Veterans' Health Issues

DIABETES PART 2 : PEOPLE WITH DIABETES OFTEN DON'T GET RECOMMENDED CARE

Written By: Douglas J. Lanska, M.D.
Neurologist Chief of Staff
Tomah VA Medical Center, Tomah, WI

People with diabetes often develop disabling complications, including amputations, heart attacks, strokes, kidney failure, blindness, blockage of blood vessels in the legs, and nerve damage. While many effective treatments exist that can prevent or delay these devastating complications, more than half of those with diabetes do not receive recommended care.

Current treatment recommendations for people with diabetes include control of blood sugar, cholesterol, triglycerides, and blood pressure, as well as early detection and treatment of diabetic eye, kidney, and foot disease.

Control of blood sugar is very important, because the rates of heart disease, stroke, and death increase steadily, even at glucose levels well below the threshold for diabetes.

The best test of long-term blood sugar control in people with diabetes is a blood test called the "hemoglobin A1C test." It is a measure of blood sugar control over n ~evernl month period. A normal AlC value is 6% or less.

Diabetic patients should have AlC levels of ]°/0 or less. Each one-point drop in A1C levels decreases risk of diabetic complications by about 25%. Nevertheless, in a recently reported national study, nearly one in five diabetics had very poor blood sugar control, which means A1C values were greater than 9.5%.

Current recommendations call for monitoring AlC values twice a year in stable diabetics, and four times a year in those whose blood sugar is not controlled and those whose diabetic medications are being adjusted.

Abnormal cholesterol and triglycerides contribute a two- to four-fold increase in risk of heart attacks in people with diabetes. One goal of treatment is to decrease the risk of heart attacks, by achieving low-risk levels of LDL cholesterol ("bad cholesterol"), HDL cholesterol ("good cholesterol"), and triglycerides.

Lowering bad cholesterol (LDL) levels is the first treatment goal. Most diabetic patients get regular cholesterol monitoring at least twice a year, but many are not adequately treated. Indeed, more than half of people with diabetes continue to have bad cholesterol levels in the high-risk range (~130).

High blood pressure affects up to 30% to 60% of patients with diabetes during the course of their illness. High blood pressure substantially increases the risk of major diabetic complications, including heart attacks, stroke, kidney failure, and blindness.

For each 10-point drop in systolic blood pressure in diabetic patients, there is a 100/0 to 15% drop in risk of heart attacks and other diabetic complications. The blood pressure goal for people with diabetes is 130/80.

Diabetics may require several blood pressure medications, in addition to lifestyle changes, to achieve this target blood pressure.

People with diabetes should also have

1. . An annual eye examination by an eye doctor, using eye drops to dilate the pupils and obtain a good look at the back of the eye.
2. . A foot examination by their primary care provider at least once a year.
3. . An annual check of a protein in the urine called albumin to check for kidney damage.
4. . An annual influenza vaccination C'flu shot").
5. . A "pneumonia vaccination" with pneumococcal vaccine.

Unfortunately, only two thirds of people with diabetes get an annual eye exam, only half get an annual foot exam, only half get an annual flu shot, and only a quarter have ever received a pneumococcal vaccine.

Many healthcare providers are reluctant to be aggressive in managing diabetic patients, but numerous studies have now demonstrated the benefits of optimizing diabetic management. Generally, providers should wait only three months to see if a prescribed treatment controls their patient's diabetes, before changing or adding treatments.

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