I. Introduction
a. Coordination of care presents many challenges when delivered by multiple
providers in a variety of settings. This coordination helps ensure adherence to the
intended treatment plan and identify drug and disease management problems in a
timely manner.
II. Team Approach
a. A multidisciplinary team approach is critical to success in diabetes care and
complications prevention.
b. Pharmacist, podiatrist, optometrist and dental care (PPOD) professionals are often
a primary point of care for people with type 2 diabetes. These professionals play
an important role in ensuring that diabetes care is continuous and patient
centered.
c. The purpose of this lecture is to encourage primary care physicians to establish a
multidisciplinary team of healthcare providers to treat diabetes.
d. The goals of Working Together to Manage Diabetes: A Guide for Pharmacists,
Podiatrists, Optometrists, and Dental Professionals is to reinforce consistent
diabetes messages across the PPOD and all medical providers.
III. Foot Health and Diabetes
a. Risk Factors
1. peripheral Neuropathy
2. biomechanics
3. peripheral Vascular Disease
4. prior Ulceration
5. prior Amputation
b. A comprehensive foot examination for abnormalities, including evaluation of
pulses, sensation, foot biomechanics, and nails helps determine the person’s
category of risk for developing foot complications. Persons with diabetes who are
at high risk have one or more of the following characteristics: loss of protective
sensation, absent pedal pulses, foot deformity, history of foot ulcers, or prior
amputation.
IV. Eye Health and Diabetes
a. Diabetes is the leading cause of new cases of blindness among adults aged 20 to
74 years. Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness
each year. People with diabetes can maintain optimal vision and healthy eyes by
having an annual comprehensive vision examination, including a dilated eye
examination, with early intervention if retinopathy is found.
b. Vision Loss From Diabetes
c. Retinal Signs of Hypoxia
1. Cotton wool spots
2. Venous caliber abnormalities (VCAB)
3. Venous tortuosity
4. Arteriolar abnormalities
5. Intraretinal microvascular abnormalities (IRMA)
6. Featureless retina
d. Other Common Eye Complications in Diabetes
1. Fluctuating vision
2. Cataracts
3. Double vision
4. Corneal abrasion/ulcers/dry eye
5. Glaucoma
V. Oral Health and Diabetes
a. Diabetes can lead to changes in the oral cavity. Of particular concern to dentists
and dental hygienists are the effects of diabetes on the health of the gingiva
(gums) and periodontal tissues. Poor glycemic control is associated with gingivitis
and more severe periodontal diseases. Oral signs and symptoms of diabetes can
also include a neurosensory disorder known as burning mouth syndrome, taste
disorders, abnormal wound healing, and fungal infections.
b. Individuals with diabetes may notice a fruity (acetone) breath, frequent
xerostomia (dry mouth), or a change in saliva thickness. Dry
mouth can also lead to a marked increase in dental decay.
c. Unfortunately, caring for the mouth is often overlooked when trying to control
other problems associated with diabetes. Good oral hygiene combined with good
glycemic control can prevent many of these problems.
d. People with diabetes and severe periodontal disease have:
1. 6x increased risk of poor glycemic control
2.82% had 1 or more macrovascular complication (CVD, CVA) (vs. 21%
w/o periodontal dz)
3. Death rate due to CVD 2.3x higher
4. Death rate from nephropathy 8.5x
e. Control of Glucose Matters in Oral Health
f. People with poorly controlled diabetes had more periodontal disease than people
well controlled
g. In a study with Pima Indians, improved periodontal disease correlated with better
glucose control
h. Effective interventions promote multiple good outcomes
VI. Drug Therapy Management and Diabetes
a. People with diabetes should establish a relationship with a pharmacist who can
help monitor drug regimens, advise how to take medications properly, and provide
other information to help them control their diabetes.
b. Use of medications
c. Self-treatment and over-the-counter medications
d. Selecting and using a blood glucose meter
e. Cost control
VII. Why
a.
b.
c.
d.
Does Diabetes Continue to Command Our Attention?
Estimated Cost of Diabetes in the United States
Direct Medical Cost: $92 billion
Indirect Cost: $40 billion
Total Cost: $132 billion
VIII. U.S. Diabetes Prevalence All Ages, 2007
a. 20.8 million people have diabetes
b. Diagnosed: 14.6 million people
c. Type 1 diabetes accounts for 5 – 10%
d. Type 2 diabetes accounts for 90 – 95%
e. Undiagnosed: 6.2 million people
IX. Obesity Trends
a. Countries With Largest Number of People With Diabetes
India
19 million
57 million
China
16 million
38 million
USA
14 million
22 million
Pakistan
4 million
15 million
Indonesia
5 million
12 million
Mexico
4 million
12 million
X. U.S. Diabetes Prevalence 20 Years or Older, by Race/Ethnicity, 2005
a. American Indians and Alaska Natives Aged 20+
1. 12.8 percent (99k) of American Indians and Alaska
Natives had diabetes in 2003
2. 2.2 times as likely to have diabetes as non-Hispanic
whites
b. Hispanic/Latino Americans and Diabetes
1. 2.2 times as likely to have diabetes as non-Hispanic
whites
2. 9.5 percent (2.5 million) of all Hispanic/Latino
Americans have diabetes
3. Mexican Americans are 1.7 times as likely to have diabetes as nonHispanic whites
c. African Americans and Diabetes
1. 13.3 percent (3.2 million) of all African Americans have
diabetes
2. African Americans are 1.8 times as likely to have
diabetes as non-Hispanic whites
d. Asian Americans and Pacific Islanders and Diabetes
1. Total prevalence of DM not available; absence of data does not mean not
affected
2. In Hawaii: Asians, Native Hawaiians, and other Pacific Islanders are more
than 2 times as likely to have diabetes as non-Hispanic whites
3. In California: Asians are 1.5 times as likely to have diabetes as nonHispanic whites
XI. Preventing Diabetes Complications
a. Glucose control (micro 40%)
b. Blood pressure control (CVD/CVA 33-50%; micro 33%)
c. Blood lipid control (CVD 20-50%)
d. Preventive care practices for eyes (50-60%), kidneys (30-70%), feet (45-85%)
XII. How can we harness our efforts into true multidisciplinary team care?
a. NDEP structure
b. Joint initiative of the National Institutes of Health and the Centers for Disease
Control and Prevention
c. Partners with over 200 other organizations:
1. State Diabetes Prevention and Control Programs
2. Public and private organizations (e.g. AAO)
3. Traditional (e.g., American Diabetes Association) and non-traditional
partners (e.g., National Urban League)
4. PPOD Goals
5. Promote the objectives of NDEP by utilizing Pharmacy, Podiatry,
Optometry and Dentistry organizations and providers to increase
awareness of and access to quality care for persons with diabetes
6. PPOD Primer Goals
7. Promote multidisciplinary diabetes care
8. Section on “What You As A Health Care Provider Can Do”
9. Intended as a “cross-training” document, not a comprehensive guide to
sub-specialty care
10. Educate PPOD providers so they can educate patients in turn
11. Sections specific to each discipline
12. Key issues in each PPOD discipline
13. Referral recommendations
14. Patient education for self-management
XIII. Working Together Key Messages
a. Recommend routine exams for complication prevention: oral health,
comprehensive foot, dilated eye
b. Reinforce self-exams
c. Recognize danger signs
d. Pharmacist role in diabetes care team: medications management, individualized
plans, use of glucose meter and other supplies
e. Importance of metabolic control (ABCs)
XIV. Sample vignettes – team care
a. A dentist notes that his patient smokes. In addition to telling the patient that
smoking can cause oral cancer, he describes the impact tobacco use can have on
increasing diabetes complications. He asks the patient to consider quitting as an
important step in controlling diabetes and gives him the 1-800-QUITNOW number.
b. Sample vignettes (continued)
A 40-year-old woman asks her local pharmacist for advice on reading glasses. She
says, “I must be getting older, everything is just blurry.” The pharmacist uncovers a
history of diabetes diagnosed the previous year, but that the patient never returned
for follow up. The pharmacist advises the woman that her blurred vision may be a
sign of diabetes and arranges for the woman to be seen by a primary care provider
and eye care provider for follow up.
XV. PPOD Poster in Spanish Translations
XVI. Pre-Diabetes
a. At least 54 million U.S. adults age 20 and older have pre-diabetes— which raises
their risk for type 2 diabetes and cardiovascular disease
b. Diabetes Prevention Program (DPP)
c. Lifestyle Intervention
d. Statistics on rising prevalence of diabetes and prediabetes
e. Findings of the Diabetes Prevention Program (DPP)
f. Risk factors for type 2 diabetes
g. Ask – Advise – Assist approach
h. Includes the challenge: It is estimated that of persons born in 2002, 1 in 3 will
develop diabetes in his or her lifetime … unless something changes
XVII. Where to go for further information
a. How do I get NDEP materials?
b. All NDEP materials are copyright-free and available by calling toll free 1-800-4385383 or downloading from www.ndep.nih.gov
REFERENCES:
www.ndep.nih.gov
www.betterdiabetescare.nih.gov
www.cdc.gov/diabetes/ndep
www.diabetesatwork.org