Homework
0:00:02.6 Professor Walden: Alright. Good evening everyone, we are back. We are back, and I am excited. So we’ll give everyone a second just to fall in and catch the live, and be live. So as we do that, I’m actually just chit-chatting a little bit with our guests, and talking about a little bit of self-care, and just reminding everyone to do that, and be aggressive about it. I am not doing a good job at that, I fully admit that. But I will report back to you that we are going to do better, and I’ll report to you what we are going to be doing about that. But in the meantime we are gonna get started for this evening, and I know you guys are excited.
0:00:49.6 PW: So welcome back. I feel like I’ve seen you guys a lot in the last couple of weeks, ’cause we’ve had a few guest speakers. But we’re gonna get right to it because she’s ready to go, and we are going to be protective of your time. So just a reminder, this is Miss Kimberly Ellis. Remember, she’s got lots and lots of years of experience that she’s sharing with us graciously, having to do with diabetes and those who are pre-diabetic. So giving us really that knowledge and that clinical depth that we are looking for so that we can be better providers and understanding our patients. So I’m gonna bring her up to the screen right now. Hello. Good evening.
0:01:30.9 Kim Ellis: How are you guys?
0:01:31.8 PW: Good, good. So they’re all jumping in saying hi, but just letting them know you are ready, so if you wanna bring on your screen…
0:01:43.5 KE: Okay.
0:01:44.5 PW: And I’ll add it when I see it.
0:01:47.7 KE: Do you see it now?
0:01:49.0 PW: Uh-huh.
0:01:50.0 KE: Okay, let me…
0:01:52.9 PW: No, you’re fine.
0:01:53.6 KE: In a minute. I gotta remember how to do. I’ve been doing Zoom and I feel I’m like…
0:02:00.2 PW: Switching gears.
0:02:00.4 KE: Yeah, I was like, Wait a minute. Okay, so you want me to share my screen. Okay, alrighty. And you see me now?
0:02:12.7 PW: Nope.
0:02:13.5 KE: Okay, how about now?
0:02:14.8 PW: Yeah, yeah, it’s coming. Yes.
0:02:16.1 KE: Okay, here we go.
0:02:17.2 PW: Now pull up your PowerPoint.
0:02:19.7 KE: Okay.
0:02:20.7 PW: I’ll save it so you don’t see all your stuff. [chuckle]
0:02:24.4 KE: Okay.
0:02:24.5 PW: Perfect.
0:02:26.4 KE: Okay.
0:02:27.6 PW: So here we go, we are going to do that and she is going to go ahead and get started, and I will do what I do, which is fade to back. Alright.
0:02:35.9 KE: Alrighty, so just wanna check, you can hear me, everybody just… Okay, stop me if you can. Okay? So, let’s get right into it. We’re going to cover a lot, so hopefully I don’t sound like I’m losing through this, and so we’ll just get right into it, so our crash course to diabetes management. Now, last time I came on with you guys, we really set the foundation, we talked about how to diagnose it, what are your benchmarks, what’s the range, we talked a little bit about pre-diabetes, and just some lab tests. And so now we’re gonna talk about if… We’re just gonna go ahead and talk about we’ve diagnosed now diabetes so we’re here now, okay? We have diagnosed diabetes so let’s get into it.
0:03:25.2 KE: I wanna first go over the different types of diabetes, I’m sure you all know this, but I just wanna give just a brief overview and just put my thoughts in on the individual types, but we have type 1 diabetes, this was formerly known as juvenile diabetes, insulin-dependent diabetes. The terminology now is not that because it’s just not with juveniles anymore, there are other types that we have seen now where adults can develop type 1 later in life, and so we prefer to call it the autoimmune destruction of the pancreatic beta cells. And so this is cellular mediated and it accounts for actually 5% to 10% of the diabetes that you will see. Now the big kahuna here is type 2, and with this one, it’s not so much that the pancreatic cells have been disturbed, but more so that there’s an insulin deficiency and peripheral insulin resistance.
0:04:32.7 KE: Now, this is clearly going to be the most common type that you’re going to see. As nurse practitioners, we know that statistics have told us that the majority of us work in rather family practice, we work in internal medicine primary care or anything that’s adjacent to that, and so this is going to be the type that you’re gonna see the most of. You do need to have an understanding of the other ones, but this is the one that you really need to get familiar with and at least feel comfortable with, and since we’re talking about insulin resistance, because with type 2 diabetics, this is pretty much the underlining issue that you’re gonna see with them, so I do wanna take a little bit of time just to go over insulin resistance so you understand what’s going on.
0:05:21.8 KE: I’m a visual learner, and so I love giving visuals. And so this is a good picture of how insulin works, this is like the normal cell, the normal glycemic cell, this is how it works. A lot of times, I think we can think about insulin as, Oh, insulin takes down the glucose level. Well, this is how it does it. Insulin actually assist glucose into the cell. We know glucose is the primary energy source, this is what the body wants, it doesn’t want fat, we don’t wanna break down fat, we want glucose. Our brain loves it, it craves it. This is the natural order. And so what insulin does, it goes to the cell into an insulin receptor and like a key, a lock and key, it locks in and it opens up the glucose channel, glucose goes into the cell, our cells are happy, this is what we want.
0:06:17.8 KE: But with insulin resistance, what happens is, that insulin receptor becomes defective and that insulin molecule cannot bind correctly. So what you’ll have is, whether that glucose channel, it does not open up completely, maybe it doesn’t open up at all. Regardless of the fact, the glucose cannot properly get into the cell, then there’s an accumulation of glucose. Now the pancreas, being what the pancreas is, doing what it’s supposed to do, it just registers, Okay, I sense glucose in the system, let’s crank out more insulin. Well, that’s a problem because the insulin is not being properly used, so there is an influx of insulin molecules that are not doing anything to the cells, not helping the cells, and we call that hyperinsulinemia. There’s lots of insulin, lots of glucose in the bloodstream and nothing is working on the cells and nothing is getting into the cells, and this is how you end up having insulin resistance, this is the mechanism that happens behind that, and with your type 2, this is one of the hugest underlying things that’s going on with them.
0:07:34.7 KE: Now, the good thing about insulin resistance, it is reversible. Just like people have modifiable risk factors, like Wait, they have… What are some of the other things that they have? We have weight, we have also cholesterol, all those things we can modify, these are the things that people can do to reverse it. So just keep that in mind when you’re dealing with your type 2s. Another thing to keep in mind too, because of the insulin-resistance, when it comes to insulin treatment, you’re probably going to have to give them higher doses of insulin because of this very thing compared to your type 1 diabetics. So just keep that in mind.
0:08:20.8 KE: So next we have our gestational diabetes and the diabetes in pregnancy, which basically the difference between the two, one comes on during pregnancy and one is like a pre-existing and it’s just the woman who had diabetes prior to pregnancy. Now, these are your B3. These are your B3 types, there are others. We’ll discuss those next month because they are rare and they’re like subtypes of type 1, and as you can see, 90% to 95% of the diabetes you’re gonna see is going to be type 2, 5% to 10% is going to be type 1 while those other subtypes are gonna be even less than that. These are what you’re gonna have, what we’d like to call zebras, you’re not gonna see them walking through your door everyday, and you’ll probably end up referring them out and they’ll end up coming back and telling you that the endocrinologist told them that they have X, Y and Z.
0:09:23.6 KE: The last thing I wanna say here is that there is a misconception when it comes to diagnosing the type of diabetes, and a lot of people don’t know this. The thing about the typing the diabetes is that a lot of times, it is very common to mistype the diabetes. What I mean is, diabetes in general, it doesn’t matter what type it is, across the board the diagnosis is the same, the screening is the same. You can run an A1C for every single type, you’re gonna be able to pick it up, it doesn’t matter. The tricky part is figuring out which type it is, and like I said earlier, back in the day, we always associated type 1 with children… Well, that has changed. That’s no longer the case. We know that adults can develop type 1 later in life, we also know that children, more so in America, have started to develop type 2. So you really have to do process of elimination.
0:10:28.9 KE: Now, granted, some of these things they have telltale signs, clearly with your gestational diabetes, diabetes in pregnancy, we don’t have to talk about that because a person’s where they’re pregnant or they’re not. And so that’s a very simple thing, but when it comes to type 1, type 2, a lot of times you do your best, you look at the risk factors that the person has, how they present clinically, and then you go from there. If by chance, you feel like maybe you start somebody on metformin and it’s not working, the hyperglycemia is getting worse, then that’s when you start to investigate and then you’re going down process of elimination.
0:11:10.3 KE: So really, honestly, guys, it’s very common to misdiagnose the type of diabetes, but that’s okay. Don’t feel like you have failed, don’t feel like you’re going to break your patient, it’s a common thing and it’s a known thing too. So after we have decided, okay, we see that our patient has diabetes, what do we do? Well, I wanna introduce you all, if you’ve not already been introduced to this is, diabetes self-management education and support. I am so passionate about this because it is the cornerstone of diabetes management. There are articles upon articles, research upon research at how effective DSMES is. Now if you don’t know what it is, it’s the collaborative process through which people with or at risk for diabetes gain knowledge and skills needed to modify behaviour and successfully self-manage the diagnosis. Now, why this is important is because point blank period, we figured out that just barking orders at our patients and expecting results was not working. We had to get patient buy-in and really, honestly, they have to drive this boat. They have to know how to self-manage.
0:12:40.1 KE: So the reason being is because the majority of their time is spent outside of the clinic, there’s no clinic that they’re gonna be in more than they spend at home away from their doctors. They need to know how to troubleshoot. They need to have the basic knows of how to keep themselves safe. They need to know how to do these things. And part of this, I think… Let me back up. I think a lot of providers don’t realise that this is a whole program. This is a whole program. And these links up here, you can click on these links, but the CDC has a whole toolkit of the different subjects that people need to go through once they have diagnosis. Once they have their diagnosis, there are different topics that need to be covered with them. Also, it also gives you a registry of different programs certified in accredited programs. It could be an individual provider that has a program of education curriculum, it can be a hospital, there are different clinics that they see so many diabetic patients that they have adopted basically the curriculum, the national curriculum.
0:13:56.2 KE: And so when you go to these websites, not only will you have tools on how to go about helping your patients with this, but you can also locate diabetes educators. Because typically the people who do this, you can do it but to go through the whole process, you probably want to add on a diabetes educator, which the formal name is the Certified Diabetes Care and Education Specialists, it’s a whole mouthful. But basically, these are the education classes. In my area, they are primarily in the hospital and they’re free. Sometimes you can get them at libraries, it just really depends, but again, at this diabeteseducator.org, you can go and you can search for programs in your area and you need to get your patient over there.
0:14:47.2 KE: So you may be asking what are the things that they’re learning. Well, medical nutritional therapy, they’re learning how to go about eating, what would be a better eating pattern for them now; the appropriate weight management, it’s not enough to just tell people they need to take off weight. There’s a certain amount of weight that people that have pre-diabetes need to be targeting, and there’s a certain amount of weight for those who have diabetes. Physical activity, there’s actually a recommendation of how much physical activity people should be taking in. You wanna teach medication education and safety, glucometer education, foot care, and so much more. This is what they will get out of this program. So it is very important to get them in there. And on top of that, you don’t have to feel like you have to do it all, you have people that are already… It’s just a referral for us, and for those who are maybe asking Medicare and Medicaid, they do reimburse for this as well.
0:15:56.0 KE: So when are the best times to do this and have your patient go through this whole process? You can do it at any time that there are four critical times that it is recommended by the standards to do this. This is outlined in the standards of care, as well as the AACE, which is the American Association of Clinical Endocrinologists. They’re all on board with this exact model, but at diagnosis, because when people are introduced to something new, they’re the most vulnerable, they’re the most open, and there’s really a lot of education that needs to go on at diagnosis. And again, you’ll start that diagnosis, but you also wanna be able to refer them out. Think of yourself as kind of like a guide, you’re the guide that’s helping the patient walk through this diagnosis. The second time is annually. Every year they should go back and, “We need to review your medications. Do you have any questions with anything? Any new complications have come up? Any questions you have?”
0:17:07.5 KE: Now, clearly, throughout the year, you’re gonna be talking to your patient, but you definitely wanna do this every year, if there’s any complicating factors, and this is more so like if anything new arises that complicates their diagnosis, so diabetic complications, if they develop any type of neuropathy, nephropathy, retinopathy, anything like that, anything that’s complicating, making the disease process, making the management of the process harder, more complicated for them, it’s time to re-educate and then also at transition, times of transition. So this could be if a patient moves, if they have a change in care team. So let’s say that they have a new PCP, it’s time to A] If they have a new endocrinologist, you need to re-educate at that time as well. I think a biggie is if a patient goes from living on their own to now going into assisted living, or maybe they’ve been in assisted living and now they’re gonna live with their adult children, that’s an example of times of transition.
0:18:20.4 KE: Now, so that you know what the process actually is, the education process is, I’ve listed here the cycle of the process. It’s very self-explanatory, you start out and it’s an assessment, and the thing about DSMES is that because it’s going to have to be a management that the patient is gonna have to do, it’s very patient-centered. So this assessment is really asking, really trying to find out the areas of need of education. Some people, they’re okay with taking medications, but they don’t know how to eat, so maybe you’ll focus more on the MNT part; maybe they got the diagnosis and now they have depression over it, that is a very common thing, and a lot of people overlook the psychosocial aspect of diabetes. There is a dark cloud that hangs over diabetes, so sending people out for referrals, they are talking to your patients.
0:19:22.0 KE: Monitoring your patients. That’s what that assessment is, it’s just gathering the information, and then of course, setting the goals. And again, this is very patient-centered, okay. We as the provider, we may know that we want to get that A1C down, but right now what’s important to that patient is that they decrease their medications. So we have to take what we know and hear what they wanna do, and we merge the two. And this is a collaborative effect, okay. This is the collaborative process. So the goal-setting is not what you want, and I know that’s very hard as the provider, okay, because this is part of getting the patient buy-in. You have to hear your patient and you have to hear what’s important to them. Some people just… They don’t wanna be on insulin.
0:20:08.8 KE: Okay, so let’s break that down. What does that mean for you? Most people don’t start out the gate on insulin. And so you set goals. And I prefer to do SMART goals, that’s the easiest thing because it’s very uniform, it’s very specific, you can get… It’s very relevant and it helps them be able to break down themselves what they want to accomplish. After you do your goals, you start in on your action plan, then you implement that action plan, and then you evaluate and you monitor. And it’s a cycle, y’all.
0:20:41.0 KE: It’s not linear. There’s not a hard start, there’s not a hard stop. It’s a very circular… A person can enter in this cycle at any point. There are times when people have to go back to other places. So maybe you’re in the implementation stage and you realise “You know what, maybe this goal was a little bit too stout, so maybe we need to get a new action plan. Let’s go back and make some new goals, let’s get some better planning, and then we’ll implement again.” Okay. Now, I do want to go over lifestyle modifications because we hear that a lot, okay. Always start with lifestyle modifications. But really, what is it? Okay.
0:21:25.1 KE: And I really don’t want to insult anyone’s knowledge, but one of the things that I have gotten more specifically from more seasoned nurse practitioners, it’s kinda like, “Well, I already know that I’m supposed to be educating on lifestyle modifications. Well, the research tells us it’s not working, [chuckle] because our patients, a lot of them have never had education done, like formal education done, when it’s clear that it’s very, very effective. It brings down A1Cs tremendously.” We’ll talk about that a little later. But most patients have never seen a dietician, they’ve never been to a podiatrist, they’ve never been talked to about weight loss, so there’s some type of breakdown somewhere. And we can put it on the patients and we can say, “Well, some of them are just not adherent.”
0:22:17.0 KE: Okay, I’ll give you that, but that’s not the case with everybody. Okay. And I know for myself, and I’ve heard many colleagues of mine do this as I’ve overheard patient education, when we talk about lifestyle modifications, we’ll do this feel of, “Okay, you need to exercise more and you need to eat more fruits and vegetables.” Well, that’s not good enough, okay. We cannot assume that people know what we’re talking about when it comes to the different lifestyle modifications, okay. And I wanna just point out to you guys, I put a lot of time and effort here because nothing… I mean, nothing is more effective than lifestyle modifications. When it is implemented and taken out, it will bring down that A1C more than Metformin, hands down, hands down, okay.
0:23:07.8 KE: And you don’t have to worry about kidney issues with lifestyle modifications. You don’t have to worry about liver issues and all these other things. It’s more effective than Metformin. Now, mind you, we know that some patients are going to have to get on medications, diabetes is a progressive disease, we know that’s coming, but there are so many patients that would do better if they knew better, okay. So first things first, let’s talk a little bit about MNT, which is Medical Nutrition Therapy.
0:23:35.5 KE: It is not considered MNT unless it’s delivered by a registered dietician nutritionist, so that means we need to refer out, okay. It is not expected that we should know everything, but we should know how to coordinate here. That’s probably your best… The best piece of advice as a nurse practitioner that I can tell you. You don’t have to know everything about the patients and everything known to diabetes, but you do need to know your demographic. You need to know your community. What community resources are out there? You do need to be collaborating with other disciplines. We cannot do this by ourselves, and we cannot function in a silo. So MNT alone reduces, catch this right here, Type 1, 1% to 1.9%.
0:24:27.3 KE: Let’s think about that. That’s almost 2%. So if a person is at a six at a eight, they’re almost at a six, y’all. That’s huge. That is huge, okay. Now, with Type 2, it’s 0.3% to 2%. And this is just nutrition therapy, okay, y’all. This is not losing weight. This is just changing their diet, which honestly, we all could probably [chuckle] stand to do that. But I think one of the reasons why that range is so low there is because of the insulin resistance. But I have seen a lot of patients that they change up how they eat, their eating pattern. I mean, quite naturally, most people are gonna lose weight, and because of that, their A1C drops, they reverse their diabetes. And I have not seen it from just one person, I have seen it from a ton of people And that’s just MNT by itself, okay. Weight management. Now, a lot of people don’t know that if a person is at risk for diabetes, that they should try… Their target should be 7% to 10% of their body weight. If they are already diagnosed with Type 2, their target should be 5% of their body weight.
0:25:49.7 KE: That’s how much they… That’s their target. We don’t like to say goals, because we really try to watch our language, we try to say their target, okay. But let’s think about that. Let’s take a practical… Let’s take a practical approach. Let’s say you have a patient that’s 200 pounds. 10% of their weight is, what, 20 pounds? And if you spread that over six months, that’s very doable. That’s very doable. And you may not even say to your patient, “I need you to… The next time I see you, I need you to lose 20 pounds.” No, you may give them bite-sized goals. “Next time I see you, I’m gonna see you back in a month, let’s have three pounds off.” Who wouldn’t say yes to that? You know what I’m saying? And so a person that has Type 2, that’s… Let’s keep with the 200-pound patient. That’s 10 pounds. That’s not a lot, y’all, okay. So it’s not… When you start talking to your patients and breaking it down and letting them see, “You can do this,” that’s how you get the buy-in. That’s how you get that, “Okay, I’m hopeful I can do this” type of energy from your patient.
0:27:02.6 KE: Now let’s talk about physical activity. Now, there is a slight difference between physical activity and exercise. Physical activity is more of the broad term. Exercise, we know what exercise is, is the intentional, I’m doing some type of physical exercise, okay. But physical activity could be them doing yard work, honestly. I see this a lot with my older patients. They’ll just… Even them just going to the park and walking around with their grandkids, that’s physical activity. But exercise is more like your aerobic, your resistance training, things like that. But it is recommended that people get 150 minutes a week of moderate activity, okay. Now, when you say that 150 to people, their eyes get a little bit… ‘Cause that seems like a lot. But you have to break it down to them. This is over seven days. That can be 30 minutes over five days for you. You can break that down however you want, and it’s really not hard to do, okay. And you have to keep affirming your patients because this is what they need. Think of yourself not only as the God but the coach as well, okay.
0:28:11.2 KE: Now, something else that a lot of people don’t know is that you also need resistance exercise two to three times a week on nine consecutive days, and this is like your weightlifting, but that’s not for everybody. Everybody can’t do weightlifting. This could also be considered like push-ups. People could use their own body weight for this as well, sit-ups, things like that. You know what I’m saying? You don’t wanna do these in days together because you could have muscle damage, but you wanna spread that out over the week, two to three times over the week, okay. Now, flexibility and balancing exercises are recommended for your adults, your older adults. This is like your yoga, this is like your Tai Chi. And I don’t know about you all, but I know in Tennessee, because my parents are part of the Silver Sneakers, and I know out here in Texas, all of my patients are a part of Silver Sneakers. But basically, if you don’t know what Silver Sneakers is, it’s a program that is offered by Medicare and Medicaid, when people retire, they’re eligible for Medicare. And part of their program is that they get silver sneakers.
0:29:22.6 KE: And basically the insurance company contracts with all of these different gyms all around the nation, and basically they pay the fee of the elderly person, the older person, the retired person. So they could go to the Y, they could go to 24-Hour Fitness, Gold’s Gym, and they’ll have a card and they charge the insurance company and the person can go for free. And within these gyms, they have classes that are tailored to people who are elderly, people who are retired, and they actually have balancing courses. Well, that is something that can be under that category. And then when it comes to our children, 60 minutes of moderate to vigorous exercise every single day for children. And this is really because we’re actually in an epidemic of childhood obesity. We have so many children that are overweight, obese, and we’re seeing a very, very alarming number of children that have insulin resistance, and there…
0:30:25.7 KE: And even a lot of them that have diabetes, diabetes Type 2. And so they need to be exercising every single day, getting at least an hour, doing something. So let’s get into the treatment of diabetes, and part of understanding diabetes, we need to understand the Ominous Octet, okay. And I get this question a lot. I get medication questions all the time, and people want to hop right into medications. But before you do that, I ask you to resist that urge because before you do it, you do need to understand what the Ominous Octet is, and it will help you better, it will guide you to better… To pick the better medication. Sorry about that. So what is the Ominous Octet? It’s the eight defects in the body that cause hyperglycemia, okay.
0:31:19.1 KE: If you correct the defect, you correct the hyperglycemia. And your strategy is to try to pick a medication or a treatment that tackles more than one of those defects. And the great thing about it is many of the medication classes, especially the ones that are higher up on the algorithm, they tackle anywhere between two to three, on average, okay. Metformin is about three. I think insulin is about three. And that’s why they’re high up on the algorithm, y’all. And so now let me give you a little history about the Ominous Octet. Years ago, it was called Triumvirate, okay, where they only…
0:31:58.0 KE: They did research and they knew about three body systems that had a defect, then it went in and progressed to the Disharmonious Quartet, it went to Quintessential Quintet, to Setateous Sextet, to Septicidal Septet, and now we’re with the Ominous Octet, and then they’re even developing an Egregious 11, okay. And these are the systems that are… I don’t like to use the word the broken systems, but when you read articles, you may see it worded like that. But these are the defects in the different body systems. I would suggest you all, do a simple Google search of the Ominous Octet, it’s great reading and it’s very interesting, and it will really help you understand better when it comes to treatment, hands down, okay. Now, here’s another visual for you that tells you the different defects, and it tells you the medication class that corrects that defect. And if you see there, Metformin, that’s three, GLP-1RAs, four.
0:33:05.9 KE: Okay, insulin, that’s three. And you see why they’re high up on the algorithm, because when you take this medication, it corrects multiple defects, okay. It gives our patients a fighting chance. And you pair that with lifestyle modifications, DSMES, I mean the patients, they will get that A1C down quickly. So let’s quickly go through individually what each defect is. And so first up, a decrease in insulin secretion, and you’ll get this when you have beta-cell dysfunction, okay, your decreased incretin effect. When you’re talking about incretins, you’re talking about the gut, you’re talking about the intestines, and this hormone is released after eating and stimulates the blood sugar to drop, okay. That’s what an incretin is. And with this defect, that does not happen. Okay. Increased lipolysis. There’s an increase in fat breakdown, an increase in glucose reabsorption. The kidney basically is holding on to too much glucose. And there are medications that help dump that glucose out.
0:34:19.2 KE: The next one, decreased glucose uptake, this is in your muscles, that’s where extra glucose can be stored is in the muscles and they cannot build it up, they can’t uptake it, okay. Neurotransmitter dysfunction. You’re really gonna see this with your appetite. There’s a disruption in the signalling. So at a point in time, our body tells us that we’re full and we stop eating, [chuckle] and it’s just really that simple. We feel full, we stop eating. There’s no carb intake. Okay. Then that means there’s no glucose, no hypoglycemia. Well, there are medicines that basically, they stand in as that signalling and they tell our body that we’re full, and so we stop. Those medicines typically are good for weight loss as well because people are not eating as much.
0:35:07.5 KE: Increased hepatic glucose production. So basically, the liver is glucose dumping, basically. This is where you’ll see your Metformin take place. Increased glucagon secretion. We know that glucagon is used in hypoglycemia. When a patient has hypoglycemia, we will give them glucagon and boost that glucose production. Well, with this, in a diabetic patient, you don’t want somebody who’s already experiencing hypoglycemia to have an increase in glucagon secretion. So that’s where you’ll see that. So let’s talk a little bit about the algorithms. I don’t have enough time to run through the algorithms, but I have linked them here with you, this is what you have to guide you, the American Diabetes Association and American Association of Clinical Endocrinologists. I have had the question, “Which one is better?” They’re both the same. In a court of law, either one will work.
0:36:10.1 KE: They need to know that you’re using guidelines. The great thing about these two organizations is that they collaborate. So their algorithms are not that different. Now, you can just imagine that endocrinologists, they are the specialists. Their focus is a little bit different from the general clinician. So their algorithm is a little bit more aggressive, but they’re both very self-explanatory. And what I tend to do is I tend to read them every year, I print both of them out, I save both of them, and I do kind of a hybrid of both. Now, mind you, I have been working as a nurse practitioner for a while and I’m very comfortable with it, but what I tell people, find the one that you’re comfortable with and stick to it. That’s it. They’re both regularly updated. They have common things. Like I said, they’re not gonna be like, one’s gonna be totally in left field and the one’s gonna be over here. No, they’re very, very similar. They’re very similar.
0:37:08.9 KE: The things that they say that are similar is that they both preach comprehensive lifestyle modifications. Both of these organizations, they both support diabetes self-management education and support, so you’re gonna see that all and through their guidelines, their standard of care, everything, everything. They both keep the patient at the center. One of the things that I see, not so much with younger practitioners, but more so some of the more seasoned ones, we can get caught in our ways and we just wanna… We just wanna give the person what the algorithm says. But if you know that your patient is not going to… They’re afraid of needles, why would you give them a medication that you know they’re not gonna take? Even if it’s the best medicine in the world.
0:37:57.8 KE: Another example, if you know that they can’t afford the medicine, which is probably gonna be the case for a lot of people, that is a problem that we are working on in our country, is that healthcare is very expensive and diabetes is probably the number one disease that is so expensive, people can’t afford it. But if you know that a patient cannot afford something, you might as well don’t even start because I’m gonna tell you, they’re gonna leave that prescription at the pharmacy, it happens all the time. Because I work in community health, I go behind a lot of PCPs and I cannot tell you how many times I’ve had patients, they’ll be like, “Well, yeah, I’ve been prescribed this, but I can’t afford it.” “Did you tell your doctor that?” “No, I didn’t.” “Okay, you need to tell your doctor that.” And the reason why I tell people this, is because if you don’t ask, they won’t tell.
0:39:01.7 KE: And so just know, ask your patients, Are you taking your medications? And so anyways, I went off on a tangent. Sorry about that. But always keep your patient at the center of your care. Always keep them in mind, alright? Metformin is first-line medication when appropriate, and that’s a big when appropriate. Both of the algorithms give you the caveat, and it walks you through it, guys. So don’t worry, it walks you through it, and typically it’s when you have a heart patient and you have a kidney patient, they’re going to suggest the SGLT2i’s and the GLPRAs. The thing about that is, it’s not always affordable, unfortunately. But you can get it done, you just maybe have to fight the insurance a little bit. Both of them give a hierarchy of medication, and the thing that I love about both of these algorithms is that they still leave room for clinical judgment, and it actually says that. And I mentioned this last month as well, they will give you direction, but they also understand that you know your patient better than they do.
0:40:08.4 KE: And so, you know that you always have to think about if a patient is allergic to something. You gotta also think about polypharmacy. You know what I’m saying? You know about these things. So they are telling you, This is what we suggest, but we also understand, we give you other options as well. And then with the AACE algorithm, they give you a strength recommendation, and it’s very clear when you look at theirs. The thing I love about the AACE one as well is that they don’t only give you an algorithm for diabetes, they also give you something for blood pressure, they give you something for obesity, weight management. It’s great. So I suggest that everyone bookmark both of these, keep them near and dear to you.
0:41:00.6 KE: So let’s run through quickly what the medication classes are. I am going to tell you what they do and not so much of how they do it because that takes a more deeper conversation, but let’s get into the oral medications first. These are gonna be most likely the ones that you’re gonna start with, and let me also say this is for your type 2s. Most of these medications, except for, I wanna say amylin, all of these are only gonna be indicated for type 2 diabetics. And on top of that, insulin is the treatment for people who have type 1, so it’s really open and shut, which also, again, that’s a part of the algorithm as well. So you’re not alone.
0:41:46.2 KE: So starting out, our big one is the biguanide, this is metformin. Metformin is the only drug in this class in the US, so we don’t have to learn anything else, you just gotta learn metformin. Now it inhibits glucose, hepatic glucose output. Tongue tie right there. Okay, y’all remember that from the Ominous Octet? Sulfonylureas and meglitinides. I’m gonna talk about them together. Your sulfonylureas are like your glipizide, your glimepirides, your glyburide. I’ll be honest, you’re probably gonna be prescribing this the most because it’s on every $4 list, it’s like tier one for a lot of insurance companies. It is not the best medication but it gets the job done and it’s, out of all the other ones, it’s affordable. It’s very, very affordable. And between this one and meglitinides, they do the same thing and they stimulate insulin release. Now, start to think about that a little bit. You have, you inhibit the glucose output with the metformin and you stimulate insulin release, do you see how you can start piecing together the puzzle? The diabetes puzzle?
0:42:57.8 KE: Now, mind you, I’m a diabetes geek, and I love the puzzle so I start to think about, Okay, what am I trying to do? Am I trying to decrease the glucose? I’m trying to increase the insulin production? Yes. That’s how you start picking out which medications would be best, guys. The difference between the sulfonylureas and the meglitinides, meglitinides, that’s gonna be like repaglinide, you probably have not heard a lot about this medicine for two reasons: 1] it’s very expensive, 2] it’s the short-term version of sulfonylureas. That’s the difference between the two, it’s more expensive and it’s short-term. So, why would we waste our time with that? But you have an option. You do that, it is an option.
0:43:46.1 KE: Your next medication is thiazolidinediones. That is a tongue tie. We call them TZDs, also glitazones. This is pioglitazone, which is Actos. It used to have rosiglitazone in it, which is Avandia, but it’s no longer in there, and what this one does is… It’s no longer on the market, I mean. It enhances insulin sensitivity, so it works on your muscles.
0:44:11.7 KE: Next one is sodium/glucose cotransporter-2 inhibitors, your SGLT2i’s. This is like your Jardiance, your Invokana. This is the medication that helps that… It works in the kidneys. And so, it basically prevents the glucose reabsorption and it dumps it out through the urine. With this medication, you’re going to have to get blood work because every urine dip is gonna have a high amount… It’s gonna register high glucose, it’s gonna be a 4+, whatever dip that you use. So you have to get a blood stick. So just know if you see them any medicines from this drug class, your minds will disregard that urine because you’re supposed to see glucose in the urine. This is how it gets rid of the glucose, and gets it out of the body.
0:45:01.8 KE: Dipeptidyl peptidase-4 inhibitors, DPP4i’s. This is your Januvia. This is like your Januvia. What this one does, it restores the GLP-1 levels by blocking the enzyme DPP-4. DPP-4 breaks down GLP-1. Why do we want that not to happen? Well, GLP-1 increases insulin sensitivity and secretion, it reduces glucagon concentration, it slows gastric emptying and it reduces food intake. So you can see right there why we want GLP-1 to be in abundance, this will help the person with diabetes, we don’t want anything that’s gonna break down GLP-1. So this is what this medicine does, it inhibits the enzyme that breaks that down.
0:45:55.0 KE: Now let’s get into our injectables. I think the DPP-4 one leads us into GLP-1 receptor agonist. Now what this does, it binds and it activates the GLP-1 receptors, it stands in the gap and it makes the body think, Okay, this is GLP in this system. And we want that. Now you may be asking yourself, Well, if that’s what we want, why would we prescribe DPP-4i’s? Well, two reasons. This is injectable. There’s a lot of people that have aversions to giving themselves injections. Many people when you start giving a GLP-1, which this will be like your Victoza, this would be your Trulicity. This is what that class is. A lot of people don’t understand, going back to week, that’s why we need to educate. A lot of people don’t know the difference between this and insulin, all they see is a pen and they automatically think that it’s insulin. Also, these are expensive. They’re expensive. Great medication. Very expensive for many people. So that is why the DPP-4i’s are more… They’re preferred because it’s more accessible to our patients.
0:47:14.6 KE: Then you have your amylin analog, and this acts like amylin, that’s what the analog is, and what it does is, it affects the postprandial glucose by slowing the gastric emptying, so people are gonna feel full, they’re not gonna wanna eat as much, it suppresses glucagon secretion and it reduces the total caloric intake. So people can lose weight on this, people do feel some GI upset because of the gastric emptying, they have a full stomach. And so, this is one of the medicines that can be given to type 1s… It’s what the body needs, you know I’m saying? That’s why we give it, it aids in entry of the amino acids and enhances the protein synthesis. The big thing is that it aids in the entry of the glucose in the cells, and that we talked about that earlier, it stops the formation of glucose, it helps with the fat storage and prevents fat from becoming the primary energy source; very, very important to prevent DKA. We do not want our body to break down fat for energy, we want it to use glucose, so that’s why we have to get the glucose in the cells. Otherwise, we’re gonna have DKA on our hands. And it also lastly, it stops production of glucose from the liver and the muscles ’cause that’s where it’s stored, so we don’t want it to be taken from there.
0:48:49.6 KE: And then lastly, these are your adjunct medications. Now I’m gonna be honest with you guys, you’re probably not gonna be pulling from these. You’ll see why for obvious reasons. So bile acid sequestrants, it blocks glucose absorption, but we really don’t know why, and that’s really all I gotta say about that one. This is your Welchol. We know more about it when treating hyperlipidemia, but we have noticed, research has also shown us that it helps bring down the blood glucose. We just don’t really know the mechanism of action why. Many people cannot tolerate Welchol because it comes in two forms. If you do the pill form, they’re big old horse pills and they have to take a whole bunch of them. It’s like four to six of ’em. And then there is a powder that they can mix in as well, but it’s gritty and people hate it. It does not mix well. It’s like sand. I can’t even call it a powder, if feels like sand. And so, mixing it with water is horrible for patients. I’ve heard some people saying that they can at least stomach it with orange juice, but people hate it. And for us to not get a huge reduction in A1C, and then it may or may not be covered, you see what I’m saying?
0:50:16.4 KE: Your alpha-glucosidase inhibitors, this is like your acarbose. It delays carb absorption. Now, I’m gonna tell you the reason why we don’t go for this one so much is because the majority of patients can’t tolerate this one. Flatulence is a huge thing here and very oily and loose stools. People do not stay on this medicine, they will take it and they will be off quickly. And again, the reduction in A1C, it’s just not worth it. It’s just not worth it.
0:50:49.9 KE: And then your dopamine receptor agonist, this is like your Cycloset. Mechanism of action is unknown. We have absolutely no idea how it works on the blood sugar, and we do not get a big return on it. But I’d wanted to bring these up because these are options if you have no option, but I’m gonna be honest, I have not prescribed these. I have never prescribed dopamine receptor agonist. Never. I’ve tried the other two and that’s how I’m able to speak on those but that dopamine receptor agonist, I have never, and I’ve never seen anybody had it.
0:51:34.3 KE: So we are at the end. What’s next? We’re gonna talk about maintenance care next month. We’re gonna talk about complications of diabetes and how to go about treating that, and how to go about diagnosing, and then we’re gonna talk about the zebras of primary care. I don’t know if y’all know that terminology but when I was in nursing school and NP school, one of my professors used to say, “Common is common, but zebras are zebras.” Because these are not things that you see everyday, we don’t walk around and see zebras, and these are the things that may come into your office but you’re not gonna see ’em often, but when you do see ’em, you’re gonna always remember ’em. And so if you need a deeper dive into the medications, I wanna remind you that I have the play list, if you click this link, you’ll be able to go to the YouTube playlist that I have. They come with accompanying med cheat sheets, so you can print them off, you can write on them if you want to, and then if you need a deeper dive, you can purchase my diabetes boot camp course, it comes with continuing education, and if you use the MP collective code, use that as your code, you’ll get a huge discount. And that’s all I have.
0:52:53.6 PW: I’m back. That was great. No, I was sitting here writing notes and… Yes, so you said a lot that…
0:53:02.0 KE: I do.
0:53:06.1 PW: You did. You did. But I wrote down some notes because I was excited. I think that we probably treat patients the same in our practice. There are a few things you said that were like, Yes, we probably have the same kind of methodology, but I did have one question. In the beginning, you were talking about diagnosing diabetes and how we make it wrong, it may be type 1 or type 2 but I see the same thing issue, it’s all diabetes, diabetes, diabetes, and diabetes. Would you see it being a different type of diabetes, maybe when you start to do the medication management, realising that the oral meds aren’t working, but the insulin seems to be working, this might not be type 2 that I thought it was?
0:54:00.8 KE: Yeah, that’s how it typically manifests and really where you would see that at… The thing about type 1, because it is cellular mediated, there are antibodies in that person and you can send the patient out and you can quickly find out if they have the antibodies, the auto, anti… Auto… I’m getting tongue-tied, but they have the antibodies. And so the type 2 is not gonna have that at all. Typically, how it happens is that you think that an adult has type 2 because they may be overweight, they maybe 45, they have all the things that we think type 2 in our head but guess what? Their A1C, now they’re up to 300 and 400 and they’ve been on metformin and you’re like, “Wait a minute… ” [chuckle]
0:54:51.4 PW: Exactly. This has been my experience, and this is when, again, I worked free at a free clinic so this is… Or getting referrals is not something that is easily done, my patients do not have money, so there is no one typically else to go see, and we can’t run those expensive tests to figure out. So what I have noticed is when I go to give meds to, like you said, someone who checks all the boxes, that looks like diabetes type 2 and I’m giving, starting the oral medications, but they’re not being effective, and their numbers are still rising, or I find out they were in the hospital suddenly, it’s like, “Wait a second, this might not be type 2, like you have to do… ” And I say all this so the students can understand, you gotta put it together, those critical thinking skills, yes, we have guidelines and that is what we are doing and giving you those guidelines and all of those things, but you have got to use that clinical judgment and put it together and be like, “Hold on. This is not making sense so this may be one of those outliers.”
0:55:58.7 KE: Yeah. And really one of the best things you can do is just take a step back and you just think, just think what’s going on here, what do I know and what’s going on here? And just work it that way, and then ask other people. If you’re in a clinic that has other providers in there, ask somebody. When I was a brand new nurse practitioner, I remember calling some of my old preceptors, a state… Because I trusted them. ‘Cause I had a horrible first doctor, my first collaborating doctor, he would leave me and desert me. And as a brand new nurse practitioner, I ran that clinic by myself, ran staff, and I was brand new and I could not get him on the phone, and so I called a past preceptor that walks me through it, that walked me through it. So don’t be afraid to ask just to ask, “Hey, can I step out right quick? Let me go check something right quick.” Patients, they don’t think anything.
0:57:02.0 PW: They don’t think anything that I tell people that all the time. I tell students all the time, they think nothing of it, when you work on them and you have to look things up, then it’s normal to them. So that’s good. I wanted to say that so they can put things together. The second thing you talked about that was really crucial was the diabetes educator piece, and I haven’t even talked about the registered dieticians and those folks. Basically, your point is, yes, we do a lot of teaching as nurses, but when we graduate into that provider role, we’ve got a lot more responsibilities. I need students and even current nurse practitioners that we have in here to understand what you were saying, which is to use your resources.
0:57:48.4 KE: Yes.
0:57:50.1 PW: We are so used to diagnosing and then giving the meds to fix, don’t fall into that trap of, in addition to teaching your patient, if you don’t have the time or you are not capable because maybe you just don’t know, you know some basics, you need to use your resources and send those patients out to those people you were talking about.
0:58:11.8 KE: Yeah, and here’s a practical thing that you can do too, because you’re gonna be busy, most of us are. You know I’m saying? You can always have the patient come back. [laughter] You can always have them come back.
0:58:25.6 PW: So useful. So easy. Yes! [laughter]
0:58:29.6 KE: You can train your nurses, your MA to like, I want my patient to be this, and when they come back, you schedule them for a nurse visit. You know I’m saying? I think we have to make that transition. We’re no longer the task doers, we’re the organizers.
0:58:47.1 PW: Yes.
0:58:49.9 KE: And that’s different, that’s a whole mind shift for us. If you don’t have time, have ’em come back. And here’s the great thing, once you get your process, the great thing about the diabetes educator program, and you look and you look at the diabetes prevention program, ’cause when you go on those sites, you’ll see a lot; it tells you what you’re supposed to be educating over so once you find it and you say, Okay, let me tweak this to my demographic, once you do it one time, you just rinse and repeat.
0:59:17.9 PW: Rinse and repeat. It becomes like second nature, guys. I mean, it really does. I’ve done it enough. Kimberly, I know you’ve done it enough where it is so natural that you start to do it as you are talking to the patient in the exam room. There is no extra time anymore because you’re spitting it out, because you’re like, Oh, in your head, you’re like, This is the diabetes patient, let me pull from that file and run down my list of things that I need to discuss with them. So it becomes good. And then the last thing that you talked about was goals, and I think this is the part, this is so important and then we’re gonna have… You talked about SMART goals, we’re gonna put some stuff out there for you guys to help you narrow this down. But I think this is where a lot of providers build that rapport, one, with your patient, and because if you make it attainable and easy for them, they’re gonna listen and they’re gonna try.
1:00:18.6 PW: The second piece is, this is where a lot of providers alienate patients, because if you say, like you were talking about exercise, lots of exercise required, however, when you break it down, don’t go out there telling your patient that they need to exercise six days a week. ‘Cause if you tell me that, and I have never gotten off my couch or it’s been several years since I’ve done that, I’m gonna look at you like you crazy, and then also I might be that overachiever who’s suddenly trying to run 2 miles, I could barely walk around the block. I used to always tell my patients, I need you to walk more intentionally. And I used to be very specific, and I would tell ’em, “I’m not asking you to go outside and run a mile tomorrow, what I’m asking you to do is go and take a saunter around a block briskly three times a week. That’s it. That’s all I’m asking you to do. When you come back, we’ll do some more.” But I think that’s such a critical moment where you can either alienate, you can build that rapport with your patients.
1:01:26.9 KE: And then you gotta also… Keeping the patient in mind will guide you everywhere, and then you have to also keep in mind the culture, the generation, you gotta take in consideration literacy, health literacy and numeracy. Just because somebody dressed nice, you can’t judge a book by its cover, you gotta ask those questions and do some good interviewing, like motivational interviewing, we’re good at that as nurses. I also will say I learned my lesson, I took a course, I went to actually an all-day summit, and it was put on by three nutritionists, one was black, one was Mexican, one was Chinese, and they specifically talked about those individual groups, and they were talking about how when we were talking to our patients, we have to keep that in mind and there are things like…
1:02:27.3 KE: The thing that blew my mind because clearly I’m black, and I work in Texas, so I deal with the Hispanic and Latino X community a lot, but what I don’t do a lot of is Chinese people. And so this person, this nutritionist was saying that especially when you get the elderly, they still believe in yin and yang. And she was giving an example of her mother, because she was like, with their culture, and this is not everybody, so you can’t be a blanket statement, but this is about you knowing your patient. But diabetes can be looked at as a cold disease and they’re treating with hot because that’s what yin ang yang is, and that hot may be rice. [chuckle] And I was like, Well, I didn’t even think about that.
1:03:17.2 PW: No, that’s true. It’s very, very true. I think we forget those generational gaps that you have to think of, like you said, because if someone comes in there who is old enough to be my grandmother, I’m not going to ask her to go to the gym and go lift some weights for me. That is not appropriate for me to say to her. She’s not gonna do it, one. She may not have the resources or the capacity just to even get to the gym, so I need to be cognizant of that. Like you said, there’s so much that goes in to advising a patient. You have to know your patient, and so that’s why a lot of times in my teaching, a lot of it is, it depends. What is your patient? Is your patient reliable? What is your patient like? Because you have to cater to them. So yeah, no, be very careful with these goals, guys. We know the big goal, the end goal, we got that, but you’ve got to really break it down. I think even when patients are eating rice everyday ’cause you have those patients who would tell you they eat rice at every meal with dinner, and I’m like, “Well, just maybe can you take it out of two meals this week and see what happens? That’s literally my first goal is just to see if you can remove it from just two nights, I’m not asking for a whole lot.”
1:04:40.0 KE: And because we have the population out here, basically, that’s all I see. I see black people and I see Mexican people, that’s what I see, and I have had this conversation all the time like switching their tortillas. Can you switch your tortillas? And I first ask, Do you eat such and such daily? Because some people don’t, and you don’t wanna assume. I’m like, Do you eat refried beans? And options like, Okay, instead of the refried beans, how about black beans? Can you do black beans instead? Can you rinse the beans when you take them out of the can because sodium is in them and you’re rinsing off about 70% of the sodium? Can you do that for me? Yeah, I can do that for you. Can your wife make fresh salsa? A lot of times if they’re older, they do anyway. “You know, Kim. Salt is fine.” Just thinking about your patients.
1:05:35.8 PW: Yes. It’s really those little things, and I think when you say, I did not know that particular statistic, when you said it’s more effective, lifestyle changes are more effective than metformin or the meds. Clearly, I knew that, but to hear it and have it be confirmed, and the research says it’s just like… Well, then I’m telling them the right things. If you can drink more water, if you can get moving so we’re burning in the glucose in your body, if you can do all of those things, you’ll be better off, and I think that that’s just a really important thing to drive home for our patients. So I’m excited ’cause this was great and I have lots of notes. Like I said, I have some things. Y’all know me, you’re gonna get some homework, you’ll be alright. But again, the homework is just to help you with the application of what you are learning from Kimberly, and so that you can understand so that when you go to treat your patients, it’s an easy thing. This starts to become… Because what we want is, we want things to become a little bit more natural for you when you are treating your patients. We want you to be very aware of your relationship with not only the knowledge that you’re learning but with your patients.
1:06:54.8 PW: So I’m excited, I appreciate it, Kimberly. I can’t wait till next month to have you back and the guys just like any time as always, protective of your time, we appreciate you listening in. And if you have questions, please let us know, you can either write them in the chat because the team does come back and look in the chat for the questions, and if there’s anything that we can’t answer, you know I will be reaching out to Kimberly to help us answer those questions, and she’ll be back with us next month. And if you missed the beginning, you’ve got the replay. So we’ll talk to you soon and I appreciate it. Alright, guys, see you later. Bye.