SEPTEMBER 13-16, 2016 SOUTH LAKE TAHOE, CA

Diabetes: Avoiding & Managing Its Adverse Impact on Claimant Recovery

Eric F. Patten, RN, BSNDirector of Clinical Management

One Call Care Management

Thursday, Sept. 15, 20163:45 – 5:00 pm

Objectives• Define diabetes – types and symptoms 

• Learn to recognize possible complications 

• Understand long‐term repercussions of uncontrolled diabetes 

• Discuss treatment considerations, including Hyperbaric Oxygen Chamber Therapy (HBOT) for wound healing

• Discuss the importance of nutrition in diabetes‐related cases, and its relationship to recovery and medical costs 

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Diabetes Types & SymptomsType 1 Diabetes: the pancreas does not make enough insulin and completely shuts down. Glucose levels rise. 

Type 2 Diabetes:  the body’s inability to use the insulin that it produces effectively causing increased glucose levels.

Symptoms

‐ Excessive thirst

‐ Frequent Urination

‐ Weight Loss

‐ Lethargic

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WARNINGPoorly controlled diabetes can result in complications.  

- Delayed Healing- Infections- Increased recovery time

Resulting in increased reserves and longer length of disability

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Scope of the ChallengeDiabetes affects 36.1 million people of all ages

‐DIAGNOSED29.1 million people

‐UNDIAGNOSED7.0 million people

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Normal Levels• Blood Sugar Range: 80‐120 mg/dcl

• A1C Levels:  Below 5.7% normal • Test the average level of blood sugar over past 2‐3 months• Between 5.7 and 6.4% could signal pre‐diabetes • Type 2 diabetes ‐ over 6.5%• The goal for people with type 2 diabetes is to lower A1C levels to a healthier percentage

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Controlling DiabetesBalance of:• Exercise• Diet • Medication • Blood Testing

• To ensure that all are working together:

The person with diabetes checks their blood with a home blood testing machine. This requires very little blood and results are known in as little as 3 seconds. 

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How Diabetes Is ControlledType I:

Insulin; from a few injections to multiple injections to the use of the pump along with diet, exercise and monitoring.

Type II:Oral medications for patients along with the diet, exercise and monitoring. In a lot of cases patients need both insulin and oral medications. 

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Insulin Production

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SEPTEMBER 13-16, 2016 SOUTH LAKE TAHOE, CA

Complications

Emergency ComplicationsKetoacidosis (key‐toe‐ass‐i‐DOE‐sis) is a serious condition that can lead to diabetic coma or even death. When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are acids that build up in the blood and make you very sick. They are a warning sign that your diabetes is out of control. Ketones also indicate that you are getting sick. High levels of ketones can poison the body. 

Hypoglycemia – Low blood Sugar require sugar to correct (use juice or sugar of some sort to balance condition) 

Hyperglycemia – High Blood Sugar that requires treatment (additional medication) to correct the blood sugar and get it within a normal range

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Diabetes Impact on Circulation

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Circulation

• #1 cause of non-traumatic amputation

• More than 60% of amputations occur in people with diabetes

• Could cause wounds that don’t heal and recurrent infections

Diabetes Affects Wound Healing• Skin breaks and infections

• Decreased immunity and ability to fight infection

• Impaired sensation

• Poor blood flow

This dangerous combination could increase the Length of

Disability as well as your Medical Reserve !!

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Graphic Images Ahead… 

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94 yr. old female Right side/Right footPeripheral Vascular Disease 1.8 x 5 cm

94 year old female Right side/Right footPeripheral Vascular Disease 4.3x7 x 0.2 cm

Impact on the Healing Process

Diabetes Impact on Ankle Fractures• Patients with diabetes – generally poor outcomes • 42.3% incidence of complications (McCormick and Leith)• 32% higher infection rate (Flynn, et. al.)• Conservative management, preferable to surgical treatment• Those treated conservatively – greater tendency to become

infected versus those treated with open reduction internal fixation (ORIF)

• Those with poorly controlled diabetes and evidence of neuropathy – shown to be very difficult to manage

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Diabetes Impact on the Heart• Greater risk for heart disease, can lead to heart attack or stroke

• Vessels, thicker and less elastic, make it harder for blood to flow• Damaged vessels can lead to heart attack and stroke• Cardiac death rates 2 - 4x higher than non-diabetics • Incidence of stroke is 2 - 4x higher in diabetic population and

subsequent death, almost 3x higher• Heart disease and stroke: 65% of deaths in people with diabetes

• Controlling blood glucose levels, blood pressure and cholesterol can all help decrease heart disease

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Diabetes Impact on the Eyes• Diabetic eye disease – group of eye problems, may cause

severe vision loss or blindness:• Cataract - clouding of the eye's lens• Retinopathy• Glaucoma

• Diabetic Retinopathy – most common diabetic eye disease, leading cause of blindness in American adults• Blood vessels of retina may swell and leak fluid causing scarring• Abnormal new blood vessels may grow on the surface of the retina,

which can decrease vision or lead to blindness• Often there are no early symptoms – DETECTION is the KEY!

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Other Systematic ComplicationsIncreased Risk for Depression – 2x as likely to suffer from• Higher incidence in women than men

Nervous System – Excess glucose causes damage• 60-70% have mild to severe nervous system damage, causing

o Impaired sensationo Pain in hands and feeto Slow digestion o Carpal Tunnel Syndromeo Almost 30% of diabetics 40 years old or older have impaired

sensations in the feet increasing the risk of injury and sometimes requiring amputation

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Other Systematic ComplicationsRespiratory System•More likely to succumb to pneumonia or influenza Kidneys•Diabetes – leading cause of kidney failure, 44% of new cases •44,000 diabetics a year begin dialysis for end-stage renal disease•Blood vessels begin to leak, protein from blood is excreted in urine•Eventually vessels collapse and failure beginsFeet•Diabetes may damage nerves and vessels in feet •Decreased circulation, numbness, burning, “pins and needles” feeling •Reduced feeling leads to increased the risk of injury•Lack of blood flow – decreased healing, increased infection

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Other Systematic ComplicationsSkin• Dryness • Infection• Increased urination and dehydration • Nerves that control sweat glands can become damaged and your body

will not sweat enoughSexual Dysfunction• Erectile dysfunction • Inability to ejaculate

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Other Long‐Term Complications• Atherosclerosis• Diabetic Nephropathy• Diabetic Neuropathy• Hyperlipidemia• Hypertension• Peripheral Vascular Disease (PVD) 

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SEPTEMBER 13-16, 2016 SOUTH LAKE TAHOE, CA

Treatment Considerations

Hyperbaric Oxygen Therapy Chamber• Oxygen – powerful, versatile agent, used to assist in healing of

wounds for more than 40 years• Hyperbaric oxygen chamber therapy (HBOT) – therapeutic use

of oxygen under pressure • Treat hypoxic or ischemic wounds such as diabetic wounds • Hypoxia – insufficient supply of oxygen, prevents normal healing• Combats infections (e.g. gangrene), acting on anaerobic bacteria,

while helping the effects of antibiotics• Provides oxygen needed to support and stimulate wound healing

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Treatment Considerations forInjured Workers with Diabetes• Strict metabolic control for patients with diabetes• Bone fracture and poorly controlled diabetes – decreased bone

formation and mechanical stiffness (Beam, et. al.) • When blood glucose levels were tightly controlled, the fracture

healing is similar to those patients without diabetes• Conservative care for diabetics, e.g. extensive period of non-

weight bearing (2x as long) for patients with diabetes • 6 weeks of non-weight bearing for patient without diabetes • 12 weeks of non-weight bearing for patient with diabetes

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Treatment Considerations forInjured Workers with Diabetes• Utilize casts that are well padded or a total contact cast• Protect areas that are predisposed to irritation or breakdown • Frequently change casts to inspect areas underneath• Instruct diabetic patients to protect contralateral extremity while

wearing casts• Wrap contralateral limb lightly in an elastic bandage up to the

knee and utilize a pillow in between the legs during sleep• Avoids development of iatrogenic wounds

• Limit activity, e.g. avoid excess weight bearing, prevent overuse• Patients with longstanding diabetes are more difficult to manage

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SEPTEMBER 13-16, 2016 SOUTH LAKE TAHOE, CA

Nutrition is Key

Diabetes, Nutrition and Wound Healing• When blood glucose levels are persistently elevated the normal

process for healing is impaired.

• Patients with diabetes often have wounds that are difficult to heal.

• The initial barrier to healing is an increased blood glucose level, resulting in increased cell wall rigidity & decreased perfusion.

• This prevents adequate oxygen & nutrition to be delivered to the wound.

• Immune function is also decreased contributing to poor wound healing.

• Healing is delayed & medical costs rise.

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Diabetes, Nutrition and Wound Healing• Chemotaxis is the process by which white cells are attracted to the site

of an infection.

• Phagocytosis is the ingestion of bacteria by white cells.

• Both processes are important in controlling wound infections and are impaired in patients with diabetes if blood sugars are not controlled.

• Diabetic infections take longer to heal for this reason

• Patients with diabetes often have a progressive loss of lean body mass, which is replaced with a metabolically inactive fat mass.

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Diet• The nutritional plan (Diet) is used to control intake of sugar, fats and

sodium under the guidance of a Nutritionist..

• Diets can help to control blood pressure levels, decreasing hypertension

• Educating both the patient and their family members about the role of the diet in diabetes management is very important.

Nutrition Therapy (Diet)• The patient may need several sessions with a nutrition professional to

understand the diet and how food intact affects their blood sugar.

• Not enough Carbs= Low Blood Sugar (Hypoglycemia)

• Too many Carbs = High Blood Sugar (Hyperglycemia)

• There are many free sites for complete meal planning, via a simple Google search. Although not ideal the diabetic diet can also be found on the internet.

• Key website in assisting you find samples or resources for nutrition help is you state ADA (American Diabetes Association) website.

Nutrition Therapy (Diet)• Because hyperglycemia impedes wound healing, Nutritional Therapy

(Diet) should be discussed during each wound care visit.

• Many different nutritional approaches to diabetes are available:

• No Concentrated Sweets • Exchange system • Carb Counting • Glycemic index

• Any system is good as long as it is followed

• The Nutritional Therapy (Diet) should be individualized

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No Concentrated Sweets (NCS) Diet• Simplest dietary approach

• Eliminates all concentrated sources of "sugary foods,” such as cake, cookies, ice cream, and table sugar

• Often used in long-term-care facilities

• New information on mechanism of diabetes determined that the amount of carbs in meals and snacks is more important than type

• A Carb is a Carb is a Carb! – True but be careful!!!

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The Exchange System• The Exchange System is a more comprehensive diet approach

grouping foods with similar nutrition profiles

• Categorizes food into 3 main groups: 1) Carbohydrates – starch, fruits, milk, vegetables, and "other"

carbohydrate lists2) Meat and meat substitutes – includes very lean and lean meat

exchange lists3) Fats

• Under "fruit choices” – both ½ cup applesauce and ½ medium banana equal 1 fruit exchange (60 calories, 15 g of carbs, no protein or fat)

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Carbohydrate Counting• The daily intake of carbohydrates must be consistent to avoid

fluctuations in blood sugar

• Carbohydrate counting calculates the grams of carbohydrates in foods eaten during meals and snacks

• This is a more mathematically involved diet and each patient needs understand how much carb is in each food along with knowing the right portion amount

15gm of Carb = 1 slice of bread

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Carbohydrate Counting• Starches and fruits - 15 grams of carbohydrates per serving • Milk - 12 grams• Non-starchy vegetables - 5 grams• Meat and fat are not considered carbohydrates

Breakfast Example: 45 grams of carbs needed • 1 serving of cereal (15 grams)• 1 serving of milk (12 grams)• 1 serving of sliced strawberries (15 grams)

Each cereal has a different portion size: • 1/4 cup of granola• 1/3 cup of sugar-coated corn flakes• 1 cup of unsweetened Cheerios• 1 1/4 cups of puffed wheat

Each contain the same amount of carbohydrates -- Portion control is key

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Glycemic Index• Glycemic index (GI) ranks carbohydrate-rich foods by how much they

raise blood glucose levels

• GI characterizes the postprandial glucose response of various foods relative to white bread (which has a GI of 100)

Example

• Mixed-grain bread – low GI food (GI of 64)

• Kaiser roll – high-GI food (GI of 104)

• Diabetic patients should select a diet of low-GI foods

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SEPTEMBER 13-16, 2016 SOUTH LAKE TAHOE, CA

Advancements

Service Dogs 

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Wearables: Insulin Pumps

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MiniMed 640G Omnipod

Tandem t:slim

Wearables:Continuous Glucose Monitoring

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Big Foot Biomedical

Dexcom G5

Oral Medications

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Diabetes Pills How to take How they work Side Effects

Metformin / Glucophage

Usually 2x a day Decreases amount of glucose released from liver

Bloating, gas, diarrhea, upset stomach

Yeast infections

Januvia(Sitagliptin)

1x a day Allow pancreas to function more properly 

Skin rash, itching, hives, diarrhea  

Possible link to thyroid and pancreatic cancer

Janumet XR 1x every 24‐36 hours

Decreases amount of glucose released from liver

Allow pancreas to function more properly 

Skin rash, itching, hives, diarrhea  

Possible link to thyroid and pancreatic cancer

SEPTEMBER 13-16, 2016 SOUTH LAKE TAHOE, CA

Key Takeaways

Key Takeaways• Identify early whether injured workers might have diabetes

• If so, use A1C tests to assess how well they’re controlling their condition

• Normal levels – may recover at similar rate to non-diabetic

• High levels – may have issues with delayed healing and recovery

• Work with medical professionals to alleviate impact on claimant recovery

• Wounds may heal slowly or may not heal – may require HBOT

• Infections could occur and frequently recur – monitor

• Conservative care for fractures, e.g. 2x as long non-weight bearing

• Determine if experiencing other complications that could impact recovery and take these into account when developing treatment plan

• Determine if nutritional counseling might benefit claimant recovery, as well as cost and duration of the claim

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SEPTEMBER 13-16, 2016 SOUTH LAKE TAHOE, CA

Questions & Answers

Eric F. Patten, RN, BSNDirector of Clinical Management

One Call Care Management

Phone: 781-733-1242Email: eric_patten@onecallcm.com

Website: www.onecallcm.com