Shireen: Dr. Nicole Ehrhardt talks to us about her new research in which she studies, how a culturally tailored diabetes education program combined with realtime glucose monitoring can help Latinex populations with type two diabetes.

Podcasting from Dallas, Texas, I am Shireen and this is the Yumlish podcast. Yumlish Is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week.

Dr. Nicole Ehrhardt is an adult endocrinologist with 15 years of working with patients living with diabetes, with the focus on whole person body health, and also empowering patients living with diabetes. Welcome Dr. Ehrhardt.

Dr. Ehrhardt: Thank you so much.

Shireen:  An absolute pleasure having you on. So Dr. Ehrhardt, can you talk to us about how you found an interest in diabetes research in treatment?

Dr. Ehrhardt:  Yeah. So I think people are sort of surprised because what I tell people first, I was actually an old army doctor or a military physician and an endocrinologist. And, you know, in that work, I got to work with a lot of many people from diverse backgrounds. And, you know, we, even in that population, there was people living with diabetes and I saw the impact on them.

And, you know, in this population, Really had healthcare access for all. So then when I left the military, I joined the George Washington University in the Washington DC area, and I really wanted to focus on underserved communities and empowering patients living with diabetes there. I think what I tell people, what, why I wanted to be a diabetologist is that it's one of those diseases that you actually have to know the person to, treat the disease and partner with them, for them to live well with the disease. So you have to know about their daily life, their stresses, their activity, their typical foods to really best treat them living with diabetes. And I think that's why we go into medicine. Right? We want to have relationships with our patients. I'm very lucky I get to do that. 

Shireen:  That Is so interesting. Your journey sort of coming you know, coming from the army and coming into this specific work. You recently received a grant for a new research project, a culturally tailored diabetes education program, combined with real time glucose monitoring. Who is the focus of this study?

Dr. Ehrhardt:   Yeah, we're really lucky. We are going to be working with the Latinx population and we're focusing on the greater Washington region. We're partnering with Sea Mar healthcare centers, which is a federally funded healthcare system that works a lot with a Latinx population. So we're taking UW experience.

So the university of Washington and our community health providers, educators, experience, and we're hoping to really work with this population and see some great things.

Shireen:  That's lovely. And why did you choose this group in particular?

Dr. Ehrhardt:  So in general, what do we know? We know we have a lot of tools available for diabetes management, including newer medications, our newer technology, like continuous glucose monitoring.

But we also know that in general we're not really moving that dial for people who have uncontrolled diabetes. It actually hasn't decreased over time and more, not more people are getting to our goal for our diabetes management. And we're especially seeing that in our populations, like the Latinx population.

Now there's no registry for type two diabetes, but using our patients living with type one diabetes, they have a registry and they have access in general to this populate, to the continuous glucose monitoring technology. It is typically covered by their insurance. But what we see in this registry is primarily the patients who have access to this medication are Caucasian and have commercial insurance. So really, what we want to do is target a population that needs additional support and then show the benefit of it. So then we make it more accessible to type two patients living with diabetes and then diverse populations. 

Shireen:  Absolutely love that. And there's, there's so much intersection with even what we do at Yumlish. This specifically, looking at Latino communities and being able to provide a program that is culturally tailored to them. So I want to dive a little bit more into that cultural competence piece, right? So in what ways will your diabetes education and self-management curriculum program really cater to the cultural context of the Latinx people?

Dr. Ehrhardt:  Yeah, that's a great question. So, you know, my focus has been on continuous glucose monitoring, but I'm partnered with a great co-investigator. Her name is Dr. Sinclair. She's actually Western Cherokee and she has made a lifetime of research working with diverse populations and diabetes education curriculum, and sort of the pieces of her curriculum is sort of storytelling.

So she sort of sells a story. Throughout the educational curriculum that tends to talk to the different cultures and they adapt it based on the culture or ethnicity they're working with. And then as well, it's done very much in layman's term. And so that it's accessible to people across all education levels.

And then, you know, really the idea behind it is it empowers them to partner with their primary care provider. and know how to ask questions so they can engage in their health. 

Shireen:  I really find that approach fascinating. Can you expand a little bit more on the storytelling piece and how that works? 

Dr. Ehrhardt:  Yeah. So it's really interesting.

Again, you should probably have Dr. Sinclair on to talk about it in detail, but I believe how it started is there was a symbol, right? So there was a symbol of like an Eagle and one of her storytellings and then, it went across the story and it follows the story of like a child who's asking about diabetes and the grandfather living with diabetes.

But, and particularly, I guess for the Latinx culture, they actually chose a cactus to be their symbol. And because it's like stem fast. And I just learned about this as well. So I'm learning more about it, but again, what she's done is that of taking feedback from the community members and adapted it based on what, they feel like will resonate with the community, but you know, the underlying diabetes education is simple and straightforward and sort of, you know, standardized, but then the way it's presented as unique to the different cultures.

Shireen:  That is very interesting. You mentioned a little bit ago, the glucose monitoring. What is real time glucose monitoring? Cause we're, we're very familiar with the ones where we have to prick ourselves every day, but what is the real time glucose monitoring? How will using this technology really serve the study. 

Dr. Ehrhardt:  So basically what it is, it's a device that sits on top of the skin, and then there's a little filament that sits under the skin and it will actually record your glucose every one to five minutes based on the device you're using.

And then that information actually can be. Wirelessly to either your smartphone, which is great because everyone has their smartphone these days, or if you don't have that, a receiver, and then you can view that information. So you can view the glucose or sugar in real time. And what's important about this technology,

it's just not a static number. It has an arrow. So it says it shows directionality so you can know what the prediction of glucose is going to be over the next 30 to 60 minutes, and this helps patients make the right decisions, also gives them feedback on what they just did from a nutritional standpoint.

Or perhaps if they're high, they might say, oh, I'm high and I'm not coming down, I should go take a walk. So our hope is, is that coupled with the diabetes education sort of reinforces, both positively and negatively those things they should do for their diabetes management so that they can optimize their diabetes control.

Shireen:  That is interesting. And do you have any examples of that, that you can share?

Dr. Ehrhardt:  Yeah. So that's a great question. I think, you know, the problem is, is that when we're looking at the research on continuous glucose monitoring, there's a lot of data on, improving A1C, which is a marker of our glycaemic control and reducing risk of hypoglycemia, but my interest, and I think what the clinicians and the community's interests are, how does it affect behavior?

And we have some small amount of research that look at how it works as a behavior modification tool and enhances and encourages people to make healthy lifestyle changes. But, you know, that's what we really hypothesized that it does do this. And that's what we see in our clinics. So I'm going to give an example.

I was working with a primary care clinic and they presented a case of a Mexican construction worker. His glycaemic control or average sugar control was in the two hundreds plus, which is very high for the diabetes and he was on several medications for it, but we were able to get him the device.

So he was able to wear the continuous glucose monitor. With no change in his medications, his average sugars went down in the one fifties, one sixties, which is close to his glycaemic goal of an A1C of seven. And I think what it was is that he was on a long acting insulin. And, you know, as a construction worker, he's very physically active.

So he's probably nervous about low blood sugars. And so he was able to see what his blood sugars were doing in real time at his job, and then feel comfortable. Taking the medications, his primary care physician also felt like it was good feedback from a nutrition standpoint. And he made some really smart small changes in his healthy eating based on what he saw.

And you can still see the benefit, no escalation of medication, but significant change in his blood sugar. So, and we, we see these things pretty powerfully. You know, most days of the week in our clinic.

Shireen:  That is interesting. Can you, can you speak to the adoption of some of this technology, right? Like downloading an app on the phone to be able to track things like that. How do you see tech literacy playing into this.

Dr. Ehrhardt:  Yeah. I mean, I think the benefit is, is we've been living in the pandemic, right? And so we are moving a lot of our health to tell a health and what I found,

and again, this is going to be what we're looking at in the study, and it may be a barrier. But we are going to be giving our educational curriculum via zoom. So through telemedicine. And the idea is, is that hopefully people have a smartphone, so they won't have to use a separate receiver for their continuous glucose monitoring.

You know, what I found is that if you can simply walk people through the initial setup, most people can utilize the technology because it's become very simple. If not, that's what's great about family members. Most people have like a son, a daughter, grandchild that can help them with it. And then once it's set up, right, it just like a click so people can work together on it.

Again, this could be a barrier in different communities and that's what we're further looking at, but because we've done a lot of tele-health over the last two years. Well, we've seen as it has been effective. And actually my community partners Sea Mar during the pandemic gave the diabetes prevention program via tele-health working a lot with this particular population.

And they actually felt like it was fairly effective. And that it wasn't a barrier to use. So, we're hoping to see the same thing with our study and that people have access to it. So.

Shireen:  So what does your team hypothesize about the results of this study?

Dr. Ehrhardt:  Yeah. So we're really hoping to see that, you know, with no escalation of medication from the education and the real-time continuous glucose monitoring, you know, more people will be at goal for their diabetes management and they'll feel supported and empowered.

Like they have a tool that helps them manage it. However, you know, what we always know is that sometimes. There are more social determinants of health out there that affect the actual intervention, whether it's a medication or an educational tool. So one of the parts of our study is actually to engage a little bit about those social determinants, like neighborhood safety.

So if you can't walk in your community, you may not be able to walk after a meal to help your blood sugar, right. And food insecurity, which is always an issue in food deserts. I find that our intervention isn't as successful. The question is, is, is the tool not successful in this population or is there barriers within the community that we need to address to better manage their diabetes?

Right. So we're excited to look at that and we're excited to partner with different members of the community. Hopefully. Medicaid derivatives to take a look at how we can enhance and limit those barriers. So. 

Shireen:  And then what you know, what direction do you hope to see more of the diabetes education programs going in the future with that?

Dr. Ehrhardt:  Yeah, I think for diabetes education, it's always been a cornerstone. I think the problem is honestly, is sustainability and reimbursability. Unless you have like an ADA accreditation, a lot of time, these community clinics do not have like a certified diabetes educator or if they do, there's just too much workload to get it certified.

And so there's no reimbursement available for these programs, which are such a cornerstone of diabetes education. We're hoping to show that, you know, it is useful and it should be, you know, paid for and reimbursed as part of diabetes education. And then when it comes to the continuous glucose monitoring rate.

Now, if you do have insurance if your Medicaid, Medicare, it's only paid for, if you have or on intensive insulin therapy, right? So that's even patient living with type two diabetes. It's already on three to four shots of insulin a day. That's sort of late in their disease progression. So what we want to do is make the technology available early to those that are not on intensive insulin therapy.

So hopefully they never get to that point and they never develop the complications from their diabetes. So.

Shireen:  Interesting. Are you, so what does, what does the future hold in terms of additional research for you? Especially as you, sort of come out of this one, where do you think that research direction is headed next?

Dr. Ehrhardt:  Yeah. I mean, I think this is a pilot. So again, what you really have to see is across different cultures, different regions that this works. And so we would really love to do a larger study looking at diabetes education, across different cultures, and then across, you know, across the nation to really show a fact because we really want it to be standard of care for patients living with diabetes.

You know, I always tell people I'm probably not going to be the person who cures diabetes, but I hope someone does soon. But until then, you know, really my research will continue on empowerment and tools for patient engagement and enhancement. 

Shireen:  You mentioned just a little bit ago, the payers element, right?

Getting these services to be covered by a payer and getting it reimbursable, because a lot of the communities, even the ones that you're working with in particular cannot afford to pay for, you know, for these services. How do you plan on bringing payers to the conversation or sharing this information with them to help drive that, that conversation?

You know, we always hear, you know, Instead of taking a reactive approach to healthcare, let's take a more preventative approach. Let's prevent this, let's invest more on that side. And there's just so much to do still in just managing diabetes that preventing it and all of that, it just sort of takes a back seat.

But anyways, my long-winded question is how do you, how do you you know, plan to navigate that conversation with a payer. 

Dr. Ehrhardt:  Yeah. I mean, a component of our research has actually just set up an advisory council where we're trying to engage both some participants, those that complete the program, those that actually drop out of the program.

We have some community partners that are specific with the Latinx population that we're going to engage in. We are trying to engage with the Washington Health Authority and the Department of Health, so that we're all at the table when we're discussing these things. And then we can move forward with a sustainability plan. So that's the idea. 

Shireen:  Lovely. And so with that, Dr. Ehrhardt, we are toward the end of the episode, at this point, can you tell our listeners how can they connect with you and just really learn more about your work? 

Dr. Ehrhardt:  Yeah, so. We have a research email, which is lcgm@uw.edu. And you can also check us out in general at the Diabetes Institute and feel free to donate to the Diabetes Institute.

We do lots of great research there. So, you know, we love support in any way. And so as well, You know, you in the Washington community have an, our provider and have patients that you think would match with our program, please do reach out to us so that we can engage them as well. Because you know, our goal is to touch as many people as possible.

And that's the great thing about tele-health like, we, you know, it's not as geographically exclusive, it can be more inclusive. And so finally, the last thing I would just wanted to mention is, one thing I'm a great advocate for is not just an important for us to be inclusive and research across all races and ethnicities, but I really want to make sure, and this is a shout out to all you researchers out there that we have our diverse research team that mirrors the population that we're supporting. And so, you know, I as a researcher, I've had some advantages and protected time. Some of my co-investigators are more clinicians and don't have that protected time.

So I've made very important things to place on my research and have them as components of my research. Patients who co-investigators, who have, are Native Americans and Mexican-American. And so we really want to mirror the population that is struggling with diabetes. and so you know, everyone's goal should be inclusive as researchers.

So then we have more patients and more researchers that look like the patients we're taking care of. So I, I challenge people to do that. I'm a fairly junior investigator, but it is one of the components that I've really prioritized. And I hope to see others doing the same. And I actually do think we're doing a lot in this, in this area.

So thank you very much for your time.

Shireen:  Indeed. And thank you so much, Dr.Ehrhardt for your time, really appreciate it. Thank you for coming on the podcast and to our listeners out there, head over to our social media or Facebook or Instagram. Let's continue the conversation there and answer this important question:

what is the importance of culturally tailored health education to you? That's right. We want to hear from you. What does it mean to you and why is it important? Head over to our Facebook, our Instagram, we will see you there after the episode and with that, Dr. Ehrhardt, thank you so very much for your time.

Dr. Ehrhardt:  Thank you having me. It was so fun. And of course I love talking about this type of stuff!

Shireen:  Oh We can nerd out all day. We can nerd out all day!

Dr. Ehrhardt: I was gonna say the same thing. I'm a total dork. Cause I love it. I love it. Love it. It's such a pleasure.

Shireen:  Thank you for listening to the Yumlish Podcast. Make sure to follow us on social media @Yumlish_ on Instagram and Twitter and @Yumlish on Facebook and LinkedIn. For tips about managing your diabetes and other chronic conditions and to chat and connect with us about your journey and perspectives. You can also visit our website Yumlish.com for more recipes advice and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week's show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we'll see you next time. Remember your health always comes first. Stay well.

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Latinx CGM Research– if you live in the local washington area and self identify as Latinx and want help with with your diabetes.