Woring Together to Manage Diabetes

8/8/2019 Woring Together to Manage Diabetes

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WORKING

TOGETHER

TO MANAGE

DIABETES

A Guide for Pharmacy, Podiatry,Optometry, and Dental Professionals

May 2007


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WORKINGTOGETHER

TO MANAGE

DIABETES

A Guide or Pharmacy, Podiatry,

Optometry, and Dental Proessionals


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Credits and AcknowledgementsThis material was developed by the National Diabetes Education ProgramsPharmacy, Podiatry, Optometry, and Dental Proessionals Work Group. NDEPwould like to acknowledge the ollowing work group members or their workon the revision:

Barbara Aung, D.P.M.

W. Lee Ball, Jr., O.D.

Joseph M. Caporusso, D.P.M.

JoAnn Gurenlian, R.D.H., Ph.D.

Stuart T. Haines, Pharm.D., F.C.C.P., F.A.S.H.P., B.C.P.S.

Mimi Hartman, M.A., R.D., C.D.E.

Cynthia Heard, O.D.

Cynthia Hodge, D.M.D.

Milissa A. Rock, R.Ph., C.D.E.George W. Taylor, III, D.M.D., Dr.P.H.

Jaime R. Torres, D.P.M., M.S.

NDEP also thanks the ollowing individuals or their work on the original

Working Together document upon which this revision is based:

Norma Bowyer, O.D., M.P.H., F.A.A.O.

Caswell Evans, D.D.S., M.P.H.

Deborah Faucette, R.Ph.Lawrence Harkless, D.P.M.

Tom Murray, Pharm.D.

Ross Taubman, D.P.M.

In addition, the ollowing NDEP sta at the Centers or Disease Control andPrevention (CDC) and the National Institutes o Health (NIH) contributed to thereview and revision o these materials:

Pamela Allweiss, M.D.

Sabrina Harper, M.S.

Joanne Gallivan, M.S., R.D.

Jane Kelly, M.D.

Linda Orgain, M.P.H.


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Continuing Education CreditThe Centers or Disease Control and Prevention is accredited by the

Accreditation Council or Continuing Medical Education (ACCME) to providecontinuing medical education or physicians.

The Centers or Disease Control and Prevention designates this educationalactivity or a maximum o 1.25 category 1 credits toward the AMA PhysiciansRecognition Award. Each physician should claim only those credits that he/sheactually spent in the activity.

The Centers or Disease Control and Prevention is accredited bythe Accreditation Council or Pharmacy Education as a provider ocontinuing pharmacy education. This program is a designated eventor pharmacists to receive .1 Contact Hour in pharmacy education.The Universal Program Number is 387-603-06-042-H-01.

This activity or 1.25 contact hours is provided by the Centers or Disease

Control and Prevention, which is accredited as a provider o continuingeducation in nursing by the American Nurses Credentialing CentersCommission on Accreditations.

The CDC has been reviewed and approved as an Authorized Provider by theInternational Association or Continuing Education and Training (IACET)8405 Greensboro Drive, Suite 800, McLean, Virginia 22102. The CDC hasawarded 0.1 CEUs to participants who successully complete this program.

To receive continuing education credit or this course:

Go to the CDC/ATSDR Training and Continuing Education Online at

http://www.cdc.gov/phtnonline . I you have not registered as a participant,click on New Participant to create a user ID and password; otherwise clickon Participant Login and log in.

Once logged on to the CDC/ATSDR Training and Continuing EducationOnline Web site, you will be on the Participant Services page. Click onSearch and Register. Enter the course number (SS1126) or a keywordunder Keyword Search. Click on View.

Click on the course title (Working Together to Manage Diabetes). Selectthe type o CE credit you would like to receive and then Submit. Threedemographic questions will come up. Complete the questions and then

Submit. A message will come up thanking you or registering or thecourse. I you have already completed it, you may choose to go straightto the evaluation and posttest. Complete the evaluation and Submit.Complete the posttest and Submit. A record o your course completionwill be located in the Transcript and Certicate section.


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When asked or a verication code, please use PPOD-07. Continuing education credits or additional proessions may be oered

in the uture. Visit www.cdc.gov/phtnonline or updates.

I you have any questions or problems please contact: CDC/ATSDR Trainingand Continuing Education Online, 1-800-41TRAIN or 404-639-1292. E-mail

at [email protected].

The materials and continuing education credits are ree. Requirements orobtaining continuing education include reading Working Together to ManageDiabetes: A Guide for Pharmacists, Podiatrists, Optometrists, and DentalProfessionals and the Working Together to Manage Diabetes patient educationposter, registering on the Centers or Disease Control and Preventionscontinuing education Web site (www.cdc.gov/phtnonline), and completingan evaluation orm and posttest.

Release Date: January 24, 2007Expiration Date: January 23, 2010

CDC, our planners, and our content experts wish to disclose that they have nonancial interests or other relationships with the manuacturers o commercialproducts, suppliers o commercial services, or commercial supporters, with theexception o Dr. Haines, who discloses that he is a Merck minor shareholder,and Dr. Taylor, who discloses that he has received research grants rom NIH/NIDCR, Blue Cross Blue Shield o Michigan, and the Foundation or OralHealth or diabetes-related research projects, and he is a scientic consultantor the Colgate Palmolive Company. Content will not include any discussiono the unlabeled use o a product or a product under investigational use.

NDEP would like to thank the ollowing individuals who pilot tested thematerials or continuing education credits:

Theresa Aldridge, O.D.Chris Allen, R.Ph., M.P.H.Pam Allweiss, M.D., M.P.H.Gary Baker, R.Ph., M.B.A.Silvia Benincaso, M.P.H., R.D., C.D.E.Dan Bintz, O.D.David Bordeaux, D.D.S., M.A.G.D.Heidi Brainerd, M.S., R.Ph.Kat Chinn, R.N., M.S.,F.N.P.Dawn Clary, O.D.Gay Craword, R.D., M.P.H., C.D.E.Eugene Dannels, D.P.M.

Michael Duenas, O.D.Charles Edwards, D.P.M.Kris Ernst, B.S.N., R.N., C.D.E.Pamela Euliss, R.D.H.Beth Finnson, R.D.H., M.P.H.Adam Gordon, O.D., M.P.H.Chris Halliday, D.D.S., M.P.H.Larry Herman, D.M.D.Kim Hort, D.M.D.Mark Horton, O.D., M.D.Laurie Hynes, R.D.H.Ankur Kalra, O.D.

William Kohn, D.D.S.Marsha Lambrou, R.N.Chris Lamer, Pharm.D., C.D.E.Donnie Lee, M.D.Flora Lum, M.D.Maria MatthewsCheryl Metheny, M.S., R.D./L.D.N., C.D.E., C.L.C.Kristin Nichols, Pharm.D.Roland Palmquist, D.P.M.Lauren Patton, D.D.S.Dennis Pena, D.P.M.Matthew Pettengill, D.P.M.

Meerah Ramesh, M.S., R.D., C.D.E.Terry Raymer, M.D., C.D.E.Stephen RithNajarian, M.D.Thomas Rogers, D.D.S.Jody Rosendahl, R.D.Mark Rothstein, D.P.M., M.P.H.Michael Schroeder, D.D.S.Mark Sherstinsky, O.D.Judith Thompson, Pharm.D., B.C.P.S.Carol Treat, M.S., R.D., C.D.E., L.D.Roger VanDyke, R.N.Nicole Vesely


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Contents

Credits and Acknowledgements .................................................. ii

Continuing Education Credit........................................................ iii

Foreword .......................................................................................viiiHypothetical Case Examples........................................................ ix

Sections

Section 1: Diabetes A Major Health Problem ...................................... 1

Section 2: Impact o Controlling the ABCs o Diabetes ......................... 7

Section 3: Diabetes Management and Team Care ............................. 11

Section 4: What to Dicuss with Patients with Diabetes ........................ 15

Section 5: Foot Health and Diabetes ................................................ 23

Section 6: Eye Health and Diabetes ................................................. 29

Section 7: Oral Health and Diabetes ................................................ 33

Section 8: Drug Therapy Management and Diabetes ......................... 37

Section 9: Coordination o Care ...................................................... 41

Section 10: Pre-diabetes and Primary Prevention ................................. 43

Appendices

Appendix A ...................................................................................... 48

Appendix B ...................................................................................... 49Appendix C ...................................................................................... 50

Appendix D ...................................................................................... 52

Additional Resources .................................................................. 53

Reerences.................................................................................... 61


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ForewordThe goals o Working Together to Manage Diabetes: A Guide for Pharmacists,Podiatrists, Optometrists, and Dental Professionals is to reinorce consistentdiabetes messages across the our disciplines, pharmacy, podiatry, optometry,and dentistry (PPOD), and to promote a team approach to comprehensivediabetes care that encourages collaboration among all care providers.

The ollowing are the learning objectives or these materials:Ater this activity, the participant will be able to

Identiy the ABCs o diabetes and their role in preventing complications.

Name key messages that PPOD providers should all convey to patients withdiabetes.

Describe the key concerns or drug management and oot, eye, and oralhealth care or people with diabetes.

Identiy the results o the Diabetes Prevention Program (DPP).

The target audiences that may best benet rom these materials includepharmacists, podiatrists, optometrists, dentists, dental hygienists, physicians,nurses, dietitians, and others who provide care to people with or at risk ordiabetes.

Working Together to Manage Diabetes is a cross-training document. It is nota comprehensive guide to all diabetes concerns in any one o the PPODdisciplines, but is instead a key issues guide to messages that every healthcare proessional can give to support comprehensive care.


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Hypothetical Case Examples A 70-year-old woman with diabetes tells her eye care provider that her

blurred vision is such a problem that she is araid to cut her toenails.She states They are so long, my shoes dont t! She has worn oversizedbedroom slippers to the appointment. The eye care provider asks thepatient to take o her slippers, and nds overgrown, thickened toenailsthat have curled around and are cutting the skin. The woman has littlesensation and has noticed no pain though several areas are red. The eyecare provider arranges or the patient to be seen that day by her primarycare provider or a podiatrist or oot care and emphasizes the importanceo prompt treatment to avoid serious injury.

A dental hygienist notes that her patient smokes. She tells him that smokingcan cause oral cancer and she describes the impact tobacco use can haveon increasing diabetes complications. She asks the patient to considerquitting as an important step in controlling his diabetes and gives him the1-800-QUITNOW number.

A 40-year-old woman asks her local pharmacist or advice on readingglasses. She says, I must be getting older, everything is just blurry. Thepharmacist uncovers a history o diabetes, diagnosed the previous year,but discovers that the patient never returned or ollow-up. The pharmacistadvises the woman that her blurred vision may not be a need or readingglasses but in act a sign o diabetes and arranges or the woman to beseen by a primary care provider and eye care provider or ollow-up.

A podiatrist notices his 35-year-old patient with diabetes has terrible breathand asks about it. The patient is embarrassed but admits that he hasnoticed a bad taste as well. A quick look in the patients mouth reveals

infamed, swollen gums with pus at the gum line. The podiatrist describesthe link between periodontal disease and poor blood glucose control andstresses the need or urgent dental attention or a possible abscess.The podiatrists oce helps the patient obtain a same-day dentalappointment or care.

A dentist needs to schedule a patient or several procedures and asks aboutthe timing o the patients morning insulin. The patient is conused about hiscomplicated medication regimen and asks, Should I just skip all medicinesthat day until ater you work on my teeth? The dentist phones the patientspharmacist to arrange a consultation. The pharmacist collaborates with theprimary care clinician to develop an individualized medication schedule

and advises the patient and his dentist on whether to hold medications theday o the procedure.

A man with diabetes o more than 20 years duration, and neuropathy,asks the pharmacist or an Ace wrap and advice on care o his oot, whichis warm, red, and swollen. The man recalls no trauma and there is noevidence o skin breakdown or an open wound. The pharmacist arrangesor a same-day reerral to a podiatrist or possible cellulitis. Upon physicalexam and X ray o the aected oot, the podiatrist diagnoses Charcotarthropathy and implements a plan o treatment with no weight bearing andclose ollow-up, with casting, until the edema resolves.


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Where can I ever nd the time?How realistic is it or a busy optometrist to look at a patients eet?Or any o the scenarios described above? You have limited timeto provide patient care. But research has shown that health messages

direct rom the provider, e.g., I recommend that you are moreeective than generalizations or third-person recommendationssuch as You should see someone about that or The AmericanDiabetes Association says that

You dont need to be an expert or do a thorough exam to identiy thata problem needs attention by a specialist. It takes less than a minuteto look at a persons oot, mouth, or eye, or to ask a ew questionsabout medications, supplies, or tobacco use. You reinorce theimportance o preventive care i you take time to check a complaintyoursel beore recommending reerral to another provider. Supportcomprehensive diabetes care: think beyond your own discipline to

identiy other potential problems. Then reer with an I recommendmessage. Patients will appreciate your concern or their health andwell-being as a whole. Establishing a reerral system with otherproviders can improve your patients health and increase your reerralbase as well.


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Diabetes: A Major Health Problem

Section 1


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Diabetes is a serious, common, costly, but controllable disease. Diabetesis the sixth leading cause o death in the United States and aects almost 21million Americans, an estimated 6.2 million o whom are as yet undiagnosed(1). In 2002, diabetes cost the nation an estimated $132 billion in direct andindirect costs (2). Diabetes is the number one cause o lower limb amputationnot related to trauma, the number one cause o acquired blindness, and the

number one cause o kidney disease leading to dialysis in the United States.Diabetes is a major contributor to cardiovascular disease, the number onecause o death in this country. About 65% o people with diabetes die romcardiovascular disease (3).

Diabetes prevalence is rapidly increasing. Figure 1 shows sel-reported rateso diabetes gathered through the Behavioral Risk Factor Surveillance Study(BRFSS) by state. Diabetes prevalence has tripled rom 1990 to 2005, andin some states more than 25% o the adult population aged 20 years and

older has diabetes. The number o people with diabetes in the United Statesis projected to reach 39 million by the year 2050 (4). I current trendscontinue, 1 in 3 Americans will develop diabetes sometime in his or herlietime, and those with diabetes will lose, on average, 10 to 15 years o lie (5).

Types o DiabetesType 1 diabetes. Type 1 diabetes (ormerly known as insulin-dependent orjuvenile-onset diabetes) is an autoimmune disease that is distinguished by thedestruction o insulin-producing beta cells. Type 1 diabetes can occur at anyage, but onset usually begins in childhood or the young adult years. Peoplewith type 1 diabetes are ketosis-prone, although ketoacidosis can developin type 2 diabetes as well. People with type 1 diabetes must take insulin

daily. Delivery mechanisms or insulin include injection, insulin pump, andinhalation, although at this time inhalation must be combined with anotherdelivery method. For optimal management, people with type 1 diabetes musttest their blood glucose levels several times a day, ollow an individualizedmeal plan, and engage in regular physical activity.

Type 2 diabetes. Formerly known as non-insulin-dependent or adult-onsetdiabetes, type 2 diabetes is related to insulin resistance. The pancreascontinues to make insulin, but the insulin is not used well by other bodytissues. Eventually, insulin production decreases. People with type 2 diabetes

Diabetes Impact* Aects almost 21 million people in the United States. One third (more than 6 million people) are as yet undiagnosed. Costs more than $132 billion/year in health care expenditures. One o the six leading causes o death in the United States.

Number 1 cause o acquired blindness. Number 1 cause o kidney ailure. Number 1 cause o non-traumatic amputation. Major contributor to cardiovascular disease, the #1 cause o death.

* Source: 2005 Diabetes Fact Sheet


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may be treated with insulin, oral medications, or a combination o bothor be controlled with a ood plan and physical activity alone. Type 2 diabetesaects 9.6% o the U.S. population aged 20 years and older, and 20.9%of the population aged 60 years or more, occurring more oten in adultswho are overweight and sedentary (3). In recent years, however, it has beenseen increasingly in young people, including children. The prevalence of type

2 diabetes in younger age groups is of specialconcern because the risk ofcomplications increases with the diseases duration.

Type 2 diabetes disproportionately aects Arican Americans, Hispanics/Latinos, American Indians, and Alaska Natives, and some groups o Asiansand Native Hawaiians or other Pacic Islanders. Arican Americans andHispanic/Latino Americans are about twice as likely to have diabetes as non-Hispanic/Latino whites in a similar age group. Some populations o AmericanIndians have the highest rates o diabetes in the world.

Gestational diabetes is a orm o glucose intolerance diagnosed in somewomen during pregnancy. Gestational diabetes occurs more requently among

Arican Americans, Hispanic/Latino Americans, and American Indians. It isalso more common among obese women and those with a amily historyo diabetes. During pregnancy, gestational diabetes requires treatment tonormalize maternal blood glucose levels to avoid complications in the inant.

Ater pregnancy, 5% to 10% o women with gestational diabetes are ound tohave type 2 diabetes. Women who have had gestational diabetes have a 20%to 50% chance o developing diabetes in the next 5 to 10 years (5).

Other types o diabetes result rom specic genetic conditions (such asmaturity-onset diabetes o youth), surgery, drugs, malnutrition, inections, andother illnesses. Such types o diabetes account or 1% to 5% o all diagnosed

cases.

Diabetes and Obesity TrendsThe development o type 2 diabetes is multiactorial, with insulin resistance,sedentary liestyle, increasing age and increasing obesity contributing to thisincrease. A body mass index (BMI) o 25 or more (> 23 or Asian Americansand > 26 or Pacic Islanders) is a risk actor or the development o type 2diabetes. Figure 2 shows the parallel increases in the prevalence o diabetesand mean body weight by year in the United States from 1990 to 2000 (68).

As o 2005, approximately two-thirds o American adults were overweight orobese, with BMI more than 25.

The prevalence o obesity has increased by 61% since 1991. More than 60% o U.S. adults are overweight. BMI and weight gain are major risk actors or diabetes.


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Figure 2. Diabetes and Obesity

Source: Behavioral Risk Factor Surveillance System, CDC.

15%19%No data

available


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Diabetes Morbidity and MortalityAdults with type 2 diabetes are two to our times more likely to have heartdisease or suer a stroke than those without diabetes. Cardiovascular diseaseis the major cause o death or people with diabetes. They are also at risk orother complications, such as blindness, kidney disease, amputations, nervoussystem disease, and oral complications, including gum or periodontal diseaseand tooth loss (3).

Fortunately, many studies in recent years have demonstrated eectiveinterventions to help prevent or delay diabetes complications as well as thedisease itsel (921).


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Impact o Controlling the ABCso Diabetes

Section 2


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Impact o glycemic controlTable 1 summarizes some o the major studies that have demonstrated theimpact o glycemic control on complications prevention. The Diabetes Controland Complications Trial (DCCT) showed that tight glycemic control reducedrisk o microvascular disease in persons with type 1 diabetes (76% reductionin eye disease overall with 63% reduction in retinopathy, 54% reduction innephropathy, 60% reduction in neuropathy) (9, 10). The United KingdomProspective Diabetes Study (UKPDS) showed that among people with type 2diabetes, improved glycemic control (average A1c = 7% vs. average A1c =7.9% in the conventionally treated group) led to a reduction in risk o 25% ormicrovascular disease overall, 17%21% or retinopathy, and 24%33% oralbuminuria. Lower A1c values also reduced the incidence o macrovasculardisease with a 16% reduction in myocardial inarction, and contributed to a24% decrease in cataract extraction (12).

Table 1. Impact o Glycemic Control (911, 26)

Impact o Blood Pressure ControlThe United Kingdom Prospective Diabetes Study (UKPDS) ound thatimproved glycemic control not only reduced diabetes complications, butalso demonstrated the impact o improved blood pressure control. UKPDSparticipants in the tight control blood pressure group maintained on averageor the duration o the study 10 mm Hg lower systolic and 5 mm Hg lowerdiastolic pressures than controls. Table 2 summarizes the impact o that

reduction. Improved blood pressure control (average o 144/82 mm Hg vs.154/87 mm Hg control) during the 8 years led to a reduction in risk o 34%or retinopathy, 47% or vision loss, 37% overall or microvascular disease,56% or heart ailure, and 44% or stroke incidence (12).

Good Glycemic Control (Lower A1C)Reduces Incidence o Complications

DCCT UKPDS

A1C 9>7 8>7

Retinopathy 63% 1721%

Neuropathy 54% 2433%

Nephropathy 60%

Macrovascular

Disease 41%t 16%t

t Not statistically signicant


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Table 2. UKPDS: Impact of Blood Pressure Controlin Diabetes (12)

Furthermore, clinical trials, such as ABCD (Appropriate Blood Pressure Controlin Diabetes Trial) and HOPE (Heart Outcomes Prevention Evaluation Study),also show that use o an ACE inhibitor reduces the risk o heart attack, stroke,or cardiovascular death by 25%30% in patients with type 2 diabetes, andslows the progression o the kidney damage o diabetes (14).

Impact o Cholesterol and Other Lipid ControlAmong people with diabetes, 67% have one or more lipid abnormalities.Multiple studies, including CARE (Cholesterol and Recurrent Events Trial) and4S (Scandinavian Simvastatin Survival Study), have shown that lipid therapycan reduce the risk o coronary events such as nonatal heart attacks andCVD-related deaths, as summarized in Table 3 (13, 19).

Table 3. CARE and 4S: Impact o Cholesterol Controlin Diabetes

Tight blood pressure controlreduces risk o:

Retinopathy progression (34%)

Vision loss (47%)

Diabetes-related deaths (32%)

Microvascular disease (37%)

Heart ailure (56%)

Stroke (44%)

UK Prospective Diabetes Study Group (UKPDS) 33: Lancet. 1998; 352: 837-853.

Lipid therapy reduces risk o coronaryevents

Cholesterol and Recurrent Events Trail (CARE)Reduced risk by 24%

Scandinavian Simvastatin Survival Study (4S)

Reduced risk by 42% to 55%


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Preventing ComplicationsComprehensive diabetes care is a team eort involving sel-managementbehaviors (see Sel-Management Support at the end o this section) by thepatient and preventive care services by health care providers. At routine visits,providers o oot, dental, and eye care and drug therapy management canmonitor, prevent, and treat complications, not only or conditions specic totheir proessional discipline, but or the patients overall health. Cardiovasculardisease (CVD), including heart disease and stroke, is the number one cause odeath or people with diabetes. All health care providers can contribute to thereduction o risk actors or CVD, and potentially reduce other complicationsas well, by reinorcing control o the ABCs o diabetes:

A is or A1C, previously known as hemoglobin A1Ca test that refectsaverage blood glucose over the last 3 months. The goal or most peoplewith diabetes is 50Triglycerides < 150

Individualize Treatment GoalsFor example, consider:

A1C goal as close to normal (< 6%) as possible without signicanthypoglycemia. Less stringent AIC goal or people with severe or requent

hypoglycemia. Lower blood pressure goals or people with nephropathy.

The NDEP promotes control o the ABCs o diabetes and use o theterm A1C or Hemoglobin A1c.

Source: Numbers At A Glance www.ndep.nih.gov


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Diabetes Management andTeam Care

Section 3


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Diabetes Management And Team CarePeople with diabetes can take action to lower their risk or heart attack,stroke, and other diabetes complications by controlling the ABCs, ollowingan individualized meal plan, engaging in regular physical activity, avoidingtobacco use, and taking medicines as prescribed. A multidisciplinary teamapproach is critical to success in diabetes care and complications prevention.Medical nutrition therapy education by a dietitian is critical to developing anindividualized meal plan. A certied diabetes educator not only teaches actualinormation about diabetes but also provides sel-management support,enabling the patient to gain skills in problem solving and sel-care. All healthcare providers can help by discussing how sel-management and diabetescontrol relate to preventing complications.

Tools or health care providers and patients can be ound on the NDEP Website at http://ndep.nih.gov/. The NDEP Team Care monograph, available athttp://ndep.nih.gov/diabetes/pubs/TeamCare.pd (28), can tell you moreabout the advantages o team care and how to orm a team, and gives

examples o eective team care. For inormation on the link between diabetesand cardiovascular disease, see http://ndep.nih.gov/control/cvd.htm.

Sel-management SupportPatient sel-management support is important in helping people achieve goalsin both diabetes control and prevention. In contrast to traditional patienteducation, in which inormation is delivered to the person with diabetes,sel-management support involves teaching the behavioral skills needed tomake decisions about diabetes management in daily lie. Sel-managementsupport is a partnership between patient and health care provider. It involvescollaborative goal-setting, problem-solving, and individualized behavior-change plans that address concerns identied by the patient as highest priority.

All health care providers can provide sel-management support, reinorcingpatient problem-solving skills and giving consistent, proactive health caremessages.

Sel-management support relies on principles o sel-ecacy (condence inones ability to perorm a task successully), short-term action plans, realisticgoal setting, and proactive identication o barriers to optimal diabetescontrol. Sel-management support involves asking the person with diabetesto identiy an accomplishable action he or she would like to take in changinga behavior (e.g., walking 10 minutes a day beore dinner starting tomorrow),not telling the individual what to do. Sel-management support also includes

trouble-shooting about missed appointments, establishing routines arounddaily activities such as dental hygiene, oot care or blood glucose testing, andhelping people overcome the barriers to receiving regular screening exams oreye, oot and oral health.


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Sel-management support does not replace traditional patient education butcomplements it. Because diet and physical activity patterns are importantin both diabetes control and prevention, it is important that all providersparticipate in patient sel-management support or healthy ood choices andregular exercise. Prompting a patient to consider and plan or challengingevents is sel-management support. Problem solving discussions can helpprepare the patient to deal eectively with sel-management issues.

Sel-Management SupportAt each visit, the provider and patient need to consider the ollowingpatient sel-management tasks. How to:

Take care o diabetes and its complications.

Incorporate behavior changes into daily lie activities.

Manage emotions, including uture concerns.

Source: http://www.betterdiabetescare.nih.gov/WHATpatientcentereddimensions.htm.

Sel-management Support ExampleA 50-year-old man with diabetes and obesity has been told he wouldbenet rom a less calorie-dense diet, but he conesses to you that hejust doesnt think he can do it. You are not a dietitianhow can you

help him make such a change?

Ask what he thinks will be the biggest challenge to making thesechanges.

Ask i he can identiy one thing he can do dierently.

Reinorce all positive steps, even i small.

Reer him to a dietitian or diabetes educator who can continuesupport.

Follow up at the next visit by asking about progress.

In this example, the man might identiy eating dessert as a challenge,and a change in portion size (e.g., eating one scoop o ice creaminstead o two) as one thing he can do dierently. This is anacceptable short-term goal. It is a step in the right direction. All healthcare providers can contribute to sel-management support by helpingpatients plan and troubleshoot the many daily decisions they mustmake or diabetes control.


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Sel-management support also involves ollow up: asking about progressin achieving behavioral goals and sustaining problem-solving skills (29).To learn more about sel-management support, consult the NDEPs BetterDiabetes Care Web site www.betterdiabetescare.nih.gov.

Psychosocial considerations and comorbid conditions such as depression can

adversely infuence sel-management behaviors. Multi-disciplinary team careincludes working closely with social services, certied diabetes educators,and mental health specialists who can help address these concerns. Moreinormation can be ound in the NDEP Team Care monograph availableat http://ndep.nih.gov as well as at www.betterdiabetescare.nih.gov.


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What to Dicuss with Patientswith Diabetes

Section 4


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What to Discuss with Patients with DiabetesThis section provides messages that you as a health care provider shoulddiscuss with people with diabetes about oot, eye, and oral health andabout drug therapy management. The bullets highlight questions to askand inormation to discuss about diabetes-associated risks, the benets ocomprehensive care, the need or regular medical examinations, symptoms tolook or, and sel-care issues. You can discuss these topics, when appropriate,over a series o patient visits; you need not cover all the material with everypatient. Guidelines or reerral to other health care providers are alsoprovided.

Promote the ABCsA1C, Blood Pressure, andCholesterolIt is important to control risk actors or cardiovascular disease. Ask about the

ABCs o diabetes.Ask: Do you know your ABC goals and how to reach them? Recommend

working with the health care team to determine both long-and short-termgoals or each ABC.

Advise: You can take action to prevent or delay type 2 diabetes

complications. Controlling the ABCs can reduce the risk or heart attackand stroke, and inorm them that poor control can lead to problems in oot,eye, and oral health. Explain that screening and team care can preventcomplications.

Assist: Reer to a primary care provider. Give your patients resourcesto help them make healthy changes by contacting the National DiabetesEducation Program (NDEP) or FREE inormation and materials on diabetesprevention and control. Recommend that they call 1-800-438-5383 or visitwww.ndep.nih.gov.

Key Messages all Health Care ProvidersCan Reinorce

Emphasize the importance o metabolic control (ABCs).

Promote a healthy liestyle.

Explain the benets o diabetes comprehensive team care.

Recommend routine exams or complication prevention: oral health,comprehensive oot exam, complete dilated eye exam.

Reinorce sel-exams.

Recognize danger signs and seek help.

Promote pharmacist role in drug therapy management.


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Promote a Healthy Liestyle

Healthy liestyle is key to diabetes control.Weight.Advise people with diabetes to aim for a healthy weight. Emphasize

the importance o setting stepwise and realistic goals or weight reduction.

Healthy Food Choices. Encourage meal planning that includes a varietyo oods and controls portion sizes and snacks. Increasing ber and limitingsaturated ats and salts will help control blood glucose, blood pressure, andcholesterol. Recommend consultation with a dietitian or additional helpwith meal planning and learning how to make healthy ood choices.

Physical activity. Advise people with diabetes that moderate physicalactivity (such as walking) can help control the ABCs and prevent complications.

Sel-management. Ask people with diabetes to identiy their high priorityconcerns. Prompt them to plan or challenging situations and set short-term

achievable goals. Compliment them on any steps taken toward these goals.See Sel-Management Support in the previous section.

Tobacco. Ask about tobacco use. Encourage people with diabetes toavoid smoking and using smokeless tobacco products. Recommend callingthe FREE tobacco quit line 1-800-QUITNOW. People who use tobacco areat greater risk or stroke; heart, kidney, and eye diseases; nerve damage;and lower-extremity complications. To learn more about tobacco cessationstrategies, consult the CDCs Tobacco Inormation and Prevention Source(TIPS) Web site at www.cdc.gov/tobacco/.

Explain the Risks o Disease and Benets o CarePeople with diabetes make daily decisions that aect their diabetes control.Cornerstones o diabetes sel management include meal planning, physicalactivity, and sel monitoring o blood glucose. Routine sel-care behaviorsalso impact diabetes complications prevention. See appendix C or a list ocommon diabetes-related oot, eye, and oral health complaints and exampleso inappropriate sel-care.

At each patient encounter, remind patients o the risks o diabetescomplications and the benets o oot, eye, and oral health care as well asdrug therapy management. Ask about annual screening exams. Ask aboutroutine sel-care behaviors. Assess symptoms that warrant urgent reerral.

Foot health. Ask people with diabetes i they know how diabetes aectstheir eet. Explain that diabetes raises the risk o oot ulcers, which can leadto amputation, and that proper oot care reduces their risk.

- Foot exams. Ask people with diabetes i they have had acomprehensive oot examination (including a sensory exam with amonolament) in the past year. Recommend a comprehensive annualoot exam by a podiatric physician or primary care clinician and a ootinspection (visual oot check) at every primary care provider visit.


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- Daily oot care. Ask about proper daily oot care. People withneuropathy may not notice injuries as they do not eel pain. Advise allpeople with diabetes to take the ollowing steps:

- Examine eet daily, both by looking and touching. Look or cuts,bruises, puncture wounds, corns or calluses, areas o redness, or

pus. Seek podiatric medical advice right away or these symptoms.- Clean eet (both skin and nails) daily and dry the spaces between

the toes gently. Check the insides o shoes or objects beore puttingthem on.

- Never walk bareoot, not even indoors. Wear appropriate ootwear,such as athletic or walking shoes that t well and cover the eet (i.e.,NOT sandals).

- Foot symptoms. Ask about oot symptoms and recommend promptpodiatric medical attention or bruises, lacerations, puncture wounds,swelling, and areas o redness or pus rom any area o the oot.

These signs and symptoms can be the earliest harbingers o seriousinjury leading to amputation. Be proactive.

- Reer people with these symptoms to a podiatric physician or to theirprimary care provider.

Eye health. Advise people with diabetes about the risk o diabeticretinopathy, a leading cause o blindness in adults and one that maybe prevented or delayed by good control o blood glucose. People withdiabetes also may be at greater risk or eye problems such as cataracts andglaucoma. Ocular symptoms associated with diabetes include fuctuation invisual acuity, double vision, dry eye, recurrent lid inections (blepharitis) andchanges in color vision.

- Eye exams. Ask when the person with diabetes last hada comprehensive dilated eye exam by an optometrist or anophthalmologist. Reinorce the need or regular screening eye examsto prevent or delay the onset o blindness due to diabetic retinopathy.Most people with diabetes should have a dilated eye examination byan optometrist or an ophthalmologist annually. An eye care providermay suggest less requent exams (every 23 years) in the setting o anormal eye exam (30). Examinations will be needed more requently iretinopathy exists or is progressing.

- Eye care. Advise people with diabetes to report eye symptoms to

their health care provider and to maintain a current prescription oreyeglasses, contact lenses, or low-vision aids.

- Eye symptoms. Ask about eye symptoms and their requency andduration. Encourage people with diabetes to report any changes in theireyes or vision, such as sudden onset o blurriness, seeing spots,or persistent redness or pain to their health care provider.

- I there is sudden change in vision, reer the person at once to anoptometrist or ophthalmologist.


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Oral health. Explain the link between poor control o blood glucose andperiodontal (gum) disease. Good oral health may help control diabetesand controlling blood glucose levels my contribute to improved oral health.

- Oral health exams. Ask the date o the last dental/oral health exam.Stress the importance o good oral hygiene and regular exams, including

regular cleanings perormed by a dental hygienist or dentist to preventperiodontal disease. Even people with who wear dentures or haveno teeth need an oral health exam once a year to screen or cancer,inection, or other lesions.

- Daily oral care. Advise about the need to brush the teeth ater eatingand to foss at least once a day. I dentures are worn, advise about theircare: daily cleaning and a dental visit i dentures become looseor irritation develops.

- Monthly oral sel exam. Advise people with diabetes to do amonthly sel exam and to contact their dentist i they notice signso inection, such as sore, swollen, or bleeding gums; loose teeth;

or mouth ulcers.

- Oral symptoms. Ask about oral health symptoms that may indicateinection such as a bad taste or bad breath, or pain. Evaluate whetheran acute problem, such as inection, is present that requires immediateattention.

- Reer individuals with oral ndings or complaints to a dentist orperiodontist and/or their primary care provider, as indicated.

- Oral inections may worsen glycemic control, progress to seriouscomplications quickly, and need prompt treatment.

Drug therapy management. Discuss the benets o proper drugtherapy management. Recommend that your patients with diabetes talkwith their pharmacist about how to get the most benet rom medicationsby individualizing dosage regimens. Pharmacists can provide regularmedication reviews to ensure that people with diabetes take medicationsas prescribed and understand the risks o using over-the-counter (OTC)medications.

Regular Medication Review. Advise people with diabetes that regularmedication reviews, individualized drug regimens, and screening orinteractions and side eects rom medications, OTC medications, herbalproducts, and supplements can help them get the most rom their drug

therapy.

- Medications. Ask people with diabetes i they take their medicationexactly as prescribed. Advise them to talk to their pharmacist or primarycare provider i they are unable to ollow the medication plan prescribed.

- Remind people with diabetes that they should seek advice romtheir pharmacist or primary care provider beore taking any OTCmedications, herbal products, or other supplements.


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- Drug Therapy Management Medication-related symptoms.

- Ask at every visit about medication use.

- Ask people with diabetes to report any changes in symptoms,medical conditions, medications, doses, supplements, or liestyleto all health care providers.

- Reer individuals to a pharmacist or primary care provider,as indicated, or evaluation.

Selection and use o a blood glucose meter. Reer people withdiabetes to a pharmacist or diabetes educator or help in choosingan appropriate blood glucose meter, learning how to use it, and under-standing the results to check how medications are working.

ABC monitoring. Ask your patients with diabetes when they last had theirA1C, blood pressure, and cholesterol levels checked and i they know theresults o these tests.

Personal ABCs. Ask i they know what they need to do to control theirABCs. Advise about the ABC goals: A1C


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This table outlines messages that health care providers should discuss with people who have diabetesregarding oot, eye, and oral health and about drug therapy management.

Health care providers in these our disciplines are well positioned to deliver these overarching prevention messages,

communicate the need or metabolic control, and encourage multidisciplinary team diabetes control.Promote the ABCsA1C, Blood Pressure, andCholesterol:

Ask about Health Examinations:

Controlling the ABCs can prevent complications andreduce the risk o stroke and heart attack.

Foot exams.

Ask: Do you know your ABC goals and how to reachthem?

Eye exams.

Explain that poor ABC control can also lead to problemsin oot, eye, and oral health.

Oral health exams.

Drug therapy management.

Promote a Healthy Liestyle: ABC monitoring and control.

Weight control.

Healthy ood choices. Support Sel-Care Behaviors:

Daily physical activity. Daily oot care.

Support sel management. Eye care.

No tobacco use (call 1-800-QUITNOW or help). Daily oral care.

Monthly oral sel-exam.

Explain the Risks and Benets o DiabetesComprehensive Control:

Selection and use o a blood glucose monitor.

Foot health. Know your ABC goals and how to reach them.

Eye health. Medication management.

Oral health.

Drug therapy management. Assess Symptoms that Require Reerral:

Foot symptoms.

Eye symptoms.

Oral symptoms.

Medication-related symptoms.

Table 4. SummaryWhat to Discuss with Patients with Diabetes


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The inormation below lists some o the common issues specic to oot, eye, and oral health, and drug therapymanagement.When health care proessionals understand the diabetes care issues o other disciplines, they can recognize symptomaticconcerns warranting urgent reerral, reinorce annual screening recommendations, and contribute to a proactive approach

to diabetes care beyond the scope o their particular discipline.

Foot Health Eye Health Oral Health Drug Therapy Management

Diabetes-Related FootConditions:

Diabetes-Related EyeConditions:

Diabetes-Related OralHealth Conditions:

Diabetes drug managementissues:

Neuropathy Retinopathy Changes in the oral cavity Improper drug choice

Vasculopathy Double vision Periodontal disease Underdosage

Dermatological conditions Vision fuctuations Oral Candida (thrush) Overdosage

Musculoskeletal problems Cataracts Adverse drug reactions

Macular edema Drug interactions

Ocular nerve palsy Undertreatment

Comprehensive FootExamination to identiy thehigh-risk oot:

Comprehensive EyeExamination:

Comprehensive OralExamination:

Strategies or ManagingDrug Therapy:

Loss o protective sensation Visual acuity Teeth Use o medications

Skin and nail condition Visual elds Gums Monitoring treatment

Absent pedal pulses Pupillary reaction Periodontal probing Sel treatment and OTCmedications

Foot deormity Intraocular pressure Intraoral lesions,inections, or masses

Selecting and using ablood glucose meter

History o oot ulcers Cranial nerves Adequate saliva fow Cost control

Prior amputation Slit-lamp exam Dilated retinal exam Coordination o Care

Table 5. SummaryWhat to Discuss with Patients with Diabetes


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Foot Health and Diabetes

Section 5


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Foot Health and Diabetes

Prevalence o Foot Symptoms and ComplicationsEarly maniestations o diabetes may present initially in the oot. Footsymptoms increase the risk or co-morbid complications, o which non-

traumatic lower-extremity amputations (LEAs) are the greatest concern.According to 1997 hospital discharge data, diabetes accounted orapproximately 87,720 LEAs in the United States, ully 67% o all LEAs (31).Between 1980 and 2001, the number o diabetes-related hospital dischargeswith LEA increased rom an average o 33,000 to 82,000 per year (32).LEA rates were highest among men, non-Hispanics/Latinos, Arican Americans,and the elderly. In 2003, there were about 75,000 diabetes-related hospitaldischarges with LEA. The LEA rate per 1,000 persons with diabetes that yearwas 3.9 among persons aged less than 65 years, 6.6 among persons aged6574 years, and 7.9 among persons aged 75 years or older.

One study ound that 80% o non-traumatic LEAs are preceded by a oot

ulceration, which provides a portal or inection (33). According to BehavioralRisk Factor Surveillance Study (BRFSS) data, approximately 12% o U.S. adultswith diabetes had a history o oot ulcer, a risk actor or LEA (34). Anotherreport identied minor trauma, ulceration, and aulty wound healing asprecursors to 73% o LEAs, oten in combination with gangrene and inection(37). Other risk actors include the presence o sensory peripheral neuropathy,altered biomechanics, elevated pressure on the sole o the oot, and limitedjoint mobility (35).

The Charcot FootPatients with neuropathy are at risk or painless degenerativearthropathy that typically aects the tarsometatarsal andmetatarsophalangeal joints, resulting in a red, swollen, and possiblydeormed oot that can be mistaken or cellulitis. Radiographsmay show collapse o joint structure, and can be misinterpreted asosteomyelitis. Treatment or Charcot arthropathy, however, is notantibiotics but a non-weight-bearing cast (once any acute edema hasresolved) and special shoes to correct altered biomechanics. Withoutproper treatment, the Charcot oot can progress to urther deormity,ulceration and lead ultimately to amputation.

Consider it a red fag when a patient complains that his shoesno longer t, or is wearing slippers or shoes with sections cut outto accommodate changes in oot shape, or walks with a new limp.

A Charcot oot usually causes little to no pain and may be slowlyprogressive over weeks to months beore coming to a oot careproviders attention. All health care providers can contribute toamputation prevention by reerring patients with these signs andsymptoms to a oot care specialist.


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People with diabetes who have neuropathy are 1.7 times more likely todevelop oot ulceration; in persons with both neuropathy and oot deormity,the risk is 12 times greater; and in those who also have a history o pathology(prior amputation or ulceration), the risk is 36 times greater (36, 37).Factors that increase risk or lower-extremity ulceration and amputation aremale sex, the existence o diabetes or more than 10 years, tobacco use, a

history o poor glycemic control, or the presence o cardiac, retinal, or renalcomplications (3840).

Foot Evaluation in People with Diabetes

Podiatrists use the ollowing considerations to assess the risk or complicationswhen evaluating the eet o people with diabetes.

Neuropathy. The presence o subjective tingling, burning, numbness, orthe sensation o bugs crawling on the skin may indicate peripheral sensoryneuropathy. On clinical examination, this condition can be detected with aninstrument known as a Semmes-Weinstein 5.07 (10 gram) monolament.

A description o how to use this monolament to perorm a comprehensiveoot exam can be ound in the ree NDEP health care provider kit, Feet CanLast A Lietime, http://www.ndep.nih.gov/diabetes/pubs/Feet_Kit_Eng.pd.

Vasculopathy. Cramping o cal muscles when walking (charley horse)

that requires requent rest periods suggests intermittent claudication. Thiscondition, oten caused by insucient blood supply to the region beneaththe knee, indicates the presence o early or moderate occlusion o thearteries that is common to the lower extremities o people with diabetes.Intense cramping and aching in the toes only at night, called rest pain, isusually relieved by hanging the eet over the side o the bed and by walking.This symptom signies the end-stage blood vessel disorder and tissueischemia that precedes diabetic gangrene. Although most clinical research

Foot Complication Prevention Up to 20% o people with diabetes who present or routine care will

have a treatable oot care problem. Have the patient remove socksand shoes and inspect both eet or acute problems at each visit.

The lietime incidence o oot ulcers among patients with diabetes is

15%. Most o these are preventable though interventions availablein most primary care settings.

Patients with diabetes on dialysis are at extreme risk or ootcomplications. Foot care programs that provide outreach to thisgroup are associated with improved oot outcomes.


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continues to list the loss o sensation/neuropathy as the leading actor inulceration and associated complications, poor blood supply can contributeto poor ulceration healing and is a signicant risk actor or amputation.Both actors need to be addressed in comprehensive diabetes oot carewith diagnostic testing or treatable vascular lesions and intervention aswarranted.

Dermatological conditions. Corns and calluses (hyperkeratoticlesions) o the eet result rom elevated mechanical pressure and shearingo the skin. They oten precede breakdown o skin and lead to blistersor ulceration. Supercial lacerations and heel ssures, or maceration(sotening caused by wetness) between the toes, can all serve as portals orinection. Corns, calluses, toenail deormity, and bleeding beneath the nailmay signiy the presence o sensory neuropathy. Fungus inections o skin ornails can lead to secondary bacterial inections and should be treated.

Musculoskeletal symptoms. Structural changes in the diabetic oot

may develop in combination with muscle-tendon imbalances as a result omotor neuropathy. These deormities include the presence o hammertoes,bunions, high-arched oot, or fatootall o which increase the potentialor ocal irritation o the oot in the shoe.

Liestyle and amily history. People with diabetes who smoke are ourtimes more likely than non-diabetic smokers to develop lower-extremityvascular disease. Unhealthy ood choices and low physical activity levelscontribute to poor long-term control o blood glucose and increase therisk that peripheral nervous system and/or blood vessel disorders willprogress. A amily history o cerebrovascular accidents and coronary arterydisease may indicate a urther increased risk o developing lower-extremity

arterial complications. Inherited oot types (e.g., shapes) may predispose tobiomechanical deormities that lead to problems with skin breakdown.

Comprehensive Foot ExaminationA comprehensive oot examination or abnormalities, including evaluation opulses, sensation, oot biomechanics (general oot structure and unction),and nails helps determine the persons category o risk or developing ootcomplications. Persons with diabetes who are at high risk have one or more othe ollowing characteristics: (1) loss o protective sensation, (2) absent pedalpulses, (3) oot deormity, (4) history o oot ulcers, or (5) prior amputation.Low-risk individuals have none o these characteristics (41). Assessment o riskstatus identies people who need more intensive care and evaluation. Further

patient education, early intervention, and special ootwear i indicated canprevent ulcers and ultimately LEAs.


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Patient EducationThe goal or low-risk patients is to keep them at low risk through control o the

ABCs and tobacco cessation in those who use tobacco. In high-risk patients,the goal is to prevent ulcers though sel-management education, podiatrycare, and proper use o appropriate ootwear. Minor trauma, such as stubbinga toe or stepping on a sharp object, is the most requent precipitating eventleading to ulcer. Emphasize to patients and their amilies the need to bediligent in clearing the walking spaces, especially around the bed and the path

to the bathroom, and to use night-lights. High-risk patients also need to knowwhen and whom to call with specic oot problems. Patients with a puncturewound, ulcer, redness, or new-onset oot pain should call and see theirprimary care provider or podiatrist that day. Patients with callus and/or thick oringrown nails should call a podiatrist and be seen within a ew days.

Foot care educational materials or patients are available rom NDEP inEnglish and in Spanish at http://www.ndep.nih.gov/diabetes/pubs/Feet_broch_Eng.pd (42).

To obtain ree print copies o these patient education materials, the FeetCan Last a Lietime health care provider kit, and other materials on diabetes

prevention and control visit http://www.ndep.nih.gov or call 1-800-438-5383.

Foot Risk StatusThe American Diabetes Association and American PodiatricMedical Association consider two categories o risk or developingoot complications.

High Risk (one or more o the ollowing):

(1) Loss o protective sensation.

(2) Absent pedal pulses.

(3) Foot deormity.

(4) History o oot ulcers.

(5) Prior amputation.

Low Risk: None o these characteristics.

See text or interventions or patients with high- and low-risk eet.


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High and Low-Risk Foot Patient Education

The goal or low-risk patients is to keep them low risk:

Control the ABCs.

Tobacco cessation.

The goal or high-risk patients is to prevent oot ulcers:

Sel-management education:

Stress the role o minor trauma.

Clear walking spaces o potential hazards.

Prompt (same day) care or injuries.

Regular podiatry care.

Use appropriate ootwear.


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Eye Health and Diabetes

Section 6


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Eye Health and DiabetesDiabetes is the leading cause o new cases o blindness among adults aged20 to 74 years. Diabetic retinopathy causes 12,000 to 24,000 new cases oblindness each year (43). People with diabetes can maintain optimal visionand healthy eyes by having an annual comprehensive vision examination,including a dilated eye examination, with early intervention i retinopathy isound.

Diabetes-related Eye ConditionsPeople with diabetes are at 25 times greater risk or blindness (44). Peoplewith diabetes who smoke, have poor nutrition, and do not control theirdiabetes have an even greater risk o developing eye complications. Becausemany people with diabetes have slower healing time, eye injurieseven minorcorneal scratchesshould not be taken lightly.

RetinopathyDiabetic retinopathy (DR) is a common complication o diabetes. Elevatedblood sugar damages the retinal blood vessels, causing them to break down,leak, or become blocked. Over time, this causes retinal hemorrhage andimpaired oxygen delivery to the retina that can lead to the growth o abnormalvessels. These new vessels are ragile and can break easily, causing permanentvision loss. One in 12 people with diabetes aged 40 years and older hasvision-threatening diabetic retinopathy (45). Studies have shown that aspirinuse (e.g., or CVD prophylaxis) is sae in persons with retinopathy and has noadverse effect on the development or progression of diabetic retinopathy (46, 47).

Poor glycemic control and longer duration o diabetes lead to increased rateso retinopathy in people with type 1 and type 2 diabetes. Diabetic retinopathy,

however, is treatable, and one o the most preventable causes o vision lossand blindness. The risks o DR are reduced through disease management oblood sugar, blood pressure, and lipid control. Early diagnosis and propertreatment reduce the risk o vision loss; however, as many as 50% o patientsare not getting their eyes examined or are diagnosed too late or treatmentto be eective. Individuals with diabetes are also at an increased risk orglaucoma and cataracts.

Early detection and treatment can prevent or delay blindness due to diabeticretinopathy in 90% o people with diabetes. Good glycemic control has beenshown to reduce or delay by 76% the development o retinopathy in peoplewith diabetes (47). Intensive therapy reduces the rst appearance o any

retinopathy by 27%. Retinal laser photocoagulation surgery can reduce the risko severe vision loss rom the worst orm o the disease, prolierative diabeticretinopathy (PDR), to 4% percent or less (48).


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Optometrists and ophthalmologists can provide low-vision aidsrom simplehand magniers to innovative optical devicesto help those who haveexperienced uncorrectable vision loss due to diabetic retinopathy. These eyecare proessionals can additionally provide or assure the provision o a ullspectrum o care and services that may allow people with vision impairmentand diabetes to maintain their independence and quality o lie and help

control their diabetes (e.g., to read instructions, take medication, continue withhousehold tasks).

Other Common Eye Complications in Diabetes

Cataracts are a clouding o the eye lens most oten caused by aging. Thelens is responsible or ocusing the images onto the retina, and thus a cloudingo the lens can result in diminished vision and increased sensitivity to glare.Over hal o all Americans aged 65 years and older have cataracts (3).

Glaucoma is a progressive disease that damages the optic nerve. It is this

nerve that carries the retinal image to the brain, so disruption o thistransmission can cause irreversible blind spots or eld loss, which over timecan lead to total blindness. A view of the optic nerve during a dilated eye exam,combined with visual eld testing, intraocular pressure testing (IOP), and othertests can oten reveal damage at an early stage, thus providing opportunityor treatment. It is important to note that IOP should never be used as a solediagnostic indicator. Among Americans aged 40 years or older, 2.2 millionhave glaucoma and another 1.1 million are unaware o having the disease(46). For this reason, glaucoma oten is reerred to as the silent thie o sight.Glaucoma is twice as common among older black adults as among whites.

Double vision. People with diabetes may complain about sudden onseto double images. Because this can be due to damage to the nerves romthe brain to the eye, it is important to see an optometrist or ophthalmologistimmediately. This symptom can be misinterpreted by the patient or by a non-eye care provider unamiliar with this ocular complication as a sign o a strokeor other neurological problem, prompting unnecessary diagnostic proceduressuch as radiological exams. Double vision (or diplopia) may instead be dueto mononeuropathydamage to a single nerveusually cranial nerves III,IV, or VI. The sixth and third nerves are most requently aected. Third-nervepalsies occur with pupillary sparing in 80% o cases. Most diabetic third-nervepalsies usually resolve spontaneously within 2 to 3 months and the symptom odouble vision can oten be controlled with the use o special lenses.

Vision fuctuation. Poor control o blood glucose levels can lead to afuctuation in vision. These temporary visual fuctuations occur because ofuid imbalance in the crystalline lens. When the glucose level is elevated, thelens thickens, causing vision changes that may increase nearsightedness orarsightedness. When the glucose level returns to normal, the lens can shrinkback to its normal state. For those who need glasses, i the glucose level ispoorly controlled, the constant state o fux can make it dicult to determinethe best lenses.


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Comprehensive Dilated Eye ExamHow Oten and by Whom?

Most people with diabetes should have a dilated eye examination

by an optometrist or an ophthalmologist annually.

I a person with diabetes has had a normal result or their eyeexam, an eye care provider may suggest less requent exams(every 23 years (30).

Examinations will be needed more requently i retinopathyexists or is progressing.

People with diabetes should have an exam by an eye specialist.A primary care medical proessional (physician, nurse practitioner,or physician assistant) does not have the training, or oten the

equipment, to do a comprehensive diabetes eye exam.


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Oral Health and Diabetes

Section 7


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Oral Health and Diabetes

Changes in the Oral CavityDiabetes can lead to changes in the oral cavity. O particular concernto dentists and dental hygienists are the eects o diabetes on the health

o the gingiva (gums) and periodontal tissues (49). Poor glycemic controlis associated with gingivitis and more severe periodontal diseases (5052).Oral signs and symptoms o diabetes can also include a neurosensorydisorder known as burning mouth syndrome, taste disorders, abnormal woundhealing, and ungal inections (candidiasis). Individuals with diabetes maynotice a ruity (acetone) breath, requent xerostomia (dry mouth), or a changein saliva thickness. Dry mouth can also lead to a marked increase in dentaldecay. Oral ndings in people with diabetes are associated with other systemicndings such as excessive loss o fuids through requent urination, alteredresponse to inection, altered connective tissue metabolism, neurosensorydysunction, microvascular changes, medications causing dry mouth, andpossible increased glucose concentration in saliva (53). Smoking oten makes

these problems worse. Unortunately, caring or the mouth is oten overlookedwhen trying to control other problems associated with diabetes. Good oralhygiene combined with good glycemic control can prevent many o theseproblems.

Periodontal DiseasePeople with diabetes are two to three times more likely than persons withoutdiabetes to have destructive periodontal disease, such as periodontitis (54).Periodontal disease is a bacterially induced, chronic infammatory disease thatdestroys the connective tissue and bone supporting the teeth and can leadto tooth loss. Periodontal disease is more prevalent, progresses more rapidly,and is oten more severe in individuals with both type 1 and type 2 diabetes(55). Recent research suggests a two-way connection between diabetes andperiodontal disease. Not only are people with diabetes more susceptible toperiodontal disease, but the presence o periodontal disease may also makeglycemic control more dicult (56-59). Proper care o the mouth that includestreatment o peridontal disease may help people with diabetes achieve betterglycemic control.


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Some studies have suggested a relationship between insulin resistance andinfammatory mediators. The infamed periodontal tissue, which can beequivalent to an area as large as an adult palm, is highly vascular and may

become ulcerated. This inection may introduce infammatory mediators,as well as bacterial lipopolysaccharides and other toxins, into the systemiccirculation. Some o the infammatory mediators produced in periodontitisalso stimulate the liver to produce acute-phase proteins, such as C-reactiveprotein (CRP), serum amyloid A, and brinogen. These proteins can beelevated in the peripheral blood o patients with periodontitis (60) and areassociated with harmul eects on organs. Thus, periodontal infammationpotentially contributes to a systemic, chronic infammatory state that alsois a component o other infammation-related diseases, including diabetesmellitus, cardiovascular diseases, and others. Treatment o periodontal diseasedecreases periodontal infammation, and evidence is accumulating to supportperiodontal treatment contributing to improvement o glycemic control (61).

Figure 6. U.S. Adults, Ages 45+, with Severe, ActivePeriodontitis* by Glycemic Control Status

0

2

4

6

8

10

12

14

16

No DM Better

Control

Poorer

Control

Percent

4.3

6.0

15.1

Source: NHANES III *1+sites: LPA 6+mm and gingival bleeding


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Signs and symptoms o severe periodontal disease can includered, swollen, tender and bleeding gums; gums that have pulled away romthe teeth; pus between the gums when they are compressed; persistent badbreath or bad taste in the mouth; permanent teeth that are loose or movingapart; any change in the way the teeth t together when the patient bites; andany change in the t o removable partial dentures. Most people with diabetesdo not experience pain with periodontal disease, and many have periodontal

disease and be asymptomatic. This highlights the importance o regularproessional check-ups and care. Periodontal probing perormed by a dentistor dental hygienist is a primary diagnostic assessment tool and can be used tomeasure response to treatment.

Recognize Oral Signs that maybe Symptomatic or Diabetes:

Xerostomia

- Dry mouth may also cause an increase in dental decay

Periodontal (gum) disease- Red, swollen or bleeding gums- Gums pulling away rom teeth- Abscesses (pus) between gums- Loose teeth or change in bite or tooth position

Candidal inection (thrush)

Persistent bad breath or bad taste, or ruity, acetone odor


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Drug Therapy Managementand Diabetes

Section 8


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Drug Therapy Management and DiabetesDrug therapy management has traditionally been concerned with ensuringcorrect dosage, avoiding drug interactions, and educating patients aboutpossible side eects. People identied as being at high risk or medication-related problems include those with chronic and multiple diseases, those whotake multiple (ve or more) medications, and those who see multiple healthcare providers. Because people with diabetes oten all into these categories,drug therapy management is especially important. It includes comprehensivereviews o medication and medical records, education o patients to improvecompliance with medication regimens, and an assessment o individualresponse to therapy to ensure timely interventions and coordination andcontinuity o care.

Drug-related ProblemsTodays pharmaceuticals and advanced medical technologies providemany therapeutic options or treating diabetes and its comorbidities. Iused inappropriately, however, they can cause serious illness, long-term

disability, or even death. A study released in February 2001 shows thatmisuse o prescription drugs in the United States costs $177 billion annuallyin additional treatments, hospital care, and doctor visits, up rom $76.5billion in 1995. More important than the costs, however, the study estimatesthat 218,000 prescription drug-related deaths annually are due to misusedprescription medications (62). The study identies several categories o drug-related problems, including improper drug choice, underdosage, overdosage,adverse drug reactions, drug interactions, and undertreatment. Additionalidentied actors include untreated medical conditions and medication usewith no indication (63, 64). More than 50% o those with chronic disordersdo not take their medication properly. Over 60% o persons with diabetes donot adequately control their blood glucose. O persons treated or high bloodpressure and high cholesterol, 65% and 49%, respectively, are unable to reachtarget blood pressure and total cholesterol levels (65). To improve complianceand minimize these health care adversities, medication therapy regimens mustbe consistently and careully monitored. Correct use o medication improveshealth and saves money or the health care system (6668).


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Strategies or Managing Drug TherapyPeople with diabetes should establish a relationship with a pharmacist whocan help monitor drug regimens, advise how to take medications properly,and provide other inormation to help them control their diabetes. Strategiesinclude the ollowing:

Use o medications. Individualize drug regimens to determine thebest time to take medications to reduce side eects and drug interactions.Oer behavior strategies, compliance aids, appropriate dosage orms,and a drug delivery system.

Sel-treatment and over-the-counter medications. Ask patientswith diabetes i they are using nonprescription medications; vitamin, herbal,or nutritional supplements; or topical and skin-care products. Assess theseverity and urgency o the persons complaint, the appropriateness or sel-treatment, and any precautions and contraindications. Recommend sel-treatment, ollow-up, and/or reerral to another health care proessional,

as appropriate.

One study reported that over 57% o people with diabetes use complemetaryand alternative therapies (69).

Selecting and using a blood glucose meter. Help the patientchoose an appropriate blood glucose meter and provide training on howto use it. Educate the person about the results, actions to take, and whento seek help. Sel-monitoring blood glucose (SMBG) is an important way toassess the eectiveness o therapy.

Cost control. Advise on ways to decrease costs o medications and

supplies by providing inormation on private insurance plans, prescriptiondrug programs, Medicare and Medicaid, the role o generic medications,and possible coverage or reerrals to other health care providers.


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Coordination o Care

Section 9


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Coordination o CareCoordination o care presents many challenges when delivered by multipleproviders in a variety o settings. Changes in drug therapy may occur whenpatients see specialty providers or during acute illness or hospitalization. Whena case includes multiple disease states and multiple drugs, along with OTCdrugs, herbal products, and other supplements, diligent case management isrequired to ensure continuity o care that is well coordinated (69).

As an extension o the dispensing role o pharmacists, central medicationreview and drug therapy management (including nonprescription products)can ensure that a current drug therapy plan is appropriately implemented.In one study, collaborative drug therapy management (CDTM), provided bypharmacists in collaboration with other health care providers, resulted inidentication o problems in 65% o patients drug regimens (70). In otherstudies, CDTM resulted in decreased morbidity and mortality, as well asdecreased costs attributable to ewer unscheduled physician visits, urgent carevisits, emergency room visits, and hospital days (7173).

With coordinated care, all members o the health care team, including thepatient, benet rom having a primary resource to deliver intended drugtherapy, inormation, and monitoring or eectiveness and adverse eects.This coordination will help ensure adherence to the intended treatment planand identiy drug and disease management problems in a timely manner.

Coordination o Care: Engage clinic leadership in establishing diabetes quality care in the

strategic plan.

Support a designated diabetes coordinator and diabetes team.

Provide sel-management education services according to theNDEP and ADA standards.

System redesign:

-Use registries and tracking systems or appointments.

-Prescreen charts to prepare or the oce visit.

-Case management through a care coordinator.

Decision support such as fow sheets and electronic health recordautomated prompts.

Establish links to community resources.


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Pre-diabetes and PrimaryPrevention

Section 10


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Pre-diabetes and Primary PreventionAn estimated 54 million Americans aged 40 to 74 years (40.1% o the U.S.population in this age group) have pre-diabetes, a condition that puts themat high risk or developing type 2 diabetes. Without intervention, people withpre-diabetes will progress to type 2 diabetes at a rate o 10% per year. Pre-diabetes also increases the risk o heart disease and stroke (3).

Pre-diabetes is a condition in which blood glucose levels are higher thannormal but not in the diabetes range. Pre-diabetes is dened as impairedasting glucose (IFG) o 100 to 125 mg/dl or impaired glucose tolerance(IGT) diagnosed by a post 75-gram glucose challenge (oral glucose tolerancetest or OGTT) o >140 to


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These liestyle changes were eective in preventing or delaying diabetes inall ages and all ethnic groups in the DPP. Among people aged 60 years andolder, progression to type 2 diabetes was reduced by 71%. The DPP showedthat moderate changes resulting in modest weight loss can make a difference (9).

DPP participants have been enrolled in a continuation study and ollow-updata will be orthcoming. Further inormation on pre-diabetes, testingrecommendations, and inormation on the NDEPs Small Steps. Big Rewards.Prevent Type 2 Diabetes. campaign and tools can be ound on the NDEP Website at http://ndep.nih.gov/campaigns/SmallSteps/SmallSteps_index.htm.

The Role o PPOD Providers in Primary PreventionAll health care providers can play a role in diabetes primary prevention anddiabetes control. As a pharmacist, podiatrist, optometrist, dentist, or dentalhygienist, you can make a dierence in primary prevention:

You know your patients. Your patients trust you. A ew words rom you can go a long way.

You can determine with just a ew questions who is at high risk or diabetes(see risk actor list below).

Do Your Patients Have any o the Following RiskFactors? Family history o type 2 diabetes. Overweight or obesity. High blood pressure or cholesterol. Arican American, American Indian/Alaska Native, Asian American,

Hispanic/Latino, Native Hawaiian/Pacic Islander ethnicity. Pre-diabetes.

Age o more than 45 years. History o gestational diabetes (GDM).

Gestational Diabetes Mellitus (GDM)It is estimated that women who have had GDM have a 20% to 50% likelihoodo developing type 2 diabetes in the 5 to 10 years ollowing pregnancy.Without intervention, progression rom Pre-diabetes to type 2 diabetes occursat a rate o approximately 10% per year. With NDEP resources and sel-management support or behavior change, diabetes can be preventedor delayed.

Test Value Diagnosis

FPG* 100125 mg/dL IFG (pre-diabetes)

FPG >125 mg/dL Diabetes

OGTT** 2-hour value 140199 mg/dL IGT (pre-diabetes)

OGTT 2-hour value >200mg/dL Diabetes*FPG = asting plasma glucose**OGTT = oral glucose tolerance test, blood glucose measured 2 hours ater 75gm glucose

load

Table 6.


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A Few Words Can Go a Long WayYou dont need to do it allresources are available to help. Your patients willappreciate that you care about their overall health

Ask: Has anyone ever told you that you are at risk or diabetes?Advise: You can take action to prevent or delay type 2 diabetes.Assist: Give your patients resources to help them make healthy changes: Reer to a primary care provider. Use the ree primary prevention materials available rom the National

Diabetes Education Program (NDEP)call 1-800-438-5383, visitwww.ndep.nih.gov or use the order orm in the Appendix.

Primary Prevention Hypothetical Cases A 30-year-old woman at a routine dental hygienist appointment shares

that act that she recently delivered a nine-pound baby ater a pregnancycomplicated by GDM. She exclaims Thank goodness thats all over!The dental hygienist tells her o the high lielong risk o developing type 2diabetes in women who have had GDM. The patient learns about the reeNDEP materials available to help her lose weight and prevent or delay theonset o type 2 diabetes.

A 45-year-old Arican American woman brings her mother in or her annualcomprehensive diabetes eye exam. The eye care provider asks i she everconsidered that she, too, might be at risk or developing diabetes. Thewoman is surprised. Me? I just never thought much about it. Ive alwaysbeen ocused on Mama. The eye care provider gives the woman the Am I

At Risk? brochure, NDEPs toll-ree number and Web site URL, and suggests

she make a ollow-up appointment with her own primary care provider.

A 50-year-old man accompanied by his overweight teenage son asks thepharmacist about weight loss pills. The pharmacist asks to talk to bothather and son together. The teen seems embarrassed and unconvinced.He says What am I supposed to eat when the guys are all eatingcheeseburgers and ries ater school?! The pharmacist agrees thatchanging eating habits is hard, but not impossible. Smaller portions, orchoosing a plain hamburger instead o the oversized one with cheese, canmake a dierence. He suggests the amily take a look at NDEPs Web siteor tip sheets on healthy eating and physical activity, and that they talk toa dietitian. Dad agrees to play basketball with his son a couple o nights a

weekgood exercise or both o them.

A 70-year-old man consults a podiatrist because o painul corns on hiseet. He says I dont walk anymore because o these corns, but I guessthat doesnt matterIm too old to be walking much now. The podiatristemphasizes the many benets o regular physical activity such as walking,including diabetes prevention. He explains that 1 in 5 people over age 60have diabetes, but that the disease can be prevented or delayed. He sharesthe NDEP Its Not Too Late to Prevent Diabetes tip sheet with the man andpoints out NDEPs toll-free number and URL. He says, Ater we get thesecorns xed up, I want to see you out there walking!

Always advise

patients to check

with their primary

care provider

before beginning a

exercise or physical

activity program.


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Appendices


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Appendix A

Set Up a Reerral SystemIntegrated, multidisciplinary team care is key to successul diabetesmanagement, and coordination o care can be acilitated by setting up a

system o reerrals or routine preventive care as well as or urgent needs.

Create a mechanism or preventive care and urgent reerrals; dont just tellthe person with a potentially serious problem to consult a health specialistright away. Contact primary care and specialty providers to discuss with themcriteria and ensure that procedures are in place or seeing a person whois reerred or preventive care or an urgent basis.

Make a list o providers, case managers, phone numbers, and other contactinormation; keep it handy or quick reerence. Consider giving individualshandouts with reerral inormation, or calling clinics directly or urgent reerrals.

Check the NDEP health care providers Web site,http://www.betterdiabetescare.nih.gov , or tools to help set up a reerralsystem.


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Appendix B

Blood Glucose TestingDiagnosis is based on plasma glucose levels obtained rom a venous sample(74). Inormation on diagnostic criteria, relative merits o dierent screening

tests, and an algorithm or evaluating people at risk can be ound athttp://ndep.nih.gov/ddi/#HC. Blood glucose testing can be perormedusing dierent methods or dierent purposes.

Screening reers to testing asymptomatic individuals at high risk or diabetesvia venous sample (preerred) or a capillary sample to determine i ollow-updiagnostic testing is indicated (75).

Blood glucose testing to monitor glycemic status by patients and health careproviders is considered a cornerstone o diabetes care. Results o monitoringare used to assess the ecacy o therapy and guide adjustments in medicalnutrition therapy (MNT), exercise, and medications to achieve the best possible

glucose control (76).

Blood glucose testing by people with diabetessel-monitoring o bloodglucose (SMBG)is recommended or all people with type 1 diabetes.For most such patients, SMBG three or more times a day is recommended.For people with type 2 diabetes, the requency o testing should be sucientto acilitate reaching glucose goals. The requency o testing should beincreased with therapy modication (77).

Because the accuracy o SMBG depends on both the instrument and the user,the technique should be evaluated by a health care provider initially and thenperiodically (78).

Requirements or Laboratory TestingAll health care providers who perorm nger sticks or other laboratorytesting must be registered with the Centers or Medicare & Medicaid Services(CMS) under the Clinical Laboratory Improvement Amendment (CLIA), whichestablished quality standards to ensure the accuracy, reliability, and timelinesso patient test results regardless o where the test is perormed. Threecategories o tests and certication have been established, dependingon the complexity o the test method. CLIA has established complianceregulations or each level o testing that require quality control anddocumentation procedures (79).

Certain states have established additional requirements or various sitesor health care providers. For specic additional requirements, health careproviders should contact their state agency (see http://www.cms.hhs.gov/clia or contact inormation). Compliance with the Occupational Saety and Health

Administrations regulations or bloodborne pathogens must alsobe documented and maintained.


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Appendix C

Multidisciplinary Care in ActionPeople with diabetes may present with a complaint best treated withmultidisciplinary care. Common symptoms or concerns and possible

presentation and management scenarios are given below as examples.

Foot and Skin Care Dry skin. Wounds, ungal and bacterial inections, ulcers. Pain, numbness, tingling o extremities. Corns, calluses, bunions, ingrown toenails.

Example:A person requests a oot soak rom the pharmacist or an ingrown toenail.Assessment reveals that he or she has diabetes and or 3 weeks has had aseverely infamed ingrown toenail that has not responded to topical antibiotic

ointment. The pharmacist discusses with the person the relationship betweendiabetes and its complications, as well as the need to seek immediateattention rom a podiatrist or primary care physician. The pharmacist alsoemphasizes that people with diabetes should NOT soak their eet. Soakingdries the skin and can cause more skin and oot complications.

Eye Health Dry itchy eyes. Blurred vision, poor vision (seeking reading glasses). Eye pain. Conjunctivitis.

Other eye problems such as partial vision, hemorrhages, foaters, spots,oreign objects, contact lens problems.

Example:A 45-year-old woman tells her podiatrist that she cant check her eet becauseshe just cant see as well as she used to. She was recently diagnosed withdiabetes. She assumed that she needed reading glasses, but has not had aneye exam because she never had poor vision beore. The podiatrist recognizesthat the patients blurred vision could be a sign o poor glucose control or eyepathology, and explains to her the relationship between diabetes and visionproblems, both transient and long term. The podiatrist then reers the patientto an optometrist or an ophthalmologist or a comprehensive eye examination,

including pupil dilation, and to a primary care provider or ollow-up.


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Oral Health Sore, red, infamed, bleeding gums. Toothache, pain, inections. Dry mouth. Candida inections. Denture pain. Cold sores, canker sores.

Example:A person with diabetes asks the pharmacist or a product to use

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Woring Together to Manage Diabetes