Managing Diabetes & COVID-19 in the Wintertime

Dr. Wysham:
Wintertime can present some difficult challenges for our patients with chronic disease, such as diabetes. And now, you factor in the COVID-19 pandemic – we can see that the challenges are even compounded. So what steps can we help our patients take to keep them safe and healthy all winter long? Welcome to Diabetes Discourse on ReachMD. I’m Carol Wysham, and I’m joined in this discussion with two of my fellow hosts for this series, Dr. John Buse, and Dr. John Anderson. Dr. Buse, would you like to introduce yourself?

Dr. Buse:
Yes. John Buse, I’m a Professor of Medicine at the University of North Carolina.

Dr. Wysham:
Thanks John. And Dr. Anderson, would you like to tell our audience a little bit about yourself?

Dr. Anderson:
Yes, my name’s John Anderson. I practice internal medicine and diabetes at a large, multi-specialty clinic called the Frist Clinic in Nashville, Tennessee.

Dr. Wysham:
Well, that’s great, and thank you both. So now, let’s just dive right into our discussion. So, John Buse, would you like to start and just tell us a little bit about what you tell your patients in general about the winter, and then specifically, what are you covering as it relates to the COVID-19?

Dr. Buse:
Yeah, with regards to winter, I tell people that we’ve done these analyses of huge laboratory data sets. And what they show is nationally that A1C tends to rise over the early winter and peaks in about April or so, and then falls during the rest of the year, and there’s a nadir around September or October. So, this is a cycle that happens across the country, and why does it happen? Largely because, in the summer months, and the spring, the weather’s nice and people are more active outside, and in the winter months, there’s fewer vegetables, and as a result, people are tending to eat more carbohydrates. And we can fight this both by ensuring that people try and stay active during the winter months. And being careful with their carb intake. Those are the major messages. With regards to COVID-19, what I’m telling people is most important, is the standard stuff: wear a mask, wash your hands, stay out of crowds, practice social distancing. But also, I think it’s very important that people understand that if they are ill, it is absolutely essential that they seek medical care. I personally believe that there are more people getting into trouble with the standard complications of diabetes and other medical problems, deferring getting medical care because of fear of engaging the health care system. So those are the most important COVID messages from me.

Dr. Wysham:
And John, how do you handle your patients during the winter, in terms of helping them stay safe? Do you have any tips or things that you do on a regular basis, and of course, still interested in your recommendations regarding COVID as well.

Dr. Anderson:
Well, Carol, much like John Buse just said, we have to get our patients prepared ahead of time. We need to be having these discussions now. This is going to be the silly season. You’re going to have Thanksgiving. You’re gonna have Christmas and other holidays. You have New Year’s, Superbowl. People are going to be inside. It gets dark in Nashville, Tennessee at 4:30 in the afternoon. So patients are going to have pressure to eat at holidays. They’re gonna want to overeat if they’re under stress. Their routine exercises, the ability to work outside, mow the yard, play tennis, play golf, a lot of those are going to be off limits during the cold winter months. And as John had pointed out, even things like gyms and rec centers may not be open, or the patients may be afraid of going to those because of this pandemic. As far as COVID-19 is concerned, during the first part of this, I mean, there was a great stress relief to going to play golf on golf courses that were open, and playing tennis, and people going fishing and people going to parks and walking and hiking. That may not be available now, so I also worry about the mental health and the stress of people being kept up inside during the winter. And they need to have a way to cope with that as well.

Dr. Wysham:
Thank you. Well, I’m sure it goes without saying that all of the things that you’re talking about is important. I tell my patients that diabetes is not a seasonal disorder, that you have be planning how you’re gonna work diet and exercise all year round. But we’re also, importantly, need to emphasize our routine health care, making sure they’re getting their appropriate immunizations. And I’m specifically talking to each of my patients as they come in, about what their perception of the vaccine is, and making sure that we address any of their concerns about the safety of the vaccine as well.

Dr. Buse:
Well I do think one of the end of the year opportunities, that many people have met their deductibles for the year, and if they’re thinking about upgrading their care, you know, perhaps getting a CGM, or they were thinking about pump therapy, this is a great time of year to pull the trigger on that. The second thing is, I was just gonna point out that the Medicare rules around the donut hole changed, and, people just need to prepare for that, as well.

Dr. Wysham:
For those of you just turning in, you’re listening to Diabetes Discourse on ReachMD. I’m Dr. Carol Wysham, and today I’m speaking with my two fellow hosts, Dr. John Buse and Dr. John Anderson, about essential wintertime safety and health tips for our patients with diabetes. Well thank you for your ideas about helping counsel your patients about trying to avoid that A1C creep in the wintertime, but we have an additional challenge right now, in terms of making sure that our patients are getting appropriate care during the COVID-19 pandemic. So, John Buse, would you like to just outline how you are working with your patients when everything is locked down, and how are you monitoring your patients?

Dr. Buse:
So right now in North Carolina, things are still pretty open. I’d say that 75% of our patients are coming in for face-to-face visits. We’ve also taken advantage of the liberalization around the rules around virtual care. And we have a pretty big group of patients that are doing more frequent visits than they normally did because the barriers to coming, or making contact with their doctors are reduced. And particularly those patients on CGM and insulin pumps, if they’re not under control, we’ll talk to them every couple to four weeks to see where they are.

Dr. Wysham:
Is that true that Medicare has loosened some of the guidelines for CGM? Have you found it easier to get CGM for some of your patients who, for instance, may not be testing four times a day or even taking insulin three times a day?

Dr. Buse:
In North Carolina, unfortunately, that’s not true. You know, it’s interesting Medicare is a federal program but, the rules are applied state-by-state. And to my knowledge, it hasn’t changed in North Carolina. One thing that is different with Medicare is the rules for next year with regards to the donut hole. And I don’t know the numbers precisely, but I think what people should expect is that they will pay 25% of the cost of the prescription in the beginning. When their out-of-pocket cost gets to about $4,000, it’s more of a flat rate, and around $6,000 is the so-called catastrophic coverage. So, people should just be aware of what the new rules are for Medicare paying for drug benefits.

Dr. Wysham:
Oh, interesting. So, John Anderson, tell me a little bit about your experiences and how you’re monitoring your patients and managing them. I don’t know what Nashville is like. We’re closed down. We’re like almost totally locked down again. And so we’re doing almost all of our visits virtually. What’s going on in Nashville?

Dr. Anderson:
Unlike Washington, we’re pretty open here in Tennessee and in Nashville. I think we’re probably at 85% capacity. Now, bars and restaurants – things like that – they’re at 50% capacity, or two-thirds capacity. But as far as physician offices, almost everybody is seeing people in person. Now, I probably do one telehealth visit a day. I probably was doing ten telehealth visits a day back in the middle of this. One of the things that is a challenge, and you pointed it out earlier, is making sure our patients feel safe enough to come to the office. I will pass going to the exam room, and hearing my nurse on the phone, reassuring them that we have a waiting room that is doing this, reassuring that we have temperature checks, reassuring them that we’re not letting fever and cough into the office without a COVID test first. I mean, just last week, I had a patient who had her last visit. A1C was okay, but her renal function had markedly and drastically worsened. She was off of her statin, with an LDL cholesterol over 220, clearly out of control, and it was that type of patient where that’s not appropriate for telehealth. I need to see them. I need to measure renal function. I need to get a urine. I mean, we have to be able to make sure that these patients are not neglecting care when it’s absolutely needed.

Dr. Wysham:
Well, and if nothing else, the counseling that we can provide them to help keep them safe and healthy is really important. Well, any other comments that you guys wanna make about what you do with your diabetes patients during the wintertime and helping to keep them healthy?

Dr. Buse:
You know, I think a most important thing in these COVID times is to keep people upbeat, and so I make an extra special point of wishing them a Happy Thanksgiving and telling them to be careful with, you know, how many people they bring to their table. And to, you know, enjoy the holidays, and to remind them that the vaccine trials look amazing. Much better than we expected. And that if they can stay safe for a few more months, the vaccine seems like a great opportunity to end the suffering that we’ve had over the last year.

Dr. Wysham:
I agree with that. John Anderson, any final points on your recommendations for your patients?

Dr. Anderson:
I think John makes a great point. Try to stay upbeat. Give ‘em positive energy. Give them positive things they can be doing for diet and exercise. But I’m also having that same conversation in sort of a questioning way. You know, like, “Okay, what are you doing for Thanksgiving? Whose house are you going to? How many people are going to be there?” And if this is a relatively young, healthy patient, it’s one thing, but if this is a fragile 82-year-old, who, you know, is at significant risk, in sort of a non-judgmental way, just say, “Have you thought about this?” And to John’s point, we do have, perhaps, a vaccine around the corner, and some of these people may be on the front line of getting it. But, you know, not to dispel Thanksgiving, not to dispel other holidays, but to just show a little bit of caution as you think about how you interact with large groups.

Dr. Wysham:
And I just can’t reiterate enough the exciting news for the vaccine and taking time to talk to my patients about my perceptions of the safety, and the importance of being willing to take the vaccine. I think that’s gonna be important. Well, that’s about all the time we have for today. I really wanna thank my two fellow hosts for joining me to discuss how we can keep our diabetics safe and healthy throughout the winter season. Dr. Buse, Dr. Anderson, it was great speaking with you today.

Dr. Anderson:
Thank you, Carol.

Dr. Buse:
Thank you, it was a pleasure.

Dr. Wysham:
I’m Dr. Carol Wysham. To access this episode, and others in our series, visit ReachMD.com/diabetes discourse, where you can Be Part of the Knowledge. Thanks for listening.