Transcript Diabetes - Home - Tennessee Public Health Association

The Goal is in Sight:
Eye Care Concerns for
Patients with Diabetes
Richard Savoy, OD, MPH, FAAO
Wilson McGriff, OD, MPH
Workshop Objectives

Review the epidemiology of diabetes in the U.S. and
Tennessee

Discuss the effects and potential impact of diabetes on
vision

Instruct in the use of the Health Belief Model to promote
behavior change

Review initiatives and recommendations for preventing
and minimizing diabetic complications
Diabetes: A Definition


Failure of the pancreas to produce sufficient amounts of
insulin
-ORResistance of the body’s cell to the action of insulin
Epidemiology of Diabetes in the US

29.1 million people have diabetes

1.7 million people 20 years old and older diagnosed in
2012

86 million people have prediabetes

15-30% of people with prediabetes will develop diabetes
(Type 2) within 5 years
Complications: Diabetes in the US is…

The 6th leading cause of death

The LEADING cause of:


Kidney failure

Non-traumatic lower limb amputation

New cases of blindness in adults
A MAJOR contributor to:

Heart disease (2nd leading cause of death)

Stroke (4th leading cause of death)
Some Bad News and
Some Good News with Diabetes


Bad:

Medical costs for people with diabetes are twice as high as for
people without diabetes

Risk of death for adults with diabetes is 50% higher than for adults
without diabetes
Good:

Prediabetics who lose weight by eating healthy and being more
active can cut their risk of getting Type 2 diabetes in half
Diabetes by Age (Years)
Tennessee, 2005
20
18.4
19
Percent with Diabetes
18
16
14
12
10.5
10
8
6
4.9
4
2
0.8
1.5
0
18-24
25-34
35-44
45-54
55-64
65+
Diabetes by Gender and Race
Tennessee, 2005
14
13.2
Percent with Diabetes
12
10
9
8.8
White Males
White Females
8.4
8
6
4
2
0
AA Males
AA Females
Diabetes by Educational Achievement
Tennessee, 2005
18
16.7
Percent with Diabetes
16
14
12
9.6
10
7.9
8
6.1
6
4
2
0
< High School Education
High School/GED
Some Post-High School
College Graduate
Diabetes and Cardiovascular Disease
Tennessee, 2005
Percent with Designated
Cardiovascular Comorbidity
80
66.7
70
60
50
40
30
20
10
26.3
16
10.1
3.6
2.4
Coronary Heart
Disease
Stroke
0
High Blood Pressure
With Diabetes
Without Diabetes
Diabetes and Specific Risk Factors
Tennessee, 2005
90
Percent with Risk Factor
80
80.1
70
60
60.4
54.9
50
40
30.7
30
20
10
0
Overweight or Obese
Sedentary Lifestyle
With Diabetes
Without Diabetes
Types of Diabetes Mellitus


Type 1

5-10% of cases

Loss of ability to produce insulin
Type 2

90-95% of cases

Loss of ability to use insulin

Gestational and other types

Hyperglycemia is the defining feature of all types
Effects of Chronic Hyperglycemia

Microvascular disease

Retinopathy

Diabetic nephropathy

Diabetic neuropathy
Ocular Symptoms of Diabetes

Blurry vision at near or far

General decline in visual acuity

Spots or floaters

Straight lines do not look straight

Double vision

Persistent, red, painful eye

Increasing sense of pressure in the eye
Refractive Error and Cataracts

Excess glucose causes the crystalline lens to swell

May alter or delay glasses prescription

40% increase in risk for developing cataracts
Glaucoma

Twice as likely in persons with diabetes

Gradual destruction of optic nerve

More likely to cause vision loss
Diabetic Retinopathy

Most significant ocular complication

Leading cause of blindness: ages 20-74

Slow progression in the beginning

Incidence increases with duration of diabetes

>10 years: >50% incidence of retinopathy

>15 years: ~90% incidence of retinopathy
Diabetic Retinopathy
Photos: National Eye Institute / National Institutes of Health
Severity of Diabetic Retinopathy

Depends on

Disease Duration

High Blood Pressure

Smoking status

Hemoglobin A1c level (HbA1c)
Hemoglobin A1c (HbA1c)


AVERAGE blood sugar level over 3 months

Normal HbA1c is below 5.7%

Average patient with diabetes is around 8.5%

Goal is <6.5% for newly diagnosed
Predicts likelihood of disability and death

Only 24% of persons with diabetes can remember their last
HbA1c value
HbA1c and Retinopathy
Adapted from The Diabetes Control and Complications Trial Research Group, Diabetes 44:968, 1995
Healthy Retina

Häggström, Mikael. "Medical gallery of Mikael Häggström 2014". Wikiversity Journal of Medicine 1 (2).
DOI:10.15347/wjm/2014.008. ISSN 20018762.
Diabetic Retinopathy
Mild
Neo of the optic disc
Moderate
Neo elsewhere
Images from the Early Treatment Diabetic Retinopathy Study
Severe
Pre-retinal hemorrhage
Clinically Significant Macular Edema

Responsible for nearly HALF of all vision loss in
diabetes!

Referred for immediate treatment
Images from the Early Treatment Diabetic Retinopathy Study
Other Ocular Manifestations
Anterior Ischemic Optic Neuropathy
Cranial Nerve Palsies
Corneal Ulcers
Prevention and Treatment of
Diabetic Eye Disease


Prevention

Annual dilated exams

~75% reduction of diabetic retinopathy with proper control

Less than 50% of persons with diabetes get annual dilated eye
exams
Treatment

Laser

Injections

Invasive surgery
Health Insurance and Diabetes

Medicare

BlueCare/TennCare/United/AmeriGroup

Private insurance

Affordable Care Act
Diabetes Health Promotion Programs
National Level Initiative:
Healthy People 2020
Healthy People 2020

D-1 Reduce the number of new cases of diabetes

D-2 Reduce the death rate

D-3 Reduce the diabetes death rate

D-4 Reduce the rate of lower extremity amputations
Healthy People 2020

D-5 Glycemic control

D-6 Lipid control

D-7 Blood pressure control

D-8 Annual dental examination

D-9 Annual foot examination

D-10 Annual dilated eye examination
Healthy People 2020

D-11 Twice a year glycosylated hemoglobin measurement

D-12 Annual urinary microalbumin measurement

D-13 Once daily self-blood glucose-monitoring

D-14 Formal diabetes education

D-15 Diagnosed proportion of persons with diabetes

D-16 Prevention behaviors in persons with prediabetes
Retrieved from: http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx on 09/02/14
Diabetes Health Promotion Programs
State Level Initiative:
Project Diabetes
Tennessee’s Project Diabetes

Goals:
 Decrease
the prevalence of overweight/obesity across
the State and, in turn, prevent or delay the onset of
Type 2 diabetes and/or the consequences of this
devastating disease.
 Educate
the public about current and emerging health
issues linked to diabetes and obesity
 Promote
community, public-private partnerships to
identify and solve regional health problems related to
obesity and diabetes
Tennessee’s Project Diabetes

Goals
 Advise
and recommend policies and programs that
support individual and community health improvement
efforts
 Evaluate
effectiveness of improvement
efforts/programs that address overweight, obesity,
prediabetes, and diabetes
 Disseminate
best practices for diabetes prevention and
health improvement.
Retrieved from: http://health.state.tn.us/projectdiabetes.htm on 09/02/14
Social Ecology of Health Model

A. Level I:
Intrapersonal

B. Level II: Interpersonal

C. Level III: Organizational

D. Level IV: Community

E. Level V:
Societal
Diabetes Health Promotion Programs
Patient Level Initiative:
Intrapersonal/Interpersonal
Behavioral Change
Health Belief Model
Cue to Action
Perceived Susceptibility
Perceived Benefits
BEHAVIOR
CHANGE!!
Perceived Severity
Perceived Barriers
Self-Efficacy
1. Coreil, J. (Editor)(2010). Social and Behavioral Foundations of Public Health, 2nd Edition. Thousand Oaks, CA:Sage.
2. Retrieved from: http://www.utwente.nl/cw/theorieenoverzicht/theory%20clusters/health%20communication/health_belief_model/ on 09/02/14
Health Promotion and Social Support

“People, unlike fish, are unable to swim upstream for any length of
time. When the entire responsibility for health enhancement and risk
reduction rests with the individual, independent of the health
norms……….the probability for success is very small”

Bellingham, 1990
Diabetic “Bullets”
Potential Benefits of Preventing and
Treating Diabetes

Feel better

Fewer symptoms

Longer, healthier life

Good vision

Reduce the risk for complications involving eye, foot,
kidney, heart, and nerve disease
Basic Recommendations for Preventing
and Minimizing Diabetic Eye Disease
1.
In consultation with a physician knowledgeable about
diabetes care, and through proper diet, exercise, and
medication:
A.
Keep blood sugar levels as close to normal as possible
B.
Check and control even mild high blood pressure
C.
Check and improve blood lipid profile
2.
Check blood sugar levels at home on a regular basis, and
know HbA1c levels
3.
Quit smoking
4.
Have a dilated eye examination each year, more often if
specifically recommended
Diabetes “Team”

Family Physician

Optometrist

Podiatrist

Dentist

Retinal Specialist

Diabetic Educator

Dietician
Additional Acknowledgements

Some information courtesy of your
American Optometric Association 