Lakshmi Singh: Using Technology to Help Veterans Manage Diabetes

A clinical pharmacist practitioner at the VA Maryland Health Care System since 2009 with an interest in research that advances the care for Veterans living with diabetes, she focuses on the new and emerging technologies used to treat the chronic metabolic disease characterized by elevated blood glucose (sugar) that over time can seriously damage the heart, blood vessels, eyes, kidneys, and nerves. Her dedication to tackling the condition is demonstrated in her role as a diabetes provider, diabetes educator, and the Diabetes Technology Program coordinator where she spends her time working to improve the care for those with type 1 and type 2 versions of the disease. 

“I was long interested in diabetes, even before I myself became diagnosed with type 1 when I was 24 years old and, at the time, a student in pharmacy school,” she said. 

When she was diagnosed with type 1 diabetes, like most patients with this version of the disease, her treatment started with four insulin injections a day, and she was given a continuous glucose monitoring (CGM) device, a wearable tool that tracks glucose levels in real time. Some CGM devices are integrated with an insulin pump, creating a hybrid closed-loop system that helps manage blood sugars level automatically. 

Type 1 diabetes, considered an autoimmune condition, is less common than type 2 diabetes. In type 1, the pancreas stops making insulin, whereas with type 2, the body often makes insulin but can’t use it well. 

Historically, CGM devices were reserved for individuals who required three to four insulin injections daily. Nationally, the Veterans Health Administration changed this requirement for VA medical centers to allow single insulin injections per day, opening the door to this important tool for many more Veterans. As the Diabetes Technology Program coordinator for the VA Maryland Health Care System, Singh began wondering how to expand prescribing the device and its use at the health care system beyond the endocrinology specialists who treat Veterans with the more severe versions of the condition to ensure all eligible Veterans would have access no matter which service within the system managed their care. 

She led and organized the expansion effort along with a large interdisciplinary coalition from nursing, nursing education, pharmacy, endocrinology, primary care, prosthetics, and other areas that pushed forward education and training in 2024. This, in turn, led to the expanded prescribing of the CGM devices to any Veteran patient within the VA Maryland Health Care System who is living with and managing diabetes, potentially impacting thousands of additional Veterans using insulin. 

She also has a strong interest in expanding the use of automated insulin delivery technologies for all people with diabetes, including those who are insulin dependent due to type 2 diabetes. Automated insulin delivery systems have long been shown to be beneficial for patients with type 1 diabetes, but there is an ongoing need for data to approve these technologies for patients with type 2. 

To this end, Dr. Elias Spanakis, chief of Endocrinology Service and primary investigator; Jade Churchill, primary study coordinator; and Lakshmi Singh, the lead co-investigator, conducted a 13-week, multi-center (among 25 total international sites) randomized controlled trial which enrolled 319 adults with insulin-treated type 2 diabetes. Some were randomly assigned to automated insulin delivery systems (insulin pumps), and others were managed by typical insulin injections. The A1c levels of both groups were tested at the end of 13 weeks. The results showed that at the end of the trial period, the patients managed by the automated insulin delivery method were associated with greater reduction in glycated hemoglobin A1c levels compared with the group managed by the typical treatment plan for insulin injections. The results were published in the New England Journal of Medicine in March 2024, (https://www.nejm.org/doi/full/10.1056/NEJMoa2415948) Furthermore, the data collected from this trial were used by the company to submit a request to the Food and Drug Administration for an expanded indication for use of this device in Type 2 Diabetes, approved in August 2024.

These devices are lifesaving for individuals with insulin-treated diabetes. Consider Andrew Francis, a 28-year-old Marine Veteran, diagnosed with type 1 diabetes at age 19 just after boot camp when he was in his first training school. As a result of his diagnosis, he was medically retired from the Marines. Early in his effort to manage the condition, he was using finger sticks and self-administered insulin injections. “I was doing five or six finger sticks a day and then injecting the insulin.”  It became hard to manage and then he decided to try a continuous glucose monitoring insulin delivery device and had a bad experience. After that, he returned to the finger stick/insulin injection system. Before he met with Lakshmi Singh, he had convinced himself that it would be better to stay away from devices because of his bad experience with the one he had. 

“When I met with Dr. Lakshmi, she convinced me to try a device again, on a trial basis. She explained it to me. Showed me how to set it for normal activity days and high activity days,” he said, noting that managing diabetes became much simpler with her help and support. “The technology has advanced so much. I can use my [smartphone] to control the device.”

Francis has now been wearing the device for a little over a year, and, as a result, his array of activities has expanded. “I work in construction. It wasn’t easy to find a clean space where I could wash my hands, do the finger pricks, and then make sure things were sterile enough for the insulin injection,” he said, noting that “one of the things I feared was having a blood sugar level that is too low. Things get serious really fast when the levels are too low.”

Having the CGM device that connects with his smartphone has eased that fear and transformed his ability to manage the condition. 

This is something not lost on 90-year-old Army Veteran Howard “Jim” Carney, a Michigan native who has been managing type 1 diabetes for 50 years, diagnosed when he was 35.

“When I first was diagnosed, I thought I could take a couple of pills and stay away from chocolate bars,” he said, noting that his doctor told him he needed to use insulin to control it. “Back in 1975, [pharmaceutical companies] used to go into slaughterhouses to collect pig pancreases to produce insulin to treat diabetes.” 

In the late 1970s, pharmaceutical companies successfully created synthetic insulin, now used routinely to treat diabetes. “I took having diabetes very seriously from the beginning,” he said. “Diabetes is unpredictable.”

He joined the VA health care system in Michigan and then moved to Maryland to be closer to his children in 2004, his care transferring to the VA Maryland Health Care System. “I have all good things to say about my care at the VA, particularly Lakshmi Singh, who is the best. She also has type 1 diabetes and understands how unpredictable type 1 diabetes can be,” he said.

“I’ve been working with Mr. Carney since my days as a resident,” says Singh, who introduced Carney to the latest technology for diabetes management.

“She arranged for a representative from the manufacturer of this device to come to my house to show me how to set up the machine and how to work it,” he said. “At my next appointment, she is going help me connect the device to my [smart] phone so that it would be more convenient - being able to control it that way instead of using the device controller.”

Like Francis, Carney is keenly aware of the dangers of blood glucose levels dropping too low. He appreciates most that the device begins beeping nonstop if his levels drop while he’s sleeping. “When it starts beeping in the middle of the night, I know I have to get up to eat something, a carb. It also notifies both my sons, who call to see if everything is okay,” he said. 

Carney has seen tremendous advances in diabetes management tools since 1975 with the advancing technology playing a vital role in improving quality of life; the CGM devices seamlessly interact with an insulin delivery system helping him stay on track.  

Because of Singh’s passion and commitment, she made it a priority to become an expert on diabetes treatment technologies. 

“I want to make sure that Veterans in our care who are living with diabetes get every treatment option available to them. I made it my business to be involved in the technology of diabetes treatment across the VA Maryland Health Care System, whether it is smart insulin pens, insulin pumps, CGM devices, or any other technological option,” she said. 

Technology used to treat diabetes can transform the lives of Veterans living with the condition and reduce the burden for individuals and family members who must manage it.  With clinicians like Lakshmi Singh on the team working with Veterans, managing the condition can be a lot less stressful.