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Diabetes kills one American every three minutes, causing more deaths than AIDS and breast cancer combined. This progressive disease affects more than 150 million people worldwide, and that number is expected to rise to 300 million by 2025.
According to FP Jeffrey Unger, M.D., director of the Chino Medical Group Diabetes Intervention Center in Chino, Calif., "primary care physicians manage 90 percent of all diabetes patients in the United States, but on average physicians receive only four hours of diabetes training while in medical school."
Unger led an Assembly two-hour seminar, "Intensive Management of Type 1 and Type 2 Diabetes." He urged FPs to be aggressive in managing patients who have diabetes or risk factors for the disease. "Aggressive control of hyperglycemia and diabetes risk factors reduces micro- and macrovascular complications and decreases endothelial cell inflammation," Unger said. "Your patients will live longer with less morbidity!"
It's the micro- and macrovascular complications of diabetes -- cardiovascular disease; peripheral artery disease; and diabetic retinopathy, nephropathy and neuropathy -- that usually kill people rather than the disease itself, he added.
Screening patients
Unger suggested family physicians begin screening low-risk patients every three years after patients turn 45. "A two-hour glucose challenge test is indicated if their fasting plasma glucose is between 110 mg/dL and 126 mg/dL, indicating impaired fasting glucose," he said.
Early screening, beginning at age 30, is warranted for patients with multiple risk factors for diabetes, such as those with a family history of diabetes or coronary artery disease, overweight or obese patients, those who lead a sedentary lifestyle, and minorities.
FPs should also be aware of the insulin resistance syndrome, a cluster of metabolic abnormalities headed by insulin resistance that significantly increases a patient's risk of developing cardiovascular disease. "Fifteen percent of patients with insulin resistance syndrome will develop type 2 diabetes mellitus," Unger said.
To help prevent patients from developing diabetes, family physicians can recommend lifestyle interventions, such as exercise, weight loss and a healthy diet. This especially applies, said Unger, to those with impaired glucose tolerance, as indicated by two-hour postprandial blood glucose levels between 140 mg/dL and 200 mg/dL.
Lifestyle interventions are also critical in the treatment of those who develop diabetes. "Behavior modification is key to successful intervention," Unger said. "Set reasonable goals for weight loss and exercise for your patients. A seven-pound weight loss is a good start. Ten percent of starting weight is a good weight-reduction goal. Exercise improves glycemic control and enhances weight loss." Diabetic patients should also stop smoking cigarettes and drinking alcohol.
Medical interventions
Unger asked FPs to consider prescribing statins and aspirin therapy for all diabetic patients at high risk of cardiovascular disease, regardless of their lipid levels. Hemoglobin A1c levels should be below 7 percent. Prescribe angiotensin-receptor blockers to prevent diabetic nephropathy and treat hypertension.
"Think insulin early in treatment," Unger said. "Diabetes is a progressive disease characterized by persistent insulin resistance and deterioration of beta-cell function. Over time, most patients will need insulin to control glucose."
Family physicians should start type 2 diabetes patients on insulin therapy when the patient has these characteristics:
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Copyright © 2004 by American Academy of Family Physicians.