This Physician’s Weekly feature covering effective approaches to managing newly diagnosed diabetes patients was completed in cooperation with the experts at the American Diabetes Association.
According to the American Diabetes Association, 23.6 million children and adults in the United States have diabetes, 25% of whom are undiagnosed. Approximately 1.6 million new cases of diabetes are diagnosed in people aged 20 and older each year. In addition, another 57 million people have pre-diabetes, a condition in which blood glucose levels are higher than normal but not yet high enough to be diagnosed as diabetes. People with pre-diabetes are at an increased risk of developing diabetes and cardiovascular disease. “Identifying diabetes and pre-diabetes early is critical because the earlier clinicians take measures to help patients with lifestyle changes and appropriate medication choices the most initial success they will have and the more successful they will likely be in the long run in controlling their disease and preventing diabetes complications,” says Richard M. Bergenstal, MD.
Making the Diagnosis
Historically, clinicians have used tests that are based on the measurement of plasma glucose to detect diabetes in people without symptoms. These tests include a fasting plasma glucose (FPG) test or an oral glucose tolerance test (OGTT). Recently, the American Diabetes Association suggested adding the A1C test as another diagnostic tool for identifying diabetes and pre-diabetes (Figure 1). The A1C test reflects the average amount of glucose in the blood over the last 2 to 3 months, and is not affected by short-term physical and emotional stresses that can temporarily affect a blood glucose test. “A1C tests are accurate and precise, and offer several advantages over FPG and OGTT in diagnosing diabetes, including better technical attributes and greater clinical convenience,” Dr. Bergenstal says. “A key advantage of the A1C test is that patients don’t have to fast for 8 hours, which is necessary for the FPG test. They also don’t have to endure several blood samples being taken over 2 hours, which is required for an OGTT.”
Another advantage of the A1C test is that the sample is stable and can be stored at room temperature for longer times than samples for glucose testing. It should be noted, however, that using the A1C test to diagnose diabetes may not be appropriate in some situations, such as patients with heavy bleeding, those who are pregnant, and those with certain anemias. “Great strides have been made in standardizing the A1C test,” says Dr. Bergenstal, “and these assays are now accepted as diagnostic and screening tools if run in labs with appropriate standardization.” He adds that it is equally important for clinicians to understand who should be screened, as patients with several characteristics are considered at higher risk (Figure 2).
Delivering the News
It can be challenging for clinicians to inform patients that they have a type 2 diabetes diagnosis because they are often forced to balance being supportive with instilling a sense of urgency. “As clinicians, it’s important to recognize that a diabetes diagnosis may leave patients in shock or feeling disappointed in themselves,” Dr. Bergenstal says. “Patients may also be in disbelief, or they may feel stressed, angry, or guilty upon hearing their diagnosis. It’s important for physicians to take extra time to tell patients that they’re there to support them through their journey and that effective treatments are available to enable them to live long, healthy lives. At the same time, patients must understand that their disease is serious. Actions must be taken because their diabetes must not be ignored.”
Dr. Bergenstal also says that clinicians should take time to find out what patients know about diabetes. He stresses that patients understand the ramifications of letting their diabetes go uncontrolled. “In addition to managing blood glucose, patients must also be advised to get their blood pressure and cholesterol levels under control and to exercise and eat right. The sooner actions are taken to fight diabetes, the better the long-term outcomes. Intervening early can pay off in the long run. Patients should become involved with a multidisciplinary team, which will treat them throughout their disease course. They should also talk with family, friends, and others with diabetes, and seek out ways to reduce stress, become more informed, and engage in a healthy lifestyle.”
Support is Available
The American Diabetes Association (www.diabetes.org) is one of several well-respected advocacy groups that provide resources for newly diagnosed patients to improve their knowledge and understanding of diabetes. In November 2010, the ADA will make a new booklet available called Where Do I Begin Living With Type 2 Diabetes. Designed to help answer many of the questions new patients have on day one of diagnosis while not overwhelming them with too much information, this new patient resource launches the Living With Type 2 Diabetes program. It engages newly diagnosed patients by providing them with educational materials at various intervals in order to share information and support throughout their first year of life with type 2 diabetes. Dr. Bergenstal says “the hope is that clinicians will provide their patients with this booklet and encourage them to enroll in the Living With Type 2 Diabetes program so that they can live long, healthy lives even though they have this chronic disease.”
American Diabetes Association: http://www.diabetes.org/living-with-diabetes/recently-diagnosed/.
National Diabetes Education Program: http://ndep.nih.gov/.
American Association of Diabetes Educators: http://www.diabeteseducator.org/.
American Diabetes Association. Standards of Medical Care—2010. Diabetes Care. 2010;33(Suppl 1):S11-S61. Available at: http://care.diabetesjournals.org/content/33/Supplement_1/S11.full.
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010;33:S62-S69.
Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2009;32:193-203.