Caring for Persons with Diabetes Developed by: American Optometric Association Health Promotions...

Caring for Persons with Diabetes Caring for Persons with Diabetes

Developed by:

American Optometric Association

Health Promotions Committee

Epidemiology of DiabetesEpidemiology of Diabetes

26 million Americans have diabetes– 90% have type 2 diabetes

79 million more Americans are at high risk for developing diabetes within ten years

1.8 million new cases diagnosed each year

Diabetes care accounts for 1 of every 6 health care dollars spent in the US

Epidemiology of Diabetes

The incidence of Type 2 diabetes in Americans < 20 years of age has grown 1100% since 1970

It is the fastest growing sub-population of diabetes by far

Diabetes is the 6th leading cause of death in the US

The leading cause of blindness in those < 74 yo

The leading cause of kidney failure

The leading cause of non-traumatic amputation

Diabetes MythsDiabetes Myths

Diabetes is caused by eating too much sugar

Not taking medications to control diabetes means the disease is less serious

Having type 2 diabetes is ‘better’ than having type 1 diabetes

Type 2 diabetes is not hereditary

A Look at the Numbers…A Look at the Numbers…

Diabetes Affects 28.5 Million AmericansDiabetes Affects 28.5 Million Americans

Of those:– 18.8 million diagnosed– 7 million not yet diagnosed– 215,000 are under 20 and mostly have

type I diabetes

Diabetes is…Diabetes is…

The LEADING cause of– Kidney failure– Non-traumatic lower limb amputations– New cases of blindness in adults

A MAJOR cause of – Heart disease– Stroke

The 7th leading cause of death in USA

Diabetes: A DefinitionDiabetes: A Definition

Failure of the pancreas to produce sufficient amounts of the hormone insulin

- or - Resistance of the body’s cells to the action of insulin

InsulinInsulin

Insulin allows cells throughout the body to absorb sugar (glucose) from the bloodstream

The source of glucose is mostly from carbohydrates in the foods we eat, but it can also be made by breaking down glucose stored in our muscles and liver

Insulin & Glucose are necessary for the brain, heart & kidneys to function

When Insulin isn’t Helping Glucose into the Cells…When Insulin isn’t Helping Glucose into the Cells…

Hyperglycemia occurs (blood sugar levels go up)

This causes damage to body tissues, especially blood vessels

This then leads to eye disease, kidney disease, nerve disease and heart disease

Diabetes-related eye disease predicts these other diseases

Diabetes Mellitus - ClassificationDiabetes Mellitus - Classification

Insulin Dependent (IDDM) Non-Insulin Dependent (NIDDM) Gestational (GDM)

Insulin-Dependent Diabetes Mellitus (IDDM)Insulin-Dependent Diabetes Mellitus (IDDM)

Results from destruction of islet cells in the pancreas More common in persons under 20 years of age Etiology both genetic and environmental Patients acutely symptomatic at the time of onset (“the polys”)

Non-Insulin Dependent Diabetes Mellitus (NIDDM)Non-Insulin Dependent Diabetes Mellitus (NIDDM)

Resistance of body tissues to the action of insulin:– Insulin resistance– Beta-cell failure

Usually occurs after age 40 Gradual onset of symptoms (half are unaware) Occurring more frequently in children Risk factors:

– Overweight & sedentary– Family history of diabetes– Ethnic origin

Gestational Diabetes Mellitus (GDM)Gestational Diabetes Mellitus (GDM)

Glucose intolerance of variable severity with onset or first recognition during pregnancy (2nd & 3rd trimester)

Complicates between 1% and 4% of pregnancies Limited to the term of the pregnancy Fetal outcome - Macrosomia GDM Moms are 50% more likely to develop NIDDM later Offspring are more likely to develop NIDDM during their lifetime

What Are the Symptoms?What Are the Symptoms?

All type 1 patients have symptoms

Many type 2 patients have few or no symptoms until serious complications develop

(e.g. a heart attack)

Symptoms of HypoglycemiaSymptoms of Hypoglycemia

Shaking Weakness

Sweating Fatigue

Fast heart beat Head Ache

Dizziness Irritable

Anxious

Hunger

Impaired vision

Symptoms of severe low blood sugarSymptoms of severe low blood sugar

Seizure

Loss of consciousness (coma)

Stroke

Death

Treatment of HypoglycemiaTreatment of Hypoglycemia

15 to 20 grams of carbohydrate that puts glucose into your bloodstream in about 5 minute will raise your blood sugar about 30 milligrams per deciliter (mg/dL) in about 15 to 20 minutes

Check your blood sugar level again 15 minutes Have person drink ½ glass of juice or regular soft drink,or 1 glass of milk

If symptoms don’t stop, call internist

Then eat a light snack (1/2 peanut butter or meat sandwich and ½ glass of milk)

Always have a rapid-acting carbohydrate in the office

Symptoms of HyperglycemiaSymptoms of Hyperglycemia

Extreme thirst Blurred vision

Frequent urination

Dry skin

Healing difficulties

Hunger

Drowsiness

Treatment of HyperglycemiaTreatment of Hyperglycemia

Have patient test blood sugar You can often lower your blood glucose level by exercising.

However, if your blood glucose is above 240 mg/dl, check your urine for ketones.

If you have ketones, do not exercise Exercising when ketones are present may make your blood

glucose level go even higher. Drink more water Change medication/ eating habits If >200mg/dl for several tests, for two days, or if extremely

elevated:

Call internist

Treatment Modes Treatment Modes

Pen injectors

Inhaled Insulin (currently off the market)

Insulin pumps

CGMs

Net based education

New medications

Insulin used more than in past

Non-Retinal Eye ComplicationsNon-Retinal Eye Complications

CORNEA - One of two clear tissues in the body

LENS - The other clear tissue– It is a very complex process to keep these tissues clear

Refractive errorRefractive error

In poorly controlled diabetes very high levels of glucose can cause the lens metabolism to shunt down a sorbital pathway

Sorbital buildup in the lens creates an osmotic swelling of the lens with resulting in refractive changes

Poor Pupil ResponsePoor Pupil Response

Before DilatingDrops

30 minutes AfterDilating Drops


IRIS - Colored part of eye - rubeosis irides - new vessel growth that can cause serious glaucoma complications and is usually associated with PDR– Typically is associated with advanced diabetic retinopathy;

not easy to identify

GLAUCOMA - Twice as likely in persons with diabetes and more likely to cause vision loss


OPTIC NERVE - Can sometimes swell (optic neuritis) - generally found in younger persons with diabetes and can lead to permanent vision loss

CRANIAL NEUROPATHIES - Ptosis (lid droop) and proptosis (eye bulge); occasional reversible diplopia; Bell’s Palsy

Eyelids - Skin related problems

Eye Muscle Problems

Retinal Eye ComplicationsRetinal Eye Complications

BDR - Background Diabetic Retinopathy– Microaneurysms, leakage of intravascular fluid,

intraretinal hemorrhage, retinal ischemia

PPDR - Pre Proliferative Diabetic Retinopathy PDR - Proliferative Retinopathy

– New Vessel Growth

Remember – the retina is a very thin tissue

Mild NPDRMild NPDR

Standard Photo 1

Moderate NPDRModerate NPDR

Standard Photo 2A

Severe NPDRSevere NPDR

Standard Photo 2B

Very Severe NPDRVery Severe NPDR

Standard Photo 5

Proliferative Diabetic Retinopathy (PDR)Proliferative Diabetic Retinopathy (PDR)

Neovascularization of the Disc (NVD) Neovascularization Elsewhere (NVE) Pre-retinal Hemorrhage (PRH) Vitreous Hemorrhage (VH)

Non-High Risk Proliferative Diabetic RetinopathyNon-High Risk Proliferative Diabetic Retinopathy

Standard Photo 10A Standard Photo 6B

High Risk Proliferative Diabetic RetinopathyHigh Risk Proliferative Diabetic Retinopathy

Standard Photo 10C Standard Photo 7 Standard Photo 10 Standard photo 13

Laser Photocoagulation TreatmentLaser Photocoagulation Treatment

InjectionsInjections

Triamcinolone acetonide

Lucentis and Avastin

Diabetic Macular Edema(DME)Diabetic Macular Edema(DME)

The collection of intraretinal fluid in the macular area Disrupts retinal structure With or without lipid exudate or cystoid changes Focal or diffuse Can occur at any stage of retinopathy Only treated when it becomes “clinically significant” Follow-up every 3 to 4 months by a retinal specialist

Clinically Significant Macular Edema (CSME)Clinically Significant Macular Edema (CSME)

Patients referred for treatment immediately. CSME responsible for nearly HALF of all vision loss in diabetes!

Diabetic RetinopathyDiabetic Retinopathy

The most significant ocular complication of diabetes The leading cause of blindness - ages 20-74 All complications of diabetes have a slow progression

in the beginning– leads to patient non-compliance

Type I DiabetesType I Diabetes

Past thinking: Usually free of retinopathy for first ten years after diagnosis

Present Thinking: 20% have retinopathy at one year; 67% have retinopathy at five years

95% have retinopathy after 15 years or more

Type II DiabetesType II Diabetes

May have retinopathy at diagnosis

30% have retinopathy within 5 years

80% have retinopathy within 15 years

Severity of Diabetic RetinopathySeverity of Diabetic Retinopathy

Depends on– Disease Duration - always ask how long– High Blood Pressure - very serious– High Glycosolated Hemoglobin– Smoking = major risk

Example:– Patient A.J. (HTN, A1c = 10, smoker): diabetes

less than 20 years; vision: 20/800– Patient D.D. (good control of all risk factors):

diabetes greater than 25 years, vision: 20/15

Optometric Management of Persons with DiabetesOptometric Management of Persons with Diabetes

Frequency of Exams– After Diagnosis: Every Year Dilated Pupil Exam

(Should be pre-scheduled)– After First Diagnosis of Diabetic Eye Changes:

Every year or six months– At Pre-Proliferative Stage

Should be referred to retinal specialist Less than 50% of persons with diabetes get dilated

eye exams yearly– You must preschedule!!

Treatment OptionsTreatment Options

PREVENTION - 75% of all diabetic retinopathy could be eliminated with proper control of the disease– Medication - Drs. do adequate job– Exercise - Drs. do poor job– Diet - Drs. do poor job

One of the greatest causes of death and disability in the USA is overeating and a diet heavy in fats, meats, and sugars


Argon Laser Photocoagulation Pan Retinal Photocoagulation

– Laser kills peripheral retinal tissue– feedback to brain says - “this is dead tissue, no

need to grow vessels here” Victrectomy

– Remove bloody scarred vitreous and replace with saline

– Injections

Laser PhotocoagulationLaser Photocoagulation

Reduces visual loss by 50% Goals:

– Prevent further neovascularization– Reduce risk of vitreous hemorrhage and/or reduce

traction retinal detachment Side Effects (lessened now with injections)

– Constriction of peripheral vision– Decreased night vision– Loss of acuity


Early Diagnosis is the Key– ALWAYS preschedule your patients with diabetes

for annual (and other) visits Education/Motivation is Essential

– 1-800-DIABETES/diabetes.org– Diet Consult– Exercise Consult– Diabetes Education Classes now covered by

major medical and Medicare

Why Does Diabetes Kill So Many Americans?Why Does Diabetes Kill So Many Americans?

Doctors do not seem to understand the disease

Patients do not seem to understand the disease

The public does not seem to understand the disease

Not many people care– primarily affects older people, or under/un-insured

Obesity by the numbersObesity by the numbers

Complications from obesity kill more Americans than smoking – and smoking kills 1000 Americans per day!!!!

Strokes, hypertension, cardiovascular disease, and diabetes can all cause blindness, as well as other disabilities and death

Supersized SuicideSupersized Suicide

The food industry produces 3800 calories per day for every person in the USA; up from 3300 from the 70s.

Adult females need 2200; adult males 2500 The food industry spends 10 billion dollars

yearly in direct advertising and another 20 billion in indirect advertising (school scoreboards etc.)

Two words: Free Refills!! (and what ever happened to a ten ounce bottle of soda?)

Supersized SuicideSupersized Suicide

The campaign for fruits and vegetables spends about 2 million per year on public education

The food industry pushes processed foods (potatoes are cheap; potato chips are not)

Portion sizes have increased dramatically

Kids in the line of fireKids in the line of fire

70% of obese children will become obese adults

Most breakfast cereals and kid drinks should be labeled as candy – Froot Loops has no fruit and no fiber

Soda Pop parties; food as a reward; candy and bake sale fundraisers; terrible cafeteria food; less exercise, more video games, and more computer time

A paradigm shift needs to occurA paradigm shift needs to occur

Insurance will pay for special shoes, medical procedures (such as amputation), however, dietary counseling needs to be covered as well.

Nutrition training is important for doctors, additionally it is important to discuss weight even when the patient’s ‘vital signs’ seem OK

Obesity is not a cosmetic issue, it is a medical issue

Research on obesity is obsceneResearch on obesity is obscene

NIH = 226 million for obesity research

NIH = 2 billion for cardiovascular research

If we cured the obesity, we wouldn’t have near the cardiovascular disease!

Are we just overeating?Are we just overeating?

We are exercising less Our jobs require less manual labor We have larger portions shoved at us We have advertising bombarding us We are eating out more For easing stress, if we don’t do drugs, we do

food Even as adults, food is a reward

Is this just a USA thing?Is this just a USA thing?

Well, no, but look at this……….

Great Marketing TricksGreat Marketing Tricks

Millions of dollars are spent encouraging us to eat more highly processed foods

What can WE do??What can WE do??

Share portions Special order Take home boxes or just leave it on the plate Don’t be blinded by the advertising Eat less processed foods Reduce meats, fats, and high sugar foods Forget about special ‘no protein, all protein, no white

food, blah, blah, blah diets and simply change your eating behavior

Exercise more

Self Monitoring of Blood GlucoseSelf Monitoring of Blood Glucose

One Touch Ping and Animas Pump

SMBGSMBG

Self-monitoring of blood glucose

All patients should perform SMBG– Fasting and after meals (ideally, but rarely done,

and if so usually on Type I persons)– 50% of people with diabetes do NO SMBG

Normal blood glucose is between 70-110– Up to 150 after a meal– Less than 90 in the morning after fasting

Continuous Glucose MonitorsContinuous Glucose Monitors

Inserted under the skin Replaced generally weekly Shows trends Still must be calibrated with finger sticks

twice daily Alarm settings can signal a call to action Some will “talk” to an insulin pump but not

make automatic changes

Dexcom Continuous MonitorDexcom Continuous Monitor

Transmitter and receiver

What Does Diabetes Research Tell Us?What Does Diabetes Research Tell Us?

Keeping blood pressure levels below 130/80 lowers the risk of all diabetes complications

Getting an annual dilated eye exam cuts the risk of going blind from diabetes by up to 95% by allowing for early detection of eye complications

Hemoglobin A1c (HbA1c)Hemoglobin A1c (HbA1c)

HbA1c measures the AVERAGE blood sugar level over the preceding 3 months

HbA1c predicts those people most likely to go blind and/or die from diabetes

“Normal” HbA1c is around 5%

The average patient with diabetes has an HbA1c of 8.5%

For most people with diabetes, the HbA1c goal is <6.5%– Exceptions are kids and those with established CVD

What Does Diabetes Research Tell Us?What Does Diabetes Research Tell Us?

Keeping blood sugar levels as close to normal as possible lowers the risk of all diabetes complications– Diet (especially portion control)– Exercise (lowers blood sugar & improves

insulin resistance)– Medication

Patients & Doctors need to know their numbers and what they mean…

Preventing DiabetesPreventing Diabetes

Walking 30 minutes each day, five days each week, reduces the risk of developing diabetes by up to 60%

Sleeping 7-8 hours and eating more vegetables also lowers diabetes risk

If you don’t get diabetes, you can’t go blind, lose a foot, or die from diabetes!

Who Should Educate?Who Should Educate?

Each and every health care provider, including para-optomteric staff

The best way to change unhealthy behaviors is by building a relationship with your patient

If the patient hears the same plan from every provider, they are more likely to follow through on proper care

Practical Tips for Health Care TeamPractical Tips for Health Care Team

Tell the doctor you’re interested in helping provide excellent diabetes care

Learn all you can about diabetes

Make sure you’ve got orange juice or sugared soda set aside for patients

Develop a plan to measure blood pressure & ask about HbA1c for every patient with diabetes


Ask about SMBG

Ask about physical activity

Ask about common diabetes medicines– Insulin and/or pills for blood sugar– Blood pressure & cholesterol medicines– Aspirin therapy


Ask who treats their diabetes & how often they’re seen

Ask if they would like more information on diabetes and preventing complications

Help the doctor to make sure that every patient with diabetes is dilated annually

Remember that diabetes is not who they are, but a condition they have

What the DCCT Told UsWhat the DCCT Told Us

Prevention IS the cure– 76% less retinopathy– 54% less kidney disease– 60% less neuropathy– 50% less amputations

These results are over ten years old and doctors and patients still do not understand

Key PointsKey Points

Diabetes is a serious disease Diabetes has become an epidemic Treating diabetes complications like eye disease and

heart disease is a LOT more expensive than preventing those complications

Eye doctors and their assistants are on the ‘front line’ in the battle against diabetes, and can make a real difference

Optometric Role in Managing Patients with DiabetesOptometric Role in Managing Patients with Diabetes

Take a good case history to find the undiagnosed (6 million)– Episodes of blurred vision?– Polys – Increased thirst, hunger, urination, – FFFF – Fat, Forty, Female, Family History

Low Vision Training– provide low vision care for the partially sighted

Pre-schedule all persons with diabetes Refer to diabetes specialists

– Internists– Dieticians– Diabetes educators

Low vision examsLow vision exams

Low Vision exams

-evaluate functional vision and

-assesses individual needs (especially

important for those with vision loss due

to diabetes)

LCD video magnification LCD video magnification

Sharper image than TV Up to 50X magnification Takes up less space Around 2200.00 Enables patient to read or

look at pictures And write checks and

letters

Lighted magnifiers reduce glare and provide contrast

Lighted magnifiers reduce glare and provide contrast

Spectacle mounted telescopes can improve distance vision dramaticallySpectacle mounted telescopes can improve distance vision dramatically

State Department of RehabilitationState Department of Rehabilitation

Can Give a Workshop on Services They Provide

Can Be A Great Referral Service for Low Vision Patients

Summary:Summary:

Very Serious Disease Early Detection Essential Education Essential Good Control = Less Complications Intervention/Treatments = Less Blindness Low Vision Services May Help to

Rehabilitate Patients Who Have Lost Vision

THANK YOU!THANK YOU!

For More Info:

American Optometric Association: aoa.org

American Diabetes Association: diabetes.org

National Institutes of Health: ndep.nih.gov

Caring for Persons with Diabetes Developed by: American Optometric Association Health Promotions...

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