Effectively Educating Your Newly Diagnosed Patient with Diabetes

CARLOS R. HAMILTON, JR., MD, FACE: Hello, I'm Dr. Carlos Hamilton and welcome to the AACE Clinical Conversations. In this program, we will discuss how we can effectively educate our newly diagnosed patients with diabetes.

Joining me today is Dr. Brian Tulloch, Clinical Associate Professor of Medicine at the University of Texas Medical School at Houston and endocrinologist at the Diagnostic Clinic of Houston.

And also with us is Dr. Naveed Iqbal, an endocrine fellow at the Baylor College of Medicine. Thanks to both of you for being with us today.

We all know that education is a critical part of the management of diabetic patients, and it's always important to do it right from the beginning if you possibly can, rather than to try to make it up later.

Brian, how do you generally approach a newly diagnosed patient that is in your office for the first time?

BRIAN R. TULLOCH, MD: We explain to them that it's a metabolic condition which they'll have for the rest of their life. We now have the tools and the medications to help them live as near to normal a life as possible, and with a home glucose monitor, they can remain in control of their condition from minute to minute.

Moreover, I tell them that there is a long-term judge called the glycohemoglobin or hemoglobin-A1c which will help their doctor understand how well they've been doing, and how nicely they've been controlling their blood sugars from the day out.

From that start, we're then going to explain that there is actually more than one form of diabetes. Diabetes is two totally different conditions. The first is an autoimmune condition.

The pancreas in that particular patient happens to have been hit, but in other members of their family, four other of the endocrine organs might have been hit as well. And when you ask, they will tell you, they have a patient (sic) with a thyroid problem, another patient (sic) with an adrenal problem, a third relative with a gastric parietal cell problem, so they ended up with vitamin B12 injections in their later years.

And finally, they have other members of their family who might have had a hypogonad problem. Each of these are manifestations of an autoimmune self rejection problem which they inherited.

CARLOS R. HAMILTON, JR., MD, FACE: Now Naveed, when you see a new patient with diabetes in the clinic, and you explain to them something about the treatment, tell me a little bit about how you would approach them and what you might think would be helpful to tell them.

NAVEED IQBAL, MD: Most of the time, the patients I see in the clinic are type 2 diabetics. So what I tell them is it is a condition of mismatch between the insulin production and the insulin demand. It could be because, most of the time in type 2 diabetics, it's because of the insulin resistance.

By that what we mean is the pancreas is producing insulin, but the body is not just responding to it adequately. They just need a higher dose of insulin to respond and to bring their blood sugars under control.

And as time passes by, the pancreas eventually cannot make enough insulin, and that's the time the blood sugars start going up. That's when we call the patient diabetic, once their blood sugar is above a particular value.

Now coming to the treatment, there are lots of options we have here. These include non-drug options like diet, exercise, weight loss.

CARLOS R. HAMILTON, JR., MD, FACE: Yes.

NAVEED IQBAL, MD: These include some pills like metformin, sulfonylurea, TZDs, and plus there is a new upcoming treatment, the GLP analogs. The common one in the market is Byetta. And Januvia is an oral form of the same thing. It enhances the GLP production.

CARLOS R. HAMILTON, JR., MD, FACE: So telling patients that there are a lot of different possible treatments for diabetes is certainly something you like to do early on in your management of their care. You explain to them that you're going to start off with simple treatment, and that as time goes on, you will expect to add other medications to their program. Is that...

NAVEED IQBAL, MD: That is correct. That is correct.

CARLOS R. HAMILTON, JR., MD, FACE: It's very helpful to let people know that the fact that you have to increase the dose or change the medicine is not necessarily a matter of a failure of the treatment or a failure on their part, but is a part of the natural history or the natural expectations of diabetes.

This is very helpful to let people know this early on so that later on, they won't, you know, feel as though that they're -- you know, had failed treatment at some later on point.

NAVEED IQBAL, MD: I definitely agree with that. I actually emphasize that fact, that only 3% of diabetics can actually maintain the euglycemia -- that is normal blood sugars -- without the help of oral agents or eventually insulin. And as time passes by, diet and exercise would not be sufficient. In fact, only 3% of patients can do that.

And also when I emphasize the weight loss, I also try to quote that only 5% of patients can actually maintain and -- maintain a weight loss of around 10 pounds, so if they are unable to do it, they are with the majority, and they shouldn't blame themselves or become disheartened. They should just continue to do the best effort.

Because if they do not, instead of losing weight, they'll just continue to gain weight. So even if they can maintain their weight, all they can do is the best they can for all the non-drug treatments, that is diet, exercise and weight loss.

But it is very important to do these non-drug treatments in relation to pills and insulin.

CARLOS R. HAMILTON, JR., MD, FACE: Do you tell people that insulin treatment is likely to be necessary early on even in type 2 diabetics so that they expect this later on in therapy?

BRIAN R. TULLOCH, MD: Very much so Carlos. I think what one has to explain now is that type 2 is indeed a progressive condition. The pancreas, having worked very hard from the time they were born until their sugar first become high, is slowly losing function at a rate of 10-12% per year unless some of the new medications will change that rate of apoptosis.

And therefore we will expect to have a progressive list of options for them to maintain euglycemia. But again, they can monitor it by watching their home glucose monitor levels and by looking at the hemoglobin-A1c values, which we normally pick up for them every 6 to 12 weeks.

CARLOS R. HAMILTON, JR., MD, FACE: Absolutely. Naveed, we all believe that lifestyle modifications are very helpful, especially in the early management of diabetes. What might you suggest a patient do in a realistic world -- I mean, in which we all live?

What kind of advice can you give someone about diet and exercise?

NAVEED IQBAL, MD: I think diet and exercise is something for which the patient needs to use his will or her will and that they would only do if they understand how important that is. And we should -- we can quote latest scientific literature to show, for example, in the DPP trial -- that is a trial for prevention of diabetes -- one of the most commonly used oral agents, metformin, which is like number one recommendation from the Diabetes Consensus Panel -- it reduces the diabetes incidence by 30% -- actually 31% -- and lifestyle modification reduced the incidence by 58% of new onset diabetes.

CARLOS R. HAMILTON, JR., MD, FACE: So motivation by knowing how important this is can often stimulate people to do that. What sort of diet information do you -- do you give people or do you recommend to people?

NAVEED IQBAL, MD: I would go ahead with that also, but one other thing that I wanted to mention about the last point was that when you're talking about lifestyle modification, we are not talking about unrealistic goals or something which the patients cannot do.

In the DPP trial, all they had to do was 30 minutes of exercise 5 days a week and they had to lose 7% of the body weight, which corresponded to about 5 to 6 kg in those people.

Coming to the exact diet -- exact dietary interventions, for the type 2 diabetics, the single most important dietary modification is caloric restriction. Because if they lose their weight, then they are going to become more insulin sensitive, and that is the big -- basic pathophysiologic fact in them, which they need to overcome.

Carbohydrate restriction also is important, but the number one important thing in my mind is caloric restriction and weight loss.

Once the patient becomes insulin dependent, then they need to maintain their carbohydrate consistent -- their carbohydrate intake consistent at different times of the day. Otherwise, if they take too much insulin and less carbohydrates, the blood sugar could drop. Or if they take too much carbohydrate and not enough insulin, then the blood sugars could go too high.

But for type 1 diabetics, caloric restriction is not as important. The consistency in the diet is much more important. They are very insulin sensitive and the consistency in the carbohydrate intake is really important.

CARLOS R. HAMILTON, JR., MD, FACE: There's -- there's no question that this is true and that type 1 diabetics have very different dietary needs and dietary management than do type 2s.

NAVEED IQBAL, MD: And later on we can also refer them to a nutritionist, but the thing, again, 'til they understand the importance of diet and exercise, they're not going to listen to the nutritionist that much. So therefore, once you emphasize it, they can go to the nutritionist. They can tell them what are the low glycemic index foods. They can help them lose the weight.

BRIAN R. TULLOCH, MD: Carlos, I think we're at a very exciting time in the phase of treating diabetes right now. Traditionally, we followed the DPP conclusions that lifestyle was very important followed by metformin, and that anything else helped patients to gain weight. Metformin was either weight-neutral or weight-losing.

Since that time, we have had new data. We now have good data that the TZDs as a family -- it started with the TRIPOD study and then it went on to the PIPOD study. That was referring to the demonstration that troglitazone and later pioglitazone were able to be beta-cell sparing in newly diagnosed gestational diabetic women, a very, very exciting demonstration.

Since then, we had another study that showed Avandia or rosiglitazone can have the same properties. So there is the potential that an initial choice of medication can actually preserve beta cell function.

In vitro and in experimental animals, we now have the same demonstration that the incretins, a totally new group of diabetes treatment options, might also be preserving of beta cell function. So what we say this year may be superseded by a choice of a TZD plus an incretin at the very, very first time that the type 2 diabetic is diagnosed. That's a very exciting area to me.

CARLOS R. HAMILTON, JR., MD, FACE: It really is. But at this particular point in time, most of us probably would start with metformin and a TZD or a combination or one or the other, and perhaps the newer information may indicate that the TZD might actually be more effective for a longer period of time as a sole therapy.

NAVEED IQBAL, MD: I think we have to be a little cautious with these newer agents also because, for example, when the diabetic consensus panel, they recommended their first agent is metformin, and then their second line agent, there is different options which include either insulin or adding a glitazone.

But they do not talk about these newer agents. We just have to take them with a grain of salt because though pathophysiologically they are great drugs, they increase the GLP-1 production or maintain the same level, and there is less glucagon production. All that does make sense.

But the maximum efficacy, for example, for Januvia or sitagliptin, which is an oral DPP-4 inhibitor at 0.77 A1c points as opposed to the older agents like TZDs, which reduce A1c by 2 points, as opposed to sulfonylureas and metformin.

And metformin does have side effects, but in the UKPDS trial it showed it reduces mortality by 46%. These newer agents could be more effective than metformin. And in the future time, they might become the number one agent of choice once the patient is diagnosed. But at this point, I prefer the older agents and use them as an adjunct, not as the main therapy.

So I usually start off with metformin...

CARLOS R. HAMILTON, JR., MD, FACE: I think most of us would -- would agree with that, that the older agents have a proven track record, and at least in the initial therapy, these are the ones that we would go with.

Brian, when you first see a patient with diabetes, do you -- do you make an attempt to explain to them the long-term outlook, especially in type 2 diabetes and the importance of -- of careful control of their disease?

I help them understand how the different groups of medications work, and promise that we as the team -- and the team would be the physician, the family practice member and the diabetes educators -- will be there to be with them all the way.

But after that, I leave them to make the choice. Their choice is how they live their life. We will be there to be with them, but we're not there every day to make their choice for them. And that the periodic visits to the physician would be the best way to monitor how they've been making progress.

I would certainly agree with that, and obviously what you're saying is that education is not only important at the outset of the treatment, but it's an ongoing process that must continue throughout the lifetime of the patient and the lifetime of your experience with them.

I want to thank both of you for being with us today. This has been a very interesting conversation, and I want to thank all of you for watching.

Once again, I'm Dr. Carlos Hamilton, and thank all of you for being with us today.