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Caring for Patients with Chronic IllnessIntroduction to Diabetes Mellitus

Debra L. Simmons, MDAssistant Professor of Medicine

Director, Arkansas Diabetes ProgramDirector, Training Program Endocrinology, Diabetes

and MetabolismUniversity of Arkansas for Medical Sciences

and Central Arkansas Veterans Healthcare System

General Attributes of Medical Visits

Acute• patient seeks doctors

advice for a problem• frequently a “complaint”

– headache– chest pain– cough

Chronic• regularly scheduled

appointment• usually no “complaint”

– fu effectiveness of treatment

– monitor for complications of treatment or disease

General Attributes of Medical Visits cont.

Acute• History and physical

– focuses on determining the cause of the complaint

• More likely to be physician directed for treatment

Chronic• History and physical

– focuses on issues related to the chronic disease

• Usually requires the patient actively deciding goals of therapy and treatment

Introduction to Diabetes Mellitus

• Epidemiology

• Diagnosis and classification

• Goals of diabetes management

Epidemiology of Diabetes

• 15.7 million Americans have diabetes

–10.3 million diagnosed

–5.4 million not diagnosed

• 90% have type 2 diabetes• 8.2% of people aged 45 to 64 in

Arkansas have diabetes

NDEP

Percentage of US Population by Age and Race With Diagnosed Diabetes

Harris MI et al. Diabetes Care. 1998;21:518-524.

*% based on medical history interview insubjects asked about previous Dx by physician.

1.1

3.9

8.0

12.6 13.2

3.3

7.5

11.312.6

1.6

6.2

13.8

20.9

17.5

0.8

7.3

16.0

24.4

21.7

1.0

02468

101214161820222426

20-39 40-49 50-59 60-74 75

All races Non-Hispanic white

Non-Hispanic black Mexican-American

%

Age group (yr)

Seriousness of Diabetes• Diabetes increases risk of

– death– cardiovascular disease– stroke

• Diabetes is the leading cause of – adult blindness– end stage renal disease– nontraumatic amputations

45-64 65-74 >740

2

4

6

Age (yr)

Men Women

Relativerisk

Risk vs nondiabetic

Ford ES et al. Am J Epidemiol. 1991;133:1220-1230.

Mortality in People With Diabetes:US Population

0

10

20

30

40

50

%of deaths

Ischemicheart

disease

Otherheart

disease

Diabetes Cancer Stroke Infection Other

Geiss LS et al. In: Diabetes in America. 2nd ed. 1995; chap 11.

Mortality in People With Diabetes:Causes of Death

%of new casesof blindness

Age (yr)

Due to diabetes Due to diabetic retinopathy

45 65 75 850

10

20

30

Klein R et al. In: Diabetes in America. 2nd ed. 1995; chap 14.

New Blindness in US Adults: Contribution From Diabetes

Prevalence of ESRD by Primary Diagnosis, 1996*

*Prevalence as of December 31, 1998 derivedfrom Medicare billing records.

32.5%Diabetes

24.5%Hypertension

Other20.6%

Glomerulo-nephritis

17.7%Cystic kidneydisease 4.7%

NIDDK. USRDS1998 Annual Report.

% of population

Reiber GE et al. In: Diabetes in America. 2nd ed. 1995; chap 18.

Diabetes and Lower Extremity Amputations:Prevalence of All Lower Extremity Amputations

0

0.5

1

1.5

2

2.5

3

3.5

18-44 45-64 >64

Nondiabetic Diabetic

Chronic Complications of Diabetes

• Macrovascular– coronary artery disease– cerebral vascular disease– peripheral vascular disease

• Microvascular– retinopathy– nephropathy– neuropathy


• Epidemiology



ADA 1997 Diagnostic Criteria for Diabetes Mellitus

1. Fasting plasma glucose >126 mg/dl* or

2. Symptoms plus random plasma glucose >200 mg/dl* or

3. Oral glucose tolerance test 2-hr plasma glucose >200 mg/dl*

* Must confirm on another day unless DKA or HHNC; not for pregnancy

ADA Diabetes Care 2000


1. Fasting plasma glucose >126 mg/dl – 8 hour fast– preferred test for diagnosis– NOT capillary blood glucose


2. Symptoms plus random plasma glucose >200 mg/dl – polyuria– polydipsia– polyphagia– weight loss– fatigue– poor healing


3. Oral glucose tolerance test plasma glucose 2-hr >200 mg/dl

– 75 gram glucose load– 2 hour post glucose load plasma glucose– primarily for research

ADA 1997 Etiologic Classification of Diabetes

• Type 1 diabetes

• Type 2 diabetes

• Gestational diabetes

• Other specific types


Type 1 Diabetes

-cell destruction

• Usually leading to absolute insulin deficiency

• Ketosis prone

• Two forms– immune-mediated – idiopathic which is rare and without known cause

Type 1 DiabetesImmune-mediated

• Commonly occurs in childhood• May occur any age, even 9th decade• Rate of -cell destruction variable

– usually rapid in childhood– may be slow in adults

• Markers include– islet cell autoantibodies– autoantibodies to glutamic acid decarboxylase

Type 1 Diabetes:Typical Presentation

• Young age

• Thin

• Classic symptoms– polyuria, polydipsia, polyphagia and weight loss

• May have diabetic ketoacidosis

• No family history of diabetes

Type 2 Diabetes

• Impaired insulin action– insulin resistance– primarily peripheral tissue defect

• Impaired insulin secretion– relative insulin deficiency– primarily -cell defect

Glucose

Liver

Peripheral Tissues(Muscle)

Pancreas

Increased glucoseproduction

Impaired insulinsecretion

Insulinresistance

Causes of Hyperglycemia in Type 2 Diabetes

Type 2 Diabetes

• Most are obese

• Spontaneous ketoacidosis rare

• Ketoacidosis may occur with stress

• Strong genetic predisposition

Type 2 Diabetes:Typical Presentation

• Many people are asymptomatic– Routine physical– Preop labs

• Not uncommon to present with complication– MI– Peripheral neuropathy– Foot ulcer

• Frequently family history diabetes

Gestational Diabetes Mellitus

• Any degree of glucose intolerance

• First recognition during pregnancy

• Reclassify 6 weeks postpartum

Other Specific Types

• Diseases of the exocrine pancreas– pancreatitis

• Drug- or chemical-induced– glucocorticoids– nicotinic acid

• Many others


• Epidemiology



Goals of Diabetes Management

• Prevention of acute complications– significant hypoglycemia– symptomatic hyperglycemia including DKA

• Prevention of microvascular complications

• Prevention of macrovascular complications

• Attainment of normal quality of life

Diabetes Control and Complication Trial

• 1441 type 1 diabetes

• Conventional therapy: 1-2 insulin injections per day

• Intensive therapy: 3-4 insulin injections per day or insulin pump

• Followed average of 6.5 years

• Published 1993

Effect of Intensive Glycemic Control in the DCCT: HbA1c Levels

Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993;329:977-986.

0 1 2 3 4 5 6 7 8 9 105

6

7

8

9

10

11

HbA1c

(%)

Study year

Conventional therapy

Intensive therapy6.05

Normal

Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993;329:977-986.

DCCT: Results of Intensive Therapy

Retinopathy 76%

Nephropathy 54%

Neuropathy 60%

Rate/100person-years

24

20

16

12

8

4

09876543210

Mean HbA1c = 11% 10%9%

8%

7%

Conventional treatment

Time during study (y)

DCCT Research Group. Diabetes. 1995;44:968-983.

DCCT: Absolute Risk of Sustained Retinopathy Progression by HbA1c and Years of Follow-up

United Kingdom Prospective Diabetes Study

• 5102 newly diagnosed type 2 diabetes

• Conventional policy: diet

• Intensive policy: sulfonylurea, metformin (in overweight patients), or insulin

• Mean 10-year follow-up

• Published 1998, designed 1970s

Cross-sectional and 10-Year Cohort Data:Intensive vs Conventional Policy

UKPDS GroupUKPDS Group. Lancet. 1998;352:837-853.

All patients assigned to regimen

IntensiveConventional

Patients followed for 10 years

IntensiveConventional

Time from randomization (y)

60 3 9 12 15

Time from randomization (y)

60 3 9 12 15

0100

FPG

MedianFPG

(mg/dL)

HbA1c

7

8

9

6

Median HbA1c

(%)

200

180

160

140

120

UKPDS Results of Intensive Policy:Sulfonylurea/Insulin

Microvascular complications 25% Retinopathy progression 21% Nephropathy 34%

UKPDS Group. Lancet. 1998;352:837-853.

ADA Recommendations for Glycemic Control

Goal Take ActionPreprandial glucose mg/dl

80-120

<80>140

Bedtime glucose mg/dl 100-

140

<100>160

HbA1c %

<7 >8


Prevention of Macrovascular Disease

• Control of hypertension

• Control of lipids

• Cessation of smoking

• Aspirin use

Prevention of Macrovascular Disease: Control of Hypertension

• UKPDS substudy proved effectiveness of BP control– Intensive control (mean 144/82 vs 154/87)

reduced strokes 44%, diabetes related deaths 32% and heart failure 56%

• Goal <130/85 mmHg

• ACE inhibitor currently preferred due to renal protective effect


Prevention of Macrovascular Disease:Control of Lipids

• Primary goal is LDL cholesterol <100 mg/dl– same as NCEP guidelines for secondary

prevention– due to very high risk of CAD in diabetes

• Secondary goal is HDL cholesterol >45 mg/dl for men and >55 mg/dl in women


Prevention of Macrovascular Disease: Cessation of Smoking

• Cigarette smoking and diabetes– increases risk of morbidity and mortality of CVD

• Counsel to quit smoking


Prevention of Macrovascular Disease: Aspirin Use

• Low dose aspirin– 81-325 mg/day if >21 YO

• Secondary prevention – MI, stroke, TIA, PVD, angina, claudication

• Primary prevention if high risk– family history CVD, cigarette smoking,

hypertension, obese, albuminuria, dyslipidemia


Attainment of Normal Quality of Life

• Patient at center of team of health care providers

• Psychosocial issues extremely important

Diabetes Team

PATIENT

Primary care provider

Endocrinologist

Diabetes educator

Nutritionist

Podiatrist

Social worker

Psychologist

Exercise physiologist

Patient Education: Diabetes Self-Management

• Understand diabetes disease process– emphasis on benefit of good control

• Learn appropriate diet– individualized diet plans

• Learn self-monitoring of blood glucose– use of meter– what to do with the results

Patient Education: Diabetes Self-Management cont.

• Learn how to use prescribed medications– how it works– when to take it– side effects

• Learn how to balance diet, exercise and medications as well as stress

• Learn sick day rules

Psychosocial Issues:Impact of the Disease

• May be devastating due to fear of complications

• May be overwhelming due to complexity of caring for the disease– must watch what they eat, when they eat, take

medications on time, juggle activity with food intake and medications, go to the doctor regularly

– can not just think about it occasionally

Psychosocial Issues:Other

• Many psychosocial issues may impact the ability of the patient to care for themselves– lack of money, access to healthcare providers– turmoil in family such as caring for a dying

parent, spouse with Alzheimer’s disease, child involved with drugs

– psychiatric illness such as depression greatly impairs the patient’s ability to care for diabetes

Summary of Goals of Diabetes Management

• HbA1c <7%

• BP <130/85

• LDL cholesterol <100 mg/dl

• Smoking cessation

• 1 aspirin/day

• Normal quality of life

Follow Up Visit for Diabetes

• Chief complaint

• History since last visit

• Physical exam

• Laboratory

Follow Up Visit for Diabetes: Chief Complaint

• Usually routine visit

• May have additional complaint(s)– evaluate as usual in addition to routine visit if

possible

Follow Up Visit for Diabetes: Basic History

• Can be from chart and/or obtain from the patient– type of diabetes– duration of diabetes– complications of diabetes– medications for treatment of diabetes (always

confirm)– all other medications (always confirm)

Follow Up Visit for Diabetes:History Since Last Visit

• Problems with management plan– medication, diet, exercise

• Results of self-monitoring of blood glucose– review log book of results and comments

• Specifically question about hypoglycemia– do not assume they will tell you or that it is

marked in their log book

Follow Up Visit for Diabetes:History Since Last Visit cont.

• Question about any changes – health– social issues– family history that effects patient’s CVD risk

• Review need for referral for yearly dilated eye exam (screening for retinopathy)

Follow Up Visit for Diabetes:Laboratory

• Review HbA1c results and goals

• Review lipid results and goals

• Review need for yearly lab– microalbuminuria (screening for early

nephropathy)

Follow Up Visit for Diabetes:Physical Exam

• BP, weight, height (yearly for adults)

• Previous abnormalities on exam– Focus is commonly cardiovascular as well as

funduscopic exam and insulin injection sites

• Foot exam in high risk patients– peripheral neuropathy– prior foot ulcer or amputation

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