The Dynamics of Diabetes
Today’s Dietitian
By Victoria Shanta-Retelny, RD, LD
Vol. 6, No. 8, p. 24

How far have we come in diabetes prevention and management and what challenges remain?

Alarming statistics reveal that diabetes is as American as apple pie—no pun intended. The rising rates of diabetes in the United States are staggering. According to a recent report in Nutrition Action Healthletter, one in 10 middle-aged Americans has diabetes and among people 60 or older, it’s nearly one in five.1 One in five people are classified with prediabetes—those at high risk for full-blown diabetes in the future. Prediabetes is a precautionary sign of higher-than-normal blood sugar levels but not high enough to be called diabetes. Depending on the type of test used, the term prediabetes encompasses either impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Healthcare professionals who educate people with either prediabetes or diabetes must drive home the fact that either condition poses a systemic threat for a cluster of health risks—including heart attack, stroke, kidney failure, blindness, nerve damage, and amputation.1

Prediabetes vs. Diabetes — How Do the Numbers Stack Up?
Of the 18 million Americans with diabetes, an astonishing one-third of them are unaware of it.1 According to the National Institute of Diabetes & Digestive & Kidney Diseases, people often do not know they have insulin resistance or prediabetes because they have no symptoms. Cosmetic indicators of severe insulin resistance include dark patches of skin at the elbows, armpits, knees, or knuckles or a ring around the neck—a clinical skin condition known as acanthosis nigricans.2 For mild to moderate insulin resistance, blood tests reveal normal to high glucose levels with simultaneously high levels of insulin. Thus, knowing what to look for inside and out is the key to determining a diagnosis of a diabetic state. In a cross-section of U.S. adults aged 40 to 74 tested from 1988 to 1994, 33.8% had IFG, 15.4% had IGT, and 40.1% had prediabetes (IGT, IFG, or both). Applying these percentages to the 2000 U.S. population, approximately 35 million adults aged 40 to 74 would have IFG, 16 million would have IGT, and 41 million would have prediabetes.2

Criteria for Taking Action
Whether after a 12-hour fast (fasting blood sugar) or two hours after drinking a sugar-laden liquid (oral glucose tolerance test), what is the nominal impetus for action?

IFG is when blood sugar falls in a range between 100 milligrams per deciliter or higher but below 126 milligrams per deciliter; results reveal diabetes if fasting blood sugar is 126 milligrams per deciliter or higher. On the other hand, IGT is detected between glucose levels of 140 milligrams per deciliter and 200 milligrams per deciliter; if 200 milligrams per deciliter or higher, it is diabetes.3

The body is a systemic marvel with a highly advanced communication network. When one system fails or breaks down, it involves another system—setting off a type of domino effect. Action need not be taken only after blood sugar testing; prevention can be practiced if the physiological relationships that correspond with insulin resistance and subsequent diabetes are present, such as genetics (since insulin resistance can run in families), excess abdominal girth, high low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, high triglycerides, and high blood pressure. In other words, the cluster of conditions associated with the metabolic syndrome or insulin resistance syndrome—formerly known as Syndrome X.2

The Heart Disease and Diabetes Connection
The most common long-term problems that develop with diabetes are related to cardiovascular complications, according to literature by the Joslin Diabetes Center in Boston. There are a couple reasons that people with diabetes are more prone to heart disease: first, high blood sugar levels damage blood vessels. They make the walls thicker and less elastic so blood has a harder time passing through. Second, people with diabetes tend to have higher fat levels in their blood. Higher blood sugars can cause this. These fats, or lipids, clog and narrow the blood vessels. Sometimes they clog completely (atherosclerosis). This can happen in any blood vessel in your body and can lead to a heart attack, angina (heart pain), stroke, or painful legs.4

Collaboration between cardiologists and nutrition professionals is instrumental to disease prevention and educating patients/clients on heart disease risk factors associated with diabetes. “We live in a disease-driven society,” explains David N. Fredericka, MD, FACC, a clinical cardiologist in Warren, Ohio. Fredericka’s practice, Cardiac Management, Inc., is based on prevention as the first line of defense. Many of his patients are hard-working, older immigrants on fixed incomes who “feel better seeing an MD for their healthcare advice,” explains Fredericka. “Secondary prevention, such as statin medications, [is] working great for patients,” but Fredericka believes primary prevention is the key to controlling and limiting disease states. “When we expanded our patient services to include dietary instruction as part of a preventive cardiology focus, 50% of patients made slight improvements,” he says.

“It is a work in progress and very labor-intensive,” according to Fredericka. He works with Jacqui Pressly, RD, on developing patient treatment protocols, follow-up goals, and outcomes measurements. Pressly simultaneously meets with the patients and the MD to establish a repertoire. “If they take away one small thing and/or make at least one change, such as switching from whole to skim milk or increasing dietary fiber, we are making progress,” claims Fredericka.

Pressly is a dietetics pioneer in her own right. She owns and operates a private practice in northeast Ohio. The cardiology prevention program is only one component of her business. The other aspect is her brainchild, a 10-week lifestyle change program called Changing My Style. The comprehensive program provides support and educational tools for people with diabetes. “It’s basic nutrition from A to Z. Within 21/2 years, 30 groups [five people per group] have come through the program,” she states.

One of the outcomes Pressly enjoys most is how her clients come to appreciate each other and bond over the 10 weeks. Ninety percent of her patients have type 2 diabetes or related blood sugar complications, such as polycystic ovarian syndrome. Each of the 10 21/2-hour sessions (25 hours total) provides personalized attention for patients since the sessions are held either at Pressly’s home office or a patient’s home—not in a hospital setting. Since many of her patients are paying out of pocket for her services, Pressly sees a high compliance rate and increased level of understanding.

“I am like a living book. I teach patients what they can read from a book, but with a personal, human touch,” says Pressly. As a result, patients emerge from her program with improved glycemia, appetite control, and weight loss. “A large percentage have lessened their insulin dosages, decreased oral medications, and improved their lipid profiles,” she says. In her collaboration with both endocrinologists and cardiologists, Pressly’s work is a dynamic force in the diabetes community—where she is a key player in disease prevention and improved patient outcomes.

Reimbursement for Services — Is It Worth It?
On December 29, 2000, the Centers for Medicare & Medicaid Services (CMS) published the final regulation on diabetes self-management training in the Federal Register. According to this document, diabetes self-management training is an interactive, collaborative process involving diabetic Medicare beneficiaries and their physicians and instructors. Appropriate training should provide these beneficiaries with the knowledge and skills needed to care for themselves, manage diabetic crises, and make lifestyle changes to successfully manage the disease.5

This training opened a huge door for certified diabetes educators to be accredited and reimbursed for diabetes education programs—if they met certain conditions. The training must meet three conditions to be covered by Medicare. First, it must be ordered by the physician (or qualified nonphysician practitioner) treating the beneficiary’s diabetes. Second, it must be included in a comprehensive plan of care. Third, it must be “reasonable and necessary,” from Medicare’s perspective, for treating or monitoring the beneficiary’s condition.6

According to the Medicare stipulations, to be reimbursed for services, the following Healthcare Common Procedure Coding System codes must be used6:
• G0108: “Diabetes outpatient self-management training services, individual, per 30 minutes.”
• G0109: “Diabetes self-management training services, group session (2 or more), per 30 minutes.”

What Are the Medicare Coverage Conditions?
The beneficiary receiving training must have one or more of the following conditions within the 12 months before the training begins:
• new-onset diabetes;
• inadequate glycemic control (ie, an HbA1C level of 8.5 or more on two consecutive determinations at least three months apart);
• change in treatment either from no diabetes medication to any diabetes medication or from oral diabetes medication to insulin;
• high risk for complications based on inadequate glycemic control (ie, documented acute episodes of severe hypoglycemia or severe hyperglycemia requiring emergency department visits or hospitalization); or
• high risk for at least one of the following documented complications: lack of feeling in the foot or other foot complications (eg, ulcers); preproliferative retinopathy or prior laser treatment of the eye; or kidney complications manifested by albuminuria or elevated creatinine.6

Whether or not it is worthwhile to become accredited and approved for Medicare reimbursement is going to depend on every patient care situation. It is worthwhile to explore the option—to take a look at the CMS’s final rule on this subject in the December 29, 2000, Federal Register, accessed through the U.S. Government Printing Office at www.gpo.gov.

New Approaches to Education and Quality Improvement
The multidisciplinary team approach to patient care is catching on like wildfire. Large medical institutions are looking to diabetes care specialists to spearhead quality improvement programs that improve patient outcomes. Rush Presbyterian St. Luke’s Health Associates is “integrating diabetes care into the medical care system,” according to Barbara Eichorst, MS, RD, CDE, a diabetes care specialist at this Chicago-based institution. “We are involving physicians—mainly primary care physicians—into a new diabetes care model that is convenient for patients to achieve medical behavioral objectives,” she states.

With research such as the Diabetes Prevention Program offering strong support for diet and lifestyle changes in the prevention of diabetes, Rush Presbyterian and other programs are treating diabetic patients with lifestyle modifications and medical nutrition therapy (MNT) to control glycemia and reduce HA1C. Clinical outcomes, such as metabolic changes and self-care behaviors, will be some of the indicators used to evaluate the success of Rush’s program. With increased input from physicians, diabetes classes will be taught by both the diabetes educator and physician with a focus on lifestyle improvements. “A new discipline of medicine is being created—lifestyle disease management. We are dictating future clinical guidelines by pioneering a new diabetes delivery care system,” explains Eichorst. With the identification of biological markers, blood sugar trends, insulin patterns, and daily progress, updating existing evidence-based guidelines will be possible.

What is the future of diabetes care delivery? According to Eichorst, “We are experimenting to find the best method of patient care.” She mentions a possible route is a lifecycle approach, in which treatment is accessed based on what phase of the lifecycle a patient is in—child, adolescent, adult, or older adult. By taking an individualized approach to patient care, programs are able to innovate and exceed current standards of care for long-term benefits. “Forecasting the future and getting support for MNT by all disciplines,” explains Eichorst, is essential to effective care.

Cultural Barriers to Diabetes Self-Care
“A common misconception among my patients is that they think diabetes will go away once blood sugars return to normal,” says Lorena Drago, MS, RD, CDN, CDE, diabetes educator and consultant in New York City. With a specialty in multicultural aspects of diabetes care, Drago’s extensive community work puts her in contact with three populations: Orthodox Jews, Latinos, and African Americans. With more than eight years in private practice and myriad professional responsibilities for products and organizations, such as national spokesperson for Glucerna and incoming president for the American Association of Diabetes Educators, she keeps her messages simple and practical. Her teaching protocol incorporates the ABCs for diabetes management (ie, HA1c, blood pressure, and cholesterol testing).

Part of Drago’s success comes from making house calls. Since many of her patients are newly diagnosed diabetics, she will go into the home to help them understand food labels. “In the Orthodox Jewish population, many are high-risk patients with family history of diabetes, obesity, and inactivity.” Since it was never addressed in the house, “complete diabetes 101” is Drago’s first lesson plan. Part of her program is called “Minding your Ps and Qs”—Portions and Quality. “The premise is that we should keep portions under control and select better quality foods,” explains Drago, “...such as whole wheat, whole oats, buckwheat instead of white flour products, or instead of choosing iceberg lettuce for salad, using baby spinach or romaine lettuce.” She reinforces her messages with high-impact words such as “power foods” and “Oscar winner” to emphasize high nutrient value foods. “Most of my patients find the concept of Ps and Qs easy to remember; it’s a simple concept and most people can get it.” Depending on the cultural background, Drago customizes education materials to include commonly eaten foods.

“Small changes seem to be the key,” explains Drago, as her patients are not always motivated. Most are beyond the precontemplation stage of change but do not believe that changes will make a difference. By setting small attainable goals, such as decreased HA1c levels and no weight gain upon follow-up, patients return feeling successful. “If they are overwhelmed, I give them two to three assignments to work on, such as cutting back juice to one cup every other day or mixing skim with 2% milk.”

In her expert opinion, Drago believes the future of diabetes care is for providers to branch out and not focus only on diabetes but educate on the importance of chronic disease prevention. Her philosophy includes bringing chronic disease programs to the corporate sector, such as a “lunch and learn” series educating those without disease to become aware of the potential risks for onset (eg, overweight, obesity, inactivity, poor nutrition). By getting the human resource departments involved with the development of such a series, Drago optimistically points out, “it would enhance productivity, decrease health insurance costs, and influence positive employee morale.” It’s a win-win situation.

— Victoria Shanta-Retelny, RD, LD, is a practicing dietitian at Northwestern Memorial Wellness Institute in Chicago, a freelance food and nutrition writer, and a culinary spokesperson.

Proper Charting for Diabetes Care
Every three to six months (at each medical visit):
• Hemoglobin A1c test
• Blood pressure check
• Weight check

Every year:
• Blood fats check (total cholesterol, low-density lipoprotein and high-density lipoprotein cholesterol, and triglycerides) if previous levels were normal
• Urine check to measure kidney function
• Talk to other professionals (a dietitian, exercise specialist, nurse educator) for help losing weight, starting an exercise program, or improving blood sugar control as needed

— Source: Joslin Diabetes Center http://www.joslin.harvard.edu/education/library/preventing.shtml

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