetes space the optimum dose of CGM Was it in your experience? How are you approaching this? Because there's a health economic perspective, who's going to pay for it? I mean, do you think people should be on it all the time or intermittently, and how intermittent is intermittently?
Anne Peters:Well, I'm not a healthcare economist, fortunately, but I'm all about the patient and I can tell you that I have patients in any part of town where I put CGM on them, no matter what. They have pre-diabetes diabetes treated with metformin, and they love the CGM. They feel that it helps guide them with what they eat. They feel that it helps them keep a sense of control about their blood sugars and I think if you want it, you should have it. I mean, I know this is not economic, but there are people that in my under-resourced clinic where they just can't, they don't want to give it up and so it's really hard because insurance isn't going to pay for it and they don't have the money to buy it, but it just is something that a lot of people seem to just love.
Anne Peters:There are other people and I have a lot of these people, interestingly more on my West Side practice, my more affluent practice, where people don't want to wear it all the time because they don't want to be bothered. For instance, my husband, who has type 2 diabetes, who knows what's going to happen when he sneaks candy, which he tries to do all the time and he doesn't like the monitor beeping at him that he's high, so he will wear it episodically, and what I tend to do is have people wear CGM for two weeks before they come to see me, so I use it as a tool in my hands to retrospectively look at what's going on. But they're looking at it in real time, so they get a sense of it too, and I think that helps them get better and then helps us troubleshoot what needs to happen in the future.
David Kerr:You said a really intriguing comment about diabetes education and we find that for the north here in California, where we deal with Hispanic Latino population, and what's your thoughts on what's on offer traditionally in terms of diabetes education, do you think we've done a good job? If so, fine. If not, what needs to be done differently going forward?
Anne Peters:Well, many things. We need many, many, many, many, many more educators, because we don't have access to enough. So in the county of Los Angeles we have very few actual educators and I have my research staff, are my educators, but I'm the one supporting them, not the county, and we've been doing this big project where we take CGM and, as I said, we put it on everybody who wants it and my educators are there to train people on the CGM and then to follow up. So when the connection gets lost and they can't use it or the thing falls off or their life is changing, and a lot of these people, by the way, are doing manual labor and that makes them sweat, particularly in the summer, and they come off and we give them free overbandages. We do whatever it takes, but it's not like you can say here, watch a video where this and go out and use it.
Anne Peters:So we need a lot more education up front, but then it's ongoing, and then what also needs to happen is that it needs to integrate in primary care, and so my educators use the CGM in our patients and then they show me the tracings and then I give recommendations to primary care and they're doing great, but the primary care doctors don't really have the resources to start CGM. They don't have the resources to do the prior or after CGM. There's a whole list of barriers that make it hard with. The educators say we don't have enough, but then we need to spill over for primary care. So there are a lot of steps and, by the way I forgot to mention, we need educational guides. We need tools that patients can understand, that are written at lower literacy levels and I've worked on that and that is beyond just CGM. That's for pumps and other automated insulin delivery systems, which are sort of even harder to use in that way, because you need a lot more follow-up.
David Klonoff:And could you say something more about pumps and automated insulin delivery systems? Many patients start out with injections, especially people with type 2. Do you think there's a role for either pumps or AIDs in both type 1 and type 2?
Anne Peters:Well, I couldn't be a bigger advocate for using automated insulin delivery systems in anybody who's on insulin. And we've been doing research with the Omnipod 5 system in our under-resourced population and I can tell you it's like magic and I'm not that much a believer that you can just fix everything with one tool. But we have our patients who obviously want to come into the research study, who've been on multiple daily insulin injections for a long time and their A1Cs are 12. And these are people with either type 1 or type 2. And we put them on the automated insulin delivery system and they just get better.
Anne Peters:I mean honestly, when these people my patients are going through their lives, their lives are so hard and they're working three jobs and they've got family members they're caregiving for and all this other stuff, and if they can just push a button to give themselves insulin before a meal or there's automation overnight that keeps them safe, it's life changing. And to me I don't differentiate type 1 and type 2 on insulin, especially on multiple daily insulin injections. They all benefit from automated insulin delivery. Again, it takes education to get them there, but I have so many patients where we've made such a difference and these are people who've spent years in our clinics even in our diabetes clinics, where we've been trying to get them under better control with multiple daily insulin injections, and it hasn't worked. So I couldn't be a bigger advocate for automated insulin delivery for both people with type 1 and type 2 diabetes who need it. I mean, this isn't just everybody if you're doing great on whatever you're on, but I have so many patients who aren't and they do so much better on these systems.
David Klonoff:Well, maybe the AID systems will be approved for type 2 soon. One treatment that we're hearing a lot about now is use of the glucagon-like peptide 1 receptor agonist, so-called GLP1 receptor agonists. They're used for type 2 and obesity. What do you think about those drugs?
Anne Peters:Well, I'm a great fan of incredent therapy, both GLP1 receptor agonist and GIP GLP1 receptor agonist therapies because they work so well at lowering glucose and obviously I'm a diabetes doctor, so that's what is the most important in a way. But they also help with weight loss, and so I love that. I can see people be successful, and one of the things that happened when I did my study with CGM is I identified a lot of patients who, based on our countywide protocols, said that they could be on somagelotide, on ozampic, if their provider wanted it, and so I use the CGM to drive use of the GLP1 receptor agonist therapies and I got people on lower doses of insulin. I got there when C is better.
Anne Peters:The big thing that I use CGM to do was to help move use of the GLP1 receptor agonist class and it really made a difference. So I think that we can couple using CGM with understanding what next therapies our patients need. So I'm really a fan of those agents. The problem, of course, is if you stop them, your glucose levels go back up and the weight comes back, and in a county system where there's people who come in and out of having health coverage, then you run the risk of them only episodically getting treatment, and these patients can't afford the out-of-pocket cost for these drugs. So you really have to be able to make sure that the patients you put on them can stay on them and really work with them to continue the therapy.
David Klonoff:And thank you very much for those comments. I thought it was particularly interesting how you see the similarities between treating type 1 patients and type 2 patients on insulin. I'd like to thank you for being on this podcast today Also, thank, dr Kerr. This diabetes technology report is available at the Diabetes Technology Society website and on Spotify and at the Apple Store, and we look forward to seeing you and talking with you at the next Diabetes Technology Report. Thank you for listening.
Anne Peters:Thank, you, anne, thank you.