If you live with diabetes and haven’t yet heard of Virginia Valentine, we have a treat for you.
Virginia is a Certified Diabetes Educator (CDE) extraordinaire located in New Mexico, who was recently named 2019 Outstanding Educator by the American Diabetes Association. She also happens to be living with type 2 diabetes herself for almost four decades now.
Virginia has been an insulin pump expert and influential mover-and-shaker in the diabetes space for decades. Among various ongoing advisory roles, she’s currently working at a clinic in Albuquerque, NM, where she helps serve a large population of rural and underserved patients.
We spoke with Virginia recently at length about everything from her passion for addressing diabetes stigma to her own use of the new FreeStyle Libre Flash Glucose Monitoring system for the past year-and-a-half, and how she thinks that has “cracked open the CGM market” in many ways…
DM) Hi Virginia, can we start with you personal diabetes story?
VV) I’ve been working in the field of diabetes for over three decades now and was diagnosed with type 2 diabetes 39 years ago while I was in graduate school. I was only 31 years old, and at that time it was really young to get type 2. My primary care doctor actually thought I had “juvenile diabetes” (or type 1 as it was referred to at the time). I’d had a 12-pound baby five years earlier and had gestational diabetes, which they didn’t treat back then… they just said don’t eat sugar. It kind of solidified my desire to work in chronic conditions, especially in diabetes.
Did your diagnosis come as a surprise?
No actually, I wasn’t shocked. Everyone in my family on both sides has had type 2 diabetes. And my dad’s father might have had adult-onset type 1, because he was in his 40s and on insulin, but who knows. So I find working in diabetes very interesting and personal.
What motivated you to start out in healthcare?
My mom was a nurse, but when I first went to college I was an art major and also studied marketing. My mom was the smartest person I knew, and I didn’t think I could do that (nursing). But one summer, I was really looking forward to sleeping in and she said, ‘You need to come to work with me today.’ She was an evening supervisor at the University of Oklahoma hospital, and they were short-staffed in the nursery so I could go feed the babies. I was never one of those who loved everyone else’s babies, but they put me in there. I soon discovered that nursing is more about the people relationship than it is about the technical side of giving shots and wrapping up bandages.
It’s really about empowering people. And I also discovered that not all nurses were as smart as my mom, and maybe I could pull this off. I started out by taking chemistry and algebra, and thinking that if I can pass those, I’d be OK… which I did. I ended up working in hospitals, and after a few years I thought there must be more to it than this. I went to graduate school to get a Master’s in nursing. I wasn’t exactly sure what I would do once I got out of school but ended up being recruited to the Oklahoma State Department of Health, in charge of diabetes and hypertension in chronic disease division.
What was that like working for a state health department?
It was a lot of fun. I was able to start diabetes education programs in county health departments around the state. That was ideal in some communities, because they’d have two or three local hospitals, and there would be a sort of competition for patients going on. But the state health department is sort of neutral territory, so it made it more accessible for everyone. I know a couple of those are still going now.
Can you tell us where you’ve worked over the years?
I have worked in primary care, with specialists and consulting in clinics and other groups. After the state department, I moved to New Mexico because a good friend was in charge of diabetes programs for Indian health services. When we had worked together in OK, we’d put together a professional training program, and when she and her husband – who’s an endo – started a program there, they recruited me to come to New Mexico and setup a diabetes program for a Presbyterian Hospital there. We had an inpatient and outpatient program, and over the next few years, we were doing a much better job of taking care of diabetes outpatients, so we didn’t need a specialized unit within the hospital.
I then worked with a group of endos for many years, and I ended up going to work at the University of New Mexico. We started working on diabetes case management, to reduce the ‘frequent flyers’ who kept coming back. That was a lot of fun and I enjoyed the university environment and people there.
All that led to you starting a diabetes network?
Yes. By 1998, a friend and I had setup a freestanding diabetes center and created a network of diabetes educators. We had educators in primary care offices throughout the community. That was very successful. Early on, to have a freestanding diabetes center that could be successful and make a living, was important. But then the biggest payor decided to cancel our contract to have educators in all our clinics, we had to shut that down. I ended up working with a primary care group, and I’ve really loved working with primary care providers and being their helping hand in managing diabetes.
What stands out to you the most about working in diabetes?
I’ve always found anyone with chronic diseases more fun and interesting than working in ICU or with surgical. I’ve always enjoyed the fact that it’s a long-term relationship, and for me it’s that relationship that is the most rewarding thing about caring for people with diabetes.
What are you doing now?
I was sort of trying to retire a few years ago, and the group that I’m with now talked me into working with them. So I work two days a week in Clinica La Esperanza in a very under-served part of Albuquerque, New Mexico. It’s been incredibly rewarding, and the patients are lovely. It’s owned and staffed by nurse practitioners, and I am their diabetes specialist.
My vision going to Clinica La Esperanza was that I’d be able to help them become diabetes managers, in part because I didn’t plan to work forever. A lot of times there are things they aren’t comfortable doing, and I haven’t quite figured out how to give them that confidence. They’re still primary care physicians, and I love those referrals and taking care of patients, but I want them to develop more skills for themselves.
You’re also working on some campaigns for diabetes care in underserved and rural communities, correct?
Yes, I’m involved with a phenomenal thing known as the endocrinology TeleECHO Clinic (or Endo ECO). This was developed by a GI doc that I worked with at university, to deliver specialty endocrinology care in rural and underserved areas for primary care physicians. New Mexico is such a huge state and very rural, so if you’re a nurse practitioner outside of Silver City, that’s a five-hour drive to get to Albuquerque. You can’t expect your patients to get there. And then the specialists and sub-specialities are in short supply, like endos. They put together this ECHO team where you have these specialties available all the time.
We have primary care and some specialists who Skype in from all over the country as well as New Mexico, and that includes sending in cases that we can discuss during two-hour sessions for practitioners. The primary care docs present their cases, and the network people can ask questions and come up with answers and solutions. We also have community health workers in the conversations, as well as pharmacists, endos, and others in our core team. It’s really a wonderful way to connect and help in these areas, and I never sit through the sessions without learning something. That’s one of the things I thoroughly enjoy about diabetes, that it’s such a complex set of issues – scientifically, emotionally, socially – and it’s what keeps my brain engaged.
How does it feel to get this “Outstanding Educator” award from ADA for your work?
It was quite an honor. I was actually quite shocked, but very excited. My talk (at the ADA annual meeting) was about stigma, which has been my mission from the beginning when I first started working in diabetes. It’s trying to help people understand that this is not a character flaw. It’s a genetic, metabolic disarray and it’s not the person’s fault. Unfortunately, the way that diabetes is treated in this country is primarily with blame and shame, and it’s not very successful.
Do you think stigmatization has changed or gotten any better over the years?
No, I don’t. Not at all. And I have to say, when the Diabetes Prevention Program (DPP) results were announced for type 2, I thought to myself that this was going to be bad. The reason was that it just gave a lot of the public the idea that diabetes is, in fact, preventable. They could say, ‘See, I told you it’s your fault! If you’d just lose weight and exercise, you wouldn’t have this!’ But the truth is, a three-and-a-half-year study did not prove that type 2 diabetes is preventable.
What I try to explain to people, especially about pre-diabetes, is that it’s not something that is specifically your fault and that it’s not always possible to prevent it – even if we can delay it. Honestly, it would’ve been better had they called this the ‘Diabetes Delay Program.’ Absolutely, lifestyle is a cornerstone of managing any type of diabetes, but that doesn’t prove that it’s a character flaw if you develop it.
It sure does seem that the term “prevention” gets used too much, doesn’t it?
If you scroll through your Facebook feeds, every now and then there will be somebody blaming and shaming people for their weight or the way they look. Even today, I’ll be in an advisory group – I’m on many boards and in these advisory roles – and someone will say, “Well, type 2s just need to do this or that.” It makes me cringe and always aggravates me, and I have to call it out.
Look, our brains aren’t different. People with type 2 diabetes have a disease that’s more genetic than type 1, if you study the statistics. But you hear it out there every day and it affects patients, being blamed and shamed. Really, it’s about visibility. A lot of people with type 2 diabetes are in the closet, or as I say ‘in the pantry.’ They don’t admit that they have diabetes because they feel they will be judged or stigmatized.
Do you see that negativity even within the medical profession?
Yes, I do. Almost a decade ago, I was putting together a presentation for AADE (the American Association of Diabetes Educators) about health professionals who have diabetes and how it impacts their role. I put the word out that I needed people with both types to be on my panel. I got about 20 people immediately with T1D who wanted to be on the panel, but nobody with T2 wanted to. Really? You think that this organization with 5,000-6,000 people doesn’t have a single type 2 among them? I had to out one of my friends who I knew had type 2, but hadn’t made it public until then. It’s just incredible how that happens.
We don’t make room for the reality of type 2. People just say: “Well, they’re fat and it’s their fault!” Yet, obesity has a lot of genetic components, and many of us struggle with weight that was just a gift from Mother Nature 100,000 years ago. As soon as food became available, we were fine as long as we chased it down and walked everywhere… but that eventually became an obese-ogenic environment. We have a lovely gift to store food really well. Storing fat is my best trick, and it’s a real challenge. So we need to accept people for their body type and figure out how to live in this world and environment, and live healthfully with diabetes.
Any thoughts on combating this big issue of diabetes stigma?
I’m excited to be a part of the diaTribe D-series events, which have been going on for four years now. That’s an executive innovation lab where people from all different areas – pharma, product companies, health professionals, advocates, people in the business world, marketing – all come together to consider problems in diabetes. One of those is stigma, and I’m really proud to be a part of that. It’s so stimulating and it just stretches your brain, and it’s great fun to be a part of those discussions.
Overall, I encourage everyone to join in alliance for diabetes dignity, and to call out shame and blame when you hear it. Don’t let your colleagues get away with talking about their patients as if diabetes is a character flaw. Be open with your patients to make sure they know it’s OK to have diabetes, to come out of the closet, and share their stories. It’s incredibly powerful for a patient to hear that you, too, have diabetes… AND that you’re not perfect! When I show off my own Abbott Libre sensor, I let them see the number and the trend graphs. It’s not always pretty, and I work hard at it, but it’s real. We all need to start working together better to stop diabetes stigma.
What are your thoughts on new technologies for diabetes care, especially the Abbott Libre Flash Monitor that you’re using yourself?
I started working in diabetes about the time that ChemStrips became available, so I absolutely love CGM for all its done for us with diabetes. I think it’s fundamentally changing the way we take care of diabetes.
And then Abbott comes along and busts it wide open with the FreeStyle Libre. Sure, it may not be the same as a Dexcom (or Medtronic or implantable Eversense CGMs) with alerts, but it depends on what you need. What it has done is that it makes CGM more accessible, and so easy to use.
For example, I had one of my type 1 guys that I’ve been seeing for about 20 years, and there was a time he was on a pump and just hated it… over the years, we’ve struggled with getting his A1C down lower. The last time I saw him I’d slapped a Libre on him. So he comes back and was beside himself. This changed everything for him. We tested his A1C in the office and it was down considerably, and he was just amazed! The system gave him the information to live more confidently with his hypo unawareness. He has basic insurance off the Exchange and it wouldn’t cover the Libre or a Dexcom, so the cost is just so prohibitive for him. But he can pay cash and get his two Libre sensors for $75 a month, and this opens the door for him. It’s a night and day difference. And before long, once it gets FDA approval, the Libre 2.0 will be available with optional real-time alarms. The accessibility is such a critical factor.
How about newer medications we’ve seen for diabetes?
The advances in medications is impressive, too. The fact that we now have two new classes of drugs, with GLP-1s that greatly reduce cardiovascular and SGLT2s that have shown to be renal protective, is just amazing. It just kills me when I can’t use them because I have half my patients on Medicaid, and those plans won’t cover without a Prior Authorization, and you can’t get that without a fight to death. This is not right. If they had commercial insurance, it’d be so much easier for them.
Where do you think we need to go from here in diabetes education?
Insurance will pay for diabetes prevention but not education… and it puts risk onto the provider. So we need to improve the ability of people to get access to a diabetes educator. We need primary care to realize the value of CDEs, and diabetes education overall, in their practices. I’m still pretty clueless as to why primary care physicians are still so reluctant to refer to diabetes education or even advanced diabetes care at a physician level. It’s still a mystery to me. Many of these physicians don’t realize how much they don’t know. I hear it so many times a week, that someone’s primary care doctor never mentioned something to them or brought it up. We need to do better there!
Thank you for taking the time to talk with us, Virginia. And thank you for the impact you’ve made in diabetes care over the years! Here’s to wider access and more CDEs like you in all of our futures.