New guidelines to identify 2 million more diabetics
ADA suggests lowering plasma-glucose standard
New guidelines released by the American Diabetes Association (ADA) could result in the identification of up to two million undiagnosed people with diabetes and provide disease management programs with a great opportunity to do what they do best: educate patients on the disease so they can prevent or delay serious complications.
The guidelines, based on a two-year review of research by an expert committee convened by the Alexandria, VA-based ADA, recommend lowering the number for diagnosis on the fasting plasma glucose test from 140 mg/dl to 126 mg/dl, which should result in identifying up to two million of the eight million undiagnosed Americans with diabetes. The new guidelines also urge testing every three years all people age 45 and over and more frequent testing of high-risk groups, such as people who are obese, have a close relative with diabetes, or are members of a high-risk ethnic group (African-American, Hispanic, Native American, Asian).
"We’ve come as close as we can in 1997 to recognizing the beginning of the disease. From a lifestyle and good health point of view, the opportunity to intervene at that point is maximum. You can really turn diabetes around and put it back to sleep for a significant number of years," says Gerald Bernstein, MD, president-elect of the ADA and associate clinical professor of medicine at Albert Einstein College of Medicine in New York. "The guidelines are critical because we know that diabetes costs the country $138 billion a year, which is about 15% of every health care dollar. All of this is preventable."
The guidelines suggest the fasting plasma glucose (FPG) test be used universally for testing and diagnosis because of its ease of administration, convenience, acceptability to patients, and lower cost compared to the other frequently used test, the oral glucose tolerance test. Research examined by the committee shows that microvascular complications of diabetes occur in people with FPG values in the low- to mid-120s. Patients with undiagnosed type II diabetes (formerly known as non-insulin-dependent diabetes) are at a significantly greater risk for heart disease, stroke, peripheral vascular disease, hypertension, and obesity.
"The problem is, we see so many people come in with very modest elevations of blood sugar who are asymptomatic, but by the time they come into our office at age 40, they have already developed significant complications," Bernstein says. "They felt so well all these years, so they never went to see a doctor. The average type II patient has probably had diabetes for 10 years at the point their blood sugar is over the old cutpoint."
The emphasis the new guidelines put on early identification and intervention is a perfect opportunity for disease state management programs to make an impact, says Christine Beebe, MS, RD, CDE, president of health care and education for the ADA and director of health and wellness at St. James Hospital and Health Centers in Chicago Heights, IL. "By intervening early with lifestyle changes like diet and exercise, we can hopefully prolong the time before patients need expensive medications and prevent the human suffering caused by complications," she says. "As a dietitian, I look at this as a real opportunity for me to play a key role in saving the company and the patient money."
Ideas to make the most of the new guidelines in your disease state management program include:
• Get patients to take diabetes seriously.
Make sure patients know their blood sugar is too high and that serious complications such as vision and kidney problems will occur if they do not take action, Bernstein says. "I analogize it to lead," he says. "If you had lead in your apartment, you’d go crazy. You’d get the mayor, the police, everybody you could to get the apartment cleaned up. Elevated blood sugar is the same thing. It’s a toxic substance."
• Provide continual reinforcement.
Tell patients frequently what will happen if they don’t make lifestyle changes, and put it in concrete terms, Bernstein says. Make sure they know about the interplay between diabetes and vascular disease, and let them know that the disease is progressing right now, even though the complications may not show up for years. "Twenty years is too far ahead for most people to think, so you have to tell them it’s starting now," Bernstein says.
Beebe adds that lifestyle changes such as diet and exercise must be monitored periodically. "You can’t just tell them to do it; you can’t change them overnight," she says.
• Encourage physicians to test high-risk patients.
Anyone in a high-risk group who is getting regular physicals probably has been tested for diabetes, but what about all those people who never get a check-up? Bernstein advises physicians to seize the opportunity to test high-risk patients anytime they come to the office, regardless of the problem that brought them in.
• Keep physicians in the loop.
Jill Helm, PharmD, director of product development for Northbrook, IL-based Caremark International, says her company’s Care Patterns disease management program for diabetes stresses communication with physicians. It’s important that the guidelines are reinforced at the provider level, she says, because if physicians don’t test more people and don’t refer patients, nothing will change. "Finding patients earlier gives more of an opportunity for programs like ours to help patients avoid complications," she says. Caremark has already provided inservices and written materials on the new guidelines for its nurse educators.
• Use specialists’ skills.
Identifying diabetes earlier gives specialists the chance to make a greater impact than ever, Beebe says. Make sure your disease management program makes maximum use of such experts as nurses, exercise physiologists, and dietitians in helping patients with weight reduction, exercise programs, and eating habits. "There is no one-dose approach to diabetes; it requires a fair amount of intervention," she says.
• Look at different intervention strategies.
Capitalize on the enhanced public awareness of diabetes brought on by the new guidelines by looking at alternative ways to help people make behavioral changes, Beebe says. Consider working with corporations on wellness programs, getting involved with the high-risk population through public health departments, and running new types of prevention programs. For example, consider hooking diabetes patients up with a cardiac rehabilitation program that can help them with an exercise plan. "We offer a membership through cardiac rehab to encourage diabetes patients to exercise. Many of our patients are obese, and they don’t want to go to a health club where people are in thongs. They feel much more comfortable in a medical setting," Beebe says. Another idea is to provide screenings at high schools and colleges, as more young people in high-risk groups are developing diabetes.
[For more information on the new diabetes guidelines, contact: American Diabetes Association, National Service Center, 1660 Duke St., Arlington, VA 22314. Telephone: (703)-549-1500.]
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