Type 2 diabetes requires multilevel care

Primary care physicians are often the main line of defense protecting patients with diabetes from major complications. It's a tough job.

By Susan J. Landers, amednews staff. June 23, 2003.

Washington -- Uncontrolled diabetes. It's a problem often more complicated than single solutions or interventions can resolve.

For instance, it can take a team effort, plus judicious use of the newest generation of insulin, to bring the blood sugar levels of many of these patients under control, said physicians participating in a June 3 briefing at the New York Academy of Science.

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Active patient participation and counseling and education programs are key to bringing blood sugar levels to 7% or less as measured by the hemoglobin A1c test, said Scott Nelson, MD, a family physician from Cleveland, Miss.

"Diabetes is becoming a progressive problem," he said, and the solutions devised in the Mississippi Delta may foreshadow what will happen in the rest of the United States.

Mississippi is now in hot competition with Alabama for the dubious distinction of being the state with the highest prevalence of diabetes. As many as one in five of Mississippi's Sunflower County's 40,000 residents may have diabetes, said Dr. Nelson.

"We've got dietary problems," he noted. Fried food and heavily sweetened tea help boost the diabetes rate. Obesity levels are also high.

Meanwhile, across the nation, diabetes affects about 17 million adults with another 6 million undiagnosed. And despite the vastly increased numbers of medicines and other management tools, nearly half of individuals diagnosed continue to live with uncontrolled diabetes, placing them at risk for the usual long-term serious consequences, including blindness, kidney failure, amputations and cardiovascular disease.

Primary care at the epicenter

Primary care physicians remain not only the first line of defense, but the major line of defense for most of these patients, according to the Joslin Diabetes Center in Boston. Most patients do not have access to specialized referral centers, and the care of these complex patients is most often the job of the primary care physician.

The first step is getting patients' attention, said Dr. Nelson. He uses the hemoglobin A1c test to achieve this goal. "The number may vary a little, but I think there is general consensus that if you can consistently keep your A1c at 7% or below, your risk of complications from diabetes will be less." He tells his patients to post the 7% on the refrigerator door and realize "you can be a controlled diabetic or an uncontrolled diabetic."

17 million adults have type 2 diabetes; another 6 million are undiagnosed.

Dr. Nelson's advice to fellow physicians: "If you don't have a hemoglobin A1c machine in your office that can run these tests, you'd better get one."

Doctors also don't use insulin very well, said physicians at the briefing.

While insulin is essential for the management of type 1 diabetes, it is viewed as a negative with type 2 diabetes, said Richard Beaser, MD, author of Joslin's Diabetes Deskbook, the Joslin Center's guide to diabetes for primary care physicians. However, insulin can be an appropriate therapy for patients with type 2 diabetes. Insulin doesn't hasten the onset of insulin resistance, nor does it increase a patient's risk of cardiovascular disease. It can also come much closer to mimicking the body's natural production of insulin, said Dr. Beaser.

He cautioned, however, that older patients might find it difficult to administer the insulin shots.

"We are getting patients on insulin too late," said Dr. Nelson. "The train has already run down the mountain and crashed into the village."

Dr. Nelson tells patients, "This is not your grandmother's insulin."

Patients need to realize that daily injections -- with tiny, easy-to-use needles -- can be given on a predictable schedule. "Once patients understand that concept, they are fine," he said.

But, convincing them of the importance of lifestyle changes, including weight loss and increased exercise, is likely to be difficult.

States with the most diabetics: Alabama and Mississippi.

Stephen Brunton, MD, executive director of Stamford (Conn.) Hospital's Family Practice Residency Program, described his eight-year project to demonstrate to interns just how difficult it is to change behavior. He asked the interns to change one of their own behaviors, whether it was eating cookies or smoking. Not a single intern was able to make a change stick.

"I think patients are also trying to change behavior without making the commitment," he said. "We need the sensibility to work with patients and not force lifestyle changes on them."

Alan Jacobson, MD, a Joslin Center senior vice president, recommended that physicians focus on positive messages rather than a patient's fear, shame or embarrassment. Urge patients to take gradual steps toward change and to understand that relatively modest improvements can make a difference, he said.

Educational materials and programs are also important for both physicians and patients, and several are in practice or soon will be.

Dr. Jacobson described a new Dept. of Agriculture program for migrant farm workers that puts USDA extension workers in the field with bilingual flip charts on diabetes and meters that can check for eye problems.

Dr. Nelson noted that the Joslin Center, the University of Mississippi Medical Center and local hospitals are developing a diabetes education and research center in his home town.

Dr. Brunton is working with the Texas Academy of Family Physicians and several endocrinologists on a tool box for physicians called "Pathways to Seven." This resource will include audio tapes and CD-ROMs for patients, a flip-chart on blood sugar and instructions on how to read food labels and give self-injections.

"Our job is to provide knowledge and tools to patients," said Dr. Brunton. "The bottom line is, this disease is probably like no other and I hope with everyone working together we can get a handle on this epidemic."

ADDITIONAL INFORMATION:

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Joslin Diabetes Center (www.joslin.harvard.edu)

National Institute of Diabetes and Digestive and Kidney Diseases, National Diabetes Information Clearinghouse, on insulin-dependent diabetes (www.niddk.nih.gov/health/diabetes/pubs/iddm1/iddm.htm)