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Patient-Centric DM Care: Challenges & Solutions
Paul Aoun, D.O., Ph.D. Clinical Endocrinologist, PBDES
Affiliate Assistant Prof, Univ of Miami
Disclosure
• I do not have any financial relationships relative to the content of this program
• Today in the U.S., ________ will be diagnosed with diabetes. This is equivalent to about _______ per minute
ADA
4,660
3
Prevalence of Diabetes and Prediabetes in the United States
4 1. CDC. National diabetes fact sheet, 2008. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2008.pdf. 2. CDC. National diabetes fact sheet, 2011. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. 3. CDC. National diabetes statistics report, 2014. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf
Prediabetes 37% of US population
Diabetes 9.1% of US population
57 79 86
17.9
18.8 21.0
5.7
7 8.1
0
20
40
60
80
100
120
140
2007 2011 2014
Pers
ons
(mill
ions
)
Undiagnosed DMDiagnosed DMPrediabetes
1 2 3
1 in 3 MEDICARE $ People with Diagnosed Diabetes
ADA AACE
HOW ARE WE DOING?
The Good
Improving Survival Reducing complications New discoveries Novel technologies
The Bad
WHY?
PHYSICIAN
E
M
L E G S L A T I O N S
EB
V A L U
S E
M
E
System Malfunction….
OBJECTIVES
?
-Patient-Physician -EBM -Legislations
1. FIX 2. MARKET
16 1. Ali MK, Bullard KM, Saaddine JB, et al. Achievement of goals in U.S. diabetes care, 1999-2010. N Engl J Med. 2013;368:1613-1624.
Are 50%+ not reaching Treatment goals
AND/OR
Are we NOT reaching THEM?
COMPLIANCE?
COMPLIANCE CONCORDANCE
COMPREHENSION
CONDITION(S) CONCERNS
Compliance Concordance
COMPREHENSION
CONCERNS: -Values -Preferences -Occupation -Living Conditions -Socioeconomic status -Psychosocial barriers
CONNOTATION
Compliance Concordance
COMPREHENSION
CONCERNS: -Values -Preferences -Occupation -Living Conditions -Socioeconomic status -Psychosocial barriers
CONDITION(S): -Diabetes -Treatments: -Dietary Choices -Physical Activity -Medications
COMPREHENSION
CONCERNS: -Values -Preferences -Occupation -Living Conditions -Socioeconomic status -Psychosocial barriers
CONDITION(S): -Diabetes -Treatments: -Dietary Choices -Physical Activity -Medications
Why do you think you
developed diabetes?
The genes set the stage, the behavior tells the tale…
Dealing with diabetes can be overwhelming,
“but if it is understood better, it is underwhelming.”
Patient
COMPREHENSION
CONCERNS: -Values -Preferences -Occupation -Living Conditions -Socioeconomic status -Psychosocial barriers
CONDITION(S): -Diabetes -Treatments: -Dietary Choices -Physical Activity -Medications
Two fallacies of extrapolating basic thought processes to complex
scientific principles and mechanistic pathways:
1. HIGH FAT: REDUCE FAT
2. SUGARS BAD: SUBSTITUTE SUGAR
Artificial sweeteners
Brain: Alter reward center activity (Green E. & Murphy C. 2012; Frank G.K.W et al, 2008)
Tongue: Dull taste buds (Ann Alexander. Prevention)
Gut: Trick the gut (Susan Swithers, Ph.D. @ Purdue)
Pancreas: insulin spikes (Fowler SP et al. Obesity 2008)
Behavior: False perception of eating healthier Nutrition: calorie-free and nutrients-free
Almost all diets (and diet pills) work initially Almost all diets (and diet pills) fail eventually
As A Medical Community: We Must Aim for
Long-Lasting SUSTAINABLE Results
Portion Control &
Restrict refined carbs and simple sugars
Mayo Clinic
Total Calories: 350 vs. 1400 Mayo Clinic
200 calories
WiseGeek.com
NUTRITION HEALTH = CALORIES
Furhman, J 2003
Physical Activity Altering the perception
Physical Activity Exercise
• Exercise: a structured form of activity for a defined purpose, often to compete in a sport or strength-training to maintain a certain fitness level.
• Physical activity: Any bodily movement that involves muscle contraction.
James A .Levine, 2007
James A .Levine, 2007
COMPREHENSION
CONCERNS: -Values -Preferences -Occupation -Living Conditions -Socioeconomic status -Psychosocial barriers
CONDITION(S): -Diabetes -Treatments: -Dietary Choices -Physical Activity -Medications -Cost -Complexity
What are you treating with the medication?
the insulin resistance
and/or will-power resistance
Incentive
You are _____ lbs away from coming off _____________
How many of the DM-2 patients on insulin, truly need it?
Some do
Many do not
• B cell failure: – Dysfunction (“stunned”) – De-differentiation – Death?
Halban PA et al. JCEM 2014
Effects of Wt loss on B-cell parameters
Insulin Sensitivity Insulin Secretion
Obese Diabetics
Kelley DE et al, JCEM 1993 Ferrannini E et al, Diabetes 2004 Robertson SP et al, Diabetes 2004
• “Interestingly, the greatest HbA1c reduction was the fall of 2% during the first 3 months with intensive diet and 5% weight loss”
R. Holman, Oxford, U.K (Chief Investigator-UKPDS)
If insulin indicated,
Simplicity Improves Adherence …AND OFTEN SAFETY
Real-World Severe Hypoglycemia in Diabetics Exceeds Trial Rates
Gao J et al. Biomedical Reports. 2015:3(3)
Gao J et al. Biomedical Reports. 2015:3(3)
A1C-8.6% Wt: 188 lbs
A1C-6.5% Wt: 164 lbs
• AVOID OVERINSULINIZATION – Revisit the need for insulin – Minimize/eliminate complex regimens, ESPECIALLY
IN THE ELDERLY
• Educate on OADs assoc. w/ HYPOGLYCEMIA • RE-INTRODUCE METFORMIN (if a candidate)
Simplicity improves adherence
Ask your doctor if Metformin is again right for you
Insulin Metformin
Patient-Physician: -Concerns & Values -Compliance -Cost -Complexity EBM Legislations
Reconcile
Research with
Reality
DM trials
Purpose: 75% therapeutic; 10% preventative Funding: 51% Industry; 25% industry-funded multicenter
Interventions: 64% Drugs; 12% Behavioral Size: 91% <500 Mean time to completion: 1.8 years >65 y.o excluded: 30% >75 y.o. excluded: >90% Trials targeting >65 y.o.: 0.6%
From: Sugar-Sweetened Beverages, Weight Gain, and Incidence of Type 2 Diabetes in Young and Middle-Aged Women
JAMA. 2004;292(8):927-934. doi:10.1001/jama.292.8.927
Reconcile
Guidelines with
Insurance coverage
Present & Future of
Food Supply
"Between today and the year 2050, farmers will be required to grow twice as much food to feed a rapidly growing world population. Food will be grown in the face of increasingly severe weather and environmental conditions, with greater strains on water, soil and energy resources,“
FbNews May 2016
:
Legislative Efforts
S. 586/H.R. 1192
Florida Members of Congress Not Currently Co-sponsors
• 13 out of the 29 Members of the Florida Delegation currently support this bill!
• Additional House co-sponsors will help ensure passage this month
• S. 586 has 33 co-sponsors and only Sen. Bill Nelson (D) has signed on for Florida
• Send a message to Sen. Rubio and your Representative, if not currently co-sponsoring the bill, at https://www.aace.com/diabetesbill
National Diabetes Clinical Care Commission Act (H.R. 1192/S. 586)
Sen. Marco Rubio [R] Rep. Jeff Miller [R-1] Rep. Curt Clawson [R-19] Rep. Patrick Murphy [D-18] Rep. Ander Crenshaw [R-4] Rep. Bill Posey [R-8] Rep. Carlos Curbelo [R-26] Rep. Tom Rooney [R-17] Rep. Ron DeSantis [R-6] Rep. Ileana Ros-Lehtinen [R-27] Rep. Mario Diaz-Balart [R-25] Rep. Debbie Wasserman Schultz [D-23] Rep. Gwen Graham [D-2] Rep. Daniel Webster [R-10] Rep. John Mica [R-7] Rep. Ted Yoho [R-3]
Patient-Physician: -Concerns & Values -Compliance -Cost -Complexity EBM Legislations
Patient-Physician: -Connotation -Comprehension -Cost-effective -Convenience EBM -Reconcile Research w/Reality -Preventative Legislations -S. 586/HR 1192
It is not what you look at that matters,
it’s what you see
Henry D. Thoreau
“To me, marketing is about values”
Steve Jobs
Thank you
