Advances in Diabetes Technology and Education

David Klonoff 0:15

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 0:42

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 1:16

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 2:10

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 2:24

My very first research with diabetes technology might have been 20 years ago .

Anne Peters 2:30

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 2:54

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 4:09

And how do you feel that technology supplements or complements traditional diabetes treatments , which are lifestyle , healthy diet , in some cases , medication ?

Anne Peters 4:23

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 5:23

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 5:40

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 6:31

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 7:02

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 7:52

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 8:38

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 9:06

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

Improving Diabetes Treatment With Technology

Anne Peters 9:37

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 9:57

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 10:59

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 11:16

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 11:56

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 13:04

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 13:25

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 14:16

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 15:06

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 15:41

Thank , you , anne , thank you .