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 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]
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
FPG 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.* or
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.*
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose 200 mg/dl (11.1 mmol/l)
“ Standards of Medical Care in Diabetes-2011” by ADA, DIABETES CARE , VOLUME 34, SUPPLEMENT 1, JANUARY 2011
pain or loss of feeling in the toes, feet, legs, hands, and arms.
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.
pain in the thighs, hips, or buttocks and leads to weakness in the legs.
Sudden muscle weakness or pain one nerve or group of nerves (Bells palsy, chest pain can be mistaken for heart attack).
About 60 to 70 percent of people with diabetes have some form of neuropathy http://diabetes.niddk.nih.gov/DM/pubs/neuropathies/