Spotlight on Diabetes Educator Carla Cox

Sometimes, you come across someone with a calling or purpose that drives them to reach out to those in need. You can recognize them by the lengthy titles after their name, but often, their knowledge, support, and compassion proceed their accolades. Carla Cox is one such individual.

Whether taking a group of type 1 teenagers on an adventure hike through the arctic tundra or bringing her dog sled team to a diabetes camp for kids, Carla Cox has dedicated her life to helping children and young adults overcome the challenges of type 1 diabetes.

About Carla Cox

With over 30 years of experience working in the field of diabetes, Carla is a certified diabetes care and education specialist and registered dietitian at Mountain Vista Medicine and Pediatric Endocrinology in Utah. She teaches diabetes management skills like insulin pump/continuous glucose sensor set-up and provides nutrition, sports, and mental health guidance.

Carla holds a Ph.D. with an emphasis in exercise physiology and has taught sports nutrition and classes at the university level for over 14 years and hosts the American Diabetes Association’s (ADA) Ask the Experts series. She has authored numerous articles on diabetes management technology, reviewing all the pumps and automated delivery systems and currently writes Tip Sheets for the American Diabetes Association Kids Camps. Carla has shared her expertise as a dietitian and teen medical coordinator for ADA youth camps in Montana, Colorado, and Utah, and she lends her technology proficiency by speaking at local and national conferences for JDRF and ADA. She loves spending time outdoors, especially volunteering at diabetes youth clinics. This year, Carla has volunteered at seven different diabetes camps nationwide.

T1D Strong spoke with Carla about her adventures, technological trends, and contributions to the T1D community.

Career Choices

T1D Strong: Early in your career, you switched your focus to type 1 diabetes. What was your motivation?

Carla: I was working in a pediatric office as a dietitian. There was no peds-endo office back in the day. We were still finger-poking and waiting two minutes to get a result and had very few insulin choices. A young wrestler came in who had a hypoglycemic episode in the middle of the night with a seizure. He was from a family of wrestlers—all-state champs; his parents told him he would never wrestle again. The standard of care was much different at the time. It was a pivotal point for me. I thought we can’t do this. People with diabetes need to live their lives like everyone else. They have to fulfill their passion, and we have to find a way to make it work. 

So that was the beginning of my career, which is what I spend my time on. I now work for an endo office where I do all the pump starts and nutrition therapy. Sometimes, we’ll have a 28-year-old who loves their pediatric endo and doesn’t want to leave.

Tech World Trends

T1D Strong: You are an expert on insulin pumps and continuous glucose monitors. Why is this technology so vital to good diabetes management?

Carla: I think they give people with diabetes their brains back because there is no way that caretakers or T1Ds can adjust their insulin every five minutes. It’s just not possible. Type 1 diabetes is tedious and draining, so if something can take that power over and be adjusting all the time—that’s amazing.

We now have six different insulin pumps that can do that. In 2015 – there was just one that did it but didn’t do it well, and now we have these great options. It’s very exciting, and when talking with the people from Stanford and Barbara Davis where they research these technologies, soon all someone will have to say is – “I’m having a small, medium or large meal,” instead of doing all the carb counting and corrections. They’re also talking about implantable sensors that monitor your activity so that as soon as you start to move, it will know that you’re moving and indicate that to the pump so that the pump will start adjusting to your movement. So, lots of cool things are coming up. I write all of the Tip Sheets for the American Diabetes Association Kids Camps and am currently writing three more of these systems.

Automated Insulin Delivery (AID) systems automatically adjust insulin delivery to control blood sugar levels, reduce hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), and increase time in range (TIR). These hybrid closed-loop systems allow constant communication between your insulin pump and continuous glucose monitor (CGM).

Carla: The research data says that people stay in range 70 to 80% of the time, which is amazing because that has been almost unreachable. The quality of life is just so much improved.

Welcome to the Club

Type 1 Strong: What would you tell a newly diagnosed adult who is reeling from the shock of having to learn so much in so little time?

Carla: I would probably start, and I do start by saying, no one raises their hand and says I would like to have type 1 diabetes, but it’s a club. Many people have type 1 diabetes—one out of every 350 people, and it is a club. When you see someone else wearing a pump, I just saw a woman at a football game wearing a Tandem pump, and I told her I’ve taught over 1,000 people on this pump! So, welcome to the club is number one, and number two is that you can do anything you want to do except be in the service (military service).

Interesting Fact: The U.S. military does not accept recruits with pre-diabetes, type 1, or type 2 diabetes. However, military personnel already serving who develop diabetes and keep it well-controlled with an A1C below 7% are often allowed to remain, although their roles might change.

T1D’s Can Perform all Types of Jobs

Carla: Everything else is open: climbing mountains, being a cellist, being a scientist, being a garbage collector, it doesn’t matter, whatever your goals are, it’s just tedious, and you must deal with it.

Carla’s Top Three Nutrition Tips

Type 1 Strong: As a dietitian/nutritionist, what are the top three tips you suggest to improve your A1C?

Carla: Number one is to eat healthy, just like everyone else should. It’s not like you should have this special diet that only works with people with diabetes. That’s not true, so it’s ‘eat healthy.’ Watching your carbs, moderating them, or at least thinking about them when dosing insulin. You know, none of us should be eating a bunch of processed foods. We shouldn’t be eating meals with 200 grams of carbohydrates; nobody should be, so the idea is to tone down the carbohydrates, which means the starches, the desserts, and most of the processed foods, like energy bars and things like that. Also, eat foods in their natural state; for example, instead of drinking apple juice, have the apple, and instead of potato chips, have the potato. And then the third thing is adding protein. It’s not just that we need protein for health; if we eat protein before or mixed in with carbohydrates, the rise in glucose is slower. So we’re not seeing these great accelerations in glucose, but we’re seeing a slower rise, not so quick, and the advantage to that is that insulins aren’t straight up either; insulins work as a slower rise, as well, so they match, so glucoses doesn’t go as high.

T1D Strong: What do you advise T1Ds who want to start an exercise regime?

Carla: Everyone with T1D is different, so there aren’t any one-off sheets to tell you what to do, but in general, if you have an automated insulin delivery system, they have an exercise mode, and what it does is you adjust your target, so as it’s modulating your insulin dosing it’s going to have a higher target so you’re not as likely to go low.

The other thing you need to think about, which unfortunately makes this very tedious, is you have to consider an hour to an hour and a half ahead. So, let’s say that I’m going to ride my bike for 25 miles, and I’m going to do it at two o’clock in the afternoon with my buddies, well, at 12:30 p.m. I need to start thinking about if I want to bolus less for that meal. Suppose I’ve got an automated insulin delivery system. In that case, I will turn it on exercise mode because moderately long exercise, an hour, half-hour, tends to make your insulin more efficient, so it works better.

The second tip would be if you lift weights, it’s actually going to raise your glucose because it’s strength training. Epinephrine goes up, but afterward, it will come down, so that’s when you need to start thinking, okay, if I eat a little snack later, I’m not going to bolus for it. Or if I have an AID system or insulin pump, I’m going to cut the insulin amount down after I’ve exercised because that’s when it’s going to start to fall.

T1Strong: We hear about a lot of T1Ds battling mental health issues. What do you recommend to someone facing diabetes burn-out?

Carla: I think if they are getting really depressed or down, whether it’s clinical depression or just the blues, they need to reach out to someone, maybe their parents, maybe a friend, maybe a counselor, social worker, or psychologist, it could be, and I’m being very careful about support groups, especially online because you don’t want to get one that is more of a “Debbie Downer,” group, but one that makes you feel better, so you have to kind of pick and choose, what support groups you use.

Also, getting involved, so if you’re a young adult with type 1 diabetes, volunteer for a kids camp, where there are a bunch of T1D kids running around and dealing with it, and they’re fine. They’re having a blast because it’s not a big deal when they’re young. It’s like I got this thing, right, and my parents are helping me, and it’s okay.

But there is this increased risk of depression, and I think if you need help, you need help, but I just hope people embrace this and see it’s not necessarily bad. Teenagers who have diabetes tend to be more responsible. When I do these hikes with kids with type 1, everyone supports one another. As I mentioned, it’s really a club. So, I encourage them to embrace the club rather than say oh, I got this, and it’s so terrible. No one wants it, but it’s something that’s very doable. You just have to accept it and go with it.

T1D Strong: Tell us about your experience with the kids’ camps. (Carla heralds adventure camps for T1Ds where kids raft, mountain bike, rock climb and hike across the Arctic Circle.)

Carla: It’s a volunteer effort on my part. I love being with the kids and helping out; it brings you into this buddy system. In fact, the kids automatically start texting one another, and some end up getting married! Fellowship is important; not feeling alone is important. I encourage people to get involved; camps are a great way to do that.

T1D Strong: Tell us about the groups specifically for adults.

Carla: Connected in Motion is a group that offers physical activities for people with type 1 diabetes. It’s nationwide. Some of it is high-level activity, and some things aren’t. And then I think the ADA is another great place for online support, at least getting you more tools and information. The Barbara Davis Center in Denver is excellent and has gone beyond just kids.

And another really good one is DiabetesSisters. It’s women who have mostly type 1 diabetes. They have a conference once a year, and of course, JDRF always has a bunch of things going on, like bike rides and meet and greets. So that would be another place to start googling and finding things you can get involved in.

In Utah, a camp called REACH in Weber, Utah hosts diabetes recreation programs. It’s two camps, one in the summer and one in the spring, and one is a family camp. ADA’s Tour de Cure used to have a lot more options, but they cut it way back a few years ago. If you want to find a stage near you, I know there is one in California, and I think Oregon, and there is one in Colorado, and there are a bunch back east.

Carla’s Parting Words

Carla: You have it (T1D), and it’s not going to go away; sometimes, fighting it takes more time and energy and more mental strain than just doing the things you should do. You need to embrace it and deal with it. And if you deal with it, you’re going to be fine, and you’re going to live a long, healthy life.