The Dialogues – Episode 2

For the second episode of our series, we have invited Jane Overland. Jane is a Credentialed Diabetes Educator, Clinical Associate Professor, Nurse Practitioner, and ex-Board Member of JDRF who now runs a private diabetes clinic in Sydney called Total Diabetes Care. Jane has over 30 years experience helping people with Type 1 Diabetes improve their health and live a full life.

Watch the entire video:

Why diabetes?

Passion! I really like getting to know people as people. You can really make a difference in someone’s life and it is really rewarding in getting to know people and their families. Even though my father is a T1D, I do not think that this was necessarily the reason.

How is diabetes in the health sector space compared with other diseases?

It is not sexy having T1D. There is a misconception that if you have diabetes you have done something to give it to yourself, and it is like “suck it up, princess”. Also, this misconception that if you take a tablet and insulin you will be ok, and if your glucose level is not perfect, then what are you doing wrong? But that is not the case. It is a very intriguing condition, and many factors can affect your blood sugar.

So are diabetes care professionals viewed really well by other care professionals? Not necessarily. But are we amazing? Absolutely! The advances that have been made in diabetes management in the 30 years I have been working are unbelievable. I mean, to check your blood sugar level 30 years ago it took you about 5 minutes. You had to put your meter, because it was a brand-new invention and you had to calibrate it before every glucose check. And then there was this timing issue and then you had to press the button at the right time to start the machine. It was pretty complicated.

Yes! In 30 years we went from measuring our blood glucose from urine to measuring it with our mobile phones.

Exactly! It is mind-blowing. And some people when they go with CGMs they say that they are worried about the accuracy of the system. But when you measure it and it is 6.7 coming down screaming, or going up, your approach to your management is totally different. So you get all this information which might at times be overwhelming, but if you learn to use it, it can be an absolute game-changer. 

I might rightly or wrongly look at some 95 years olds who have diabetes since they are young and I will go “Well, I am exponentially better at what means management, therefore I can be more relaxed. If that person reached that age treating and managing diabetes with the technology from 40-50 years ago, then I have to be ok. 

I have seen a number of people who have lived with diabetes for 50-60 years, and there is something common with those people, they have been incredibly regimented. I saw a lady the other day, and she is on the same treatment she has been prescribed 60 years ago and I was trying to get her to have a piece of chocolate at the end of the day, but she found it really difficult because she has been indoctrinated. But what we are having now is allowing you to have a life. You still need to take care when you are exercising, because different exercises have a different impact on you. For example, a high-intensity workout is gonna set up your blood glucose initially, but you can do all these things. You just need to have a strategy around it. 

The average age of death for a male might be what, late 70’s or something, and for women almost mid 80. For diabetes is a little bit lower?

When you look at those numbers you have to remember that those people were diagnosed 50-60 years ago. I will give you a story of one of my favourite patients who I first met 26 years ago, and he emigrated to Australia and at that time we were discussing that he would have to get on dialysis in 4-5 years. That was 26 years ago and he is going strong. His kidneys are going strong. He recently went on wearing a CGM and his glucose level is amazing. So I think that with the new technology and advice from the health care professional you are on top of what your cholesterol and blood pressure are. Do not smoke, that is just stupid. Drink on special occasions. Do not become overweight – all the things all people without diabetes should think about as well. 

He did something to improve his kidneys? 

Good question! We were talking about the development of technology. Well, around 20 years ago there were some medications good for the blood pressure and protection with the kidneys, and they really are protective with it! That is why it is recommended to check these things, because if we see some signs of early damage, there are things we can do to stop it progressing. 

So what did Andrew do?

Well, we put him under those pills and started to control his glucose. The reason why he decided to go with the pump this year is that he had a little bit of a decline in his kidney function. But that was because he started to take some anti-inflammatory tablets.   

Is dialysis right and how much of a reality is for diabetics? 

It is difficult as a young adult to think that the decisions you make today will impact you 20-30 years later. If you are diagnosed with diabetes, the first 5-10 years are the most important. Try to keep your glucose levels close to as normal as possible – let’s say around 6.5 – 7. That will set a very good solid foundation which will protect you for many years to come. Once you have diabetes for 10 years it is going to be harder. But your base should protect you from needing dialysis. That being said, because you have diabetes it does not mean that your kidneys will not fall in some other sort of way. Dialysis is harder and time-consuming, but it is life saving. If you need it, you need it. 

Let’s jump into CGM. I wear a Freestyle Libre for 3 years, and that was one of the reasons I started designing a patch – to support the Libre cause it was coming off when I was swimming. I am curious about other CGMs as well, and about the perspective of someone in your position. I know about 3 of them – Dexcom, Freestyle Libre, and Medtronic. I am sure there are others as well. What do you think about them?

In Australia, there are 3 models of CGMs – the Libre, the Guardian system which is Medtronic, and we got the Dexcom, which is a real-time glucose monitoring. However, both Libre and Medtronic are a continuous glucose monitor which means that there is enough power in the transmitter to send immediately those readings across to a phone. And because it is real-time we can set limits on the receiver. All the systems use a filament which is inserted underneath the skin, and the transmitter attached to the sensor. It is an electron reading converted into a glucose reading which is done every 5 minutes. Now, there is a bit of a lag time between the blood glucose and tissue glucose (the sensor is inserted in the tissue), and that lag time depends on whether you had something to eat or you exercised. If you haven’t been eating or moving a lot then there will be very little difference between the 2 results. But if you just had something to eat the blood will go up and then down. Clinically, it does not mean anything. 

A lot of people with T1D have a drop in the glucose at night, they sleep through it and wake up the next morning. And the only way you can pick that up is by doing some form of glucose continuous monitoring. The system is excellent at checking what was going on at night, so you can make decisions about long term actions. 

There are some food that can help you. For example, 3 types of breed. They have the same amount of carbohydrates, so they make the same amount of insulin, but one gets digested much faster, so the glucose shoots up quite quickly after a meal, where the other one does not do so. It is different from people to people. For some the white bread really has minimum impact within the first hour of eating. It is a very individual thing. There have been some studies in Israel, and the Glycaemic index which was tested over 1000 people went to being highly variable. That is why you have to personalize things. So, you could say what happens only when YOU have that type of food. And if that food is sending your glucose high really quickly it might be that time lag we have discussed. So perhaps measure your glucose 10-15 minutes earlier.

My reaction to the same type of food varies based on so many things anyway. So the system is good that it can help you see how well you are controlling those variables, you get the real-life picture very quickly.  

Yes, so only what you can do is to observe what is happening on the average. So Libre is very good to do that sort of stuff.

If you are unable to recognize your lows until you are really low. I have met people who were almost 2.2. At 2.2 you are not very far to fall into a coma. So without a CGM you are not getting that warning until you are at that critical point. Therefore, you need some other ways knowing you are approaching that point. So that is when systems like Dexcom are more useful. If someone has a history of continuous hypoglycemia, I will always recommend they do real-time glucose monitoring rather than flash glucose monitoring.

It is interesting if we look at some sort of market share for the three, I think Libre has the biggest market share. Is that because it is cheaper? Or why is it selling more?

I actually do not know what the market share is in Australia, but I think there is some appeal that it has been sold that you do not need to do finger pricks – which is not 100% true. Another appeal is that with the Libre you know the cost of the sensor and you can just order it immediately if you want to. You cannot do the same thing with the Guardian and Dexcom. The cheapest way of getting a Guardian is to have a subscription. I honestly think that the reason that Libre is doing better is that it is very good at marketing. I do not necessarily think it is a better system than the others because in some cases the others are better than Libre. I do find that for probably 60% of the people Libre is very accurate, but for 20% it overestimates and for the rest of 20% it underestimates. But as long as people are aware of that it is alright.

To decide what CGM to use it is not as simple as that. A couple of years ago I would have said I want a pump, that I would give my son one, and my daughter one. But there are features more appealing to me, others more appealing to my son and others to my daughter. And those features are not the same for all the 3 of us. 

In Australia, we have such regulations that oversee anything that comes into Australia. Any medical device that gets to get in the country has to fulfill very specific guidelines, otherwise, you cannot sell it. 

It is that why the G6 is taking so long to get to Australia?

In order for a new system to come to Australia, it has to have both approval of America, and Europe. 

I wast talking with someone yesterday about the G6, and they said that they would be happy to have it, but it will have a delay because the current G6 in Australia doesn’t have the alert system. Is that alright?

We got the G6 system in Australia, and we can use it with the G6 app on your phone. But if you are going to use it with a pump, and the pump that uses Dexcom in Australia is the t:slim. So, the G6 has got approval, the t:slim has got approval, but the new algorithm called “controlled IQ” does not. We have been at the IDD conference in Madrid, and they were saying it to be released in early August, so I think it is almost here. 

I have always been interested in Governments and health. I look at these things and how they reimburse it. I am biased, so I say Governments need to do this because it is gonna actually save them money in the long run. Because it is going to help you manage your diabetes, and it is a massive burden on the health system and so on. Obviously, Governments have a little money to spend, so they have to be cautious. We are seeing it rolled out in countries, with NHS, Australia – are reimbursing for certain categories. I am just curious about your general perspective. For example, I am not getting my CGM for free now. Will I be getting it for free?

I have recently been on a writing group with the Australian Diabetes Society and other professionals. The way the ADS sees it is that in Australia anyone with T1D should have access to it, at least subsidized CGM. But I think that nothing is certain in this world, and the Government’s budgets are under a lot of strength. But if anyone has their health benefits card you can get access to the ANDSS funds and get a CGM. But for everybody who is one dollar over to have a health beneficial card.. I do not know what it would be. 

Here is one last question – when are you talking with patients about compliance, what is the general advice on that?

Do you mean compliance as in how long the sensor is going to stay stuck on? I know people whose sensors did not want to come off and others who would have sneezed and it would easily come off. And for those people, Not Just a Patch is just a God sent. I would have thought that about a third of people have issues with their sensor’s lasting. It is about where you are putting it, so have a chat-chit with your health care professional, and use something like Not Just a Patch – they are fabulous. Lots of people are very happy with your product. 

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