Digital Health Device Misconceptions in the Management of Patients With Diabetes
Medicare has expanded coverage of continuous glucose monitors (CGMs) for all beneficiaries with diabetes who use insulin or have a history of hypoglycemia.1
Lisa Jones, MA, RDN, LND, FAND, interviews Rachel Stahl Salzman, MS, RDN, CDN, CDCES, on episode 14 of Nutrition411: The Podcast to help clinicians unravel possible misconceptions about the use of technology in the management of patients with diabetes.
Rachel is a registered dietician and Diabetes Care and Education Specialist in the Division of Endocrinology, Diabetes, and Metabolism at Weill Cornell Medicine in New York City. She is passionate about empowering individuals to make sustainable lifestyle changes and leveraging diabetes technology to improve their health and quality of life.
The following is an excerpt of the transcription from the podcast episode “Smart Solutions for Diabetes Care: Combining Nutrition, Dietitians, and Technology.”
Lisa Jones: There are probably many misconceptions that come up about using technology, especially when we're talking about managing diabetes. And my question is, since there are so many, could you start by just telling me about what is the one that you see the most?
Rachel Stahl Salzman: Well, one that is fresh in my head from this past week in my clinical care was the misconception that using technology is going to be too complicated. For some people, there is, and thinking about my patient this past week, a fear of change. We want to remind patients that the goal of this technology is used to help decrease the burden for them and ultimately help improve our collaboration by having all this data and all this technology to support them. It is important for the dietician as part of that care team to help patients overcome it, and I love doing that by bringing them into the office. It is kind of like a show and tell–showing them all the different options out there.
My goal is to help give them the knowledge and tools so that they could ultimately make the decision and know that we're here to support them in whatever it might be. And this example of this patient was like an eye-opener and a game-changer when she decided to try a CGM, we just placed a sample on her. She tried it for 10 days and she came back to me and said, "I can't believe I waited this long." Those were her words. It is just so powerful for us to be able to provide patients with these things that are going to help them.
I also think it is so important to meet the patient where they are. Technology, there are simpler types of systems to more advanced, and certainly we want to give patients what we feel is the highest level. But we need to remember to meet the patient where they are and what is going to be most helpful for them now in their diabetes journey.
Lisa Jones: Yes, so true. Excellent point. Now, if you had to mention another misconception, I know there are probably many, but which is another one that you would say?
Rachel Stahl Salzman: Yes, great question. I think another common misconception for some patients could be this idea that once they start the technology, it is kind of like a plug-and-play, right? The minute they start it, they are going to be cruising, their numbers will be perfectly in range and they just kind of sit back. We need to remind patients that it is not fully a plug-and-play system. Maybe ask me in 10-to-15 years from now with all the advances we will see, they certainly will get patients closer to that. But we need to remind patients that they are still in control at the most, and these systems help move them towards what I consider cruise control. When we think about driving, we think about how cars can go on cruise control, but we still need to be there to monitor if some variables change and be able to quickly address anything going on.
It is important to teach our patients about the benefits of these technologies. What are the components that are going to be automated and what is part of what they still need to control? A perfect example that I just had with a patient recently who was starting an insulin pump from using multiple daily injections of insulin, I needed to remind her that the insulin could do various things. The pump is going to help them to provide a basal rate and help keep their numbers tight overnight and between meals, it is going to help with these automated systems to correct high glucose values. But she still needs to be in control of putting in for meals, the carbs and control some of that mealtime insulin dosing decisions. While the pump provides a lot of support, she is still in the driver's seat.
Lisa Jones: I would love to hear one story showcasing your work. I know you've already said an example earlier, but is there another one that particularly sticks out for you?
Rachel Stahl Salzman: Okay, yes. I am sure I'll think of some examples here. I would say I think with CGMs and just how it is helped them expand their ability to understand how their food and factors affect their glucose levels. I think of patients, for example, who were told they cannot eat fruit.
They said, "Oh, it is going to raise my blood sugar, I have diabetes." And I feel like as the dietitian, I always like to think of what we can add more of, how we can show them that they can eat foods that they thought for years that they could not eat. And by wearing these technologies, putting this CGM on the patient, we talk about meal planning and they are able to realize, “Oh wow, I could eat this orange, I could eat this banana.”
And we talk about in what portions, what may be combinations of food choices, what time of day, and maybe their activity levels to help them. My goal is to make their favorite foods fit, find ways to help support them, use technology, and give them the confidence that they can use it in an easy way. They do not have to suffer in those ways. So, I feel like in a way, I unlock a lot of that for many patients.
I also think about, for some patients with diabetes, how it can be hard for the family. I think of a patient I have who is blind, and her daughter was leaving work multiple times a day to give the patient her insulin injections. So, thinking about not only for the patient, but how family members and loved ones are supporting patients and how it is hard work. We were able to talk to the patient and her daughter about trying one of these insulin patches, where the daughter could fill the insulin into this patch once every 2 to 3 days, place it on the patient and the daughter can go to work and live her life. And the patient again, who is blind, is able to do the clicks for her meals. That is easing the burden for not only her, but for her family. That was really an amazing way of how technology can help support patients and their caregivers.
Lisa Jones: What is the bottom-line takeaway message for readers?
Rachel Stahl Salzman: I think with all this technology, I think two things, you've asked for one, I'm going to give you two. Stay and be a sponge. Stay open-minded, experiment, and learn about it as much as you can. And the big piece takeaway with all these technologies, we need to remember that we need to address the psychosocial component. Diabetes distress and diabetes burnout are real and effects a high and growing percentage of patients. We need to work with the patient and remember that at the forefront of everything we do. And really be curious. Learn from the patient, find out what their pain points are before we are ready to bring on the technology, and meet them where they are. Maybe it is just having a meeting of talking, seeing how they are doing, not looking at data for one day, and really taking that approach of addressing their psychosocial needs. I do want to make a big plug about the importance of that.
- Glucose monitor – policy article. Centers for Medicare & Medicaid Services. October 01, 2015. Updated April 16, 2023. Accessed June 28, 2023. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52464&ver=49&contractorName=all&sortBy=updated&bc=13