Glycemic control, lifestyle key in combating diabetes complications

Diabetes costs exceed $254 billion annually, with 18% of expenses attributable to complications.

Nashville -- The number of U.S. adults with diabetes is projected to increase from one in 10 to three in five from 2012 to 2050, and reducing complications associated with the disease will be vital to keeping down health care costs, according to a speaker at the American Association of Nurse Practitioners 2014 meeting.

Average medical costs for people with diabetes are 2.3 times higher than those without the disease, according to Tomas C. Walker, DNP, APRN, of Henderson, Nevada.

In 2012, direct and indirect costs associated with diabetes exceeded $254 billion, with 18% of expenses attributable to medications used to treat complications of the disease, CDC data indicate.

Diabetes complications include hypertension, dyslipidemia, renal failure, chronic kidney disease, eye disease and neuropathies resulting in infections and limb amputations.

The good news is that many of the micro- and macrovascular complications of diabetes can be delayed or prevented with glycemic control, lifestyle medication and medication, Walker told The Clinical Advisor.

Macrovascular Complications

Cardiovascular disease is the leading cause of death among people with diabetes, accounting for 70% to 80%, and controlling hypertension and dyslipidemia is a major concern in this population.

Hypertension interventions should center on weight loss, adherence to the DASH diet, restricting sodium and alcohol intake and increasing exercise, Walker advised. Efforts should be tailored to the individual patient.

Target blood pressure goals in individuals with diabetes are <140 mm Hg systolic and <80 mm Hg diastolic, according to guidelines from the American Diabetes Association.

 Achieving these goals can reduce the risk for major macrovascular events (relative risk, 6; 95% CI: -6-16), including reductions in nonfatal myocardial infarction (RR, 2; 95% CI:-23-22), nonfatal stroke (RR,-2; 95% CI: -24-15) and cardiovascular death (RR, 12; 95% CI: -4-26).

Reducing BP <130 mm Hg systolic does not benefit patients with diabetes, data indicate. “Excessively tight control does not appear to improve outcomes,” Walker said.

Hypertension medications include ACE inhibitors, angiotensin receptor blockers, calcium channel blockers, betablockers and diuretics.

No matter what combination of lifestyle modifications and medications are chosen, Walker emphasized the importance of long-term maintence.

Lipid panels for dyslipidemia should be performed annually. Lipid targets for low-risk diabetes patients are LDL <100 mg/dL, HDL <50 mg/dL and triglycerides <150 mg/dL. For high-risk patients, targets are LDL <70 mg/dL, HDL >50 mg/dL and triglycerides <150 mg/dL.

Lifestyle modifications for lipid management in patients with diabetes consist of reducing saturated, trans fat and cholesterol intake; increasing omega-3 fatty acid and fiber intake; losing weight and increasing exercise.

Statin therapy should be initiated regardless of baseline lipid levels in patients aged older than 40 years who have one or more cardiovascular disease risk factor, such as family history, dyslipidemia, hypertension, albuminuria and smoking.

Microvascular Complications

Diabetes is the leading cause of chronic kidney disease, renal failure, adult blindness and nontraumatic lower-limb amputations, with about 60% to 70% of patients showing signs of severe nervous system damage and 20% to 30% developing signs of nephropathy.

Regular screening, good glycemic control and hypertension management are critical in preventing renal complications, diabetic retinopathy and neuropathies.

Patients should undergo annual urinary screening for microalbuminuria and serum chemistry for BUN/Cr to detect renal complications. Patients with abnormalities should be referred to a nephrologist.

Annual dilated eye exams with an optometrist or ophthalmologist are advised at the time of diagnosis for patients with type 2 diabetes and within five years of diagnosis for patients with type 1 diabetes. Because pregnancy increases the risk for retinopathy progression, so ophthalmologic evaluation should also be performed during the first trimester and one year postpartum.

Neuropathy screening guidelines are similar, with annual screening recommended thereafter. Tests for neuropathy include postural BP measurements, 10 Gm monofilament testing of feet, distal pulses and reflexes and vibration threshold. Patients should be educated about the risk for foot problems. “Patient education is the most cost-effective intervention,” Walker said.

All patients with diabetes are advised to get at least 150 minutes of moderate-intensity exercise per week and at least 75 minutes of vigorous aerobic exercise.

“Even a 5% to 7% weight reduction in those who are overweight or obese improves the risk of micro- and macrovascular disease,” Walker said.

Reference

  1. Walker TC. #14.2.064. “Diabetes Complications: Impacting Patient Outcomes.” Presented at: AANP 2014. June 17-22, 2014; Nashville, Tenn.
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