Diabetes can be a devastating disease if not carefully managed, as suboptimal control of blood glucose (or blood sugar) levels can increase the risk for cardiovascular disease, kidney damage, vision loss, and other grave conditions. Overall, 11.6 percent of people in the United States have diabetes according to the American Diabetes Association, though rates are highest within certain populations, including Black, Hispanic, Asian American, and American Indian adults.
Four faculty members at the Connell School of Nursing (CSON) are searching for ways to fill gaps in the care of diabetes that affect underserved communities and other patient groups that often struggle to receive adequate treatment and preventive measures. These researchers are driven to improve diabetes care as part of their commitment to Boston College’s mission of living in service to others.
EMBRACING TECHNOLOGY TO CONTROL DIABETES
One important lesson of the COVID-19 pandemic was that diabetes is a condition that is amenable to virtual medicine. “It really changed the landscape of how we were able to deliver care,” says Assistant Professor Patricia Underwood, who is also an endocrine nurse practitioner at the VA Boston Healthcare System (VA). When physical distancing became necessary, Underwood and her colleagues at the VA pivoted and were soon conducting 12–14 virtual appointments a day through teleconferencing or phone calls. They made that possible by training patients to use technology called continuous glucose monitoring (CGM), which consists of a wearable device that tracks blood glucose levels in real time and transmits that information to a smartphone or receiver. Importantly, CGM data can be uploaded to a website that a clinician can view to determine whether a patient’s treatment plan is maintaining healthy blood glucose levels.
“We were able to deliver care to patients who otherwise wouldn’t have received it,” says Underwood. She was lead author of a 2022 paper that described several patients in her clinic who successfully overcame obstacles to controlling blood sugar with CGM and virtual visits, and how to integrate this technology into practice, published in the .
In other work, Underwood recently used an experimental metric developed by her colleagues at the VA called A1C time-in-range (TIR) to show that diabetes patients whose blood glucose frequently rises too high or drops too low have an increased risk for dementia. “People don’t think of dementia as a complication of diabetes, but it is,” says endocrinologist Paul Conlin, MD, chief of medicine at VA Boston (and Ď㽶Đă Class of ’79), who heads the team that developed the A1C TIR. Next up, Underwood, who has worked alongside Conlin as a clinical scientist since 2022, plans to examine how patient lifestyle behavior, medication, and provider practices affect A1C TIR. “If we can understand predictors of this metric,” says Underwood, “it would help us to design better clinical interventions.”
“We were able to deliver care to patients who otherwise wouldn’t have received it.”
—Assistant Professor Patricia Underwood
COPING WITH HEALTH DISPARITIES IN DIABETES
Assistant Professor Cherlie Magny-Normilus is seeking to improve self-management of type 2 diabetes (T2D, which occurs when cells resist the hormone insulin) among Haitian immigrants in the United States, who experience higher rates of complications from the disease than other comparable ethnic groups. With support from the National Institute for Nursing Research, Magny-Normilus has developed a multilevel, culturally tailored intervention program that educates Haitian adults with T2D about the roles of diet, physical activity, and medication in managing the disease, which she is currently pilot testing.
Magny-Normilus used a variety of resources to design the six-part program, including a preliminary study of 81 Haitians with T2D, who described their management behaviors and barriers to effective blood sugar control. Participants also wore CGMs and actigraphy devices for 14 days to provide data about their blood glucose variability and level of physical activity.
In that preliminary phase, Magny-Normilus discovered that participants were able to see from their CGM’s graphics how eating a high-carbohydrate meal caused blood sugar to soar, helping them understand the importance of diet modification. “No wonder my A1C continues to be high,” one participant said. Meanwhile, she also discovered that many study participants said they didn’t feel safe exercising outdoors in their neighborhoods and couldn’t afford gym memberships. “So I’m trying to embed instructions about ways to get physical activity even at home by moving around more into the intervention,” says Magny-Normilus.
Importantly, Magny-Normilus learned that housing issues, lack of access to healthy foods, and racial discrimination act as barriers to diabetes management, but many study participants were reluctant to seek help with these problems. “This is a population that is very prideful,” says Magny-Normilus, a variable she accounts for in her interventions by guiding participants in need of social-support services to agencies and organizations where they will feel comfortable and their language and culture are understood. After completing this pilot study next year, Magny-Normilus plans to evaluate it in a multi-site clinical trial.
CULTURAL ADAPTATION FOR PREVENTING DIABETES
Rates of T2D are rising faster among Asian Americans than other racial groups in the United States.Â
The landmark Diabetes Prevention Program (DPP) study found that lifestyle changes can reduce the risk for developing T2D, but Associate Professor and Strakosch Family Fellow Tam Nguyen says the implementation of this program among Asian American patients often ignores cultural and physiological realities that render it less likely to be effective. For example, the DPP demonstrated that losing 5 to 7 percent of body weight can help prevent the onset of T2D. “But a lot of Asians just don’t have a lot of weight to lose,” says Nguyen.
However, some Asian Americans who are not overweight nonetheless have significant abdominal fat, which is linked to T2D, suggesting that a custom approach may be beneficial. “For Asians, we think that exercise is more important than weight loss,” says Nguyen, who plans to work with an exercise physiologist to test different types of aerobic and strength regimens that target abdominal fat, and see if they reduce diabetes risk.
Other cultural adaptations Nguyen says are necessary include dietary recommendations for reducing T2D risk: advice to cut back on cheeseburgers and donuts won’t mean much to a Vietnamese American whose favorite foods are spring rolls and pho, for example. Nguyen has launched a pilot project to adapt the DPP for the Vietnamese community, and—thanks to a $5.5 million grant from the Centers for Disease Control and Prevention—her team will expand this initiative to include people of Chinese and Asian Indian descent, too, in collaboration with Quincy Asian Resources, the Joslin Diabetes Center, and South Cove Community Health Center.
TARGETING “DIABETES DISTRESS”
Living with type 1 diabetes (T1D, caused by a loss of insulin-producing pancreas cells) is often compared to having a full-time job, given the frequent need to administer insulin, monitor blood glucose levels, and take other steps to maintain stable blood sugar. That’s emotionally challenging for any patient, but emerging adults with T1D face unusually high levels of “diabetes distress,” says Katherine Wentzell, a pediatric nurse practitioner at the Joslin Diabetes Center who returns to her alma mater this summer as an assistant professor. Wentzell’s research focuses on understanding diabetes distress in emerging adults (aged 18 to 30) and finding ways to overcome it.Living with type 1 diabetes (T1D, caused by a loss of insulin-producing pancreas cells) is often compared to having a full-time job, given the frequent need to administer insulin, monitor blood glucose levels, and take other steps to maintain stable blood sugar. That’s emotionally challenging for any patient, but emerging adults with T1D face unusually high levels of “diabetes distress,” says Katherine Wentzell, a pediatric nurse practitioner at the Joslin Diabetes Center who returns to her alma mater this summer as an assistant professor. Wentzell’s research focuses on understanding diabetes distress in emerging adults (aged 18 to 30) and finding ways to overcome it.
“No one does diabetes on their own,” says Wentzell, but emerging adults have likely left their parents’ home to attend college or live independently, so they often lack a support team. Competing demands of higher education, work, and new social and romantic relationships can distract from diabetes management, resulting in out-of-range blood glucose. “That can lead to anger, frustration, and feeling overwhelmed,” says Wentzell, which can further interfere with completing the many daily tasks of diabetes. “And you just continue in this cycle that’s really hard to get out of.”
To better understand the experience of diabetes distress in this patient population, Wentzell developed the Problem Areas in Diabetes-Emerging Adult (PAID-EA) survey, the first of its kind, which is now being used in multiple studies and will be translated into several languages. Wentzell’s survey has revealed that about nine out of 10 emerging adults with T1D worry about the cost of diabetes, and some reports suggest that the rising price of insulin has led 30 to 50 percent of young adults to ration the drug, she says. Wentzell now hopes to launch a study of how cost worries in these patients affect their diabetes-management behaviors, and how the choices they make—such as putting off refilling an insulin prescription—influence their outcomes.
“No one does diabetes on their own.”
—Assistant Professor Katherine Wentzell
Diabetes in the United States
By the numbers
38.4 M
# of Americans who have diabetes (as of 2021)
97.6 M
# of Americans with prediabetes, a condition characterized by higher-than-normal blood glucose that can progress to type 2 diabetes
1.2 M
# of Americans diagnosed with diabetes each year
Source: American Diabetes Association, numbers in millions