Foreword | Diabetes Management in Primary Care

Authors: Unger, Jeff

Title: Diabetes Management in the Primary Care Setting, 1st Edition

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Foreword

Diabetes is epidemic in the United States and is clearly one of the most common problems seen in primary care, affecting 22% of everyone over 65 years of age. Nearly 40% of the remainder have impaired fasting glucose (prediabetes), defined as a fasting blood glucose of 100 to 126 mg/dL, which increases the risk of heart attack and stroke even if type 2 diabetes does not develop. Overall, more than 35% of adults in the United States have diabetes or prediabetes. The prevalence of diabetes is twice as high in Mexican Americans and blacks and affects 50% of Pima Indians in Arizona, the highest of any group in the world. Interestingly, Pima Indians outside the United States have no increase, probably because of the high incidence of obesity and sedentary lifestyle in the United States. By the time the diagnosis of diabetes is made in adults, 50% already have coronary artery disease, 20% have retinopathy, and 20% have microalbuminuria.

Of the many chronic diseases encountered in primary care, diabetes requires more self-management than the others. Not only must the patient adhere to a special diet, but those on insulin are always adjusting their dose and following blood sugars closely.

Proper education of a new diabetic requires considerable time, time that is often not adequately reimbursed. It thus takes a dedicated health professional to manage these patients properly.

Dr. Unger has been there, done that. His expertise at managing diabetes has been nurtured by a passionate desire to improve the lives of all individuals afflicted with diabetes. At the age of 36, Dr. Unger was diagnosed as having diabetes. He quickly realized that few of his peers were able to provide him with any meaningful advice regarding diabetes self-management. Despite becoming more symptomatic, Dr. Unger had to beg another physician to start him on insulin therapy. After transitioning from multiple daily injections to insulin pump therapy with the assistance of an endocrinologist, Dr. Unger began to develop programs designed to instruct primary care physicians in the lost art of diabetes management.

As Dr. Unger so astutely discusses in his book, we, the caregivers, blame our patients for their inability to maintain control of their blood sugars. We refer to them as being noncompliant. These patients need to lose more weight, take better care of themselves, and eat the right foods! Before we criticize our patients with diabetes, let's first consider how difficult it must be for them to function without a pancreas. Their pancreas has now been replaced by their brain. They have to think like a pancreas. However, they have the inalienable right to maintain their glycemic control, lipid levels, and blood pressures as close to normal as possible. They desperately need our help, not our criticism, to guide them successfully toward these attainable goals.

This book covers all aspects of diabetes management, from metabolic syndrome to gestational diabetes, from those patients requiring oral agents to those who may benefit from novel agents such as the DPP-IV inhibitors, inhaled insulin, or incretin mimetics. When should insulin therapy be initiated in a patient with type 2 diabetes? Should the oral agents be continued while the patient is on insulin therapy? Perhaps you have a patient in your practice who might benefit from using an insulin pump. How would you transition a patient from multiple injections to insulin pump therapy? As a primary care physician himself, Dr. Unger provides us with a clear, concise, practical, and comprehensive approach to diabetes management. After reading this book, a family doctor will be able to diagnose polycystic ovary syndrome in a patient and treat it while accurately assessing another patient with diabetic peripheral neuropathic pain. Most important, our communication and educational skills will be enhanced as we journey into the minds, hearts, and souls of our patients with diabetes.

So far, those of us in primary care have not been doing a very good job managing patients with diabetes. For example, the National Health and Nutrition Examination Survey (NHANES), conducted regularly by the Centers for Disease Control and Prevention (CDC), showed that despite having more drugs available to fight the disease we are doing a worse job than a decade ago. In 1994, we were able to get 44.5% of our patients to a goal A1C of 7%, but in 2000, only 35.8% of them. Not only that, but almost one fifth of patients with diabetes still have an A1C of 10% or greater. Our goal should be to get the patient's A1C as close as possible to the normal of 4% to 6%.

It is clear from numerous studies that the complications of coronary artery disease, blindness, amputations, and kidney failure are significantly diminished when therapy is aggressive. We have been accused of therapeutic inertia, and unfortunately the data support that view. This inertia is especially true when it comes to using insulin to control the disease. Too often we use the needle as a threat to ensure adherence to our recommendations by saying, If you do not stick to your diet and exercise program I will have to start you on insulin. Since the needle is no longer a significant problem with 31-gauge needles in pens, inhaled insulin is now available, and oral insulins are just around the corner, we must educate the patient early on that normal progression of the disease will require insulin replacement at some future date, just as a failing thyroid gland requires thyroid supplementation.

Too little attention is paid to the emotional toll that diabetes entails. The stress of having to be constantly vigilant in managing one's activity, diet, and medication, along with the guilt feelings that may follow worsening of the condition, demands that we constantly assess how the patient is dealing emotionally with his or her disease. The fact that depression is twice as common in diabetics and that the two conditions together significantly increase the risk of mortality, especially from coronary heart disease, means that we must be vigilant in monitoring these patients for depression and/or burnout. Emotional distress results in poor motivation for self-care, less adherence to treatment, and a sense of powerlessness about the disease. There is fear of long-term complications and frustration from having to constantly deal with this devastating chronic disease. We expect patients to be anxious about having cancer and what it means to their quality of life, but how often do we give the same attention and support to those equally worried about their future with diabetes.

In the Diabetes, Attitudes, Wishes, and Needs (DAWN) study conducted in 13 countries, up to two thirds of patients reported having negative emotional reactions upon learning that they had diabetes. These included feelings of guilt for having developed the disease in the first place. They also felt frustrated because their best efforts at self-management did not always yield the desired result.

All of this is presented much more thoroughly and effectively in the pages that follow. It is an honor and a privilege to be associated with a text of this quality and one of such obvious practical value to all healthcare professionals, whether family physician, internist, family nurse practitioner, physicians assistant, or office nurse.

Robert E. Rakel MD

Professor of Family Medicine

Baylor College of Medicine, Houston, Texas