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The Goal is in Sight:Eye Care Concerns for Patients with Diabetes
Richard Savoy, OD, MPH, FAAO
Wilson McGriff, OD, MPH
Workshop Objectives
Review the epidemiology of diabetes in the U.S. and Tennessee
Discuss the effects and potential impact of diabetes on vision
Instruct in the use of the Health Belief Model to promote behavior change
Review initiatives and recommendations for preventing and minimizing diabetic complications
Diabetes: A Definition
Failure of the pancreas to produce sufficient amounts of insulin
-OR- Resistance of the body’s cell to the action of insulin
Epidemiology of Diabetes in the US
29.1 million people have diabetes 1.7 million people 20 years old and older diagnosed
in 2012 86 million people have prediabetes 15-30% of people with prediabetes will develop
diabetes (Type 2) within 5 years
Complications: Diabetes in the US is…
The 6th leading cause of death The LEADING cause of:
Kidney failure
Non-traumatic lower limb amputation
New cases of blindness in adults
A MAJOR contributor to: Heart disease (2nd leading cause of death)
Stroke (4th leading cause of death)
Some Bad News and Some Good News with Diabetes
Bad: Medical costs for people with diabetes are twice as high as
for people without diabetes
Risk of death for adults with diabetes is 50% higher than for adults without diabetes
Good: Prediabetics who lose weight by eating healthy and being
more active can cut their risk of getting Type 2 diabetes in half
Diabetes by Age (Years)Tennessee, 2005
18-24 25-34 35-44 45-54 55-64 65+0
2
4
6
8
10
12
14
16
18
20
0.81.5
4.9
10.5
18.419
Perc
ent
wit
h D
iabete
s
Diabetes by Gender and Race Tennessee, 2005
White Males White Females AA Males AA Females0
2
4
6
8
10
12
14
9 8.88.4
13.2
Perc
ent
wit
h D
iabete
s
Diabetes by Educational AchievementTennessee, 2005
< High School Educa-tion
High School/GED Some Post-High School College Graduate0
2
4
6
8
10
12
14
16
1816.7
9.6
7.9
6.1
Perc
ent
wit
h D
iabete
s
Diabetes and Cardiovascular DiseaseTennessee, 2005
Coronary Heart Disease
Stroke High Blood Pressure
0
10
20
30
40
50
60
70
80
16
10.1
66.7
3.6 2.4
26.3With Diabetes
Pe
rce
nt
wit
h D
esi
gn
ate
d C
ar-
dio
va
scu
lar
Co
mo
rbid
ity
Diabetes and Specific Risk FactorsTennessee, 2005
Overweight or Obese
Sedentary Lifestyle
0
10
20
30
40
50
60
70
80
90
80.1
60.454.9
30.7
With DiabetesWithout Diabetes
Pe
rce
nt
wit
h R
isk F
act
or
Types of Diabetes Mellitus
Type 1 5-10% of cases
Loss of ability to produce insulin
Type 2 90-95% of cases
Loss of ability to use insulin
Gestational and other types Hyperglycemia is the defining feature of all
types
Effects of Chronic Hyperglycemia
Microvascular disease Retinopathy
Diabetic nephropathy
Diabetic neuropathy
Ocular Symptoms of Diabetes
Blurry vision at near or far General decline in visual acuity Spots or floaters Straight lines do not look straight Double vision Persistent, red, painful eye Increasing sense of pressure in the eye
Refractive Error and Cataracts
Excess glucose causes the crystalline lens to swell May alter or delay glasses prescription 40% increase in risk for developing cataracts
Twice as likely in persons with diabetes Gradual destruction of optic nerve More likely to cause vision loss
Glaucoma
Diabetic Retinopathy
Most significant ocular complication Leading cause of blindness: ages 20-74
Slow progression in the beginning Incidence increases with duration of diabetes
>10 years: >50% incidence of retinopathy
>15 years: ~90% incidence of retinopathy
Diabetic Retinopathy
Photos: National Eye Institute / National Institutes of Health
Severity of Diabetic Retinopathy
Depends on Disease Duration
High Blood Pressure
Smoking status
Hemoglobin A1c level (HbA1c)
Hemoglobin A1c (HbA1c)
AVERAGE blood sugar level over 3 months Normal HbA1c is below 5.7%
Average patient with diabetes is around 8.5%
Goal is <6.5% for newly diagnosed
Predicts likelihood of disability and death Only 24% of persons with diabetes can remember
their last HbA1c value
HbA1c and Retinopathy
Adapted from The Diabetes Control and Complications Trial Research Group, Diabetes 44:968, 1995
Healthy Retina
Häggström, Mikael. "Medical gallery of Mikael Häggström 2014". Wikiversity Journal of Medicine 1 (2).
DOI:10.15347/wjm/2014.008. ISSN 20018762.
Diabetic Retinopathy
Mild Moderate Severe
Neo of the optic disc Neo elsewhere Pre-retinal hemorrhageImages from the Early Treatment Diabetic Retinopathy Study
Clinically Significant Macular Edema
Responsible for nearly HALF of all vision loss in diabetes!
Referred for immediate treatment
Images from the Early Treatment Diabetic Retinopathy Study
Other Ocular Manifestations
Cranial Nerve Palsies
Corneal UlcersAnterior Ischemic Optic Neuropathy
Prevention and Treatment of Diabetic Eye Disease Prevention
Annual dilated exams
~75% reduction of diabetic retinopathy with proper control
Less than 50% of persons with diabetes get annual dilated eye exams
Treatment Laser Injections Invasive surgery
Health Insurance and Diabetes
Medicare BlueCare/TennCare/United/AmeriGroup Private insurance Affordable Care Act
Diabetes Health Promotion Programs
National Level Initiative:Healthy People 2020
Healthy People 2020
D-1 Reduce the number of new cases of diabetes D-2 Reduce the death rate D-3 Reduce the diabetes death rate D-4 Reduce the rate of lower extremity
amputations
Healthy People 2020
D-5 Glycemic control D-6 Lipid control D-7 Blood pressure control D-8 Annual dental examination D-9 Annual foot examination D-10 Annual dilated eye examination
Healthy People 2020
D-11 Twice a year glycosylated hemoglobin measurement
D-12 Annual urinary microalbumin measurement D-13 Once daily self-blood glucose-monitoring D-14 Formal diabetes education D-15 Diagnosed proportion of persons with
diabetes D-16 Prevention behaviors in persons with
prediabetes Retrieved from: http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx on 09/02/14
Diabetes Health Promotion Programs
State Level Initiative:Project Diabetes
Tennessee’s Project Diabetes
Goals: Decrease the prevalence of overweight/obesity
across the State and, in turn, prevent or delay the onset of Type 2 diabetes and/or the consequences of this devastating disease.
Educate the public about current and emerging health issues linked to diabetes and obesity
Promote community, public-private partnerships to identify and solve regional health problems related to obesity and diabetes
Tennessee’s Project Diabetes
Goals Advise and recommend policies and programs
that support individual and community health improvement efforts
Evaluate effectiveness of improvement efforts/programs that address overweight, obesity, prediabetes, and diabetes
Disseminate best practices for diabetes prevention and health improvement.
Retrieved from: http://health.state.tn.us/projectdiabetes.htm on 09/02/14
Social Ecology of Health Model
A. Level I: Intrapersonal B. Level II: Interpersonal C. Level III: Organizational D. Level IV: Community E. Level V: Societal
Diabetes Health Promotion Programs
Patient Level Initiative:Intrapersonal/Interpersonal
Behavioral Change
Health Belief Model
Cue to Action
Self-Efficacy
Perceived Susceptibility
Perceived Severity
Perceived Benefits
Perceived Barriers
BEHAVIOR CHANGE!!
1. Coreil, J. (Editor)(2010). Social and Behavioral Foundations of Public Health, 2nd Edition. Thousand
Oaks, CA:Sage.2. Retrieved from: http://www.utwente.nl/cw/theorieenoverzicht/theory%20clusters/health%20communication/health_belief_model/ on 09/02/14
Health Promotion and Social Support “People, unlike fish, are unable to swim upstream for any
length of time. When the entire responsibility for health enhancement and risk reduction rests with the individual, independent of the health norms……….the probability for success is very small”
Bellingham, 1990
Diabetic “Bullets”
Potential Benefits of Preventing and Treating Diabetes
Feel better Fewer symptoms Longer, healthier life Good vision Reduce the risk for complications involving eye,
foot, kidney, heart, and nerve disease
Basic Recommendations for Preventing and Minimizing Diabetic Eye Disease1. In consultation with a physician knowledgeable
about diabetes care, and through proper diet, exercise, and medication:A. Keep blood sugar levels as close to normal as possible
B. Check and control even mild high blood pressure
C. Check and improve blood lipid profile
2. Check blood sugar levels at home on a regular basis, and know HbA1c levels
3. Quit smoking
4. Have a dilated eye examination each year, more often if specifically recommended
Diabetes “Team”
Family Physician Optometrist Podiatrist Dentist Retinal Specialist Diabetic Educator Dietician
Additional Acknowledgements
Some information courtesy of your American Optometric Association