PREVENTING
DIABETES-RELATED
MORBIDITY
AND
MORTALITY
IN
THE
PRIMA1RY
CARE
SETTING*
Samuel
Dagogo-Jack,
MD,
FRCP
Memphis,
TN
Diabetes
is
the
leading
cause
of
blindness,
end-stage
renal
failure,
non-traumatic
limb
amputations,
and
cardiovascular
morbidity
and
mortality.
The
vast
majority
of
patients
with
diabetes
receive
routine
care
from
primary
care
providers
who
are
not
endocrinologists.
Primary
care
providers,
including
internists,
family
practice
physicians,
and
physician
extenders
with
advanced
skills,
face
the
important
task
of
implementing
standards
of
care
recommendations
for
persons
with
diabetes.
These
recommendations
draw
upon
an
emerging
body
of
compelling
evidence
regarding
the
prevention
and
management
diabetes
and
its
complications.
The
chal-
lenge
of
diabetes
must
be
tackled
on
three
fronts:
Primary
prevention,
secondary
prevention
(of
diabetes
complications),
and
tertiary
prevention
(of
morbidity
and
mortality
from
established
complications).
There
is
now
abundant
evidence
that
type
2
diabetes,
which
accounts
for
greater
than
90%
of
diabetes
world-wide,
is
preventable.
Moreover,
the
complications
of
diabetes
are
preventable
by
a
policy
of
tight
glycemic
control
and
comprehensive
risk
reduction.
Even
after
complications
have
set
in,
intensive
glucose
control
dramatically
reduces
the
risk
of
progression
of
complications.
The
challenge,
therefore,
is
the
identification
of
strategies
that
enable
transla-
tion
of
existing
scientific
data
to
pragmatic
benefits.
This
article
proposes
10
strategies
for
preventing
or
reducing
diabetes-related
morbidity
and
mortality
at
the
primary
care
level.
These
strategies
include
provider
education;
patient
empowerment
through
promotion
of
lifestyle
and
self-care
practices;
surveillance
for
microvascular
complications;
cardiovascular
risk
reduction;
efficient
use
of
medications;
goal
setting;
and
stratification
of
patients
and
triaging
of
those
with
poor
glycemic
control
for
more
intensive
management.
(J
Natl
Med
Assoc.
2002;94:
549-560.)
©
2002.
Professor
of
Medicine,
Division
of
Endocrinology,
Diabetes
&
Metabolism,
University
of
Tennessee
College
of
Medicine,
Memphis,
TN
Address
for
correspondence:
Samuel
Dagogo-Jack,
MD,
University
of
Tennessee
College
of
Medicine,
951
Court
Avenue,
Room
335M,
Memphis,
TN
38163.
Tel.:
901-448-5802
Fax:
901-448-5332
E-
mail:
Dr.
Dagogo-Jack
is
supported
in
part
by
NIH
Clinical
Research
Center
Grant
MO
1
RR002
1
1
*Presented
in
part
at
the
Southern
Medical
Association
95th
Scien-
tific
Assembly,
Nashville,
TN,
November
8-10,
2001
INTRODUCTION
Diabetes
mellitus,
which
currently
affects
more
than
16
million
Americans,
continues
to
be
a
major
clinical
challenge,
both
in
terms
of
the
undiagnosed
disease
burden
and
the
obstacles
to
optimal
glycemic
control.-3
Diabetes
is
a
public
health
problem,
accounting
for
the majority
of
patients
with
adult-onset
blindness,
end-stage
re-
nal
failure,
and
non-traumatic
limb
amputations.
Furthermore,
diabetes
is
the
leading
underlying
cause
of
coronary
heart
disease,
stroke
and
pe-
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION
VOL.
94,
NO.
7,
JULY
2002
549
DIABETES
PRIORITIES
IN
PRIMARY
CARE
ripheral
vascular
disease.2-5
In
fact,
a
diabetic
pa-
tient
without a
prior
history
of
myocardial
infarc-
tion
has
a
greater
risk
of
suffering
a
heart
attack
than
a
nondiabetic
subject
with
a
prior
myocar-
dial
infarction.6
Both
the
incidence
and
prevalence
of
diabe-
tes
are
increasing
worldwide.
In
the
United
States,
there
was
a
33%
increase
in
the
preva-
lence
of
diabetes
between
1990
and
1998.7
Be-
sides
the
human
toll,
the
economic
burden
of
diabetes
is
staggering.
The
total
annual
health
care
costs
attributable
to
diabetes
in
the
U.S.
is
in
excess
of
$105
billion.8'9
The
increasing
prev-
alence
of
diabetes
is
particularly
marked
in
the
southeastern
region
of
the
U.S.,
which
appears
to
be
the
epicenter
of
the
diabetes
epidemic.7
For
instance,
in
the
author's
state
of
residence,
Tennessee,
approximately
206,042
adults
(5.1%
of
the
population)
had
a
diagnosis
of
diabetes
in
1997,
and
an
additional
1,750,
245
persons
were
at
risk
for
development
of
diabe-
tes
because
of
demographic
and
other
predis-
posing
factors.1-'12
Statewide
health
statistics
analyzed
in
1997
indicated
a
considerable
bur-
den
of
diabetes-related
complications
in
Ten-
nessee:
There
were
74,616
diabetes-related
hos-
pitalizations
(including
23,583
admissions
for
cardiovascular
disease),
315
new
cases
of
blind-
ness,
654
new
cases
of
end-stage
renal
failure,
and
1,441
lower
extremity
amputations.
Fur-
thermore,
diabetes
contributed
to
4,054
deaths
and
accounted
for
a
total
health
care
expendi-
ture
of
2.7
billion
in
the
state
of
Tennessee.10-'2
Remarkably,
one
year
later,
the
1998
data
from
the
Centers
for
Disease
Control
showed
that
the
prevalence
of
diabetes
in
Tennessee
had
risen
to
6.6%,
making
Tennessee
the
gth
lead-
ing
state
in
the
hierarchy
of
diabetes
preva-
lence
(8).
These
disturbing
trends
in
diabetes-
related
statistics
are
representative
of
the
picture
across
the
entire
United
States.24-9
'2
There
is
a
direct
relationship
between
the
degree
of
poor
diabetic
control
and
the
devel-
opment
of
long-term
complications
and
the
resultant
prohibitive
rise
in
health
care
costs.
Nationally,
the
per
capita
health
care
cost
in
patients
with
diabetes
is
considerably
higher
than
that
incurred
by
patients
without
diabetes.
In
specific
terms,
the
differences
can
be
stag-
gering.
For
example,
the
annual
per
capita
cost
of
health
care
in
Tennessee
in
1997
was
$13,000
for
persons
with
diabetes
compared
with
$2,700
for
persons
without
diabetes.'2
Na-
tionally,
the
quality
of
diabetes
care
is
deemed
to
be
very
poor
(hemoglobin
{Hb}Alc
>9%)
in
-25%
of
patients,
poor
(HbAlc
8-9%)
in
-15%,
and
suboptimal
(HbAlc
7-8%)
in
-20%
of
the
remainder.'3
Thus,
only
about
40%
of
patients
are
in
good
metabolic
control.
The
patients
with
the
poorest
state
of
glycemic
control,-25%
of
the
diabetes
population,
gen-
erate
exponentially
greater
health
care
costs
than
those
with
better
control.'4
Unquestion-
ably,
these
poorly
controlled
patients
present
an
opportunity
for
the
application
of
focused,
innovative,
cost-containment
strategies
that
are
mediated
through
optimization
of
glycemic
control
and
reduction
of
diabetes
complica-
tions.
FOCUS
ON
ETHNIC
MINORITIES
Measures
of
health
care
delivery,
health
care
outcomes,
and
vital
statistics
indicate
an
emerg-
ing,
if
not
fully
established,
health
care
crisis
in
urban
America.'1
Urban
America
is
inhabited
by
a
disproportionate
number
of
ethnic
minor-
ities
as
well
as
economically
disadvantaged
cit-
izens
from
all
ethnic
and
racial
groups.
From
the
2000
census
figures,
ethnic
minorities
con-
stitute
approximately
25%
of
the
overall
U.S.
population.
The
population
of
these
minority
groups
has
been
increasing
at
a
faster
rate
than
the
national
average.
There
are
many
reasons
why
special
atten-
tion
ought
to
be
focused
on
ethnic
minority
populations
in
relation
to
diabetes.
First,
these
populations
suffer
disproportionately
from
type
2
diabetes:
Compared
with
caucasians,
the
prevalence
of
type
2
diabetes
is
2-10
times
higher
in
African
Americans,
Hispanic
Americans,
Asian
Americans,
and
Native
Americans.16
In
fact,
type
2
diabetes
is
being
diagnosed
at
alarming
rates
among
ethnic
minority
subjects,
including
chil-
dren
and
adolescents.'7,18
550
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ASSOCIATION
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2002
DIABETES
PRIORITIES
IN
PRIMARY
CARE
Table
1.
Schedule
of
surveillance
for
diabetic
complications
Complications
Method
Frequency
Goal
Hyperglycemia
Hemoglobin
Al
c
2-4/yr
<7%
Retinopathy
Dilated
funduscopy
Yearly
Normal
retina
Nephropathy
Microalbuminuria*
Yearly
<30
mg/g
creatinine
Neuropathy
Light
touch
sensation
(Monofilament)
Every'visit
Intact
sensation
Hypertension
Sphygmomanometry
Every
visit
<
1
30/80mmHg
Dyslipidemia
Fasting
lipid
profile
Yearly
Normal
lipids
Heart
disease
Electrocardiogram**
Yearly
No
ischemic
changes
Diabetic
foot
Clinical
examination
Every
visit
No
ulceration
*24-hour
urine
(normal
<
300
mg
microalbumin
per
day)
or
spot
urine
(microalbumin:creatinine
ratio).
**Stress
cardiac
testing
is
warranted
in
symptomatic
patients
and
those
with
additional
risk
factors.
Second,
virtually
all
of
the
long-term
compli-
cations
of
diabetes,
including
premature
death,'9
occur
several-fold
more
frequently
among
minorities
compared
with
non-His-
panic
whites.
Acute
diabetic
complications
oc-
cur
with
varying
frequencies
in
the
different
ethnic
groups,
but
there
are
suggestions
that
the
rate
of
hospitalization
for
diabetic
ketoaci-
dosis
and
nonketotic
coma
may
be
higher
among
certain
minority
groups,
such
as
African
Americans.20
Third,
there
are
indications
of
disparities
in
access
to
care
and
quality
of
metabolic
control
among
diabetic
patients,
as
a
function
of
their
demographic
and
socioeconomic
characteris-
tics.21'22
Finally,
the
demography
of
the
south-
ern
states,
the
epicenter
of
the
diabetes
epi-
demic,
is
consistent
with
under-served
patients
from
the
African
American
and
other
minority
populations
bearing
the
brunt
of
the
dis-
ease.7,17,18
STANDARDS
OF
CARE
GUIDELINES
There
is
now
compelling
evidence
that
in-
tensive
treatment
to
control
blood
glucose
lev-
els
in
patients
with
type
1
and
type
2
diabetes
can
dramatically
reduce
the
risk
of
develop-
ment
of
diabetes-related
complications.23-25
Concurrent
management
of
co-morbid
condi-
tions
(e.g.,
dyslipidemia,
hypertension)
re-
duces
morbidity
and
mortality
in
patients
with
diabetes.26'27
The
Diabetes
Control
and
Com-
plications
Trial
(DCCT)23
and
the
Kumamoto
study24
showed
a
nearly
60%-80%
reduction
of
the
risks
for
microvascular
complications
(reti-
nopathy,
neuropathy,
nephropathy)
in
patients
whose
HbAlc
was
maintained
at
-7%.
The
DCCT23
and
the
United
Kingdom
Prospective
Diabetes
Study
(UKPDS)25
found
that
every
1%
absolute
decrease
in
HbAlc
yields
35%
-
45%
reduction
in
the
risk
of
development
or
pro-
gression
of
microvascular
complications.
In
the
UKPDS,
a
0.9%
reduction
in
median
HbAlc
(7%
in
intensive
group
vs.
7.9%
in
con-
trols)
resulted
in
74%
reduction
in
the
risk
of
doubling
of
serum
creatinine
levels
(among
other
benefits),
which
could
considerably
delay
the
progression
to
end-stage
renal
failure.
Fur-
thermore,
blood
pressure
control
to
144/82
mmHg
(vs.
154/87
mmHg
in
the
comparison
group)
reduced
the
risks
of
development
of
any
diabetes-related
endpoint
by
24%,
diabe-
tes-related
death
(32%),
stroke
(44%),
micro-
vascular
complications
(37%),
and
heart
fail-
ure
(56%).26
Based
on
these
compelling
data,
the
Ameri-
can
Diabetes
Association
has
reiterated
existing
guidelines
that
the
goal
of
diabetes
manage-
ment
should
be
the
attainment
and
mainte-
nance
of
an
HbAlc
level
of
<7%28
numerous
other
tasks
are
called
for
in
these
guidelines
(Table
1),
including
monitoring
of
HbAlc;
methods
and
frequency
of
surveillance
for
re-
nal,
retinal,
neuropathic,
cardiac,
and
circula-
tory
complications
of
diabetes;
optimal
blood
pressure
control;
implementation
of
self-man-
JOURNAL
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VOL.
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2002
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DIABETES
PRIORITIES
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CARE
agement
and
lifestyle
recommendations,
among
others.
The
HbAlc
goal
of
<7%
is
a
minimal
target,
because
updated
data
from
the
UKPDS
indicate
that
the
adjusted
incidence
of
myocardial
infarction
decreased
from
-25/1000
person-years
to
-15/1000
person-years
when
HbAlc
was
lowered
further
from
7%
to
6%.29
In
the
same
cohort,
the
incidence
of
microvascular
complications
decreased
from
10/1000
to
5/1000
person-years
with
further
reduction
of
HbAlc
from
7%
to
6%.29
Thus,
the
preferred
policy
of
diabetes
man-
agement
is
maintenance
of
blood
glucose
as
close
to
the
normal
range
as
possible
without
intolerable
hypoglycemia.
The
reason
so
many
diabetic
patients
are
poorly
controlled
can
be
attributed,
at
least
in
part,
to
the
fact
that
dia-
betes
care
involves
a
series
of
specialized
tasks
that
are
difficult
to
implement
satisfactorily
in
the
generalist
setting.
Ironically,
the
states
with
the
highest
prevalence
rates
of
diabetes
also
have
the
lowest
quality
indicators
of
diabetes
care,
such
as
HbAlc
test
ordering,
annual
eye
examinations,
and
screening
for
dyslipide-
mia.30
INCREASING
COMPLEXITY
OF
DIABETES
PRACTICE
In
keeping
with
enhanced
awareness
of
the
need
to
reduce
the
burden
of
diabetes
and
its
complications,
the
pharmaceutical
industry
has
been
introducing
new
agents
for
the
manage-
ment
of
diabetes
at
an
escalating
rate
since
the
mid-1990's.
As
a
result,
there
are
now
different
types
of
natural
and
recombinant
human
insu-
lins
with
varying
pharmacokinetic
profiles,
ad-
ministered
by
traditional
methods
or
via
insu-
lin
pens,
jet
injectors,
or
pumps.
The
natural
forms
of
insulin,
which
are
extracted
and
puri-
fied
from
animal
pancreata,
are
no
longer
available
in
the
United
States
but
are
still
in
use
in
other
countries.
The
complexity
in
the
field
of
insulin
delivery
will
escalate
after
ongoing
clinical
trials
of
nasal,
oral
and
other
novel
forms
of
insulin,
designed
to
bypass
the
tradi-
tional
subcutaneous
route,
are
completed
in
the
near
future.
With
regard
to
oral
antidiabetic
agents
(Ta-
ble
2),
there
are
now
six
chemically
distinct
classes
(compared
with
only
one
or
two
up
to
a
few
years
ago),
and
several
others
are
under
development.
Each
class
has
its
unique
proper-
ties
conferred
by
chemical
structure,
mecha-
nism
of
action,
efficacy,
adverse
effect
profile,
and
other
pharmacokinetic
and
pharmacody-
namic
properties.
As
many
as
seven
individual
members
may
be
found
within
a
single
oral
antidiabetic
drug
class;
oftentimes
individual
drugs
within
the
same
class
may
have
unique
dosing
and
toxicological
considerations.
In
ad-
dition
to
developments
in
pharmacotherapy,
numerous
medical
devices
are
being
intro-
duced
to
the
diabetes
care
market
at
a
brisk
rate.
Currently,
more
than
20
different
brands
of
meters
are
on
the
market
for
home
blood
glucose
monitoring:
A
new,
bloodless
device
for
transcutaneous
monitoring
of
glucose
levels
is
at
an
advanced
stage
of
development
and
deployment.
Increasingly,
insulin-requiring
di-
abetes
patients
are
being
treated
with
alterna-
tive
delivery
devices,
such
as
insulin
pens,
pumps,
andjet-injectors,
as
opposed
to
the
tra-
ditional
needles
and
syringes.
Current
limitations
Because
of
a
variety
of
reasons
(including
shortage
of
endocrinologists),
most
diabetic
patients
receive
routine
care
from
primary
care
providers.
These
primary
care
providers,
in-
cluding
internists,
family
practice
physicians,
and
physician
extenders
with
advanced
skills,
are
constrained
to
fit
diabetes
into
a
generalist
practice
that
includes
patients
with
a
broad
array
of
medical
conditions,
all
competing
for
priority
attention.
Yet,
today's
internists
and
family
physicians
are
expected
to
demonstrate
fairly
specialized
skills
and
competencies
across
a
more
demanding
spectrum
of
diabetes
care
tasks
than
was
the
case
only
a
few
years
ago.
Clearly,
the
burden
of
diabetes
and
the
range
of
clinical
tasks
mandated
by
the
existing
stan-
dards
of
care
recommendations
constitute
a
552
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NATIONAL
MEDICAL
ASSOCIATION
VOL.
94,
NO.
7,
JULY
2002
DIABETES
PRIORITIES
IN
PRIMARY
CARE
Table
2.
Oral
antidiabetic
agents
Drug
Classes
Mechanism
of
Action
HbAlc
Fire
Power*
Unique
Features
Sulfonylureas
1-2%
Many
generic
forms;
Relatively
inexpensive
First
generation
Insulin
secretion
Tolbutamide
Acetohexamide
Tolazamide
Chlorpropamide
Second
generation
Insulin
secretion
Glyburide
Glipizide
Glimepiride
Meglitinide
1-2%
Repaglinide
Insulin
secretion
Targets
postprandial
hyperglycemia
Amino
acid
derivative
-1%
Nateglinide
Insulin
secretion
Targets
postprandial
hyperglycemia
Biguanide
1-2%
Metformin
Hepatic
glucose
output
No
weight
gain
Alpha-glucosidase
Carbohydrate
absorption
-0.5%
Target
postprandial
hyperglycemia
inhibitors
Acarbose
Miglitol
Thiazolidinediones
Insulin
sensitivity
1-2%
Ancillary
benefits
on
Syndrome
X
Rosiglitazone
Pioglitazone
*"Fire
power"
refers
to
the
expected
decrease
in
HbAl
c
in
full-dose
monotherapy.
Values
are
approximate
and
vary
according
to
individual
patient
characteristics,
clinical
trial
design,
and
other
factors.
major
clinical
challenge
in
primary
care.
In-
deed,
surveys
indicate
inadequate
compliance
with
such
recommendations
in
primary
care
practice
settings.31,32
ROLE
OF
PRIMARY
CARE
PHYSICIANS
The
challenge
of
diabetes
must
be
tackled
on
three
fronts:
Primary
prevention,
secondary
prevention
(of
diabetes
complications),
and
tertiary
prevention
(of
morbidity
and
mortality
from
established
complications).
Primary
pre-
vention
of
type
2
diabetes
can
be
accomplished
in
high-risk
individuals
with
impaired
glucose
tolerance
through
lifestyle
modification.
Mod-
est
reduction
(500-700
kcal/day)
in
caloric
consumption
together
with
regular
physical
ac-
tivity
(e.g.,
walking
for
30
minutes
five
times
per
week)
exerts
a
remarkably
potent
prophy-
lactic
effect
against
development
of
type
2
dia-
betes.33'34
Primary
care
physicians
should
vigor-
ously
promote
these
primary
preventive
measures
among
relatives
of
their
patients
with
diabetes.
Once
diabetes
has
developed,
how-
ever,
the
priority
shifts
to
secondary
preven-
tion,
namely,
avoidance
of
microvascular
and
macrovascular
diabetic
complications.
The
best
prophylaxis
against
microvascular
complica-
tions
is
tight
glycemic
control
23-25.
The
best
prophylaxis
against
macrovascular
complica-
tions
is
a
policy
of
comprehensive
risk
reduc-
tion
(glycemic,
lipid,
blood
pressure,
smoking
cessation,
etc).
Even
after
myocardial
infarc-
tion
has
occurred,
careful
attention
to
blood
glucose
control
reduces
acute
and
chronic
post-infarct
mortality.35What
is
needed,
there-
fore,
is
a
more
efficient
model
of
integrated
diabetes
care
delivery
that
achieves
outstanding
glycemic
control,
maintains
updated
fund
of
knowledge
for
providers,
motivates
self-man-
agement
behaviors
in
patients,
utilizes
special-
ist
referrals
efficiently,
and
prevents
morbidity
and
mortality
from
complications
of
diabetes.
JOURNAL
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2002
553
DIABETES
PRIORITIES
IN
PRIMARY
CARE
The
following
are
some
suggestions
toward
at-
tainment
of
these
protean
goals.
1.
Diabetes
updates:
The
primary
care
physi-
cian
now,
more
than
ever
before,
needs
frequent
updates
of
diabetes-specific
knowledge
base.
Attendance
at
national
or
regional
conferences
is
an
effective
mecha-
nism
for
continuing
education.
Numerous
dinner
programs,
sponsored
by
industry,
are
also
available,
to
supplement
learning
opportunities.
Although
these
latter
pro-
grams
are
conceptually "promotional,"
they
often
provide
quality
diabetes
education
by
outstanding
experts
in
the
field.
Other
av-
enues
for
updating
fund
of
knowledge
in-
clude
journal
subscription,
affiliation
with
diabetes
faculty,
and
involvement
in
con-
tinuing
medical
education
programs
at
lo-
cal
tertiary
care
institutions.
Clearly,
there
is
need
for
innovative
thinking
in
the
de-
sign
of
training
mechanisms
in
this
area.
One
idea
involves
development
of
"mini-
fellowships"
that
enable
the
generalist
to
perform
at
advanced
levels
in
selected
dis-
ease
states
(e.g.,
diabetes,
dyslipidemia,
hy-
pertension)
after
completion
of
a
series
of
brief,
in-depth
supervised
experiences.
2.
HbAlc:
The
testing
frequency
for
HbAlc
is
suboptimal,
nationally.30
As
the
"gold
stan-
dard"
measure
of
diabetes
control
that
has
been
linked
to
outcome,
there
is
no
excuse
for
not
ordering
the
HbAlc
test
at
the
rec-
ommended
frequency.
The
recommended
testing
frequency
is
1-
4
times/year,
de-
pending
on
state
of
glycemic
control.
The
minimal
goal
for
prevention
of
long-term
complications
is
<7%.
From
the
updated
UKPDS
data,
significant
additional
micro-
vascular
and
macrovascular
benefits
ac-
crued
when
HbAlc
was
lowered
from
7%
to
6%.29
It
is
therefore
of
utmost
priority
for
patients
and
their
physicians
to
develop
an
interest
in
setting
and
reaching
HbAlc
targets.
Patients
need
to
be
told
that,
since
blood
glucose
levels
fluctuate
markedly
in
any
given
day,
and
from
day
to
day,
a
con-
venient
way
of
assessing
average
blood
glu-
cose
over
periods
of
2-3
months
is
by
mea-
suring
the
HbAlc.
Patients
unable
to
grasp
the
full
name
of
this
test
can
be
encour-
aged
to
remember
it
merely
as
the
"Alc
test."
Every
diabetic
patient
needs
to
know
that
keeping
the
HbAlc
level
below
7%
(i.e,
close
to
the
upper
normal
range
of
6%)
is
the
best
insurance
against
develop-
ment
of
long-term
complications.
Finally,
the
good
news
from
the
DCCT
data
that
every
1%
absolute
decrease
in
HbAlc
level
(e.g.
from
9%
to
8%)
translates
to
a
45%
reduction
in
the
risk
of
retinopathy
and
other
microvascular
complications
must
be
shared
at
every
opportunity,
as
a
motiva-
tional
tool
for
patients
with
diabetes.
3.
Diabetes
Education
and
Nutrition:
The
core
message
to
get
across
to
patients
is
that
control
of
blood
sugar
matters.
A
patient
with
average
blood
glucose
levels
of
200-
250
mg/dl
will
have
at
least
two-fold
greater
risk
of
developing
retinopathy,
neuropathy,
and
nephropathy
than
a
patient
with
aver-
age
glucose
levels
of
150-160
mg/dl,
over
the
course
of
several
years.
cEffective
inter-
nalization
of
this
cardinal
message
requires
that
patients
understand
the
identity
and
significance
of
the
HbAlc
test
(as
already
elaborated
in
the
preceding
passage),
and
appreciate
the
role
of
self-monitoring
of
blood
glucose
(discussed
later)
as
a
valu-
able
tool
for
optimization
of
care.
These
and
other
pertinent
self-management
tasks
in
diabetes
education
can
be
accomplished
through
referral
to
a
certified
diabetes
ed-
ucator.
However,
the
primary
care
physi-
cian
must
remain
engaged
and
must
peri-
odically
monitor
the
efficacy
of
these
referrals
by
assessing
the
patient's
grasp
of
the
aforementioned
key
concepts.
Caloric
restriction,
avoidance
of
over-eating,
and
adoption
of
wholesome
eating
habits
are
other
aspect
of
diabetes
education
that
re-
quire
emphasis
and
periodic
reinforce-
ment
(through
dietitian
referrals).
4.
Lifestyle
intervention:
Advice
on
diet
and
554
JOURNAL
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7,
JULY
2002
DIABETES
PRIORITIES
IN
PRIMARY
CARE
Figure
1.
Sample
prescription
for
exercise.
An
exercise
prescription
should
be
specific,
gradually
upgradable,
and
based
on
a
clearly
defined
rationale.
In
previously
sedentary
patients,
it
may
be
prudent
to
progress
more
gradually,
say,
weekly
increments
of
five
minutes.
exercise
should
be
delivered
with
the
same
conviction
that
accompanies
prescription
medicine.
Referral
to
a
dietitian
often
dem-
onstrates
such
seriousness
of
purpose.
Un-
til
Clinical
Exercise
Physiologists
become
routinely
available,
primary
care
physicians
should
undertake
to
actually
issue
written
prescriptions
for
exercise.
A
good
exercise
prescription
(Fig.
1)
should
have
three
el-
ements:
1)
a
clear
rationale
-
this
can
be
established
by
briefly
discussing
the
meta-
bolic
benefits
of
moderate
exercise;
2)
specificity
-
"walk
for
10
min
every
Monday,
Wednesday,
Friday"
is
a
better
script
than
"exercise
regularly",
and
3)
scalability
-
the
exercise
prescription
should
gradually
be
scaled
up:
For
example,
"Increase
walks
to
20
min
on
Monday,
Wednesday,
Friday
af-
ter
one
week".
A
clear
plan
should
be
es-
tablished
for
evaluation
of
adherence
and
efficacy
of
the
program.
Alternative
modes
of
increasing
physical
activity
should
be
considered
if
adherence
and
efficacy
are
suboptimal.
A
small
investment
in
inexpen-
sive
home
exercise
equipment
(e.g.,
sta-
tionary
bike)
may
be
necessary,
if
outdoor
opportunities
for
exercise
are
limited
or
precarious.
Of
course,
noninvasive
cardiac
screening
before
exercise
is
always
prudent
in
patients
who
have
not
been
physically
active.
5.
Self-monitoring:
Self-monitoring
of
blood
glucose
(SMBG)
predicts
adherence
to
other
medical
recommendations
and
is
as-
sociated
with
superior
glycemic
control.
Pa-
tients
who
do
not
perform
SMBG
tend
also
to
ignore
other
aspects
of
self-manage-
ment.
Thus,
successful
initiation
of
SMBG
in
any
patient
is
a
step
toward
better
glyce-
mic
control.
The
standard
recommenda-
tion
for
patients
with
typeldiabetes
is
to
perform
self-testing
of
blood
glucose
three
JOURNAL
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JULY
2002
555
DIABETES
PRIORITIES
IN
PRIMARY
CARE
to
four
times
daily.
The
optimal
frequency
of
self-testing
for
type
2
diabetes
patients
has
not
been
determined,
and
can
be
ne-
gotiated
with
patients.
Primary
care
physi-
cians
should
encourage
patients
to
perform
and
record
SMBG
results,
and
should
re-
view
the
home
record
with
interest
during
office
visits.
It
is
especially
important
that
patients
be
made
to
realize
that
the
num-
bers
are
actually
used
to
make
changes
in
the
treatment
plan.
6.
Efficient
use
of
medications:
The
rational
approach
to
type
1
diabetes
is
an
optimized
insulin
replacement
regimen
that
includes
basal
and
bolus
elements.
Because
of
the
pathophysiology
of
type
2
diabetes
(com-
bined
insulin
resistance,
beta-cell
insulin
secretory
defect,
and
excessive
hepatic
glu-
cose
production)
and
its
progressive
na-
ture,
achievement
of
optimal
glycemic
con-
trol
often
requires
the
use
of
more
than
one
agent.
As
much
as
possible,
drug
com-
binations
should
be
selected
for
their
ther-
apeutic
"fire
power,"
complementary
mechanisms
of
action,
ancillary
benefits
(especially
on
cardiovascular
risk
factors),
safety,
and
tolerability
(Table
2).
Triple
therapy
with
oral
antidiabetic
agents
(e.g,
sulfonylurea
+
biguanide
+
thiazolidinedi-
one)
is
effective
and
may
be
an
option
in
selected
patients.
Thus
various
combina-
tions
of
the
available
oral
agents
are
now
conceivable,
which
should
ensure
adequate
glycemic
control
in
virtually
every
type
2
diabetes
patient.
Combination
therapy
will
be
most
effective
if
initiated
as
part
of
a
comprehensive
diabetes
care
plan
that
in-
cludes
lifestyle
interventions.
The
decision
to
continue
a
combination
regimen
should
be
based
on
evidence
of
continuing
effi-
cacy,
safety,
and
tolerability.
There
should
be
no
reservation
in
adding
insulin
to
the
regimen,
if
glycemic
control
on
oral
agents
remains
suboptimal.
Insulin
can
be
started
as
bedtime
NPH
or
glargine
at
a
low
initial
dose
(-10
units)
and
increased
by
2-4
units
every
few
days
(while
continuing
oral
agents)
until
a
fasting
blood
glucose
level
of
130
mg/dl
is
achieved.3
Once
that
target
is
achieved,
a
more
stringent
goal
for
fast-
ing
blood
glucose
(e.g.,
1
10
mg/dl)
can
be
pursued.
Eventually,
many
patients
will
re-
quire
multiple
injections
of
short-
and
long-
er-acting
insulin
preparations
for
optimal
control.
Large
daily
doses
of
insulin
(100
U/day)
usually
are
required
to
maintain
optimal
glycemic
control
in
patients
with
type
2
diabetes.
7.
Goal
setting:
Goals
are
the
therapeutic
road
maps
that
direct
and
concentrate
all
efforts.
Without
a
clearly
defined
goal,
the
doctor
and
patient
"are
lost
at
sea."
Achiev-
able
goals
should
be
set,
and
strategies
and
tactics
marshaled
toward
attainment
of
those
goals.
A
typical
goal
in
a
patient
with
initial
HbAl
c
of
11
%
could
be
to
reduce
that
number
by
1
%
by
the
time
of
follow-up
visit
in
2
months.
The
applicable
strategies
include
review
of
current
medication
and
adherence
to
lifestyle
recommendations.
The
specific
tactics
include
maximizing
current
drug
doses,
substitution
or
addi-
tion
of
an
agent
working
by
a
differrent
mechanism,
formal
referral
to
dietitian
for
reinforcement,
and
reinforcement
of
phys-
ical
activity
plan,
including
a
written
pre-
scription
for
exercise
(Fig.
1).
8.
Cardiovascular
risk
factors:
A
comprehen-
sive
approach
to
modification
of
cardiovas-
cular
risk
factors
is
mandatory.
Targets
in-
clude
smoking
cessation,
lipids
(LDL-
cholesterol
goal
in
diabetes
is
<100
mg/
dl),
blood
pressure
(goal
<130/80),
asprin
prophylaxis,
etc.
Macrovascular
disease
ac-
counts
for
the
majority
of
deaths
in
diabe-
tes.
Coronary
artery
disease
and
myocardial
infarction
present
in
atypical
ways
in
diabe-
tes,
so
symptoms
are
unreliable.
A
high
in-
dex
of
suspicion
and
a
low
threshold
for
ordering
stress
cardiac
testing
is
appropri-
ate
in
diabetes
patients.
Intensive
glucose
control
in
patients
with
acute
myocardial
infarction
has
been
demonstrated
to
re-
duce
short-term
and
long-term
mortality
in
556
JOURNAL
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JULY
2002
DIABETES
PRIORITIES
IN
PRIMARY
CARE
diabetic
patients.35
Thus,
intensification
of
glycemic
control
in
the
peri-infarct
period
and
beyond
should
be
standard
practice
in
diabetic
patients
with
acute
myocardial
in-
farction.
9.
Surveillance
for
microvascular
complica-
tions
(see
Table
1):
The
microvascular
complications
(retinopathy,
nephropathy,
and
neuropathy)
develop
after
several
years
of
uncontrolled
diabetes.
The
usually
grad-
ual
time
course
of
these
complications
af-
fords
an
opportunity
for
early
detection
and
tertiary
prevention
(i.e.,
prevention
of
morbidity
and
mortality
from
progression
of
diabetic
complications).
a.
Preemptive
strike
at
kidney
disease.
Both
microalbuminuria,
the
earliest
(and
reversible)
stage
of
kidney
disease,
and
gross
proteinuria
precede
end-stage
renal
failure
by
variable
but
lengthy
in-
tervals.
The
limited
availability
of
organs
for
transplantation
means
that
thou-
sands
of
patients
spend
several
years
on
dialysis
without
a
chance
of
receiving
kidney
transplants.
Thus
the
emphasis
should
be
on
prevention
of
kidney
dis-
ease,
since
cure
cannot
be
offered
to
all
affected
persons.
The
initial
observation
that
microalbuminuria
precedes
more
advanced
stages
of
kidney
disease
by
sev-
eral
years
is
important
information.
This
knowledge
creates
a
window
of
opportu-
nity
to
intervene
and
prevent
further
de-
cline
in
renal
function.
The
decline
in
kidney
function
can
be
slowed
down
considerably
if
blood
pressure
is
con-
trolled
(130/80
or
lower)
in
persons
who
have
both
diabetes
and
hyperten-
sion.
It
has
now
been
established
that
angiotensin
converting
enzyme
(ACE)
inhibitors36
and
angiotensin
receptor
blockers
(ARB)37,38
are
effective
in
pre-
serving
renal
function
in
diabetes
pa-
tients
with
microalbuminuria
and
with
more
advanced
forms
of
nephropathy.
ACE
inhibitors
are
well
tolerated
by
nor-
motensive
patients.
Thus
the
approach
to
diabetic
kidney
disease
should
focus
on
prevention.
Persons
who
have
had
type
1
diabetes
for
5
years
or
longer
and
all
persons
with
type
2
diabetes
are
screened
annually
for
microalbumin-
uria.
The
screening
test
consists
of
either
a
timed
urine
collection
or
a
random
spot
urine
for
measurement
of
mi-
croalbumin-to-creatinine
ratio.
In
pa-
tients
with
microalbuminuria
treated
with
ACE
inhibitors,
follow-up
urine
test
should
be
obtained
and
the
dose
of
ACE
inhibitor
adjusted
for
maximum
ne-
phroprotective
effect.
b.
Zero
tolerance
for
amputations:
Diabe-
tes
accounts
for
50%
of
cases
of
non
traumatic
lower
extremity
amputations
in
the
U.S.
There
should
be
zero
toler-
ance
for
limb
loss
in
modern
diabetes
practice.
The
risk
factors
for
lower
ex-
tremity
amputation
in
persons
with
dia-
betes
include
peripheral
neuropathy,
peripheral
vascular
disease,
deformities,
trauma
and
deep
tissue
infections.
With
the
possible
exception
of
trauma,
most
of
these
risk
factors
are
impacted
by
the
state
of
metabolic
control.
Poor
control
of
blood
glucose
is
associated
with
in-
creased
risk
of
infections,
impaired
wound
healing,
and
development
of
long-term
diabetic
complications,
such
as
neuropathy
and
peripheral
vascular
disease.
Additional
risk
factors
for
pe-
ripheral
vascular
disease
include
hyper-
tension,
cigarette
smoking
and
elevated
blood
cholesterol
levels.
Strategies
for
limb
preservation
include:
1)
tight
con-
trol
of
blood
glucose
(and
of
blood
pres-
sure),
2)
smoking
cessation
(patients
should
be
given
every
assistance,
includ-
ing
special
counseling
and
prescription
for
bupriopion),
3)
daily
foot
inspection
by
patients,
4)
appropriate
foot
wear,
and
5)
regular
physical
examinations
by
physician,
including
an
assessment
of
ar-
terial
pulses
and
skin
sensation
(using
a
5.07/10
gm
monofilament).
Referral
for
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION
VOL.
94,
NO.
7,
JULY
2002
557
DIABETES
PRIORITIES
IN
PRIMARY
CARE
Table
3.
Strengths
of
the
Clinical
Trials
Model
1.
Common
Protocol
and
Manual
of
Operations
2.
Goal
setting/Incentives
3.
Frequent
contacts
with
patients
4.
Close
monitoring
of
endpoints
5.
Team
approach
among
multi-professionals
6.
Shared
responsibility
with
enrolled
patients
7.
Accountability
to
higher
authority
8.
Case
manager
and
patients
feel
peer
pressure
to
excel
9.
Willingness
of
staff
to
go
beyond
the
call
of
duty
routine
podiatric
evaluation
before
the
development
of
limb
threatening
lesions
has
been
demonstrated
to
reduce
ampu-
tation
rates.
Clinics
can
obtain
the
pop-
ular
"Feet
Can
Last
A
Lifetime"
kit
from
the
NIH
by
calling
1-800-GET-LEVEL.
10.
Practice-Within-a-Practice:
The
primary
care
physician's
role
in
preventing
mor-
bidity
and
mortality
from
diabetes
re-
quires
a
paradigm
shift
from
the
existing
clinical
traditions.
Diabetes
care
needs
to
be
isolated
as
a
"Practice-Within-a-
Practice",
using
methods
that
enable
ready
identification
of
affected
patients
(e.g.,
color-coded
charts,
special
chart
stickers,
electronic
medical
record
iden-
tifiers,
etc.).
Once
so
isolated
as
a
Prac-
tice-Within-a-Practice,
it
should
be
feasible
to
categorize
diabetes
patients
by
quar-
tiles
of
HbAlc
(<7%,
7-7.9%,
8-8.9%,
>9%)
and
to
triage
those
in
the
top
2
quartiles
for
more
intensive,
focused
at-
tention
and
joint
management
with
en-
docrinologists.
A
"Clinical
Trials
Model"
wherein
poorly
controlled
patients
are
identified
and
tracked
closely
by
a
nurse,
nurse
practitioner,
or
other
appointed
"Case
Manager"
within
the
practice
is
strongly
proposed.
This
adaptation
of
the
Clinical
Trials
Model
can
be
an
effi-
cient
mechanism
for
achieving
excel-
lence
in
diabetes
management
in
the
pri-
mary
care
setting,
because
of
the
inherent
strengths
of
such
a
model.
(Table
3).
CONCLUSION
Effective
diabetes
management
entails
a
multi-modality
approach
that
utilizes
lifestyle
and
pharmacological
interventions.
The
mne-
monic
MEDEM
(Monitoring,
Education,
Diet,
Exercise,
Medications)
can
be
used
to
recall
the
key
modalities
of
care.
Genuine
commit-
ment
to
the
patient's
overall
well
being
pro-
motes
adherence
to
the
multiple
behavioral
and
self-care
tasks
expected
of
the
diabetic
pa-
tient.
Excellence
in
diabetes
care
requires
fre-
quent
patient
contacts,
especially
during
the
"down
time"
between
office
visits.
These
con-
tacts
may
be
accomplished
by
means
of
tele-
phone,
facsimile,
or
via
the
Internet.
Such
con-
tacts
enable
the
diabetes
care
team
to
respond
promptly
to
laboratory
test
results,
review
self-
monitored
blood
glucose
data,
adjust
medica-
tions,
and
assess
adherence
to
lifestyle
and
pharmacological
interventions.
These
interac-
tions
also
have
a
heuristic
impact
on
patients,
build
trust
between
the
patient
and
caregivers,
and
may
help
modify
behavior.3940
Patients
with
chronically
poorly
controlled
diabetes
(HbAlc
>
8%)
will
benefit
from
joint
evalua-
tion
and
care
by
a
specialist.
Referral
to
an
endocrinologist
should
have
clear
goals
and
reasonable
time
course
(or
number
of
visits)
for
attaining
such
goals.
A
reduction
in
HbAlc
of
approximately
1-2%
from
baseline
within
2
visits
should
be
set
as
the
minimal
justification
for
the
specialist
endocrinologist's
interven-
tion.
Subjective
symptoms
suggestive
of
hypo-
glycemia
occur
frequently
when
patients
with
poorly
controlled
diabetes
experience
im-
proved
glycemic
control.
These
symptoms
oc-
cur
at
blood
glucose
levels
that
are
usually
within
the
physiological
range
or
even
higher,
and
are
attributable
to
altered
glycemic
thresh-
old
for
release
of
counterregulatory
hor-
mones.41
No
specific
treatment
other
than
re-
assurance
is
indicated
for
patients
with
such
episodes
of
"pseudohypoglycemia."
Referrals
to
other
specialists
(cardiac,
podiatry,
ophthal-
mology,
etc.)
should
be
implemented
as
neces-
sary.
558
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION
VOL.
94,
NO.
7,
JULY
2002
DIABETES
PRIORITIES
IN
PRIMARY
CARE
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