Selected Podcast

Advanced Diabetes Management

Memorial Diabetes Center's certified diabetes educators offer personalized lessons on nutrition, insulin therapy and other topics relevant to managing diabetes.

David N. Pickering, DO, BC-ADM discusses advanced diabetes management and the multidisciplinary care you will receive at Memorial Health System if you have advanced Diabetes.
Advanced Diabetes Management
Featured Speaker:
David N. Pickering, DO, BC-ADM
David N. Pickering, DO is a primary care physician and board certified in Advanced Diabetes Management (BC-ADM). He completed his residency in internal medicine at Camden Clark Medical Center in Parkersburg, West Virginia. He also completed the Diabetes Intensive Training course through the Mayo Clinic. He attended medical school at West Virginia School of Osteopathic Medicine in Lewisburg, West Virginia.

A provider certified in diabetes management (BC-ADM) validates a healthcare provider's specialized knowledge and expertise in the management of individuals living with diabetes. Practicing within their discipline's scope, healthcare professionals who hold the BC-ADM certification credential prescribe medications, treat, and monitor complications, provide medical nutrition therapy, help patients plan exercise regimens, counsel patients to manage behaviors and psychosocial issues, participate in research as well as mentor patients.

Melanie Cole (Host): Welcome, our topic today is advanced diabetes management and my guest is Dr. David Pickering, he’s a primary care physician and he’s board certified in advanced diabetes management at BayCare. Dr. Pickering, what happens when we eat? Why do we need to understand insulin and blood sugar? Speak a little bit about diabetes for a minute so that we can set the stage for advanced management.

Dr. David Pickering (Guest): Certainly, basically there’s two different types of diabetes, we have type 1 diabetic and we have type 2 diabetic. Type 1 diabetic, their body just stopped making insulin for some reason. The one that I like to focus on is type 2 diabetic and type 2 diabetic is an entirely different problem. It’s really not an insulin problem, it’s a metabolism problem where the body just doesn’t work well with the insulin that it makes. It’s called insulin resistance.

Melanie: So what are the causes of diabetes doctor?

Dr. Pickering: So diabetes starts about 15 years before the diagnosis. Basically the body gets more and more insulin resistant, and this is again with type 2 diabetes, but the body begins to get more and more insulin resistant. The pancreas starts to create insulin trying to keep up with that insulin resistance and if anybody’s ever worked overtime, they know you just can’t keep working overtime, so eventually the pancreas can’t make enough insulin to keep up with the insulin resistance of the body. So at the day of diagnosis when the sugar is 126 fasting, the body has already lost the battle against the insulin resistance and they’re termed diabetic on that day so the diabetes doesn’t start on the day your sugar’s 126; the diabetes starts in the years prior when your body’s becoming more and more resistant to the insulin that it’s making.

Melanie: So what’s the first line of defense, if someone is first diagnosed with diabetes, what is the first thing you tell them to try and manage it at the earlier stages?

Dr. Pickering: End of story, the first line of defense is diet and exercise. Eating a good healthy diet with all the food groups and getting plenty of exercise is the first line of defense. The American Diabetes Association recommends 150 minutes per week of exercise and a 10% weight loss.

Melanie: So these are lifestyle changes people can try Dr. Pickering, and what if these lifestyle changes do not work for them? Then what kinds of intervention might you try next?

Dr. Pickering: We’ve got several different classes of medications. There’s seven common classes of medications that are used and they all fight different problems of the diabetes. There’s eight core defects in diabetes. It was first described by Ralph DeFronzo, who’s an endocrinologist in San Antonio, Texas, he calls them the ominous octet and basically it’s the eight core defects of type 2 diabetes, and when we select a medication, we’re selecting one of these defects to attack and try to improve. We’ve got medications that attack and improve all of the eight. So when we see a patient for the first time or in follow up, we make sure that the patient has these eight defects covered in their treatment plan.

Melanie: So if somebody is on medication and this becomes advanced, what are some things you want them to be watching out for as they’re tending to their diabetes in terms of foot health and eye exams, speak about some of the things that you want them to really make sure to understand.

Dr. Pickering: So let’s talk about the eye exam first. I have a lot of patients come in and say, I have perfect vision, I can see just fine. We don’t do an eye exam to measure the vision, we do it because it’s the only place in the body where we can actually visualize a blood vessel and a nerve. We can see all of the optic vessels. We can see the optic nerve by doing a dilated eye exam, so we can look for microvascular changes in the eye and if we know that we have vascular changes in the eye, we know that we have them in the kidney and the rest of the body as well. So everybody needs a dilated eye exam at least once a year if you’re diabetic. The foot issue, every visit, every patient needs to have their feet examined because it’s a long way from the brain to the feet and there’s a lot of nerve cells in between the brain and the feet and these nerve cells get picked off one by one by out of control diabetes. These patients can get open sores on their feet either from pressure or from bacteria or from improper hygiene and that leads to complications down the line including amputation and infection. Because they don’t have proper feeling and proper blood flow to their feet, they are prone to wounds that don’t heel and just problems in the future.

Melanie: So if someone is on medication, they’re adhering to the lifestyle, they’re checking their feet for wounds that don’t heal, and they’re getting their eye exams, what are some other treatment options that you might recommend for diabetes, whether it’s bariatric surgery or if it becomes a serious surgical intervention.

Dr. Pickering: So there’s lots of treatment options for diabetics including insulin pumps, insulin delivery devices that are not pens, there’s the different classes of medications and very rarely do we have patients that fail all of these regimens. A person would come to see us, not because they’re failing these regimens in their primary care facility but more for help and management and polishing the regimen that they’re on. We see a lot of controlled diabetic patients that are referred to us mainly to make sure that they don’t go into problems in the future and have more problems with their vision or their feet or their kidneys. A lot of times they’ll come see us if they have kidney problems and you can’t use first line medication or if they have liver problems and you can’t use medications that are metabolized through the liver. Since we’ve studied these classes of medications in depth, we know specifically which medications in each class can be used to combat these different core defects in diabetes.

Melanie: Is there, tell us a little bit about the new multidisciplinary credential for advanced diabetes management, Dr. Pickering.

Dr. Pickering: So this is a relatively new certification that was started in 2012 by the American Association of Diabetes Educators. It’s open to all practitioners including nurse practitioners, PAs, as well as physicians. It’s a series of courses through the Mayo Clinic followed by a board certification at the end. The board certification is only offered twice a year at a national testing facility.

Melanie: So wrap it up for us, Dr. Pickering, and what you want the listeners to take away from this segment about things like you mentioned the insulin pump so that they don’t have to do a daily stick, about keeping track of their blood sugar, lifestyle management, and if they do have advanced diabetes, what you want them to know about living their best life and the things that they can do.

Dr. Pickering: So the thing that we do here and the reason that somebody would send their patient to us or a patient would want to come see us, is not only for a second opinion in their management but 87% of diabetics are managed by primary care, thus being listed as primary care, we see the majority of diabetic patients. Only 13% of these patients are seen by endocrinologists. When you come see us, we see the majority of our patients a day is a referred diabetic patient so we can be a little bit creative in our treatment. We have a blind patient that is on multiple daily injections of insulin. He was having difficulty checking his sugar and then adjusting his shot based on the number of clicks, so we hooked him up with a continuous glucose monitor that runs through his telephone and through his Alexa in his house, so he can ask his Alexa what his sugar is and know audibly what his sugar is at any time. He can then make adjustment through his V-Go device which is an insulin delivery device without using any other measurements other than knowing the number of clicks to adjust for his sugar being out of range. We also do a good job, like I said, making sure everybody’s treatment plan is attacking part of this ominous octet that was described by Dr. DeFronzo. So I guess in a nutshell we do a lot with technology in this facility with our continuous glucose monitoring and adjusting the medications based on those continuous glucose monitor devices. We do a lot of professional CGM through this office as well as personal CGM. Insulin pumps, we do manage type 1 and type 2. We’re using artificial pancreas as developed by the Medtronic, and we also use Tandem and the V-Go device. We have close relationships with all of the drug manufacturers and keep in contact with their medical liaison for anything new or interesting that comes out since we see a lot of volume of diabetic patients, these companies are very interested in what we are seeing and what we are learning from each of the classes of medications, so when anything new comes out, we’re typically one of the first people to know about it.

Melanie: Thank you so much Dr. Pickering for coming on today and sharing your expertise about the many options that are available for people with diabetes and for people for whom diabetes has become a little bit more advanced, thank you again. You’re listening to Memorial Health Radio with Memorial Health System. For more information, please visit, that’s This is Melanie Cole, thanks so much for listening.