Download downloadable resource - American Optometric Association

Caring for Persons with Diabetes
Developed by:
American Optometric Association
Health Promotions Committee
Epidemiology of Diabetes

26 million Americans have diabetes
– 90% have type 2 diabetes

79 million more Americans are at high risk for developing
diabetes within ten years

1.8 million new cases diagnosed each year

Diabetes care accounts for 1 of every 6 health care dollars
spent in the US
Epidemiology of Diabetes

The incidence of Type 2 diabetes in Americans < 20
years of age has grown 1100% since 1970

It is the fastest growing sub-population of diabetes by
far

Diabetes is the 6th leading cause of death in the US

The leading cause of blindness in those < 74 yo

The leading cause of kidney failure

The leading cause of non-traumatic amputation
Diabetes Myths

Diabetes is caused by eating too much sugar

Not taking medications to control diabetes means the disease is
less serious

Having type 2 diabetes is ‘better’ than having type 1 diabetes

Type 2 diabetes is not hereditary
A Look at the Numbers…
Diabetes Affects 28.5 Million
Americans

Of those:
– 18.8 million diagnosed
– 7 million not yet diagnosed
– 215,000 are under 20 and mostly have
type I diabetes
Diabetes is…

The LEADING cause of
– Kidney failure
– Non-traumatic lower limb amputations
– New cases of blindness in adults

A MAJOR cause of
– Heart disease
– Stroke

The 7th leading cause of death in USA
Diabetes: A Definition


Failure of the pancreas to produce sufficient amounts of the
hormone insulin
- or Resistance of the body’s cells to the action of insulin
Insulin

Insulin allows cells throughout the body to absorb sugar
(glucose) from the bloodstream

The source of glucose is mostly from carbohydrates in the
foods we eat, but it can also be made by breaking down
glucose stored in our muscles and liver

Insulin & Glucose are necessary for the brain, heart &
kidneys to function
When Insulin isn’t Helping Glucose into
the Cells…

Hyperglycemia occurs (blood sugar levels go up)

This causes damage to body tissues, especially blood
vessels

This then leads to eye disease, kidney disease, nerve
disease and heart disease

Diabetes-related eye disease predicts these other diseases
Diabetes Mellitus - Classification


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Insulin Dependent (IDDM)
Non-Insulin Dependent (NIDDM)
Gestational (GDM)
Insulin-Dependent
Diabetes Mellitus (IDDM)



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Results from destruction of islet cells in the pancreas
More common in persons under 20 years of age
Etiology both genetic and environmental
Patients acutely symptomatic at the time of onset (“the polys”)
Non-Insulin Dependent Diabetes
Mellitus (NIDDM)

Resistance of body tissues to the action of insulin:
– Insulin resistance
– Beta-cell failure



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Usually occurs after age 40
Gradual onset of symptoms (half are unaware)
Occurring more frequently in children
Risk factors:
– Overweight & sedentary
– Family history of diabetes
– Ethnic origin
Gestational
Diabetes Mellitus (GDM)



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Glucose intolerance of variable severity with onset or first
recognition during pregnancy (2nd & 3rd trimester)
Complicates between 1% and 4% of pregnancies
Limited to the term of the pregnancy
Fetal outcome - Macrosomia
GDM Moms are 50% more likely to develop NIDDM later
Offspring are more likely to develop NIDDM during their lifetime
What Are the Symptoms?

All type 1 patients have symptoms

Many type 2 patients have few or no symptoms until
serious complications develop
(e.g. a heart attack)
Symptoms of Hypoglycemia
Shaking
Sweating
Fast heart beat
Dizziness
Anxious
Hunger
Impaired vision
Weakness
Fatigue
Head Ache
Irritable
Symptoms of severe low blood sugar

Seizure

Loss of consciousness (coma)

Stroke

Death
Treatment of Hypoglycemia

15 to 20 grams of carbohydrate that puts glucose into your
bloodstream in about 5 minute will raise your blood sugar about
30 milligrams per deciliter (mg/dL) in about 15 to 20 minutes

Check your blood sugar level again 15 minutes Have person
drink ½ glass of juice or regular soft drink,or 1 glass of milk

If symptoms don’t stop, call internist
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Then eat a light snack (1/2 peanut butter or meat sandwich and
½ glass of milk)
Always have a rapid-acting carbohydrate in the office
Symptoms of Hyperglycemia
Extreme thirst
Frequent urination
Dry skin
Healing difficulties
Hunger
Drowsiness
Blurred vision
Treatment of Hyperglycemia

Have patient test blood sugar

You can often lower your blood glucose level by exercising.
However, if your blood glucose is above 240 mg/dl, check your
urine for ketones.

If you have ketones, do not exercise

Exercising when ketones are present may make your blood
glucose level go even higher.

Drink more water

Change medication/ eating habits

If >200mg/dl for several tests, for two days, or if extremely
elevated:
Call internist
Treatment Modes
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Pen injectors
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Inhaled Insulin (currently off the market)
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Insulin pumps
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CGMs
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Net based education
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New medications
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Insulin used more than in past
Non-Retinal Eye Complications

CORNEA - One of two clear tissues in the body

LENS - The other clear tissue
– It is a very complex process to keep these tissues clear
Refractive error

In poorly controlled diabetes very high levels of glucose can
cause the lens metabolism to shunt down a sorbital pathway

Sorbital buildup in the lens creates an osmotic swelling of the
lens with resulting in refractive changes
Poor Pupil Response
Before Dilating
Drops
30 minutes After
Dilating Drops
Non-Retinal Eye Complications

IRIS - Colored part of eye - rubeosis irides - new vessel growth
that can cause serious glaucoma complications and is usually
associated with PDR
– Typically is associated with advanced diabetic retinopathy;
not easy to identify

GLAUCOMA - Twice as likely in persons with diabetes and
more likely to cause vision loss
Non-Retinal Eye Complications
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OPTIC NERVE - Can sometimes swell (optic neuritis) generally found in younger persons with diabetes and can lead
to permanent vision loss
CRANIAL NEUROPATHIES - Ptosis (lid droop) and proptosis
(eye bulge); occasional reversible diplopia; Bell’s Palsy
Eyelids - Skin related problems
Eye Muscle Problems
Retinal Eye Complications

BDR - Background Diabetic Retinopathy
– Microaneurysms, leakage of intravascular fluid,
intraretinal hemorrhage, retinal ischemia

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PPDR - Pre Proliferative Diabetic Retinopathy
PDR - Proliferative Retinopathy
– New Vessel Growth
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Remember – the retina is a very thin tissue
Mild NPDR
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Standard Photo 1
Moderate NPDR
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Standard Photo 2A
Severe NPDR
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Standard Photo 2B
Very Severe NPDR
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Standard Photo 5
Proliferative Diabetic Retinopathy
(PDR)
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Neovascularization of the Disc (NVD)
Neovascularization Elsewhere (NVE)
Pre-retinal Hemorrhage (PRH)
Vitreous Hemorrhage (VH)
Non-High Risk Proliferative
Diabetic Retinopathy
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Standard Photo 10A
Standard Photo 6B
High Risk Proliferative Diabetic
Retinopathy
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Standard Photo 10C
Standard Photo 7
Standard Photo 10
Standard photo 13
Laser Photocoagulation Treatment
Injections
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Triamcinolone acetonide
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Lucentis and Avastin
Diabetic Macular Edema
(DME)
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The collection of intraretinal fluid in the macular area
Disrupts retinal structure
With or without lipid exudate or cystoid changes
Focal or diffuse
Can occur at any stage of retinopathy
Only treated when it becomes “clinically significant”
Follow-up every 3 to 4 months by a retinal specialist
Clinically Significant Macular
Edema (CSME)
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Patients referred for treatment immediately.
CSME responsible for nearly HALF of all vision loss in diabetes!
Diabetic Retinopathy
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The most significant ocular complication of diabetes
The leading cause of blindness - ages 20-74
All complications of diabetes have a slow progression
in the beginning
– leads to patient non-compliance
Type I Diabetes
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Past thinking: Usually free of retinopathy for first ten
years after diagnosis
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Present Thinking: 20% have retinopathy at one year;
67% have retinopathy at five years
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95% have retinopathy after 15 years or more
Type II Diabetes
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May have retinopathy at diagnosis
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30% have retinopathy within 5 years
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80% have retinopathy within 15 years
Severity of Diabetic Retinopathy
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Depends on
– Disease Duration - always ask how long
– High Blood Pressure - very serious
– High Glycosolated Hemoglobin
– Smoking = major risk
Example:
– Patient A.J. (HTN, A1c = 10, smoker): diabetes
less than 20 years; vision: 20/800
– Patient D.D. (good control of all risk factors):
diabetes greater than 25 years, vision: 20/15
Optometric Management of
Persons with Diabetes
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Frequency of Exams
– After Diagnosis: Every Year Dilated Pupil Exam
(Should be pre-scheduled)
– After First Diagnosis of Diabetic Eye Changes:
Every year or six months
– At Pre-Proliferative Stage
 Should be referred to retinal specialist
Less than 50% of persons with diabetes get dilated
eye exams yearly
– You must preschedule!!
Treatment Options

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PREVENTION - 75% of all diabetic retinopathy could
be eliminated with proper control of the disease
– Medication - Drs. do adequate job
– Exercise - Drs. do poor job
– Diet - Drs. do poor job
One of the greatest causes of death and disability in
the USA is overeating and a diet heavy in fats,
meats, and sugars
Treatment Options
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Argon Laser Photocoagulation
Pan Retinal Photocoagulation
– Laser kills peripheral retinal tissue
– feedback to brain says - “this is dead tissue, no
need to grow vessels here”
Victrectomy
– Remove bloody scarred vitreous and replace with
saline
– Injections
Laser Photocoagulation
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Reduces visual loss by 50%
Goals:
– Prevent further neovascularization
– Reduce risk of vitreous hemorrhage and/or reduce
traction retinal detachment
Side Effects (lessened now with injections)
– Constriction of peripheral vision
– Decreased night vision
– Loss of acuity
Treatment Options
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Early Diagnosis is the Key
– ALWAYS preschedule your patients with diabetes
for annual (and other) visits
Education/Motivation is Essential
– 1-800-DIABETES/diabetes.org
– Diet Consult
– Exercise Consult
– Diabetes Education Classes now covered by
major medical and Medicare
Why Does Diabetes Kill So Many
Americans?
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Doctors do not seem to understand the disease
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Patients do not seem to understand the disease
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The public does not seem to understand the disease
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Not many people care
– primarily affects older people, or under/un-insured
Obesity by the numbers

Complications from obesity kill more
Americans than smoking – and smoking kills
1000 Americans per day!!!!

Strokes, hypertension, cardiovascular
disease, and diabetes can all cause
blindness, as well as other disabilities and
death
Supersized Suicide
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The food industry produces 3800 calories per
day for every person in the USA; up from
3300 from the 70s.
Adult females need 2200; adult males 2500
The food industry spends 10 billion dollars
yearly in direct advertising and another 20
billion in indirect advertising (school
scoreboards etc.)
Two words: Free Refills!! (and what ever
happened to a ten ounce bottle of soda?)
Supersized Suicide
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The campaign for fruits and vegetables
spends about 2 million per year on public
education
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The food industry pushes processed foods
(potatoes are cheap; potato chips are not)
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Portion sizes have increased dramatically
Kids in the line of fire
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70% of obese children will
become obese adults
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Most breakfast cereals and kid
drinks should be labeled as
candy – Froot Loops has no fruit
and no fiber
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Soda Pop parties; food as a
reward; candy and bake sale
fundraisers; terrible cafeteria
food; less exercise, more video
games, and more computer time
A paradigm shift needs to occur

Insurance will pay for special shoes, medical
procedures (such as amputation), however, dietary
counseling needs to be covered as well.
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Nutrition training is important for doctors, additionally
it is important to discuss weight even when the
patient’s ‘vital signs’ seem OK
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Obesity is not a cosmetic issue, it is a medical issue
Research on obesity is obscene


NIH = 226 million for
obesity research
NIH = 2 billion for
cardiovascular
research
If we cured the
obesity, we wouldn’t
have near the
cardiovascular
disease!
Are we just overeating?
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We are exercising less
Our jobs require less manual labor
We have larger portions shoved at us
We have advertising bombarding us
We are eating out more
For easing stress, if we don’t do drugs, we do
food
Even as adults, food is a reward
Is this just a USA thing?

Well, no, but look at
this……….
Great Marketing Tricks
Millions of dollars are spent encouraging us to eat
more highly processed foods
What can WE do??
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Share portions
Special order
Take home boxes or just leave it on the plate
Don’t be blinded by the advertising
Eat less processed foods
Reduce meats, fats, and high sugar foods
Forget about special ‘no protein, all protein, no white
food, blah, blah, blah diets and simply change your
eating behavior
Exercise more
Self Monitoring of Blood Glucose
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One Touch Ping and Animas Pump
SMBG
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Self-monitoring of blood glucose
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All patients should perform SMBG
– Fasting and after meals (ideally, but rarely done,
and if so usually on Type I persons)
– 50% of people with diabetes do NO SMBG

Normal blood glucose is between 70-110
– Up to 150 after a meal
– Less than 90 in the morning after fasting
Continuous Glucose Monitors
Inserted under the skin
 Replaced generally weekly
 Shows trends
 Still must be calibrated with finger sticks
twice daily
 Alarm settings can signal a call to action
 Some will “talk” to an insulin pump but
not make automatic changes
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Dexcom Continuous Monitor
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Transmitter and receiver
What Does Diabetes Research Tell
Us?
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Keeping blood pressure levels below 130/80
lowers the risk of all diabetes complications
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Getting an annual dilated eye exam cuts the risk
of going blind from diabetes by up to 95% by
allowing for early detection of eye complications
Hemoglobin A1c (HbA1c)
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HbA1c measures the AVERAGE blood sugar level over
the preceding 3 months
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HbA1c predicts those people most likely to go blind
and/or die from diabetes
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“Normal” HbA1c is around 5%
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The average patient with diabetes has an HbA1c of 8.5%
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For most people with diabetes, the HbA1c goal is <6.5%
– Exceptions are kids and those with established CVD
What Does Diabetes Research Tell
Us?
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Keeping blood sugar levels as close to normal as
possible lowers the risk of all diabetes
complications
– Diet (especially portion control)
– Exercise (lowers blood sugar & improves
insulin resistance)
– Medication

Patients & Doctors need to know their numbers
and what they mean…
Preventing Diabetes

Walking 30 minutes each day, five days each
week, reduces the risk of developing diabetes by
up to 60%
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Sleeping 7-8 hours and eating more vegetables
also lowers diabetes risk

If you don’t get diabetes, you can’t go blind, lose
a foot, or die from diabetes!
Who Should Educate?

Each and every health care provider, including
para-optomteric staff
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The best way to change unhealthy behaviors is
by building a relationship with your patient

If the patient hears the same plan from every
provider, they are more likely to follow through
on proper care
Practical Tips for Health Care Team

Tell the doctor you’re interested in helping
provide excellent diabetes care
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Learn all you can about diabetes
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Make sure you’ve got orange juice or sugared
soda set aside for patients

Develop a plan to measure blood pressure & ask
about HbA1c for every patient with diabetes
Practical Tips for Health Care Team

Ask about SMBG
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Ask about physical activity
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Ask about common diabetes medicines
– Insulin and/or pills for blood sugar
– Blood pressure & cholesterol medicines
– Aspirin therapy
Practical Tips for Health Care Team

Ask who treats their diabetes & how often they’re
seen

Ask if they would like more information on
diabetes and preventing complications

Help the doctor to make sure that every patient
with diabetes is dilated annually

Remember that diabetes is not who they are, but
a condition they have
What the DCCT Told Us

Prevention IS the cure
– 76% less retinopathy
– 54% less kidney disease
– 60% less neuropathy
– 50% less amputations

These results are over ten years old and doctors and
patients still do not understand
Key Points
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Diabetes is a serious disease
Diabetes has become an epidemic
Treating diabetes complications like eye disease and
heart disease is a LOT more expensive than
preventing those complications
Eye doctors and their assistants are on the ‘front
line’ in the battle against diabetes, and can make a
real difference
Optometric Role in Managing
Patients with Diabetes
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Take a good case history to find the undiagnosed (6
million)
– Episodes of blurred vision?
– Polys – Increased thirst, hunger, urination,
– FFFF – Fat, Forty, Female, Family History
Low Vision Training
– provide low vision care for the partially sighted
Pre-schedule all persons with diabetes
Refer to diabetes specialists
– Internists
– Dieticians
– Diabetes educators
Low vision exams
Low Vision exams
-evaluate functional vision and
-assesses individual needs (especially
important for those with vision loss due
to diabetes)
LCD video magnification
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Sharper image than TV
Up to 50X magnification
Takes up less space
Around 2200.00
Enables patient to read or
look at pictures
And write checks and
letters
Lighted magnifiers reduce glare and
provide contrast
Spectacle mounted telescopes can
improve distance vision dramatically
State Department of Rehabilitation

Can Give a Workshop on Services They Provide

Can Be A Great Referral Service for Low Vision
Patients
Summary:
Very Serious Disease
 Early Detection Essential
 Education Essential
 Good Control = Less Complications
 Intervention/Treatments = Less
Blindness
 Low Vision Services May Help to
Rehabilitate Patients Who Have Lost
Vision

THANK YOU!
For More Info:
American Optometric Association: aoa.org
American Diabetes Association: diabetes.org
National Institutes of Health: ndep.nih.gov