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Meet The Expert: Acknowledging The Daily Burden Of Type 1 Diabetes –

Margaret Zupa, MD, MS, is an Assistant Professor of Medicine in the Division of Endocrinology and Metabolism at the University of Pittsburgh and an adult endocrinologist at the UPMC Center for Diabetes and Endocrinology. 

Dr. Zupa is a health services researcher and current KL2 Scholar through the University of Pittsburgh Clinical and Translational Sciences Institute and Associate Director of the Caring for Complex Chronic Conditions Research Center at the University of Pittsburgh. Dr. Zupa’s research focuses on leveraging technology to optimize care and outcomes for people living with Type 2 diabetes (T2D).

Interview with Margaret Zupa, MD

In this interview, Dr. Zupa discusses her involvement with the T1D Exchange Quality Improvement Collaborative (T1DX-QI) as an adult endocrinologist and researcher focused on leveraging technology to decrease inequities and improve the quality of care and outcomes for people with Type 1 and Type 2 diabetes.

The T1DX-QI was established in 2016— with the support of The Leona M. and Harry B. Helmsley Charitable Trust — to refine best practices and improve the quality of care and outcomes for individuals living with T1D. Growth has been tremendous, with 60 endocrine clinics from across the U.S. participating in the Collaborative. 

Fueled by top leaders in diabetes care, the T1DX-QI has become an engine of innovation and inspiration. By engaging with the shared, data-driven, and systematic methods of the T1DX-QI, clinics have seen unprecedented success in their approach to diabetes management. 

With members working closely to identify gaps in care, discover and refine best practices, and share research — the process has become knowledge-sharing at its very best. While collated data gives clinics a clear sense of “where they are,” it also demonstrates “where they can be” by applying shared, evidence-based methods for improving care.

Why adult endocrinology?

“I love outpatient medicine, building relationships, and getting to know people over the long term. Endocrinology simply felt like ‘home’ to me,” said Zupa who completed her residency and endocrinology fellowship at UPMC.

“In medical school, everything feels overwhelming at first, and I think it’s common to be drawn toward things you’re familiar with or had some exposure to,” said Zupa. “I happened to grow up with a dad who lives with T1D and a mom who’s a nurse.”

“Having a lived experience with a family member with diabetes can be helpful in terms of understanding the daily burdens people carry,” said Zupa. “I have a special passion for working with people living with diabetes, and this perspective has been helpful in building collaborative relationships with patients in my practice.”

What do you enjoy most about your work?

“The days I get to see my patients are the best days of the week,” said Zupa. “I love in-clinic time with patients, providing support and guidance towards their individual goals. It’s been a privilege to share this aspect of people’s lives with them.”

“I always tell my patients, ‘You know your disease better than I do,’ so while I have suggestions and perspectives to offer, ultimately diabetes care is a partnership — and I’m their resource,” said Zupa. 

“People make hundreds of diabetes-related decisions every day and become true experts in their care. As a provider, I need to understand someone’s journey to help shape their care. While everyone would love to have a great A1C, its relative importance has to be in alignment with someone’s values, priorities, and other life circumstances,” said Zupa, who provides empathetic and person-centered endocrine care.

T1DX-QI and the T2D pilot at UPMC

The University of Pittsburgh is a relative newcomer to the T1DX-QI, having begun the process in the summer of 2022, explained Zupa, who serves as co-PI for adult endocrinology, along with Dr. Jason Ng who also serves as co-PI for adult endocrinology and Dr. Alissa Guarneri and Dr. Ingrid Libman of pediatric endocrinology at UPMC.

“We’ve joined the T1DX-QI in sync with our pediatric division, which has enabled us to share data mapping resources as we onboard together,” said Zupa. “We’re close to being fully data mapped which is really exciting.”

“In terms of my T1DX-QI research, I’ve been leading the T2D pilot efforts at UPMC,” said Zupa. “The end goal of this pilot is to globally increase uptake of CGM among adults with T2D, with a special focus on reducing racial and ethnic disparities. As it’s been repeatedly demonstrated in T1D, there are known disparities with CGM uptake in T2D, too.”

“One of the approaches pilot sites have taken is to ensure T2D patients are aware of what a CGM is and its potential benefits,” said Zupa. Through awareness campaigns and providers readressing CGM use at each visit for those who qualify, the pilot is set to tackle underutilization from both ends.

What led to your current research interests?

“My first research exposure during residency and fellowship was focused on discovering new ways to deliver diabetes self-management education and support to adults with T2D,” said Zupa. 

“During my postdoctoral training, my primary mentor’s research was on adults with chronic conditions, including T2D,” said Zupa. “These experiences led to some of my early research around the value of non-medical health supporters like family, friends, spouses, and adult children in supporting care and self-management for adults with T2D.”

“Then, things shifted. While I was still in fellowship and just starting to establish my research agenda — COVID hit,” said Zupa. “As an endocrinologist, I didn’t feel like telemedicine was working well for many patients, mostly because we couldn’t deliver similar care and resources, as we had been, with in-person care. So, from a clinical perspective, I felt like, ‘Gosh, maybe we should be looking deeper into this.’”

“Here’s the thing, COVID was a massive natural experiment for us — where everyone started using telemedicine all of a sudden,” explained Zupa. “So it makes sense that it might not be perfect at first, and there might be a lot to learn.” 

“Because of this, I began to study virtual care surrounding the pandemic: Who used it, who did well with it, and who didn’t. Which led to examining ways in which telemedicine could be improved for diabetes care — and to better support folks who face barriers to in-person care,” said Zupa.

“My research focus remains on leveraging technologies to improve access to quality care and outcomes for adults with T2D,” explained Zupa. “Most of my work is on examining real-world experiences and outcomes associated with the use of telemedicine and other technologies for diabetes care, to better understand how we can improve — or optimally use these tools — to benefit more patients.” 

“This is especially important for people living in medically under-resourced communities, or with multiple chronic conditions, for whom access to this care can be critically important,” explained Zupa, who dedicates 85% of her time to diabetes-related research.

Let’s talk about the stigma surrounding T2D — how can we improve? 

“I do think we’ve seen a social and cultural shift over the last few years, similar to the way society talks about obesity. It’s changing, and I think we’re increasingly understanding that a person’s genetics and environment play a huge role in the development of T2D,” explained Zupa.

“The conversation is changing from it’s ‘your fault’ to ‘you live in a society and culture where it’s hard to walk to work, accessing healthy food may not be easy, and sometimes prioritizing health needs can take the backseat to other demands in life,” said Zupa.

“With T2D, there are so many things at play. You can have 20 people with the same BMI, and they’re not all going to develop it,” explained Zupa. 

“As providers, we need to support people as they make lifestyle changes that are feasible and sustainable for them as individuals. But, we also have to treat this for what it is — a medical condition — and not something an individual has ‘caused’ to happen,” said Zupa. “This can help to erase some of the stigma, shame, and self-blame people are feeling.”

“It’s been drilled into people that what you eat, how much you move, and other lifestyle factors are all on them, and of course, all of those things are crucial, but maybe some of it is also on me as their doctor, that I haven’t found the approach that’s going to work best for someone’s underlying pathophysiology,” said Zupa.

What is your involvement in the Caring for Complex Chronic Conditions (C4) Research Center at UPMC?

“At C4, our primary goal is to bring together different health services and clinical researchers with a focus on improving health and healthcare for adults with chronic health conditions,” said Zupa, who serves as an associate director with C4 director, Dr. Ann-Marie Rosland.

“While there are different research focuses within the center, as a group, we all have similar agendas. C4 fosters collaboration and interaction around each investigator’s research area. It’s similar in a way to the T1DX-QI, but on a much smaller scale, connecting trainees, students, faculty, researchers, and others who hold an interest in healthcare quality and delivery in adults with multiple comorbidities,” said Zupa.

What’s next? What’s your hope for the future?

“I think a lot about the mental bandwidth associated with diabetes decision-making and the toll it takes on folks,” said Zupa.

“My hope is, as we continue to see progress with advancements in technology and treatments, they’ll give way to achieving individual goals with less mental burden and bandwidth. And in turn, improve day-to-day life with diabetes,” said Zupa. 

“While work is still underway on closed-loop systems and other therapies, as they advance, there will be a lightened burden on everyone living with diabetes,” said Zupa. “And as we see improvements in access and drug delivery technologies, people will achieve their goals with less effort.”

What do you enjoy outside of work?

Outside of work, Dr. Zupa enjoys gardening, reading fictional novels, trail running, and hiking in the state parks of Western Pennsylvania with her husband and dog, Birdie.