Diabetes presentation nosscr 112011 san antonio 2


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  • Good afternoon everyone and welcome to the update from the May 2010 New Orleans NOSSCR Conference presentation on Diabetes. My name is Suzanne Villalon-Hinojosa and I am an attorney practicing primarily Social Security Disability here in San Antonio since 1996. I became Board Certified in Social Security advocacy in 2008 and have represented many diabetic claimant’s before the Social Security Administration over the years. I was recently asked to join the Latino Diabetes Action Council of the American Diabetes Association by Dr. Victor Gonzalez, Chairperson of the Texas Diabetes Council and former classmate of mine from our undergraduate years at Princeton University. The request was timely because it coincided with SSA’s proposal to eliminate the listing for diabetes. Those proposed rules were published in December of 2009. I have worked with both NOSSCR and the ADA to inform SSA about diabetes and disability and hope that our efforts will lead to a helpful ruling on the condition. Today I have the pleasure of presenting with Dr. Melissa Kempf, a San Antonio Doctor who is Board Certified in Family practice. Dr. Kempf blends a traditional approach with alternative therapies in her practice and is well suited to provide for us “the physician perspective” on the diabetic patient/social security claimant. Dr. Kempf attended Texas Tech University Health Science Center School of Medicine. She was stationed at Biloxi MS at Keesler AFB for her Air Force active duty and was deployed to Incerlik Turkey just after 9/11. Before her tenure in Family Practice Dr. Kempt was a primary investigator for a study related to gut dysfunction in autistic children. This lean to an appreciation for some alternative medicine therapies, mostly nutritional/vitamin supplement based rather than prescriptions. After 6 years with a group of doctors in San Antonio, she decided to set off on her own for the freedom to develop a more preventative approach to medicine rather than just traditional sick care. Dr. Kempf is “in the trenches” so to speak the type of typical diabetic clients we see daily and we are very pleased that she here to provide her perspective for our discussion.
  • The CDC Fact Sheet for 2007 reported: 23.6 million people—7.8 percent of the population—have diabetes. Diagnosed: 17.9 million people  Undiagnosed: 5.7 million people 57 million people—pre-diabetics By 2025, it is estimated that 50 million people will be living with diabetes Why have the numbers increased so significantly? Is there evidence to suggest that the use of A1C to diagnose diabetes accounts for the rise in numbers? Dr. Kempf In contrast to National Diabetes Statistics, 2007 , which used fasting glucose data to estimate undiagnosed diabetes and pre-diabetes, National Diabetes Statistics, 2011 uses both fasting glucose and A1C levels to derive estimates for undiagnosed diabetes and pre-diabetes. These tests were chosen because they are most frequently used in clinical practice. National Diabetes Information Clearinghouse. Wider application of a more convenient test (A1C) may actually increase the number of diagnoses made. ADA Standards of Care 2011
  • Earlier this year, researchers at the Centers for Disease Control and Prevention reported in the American Journal of Preventive Medicine that a swath of the Deep South and Appalachia has emerged as the US “diabetes belt.” Study Conclusions: Nearly one third of the difference in diabetes prevalence between the diabetes belt and the rest of the U.S. is associated with sedentary lifestyle and obesity. The Diabetes Prevention Program (DPP) was a major multicenter clinical research study aimed at discovering whether modest weight loss through dietary changes and increased physical activity or treatment with the oral diabetes drug metformin (Glucophage) could prevent or delay the onset of type 2 diabetes in study participants. At the beginning of the DPP, participants were all overweight and had blood glucose, also called blood sugar, levels higher than normal but not high enough for a diagnosis of diabetes-a condition called pre-diabetes. The DPP found that participants who lost a modest amount of weight through dietary changes and increased physical activity sharply reduced their chances of developing diabetes. Taking metformin also reduced risk, although less dramatically. The DPP resolved its research questions earlier than projected and, following the recommendation of an external monitoring board, the study was halted a year early. The researchers published their findings in the February 7, 2002, issue of the New England Journal of Medicine . DPP Results The DPP's results indicate that millions of high-risk people can delay or avoid developing type 2 diabetes by losing weight through regular physical activity and a diet low in fat and calories. Weight loss and physical activity lower the risk of diabetes by improving the body's ability to use insulin and process glucose. The DPP also suggests that metformin can help delay the onset of diabetes. Participants in the lifestyle intervention group-those receiving intensive individual counseling and motivational support on effective diet, exercise, and behavior modification-reduced their risk of developing diabetes by 58 percent. This finding was true across all participating ethnic groups and for both men and women. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71 percent. About 5 percent of the lifestyle intervention group developed diabetes each year during the study period, compared with 11 percent of those in the placebo group. Participants taking metformin reduced their risk of developing diabetes by 31 percent. Metformin was effective for both men and women, but it was least effective in people aged 45 and older. Metformin was most effective in people 25 to 44 years old and in those with a body mass index of 35 or higher, meaning they were at least 60 pounds overweight. About 7.8 percent of the metformin group developed diabetes each year during the study, compared with 11 percent of the group receiving the placebo.
  • On April 8, 2011 the proposed revised criteria for the evaluation of Endocrine Disorders became final. The diabetes listing is now eliminated. Does this mean that we should go straight to Step 5? No. SSA explains in the new listing that long term uncontrolled diabetes can lead to “serious complications”. For instance, treatment for DKA may be evaluated under cardiac arrhythmias (4.00), intestinal necrosis (5.00), cerebral edema & seizures (11.00. Also episodes of DKA may result from mood or eating disorders (12.00). Long term elevated blood sugars can lead to amputation of an extremity (1.00), diabetic retinopathy (2.00), coronary artery disease & peripheral vascular disease (4.00), diabetic gastroparesis (5.00), diabetic nephropathy (6.00), skin infections (8.00), peripheral & sensory neuropathies (11.00), cognitive impairments, depression, & anxiety (12.00) Hypoglycemia unawareness: seizures or loss of consciousness (11.00), altered mental status & cognitive deficits (12.00) Dr. Kempf this is an interesting concept. What is Hypoglyciemia unawareness? Hypoglycemia unawareness is not rare, occurring in 17 percent of those with Type 1 diabetes. A study using tight control in Type 2 diabetes done by the Veterans Administration showed that severe lows occurred only four percent as often in Type 2 compared to Type 1. http://www.diabetesnet.com/diabetes-control/low-blood-sugars/hypoglycemia-unawareness It can be caused by nerve damage that affects the body’s ability to secrete epinephrine. http://www.diabetesselfmanagement.com/Articles/Diabetes-Definitions/hypoglycemia_unawareness/ Does this mean that nerve damage from diabetes can cause hypoglycemia unawareness ? Could this also be a sign of autonomic neuropathy? Since epinephrine release is a function of the autonomic nervous system , the presence of autonomic neuropathy (i.e., a damaged autonomic nervous system) will cause the epinephrine release in response to hypoglycemia to be lost or blunted. http://www.news-medical.net/health/Hypoglycemic-Unawareness.aspx
  • Dr. Kempf what is diabetic ketoacidosis? Diabetic ketoacidosis (DKA) is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. DKA occurs mostly in type 1 diabetes mellitus (DM). It causes nausea, vomiting, and abdominal pain and can progress to cerebral edema, coma, and death. DKA is diagnosed by detection of hyperketonemia and anion gap metabolic acidosis in the presence of hyperglycemia. Treatment involves volume expansion, insulin replacement, and prevention of hypokalemia. www.merckmanuals.com Why did SSA eliminate the amputation listing? Since we last published these listings, significant refinements in surgical techniques (e.g., development of improved soft tissue flaps) to cover the bone stump have been made. This has resulted in more durable stumps. Engineering advances have produced prosthetic devices which minimize and distribute stress so that some individuals wearing artificial limbs after amputation above the tarsal level for any reason (including diabetes mellitus, and vascular and arterial disease) are able to work. 66 Fed. Reg. 58018 But do diabetics benefit from these advances in medicine? In fact, not only are diabetics less likely to heal well enough to use a prosthetic, they are also more likely to endure more amputations. In a study published well before the listing changes, from 9 to 20 percent of people with diabetes, who had already experienced an amputation, underwent a second amputation within 12 months of the first surgery. Five years after the first surgery, 28 to 51 percent of diabetic amputees had undergone a second amputation. Similar data was confirmed more recently in studies in Texas. Gayle E. Reiber, PhD, et al., Lower Extremity Foot Ulcers and Amputations in Diabetes, in Diabetes in America, eds. Maureen I. Harris, PhD, et al., 2nd ed., 409-28 (Bethesda, MD: National Institutes of Health publication, 1995). Izumi Y, Lee S, Satterfield K, Harkless LB. Risk of reamputation in diabetic patients stratified by limb and level of amputation. Diabetes Care 2006;29:566--70. See also Geographic Disparities in Diabetes-Related Amputations --- Texas-Mexico Border , 2003, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5546a3.htm Symptoms of hypoglycemia include sudden mood swings, difficulty staying focused, tingling around the mouth, uncoordinated movement, undue sweating and paling skin. Symptoms of hyperglycemia include excessive hunger or thirst, dry mouth, blurry vision, sudden weight loss and frequent urination. Read more: http://www.livestrong.com/article/18510-hypoglycemia-vs.-hyperglycemia/#ixzz1cPE8Zazy
  • Traditionally, endocrine disorders have not been considered as the main cause of disability according to SSA statistics.
  • Diabetes presentation nosscr 112011 san antonio 2

    1. 1. Diabetes Update NOSSCR Fall 2011 Social Security Disability Law Conference San Antonio, Texas Suzanne Villalón-Hinojosa, Esq. 1-800-481-0302 [email_address] Dr. Melissa Kempf, MD 210-491-1509 [email_address]
    2. 2. Why Diabetes? <ul><li>Diabetes affects 25.8 million people of all ages 8.3 percent of the U.S. population DIAGNOSED 18.8 million people UNDIAGNOSED 7.0 million people </li></ul><ul><li>33% of the US adult population could have diabetes by 2050 </li></ul>http://diabetes.niddk.nih.gov/dm/pubs/statistics/#fast
    3. 3. Diabetes Belt <ul><li>People living in the diabetes belt counties were more likely to be: </li></ul><ul><li>black (23.8 percent in diabetes belt counties versus 8.6 percent in the rest of the country), and </li></ul><ul><li>obese (32.9 percent in the diabetes belt compared to 26.1 percent in the rest of the country). </li></ul><ul><li>And, a sedentary lifestyle was more common in the diabetes belt areas than nationally (30.6 percent versus 24.8 percent, respectively). </li></ul>http://www.ajpmonline.org/article/PIIS0749379711000353/abstract
    4. 4. Diabetes listing eliminated <ul><li>We have determined that, with one exception, we should no longer have listings in sections 9.00 and 109.00 based on endocrine disorders alone. </li></ul><ul><ul><ul><li>Revised Medical Criteria for Evaluating Endocrine Disorders – 76 Fed. Reg. 19692, April 8, 2011 </li></ul></ul></ul>
    5. 5. Historical Changes to Diabetes Listing <ul><li>Diabetes listing 1985-2001 </li></ul><ul><ul><li>neuropathy, episodic Acidosis, lower extremity amputation (LEA), retinopathy </li></ul></ul><ul><li>Diabetes listing 2001-2011 </li></ul><ul><ul><li>referral to neurological & visual listings, elimination of LEA but referral to new musculoskeletal listing. </li></ul></ul><ul><li>Diabetes listing 2011 Explanatory and referrals to listings 1,4, 5, 6, 11, 12: </li></ul><ul><ul><li>Disease (type 1 & 2) </li></ul></ul><ul><ul><li>Non-exhaustive list of reasons for inadequate control </li></ul></ul><ul><ul><ul><li>Hypoglycemia unawareness </li></ul></ul></ul><ul><ul><ul><li>Other disorders affecting blood glucose levels </li></ul></ul></ul><ul><ul><ul><li>Mental disorders </li></ul></ul></ul><ul><ul><ul><li>Inadequate treatment </li></ul></ul></ul><ul><ul><li>distinction between Hyperglycemia & Hypoglycemia </li></ul></ul><ul><ul><ul><li>acute & chronic DKA in Hyperglycemia </li></ul></ul></ul>
    6. 6. Table 21. Distribution, by diagnostic group, December 1996-2010 SSA, Annual Statistical Report on the Social Security Disability Insurance Program, 2010 http://www.ssa.gov/policy/docs/statcomps/di_asr/2010/sect01c.pdf Year All Groups Total Endocrine Diseases Numbers Endocrine Diseases Percentage 1996 4,399,932 197,272 4.5 2000 5,042,333 244,456 4.8 2005 6,519,001 252,933 3.9 2010 8,203,951 288,146 3.5
    7. 7. Why is SSA eliminating the Current listing for Diabetes? <ul><li>Since 1985, medical science has made significant advances in detecting endocrine disorders at earlier stages… </li></ul><ul><ul><li>and newer treatments have resulted in better management of these conditions. </li></ul></ul><ul><li>Adequate glucose regulation is achievable… </li></ul><ul><ul><li>with improved treatment options… </li></ul></ul><ul><li>76 Fed. Reg. 19692 </li></ul>
    8. 8. History of Diabetes treatment <ul><li>Prior to 1920s </li></ul><ul><ul><li>diagnosis of diabetes was a death sentence, although doctors experimented with restrictive diets </li></ul></ul><ul><li>1921 </li></ul><ul><ul><li>discovery of insulin </li></ul></ul><ul><li>1942 </li></ul><ul><ul><li>first “anti-diabetes” drug: sulphonylurea (Glimepiride) </li></ul></ul><ul><li>1994 </li></ul><ul><ul><li>Metformin marketed in US </li></ul></ul><ul><li>Late 1990s </li></ul><ul><ul><li>more medication therapy: thiazolidinedione (Avandia, Actos, Resulin) </li></ul></ul><ul><li>Today </li></ul><ul><ul><li>DPP-4 inhibitors </li></ul></ul>
    9. 9. Examples of listing level diabetes complications <ul><li>Cardiac arrhythmias </li></ul><ul><li>Intestinal necrosis </li></ul><ul><li>Cerebral edema & seizures </li></ul><ul><li>Recurrent episodes of DKA resulting from mood or eating disorders </li></ul><ul><li>Diabetic peripheral neurovascular disease leading to amputation </li></ul><ul><li>Diabetic retinopathy </li></ul><ul><li>Coronary artery disease and peripheral vascular disease </li></ul><ul><li>Diabetic gastroparesis resulting in abnormal gastrointestinal motility </li></ul><ul><li>Diabetic nephropathy </li></ul><ul><li>Diabetic peripheral and sensory neuropathies </li></ul><ul><li>Cognitive impairments </li></ul><ul><li>Altered mental status and cognitive deficits </li></ul>
    10. 10. Medical advances have not reduced the incidences and prevalence of Diabetes <ul><li>Better management of diabetes has not been achieved. </li></ul><ul><ul><li>It requires a team approach and not all diabetics have access to team members. </li></ul></ul><ul><li>Medication management is not the panacea as suggested by SSA. </li></ul><ul><ul><li>The ADA frowns on the use of medications to treat and prevent diabetes. </li></ul></ul><ul><ul><ul><li>ADA, Standards of Care, 1/2010 p. S16 </li></ul></ul></ul>
    11. 11. Potential negative efffect of new regulation <ul><li>Adjudicators will view the elimination of the diabetes listing changes as a more stringent standard at both Step 3 and Step 5. </li></ul><ul><li>Hypothetical question to VE must include all impairments found by the ALJ. </li></ul><ul><ul><li>Bowling v. Shalala, 36 F.3d 431 (5 th Cir. 1994) </li></ul></ul><ul><ul><li>Baugus v. Secretary, 717 F.2d, 443 (8 th Cir. 1983) </li></ul></ul><ul><ul><li>Diabetes case: Clifton v. Astrue, 2011 WL777889 W.D.La., 2/8/2011 </li></ul></ul>
    12. 12. Two Types of Diabetes <ul><li>Type 1 Diabetes </li></ul><ul><li>Old name: </li></ul><ul><ul><li>insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes </li></ul></ul><ul><li>an autoimmune disease in which the body's own immune system attacks the pancreas, rendering it unable to produce insulin </li></ul><ul><li>Type 2 Diabetes </li></ul><ul><li>Old name: </li></ul><ul><ul><li>non–insulin-dependent diabetes mellitus (NIDDM) or adult onset diabetes </li></ul></ul><ul><li>a resistance to the effects of insulin or a defect in insulin secretion may be seen; gestational diabetes; and other types. </li></ul>
    13. 13. Comparison of Type 1 and Type 2 Diabetes <ul><li>Type 1 diabetes </li></ul><ul><li>Onset primarily in childhood and adolescence </li></ul><ul><li>Often thin or normal weight </li></ul><ul><li>Prone to ketoacidosis </li></ul><ul><li>Insulin administration required for survival </li></ul><ul><li>Pancreas is damaged by an autoimmune attack </li></ul><ul><li>Absolute insulin deficiency </li></ul><ul><li>Treatment: insulin injections </li></ul><ul><li>Increased prevalence in relatives </li></ul><ul><li>Identical twin studies: <50% concordance </li></ul><ul><li>HLA association: Yes </li></ul><ul><li>Type 2 diabetes </li></ul><ul><li>Onset predominantly after 40 years of age </li></ul><ul><li>Often obese </li></ul><ul><li>No ketoacidosis </li></ul><ul><li>Insulin administration not required for survival </li></ul><ul><li>Pancreas is not damaged by an autoimmune attack </li></ul><ul><li>Relative insulin deficiency and/or insulin resistance </li></ul><ul><li>Treatment: (1) healthy diet and increased exercise; (2) hypoglycemic tablets; (3) insulin injections </li></ul><ul><li>Increased prevalence in relatives </li></ul><ul><li>Identical twin studies: usually above 70% concordance </li></ul><ul><li>HLA association: No </li></ul>The Genetic Landscape of Diabetes [Internet]. Dean L, McEntyre J. Bethesda (MD): National Center for Biotechnology Information (US) ; 2004.
    14. 14. Criteria for the diagnosis of diabetes <ul><li>A1C 6.5%. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay. or </li></ul><ul><li>FPG 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.* or </li></ul><ul><li>2-h plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 ganhydrous glucose dissolved in water.* </li></ul><ul><li>In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose 200 mg/dl (11.1 mmol/l) </li></ul>“ Standards of Medical Care in Diabetes-2011” by ADA, DIABETES CARE , VOLUME 34, SUPPLEMENT 1, JANUARY 2011
    15. 15. prediabetes <ul><li>FPG 100–125 mg/dl (5.6–6.9 mmol/l): IFG </li></ul><ul><li>2-h plasma glucose in the 75-g OGTT 140– 199 mg/dl (7.8–11.0 mmol/l): IGT </li></ul><ul><li>A1C 5.7–6.4% </li></ul>“ Standards of Medical Care in Diabetes-2011” by ADA, DIABETES CARE , VOLUME 34, SUPPLEMENT 1, JANUARY 2011
    16. 16. long-term complications of diabetes & physical activity <ul><li>Retinopathy </li></ul><ul><ul><li>Vigorous & resistance may be contraindicated </li></ul></ul><ul><li>Peripheral neuropathy </li></ul><ul><ul><li>Moderate intensity walking (only if no foot injury or open sore) </li></ul></ul><ul><li>Autonomic neuropathy </li></ul><ul><ul><li>Cardiac evaluation is recommended before beginning a new exercise program </li></ul></ul><ul><li>Albuminuria & nephropathy </li></ul><ul><ul><li>No need for any specific exercise restrictions </li></ul></ul>“ Standards of Medical Care in Diabetes-2011” by ADA, DIABETES CARE , VOLUME 34, SUPPLEMENT 1, JANUARY 2011pg. S24-25
    17. 17. Forms of Diabetic Neuropathy <ul><li>Peripheral neuropathy </li></ul><ul><ul><li>pain or loss of feeling in the toes, feet, legs, hands, and arms. </li></ul></ul><ul><li>Autonomic neuropathy </li></ul><ul><ul><li>changes in digestion, bowel and bladder function, sexual response, and perspiration. It can also affect the nerves that serve the heart and control blood pressure, as well as nerves in the lungs and eyes. Autonomic neuropathy can also cause hypoglycemia unawareness, a condition in which people no longer experience the warning symptoms of low blood glucose levels. </li></ul></ul><ul><li>Proximal neuropathy </li></ul><ul><ul><li>pain in the thighs, hips, or buttocks and leads to weakness in the legs. </li></ul></ul><ul><li>Focal neuropathy </li></ul><ul><ul><li>Sudden muscle weakness or pain one nerve or group of nerves (Bells palsy, chest pain can be mistaken for heart attack). </li></ul></ul>
    18. 18. About 60 to 70 percent of people with diabetes have some form of neuropathy http://diabetes.niddk.nih.gov/DM/pubs/neuropathies/ <ul><li>Peripheral neuropathy affects </li></ul><ul><ul><li>toes </li></ul></ul><ul><ul><li>feet </li></ul></ul><ul><ul><li>legs </li></ul></ul><ul><ul><li>hands </li></ul></ul><ul><ul><li>arms </li></ul></ul><ul><li>Most common </li></ul><ul><li>Autonomic neuropathy affects </li></ul><ul><ul><li>heart and blood vessels </li></ul></ul><ul><ul><li>digestive system </li></ul></ul><ul><ul><li>urinary tract </li></ul></ul><ul><ul><li>sex organs </li></ul></ul><ul><ul><li>sweat glands </li></ul></ul><ul><ul><li>eyes </li></ul></ul><ul><ul><li>lungs </li></ul></ul><ul><li>More deadly </li></ul>
    19. 19. Autonomic neuropathy may be disabling <ul><li>Symptoms of autonomic neuropathy may be intermittent [but]…are responsible for…the most troublesome and disabling problems of diabetic neuropathy. </li></ul><ul><ul><li>urinary incontinence </li></ul></ul><ul><ul><li>syncopal episodes </li></ul></ul><ul><ul><li>gastropathy can result in vicious cycles of glycemic control problems, poor nutritional status, and advanced gastrointestinal complications. </li></ul></ul><ul><ul><ul><li>http://journal.diabetes.org/diabetesspectrum/98v11n4/pg224.htm </li></ul></ul></ul><ul><ul><li>Due to strong association with CVD, ADA against vigorous exercise. </li></ul></ul><ul><ul><ul><li>http://care.diabetesjournals.org/content/33/Supplement_1/S11.full.pdf+html </li></ul></ul></ul>
    20. 20. Foot damage <ul><li>Five simple clinical tests are considered useful in the diagnosis of loss of protective sensation (LOPS) an indicator of risk of ulcers and amputation. </li></ul><ul><ul><li>10-g monofilament </li></ul></ul><ul><ul><li>Vibration testing using a 128-Hz tuning fork </li></ul></ul><ul><ul><li>Tests of pinprick sensation </li></ul></ul><ul><ul><li>Ankle reflex assessment </li></ul></ul><ul><ul><li>Testing vibration perception threshold with a biothesiometer </li></ul></ul><ul><ul><ul><li>ADA, Diabetes Care, Volume 33, Supplement 1, January 2010 </li></ul></ul></ul><ul><ul><li>Nerve conduction studies add little. </li></ul></ul><ul><ul><ul><li>J Neurol Neurosurg Psychiatry 2003; 74 (Suppl II)ii15-ii19 </li></ul></ul></ul><ul><li>Amputation and foot ulceration are the most common consequences of diabetic neuropathy and major causes of morbidity and disability in people with diabetes. </li></ul><ul><ul><ul><li>ADA, Diabetes Care, Volume 28, Supplement 1, January 2005 </li></ul></ul></ul>
    21. 21. Distal symmetric polyneuropathy (DPN) with autonomic neuropathy <ul><li>Up to 50% of DPN may be asymptomatic </li></ul><ul><li>Autonomic function tests show abnormalities in 97% of patients with DSNP </li></ul><ul><li>Autonomic neuropathy may involve every system in the body </li></ul><ul><li>Cardiovascular autonomic neuropathy causes substantial morbidity and mortality. </li></ul><ul><li>Specific treatment for nerve damage is not available other than improved glycemic control, which may slow progression but not reverse neuronal loss. </li></ul><ul><li>Strict glucose control provides no clinically significant improvement from the patient’s perspective, despite modest improvement in vibration threshold and nerve conduction studies. </li></ul>ADA Diabetes Care , Volume 33, Supplement 1, January 2010 & J Neurol Neurosurg Psychiatry 2003; 74 (Suppl II)ii15-ii19
    22. 22. Eye damage <ul><li>Diabetic retinopathy is estimated to be the most frequent cause of new cases of blindness among adults aged 20-75 years. </li></ul><ul><ul><ul><li>ADA, Diabetes Care , Volume 28, Supplement 1, January 2005 </li></ul></ul></ul>
    23. 23. Stages of retinopathy <ul><li>Mild non-proliferative retinopathy </li></ul><ul><ul><li>small areas of balloon-like swelling occur in the retina's tiny blood vessels. </li></ul></ul><ul><li>Moderate non-proliferative retinopathy </li></ul><ul><ul><li>some blood vessels that nourish the retina become blocked. </li></ul></ul><ul><li>Severe non-proliferative retinopathy </li></ul><ul><ul><li>The damaged retina signals the body to produce new blood vessels. </li></ul></ul><ul><li>Proliferative retinopathy </li></ul><ul><ul><li>New blood vessels are abnormal, they can rupture and bleed, causing hemorrhages in the retina or vitreous. </li></ul></ul><ul><ul><li>Scar tissue can develop and can tug at the retina, causing further damage or even retinal detachment. </li></ul></ul><ul><ul><ul><li>http://www.nei.nih.gov/health/diabetic/retinopathy.asp </li></ul></ul></ul>
    24. 24. Symptoms of diabetic retinopathy <ul><li>Blurred or double vision </li></ul><ul><li>Flashing lights, which can indicate a retinal detachment </li></ul><ul><li>A veil, cloud, or streaks of red in the field of vision, or dark or floating spots in one or both eyes, which can indicate bleeding </li></ul><ul><li>Blind or blank spots in the field of vision </li></ul><ul><ul><li>http://www.visionaware.org/how-diabetes-affects-eyes-and-vision </li></ul></ul>
    25. 25. Functional effects of retinopathy <ul><li>Fluctuating vision in response to changing blood glucose levels; vision can change from day-to-day, or from morning to evening </li></ul><ul><li>Blurred central vision from macular edema can interfere with reading </li></ul><ul><li>Decreased visual acuity can interfere with seeing the markings on an insulin syringe or the display on a standard blood glucose monitor </li></ul><ul><li>Irregular patches of vision loss or &quot;blind spots&quot; can make it difficult to judge the size of food portions on a plate. </li></ul><ul><li>Decreased depth perception, in combination with decreased visual acuity, can make it difficult to see curbs and steps, or walk to the diabetes clinic. </li></ul>
    26. 26. Does treatment of long-term complications cure? <ul><li>Similar question: With good control, does damage reverse? </li></ul><ul><li>No. </li></ul><ul><li>“… interventions do not change the underlying pathology and natural history of the disease process, but may have a positive impact on the quality of life of the patient.” </li></ul>“ Standards of Medical Care in Diabetes-2011” pg. S36 by ADA, DIABETES CARE , VOLUME 34, SUPPLEMENT 1, JANUARY 2011
    27. 27. Type 2 diabetes is difficult to control <ul><li>Only 37% of adults with diagnosed diabetes achieved an A1C of <7%, only 36% had a blood pressure <130/80 and just 48% had a cholesterol level <200 mg/dl. </li></ul><ul><li>Only 7.3% of diabetes subjects achieved all three treatment goals. </li></ul><ul><ul><ul><li>Saydah SH, Fradkin J, Cowie CC: Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA 291:335-342, 2004. </li></ul></ul></ul>
    28. 28. ADA Treatment Guidelines <ul><li>Initial referral to a diabetes educator with an annual follow up. </li></ul><ul><ul><li>http://www.diabeteseducator.org </li></ul></ul><ul><li>Quarterly check-up </li></ul><ul><ul><li>Blood work (AIC quarterly if uncontrolled, 2 times a year if under control) </li></ul></ul><ul><li>Annual examinations </li></ul><ul><ul><li>Urine test (screening for microalbuminuria) </li></ul></ul><ul><ul><li>Eye exam (opthalmologist or optometrist) </li></ul></ul><ul><ul><li>Foot exam with nerve testing (Semmes-Weinstein monofilament & tuning fork ) </li></ul></ul><ul><ul><li>Cardiovascular exam (with cholesterol and triglyceride profile) </li></ul></ul><ul><ul><li>Influenza vaccine </li></ul></ul>
    29. 29. Diabetes Management <ul><li>People with diabetes should receive medical care from a physician-coordinated team: </li></ul><ul><ul><li>Physicians </li></ul></ul><ul><ul><li>Nurse practitioners </li></ul></ul><ul><ul><li>Physician’s assistants </li></ul></ul><ul><ul><li>Nurses </li></ul></ul><ul><ul><li>Dietitian </li></ul></ul><ul><ul><li>Pharmacists </li></ul></ul><ul><ul><li>Mental health professionals with expertise and a special interest in diabetes. </li></ul></ul>ADA Standards of Care, 1, 2010
    30. 30. Different types of insulin
    31. 31. Different types of oral medication The choices of oral drug therapy for type 2 diabetes have become extremely complex. AACE Diabetes Guidelines, 2002
    32. 32. Use of diabetes pills up, insulin use down <ul><li>The proportion of Americans taking insulin fell from 38 percent to 24 percent from 1997-2007. </li></ul><ul><li>During that same period, the proportion of Americans who took oral medications increased from 60 percent in 1997 to 77 percent in 2007—a 28 percent increase. </li></ul><ul><ul><li>Sulfonylureas declined from 51 percent to 40 percent. </li></ul></ul><ul><ul><li>Biguanides rose from 21 percent to 55 percent. </li></ul></ul><ul><ul><li>Thiazolidinediones increased from 5 percent to 25 percent. </li></ul></ul>http://www.ahrq.gov/research/nov10/1110RA25.htm
    33. 33. Side Effects of Metformin <ul><li>Diarrhea – this occurs to up to 53.2 percent of people </li></ul><ul><li>Nausea or vomiting – this happens to 25.5 percent </li></ul><ul><li>Gas – this occurs to up to 12.1 percent of people </li></ul><ul><li>Weakness – this happens to up to 9.2 percent of people </li></ul><ul><li>Indigestion – this usually occurs to 7.1 percent of people </li></ul><ul><li>Abdominal discomfort – this merely happens to 6.4 percent of people </li></ul><ul><li>Headache – this is experienced by 5.7 percent of people </li></ul>http://www.metforminsideeffects.org/
    34. 34. ADA accommodations “tight control” <ul><li>a private area </li></ul><ul><ul><li>to test blood sugar levels or to take insulin </li></ul></ul><ul><li>a place to rest </li></ul><ul><ul><li>until blood sugar levels become normal </li></ul></ul><ul><li>breaks </li></ul><ul><ul><li>to eat or drink, take medication, or test blood sugar levels </li></ul></ul><ul><li>leave </li></ul><ul><ul><li>for treatment, recuperation, or training on managing diabetes </li></ul></ul><ul><li>modified work schedule or shift change </li></ul><ul><li>allow a person with diabetic neuropathy to use a stool. </li></ul>