Diabetes – An Overview, By Dr. Joy Johnson
What is Diabetes?
Diabetes is a disease characterized by high levels of blood glucose. The rise in blood glucose is due to problems in the production or utilization of insulin. Insulin is a hormone produced in the pancreas and is required to convert sugar and starches into energy. Diabetes is a chronic illness requiring continuous medical care in conjunction with vigilant patient self management, to guard against acute and long-term complications. Some of the common and serious complications from this disease include heart disease, blindness, kidney failure, nerve damage and premature death.
Types of diabetes
Type 1 diabetes previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes accounts for 5-10% of all diagnose diabetes cases in the US. In Type 1 diabetes the body’s immune system destroys the cells in the body that makes insulin. This form of diabetes usually affects children and young adults and is treated by the administration of insulin. Currently no form of prevention is known. [1]
Type 2 diabetes formerly known as non-insulin dependent diabetes mellitus (NIDDM or adult-onset diabetes is more prevalent and accounts for 90-95% of all diagnosed cases. Type 2 diabetes usually occurs in adults and is characterized by the body’s inability to adequately utilize the insulin being produced. These patients are generally managed in a multi-faceted manner, with diet and nutrition, exercise, oral anti-glycemics and insulin. In the more recent years increasing number of young adults are being diagnosed with Type 2 diabetes, possibly due to decrease activity and increasing obesity. [1]
Gestational diabetes is a form of glucose intolerance diagnosed during pregnancy. Treatment is required during pregnancy to correct blood glucose levels to prevent complications in the infant. After pregnancy 5-10% of these women are often found to have Type 2 diabetes. There is also a 20-50% chance that women diagnosed with gestational diabetes will develop diabetes in the next 5-10 years. [1]
Other types of diabetes reported accounting for 1-5% may be due to genetic conditions, surgery, drugs, infections and other illnesses
Pre-diabetes is a condition in which blood glucose levels are higher than normal, but not high enough to be classified as diabetes. Persons with pre-diabetes have impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT). These persons have an increase risk of developing type II diabetes, heart disease and stroke. [1]
Diagnosis
Diabetes is usually diagnosed using a fasting plasma (component of blood) glucose test (FPG). Fasting means that nothing is consumed for at least 8 hours before the test.
Pre-Diabetes diagnosis [2]
• Impaired fasting glucose (IFG) – FPG 100-125 mg/dl
• Impaired glucose tolerance test (IGT) – 2 hr plasma glucose 140-199 mg/dl
Diabetes Diagnosis [2]
• Fasting Plasma Glucose (FPG) greater than 127mg/dl or
• Symptoms of high blood glucose, such as increase thirst and increase urination and a non-fasting plasma glucose greater than 200mg/dl or
• 2-hr plasma glucose greater than 200mg/dl during an oral glucose tolerance test.
Prevalence
The Center for Disease Control (CDC) reports in 2007 that in the United States 23.6 million people, 7.8% of the population, have diabetes. Of those 17.9 million are diagnosed and 5.7 million remain undiagnosed. [2]
It is also estimated that 57 million Americans adults age 20 years and older have IFG (impaired fasting glucose) which is pre-diabetes. The last estimate for persons less than 20 years old was compiled in 1999- and reported as 7% of the adolescent population. We know based on reports from Healthy People 2010 that that number is rising but the data is not yet available. [2,3]
Prevalence by ethnicity shows the highest rate reported in American Indians/Alaska natives (16.5%) followed by non-Hispanic Blacks (11.8%), Hispanics (10.4%), Asian Americans (7.5%) and non-Hispanic whites (6.6%). [2,3]
In 2006 diabetes was the seventh leading cause of death in the US and 800,000 new cases are being diagnosed each year. In 2007 the direct and indirect costs from the disease were estimated to be $174 billion. Direct medical costs were reported at $116 billion, with indirect cost (disability, work loss, premature death) estimated at $58 billion. [2]
Risk Factors for Diabetes [4]
• Overweight
• Physical inactivity
• First-degree relative (mother, father, sibling) with diabetes
• Member of high risk ethnic population-(e.g. African American, Latino, Native American, Asian American, Pacific Islander)
• Hypertension (> 140/90)
• High Cholesterol
• History of cardiovascular disease
• Women who had a baby > 9lbs or was diagnosed with gestational diabetes
Symptoms
• Increase urination
• Increase thirst
• Weight loss
Complications of Diabetes
Major complications in the US from the disease are:
• Heart Disease and Stroke – report from 2004 shows there is a 2-4 time higher death rate from heart disease, and risk of stroke in adults diagnosed with diabetes.
• High Blood Pressure – 75% of adults with diabetes in 2003-2004 had Blood pressure greater than the recommended range or was using medications to treat hypertension
• Blindness- 12,000-24,000 new case of blindness in the US is secondary to diabetic retinopathy, which makes diabetes the leading cause of blindness in adults.
• Kidney Disease –in 2005 diabetes was reported to be leading cause of kidney failure, making up 44% of all new cases that year.
• Nervous System Disease – 60-70% of persons with diabetes have some form of nerve system damage, resulting in impaired sensation in hands and feet. Diabetic nerve damage is one of the major causes for lower-limb amputations.
• Amputations – In 2004, approximately 71,000 lower-limb amputations were performed on diabetics not involved in some traumatic accident.
• Dental Disease – approximately one-third of persons with diabetes have severe periodontal (gum) disease.
• Other – persons with diabetes are susceptible to other illnesses.
Treatment and Prevention of Complications
Diabetes can lead to debilitating complications affecting many different systems in the body. However the incidences of these complications can be lowered by patients working closely in conjunction with their health care providers to control blood glucose levels, blood pressure and blood lipids, and by obtaining preventive care in a timely consistent manner.
• Type 1 diabetics must take insulin by injection for survival
• Type 2 diabetics are usually controlled with diet, exercise and oral medication. Some Type 2 diabetics may require insulin injections. HBa1c goal is <7%. [2]
• Most diabetics will need medication to control their Blood pressure to a treatment goal of 130/80, as well as cholesterol. Lipid treatment goal for adults with diabetes is LDL cholesterol <100mg/dl.
– Studies have shown that Blood pressure controls reduces the risk of cardiovascular disease by 33-50% and risk of kidney, eye and nerve damage by approximately 33%.
– Studies have also shown that improved control of LDL cholesterol can reduce cardiovascular complications by 20-50%. [1,2]
• A key step in treatment that leads to improved outcome and quality of life is self-management. Self-management, allows the individual to be an active participant in the management of the disease. Focus is on self-care behaviors such as healthy eating, exercise, compliance and monitoring of blood glucose. These patients gain insight and education about the disease, to assist them in making intelligent choices in the self-management of the disease and associated complications.
• Patients are required to have routine eye, feet and kidney examinations at least annually, in an effort to reduce the incidences of complications through early detection. [2]
• Obese persons with pre-diabetes or diabetes are encouraged to lose weight and increase activity.
– In one large study it was found that lifestyle changes reduced development of the disease by 58%. Lifestyle changes are usually more cost-effective than medication. [2]
• Diabetics are also encouraged to obtain influenza and pneumococcal vaccines.
It is reported that persons with diabetes are more likely to die with pneumonia and influenza than people who do not have the disease. [1,2]
Diabetes is a chronic debilitating disease affecting a very large portion of the population. The disease can result in serious complications, adding significant burden to our already heavily utilized health care systems, as well as families.
In a number of studies, including The Asheville Project it has been shown that the medical burden from the disease can be reduced and outcomes and quality of life improved if the disease is vigilantly monitored. [5] This is highly dependent on the individuals, working in conjunction with their health care providers to ensure appropriate blood glucose levels are achieved, and preventive measures are performed on a routine basis. This requires compliance with medication regimen as well as diet restrictions and increase physical activity, in addition to ensuring that annual eye exams and other screening are done. With appropriate monitoring in place, complications can be reduced and quality of life can improve.
Additional information on diabetes can be found at:
www.cdc/gov/diabetes
www.diabetes.org
www.ndep.nih.gov/diabetes/prev/prevention.htm
References:
1. National Diabetes Statistics, 2007. Available at http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf accessed August, September 2008
2. Executive Summary: Standards of Medical care in Diabetes-2008. Available at http://care.diabetesjournals.org/cgi/reprint/31/supplement_1/S5, accessed August 2008
3. Healthy People 2010 and Steps to a Healthier US: Leading Prevention. Available as: www.healthypeople.gov accessed August 2008.
4. Fagan SC, Hess DC. Stroke, in DePiro JT, Talbert RL etal. Pharmacotherapy: A Pathophysiologic Approach. 6th ed New York, NY McGraw-Hill; 2005:415427
5. Cranor C, Bunting B, Christensen. The Asheville Project: Long-Term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc 2003;43:2:173-189
Joy Johnson Consulting LLC based in Oakland, NJ, provides consultant pharmacy services to Long term care facilities as well as to persons in the community managing complicated drug regimen. Dr. Joy Johnson is a certified geriatric pharmacist and has been practicing pharmacy for over 20years. She can be contacted at jjconsult@optimum.net or 201-651-1677.