Anna Kahkoska is finding new ways to help older adults with diabetes

The recent NC TraCS KL2 Scholar wants to help older adults navigate the daily challenges of staying healthy while living with diabetes.

"The day-to-day management of diabetes," says Anna Kahkoska, "is both complex and relentless."

Diabetes can have a significant impact on some of the most personal and meaningful aspects of a person's life, from the way they eat to the way they exercise. As a result, every person with diabetes has their own methods of navigating life with the disease, with unique support systems, routines, and technology use—all of which can also change over the course of a person's life.

Kahkoska, a researcher at the UNC School of Medicine and Gillings School of Global Public Health, has thought a lot about the challenges of diabetes management. Throughout her career, she's studied diabetes from numerous angles, including biochemistry, epidemiology, behavior, and nutrition. But now, she's pulling all these threads together—with a focus on helping older people manage the daily realities of this life-altering disease.

Her faculty career kicked off with a KL2 early-career development award at the North Carolina Translational and Clinical Sciences (NC TraCS) Institute. As part of her research for that project, Kahkoska studied how to help older adults effectively use continuous glucose monitors, or CGMs, a powerful technologic tool for diabetes self-management that provides a real-time look at a person's blood sugar levels.

For people living with diabetes, the risk of low blood sugar, or hypoglycemia, gets higher as they get older. CGMs can provide potentially life-saving benefits by preventing dangerous episodes of severe low blood sugar. But many older adults don't use CGMs, for any number of reasons. Research has shown that some people, for instance, find this new technology confusing, while others might not trust it. For Kahkoska, the challenge was to understand where those feelings came from, how they were shaped, and ultimately, how they could be addressed with solutions specifically tailored to older adults and their needs.

That's become a defining theme of her career. By combining the nuances of people's experiences and stories with a scientific approach to problem-solving, Kahkoska is bridging the often-overlooked gaps between medicine and patients. And through this process, she's making sure that everyone can live a full life at any age—even with such a challenging disease.

Before starting her undergraduate work at Syracuse University, Kahkoska had planned to study visual art. But that was before she got a chance to work in a lab with Robert Doyle, a researcher in the chemistry department. Doyle, she says, dedicated a "tremendous amount of energy" to undergraduate student research, giving students ownership over a research project, which seemed like too good an opportunity to pass up, and provided its own form of creativity.

"It's why I'm in this career, right?" Kahkoska says. "To have this sort of creative autonomy that allows me to always be asking questions, alongside the privilege to be able to pursue answers to those questions."

That lab was also where she began her research on diabetes, which continued after she enrolled in the dual degree MD/PhD program at UNC. Her doctoral training, at the Gillings School of Global Public Health, focused on epidemiology, precision medicine, and nutrition—all in the context of type 1 diabetes—under the mentorship of Beth Mayer-Davis, a nutrition researcher. And through her clinical rotations as a medical student, she learned that she most enjoyed working with older adults.

When we think about type 1 diabetes, Kahkoska says, older adults represent something of a new frontier. Due to improvements in diabetes care, it is now common for people with type 1 diabetes to live as long as people who don't have diabetes. While this is, overall, a good thing, it also means that scientific research into type 1 diabetes among older adults is lagging.

"We now have this growing population of older adults living with type 1 diabetes, and we actually don't have a lot of scientific data to tell us what their needs are and what their care should look like," Kahkoska says.

One method of keeping older adults with diabetes safe is continuous glucose monitoring. Traditionally, people with diabetes measure their blood sugar levels with a finger-prick glucose meter—but that only provides a snapshot of blood sugar levels at the time of the finger prick and requires drawing blood every time someone wants to test their blood sugar.

CGMs, on the other hand, include a sensor under the skin, attached to a transmitter. These sensors provide constant, real-time data on a person's glucose levels, which is transmitted to a separate monitoring device or a smartphone app. For people using insulin pumps, the information from CGMs can also be used to automate some aspects of insulin delivery, such as stopping insulin when someone's glucose level is low or adding doses when it is high.

Yet many people with diabetes still don't use CGMs, including many older adults. So Kahkoska began research for her KL2 by asking: Why aren't more older adults using CGMs?

That question could have as many answers are there are people with diabetes. So, for her project, Kahkoska dove into the world of systems science—the study of how to analyze and understand complex, multi-dimensional phenomena—with Kristen Hassmiller Lich, a health policy researcher at Gillings. Together, they developed an innovative study design that engaged older adults and their caregivers to talk, write, and draw about their experience using CGMs. She also asked about their thoughts and feelings around how these devices could help them manage their diabetes, and what would help make the challenges easier.

These interviews yielded loads of content—hundreds of pages of transcripts, drawings, and brainstorming posters. And Kahkoska is quick to point out that the perspectives and challenges people expressed in these interviews didn't necessarily line up with expectations. For example, she says, she expected to hear that participants were resistant to or uninterested in using technology.

"And it really wasn't what we heard at all," Kahkoska says. "What we heard was a lot more complex narratives about issues accessing technology, or feeling intimidated by learning how to use technology, especially after managing diabetes for so long in a way without it."

Kahkoska used the data to develop a large "system model" illustrating all the factors that play into an older adult's experience accessing, learning about, and using CGMs, published in a 2022 paper in the journal Diabetes Research and Clinical Practice. The model reads like a map and contains a collection of "feedback loops" that show how various experiences and sequences of events can affect a person's perception and future use of CGMs.

For example, she found that failed attempts to use a CGM, such as in the process of inserting the sensor, can initially erode a person's confidence in using the device, a feeling that can be reinforced by internalized stereotypes about older people and technology. But she also discovered that when someone has more and more successful attempts inserting the CGM sensor, that can cause them to feel more skilled with the technology, creating positive reinforcement that encourages future CGM use.

Kahkoska also found that having a constant stream of data on glucose levels, with new alarms and alerts, could sometimes make people feel burned out in managing their diabetes, especially if someone did not understand how to interpret this new data. In addition, those alerts could feel intrusive to many people, resulting in less desire to use CGMs. At the same time, those alerts could also help people manage their diabetes better, which could lead to people feeling better and help reinforce CGM use.

To expand her work to a larger population, Kahkoska then led a follow-up study with Cambray Smith, an MD/PhD student at UNC, to include a more diverse sample of older adults living with both type 1 and type 2 diabetes. That paper, also published in the journal Diabetes Research and Clinical Practice, emphasized many of the same themes and feedback loops the team found with the first study.

Kahkoska is keen to credit the support she received from other researchers who have helped guide her so far in her career, going all the way back to those who gave her opportunities for research as an undergraduate at Syracuse, such as Robert Doyle and endocrinologist Ruth Weinstock, the latter of whom remains one of Kahkoska's research collaborators. And at UNC, those mentors make up a diverse coterie of researchers including Mayer-Davis, biostatistician Michael Kosorok, and endocrinologist John Buse, who helped guide her PhD work—as well as Hassmiller Lich, health policy researcher Morris Weinberger and epidemiologist Michele Jonsson-Funk, who have helped shape her research and career development as faculty.

Now, following the conclusion of her KL2 project, Kahkoska's career has expanded into numerous new research pathways, each examining a unique aspect of life with diabetes. To start, she's turning her K project back around to design a program that could help older people learn to use CGMs. That project aims to kick off as soon as this spring. In addition, she was recently awarded an independent K01 award from the National Institute on Aging to study patterns of diabetes technology use on a larger scale, using data from Medicare claims and electronic health records.

During her K, Kahkoska noticed nutritional challenges the participants were facing, so she's started additional studies to examine other aspects of care and self-management in older adults, such as dietary practices and beliefs. Kahkoska was also one of two recipients of the American Diabetes Association Pathway to Stop Diabetes Accelerator Award, focused on integrating screening and treatment for diabetes distress (the emotional challenges that can accompany the burden of managing diabetes) into the diabetes clinic at UNC.

Tackling this broad and impressive collection of research questions is, to be sure, an ambitious undertaking. But this diversity of work demonstrates how Kahkoska is using the "creative autonomy" of a research career to understand the complex forces that shape people's everyday lives—and how her focus on translational science is helping to turn that research into tangible improvements to people's health and wellness.

"That's why I love this work," Kahkoska says. "There are so many decisions that come up as part of designing a program of research, starting with thinking very carefully about the questions we even want to ask... I think there is creativity in every step that follows from there, and that is how we can make the work both innovative and pragmatic. That's what will make it impactful for the people who need it."