DOs share advice on managing patients with diabetes mellitus

In the United States, 18.8 million individuals have been diagnosed with diabetes mellitus, indicated by a glycated hemoglobin (HbA1c) measure of at least 6.5%, while 7 million people with the disease remain undiagnosed, according to the American Diabetes Association (ADA).

Besides an estimated prevalence in the population of 8.3%, the incidence of the disease is surging. In 2010, U.S. physicians diagnosed diabetes for the first time in 1.9 million people. And internationally, the disease has grown exponentially, as newly developed countries embrace the sedentary lifestyles and high-sugar, obesity-inducing diets of more affluent nations, notes Misha Denham, DO, an endocrinologist in Miami Beach, Fla.

“It’s amazing how quickly diabetes is spreading,” Dr. Denham says. “I believe diabetics will make up roughly 15% of the planet by 2020.”

The vast majority of diabetics have type 2, the slow-progressing form of the disease in which the body doesn’t effectively use insulin produced by the pancreas. Only 5% of diabetics have type 1, the most aggressive form, caused by the pancreas’ failure to produce insulin. Approximately 10% of diabetics have latent autoimmune diabetes of adults (LADA), known as type 1.5, which progresses more slowly than type 1 but faster than type 2.

Although diabetes in general isn’t hard to diagnose in patients suspected of having the disease, the subtypes can be difficult to distinguish. Physicians sometimes misdiagnose LADA as type 2, for example, and underestimate its aggressiveness. And some patients with type 2 diabetes have gone on to develop LADA, Dr. Denham says.

It is well-known that increasing numbers of overweight children are developing type 2 diabetes. Dr. Denham notes that recent research indicates type 2 can be worse for children in the long run than type 1, in part because of the many health problems associated with obesity.

“The distinction between type 1 and type 2 is very much blurring, which is across-the-board confusing to physicians and patients,” he says.

In addition to being more complex than once thought, diabetes has become more vexing for primary care physicians to manage because of the emphasis today on measuring performance and improving outcomes. No matter how diligently physicians monitor patients’ diabetes and how conscientiously patients follow prescribed regimens, HbA1c levels will fluctuate, the disease will progress and complications will eventually occur, Dr. Denham observes.

“The pathology, frankly, escapes even our best care,” he says.

But by implementing certain strategies and protocols, physicians can reduce their frustrations and improve patient care overall, say a number of DOs with expertise in diabetes.

Optimal appointments

Primary care physicians should make sure that each of their diabetic patients has four appointments a year devoted to diabetes and nothing else, stresses diabetologist Jay H. Shubrook Jr., DO, who runs the diabetes center at the Ohio University Heritage College of Osteopathic Medicine at Athens (OU-HCOM). Because they are focused on the one disease and its complications, these appointments can be 15 or 20 minutes, the length of a typical office visit, he says.

Dr. Shubrook learned this lesson when he was a primary care physician. Many times his diabetic patients wanted to talk about an array of bothersome symptoms that were not related to their diabetes. “They would want to talk about their headache, their sore throat or their urinary tract infection,” he remembers. “So I would say, ‘We can talk about your headache if that’s what is really bothering you today. But you have to come back next week to talk about your diabetes.’ ”

To maximize efficiency during the diabetes visit, Dr. Shubrook advises having patients upload data from their blood glucose meter into the electronic health record system before the examination. “This saves at least 10 minutes per patient,” he says.

Physicians can spend that additional time asking patients more questions and being more collaborative and supportive when discussing care management plans, Dr. Shubrook says.

Because diabetes is largely self-managed, patients often fret about being judged by their physicians. “Many patients feel that when they go to a doctor for diabetes-related care, they get a report card and their grade is their A1c,” Dr. Shubrook says. “A number of patients have told me that they don’t like that. They don’t want to be graded.”

Given that diabetic patients are human, they will have lapses from time to time, Dr. Shubrook says. Even the most diligent may eat a slice of birthday cake at a party or fail to exercise for a few days. “You need to be very careful not to be critical of some of those lapses,” he says.

HbA1c readings also have natural peaks and valleys. “One of the things patients learn is that when they have their best-ever A1c with me, it’s likely that the measure won’t be as good next time,” Dr. Shubrook notes. “It’s not like A1c levels continue to drive better and better and better. Physicians need to prepare patients that there will be fluctuations, support them through setbacks and be encouraging when they’re making progress.”

Staying positive is essential but can be difficult for physicians, who are starting to be rewarded based on outcomes, Dr. Denham says. “I’ve seen a lot of physicians put their patients on the hook and say, ‘You didn’t do what I told you to do.’ Patients are getting blamed for poor outcomes,” he says. “Today, you can get penalized if you don’t have a certain percentage of your patients controlled.

“I’ve actually seen some physicians fire their diabetic patients for perceived noncompliance, such as not getting a retinal exam in the expected time frame.”

Despite what he refers to as “demoralizing pressure” to improve quality measures, “pitting physicians against patients and one another,” doctors need to empathize with their diabetic patients and buoy up their spirits, Dr. Denham maintains.

Ask open-ended questions

Despite its severity, type 1 diabetes tends to be better self-managed than type 2 because patients typically have been following a strict routine since childhood. The lifestyle habits that cause and aggravate type 2 diabetes can be difficult to overcome, and the treatment options are more variable than for type 1. Primary care physicians are more likely to manage patients with type 2 diabetes, Dr. Shubrook points out. Type 1 diabetics, who present with more severe symptoms at the onset of the disease, are commonly referred to an endocrinologist or diabetologist for treatment and ongoing management.

Counseling type 2 diabetics about their routines requires careful consideration. For one thing, physicians should ask each patient open-ended questions—not just look at the patient’s chart to ascertain his or her medication or insulin routine and diet and exercise plan, Dr, Shubrook says.

“Ask patients what medications they’re on and how they’re taking them,” he suggests. “I get a lot of information this way, as opposed to just asking, ‘Are you still taking metformin?’ to which a patient can simply reply yes.”

Dr. Shubrook also asks diabetic patients to describe their food and drink consumption and physical activity and discuss how they feel about their dietary and exercise plans. And he asks about patients’ perceived quality of life.

“These questions give me a chance to discuss diabetes self-management in a nonjudgmental way,” Dr. Shubrook says.

Such conversations reveal misconceptions patients may have, says Gautam J. Desai, DO, a professor of family and community medicine at the Kansas City (Mo.) University of Medicine and Biosciences College of Osteopathic Medicine. For example, patients frequently assume salads are healthful, without realizing that adding sugary dressing can make them bad for diabetics.

For diabetic patients, portion control is critical, Dr. Desai notes. But patients are often confused as to what constitutes a serving size, having eaten at restaurants that serve huge portions of food. “They don’t realize that one portion is about the size of a deck of cards,” he says.

By eating small meals more frequently, diabetics avoid surges in blood sugar and are less likely to feel extremely hungry and gorge on a huge meal, he adds.

Dr. Desai tries to be realistic when he counsels obese patients with diabetes about the importance of exercise, which is essential to minimizing the circulatory complications of the disease. “Obviously, a very obese patient isn’t going to go out and run six miles every day,” he says. “So I’ll ask them to take baby steps at first. ‘While you’re watching TV, why don’t you stand up during the commercials and walk in place?’ Then after doing that for a couple of weeks, they’ll be ready to walk during the entire show.”

Patients newly diagnosed with the disease are sometimes referred to diabetes education classes in the community. “But insurance doesn’t always cover these classes, so it is up to the physician to talk to that patient and make sure he or she knows what diabetes is, how it is treated and why it is so important to manage it carefully,” Dr. Desai says.

Dr. Shubrook recommends the free yearlong ADA program called Living With Type 2 Diabetes, in which newly diagnosed patients receive personalized text messages on healthful eating, information packets, an electronic newsletter and access to an online community. He suggests that children, and parents of children, with type 1 diabetes visit the website of the nonprofit Children With Diabetes.

Dr. Shubrook points out that many smartphone apps are now available that help diabetic patients manage their disease. Some provide nutrition or fitness advice, while others calculate medication doses or track blood-sugar levels in conjunction with a glucometer.

Treatment challenges

Primary care physicians can become overwhelmed by the choices of diabetes medications and can have trouble with insulin titration, says Dr. Shubrook, who directs the diabetes fellowship at OU-HCOM. He recommends that patients see a diabetes specialist for a consultation right after the initial diagnosis.

“When I practiced as a family doctor, there were three classes of medication for diabetes,” Dr. Shubrook recalls. “Now there are 12 classes of medication. So it’s really hard for primary care physicians to keep up with all of them when diabetes is just one of some 100 diseases they are treating.”

All patients with type 2 diabetes will eventually need insulin, says Dr. Shubrook. He notes that the tendency to delay the use of insulin in treating type 2 has been called into question.

“We’ve had some success in using insulin as the first treatment for type 2—for a period of time, such as 12 to 16 weeks—and then getting the patients off insulin and all of their other medications for up to six years,” Dr. Shubrook says. “So I wouldn’t delay the use of insulin. The longer you wait for any treatment, the less effective it is.” The early intensive treatment with insulin slows but does not stop the progression of the disease.

The International Diabetes Federation now recommends weight loss surgery as one of the primary treatments for type 2, Dr. Shubrook notes. “We do suggest it for certain individuals,” he says. “The patient must be emotionally stable, have a positive outlook and be someone who is willing to make drastic lifestyle changes and stick to a very restricted diet for the rest of his or her life after the surgery.”

Dr. Denham stresses that too many type 2 patients are being treated with sulfonylurea medications because they’re less expensive and widely covered by health insurance plans. “These medications can be moderately effective for a year or so,” he says. “If a patient’s A1c is 9, a sulfonylurea will bring it down to 8. As a result, the patient and physician feel heartened because they’re making progress.

“But the problem with sulfonylureas is that they cause hypoglycemia and promote weight gain. Every day, I see patients in the hospital who have overdosed on these medications. They have severe hypoglycemia, renal numbers out of control, heart problems. Overall, this is a class of medication that should be de-prioritized.”

Dr. Denham is enthusiastic about the technologies available to diabetics today, such as insulin pumps and continuous glucose monitors. “They help patients improve their diabetes control and decrease complications from the disease,” he says. These technologies aren’t always covered by health insurance plans, however, especially for patients with type 2 diabetes.

Disparities in care

As with other chronic diseases, affluent individuals with diabetes fare much better than the economically disadvantaged. Impoverished individuals are diagnosed much later in the disease process, especially when they have type 2 diabetes, which has no or only subtle symptoms initially.

Diabetic children who are eligible for Medicaid lose their eligibility as adults and no longer can afford their insulin, Dr. Denham points out. “Some of them are buying insulin on the street. There is an underground market,” he says.

Since he entered practice in 2007, Dr. Denham has seen scores of low-income people in the Miami area who are suffering from diabetes’ worst complications—relatively young adults who’ve had their feet amputated and are in wheelchairs or who are on dialysis due to kidney failure. “Only when they’ve lost a limb or are on dialysis can they finally get government benefits that are available for catastrophic care. The system has failed them,” he says. “The socioeconomic disparities in managing diabetes are enormous.”

Even when low-income people are receiving treatment for their disease, they have trouble complying with the diet recommendations. “If you have less money, you’ll buy food that is less expensive,” Dr. Denham says. “The least expensive foods have the highest sugar content. It’s very expensive to eat well.”

But it’s not just the underserved who have unhealthful lifestyles, he points out. “In the U.S. we never sleep. We never fast. We go right to the fridge, put a bunch of stuff in our mouth and go to the television. We’re not exercising at all.

“Our ancestors had to work to make food. If you raised corn, it took a while before you enjoyed that harvest. Now we’re eating a harvest every single day. It’s no wonder that diabetes is spreading like wildfire and increasingly out of control.”