The buzz in family medicine or other outpatient practices is “what is the desired blood pressure goal for a patient with diabetes?” As an academician, I am teaching my current student pharmacists about the new hypertension guidelines. However, there seems to be confusion with what goals are set by the specific guidelines. As an end result, there are three different blood pressure goals for patients with diabetes. Practitioners have been waiting for updated guidelines, particularly the anticipated Joint National Committee (JNC) VIII guidelines; this set of guidelines was published in late 2013 and specifically address other patient populations and new blood pressure goals. For this blog, I wanted to focus on the differences between the guidelines in desired blood pressure and recommended treatment.
Blood Pressure Goals
1 = first-line therapy; 2 = second-line therapy; 3 = third-line therapy
As the saying goes – out with the old and in with the new… Let us know which guidelines you and your practitioners are following for practice. What blood pressure goal do you want to achieve with your patients? What are your thoughts of these guidelines?
I have been so fortunate to have been able to volunteer in a variety of ways from local walks to medical work internationally. Although it is usually long days (and even nights) finding the time to organize and accomplish volunteer work, I always finish with a big smile on my face and feel so lucky to have shared in the experiences. If you haven’t gotten your feet wet in volunteering, here are some ideas!
If you feel you have limited time to volunteer (kids at home, aging parent responsibilities, physical limitations), start locally. Diabetes walks are available throughout the country, and if you do not have one in your city or town, consider starting one! Contact either the American Diabetes Association or JDRF – or start one for your own as a diabetes awareness campaign! Bike rides for diabetes are also spread throughout the country. You can give a few hours helping out the day of the event, joining a committee and helping to recruit volunteers, planning the food, being a bike coach or providing support along the route. Your family (large and small) can usually take part in these activities as well. It’s a great day! When riders cross the finish line with big smiles on their faces, I often have tears in my eyes and realize how lucky I was to have been a part of the event. I bet you will, too.
It is easy to volunteer for children’s diabetes camps. It’s a huge learning curve for those new to kids with type 1 diabetes. Now that is something I would just as soon do all summer long; just leaping from one camp to the next. From nurses, dietitians, pharmacists, and physicians – everyone is needed at kid’s camp. I happen to love the outdoors – and Montana and Colorado, where I volunteer, have the most beautiful camp locations! It was just a phone call and I was volunteering to be a counselor – oh so many years ago. That has morphed into planning all the menus and seeing over the medical needs of kids at camp. It takes a lot of my time, but with a supportive husband, and a job that allows me to take some “leave without pay,” I’m able to spend time in the outdoors, helping to guide children with diabetes in decision making that hopefully can make a difference (or at least keep them safe and happy at camp!) My husband volunteers with me on diabetes backpack and raft trips as a guide and chef, and has learned so much of what I do and has been amazed at the intensity required to manage diabetes!
There is also international volunteering – seeing new places and helping people around the world with diabetes or other medical conditions. I have traveled to places (Liberia, Honduras, Jamaica, and more) that have not been on my travel bucket list – staying in not so comfortable accommodations, rinsing off in freezing cold showers with water surrounding my feet, eating food I had no idea what it was, seeing 700 patients in a long day and loving every bit of it. It is exhausting and wonderful all at the same time. Contact your local hospital or church. They may have a fit for you!
And if you are a bit more conventional, volunteer for your professional organizations such as AADE and ADA. I have met wonderful colleagues from around the country volunteering for national committees as we have worked together to help shape a part of the guidelines for diabetes education.
It’s all there – waiting for you. Find your match and receive the warm feeling of giving freely of your time and energy to a cause beyond your work environment.
I know MANY of you are passionate about what we do and volunteer in a wide variety of capacities. Please share your activities and provide insight for those looking for their volunteer match.
Special Guest Blog from Hope Warshaw, MMSc, RD, CDE, BC-ADM, Owner, Hope Warshaw Associates, LLC, Alexandria, VA, and Immediate past AADE member Board of Directors
On March 13, 2014, I had the privilege of representing AADE on Capitol Hill for a congressional briefing presented by the Health IT Coalition (link), of which AADE is a member. The goal of this briefing, The State of Technology Enabled Care, was to highlight the need for modernized telemedicine regulations. Other panel members were a Parkinson’s patient using telehealth with a distant provider and a psychiatrist who’s used telehealth for a decade. View an abridged version of the briefing.
The following summarizes my key points. Read them in their entirety here. Also, consider reading Update Health IT Policy Now, an article by Joel White, executive director of HealthITNOW published in Roll Call.
- To offer examples of the use of novel communications in diabetes care I shared my experiences as an online weight management coach using a research-based intensive lifestyle intervention based on the Diabetes Prevention Program (DPP) with a population of people with and at risk of diabetes and weight related diseases. I also shared my experience as an insulin pump trainer and diabetes educator working with intensively managed clients virtually. I reinforced the point that research continually demonstrates that frequent clinician interaction with patients, including with a diabetes educator, increases successful outcomes.
- I reviewed key statistics: the numbers of Americans with diabetes, according to CDC estimates, and the American Diabetes Association estimates for diabetes-related cost expenditures. I then emphasized that research shows providing people with Diabetes Self-management Training (DSMT) can bend the healthcare cost curve.
- I described DSMT in detail including the common settings, the National Standards, accrediting bodies and Medicare reimbursement. I mentioned that CMS has recognized significant underutilization of the DSMT benefit and due in part to this factor has added DSMT to the list of available telehealth services.
- I then segued to the point that delivering DSMT using telehealth should be a natural evolution of healthcare delivery innovation noting it could address some of the hurdles people with diabetes currently have obtaining DSMT in person.
- I provided the three common sense actions AADE is encouraging Congress to consider to embrace teleheath and bring healthcare delivery into the 21st century:
1. Remove the geographic and provider barrier limitations. Today, under current law, Medicare can only reimburse DSMT delivered using telehealth for beneficiaries located outside city limits or in areas with a provider shortage. For people to make the critical and permanent healthy behavior and lifestyle changes they need frequent and continuous support. House bill (HR 3077) would help remove some of these barriers by facilitating interstate licensure for health care providers.
2. Remove the limitation of the physical setting for delivery. Today the list of sites where a service such as DSMT can be delivered via telehealth is a physician’s office, a hospital and a limited scope of other named facilities. Congress needs to widen the scope of approved venues for delivery of DSMT by telehealth.
3. Add federally qualified diabetes educators to the current list of practitioners for telehealth services. I requested support for our legislation, the Access to Quality Diabetes Education Act of 2013 (HR 1274/S 945)
I concluded by noting these three measures are what AADE members believe are very cost effective and efficient changes in telehealth regulations. These changes could increase utilization of DSMT which in turn could prevent and delay the costly complications of diabetes and improve the long term health and productivity of people at risk for and with diabetes.
Tuesday, March 25th has been designated by the American Diabetes Association as Diabetes Alert Day. On this day, individuals are encouraged to take a one-minute diabetes risk test. After taking the test, individuals are encouraged to participate in a Walk to Stop Diabetes in their communities. TAKE IT. SHARE IT. STEP OUT. This is their motto.
The numbers are staggering -
As bad as the numbers are in the US, other countries are worse. In an article published earlier this year in the Journal of the American Medical Association, the findings of the most comprehensive survey for diabetes ever conducted in China shows 11.6 percent of adults, or 114 million people, have the disease. This finding adds 22 million people with diabetes to a 2007 estimate. What this means is that nearly one in three people with diabetes lives in China.
Another significant finding is that people in China are developing the metabolic disease at a lower body mass index than Americans. Researchers speculate this may be due to changes in diet and physical activity fueled by rapid economic development. There are concerns that the epidemic will worsen as 40 percent of 18 to 29 year-olds are on the verge of developing diabetes. In the study, the average BMI in China was 23.7, compared with 28.7 in the US. The study also reported prediabetes was present in 40 percent of adults ages 18 to 29, and 47 percent among those 30 to 39.
India is also experiencing a major epidemic. In a 1998 survey done in India, researchers tracking the disease found that rates were high in the middle class and negligible among the poor. Ten years later, the Madras Diabetes Research Foundation (MDRF) found that diabetes rates among people earning less than $94 a month more than doubled from 6.5 to 15.3 percent. They also discovered that 10 percent of the population in other rural areas had diabetes where there had been virtually a zero prevalence 10 years ago. A study done by researchers from MDRF and published in December 2011 estimated that there were 62.4 million people with diabetes across India - up 65 percent from a 2004 estimate. The study theorized that an additional 77.2 million Indians could have prediabetes and that by 2030, 100 million peopld in India could suffer from diabetes.
Amazing numbers for this worldwide crisis.
Sometimes as educators we can get caught up in the typical definition of exercise and emphasize walking, sports involvement or exercise classes. However, we often neglect to mention one of the most natural forms of activity that has an impact on both nutrition and physical fitness: gardening. Our ancestors gardened out of necessity and these days it is rare find. The benefits of eating fresh vegetables are known and accepted, but some of our patients may not realize the physical benefits of gardening and the impact on BMI.
Last April, the University of Utah's Department of Family and Consumer Studies published a study on the benefits of community gardens. They compared BMI of 198 gardeners who participated in the community gardens to the BMI of various combinations of neighbors and family members of the same age and gender. They found female gardeners had a 1.84 lower BMI than their neighbors or that they weighed 11 pounds less for a 5’5” woman. Male gardeners had a BMI of 2.36 less which equates to a difference of about 16 pounds for a 5’10” man. This was an example of the benefits of community gardens, which is starting to increase in popularity in urban areas.
I live in Lexington, Kentucky and there have been several community garden projects in the past decade. It has really taken off with low-income neighborhoods and our refugee population. Another study suggested the Navajo population should have a multidisciplinary approach integrating gardening and agriculture activities to help reduce diabetes risk.
Other benefits of gardening are getting outdoors, soaking up vitamin D from the sun, and the social connection of sharing produce and working together on a project. All things that also help reduce depression, which is a higher risk for the diabetes population. I am not a gardener myself and barely have a backyard in the neighborhood where I live, but I have just been thinking recently about the benefits of gardening and thinking about trying to grow a few things for my children so they can learn how things grow. I encourage you to discuss gardening with your patients. Please comment below if you have success stories of patients with diabetes who have seen benefits of gardening with their diabetes.
AADE’s strategic plan for 2013-2015 includes a priority of “Empowering People with Diabetes” with a purpose of heightening “awareness of the power of diabetes self-management and the value of diabetes educators...” One component of the plan for this priority includes work with a professional public communications firm, pci® (Public Communications Inc.), to increase awareness to stakeholders including people with diabetes, healthcare professionals, and third-party payers. This is a multi-year, multi-faceted outreach campaign to increase awareness of the value of diabetes self-management education and support (DSME/S). Recently, eYI included a PowerPoint presentation, which any of us can use to promote DSME/S.
I am one of a team of members enlisted as AADE media spokespersons. To prepare for this role, we attended media training. It was a great opportunity to learn tips for working with media as we represent diabetes educators (DEs). But, it isn’t just this team that increases awareness of the benefits of DEs and DSME/S. We all do this in some form by providing exceptional care; participation in health fairs; and communications with referring providers, insurance companies and to the general public.
During the media training, we were videotaped as if in real interviews, and then critiqued ourselves and each other. I am not sure what I expected when I got to the training; in hindsight, the camera shouldn’t have been a surprise. This was an incredibly helpful, but humbling, experience!
I expect many of you are called on to give interviews about diabetes and diabetes education, from local newspapers, new/radio stations, magazines, etc. pci® provided us with great input and some tips for effective interviews. I wanted to share some of them with you, in case your phone rings tomorrow morning with someone requesting an interview.
Probably the most important thing I learned is that I can be in charge of the interview. I always relied on the reporter to ask me questions and I answered. Not the most effective way to get the important points to the reader/listener. Go in with a plan. Know your primary message and don’t hesitate to get it out there more than once. Lead into your point with emphasis saying something such as “A very important point is…” or “One key point people should remember is…” Then, give examples to support the point.
Of course, one key message we should include is the benefit of working with a diabetes educator. Toot our horn, get our message out, let the world know, with self-management education from a DE, a person with diabetes can have improved clinical outcomes, decreased long term complications, and better satisfaction.
Prepare for the interview by learning about the show/paper/blog/reporter and determine what part you play in the story. Think about questions you might be asked and how you will answer them.
When choosing words, avoid jargon, acronyms, and big words; be conversational, relaxed, yourself; yet be concise. Give examples or tell a story if it helps to support your point (remembering that nothing is ever “off the record” especially when it comes to confidentiality).
Let’s work together to get the word out about the importance of diabetes educators and DSME/S for people with diabetes.
In May 2013, I wrote a blog about INVOKANA [canagliflozin] – the first sodium glucose co-transporter 2 (SGLT-2) inhibitor. It was the first Food and Drug Administration (FDA)-approved agent in this new therapeutic class for the management of type 2 diabetes. This new class was developed to target another defect for hyperglycemia (i.e., kidneys). In development, it had desired characteristics for an anti-hyperglycemic agent, such as minimal to no risk of hypoglycemia and weight loss with an effective, proven A1c reduction.
Another SGLT-2 inhibitor was approved in January 2014 for the management of type 2 diabetes – dapagliflozin or FARXIGA. In healthy individuals, approximately 90 percent of the filtered glucose is reabsorbed by SGLT2 in the proximal renal tubule. The kidney desires to excrete excessive, filtered glucose in order to restore normal levels of glucose in the blood. In a patient with type 2 diabetes, the kidney is dysfunctional and responds to hyperglycemia through glucose reabsorption. (Defronzo RA, Diabetes 2009)
Dapagliflozin works similarly to canagliflozin to decrease plasma glucose due to increased glucosuria. Theoretically, this primary action would lead to: (1) increased insulin sensitivity; (2) increased insulin secretion; and (3) decreased glucose production by the liver. Based on the evidence, dapagliflozin has similar A1c reduction and weight reduction as canagliflozin.
While there may be benefits to this new class, there are still some concerns. For example, there is a risk of urinary tract or genital mycotic infections from its activity of glucosuria with canagliflozin and dapaglifozin. On a serious note, bladder and breast cancer was found in a small number of patients who received dapagliflozin; this adverse event was the reason for its first drug application to be denied by the FDA.
In recent evidence from the Journal of Clinical Investigation, there were two studies with a small number of patients that demonstrated the effectiveness of canagliflozin and empagliflozin (not approved in the United States) on glycemic control. In the studies, both agents increased glucose excretion in the urine. However, both studies demonstrated an increased endogenous glucose production through elevations in glucagon levels. This new evidence may be preliminary data showing a compensatory increase in glucagon secretion, which would contradict the class’ theoretical mechanism of action.
Providers will either prescribe or wait to write a prescription for these products as they become available on the market. However, there may be some reluctance especially as more evidence is evolving that may counteract the proposed theories for canagliflozin and dapagliflozin.