ADA Postgrad 2020

January 31-February 2, 2020; San Francisco, CA; Highlights Report – Draft

Executive Highlights

  • Greetings from San Francisco, where ADA Postgrad 2020 just wrapped up! Read on below for our top highlights from the weekend’s gathering.

  • Kicking off Saturday morning’s sessions, Dr. Irl Hirsch (University of Washington), Dr. Diana Isaacs (Cleveland Clinic), and Ms. Kelly Close (Close Concerns) discussed the power of Time in Range and CGMs for all people with diabetes (including those on basal-only insulin or not on insulin), while sharing a few clinical hurdles that still need to be overcome to enable CGM-driven clinical decisions to broader populations. Ms. Close shared data from dQ&A showing that Time in Range has had “the biggest impact on daily life across type 1, type 2 on insulin, and type 2 not on insulin.” While the results are telling, they’re not really surprising. Especially in 2019, we started to see serious acceleration in the Time in Range movement and heard people from around the world talking about Time in Range (see our Reflections 2019+2020 theme). Ms. Close highlighted a “cultural shift” that was occurring as people with diabetes (particularly type 1s) move increasingly from discrete, sparse BGM values to continuous glucose graphs with standardized displays (e.g., AGP); too, she emphasized that Time in Range (and related metrics) exist even if they are not being measured, and said that connected BGM is a wonderful entry point into Time in Range for those without access to CGM. We have, for a long time, written about bringing Bluetooth connectivity to BGMs as low-hanging fruit that could improve quality of care for people with diabetes. The group also discussed various ways in which CGM could be easier to access (the Medicare coverage requirements should be relaxed, they stressed, and this is a perfect area for advocates to work together on) and all speakers lit up about the power of professional CGM for valuable therapeutic and nutritional interventions.

  • Later on Saturday afternoon, Dr. Irl Hirsch expanded his collection of highly actionable clinical pearls in an intriguing session on insulin therapy in type 1 diabetes. Dr. Hirsch began the session by giving a rousing call to action regarding the current state of insulin access and affordability in the US, and then provided a number of tips and tricks on using human insulin, understanding the importance of PK/PD profiles with various insulins, and much more.  

  • NASH expert Dr. Kenneth Cusi overviewed the landscape in NASH, with a focus on educating the audience on practical diagnosis in clinical settings. Notably, he pointed to the free and online available “Fib-4” score, which allows providers to input several commonly available variables (age, AST and ALT levels [liver enzymes], and platelet counts) and receive an estimate of liver fibrosis levels. We’re hoping to see the broader use of noninvasive tools like these, since the current gold-standard for NASH diagnosis remains invasive biopsies, which are not scalable to the size of the current problem. According to Dr. Cusi, treatment should focus on lifestyle modification and the use of agents recommended in current guidelines (AASLD) such as vitamin E at 800 IU/day  (if diabetes not present) and pioglitazone (30 t 45 mg/day) for patients with or without type 2 diabetes.

  • We’d like to give an enormous thank you to ADA for accommodating >20 college seniors who were able to attend this meeting as part of recruiting weekend for Close Concerns/The diaTribe Foundation/dQ&A. Students were absolutely thrilled to learn up-close from leaders in the diabetes field and get a taste of all of the important innovation that’s happening in diabetes! They tried their hand at writing up the sessions as well – we can’t wait to review them in depth.

Top Eight Highlights

1. Integrating CGMs into Care: Downloading Data Needs to be Easier, Professional CGMs Are Under-Utilized, and Time in Range’s Big Impact on Daily Life

Kicking off Saturday morning’s Postgrad sessions, Dr. Irl Hirsch (University of Washington), Dr. Diana Isaacs (Cleveland Clinic), and Ms. Kelly Close (Close Concerns) discussed the power of CGMs for all people with diabetes (including those on basal-only insulin or not on insulin), while sharing a few clinical hurdles that still need to be overcome to enable CGM-driven clinical decisions to broader populations. Both Dr. Hirsch and Dr. Isaacs highlighted downloading CGM data and reports as a pain point in clinical workflow. Dr. Hirsch called the process “extremely intensive”; even though data downloads are ideally performed at home by the patient, this often doesn’t happen. Dr. Isaacs made her point by showing page lengths from three different CGM reports: for two weeks of data with default settings, Dexcom Clarity generated 19 pages, Glooko generated 25 pages, and LibreView generated 89 pages. In an informal survey of about 200 audience members at the Endocrine Society Meeting in 2018, Dr. Hirsch found that four-fifths of endocrinologists spent 20 minutes or fewer during patient visits on all aspects of care. Especially as CGMs become more broadly used, the role for non-physician training on using CGM and group classes on CGM education may grow, hopefully quickly. In the meantime, more training and encouragement for patients on using apps so that at least Time in Range data summaries along with AGP (advanced glucose profile) can be shown.  

  • We were especially encouraged to see both Drs. Hirsch and Isaacs highlight the absolute importance of professional CGM – Dr. Isaacs specifically called them an “underutilized resource.” At Dr. Isaacs’ practice, patients often prefer FreeStyle Libre Pro over other professional CGMs (Medtronic’s iPro 2 and Dexcom G4 Pro), because of the no-calibrations. Dexcom G6 Pro is set to launch in “early 2020,” becoming the second factory-calibrated professional CGM on the US market. When using professional CGM, Dr. Isaacs emphasized the importance of having patients log food, medication, and activity, particularly when using blinded CGM. As we’ve heard for many years, Dr. Isaacs testified to the power of CGM to create behaviors. After struggling to convince one of her patients with type 2 diabetes to start on insulin, the patient was quickly convinced after just one session with FreeStyle Libre Pro. 

    • Dr. Isaacs noted that reimbursement for professional CGM is “good,” with CPT codes for using professional CGM and for interpreting the data. While only physicians, nurse practitioners, and physician’s assistants are formally allowed to perform the data analysis portion, Dr. Isaacs explained that a collaborative practice agreement allowed her (a pharmacist) to perform the analysis and have a physician as the billing provider.

  • Our own Ms. Kelly Close shared data from dQ&A showing that Time in Range has had “the biggest impact on daily life across type 1, type 2 on insulin, and type 2 not on insulin.” While the results are telling, they’re not surprising. Especially in 2019, we started to see serious acceleration in the Time in Range movement, hearing people from around the world talking about Time in Range (see our Reflections 2019+2020 theme). Ms. Close highlighted a “cultural shift” that was occurring as people with diabetes (particularly type 1s) move increasingly from discrete, sparse BGM values to continuous glucose graphs with standardized displays (e.g., AGP); however, she also noted that Time in Range (and related metrics) can certainly exist without CGM. We have, for a long time, written about bringing Bluetooth connectivity to BGMs as low-hanging fruit that could improve quality of care for people with diabetes. 

  • According to Dr. Hirsch, the time challenge faced by clinicians is only getting worse as healthcare becomes increasingly “RVU-centric.” Diabetologists face an average of ~1500 hours/year of administrative burden. Dr. Hirsch presented the chart below to a mixture of laughter, groans, and gasps from the audience. In a similar vein, Dr. Hirsch’s “Ranting in 2020,” published in last month’s DT&T, briefly mentioned that the lack of physicians is hitting endocrinology, in particular, as “endocrinology fellowships are less competitive and attractive than in years past.”

2. Dr. Irl Hirsch Shares Clinical “Pearls” on Using Human Insulin, Importance of Understanding PK/PD, and More

University of Washington’s Dr. Irl Hirsch expanded his collection of highly actionable clinical “pearls” in an intriguing session on insulin therapy in type 1 diabetes. To begin his session, Dr. Hirsch delivered a rousing call-to-action regarding the current state of insulin access in the US. He pointed to a 2016 survey by T1International that found that 26% of those with type 1 diabetes in the US ration their insulin due to price; in Seattle, 20% of Dr. Hirsch’s patient travel to Canada to buy insulin.

  • Dr. Hirsch explained that for individuals who cannot afford insulin analogues, human insulin continues to be a useful option (and even an effective one for those with access to CGM), echoing many themes we heard at Dr. Hirsch’s presentation at Endo Fellows 2019. In a case study, one of Dr. Hirsch’s patients who had been forced to transition to NPH due to cost was able to identify his nighttime hypoglycemia using CGM, then effectively prevent the hypoglycemia with snacking. In terms of specific pearls of knowledge on use of human insulin in type 1, Dr. Hirsch shared:

    • Location matters: abdomen > arms > thigh > buttocks. Generally, regular insulin is best administered in the abdomen, and NPH needs to be consistently administered in the same location (thighs or buttocks). 

    • NPH needs to be mixed well.

    • Lag times exist for regular insulin. Usually, a 20-30 minute minimum is required to prevent a large, post-meal spike.

    • Snacking is often required to prevent nocturnal hypoglycemia.

  • In a small but useful moment, Dr. Hirsch noted that U300 insulin glargine consistently has a longer duration than U100, and twice daily dosing is not required. In addition, studies of U300 have shown that patients treated with glargine U300 used 17.5% more basal insulin than patients treated with U100, therefore higher doses of U300 are needed compared to U100.

  • Surprisingly, a number of audience members voiced an unfamiliarity with the concepts of drug pharmacokinetics (PK) and pharmacodynamics (PD), despite the two parameters being very clinically meaningful. As a reminder, PK represents the time course of circulating concentration of insulin resulting from a dose of insulin, while PD is a time course of the insulin’s effect on blood glucose concentrations.

    • Dr. Hirsch recently illuminated the applicability of both measurements in a JCEM publication entitled “Transition of Patients to and from Insulin Degludec: A Clinical Challenge,” stating, “One of the most pressing issues has become an issue of switching patients to and from newer insulins in various clinical situations. A proper switch from one medication to another requires understanding of the PK and PD of both drugs.” On that front, Dr. Hirsch presented a case study detailing a 29-year-old obese patient with type 1 diabetes, currently on insulin degludec and pre-meal insulin aspart, who decided to begin insulin pump therapy. Because insulin degludec has a half-life of 25 hours, stopping the degludec 48 hours before starting the pump and reducing the first dose of basal insulin by 50% would be a reasonable way to perform the transition, and one that might be missed without a look at the PK/PD profile of the treatments. In sum, Dr. Hirsch emphasized that while these newer insulins improve outcomes, such as lowering hypoglycemia, they also create new challenges for patients and healthcare providers.   

3. Dr. Kenneth Cusi Provides Clinical Tips for NASH Diagnosis, Expresses Optimism for Semaglutide in NASH, and Expects Approval of Intercept’s OCA as First FDA Approved NASH Therapy

NASH expert Dr. Kenneth Cusi (University of Florida) provided a broad overview of the field, with a focus on practical implications for clinicians unfamiliar with diagnosing and treating NASH. Detailing the vast prevalence of NAFLD/NASH, especially amongst people with type 2 diabetes, Dr. Cusi noted that “if you didn’t diagnose anyone with fatty liver in the clinic last week, you probably weren’t doing it right.” Dr. Cusi underscored difficulties in diagnosing NASH and urged clinicians to better consider NASH in their daily practices. Of course, serious bottlenecks still exist in terms of diagnostic tools and long-term outcomes studies in NASH, which has made it difficult to better understand the disease. On the diagnosis front, Dr. Cusi provided a few clinical pearls that the audience could immediately implement in their practices: he pointed to the free and online available “Fib-4” score, which allows providers to input several commonly available variables (age, AST and ALT levels [liver enzymes], and platelet counts) and receive an estimate of liver fibrosis levels. We’re hoping to see the broader use of noninvasive tools like these, since the current gold-standard for NASH diagnosis remains invasive biopsies, which are not scalable to the size of the current problem.

  • Regarding the NASH drug landscape, Dr. Cusi seemed confident in the approval of Intercept’s obeticholic acid. Dr. Cusi explained that he expects the drug to be approved – as a reminder, Intercept has submitted OCA to FDA, and a decision is expected in the following months (an Ad Comm is also set for late April). OCA could be the first FDA approved drug for NASH, marking a true landmark moment in the field. See our coverage of Intercept at JPM 2020 for more details on how the company is preparing for this pivotal stretch. Notably, Dr. Cusi also expressed optimism for semaglutide’s ongoing trial in NASH, which is expected to complete and have results released this summer, according to Dr. Cusi. Dr. Cusi believes that the impressive weight loss that semaglutide confers to patients will results in a positive result in this trial. Novo Nordisk also has ongoing combination trials of semaglutide with Gilead’s FXR agonist cilofexor (GS-9674) and ACC inhibitor firsocostat (GS-0976). Broadly, KOL enthusiasm for GLP-1 in NASH has been high, with many experts aligning with Dr. Cusi’s optimism for this therapy class. At Obesity Week 2018, GLP-1 expert Dr. Dan Drucker predicted the class’ future success based on positive changes in human liver histology with liraglutide treatment in the phase 2 LEAN study – given semaglutide’s more potent effects on weight loss, expectations are high for its performance in NASH as well.

4. Dr. Michelle Magee on Mitigating CV Morbidity Risks and Updates on Diabetes and Cardiovascular Disease

Dr. Michelle Magee provided a valuable overview of mitigating risks of cardiovascular morbidities and presented a series of intriguing case studies to highlight important treatment decisions. Dr. Magee began by overviewing type 2 diabetes prognosis trends over the last several decades, noting that “in 2010, we were excited about lowering rates of MI, stroke, amputations, and ESRD…however, those things have gone back up since 2009 – that’s not good news!” Why has this trend reversed? Dr. Magee split up these trends by age group, showing that the rates of these complications have most seriously increased in the youngest cohort of those 18-44 years old. She cited a few potential reasons for this increase, including stagnation in preventive care, policy-level factors affecting access to healthcare and the growing prevalence of high-deductible healthcare plans, and broader socioeconomic trends that have accentuated effects in vulnerable populations following the recession of 2008-2009. Dr. Magee also pointed to the recently published and extremely worrisome JAMA investigation that found that the rate of adults with diabetes achieving A1c, blood pressure, and cholesterol targets has not improved significantly since 2005. Building off of this, Dr. Magee underscored how much work there is to do in terms of helping patients meet targets on A1c, cholesterol, blood pressure, smoking status, albuminuria, and whether they take aspirin. Dr. Magee then went through a series of helpful case studies that educated the audience on how to assess a coronary artery calcium score, how to better prescribe aspirin, how to promote healthy food choices and limit sodium intake, and the proper timing of initiating anti-hypertensive medications.

  • In a different session, Dr. Magee provided a wide-scope overview of the state of diabetes and cardiovascular disease. She summarized results from the most recent, pivotal CVOTs and contextualized them in the ADA 2020 Standards of Care. These CVOTs investigated SGLT-2 inhibitors and GLP-1 agonists, which have changed the diabetes treatment landscape tremendously throughout the 2010s. GLP-1s have been touted for their ability to reduce MACE outcomes (in patients with or without established CVD), stroke risk, and improve renal outcomes. SGLT-2 inhibitors also reduce MACE outcomes, seemingly in patients with existing CVD only, but show impressive reduction in the progression of chronic kidney disease. Dr. Magee discussed these results in detail CVOT by CVOT- see below for a summary of the main points from each study. Overall, Dr. Magee concluded that patients with predominant ASCVD should consider taking GLP-1s, while patients at risk for HF or CKD should more strongly consider SGLT-2s.

  • REWIND investigated CV outcomes in patients using the GLP-1 analog dulaglutide and demonstrated superior reduced MACE outcomes and protective effects on renal outcomes in both primary and secondary prevention patient populations. This study included a large and geographically diverse patient population (N = 9901), the majority of which did not have prior CV disease (68.5 %). REWIND represents the only clinical trial of a GLP-1 analog to show a statistically significant reduction in CV outcome in patients with no prior CVD (HR = 0.88). In terms of adverse events, dulaglutide caused typical adverse GI events, but did not significantly increase a patient's risk of acute pancreatitis or cancer despite longstanding concerns over this issue.

  • PIONEER-6 demonstrated that an oral form of the GLP-1 agonist semaglutide significantly reduces CV death (HR = 0.49) and all-cause mortality (HR = 0.51) but does not confer a reduction in MACE outcomes. Oral semaglutide represents the first GLP-1 analog that can be taken daily by mouth as opposed to injected subcutaneously. The lack of statistically significant results regarding MACE 0utcomes may be due to the short study period (83 weeks) and small sample size (N = 3,183). In addition, the majority of patients recruited for the study already have CVD (84.9%).

  • DECLARE TIMI-58 demonstrated that dapagliflozin reduces CVD and hospitalization due to heart failure (HHF) regardless of a patient's baseline ASCVD or HF status. SGLT-2 inhibitors may be used for both primary and secondary prevention cases using a large sample size (N = 17,160) with a long median follow-up time (4.2 years). While MACE outcomes were also investigated as a primary endpoint, dapagliflozin failed to show a statistically significant reduction. It is important to note that this study showed that dapagliflozin increased a patient's risk of diabetic ketoacidosis, but not amputation or fracture.

  • CREDENCE demonstrated that the SGLT-2 inhibitor canagliflozin improves renal outcomes in type 2 and nephropathy patients. This trial was moderately sized (N = 4,401) and recruited patients with long-established T2DM (mean duration 16 years). In addition to improving composite renal outcomes in primary and secondary prevention populations, canagliflozin also reduced major CV events and HHF without increasing the risk for limb amputation or fracture.

  • DAPA-HF showed that dapagliflozin may reduce the risk of hospitalization for heart failure in patients with and without type 2 (HR = 0.74) without serious side effects. This moderately sized study further provides evidence that SGLT-2 inhibitors may be helpful for patient populations at risk for heart failure.

5. So Many Medications to Choose From! A Case Study and Panel Discussion on Practical Applications of New Medications in Type 2 Diabetes

Dr. Joshua Neumiller moderated a dynamic panel featuring Dr. Michelle Magee (MedStar Diabetes, Research and Innovation Institutes) and Ms. Geralyn Spollett (Yale Diabetes Center) on practical applications of new medications in type 2 diabetes. Intriguingly, advice from both clinicians combined evidence-based recommendations from the ADA Standards of Medical Care in Diabetes for 2020, as well as personal recommendations from their own years of experience (to address situations in which data is not yet available). To structure the session, Dr. Neumiller presented a case scenario on a 64-year-old patient named RJ, who has had type 2 diabetes for the past eight years. Most prominently, RJ has a baseline A1c of 7.2%, an eGFR of 43 mL/min/1.73 m^2 and struggles with hypertension and obesity. Find the treatment questions posed by Dr. Neumiller and thoughts from Dr. Magee and Ms. Spollett below.  

Dr. Neumiller: To begin, let’s hear some of your general thoughts on RJ’s case?

Dr. Magee: RJ is at a high risk for CVD and already has established kidney disease with proteinuria. At this point, because of the presence of established kidney disease, I would go with the SGLT-2 inhibitor first. I would need to look back at his medications and would probably stop linagliptin while continuing metformin. There hasn’t been a study on the combination of GLP-1s and SGLT-2s, and you could make a case for using both of them, but I think that’s too expensive to be sustainable. 

Ms. Spollett: For the sake of argument, he is overweight and that can’t be good for his heart. I’m concerned about that. His blood pressure is at goal, but I’m still concerned about heart disease, CABG, and peripheral vascular disease given that his circulatory system is compromised. Using an SGLT-2 is fine, but if there are no existing renal problems, I would think about using a GLP-1 for weight loss over a DPP-4. 

Dr. Neumiller: Would either of you change the metformin dose based on RJ’s eGFR?

Ms. Spollett: I would. I have seen studies that say if the eGFR is less than 45, then the metformin dosage should be cut in half. 

Dr. Magee: That approach was taken in the diabetes prevention study 25-year follow up to the DPP study, and a lot of people are now developing kidney disease. I don’t think that linagliptin adds much in this case - it’s not that robust of an A1c lowering medication. The early trial had a sign for amputations, but now there’s reassuring data from CREDENCE, as well as the aggregate data from the more recent meta-analysis. This drives how we pick our drugs. Some of us would feel uncomfortable with that as the first choice among this class of agents. 

Ms. Spollett: We try to use empagliflozin because it was the first SGLT-2 inhibitor that came out with a CV benefit. I would say that benefit with the SGLT-2 class is important to avoid peripheral vascular disease and complications.


Dr. Magee: SGLT-2s do have an impact on MACE, so we’re not not doing anything for him based on that. I don’t believe that he doesn’t have neuropathy, because that is so closely tied to peripheral cardiovascular disease, so I would test him very well. 

I’m a big believer in a continued spectrum of risk, and those with prediabetes are at a greater CV risk, so I think the risk is there. The spectrum goes from normal to prediabetes and microalbuminuria, and you can then have a patient with well-controlled risk factors become a patient with poorly controlled risk factors that develops established CVD. 

Ms. Spollett: The other thing to keep in mind is that the patient’s renal condition is at a point where if you don’t intervene [with an SGLT-2 inhibitor], they’ll be beyond it. The same applies with some GLP-1s. I’m concerned about this fellow because he’s not doing any of the things people with CABG do: he’s not walking and he’s overweight. He doesn’t smoke or drink much, which lessens some of the complications, but this is also a fellow who is ripe for change. He has the change for a longer, older lifespan. It’s worth trying to encourage him to very actively do something. I would not encourage him to take three medications to think things over. I would want him to be a little more aggressive with his lifestyle and consult a nutritionist and trainer. 

Dr. Magee: I want him to address is LDL-cholesterol. He’s on a good statin, but you could strongly argue that he needs to add ezetimibe (Zetia) as a second choice lipid-lowering medication. I want to see his LDL be at least under 17 mg/dL, if not lower. 

Selected Question and Answer 

Q: You mentioned that from the SGLT-2 inhibitors, you were leaning towards empagliflozin, but I thought empagliflozin was not recommended for those with an eGFR <45? 

Dr. Magee: It’s a balancing act. You just have to figure it out for the patient and wait for new data. 

Dr. Neumiller: I think the nephrology folks are a little more willing...I would suspect that the eGFRs will go down with new data. 

Q: What happens if we come back in six to twelve months, and RJ is on Medicare and can no longer afford the SGLT-2 inhibitor due to a high co-pay? 

Dr. Magee: It takes health policy and Medicare policy, but there’s a huge time lag in how they view this kind of data. I would hope that the health economists would do some modeling and show that keeping people off dialysis and prevent major cardiovascular events would save a lot of money, then move these drugs onto their formularies. 

Ms. Spollett: I agree with all that, but the practical person in me says I can’t wait for policy to change. I’m going to look for a GLP-1 covered by RJ’s formulary because at least I can offer CV benefit, if not offering as much for renal. 

Q: If his blood pressure (BP) seems pretty well-controlled, would you reduce the amlodipine or lisinopril? Or wait and see the effect on BP? 

Ms. Spollett:  There is no data, but I don’t take them off BP medication. Diuretics I’m more concerned about. I wouldn’t want to mess with BP medication until the point that he is becoming hypotensive, but that's me in my practice. I can’t direct you to an article that tells you to do that. 

6. Dr. Leonard Egede On the Importance of Knowledge of Social Determinants in Clinical Care

Dr. Leonard Egede (Medical College of Wisconsin) took the audience through the basic tenets of social determinants of health, terminology, and screening tools, culminating his talk by providing real-world examples of successful interventions. Social determinants of health (SDOH) are a combination of social and economic conditions that interplay to affect health outcomes. Different frameworks to understand this phenomenon exist, but the WHO model is often used because of its ability to relate the macroenvironment (i.e. policies) to the individual, emphasizing that people at different levels all have stake in an individual’s health outcomes:

  • While academic terminology of SDOH centers on social risk factors, behavioral risk factors, and social needs, Dr. Egede believes that terminology for clinicians should center around social prescriptions, social needs-informed care, and social needs-targeted care. Social prescribing, identifying patient needs and writing a prescription to meet it is often successfully implemented in the UK.  However, it’s less successful in the US because of its inability to account for risk, the diverse environments across the US, and implementation outside of a nationally sponsored healthcare system. Social needs informed care (i.e. incorporating modifications to care delivery) is more feasible; for example, some US hospitals provide transportation to appointments for patients. Similarly, social needs targeted care involves incorporating activities into clinical care to address a social need, like helping patients sign up for financial assistance programs. These issues further demonstrate that standardization of key terminology is needed to better inform both clinicians and policy leaders, but different patients require unique care. Subtle differences exist between the definitions of social determinants of health, social risk factors, behavioral risk factors, and social needs. Understanding individual differences in these regards is critical to optimizing patient care.

  • Studies on different ways to address SDOH are the best way forward to determine the most effective investments and changes in healthcare. Studies on the effects of economic stability, education, social community, built environment, and access point to chronic stress being the mediating variable driving worse health outcomes. Dr. Egede stresses that clinicians need to devote five minutes of their appointments to ask meaningful, respectful questions to find out more about what is going on in a patient’s life beyond their A1c. He added that patients are very grateful when clinicians take the time to learn about their unique lives and challenges. Other prominent challenges include a lack of electronic medical health record standardization, provider screen time, and lack of SDOH diagnostic codes.

  • At a preventive level, improving the infrastructure for screening tools is imperative. Dr. Egede introduced the audience to three major screening tools that are used to identify social determinants of health in the clinic: The Accountable Health Communities Health-Related Social Needs Screening Tool, PREPARE, and CLEAR Toolkit. The Accountable Health Communities Health-Related Social Needs Screening Tool is the most commonly used screening tool currently, giving physicians the opportunity to assess their patients in a straightforward, non-judgmental manner. PREPARE is the more comprehensive and detailed than comparable tools, and clinicians are beginning to adapt this measure for patient testing. Finally, the CLEAR Toolkit is unique in allowing results to be made publicly available. While each screening tool has its own set of strengths and weaknesses, Dr. Egede encouraged those in the audience to try all three and decide which tool works best for the given context. However, a myriad of challenges involving standardization for electronic medical records and diagnostic codes limit the streamlined use of screening tools. Policy actions to improve standardization will allow SDOH to be integrated into patient care more seamlessly. As standardization and diagnostic coding advance, provider time to screen and compensation will likely improve and clinicians will be more attracted to implement SDOH concepts in their practice.

  • Of note, simply increasing access alone does not improve health outcomes, so tools which can indicate the specific ways in which healthcare should be adapted and personalized to meet the needs of a patient and address individual SDOH are necessary.  While a primary effect associated with SDOH is a decreased access to healthcare, simply providing access to a provider does not drive health if that provider’s practice is not prepared to both evaluate individual determinants and utilize community resources to address those disparities.  Healthcare providers must become increasingly responsible for remaining up-to-date and connected with the relevant resources provided by local governments, community groups, and state and local social services agencies.
  • SDOH studies have found that relationships between SDOH and diabetes-specific outcomes are rarely direct but are instead mediated by factors caused by SDOH. For example, a 2015 study showed no direct relationship between self-care and A1c, but psychological distress, social support, and self-efficacy had direct effects on both self-care and glycemic control. Later studies found that depression and fatalism, food insecurity, and discrimination influence glycemic control through self-care, while social cohesion and medication adherence have direct effects on glycemic control. These results have influenced the creation of the COME ALIVE observational study that aims to create a conceptual framework for addressing SDOH in urban environments, and various interventions. Future studies should further explore the impacts of social determinants of health on diabetes outcomes, which will have major implications for clinical practice. Such research should not only investigate the links between social determinants and diabetes outcomes but also analyze effective, nonjudgmental implementation of the findings in clinical and nonclinical settings.

  • Financial incentives are some of the most powerful interventions right now, having been known to show significantly improve health outcomes, especially if patients are able to shift from external to internal motivators. Dr. Egede’s study showed that the strongest way to drop A1C in a diabetes patient population was to provide financial incentives. This takes advantage of the burgeoning and effective idea that empowering patients to help themselves leads to the best health outcomes. However, it is important to consider the sustainability of such programs due to limitations in duration and funding. Incentive-based interventions must be able to help patients switch from external to internal motivators during the trial period. If this is successful, then the robust effects of financial incentives can be sustained once the incentive period is over. Strategies for sustainable resource delivery will be critical as health care increasingly implements SDOH concepts in patient care.

7. Interactive Session Dives into Real-World Intricacies of Insulin Therapy Use with Intriguing Case on Brittle Diabetes

Dr. Irl Hirsch and Ms. Geralyn Spollett (M.S.N., A.N.P., D.C.E.S., Yale Diabetes Center) led the audience through a number of case studies in an engaging workshop on insulin use in type 1 and type 2. From the enthusiastic audience participation, it was clear that so many providers have dealt with similar quandaries regarding clinical care in diabetes. As always, ADA Postgrad continues to be one of our favorite meetings of the year for its emphasis on this type of open dialogue between presenters and attendees!

  • Dr. Hirsch discussed a particularly intriguing case on a 24-year-old woman referred to him for brittle diabetes. The patient was reported to be taking over 1000 units of insulin per day (!) but still presented with an A1c of 10% while on CGM. After the patient tested negative for insulin antibodies, Dr. Hirsch (as well as the audience) had suspicions that the patient was not actually taking her insulin. To check his hypothesis, Dr. Hirsch proposed testing the patient’s glucose levels in office. The patient came in supposedly having taken 150 units of insulin lispro 45 minutes prior to the visit. To follow, Dr. Hirsch administered 10 units of insulin lispro from a new vial and took insulin measurements for three hours. Over the time course, the patient’s insulin levels consistently rose from around zero at baseline, and glucose levels safely dropped, confirming Dr. Hirsch’s suspicions. At this point, Dr. Hirsch emphasized that the patient would be most helped by psychiatric help, rather than further intervention from an endocrinologist.

    • Excitingly, Dr. Hirsch shared details on an upcoming paper he is writing with Dr. Linda Gaudiani on new classifications within brittle diabetes. The four proposed groups include (i) “classic,” typically women, often working in healthcare, with psychiatric or social issues; (ii) “medical,” atypical diabetes from conditions such as pheochromocytoma, lipohypertrophy, or severe Cushing’s disease; (iii) geriatric patients; or (iv) insulin or food insecure individuals. We’ll be on the lookout for the paper once published!

8. Dr. Cynthia Muñoz on Behavioral Health in Diabetes Care

Dr. Cynthia Muñoz (Children’s Hospital Los Angeles) guided diabetes educators in incorporating behavioral health into diabetes care. She prefaced her talk by addressing the complexity of diabetes, stating that it’s a 24 hour/day job, and that psychosocial wellness must be integrated into diabetes management because of its effects on self-care and outcomes. She outlined a set of psychosocial guidelines, which include (i) communication; (ii) maintaining the person with diabetes as the center of care; (iii) screening for psychosocial conditions; and (iv) referring patients to mental and behavioral health providers. One can promote patient-centered care with adaptive coping strategies, acknowledgement that no one is perfect, realistic goals, and realizing that psychosocial factors, like a fear of hypoglycemia, lie on a continuum. Clinicians and diabetes caretakers are responsible for checking in, and when they do, should do so respectfully in a way that does not incite feelings of shame. Education can also alleviate diabetes distress, so learning should be actively incorporated into diabetes-care interactions. To further drive the point home, Dr. Muñoz shared that diabetes distress has been shown to be more closely linked to higher A1c than a depressed mood, so checking in is of the utmost importance. Broadly implemented screenings could help clinicians identify who may need more psychosocial support and inform treatment plans for the same reason. Lastly, Dr. Muñoz stressed that diabetes caretakers, clinicians, and caretakers need to take care of their own mental health before they can help those around them.


--by Albert Cai, Ursula Biba, Rhea Teng, Martin Kurian, and Kelly Close