Dissecting Diabetes

When Steve Lawthers takes a golf swing, his arm rubs against a small device attached to his skin, near his belt. “Other than when I play golf, I don’t know it’s there,” says Lawthers, 61, of McCandless.

The device constantly measures his blood sugar and displays it on his iPhone. He got it by participating in a clinical trial run by UPMC. It’s known as a continuous glucose monitor (CGM) but Lawthers calls it a “life-changer.”

Diagnosed at age 5 with type 1 diabetes, Lawthers has seen many advances come along in his lifetime: in the ’70s, fast-acting insulin; in the ’80s, finger-stick tests to check his blood sugar several times a day; and in 2016, the glucose monitor. “I got it in February and within a week, I knew this was amazing,” he says. “It takes all of the diabetes complications for me off the plate.”

CGM devices were developed more than a decade ago for those like Lawthers, who have type 1 diabetes but now are also being used by those with type 2 diabetes. It’s one of many ways—from surgery to mindfulness to team-based care—being used to stem a costly epidemic.

About 20 percent of U.S. healthcare spending is for people with diagnosed diabetes. The rate of new cases has been falling slightly since 2008. Still, more than 29 million U.S. adults (including 7 million who don’t know it) are living with diabetes. Another third of U.S. adults have pre-diabetes and 90 percent of them don’t know it, according to the Centers for Disease Control and Prevention.

In western Pennsylvania, 306,000 people have been diagnosed with diabetes, and 500,000 are considered pre-diabetic. The average hemoglobin A1C level is 9 percent for people with diabetes in Pennsylvania. An A1C blood test measures average blood glucose during the previous few months. (A normal blood sugar is between 4 and 6 percent.)

“Diabetes is one of the biggest health issues in the country, especially in western Pennsylvania, for two reasons: No. 1 because of obesity and No. 2 because of our aging population,” says Dr. Wayne Evron, an endocrinologist who runs a solo practice at St. Clair Hospital’s Bethel Park location. About half of his patients have diabetes, mostly type 2. As a longtime doctor, Evron sees encouraging trends. Thanks to advances in medication and devices, diabetics can live long, healthy lives (one of his patients is 92 and has had diabetes since childhood).

“Complication rates have gone way down,” Evron says. “They’re not even comparable to what they used to be. No one loses their driver’s license anymore because they can’t tell when their blood sugar is too low.”

Regardless of advances in treatment, there’s no quick fix to managing diabetes. Diabetics need to check their blood sugar levels often, watch their diet, and exercise. This gets even more challenging when you consider that 30 percent of diabetics deal with depression. Many also face addiction, food insecurity and high levels of stress.

Monica DiNardo, Ph.D., a nurse practitioner and certified diabetes educator with the Veteran Affairs Pittsburgh Healthcare System, used to see patients at UPMC. “I was very struck by the fact that a day would not go by without a patient telling me that their diabetes was being complicated because they were under stress or just how burned out they felt because of all the tasks that managing diabetes requires,” she says.

When DiNardo enrolled in Pitt’s Nursing Ph.D. program, she decided to make reducing stress the focus of her dissertation and oversaw a small pilot study that taught 34 military veterans with diabetes how to use mindfulness practices to reduce their stress. “We followed this group over a threemonth period and found a tremendous improvement in their levels of diabetes-related distress. We also found that their hemoglobin A1C had improved significantly.” This fall, DiNardo and her team began enrolling veterans to take part in a larger VA study to compare routine diabetes education with diabetes education that includes mindfulness training and asks those participants to practice mindfulness 10 to 15 minutes each day.

Like other area hospital networks, Allegheny Health Network is making diabetes care a priority. AHN launched an ambitious team-based initiative that is “taking the diabetes care going on for the last 20 years and turning it upside down,” says Dr. Paul Lebovitz, vice chair in the Department of Medicine at AHN, whose network of clinics and hospitals cares for an estimated 50,000 diabetics.

Key components of AHN’s program include: specialized training for primary care providers (PCPs), who provide the bulk of diabetes care; new diabetes care centers across the region staffed with certified diabetes educators and trained PCPs; nurse navigation to ensure better follow-up care; realtime glucose monitoring; and connections with community partners such as food banks to provide access to healthy food.

“Without major changes, as many as 1 in 3 U.S. adults could have diabetes by 2050.”
Source: U.S. Centers for Disease Control and Prevention

The program is designed for those who may need doctors in a variety of specialties, from cardiology to podiatry to psychiatry. “Patients will have unlimited visits with diabetes educators and access to tele-visits so they don’t have to miss work,” says Dr. Patricia Bononi, medical director of AHN’s Center for Diabetes.

AHN’s first diabetes specialty center opened in October in Wexford. The next is planned to open in Bloomfield in January.

To accomplish this, AHN has the backing of its parent company, Highmark Health, as well as a $6 million grant from the Richard King Mellon Foundation—the largest that foundation has ever awarded to a healthcare provider.

Dr. Lebovitz says this new model is designed not only to provide better and more efficient care, but to make chronic disease care more cost-effective. “One of the nice things about being part of Highmark is that we have a payer partner trying to put together new models of reimbursement.”

“Diabetes is already a top-10 killer and deaths from diabetes are projected to increase 34 percent in the next 15 years.”
SourceL World Health Organization

While the cost to society of rampant diabetes is great, so too are the individual costs. “The money aspect is ridiculous. It’s very expensive to have diabetes now. Mainly because insulin is so expensive,” says Dr. Evron of St. Clair. About 20 percent of his patients take advantage of the increasing number of technologies for managing diabetes, which can run in the thousands of dollars. Medicare patients often get stuck paying full price, Evron says. Private insurers will usually help cover costs, but only because he has a full-time staff member whose sole role is to fight for coverage.

“One of the things we’re working hard on is making sure that people have access to this kind of technology and educating our providers in the community that these tools are available,” says Linda Siminerio, Ph.D., a nurse and certified diabetes educator who directs the University of Pittsburgh Diabetes Institute. She adds, “Diabetes is a 24/7 disease. You have to make decisions all day, every day, for the rest of your life.” Technology like real-time glucose monitors is helping motivated patients like Steve Lawthers make better decisions, but clinical trials are still underway to prove whether this is an effective tool. Lawthers has no doubt about its effectiveness; his monitor showed him that his “fast-acting” insulin took an hour to start working. It also alerts him whenever his blood sugar is too high or low.

Lawthers has always been on top of his diabetes, but about 20 years ago he developed hypoglycemic unawareness (he couldn’t tell when his blood sugar dipped too low.) “I’d be there one minute and gone the next,” he says. He no longer has to worry about passing out while driving or at the office where he sells railroad freight car parts. “I just got new transmitters for my monitor. It’s an expensive piece of apparatus, but to me, it is well worth it.” Even during golf, he wouldn’t go without it. “It would never leave me. I plan to wear it for the rest of my life.”