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Health Spotlight


American Diabetes Alert Day - Tuesday, March 25

man getting exercise

Diabetes is one of the leading causes of death in the United States and is associated with long-term complications that can lead to blindness, heart disease, stroke, kidney failure, and amputations. Direct medical costs (e.g., hospitalizations, treatment) and indirect costs (e.g., disability payments) associated with diabetes are in the billions of dollars.1

More than 20 million American adults and children (7% of the population) in the United States have diabetes, of which more than 6 million have not yet been diagnosed.1 Moreover, diabetes is becoming more common - from 1980 through 2004, the number of Americans with diabetes more than doubled.2

Diabetes affects nearly 20% of veterans who receive care in the VA healthcare system, with at least 75% of non-traumatic amputations in VA involving veterans with diabetes.3

Types of Diabetes

  • Type 1 Diabetes is an autoimmune disease in which the immune system attacks the insulin-producing beta cells in the pancreas and destroys them, thus the pancreas produces little or no insulin.
  • Type 2 Diabetes is the most common form of the disease - 90-95% of those people with diabetes have this type, and it is being increasingly diagnosed among children and adolescents. With Type 2, the pancreas is still producing insulin but, for unknown reasons, cannot use it effectively.
  • Gestational Diabetes develops only during pregnancy and usually disappears after the mother gives birth. However, women who develop gestational diabetes (3-8% of pregnant women) are at higher risk for Type 2 diabetes later in life.1

Diabetes Resources

Symptoms and Risk Factors

Symptoms for diabetes can include: Frequent urination, excessive thirst, unexplained weight loss, extreme hunger, sudden vision changes, regular and unexplained fatigue, sores that are slow to heal, and more infections than usual.

Risk factors for type 2 diabetes include:

  • older age,
  • obesity,
  • family history of diabetes,
  • prior history of gestational diabetes,
  • impaired glucose intolerance,
  • physical inactivity, and
  • race/ethnicity (e.g., African Americans and Hispanic Americans are at greater risk).4

If you suspect that you have diabetes, your doctor may suggest a fasting blood glucose test - the preferred method of testing in children, and adults who are not pregnant.

Treatment

The treatment regimen for type 1 diabetes includes healthy eating, physical activity, and taking insulin. For type 2 diabetes, therapies include healthy eating, physical activity, and blood glucose testing. In addition, many with this type of the disease require oral medication, insulin, or both to control blood glucose levels. Because adults with diabetes are at higher risk for heart disease, it also is important to manage blood pressure cholesterol levels. 1

Over the past several years, there has been several advances in diabetes treatment including: inhaled insulin, external insulin pumps that replace daily injections, and islet cell (cells that produce insulin) transplantation.1

Research

Due to its prevalence among veterans and the general population, VA has made diabetes care and research a priority. In addition, VA/HSR&D's Diabetes Mellitus Quality Enhancement Research Initiative (DM-QUERI) conducts a diverse portfolio of projects that focus on health issues of critical importance to veterans with diabetes. Here are a few examples of diabetes research being conducting by HSR&D investigators.

Peer Support for Veterans with Diabetes

DM-QUERI investigators are conducting a randomized trial to evaluate a multi-faceted intervention for veterans with diabetes who have poor glycemic control. This intervention involves group sessions, led by case managers, in conjunction with an interactive voice response (IVR) exchange system. The IVR system allows participants to talk by phone with a peer who is facing the same self-management challenges between the scheduled group sessions. This enhanced support will be especially important for veterans who are undertaking new self-care tasks or intensifying insulin treatment regimens. 5

Using the Web to Improve Diabetes Self-Management

Recently, healthcare models that support enhancing patients' disease self-management have demonstrated positive outcomes. The University of Pittsburgh Medical Center has implemented a personal health record to assist patients with diabetes self-management - the UPMC HealthTrak uses web-based tools that are linked to patients' electronic medical records. Researchers in this study describe initial patient reaction to the technology, as well as office-based implementation challenges. Findings show that patients thought the UPMC HealthTrak system would be helpful in improving their disease management, and especially liked having remote access to laboratory results, as well as the ability to schedule and cancel appointments at their convenience. Patients also identified problems with the system, such as inaccurate information and slow responses from nurses or physicians.6

Prevalence of Substance Abuse and Mental Illness Differs by Socio-Demographics among Veterans with Diabetes

Some studies suggest that co-occurring mental illness or substance use disorders (SUDs) can affect quality of care and patient outcomes for those with diabetes. This study sought to examine the predictors of the often co-occurring conditions of mental illness and SUDs in veterans with diabetes. Investigators used VA and Medicare data for nearly 500,000 veterans with diabetes who used VA clinics in FY99, and who used VA healthcare only -- or both VA and Medicare. Socio-demographics and diabetes-related complications also were assessed. Findings show that the prevalence of substance use disorders and mental illness differs by socio-demographics among veterans with diabetes, suggesting the need for tailored interventions. For example, women veterans with diabetes were more likely than male veterans with diabetes to have serious mental illness (26% vs. 13%), and African Americans and Latinos with diabetes were more likely to have drug and/or alcohol use. Tobacco use was very common among veterans with diabetes (48%), but African Americans were less likely to use tobacco.7

Performance Measures for Veterans with Diabetes and Comorbidities

For people with diabetes, clinical practice guidelines recommend an optimal A1C (glycosylated hemoglobin) level of < 7%. However, multiple clinical guidelines recommend individualizing A1C targets for some patients, including those with comorbid conditions that may limit life expectancy, and in whom intensive glycemic control might be risky. This study evaluated the presence of comorbid conditions that might affect the risk and/or benefit for intensive treatment among younger veterans (< 65 years) with diabetes. Investigators analyzed administrative data for 220,922 veterans at 144 facilities who used VA healthcare in FY99 and FY00. Veterans were followed for five years, and investigators found that about 1 in 3 veterans had comorbid conditions that would increase the risks or decrease the benefits of intensive glycemic control (i.e., insulin use). Thus, the authors suggest that a performance measure requiring < 7% A1C levels may not be optimal for this group of patients.8,9

References

  1. Diabetes Overview. National Diabetes Information Clearing House. A service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). National Institutes of Health.
  2. Data & Trends. National Diabetes Surveillance System. National Center for Chronic Disease Prevention and Health Promotion.
  3. Diabetes Mellitus QUERI Fact Sheet. VA/HSR&D.
  4. Basic about Diabetes. National Center for Chronic Disease Prevention and Health Promotion.
  5. Peer-to-Peer Study: Improving Diabetes Therapy with Enhanced Care Management and Peer Support. VA's Diabetes Mellitus Quality Enhancement Research Initiative Update. February 2008.
  6. Hess R, Bryce C, Paone S, Fischer G, McTigue K, Olshansky E, Zickmund S, Fitzgerald K, and Siminerio L. Exploring Challenges and Potentials of Personal Health Records in Diabetes Self-Management: Implementation and Initial Assessment. Telemedicine and e-Health October 2007;13(5):509-518.
  7. Banerjea R, Sambamoorthi U, Smelson D, and Pogach L. Chronic illness with complexities: Mental illness and substance use among veteran clinic users with diabetes. The American Journal of Alcohol and Drug Abuse September 2007;33(6):807-821.
  8. Pogach L, Tiwari A, Maney M, et al. Should mitigating comorbidities be considered in assessing healthcare plan performance in achieving optimal glycemic control? The American Journal of Managed Care March 2007 13(3):133-140.
  9. Hayward R. All-or-nothing treatment targets make bad performance measures. The American Journal of Managed Care March 2007;13(3).