Maine Physician Assistant Workshop Intelligent Diabetes Maine Physician Assistant Workshop Intelligent Diabetes : PA’s Pioneering, Progress, Creativity

Maine Physician Assistant Maine Physician Assistant WorkshopWorkshop

Intelligent Diabetes Intelligent Diabetes : PA’s Pioneering, Progress, Creativity and Solutions in Outpatient

Care

Dana L. Green, PAC, DFAAPADana L. Green, PAC, DFAAPAEllsworth Internal MedicineEllsworth Internal MedicineEllsworth Family PracticeEllsworth Family PracticeMCMH Geriatrics ServicesMCMH Geriatrics Services

Tel 207-469-3150 (home)Tel 207-469-3150 (home)Cell 207-322-4805 (work)Cell 207-322-4805 (work)

GoalsGoals of Diabetes of Diabetes TreatmentTreatment

Sustained Normal BloodSustained Normal Blood No Long Term No Long Term DiabetesDiabetes

Glucose Glucose ControlControl ComplicationsComplications

Lowest Possible IncidenceLowest Possible Incidence No Acute DiabetesNo Acute Diabetes of of HypoglycemiaHypoglycemia ComplicationsComplications

Best Quality of Life with a Chronic Best Quality of Life with a Chronic DiseaseDisease

=

=

New Targets New Targets of of Intensive Diabetes Intensive Diabetes

ManagementManagement

Near normal glycemiaNear normal glycemiaHbA1c less than 6.5%HbA1c less than 6.5%Post prandial: < 140 at 2 hrs.Post prandial: < 140 at 2 hrs.Heart disease patients 7.0 to 7.5%Heart disease patients 7.0 to 7.5%

Avoid short term crisisAvoid short term crisisHypoglycemiaHypoglycemiaHyperglycemia and DKAHyperglycemia and DKAMinimize long term complicationsMinimize long term complicationsImprove quality of lifeImprove quality of life

ADA: Clinical Practice Recommendations, 2010ADA: Clinical Practice Recommendations, 2010AACE and ESADAACE and ESADDCCT Research Group, N. Eng J Med DCCT Research Group, N. Eng J Med

Percentage of Patients with Percentage of Patients with DM Having HbA1c < 7%DM Having HbA1c < 7%

Harris MI, et al Harris MI, et al Diabetes CareDiabetes Care. 1999; 22: 403-408. 1999; 22: 403-408

Relationship between % BG Relationship between % BG in Target and HbA1c Levelin Target and HbA1c Level

Brewer K, Chase P, Owen S, Garg S, Brewer K, Chase P, Owen S, Garg S, Diabetes CareDiabetes Care 1998, 21: 2 1998, 21: 2

The Facts of Poor The Facts of Poor ControlControl

ComplicationsComplicationsConventionalConventional IntensiveIntensive EventEventTherapyTherapy TherapyTherapy CostCost

BlindnessBlindness 34%34% 20%20% $$$$$$$$$$$$Early stage diseaseEarly stage disease 48%48% 15%15% $$$$$$$$$$$$End stage renal End stage renal 24%24% 7% 7% $58,000$58,000NeuropathyNeuropathy 57%57% 31%31% $$$$$$$$$$$$LL amputationLL amputation 7% 7% 4% 4% $29,000$29,000

Cumulative incidence of diabetesCumulative incidence of diabetesRelated complications Type 1 Related complications Type 1 Age 70 yr.Age 70 yr.

OO ’’Brien JA, et al., Brien JA, et al., Diabetes CareDiabetes Care 2002, 21: 1122-1128 2002, 21: 1122-1128

PA Reported Treatment PA Reported Treatment Choices with InsulinChoices with Insulin

Patients Using Insulin Patients Using Insulin PumpsPumps

360,000360,000

20142014

Most DM Patients Feel That Most DM Patients Feel That They Are In Good ControlThey Are In Good Control

Are you satisfied with your Are you satisfied with your

diabetes control?diabetes control?

19% Needs 19% Needs improvementimprovement

81% Good Control81% Good Control

Satisfied with Satisfied with overall overall

health…health…

72% non DM…(yes)72% non DM…(yes)

86% with Type 186% with Type 1

71% with Type 271% with Type 2

Key PointsKey Points Diabetes prevalence and cost continue to growDiabetes prevalence and cost continue to grow

Lower treatment targets are driving the Lower treatment targets are driving the adoption of more intensive managementadoption of more intensive management

The use of The use of intensive insulin managementintensive insulin management continues to grow… due to insulin changes in continues to grow… due to insulin changes in productsproducts

Large increases in insulin pump use and acceptabilityLarge increases in insulin pump use and acceptability

barrier to intensive management barrier to intensive management is patientis patient’’s lack s lack of awareness and perception of good controlof awareness and perception of good control

Guidelines for Diabetes Guidelines for Diabetes Care Care

Blood PressureBlood Pressure 130/80 (140/90 HD)130/80 (140/90 HD) A1C GoalA1C Goal under 7.5 to 6.5under 7.5 to 6.5 Micro albuminMicro albumin Less than 5.0…Less than 5.0… TSHTSH 0.40 to 4.000.40 to 4.00 LipidsLipids LDL under 100 (70) LDL under 100 (70)

(40yr)(40yr) CreatinineCreatinine under 1.4 (f) to 1.6 (m)under 1.4 (f) to 1.6 (m) WeightWeight 10 to 20 lbs wt loss10 to 20 lbs wt loss

Guidelines for Diabetes Guidelines for Diabetes Care Care

SmokingSmoking get patients to quitget patients to quit Eye examsEye exams Annually (Laser age 50-Annually (Laser age 50-

60)60) Foot examsFoot exams Every office visit (Shoes ?)Every office visit (Shoes ?) Oral examsOral exams Every 6 monthsEvery 6 months Skin examsSkin exams Every 6 monthsEvery 6 months Flu vaccineFlu vaccine AnnualAnnual PneumovaxPneumovax Follow guidelines of CDCFollow guidelines of CDC

Defining the Metabolic Defining the Metabolic SyndromeSyndrome

TriglyceridesTriglycerides over 150 mg/dlover 150 mg/dl HDL cholesterolHDL cholesterol less 35 (m), 45 (f) less 35 (m), 45 (f) Blood PressureBlood Pressure >130 (s)/ (d) >85 mg Hg>130 (s)/ (d) >85 mg Hg ObesityObesity BMI > 30 kg/m2BMI > 30 kg/m2 GlucoseGlucose Fasting >110 mg/dlFasting >110 mg/dl Micro albuminMicro albumin Overnight MA excretion Overnight MA excretion

GFR >60GFR >60 rate >30 mg/g creatinine rate >30 mg/g creatinine or 20 mcg/minor 20 mcg/min

The Links Between Insulin The Links Between Insulin Resistance and CVDResistance and CVD

HypertensionHypertension DyslipidemiaDyslipidemia HyperglycemiaHyperglycemia HyperinsulinemiaHyperinsulinemia InflammationInflammation Impaired FibrinolysisImpaired Fibrinolysis Endothelial Endothelial

DysfunctionDysfunction

AtherosclerosisAtherosclerosis HypercoagulabilityHypercoagulability

Net Result.Net Result.

Insulin Insulin ResistanceResistance

Leads to … orLeads to … or

Equals CVDEquals CVD

Estimated Number of Estimated Number of CHD Events AvertedCHD Events Averted

38

2016

36

58

78

0

10

2030

40

50

6070

80

90

A A B B C C D D Normal Normal BP BP HDL-C LDL-C A+B+C A+B+C+D HDL-C LDL-C A+B+C A+B+C+DAICAIC 130/85 45-50 100 130/85 45-50 100

Meet your destiny head Meet your destiny head onon..

Differences among types of oral Differences among types of oral Diabetes MedicationsDiabetes Medications

Medications that increase insulin Medications that increase insulin production (sulfonylureas) Dosed QD or BIDproduction (sulfonylureas) Dosed QD or BID

1. (chlorpropamide) Diabinese x 50 yrs.1. (chlorpropamide) Diabinese x 50 yrs. 2. (2. (glipizideglipizide) Gluctrol, Gluctrol XL) Gluctrol, Gluctrol XL 3. (glyburide) Micronase, Diabeta, Glynase3. (glyburide) Micronase, Diabeta, Glynase 4. (4. (glimeprideglimepride) Amaryl) Amaryl --stimulate the pancreas to produce more --stimulate the pancreas to produce more

insulin --insulin --


Meglitnides = stimulate release of Meglitnides = stimulate release of more insulin from beta cells (dosing more insulin from beta cells (dosing TID/meals)TID/meals)

1. (repaglinlide) Prandin1. (repaglinlide) Prandin 2. (nateglinide) Starlix2. (nateglinide) Starlix


Biguamides = Medications that Biguamides = Medications that decrease glucose production & decrease glucose production & increase insulin sensitivityincrease insulin sensitivity

1. (metformin) Glucophage, XR, 1. (metformin) Glucophage, XR, GlumetzaGlumetza

Riomet (liquid). Riomet (liquid). Decrease liver glucose release and Decrease liver glucose release and

increase muscle uptake (sensitivity)increase muscle uptake (sensitivity)


ThiazolidinedionesThiazolidinediones 1. (rosiglitazone) Avandia1. (rosiglitazone) Avandia 2. (pioglitazone) Actos2. (pioglitazone) Actos


Alpha-glucosidase inhibitAlpha-glucosidase inhibitorsors

Medications that slow the breakdown Medications that slow the breakdown of carbohydrates. of carbohydrates. Slow down the Slow down the breakdown of starches in the breakdown of starches in the intestines during the post meal period.intestines during the post meal period.

1. (acarbose) Precose1. (acarbose) Precose

1. (megitol) Glyset1. (megitol) Glyset


DPP-4 inhibitors = Medications that DPP-4 inhibitors = Medications that increase insulin production & increase insulin production & decrease glucose production in the decrease glucose production in the liverliver

1. (sitagliptin) Januvia1. (sitagliptin) Januvia 2. (saxagliptin) Onglyza2. (saxagliptin) Onglyza 3. (linagliptin) Tradjenta3. (linagliptin) Tradjenta


GLP-1 = non insulin injectables GLP-1 = non insulin injectables (exenatide) Byetta (pens), used with (exenatide) Byetta (pens), used with oral meds. Trigger the release of oral meds. Trigger the release of insulin from the pancreas when BS insulin from the pancreas when BS rise. BID dosing and newer versions rise. BID dosing and newer versions are used weekly.are used weekly.

2. Bydureon (pens)2. Bydureon (pens) 3. Victoza (pens)3. Victoza (pens) 4. Trulicity (pens)4. Trulicity (pens)


SGLT-2 SGLT-2 = Na glucose co-transport 2= Na glucose co-transport 2 Stops BS (glucose) from getting Stops BS (glucose) from getting

reabsorbed by the kidneysreabsorbed by the kidneys, ?? helps , ?? helps with wt loss with wt loss (single use medication with (single use medication with metformin)metformin)

1. (canagliflozin) Invokana1. (canagliflozin) Invokana 2. (dapagliflozin) Farxiga2. (dapagliflozin) Farxiga 3. (empagliflozin) Jardiance3. (empagliflozin) Jardiance --concerns with dehydration and low BP, --concerns with dehydration and low BP,

dizziness and impaired renal function--dizziness and impaired renal function--

With age comes wrinkles With age comes wrinkles but also wisdom.but also wisdom.

Insulin vs. the Resistance DilemmaInsulin vs. the Resistance Dilemma

Patient Patient

Occupation 36+ hrs. wklyOccupation 36+ hrs. wkly

Things that matter:Things that matter:

fisherman & wrangler, fisherman & wrangler,

fiddle player, travel,fiddle player, travel,

hockey and good foodhockey and good food..

Insulin vs. The Resistance Insulin vs. The Resistance DilemmaDilemma

Patient Patient

Stats:Stats: 55‘‘l0.75” (in skates 6’!) l0.75” (in skates 6’!)

wt. 204wt. 204(highest wt last 3 yrs. 232, (highest wt last 3 yrs. 232, lowest 200)lowest 200)

Blood pressureBlood pressure… … 136/88 136/88 (ACE)(ACE)

A1CA1C 8.98.9 A1C history A1C history = 8.8, 10.2, 9.5= 8.8, 10.2, 9.5

TSHTSH 3.503.50…(Synthroid 112mcg)…(Synthroid 112mcg)

RenalRenal GFR 60GFR 60 Microalbul. 35 Microalbul. 35 ((Altace 10mgAltace 10mg))

Chol Chol resultsresults Total 200/ Total 200/

TG 255TG 255/HDL 45//HDL 45/LDL 105LDL 105((Lipitor 10mgLipitor 10mg))

Insulin vs. The Resistance DilemmaInsulin vs. The Resistance Dilemma

Other labs results:Other labs results:Bun = 20 Bun = 20 creat.= 1.3creat.= 1.3Cal+ = 8.9, K+ = 4.8 Cal+ = 8.9, K+ = 4.8 Mg+ = 1.9Mg+ = 1.9, Na = 138, Na = 138Uric Acid = 4.8Uric Acid = 4.8

B12= 270B12= 270, Iron 60/413/20%, Iron 60/413/20%Hgb = 13 and Hct = 35Hgb = 13 and Hct = 35AST = 19, ALT= 22AST = 19, ALT= 22

Insulin Level 5.5Insulin Level 5.5C-peptide Level 2.5C-peptide Level 2.5Fructosamine level 362…equalsFructosamine level 362…equals... A1C 9.0 or daily avg of 210mg/dl... A1C 9.0 or daily avg of 210mg/dl

1. BS mg/dl = 30 (A1C – 6) + 1201. BS mg/dl = 30 (A1C – 6) + 120

2. BS mg/dl = 30 ( 9.0 – 6) + 1202. BS mg/dl = 30 ( 9.0 – 6) + 120

3. BS mg/dl = 30 (3) + 1203. BS mg/dl = 30 (3) + 120

4. BS mg/dl = 90 + 1204. BS mg/dl = 90 + 120

5. BS = 210 mg/dl5. BS = 210 mg/dl

Insulin vs. The Resistance Insulin vs. The Resistance DilemmaDilemma

Medical Dx:Medical Dx:

Diabetes Type 2Diabetes Type 2hypertensionhypertensionhyperlipidemiahyperlipidemiamicroabluminuriamicroabluminuriahypothyroidism,hypothyroidism,neuropathy neuropathy (leg pain/restless leg syndrome)(leg pain/restless leg syndrome)

anxietyanxietyimpotenceimpotence

MedicationsMedications

1. Metformin ER 500 mg, 2 tabs 1. Metformin ER 500 mg, 2 tabs AM and PM meals (max. dose)AM and PM meals (max. dose)

3. Amaryl 4 mg AM and PM meals 3. Amaryl 4 mg AM and PM meals (max dose)(max dose)

4. Januvia 100mg after supper4. Januvia 100mg after supper5. Lisinopril 10mg, 5. Lisinopril 10mg, 6. Lipitor 10mg, 6. Lipitor 10mg, 7. Synthroid 112mcg, 7. Synthroid 112mcg, 8. Alphabetic Mvit 8. Alphabetic Mvit 9. Lyrica 75mg AM and PM (bedtime)9. Lyrica 75mg AM and PM (bedtime)10. Zoloft 100mg daily AM10. Zoloft 100mg daily AM11. Cialis 20mg prn11. Cialis 20mg prn12. Vit D 3, 1000 IU 12. Vit D 3, 1000 IU 13. B12 500 mcg 13. B12 500 mcg

Types & Actions of Types & Actions of InsulinInsulin

Rapid - ActingRapid - Acting

Short - ActingShort - Acting

Intermediate - ActingIntermediate - Acting

Long – ActingLong – Acting

Combinations insulinCombinations insulin

Humalog-Novolog-ApidraHumalog-Novolog-Apidra

Humulin R (?...with whom)Humulin R (?...with whom)

Humulin NPH (best choice?)Humulin NPH (best choice?)

Lantus & LevemirLantus & LevemirHumulin L/U (gone)Humulin L/U (gone)

75/25 & 50/50 Humalog Mix75/25 & 50/50 Humalog Mix 70/30 Novolog Mix70/30 Novolog Mix

Clinical Experience with Clinical Experience with InsulinInsulin

How do you define oral agent failure?How do you define oral agent failure?

What are the What are the obstacles to insulin initiation?obstacles to insulin initiation?

What What strategies strategies do you use to overcome do you use to overcome ““insulin insulin resistanceresistance”” in your patients? in your patients?

What do your patients believe once they have What do your patients believe once they have initiated insulin therapy?initiated insulin therapy?

Who has Who has experience with experience with Mix 70/30 or 75/25?Mix 70/30 or 75/25?

Who has Who has experience with experience with Lantus/Levemir?Lantus/Levemir?

Why Start Insulin in Type 2 Why Start Insulin in Type 2 Diabetes?Diabetes?

Blood glucose Blood glucose notnot at goalat goal

Serum Serum triglycerides out of controltriglycerides out of control

Timely initiation of insulin replaces Timely initiation of insulin replaces failingfailing beta-cell functionbeta-cell function

After OAD failure = After OAD failure = combination insulin + combination insulin + OAD OAD may improve glycemic control with may improve glycemic control with less less weight gainweight gain than insulin alone than insulin alone

Patients with Patients with severe glucose toxicity severe glucose toxicity may may benefit from immediate insulin therapybenefit from immediate insulin therapy

Basal/Bolus Insulin Basal/Bolus Insulin ConceptConcept

• Basal InsulinBasal Insulin• Suppresses glucose production between meals Suppresses glucose production between meals

and overnightand overnight• 40% to 50% of daily needs40% to 50% of daily needs

• Bolus insulin Bolus insulin • Limits hyperglycemia after mealsLimits hyperglycemia after meals• Immediate rise and sharp peak at 1 hourImmediate rise and sharp peak at 1 hour

10% to 20%10% to 20% of total daily of total daily insulin insulin requirement requirement

each mealeach meal

Solutions to the Insulin resistance dilemma

Step One ( patients with A1C 8.0 to 8.5 )Step One ( patients with A1C 8.0 to 8.5 )

1. Basal Insulin Treatment method1. Basal Insulin Treatment method Lantus start 20 unit 3 hrs after supperLantus start 20 unit 3 hrs after supper…then……then… Continue Metformin, Amaryl,Continue Metformin, Amaryl, Glipizide/Glyburide Glipizide/Glyburide Get Get bedtime readings to 100-150bedtime readings to 100-150 Get AM (Get AM (before breakfast 100-150before breakfast 100-150)) Pre meal level should initially be 100-150Pre meal level should initially be 100-150

Solutions to the Insulin resistance dilemmaStep Two (patients with A1C 8.5 or higher)Step Two (patients with A1C 8.5 or higher)2. Basal Insulin + fast acting + orals2. Basal Insulin + fast acting + orals Lantus 60 PM or Levemir 60 PM or try 40 PM + 20 AMLantus 60 PM or Levemir 60 PM or try 40 PM + 20 AM

Guide dose on PM and AM readings (goal 80-150)Guide dose on PM and AM readings (goal 80-150)

Novolog/Humalog/Apidra Novolog/Humalog/Apidra (fast acting (fast acting mealtime insulinmealtime insulin))4 to 10 units with meals initi4 to 10 units with meals initiallyally0 to 4 units at bedtime if BS are above 175 to 200s0 to 4 units at bedtime if BS are above 175 to 200s

Continue Metformin if no renal disease Continue Metformin if no renal disease Discontinue Amaryl, Discontinue Amaryl,


Step Three (patients with A1C 8.0 or higher)Step Three (patients with A1C 8.0 or higher)3. 3. 75/25 Humalog Mix or 70/30 or 50/50 75/25 Humalog Mix or 70/30 or 50/50 Start: 8 units meals and 4 units bedtimeStart: 8 units meals and 4 units bedtime

Dose up to ranges: Breakfast 8-15 u, Lunch 4-8 u, Dose up to ranges: Breakfast 8-15 u, Lunch 4-8 u, Supper 10-16 u, Bedtime if BS 170 or higher 4-8 uSupper 10-16 u, Bedtime if BS 170 or higher 4-8 u

Goals BS always 80-180 initiallyGoals BS always 80-180 initially… … then get them to 80-150 pre meal and bedtimethen get them to 80-150 pre meal and bedtime……may use Metformin with this method to reduce may use Metformin with this method to reduce

insulin resistanceinsulin resistance


Step Four (patients who ……. scratch your head?)Step Four (patients who ……. scratch your head?)4. 4. 75/25 Humalog Mix + Humalog75/25 Humalog Mix + Humalog (difficult patients with 300+ BS)(difficult patients with 300+ BS)

Patients using 35 to 50 units of 75/25 at meals and Patients using 35 to 50 units of 75/25 at meals and failing to keep Blood Sugar levels under 180 pre mealfailing to keep Blood Sugar levels under 180 pre meal

Add Humalog to syringe…start with 5 units at meals & bedAdd Humalog to syringe…start with 5 units at meals & bedKeep adding novolog…until results desired are achievedKeep adding novolog…until results desired are achieved

Example: Example: 50u50u (75/25 Humalog Mix) + (75/25 Humalog Mix) + 15u Humalog 15u Humalog = = 65u meals65u meals … …for Bedtime use only 75/25 Humalog Mix 20-25units for Bedtime use only 75/25 Humalog Mix 20-25units


Step FiveStep Five (you tried everything…but something is missing)(you tried everything…but something is missing)

5. When Lantus and Levemir are at high doses in the PM 5. When Lantus and Levemir are at high doses in the PM and your mornings are still high (above 160 – 200)and your mornings are still high (above 160 – 200)

Add NPH single dose in PM at bed (around 10-20 units)Add NPH single dose in PM at bed (around 10-20 units) Problem solved.Problem solved.

5. 5. New New thoughtsthoughts…Humalog 50/50 Mixture …Humalog 50/50 Mixture Can be used in those Can be used in those heavy obese patientsheavy obese patients…… Try starting those patients out with either Try starting those patients out with either 25 or 35 or 50 25 or 35 or 50

units with mealsunits with meals. And use a dose of . And use a dose of 20-25 at bedtime20-25 at bedtime.. Continue MetforminContinue Metformin


Step FiveStep Five (you tried everything…but something is missing) (you tried everything…but something is missing)

5. 5. Prednisone patients Prednisone patients (temporal arthritis, rheumatoid, (temporal arthritis, rheumatoid, COPD, ?)COPD, ?)

Amaryl 0.5 to 1 mgAmaryl 0.5 to 1 mg with often times cure this high with often times cure this high Amaryl and NPH at noontime Amaryl and NPH at noontime in combination work wellin combination work well Small dose needed of each.Small dose needed of each.

5. 5. Prednisone patients who are on insulin Prednisone patients who are on insulin already and get illalready and get ill Increase the fast acting insulin by 5-8 with meals Increase the fast acting insulin by 5-8 with meals and and

bedtimebedtime for for 3 days3 days then reduce…and go back to prior then reduce…and go back to priordosing levels.dosing levels.

Solutions to the Insulin resistance dilemmaStep FiveStep Five (you tried everything…but something is missing)(you tried everything…but something is missing)

5. 5. Changing Medicare/Medicaid patients over from Changing Medicare/Medicaid patients over from

Lantus to LevemirLantus to Levemir…or Levemir to Lantus.…or Levemir to Lantus. Example:Example: Lantus dose PM was 60Lantus dose PM was 60

or Levemir 40 PM and 20 AMor Levemir 40 PM and 20 AM

……Goal PM BS 80 to 150 Goal PM BS 80 to 150

……Goal AM BS 80 to 150Goal AM BS 80 to 150

……Goal pre meal (especially supper under Goal pre meal (especially supper under 150)150)

Keep mooving forward.Keep mooving forward.

Glucose logs review. These Glucose logs review. These are patients examples that are patients examples that can teach us can teach us what to discuss what to discuss and help with our next and help with our next adventureadventure..

Diabetes Food & Soul Therapy: Secrets Diabetes Food & Soul Therapy: Secrets Revealed for Everyone Living with Revealed for Everyone Living with DiabetesDiabetesBy Dana & Eileen GreenPublication date: March 6, 2013 as By Dana & Eileen GreenPublication date: March 6, 2013 as

Book 1 (Released iTunes April 2013)Book 1 (Released iTunes April 2013)Diabetes Food & Soul Diabetes Food & Soul Therapy offers you solutions and guidance for how Therapy offers you solutions and guidance for how to live a life of joy and happiness while facing the to live a life of joy and happiness while facing the daily challenges of dealing with diabetes related daily challenges of dealing with diabetes related concerns. Suggestions on eating, cooking, dealing concerns. Suggestions on eating, cooking, dealing with sick days, blood control solutions for insulin with sick days, blood control solutions for insulin and non-insulin diabetes patients. [The book and non-insulin diabetes patients. [The book contains: shopping list, medication information, contains: shopping list, medication information, charts, glucose logs, tools to help with meal charts, glucose logs, tools to help with meal planning tools and dietary requirements.]planning tools and dietary requirements.]

Available free on iTunesAvailable free on iTunes 30 Chapters (current 2013 edition)30 Chapters (current 2013 edition) 4 new chapters coming in 2016 (24 new chapters coming in 2016 (2ndnd edition) edition) 3,999 downloads in its first 21 months of availability (April 1 3,999 downloads in its first 21 months of availability (April 1

2013): 2013):

2,940 in US and Canada2,940 in US and Canada

449 in Australia and Asia Pacific449 in Australia and Asia Pacific

528 in United Kingdom and Europe528 in United Kingdom and Europe

67 in Latin America and Caribbean67 in Latin America and Caribbean

136 downloads in other countries136 downloads in other countries

Downloads in Italy, New Zealand, Ireland, Mexico, Brazil, Denmark, Downloads in Italy, New Zealand, Ireland, Mexico, Brazil, Denmark, Bolivia, Belgium, Chile, Colombia, Costa Rica, Dominica Republic, Bolivia, Belgium, Chile, Colombia, Costa Rica, Dominica Republic, Estonia, Greece, Lithuania, Malta, SloveniaEstonia, Greece, Lithuania, Malta, Slovenia

Averaging 190 downloads per month (ranges from 123 to 438)Averaging 190 downloads per month (ranges from 123 to 438)

https://itunes.apple.com/us/book/diabetes-food-soul-therapy/id631859806?mt=11







Can you say Moo?Can you say Moo?

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Maine Physician Assistant Workshop Intelligent Diabetes Maine Physician Assistant Workshop Intelligent Diabetes : PA’s Pioneering, Progress, Creativity