Diabetes: The Eye of the Beholder
A. Paul Chous, M.A., O.D.
Chous Eye Care Associates
6720 Regents Blvd. Tacoma, WA 98466
425-736-6251
Dr.Chous@DiabeticEyes.com
Course Level: intermediate
practice emphasizing diabetes care and education
Type 1 diabetic since 1968
author of Diabetic Eye Disease: Lessons From A Diabetic Eye Doctor – How To Avoid
Blindness and Get Great Eye Care (Fairwood Press, 2003)
feature writer for DiabetesInControl.com and dLife.com
consultant to Children With Diabetes & the Diabetes Exercise and Sports Association
I. Introduction: Speaking as a patient who has had type 1 diabetes for 38 years now, I
want you to know that I have made virtually every mistake possible……
a. My Mistakes: not checking my blood glucose; not taking my medications on
time; poor dietary choices; insufficient exercise; infrequent eye,
foot and endocrinology appointments; not taking the time to
learn about diabetes and diabetes complications
I Am Not Alone
b. All this Begs the Questions: Why am I giving this talk? Why did I write a book?
- To help you more effectively understand and communicate with your
patients who have diabetes from an ‘insider’s’ perspective
- To educate patients and providers about the myriad ways diabetes
affects the eyes and visual system
- To help patients understand the importance of good metabolic control
and, hopefully, avoid the mistakes I have made
- To present a much needed, objective look at the important role played
by doctors of optometry on the diabetes care team, and give ODs a
resource they can feel good about recommending to their patients
2. Addressing MY Mistakes To Help OUR Patients – Be a PEST (a – d)
a. Portion control and carbohydrate restriction
- metabolic defects of DM suppress normal inhibition of appetite
1. IR blunts hypothalamic satiety receptors (decreased leptin release)
2. Hypoglycemia triggers appetite via the endocannabinoid system
- portion size is the most important element on any food label
1. CHO raises blood glucose
2. CHO utilization and caloric load drive insulin resistance (IR)
- the Super Size It phenomenon – “bad news” for us all
b. Exercise – the key to good diabetes self-management
- enhances insulin action & augments insulin-independent glucose transport
- reduces visceral adiposity, thereby decreasing IR and blood pressure
- psychic benefits ameliorate depression & enhance self-control
- HCPs should discuss exercise & set good examples
1. Exercise decreases visceral fat that modulates IR
2. Walking 5 miles each day adds about a month of life expectancy/year
c. Self-monitoring of Blood Glucose (SMBG)
- 50% of patients don’t perform ANY SMBG
- blood glucose control is almost entirely about pattern management –
without data points (SMBG), there are no patterns to manage
- the average patient with DM performs SMBG 0.6 times/day (50% do none)
1. Pain: can be minimized via adjustable lancets & alternate site tests
2. Cost: $1 a test (most insurers cover test strips)
- The Grand Delusion: “I can feel if my blood sugar is high or low”
1. 81% of patients were off by > 50 mg/dl in my in-office study (n=148)
2. tell patients to “Test…Don’t Guess”
- some glucose meters make “game” of it (statistics, graphs, game rewards)
- the first generation of continuous interstitial glucose sensors display
glucose trends and teach patients how to ‘think like a pancreas’ (e.g.
DexCom STS, Medtronic Guardian RT, Abbott Freestyle Navigator)
d. Timing of meals & medications
- insulin onset takes 15-60 minutes; maximum insulin effect in 2-4 hours
- medications should precede meals, informed by SMBG
- smaller, more frequent meals help level ‘glycemic excursions’
1. The goal is for insulin action to simultaneously match blood glucose
2. A challenge due to variable absorption of glucose, insulin, oral agents
3. The “law of small numbers” states that absorptive uncertainty is less
problematic if meals and medication doses are small
Reality – Hypoglycemia is disabling and can quickly lead to
incapacity (confusion, tremor, syncope) – many patients opt
for chronic hyperglycemia because it has far less impact on
function & its consequences are distant in time
Beyond PEST
e. Frequency of Health Care Visits
- 50% of patients with DM do not receive annual DFE
missed opportunity to Dx eye disease
missed opportunity to educate and reinforce good care
- Public health & economic reasons to incentivize care & follow-up
f. Lack of Patient Understanding
- lack of health literacy
- fear of finding out ‘something is wrong’
- lack of high quality diabetes education in many areas
- patient education is paramount to living well with chronic disease
3. How we can help patients avoid these mistakes
a. generally, scare tactics don’t work (not conducive to good relationships)
b. building a relationship works:
- let patients know you’re ‘on their side’
- use positive language to change behavior (“if we reduce your A1c to 7.3%,
we’ll cut the risk of your retinopathy getting worse in half”)
- take every opportunity to educate patients & reinforce good care
use written materials & send a diabetes eye exam report
use retinal imaging to involve, inform & motivate
know the best diabetes specialists in your area & build a team
c. understand diabetes & the major studies (DCCT, UKPDS, DPP, ETDRS)
- Connect the Dots for patients between good metabolic control and diabetic
eye disease
ask about meds, exercise, diet, SMBG, HbA1c & tell them why
measure blood pressure on every patient & tell them why
measure blood glucose on every patient; consider in-office HbA1c
(1) facilitates better care
(2) easy & cost-effective
(3) if you think it’s important, so will they
(4) CLIA-waived; Use ICD-9 codes 250.00-250.93 & CPT codes:
82962QW – measurement of blood glucose by devices FDA-approved for home use
83036QW – glycated hemoglobin using CLIA-waived method (83037QW for InViewTM)
(5) In-office Hypoglycemia (BG < 70 mg/dl):
15 grams of carbohydrate will raise blood glucose about 30-40 mg/dl
4. Conclusion: Those Who Aren’t What We Call Them
a. calling someone a “diabetic” is existentially diminutive
b. few people want to be known AS or even BY their health status
c. language is power
Selected References
1. Chous AP. Diabetic Eye Disease: Lessons From A Diabetic Eye Doctor – How To Avoid
Blindness and Get Great Eye Care. Fairwood Press, Seattle. 2005
2. Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of highrisk patients with diabetes: motivation and teaching intervention: a randomized,
prospective 8-year follow-up study. J Am Soc Nephrol. 2005 Mar;16 Suppl 1:S22-6.
3. Textbook of Diabetes 3rd ed. Chapter 68. Pickup J Ed. Blackwell Pub., London 2002
4. The Art and Science of Diabetes Self-Management Education: a desk reference for
healthcare professionals. American Association of Diabetes Educators, Chicago 2006
Diabetes: The Eye of the Beholder
A. Paul Chous, M.A., O.D.
Course Description:
Gets an insider’s view of living with diabetes from an eye doctor specializing in
diabetes eye care and education. Learn the common mistakes made by our patients and
how you can help avoid them.
Learning Objectives:
Attendees will be able to:
1. describe major diabetes self-management pitfalls facing patients, and their impact
2. describe some strategies for changing patient behavior
3. explain the rationale for metabolic assessment by doctors of optometry, including
in-office blood glucose analysis