Improving Diabetes Care in the Clinic Jayendra H Shah
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1Improving Diabetes Care in the Clinic2
3Improving Diabetes Care in the Clinic
Editor Jayendra H Shah MBBS MCPS FACP FACE Professor of Medicine and Radiology University of Arizona College of Medicine Former Chief of Staff, Southern Arizona VA Health Care System, and Network Research Officer, Veterans Integrated Service Network-18 Tucson, Arizona, USA
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Improving Diabetes Care in the Clinic / Ed. Jayendra H Shah
First Edition: 2014
Printed at
5Dedicated to
Reverend Pandurang Shashtri Athavale (Dadaji), philosopher and modern day sage (Rishi), for teaching the Way of Thinking, Way of Life, and Way of Devotion to humanity through the medium of Swadhyay,
My parents, Hiralal and Radhaben Shah, for their constant love and inspiration to excel in all endeavors.
Contributing Authors
Globally, diabetes has reached an epidemic proportion. According to United States (US) Center for Disease control and Prevention (CDC), nearly 26 million American have diabetes and 79 million adults (more than one third adults) in US have pre-diabetes. Blood glucose higher than normal, but not high enough to be diagnosed as diabetes defines pre-diabetes, which increases individual's risk for developing type 2 diabetes, heart disease, and stroke. Incidence of diabetes in US is 8.3% in persons of all ages, but 11.3% in persons aged 20 and older. Approximately seven million people (27%) of those with diabetes are unaware that they have diabetes. If this statistical trend continues, CDC has projected that by year 2050, as many as 1 in 3 adults in US may develop diabetes. The International Diabetes Federation has estimated that in 2011, 7% adults (366 million) in the world had diabetes; and further estimated that by 2030, 8.3% (552 million) adults globally will be suffering from diabetes. It is estimated that type 2 diabetes accounts for up to 95% of all individuals with diabetes. In recent years, incidence of type 2 diabetes in youth, 10 to 16 years of age, is also increased. The sedentary lifestyle, ever increasing obesity, and longevity are main causative factors in the increased incidence of type 2 diabetes in adults and youth. The incidence of diabetes is higher in geriatric (individuals above the age of 65) population. It is estimated that in US, over one-fourth of geriatric population suffer from diabetes and nearly half have pre-diabetes. Diabetes affects all organ system in the body and its microvascular complications cause neuropathy, nephropathy, and retinopathy; whereas macrovascular complications cause peripheral vascular, cardiovascular, and cerebrovascular diseases. Diabetes complications are responsible for blindness, amputations, stroke, acute myocardial infarction, heart failure, and chronic renal failure requiring dialysis. This increase burden of diabetes and its complications has profound social and economic implications on the individual patient, family, and society. In US, yearly cost for diabetes is estimated to be $174 billion including $116 billion in direct medical care cost. Indeed, type 2 diabetes is a preventable and manageable disease and a burden of this chronic disease of epidemic proportion is an embarrassment to health care profession.
In providing care to diabetic patients, education to patient and family members is one of the most important aspects of management. The informed decisions about self-monitoring of blood glucose (SMBG), nutrition, exercise, weight control, eye and 14foot care, use of oral medications and insulin, prevention of micro- and macrovascular complications cannot be effectively managed without knowledge of diabetes. Also, factors such as desire to learn, cognitive abilities, attitudes, depression, family support, barriers to diabetes care, and cultural and ethnic background, influence the learning process. Obviously, physicians and other health care professionals play a pivotal role in providing education and care to patients with this chronic devastating disease. Diabetic patients frequently find that lifestyle changes are overwhelming and for health care providers, managing their diabetes is challenging. The Food Frequency Questionnaires (FFQ) is a tool to quickly identify patients with poor adherence to diet recommendation and poor metabolic control. This can provide information for appropriate intervention, whether for glycemic control or for managing hypertension or hyperlipidemia. FFQ can be easily completed at home by patient with help of spouse or other family members in a non-threatening environment. Health care providers can use information from FFQ in combination with other parameters such as SMBG, HbA1c, weight, blood pressure readings, lipid levels etc. and discuss with the patient attainable realistic goals for diet and overall metabolic control. Frequently, health care providers only focus on glycemic control with pharmacologic agents, while management of hypertension, hyperlipidemia, obesity, and foot hygiene is neglected in diabetic patients. It has been shown that presence of several risk factors in diabetic patients increase mortality to a greater extent at young age than a single factor. Studies have confirmed that treating hyperglycemia, hypertension, and hyperlipidemia decrease mortality. In fact, when hypertension and hyperlipidemia are well controlled in type 2 diabetic patients, the benefit of glycemic control was difficult to ascertain. The pharmacologic treatment should not distract health care providers in dealing with the factors to prevent diabetes and its complications.
In the forthcoming health care reform in USA, emphasis will be placed on prevention, outcomes, quality of care, patient's need, reducing cost, and evidence based guidelines. A new concept in the health care delivery, “Medical Home”, for management of chronic disease such as diabetes, which leverages resources and improves the outcomes while holding down the cost, will be utilized for diabetes management. The advent of electronic medical record will aid in processing of complex medical data on individual patient and help the health care provider for care coordination. The electronic data will ease in the formation of patient registries. Diabetes registry can identify which diabetic patient is in need of specific care and it will help health care provider to coordinate SMBG, nutritional, and weight loss tracking; management of hyperglycemia, hypertension, hyperlipidemia, heart failure, and depression; preventing microvascular and macrovascular complications and providing appropriate vaccinations. When most sensitive patient data are used then the diabetes registry will help prevent progression of early diabetes. The diabetes registry can identify patients who can benefit from structured yet parsimonious and cost-effective SMBG to achieve glycemic control and appropriate health care outcomes. The prevention of micro- and macrovascular complications is the arduous task for clinicians caring for diabetic patients. Once the diabetic complications 15sets in, the health care providers face some of the complex management challenges of diabetic retinopathy leading to blindness, diabetic nephropathy leading to chronic renal failure, dialysis, renal transplantation, diabetic peripheral vascular disease, and neuropathy leading to lower extremity amputations, and diabetic heart disease with or without atherosclerosis leading to coronary artery bypass surgeries and/or onerous treatment task of chronic heart failure. The aforementioned issues are expertly discussed in the exclusive chapters in this book.
Diabetes with its complications has become a multisystem and multifactorial disease. Therefore, it appears that for a physician, knowing diabetes is like knowing internal medicine, sometimes complex and puzzling. There is a vast amount of literature, often confusing and conflicting, is available on multitude of topics concerning diabetes and its complications. To write and publish another such book would be an exercise in futility. However, this book has made a sincere effort to provide new and futuristic information in diabetes management, and it is not overwhelming. The chapters in this book have made an attempt to provide unbiased and evidence-based information in a comprehensive yet concise manner to be a useful guide for practicing primary care physicians, endocrinologists, and other health care providers in their quest of providing excellent care to their diabetic patients. The authors have taken meticulous efforts to provide current practice recommendation. In many chapters, the tables and figures stipulate clear and concise guidance which can be used as ready reference material by busy practitioners. Most of the care of diabetes and steps taken to prevent its complications occurs in the institutional or private practice clinics. I sincerely hope that this book can be used as a diabetes management compendium to improve diabetes care in the clinic.
Jayendra H Shah
This book is a concerted effort of many individuals. I am indebted to all contributing authors for their hard work and for making unbiased recommendations in their chapters. They have also tried their utmost to provide an evidence based reviews to make this book unique. Without their contributions, fruition of this book would have been difficult.
I want to express my sincere gratitude to my dear wife, Saroj J Shah, MD for her constant encouragement and support. She has made many sacrifices to support my academic and administrative life and to maintain our family's harmony. She has been a ‘sounding board’ and constant source of inspiration for me.
I wish to thank Jaypee Brothers Medical Publishers (P) Ltd for publishing this book. I want to extend my special thanks to Dr. Madhu Choudhary, Senior Editor, whose persistent efforts to convince me to write and edit this book paid off. She also provided all the technical help to the contributing authors and I needed to continue writing the chapters.
I am grateful that Veterans Health Administration (VHA) and specifically Southern Arizona VA Health Care System (SAVAHCS) in Tucson, Arizona have provided me the platform to participate in making innovative changes in improving patient care as well as performing clinical research in the field of diabetes. I also wish to thank Lynn Flance MLS and Karen D Douglas MLS, the librarians at SAVAHCS for willingly helping several contributing authors and me in finding appropriate references for the chapters.
Finally, in some of the chapters, I and other authors have used clinical findings emanated from our research which was supported by the VHA and SAVAHCS Research Services.