Transcript: Diabetes and Your Vision

HadleyDiabetes and Your VisionPresented by Dr. Cynthia HeardDate September 10th, 2014

HostYou’re listening to Seminars@Hadley. This seminar is “Diabetes and Your Vision,” presented by Dr. Cynthia Heard, moderated by Tom McCarville.

Tom McCarvilleWelcome to Seminars@Hadley. My name is Tom McCarville; I’m the Director of the Low Vision Focus at Hadley. And today we’re going to be talking about Diabetes and Your Vision.”

Your presenter will be Dr. Cynthia Heard. Dr. Heard received her Doctorate of Optometry degree in 1992 from The Ohio State University College of Hadley.edu | 800.323.4238 Page 1 of 40

Optometry. She’s completed a postgraduate residency in geriatric vision and visual rehabilitation at the Birmingham VA Medical Center.

Dr. Heard is currently an Associate Professor of Optometry at the Southern College of Optometry. She’s a former member of the Podiatrists, Pharmacists, Optometrists and Dentistry Workshop for the National Diabetes Education Program. This group worked to educate members of those disciplines as well as primary care providers on how to educate patients with diabetes on treatments and prevention.

Dr. Heard’s professional interests include management of dry eye, glaucoma, and care of low vision patients. It’s my pleasure now to introduce Dr. Cynthia Heard. Dr. Heard?

Dr. Cynthia HeardThank you, Tom. I really appreciate you all checking in today and participating in this seminar. Hopefully I can provide you with some information that will be helpful to you.

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First of all I’m going to just tell you how I’m going to break it up into a few different parts so that we can hopefully have a little bit of time to do some question-and-answer. Or if anyone has comments that they think can contribute to the discussion I would really appreciate that, too. I find that talking to individuals about common things teaches me more than textbooks and other things that I read on a routine basis.

So the way that I’m going to do it here is I’m going to talk about diabetes in general first. Some of the things I’m going to mention here are things you probably have heard on the evening news, things you may have read if you read popular culture kinds of magazines and things. Some of it may be a little new to you, so hopefully there’s something that you’ll pick up from that section.

Then I’m going to talk about specifically how diabetes affects the eyes and the vision, especially the health of the eyes. And finally I’m going to talk about some interdisciplinary concerns in relation to things that I learned that I thought were very

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valuable to me as a healthcare professional in interacting with the PPOD Workgroup, where I learned things about what podiatrists do routinely with diabetic patients as well as pharmacists, dentists, and of course optometrists.

First, let me start talking a little bit about diabetes in general, and hopefully again like I said this is something that will be illuminating to you or at least giving you a little additional information if you have some already.

As we know, diabetes is a metabolic disease resulting in an elevation in the blood glucose level. Now this elevation can be difficult for the body to respond to in that insulin may not be secreted at a proper amount or there’s insulin resistance of the cells of the body. So the cells kind of have a lock on the cell wall and you can’t get that insulin into the cell to break down the glucose that’s in there.

Diabetic Eye Disease is probably the most common small vessel complication leading to new cases of blindness and low vision in America, especially in the working-age group. That is in reference to

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individuals who are between the ages of 20 to 74 years old. So that’s definitely the working group ages in this country.

Diabetes is the seventh leading cause of death in the United States but it may also contribute to other types of death prematurely, especially in relation to heart disease or even complications from stroke because diabetes is very much related to those conditions as well.

The expense of managing individuals with diabetes is as high as $245 billion per year. That is in relation to direct costs where individuals may go to the doctor or have to be treated in the hospital, or indirect costs where there’s lost days at work or things that are not directly related to the actual cost of taking care of someone.

It is estimated at this time that almost 26 million individuals in the United States have diabetes. That comes to about 8.3% of the US population. But because of the numbers of individuals as far as the rate of diabetes increase annually, it’s thought by 2050 about one in three adults will have the

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condition. So that is 33% of the population who could potentially have the condition.

And that’s not so far-fetched in my thinking because as we look at pre-diabetes or the condition that tends to precede diabetes, at this moment about 70 million adults in the United States have pre-diabetes. So that’s a major concern, and I can see why those numbers could jump to that level by 2050.

As many as 40% of people who have diabetes, at the time of diagnosis, have no idea that they have had the symptoms for this condition. And about 20% to 40% of people have diabetic eye disease at the time of diagnosis. So the thinking behind that is there are many individuals who have diabetes for several years before they even go to the doctor and have the diagnosis formally made.

As a result of that, individuals could already be experiencing breakdown in the blood vessels inside the body, in fact all over the body with the eyes being a prime place for eye care practitioners to examine a patient – and we can see those changes

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fairly quickly or fairly easily once we employ our instruments to take a look.

Now diabetes in the United States again is developing fastest in individuals over the age of 65 years and in individuals who are overweight. So that group is a little bit different from the group it’s developing in the fastest throughout the world. Worldwide it’s developing fastest in middle-age individuals, so those between the ages of 20 to 50 years old.

One other thing that I forgot to mention a moment ago is in looking at the rates of diabetes the numbers have really jumped especially in the last 10 to 15 years because there actually was a change made in the guideline to establish the diagnosis of diabetes. In 1997 it was decided that the number as far as the diagnosis for diabetes was changed from 140 mg/dl to 126 mg/dl. So that’s just the number that the labs and doctors use to go by when they’re looking at your fasting blood glucose.

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So you can see that number was actually brought down significantly so it will capture more people at an earlier stage in the development of the condition. So it would stand to reason also that that would increase the numbers as far as diabetes prevalence in the United States.

Now when we’re talking about diabetic eye disease, that is something that accounts for at least 12% of new cases of blindness in the United States annually. And remember, this is happening in individuals who are in those working age groups. So this absolutely affects the livelihood of individuals who are affected by this condition.

One promising thing, though, is it’s been determined through research and study that individuals who maintain their blood glucose as close to a normal level as possible can decrease their risk of developing vision loss and eye disease by 76%. And many times individuals have no idea that they can potentially have a lot to do with the control of how things turn out as far as vision and eye health.

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Now I’d like to talk a little bit about diabetes classification. This is something that changes a little bit as time goes on and I want to just talk about the types of diabetes as it stands at the moment. Most of us do know about Type I diabetes. This accounts for a small percentage of the overall amount of diabetes in the country as well as worldwide. It accounts for 5% to 10% of cases.

This condition is associated with changes that can happen with the immune system. It’s something that happens with the immune system where it will attack certain cells in the pancreas. Those cells in the pancreas are responsible for developing the insulin that our body needs in order to metabolize the glucose that we take in.

It’s also found that Type I diabetics have these autoimmune markers or antibodies in their blood that can be detected in many cases. So this is something that doctors are starting to look at even more frequently when they find that someone does appear to be developing diabetes because it can be a difference between determining if the person

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is Type I versus Type II – especially if it’s not clear exactly which type they may be contracting.

Another thing about Type I diabetes is in some cases, the cause is really not well known simply because there is not an attack on the pancreas but there could be a strong inheritance pattern in the family. And this particular case of Type I diabetes tends to occur more so in Africans and individuals of Asian dissent. So you do have that small percentage.

Type II diabetes accounts for 90% to 95% of cases in the United States. In this situation it’s determined that the insulin that the body produces either isn’t enough insulin or the insulin produced is not effectively used by the cells in the body. Like I said, there’s a little lock on the cell wall, and if the insulin can’t unlock that lock and get into the gate that allows the glucose to be metabolized then the insulin just kind of floats around in the bloodstream. And the person still ends up with symptoms of diabetes.

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There can also be autoimmune destruction, meaning that the body itself will attack the pancreatic cells. This doesn’t tend to occur with Type II diabetes but it is something that has to be looked at carefully to determine if it’s a factor.

Typically diagnosis can take as many as five to ten years, especially if the individual has no symptoms. Those symptoms can be, the person may feel that they are hungry all the time; they may want to eat more than usual and they have to use the bathroom all the time or urinate all the time. So those are the main things that people will have problems with while they’re developing diabetes but they may not necessarily know they have it.

Now, there is also an increase in prevalence in Type II diabetes in children of high-risk groups. So some of those high-risk groups are Hispanic-Americans, African-Americans, Alaska Natives, Asian-Americans, Native Hawaiians and other Pacific Islanders. So we’re talking about a good number of folks who are potentially at greater risk for diabetes even though they may not be adults.

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Now let’s look a little bit at pre-diabetes. Because this is such a large group of especially Americans – like I said earlier on, 79 million Americans are considered pre-diabetic. These individuals tend to have a blood glucose that runs higher than normal but does not meet the criteria for diabetes diagnosis.

Like I said before 126 mg/dl is the diagnostic number that we are referring to. These individuals tend to have impaired glucose tolerance, so their fasting blood glucose will be somewhere between 100 mg/dl to 125 mg/dl. So they aren’t quite at the normal stage which is typically about 100 mg/dl and less, especially on their fasting situation.

Now hemoglobin A1-C is another value that we use. That is a value that is determined to look at what amount of hemoglobin, which is a protein in the blood that carries oxygen to all the tissue. And it’s really important that hemoglobin is free to carry the oxygen because once it gets to the organ it will release that oxygen and then go back to the source to get more oxygen and flow through the body all over again.

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Now in people with diabetes, they can have what’s called a hemoglobin-glucose bond that forms between those two molecules. In that situation the connection between the glucose and the hemoglobin is permanent, so it will just float around in the body that way. And all the cells or all the hemoglobin that is bound to the glucose is not available any longer to bind to oxygen so that oxygen can get to the tissue the way it needs to.

So this value comes in a percentage and the hemoglobin A1-C between 5.7% and 6.4% is considered pre-diabetic. So individuals who have 5.5% are considered normal as far as having no diabetes or no pre-diabetes at the time.

The other thing about pre-diabetes and even diabetes for that matter, it causes an increased risk for heart disease as well as stroke. And of course being pre-diabetic increases the risk for diabetes in general.

A couple of other things to note, too, as far as diabetes types, gestational diabetes is one that we

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also want to look at. This type of diabetes occurs during pregnancy due to glucose intolerance. Now these individuals typically have to go through an oral glucose test, or glucose challenge test is what it’s called, to determine if their body is having a difficult time metabolizing the glucose.

This occurs in about 5% to 10% of pregnancies but the blood glucose should return to normal after about six weeks post-pregnancy. So most women do go back to a normal glucose. There is a concern though that anywhere between 30% to 60% of these individuals will have a chance to develop diabetes later especially ten to twenty years down the road. So having gestational diabetes does put that mother at risk for developing diabetes later, especially if she has other risk factors such as being overweight or obese.

Now I wanted to stop here just to see if there are any questions that anyone has and to check in with Tom.

Tom McCarville

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Thank you, Dr. Heard. Now at this point if there are any questions we’d be happy to take them. One more chance, anybody with any questions pop in… Okay, Dr. Heard, I guess we’ll continue.

Dr. Cynthia HeardI do see one question here, Tom. It looks like Debra McDonald is asking if I can talk about pancreas transplants and the effect on the eyes.

Tom McCarvilleYeah, go ahead. Do you want to speak to that at that point?

Dr. Cynthia HeardI wanted to answer the question by Debra McDonald, talk about pancreas transplants as well as the effect on the eyes. One thing that we do know is once the blood glucose level is returned close to normal, which hopefully pancreatic transplants will be able to assist in that process, then the effects of changes on the eyes from diabetes will be lessened. So that is definitely a positive thing.

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Now, how close are we to pancreatic transplants? Well, I know there’s work going on right now looking at artificial pancreas to help control blood glucose as much as possible. So that’s something where more research is coming along in that area.

But for sure, if the individual has not experienced any major problems with their eyes or their vision and the pancreatic transplant can allow a more normal function of the blood glucose again then that individual doesn’t have to experience any major problems later. Great, thank you for sharing.

Now, is this eye disease different whether the individual has Type I versus Type II? There’s actually quite a bit of a difference. Let me just give you a little bit of information about how Type I can affect the eyes and the vision versus Type II.

Now in Type I diabetes or in all diabetes it’s thought the years of duration is the biggest factor as far as how much eye disease will show up or develop in an individual. For Type I cases, having diabetes over 15 years of duration up to about 97%

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of those individuals will have some diabetic eye disease. So that’s a pretty big number.

At some point along the way in this condition or in this disease over a Type I diabetic patient’s lifetime retinal disease will develop in about 86% of those individuals. So most individuals will have some kind of symptom or sign.

For Type II cases, up to 39% of those individuals have eye disease at the time of diagnosis. So remember, I told you that it takes anywhere between five and seven years before an individual even starts to have symptoms where they may not even notice that they’re having problems just yet.

So diagnosing a fair number of people with eye disease is something that I myself as an optometrist and other eye care providers can definitely do and steer the patient to their primary care provider so that they can get the appropriate testing done and the appropriate treatment.

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Now, once a Type II diabetic has diabetes up to fifteen years’ duration there can be up to 80% of those individuals with some retinal disease of some kind. Up to 20% of those individuals will progress to what we call proliferative retinal disease. That is new blood vessels growing in the retina because two things happen with diabetic eye disease.

One, the blood vessels will get very leaky because the walls of those vessels are very sensitive to a high level of glucose that might be flowing in the blood. As a result of those cells being sensitive they die off and make the walls of those vessels leaky. That can cause fluid and blood to leak from those vessels at any point.

The other thing that happens is the tissue in the body, once those blood vessels leak or once those blood vessels become so damaged they actually start to die and the tissue will not have the oxygen that it needs because the blood vessels go away.

So the body tries to fix the problem and it will actually grow new blood vessels, but unfortunately the new blood vessels are very fragile and they can

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leak and break and cause many kinds of problems. One problem they can cause is there can be hemorrhage into the vitreous or the gel that is inside the eyes in front of the retina. That can lead to sudden vision loss, I mean like overnight.

Then the other thing that can happen is those new blood vessels can also send out this sensor substance that can create scar tissue to form around them. So it’s kind of like a scaffold or support so that the blood vessels have somewhere to grow. Now, that support is just scar tissue that actually contracts and it can pull the retina loose and cause a retinal detachment, and that can definitely lead to permanent vision loss.

That is something that is very concerning for an eye care practitioner, especially someone who manages these kinds of diabetic eye conditions such as an ophthalmologist.

Now the other thing that you should be aware of is the fact that because of the leaking of the vessels of fluid and blood, that is considered diabetic retinal edema. So fluid will get into the retinal

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tissue and if it gets in the macular area which is the area of the retina that’s most sensitive to change in the vision and it’s also responsible for color vision – if it gets there it will blur the vision as long as that fluid accumulation is there.

Now, there are very effective treatments to get rid of that fluid accumulation if the person gets to a doctor who can treat it in a reasonable amount of time. If it’s been there for a considerable period of time, like more than a year, more than two years, then it can cause the photo receptors or the tissue in that area to become disfigured; and even removing the fluid from that area will leave those deformed photo receptors there and the vision may not come back to its normal state any longer. So it’s important to get that treated in a reasonable period of time.

The other thing that’s very effective is to get rid of those new blood vessels if they grow into the retina especially in the early stages. Unfortunately it does require some treatment that may affect the vision in a negative way. Now, if the individual needs to have what’s called pan-retinal laser therapy, then laser marks or laser scars are

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actually applied to the outer parts of the retina to kill off the sensation that more oxygen is needed.

So essentially what happens is the surgeon will kill off some of the tissue in the periphery of the retina or in the outer parts of the retina to save the central part, because the oxygen and the blood that’s still in the eye that’s still normal, the central part of the retina really needs that nutrition.

So saving that part is a very good thing. But the person can end up with problems with the visual field or the side vision not being as good as it once was; and night vision can also be affected. So the person may have to be much more careful trying to navigate, especially at times when illumination is poor or when it’s nighttime – and of course it’s difficult to see as a result of it.

Now, other things that can happen with diabetes of course is loss of vision. There can be degrees of loss of vision. So if an individual experiences problems with loss of their vision, especially if it doesn’t go away after a few days up to a week, that’s something that needs to be treated or at

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least looked at by a doctor and it may need to be treated.

There can be fluctuations in the refractive error or the prescription for glasses in association with fluctuations in the blood glucose level. So sometimes people can have these changes where they feel like their glasses will work on Monday but not work on Tuesday and Wednesday, and then they’ll go back and their glasses will work again on Thursday. So if you notice those kinds of fluctuations that’s something that needs to be looked at as well.

The acquired changes or things that can happen to the color vision, something that is routinely observed – I don’t routinely see that in my patients but that’s something that people may complain of. There can be focusing problems where the individual has a difficult time being able to focus on things up close or being able to switch focus, where they can see things up close clearly and then they can look at something far away – like a clock on a wall – and see that clearly as well, where there can be problems with the flexibility in that system.

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There could also be visual field changes. The visual field can be affected not only by changes from the diabetes such as the retinal detachment that can occur, but also from complications from the surgical intervention that happens. So if the surgeon needs to actually apply laser scars to get rid of some of the response of the tissue needing that oxygen that can change things as well.

Now, three can be eye movement changes where the person can see double. That’s something that can resolve on its own, but it may take several months, it could take up to six months. When I see patients in this situation I will basically just have them wait it out and see if the muscle that controls the eye movement goes back to its normal movement.

Now, this occurs because the blood supply to those nerves can sometimes be affected by the diabetes directly. But the blood supply can be reestablished and that’s why we wait that length of time before we decide to do anything more substantial like eye

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surgery. Or it may take prisms and glasses or other methods like that to resolve the issue.

Other things that can also occur with diabetes: dry eye is a problem that people complain about. It comes about as a result of the gland that produces most of the tears, which is called the lacrimal gland, can be impaired by diabetes. This can cause poor tear stability. It can also cause discomfort of the eye as well as red eyes, watery eyes and people can even complain about more severe complications like problems with glare or light sensitivity. So that’s all related to poor tear stability in relation to diabetes.

The surface of the eye, which is called the cornea, can have a difficult time healing. So wound healing can be a major issue, wearing contact lenses should be done with caution. The iris can be affected by diabetes especially if those new blood vessels that grow in the back of the eye grow into the iris as well. This is very problematic.

And I can also move on to some other changes that happen with the eyes. Probably one other I want

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to mention before I answer any questions for you is cataracts. Cataracts actually develop in a younger age group and at a more advanced staging. So I find that many of my diabetic patients actually need cataract surgery at younger ages than individuals who develop cataracts at typical age-related paces. Where folks typically need cataract surgery in their 70s and 80s, diabetic patients need them sometimes 20, maybe even 30 years younger than that.

Now, one other question that I wanted to address here is in regards to the growing population of new eye disease: “Do we see Medicare including assistive devices as far as coverage?” That is something definitely that the government is looking at. In fact, they are about to start a five-year program looking at that process because we know that so many people, even young people, have eye conditions where devices could be of significant benefit to them – maybe even get them back into the workplace if they currently cannot work because of loss of function.

So once that program is looked at, I don’t remember the exact timeframe as far as when it

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will actually be done, when the government will be done looking at it, there is the thinking that insurances will definitely cover assistive technology at that point. And I’m very happy to hear that because I talk to patients every day about problems with the loss of vision and the fact that there are very limited resources to address it.

Someone asked what causes loss of color vision? The reason I think color vision is affected, there’s probably a couple of reasons but the two that I’m thinking of right away is that if something happens to the macular area, that’s the part of the retina that actually provides us with our best color vision and our best visual acuity. If that area becomes damaged, if that area develops a lot of fluid accumulation or if that area loses the blood supply and there is what we call atrophy where the tissue just becomes thin and it doesn’t produce the vision the way it used to, it actually causes vision loss.

So color vision can be lost as a result of that as well as the optic nerve can be affected in some cases – it’s not a large percentage though, in some cases of diabetes – and that can cause the nerve fibers to experience a lot of loss. And as a result of

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that it will actually not only affect the color vision but it will affect the contrast sensitivity.

Contrast sensitivity is the part of your vision that you use the most. In fact, people feel that it creates the biggest loss for them when they do lose it. That’s when you’re not able to see figures or objects from the background that they’re sitting in front of.

So the ability to see objects the way you need to especially as you’re sweeping your eyes across a scene, and say if a scene is moving and so are your eyes moving, then it can be difficult to watch say for example a baseball flying across the sky. When people lose those sensations then that is really problematic for them to be safe in an environment where things are moving as well as the individual is moving.

There’s a question about “Is it normal to have light sensitivity and problems with glare if you’ve had cataract surgery?” Yes. The implant from cataract surgery can sometimes be positioned in such a way that light bounces off of it at an unusual angle

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and then that can cause the glare from the implant itself. That’s something that I’ve seen over the years many people complain to me about.

So trying to keep the sun directly out of your eyes as well as having glasses with anti-reflective coating on them, or even sunglasses more darkened than the regular ones – we sometimes will provide sunglasses for people that will darken all the way down to anywhere like a 4% transmission, which is very, very dark. Those will help people to get rid of some of that light sensitivity that regular sunglasses that we can typically prescribe won’t get rid of.

So you can’t necessarily find these in the store where you might find others, especially in department stores or dollar stores, things like that. You may have to go specifically to a low vision specialist in order to get that type of item.

Another question from Rachel: “With diabetic neuropathy what factors affect how fast the vision is lost? And is there anything people can do to

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slow down the progression?” That’s an excellent question.

Factors that affect the loss of vision more than anything, and I mentioned this earlier on, is the duration of which the person has had diabetes. So once you know you have diabetes the biggest thing that you can do to help yourself is to keep your blood glucose as close to normal as possible.

The other thing, especially in the UK or the United Kingdom, they’ve looked at people with diabetes who also have high blood pressure. Individuals who have uncontrolled high blood pressure tend to have worse diabetic eye disease. So controlling your blood pressure is a big, big deal. Also making sure that the cholesterol level is controlled at a good level is a big deal as well because those are things that will help keep the blood glucose in control when you control those other two parameters as much as possible.

Other things you can do of course i stalk to your doctor about seeing someone who can make sure that you know how to count your carbohydrates

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the way you need to so that you can make substitutions in your meals and in your snacks when you need to. And that’s more for individuals who may be using insulin versus those individuals who use some sort of oral hypoglycemic medication. But that’s important for every person who has diabetes though, so that you know what carbohydrates you’re taking in and know if your medication can compensate for that carbohydrate intake.

Eating things that have a whole grain base to them or that have fiber and whole grain will help the body metabolize sugar at a slower rate, and that will keep you from experiencing a high carb load in a short amount of time – which actually can affect the way you feel. And if you don’t feel good then it can be more difficult to take care of yourself in a fashion that you feel would be most important for your livelihood over the long haul.

I just wanted to see if there are any other questions for me. Are there any other questions for me right now other than the ones that have been showing up on the screen here?

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Tom McCarvilleI think you have one more that’s being written. I think Rachel’s writing one at the moment.Dr. Cynthia HeardThe final part here, and I’m going to probably have to talk pretty quickly, I just want to talk about some things that people with diabetes can do in general that I think can be very helpful to your overall well-being.

You need to know your ABCs, meaning you need to know your hemoglobin A1-C. It should be below 6.5 for individuals with diabetes. You should know your blood pressure, “B” for blood. That value should be below 130 over less than 80. So those are important numbers to know. You should also know your cholesterol. Your LDL should be less than 100; your triglycerides should be less than 150. And your HDL for men should be greater than 40 and for women it should be greater than 50.

So those are numbers that you should have tucked away somewhere so that when you go to your

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different healthcare providers, they are going to ask you these questions and you can give them some meaningful information.

Now let’s talk a little bit about the PPOD healthcare providers. First let’s talk about podiatrists or individuals who perform foot care. It’s important to have this care on an annual basis at least. That should be in addition to what your primary care provider does in-office.

They may look at your feet but if they need to refer you on to a podiatrist then that service can be invaluable, because they can education you about the conditions that may be present. They can also look at things like the condition of the skin on your lower leg/foot area as well as your nails. They can clip your nails because that can be really important. You don’t want to clip a nail and cause a cut in the skin because that can be difficult to heal. If you have a history of ulcers or red areas on the foot that’s really important to let your podiatrist know.

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Now the next provider would be the pharmacist. When you’re talking to your pharmacist you want to make sure you know how to use your medications properly, and you may want to talk to them about adverse reactions, drug interactions, or if you think you’re being under-treated. That is something that you can run by your pharmacist and talk to your physician about on your next visit with them.

Make sure you know how to use your medications, what time of day you should use them. Sometimes it can be difficult figuring out exactly when you should use your medications so that it doesn’t interrupt your day. For example, not only using medication for diabetes but even for hypertension or high blood pressure – if you take a diuretic that causes you to go to the bathroom a lot it may be better to use that at a certain time of day when it’s easier for you to make those kinds of trips than at other times when you know you can’t make those trips.

Self-treatment is important. Make sure your doctor knows if you’re on an over-the-counter medication, and please know that those can interact with your

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medication for your glucose as well as your blood pressure, particularly blood pressure. There can also be cost issues with medications and many companies now that make drugs have patient assistance programs where they can assist you if the cost of medications is not within your budget limit. And that’s something that I think every individual should know about so that you can take advantage of it.

Of course for eye care you should see your doctor, your eye doctor once a year. Have a comprehensive eye exam with pupillary dilation. It’s important that the eyes be dilated so that we can look for cataracts as well as signs of glaucoma which is another disease that can be very debilitating to an individual; and retinal disease related to diabetes or anything else that you may be at risk for.

And then the final individual is the dentist. You want to make sure you’re seeing your dentist routinely. If there are changes in the mouth that are happening make sure you make that clear. Periodontal disease or disease of the gums is really prevalent, even in individuals who are not diabetic.

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So individuals with diabetes can have major problems with their gums and their dental hygienist is the person to really manage that for you.

Oral infections can be more common in people with diabetes so it’s important to have those areas looked at as well and get them treated properly, because you don’t want to end up with problems with your overall health because your mouth or your gums are not in good condition.

A couple of things that every diabetic should do especially if your doctor recommends it is you want to make sure you’re following up with your routine immunizations. You want to get your flu shot annually and you want to get your pneumonia vaccination however often your doctor recommends it for you. That way it’ll keep you from getting sick with potential infections that could really make it difficult to control your blood glucose.

Someone asked “Does pre-diabetes mean that I will get diabetes?” No, it does not. There is a

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certain percentage of individuals who, if they take care of themselves where you control your weight, physical activity which I didn’t mention before now but it’s extremely important. Physical activity gets your blood pumping more freely and it actually can help control your blood pressure, which if your blood pressure is in control well then that also helps control your blood glucose.

So eating foods that don’t have a high glycemic index or those that will raise your blood sugar really quickly, and there’s lots of information on the web or even in books or magazines that you can find about those kinds of foods. And you want to avoid those. Of course I like sweets so I thank God I don’t have diabetes, but it would be really rough if I did. So you can just make sure you do the things that you need to.

Now, if you do contract diabetes and of course have been considered a pre-diabetic, treatment is very effective especially oral treatment. So if that is something that has become an issue for you or can potentially become an issue for you then just partnering with your doctors, not only your primary care physician but also your other doctors – your

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eye doctor, your podiatrist, your dentist, your endocrinologist and maybe even seeing a certified diabetes educator and a registered dietician.

Those are individuals who we are all here to help you maintain as good health as possible. And we know our parts in the healthcare arena as long as you keep coming back on a routine basis and making sure you’re not letting things drop because those are the people who unfortunately are the hardest ones to reach and are the hardest ones to manage.

It’s when we get individuals into our offices who we could have almost absolutely prevented eye disease and blindness but they end up with problems because they didn’t come in and see us fast enough. And so now they have a retinal detachment that we can’t manage, because there’s nothing to do once that happens. But if we caught it with the new blood vessels on the front end then we can use treatment to make those new blood vessels go away, and then the person never gets to the point of retinal detachment.

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So that’s basically what I wanted to say today, and I’d like to address any other questions directly if you have them. I’m going to turn it back over to Tom momentarily to see if there’s anything else that’s been conveyed to you.

Tom McCarvilleGreat. Thank you, Dr. Heard, that’s been wonderful. The amount of information you’ve given has been extremely good and I think we may have one more question coming in before we end.

I would like to remind everyone though that the Seminars@Hadley will all be archived on our website. So this seminar as well as hundreds of other ones can be accessed anytime of the day or night by going to our website. And each of the popular Seminars@Hadley is now available as a podcast which you can download and listen to on your computer or mobile device.

And don’t forget, Hadley does have indeed over 100 different courses that are well worth exploring. If you’d like to take a distance education course Hadley is your place to go.

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I want to thank Dr. Heard for all the wonderful information that you’ve given us and taking the time to put this seminar together. I see that we don’t seem to have anymore questions. Dr. Heard, I’ll just pass it back to you so that you can say any parting words you’d like.

Dr. Cynthia HeardI’d really like to thank you all for listening in. This is definitely something that I am very passionate about and I appreciated the opportunity to be on the Workgroup for six years that I previously served on about ten years ago.

It has also opened my eyes to the fact that many times people don’t know exactly who to go to. I think that if you are not comfortable with the care you’re getting from your healthcare provider then you may need to fire them and get a doctor that you will be comfortable with. That way if you need a referral they can give you an appropriate referral, and I think that’s really important.

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So if you feel you need to see your endocrinologist or a diabetes educator or a registered dietician and your doctor is not assisting in that process the way you’d like then just make it known. Thank you.

Tom McCarvilleAgain, thank you and thank you all for participating.

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