Taking a Big Swing at Diabetes in Baltimore

Leaders of the Baltimore Metropolitan Diabetes Regional Partnership are, from left, Nestoras Mathioudakis, Alice Siawlin Chan and Nisa Maruthur.

By Patrick Smith on 07/22/2022

Published in Dome - Dome July/August 2022

When West Baltimore resident Robert Scott found out he had type 2 diabetes in 2009, his blood sugar was almost three times too high.

“If I didn’t change something fast, diabetes was going to take me out,” Scott says, shaking his head.

Today, the 49-year-old Scott is almost 60 pounds lighter than when he was diagnosed. He pays close attention to what he eats and has cut back his fast food consumption. And he continues to get plenty of physical activity in his job at the Baltimore Convention Center, where he’s responsible for keeping the facility’s 10 acres of carpet looking fresh and new.

“There’s always some work to do,” he says. “I don’t like just sitting around at a job.”

During a regular visit with certified diabetes care and education specialist Gene Arnold at the diabetes center on Johns Hopkins’ East Baltimore campus, Scott learns that his three-month blood sugar averages are not quite where he wants them to be, but are trending in the right direction.

Seated on a wheeled stool in an exam room, Arnold squints at a computer screen packed with tiny numbers. He reviews a few months’ worth of Scott’s blood sugar statistics that have been transmitted from a small device affixed to his abdomen. The continuous glucose monitor (CGM) collects data generated by the ups and downs of Scott’s blood glucose levels. An app on his mobile phone sends him alerts when the CGM detects any abnormality related to his diabetes. And during visits, Arnold can access the CGM’s data, providing a full picture of his patient’s diabetes management. Arnold gave Scott the CGM more than a year ago, and Scott says he wears it constantly to make sure his glucose is under control.

“So, how’re you doing?” Arnold asks, still examining the screen. “Your sugar’s looking pretty good.”

“I’m trying, I’m trying,” says Scott, seated on an exam table. He thinks back to his most recent meals. “I haven’t been eating my salads lately,” he says. “You know, it’s a struggle. But I’m grinding.”

Arnold acknowledges Scott’s efforts.

“I know it is,” he says, turning around to face his patient. “But you’re doing great.”

A $43 million collaboration

The diabetes self-management training (DSMT) that Arnold uses in caring for patients like Scott has been a staple of diabetes care at Johns Hopkins for years. Accredited by the American Diabetes Association, it is designed to help people take charge of their disease. Participants who follow its guidelines should see positive results not only in blood sugar levels but also in blood pressure and cholesterol, both of which are affected by diabetes. The improvements lead to fewer diabetes-related complications and hospitalizations.

Over the next four years, Johns Hopkins Medicine will collaborate with the University of Maryland to bring both a self-management training program and a prevention program to thousands more people, combatting a growing diabetes epidemic in Baltimore City as well as in pockets of Howard and Montgomery counties.

In 2019, the state agency dedicated to containing Maryland’s health care costs asked hospitals for proposals to implement two evidence-based diabetes programs — one that can help people manage their disease and another to help those at risk of developing diabetes avoid it altogether. Johns Hopkins Medicine and the University of Maryland Medical Center submitted a detailed collaborative plan to boost their diabetes management and prevention programs to make population-level progress on a problem that costs Maryland thousands of lives and billions of dollars each year.

In late 2020, the Maryland Health Services Cost Review Commission awarded the two institutions a five-year, $43 million grant for the work. Program officials say infrastructure was built during the first year of the Baltimore Metropolitan Diabetes Regional Partnership, as the alliance is known. Now in its second year, the program has shifted its focus to physician referrals and patient recruitment.

While the University of Maryland concentrates its diabetes prevention efforts on the southern and western parts of Baltimore, Johns Hopkins will focus on the east side of the city and a slice of eastern Baltimore County, including Sparrows Point, Dundalk and Essex. Johns Hopkins’ diabetes management will cover the same areas as its prevention program, with additional pockets of Howard and Montgomery counties.

The program’s goals are ambitious. Both institutions have committed to increasing prevention program access by 20% and diabetes management by 25%. The grant mandates that services be available not just in hospital clinic settings but also in places of worship, community centers and pharmacies.

Johns Hopkins endocrinologist Nestoras Mathioudakis directs the diabetes self-management part of the regional partnership. Specializing in diabetes care and research, the associate professor is the primary investigator for a major National Institutes of Health grant that examines whether automated diabetes prevention programs are as effective as those that rely on lifestyle coaching.

Mathioudakis says that while DSMT has had proven success in recent years, there is potential to reach more people.

“Even though this is what’s known as a standard of care intervention,” he says, “only 5% of eligible people in Maryland have gotten DSMT. Our job is to scale that percentage way up.”

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Stopping diabetes before it starts

Johns Hopkins associate professor of medicine Nisa Maruthur directs the regional partnership’s diabetes prevention efforts. She is also a faculty member at the Brancati Center for the Advancement of Community Care, where diabetes prevention has been a focus for seven years. Much of Maruthur’s career has been dedicated to grass-roots, neighborhood-level approaches to improving diabetes outcomes.

According to the Centers for Disease Control and Prevention (CDC), as many as 38% of Americans age 18 or older have pre-diabetes — their blood sugar is higher than normal but not high enough to be considered diabetes. The condition increases the risk of developing diabetes as well as heart disease and stroke. Physicians treating patients with pre-diabetes urge them to get regular physical activity and to eat a healthy diet to help the body improve its ability to control blood sugar.

Maruthur says Johns Hopkins’s approach to prevention is rooted in an evidence-based program informed by decades of research and established by the CDC in 2010. Her aim is to provide affordable, convenient options to help people with pre-diabetes make lifestyle changes that can reduce their risk of developing type 2 diabetes. Short-term prevention program goals include increasing the number of people who attend group meetings with a Johns Hopkins lifestyle coach, either in person or online. Among the longer-term goals is a measurable decrease in diabetes diagnoses in Baltimore.

The Johns Hopkins prevention program was the first in Baltimore to be fully recognized by the CDC, Maruthur says.She is encouraged that the regional partnership represents a dramatic change in funding priorities for the state.

“It isn’t too common for the investment to really match the scale of the problem,” she says. “I think that’s going to make a big difference.”

Over the past decade or so, Maruthur has received several small grants to pursue the CDC’s diabetes prevention objectives.

“We’ve shown that the model works,” she says. “In our first year, with one of the grants, we had 33 people in our program and all of them stayed all the way through.” The group’s weight-loss goal was 5% of total body weight. “That group had a 6% weight loss average,” Maruthur says. “They really showed that by using evidence-based approaches, combined with the strengths of our community, we can reduce diabetes risk in Baltimore.”

Peer support for people with prediabetes

Tracy Newsome is asking for volunteers: “Who wants to start?”

Ten women have joined Newsome on a weekly Zoom call to discuss the challenges and successes of their efforts to avoid diabetes. The women are among the 96 million Americans that the CDC estimates have pre-diabetes.

Newsome is a community liaison and lifestyle coach with the Brancati Center’s diabetes prevention program team, and she is one of three people who host weekly, hour-long group meetings for prevention program participants. Most meetings are online, though Newsome hopes to establish more in-person groups to meet at churches and community centers.

“I’ll start,” says Angela during the Zoom call. “I didn’t do too well this week.”

She says she traveled to Georgia to attend a family member’s retirement party, and the food and drinks were “not very healthy.”

“You know — a lot of sweets and things like that,” she says.

Angela says it was difficult to avoid unhealthy food when she was around family and friends.

“OK,” Newsome says patiently. “We have a session coming up soon called How to Eat Well Away from Home. In the meantime, here are some suggestions for sticking to healthy eating goals at family gatherings. We can choose healthier options, we can bring a healthy dish, or we can just share with our families that we’re making lifestyle changes to prevent diabetes and will pass.”

Newsome asks if Angela was able to have any physical activity at the event.

“Oh, I had to do a lot of walking,” Angela exclaims. “And it was hot!”

“All right! There we go,” Newsome says, smiling. “See? Even when eating isn’t going all that well, we can still do things like walk and get a little exercise, right?”

Angela and her classmates agree, and it’s time for the next participant to report on her week.

Maruthur says the classes, whether online or in-person, show that, with the right tools, people can make the changes that are necessary to prevent diabetes.

“Early in each person’s program, we try to determine what motivates them,” Maruthur says. “That helps us the rest of the way. Sometimes it’s weight loss, sometimes they want to fit into their clothes better. And sometimes they’re just afraid of getting sick. But learning their motivation is important. Because once the going gets hard, we need to go back to why that person joined the program in the first place.”

While Maruthur and Mathioudakis oversee the grant’s management and prevention elements, Alice Siawlin Chanserves as administrative director for the Johns Hopkins Health System side of the Baltimore Metropolitan Diabetes Regional Partnership. She and her team supervise the overall project, tracking progress in both prevention and management. Because an important component of the partnership is the ability to offer services in community settings, Chan works with churches, mosques, senior housing facilities and recreation centers to provide access to the programs.

“We want to be in the places where people already are,” says Chan. The administrative team has assembled what Chan calls a “traveling show,” during which she and her team explain the benefits of diabetes prevention and self-management to community leaders and nonprofit executives. “We know these programs are effective,” she says. “So it’s up to us to convince places like churches and YMCAs and other centers to allow us a presence.

“We’re building a standard-of-care clinical practice for our pre-diabetes and diabetes populations. We also need to make sure the infrastructure and resources we are investing in resonate within the community we serve.”

Not just type 2 diabetes

Back at the diabetes center, diabetes educator Gene Arnold’s next appointment is with Glynnis Macklin, a 57-year-old woman who walks a few blocks from her home. Her primary care physician thought she could benefit from some diabetes management training. Unlike Scott, who has type 2 diabetes, Macklin has type 1 diabetes, an autoimmune disease that causes the body to attack and destroy the cells that make insulin, leaving glucose to build up in the blood. While type 2 diabetes can sometimes be reversed with better eating and exercise habits, type 1 diabetes has no cure. Management is the only option.

“How’s everything, Ms. Macklin?” Arnold asks.

“Well, I just can’t stop eating bad food,” she replies. Macklin needs to inject insulin before she eats — how much insulin depends on the type and amount of food. As she chats with Arnold, she explains that she hates the feeling when her blood sugar goes low: “It makes me dizzy and I feel like I might faint.”

It’s soon evident to Arnold that, when Macklin fears her glucose is too low, she bombs her system with sweets or carbohydrates to bring it back up.

“Twinkies, especially,” she says. “I love ’em.”

As they discuss her eating and insulin regimen, Arnold explains that different foods and different portion sizes call for different insulin doses. Generally, Macklin has been taking too little insulin. To help her get a better handle on her diabetes, Arnold gives her a CGM and explains that she should leave it attached for two weeks. After that, she’ll receive a replacement in the mail.

Macklin’s orange sleeveless shirt leaves her toned arms exposed. When Macklin says she’s ready, Arnold gently pushes the CGM against the back of her left upper arm.

“It’s got a little needle in it, so it might pinch,” he says, fastening the device.

“That wasn’t bad,” says Macklin, looking over her shoulder at her new glucose monitor. “And now I don’t have to prick my finger, right?”

“A lot less often,” Arnold replies.

“OK! Nothing wrong with that!”

To learn more, visit hopkinsmedicine.org/population-health/dpep/

“We’re building a standard-of-care clinical practice for our pre-diabetes and diabetes populations. We need to make sure it resonates with the community we serve.”
Alice Siawlin Chan, director of the Baltimore Metropolitan Diabetes Regional Partnership

What’s So Bad About Diabetes?

After we eat, the digestive system breaks food into the components that become the fuel that nourishes our bodies. Fatty acids, amino acids, peptides and glucose each play a key role in feeding and maintaining the many complex systems that keep us alive and active. For people who do not have diabetes, insulin — a hormone produced in the pancreas — acts as a regulator that maintains just the right balance of sugar in our cells. Insulin instructs muscle and fat cells to absorb glucose from the bloodstream and either use it for energy or convert it to fat and store it for later.

More than 34 million Americans have type 2 diabetes, which means their bodies either no longer make insulin or no longer respond to the hormone normally. When cells ignore insulin, glucose builds up in the blood. Rather than providing the cells with energy, the sugar remains in the bloodstream. Elevated blood sugar, also known as hyperglycemia, can lead to severe health problems and make it harder for the body to fight off infections. For instance, recent studies suggest that people with diabetes account for as many as 40% of deaths from COVID-19 in the United States.

Type 2 diabetes takes a disproportionate toll on minority communities. For instance, Black Marylanders are twice as likely as white Marylanders to be hospitalized for diabetes-related problems.

Medications can replace insulin or help the body make and respond to insulin better. But the best treatment for diabetes is a healthy lifestyle that includes a nutritious diet, regular physical activity and, for many people, weight loss.

People who have diabetes face increased risk of blindness and heart and kidney disease. Diabetes also significantly elevates the risk of many cancers including breast cancer, colorectal cancer and cancer of the liver, pancreas and bladder. The disease can damage nerves and blood vessels, and it even makes tooth decay and sexual dysfunction more likely.

Research has shown that patients with COVID-19 who also have diabetes are much more likely to have symptoms serious enough to require hospitalization.

The Centers for Disease Control and Prevention (CDC) estimates that one of every four health care dollars in the United States is spent on care for people with diabetes. The estimated total cost in the U.S. for diabetes last year was $327 billion according to the CDC.

The financial burden for patients is significant. According to the U.S. Centers for Medicare and Medicaid, Americans spend an average of about $12,500 on health insurance and medical expenses each year. That number is nearly twice as high for Americans who have diabetes.

Maryland’s One-of-a-Kind Health Care Payment System

In 49 states, insurers pay hospitals different rates for the same medical services. A hospital might charge Medicare one price and a private insurer a completely different price for the same procedure.

But since 1977, hospitals in Maryland have received the same amount for care they provide, no matter who the payer is. Under an agreement with the U.S. Centers for Medicare and Medicaid, the Health Services Cost Review Commission (HSCRC), an independent body, sets the state’s health care payment rates.

Katie Wunderlich, HSCRC executive director, says Maryland’s rate-setting system encourages creative solutions to problems like diabetes.

“We’re able to leverage federal dollars that actually cover the cost of care,” she says. “A patient can be insured by Medicare or Medicaid, or they can have commercial insurance. In other states, they’ll all pay different amounts — sometimes well below the cost of care. In Maryland, those payers all pay the same amount.

“That’s how we have additional resources that pay not only for hospital care, but for keeping populations healthy.”

Wunderlich explains that, under an agreement with the Centers for Medicare and Medicaid Innovation (CMMI), Maryland has goals that, while focused on health care cost containment, are also directed at the bigger picture.

“We definitely have financial goals” with CMMI, says Wunderlich, “but they’re also really concerned with and focused on quality improvement and population health improvement.”