Guest Editorial: Stephen Freed, RPh, is the Diabetes Educator Publisher of DiabetesinControl.com Newsletter Stephen Freed has been a registered pharmacist for the last 30 years and a Diabetes Educator for over 15 years becoming a certified diabetes educator 1995 and for the last 16 years has been dedicated in advancing diabetes care to physicians, pharmacists and nurses. He is the founder and publisher of www.diabetesincontrol.com, a diabetes newsletter that goes out to over 77,000 medical professionals in diabetes care.

     —John Steinberg, DPM, PRESENT Editor

Stephen Freed, RPh Diabetes Educator Publisher DiabetesinControl.com

Making Podiatrists A More Integral
Part of the Diabetes Team

Diabetes is a growing epidemic all over the world. The Centers for Disease Control and Prevention (CDC) has stated that any child born in the year 2000 and after has a one in three chance of getting diabetes and if that child is African American, Hispanic American or Native American, every other person, 50%, will get Type 2 diabetes[1].  Right now 12% of the US population has diabetes and it is expected to explode to 40%. 

If not in control, patients who are diagnosed at the age of 40 will die 12 years prematurely and diabetes will negatively affect their quality of life for the last 20 years.  Those that are diagnosed at the age of 50 will die 9.3 years prematurely and the disease will affect the quality of their life for the last 16 years [2]. What does that mean for those diagnosed at 30 years of age and below? And it is all preventable.

Today, most podiatrists’ practices consist of a high proportion of patients with diabetes, due to the fact that according to the National Diabetes Information Clearinghouse, 60-70% of patients with diabetes have neuropathy affecting the lower extremities. In the US, our medical system is so fragmented that a newly diagnosed patient with diabetes will see a primary care physician, then an endocrinologist, rarely a diabetes educator, and an eye doctor, as part of their initial workup, but only see a podiatrist after they have a foot problem.  Now with new technologies such as an IR foot thermometer, a podiatrist can detect foot problems before there is tissue loss. But most family physicians do not refer the patient to a podiatrist until after a problem develops.  Why is that?

This may be because the podiatrist is not perceived as being an essential part of the Diabetes Team by medical community, or even by patients.  Many podiatrists are not seen as being focused on the whole patient.  They are seen as being focused only on the lower extremity. We also do not emphasize and are not rewarded for the practice of preventative medicine.  We now have a great opportunity to change that perception and make the podiatrist a more integral part of the diabetes team, which is currently seen as consisting of the primary care physician, dietitian, nurse educator, pharmacist and eye doctor.

Toward Being a More integral Part of the  Diabetes Team

How can podiatrists become a more integral part of the diabetes team?  Type 2 diabetes accounts for 90% of the diabetes cases, which make up a majority of podiatrists' diabetic patients.  And Type 2 diabetes is a lifestyle driven disease.  That means that if a patient is not educated as to how to make the right lifestyle decisions, they are likely doomed to failure.  Educating the patient as to how to self-manage their diabetes is 98% of controlling their diabetes.  If they don’t know how to read a food label, understand the importance of monitoring and how to interpret the numbers, the importance of physical activity or how to examine their feet on a daily basis, they will never control their diabetes.

What can you do as a podiatrist? 

First, recommend that your patient attend diabetes classes and facilitate their finding such classes run by the most talented diabetes educators in your area. Make that recommendation a routine part of your initial visit with your patients with diabetes. Contact the local diabetes educators by going to www.diabeteseducator.org and find an educator by zip code.  Ask them where classes are held and what the cost is.  Contact your local Lilly, Aventis, Novo, etc... representatives and ask for free educational materials that you can provide to your patients.

Importance of In-office A1c Testing

But most importantly of all, provide an instant A1c test in your office and discuss the results with your patients. Many patients with diabetes and prediabetes (over 60 million) do not understand exactly what the A1c result actually means and the great value that it has for them.  The A1c test result is an accurate long term measure of serum glucose.(90-120 days), and has now been recommended by the American Diabetes Association as one of 3 tests to be used to make the initial diagnosis of diabetes (along with Fasting Blood Glucose - FBG and Glucose Tolerance Test - GTT).  Since elevated glucose affects so many body systems, a high A1c can increase the risk for heart disease, cancer, tooth decay, colds, flu’s and even Alzheimer’s.[7] The higher the number, the greater your risk for many diseases. It is also being used successfully to motivate patients to better self-management of their diabetes.

Convert the A1c number into an average blood glucose (see formula at www.a1ctest.com), so that your patients will have a better understanding of their diabetes control.

Average blood sugar = (28.7 x A1c) -46.7 (From Diabetes Care – Aug. 2008)

Then fax a letter to their primary care physician letting them know the results of the foot exam and the results of the A1c test, so that they can enter this information into the patients chart. This can increase your referrals from those physicians.

Are you aware that, according to a study published in Diabetes Care, by providing an A1c test in the office and discussing the results with the patient, you can lower A1c results by a full point [3]?  And just by reducing the A1c result a full point, you can reduce the risk of complications of diabetes by up to 43%. [4]

Seventy-five percent of patients with Type 2 diabetes do not understand what an A1c test is.  Ninety-nine percent of people with prediabetes have never even heard of the A1c test.  And soon the American Diabetes Association (ADA) will be recommending the use of the A1c test to diagnosis diabetes, instead of the commonly used fasting blood sugar -- more on that later.  For most patients with Type 2 diabetes, an A1c result has no meaning because they do not convert the A1c result to an average blood sugar. Let your patients know that the A1c result is a number that represents their quality of life as they get older.  And they need to be aggressive in getting that number as close as possible to normal.  So what is normal?  Most physicians stop treating at an A1c of 7% or below.

What are the A1c Goals?

In my practice as a diabetes educator, I tell my patients that the A1c number can determine your quality of life as you get older.  And my goal with my patients is to reduce that number to as close as possible to a normal A1c, as if they did not have diabetes.  What does that mean?  You should work towards lowering your A1c to as close as possible to what it would be if you did not have diabetes, but using caution if you have co-morbidities and have had diabetes for many years.

In a number of studies, including the Epic-Norfolk study [5], where researchers compared A1c results for thousands of patients, regardless of whether they had diabetes or not, they found that when they compared those people with an A1c of 6%, which is below the ADA’s recommendation of 7% to those people with 5%, those people with an A1c of 6% had an increase in cardiovascular death of 28% for women and 26% increase for men.  So why do most doctors stop being aggressive with their treatments when a person has a 7-6.5% A1c?

Because the A1c result affects the quality of life for that person, it also affects the quality of life for everyone around that person.  It affects the whole family, not just the person with diabetes.

So what exactly is a normal A1c for a person in good health that is not overweight and does not have diabetes?  If we looked at the A1c’s of healthy people without diabetes and not overweight, their A1c’s would most likely fall below 5%, because their blood sugars very rarely go over 100mg/dL.

So, shouldn’t patients be aware of this information and be able to make a decision with their doctors as to where they would like their A1c result to be?

For less then 10 dollars for an in-office A1c test (www.a1ctest.com), (reimbursement from Medicare is $14; reimbursement from private payers varies) you can change the quality of life for your patients.  I hope by now you can see why I call it the "Quality of Life" number.

You can Make the Diagnosis of Diabetes

Until recently the ADA primarily recommended the use of a fasting blood sugar to diagnose diabetes.  Until recently, if you had a fasting blood sugar of over 125mg/dL, you were diagnosed with diabetes and if you had a fasting blood sugar of 100-125mg/dL, you were diagnosed with a “touch of sugar” or Pre-Diabetes, which is like being a little pregnant.  The problem with using a fasting blood sugar is that you could be on your best behavior with your diet before going to see the doctor, or you could be lucky enough to have a blood sugar below 100mg/dL at that office visit, but that same day you go for dinner and eat too many carbohydrates and your blood sugar could be over 200mg/dL, which is the diagnosis of diabetes, but since no one is checking your blood sugar at that time, you go undiagnosed for many years, until you happen to be in the doctor's office and he checks your fasting blood sugar and it is over 125m/dL., or he can do a glucose tolerance test and your blood sugar is over 199mg/dL.  By the time you are diagnosed with diabetes with a fasting blood sugar of over 125mg/dL, you could have had diabetes for 10-15 years and probably have killed off 60-80% of your beta cells that make the insulin. Most people with diabetes that are not in control, if they live long enough will eventually progress to Type 1 diabetes, destroying most of their beta-cells.

Can the A1c test be used for the diagnosis of diabetes or prediabetes?  According to the new guidelines published in Jan. Diabetes Care[6],, the ADA is now recommending using the A1c test for the diagnosis of diabetes and they've recommended using the result of an A1c of 6.5% as the determining number at which the diagnosis can be made.  The closer you are to 6.5%, the greater the risk for getting diabetes.  Plus, the A1c test can also tell you how knowledgeable your doctor is in treating diabetes.

There is no reason why any person should have an elevated A1c with all the knowledge we have in treating diabetes. Make your practice a Center of Excellence in the care of patients with diabetes.

Ask you patients:  Do you know what your Quality of Life number is?

To view the new 2010 ADA Guidelines for A1c testing and diagnosing diabetes:  2010 ADA Guidelines.

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References:

1. CDC, One in three children born 2000 and above will develop diabetes.
2. Type 2 diabetes results in premature death: JAMA 2003;290: 1884-1890
3. Effect of Immediate Hemoglobin A1c Results on Treatment Decisions in Office Practice.
   Diabetes Care 2 2 :1 7 8 5–1789, 1999
4. UKPDS=United Kingdom Prospective Diabetes Study. Stratton IM, et al. BMJ. 2000;321(7258):
   405-412.
5. Glycated Hemoglobin, diabetes, and mortality in Norfolk cohort of European Prospective Investigation of Cancer and Nutrition (EPIC-Norfolk); BMJ 2001;322:15 Jan. 6
6. ADA recommendations for A1c and diagnosis of diabetes

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