Kristin Phair: 

“Thank you, everybody for being here and for being so patient. My name is Kristen Phair. I am a board-certified family nurse practitioner. I have been with Nice health care for almost two years. Before that, I was a bedside nurse. I worked in acute care. I did that for seven years. But today, I am really excited to talk with you about diabetes and about what Nice Healthcare can do for you.

So, a lot of people may be familiar with diabetes, a lot of you may not be. I just want to touch on a few key terms to know, before we get started. 

A few key terms to know:

Insulin:

First of all, it's a pretty big one. Insulin is a hormone. It is produced by the pancreas and I will refer to it as a key, kind of, throughout this presentation. So, it is a very important part of diabetes and understanding what diabetes is. It is the key that opens up cells, so that sugar can enter in to fuel the cell. 

Glucose:

Glucose is a fancier name for sugar. So, it's what's circulating in our blood when we eat a hamburger. We don't have food circulating in our blood, we have the broken-down form of that, which is glucose.

Insulin deficiency:

So, this is just meaning that the pancreas is not producing enough insulin to actually, properly handle all the glucose that's in our bloodstream. 

Insulin resistance:

Insulin resistance just means that the tissue in our body, the cells, they're not responding like they should be to insulin. They're not responding to the keys that are trying to open up passageways or doorways for that glucose to enter into the cells.

So, what is diabetes?

Diabetes is a disease with either partial or complete insulin deficiency. This also is along with varying degrees of insulin resistance. What this does is it leads to increased levels of sugar, or glucose, in the bloodstream and that can wreak havoc on the body.

So, here's my little diagram to hopefully help this make a little bit more sense. It might look confusing but bear with me... 

So, if you look to the left-hand side of the screen, you'll see that cupcake. This is going to kind of go through the process of what happens when someone who is healthy, who does not have diabetes, eats food or when we go through the bottom, when they're fasting. 

So, looking back at that cupcake when we food our pancreas is triggered to release insulin. Now, the broken-down food, that is now glucose, and insulin travels around the body and makes a pit stop at the liver, and some of that glucose is stored in the liver as glycogen. The rest of it circulates throughout the body, travels to all of the tissue and when it passes by a cell (which is constantly because our body is a bunch of cells) the insulin unlocks the cell and opens a door and allows some of that sugar to go into the cell. At that point, our blood sugar levels go down and we reach this level of homeostasis, which is just a fancy way of saying that our body is in a very balanced and happy state. Our body likes to be somewhere around 90 to 100 (mg/100mL of blood), a little bit higher, a little bit lower for blood sugar, but our body does like to be there. If we get too high, we are in a state of hyperglycemia, which means our blood sugars are too high. And if we're in a state where it's too low, that's hypoglycemia. Both of them are bad for their own reasons. 

So, if you then look again to the left-hand side of the screen and you see that clock this is representing time passing. So, someone is fasting when blood sugar levels start to drop because we don't have food in our system. The pancreas is stimulated again, and it releases something called glucagon.

You don't really need to know all the fancy G words that I’m throwing out here, but basically, the glucagon goes to the liver, asks the liver to please turn the glycogen into glucose and send it out to the body, so that we can once again bring our blood sugar levels up and get back into that balanced state that our bodies like to be in, and we work the best in.

So here, I want to kind of talk about the different issues versus a non-issue and the first picture on the far-left hand side of your screen.

In someone who is not a diabetic, we can see what is supposed to be the blood vessel on the top. And circulating within that blood vessel, we have the purple diamonds that represent insulin and blue circles that represent the glucose. The area on the bottom is supposed to be a cell. The green bars, that would be the key (pole, I guess) and then the yellow circle semi-circle is representing a door.

So, when someone who is not diabetic eats some food and that food turns into glucose for the body to use, insulin is pumped out into the bloodstream and travels along with the glucose. The insulin, or that key, then unlocks a door and that door opens and allows glucose to enter into the cell and then the cell can be fueled.

For someone who has type one diabetes - look at that middle picture, please - there is a lack of insulin. There is little to none that is produced by the pancreas. And so, when someone consumes food and that food turns into glucose, the glucose can get into the cells, that door is locked. There is no key to actually get in.

And then, on the right-hand side of your screen, there's a picture depicting type two diabetes. Once again, we have insulin and we have glucose circulating in the blood. But when one of those keys, one of the insulin (well, part of the insulin) tries to attach to that cell it doesn't respond like it should. The door to that cell doesn't open, so we once again can get the fuel inside the cell and blood sugar levels rise.

So, there are three main types of diabetes. There are subcategories, but it gets a little bit complicated so we're going to keep it as simple as possible.

Type one diabetes: 

I think about that as insulin dependent diabetes. This is when there is near complete or complete insulin deficiency and so someone is dependent on insulin replacement. This is usually diagnosed in childhood.

Type two diabetes:

And with type two diabetes, there may not be enough insulin being produced by the pancreas and there's a certain degree of insulin resistance. Usually, it's the insulin resistance that is noticed first, and over time, the pancreas, as it's damaged, produces less and less insulin.

Gestational diabetes:

And then the last one on the page is gestational diabetes. This is referring to diabetes when someone is pregnant. So, pregnancy affects every aspect of the body, really, and the pancreas is no exception. So, people can develop gestational diabetes, while pregnant.

Why is diabetes an issue? 

Great question! Diabetes is usually a silent disease, and we don't necessarily know someone is diabetic. They may not have symptoms and we may need to do lab work in order to see what's going on. But that doesn't mean that you're not being affected by diabetes if you have it.

Type two diabetes can go undiagnosed and often does go undiagnosed for several years, and over time, numerous issues can pop up because of elevated blood sugar levels. So, if you look on the right-hand side of the screen, this is not a comprehensive list, but there's some points that I wanted to touch on here. 

So, for the heart and the vascular system, high blood sugar damages the blood vessels. It stiffens and narrows them, and this leads to decreased oxygen supply to all the tissue in the body. This can lead to elevated blood pressure. Less oxygen to the heart can weaken the heart and cause an increased risk for heart disease, heart attack and heart failure. Narrowing of a blood vessel also means that we have loss of oxygen circulating to our organs. 

Our eyes, our kidneys, our skin - every organ of the body - needs oxygen and can be greatly affected when not receiving adequate amounts. 

For example, our eyes. People with diabetes are at an increased risk for glaucoma cataracts vision loss. 

For the skin, if someone has diabetes, they may develop ulcers in their skin because of a lack of oxygen to the distal end of our bodies. Our fingers and our toes and our feet, they're more susceptible, but it can happen anywhere.

And with decreased oxygen supply, and the damage to the blood vessels, and the issues that it causes, wounds are more difficult to heal, or they have more difficult time to heal. This can lead to infection and this can also eventually lead to amputation.

Another issue that can arise with uncontrolled diabetes is diabetic neuropathy. This is numbness and tingling to the extremities. It happens because of nerve damage elevated levels of sugar in the blood overtime can cause nerve damage. And not only is neuropathy painful or uncomfortable for patients or people, but it also causes issues. Imagine if you can't feel your feet and you step on a piece of glass and you get a cut. You might not necessarily know the other cut, even if it's small you might not know it's there and it can get worse. It cannot heal as well. Infection can happen, and then, we run into issues and potentially need amputation, and that's always kind of a scary thought. I don't want to be a fear monger and just creep people out, or scare people about it, but it's a real deal. It's a real issue that people can come across.

Another thing on here that I haven't touched on yet would be kidney disease. So, the kidneys are very sensitive organs, but they're very important. Kidneys are responsible for getting rid of excess fluid in the body and excess toxins in the body. It helps regulate electrolytes and gets rid of the excess of that. It also helps with blood pressure management and they like, I said, are very sensitive. So, when there are damaged blood vessels and high blood sugar levels, this can cause damage to the kidneys. People can experience acute kidney issues. They can also experience chronic kidney disease and potentially need dialysis. They might have kidney failure.

The last bullet point on here is diabetic ketoacidosis. This is another one of those scary ones for diabetes. It's when the blood sugar is really, really, really high and the cells are not getting the food that they need. They're not getting the glucose, so the body starts breaking down fat. Ketones are released into the blood to help fuel the cells, so that someone can survive, but ketones and an excessive amount, can be toxic to the body. So, this can be a really dangerous situation for people. 

But I just wanted to touch on some others, of course. So many others. I would be able to talk about this for a long, long time, but those are some of the big ones I wanted to tell you about.

So, some statistics for you:

1. More than 90% of cases of diabetes are type two.

2. Only about 5-10% are type one. 

3. Cardiovascular disease is an issue for the general population, but for those with diabetes, it is an even bigger issue, it is the number one cause of death in people with diabetes, resulting in two thirds of deaths, for those that are diabetic. 

4. Also, people with diabetes are twice as likely to have heart disease or stroke than those that do not have diabetes.

How is diabetes diagnosed?  

Bloodwork, basically. People can have symptoms. I didn't really touch on the symptoms, because it can be a silent disease but some that kind of would-be red flags for me, just to quickly touch on before I get actually to the slide, I guess, would be:

• if someone is complaining of excessive thirst or

• excessive urination

• Weight loss - I think about more for type one diabetes

• Blurry vision is another one 

• feeling tired

But again, people might be completely asymptomatic and just not know that they have diabetes. 

People that have a family history, people that are overweight, those are some of the people that I kind of am looking at a little bit closer and thinking like ‘well we really want to make sure that we're watching for elevated levels of hemoglobin, A1C or something other lab work that I’ll talk about. But obviously, I want to check in on everybody because you don't have to be overweight. You don't have to have a family history of diabetes to be affected by it. 

Hemoglobin A1C Test

So, hemoglobin A1C that's the first, and I think probably the most common blood test that comes to mind when diagnosing diabetes. On the bottom there's a scale and that is reflective of what an A1C would show. So, an agency looks at blood sugars over the past two to three months and gives us a percent. If we see a percent that's less than 5.7, that is normal. Between 5.7 and 6.5, that's pre-diabetic. Then, above 6.5 is diagnostic for diabetes.

Fasting plasma glucose, or a fasting blood sugar:

Fasting plasma glucose, or fasting blood sugar means that we are checking someone's blood sugar levels after they have not eaten for at least eight hours. I would expect to see this number less than 125. Over that, concern that they have diabetes. 

Oral Glucose Tolerance Test

Then, there's an oral glucose tolerance test. Anybody who's had a baby and failed their fasting plasma glucose will be asked to complete this three-hour test. It is not a test that's done really in the general population but some of those who have been pregnant in the past may have had to do this.

Random Plasma Glucose Test

And then, the random plasma glucose test. This is just a random sugar test so someone may have just eaten or maybe they ate a couple of hours ago, but I would not expect this to be over 200. If a random plasma glucose is more than that, on more than one occasion, or it's higher than 200 and they are also having symptoms like I was explaining some of those symptoms before, that is another way to diagnose diabetes. But I would say that the hemoglobin A1C is the most common way to diagnose.

Alright, so there's a lot of things you can do diabetic or not. I want to help people prevent, that's why I'm in primary care. And so, this slide is very important. I feel like because a lot of people don't necessarily see a provider unless they're feeling sick. But with something like diabetes, you might not feel sick for a long time. And just the general population should have a primary care physician or primary care provider of some sort.

So, I recommend everybody to establish care with a provider. Come to Nice if you want, because I’d love to talk to you. But establishing care, that's the first thing. And then, develop a plan. Follow it as much as you're able to and following up with your provider is crucial. You can't just see someone one time and then expect that the plan of care is never going to change. The plan of care will continually change over time, so it's just really important to follow up. 

And I don't have it on here but be an advocate for yourself. I want to advocate for you but be an advocate for yourself. Do your research. If you don't know where to look because Google is not exactly the greatest place to search for healthcare concerns, reach out to your provider and ask for some resources. I or one of my colleagues, any provider, would be very happy to provide you with resources to help educate you. 

And then, things you can do at home; try to live a healthy lifestyle to prevent and manage chronic issues:

• First and foremost, try to eat a healthy well-balanced diet. 

• Try to exercise, you know, at least 30 minutes, five days a week. A little bit more, a little bit less, whatever you can tolerate. The goal would be to do 30 minutes, every day

•  and then manage body weight.

• Get sufficient sleep, at least seven to eight hours of sleep a night. 

• And work to manage stress levels. This may be just finding what you can do to help relax at home. It may be seeking out a mental health therapist and maybe have a variety of different things.

If you don't know where to start, you can talk to us about that. Also, talk to us about any one of the above bullet points and we'd be happy to chat.

How do you get started?

So first, of course, like I said, schedule an appointment with a provider. We'd love to have you at Nice. The first thing that happens when you schedule a visit with a nice provider is you get a virtual visit. So, you'll see a board-certified nurse practitioner or physician assistant, and you can probably see them the same day, if not the next day. But we oftentimes can see people, the same day. 

From there, if needed, they can send out a home visit provider to see you at your own home. Then, if needed, we can draw lab work and have that sent in. The labs are mostly free, so a lot of them that are commonly drawn in primary care are free to our patients and the results come back in about 1-3 days. 

Once the lab work comes in, we give you a call and discuss those labs. We answer questions. And when I say we, I mean one of the providers will actually call you to go through those labs, and after we've discussed them with you, we have them uploaded to your Nice App, into the documents section, so you can access them anytime you need. 

What if your numbers are elevated?

Well, if your numbers are elevated, and we've detected it, we’ll already be coming up with a plan. If you know the sheer numbers of an elevated in the past, or you have an outside provider, but you're not so sure, and you want to talk to someone from Nice, contact us. Contact us anytime and we'd be more than happy to talk with you. You can get follow up visits and lab work as needed. 

Our visits are unlimited so you're not, you know, stuck to only being able to contact a provider once a month or something. You can contact us anytime you need. Obviously, after business hours, we’ll contact you again first thing the next morning but message in anytime. 

 You can get prescriptions. We have over 550 medications that are free for our patients and we can send those prescriptions out for free too.  You can have your medications actually delivered to you, free of charge and we offer - I guess I’m going out of order. Sorry, we do offer all those medications like I mentioned - some of them are for diabetes.

It's a limited number for diabetes, but there are some of the most common ones used. So, Metformin, Glipizide, and Glyburide are all on our formulary and ones that we could have mailed out to you for free.

So Nice Healthcare has a few different programs that you can utilize:

The first one I want to just mention is Relate. 

Relate

This offers support and coaching for general wellness, for Disease Prevention and for those with chronic issues, such as diabetes. It's really, really simple. It's text-based and it's quick, so quick. So, they don't send out really long rambling paragraphs of tips and tricks. They send out pretty efficient and short text messages to you that are hopefully beneficial. They send out tips, encouragement and they help you monitor your goals.

Pops Diabetes

And then, I'm really excited about this one. So, we just are launching Pops, which I'm so happy that we have someone here to talk with you about today. So as of April, of this year, we are introducing this program and it's designed to help manage diabetes. But I am going to stop there. 

I'm going to let Lonny from Pops, the CEO, take over and explain what it is and why it's such an awesome program and I'm so excited.

Lonny Stormo:

“Thanks Kristen! Great explanation, in terms of what's going on with diabetes and I am one of those people. I live with diabetes and one of the things I can guarantee anybody on the call today is, if you ask a person with diabetes “what's the most important thing in your life?”.

You are never going to hear the answer ‘diabetes’. You're going to hear ‘living my life, you know my career, my family, you know, my hobbies etc’. 

And so, if we make it too difficult for people to choose between, you know, living their life or managing their diabetes, they're always going to choose living their life first.

And that was my situation before Pops.

So, I go see a doctor every six months for about 15 minutes. And then, when I left his office, I was basically on my own. And, for me, I had a test kit - just like this one, you probably have seen these test kits-  And for me, that always sat in my bathroom, not with me. So, I was truly choosing to live my life over manage my diabetes and unfortunately, too many people are doing that.

Now, Nice is already a step above that, by itself, because of the easily accessible care and medications that Kristen just went over you with. Now, you take Nice and Pops, and what we really want you to do on the next slide is live your life and manage your diabetes, because we've made it so simple for you to do. And we do that with Mina, your virtual health assistant, and we do that with the Pops Rebel Meter, to replace that kit.

So let me tell you about each one of those a little bit more, if you go to the next slide. 

Mina - The Virtual Health Assistant

Mina is an AI, virtual health assistant that is there to help you focus on getting better behaviors and also in keeping you engaged in your process. So, Mina, on the next slide, is using a technique that is called motivational interviewing. It's well understood and well used in the healthcare field. And that science, that's been proven to help people with diabetes, is what's built into Mina. So, Mina is not a chatbot. She's not going to bug you to death and do lots of different things, but once in a while, she's going to prompt you about things that are important to you and she's personalizing to each person that's using the product based on a variety of factors. 

So, as an example, on the next slide, Mina might ask you a question, “Do you have a plan for low glucose moments?”. So, that's an important behavior for a person with diabetes to have, so they don't get that hypoglycemic event that Kristen was talking about. And so, now the person with diabetes sees the desired behavior ‘have a low glucose plan’. So, if I click ‘No’ to that, on the next slide, Mina is going to show me a way to create that low glucose plan in an easy, simple way.

So, we give you that information and so now what you've seen with this motivational interviewing example is your desired behavior, where you're at today, and an easy way to get to the desired behavior.

Pops Bingo

And then, when you do that on the next slide, we have a game we call Pops Bingo. We basically gamify this and make it easy for you to do, so that, as you complete all the desired behaviors. And now you're doing the things that you should be doing to manage your diabetes, then you win and, in this case, we give you a donation in your name. So that's kind of how Mina works. 

So, let's talk about the rebel meter on the next slide. 

The Pops Rebel Meter

So, the Rebel meter is just a very simple way to measure your blood sugar anytime, anywhere. So, if you can look at the corner, where I'm talking, there's three reasons that people don't use these test kits regularly: 

1. They are too large to carry around. The Pops Rebel meter is one fifth the size of a typical test kit. So, it's easy it's smaller than your phone to carry around

2. Second reason, you have to sit down at a table and it's not very discreet to do the assembly process with this test kit, with the strips and the lancets etc. There's no assembly with Pops. I do this when I’m walking regularly without ever stopping and nobody knows what I'm doing.

3. And the third reason that people don't like these test kits is that the lancing tool hurts too much. In a study we did, 93% of people said this hurts much less than that lancing tool

So, the top three reasons that people don't test their blood sugar regularly, we take those away and make it easy for you to know your blood sugar anytime, anywhere.

So, on the next slide, you can basically see that the way this works is like any consumer program we would expect to use. You just download the App and register. And when you register, you get the welcome kit sent right to your home and then, when you need more test modules that come in the Rebel meter, Your Mina will tell you you need more. You hit OK and they'll show up at your home.

This information is being shared with your Nice Healthcare provider and, importantly, you can also share it with your loved ones. 

As an example, I invited my wife to be part of my support circle and she went in and said alert if Lonny’s blood sugar is ever less than 60 send me a notification on my phone. So, she'll know immediately when I get a low blood sugar reading. So, I know, in addition to Mina, in addition to my Nice Healthcare professional, that I have my wife watching out for me and that's really comforting.

So, what we've shown is when you give people a better experience like this, they get significantly better control of A1C and Kristin explained to you what A1C is about. 

So, not only short term, but we have data now that says people that have been using this for up to 18 months are still seeing almost a full point drop in A1C, which you can see (on the next slide), can lead to significant cost savings, in terms of your healthcare claims costs. So, if you're an employer watching this, this is one way to help you control your costs better.

So, on the next slide, part of what we do here is, not only make it easy for you to manage your diabetes, but make it, hopefully, fun for you to manage your diabetes. And to learn a little bit more about diabetes and so far.

So, I mentioned Pops Bingo earlier. So, we've identified 16 behaviors that are recommended by the American diabetes association as things you should be doing to help you better manage your condition. And so, Mina’s prompting you about those things. Mina’s helping educate you about those things, like your low blood glucose plan, that I showed earlier. And as you check off, ‘yes, I have those things in place’, ‘I have a low blood glucose plan’, ‘I did get my eyes checked last year’, ‘I did get my dental exam last year’. Then, when you get all 16 checked off, that's when you get your Bingo. That's when you get rewarded. You feel good about yourself and we're helping other kids with diabetes too, through the donation that we make. There's also an ongoing kind of points gamification in here, for those who get challenged by it, like I do. I want to be at the guru level. I want to be at the top of managing my diabetes and you have the choice to do that and Mina showing you where you're at.

In addition to the next slide, you can see the other things that we do as you become a person using the product. 

By the way, if you start using the Pops solution, we don't call you a participant, we don't call you a user, we call you an owner, because we want you to own your life, own your diabetes, and we're trying to enable you to do that through this solution. And we want honor students who might, you know, be invited to Mina’s studio which are fun, kind of entertaining ways to be more aware of what's going on with diabetes. 

And as an example, at the last one we had a gentleman that joined us who had diabetes, since he was like 10 years old and he's biking across the country this year to raise money for diabetes awareness and it was fun to talk to him.

We also put out regular information in blogs and in newsletters about how you can better manage your diabetes. 

So, you know, I’ll leave you here with some comments about what people think when they're managing their diabetes, using the Pops solution and kind of what they like about it and how it's working for them.  

And the last one I leave you with is my own one. So, I have been managing my diabetes, using the Pops solution for more than three years now. And every day, I trust my life, using the Pops solution. And if you go to the next slide, this is me down at the farthest tip - well I guess, I guess you're not going to see that. But if it was, you would see me at the farthest tip of South America, in the most remote place I’ve ever been in my life, living my life and managing my diabetes, using the POP solution. And that's what we would love everybody to do. Thank you very much”.