Ronald Tamler, MD reviews diabetes as it relates to the podiatrist. Arguing that podiatric physicians are on the front lines of the diabetes epidemic, Dr Tamler discusses when and how to screen for diabetes and what to do with the results obtained therein.
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A Primer on Diabetes for the Astute Podiatrist
Thank you very much, wow thank you so much for a very warm welcome. Before we get started I do need to disclose something, I was the site PI for a study that was supported by Bayer. I didn't get any money but my division did. So, just for you to know. So, I'm going to talk to you a little bit about diabetes, some things have changed. Who in this room sees patients with diabetes? Show of hands, who in this room? Okay, who in this room is awake? Show of hands. Okay, now let's try this again, who in this room sees patients with diabetes? Ah hah, so I'd say close to a 100 %, alright. Let's try another thing, who in this room has ever diagnosed a brand new patient with diabetes? Yeah, still quite a few, and we're going to talk about just that. Because we, endocrinologist, need your help cause you are on the front lines of this diabetes epidemic.
What are you going to get out of this talk?
Well, you're not going to become the world's expert in diabetes.
But you will get a pretty good idea of when to get suspicious, when to screen for diabetes, how to do it and what to do with your results.
And I'm going to present two real cases that were referred to me by a real podiatrist that show how we can work together. And that also show the kind of situations where you should get suspicious. I'm also going to work in the brand new recommendations by the American Diabetes Association that were published this month. And they are brand new, so, you'll hear it here first.
So let's try the first case. This is a 24 year old African American man who comes to see you for burning foot pain and he never goes to a doctor.
And, he's been feeling weak and lethargic.
He's quite portly; he has a BMI of 38. Quite obese, right BMI, Body Mass Index of over 30 qualifies as obese. But, he's very proud because he's effortlessly lost 25 pounds over the past two months. And, I don't know if you have the Star Bucks phenomenal in your practice. My patients sip their coffee and they're on their cell phones while they are seeing me. This patient is happily guzzling a quart of orange juice while he's seeing his doctor.
On examination you see that he has got no sense of vibration, on the other hand when you go for monofilament testing he jumps out of the chair.
So what should you not do?
Should you not ask him whether he is having polyurpathy, polydipsia or blurry vision?
Should you get a random blood sugar with a glucometer in your office? We're going to talk about that in a moment.
Should you get a hemoglobin A1c test? Or maybe a urine dip stick?
Should you refer him to an internist?
Or should you offer him, kind podiatrist you are and excellent host, should you offer him another glass of OJ?
And, let's go for the second case. The second scenario of the typical diabetic I will present.
A 46 year old obsess Hispanic woman seeks your advice because she's got yellow toenails, and she's upset about it. And when you ask her about it she admits to having pins and needles in her feet.
She also asks you hey, do you know somebody that can take care of my extra facial hair in places where I don't really want it?
And she also tells you that everybody in her family has diabetes and she thought about it. So she checked her blood sugar with her grandmother's meter and it was okay.
So what should you not do for this lady?
Should you get a point of care hemoglobin HbA1c test? That's a finger stick test that can tell you right on the spot the patient's hemoglobin A1c.
Should you refer her to a good internist?
Should you ask the patient what she considers okay?
Should you get an oral glucose tolerance test, where a patient goes and gets 75 grams of sugar solution and then sticks around for two hours so you can see what the blood sugar level is two hours later?
Or should you just give itraconazole cream and assure the patient that her yellow toenails will turn out fine?
Now let's talk about diabetes and we're going to get back to these two cases.
It's extremely prevalent at this point if you go with the adult population, almost 13% of the population older than twenty has diabetes. Now Mount Sinai is adjacent to East Harlem, the quota there is 25%.
An additional close to 30% of the population would qualify as pre-diabetic. So they are on their way to having diabetes.
About a third to 40% are unaware that they have diabetes. They are undiagnosed.
And if you take the people already diagnosed with diabetes, around 20% of them will already have diabetic eye disease.
And around 10%, and those are the patients that you are seeing, will have diabetic neuropathy at the time of diagnosis.
And of course bad things happen to people with diabetes. So its not just the diabetic neuropathy that you are seeing,
Nephropathy leading to dialysis, retinopathy making diabetes the leading cause for blindness in the United States,
And macrovascular disease,
Which leads to premature death, which is why patients with diabetes will have a harder time getting life insurance, you know it literally shaves off seven years of your life.
And the number one factor is obesity as you can see your risk really skyrockets with body mass index. How what's a normal body index? Anything from 19 to 25 is considered normal, 25 to 30 are considered over weight, and we're talking now about the Caucasian population, other populations it's even lower. And once you get over, and this is your body mass index, 30 in relation to your weight and your height, once you have a body mass index greater than 30 your risk factor for diabetes really skyrockets.
So who should get screened?
Anybody with a BMI greater than 25.
People that have first degree relatives that have diabetes, Type II Diabetes.
If a patient tells you she had gestational diabetes that means she has a ten year of going forward of 50% or greater of developing Type II Diabetes. Now some patients will not know if they had gestational diabetes or not because they never got screened, or they never cared. So, another question to ask is did you have any children at birth that were heavier than 9 pounds? That's a pretty good indicator that they had gestational diabetes.
Patients with hypertension.
Women with polyosytic ovarian disease. That extra facial hair in that lady who was obese. Absolutely a risk factor for diabetes.
Lipid profile disturbances.
Patients with pre-diabetes have obliviously a higher risk of progressing towards diabetes.
Patients with cardiovascular disease.
And actually anybody older than 45 has an increased risk towards diabetes and deserves to be screened.
So a good podiatrist should be able to diagnose diabetes and know that you in this room have done that. But, the guidelines have changed so I am here to update you.
You might already know to diagnosis diabetes a fasting sugar greater of 126 is sufficient.
Or a random sugar greater than 200 with symptoms. So in that first guy, the one in case number 1 who has the lethargy and the weight loss, and the polyurpathy, polydipsia, since you asked about it probably, if he has a random blood sugar greater than 200 that's it. That's his diagnosis.
An oral glucose tolerance test that is greater than 200 after two hours and this is certainly the test that gives you the greatest sensitivity.
And finally, and this is new as of the guidelines from January, 2010, according to the HbA1c greater than 6.5%.
Now this is revolutionary because you don't need to be fasting, the hemoglobin A1c is your average blood sugar over the past three months. So that's pretty neat, you can just do a blot test, the patient does not need to be fasting, you know, we all know cause it's pretty hard to get people in fasting. And it's pretty hard to get people to sit still for two hours and sit in the lab. Cause nobody has time, I practice Manhattan, nobody has time to sit around for two hours. So this is a pretty neat alternative.
We spoke about pre-diabetes and pre-diabetes can be defined in two ways. Either you've got impaired fasting glucose, meaning that you fasting glucose is in the range between 100 and 126 and that's fasting. Or, you can have impaired glucose tolerance meaning that when a patient eats a meal with a certain carb content, blood sugar goes up disproportionably and this is on oral glucose tolerance test so normal is less than 140 and pre-diabetic is impaired glucose tolerance or IGT, is 140 to 200. And greater than 200 defines diabetes. And this is pretty neat because of an oral glucose tolerance test instead of a meal defines actually how much sugar they get so that makes the results more reproducible. Now again, I practice in Manhattan so it's hard to get people to sit still for two hours.
The ADA has new guidelines which defines pre-diabetes as an A1c between 5.7 and 6.4%. And again, this is pretty nifty because they don't have to be fasting, they don't have to stick around for two hours. You can just do a blood draw and send it to a lab. Or, you can do a point of care test and these kits are around eight dollars per test and Medicare reimburses it depending on what state you live in, at around thirteen dollars, something like that. So, you can actually make the diagnosis of diabetes in your office just by asking two or three smart questions and by getting one simple blood test. So what I think is very appropriate to have is a non-coding glucometer, meaning you don't have to put in a new code every time you buy a new batch of test strips. You know you can get a good glucometer at any department store for less than twenty bucks, test strips are fifty cents per test strip, and you can make the diagnosis right there in your practice. It's pretty easy.
So you don't really have to worry if your patient has a touch of sugar, you can diagnose it. And you're at the forefront of this epidemic. A lot of patients will not come see me because they don't feel like they have diabetes; they're going to come see you because they have trouble with their feet. And you can, beyond saving their feet, you can save their lives by diagnosing diabetes in a much more timely manner than I would by the time they come to me.
Now, I personally like the oral glucose tolerance test if you can do it because you have more sensitivity. Cause if you take just fasting glucose you'll miss a lot of the patients that have impaired glucose tolerance so I think that in my opinion the oral glucose tolerance test is the best test of diagnosing diabetes if your patients will allow you to do it.
And this is how I order it for Ms. Pie. You write a prescription for a glucose tolerance test, two hours and 75 grams and put the diagnosis on, give them the prescription and send them off to the lab. And if you're lucky they will do it. If you don't think they will do it just get an A1c, much quicker.
So let's talk about what happened to those two real patients.
The first one who was losing weight so effortlessly, he had a random blood sugar of 426.
He also had ketonuria, meaning that this was a candidate to actually be sent to the ER.
Instead, they drew an A1c, which you can see was quite elevated.
They e-mailed me, can you see this guy right now, which I did.
And I started him on insulin's and now he's on orals. A lot happier, he's feeling a lot less lethargic and so we caught it and he's doing a lot better now. And interestingly his neuropathy is also a little bit better.
So with the second patient it turns out that okay means different things to different people. Everybody in her family that had diabetes had uncontrolled diabetes so for her normal sugar was something like 200. And she was very excited that she had a fasting sugar in the 120's.
And then an oral glucose tolerance test showed that she actually went higher.
Over 200 after two hours so she qualified as having diabetes. She's now very happy doing on a little bit of metformin and doing quite well with life style changes and this oral medication. And her paresthesias are also doing a little bit better.
So take home messages for this audience, for you.
Type 2 Diabetes is really common.
And you are at the forefront of the diabetes epidemic whether you like it or not, many of my potential patients never get to see me, they go to see you. And you have to think, could this person have diabetes and you have the opportunity to not just save their limb, but save their life.
So get a glucometer, ideally a non-coding one so that you have less hassle with it.
Consider point of care, hemoglobin A1c testing or blood draw if you have the time.\
And again, you can have a major impact by diagnosing diabetes earlier.
Thank you very much and now I'm open for questions.