Monitor for macrovascular disease

While there is no formal recommendation for screening for macrovascular disease, this condition likely accounts for the greatest health-care costs, morbidity, and mortality related to diabetes and warrants special mention. Questioning patients about cardiovascular disease symptoms and looking for signs on examination should be part of the regular follow-up visit. Weak pulses on the foot exam should alert the clinician to the possibility of ischemic heart disease. More important, adherence to accepted guidelines for LDL lowering and BP management should be emphasized to all patients with diabetes.

When I encounter a patient who smokes and is coming to me for better blood sugar control or an elevated HbA1c, I try and put things in perspective. I caution the patient that smoking increases the risk of or worsens all the end-organ diseases we as endocrinologists/diabetologists work so hard to prevent. While we certainly need to minimize risks for eye, nerve, and kidney disease in our smoking and nonsmoking patients alike, this approach sometimes makes patients realize the serious damage that smoking does to multiple organs. I am almost never the first health-care provider to tell them this, but hearing it again from a new clinician sometimes opens patients to trying new behavioral and medical therapies for smoking cessation. The willingness to try new treatments, to see a new endocrinologist with either a new diagnosis of diabetes, or to seek care for this chronic condition in a new setting are all positive signs of a patient’s resolve to avoid end-organ damage.

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Back to basics

Let’s not forget about blood sugar control and HbA1c. We have known for years now, since the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS), that better blood sugar control will slow the progression of diabetes complications and even prevent them entirely in some patients. So while we educate our patients on better detection and treatment of diabetes complications, we still need to do what most of us do best and that is to make sure that blood sugar control is as close to accepted American Diabetes Association and or American Association of Clinical Endocrinologists guidelines as possible.

Dr. Mitzner is an endocrinologist/diabetologist at the Joslin Clinic and an instructor in medicine at Harvard Medical School, both in Boston.