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