Redefining diabetes for providers

Every person's experience with diabetes is going to be different because of the variables of their lives. Diabetes management for an athlete compared to a pregnant mother compared to the person with a 9-5 desk job is going to look pretty different. We decided to chat with Dr. Anne Peters, Professor of Medicine at the Keck School of Medicine of USC and Director of the USC Clinical Diabetes Programs, to discuss how these variables impact her work as a provider with patients across different groups.

What is the impact of menstruation on diabetes management? Is there a theme you have seen across your patients?

Every person with diabetes who menstruates has a different cycle with very individualized phenomena around how their cycle impacts their blood sugars. Often there is a phase of increased insulin resistance, along with a phase of reduced insulin resistance. This means we can find patterns in their pump data in order to deal with those fluctuations. But what I think is the most impactful is patients simply being aware that their menstrual cycle does impact their blood sugars and it isn’t a reflection of them doing anything ‘wrong’.

Every patient knows their truth - they know what happens to their own bodies.

As a provider, I have patients track their menstrual cycle and then analyze that added context in conjunction with their CGM data so that I can find patterns. Unfortunately, it can vary so much even with the same patient. We can create a period pattern in the pump, but the level of insulin resistance is not always consistent. Often the additional variables of menstrual cycles like how it has affected your stress levels, or impacted your eating habits can add some complexity to settings adjustments. Letting our patients know how these hormonal changes impact their blood sugar management is an important part of the outpatient experience, to empower them with the information they need to take care of themselves outside of the clinic setting.

What is the impact of being an athlete on diabetes management? How does this vary depending on the sport of choice?

Athletes tend to be hyper aware of their bodies. They are typically more involved in their blood sugar management than the average person so an Olympic athlete's regimen is going to be very different from a non-athlete with a 9-5 office job. The current diabetes management systems do best with predictable schedules, they don’t like variations. Carb counting and timing is everything with diabetes management, which can work out when you are on a planned training regimen.

There are varying kinds of exercise and they are so individualized. Everyone is different - especially elite athletes. They need to plan their workout patterns and also consider what they are doing on off days. My athlete patients are fun, because they are incredibly involved in their management. There is a clear value to their data, and the blood sugar management goals have a tangible result in their athletic endeavors.

What is the impact of pregnancy on diabetes management? Is there a theme you have seen across your patients?

Pregnancy is proof of concept. With enough motivation, we can do it - together. People who have their own interest in good diabetes outcomes in addition to a provider that cares can do almost anything. There are specific metabolic needs for both athletes and pregnancy with diabetes. Both sets of patients need to eat specific nutrients, either before a performance or for the different stages of pregnancy. With pregnancy, there is again a tangible result from well controlled blood sugars and the motivation to stick with it, even when it is hard.

How important is access to diabetes data in helping your patients with their diabetes management? Has Tidepool helped you serve your patients?

I have known my patients for years, so I have their AGPs in my brain. I can remember things from 3 months ago and take notes in my chart regarding the variability in Time in Range (TIR) and Total Daily Dose (TDD) and then compare. I have the kind of relationship with my patients where I can ask them ‘What was going on last week?’, because we know that every single thing in your life impacts your diabetes. You can’t hide anything from your diabetes doctor. I can tell when last week was stressful for you based on the data, but that is only possible when you know the person the data is reflecting.

Diabetes metrics are a measure of someone’s life, rather than their life being a measure for their diabetes outcomes.

To be a good doctor involves figuring out what is affecting blood sugars the most at this moment, what we can learn from that information, and how we can help the patient move forward and adapt accordingly. The data with my patients using Tandem’s t:slim X2 with Control-IQ technology (CIQ) for example, allows me to see that you ate dinner late and didn’t bolus until later, so then CIQ overdoses with a correction. But if you can’t pre-bolus because of the particulars of your circumstances, I have to adjust the settings according to what works for your life.

We’re so grateful for the time Dr. Peters spent with us, sharing insights from her decades of experience supporting her diabetes patients. If you would like to learn more about how Tidepool can support you and the rest of your clinical team, please visit provider.tidepool.org.