GO Diabetes Train the Trainer Program

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GO! DiabetesTrain the Trainer Program
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Diabetes Early Detection and Lifestyle Monitoring
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Introduction

• Type II Diabetes is almost always linked to
  insulin resistance
• As such, predictors exist up to ten years prior
  to the development of overt diabetes

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Evolution of DM

• Insulin resistance results in hyperinsulinemia
• NOT hyperglycemia at first!
• Postprandial glucose is the next to climb
• Fasting glucose levels rise with progressive
  beta-cell dysfunction

(Bergenstal, Mgmt Type 2 DM, 2001)
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Etiology of Metabolic Syndrome

• Insulin resistance
• Due to genetics and lifestyle factors
• Insulin receptors no longer recognize insulin
• Leads to Hyperglycemia and Hyperinsulinemia
• Pro-thrombotic state
• Pro-inflammatory state

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Insulin Resistance Leads to

• Increased fat storage in the abdomen
• May stimulate cancer cell growth
• Vascular changes in the endothelial lining
  leading to vasoconstriction
• Lab abnormalities elevated TG, small dense
  LDL-chol and, low HDL-chol
• Increased platlet adhesion
• Increased response to Angiotensin II
• Reduction in nitric oxide (a vasodilator)

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Metabolic Syndrome

• Requires 3 or more
• Triglycerides gt 150
• HDL lt 40
• Waist size gt40 men, gt35 women
• BP gt 130/85
• Fasting glucose gt 100
• Caveat Treatment counts for requirements

(Grundy, Circulation, 2005)
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Metabolic Syndrome cont.

• The relevance?
• 1 in 4 adults meets diagnostic criteria (at least
  3 factors)
• 4 out of 5 adults has at least one factor and is
  at risk

(Ford, JAMA, 2002)
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Metabolic Syndrome as a Risk Factor in the
Incidence of Diabetes

yes no
metabolic syndrome
Yes No
Impaired Glucose Tolerance
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Pre-Diabetes

• Key Point You have to predict the emergence of
  diabetes and head it off before it evolves in a
  patient
• Cut-off values
• Fasting sugars between 100-126
• 2-hr GTT of 140-200
• Which would catch a problem earlier?

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Pre-Diabetes Definition
If FBG gt100 there is a 10-15 risk of DM within 7
years
or
Fasting
GTT
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Who and When to Screen?

• Starting at age 45, a fasting blood glucose every
  three years
• More frequent screening if

• Family history
• Overweight (BMI 25)
• Dyslipidemia
• HTN

• High risk ethnicity
• Vascular disease
• Prior glucose elevation
• Hx or exam findings

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How to Screen

• As mentioned before, fasting glucose and oral
  glucose tolerance tests are the standard
• Important note HbA1c testing is not a screening
  tool due to lower sensitivities (think about the
  window period of hyperinsulinemia but normal
  glucose)

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What if You Dont Screen?

• Estimates show a 5-15 conversion to full
  diabetes from prediabetes per year

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Benefits of Diagnosis

• Seven trials showed a reduction of 32-62 in
  relative risk from behavioral or pharmacologic
  interventions
• Numbers needed to treat were in the 4-14 range
• Cost/benefit analysis clearly favors early
  diagnosis and intervention. Currently 50
  million prediabetics

(CDC)
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Role of Obesity in Diabetes

• Obesity (specifically abdominal) has one of the
  highest associations with insulin resistance and
  glucose intolerance
• Numerous studies have tied weight loss to
  diabetes prevention

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Obesity cont.

• A 5-10 weight loss yields a 58 reduction in the
  incidence of diabetes!
• At the end of four years
• Diet and exercise regimens average a 4kg loss
  after two years
• Advice alone results in a 1kg gain
• (Franz, Journal Amer. Diabetes Assoc, 2007)

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Quantifying Obesity

• Easiest is by waist circumferences.
• 40 males, 35 females
• Some variation by ethnicity (35 and 31 for
  Asians)
• Measured across iliac crest

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Activity Recommendations

• For general fitness 30 min/day moderate activity
  (walking) five days a week
• To emphasize weight loss 60 min/day
• For children 60 min/day
• Vigorous exercise has more cardio benefits
  (achieves target heartrate)

(DGAC, 2005)
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Fitness

• A 1999 study published in the American Journal of
  Clinical Nutrition showed a distinction between
  fitness and body mass/obesity in risk reduction
• Relative risk reduction in all-cause mortality
  was the same regardless of body size/BMI if
  physically fit

(Lee, AJCN, 1999)
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Healthcare Maintenance

• Latest ADA guidelines (2007)
• Lab surveillance
• Diabetic education
• Vaccinations/routine healthcare
• Smoking cessation
• Foot exams
• Eye exams

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Reasons to Look at Feet

• Up to 70 of diabetics eventually develop a
  neuropathy
• Up to 25 develop foot ulcers
• Diabetes doubles your risk of LE disease
  (vascular, neuro, skin)
• More than half of the foot ulcers become infected
  at some point

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The real morbidity

• 10-20 of infected ulcers lead to amputation
• Diabetes accounts for the vast majority of
  non-traumatic amputations
• One amputation increases the likelihood of
  another
• 5-year mortality rates approach 80

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Foot Surveillance

• Examine the feet at every visit
• Annual comprehensive evaluation
• Sensation
• Pulses
• Skin condition (ulcers, hair, nails)
• Anatomic deformities
• Shoe evaluation

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Sensory Exam

• 10-gram monofilament
• Patient should not watch
• Five sites per foot
• Apply filament perpendicular to skin
• Allow slight buckle of filament in one motion
• Each site should take 1-2 sec
• Do not apply to ulcers or calluses

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Foot Exam Sites

• Fewer sites than 10 years ago

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Procedures/Billing

• Foot exams
• Protective footwear
• Nail trimming
• Debridement of corns and calluses

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Diabetic Foot Examination

• G0245 - Initial physician evaluation of a
  diabetic patient with diabetic sensory neuropathy
  resulting in a loss of protective sensation
  (LOPS) which must include
• 1. the diagnosis of LOPS
• 2. a patient history
• 3. a physical examination that consists of at
  least the following elements
• (a) visual inspection of the forefoot, hindfoot,
  and toe web spaces,

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Diabetic Foot Examination

• 3.Exam cont
• (b) evaluation of a protective sensation,
• (c) evaluation of foot structure and
  biomechanics,
• (d) evaluation of vascular status and skin
  integrity,
• (e) evaluation and recommendation of footwear,
  and
• 4. patient education

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Diabetic Foot Examination

• G0246 - Follow-up evaluation of a diabetic
  patient with diabetic sensory neuropathy
  resulting in a loss of protective sensation
  (LOPS) to include at least the following
• 1. a patient history
• 2. a physical examination that includes
• (a) visual inspection of the forefoot, hindfoot,
  and toe web spaces,
• (b) evaluation of protective sensation,
• (c) evaluation of foot structure and
  biomechanics,
• (d) evaluation of vascular status and skin
  integrity,
• (e) evaluation and recommendation of footwear,
  and
• 3. patient education.

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Diabetic Foot Examination

• G0247 - Routine foot care of a diabetic patient
  with diabetic sensory neuropathy resulting in a
  loss of protective sensation (LOPS) to include if
  present, at least the following
• (1) local care of superficial wounds,
• (2) debridement of corns and calluses, and
• (3) trimming and debridement of nails.
• NOTE Code G0247 must be billed on the same date
  of service with either G0245 orG0246 in order to
  be considered for payment.

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Medicare Protective Footwear

• One pair of depth shoes and three pairs of
  inserts
• One pair of custom-molded shoes (including
  inserts) and two additional pairs of inserts

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Eye Care

• Diabetic retinopathy is the leading preventable
  cause of blindness
• Prevalence of DR increases with duration of
  diabetes (100 Type 1, 60 Type 2 after 20 years)
• Of all recommendations, eye screening is the
  least likely to get done

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Pathogenesis

• Increased circulating glucose leads to weakness
  of capillary walls
• Microaneurysms and leakage occurs causing
  eventual infarction of the nerve fiber layers
  (cotton wool spots)
• The localized hypoxia then leads to
  vasoproliferation
• Extension into the vitrea (/- hemorrhage) leads
  to fibrosis and vision loss

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Diabetic Retinopathy
Normal Retina (left) contrasted with
Proliferative Diabetic Retinopathy (right)
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Key Point

• Make the annual referral!
• Attempt screening on your own also consider a
  pan-ophthalmoscope
• There are treatments available (laser)

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Questions?