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A look at how physicians can improve their care relationships
More than 34 million Americans have diabetes and about 90% of them have Type 2 diabetes, according to the latest figures from the CDC’s division of diabetes. While this most often develops in people over 45 years of age, recently, more children, teens and young adults are developing Type 2 diabetes or are at extreme risk to do so because of obesity.
Puja Uppal, DO, chief medical officer for Think Healthy.Doctor, has managed patients with Type 2 diabetes for more than a decade. “I am not shy to discuss the potential complications of uncontrolled diabetes and find patients appreciate this greatly,” she says. “I’ve come to describe Type 2 diabetes as a cardiometabolic vascular disease, and I find this descriptor helps my patients grasp diabetes’ massive multisystem involvement. It’s not just about one’s blood sugar.”
Still, she assures patients that it isn’t a death sentence, and they can do so much to help themselves, such as improving their cardiometabolic health.
With more than 20 years of experience managing patients with Type 2 diabetes, Jay Anders, MD, chief medical officer of Chantilly, Va.-based Medicomp Systems, says the start of the conversation for new patients with diabetes always begins by explaining that their lifestyle is most likely going to need some adjustment.
“I also try to assure them that this particular illness is very treatable and controllable, usually with increased exercise, weight loss and possibly new medications,” he says.
Jaydeep Tripathy, MD, a primary care doctor at DoctorSpring, notes that in patients with obesity, the body releases more nonesterified fatty acids, glycerol, proinflammatory cytokines and imbalanced hormones, which can lead to insulin resistance. B cells in the pancreas are also affected by the excess fats in obesity that affect the body’s natural production of insulin.
“Because the body cannot produce enough insulin and the body’s ability to react to insulin is affected, glucose or sugar is slowly building up in the body and their blood sugar levels increase,” he says. “Trulicity and metformin are often prescribed together for Type 2 diabetes patients.”
Tripathy notes a healthy lifestyle is most important for patients with diabetes.
“Patients should manage their blood glucose by watching what they eat while also keeping in check their blood pressure and cholesterol,” he says. “The easiest acronym to remember is the ABCS for managing diabetes. The A1C test is your average blood sugar over three months, which should be below 7%. Blood pressure should be around 140/90mm Hg. Cholesterol should be within the healthy normal range as determined by the physician. S is for smoking, which they should stop immediately if they do.”
Scott Kirkley, MD, an internist with Parkland Health Center in Farmington, Missouri, spends 75% of his time doing outpatient work with patients averaging over 70 years of age and has experience working with those with diabetes.
“I like to sit down with a patient personally to discuss a new diagnosis of diabetes,” he says. “Explaining what diabetes is and necessary monitoring and management is crucial early on. This includes medications, diet and regular blood sugar, foot exam and eye exam monitoring.”
He recommends all patients start taking metformin immediately if tolerated.
“We order diabetic eye exams and check urine tests for protein called microalbumin,” Kirkley says. “We discuss long-term use of ACE (angiotensin converting enzyme) inhibitors/ARBs (angiotensin receptor blockers) to control blood pressures and protect kidneys. We discuss proper foot care and need for monitoring. We discuss if they would benefit from daily aspirin use as well as risk for strokes, heart attacks and peripheral artery disease.”
Additionally, Kirkley likes to order statin therapy to lower risk for cardiovascular events.
“We discuss diet and utility of home glucose monitoring and I recommend a proper diet and dietitian evaluation as well as use of home glucose monitoring for symptoms of hypoglycemia as well as management of insulin,” he says.
Managing Type 2 diabetes is often patient dependent. Uppal says a patient’s past medical history will help determine if she chooses a SGLT2 inhibitor or GLP-1 agonist. She also finds it beneficial to always involve a diabetic educator or a nutritionist.
A challenge is that the cost of SGL2 inhibitors, GLP-1 agonists and insulin can be high. Also, social determinants of health also play a large role here, as in other chronic medical conditions.
“Cost may be prohibitive. You must fight for your patient if cost is an issue,” Uppal says. “Prior authorizations and patient assistance programs are valuable options.”
Explaining to patients that they may be able to reverse diabetes is key.
“For my patients, this means that they are empowered to make a difference in their disease process and we may be able to de-escalate some meds when clinically appropriate,” Uppal says.
Stephen Wander, DC, author of “Reverse Your Diabetes, Change Your Life,” says one of the biggest challenges is a patient’s friends and family sabotaging them with food and/or peer pressure. He makes sure to talk with any patient about their responsibilities if they truly want to get better.
“Patients who want to reverse it will have to work hard and it won’t be easy, but it’s possible and physicians should do whatever they can to help them meet this important goal,” he says.
Anthony Comfort, vice president of product management at VisiQuate, says one of the most important weapons in this battle against diabetes is data.
“There is certainly no lack of data, or data-gathering capabilities, in U.S. health care,” he says. “Between electronic health records, formal remote patient monitoring programs and the health data generated by consumer devices such as the Apple Watch, digital scales and glucose and blood pressure monitoring devices sold at the local Walgreens or CVS, the capacity to keep a close eye on patient health has never been larger.”
Type 2 diabetes requires patients to follow up every 6 months, at a minimum, and in certain cases, it may need to be more frequent.
“You need to work with your patients and their schedules to make sure they can access the care they need and provide other support networks such as patient support groups,” Anders says. “Nurse practitioners and physician assistants also can be employed to create that constant touch for diabetic patients. It has been shown that this approach, usually on a monthly basis, improves compliance and control.”
When it comes to adherence by patients, there’s no big secret, but physicians need to make sure they are listening to their patients and understanding what motivates them.
“If you can speak to that, they are much more compliant with your recommendations,” Anders says.
Close follow-up is vital to success.
“I ask them to be honest with me and only then can we actually make shared decisions,” Uppal says. “There’s a lot they can do to improve their overall health; this means they can live a long,healthy life with diabetes.”
The biggest challenges for many come down to logistics.
“Getting to appointments, overcoming learning on how to monitor diet and glucose and getting and taking medication regularly are really common,” Kirkley says. “I advise every patient that if they want to live a longer and healthier life with diabetes, it is imperative to keep regular follow-ups and take metformin and statin therapy if tolerated. They need to be their own advocates for care and not be afraid to address issues with caring for diabetes.”