SARAH: Welcome back to the Southeast Ohio Qi Hub video series. Sarah Adkins, of course, your host. I will be talking today about medications in the ADA updates, tying into what Dr. Healy talked about in our February release. Um, but I also have a special guest with us today who is also gonna be talking about some ADA updates. And this person is actually an ADA specialist. Okay, who's been with the ADA for the past several years and is now the ADA President-elect for the healthcare and education piece of the ADA. LIZ: That's true. They picked me. SARAH: We're proud of you. LIZ: Aw, Thanks. Thanks Friend. SARAH: We're happy to have you on the QI hub with us. It's, it means a lot. Alright. LIZ: Thanks for having me, friend. SARAH: Always love hanging out with you. I love hanging out with you on this show. SARAH: It's so good. It's so good. Alright Lizzie. Mm-hmm. Let's get started. Let's Do this. SARAH: Alright. We're gonna talk about some ADA updates. Yes. So I think there was something we were gonna talk about. Mm-hmm. First, in section nine. Section nine. SARAH: Which is? So one of the new things in section nine, and this is great for what we're doing for the QI hub. Is they put in a new recommendation about when you're forming treatment plans that you include healthy behaviors, diabetes, self-management, education and support. And you also make sure you address social determinants of health. And to me, I think we've always thought all along, yes, we should have that, but to spell it out in writing as a formal recommendation is essential because maybe there are some clinics that aren't doing this. And now to have that recommendation, I think it's just great. So, you know, it's just a blanket statement that this is something that everybody needs to be doing. SARAH: I love that. Yeah. And it is in section nine, which is the pharmacologic approaches to treatment. So I think that's a really great place to have that. Right. I mean, when I think about standards of care, a lot of people go straight to section nine. Correct. Because you're al you're always gonna be looking for what changes. Right. In terms of, you know, the pharmacological treatment plan treatment. So, so I know so many of you are already addressing and doing some screening for social determinants of health. So I think of this as this is just the recognition of all the hard work you've been doing. SARAH: Yeah, I think so too. Yeah. I love that. So let's continue with section nine just a little bit more. Um, Dr. Healey addressed some things in section nine also from our February release. One thing I wanted to mention specifically mm-hmm is hyperglycemia caused from immunosuppressants. Tell me more. SARAH: So let's talk about this just a little bit. I think in the past we have seen insulin being used for this and the recommendations now are for oral medication. So oral treatments can be used. Um, recommendation was for DPP four, just for some mild lowering for that hypo, hyperglycemia. So remember that someone on, uh, glucocorticoid treatment, short term immunosuppressants for transplants. Also on anti-cancer medications. I think we cannot forget those, that there is a risk of, um, development of diabetes in patients who are on anti-cancer medication. So keeping an eye out for hyperglycemia and then treating that as necessary and oral agents are a possibility. LIZ: That's great. SARAH: I like that. I think that's a really good addition too. Section nine. That's great. SARAH: I think after that we should move on to section five. My favorite section Behavioral. It happens to be the section that I'm on, which might be why it's my favorite section. SARAH: That's the pressure on me. There's a little bit of pressure right now. Just A little bit. Okay. Where should we begin? SARAH: Well, since it's your section... How about I ask the first question? SARAH: I love that. Yes. Okay. So part of section five we're focusing on facilitating positive health behaviors. So the section, you know, focuses on diabetes education, it focuses on nutrition, physical activity, and then some things you might not think about like tobacco use. So Sarah, tell me what's it say about tobacco use? SARAH: I don't think we talk about it enough. I think we hear about it, but I think a reminder is very good. How important it is for tobacco cessation our patients who have diabetes. So remembering to ask questions, see if they're interested in quitting, providing resources for patients. This also please includes e-cigarettes. Um, I think it's really important to expand that to any kind of medication, or excuse me, drug that's inhaled. Um, I think that's important to keep that in mind. So please think about tobacco cessation or um, um, inhalation cessation with your patients who have diabetes. Right. And the section recommends that you screen at all visits. All visits, all visits. Right. SARAH: It's a lot. Yeah. Yeah. And in the text, you know, you're citing research on tobacco use and I think they make a really important distinction that e-cigarettes are just as harmful as combustible cigarettes. Yes. So that's just a really important thing. There's no safe cigarette. SARAH: There is not. Also, there's so many different forms of tobacco cessation assistance. So we have patches, we have gum, we have counseling, we have Chantix. There's a lot of different things you can use to help patients with tobacco cessation. And they're out there and they're available and they're really not that expensive. So I would encourage them. And do they recommend doing two at one time? SARAH: Two at one time. Always. And always combined with counseling. So whatever you're using combined with that encouragement, that continuous counseling encouragement to quit smoking. That's great. Do you have you questions for me? SARAH: Well, I do. Oh, great. SARAH: As a matter of fact, while we are on section five Oh yeah. Talk to me about diabetes distress. I would be happy to. So I've covered before what diabetes distress is. And we know it has to do with emotional burdens and worries that people have about living with their own diabetes. The new recommendation that we have in the standards of care this year for section five is we encourage healthcare professionals to address diabetes distress in the clinical visit themselves. You may be asking why, right. How can I possibly address diabetes distress? The reason we ask is upwards of 60% of people with type two have distress. So that's the majority of the people that you're gonna be seeing with type two diabetes. SARAH: Yeah. That means that if 60%, maybe 70% of people have diabetes distress, you can't refer out to behavioral health. Right. There just aren't enough behavioral health professionals. Right. So what we're encouraging is you attempt to address it in the visit, you would be asking, how do I do that? Well... SARAH: How Do I do that? Thanks for asking Sarah. So how do you do that? You know, the simplest way to put it is make sure you just create an emotional space for someone to disclose how they might be doing with their diabetes. So simply asking someone, how are you handling living with your diabetes right now? Or what has been the hardest thing for you since I've last seen you in taking care of your diabetes? You know, and just making sure that they know that it's okay for them to disclose things about how they're emotionally coping with diabetes that opens the door. SARAH: Yeah. And then the next step is if someone does start talking about their feelings, validate that those emotions are real and that it's okay to have an emotional reaction to living with diabetes. 'cause diabetes is not just a physical condition. Right. It's a lot. Now things that you can do within the visit, let's say somebody does disclose, you validate those emotions and then what? SARAH: Yeah. So a lot of times distress is about distress with medication or distress with glucose monitoring. You know, it could be distress with their CGM what to eat, what to eat, How to do some physical activity. So sometimes it's just what is the biggest problem you're having with that? And then try to problem solve some of those issues. So if you're able to problem solve things and you can actually do those under five minutes. You know, a lot of those problems can be solved, you know, relatively quickly. Yes. And you're not gonna be taking an hour long visit to do so. SARAH: Just some solutions. Just some Simple solutions. Sometimes it's also just giving a few coping techniques. Right? You know, we have this, you know, ability where we can catastrophize things like, oh my A one C'S up, I can't manage my diabetes, I'm a failure. You know, what you do is perhaps you cognitively reframe that and say, okay, yes, your A1C is up. Well let's talk about things that have happened in the last three months. Maybe you find out that they lost a job or they lost a family member. There's a lot of stress going on. Lot of stress. Right. You know, so when you find those things you say, well perhaps this is the reason. Right. There are a lot of things going on, you know, and that's maybe why the A1C has gone up. Yeah. And you can say that's information for me that I can take to inform perhaps what I'm using for your treatment plan. Maybe we need to change the medication you're on. It's not you failing at diabetes. That's nice. If after doing all of that, the person's still really struggling emotionally, perhaps that's when you would refer to behavioral health. SARAH: Okay. I think that's great. Does that, when you talk about diabetes distress, does that include like depression, anxiety? Or does that, That's a great question. So diabetes distress is distinct from anxiety and depression. Okay. That doesn't mean that a person with high distress doesn't also have anxiety and depression. Okay. Okay. So a lot of the time you'll have overlap. If there's overlap and someone does have depression or anxiety, you have to treat the depression and anxiety, which you would normally, whatever that evidence-based treatment is for anxiety, Depression. SARAH: Awesome. Okay. Yep. That's fantastic. Thank you. Now you did bring up anxiety. We have a new recommendation for anxiety in the standards of care and that is for the first time we recommend annual screening for anxiety. Now you may be thinking, wow, you ask for a lot of screening and we do. SARAH: It's a lot. It is a lot of screening. But the good news is we do have codes for that. Check these out. [codes appear on screen] And if you do address diabetes distress or anxiety in a visit, you can also use these codes and we'll also make a handout for you. SARAH: Hey, that's fantastic, it's a great idea. Thank you. LIZ: You're welcome. There is the general anxiety disorder two, which is just two questions. It's called the GAD two. And if you could perhaps, you know, somehow put that in, if you're doing the patient health questionnaire two already, maybe see if you could add the GAD two as well. Yeah, That's Great. And the reasons for screening for anxiety. You know, the U-S-P-S-T-F does recommend screening for adolescents and adults for anxiety. In terms of diabetes, we know that people with anxiety and diabetes have higher A1C. They do less self care, they have more macrovascular and microvascular complications and we also know that it increases risk for mortality. So there are real reasons why we should be screening for anxiety. SARAH: That's great. Okay. If you do screen for anxiety and someone's positive for the screener, if it's in your scope of practice, you can do an evaluation to see if they have anxiety. You know, the screener itself doesn't tell you if they have anxiety, it's just a screener. But you'd have to do a comprehensive evaluation. Nice. If you don't feel that's within your scope of practice, you can refer out to a behavioral health professional or someone who's trained to do the comprehensive evaluation. SARAH: Okay. That's fantastic. I think along those lines, thinking about from anxiety, I think also we had talked about there's something now for sleep. Um, thinking about those behaviors. Yeah. So section five includes, a brief section on sleep health. And we actually have a recommendation that also asks that in a visit that you include some screening questions on sleep health. I think we're finally understanding that sleep is pretty important. Yeah. And it affects all of us and we really need to care about it. SARAH: It's so true. So we're not saying, you know, maybe you have to administer questionnaires or surveys for doing the sleep, you know, screening. Something ask for, I could be like, "Sarah, you know, how many hours of sleep do you get?" SARAH: Such a wonderful question. Right. Or you could say, "Sarah, when you wake up, do you feel refreshed?" You know, so some of those questions or has anyone ever noticed that you stop breathing when you're sleeping? And that would be important because we know that people with type two diabetes, greater risk for, um, obstructive sleep apnea. So asking those questions, if somebody tells you, you know, I only sleep four hours a night. I never wake up feeling refreshed. That's where you say, okay, let's talk about this. And I might need to, you know, refer you to sleep medicine. SARAH: Yeah. So that's fantastic. Those are so good. I think it's nice that we're bringing things to light that we haven't really talked about as much in the past that I think really do affect people with their diabetes control. So I agree. It's fantastic. It's a great section. LIZ: It's a great section. Check it out. Section five. SARAH: Alright, so I just have a couple more things I wanted to add 'cause I like to talk about medications. Please, please. SARAH: So In scanning through the remainder of the guidelines, there was one thing I wanted to include from section six that I thought was super cool and that we don't talk about enough. And that is putting glucose, emergency glucose supplies into a first aid kit. This is not a hard thing to do. The glucose tablets, in fact, glucose tablets last forever. Um, you can also do the gel, and I would recommend this is for institutions, workplaces, schools, keeping those glucose tablets available in the first aid kit. I think it's a great idea. I agree. I really hope that, you know, people follow these recommendations and we start seeing glucose tabs in first aid kit. SARAH: It's so easy. It's an easy thing to do. Easy thing to do. One other thing I wanted to re is what I wanted to mention, what I think is super cool actually, is that they have now included cost on some of the charts and tables in the ADA standards of care. And I like the way they did it so that it's a, it's a range, right? Because these are the, the costs can change. And so in a couple of the tables, so in the obesity chapter and in the type one diabetes and in the type two diabetes sections, there are several charts that talk about cost. I think it's just a nice thing to have there, um, as a provider looking at what that impact might be on your patients. So I just think it's a great thing to add. I agree. SARAH: That's all I had. That's all I had. I think we covered some good stuff. SARAH: I think it's great. I I love the updates. I just, I love the updates. Yeah. It, the standards of care are pretty cool. SARAH: They're pretty cool. I mean, kind of nerding out on the standards of care right now. You know, it's, I just kind of like read it at night before bed. SARAH: On that note, thank you for joining us again for another episode of the Southeast Ohio QI Hub video series. And we hope you have a great day.