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

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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