Download The Critical Role of the Practitioner in Diabetes Mellitus Treatment

NHMA – NATIONAL HISPANIC
MEDICAL ASSOCIATION
NHMA 16TH Annual Conference
Innovations that Improve the Health of Hispanics,
Families and Communities
Dinner Plenary – The Prevalence of Diabetes in
Hispanic Populations
Washington, D.C.
April 27, 2012
Contents
KATHERINE FLORES, MD – CHAIRWOMEN, NHMA .................................... 1
THE CRITICAL ROLE OF THE PRACTITIONER IN DIABETES MELLITUS
TREATMENT MANAGEMENT AND CONTROL IN THE HISPANIC/LATINO
POPULATION - CARLOS CAMPOS, MD, MPH ................................................ 5
DIABETES MELLITUS PATIENT SELF MANAGEMENT - JOEL ZONSZEIN,
MD, CDE, FACE, FACP ..................................................................................... 18
NEW EMERGING TRENDS IN CARE FOR DIABETES MELLITUS
TREATMENT, MODELS OF CARE – ANTHONY J. CANNON, M D ............... 29
Q & A.................................................................................................................. 43
Katherine Flores, MD – Chairwomen, NHMA
[START NHMA_4.27_Dinner_Plenary.mp3]
KATHERINE FLORES, MD: Welcome to this evening’s event. We
appreciate that you took time to come out and listen to an
amazing group of physicians speaking to you tonight on
diabetes. They asked me to ask you how many of you are
students? First of all, how many are undergraduate
students? Yeah, undergraduate students.
[Applause]
Welcome.
How many of you are medical students?
[Applause]
Yeah, medical students.
How many of you are residents?
[Applause]
Yeah, residents. And how many of you are non-resident MDs?
Yeah, old people.
[Applause]
No, just teasing.
[Laughter]
Just teasing. Anyway, and how many of you are physician
assistants? Yeah, physician assistants.
[Applause]
And how many of you are nurses?
Yeah, nurses.
[Applauses]
And how many of you are something other than those things?
Whoa, and you are the bulk.
[Applause]
Well, welcome to everybody. We do appreciate that you came
out like I said. Then I need to remind people that we do
have continuing medical education, and there are, you
signed in, and there will be an evaluation at the end.
There also is going to be a pre- and a post test, and
that’s why you have your little deely boppers, yes, that’s
NHMA – NATIONAL HISPANIC MEDICAL ASSOCIATION
NHMA 16th Annual Conference
April 27, 2012
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what, okay, what do you call them?
MALE VOICE:
ARS.
DR. FLORES: ARS. Okay. Whatever, they’re our deely bopper.
And what you’re going to do is when we get there, we will
be asking the questions, you will push your little deely
bopper and that’s the pre-test and then you’ll listen to
these three wonderful presentations and then we will do a
post-test. I do need to let you know that you need to do
well on the post-test or we don’t get funding for this.
Yes. And I'm not going to help you cheat, so you need to
do well on your own. That means you’ve got to listen. I
was telling the guys, I said you know, they’re going to
[speak in Spanish] they’re going to fall asleep, because
it’s time to go to bed. But they said no, that you
wouldn’t do that, so let’s hope not. The other thing I
needed to share is that each one of the presenters are
going to do disclosures. They will tell you if they have
anything to disclose prior to their actual talk. And I
just want to give the few people that are still up a minute
to be able to sit down. Dies everybody have the ARS
instrument in front of them? Okay, good. I just want to
be sure nobody’s missing. There are too seats here,
gentlemen. Okay. Back to your old seats, without your
beer to begin with? Yeah. Okay.
MALE VOICE:
- - .
DR. FLORES: Make sure he’s 21 too. He doesn’t look it but I
won’t say anything. Okay. I think almost everybody is
sitting down. Do you guys need a place to sit? You have a
spot? I don’t want you out in the hallway. We’ve got
chairs up here. Please sit up here. We don’t want anybody
having to sit outside. And there’s a chair, an open chair
over here with a table. We have an open chair over here.
So there are several open chairs if you want to sit down,
okay? Right over here, so please, and one over there too.
So there’s three. Okay, we don’t want anybody to have to
be out in the hallway, we don’t want anybody to leave.
Going to close the doors, you’re stuck with us. No, okay.
So we are going to go ahead and get started. I think I did
all of the requirements. Yes, okay. Well, I have the
pleasure unexpectedly for the last hour and a half of
getting to know these three gentlemen because we were stuck
waiting. And they are actually very, very nice men. And
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NHMA 16th Annual Conference
April 27, 2012
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they’re very accomplished providers and very bright in
their areas of diabetes, what they’re going to speak about.
There are actually open seats over here with a table. You
don’t need to go... okay.
So our first speaker is Dr. Carlos Campos. Dr. Campos was
born and raised in—I did this at the plenary, didn’t I?
New Braunfels, Texas, where he attended the local public
schools. He received an Associates of Arts degree from
Schreiner University, and a Bachelor’s degree from Baylor
University. I know we have Baylor in the house. Who’s
from Baylor? There you go. Okay. Followed by medical
school at Baylor College of Medicine. In addition, Dr.
Campos also received a Master’s of Public Health degree
from the University of Texas School of Public Health. He
completed his family medicine residency at the Bexar County
Hospital District in, well, we won’t say when. He has been
in a private family medicine practice in New Braunfels,
Texas since 1984 where he has done the gamut of family
medicine from delivering babies to seeing patients in the
nursing home. Presently, he concentrates in disease states
related to type 2 diabetes mellitus, and I'm doing the
wrong thing, but I’ll go back.
Dr. Campos was appointed by the governor to the Texas state
of medical examiners and served from 1993 to 1999. In
1993, he was also the Chief of Staff of the local New
Braunfels Hospital, McKenna Memorial Hospital. He also
serves as a clinical adjunct professor for the Department
of Family Medicine at the UT Health Science Center in San
Antonio. He has been active in the community both locally
and regionally. He served on the local school board as its
Vice President, and was President of the Alamo Chapter of
the American Diabetes Association. In 2000, Dr. Campos
established the Institute for Public Health and Education
Research Incorporated or TIPHER, a non-profit corporation.
Dr. Campos now serves as Executive Director for TIPHER,
whose mission is to improve the quality of life by
addressing public health needs and critical education
issues. In 2011, Dr. Campos became the Medical Director
for Resolute Health Center for Wellbeing Diabetic Center.
So what we’re going to do before he comes up is we’re going
to do the ARS, but before we do that, if anybody would like
a seat, again, can people raise their hand where there are
empty slots. There’s one in the very front row. There is
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April 27, 2012
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one over there. Any other open seats? Okay. Students,
come on in. You’re going to take care of them, I don't
have to... okay. Okay. So we’re going to, if you can each
pick up your ARS apparati and I will read the questions to
you. That’s part of the thing, I’ve got to read.
A principal of a predominantly Latino medical school is
concerned about the apparent rise in the number, I'm sorry,
Latino middle school, is concerned about the apparent rise
in the number of obese children at her school. She has
heard the reports in the media lately about the increasing
incidence of type 2 diabetes in overweight children. So
she contacts the local HCP for recommendations. Which of
the following is the most appropriate recommendation to
prevent diabetes in the children? A) Organize a school
assembly with presentations by a dialysis nurse and
patient; B) Encourage daily physical education and modify
cafeteria food choices; C) Write a letter to the parents of
the children linking obesity and diabetes; or D) Offer a
plasma glucose screening of parents at the school. Please
vote now, and you have eight seconds.
[Music]
We’re not supposed to have the answers. The next time we
won’t have the answer. That was just a freebie.
The second question, an overweight 11-year old Hispanic boy
with type 2 diabetes presents to the registered dietician
for meal planning. His mother and father accompany him.
Both are obese and have type 2 diabetes. Which of the
following is the most appropriate advice for this patient?
A) Avoid eating fast food; B) Eliminate high fat calorie
dense foods; C) Get involved in a soccer, basketball, or
baseball league; or D) Aim for at least 60 minutes of
moderate intensity, physical activity daily. Please vote
now.
[Music]
So with that, could you please welcome Dr. Carlos Campos.
[Applause]
Mind that we are being videotaped, just so you know that.
[Break in recording]
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NHMA 16th Annual Conference
April 27, 2012
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The Critical Role of the Practitioner in Diabetes
Mellitus Treatment Management and Control in the
Hispanic/Latino Population - Carlos Campos, MD, MPH
DR. CARLOS CAMPOS: —that I got today was, The Critical Role of
the Practitioner in Diabetes Mellitus Treatment Management
and Control in the Hispanic/Latino Population. And I
looked at my speakers that are going to come after me, and
I looked at their slides, and they’re going to talk about
guidelines and studies and emerging, new emerging medicines
that are coming out, and that’s going to be great, and the
slides are great, you guys are going to really enjoy their
talk, but what I wanted to do was to focus on something
different because the critical role of the practitioner is
critical because we have a critical problem in our
community. And that’s the ever rising epidemic that we see
in diabetes. And what I wanted to do was to really focus
on the role that we have to do, not only, we’re going to
talk about what we need to do in our clinics when we see
our patients individually, but what do we do outside the
clinic? Because if we’re really going to look at our
patients and look at them from a holistic standpoint, we
have to do more than just being doctors, practitioners,
whether you’re a PA or nurse practitioner or nurse,
whatever. We have to do more because soon we’re going to
have this avalanche of patients with diabetes in our
community, in our Latino community. We know for example,
you know the stats, we know that people that are born after
the year 2000, their risk of having diabetes is what? One
in two. In the ethnic minorities. So if you’re a Hispanic
child that was born after the year 2000, your risk of
having type 2 diabetes is going to be one in two. Is that
incredible? And so those are the kind of issues that we’re
going to have, and we’re going to as practitioners, we’re
going to have to do more.
So I want to tell you a little bit about myself. I think
Dr. Flores went through that and you’re right, it’s Bayer
[phonetic] County, not Bexar [phonetic], and it’s Tee-pher
[phonetic], but that’s Texas, California... we’re sort of a
different country in Texas, but it was good to see so many
students and people from Texas here. How many people are
from Texas?
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NHMA 16th Annual Conference
April 27, 2012
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[Applause]
We’ve got the great state of Texas well represented here.
And I wanted to tell you that when I started practice, I
did a variety of different things but I quickly realized
that I was sending people to diabetic education and they
weren’t going. You know why? Because they couldn’t afford
it. I mean it cost what, $300, $400 when the hospital
bills that. So I said, why don’t we start a non-profit
organization where we can do free diabetic education, and
so we did. We stared TIPHER, the Institute for Public
Health and Education Research about 12 years ago, and since
then, that has flourished into the west side community
centers, about $1 million community center that we built.
I it we have a soup kitchen, we have prediabetic education
classes, we have ESL classes, GD classes, health literacy
classes, citizenship classes, and that has absolutely grown
because that’s where the need was. And so that has
evolved, and what I really learned that we have to do more
than just practice in the office, and that’s what I want to
talk about today.
Let
I'm
for
any
me just tell you about my disclosures. Those are it.
the consultant and speaker and on the speaker bureau
those companies. There’s nothing here that there’s not
medicines that I'm going to be promoting here today,
Let’s look now at the geographic distribution of the
Hispanic and Latino population of the U.S. You guys have
been to many lectures here today and I'm sure they’ve
probably shown you this slide, and the darker the blue, the
darker is where the Latinos... what was that? The darker
the blue, the heavier the concentration in Latinos. You
would think that we’re right next to Mexico, right? So
that makes sense. And you can see it’s mainly in the
Southwest here, but we’re going all the way up to
Washington, and in fact a couple of years ago I was asked
to give a talk at Wake Forest because I wrote this paper on
addressing cultural barriers and taking care of Hispanics.
And I said why do you want me to come to Wake Forest to
talk about this? They said, Dr. Campos, 15 years ago we
didn’t have any Hispanics in our community, and now it’s
absolutely exploded. And then you can see, well, obviously
in Florida, is where our Cuban brothers are and sisters are
and then up in northeast we have mainly our Puerto Rican
friends. This is what we see, and we know that as we go
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on, the next 50 years, this map will bleed blue ac ross the
entire United States.
So let’s look at the diversity within the Hispanic/Latino
community and when you look at this, you’ll see that we
have people of Mexican descent. Just full disclosure, I am
of that tribe. Both my parents, my grandparents were from
the Monterrey area. Puerto Rican, Cuban, Dominica
Republic, Central America, South America and other. But
still, it shouldn't surprise you that 64% of Latinos in
this country are of Mexican descent. And it makes sense
just because we’re sitting next to that country. I was
sharing this with some of my Puerto Rican friends from New
York, and they said, no way, no way. And then you know
what I said? I said, you guys are just louters [phonetic],
is what it is. That’s what it is.
[Laughter]
But it’s true, isn’t it? But when we look at the projected
increase, now I’ve got to let somebody else talk, so let me
go on through this because as one of my patients says,
that’s another Oprah, we can do another Oprah on that one.
When we look at projected increases in the United States,
population with a diagnosis of diabetes by ethnicity, we
see a population that has a propensity or a proclivity to
beta-cell failure when you expose it to insulin resistance.
And so we know that in the year 2020, that the Latino
population will increase by 120% with that diagnosis.
So what’s the role of the practitioner? And what I want to
do today in this 29 minutes that I have is submit to you
that the role of the practitioner is to become that
physician champion. To become that health care provider
champion in addressing this issue that we have in our
community. As we become that champion, we become the
champion of what? And these are the four things that I
want to talk about today. We need to be the health care
provider champion in metabolic syndrome, with child obesity
issues in our community, whatever corner of university you
come from. Cultural competent issues, and I know there
have been maybe some lectures on cultural competence here
during this conference. Want to talk about diabetes self
management issues. We need to become these health care
champions in that, and community involvement. And to be
involved in our community and I’ll talk about some of those
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April 27, 2012
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aspects as we go through that.
Let’s first take the issue with the type 2 diabetes in
children. We know the rate of type 2 diabetes is growing
fast, the fastest in ethnic minorities in Mexican
Americans, African Americans, Native Americans. Early
intervention is critical to the prevention and
complications and sky rocketing health cost. We know that.
And what do we have a need for? We have a need for
education in schools, an increase I should say physician
awareness. This particular problem. So if you look at
what the world look like in the 1900s, I was talking to
Tony, excuse me, your name is now going to be Antonio
Cannon [phonetic], Tony. Not Anthony Cannon. Today it’s
going to be Antonio Cannon.
But we were talking about
that, in Banting and Best in January 1922, gave the child
in Toronto the first insulin injection, 90 years ago. And
this was the face of diabetes at the turn of the century.
This was mainly European white background. Now we see type
1 in ethnic minorities, but mainly European white, and this
is what we saw. So what happened? It was found in Canada,
went to Denmark in the Scandinavian countries because
that’s where the big problems were.
So this child looks like she’s coming out of Dachau, right,
concentration camp, because that was type 1. That was the
problem. This is what the problem is in the 21st century.
This is a picture that was lent to me by a friend of mine
name Stephen Ponder [phonetic], I don’t know if any of you
guys know him, he’s a pediatric endocrinologist, excellent
guy. And you can see the state of Texas back there. This
was when he was in Corpus Christi, but this is a child
who’s almost 12 years old, weight 350 in. As Tony said,
about the only thing I could help him now is probably some
bariatric surgery maybe. But you can think about the
issues that you have, but you know what I also think about?
You can think about his mother saying, come on, mijito que
chulita - - . Those are the kind of problems that we have.
And those are the things that we’re going to have to
change. That’s the epidemic that we see today.
These are the other things that we see. This is, I can’t
tell you how many times patients come to my office and say,
Dr. Campos, I'm trying to scrub that dir off her neck. And
I said, that’s not dirt. That’s acanthosis nigricans.
These are skin changes that we’re going to see with insulin
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April 27, 2012
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resistance. These are problems that we’re going to see and
these are things that we have to be aware of and even begin
to screen and I know that a lot of schools are doing that.
So problems with insulin resistance is something that we’ll
get to in just a little bit, but the problem with obesity
is going to be something that is absolutely is going to
actually cripple us. And this was a study that was done
alms ten years ago that talked about the relationship with
watching TV, and obesity and diabetes. So you see the
relative risk goes up, the more your hours of watching TV
or what we call now screen time. You can see that for
every two hours of this particular study, watching TV, your
obesity rates went up by 23%, and your diabetes incidence
went up by 13%. And so one of the things we often tell our
parents is get that TV out of the room. How many kids do
you know that have TVs in their rooms? So get that TV out
of there. Because number one, they need to do their
homework, and we don’t know what they’re watching after
they close that door. And so this is a problem.
The other day I was at one of the elementary schools and
the place was packed, and so then I started talking to one
side of the room and the other side of the room. And I said
I want to go through 5-2-1-0, and I had one side of the
room go 5-2-1-0, the other side of the room they were kind
of competing back and forth with each other, and I said,
now what does that mean? I want you all to remember 5-2-10. We want you to have kids at least five servings of
fruits and vegetables every day, two hour limit of screen
time, TV or computers. That will be difficult, do you
think? Yeah? One hour of moderate intensity physical
activity. Was that one of your questions? Okay. And zero
soda waters. We call that liquid candy in my clinic, in my
office. That’s just basically liquid candy, soda waters,
people in the Northeast might call it soda pop, whatever.
That’s just liquid candy. So those are the things. This
is a principle of 5-2-1-0 and that’s what our kids in
school need to learn.
So one of the things that we did as I started this nonprofit, we built this community center because we wanted
that community center to be a hub of things we wanted to
do. Then about a year ago, we started Resolute Health
where we developed a Center for Wellbeing. You noticed we
didn’t call it the Diabetes Center, we called it Center for
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April 27, 2012
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Wellbeing. And one of the first community things we did
was we developed a community project that we teamed up with
the local school district and others to bring fourth and
fifth graders together with seniors to grow healthy foods.
Together they cultivated, harvest, cooked, baked, a nd can
some of whatever was grown. And what was the goal? To
mutually benefit the two generations by providing positive
role models and promoting movement, nutrition, healthy
lifestyles for all involved. So it was intergenerational
project. And so we called it So Healthy. And it works with
our local school district, Comal is the county where I live
in, and we had interactive cooking classes, nutritional
classes for the kids in that area.
This is a picture of some of the kid in the areas where our
sort of volunteer people who were retired helped the kids
grow, and it’s amazing, there were some kids had never an
asparagus in their life. Had never eaten an asparagus in
their life. Or squash in their life. And it was a
tremendous project that really helped and I think both
generations. In October 2010 the Texas Department of State
and Health Services awarded this Resolute Health as well as
the Comal School District, this award for Texas schools,
again, aiming to try to improve habits and having two
different generations kind of work together.
One of the things we’re also going to have starting
September, September 15th, is a Comal Health Summit where
we do a walk run through historic New Brownville, we have
diabetes nutritional fitness centers, educational sessions
for everyone in English and Spanish. We’re also going to
do community assessment, ask the community, what do you
think we need in our community to make us a healthier
community. But these are the sort of things that we have
to do outside our offices. Outside our clinics. If we’re
going to stem the tide of the problem that we see in
diabetes in our Hispanic community.
So about six, seven years ago, one of my good friends who
is a pediatrician came to me and said, Carlos, I'm seeing
these kids now with type 2 diabetes that are 13, 14 years
old and I’ve never been trained to take care of type 2
diabetes. I don’t know how to use some of the drugs. I
really don’t know what to do. What do we do with these
kids? And I said, you know what, why don’t we start a
pediatric symposium. Pediatric obesity symposium. And now
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April 27, 2012
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we’ve been in our seventh year and it really has expanded
and so what we’re going to do on the 15th is also include
the pediatric obesity symposium with that, programs,
interventions, some tools proven to improve pediatric
obesity will be discussed. Attendees may include health
care providers, school nurses, community leaders, everybody
that we can to yell from the mountain top, this is a
problem that we have in our community.
So this is a quick question, because this is a question
that we often ask the kids and parents that we see in our
office or community center or at our Resolute Center for
Well Being, and it says, how many equivalent teaspoons of
sugar are in one inch, excuse, in one ten inch flour
tortilla? A) Would be hardly any, don’t use the ARS, it’s
not on there. A) Hardly any; B) 1 or 2 teaspoons; C) Four
to five; D) 10 – 11; and E) 12 to 13. Anybody give a
guess, what do you think?
PARTICIPANTS:
DR. CAMPOS:
FEMALE VOICE:
C.
C.
C.
DR. CAMPOS: C. And actually, remember these are Texas
tortillas, okay> No, you're right, because they can be
small or they can be big or they can be thicker, but on the
average, we tell people that a can of Coke has about ten
teaspoons of sugar, and so we haven't... if you have a 10
inch flour tortilla, and say you get up in the morning and
you just slam down two breakfast tacos, we’re talking about
20 teaspoons of sugar, not even talking about what’s in the
tortilla. We’re just talking about the tortilla itself.
So making these small changes, making these small changes
makes all the difference in the world to patients.
So this is just the picture that kind of shows that. These
are the sort of things that develop insulin resistance and
this is just a slide that looks at the prevalence of
insulin resistance in the U.S. when you look at nonHispanic whites, that’s the proper term that we use in San
Antonio, non-Hispanic white, African-American, Mexican
Americans and others. And you can see we have a population
that now has this proclivity to develop insulin resistance,
and beta-cell failure along with that. The rate of
metabolic syndrome that are also elevated in Mexican
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April 27, 2012
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Americans, these are some data that are compared to the
Framingham study, from Framingham, Massachusetts, and you
can see in the San Antonio Heart Study, as well as the
NHANES study shows that the Mexican Americans have elevated
levels and rates of metabolic syndrome.
So when you look at metabolic syndrome for the students
that are here, you look at several of the components that
make up metabolic syndrome, abdominal obesity, low HDL,
high triglycerides, high blood pressure, and that
prediabetes. That prediabetes remember is that diabetes
between 100 and 125 mg/dL now. And so our whole goal is to
try to catch them early even before they come prediabetic
and try to keep them there, or try to move them and try to
normalize their physiology.
So childhood obesity, metabolic syndrome, those are issues
that we’re going to have to take on in our community and we
have to do it more than just do it in our offices. The
other issue here is cultural competency. Cultural
competency, I know Dr. Zonszein is going to be talking a
bit about that, but let me just say that I’m going to
introduce the concept of cultural competency. There are
some challenges in managing diabetes in the Latino patients
and obviously some of those cultural issues are cultural
barriers, health beliefs, dietary preferences, cultural
aspects and poor access to treatment and services because
we know that what 47% of Latinos in this country don’t have
health insurance and access to health care.
And this is a paper that I wrote about five, six years ago
that looked about at the Hispanic cultural values that can
impact the patient provider relationship. And things are
that we have to, as we approach our patients, those are
issues, the values of kindness, of formal friendliness, of
respect, of loyalty, the extended family and the concept at
least I know in Central South Texas of fatalism. You could
almost see it, we need to get this diabetes under control.
They said, no, Dr. Campos, you know what, that’s just the
way God want it. You could almost sort of see them on the
cross, no, that’s just the way God wanted. I said, no, God
didn’t want it like that. God wanted you to have an
abundant life. He wanted to, excuse me, Tony, I'm going to
start preaching here, you’ve got to hold me back here.
It’s not what God wanted you to do. But it’s sort of tat
fatalistic view of life, and we have to change that. So
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cultural competency is an issue that we’re going to have to
take on. I really hope the National Hispanic Medical
Association in the next year really picks up the whole
mantle of cultural competency because we also have to not
only educate the physicians of our ethnic background but of
other ethnic background, how to approach our patients. And
in doing do, we have to establish trust, we have to improve
communications, overcome our language barrier, improve
nutritional management, be sensitive to the financial
concerns that our patients may have, consider the family
dynamics, and modify our office environment.
Often, I remember when I first started practice, I was in
with three or four of the doctors and one day they called
me in, and they said, you know what, your patients come in
and they’re using all our toilet paper. And all our paper
towels. And I said, well, I mean they bring in their
families with them. And that’s what we want them to do.
You walk into their rooms and they would have just one
chair, and you’d have to have three or four chairs in the
exam room so that they can bring everybody in, because you
have to listen to everyone’s help to try to approach these
particular issues.
The other issue I want to talk about is self management,
and I want to underscore self because when I was on the
school board and we looked at success literatures and you
students here, you’re successful anyway, but when you look
at success, when you look at the success literature, what
do you think was the common thread on all these kids that
were successful? Parental involvement, exactly. Parents
that would come home and say, you guys done your homework
yet? Why are you watching that TV, let’s turn that thing
down. See, it just kind of rolled off my tongue, I did it
so many times in my house. It’s easy for me to do. But
the same thing with our patients, involved patients show
improved health behavior status, fewer hospitalizations,
and shorter stays, we know that. Educated patients can
decide on to control their risk factors to become involved
in health care, but do you know what the problem is? Only
40% of patients are referred for diabetic education. What
we do know for those of us as authority figures, we have to
refer people for diabetic education. You know why?
Because it’s a team approach. How many minutes do we spend
in the office or in an exam room in this country for
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patients, on the average?
FEMALE VOICE:
Ten to 15.
DR. CAMPOS: Ten to 15 minutes, oh my God, where are you from?
Usually about seven and nine minutes. It’s what we do. In
this country, that’s the average time a doctor spends with
or providers spends with the patient. So we cannot teach
carb counting. We cannot teach, initiate insulin in that
short period of time, so we need that help. And in our
community, the reason we started our non-profit is we
didn’t have a diabetic education program. The one that we
did was so expensive people wouldn’t go to. And so we
started our own. And so that’s the important thing what I
want you to take away.
And this is kind of radical. I added this at the end, but
this is kind of radical but it’s true, and that’s that it’s
the patient that is responsible for their own care, not the
physician. You see why it’s called self management? The
other day I told Mr. Rodriquez, I said I want to see your
diabetic self management classes. He said, can you send my
wife? I said, Mr. Rodriquez, that’s why it’s called selfmanagement, okay?
[Laughter]
You’ve got to do it yourself. Your wife doesn’t have
diabetes, you have diabetes. So it’s your responsibility,
you spend just five to ten minutes with me, you’re
responsible for that. I could give you the medications,
but you’ve got to be able to take it.
The other issues on self management is patients with
diabetes want to know what this disease means to them, and
these are the things that they want to know as they survey
is that their illness is serious, that their condition is
essentially self managed, they have options, and that they
can’t change their behavior. You can do that. So this is
one of the, we started Resolute Health and we called it
resolute because we were really Resolute on trying to make
a difference in our community. And what we did wa s what my
job as Medical Director is I go around the tri-county area
talking to primary care doctors, coming to their offices
and saying, you know what, let us partner with you. We
don’t want to steal this patient from you. What we want to
do is partner with you in making this patient better,
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especially a patient with diabetes. In fact, you know
what, why don’t you send us your tough ones first? I
happen to have RN, CDEs, RV, CDEs in this center, I have
nurse practitioners that are CDEs, we have people who have
spent time, we have lasses that we could do to make this
better for them. And now as you know as we physicians get
or health care providers get judged now, how are we going
to get paid on outcomes, we need that.
I was in Southern France on vacation this past September.
I was walking through and I saw this beautiful statue, and
it was a statue of the blind man and the paralytic. Now I
wished I would have brought a picture of that here. But it
was this, and I remember we were walking by and I told the
tour guide, I said, what is this statue, this is gorgeous.
And she said, this is the French fable of the blind man and
the paralytic. Has anybody heard of that? And what it
was, it was the blind man had walked by and he was walking
by and he heard the paralytic crying. He said, hey, what’s
the matter with you? He said, well, woe is me, I can’t get
up. I can’t do anything. I’m just - - all day long. And
the blind man said, well, look at me, I'm blind. But he
said, you know what? Why don’t we collaborate in our
misery? Why don’t we work together? And so the statute is
this, it looks like a Michael Angelo Greek statute of a
blind man with no eyes, that is carrying this paralytic.
And the blind man told the paralytic, you will be my eyes,
and I will be your legs, and I will be your limbs, and
together we’re going to accomplish our goal. So that’s
what we want to do with primary care doctors in our area.
You can see the services that we provide there. Diabetes,
medical management, diabetes self management training,
medial nutrition, insulin initiation, Victoza, Byetta,
Symlin initiation, pump therapy, continuous glucose
monitors, we have education not only individual and group
sessions, but these are stuff that we have to do outside
our practice. And if you don’t have them, you have to get
involved and get them initiated. How am I doing with time?
One minute, okay.
The last thing that I do is, I feel like on a Spurs game,
one minute. The last thing what I do is this year I happen
to be... to be Chairman of the Economic Development
Foundation for our community, and I go around the
communities and I say, you guys have got to pay for
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diabetic education. And let me show you. Let me show you
some data from Gilma [phonetic], from University of
Washington that actually showed that as you lower your
A1cs, you can lower your cost. In businesses, you’ve heard
that old saying that economics is the science of
incentives. Isn’t that true? Economics is the science of
incentives so we say let me give you an incentive, you can
lower your cost by sending your patients to us. Metabolic
syndrome patients, prediabetics, diabetics, and let us do
diabetic education, but you’ve got to pay for it. And
you’d be surprised how well they respond to that.
So anyway, I'm going to wrap this thing up, and the last
thing I want to say is that I grew up in New Braunfels, and
for those of you in Texas who don’t know where New
Braunfels is, it’s an old German town, and it’s
historically old German town, in fact I had to take German
fourth, fifth, and sixth grade when I grew up, so we spoke
Spanish at home, spoke German at school, and I remember one
day my dad was a policeman there and he came home and he
heard my brother, I have a brother who now lives across the
street from me, he’s an attorney there in town, and he and
I were speaking German back and forth. We would do that
when we didn’t want our parents to know what we were
talking about. My dad walked in and he goes, hey, hey,
hey, hey. He said that’s enough of that. He said, we’re in
America. He says, speak Spanish.
[Laughter]
But I love those German, I love the German philosophers.
And this is one of my favorite saying of Goethe. And
Goethe said, “Things that matter most should never be at
the mercy of the things that matter least.” And what
should matter most, those of us who take care of patients
every day, what should matter most is we should desire our
patient’s highest good and do everything in our power to
help us achieve that highest good. That’s why we went into
medicine. That’s why you students are going to medicine,
right? Because you want your patients, you want them, you
desire their highest good, you want to do everything in
your power to help them achieve that highest good, and part
of that is getting involved in communities, getting
involved with your schools, getting involved anywhere you
can, outside your office, the day in 2002 it’s not enough
just to be a doctor in the office, or health care provider,
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you’ve got to do other things. I know we’ve got a panel;
I'm going to wait for your questions during the panel.
Thank you very much.
[Applause]
DR. FLORES: Okay. We’re going to do the posttest. So you saw
them before, you're seeing them again. Now you know the
answers. Remember, your answers if you don’t get them
right reflect poorly on the speaker, so he was a great
speaker. Okay, well, I’ll have to read it again.
A principal of a predominantly Latino middle school is
concerned about the apparent rise in the number of obese
children at her school. She has heard the reports in the
media lately about the increasing incidence of type 2
diabetes in overweight children, so she contacts the local
HCP for recommendations. Which of the following is the
most appropriate recommendation to prevent diabetes in the
children? A) Organize a school assembly with presentations
by a dialysis nurse and patient; B) Encourage daily
physical education and modify cafeteria food choices; C)
Write a letter to the parents of the children linking
obesity and diabetes; or D) Offer a plasma glucose
screening of parents at the school. We’ll see how you did
here.
[Music]
So 94% of you got B) Encourage daily physical education and
modify cafeteria food choices. Good job guys.
The second one. An overweight 11-year old Hispanic boy
with type 2 diabetes presents to the registered dietician
for meal planning. His mother and father accompany him.
Both are obese and have type 2 diabetes. Which of the
following is the most appropriate advice for this patient?
A) Avoid eating fast food; B) Eliminate high fat calorie
dense foods; C) Get involved in a soccer, basketball, or
baseball league; or D) Aim for at least 60 minutes of
moderate intensity, physical activity daily.
[Music]
And the answer is, 78% of you said, aim for at least 60
minutes of moderate intensity, physical activity daily, and
78% of you are correct. Thank you very much. I think that
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was pretty good.
Diabetes Mellitus Patient Self Management - Joel
Zonszein, MD, CDE, FACE, FACP
We’re going to move on very quickly. I'm going to read
really fast. You have this in your folder, but our next
speaker is Dr. Joel Zonszein. Dr. Joel Zonszein is the
Director of the Clinical Diabetes Center East Campus at the
University Hospital of the Albert Einstein College of
Medicine, a division of Montefiore Medical Center. He is
Professor of Clinical Medicine at the Albert Einstein
College of Medicine. In 1993, he was recruited to work
full-time to develop the clinical diabetes center at
Montefiore Medical Center. Dr. Zonszein is certified by
the American Boards of internal Medicine, Endocrinology,
and Metabolism and Nuclear Medicine. Gosh, it’s all I can
do to be one. He has ample clinical experience
particularly in the areas of diabetes. He is a coinvestigator in the Albert Einstein College of Medicine
Diabetes Research and Training Center and collaborated
landmark NIH clinical trial such as the diabetes control
and complication trial and the diabetes prevention program.
He is principle investigator of the bypass angioplasty
revascularization investigator to diabetes. An ongoing NIH
sponsored sturdy to elucidate the best management of
ischemic coronary heart disease and patients with type 2
diabetes. He has a, you know what, I'm not going to keep
reading because it’s in your package and we need to move
on. Can I have the questions, please. You guys got your
deely bopper? We are ready.
Case 1. Ms. Lopez 76-year old woman, her chief compliant
is weight loss, insomnia and knee pain. Past medical
history, hypertension, dyslipidemia, type 2 diabetes, more
than eight years, depression and osteoarthritis. Loss to
follow-up after her husband’s death 18 months earlier.
She’s sedentary, her BMI is 27, blood pressure is 155/95,
no overt abnormalities in her physical exam and/or diabetic
complications. She knows her blood sugars are high, takes
her meds regularly, she’s on an ACE inhibitor for her
hypertension only when she has a headache, is when she
takes it. She stopped the statin but takes her metformin
every day with herbal diabetes tea and prays regularly to
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mange her health. She’s concerned that the weight loss is
due to cancer. Three adult children and seven
grandchildren all live in other states, but visit
regularly. She did not graduate from high school but sent
her children to college. She lives in the same house where
she’s lived for over 40 years, manages with her husband’s
pension, and her social security check. She would like to
be a better patient and come to clinic regularly, but she
is afraid she will use up all of her visits covered by her
managed Medicare plan. What will you do in her visit? A)
Assess mental health, depression; B) Assess social supports
and family dynamics; C) Geriatric assessment and treatment
adaptations; D) Check her health policy and insurance
coverage; or E) All of the above. Please vote now.
[Music]
We’ll go to the next question. An active and healthy 39year old Hispanic man with type 2 diabetes for two years
and no complications has a hemoglobin A1c of 8.9%. The
goal should be a) Less than 8%; B) Between 7% and 8%; C)
avoid less than 7% because of the ACCORD trial; D) Less
than 6.5% without hypoglycemia. Please vote now.
[Music]
So please give a warm welcome to Dr. Zonszein.
sunshine.
JOEL ZONSZEIN, MD,
thank you all
because of us
started late,
the...
And it is
CDE, FACE, FACP: Thank you, Kathy. And
for attending the, I know you are here not
but because the dinner and I hear because we
we’re all going to have free Margaritas after
So here are my disclosures. You have it also on your
inserts. So there is no conflict of interest with this
talk, and I want to take the opportunity to thank all of
our patients who I learn a lot from them, and they’re
really the ones we should benefit from all these
presentations.
I want to take the opportunity, this is going to be a very
hard act to follow after Carlos, but I want to take the
opportunity to clear the confusion of the landmark clinical
trials and what we have learnt. In the last 30 years we
had very important, very expensive clinical trials and I
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think there is a lot of cons=fusion out there. I want to
stress the important of early intervention, and how we have
to treat, and Carlos already made the influence to that,
the patient, not the high blood sugars, and to talk a
little bit about education and patient self management or
patient empowerment.
I want to start with the clinical trials. Many of you who
have been in this area remember the diabetes control and
complication trial, our exclusion was part of that study.
It was published in 1993, the Kumamoto University in Japan
translating the same intervention, the DCCT in type 2
diabetes in Kumamoto University, and the UKPDS which was
the largest, over 4,000 patients followed for about ten
years and that was the older studies. In the newer
studies, we have a continuation of the DCCT, which is
called EDIC, it’s still ongoing, we still have it in our
center, and we’re looking at cardiovascular disease rates
in patients with type 1 diabetes, where cardiovascular
disease is rare. And there is also a long term follow-up
of the UKPDS that was published about two years ago,
following patients ten years after the study was
terminated, so this is 20 years, both the EDIC and the
UKPDS. We have three trials, the ACCORD, ADVANCE, and VADT
that also provided a lot of information.
So I'm going to review these very, very quickly, and these
are only highlights, were not going to go into details, but
in the DCCT, the study was planned to be carried for ten
years. We stopped it at nine years because there was over
50% decrease incidence in macrovascular disease. The same
thing happened in Kumamoto and if you look at the
difference in the Ac1 in the UKPDS, between 8% and 7%, it’s
about 50% over the Kumamoto and DCCT had so a lso decreased
macrovascular disease. If you look at macrovascular
disease, 16% of the patients had decreased macrovascular
disease where the P value was not significant.
Now, when we look at ten years later, ten years after the
study was stopped. This is 20 years after the initiation
of therapy was begun, we find out that mortality,
cardiovascular event rates in the DCCT was decreased by 57%
ten years after the study was stopped in patients who were
treated intensively. And when we look at MI or we look at
mortality in patients in the UKPDS intensively, there was a
decrease of 15% and 13%, so it’s not only how these
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patients were treated or how long they were being followed,
but if we look at patients who receive only metformin,
there was a subsection of patients in the UKPDS, the MI
decreased and the mortality was even higher than the
patients treated with sulfonylureas or insulin.
And then we have the new trials. The largest trial now is
the ADVANCE trial. They did not use patients in this
country. They were patients from Europe and Australia, in
Canada. It’s the largest study we have in patients with
type 2 diabetes, 11,140, the duration of diabetes was eight
years. They came in with a baseline A1c of 7.2. I would
love to see those patients in my practice. And they were
able to still improve it to 6.3 or 7.0. The goal was
really 6%, and then they said, no, it was really 6.5% but
they were able to bring it nicely down and the difference
between 6.3% and 7.0% during five years showed that there
was no decreased cardiovascular events or mortality, so
this is the largest study and a more aggressive therapy in
these patients with eight years of duration didn’t make any
difference.
The VADT is smaller study from the VA system that really
represents much more what we’re seeing in this country.
These are patients who came in with hemoglobin A1c of 9.4.
Notice also that although the patients were younger, 60
years old, versus a mean of 66, they had a longer duration
of diabetes. We’re seeing that in this country, younger
patients, longer duration, higher A1c, and this is very
prominent in the Hispanic community. So there was no
difference again in bring the A1c down from 9.4 to 6.9, and
that was an excellent job, it’s very difficult.
Obviously, hypoglycemia is always more common in patients
intensively, but again there was no worsening or benefit of
intensive glycemic control.
The ACCORD trial had 10,251 patients. The highest
recruitment actually was in the Bronx. Jacoby Hospital and
Albert Einstein were involved in that study, and the
duration of diabetes was 10 years. The patients were again
younger compared to the advanced studies, 62 years old, and
they came in with a hemoglobin A1c of 8.1, and in the
intensively arm, it was the decreased to 6.4. The study
had to be stopped because at 2.5 years, there was an
increased mortality, part of the study of the intensive
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insulin therapy, or the intensive glycemic control because
there was an increased mortality that was significant in
the patient treated intensively. And that is important
because that created a lot of confusion. Let me say that
it was not hypoglycemia, it was not Avandia, and we still
don’t know why this happened. It could be a serendipity
type of effect but we don’t know.
And then we have the Standard 2 trial, this is a
Scandinavian study done with a very small population, 160,
it’s not an expensive study. It’s in the standard clinic,
and what they did is they look at multifactorial
treatments, so when we treat type 2 diabetes, we have to
address hypertension, dyslipidemia, and not only the A1c.
So these were high risk patients with microalbuminurea,
which reflects both cardiovascular disease, and also
microvascular disease. And they were all treated with
intensive therapy for blood pressure, A1c, cholesterol,
they all received an ACE inhibitor and aspirin. So the
outcomes were that there was a decrease in a short group of
people with a significant P value. In cardiovascular
composite outcomes, and where we follow those patients
eight years later, you still have a decrease of 43%
mortality, so treating these patients is important.
So let’s talk about the importance of early intervention
because now we learn that treating high blood sugars work
but it takes 10 to 20 years to show cardiovascular events,
and certainly, we can prevent blindness, we can prevent end
stage renal disease, and we can prevent often amputations
in many of our patients.
So if we look at what happened typically in the UKPDS, and
this is from Dr. Deprio [phonetic], we find out that
patient population comes with an A1c of around 8.5% and
then we are able to bring it down and we tend to be very
slow in doing that. But then it starts to go back up.
This is the Nike symbol effect. And what we do in these
studies, in the newer studies is we decide well, let’s
bring down the A1c to normal, and let’s keep it down to
normal. So it doesn’t work, and it doesn’t work because
the patients leave for eight to ten years with a very high
A1c. And that builds up a bad metabolic memory.
Mitochondrial oxidation is affected with very short term
hyperglycemia, and this is now a well known effect in many
patients with diabetes. Very often these patients come
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already with organ disease, their GFR is decreased, they
already have an MI, they have cardiovascular , peripheral
cardiovascular disease, so they are a sicker population,
and the interventions that we do at that time, it may be
too much too late, so this is what we learn from these
studies. So treat early and treat aggressively, treatment
of diabetes is not treating only high blood sugars, it
requires a global approach. Intensive glycemic control
prevents, delays small vessel disease, microvasculopathy
that leads to retinopathy, nephropathy, and in part
amputations, delays large vessel disease, strokes and MIs
in congestive heart failures and it may preserve also betacell function. That is that if it was more aggressive
early in the disease, we need less and less medications
later on.
Now it is not what the level of A1c. There has been a lot
of debate between 6.5 or 7.0, but how is that level
achieved? What type of medications? And Dr. Antonio
Cannon is going to be the source in that later on. And
again, in which patients? So the new recommendations and
Anthony is going to be talking about that, focuses a lot on
these patients center on who are we treating and how are we
going to be treating that patient. This is going to be
published in June in Diabetes Care. It’s already online.
So treating the patient not high blood sugars, so this is
not a patient who comes to see me with diabetes in my
clinic. Unfortunately, they have exactly the opposite, so
what we want to do in treating type 2 diabetes, let’s start
with education. Self management, patient empowerment,
bringing the wife with the patient. And then we start
treating the high blood sugars, the high blood pressure,
the dyslipidemia, we don’t see high cholesterol in these
patient population. We see dyslipidemia with very high
triglycerides, very low HDL cholesterol, the good
cholesterol, with insulin resistance, not many - - only by
acanthosis nigricans, but by fatty livers, hepatitis and
cirrhosis in obesity and diabetes is becoming now the most
common cause of liver disease, so it is a very, very
aggressive disease that is completely new, we never saw
that before. And we may need antiplatelet therapy, and
obviously smoking cessation if they’re not 100 years old.
So things we can change are biological or behavioral or
social issues. The long case that you saw at the very
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beginning was transcribed from the last week issue of the
New England Journal of Medicine. As you know when you go
to premed testing now, you’re going to need not only the
biological part of knowledge, we going to have a very
important component of the social aspects, so these
behavioral and social issues are important, and education
and counseling, medical, non-adherence, mental health,
depression, anxiety, the health policy insurance are very
important. So that little old lady who came to see the
doctor in nine minutes, the doctor will have to assess, in
New York it’s probably six minutes, the doctor will have to
assess very carefully how to deal with this problem. It is
a very complex problem.
So I divide these into the disease prevalent, cultural
impact and quality of care. When we are looking at
disparities in the Latino population, so we all know that
the Latino population has more diabetes. The diabetes is
not diagnosed or is diagnosed late in the disease. When
diagnosed it is not treated for many reasons, and when
treated it’s not treated at target. And the consequences
are more complications, premature morbidity, and mortality,
and socioeconomic burden not only for the family, for the
entire country. This is the working force of this country.
The cultural impact has also a lot to do with it.
Hispanics view health as no pain, no problems. If I don’t
have to, I don’t want to spend a whole day with the doctor
or half a day with the doctor if I feel well. And they go
to the doctor and cholesterol is high, the sugar is high.
You need these medications. And they walk out and they
say, this doctor is crazy. So it’s a problem. So
believing a disease is beyond their control prevents them
seeking professional care. So that is another fatalistic
idea that Carlos already dealt with. It’s another problem
that education has to be provided to these patients, and
the lack of initiative in seeking health care contributes
tremendously to increased morbidity and premature mortality
that this special population has.
Then we go into the quality of care, so the access to care.
And we know that the Hispanic population is less likely to
have a regular doctor, and that is important. These
fractionated care that is so common nowadays, should stop,
we need a primary doctor that really coordinates all these
things. Medicine has changed dramatically in the last five
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or ten years. They have to go and see the doctor rather
than the emergency room, and we know that our Latino
community uses the emergency room for regular visits.
Screening for high cholesterol, education and exercise,
counseling is done less in these populations. So the
pieces of the puzzle that we have to deal are not only the
biological abnormalities but the socioeconomic language,
literacy and cultural characteristics of the patient. So
we’ve already talked a little bit about what is culture,
and Einstein always said that there is no cultural
competency that is more genetic or acquired ethnically.
What we have is cultural incompetency, so at Einstein we
are having, and thank you for being here, a very nice
course now on controlled competency.
So education and patient self management, I'm going to be
touching only some highlight of things that we do very,
very common. So we have to know that once size doesn’t
fit, just like medications so when we provide a curriculum
for education, it has to be tailored to the patient or the
patient community that we’re serving. There is a dose
related response, it’s a dose related effect, that is the
more common we see that patient and it can be a doctor or a
nurse or a secretary, or a health care worker, the more
common we see those patients, the better outcomes we have.
But early education and early disease is still very rare
for economic reasons or whatever, I see patients with IVs
for ten years, less than 50%, much less than 50% have had
education about their disease. Chronic diseases need to be
dealt with education. The education should be based on
outcomes. We don’t want to teach them medicine, we want to
have changes. Patient empowerment, and knowing their
numbers, so patients again as mentioned, they have to have
a responsibility of dealing with a chronic disease. We
don’t have an injection to cure diabetes in one visit.
We have different models of education and many of them are
being tried. We have a Montefiore one of the ACO, you
accountable care organization. Grants, we are trying a lot
of new things so we have a very sophisticated diabetes
disease management program at Montefiore, we have patient
centered medical homes, we have I call a dinosaur diabetes
self management education program, one of the oldest in
USD, and we have medical nutrition therapy, the tele-health
where patients download their monitors and the nurse looks
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at the blood sugar. It actually has been very effective to
the hypoglycemia. It has not been very effective to treat
hyperglycemia. Support groups, text messaging, I don’t
know how many of you have used, we’re using now text
messaging as a reminder to the patient. So we have
different techniques, different tactics, to different
patient population.
The education depends on who is giving the education. If
you give a pamphlet to a patient and you don’t follow -up or
you don’t know what is in that pamphlet, it doesn’t work.
You can give a CD, you can give a video, it doesn’t work.
You have to have a communication of the education, and it’s
very important who is doing that education, if it’s a
nutritionist, if it’s a nurse, if it is a pharmacist,
doctors don’t do a good job, we don’t do it, so we work as
a team. We have to look at the patient, the language, the
communication, the ethnicity, we don’t change their food,
we change the way they eat, but not changing the ethnic
food diet that they eat. And we need a curriculum that has
proven to work, so education is not giving a lot of slide
presentation, it’s interactive with the presentation, the
patient knowing the numbers, it becomes a little
sophisticated, but when it’s done well, and it’s done early
it works very well. Patients love it by the way. They
really like to go to those classes.
So how do we treat? We tell patients, eat less, you are
not losing weight, you are not doing a good job. And we
keep telling the patients that again and again. It doesn’t
work. Diabetes is not a punishment. The diet that the
patient with diabetes should follow is a healthy diet that
we all should be following, not different, they don’t need
a different diet, it is the entire family who needs to
follow the same diet that we’re recommending to that
patient with diabetes. And it should be a simple food, we
want a slow food. We don’t want the fast good diet, we
want to sit with the family and take away the computer, the
telephones, the iPods, sit down and have those nice dinners
where somebody, usually the mother, maybe the father is now
cooking, and there is a conversation. We don’t have that.
Everybody is watching TV, on the computer, and often they
don’t even sit in the same table at dinner. So a slow food
is very important and we have to change that.
The weight loss has to be realistic.
If we have a
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sustained weight loss of 5%, we are ahead of the curve.
But when you have a patient who is 220 lbs and says I want
to down to 160 lbs, well, our obligation is to say, no, no,
lose 2% or 3% of your weight, and I will be happy and I am
happy. So no sugary drinks, we talked about that. More
fiber, a plate portions which are finally changed from the
pyramid to the plate, and less fried foods, less saturated
fats, and no trans fats. So it’s less fast food and more
slow food.
You need to exercise more. Again, you don’t exercise. It
doesn’t work. We really have to prescribe, first we have
to see the patient is fit to exercise, because they may
have cardiac disease, or neuropathy, etc. We recommend at
least 150 minutes of moderate intensified aerobic a week,
and this is from the diabetes prevention program, so it’s
not that much. It’s five days, 30 minutes of some
exercise. And we have to monitor the prescribed exercise.
That is if you tell the patient exercise, it doesn’t work.
Just like we monitor the blood sugars, and the patients
bring back their blood sugars, we have to see what are they
doing. Did they go to the gym, we use speedometers, they
are not very fancy sophisticated methods to connect with
the iPhone so patients, they can know every day how much
they walk, what’s the weight, etc., so you can go to
technology but you need a follow-up of the prescription you
are giving.
And then we want to give pharmacotherapy for glycemic
control. And that has become a problem more and more. I
don't prescribe medications, I negotiate medications with
the patients, and they tell me, before they take the
medication they have side effects. And before when they
had the side effects, it’s going to kill me, so I have to
explain to the patient, no, no, no, it’s not the medicine
that kills your liver or kills the kidney, it is the high
blood sugar. We have to treat it. We have to look if they
take the medication. Most patients don’t take their
medications and when they take it, they take it for a week
and then they stop. They don’t believe in medications, and
the TV ads and the lawyers’ ads is not helping you. One
size doesn’t fit all. We don’t have algorithms. Again,
Dr. Cannon will be addressing that.
The target A1c is individual. So we want to be more
aggressive in a young person who’s healthy, and we want to
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be less aggressive in a patient who has a shorter lifespan
or who’s in a nursing home, who’s bedridden, etc., so it’s
not an A1c of 6.5 or 7.0 or 8.0. I like to see a lower A1c
in healthy individuals if it is brought down without
hypoglycemia. And we have to cross the medications to the
pathophysiology, if the patient is insulin deficient, they
will need insulin right away. If the patient is insulin
resistant, maybe sensitizers will be better. And we have
to tell the patients the pros and cons of each medications.
And more important diabetes is a chronic disease so when we
give the medications we want to find out if it’s working
correctly, if the blood pressure, the cholesterol is
normal, if the sugar is normal.
So we have now ten different types of medications, and we
have very sophisticated insulins, so the question is, how
can we use those medications properly. But what I want to
finish with is to give the message that instead of changing
the high blood sugars, and having a patient living with a
high A1c for a long period of time, we need to be more
aggressive and lifestyle changes with medications, probably
combination therapy, works and works very well early in the
disease. And we do have clinical trials that this is
effective not only short term but also long term. So I
will take the questions later on, but thank you very much
for this.
[Applause]
DR. FLORES: Thank you so much. That was excellent. So get
your little apparati and I'm not going to read this whole
thing again, but it’s the case where Mrs. Lopez is up here.
So what were you going to do with her visit? And let’s
just go ahead and show the answer.
[Music]
So 80% of you said all of the above. And the answer is all
of the above. Very good. Okay. The next one was your 39year old Hispanic male with no complications of his
diabetes, and what is the goal of the hemoglobin A1c?
Please vote now.
{Music]
Seventy-six percent of you. Okay. So we are going to go
to our next speaker. I saw some incredulous eyes out there
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with the hemoglobin A1c.
DR. ZONSZEIN:
We can talk after.
New Emerging Trends in Care for Diabetes Mellitus
Treatment, Models of Care – Anthony J. Cannon, MD
DR. FLORES: Okay. At the question and answer. Okay. So the
next speaker is Dr. Anthony Cannon, also known by his
colleagues as Dr. Antonio Cannon today. He is in private
practice in Hamilton, New Jersey. Dr. Cannon received his
BA degree at Clark University and a MD degree from Cornell
University. He completed his internship in internal
medicine at Harvard Hospital, a residency in internal
medicine at Baystate Medical Center and a fellowship in
endocrinology at Temple University Hospital. He is board
certified in internal medicine in endocrinology. Dr.
cannon is a past-president of the South Jersey Medical
Association and current president of the Thyroid Club of
South Jersey. He is also the current president of the
Greater Philadelphia Community Board, ADA. He is also a
member of the American Diabetes Association, African
American Initiative Committee, the American Association of
Continuing Medical Education Advisory Board, the National
Medical Association and American Association of clinical
Endocrinologist where he serves on the health disparities
up committee.
We are going to start first with the questions, so please
get your deeley boppers and the first question is,
glucagon-like peptide GLP agonist have been found to
address the following core defects in type 2 diabetes. A)
Stimulates glucose dependent insulin secretion; B)
Suppresses glucagon secretion which decreases hepatic
glucose production; C) Slows gastric emptying; D) Reduces
food intake; or E) All of the above. Please vote now.
[Music]
The next question. Evidence-based studies relating to
glycemic control of type 2 diabetes mellitus have
demonstrated which of the follow? A) An increase in
macrovascular complications; B) A reduction in
microvascular complications; C) A reduction in both
microvascular and macrovascular complications; or D) None
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of the above.
Please vote now.
[Music]
So please give a warm welcome to Dr. Cannon.
[Applause]
ANTHONY J. CANNON, MD: Good evening. I like my new name. I'm
really here with the passion that many of us have for the
treatment of chronic medical disorders. I think you’ve
seen the passion of the two previous speakers. I'm the
anchor speaker tonight whether I want to be or not. I liv e
and I Sing the Body Electric, Joe Zawinul, Weather R eport.
Yeah. The realization is that there’s a great deal of
homology between the African American community and the
Hispanic community. We are in the fine city of Washington
during election year. Let us not forget that. The
realization is that there are forces of evil as there
always are, and there are forces of goodness, which there
has to be, there’s always been Biblically Cain and Abel,
yin and yang, and so forth and so on. The realization is
diabetes afflicts people of color, period. Got it?
Disproportionately compared to people of little color.
[Laughter]
And I'm going to tell you that because it’s so important
because as I unveil my story, which fits like the puzzle
you saw earlier into our two speakers prior, analysis, it
comes down to the patient. It comes down to the family, it
comes down to the practitioner with nine or ten minutes. I
have 15 minutes when I'm really on a roll and I speak very
clearly to my patients, and I have a very significant cross
cultural population, Hamilton, New Jersey is right outside
of Trenton. Trenton is nearly a Latino City. So is
Camden, New Jersey. Did you know that? And if you believe
the media, they’ll tell you something else that is
traditionally they have been working class environments,
very tough times economically. The Industrial Revolution
has past. The manufacturing has past to those cities and
gone elsewhere, overseas. So you have a population of
underemployed individuals, you have gang warfare, the
Crips, the Bloods, and whatever, and you have families that
are disintegrating with single parent households. Thirtyfive to 40% of the patients I see are ethnic minorities
have single parents where the single parent is the
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grandmother.
Let’s give you some data that goes beyond diabetes very
quickly. New data. My middle name is Data. I didn’t have
any childhood friends. The realization is that white
females are living to 84 years of age. New CDC data.
White males are living to 82. African American women are
80, and African American males are 75.8 years. The African
American male is going to be distinct at the rate we’re
going. I don’t have the Latino data but it’s going to be
about there, that the white male and female are the market
leaders.
When we created Medicare in ’65, the average life
expectancy was nowhere near what I just told you. Now I'm
part American Indian so I spend a lot of time with America
Indian issues. I was at a Pima Indian reservation very
recently with Carlos, and Carlos, you remember that
statement? Average age of death for a Pima Indian, Salt
River Pima Indian on a reservation is 46 years. Female 52
years. And we spoke to the pharmacist if you remembered
and the statement that was made by one of the Indians on a
tribal land at age 30, he said to the pharmacists, I don’t
have diabetes yet, I'm not going to die early yet. I spent
a month on that reservation in a hut in 1981. At Cornell
they got rid of me for a little bit. They asked me to
leave and not come back because my attitudes outside of New
York was not the best, so they dropped me into Phoenix and
said we may send a plane back for you in 30 days. I said,
don’t bother. The realization was that 12 hour day, six
days a week I was Dr. Cannon and I had an opportunity to do
things I never did in medical school. I was treated like a
physician, I did a lot of things in the clinical, but the
one thing that stood out beyond anything I’d ever seen was
polycystic ovarian disease. Does anybody know what that
is? Phenomenal. Acanthosis nigricans cancer sore, every
other girl. I saw violence, I saw alcoholism, I saw
diabetes, it was just a matter of which of all three. So
this talk here is going to try to integrate the people of
color and our risk factors and try to put this together and
say, we want no more of this. We don’t want to die
prematurely.
So I'm going to walk you through this slide deck. I have
40 slides and 40 minutes or less actually 20 minutes, but
I’ll walk you through this and it will be a quiz like you
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just saw. There will be answers to the quizzes that would
be appropriate or you can’t leave.
So we’re going to advance the first slide. Let’s see if I
can get that off. And do next. Let’s see why it’s not
cooperating. There we go. We’ll just hit, up and down,
okay. This is a disclosure slide. This is something for
you to memorize. These are number of pharmas, local
corporations that I speak for on behalf of diabetes.
Oxilion [phonetic] I speak for, low testosterone syndrome,
one, about somewhere in the range of 30% of men with
diabetes in this country right now are suffering from low
testosterone syndrome. For those primary care physicians
out there, a patient says I'm fatigue in the afternoon, I
don’t have the energy that I used to have, I don’t have the
maintenance of my sexual act that I used to have, please do
a fasting total testosterone and free testosterone. You’ll
be shocked in your practice about how many men are walking
around with low testosterone syndrome aggravating their
diabetes because they get more abdominal obesity, more
insulin resistance, just by getting them up and exercising
with more energy both in the bedroom and outside the
bedroom, there is something to be said for that.
So I'm going the wrong direction.
here.
I'm going to take you
[Laughter]
These are the objectives. This is what you have to have
memorized indelible on your forehead. We look at the new
practice guidelines for the treating type 2 diabetes
mellitus, we’re going to look at the consensus
recommendations, and we’ll look at emerging issues. For
those of you who have read the New England Journal of
Medicine in the last month online officially there are two
bariatric studies that are very controversial. I do want
to cover that data because the realization is that there’s
a subset of our population that need to consider such
interventions.
This is a hard to see slide. We blew it up as much as we
could, but I want to show you a primary care study. I
spend a lot of time with primary care physicians struggling
with obesity and physical activity and there are no good
models on how to get your patients to lose weight and to
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exercise and eat more properly cross culturally. This is
one of the best studies I’ve seen published in Oct ’11, New
England Journal of medicine, looking at six primary care
physicians practices, large practices, putting a third of
each of the patients that they study, 390 patients, about
130 in each group. The first group is typically what we do
with physicians, we pat the patient on the fanny, we give
them a tear out, say good luck, your dietary
recommendations, we see them every four months, and they
get bigger, and bigger, and bigger. The second group has
some modification of that paradigm, where you allow a
medical assistant who is a lifestyle trainer, and train to
intervene and help the patients with dietary issues cross
culturally. A third group are those people who had access
to pharmacologic agents in some instances to help lose
weight, Olistat, Meridia, others had dietary modifications
like a Jenny Craig or Weight Watchers. So they also had
the same lifestyle trainers but they saw them monthly, not
quarterly.
This is the data over two years. This is the longest trial
you’ll find in the literature. These patients were not
diabetic, these are cross-sectional patients, some had
prediabetes, very little diabetes occurred over two years.
But if you look very carefully, the best group, the socalled enhanced brief enhanced lifestyle with brief
lifestyle, to me, enhanced group with brief lifestyle
counseling did the best. They had about a 4.7% reduction
in their weight. Now this is a very aggressive trial,
intent to treat trial, and this is the best they could do.
So I want you to keep this in mind as you have patients
that want to lose tremendous amounts of weight yesterday.
I typically have a mother that wants to lose weight because
her daughter or son is getting married at exactly 15 weeks.
You have to be realistic with some of your goals. Remember
now, this is not a diabetic population. I didn’t show you
the demographics, relatively young individuals, the average
age was about 47 years of age, they didn’t have a lot
comorbidities or hypertension, dyslipidemia, and
cardiovascular consequences of life. They were relatively
healthy, and the best they could do was 4.7% but you’ll
notice one thing about all the curves, they inflect back up
don’t they?
This is the problem, physical inactivity, this particular
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slide is from the Government CDC updated recently, county
level estimates of leisure time, physical inactivity
amongst adults ages above 20 years, 2009 database, this is
the newest data I have, you noticed there’s an awful lot of
blue, like Carlos showed earlier, this is not racial data,
this is America. Look down at the bottom. If you can see
the bottom, the deep blue represents more than 32.6% of
that population, that region of the country are physically
inactive. The lighter blue is not much better, it’s above
26%. So if you want to know why we are having so much
trouble with the obesity epidemic in this country, a cross sectionally, not a diabetic database, this is America.
So we spoke earlier in our talks about the A1c blood
pressure and LDL cholesterol issues. You can’t speak about
glycemic control alone without thinking about hypertension
and LDL considerations. But you now have to put in weight,
weight issues with medical nutritional therapy. We’re
looking at reductions in improving macrovascular endpoints,
as well as looking at microvascular endpoints as well. So
this is a really important slide of integrating everything
you’ve heard this evening, is that you don’t treat blood
pressure alone, you don’t treat glycemic control, and
ignore cholesterol issues.
These are the goals. These are the goals that have been
updated by all the consensus panels minimally from ADA, you
want A1cs of less than 7% but you really must try to avoid
hypoglycemia in these quests for better control. You want
blood pressures below 130/80 and you want your LDL
cholesterols less than 100. Now I'm going to ask a
question, and I'm going to really pick on a physician in
the office, this is your office, right? Okay, I want to
ask you, I'm going to shout out to you and say the
following. If you get it wrong, it’s okay, I know who you
are. The highest blood pressure of the day for someone who
sleeps at night and awake by day is what? When? When is
the highest blood pressure in an individual who doesn’t
work, shift work, who sleeps at night, and awake by day?
I'm going to give you a chance to get it right.
Three and five o’clock in the morning is correct, but the
answer is wrong because it’s meaningless, our offices
aren’t open to record it. It’s two to six o’clock in the
evening. And why do we have that diurnal change in blood
pressure throughout the day? Catecholamines. Anybody
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else? Life is a hormone. With me, life is a hormone.
Tell that to a cardiologist, it pisses him off.
[Laughter]
The realization is that people and doctors offices at eight
o’clock in the morning have good blood pressure. They come
to me and I scare them to death they say. But it’s really
at two o’clock in the afternoon the diurnal blood pressure,
lack of control. So if you have a difficult hypertensive
patient and you really want to see wh at the worse time of
the day is, waking day, it’s probably two to six o’clock in
the afternoon.
This next slide is one of my favorites because this is
describing what Eddie Murphy had described in his scene
from his movie, Welcome to America. And what you’re seeing
here is the diabesity epidemic where more colorful country
cross-sectionally, biracial, and ethnic divides but we are
more colorful with the amount of obesity and diabetes.
There’s a place in America you don’t want to be because
there’s just too much diabetes in the southeast. We call
that area the country of heart attack waiting to happen.
This is an important slide because this is newer data,
looking at the 80s to the early 2000s, we went from 5.08%
of the population being diabetic to over 8%, but not as
important as that data is, look what happened to the
obesity epidemic. We dropped the people who had normal
weight, we increased to overweight, and now we have the
super overweight. And I don’t mean boxers. This is us.
Look at the percentages as they go up, and up, and up. So
now we have categorized it as obesity one, two, three, and
then the super heavyweights. The largest group of people,
obesity in this country that are increasing are those with
BMIs over 40, and a second group of importance is BMIs
believe it or not over 50.
This is the percentage of individuals in this country with
diabetes looking at the number of patients with diabetes as
well, so to be able to present on the Y-axis, and then the
Y prime axis, the number, and this is from 1958 to ’59.
And this is exactly what’s happening to America, we have
about 25 million individuals with diabetes, both type 1 and
type 2, 24 million are going to be type 2. The majority of
the people that have diabetes that don’t know it are racial
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minorities, Hispanics, American Indians and African
Americans. This is one of my favorite slides because for
all that we know, look how few people are really getting to
control. This is A1c goals that are unmet in patients with
diabetes. We have 20% that have A1cs greater than 9%, a
large number of individuals with A1cs greater than 8% and
overall 64% of people are not at goal in 2010.
This is how we become diabetic. There’s a genetic
signaling for those who fail. We have individuals who are
lean on the left-hand side here, looking at the Y-axis
relative beta-cell volume by percent, looking at lean and
obese non-diabetic individuals. Follow the obesity model
if you would. For those who are prone to become diabetic,
that have impaired fasting glucose or pre-diabetes, they
lose beta-cell volume. This is a very important slide and
then there’s no difference between the lean and obese
individuals who become diabetic, so those who are obese
initially have the ability to rise to the occasion,
increase beta-cell mass by 50% to 100%, but for those who
are prone to diabetes, they will lose that benefit and have
beta-cell failure just like the individual who’s lean over
time.
This is one of my favorite slides because it ties in a lot
of the pathophysiology of type 2 diabetes. If you look at
the beta-cell, why is there so much emphasis on the betacell? It’s because Elliott Joslin from the Joslin Clinic
in Boston had figured it out in the 1920s, it’s all about
the beta-cell. I’ll show you a lot of pathology here but
everything comes back to beta-cell health.
The first defect in diabetes type 2 is postprandial blood
sugar loss. By the time we make the diagnoses in the
clinic, the patient has been diabetic for five to ten
years, fasting plasma defects occur later. We have insulin
resistance and most importantly, a loss of insulin
secretory capacity i.e. beta-cell function, and we can see
this that by the time from the UKPDS and other trials that
you make the diagnosis of diabetes, lost anywhere from 50%
to 70% of beta-cell functionality.
The final caveat is the mention of incretins for the first
time. Incretins are incremental hormones. I'm looking at
carbohydrates in the back. I look at carbohydrates all
night on your plate; I looked at carbohydrates for desert.
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I follow everything my patients do. I shop with them in
the supermarkets they shop in. How much fun to go into the
Italian aisle and they start dropping things on the floor
saying it’s not for them.
[Laughter]
This is the famous blue man. This is really speaking about
glucagon-like peptide 1. It’s an agonist. What it
basically does, it’s a hormone that you see food, you taste
food, you smell food, you ingest food, and food is
predominantly carbohydrates. That carbohydrate has to be
dealt with in a postprandial way. We have L cells
throughout the entire hindgut and foregut, these cells are
very, very important cells, I tell the gastroenterologist I
see why they’re here. The GI tract is the number one
endocrine organ by volume of endocrine producing cells in
the entire body. These cells are capable of baking a
substance called GLP-1, glucagon-like peptide 1, which is a
powerful short-lived hormone that goes to the beta-cell,
upregulates insulin release from preformed granules, it
actually in a glucose dependent manner tells the beta -cell
to produce more insulin, unlike a sulfonylurea, and it also
shuts down with glucagon. Remember that Cain and Abel
thing? Insulin wants to take sugar into cells, glucagon
wants to party, take sugar out of cells, make the liver, at
least glycogen, which is a preformed sugar. This is what
this is all about in a simplistic way.
Remember, the key here is glucose dependency, in other
words you can never get hypoglycemia, because it’s a
glucose dependent manner or function. Now here’s glucagon,
this is the Cain I guess here, and Abel would be insulin.
So glucagon is reduced in postprandial periods in
individuals who don’t have diabetes. You take a
carbohydrate load, in purple there, you take a glycerol
meal and you get insulin to rise in the first and second
phase manner. Glucagon is suppressed, and your sugars stay
between 180 and 120. Fast forward to someone who with
diabetes, this is exactly what you see, a deficient insulin
responsiveness, hyperglucagonemia that’s not suppressed,
and relative hyperglycemia. So this system is quite
important in regulating our carbohydrate loads and our
ability postprandially to deal with them.
This slide here recapitulates what Dr. Zonszein said
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earlier that we have trial data showing failure. No matter
what we did in the UKPDS over ten years, in Europe, in
England specifically, our A1cs decline initially from 7.2
and all the way down to about 6.0, 6.2 and then rapidly
over a year or two began to climb no matter what agents
that we treated the patients with because we didn’t have
the ability to do the following, is to save the beta-cells.
You can see that on the right hand side of this screen
looking at beta-cell functionality to a calculation called
a homo model where we can calculate beta-cell functionality
somewhat. It didn’t make a difference if you were on
metformin or sulfonylureas, versus a control group getting
medical nutritional therapy only, you lost beta-cell
functionality over time and you progress where you came
more diabetic and more hypoglycemic.
So what are our goals? We heard earlier an A1c of less
than 7% is an ideal right now for the ADA. We’re not
teaching individualizing our patients to their goals. The
new ADA recommendations have literally just come out as I
prepare these slides. I’ll show you the old
recommendations from a consensus panel that wasn’t fully
embraced by the ADA but was pretty much their mantra until
recently; I guess it was the last few days, but
nevertheless, we really treat people to less than 7%. And
A1cs are function of a measure of the percent of red blood
cells that have sugar irreversibly attached. You and I
should have between 4% and about 6% of our red cells with
sugar attached irreversibly, it’s a natural phenomena, but
above 6% is abnormal. Seven percent roughly is 150 mg
percent and that’s where we like, have our patients below
that point, but we want to individualize it. If you have a
patient who’s 80 years of age, meal on wheels, living
alone, five days a week, gets meals only two times a day,
you have to be very careful of the type of agents you give
that person, and to control their blood sugars and you want
to be careful not to get their them into a hyperglycemia.
So when we speak about that, we look at A1cs and we do the
test in my office. We do considerations, what kind of
resources or support does the individual have specifically.
We’ll get back to that. Are they a young diabetic with a
lot of resources, maybe getting down to 6.5 is not
unreasonable. If they have a long life expectancy, it
makes sense. If they have a high risk, long term of
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microvascular disease and cardiovascular disease, if we
don’t do that, that’s very - - UKPDS. But if they’re
elderly and they have other medical conditions, we really
have to taper or tailor our care accordingly.
This is really everything we speak about when we look at
any agent for any chronic disease. How expensive it is,
how easy it is to give it, how tolerable and safe it will
be, and how effective it is to prevent low blood sugar.
This is a complicated slide that Dr. Zonszein has shown you
in another way. I'm showing it in colors. These are all
the agents that we have on the marketplace today to treat
diabetes. I’ll let you read across each line. Taste
great, less filling, are my two favorite words in my
practice. Is it going to prevent hypos? Is it going to
treat the patient to goal? Is it going to avoid weight
gain? Is it going to avoid increasing blood pressure or
aggravating the lipid abnormalities in the metabolic, or
what we call cardiometabolic syndrome? Those are the
favorite agents. The agents onboard that I’d like the best
are the metformins, which is worldwide 58-year old drug,
very effective. We use a lot of metformin in our practice,
use a lot of insulin when it’s appropriate, and we use a
lot of GLP-1 agonist as well.
But I want to show you what the problem with insulin is, at
least NPH older insulin. These studies came from 1990s,
and these are various trials of oral hypoglycemic failures.
We added insulin to it, we barely got to the goal of less
than 75, but look at what we did. We created a lot of
weight didn’t we? Those are kilograms, so multiple that by
2.2, nobody, absolutely nobody wants to gain weight to get
their A1cs down. I want to show you some additional data
using NPH twice a day titrating to A1cs of less than 7%,
one file got there, but look at the amount of weight. This
is what our patients fear. We have mow moved forward to
the 21st century, we now have basal analogs, and glargine,
and detemir. We have bolus analogs and various agents that
you see here, and listed here the glycine, aspart, and
lispro. These are all agents to mimic what happens with
our meals. The light color gray is what you are doing as a
non-diabetic, you have first and second phase insulin
release. We can approximate that beautifully now with the
newer shorter acting insulins, and we can give you insulin
throughout the day with long acting agents.
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This is a summary of everything I’ve said this far. In the
five minutes I have left, you have to memorize this.
[Laughter]
So I want you to think about the yin and yang of everything
I’ve said that we have increased hepatic gluconeogenesis.
We have increase in hyperglucagonemia, and earlier diabetes
with insulin resistance issues. We have carbohydrate
absorptive problems, we have agents that really effectively
treat much of this, so we have to mix and match our
efforts. We have a decrease insulin secretion with time,
increase in appetite, and impaired incretin effects which I
didn’t go into. All of these things really perpetuate the
hypoglycemia.
So we look at medical management of hypoglycemia in type 2
diabetes, looking at the original consensus panel from the
ADA. The recommendation was there to use basal insulin,
lifestyle modification of the not so rich and famous, and
then metformin with that, less validated data, it was felt
to be metformin with pioglitazone which is a TZD agent, and
other promotions with GLP agonist, lifestyle and metformin.
I consider this dinosaurs or main street. The President of
the American Diabetes Association the Greater Philadelphia
basin, I carry a lot of weight in Philadelphia, and when I
say things, they quote me. They put them in newspapers and
they come back to bite me. Dinosaurs or main street.
Let’s go to something more reasonable. I do like
algorithms, and I like AACE, American Association of
Clinical Endocrinologists recommendations. This is A1c
characterization. If you have an A1c of less than 7.5% in
a drug naïve individual, we have a plan. Metformin, if
it’s tolerable, normal kidney function, monotherapy, if
that fails, these are all the choices we give you to add
over time, and get up to triple therapy if need be, within
a year, and I’ll walk you to the other two very quickly.
This is what we really like, if you're drug naïve, and
you’re between over 9% rather, if you have symptoms, you
get insulin. If you have no symptoms or a paucity of
symptoms, we’ll give you three different agents with
metformin as the basis, a glitazone, a GLP-1 analog and a
TZD and mixture. So this is really fascinating, this new
data. If you’re undertreatment and failure, you would get
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insulin because you’ll usually be symptomatic. Next one is
7.6 to 9.0 which primary care physicians see all the time.
You start people on two different agents, one being
metformin. If that fails, you do triple therapy within
three months and then you move on to insulin if need be.
Now diet and exercise, this is really what I really want to
bring up before I finish my five minutes. It’s really very
important deemphasize diet and exercise, but there’s a time
when we have to consider bariatric surgery. I want to show
this to you once again in terms of importance. Now if you
look at the data here, this is from the NIH, it has not
been modified since 1991. If you have a BMI greater than
35, but less than 39 with comorbidities, you’re considered
a candidate, if you’re greater than 40, you’re a candidate.
This is the recognition of obesity as a disease state from
AACE, 2011. And so we’re going to go forward, I'm sorry...
and that’s the bariatric surgery. This is the benefits of
bariatrics if you use the right patients, over 22,000
patients, we studied the met analysis. We improved but we
didn’t resolve in my opinion diabetes. I consider
bariatric surgery a treatment that puts diabetes into
remission in the right particular patient cohort but we
don’t think we cure diabetes. We do make the lipids and
the blood pressure and the sleep apnea. A full third of
your patients with diabetes with obesity will have sleep
apnea.
These are the procedures that we do, we do the lap band and
we also do what we call a Roux-en-Y. Here’s the lap band.
Here’s a study I just want to end the talk with.
Characteristics of patients in the New England Journal
study that was performed at the Cleveland Clinic.
Phenomenal study looking at 150 patients, very small
numbers of individuals. I want you to look at their
duration of diabetes which is minimum, use of insulin
minimum. Age, young. Their size between 36, about 36 to
37 BMI. Look at their body weights. Look at their racial.
Look at their sex, and look how much of metabolic syndrome,
they have quite significant. Look at the endpoints, look
at this real carefully. In a medical intensive therapy
giving multiple drugs over a year compared to gastric
bypass, a Roux-en-Y, and then what they call sleeve, are
procedure just focused on the before and after. So what’s
the percentage of people at 12 months that got to A1cs from
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9.2 to less than or equal to 6? Only medical therapy 12%,
we have 42% and 37% in surgical group. Look at the
triglycerides, look at the data for bodyweight reduction.
You go, phenomenal, you’ve lost 20% or more percent of body
mass in one year. This is the data in terms of
medications. I can’t go through all this with you but
there was a paucity of medications used with surgery, and
an increase in medications used for those on medications.
But this is the slide that impresses me the most. The
adversity at the Cleveland Clinic in terms of reoperations,
a wound dehiscence, complications of surgery was minimum
compared to medical intensive therapy, and the final slide
here is the changes in measurements. On the top left, a
change in A1cs, look at the drops in surgery compared to
medicine, look at the average number of diabetic
medications for the surgical group against the medical
group, look as the A1c drops. Notice the changes in
fasting drops in the top right, and a change in BMI. Isn’t
that impressive? But should we be considering bariatric
surgery in all our patients? I don’t think so. The
Endocrine Society has come up with some thoughts. This is
a direct rhetoric to that study and one other that was
published. The number of people who participated in the
studies were small, so it’s hard to know if the results
were also applied to everyone. The studies only follow
people for up to two years in this study one. Researchers
don’t know if the improved blood sugar control will result,
the result from different surgery will last for many years.
The residacent [phonetic] rate of bariatric surgery in all
patients is 30%. That means they gain 75% of the way
backwards in five years. Do you call that a cure?
Behavioral modification needs to what? Be modified. And a
lot of times we didn’t do that despite the surgery. And
the key here is the longer someone has diabetes, the less
likely the diabetes will go away with surgery.
So I'm going to end here with a summary. We are facing an
unprecedented public health threat referring to diabetes,
simply intensifying glucose control, with traditional
treatment strategies cannot sufficiently address this
issue. A multifactorial treatment approach then improves
metabolic control is important. I’ll let you read the
rest. I do thank you for your time.
[Applause]
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DR. FLORES: Thank you very much, Dr. Cannon. So before we get
to questions, we’re going to be sure you have your deely
bopper with you because we need to get as many of you doing
this as possible. The first question, glucagon-like
peptide GLP agonists have been found to address the
following core defects in type 2 diabetes. A) Stimulates
glucose dependent insulin secretion; B) Suppresses glucagon
secretion which decreases hepatic glucose production; C)
Slows gastric emptying; D) Reduces food intake; or E) All
of the above. Please vote.
[Music]
And this time I'm going to show you the pre and the post,
which we haven’t shown you before. And the answer is, 79%
all of the above. And it looks like... which is the pre
and which is the post? Okay, so you guys did do better, I
just wanted to be sure. Very good. Okay.
Second question. Evidence-based studies relating to
glycemic control of type 2 diabetes mellitus have
demonstrated which of the follow? A) Increase in
macrovascular complications; B) Reduction in microvascular
complications; C) Reduction in both; and D) None of the
above. Please vote.
[Music]
I see Emma doing two. Go Emma. Okay. And the answer is,
C) reduction in both microvascular and macrovascular
complications. And you guys did great, 86%. You did
great. So please give all, well, first give you guys a big
round of applause for staying here so darn late.
{Applause]
Q & A
It’s a sign that you’re getting old when you’re willing to
party of conference, but that’s okay. And we’re going to
go into question and answers, so let’s start with our first
question. There’s a line right there.
DR. LOU STEVONARDO: Get in line. Hi, good evening. Thank you
very much. Lou Stevonardo [phonetic], the family practice,
Los Angeles, California. Been taking care of diabetics
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since my medical school years. It’s refreshing to see that
finally there is some push towards a lower than 7.0 A1c
goal with the clause of the absence of hypoglycemic
episodes. Two questions after a point. It seems that many
of the primary care physicians I’ve worked with as
colleagues over the years still adhere to very old school
guidelines. There’s a lot of literature out there. We
focus on cardiovascular disease here, but there are many
studies out there from other journals and medical
associations have shown that things like, I’ll get there,
that an ophthalmology, retinopathy starts an A1c of 5.9.
So it leads many of my colleagues to have this impression
that metaphorically speaking it makes them have the
position that is similar to their large intestine when
they’re constipated. What do you guys think about a
screening A1c test which I know is kind of a controversy,
do we use it as a screening test first of all, because
diabetes is around for five or ten years before it is
diagnosed, and second of all, what about requiring a
certain number of hours of CME for board recertification
like they did for pain management so that the PCPs are
addressing this more aggressively since we see that our
colors are changing in the country. Thank you.
DR. CANNON: The first question I’ll answer. I think the second
question I’ll leave to my colleague, the harder question.
It’s very important to know that the new assay for A1c as
of 2009 ADA meetings in New Orleans, David Nathan’s group
out of Harvard had published data showing new A1c test that
is bullet proof in some ways but not always. The all A1c
could not predict diabetes. You couldn’t use a cut point,
it was 4% to 6%, and you couldn’t call it 6.5% diabetes.
There was just no nomenclature for that. It wasn’t made
for that. The new test actually allows you to diagnose
above 6.4, 6.5 and LabCorp or Quest with upper limits of
normal being 5.6 or 5.7. It is a really interesting test
but it has racial and ethnic problems. And it makes it
difficult for me to put too much credence in it by itself.
Surely, if it’s 8%, you’re diabetic. But there are a lot
of African-Americans and some Latinos, Mexican American
particularly we’re looking at that there is a differential
in the A1c of 0.332 for an African-American.
Now you say what does that mean? Well, if you’re 6.7% and
you’re African-American, are you really diabetic. If you
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really believe that you’re diabetic, I have a bridge in
Brooklyn for you. You’re unlikely to be diabetic, you’re
likely to be prediabetic at most which has a different
implication altogether. So we have to cross culturally
fine-tune this new assay. David didn’t do that. He used
one country in Africa, he has no data for the Asian Indian
continent, the one lab had a heat problem, lost all the
samples. He went to 17 cities for the African-American
Latino data in America. Not strong enough data to say it’s
cross culturally sound but it’s still our first attempt to
diagnose diabetes with a simple test in LabCorp or Quest
and you need to know something else. Early diabetes can be
missed by this assay. One in three people can be diagnosed
properly but two and three can be missed and redone a year
later and found to be diabetic, so it’s really, it’s a type
of test I use with my gold standard. I’d be curious what
Joel has to say here. I use an A1c with a two hour oral
glucose tolerance test. I call that straight with a
chaser.
[Laughter]
DR. ZONSZEIN: So just to emphasize the A1cs were standardized.
The recommendations are that it can be used for diagnosis
of diabetes, and there’s no test that is perfect. The
health disparities between the wide population of Hispanic
and African-American population is there. It moves a
little bit towards the right, and that is important. But I
see A1c as a marker of disease when we call it diabetes or
prediabetes or high risk for diabetes as the ADA wants to
call it. In the diabetes prevention program these patients
with prediabetes, very often they move from prediabetes to
normal. If we don’t do anything about 8.5% a year, they
will develop diabetes. If we do lifestyle changes, we
could decrease that by 62%. If we give metformin, it would
increase it by about 26%, 28%. It will give metformin
lifestyle changes even better, do it’s a moving target, and
I see A1c also as a marker of longevity and well being.
It’s like a HDL cholesterol, so somebody who lives with an
A1c of 5.5% or 6.0% is very, very healthy. Somebody who
gets a hemoglobin A1c of 6.2% or 6.3% even if it’s not
diabetes, it is part of the metabolic syndrome. So we look
at it as a marker and obviously, I try to make the point
that lowering that A1c very early may have implications not
only for prevention of cardiovascular disease and
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macrovasculopathy, but probably for preservation of betacell function as well. So the early intervention is
important, but so far it is a very good marker. The ERIC
trial, the atherosclerosis in communities show the nice
correlation between A1c and cardiovascular events and the
prediction of the A1c as a marker for diabetes, so it is
good.
The second question is very tough, so I’ll leave it to
Carlos.
DR. CAMPOS: I’d like to tackle both those questions. The first
is, and I agree with Dr. Antonio Cannon’s chaser portion of
it because you’ll be surprised how many people that after
they eat, their blood sugars go over 200. And I tell my
patients that we have this beautiful river that goes
through New Braunfels for those of you in Texas, called the
Guadalupe River. In fact, all the rivers in Texas are
names after Spanish names by the way, and the Guadalupe
River, we have these banks and so I tell patients you want
to keep your blood sugars between 70 and 180. When it’s
over 180, then it’s like the river becomes overflowing, it
does some damage. And I often tell patients that that
number is 200. That when that blood sugar is over 200, it
becomes a poison or a toxin and that’s why we see people in
the DPP study that had A1cs of 5.9, they had retinopathy
already. So the chaser portion of Dr. Cannon’s is
something that I like to do especially if I have a high
index of suspicion and if I know that one out of four
Latino are going to have, males anyway, are going to have
diabetes by the age of 45 that I look for reasons to check
for those things.
The second part of your question, I agree with you because
this is sort of my passion anyway, diabetes, so I think we
ought to do that but I think we ought to go in further. I
was at the ADA last year and I was talking to David Bell
[phonetic] from University of Alabama and he said, Carlos,
don’t you think we need a certification program for primary
care in diabetes? I said, yes. You know why? Because
there are not very many endocrinologists in the world, and
only 50% of them do diabetes. And less and less as time
goes on, they like to do a thyroid, they like, you know
why? Because it cost them to do that. And so who takes
care of the diabetics? We do. You and I and Dr. Flores,
primary care doctors do and so we do. In fact, we said,
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what we need to do is maybe get AACE to help us develop a
certification program where primary care doctors throughout
the country get into a certified program and they become
certified diabetologists to take care of those patients.
DR. FLORES: Okay. Thank you.
let you all go to bed.
One more question and then we’ll
FEMALE VOICE: Quick question. So I love seeing the slides that
say, use this first, then this, then if it doesn’t work use
this, but in clinics where people have no money, it’s
metformin $4, glipizide $4, and then oh-oh, because the
insulin’s not cheap and it’s not generic, and if you don’t
have a social security number you can’t get it from the
prescription company. So I just want to know if you know
of anything about insulin going generic or getting cheap
ever or anything that could help us in that because all
those fancy drugs we just can’t use them because they can’t
get them.
DR. CANNON: Yeah. You’re going to have something remarkable
within the next year or so. You’ll be able to get Lantus
or glargine for CME purposes, glargine much cheaper. It’s
going to off patent. And so you’ll have a trustworthy
basal insulin finally, analog type that meets all the
standards presuming it’s made as well and it’s reliable and
safe as what’s on the market now. I don't really like NPH.
If you’re dealing with Medicaid-based populations,
throughout the states, Alabama, Mississippi, and a couple
of others now, are forcing the only “basal” insulins, NPH.
They won’t give you a more modern insulin and this is
causing great deal amounts of hypoglycemia and obesity.
Has anyone here have been ever hypoglycemic? It’s the
scariest feeling in the world. The walls come tumbling
down no matter how good a doctor or physician assistant,
health care provider you are, you can’t coax people to want
to take something that can do that and out of the blue.
I’ve had people down in 40s and 50s and I give them all
kinds of resuscitations, get them to 150 for hours, they
feel horrible. So that’s the problem. But the bigger
problem, no pun intended, is NPH causes as I showed you,
tremendous weight gain at what cost, glycemic control.
FEMALE VOICE:
DR. CANNOT:
- - .
One year from now you’ll have that availability.
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DR. CAMPOS: Let me respectively disagree with you on that
because I don’t think it’s going to get any cheaper,
because who is going to make Lantus? Who else has the
technology to do that? There’s not going to be another
company that’s going to do it for a while. So I don’t
think it’s going to be any cheaper.
I was at a meeting not that long ago and it was reminded me
what you said is that I sort of raise my hand, I use SUs
and they went ah, because they’re cheap, right? And we
need to do whatever we need to do to bring those blood
sugars down. But at the same time, in our community, we’ve
got a group of volunteers to help physicians, actually help
the patients physicians refer to them, to fill out those
forms for them to get the access program that many of the
drug companies like Novartis has and other companies have
to get medications. The problem is people couldn’t fill
them out and we doctors didn’t have enough time to do it.
So we got the United Way to give the money and volunteer so
they could fill out those forms, but that’s going to b e a
continued problem. That’s why when I was at the doctor’s
lounge, somebody asked me why are you getting involved in
the Economic Development Foundation. That’s because we’ve
got to bring good jobs here, and we’ve got to get jobs that
give people insurance to give access to us. That’s the
issue. Got to get involved in our communities.
DR. FLORES:
I said that was it, but one last.
MALE VOICE: Last question, okay. - - about 70 million people
with prediabetes, either diagnosed with impaired blood
fasting glucose or - - postprandial, or an A1c of 5.6 to
6.4. Other than lifestyle modification, do you recommend
metformin, number one. Any comments on basal, I mean
Lantus and Byetta, the new medication which is Byetta,
that’s called Bydureon, and this question goes to Dr.
Cannon. I forgot the brand name of the medication, it’s
derived from bromocriptine. I don’t know if you have —
MALE VOICE:
[interposing] Cycloset, yeah.
DR. CANNON: I’m just going to answer one part and get the
colleagues to ask us. Cycloset, bromocriptine derivative,
it lowers A1cs marginally. Endocrinologists don’t party
very much, we wear Hush Puppies, we’re quite boring. But
what we like to do for glycemic control, we like to see
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A1cs greater than 1% drop for a pharmacologic agent based
on cost and efficiency and effectiveness. Cycloset as you
say, is a very interesting agent. It’s new, its mechanism
of action is still controversial. It has been approved by
the FDA, it does decrease insulin resistance from central
mechanism, no doubt about it. The concern I have is the
number of pills, though they’re small, you have to put the
hand to the patient and the reduction A1cs in the best of
the studies is 0.7. If you add it to metformin like a lot
of companies do in terms of using metformin simultaneously,
in a new patient, you can drop them to about 1.2. Together
that’s a very reasonable approach. But I really would
rather use agents to the max like metformin 2 grams and
then see where we go from there. So my tendency is to take
something we know of the safety, efficacy and efficiency
first, push it to the max so the patient tolerates it.
Let me ask you a question. Does anybody know how many
generic metformins there are on the marketplace today?
FEMALE VOICE:
Whatever Walmart - - .
DR. CANNON: Okay. There are 50 ways to leave your lover.
There’s 36 ways to have indigestion.
DR. ZONSZEIN:
So yeah, the...
[Laughter]
Yeah, you have to titrate it slowly. The American Diabetes
Association recommends the use of metformin in high risk
patients with prediabetes. So it’s interesting this
Medical, National Medical Association make a recommendation
for a drug that has not been approved by the FDA to be used
for patients who don’t have diabetes. So that’s based on
the diabetes prevention program that we were part of the
study as well. The reason that metformin is prescribed is
because it’s generic, doesn’t cause hyperglycemia, doesn’t
cause weight gain, but there is no good data other than D PP
that the diabetic indication would be better than something
else. Next week, the New England Journal of Medicine is
going to have an article on metformin and Avandia in
children, using children and showing the efficacy of
Avandia and metformin. Obviously, we’re not going to be
using Avandia because you can’t prescribe it anymore but
even Actos in young people which binds to a receptor and
activates about 120 genes is very unpredictable to use
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within young people. But we don’t have how to treat
younger individuals. So the answer is yes, we have to be
early and aggressive but if I have a patient with
prediabetes, I would treat number one, blood pressure,
number two, cholesterol, and number three, blood sugar.
And this is from the study that I showed, the Scandinavian
study, the standard trial where 80% of efficacy was really
the starting, but they don’t have a lot of Hispanics or
African-Americans in Scandinavia, and here the African American has a tremendous amount of stroke incidences,
often caused by hypertension. So at Montefiore, the way we
treat is blood pressure, cholesterol, and then sugar.
DR. CAMPOS: The only thing I want to say, I'm not an
endocrinologist but we family doctors are wild and crazy
guys, aren’t we? Yeah, we are. Let me just say that
despite the guidelines, those of us who deliver babies, we
used to use terbutaline and women with premature labor, and
we never had an indication for that. So I use metformin,
I’ll just tell you that, all the time in prediabetes, and
realizing that’s off label. And I'm not a Byetta user, I'm
a Victoza man so can’t help you with that.
DR. FLORES: Okay. Want to thank everybody again for staying so
late and I want to—
[Applause]
Let’s give the speakers a big round of applause. But I
want to point out that our undergraduates students were the
first ones in the room, and they’re the last ones leaving
the room. So let’s give them a big round of applause.
Thank you college students. Good night. There’s a session
at 7:30 in the morning if you’re interested.
[END NHMA_4.27_Dinner_Plenary.mp3]
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