Diabetes Technology Report
The world of diabetes research and innovation is moving forward at a lightning pace. At Diabetes Technology Society (DTS) we recognize the need for a free and easily accessible resource that provides clinicians, researchers, innovators and people with diabetes with up-to-date and authoritative information on the latest developments in diabetes technology research and innovation.
Diabetes Technology Report is a new podcast from DTS co-hosted by endocrinologists David Klonoff (UCSF), and David Kerr (Sutter Health). Here, you can learn about the latest advances in glucose monitoring, insulin delivery, digital health, cybersecurity, wearables, and artificial intelligence applied to diabetes. We will be interviewing opinion leaders, inventors, researchers, and clinicians, as well as authors of the latest scientific research.
Diabetes Technology Report
Michael Brown on the Intersection of Culture, Technology, and Diabetes Care in South Africa
A conversation on diabetes care and education in South Africa with Michael Brown, RN, Head of the CDE Academy and co-host of the "not ARTIFICIALLY Sweetened" diabetes podcast.
Welcome to Diabetes Technology Report, co-hosted by endocrinologist David Klonoff from UCSF and David Kerr from Sutter Health. Hello, welcome to the Diabetes Technology Society podcast, Diabetes Technology Report. I'm David Klonoff, an endocrinologist at Sutter Health and UCSF, and I'm here with my co-moderator, Dr David Kerr, who will introduce our special guest.
Speaker 2:Thanks, david, and hello to everyone. I'm David Kerr. I'm a UK-trained physician, but I'm now living in Santa Barbara working at Sutter Health as well. I'm now living in Santa Barbara, working at Sutter Health as well. This is a really important day for Diabetes Technology Reports, as we're expanding our global footprint, and, in order to do that, the first person that comes to mind from my perspective is Michael Brown from South Africa. Michael, a huge welcome to you and thanks for taking the time For our listeners. Could you just give us a little bit of a background about what you're up to down in South Africa when it comes to diabetes technologies and media and getting the message out?
Speaker 3:Right, david. Thank you so much for your very warm introduction. I appreciate it. Speaking out of South Africa, it's a great privilege to connect with colleagues from across the world and, yes, I've been in diabetes nearly for 30 years now. I started working with Dr Larry Distiller back in 1996, joined his very fledgling Center for Diabetes and Endocrinology back then to take over their education arm, and I've stayed. I found my passion and I found a purpose in helping health practitioners and people with diabetes to change lives and practice.
Speaker 2:Just for the audience, can you give us a kind of picture of the use and abuse, if you want, of diabetes technologies? What is access like for people with, say, type 1 diabetes, adults and children to closed loops or CGMs or this type of thing?
Speaker 3:Access to technology in South Africa is quite limited and probably it's the best in Africa and probably it's the best in Africa, but it's relatively poor compared to the rest of the world. The main barrier? I think well, there are two major barriers. One is the cost relative to how much people earn, and we have a very damaged, let's say, healthcare system. About 85% of the population make use of public health services, which are overstretched largely and underfunded. Underfunding is often not so much because they're not getting the tax allocation, but there's mismanagement, fraud, wastage and abuse which is unfortunately plaguing our country. And then we have a private healthcare system that about 15% of the population access and that costs anywhere from around 30% to 40% of your monthly salary to fund your own healthcare. So for those two reasons, healthcare technologies such as continuous glucose monitoring and insulin pumps are really not in great supply and not used greatly. However, in our center, being a tertiary high-level center, we use them frequently.
Speaker 3:My wife, who works with me and has worked with me for nearly 29 years, she is an expert on insulin pump therapy and on continuous glucose monitoring and all the technologies associated with diabetes. So I'm very privileged in our particular setting to be well-versed with these technologies, but unfortunately this is not the case for most South Africans. But unfortunately this is not the case for most South Africans. The second reason I think that most healthcare practitioners are not well-versed in diabetes. We come out of university and I can speak from personal experience. I came out of medical school as a registered nurse. We did a lot of our lectures together with the doctors, but as a registered nurse I came out of med school and I knew zero about diabetes and everything that I've learned has been in the postgraduate setting within the organization that I've grown up in in diabetes. Unfortunately, most healthcare professionals have not had the mentoring and the exposure that I've had over the last 30 years. So that's another, let's say, barrier, major barrier to the institution of technology in South Africa.
Speaker 1:Well, Michael, what you said is also true in the US that people don't learn enough in their training. If a patient comes to your center and needs education, what kind of experience do they have? What do you do with them?
Speaker 3:we hope that they have a very good experience. We pioneered diabetes education 30 years ago as an organization and we've kept that going. Unfortunately, just due to the economic environment, the political environment, the structure of the health environment, most of our educators have not been replaced and so most of us are getting old and in fact that patterns the rest of the South African healthcare profession. Most nurses are over the age of 50. And within the next 15 years the majority will have retired, with no prospect of them being replaced.
Speaker 3:In our center, as I said, we do have registered nurses who have studied long and hard to specialize in diabetes and they get a full service in terms of understanding their condition, the various treatments that may be applied to the management of their condition and how to manage it in the context of their physical, social, psychological, economic, work and school environments. So we really do try and offer a team-based approach, working on outcomes of studies like the diabetes control and complications trial from many years ago. We really try to put into practice the outcomes of the evidence that we see in the literature and we have very good outcomes. Another thing that I think has been our differentiator worldwide for the last 30 years is that we run a 24-hour hotline. So if any of our clients experience any issues 24 hours a day, they can pick up a phone and they can phone us and they get help. So we can abort something like ketosis from sliding to ketoacidosis, which would require admission.
Speaker 1:Michael, what sort of specialists or specialties are working at your education center and also who staffs the hotline?
Speaker 3:Yeah, we have a reasonably large multidisciplinary team endocrinologists, specialist physicians, also general or family physicians, registered nurses, registered dieticians, podiatrists, ophthalmologists, audiologists. Until recently, we had a biokinetic center. Unfortunately, that is no longer in operation. It wasn't bringing in the income to sustain it, unfortunately, and I think that's a great pity because we recognize that physical activity is a major component of diabetes care. Sorry, the last question. I just forgot that. Oh, who starts the hotline? Well, our doctors are very privileged. They never do call the registered nurses and registered dieticians do the 24-hour call and once or twice a year I may need to phone one of our physicians for help. Otherwise we run it and we have over the years, years, prevented literally tens of thousands of admissions. We have saved literally hundreds of lives and we have made diabetes something that is manageable in the community and we've taken away much of the anxiety that people with diabetes may face in an unsupported setting.
Speaker 2:Michael. Can I just expand on that, Because I find this absolutely fascinating. What are the sort of common questions that people with diabetes are asking when they phone up the hotline? Are they really close to the edge of catastrophe or are they asking very reasonable, practical lifestyle questions or drug questions? What are the sort of common themes?
Speaker 3:It's a full gamut so, ranging from a 2 o'clock in the morning phone call saying I'm out to dinner. I've just had a slice of cheesecake. How many units should I inject To? I have been vomiting for the last five hours to. I have been vomiting for the last five hours. I have three plus ketones and I've got chest pain and you can hear them puffing like a steam train on the other end of the line through to. My husband is in a hypoglycemic coma on the carpet. What do I do? First question I ask is he breathing? And that's something that most healthcare professionals forget is that cardiovascular disease is one of the highest forms of causes of mortality in type 2 diabetes, and so we must never forget those basics. Once I've established that he is actually breathing and has a pulse, then we can get on and treat the hypoglycemia or start CPR and treat the hypoglycemia or start CPR?
Speaker 2:What about in children, do you say? Parent families of children with diabetes, do they use this hotline?
Speaker 3:Yes, yes. So in the past we saw both children children from about the age of eight years and all the way through to the older person. In the last 10 years we've limited well, our doctors have limited the practice to people over the age of 16 years. So I have in the past had extensive experience in managing a hotline in a pediatric setting and again we had a whole gamut of experience. But again I can proudly say that we were able to calm down very hot temperatures within a family setting to enable children to continue their school life, to attend exams, and maybe that was one of the reasons why they phoned the hotline was to try and get out of doing the exam. We are pretty good at what we do and they could attend this exam, much to their chagrin, I think. But our job is to help people to attain the optimum sense of balance in their diabetes self-management and to achieve their optimum potential as human beings, and we do that with great passion.
Speaker 1:Michael, you're in Africa. Do you see a different mix of patients than what you've read are seen in other parts of the world, or are there any types of diabetes that might be unusual in the US that might be common in Africa?
Speaker 3:I don't think so, david. I think we have. You know, with the mass migration that has taken place across the world, I think that most healthcare professionals are seeing a wide gamut of ethnicities and country origins very mixed society for decades, so we see a wide range of people. I think what we do have quite a lot of experience in South Africa in is in the treatment of South Asian or Indian people, given that we have lower cut points for determination of what we might call obesity or overweight in that population and waist circumference and so on. And we see a lot of people who phenotypically are slim but they have excess visceral fat and they would present with type 2 diabetes. So within our Asian population we see high rates of diabetes.
Speaker 3:I think the other thing that, with our large population with an African ancestry, we are very attuned to cultural differences in how we perceive the causes of health issues. So in Africa there's often ideas of fatalism, that things just happen to you and that there's nothing, you have no personal agency over what happens to you, or that maybe there's been some sort of witchcraft involved, in which case you may need a traditional healer or sangoma to help guide you through the treatment, and so we're very well aware of these kinds of phenomena. We realize that about 80% of our clients of African ancestry will, concurrently seeing us, will see a traditional healer, and so that means we've got to be aware of this. We don't judge it. And we don't judge it because we want them to tell us about all the herbs and traditional remedies that they are taking, so that we can assess any potential interactions between those therapies and our more traditional therapies.
Speaker 1:Are there any foods that are popular in Africa that affect glucose either favorably or unfavorably, that are not so common in other parts of the world?
Speaker 3:I don't think so. I think the experience is fairly universal. One of the staples here? Don't think so. I think the experience is fairly universal. One of the staples here is corn or maize we would call it mealies here which is ground into a flour or eaten off the cob, which is obviously a healthy alternative if it's grilled. But most of our foods are based on maize meals and there's a large intake of carbohydrates, large intake of sweetened cold drinks yeah, very large carbohydrate intake and also high or large portion sizes, which obviously doesn't help.
Speaker 2:Very similar to what we see here in the United States. Absolutely, yeah, sadly that's the case. Michael, what about what you're doing with your education program and your podcast series? Do you want to just tell us a little bit about what you're doing in that space, getting the message out For sure?
Speaker 3:So that's something I have learned over the years that life changes more rapidly than you can conceive, and with COVID, we as an academy had to do an about turn on how we traditionally did education. So before that, we did contact courses both with people with diabetes and with healthcare practitioners. The COVID pandemic and the subsequent lockdowns, which were quite prolonged in South Africa, stopped that and to keep us sustainable, because we had to keep the lights on somehow, we pivoted very quickly to online learning. We started an online course for healthcare practitioners. We started an online course for healthcare practitioners and then last year, following the pandemic, we realized that we needed to get with the program in terms of electronic communication. So we started our podcast, not Artificially Sweetened, which is currently now has listeners in 32 countries.
Speaker 3:We're very grateful to know countries we're very grateful to know, and the podcast, I think, is unique in that it is a that is designed to bring both health care practitioners who have an interest in diabetes and people with diabetes and their families together in one environment so that we can speak to each other. We can learn from each other. We also know that a lot of learning nowadays in the modern world takes place through audio or video sources, and that much learning is social. And so we thought that was a natural extension of modern learning techniques, and that's why we went to Dr Stan Landau, who I work with. He came to me end of January last year and he said Mike, I think we need to start a podcast. I didn't know the first thing about podcasting.
Speaker 3:By 16th of January, 16th of February last year, I think, we all released our first one, and we are.
Speaker 3:Yes, last night we recorded episode 54. So it's been a lot of hard work, but I've been absolutely amazed by the quality of the guests we have featured over those 54 episodes, whether they be healthcare practitioners, whether they be policymakers and especially people with diabetes, because what we want to showcase, especially for people living with diabetes, is that diabetes does not need to hold you back. And so we've interviewed a commercial airline pilot, jonathan collins, who is a captain of a commercial airliner in south af, and his advocacy fight to regain his wings after he lost them after the diagnosis of type 1 diabetes. So, drawing on policy from all over the world for similar cases, he was able to change the South African law regarding pilots and commercial flying and many other extreme athletes, people who are academics, artists, whatever just incredible people, and I think through their stories we've been able to provide some real answers to some of the questions that many people with diabetes and their practitioners face on a daily basis with diabetes and their practitioners face on a daily basis.
Speaker 1:Michael, this is a very interesting story that you've told us today about being an educator in South Africa, and I would like to thank you for spending this time with us. I plan to listen to Artificially Sweetened now that I've learned about it, and we'll keep in touch. Thank you, david. So, on behalf of Dr Kerr and Michael and myself, thank you for listening to Diabetes Technology Report. This podcast is available on Spotify and the Apple Store and the Diabetes Technology Society website. So until our next Diabetes Technology Report, have a nice day. Goodbye everybody.
Speaker 2:Thank you, thank you very much indeed.
