November 12, 2020
Adults with certain underlying and chronic medical conditions are at increased risk for severe illness from COVID-19, according to the U.S. Centers for Disease Control and Prevention. Diabetes is one of them.
Angela Hammond is a nurse practitioner and certified diabetes educator at University Medical Center, and quality coordinator of UMC’s Diabetes Self-Management Education and Support program for patients and members of the community.
She recently spoke with UMC Chief Medical Officer Dr. Tom Weida about the impact COVID-19 can have on people with diabetes, and why it is important for diabetics to increase their knowledge of the disease by participating in a diabetes education program.
TW: Tell us about your background.
AH: I’m a nurse practitioner at University Medical Center, where I’ve been for 14 years. I’ve been a nurse practitioner a total of 26 years.
TW: What is a nurse practitioner?
AH: A nurse practitioner is a registered nurse who has had advanced training, usually two years and at least a master’s degree and sometimes a doctoral degree, as well as advanced clinical management skills in disease processes and prevention.
TW: Has COVID-19 changed how you practice?
AH: Absolutely. It’s probably changed for the majority of health-care practitioners. My role has changed from being an urgent and primary health care provider to mostly providing COVID testing services for the University and the community here in West Alabama.
TW: Your other role is as a diabetes educator. Tell us about that.
AH: Diabetes Self-management Education and Support is a program we started in 2010 at University Medical Center. It’s an educational program for our patients who are trying to manage and control their diabetes. Prior to COVID, we had group classes and also some one-on-one classes with individual patients. Now, it’s more one-on-one via telemedicine, and we have an online program that’s just beginning. We’ve got a team of professionals at UMC and they are part of the program. Kim McMillan is a licensed practical nurse and our diabetic case manager. She’s been with us from the beginning of the DSMES program, along with Dr. Dana Carroll, who’s a pharmacist, and Dr. Mark Richardson, a kinesiologist and who specializes in exercise science and the effect exercise has on a person’s body. We also have on board an outstanding nutritionist, Suzanne Henson, as well as Dr. Bob McKinney, who’s the director of UMC’s social services program.
TW: How do you, as quality coordinator, fit into this multi-disciplinary team?
AH: As quality coordinator, I am in charge of content and following the guidelines of the American Diabetes Association, where we maintain our certification. That involves looking at all the information that’s in our program booklets every year and making sure the information is updated and the guidelines are covered.
TW: Let’s start from the beginning. What is diabetes?
AH: Diabetes is a disease related to the glucose in your body. Everybody has to have glucose in their cells for energy for their bodies. People who suffer with diabetes have a problem with the utilization of that glucose. People who have Type 1 diabetes don’t have insulin. Insulin is a hormone in the body that opens a gate that allows glucose to go into cells. In Type 2 diabetes, which is the most prevalent type of diabetes in the country, 90-95% of diabetics are Type 2, the body becomes resistant to the insulin you have; it’s not utilizing it like it could.
TW: And glucose is a type of sugar?
AH: It’s a type of sugar. Whenever you eat, your body breaks down the food and turns part of it into glucose, which is, of course, the energy source.
TW: So, how do I know if I have diabetes?
AH: If you go to your doctor, or other health-care provider, and have a yearly physical they’re probably going to do some lab work, and you may show an elevated glucose level. You may experience some symptoms outside of that. If you’re thirsty all the time, if you urinate more than usual, if you have blurry vision, if you have numbing and tingling in your hands and feet. All those things can be signs and symptoms of diabetes.
TW: How is a diabetes diagnosis made?
AH: If you have a random glucose that’s over 200 that could mean that you’re a diabetic. If you have a fasting glucose that’s over 125 that could mean that you’re a diabetic. If you have a hemoglobin A1C, which is a three-month average of your glucose, that’s over 6.7, you may be a diabetic. There are different ways to find out.
TW: Why is it important to know if you have diabetes?
AH: Diabetes is a chronic disease that can cause problems with your entire body. There’s not one body system that diabetes does not affect. Long-term complications are one reason you want to find out about it so it can be treated and managed.
TW: How do you control diabetes?
AH: We usually start with lifestyle. If you’re overweight, one of the first things we want you to do is maybe try to lose a little weight. We want to try to get you to eat more healthy foods, less processed foods, and watch your calorie content. And we want you to get some exercise every day. If that’s not taking care of the problem, we might add medications. As people progress in the disease, they may need insulin.
TW: We also hear that diabetes is a co-morbidity. What does that mean?
AH: We’ve heard a lot about that with COVID-19. Since diabetes triggers inflammatory changes in the body, someone who’s a diabetic, particularly if they’re poorly managed, is susceptible to inflammatory problems. If you’re properly managed, then the inflammatory changes are lessened. There’s a co-morbidity because of that.
TW: Are there other organs that are affected by diabetes?
AH: Yes, from your head to your feet. It’s one of the leading causes of blindness. People with diabetes are more likely to have hearing problems as they grow older, more likely to have gum disease and lose teeth. They can have problems with their lungs similar to people who have chronic obstructive pulmonary disease (COPD), problems with their gastrointestinal tract, sexual disfunctions, problems with skin healing, problem with neuropathies, with numbness and tingling. But the biggest one is cardiovascular disease. That’s probably the No. 1 killer of people who have diabetes and it’s because of those inflammatory changes in the vessels that are connected and run throughout your body to supply nutrients and oxygen.
TW: And cardiovascular is heart, brain and lungs?
AH: Yes. There’s increased risk of cardiovascular problems and strokes. So, managing your glucose, your blood pressure and your cholesterol are very important when you’re a diabetic.
TW: Are there co-morbidities for COVID-19?
AH: I think one that’s been talked about most is obesity. People who are obese, who are overweight, tend to have more problems. People who have blood pressure problems or cardiovascular problems also tend to have problems with COVID.
TW: How are obesity and diabetes connected?
AH: People who are obese, who are overweight, are more at risk for developing diabetes.
TW: Does COVID-19 affect diabetes?
AH: When your body is stressed from illness or disease, it can cause your glucose levels to go up. If you’re already poorly managed and then develop COVID, you see an increase of stress on your body from both of these.
TW: We’ve heard about medications for treatment for COVID. Does that have an effect on diabetes?
AH: As a matter of fact, steroids absolutely do. Steroid use, if you’re a diabetic, tends to increase glucose levels.
TW: Do glucose levels stay the same in your body all day, or is there variability?
AH: There’s variability. Glucose levels tend to go up within two hours after you eat a meal, particularly if you have a meal that’s higher in carbohydrates or simple sugars. During the night, levels tend to go down when your body is resting and relaxing. Your body also stores glucose in your liver and in the mornings your glucose levels tend to go up because that’s a way of your body waking itself up and giving it an energy source.
TW: If people with diabetes get sick, should they continue to take their diabetes medication?
AH: Whenever your body is sick or stressed, that tends to make glucose levels go up. So, if you take that into context, if you didn’t take your medicine, you’ve just increased your glucose levels again. The best thing to do is to take your medicines as usual and also be prepared for sick days and keep yourself hydrated. You may want to call your health-care provider as well if you’re having trouble keeping liquids down.
TW: University Medical Center offers for its patients a Diabetes Self-Management Education and Support program. Why is an educational program important?
AH: As health-care professionals, we have a lot of knowledge in our heads and sometimes we forget that people, our patients, don’t have that same knowledge. In order to make good decisions about your health care, the more knowledge you have about your diabetes, then you have the tools in your toolbox to make good decisions.
TW: What kind of changes have you had to make in regard to diabetes education during COVID-19?
AH: Our group classes are not happening. You don’t want to have groups of people together in a closed room. So, we’re having more one-on-one sessions using telemedicine technology. We’ve also started an online education program. It’s self-learning and it has some interactive programs at the end of each section.
TW: And you don’t have to be a University Medical Center patient to take advantage of that program?
AH: Absolutely not. We would love for people across West Alabama to utilize the program and become more knowledgeable about diabetes.
TW: And you had a big hand in developing the program.
AH: I did. We started back in 2010 and we utilized a lot of information from the Robert Wood Johnson Diabetes Initiative that started back in 2002. It’s a wonderful resource. And then our team of experts helped in updating that information. We go through and make sure that the guidelines, medications and resources are up to date.
TW: How does the online program work?
AH: It’s divided into about 10 sections. At the end of each section, there are questions, and it will tell you whether or not you got the questions correct. If you didn’t, it will tell you why you didn’t and then refer you back to the resource to where you can find the correct answer.
TW: What’s an example of one of those questions?
AH: What is a carbohydrate, and it would show a list of foods to choose from.
TW: Is the program only for adults, or can children use it?
AH: It’s targeted for adults. Adolescents, I think, would have no trouble utilizing it. If you are 10 or 12 years old, it would probably be OK, but if you’re younger probably not.
TW: Do you envision the online program continuing even after COVID-19?
AH: Absolutely. This resource was something we dreamed about having for quite some time – an online resource that even when people weren’t in the classroom they could access and learn from.
TW: Is it important to continue diabetes education with COVID-19, or should we just all concentrate on COVID?
AH: COVID of course is at the forefront. It’s what you see and hear about all day long. But we shouldn’t forget about our other health-care needs. We shouldn’t forget our blood pressure, our diabetes, our COPD, any kind of arthritic problems that you might have. Don’t forget about those and take care of your whole body. Make sure you’re taking your medications and getting your refills. If you do have questions, we’re (UMC) here. We have multiple providers – doctors and nurses who can help you with issue you may have. Don’t forget about those in lieu of COVID. COVID is important, but all the other things are, too.
TW: What other preventive health care would you recommend?
AH: Right now, flu vaccines. If you have other co-morbid conditions, you may think about asking your doctor or health-care provider about a pneumonia vaccine and shingles vaccine. Have your colonoscopies and mammograms. Doctors’ offices and clinics have safety protocols in place to make those kinds of screenings very safe.
TW: Could people get the flu and COVID?
AH: You could. Some of the same symptoms with the flu are some of the same symptoms you would have with COVID. Cough, shortness of breath, fever, those sorts of things. If you can prevent the flu, you would be at less risk for developing both.
TW: Can you get the flu from a flu shot?
AH: You can’t get the flu from the flu vaccine. It’s an inactivated vaccine. It’s perfectly safe, and most people have no problems other than having a sore arm, or they may run a low fever for a day or two.
TW: This year, for people over age 65, there is a quadrivalent flu vaccine available (protects against four flu strands instead of three). Do you see that as an improvement?
AH: Yes, and people over the age of 65 are also getting the high dose quadrivalent vaccine. People who are older don’t have quite as much immune response to vaccines as younger people do, so the higher dose helps them have a bigger reaction to the vaccine, a better response. The quadrivalent that you get if you’re younger than age 65 is of course an improvement over the trivalent.
TW: Would you want to use the high dose quadrivalent for diabetics?
AH: It’s really for people who are age 65 and older. I haven’t seen that it’s indicated for people younger than 65.
TW: When is the best time to get a flu shot?
AH: You can get a flu shot any time. I would encourage you to try and get it sometime before the end of October.
TW: Why is that?
AH: Flu season generally runs here from December through March, and we usually see the biggest numbers in January and February. It takes about two weeks for your flu vaccine to activate, so that’s why we want people to have it early in the fall.
TW: Anything else you want people to know about diabetes and diabetes education?
AH: If you’re a diabetic, or have someone in your family who’s diabetic, and have not been to diabetes education classes, I would strongly encourage you to seek a resource for that. We have our program available at University Medical Center, and there’s also programs at DCH Regional Medical Center and Whatley Health Services.
