MDAdvisor Winter 2013 by MDAdvantage Insurance Company of New Jersey

Commissioner Mary E. O’Dowd, MPH

HISTORY OF DIABETES

REDUCING THE IMPACT OF DIABETES IN NEW JERSEY

Arleen Marcia Tuchman, PhD

VOLUME 6 • ISSUE 1 • WINTER 2013

Janet S. Puro, MPH, MBA

ANNOUNCING THE 2013 EDWARD J. ILL EXCELLENCE IN MEDICINE AWARDS ®

Diabetes: The Fight Goes On

This issue is dedicated to Arthur Krosnick, MD, who devoted his life to the prevention, management and treatment of diabetes.

MDAdvisor is published by MDAdvantage Insurance Company of New Jersey.

& ANNOUNCES THE 2013 EDWARD J. ILL EXCELLENCE IN MEDICINE AWARDS

IN SUPPORT OF THE EDWARD J. ILL EXCELLENCE IN MEDICINE SCHOLARSHIP FUND.

SAVE THE DATE WEDNESDAY, MAY 1, 2013 6:00 P.M. Greenacres Country Club in Lawrenceville

OUTSTANDING MEDICAL EDUCATOR AWARDS Nayan Kothari, MD Carol A. Terregino, MD

OUTSTANDING MEDICAL RESEARCH SCIENTIST AWARD FOR BASIC BIOMEDICAL RESEARCH Smita S. Patel, PhD

OUTSTANDING MEDICAL EXECUTIVE AWARD Robert C. Garrett, FACHE

OUTSTANDING MEDICAL RESEARCH SCIENTIST AWARD FOR CLINICAL RESEARCH Suhayl Dhib-Jalbut, MD

EDWARD J. ILL PHYSICIAN’S AWARD ® Robert L. Johnson, MD VERICE M. MASON COMMUNITY SERVICE LEADER AWARD Kathleen Horn, RN, CIC

PETER W. RODINO, JR., CITIZEN’S AWARD ® Mike Adler and the Adler Aphasia Foundation

on behalf of the Hunterdon Medical Center Infection Prevention Team

To participate in this year’s event by purchasing tickets, an Honor Roll sponsorship or an ad in the awards journal, call 609-803-2350 or visit www.EJIawards.org.

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PEER REVIEWER ACKNOWLEDGEMENTS

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The Editorial Board would like to acknowledge the following individuals who served as peer reviewers of manuscripts submitted for consideration of publication in MDAdvisor in the past year, as well as those reviewers who prefer to remain anonymous. Our reviewers are an important part of the selection process, and provide our authors with valuable insights. We gratefully acknowledge their comments and contributions.

PATRICIA A. COSTANTE, FACHE Chairman & CEO MDAdvantage Insurance Company of New Jersey

To find out how to volunteer to review content for MDAdvisor in your area of expertise, contact us at Editor@MDAdvisorNJ.com. SPECIAL MID-ISSUE ARTICLE In honor of Veterans Day on November 12, 2012, we distributed the article “Facilitating Reintegration for Veterans: Patient-Centered, Comprehensive Care,” by Florence B. Chua, MS, Christina Rumage, MSPH, CHES, Susan L. Santos, PhD, MS, and Drew A. Helmer, MD, MS, to our online subscribers. The article can be accessed at www.MDAdvantageonline.com/MDAdvisor.

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PUBLISHER

ACKNOWLEDGEMENTS

Kevin Crutchfield, MD John Eyler, PhD Peg Grandison, MSW, LCSW Gerald N. Grob, PhD Scott T. Heller, Esq. David Herzberg, PhD Paul J. Hirsch, MD William L. Holzemer, RN, PhD Sharlene A. Hunt, Esq. William G. Hyncik, ATC John Zen Jackson, Esq. Jay S. MacNeill, Esq. Rosemarie S. Moser, PhD Gregory J. Rokosz, DO, JD Paul W. Schopp Stephen H. Schneider, MD Leon G. Smith, MD Leonardo M. Tamburello, Esq. Daniel J. Tarditi, DO Allen B. Weisse, MD Marvin C. Ziskin, MD

A Journal for the New Jersey Medical Community

PUBLISHING & BUSINESS STAFF CATHERINE E. WILLIAMS Senior Vice President MDAdvantage Insurance Company of New Jersey JANET S. PURO Vice President MDAdvantage Insurance Company of New Jersey THERESA FOY DiGERONIMO Copy Editor MORBELLI RUSSO & PARTNERS ADVERTISING INC. EDITORIAL BOARD STEVE ADUBATO, PhD RAYMOND H. BATEMAN CAROL V. BROWN, PhD PETE CAMMARANO DONALD M. CHERVENAK, MD STUART D. COOK, MD VINCENT A. DeBARI, PhD

GERALD N. GROB, PhD JEREMY S. HIRSCH, MPAP PAUL J. HIRSCH, MD WILLIAM G. HYNCIK, ATC JOHN ZEN JACKSON, Esq. ALAN J. LIPPMAN, MD

EMERGING MEDICAL LEADERS ADVISORY COMMITTEE IVAN GEORGIEV OREN JOHNSON, MD

NEIL KAUSHAL, MD ARVENY NEGRON

PUBLISHED BY MDADVANTAGE INSURANCE COMPANY OF NEW JERSEY Two Princess Road, Suite 2 Lawrenceville, NJ 08648 www.MDAdvantageonline.com Phone: 888-355-5551 • Editor@MDAdvisorNJ.com INDEXED IN THE NATIONAL LIBRARY OF MEDICINE’S MEDLINE® DATABASE. Material published in MDAdvisor represents only the opinions of the authors and does not reflect those of the editors, MDAdvantage Holdings, Inc., MDAdvantage Insurance Company of New Jersey and any affiliated companies (all as “MDAdvantage™”), their directors, officers or employees or the institutions with which the author is affiliated. Furthermore, no express or implied warranty or any representation of suitability of this published material is made by the editors, MDAdvantage™, their directors, officers or employees or institutions affiliated with the authors. The appearance of advertising in MDAdvisor is not a guarantee or endorsement of the product or service of the advertiser by MDAdvantage™. If MDAdvantage™ ever endorses a product or program, that will be expressly noted. Letters to the editor are subject to editing and abridgment. MDAdvisor (ISSN: 1947-3613 (print); ISSN: 1937-0660 (online)) is published by MDAdvantage™ Insurance Company of New Jersey. Printed in the USA. Subscription price: $48 per year; $14 single copy. Copyright © 2013 by MDAdvantage™. POSTMASTER: Send address changes to MDAdvantage, Two Princess Road, Suite Two, Lawrenceville, NJ 08648. For advertising opportunities, please contact MDAdvantage at 888-355-5551.

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LETTER FROM MDADVANTAGE™ CHAIRMAN & CEO PATRICIA A. COSTANTE A MEMORIAL DEDICATION TO ARTHUR KROSNICK, MD | Submitted by the MDAdvisor Editorial Board ADVANCES IN DIABETES PREVENTION AND MANAGEMENT THROUGH THE LIFE’S WORK OF ARTHUR KROSNICK, MD | By Paul J. Hirsch, MD HISTORY OF DIABETES | By Arleen Marcia Tuchman, PhD ANNOUNCING THE 2013 EDWARD J. ILL EXCELLENCE IN MEDICINE AWARDS® | By Janet S. Puro, MPH, MBA LEGISLATIVE BRIEF: NEW JERSEY LEGISLATORS ADDRESS DIABETES & CHILDHOOD OBESITY | By Pete Cammarano REDUCING THE IMPACT OF DIABETES IN NEW JERSEY | By Commissioner Mary E. O’Dowd, MPH PATIENT-CENTRIC TOOLS FOR BETTER DIABETES SELF-MANAGEMENT | By Carol V. Brown, MBA, PhD, Diane M. Strong, PhD, Cortney M. Nicolato, CPHIT, and Carole L. Romasco, MBA THE HEART OF DIABETES | By Ian Joffe, MD GENERAL APPROACH TO THE TYPE 2 DIABETIC PATIENT | By Stephen H. Sherry, MD

WINTER 2013 – CONTENTS

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ONLINE ARTICLES – VISIT OUR WEBSITE FOR FULL ARTICLES AT: WWW.MDADVANTAGEONLINE.COM/MDADVISOR

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STAY HUNGRY–FOR KNOWLEDGE | By Robert E. Paarz, Esq. A YOUNG ADULT’S PERSPECTIVE: AN ENCOURAGING STORY FOR YOUNG DIABETICS | By Carson Scott TALKING ABOUT DIABETES | By Steve Adubato, PhD

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A Memorial DEDICATION TO ARTHUR KROSNICK, MD Submitted by the MDAdvisor Editorial Board

We dedicate this issue of MDAdvisor to a physician who dedicated his professional life to treating diabetes and to educating other physicians, other medical professionals and, especially, to educating patients about diabetes. Dr. Arthur Krosnick was the preeminent New Jersey diabetologist for many decades and was internationally recognized for his work and achievements in his field. In 1954, Dr. Krosnick completed his residency training and opened his practice, limited to the treatment of diabetes, in Trenton. From the start, he recognized the essential linking of clinical care and education in the treatment of diabetics, and therefore, his office staff included a diabetes nurse educator as well as a dietician. He recognized that clinical research was a vital pathway to improvement in the care of diabetics, and led a research team that included endocrinologists, nurse/diabetes educators

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and dietician/diabetes educators. In addition to his private practice, Dr. Krosnick served our state as the senior public health physician and coordinator of the New Jersey State Department of Health Diabetes Control Program (DCP) from 1954 to 1977; during that time, he also served as consultant to the U.S. Public Health Service DCP (1962–1970). At a recent gathering in Scottsdale, Arizona, to remember and honor Dr. Krosnick’s life and accomplishments, Larry Ellingson, a former Chairman of the American Diabetes Association, recalled Dr. Krosnick’s role in promoting “patient-centered care” for diabetics, in leading efforts to improve foot care, and in identifying signs and symptoms of depression in diabetics. Ellingson also noted Dr. Krosnick’s role as principal investigator in more than 100 research protocols, including human insulin. Dr. Krosnick’s commitment to diabetes education probably led to his interest in medical writing, medical journalism and editorial leadership. He served as Editor-in-Chief of Diabetes Forecast, a publication of the American Diabetes Association, which continues today, as it did when he was Editor, to provide “comprehensive, accurate and timely information and support on all aspects of diabetes” for diabetics and their families. Dr. Krosnick also served as Editor of Clinical Therapeutics (a journal of drug therapy) and as Editor-in-Chief of the state medical society’s journal. Even after he retired from that position, he remained active as Editor Emeritus for several years. Dr. Krosnick and his career have been recognized by many awards, including the Edward J. Ill Award in 1982, recognizing “excellence in medicine,” and the Outstanding Physician Educator in Diabetes Award of the American Diabetes Association in 1998. However, his medical career does not completely describe Arthur Krosnick. His life was a true partnership with his wife Evelyn, to whom he was devoted. They shared many passions, including architecture, music (Evelyn Krosnick has served as Director of the Greater Princeton Youth Orchestra) and furniture by famed master woodworker George Nakashima, with whom they had a close relationship. Dr. Arthur Krosnick, who died in May 2012 at the age of 88, was a conscientious and compassionate physician, an innovative educator, an unassuming humanitarian and an exemplar of “excellence in medicine.” We are proud to dedicate this issue of our journal to him and his ideals.

Advances in DIABETES PREVENTION AND MANAGEMENT THROUGH THE LIFE’S WORK OF ARTHUR KROSNICK, MD By Paul J. Hirsch, MD “Dr. Krosnick’s focus on the patient (rather than solely on the disease itself) promoted patient-centered care– before the term was in common use.”

Arthur Krosnick’s career in medicine gives concrete form to the cliché “eye on the target.” After graduating from Temple University School of Medicine in 1951, Dr. Krosnick began his residency at the University of Pennsylvania’s Presbyterian Hospital in the field that would begin, in his own words, “a lifelong passion for a career devoted to diabetes.”1 In 1954, Dr. Krosnick opened his private practice dedicated to the treatment of diabetes in a time that stood on the threshold of major advances in this field. Consider that Dr. Krosnick began his practice with glass insulin syringes with large-bore needles that were painful to use. The syringes had to be sterilized daily, and the needles had to be sharpened and sterilized after each use (so unlike today’s insulin syringes that are disposable and accurate with micro-fine needles and minimal problems with air bubbles or loss of insulin). Consider that in the 1950s oral medications were introduced to better manage blood sugars for those with type 2 diabetes. In the early 1960s, urine test strips were developed to test blood sugar. People with diabetes no longer had to use test tubes and tablets and wait for results. In 1969, the first blood glucose meter was developed.2 This was indeed a fortuitous time for a physician such as Dr. Krosnick to choose a life dedicated to the prevention, management and treatment of diabetes. TRUE PHYSICIAN EDUCATOR In this exciting environment, Dr. Krosnick immediately

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recognized and emphasized the connection between clinical care and education. Dr. Krosnick’s focus on the patient (rather than solely on the disease itself) promoted patient-centered care–before the term was in common use. With a team approach to patient care, Dr. Krosnick not only guided the patient with diabetes but also educated his entire support team, including the nurse, dietitian, podiatrist, pharmacist, family physician and the patient’s family members. His lessons targeted lifestyle as well as medical issues. Dr. Krosnick was one of the first to preach not only the importance of diet and exercise in the management of diabetes, but to explain how to adjust life habits to meet given goals. For example, he promoted meal planning based on the American Dietetic Association Exchange System. He even taught family members how to check the patient’s feet every day in the hope of reducing the relatively high number of foot amputations in New Jersey. Dr. Krosnick also brought to light the association between diabetes and depression. His persistent work in identifying signs and symptoms of depression in diabetic patients led to the Diabetes and Depression initiative with Lilly, the Lundbeck Institute in Sweden and the World Health Organization that created training and awareness programs in diabetic depression for family physicians and support personnel. Hoping to reach further beyond his immediate team

of physician colleagues, Dr. Krosnick created a curriculum to train family physicians and office staff about the management of diabetes. He also worked with the Academy of Family Physicians to provide workshops for family physicians, as well as interns and residents. By working with family practice physicians, Dr. Krosnick believed he was accepting the challenge of his teacher, Dr. Charles Best, to follow new research findings and act as “translator” 1 for primary care physicians. Dr. Krosnick had an unfulfilled passion for working with Native Americans, particularly because of their high incidence of and challenges with diabetes. He also wanted to provide a legacy in diabetes through his writings, which he started in 2002. Although he was not able to fulfill this part of his dream, his foundation in education with patients and support personnel have provided future generations with the tools to move his agenda forward. Ultimately, Dr. Krosnick became a nationally known public health educator. He produced educational films, publications and even telephone presentations for patients, physicians and the public. (One film, Diabetes and Its Long-Range Control, included an appearance by Dr. Krosnick.) RESEARCHER AND PUBLIC HEALTH PHYSICIAN Dr. Krosnick held many prestigious titles as a public health physician–with each position giving him more opportunities to diagnose cases of diabetes and to research and implement more effective treatments. For example, as Senior Public Health Physician and Coordinator of the New Jersey State Department of Health Diabetes Control Program (DCP), Dr. Krosnick developed statewide diabetes detection programs. Using the results of the first comprehensive diabetes prevalence study in the United States, Krosnick’s team distributed hundreds of thousands of Dreypaks, identification cards with an attached filter paper that could be moistened with urine and mailed to the DCP for testing. As consultant to the U.S. Public Health Service DCP from 1962 to 1970, Dr. Krosnick continued his research and public health education programs at the national level. Notably, Dr. Krosnick was the principal investigator in 1981 in the Eli Lilly recombinant DNA (rDNA) human insulin research protocols. In fact, Dr. Krosnick was the first doctor to treat a patient in the United States with

rDNA human insulin and later was involved in clinical research and treating patients with the fast analog of human insulin, Humalog. Dr. Krosnick also introduced the new rDNA insulins to a group of international investigators and was involved in assisting Lilly’s introduction of these insulins at the New York City Symposia for physicians from Sweden and Spain. In 1994, Dr. Krosnick was appointed Medical Director and Research Director of the Joslin Centers for Diabetes at Saint Barnabas, Princeton Division in New Jersey. Here, his programs, again, had a major impact on diabetes in New Jersey and the United States. Typical of all Krosnick research teams, the pharmacological research team in Princeton included three nurses/diabetes educators, two registered dietitians/diabetes educators and three endocrinologists. Their work resulted in approximately 130 protocols for many of the large pharmaceutical companies. Dr. Krosnick worked tirelessly in many other facets of diabetes as well, including safety studies and drug delivery technology. It is no wonder that his informed insights steered him to medical writing and editorial leadership. His work for notable publications such as the New Jersey Medical Journal, Diabetes Forecast, Clinical Therapeutics and Acta Pharmaceutica provided him with more opportunities for educating professionals and their support teams about the patient-centered and team approach to the treatment of diabetes that he so passionately practiced and believed in. An Edward J. Ill Physician’s Award recognizing his excellence in medicine and a Lifetime Achievement Award bestowed upon Dr. Krosnick by the American Diabetes Association highlight the well-deserved international recognition and respect that this physician garnered during his long and accomplished career. Arthur Krosnick’s life is an example to all physicians of what one human being can do with an unwavering “eye on the target.” Paul J. Hirsch, MD, a member of our Editorial Board, received his start in medical journalism under the tutelage, guidance and leadership of Dr. Krosnick. 1

Krosnick, A. (2002). Five decades of diabetes patient care: The time of my life. Clinical Diabetes, 20(4), 173–176.

Davidson, N. K., & Moreland, P. (2009). Diabetes then and now. Living with Diabetes. www.mayoclinic.com/health/ diabetes-blog/MY01115.

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Diabetes By Arleen Marcia Tuchman, PhD

THE GROWING “EPIDEMIC” The Centers for Disease Control and Prevention predicts that one out of every three people born in the United States in 2000 will develop the disease.2 Small wonder public health officials have begun to refer to a diabetes “epidemic.” The financial burden of this disease is surpassed only by the human tragedy in lives lost and in the suffering caused by such sequelae as blindness, renal failure and amputations. Diabetes has emerged as one of the most challenging chronic diseases of our time because it can prove difficult to control, and it cannot be cured. William Osler, one of the most highly regarded medical professionals around the turn of the 20th century, commented in 1892 that diabetes was still “a rare disease.”3 But even as he wrote, changes were under way. U.S. census reports showed a 150 percent increase in the diabetes mortality rate between 1850 and the end of the century. Diabetes may not yet have claimed many lives (in 1900, it ranked 27th among causes of death), but no other disease was showing such exponential growth.4

Physicians’ explanations for this disturbing trend revealed deep-seated anxieties about how the forces of industrialization, urbanization and immigration were transforming American life in the decades following the Civil War. For many, diabetes symbolized the nation’s abandonment of a life of “frugality” in favor of “lazy comforts.”5 Most striking to the modern reader is the widespread belief that diabetes primarily afflicted the affluent (in contrast to today, when, at least in the United States, it is more often considered a disease of poverty).6 To some extent, medical reasoning proved sound. Not only did the monied classes have a better chance of surviving to an age when they might develop diabetes, but they were also more likely to receive medical care and to eat enough to get fat (obesity was considered a risk factor). Race and class stereotypes buttressed the association between diabetes and wealth: Diabetes flourished where “civilized humanity” abounded, afflicting refined individuals with more advanced nervous systems. Thus, what appeared to be a

This material was originally commissioned for The Oxford Encyclopedia of the History of American Science, Medicine, and Technology edited by Hugh R. Slotten. It has been reproduced by permission of Oxford University Press. For permission to reuse this content in any way, please contact OUP.

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“

melting down of the flesh and limbs into urine.” This is how Aretaeus of Cappadocia described diabetes in the 2nd century AD.1 Credited with providing the first detailed clinical description of the disease, Aretaeus painted a disturbing picture of individuals with emaciated bodies, tortured by insatiable thirst and unable to stop drinking or urinating. Aretaeus had no effective treatment to recommend, but he could take some comfort in knowing that diabetes was “not very frequent among mankind.” Two thousand years later, that is no longer the case.

relatively low rate among African Americans was explained by recourse to racist beliefs about their “primitive” nature and lack of “nervous strain.” In contrast, Jews, stereotypically cast as “neurotic” city dwellers, overweight and highly ambitious, were widely believed to experience rates up to six times greater than any other “race.”7 Modernity and race could not, however, explain why a particular individual developed the disease. Here physicians turned to an entire grab bag of possibilities. In addition to obesity and nervous strain, hereditary explanations proved popular, but almost anything seemed capable of triggering the release of sugar into the urine. Among the many causes considered were infections, trauma, sexual excesses, syphilis and tuberculosis.8

DIAGNOSIS AND TREATMENT As physicians spun theories about the causes of diabetes, they also faced the challenge of attending to an increasing number of diabetics. They learned quickly that polydipsia and polyuria made diagnosis relatively easy. They recognized as well that among the young, the disease usually began abruptly, often ending in death within a few years; whereas among the elderly, the onset tended to be gradual and the symptoms (at least initially) milder. Despite this distinction, the consensus was that all diabetic symptoms hailed from the same fundamental pathology, differing in degree rather than kind. Treatment, in contrast to diagnosis, proved daunting. Only restricted diets seemed capable–and then just barely–of

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“ he discovery of insulin in 1921–1922 changed forever the lives of diabetics.”

extending a patient’s life; yet, even here, few agreed whether it was best to restrict carbohydrates, fats and protein or simply calories. In the early 20th century, the physician Frederick M. Allen advanced a diet that was widely employed, but it proved so restrictive that it became known as “starvation therapy.” Though its advocates insisted that they were extending the lives of their patients, its critics recoiled at the image of some of the so-called success stories. In one famous case, three years of Allen’s diet had left 15-year-old Elizabeth Hughes–daughter of Charles Evans Hughes, U.S. Secretary of State and later Chief Justice of the U.S. Supreme Court–weighing under 50 pounds and 9 barely able to walk. The discovery of insulin in 1921–1922 changed forever the lives of diabetics. The scientific work leading to the isolation of this pancreatic hormone was carried out at the University of Toronto by John J. R. Macleod, Frederick G. Banting, Charles H. Best and James B. Collip. Medical researchers had been interested in the pancreas since 1889, when Oskar Minkowski and Joseph von Mering at the University of Strasbourg had unintentionally created a diabetic condition when they removed this organ from a dog. However, Macleod and his team first isolated an “internal secretion” from the pancreas’s islets of Langerhans and subsequently named it insulin.10 Preliminary tests of insulin produced remarkable results, reducing blood sugar levels dramatically. Within five weeks of taking her first insulin injections, Elizabeth Hughes had gained 10 pounds and expressed her joy that she could now expect “a normal, healthy existence.” Newspapers hailed the new breakthrough, which they often labeled a “cure,” sharing stories about individuals who had been “rescued from death.”11 Subsequent insulin trials eventually revealed a more complex story than the initial triumphalist accounts presented. Insulin was not a cure but a new, imperfect tool for lowering blood glucose levels. It saved many lives, but it left diabetics in an ongoing battle to stave off renal failure, cardiac arrest, blindness, neuropathy and gangrene. Additionally, insulin-dependent diabetics faced the new risk of taking too much of the hormone and triggering a hypoglycemic attack that could lead to diabetic coma and death.9

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IDENTIFYING AT-RISK POPULATIONS Insulin made no impact on the increasing diabetes rates. After World War II, the U.S. Public Health Service (USPHS) undertook a community study to estimate the number of undiagnosed diabetics in the nation. It chose Oxford, Massachusetts, which it considered representative of small towns throughout the country, and in

1947 tested 70 percent of the almost 5,000 inhabitants. The results proved disturbing: For every four individuals known to have diabetes, investigators uncovered three undiagnosed cases. As an article in Time magazine pointed out, this finding suggested that there were “some 12 2,800,000 U.S. diabetics . . . and half of them don’t know it.” With hindsight, it is easy to see some of the flaws of the 1947 investigation: The USPHS’s assumptions about who was most at risk of developing diabetes led the agency to choose a town whose population lacked the racial, ethnic and economic diversity of much of the rest of the country. By framing the solution, moreover, around private medical practice (public health departments were directed to refer rather than treat anyone they found to have high blood sugar), this approach further excluded anyone who lacked the resources to seek private care. Yet evidence began mounting in the second half of the 20th century that the populations experiencing the greatest rate increases in diabetes incidence were not the middle-class Whites common in Oxford, but Native Americans and African Americans. Whether this finding revealed an actual increase or a more accurate assessment of the disease burden in these communities remained unclear. Nor was there consensus about what might be responsible for the higher rate, although the search began immediately for a possible genetic predisposition among the newly

“ n 1974[,] diabetes became the fifth leading cause of death in the United States”

designated “at-risk” populations. However, the government’s long-held policy of collecting information about race and ethnicity, but not about class, meant that explanations grounded in biological race may have reflected–as they continue to do today–the kind of data collected rather than 13 the actual distribution of the disease. THE CONTINUING SEARCH FOR ANSWERS In 1974, as diabetes became the fifth leading cause of death in the United States, Congress passed the National Diabetes Mellitus Research and Education Act. Funding increased immediately for basic research to determine the causes, cures and means of preventing diabetes; to encourage the translation of new knowledge into clinical practice; and to promote the dissemination of information to diabetics and healthcare professionals. The legislation also authorized the establishment of a network of Diabetes Research and Training Centers

(DRTCs) to coordinate the efforts among researchers, government agencies and healthcare providers in combating the disease. These centers continue to play a vital role in 14 the nation’s response to diabetes. As the government’s interest in diabetes grew, so too did the interests of the pharmaceutical and medical technology industries. They developed oral diabetic medicines, first marketed in the 1950s, as well as new insulins, lancets, syringes, glucose monitors, test strips and insulin pumps, enabling diabetics to better and more effectively manage their blood glucose levels. The new technologies not only turned huge profits for these industries but also radically altered the definition and experience of the disease. To name only one striking change: An increasing number of people learned that they had diabetes before they ever experienced the symptoms described so graphically by Aretaeus in the 2nd century. Their “symptom,” rather, was a number recorded on a

CONGRATULATES THE 2013 EDWARD J. ILL EXCELLENCE IN MEDICINE SCHOLARSHIP RECIPIENTS MICHELLE DIAZ UMDNJ-School of Health Related Professions

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ANDREW BUTLER UMDNJ-Robert Wood Johnson Medical School

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RAYMOND J. MALAPERO, III UMDNJ-New Jersey Medical School JACQUELINE PARK Cooper Medical School of Rowan University

REGINA YU UMDNJ-School of Osteopathic Medicine

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“ million people in the United States are living with the disease.” device that registered the concentration of blood glucose. In this way, individuals who felt healthy were redefined as “at risk” and prescribed drugs that added to the industry’s profit margin while treating conditions that were rendered “visible” only through clinical tests.15 Investments in research and the production of new drugs and medical devices reflect the focus on acute care that has defined the American healthcare system since the beginning of the 20th century. This system draws from laboratory knowledge, while overlooking social and cultural understandings of disease. It also favors research scientists and specialists rather than the clinicians and public health experts who encounter the disease most often either by treating patients or looking at community health risks. Guided by a disease rather than a health focus, the American system makes substantial investments in costly medical treatments and gives far less attention to and investment in costly changes in the built environment that might facilitate healthier habits and ultimately disease prevention. THE CONTROVERSY CONTINUES By all measures, a medical rather than a public health approach has proven ineffective in reversing the sharp rise in diabetes morbidity and mortality rates. At the beginning of the 21st century, estimates are that almost 26 million people in the United States are living with the disease.16 Most agree that whatever role heredity may play in predisposing someone to diabetes, such an exponential increase in rates over the past century can be explained only by changes in how and where Americans work, eat and live. Decreased levels of physical activity, increased consumption of high-calorie processed foods, exposure to high stress levels and soaring obesity rates have all driven up the diabetes rate. However, there the consensus ends, largely because few agree about who or what is responsible for the changes in how Americans live and the environments they inhabit. As in the late 19th century, when diabetes came to symbolize a nation’s abandonment of “frugality” and embrace of “luxury,” diabetes today is often blamed on a culture that has chosen “excess” and “overconsumption” over moderation. Critics contend that this perspective focuses too much attention on individual behaviors and too little on the social determinants of health, which can either facilitate or obstruct an individual’s decision to make healthy choices:

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the safety of neighborhoods, opportunities to exercise, accessibility of healthy foods, levels of stress and access to medical care. In short, the philosophy of “excess” fails to address the fact that diabetes, once most prevalent among the middle class, has become as great a threat (if 17 not greater) to those living in poverty. In stark contrast to Aretaeus’s observation two millennia ago, diabetes has become “very frequent among mankind.” According to the World Health Organization, 171 million people lived with diabetes in 2000, and experts have estimated that this will increase to 366 million by 2030.18 We have much still to learn about the global history of diabetes, but the history of diabetes in the United States suggests that reductions in the global burden of this disease in the 21st century will depend upon efforts not only to increase access to quality medical care but also to address the many social determinants of health. Arleen Marcia Tuchman, PhD, is Professor of History at Vanderbilt University where she teaches history of science and medicine. She is currently writing a cultural history of type 2 diabetes. 1

Tattersall, R. (2009). Diabetes: The biography (p. 11). New York: Oxford University Press.

Centers for Disease Control and Prevention. (2011). National diabetes factsheet 2011. www.cdc.gov/diabetes/pubs/pdf/ ndfs_2011.pdf.

Osler, W. (1892). The principles and practice of medicine (p. 296). New York: Appleton.

Purdy, C. (1890). Diabetes: Its causes, symptoms, and treatment. Philadelphia: F. A. Davis; Medicine: Diet or die. (1942). Time, p. 4. [Available at www.time.com/time/magazine/ article/0,9171,850003-1,00.html]

Purdy, C. (1890). 18; Emerson, H. (1924). Sweetness is death. The Survey, 53, 23–25; Lees, H. (1936). Two million tightrope walkers. Colliers, 97, 18, 34, 36, 38.

See, e.g., Riggs, H. C. (1892). On the treatment of diabetes mellitus. Journal of the American Medical Association, 18, 674–677; Stedman, T. L. (1895). Nutritive disorders. In T. Stedman (Ed.), Twentieth century practice. An international encyclopedia of modern medical science (Vol. 2, p. 61). New York: Wood.

Kleen, E. (1900). On diabetes mellitus and glycosuria (p. 15). Philadelphia: Blakiston’s Son; Roberts, S. R. (1931). Nervous and mental influences in angina pectoris. The American

Heart Journal, 7, 23; Lemann, I. I. (1921). Diabetes mellitus in the Negro race. Southern Medical Journal, 14(7), 524; Epstein, A. A. (1919). Diabetes among Jews: Its cause and prevention. Modern Medicine, 1(3), 270. 8

Joslin, E. P. (1917). The treatment of diabetes mellitus (pp. 49–51). Philadelphia: Lea & Febiger.

Feudtner, C. (2003). Bittersweet: Diabetes, insulin, and the transformation of illness. Chapel Hill: The University of North Carolina Press.

Bliss, M. (1982). The discovery of insulin. Chicago: University of Chicago Press.

Two important cures announced. (1922, December 6). The New York Times.

Diabetes up? (1947, October 6). Time, 50(14), 52; Wilkerson, H., & Leo, P. K. (1947). Diabetes in a New England town: A study of 3,516 persons in Oxford, Massachusetts. Journal of the American Medical Association,135(4), 209–216.

Tuchman, A. M. (2011). Diabetes and race: A historical perspective. American Journal of Public Health,101(1), 24–33; Humphreys, M., Costanzo, P., Haynie, K. L., Ostbye, T.,

Boly, I., Belsky, D., & Sloan, F. (2006). Racial disparities in diabetes a century ago: Evidence from the pension files of U.S. Civil War veterans. Social Science and Medicine, 64, 1766–1775. 14

Mauck, A. P. (2010). Managing care: The history of diabetes management in twentieth century America (Doctoral dissertation). Available from ProQuest Dissertations and Theses database. (UMI #: 612814971)

Greene, J. (2007). Prescribing by numbers: Drugs and the definition of disease. Baltimore: Johns Hopkins University Press.

Centers for Disease Control and Prevention. (2011). 2011 national diabetes factsheet. www.cdc.gov/diabetes/pubs/ factsheet11.htm; Tuchman, A. M. (2009). Diabetes and the public’s health. The Lancet, 374(9696), 1140–1141.

Chaufan, C. (2002). Sugar blues: The social (silent) side of diabetes. Clinical Diabetes, 20(4), 207–210.

Wild, S., Roglic, G., King, H., Green, A., & Sicree, R. (2004). Global prevalence of diabetes. Diabetes Care, 27(5), 1047–1053. [Available at www.who.int/diabetes/facts/en/diabcare0504.pdf]

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Announcing the 2013 EDWARD J. ILL EXCELLENCE IN MEDICINE AWARDS

By Janet S. Puro, MPH, MBA

The Edward J. Ill Excellence in Medicine Awards ® are awarded annually to honor those exemplary physicians and leaders whose dedication to education, research and public service have significantly impacted the delivery of healthcare in New Jersey and around the world. The awards are named after Edward J. Ill, MD, a physician who was a pioneer in promoting continuing education in ways that set the national standard. This year’s awards dinner will be held on Wednesday, May 1, 2013, at Greenacres Country Club in Lawrenceville, New Jersey. This event debuted in 1939 at the annual meeting of the Academy of Medicine of New Jersey and has been sponsored by MDAdvantage Insurance Company of New Jersey since 2003. Profits from the event will fund scholarships at the University of Medicine and Dentistry of New Jersey (UMDNJ), Cooper Medical School of Rowan University and Seton Hall University School of Health and Medical Sciences. The Scholarship Fund was created to encourage young people to study healthcare in New Jersey and to help improve access to healthcare for residents. To order tickets, purchase a Scholarship Honor Roll sponsorship, place an ad in this year’s awards journal or make a contribution, please contact the Edward J. Ill Excellence in Medicine Foundation at 609-803-2350 or at jpuro@EJIawards.org. For additional information on the awards program and this year’s honorees, please visit www.EJIawards.org.

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OUTSTANDING MEDICAL EDUCATOR AWARDS Presented to medical educators who have made outstanding contributions to graduate and undergraduate medical education in New Jersey.

Carol A. Terregino, MD

Nayan Kothari, MD Nayan Kothari, MD, is a practicing internist and a rheumatologist based at Saint Peter’s University Hospital. He is the Chairman of the Department of Medicine, Director of the Internal Medicine Residency Program and Clinical Professor of Medicine and Associate Dean for Education at Drexel University College of Medicine. At Saint Peter’s, he is the Chief Academic Officer for Education. He is a Fellow of the American College of Physicians, the American College of Rheumatology and the Royal College of Physicians of Edinburg, Scotland. Dr. Kothari is the recipient of many teaching awards from UMDNJ-Robert Wood Johnson Medical School and Drexel University College of Medicine. He was awarded the Laureate Award by the New Jersey Chapter of the American College of Physicians. Dr. Kothari has spent the past 35 years in active practice and medical education. He has established innovative educational reforms for medicine residents. In collaboration with Rutgers Business School, he introduced a mini-MBA program for healthcare workers at Saint Peter’s University Hospital. Recognizing that clergy generally do not receive adequate medical care, Dr. Kothari recently introduced the Clergy Health Initiative at Saint Peter’s University Hospital. The objective of this program is to provide comprehensive healthcare to any clergy of any denomination with a focus on prevention and wellness. The Bishop of Metuchen conferred the Regina Nostra medal on Dr. Kothari for his work in 2011.

Carol A. Terregino, MD, is Associate Professor of Medicine, Senior Associate Dean for Education (interim) and Associate Dean for Admissions of UMDNJ-Robert Wood Johnson Medical School. She completed her undergraduate and post-baccalaureate education at Rutgers, the State University of New Jersey. Dr. Terregino graduated from UMDNJ-Robert Wood Johnson Medical School in 1986 and then went to the Hospital of the University of Pennsylvania for residency and fellowship training in Internal Medicine and Emergency Medicine, respectively. Dr. Terregino was appointed Assistant Dean for Admissions at UMDNJ-Robert Wood Johnson Medical School in 1999 and then assumed the role of Associate Dean for Admissions in 2005. She also serves as the Senior Associate Dean for the Camden Regional Campus. Her experience in medical education is extensive and spans the four years of the undergraduate curriculum. She is the Co-director for the Patient Centered Medicine course and the Director of the Clinical Skills Center; she also chaired the working group on adult learning, assessment and evaluation for the new curriculum. Her research interests include the assessment of preprofessional competencies in medical school applicants, the development of clinical skills and innovative assessment methods for clinical competencies. Nationally, she served as a member of the Association of American Medical Colleges’ (AAMC’s) Innovation Lab Working Group of the MR 5 Committee that was tasked with undertaking the AAMC’s fifth comprehensive review of the MCAT®. She serves as a Liaison Committee on Medical Education (LCME) Site Survey Secretary and has recently been selected as LCME Field Secretary. Dr. Terregino is a 2007 graduate of the Hedwig Van Ameringen Executive Leadership in Academic Medicine Program for Women.

IN MEDICINE MDADVISOR

EDWARD J. ILL PHYSICIAN’S AWARD ® OUTSTANDING MEDICAL EXECUTIVE AWARD

Presented to a New Jersey physician who merits recognition for distinguished service as a leader in the medical profession and in the community.

Presented to an executive in a medically-related organization or field who has demonstrated exceptional leadership in the enhancement of patient care and medical practice in New Jersey.

Robert L. Johnson, MD

Robert C. Garrett, FACHE Robert C. Garrett, FACHE, President and Chief Executive Officer of Hackensack University Medical Center (HackensackUMC) began his career in 1981 as an administrative resident. Since then, his leadership, visionary ideas and strategic experience earned him the position of Executive Vice President and Chief Operating Officer, and subsequently in 2009, President and Chief Executive Officer of the organization. Since July 2009, Mr. Garrett has overseen numerous strategic, clinical and academic affiliations to strengthen Hackensack University Health Network. Such affiliations include the strengthening of the clinical affiliations with Hackettstown Regional Medical Center, Saint Clare’s Health System and Palisades Medical Center; clinical affiliations with NYU Langone Medical Center’s Division of Pediatric Surgery and MinuteClinic; a strategic alliance with the North Shore-LIJ Health System; and an academic affiliation with Stevens Institute of Technology. Under Mr. Garrett’s leadership, the Heart and Vascular Hospital and the John Theurer Cancer Center opened in 2011, with both facilities since becoming two of the nation’s leading and highestranking treatment centers in the country. Mr. Garrett has received numerous awards for his professional and personal contributions. He was ranked the second most powerful business leader in the state on the 2012 NJBIZ Power 100 List and was ranked fourth among the 50 most powerful people in New Jersey healthcare on the 2012 NJBIZ Power 50: Healthcare List. Mr. Garrett received his Master of Health Administration degree from Washington University and his bachelor’s degree from Binghamton University.

Robert L. Johnson, MD, is the Sharon and Joseph L. Muscarelle Endowed Dean, Professor of Pediatrics and Director of the Division of Adolescent and Young Adult Medicine at UMDNJ-New Jersey Medical School. His clinical expertise and research focus on adolescent physical and mental health, adolescent HIV, adolescent violence, adolescent sexuality and family strengthening. He chairs the New Jersey Governor’s Advisory Council on HIV/AIDS, the Newark Ryan White Planning Council and the Board of Deacons at Union Baptist Church in Orange, New Jersey. Dr. Johnson is a Fellow of the American Academy of Pediatrics and a member of the Board of the Division of Behavioral and Social Sciences and Education at the National Academies of Science. He has previously been the President of the New Jersey Board of Medical Examiners, the Chair of the U.S. Department of Health and Human Services’ Council on Graduate Medical Education, a member of the National Council of the National Institute of Mental Health, a member of the National Institutes of Health (NIH) AIDS Research Council and a member of the Institute of Medicine, Health Care Services Board. Dr. Johnson received his BA degree from Alfred University in 1968 and his MD degree from the College of Medicine and Dentistry of New Jersey, Newark, New Jersey, in 1972. Dr. Johnson has become a well-recognized spokesperson for adolescent and adolescent issues. He addresses many local, state, national and international audiences and frequently appears on television and radio. He has published widely, and he conducts an active schedule of teaching, research and clinical practice at New Jersey Medical School.

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VERICE M. MASON COMMUNITY SERVICE LEADER AWARD Presented to an individual who has personified, led and provided the vision for an organization, and to the organization served, for extraordinary commitment to improving the health and welfare of the citizens of New Jersey.

OUTSTANDING MEDICAL RESEARCH SCIENTIST AWARD FOR BASIC BIOMEDICAL RESEARCH Presented to an individual who has carried out biomedical research leading to important advances in biotechnology or to the understanding of disease processes.

Kathleen Horn, RN, CIC Kathleen Horn, RN, CIC, Director of Infection Prevention at Hunterdon Healthcare in Flemington, New Jersey, accepts this award on behalf of the Hunterdon Medical Center Infection Prevention Team. During her 25 years as Director of Infection Prevention, Ms. Horn has faced many challenges in the field of infection prevention and epidemiology. Under her leadership and with the support of the administrative team at Hunterdon Healthcare, the facility has experienced great success in preventing healthcare-associated infections and reducing transmission of epidemiologically significant organisms such as methicillinresistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE) and Clostridium difficile in its patients. Ms. Horn is past President of the National Certification Board of Infection Control and Epidemiology (CBIC); she received the CBIC Lifetime Achievement Award in 2006. She has twice served as President of the Northern New Jersey Association for Professionals in Infection Control and Epidemiology (APIC) and serves as its liaison to the New Jersey Department of Health, working on the Licensure Revisions and other committees. Ms. Horn currently sits on National APIC’s Practice Guidance Council. Ms. Horn is a founding member and faculty for the Northeastern Infection Control Educators, a group that provides two week-long courses each year for new infection control professionals. This group has been providing infection control education for more than 20 years and has educated more than 2,000 new professionals throughout the U.S. The group was recognized with APIC’s Heroes of Infection Prevention Award in 2011. In addition to a chapter on Borrellia burgdorferi (Lyme disease) in the APIC Text of Infection Control and Epidemiology in 2009, Ms. Horn has published articles on pericarditis as a manifestation of Lyme disease, central line associated bloodstream infection prevention and multi-hospital surveillance of MRSA, VRE and C. difficile. She has lectured internationally on the need to invest in infection prevention and achieving infection prevention through cultural changes and collaboration.

Smita Patel, PhD Smita Patel, PhD, is Professor of Biochemistry and Molecular Biology at UMDNJ-Robert Wood Johnson Medical School. Dr. Patel’s research is focused on understanding the molecular mechanisms of enzymes involved in three essential life processes: DNA replication, transcription and innate immunity. She earned her PhD in 1988 in Chemistry from the Tufts University and conducted research as a National Institute of Health postdoctoral fellow at the Pennsylvania State University, where she initiated studies of enzymes involved in DNA replication. Her series of three papers on the mechanism of DNA polymerase and fidelity are widely cited (including many biochemistry textbooks) and serves as a foundation for understanding other polymerases from virus to human. Dr. Patel has carried out pioneering work on understanding the mechanisms of helicases, which are essential enzymes in every living cell that are responsible for the separation of the strands of double helix DNA and RNA. She is best recognized for her work on helicases that form doughnut-shaped rings and move along DNA strands using the energy from ATP hydrolysis. She has now extended her work to other helicases that are involved in the replication of the human mitochondrial DNA and those involved in innate immunity. Defects in the human mitochondrial helicase cause many mitochondrial-related diseases, and innate immunity helicases are receptors that defend us against viral infections. The fundamental understanding of these enzymes will pave the way to new vaccines, as well as antiviral and therapeutic medicines. Dr. Patel is widely regarded for her dedication to excellence in the mentoring, training and education of the next generation of scientists at all levels–from high school students through postdoctoral scholars. Dr. Patel is the recipient of many distinctions, including the National Institutes of Health MERIT Award, UMDNJ Foundation Research Award for Basic Sciences and Master Educator Guild of UMDNJ Award.

IN MEDICINE MDADVISOR

EXCELLENCE OUTSTANDING MEDICAL RESEARCH SCIENTIST AWARD FOR CLINICAL RESEARCH

Presented to an individual who has made important contributions in clinical or translational research leading to advances in disease therapy.

Suhayl Dhib-Jalbut, MD Suhayl Dhib-Jalbut, MD, is Professor and Chairman of the Department of Neurology at the UMDNJ-Robert Wood Johnson Medical School and Chief of Neurology at the Robert Wood Johnson University Hospital. He is also Director of the Robert Wood Johnson Center for Multiple Sclerosis (MS). Dr. Jalbut graduated from the American University of Beirut in Lebanon and completed his neurology training at the University of Cincinnati. He then joined the NIH in Bethesda, Maryland, where he specialized in MS and neuroimmunology. Dr. Jalbut joined the faculty of the University of Maryland in Baltimore in July 1990 where he established a research program in MS before his recruitment to UMDNJ-Robert Wood Johnson Medical School in 2003. Dr. Jalbut’s research, which has been funded by the NIH, the National Multiple Sclerosis Society and industry, includes how MS therapies work, biomarkers of treatment response in MS and neuroprotective gene therapy. Dr. Jalbut has published more than 100 manuscripts in the scientific literature. He served as Associate Editor for the Journal of Neuroimmunology. He currently serves on the editorial boards of Journal of Interferon & Cytokine Research and Multiple Sclerosis International. He served on several national and international scientific committees including Chairmanship of the Scientific Committee for the World Congress on MS in 2008. Dr. Jalbut has been on the “Best Doctors in America” list since 2009 and has received several awards and recognitions. Most recently, he was awarded the Norman H. Edelman Clinical Science Mentoring Award at UMDNJ and the Medical Excellence Award by the National MS Society New Jersey Metro Chapter. Dr. Jalbut was recently named President-Elect of the Americas Committees for Treatment and Research in MS (ACTRIMS).

PETER W. RODINO, JR., CITIZEN’S AWARD ® Presented to a citizen or group of citizens of New Jersey who merits recognition for distinguished service in advancing and promoting the health and well-being of the people of our state.

Mike Adler Mike Adler and the Adler Aphasia Foundation are being recognized for their contributions to healthcare in New Jersey and around the globe. Mr. Adler is a successful entrepreneur and community activist. Following a stroke after bypass surgery more than 19 years ago, and unable to find a speech program that could help him adjust to living with the communication disorder (called aphasia) that he acquired as a result of his stroke, Mr. Adler and his wife, Elaine, started the Adler Aphasia Center, a non-profit post-rehabilitative therapeutic facility that addresses the long-term needs of people with aphasia. The Maywood, New Jersey-based Center is considered the gold standard by other aphasia centers worldwide. Led by licensed speech-language pathologists, the Center offers programs and services for people with aphasia and their caregivers that help people reengage in their communities and get on with their lives. Mr. Adler is a member of the board of the National Aphasia Association and has served on the boards of Hackensack University Medical Center and the United Jewish Community of Bergen County. In 1949, he founded Myron Manufacturing Company, one of the largest companies in Bergen County that manufactures and sells promotional products and gifts. A longtime resident of Franklin Lakes, New Jersey, Mr. Adler received an honorary doctorate degree from Ramapo College in 1999. The Adlers have been honored nationally for their work in helping individuals with aphasia as well as by the Anti-Defamation League, Boys Town of Jerusalem and Bergen Community College. With the Adlers’ commitment to and focus on the healthcare field, the college recently broke ground for the Adler Center for Nursing Excellence at Ramapo College.

Janet S. Puro, MPH, MBA, is Vice President of Business Development and Corporate Communications at MDAdvantage Insurance Company of New Jersey.

IN MEDICINE 18

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LEGISLATIVE BRIEF

NEW JERSEY LEGISLATORS ADDRESS

BESITY By Pete Cammarano In the last decade, a national battle against childhood obesity and diabetes has been waged, with New Jersey standing at the forefront of this fight. There are many reasons why the State should lead the way, considering New Jerseyans have the most to gain from doing so. New Jersey has the highest childhood obesity rate among low-income earners in the nation for children two to five years old, standing at 17.3 percent. Additionally, one in three children ages 10 to 17 is considered obese.1 These disappointing statistics contributed to the enormous estimate of $3 billion required to cover obesity-related healthcare costs in 2012.2 The cost of paying for the growing number of obesity-related diseases has led New Jersey to take innovative and aggressive measures to lower these statistics. A HISTORY OF OBESITY LEGISLATION IN NJ For many years, the New Jersey Legislature enacted laws and created programs to battle obesity-related diseases. One such effort was the creation of the Office of Nutrition and Fitness (ONF) in 2007. At that time, the ONF was the first state office of its kind in the entire nation, with the goal of reducing obesity in New Jersey by providing information and programs to those particularly at risk of these diseases.

The ONF is a public-private partnership that has implemented initiatives such as the Fruit and Vegetables program, designed to increase the amount of fruits and vegetables consumed by children in New Jersey. This program was very progressive at the time; recently, there has been movement by the New Jersey Legislature to enact additional laws to further promote healthy eating habits. ONGOING LEGISLATION AIMED AT CHILDHOOD OBESITY The Assembly and the Senate have aggressively worked to protect the health of New Jersey residents by introducing various bills that strive to reduce the incidence of diabetes and the chronic illness associated with it. Assembly Bill No. 1182: In 2012, the New Jersey Legislature actively attacked childhood obesity by introducing new and important legislation. Assemblywoman Stender (LD22) introduced Assembly Bill No. 1182 that â&#x20AC;&#x153;prohibits sale on school property of certain junk foods and sodas in elementary and middle schools during the school breakfast period and the school lunch period.â&#x20AC;? If this bill is passed, New Jersey would become one of 29 states already enforcing this ban on junk foods and soda. Assembly Bill No. 2369: Assemblyman Johnson (LD37) and Assemblyman De Angelo (LD14) recently introduced Assembly Bill No. 2369 requiring the listing of the nutritional

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value of the food and beverage items offered for sale in school cafeterias. New Jersey is currently one of 29 states with stricter school meal standards than required by the U.S. Department of Agriculture. Assembly Bill No. 3019: This bill, sponsored by Assemblyman Wilson (LD5) of Camden and Gloucester, seeks to give our public schools the ability to offer healthier meals by allowing them to serve certain produce grown in community gardens.

seventh, and tenth grades.” The records will be part of the students’ health records and will be completely confidential, although a signed statement from a parent or guardian will excuse the child from participating. Senate Bill No. 1501: Exercise is equally important in the battle against childhood obesity; therefore, Senator Turner (LD15) has sponsored Senate Bill No. 1501 that states: “Beginning with the 2012-2013 school year, a public school district must provide a daily recess period of at least 20

C MMUNITY GARDENS ”

With all safety and sanitary measures accounted for, this bill “defines ‘community garden’ as public or private land upon which individuals have the opportunity to garden on pieces of land that they do not individually own.” These community gardens are becoming more popular in New Jersey, and they may “provide an opportunity for local residents to grow fresh fruits and vegetables...[and could] provide fresh, nutritious locally grown produce to be incorporated into school meals and snacks, as well as offer educational opportunities for students.” New Jersey is one of 26 states to introduce legislation and programs of this kind. Senate Bill No. 111: In order for New Jersey to combat obesity, gathering accurate data from assessments and records is critical. New Jersey is currently looking to join the list of 21 other states that have legislation requiring body mass index (BMI) screenings and weight calculations for children and adolescents. Senate Bill No. 111, sponsored by Senator Cardinale (LD29), has been introduced to do just that. The bill would mandate all Boards of Education to “calculate body mass index for students in first, fourth,

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minutes for students in grades K-5.” This bill clearly declares this recess is not part of the daily physical education class, and no student can be denied this recess for any reason. Senator Turner’s efforts are an attempt to establish healthy habits early in a child’s life. This aggressive approach to implementing physical activity in a child’s daily routine is very necessary in New Jersey. In a recent survey, the average New Jersey high school student admitted spending three or more hours 3 per day playing a computer or video game. Inactivity and poor diet have been directly linked to chronic diseases such as diabetes, high cholesterol, hypertension and arthritis.4 Current legislation has been introduced to combat these major causes of common chronic diseases. Senate Bill No. 1623: This bill was introduced to the New Jersey Legislature in 2012 to “establish a pilot program to utilize a value-based benefit design in the State Health Benefits Program (SHBP) to increase health benefits coverage for certain employees concerning chronic health conditions.” Diabetes is one of the diseases covered by this legislation. This three-year program is sponsored by Senators

Whelan (LD2) and Weinberg (LD37) with the underlying goal to “utilize explicit financial incentives to increase the employee’s interaction with appropriate healthcare providers.” In addition, this bill will encourage the use of health benefits specifically related to the chronic disease and allow better management of the overall costs of that employee’s coverage under the SHBP. Senate Bill No. 2288: The State is well aware of the huge costs attributed to diabetes, and a new piece of legislation has been introduced by Senator Gordon (LD38) requiring certain State departments to “develop a diabetes action plan to reduce the impact of diabetes in the State of New Jersey.” New Jersey legislators have agreed that diabetes needs to be prevented and controlled, and this kind of legislation will help do that physically and fiscally. CONTINUING THE FIGHT AGAINST CHILDHOOD OBESITY The New Jersey Legislature is adamant in its stance to fight obesity-related diseases. State legislators look forward to and welcome support from the medical community to implement legislation aimed at controlling

the diseases on all fronts, including escalating healthcare costs. Pete Cammarano is a Partner at Cammarano & Layton Partners, LLC, located in Trenton, New Jersey. 1

Centers for Disease Control and Prevention. (2012). National diabetes surveillance system. www.cdc.gov/ diabetes/statistics.

Thorpe, K. (2009). The future costs of obesity: National and state estimates of the impacts of obesity on direct health care expenses (Collaborative Report from United Health Foundation, The American Public Health Association and Partnership for Prevention). [Available at www.nccor.org/downloads/CostofObesityReport-FINAL.pdf]

New Jersey Department of Education. (2012, May). New Jersey Student Health Survey 2011.

Levi, J., Segal, L. M., St. Laurent, R., & Kohn, D. (July, 2011). F as in fat: How obesity threatens America’s future 2011 (Report from Trust for America’s Health and the Robert Wood Johnson Foundation). [Available at www.healthyamericans.org/report/88/]

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REDUCING THE

IMPACT OF

DIABETES IN NEW JERSEY

By Commissioner Mary E. O’Dowd, MPH In the nation and New Jersey, diabetes is not only common but also costly and has significant impact on the health of residents. Nine percent of New Jersey’s adult population has been diagnosed with diabetes, and about one-third of the population is undiagnosed, according to the Centers for Disease Control and Prevention (CDC).1 The impact of this disease on public health is well documented. Individuals with diabetes have a higher-thanaverage risk of heart attack or stroke. Both strike people with diabetes more than twice as often as people without diabetes. In fact, two out of three people with diabetes die from heart disease or stroke. According to the American Diabetes Association (ADA), controlling hemoglobin A1c, blood pressure and cholesterol can lower the risk of heart disease and stroke.2 Additionally, because smoking is an underlying risk factor secondary to tissue anoxia at the cellular level, the Department added smoking to the list of factors that need to be controlled in diabetes management to further reduce the risk of heart disease and stroke–creating the ABCS of diabetes control. As part of the public health and healthcare community, we all have a responsibility to educate New Jerseyans on how to prevent diabetes and reduce the complications of the disease. DEPARTMENT OF HEALTH INITIATIVES The New Jersey Department of Health’s Diabetes Prevention and Control Program (DPCP) initiatives align

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with national strategies that address the ABCS of diabetes prevention. Currently, the program’s funding supports programs that are designed to promote selfmanagement resources as sustainable tools to address diabetes prevention and improve health outcomes. The Department awarded $100,000 to the University of Medicine and Dentistry of New Jersey (UMDNJ) to implement a pilot self-management program for patients with diagnosed diabetes. Patients will participate in a six-week educational and skills-building intervention. Clinical quality measures (CQMs) such as hemoglobin A1c, blood pressure, blood

DIABETES IN NEW JERSEY AT A GLANCE An estimated 65.4 percent of adults with diagnosed diabetes have been diagnosed with high blood pressure at some point in time, and 54.7 percent have been diagnosed with high cholesterol at some point 3 in time. An estimated 82.2 percent of adults with diabetes are currently overweight or obese, and about 13.6 percent 1 of adults with diabetes are current smokers.

cholesterol and smoking status will be monitored preand post-intervention for changes. The Department also provides funding to integrate community health workers (CHWs) in medical settings as healthcare extenders for the most challenging diabetic cases. By using community health workers, the Department can enhance links among patients, communities and healthcare providers. The Department supports the Vineland City Health Department with $84,000 to train CHWs to provide diabetes prevention support in rural, Spanish-speaking communities in southern New Jersey. To date, more than 30 culturally competent men and women (called Promotores) have been trained as CHWs. They serve in Atlantic and Cumberland counties with 28 health providers, working directly with patients to improve diabetes-related health outcomes. DIABETES COMPLICATIONS: BLINDNESS AND VISION PROBLEMS Among the complications affecting those with diabetes is a higher risk of blindness and vision problems. Individuals with diabetes are 60 percent more likely to develop cataracts and are 40 percent more likely to 4 suffer from glaucoma. Therefore, a complete eye exam is recommended yearly for those affected by diabetes–these screenings are critical to ensure early detection and treatment, which truly saves vision. To ensure access to screenings, the Department provides $95,000 annually to the New Jersey Commission for the Blind and Visually Impaired (CBVI) to provide diabetic eye disease screenings to low-income, uninsured and underinsured persons. CBVI also links participants

to community health services for follow-up care. Between October 2011 and September 2012, CBVI’s Diabetic Eye Disease Detection Program screened approximately 900 people. More than 600 abnormalities were detected, and 19 percent of all those screened were directly referred to ophthalmologic care for addi5 tional services. DIABETES COMPLICATIONS: OBESITY Another complication that often coincides with diabetes is obesity. If a person is obese, the odds of having diabetes are five times higher than if that person were not obese or overweight.6 The Department is addressing obesity and the chronic conditions that come along with it through ShapingNJ. Since 2009, we at the New Jersey Department of Health have been strategically working on obesity prevention through our ShapingNJ initiative–a public-private partnership of more than 200 organizations that have come together in a unique collaboration to battle this public health issue. The weapons used in the battle involve environmental and policy change from many angles, including some that are outside the traditional public health approach, such as transportation, safety and business. ShapingNJ is focused on changing five environments– worksites, schools, healthcare, communities and childcare–to ensure they support good health. This approach is different from past public health efforts because it has the potential for greater impact. The Department is no longer just telling people to eat more fruits and vegetables and to exercise; rather, we are working to create an environment that is conducive to a healthier lifestyle. The goal is to

Diabetes prevalence increases with age. The estimated percentage of adults 65 years and older with diagnosed diabetes is 21.5 percent. Diabetes prevalence also varies by race and ethnicity with the highest prevalence observed in Black adults (14.5 percent) 1 followed by Hispanic adults (9.5 percent) and then White adults (8.1 percent). Age-adjusted prevalence estimates for diagnosed diabetes vary by county and range from about 6.2 percent in Hunterdon and Somerset counties to about 10.2 percent 3 in Cumberland County.

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decrease obesity and chronic conditions by making the healthy choice the easy choice. A HOLISTIC APPROACH We at the Department of Health are also focused on measuring our progress on reducing diabetes in our state. Through Healthy New Jersey 2020 (our state health improvement plan), the Department is working to eliminate preventable disease and premature death, to achieve health equity and eliminate health disparities, to create social and physical environments that promote good health and to promote healthy lifestyles and behaviors. For diabetes, specifically, we are examining several measures, including reducing the death rate due to the disease, reducing the rate of lower extremity amputations and increasing the proportion of adults who have an annual dilated eye examination and have their glycosylated hemoglobin measurement (A1c) completed at least twice a year. Additionally, to better leverage our resources in combating diabetes and other chronic diseases, the Department of Health is embarking on a transformational public health initiative that will integrate the State’s programs for cancer, heart disease, stroke, diabetes, asthma, arthritis, obesity prevention and tobacco control. This coordinated approach will fundamentally change the way public health professionals address chronic disease–not one disease at a time but by developing strategies that concentrate resources to simultaneously address chronic diseases and the multiple risk factors that cause chronic disease. This holistic approach recognizes that disease and risk factor–specific interventions are similar. Interventions rely on the same data gathering to build evidence and the same policy expertise to take action. They also depend on the same community mobilization strategies to build demand for programs and support people’s need to manage their chronic conditions. Moreover, reducing the effects of these diseases rely on the same communication skills to make a compelling case for public health initiatives that provide a return on investment in lives saved, reductions in the incidence of diseases and disability and increased productivity and healthcare cost savings. As part of this integrated approach, the Department, in collaboration with a diverse, statewide network of partners, will develop the New Jersey Chronic Disease Prevention and Health Promotion Plan as guidance for

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future diabetes programs. Diabetes is an evermore prevalent chronic disease nationally, and New Jersey is no exception. Strategies to decrease the number of new cases of diabetes and reduce the impact of existing cases must include education and access to appropriate healthcare services. Physicians play a critical role and have the opportunity to empower patients and communities in prevention efforts. As healthcare leaders, we have opportunities to bridge services in meaningful and effective ways, ultimately leading to individuals leading healthier and more productive lives. The Department of Health looks forward to partnering with our state’s healthcare providers and leaders through the development of the New Jersey Chronic Disease Prevention and Health Promotion Plan. By combining our resources, we can strengthen our efforts to reduce overall chronic disease and lessen the impact of diabetes on our residents. Readers interested in being part of the development of New Jersey Chronic Disease Prevention and Health Promotion Plan should contact 609-292-8540. Mary E. O’Dowd, MPH, is the Commissioner of the New Jersey Department of Health. 1

Center for Health Statistics, New Jersey Department of Health. (2010). New Jersey behavioral risk factor surveillance system. www.state.nj.us/health/chs/brfss.htm#ques.

American Diabetes Association. (2012). Living with diabetes: Health ABCs. www.diabetes.org/living-withdiabetes/complications/heart-disease/healthy-abcs.html.

Center for Health Statistics, New Jersey Department of Health. (2009). New Jersey behavioral risk factor surveillance system. www.state.nj.us/health/chs/brfss.htm#ques.

American Diabetes Association. (2012). Living with diabetes: Blindness or vision problems. www.diabetes.org/ living-with-diabetes/complications/mens-health/serioushealth-implications/blindness-or-vision-problems.html.

New Jersey Commission for the Blind and Visually Impaired. (2011–2012). Quarterly Report to the New Jersey Department of Health. Unpublished raw data.

Centers for Disease Control and Prevention, Office of Surveillance, Epidemiology, and Laboratory Services. (2012). Behavioral risk factor surveillance system. www.cdc.gov/brfss/index.htm.

Patient-Centric Tools for Better Diabetes Self-Management By Carol V. Brown, MBA, PhD, Diane M. Strong, PhD, Cortney M. Nicolato, CPHIT, and Carole L. Romasco, MBA Patient engagement in managing healthcare is a major objective being addressed by the “meaningful use” criteria for the Medicare and Medicaid electronic health record (EHR) incentive programs under the HITECH Act of 2009.1 For patients with advanced type 2 and type 1 diabetes, self-managing their chronic disease condition is already a way of life. In recent decades, handheld devices have assisted these patients in making decisions that involve food intake, exercise and insulin dosages based on real-time readings of their blood glucose levels. Today, computer and communication devices with easy-to-use interfaces and wireless communication options offer a much greater range of tools for self-management. The objective of this article is to share three specific examples of how patient-centric information technology tools are not only enabling greater diabetic patient engagement but also contributing to the national goal of improved health outcomes. SMARTPHONE APPS AS PERSONAL HEALTH ASSISTANTS Today’s smartphones have the capability to be a personal health assistant in the patient’s pocket by recording an individual’s health status in real time, with automatic data

entry, and providing a meaningful, personalized status update. In collaboration with physicians and other specialists at the University of Massachusetts Medical School,

Figure 1. Screenshot of User Interface for WPI Smartphone App

Three broad principles are guiding the smartphone app initiatives at WPI: 1. Medically sound. This includes not only healthcare measures but also the frequency of collection and the desired patient behaviors to collect them. 2. Patient-centric. For self-management of a lifelong disease, the app needs to be based not only on well-tested designs for mobile device usability for the target population but also on the effectiveness in integrating the app in the patient’s daily life. 3. Technically sound. In addition to providing access to secure patient data storage, apps for chronic disease management need to be designed so that the patients’ data can be easily shared with their providers according to relevant Health Insurance Portability and Accountability Act (HIPAA) rules. MDADVISOR

academic researchers at Worcester Polytechnic Institute’s Healthcare Delivery Institute (www.wpi.edu/research/hdi.html) are developing and testing the effectiveness of mobile apps to realize the vision of the smartphone as a “personal health assistant” integrated into the daily life of a patient with a chronic disease. One project is aimed specifically at developing apps for patients with advanced type 2 diabetes that will be able to not only track glucose levels, food intake and exercise levels but 2 also to manage their weight and diabetic foot wounds. (See Figure 1.) For example, their prototype app can apply complex algorithms to analyze wound images captured via a smartphone camera to help track the healing process, and users can either automatically transmit readings from a Bluetooth-enabled glucometer and scale or enter their

blood glucose and weight data via a number picker. According to the WPI researchers, only a few of the software apps available for iPhone or Android smartphone users to download from an app store have been developed according to well-established human interface 3 designs and HIPAA privacy and security rules. COMPREHENSIVE PERSONAL HEALTH RECORD TOOLS TO CONNECT PATIENTS AND PROVIDERS Providing individual patients with secure access to a standards-based electronic record, such as a standardized personal health record (PHR), is a Meaningful Use criterion. However, even before the HITECH Act was passed, Microsoft Corporation and other IT industry players invested in platforms for storing comprehensive PHR data for individual patients, which, with the patient’s

Figure 2. From Manual to Electronic Tracking Tools for the Patient

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Figure 3. Personalized MyActiveHealth Resource Center

permission, could also be accessed by designated caregivers and healthcare providers in different outpatient and acute care settings.4 Major healthcare systems, such as the Cleveland Clinic and Partners HealthCare and the Beth Israel Deaconess Medical Center in Boston, participated in early pilots with this type of third-party platform for patient information exchange. Microsoftâ&#x20AC;&#x2122;s HealthVault is the only major IT industry platform today.5 HealthVault provides individual patients with PHR applications and data storage, under the control of the individual patient. Also available to members are applications for chronic condition and wellness management, including interfaces for data transmission from patient-operated devices developed by HealthVault partners. For example, InstantPHRTM is a comprehensive PHR platform that supports patient self-management that

was developed by Get Real Health and has been adopted by a major hospital system and chronic disease non-profit for diabetes self-management: â&#x2013; Medstar Health, an eight-hospital system in Washington, DC, offers InstantPHR on a Web-based platform named eHealth2Go (www.ehealth2go.org) that gives patients with diabetes a way to collect their health measurements (such as blood glucose, weight and A1c) and track progress on these metrics over time. (See Figure 2.) The platform can also be used to track key observations and activities for daily living not normally collected during a provider visit such as swelling levels, sleep and mood patterns as well as physical activity levels. Among Medstarâ&#x20AC;&#x2122;s patient population, there was a significant improvement in key clinical quality measures after a 90-day intervention piloting the technology. Based on these positive

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outcomes, as well as increases in eHealth literacy, Medstar is now expanding the study to include additional patient populations, as well as patient-directed care plans and mobile access to the application. ■ The American Diabetes Association (ADA) offers a free diabetes Personal Health application powered by TM (https://247.diabetes.org) that helps InstantPHR patients track their key health measurements and “know their numbers,” as well as gain access to a wealth of educational tools from the ADA. PERSONALIZED HEALTH TOOLS FOR EMPLOYEES VIA AN EMPLOYER PORTAL In the United States today, the majority of privately insured patients are covered by health plans negotiated by their employers with health insurance companies. In collaboration with these insurance companies, many large employers have increased their emphasis on encouraging wellness and other healthy behaviors. Employees living with chronic conditions like diabetes can gain access to online self-management tools as part of their employer’s health benefits. For example, an independent subsidiary of Aetna Insurance Co. (ActiveHealth) offers a patient portal for employees (MyActiveHealthSM) that combines personalized health support with interactive tools and trackers to help people with chronic conditions like diabetes better manage their health. Patients with diabetes have online access to appropriate educational content as well as software tools to help manage diabetes and improve their overall health. (See Figure 3.) Digital coaching modules focus on healthier eating and exercising, and a nutrition scoring system provides users with an easy-to-use tool to better understand nutritional information and eat healthier. The website also communicates with other ActiveHealth platforms so that the health plan member has access to biometric lab results and insurance claims data. Based on the member’s personal health data and claims information, messages are sent to the health plan member about the need to schedule appropriate screenings (such as eye exams) and recommendations for increased monitoring (such as HbA1c). LEVERAGING THE PATIENT-CENTRIC TRENDS For more than a decade, Susannah Fox and other researchers with the Pew Internet & American Life Project (www.pewinternet.org) have reported that a large number

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of online adults search for health information on the Internet, and that specific diseases and treatments are among the most commonly researched topics. A Mobile Health 2012 report emphasized that 85 percent of U.S. adults owned a cell phone, more than half of these phones were smartphones, and 52 percent of the smartphone users gathered health information via their phones. Although Fox has also reported that U.S. adults living with chronic disease are less likely than healthy adults to have Internet access (62 percent versus 81 percent), the trends are clear. We believe that the usage of patient-centric tools for tracking and decision-making, such as the three examples in this article, will increasingly become part of patients’ personal toolkits for more effectively managing chronic disease. Carol V. Brown, MBA, PhD, is a Distinguished Service Professor and Director of the Healthcare IT Management program at Stevens Institute of Technology. Diane M. Strong, PhD, is a Professor at Worcester Polytechnic Institute in Worcester, Massachusetts. Cortney M. Nicolato, CPHIT, is Vice President of Healthcare Strategies for Get Real Health. Carole L. Romasco, MBA, is Vice President of Product Development for ActiveHealth Management. 1

For a full explanation of meaningful use criteria, see www.healthit.gov/providers-professionals/ehr-incentivescertification.

This research was supported in part by the National Science Foundation under Grant IIS-1065298. Any opinions, findings, conclusions or recommendations expressed in this paper are those of the authors and do not necessarily reflect the views of the National Science Foundation.

For more details about the research program at WPI, including the three principles described in this article, see Strong, D., Agu, E., Pedersen, P., & Tulu, B. (2012). Pocket doctor. Practical Patient Care, 10, 35–37.

For more details about comprehensive PHRs as a self-management platform, see Magee, M. F., Nicolato, C., & Schladen, M. M. (2012). Consumer health informatics. Journal of Health Information Management, 26(3), 62–71.

In June 2011, Google Health announced that it would exit this market segment; they discontinued their service as of January 2, 2012.

THE HEARTOF DIABETES

By Ian Joffe, MD

Cardiovascular problems are the primary concern, and leading cause of death, in the diabetic population–but they can be managed. On November 14, 2012, major buildings and monuments around the globe were lit up blue for World Diabetes Day–and with good reason. Diabetes brings a lot of heartache to the human population, both literally and figuratively. Latest World Health Organization (WHO) estimates are that 347 million people worldwide have diabetes and that between 2008 and 2030, diabetes deaths (which are primarily attributable to cardiovascular disease) will increase by two-thirds.1 Last year’s annual worldwide event coincided with National Diabetes Month in the United States, where estimates are that more than one in four Americans has prediabetes,2 and by midcentury, one in three will have diabetes if current trends continue.3 (Amidst this epidemic, even our pets have diabetes.) Although this scourge threatens the health of a large segment of our population in varied ways, cardiovascular problems are the primary concern and leading cause of death among those with diabetes. Fortunately, these problems can be managed. CONFOUNDING FACTORS FOR CARDIOVASCULAR HEALTH Diabetes is a well-known risk factor for heart disease and stroke, primarily due to atherosclerosis. Individuals with diabetes develop heart disease at a younger age and have more severe heart disease.4 The sobering fact is that most diabetics will eventually die of heart disease,5 leading specialists in the cardiologic fields to effectively regard diabetes as a cardiovascular disease. However, medical professionals have opportunities to identify patients who are at risk of cardiac morbidity and mortality. The prevalence of heart disease in the diabetic population is due in part to diabetics typically having a number of additional risk factors or complications of diabetes that are also causes of heart disease. In addition to their struggle to maintain glucose control, those with diabetes commonly face the following challenges:

Obesity. The diabetes epidemic is closely tied to the obesity epidemic. The precise overlap between these two populations is not known, but type 2 diabetes is a primary obesityrelated condition.6 Hyperlipidemia. Diabetic dyslipidemia (also referred to as atherogenic dyslipidemia), particularly in type 2 diabetes, typically evidences as a moderate elevation of triglyceride levels and low high-density lipoprotein (HDL) levels. Low-density lipoprotein (LDL) particles are also observed to be small and dense.7 Abnormal blood pressure. In type 2 diabetes, hypertension is often present as part of a constellation of metabolic-related issues. In type 1 diabetes, hypertension may reflect the onset of diabetic nephropathy.8 Diabetes is also a risk factor for orthostatic hypotension, due to secondary autonomic failure and vascular disease,9 and thus for syncope, which increases risk of falls and stroke. Only a small minority of diabetics have these cardiovascular factors under control. This fact represents one of the greatest challenges for medical professionals today because all of these factors can be addressed, significantly or largely, directly or indirectly, with the right steps. And controlling glucose can improve each variable. Chronically elevated blood lipids and blood pressure are highly modifiable with medical therapy. CONDITIONS OF THE DIABETIC HEART Diabetics do not die of diabetes, per se, but of cardiovascular disease in most cases. A landmark finding published 15 years ago showed that asymptomatic diabetic patients have the same risk of death or myocardial infarction as nondiabetic patients who have a history of prior heart attack.10 Individuals with diabetes are disproportionately affected by the following cardiac and vascular conditions that are, at the very least, exacerbated by diabetes: Arterial disease. Coronary artery disease is common among people with diabetes11–a relationship that has been well established for years.12 In addition, diabetes is one of

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the strongest relative risk factors for peripheral arterial disease (PAD). Estimates are that one in every three individuals over 50 with diabetes 13 has PAD. PAD is a serious marker of disseminated disease. Atherosclerosis in the vascular tree rarely occurs in just one location. Studies show coronary artery disease (CAD) in about 70 percent of PAD patients. In addition, CAD and PAD together is a strong predictor of myocardial infarction and cardiovascular mortality. With atherosclerosis affecting the lower trunk of the circulatory system, erectile function can be an important indicator of vascular disease in men. Though as many as half or more of men ages 40 to 70 have some degree of erectile dysfunction,14 this type of sexual dysfunction is one of the strongest markers for heart disease, especially in men with longstanding type 1 diabetes.15 However, just as often, cardiovascular disease in diabetics may not manifest itself with any obvious, outward signs. It may smolder asymptomatically while setting up significant coronary disease. Stress electrocardiograms (ECGs) represent an important threshold in testing, but whether to stress test asymptomatic diabetic patients has been a matter of discussion and debate. The practice identifies a certain volume of disease, but controversy exists about whether the benefits outweigh the costs. 16 Still, stress testing of such patients every few years may be reasonable to detect otherwise occult disease. Cardiac arrhythmia. Individuals with diabetes are at increased risk of developing such heart rhythm irregularities as atrial fibrillation.17 Heart failure. Diabetes is one of the primary risk factors for heart failure. This link has been known for decades,18 and the risk is independent of coronary heart disease and hypertension.19 Diabetic cardiomyopathy is typically evident in diastolic left ventricular dysfunction. Cardiac remodeling. Deleterious anatomical changes to the heart are a common result of diabetic heart disease. These changes usually take the form of concentric left

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ventricular hypertrophy, diastolic dysfunction and/or enlarged left atrium. PRIMARY MEASURES ON WHICH TO INTERVENE Nationally, treatment campaigns for diabetes1 have focused on optimal management of the following: HbA1c (a measure of average blood glucose), with a goal of bringing this value to less than 7 percent. According to a recent study, patients who reduced their HbA1c levels by nearly one percentage point (from a mean of 7.8 percent to 7 percent) had a significant (45 percent) decrease in risk of cardiovascular death.20 Previous data have indicated that intensive glucose control reduces the risk of any cardiovascular-disease event by 42 percent and the risk of heart attack, stroke or death from cardiovascular disease by 57 percent.21 A significant portion of type 2 diabetics need to use insulin to achieve this control. Clinicians should stay mindful, however, of controversy regarding intensive glucose control in diabetics. Results from the ACCORD study of more than 10,000 diabetic patients revealed a previously unrecognized risk to intensive glucose control in type 2 diabetics who had either cardiovascular disease or additional cardiovascular risk factors. In this study, all-cause death was increased after several years in the group of patients who underwent intensive HbA1c control. The findings point out the need to individualize treatment for high-risk patients with type 2 diabetes.22

Blood pressure, with a goal of less than 130/80 mmHg. Findings indicate that for roughly every 10 mmHg reduction in systolic blood pressure, the risk for any complication related to diabetes is reduced by 12 percent.23 Cholesterol, with a goal of LDL less than 100 mg/dl. Improved control of blood lipids can reduce cardiovascular 23 disease complications by 20 to 50 percent. If a diabetic individual has other cardiovascular risk factors, then a better target is less than 70 mg/dl. Recent findings suggest a possible association of cholesterol-lowering statins with development of diabetes. However, for high-risk, nondiabetic patients, as well as diabetics with or without evidence of heart disease, the benefits of statin medications in morbidity and mortality still appear to significantly outweigh this risk.24 Medical and lifestyle management for individuals with diabetes is a widely accepted approach to treatment–less so, though, for cardiovascular surgical and interventional procedures, where debate remains about whether such steps are more effective than standard drug therapy, especially for patients with mild symptoms and stable ischemic heart disease. Furthermore, choice of type of invasive cardiac treatment may be particular for diabetic patients as well. A recent National Institutes of Health (NIH)-supported study showed that adults with diabetes and multivessel coronary heart disease who underwent cardiac bypass surgery had better overall heart-related outcomes than those who underwent a catheter-based artery-opening procedure to improve blood flow to the heart muscle.25 Continued aggressive medical management after invasive cardiac treatment is important for diabetics and nondiabetics alike. Postintervention treatment must include antiplatelet therapy, for which new drugs (such as prasugrel) may have a superior riskbenefit ratio for groups of patients at high risk for additional ischemic events, such as those with diabetes. A HEART PROTECTANT IN AN INFORMED, MOTIVATED PATIENT Diabetes, and the heart risk it carries, is a difficult condition and circumstance to have and to contend with. Controlling the disease and the risks it poses to heart health requires work and changes in medical regimen and aspects of lifestyle. Inquiring about and considering ways to help enhance the individual’s support network are important. Additionally, it is often difficult for medical

professionals to help diabetics control the disease because many with prediabetes and diabetes may hide or deny their condition. Patients should be encouraged to embark on exercise regimens to decrease cardiovascular risk. However, they should have a certain amount of structured guidance or monitoring of their efforts, especially when striving to attain goals such as the American College of Sports Medicine’s guideline of at least 150 minutes of moderate-intensity 26 cardiorespiratory exercise per week for healthy adults. Losing even a modest amount of weight often improves glucose control significantly for diabetic individuals. Even individuals with prediabetes can reduce their risk of developing diabetes through diet and exercise. In fact, those with the disease or at risk for it may be able to change dietary habits more rapidly than they can increase their exercise capacity. Diet, including dietary supplements, can be important for reducing a range of

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SELF-EMPOWERMENT TO SAVE DIABETIC HEARTS Left Ventricular Hypertrophy

Patients who have diabetes have to manage their own daily care–and knowledge is power in their quest to combat diabetes and reduce the risk it places on heart health. Though healthcare providers can set up the treatment plan, the patient must carry it out, making important decisions each day. Lourdes Health System works with the ABC (Achieving Better Control) Diabetes Education Program (which is recognized by the American Diabetes Association), referring patients who need help learning to confidently handle this responsibility. Insurance generally covers the educational services of ABC, which has multiple locations in the Lourdes system and in New Jersey, Pennsylvania and Delaware. Registered nurses who are certified diabetes educators lead sessions with patients. The ABC Diabetes Education Program includes individuals who are concerned about their risk, who are newly diagnosed or who have been coping with the disease for many years. Insulin-dependent and noninsulindependent persons with diabetes get essential information about the common challenges and the day-to-day requirements of diabetes. No matter how high the risk, patients with diabetes learn that they can keep it in check, bring down its severity and sometimes put it into remission through adherence to medical therapy and lifestyle changes. It takes sacrifice and commitment, but it can be done.

cardiovascular risk indices in diabetics.27 However, diabetics may have a particularly difficult time reversing heart disease (reducing heart disease endpoints) through weight loss, as shown in a recent study of overweight and obese patients with type 2 diabetes.28 A patient-centered approach to caring for diabetes emphasizes education and awareness and the importance of self-care. An established, structured program that meets the national standards for diabetes self-management education (see Self-Empowerment to Save Diabetic Hearts sidebar) can help patients take charge of their blood sugar and the many other components of controlling cardiovascular risk. Diabetes–and worry about its effects on heart health– should not deny people with diabetes all that life has to offer. In fact, an active lifestyle is in their best interest when coping with a condition that challenges them but does not have to limit their lives. Ian Joffe, MD, FACC, practices at the southern New Jersey-based Associated Cardiovascular Consultants of Lourdes Cardiology Services. 1

World Health Organization. (2012, September). Diabetes. www.who.int/mediacentre/factsheets/fs312/en/index.html. National Diabetes Information Clearinghouse, National Institute of Diabetes and Digestive and Kidney Disorders, National Institutes of Health, U.S. Department of Health and Human Services. (2011). National diabetes statistics, 2011. http://diabetes.niddk.nih.gov/dm/pubs/statistics/ #Pre-diabetes.

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Centers for Disease Control and Prevention. (2010, October 22). Number of Americans with diabetes projected to double or triple by 2050 [Press release]. www.cdc.gov/media/pressrel/2010/r101022.html.

National Heart Lung and Blood Institute, National Institutes of Health, U.S. Department of Health and Human Services. (2011). What is diabetic heart disease? www.nhlbi.nih.gov/health/health-topics/topics/dhd.

U.S. Department of Health and Human Services, National Diabetes Program. (2007). The link between diabetes and cardiovascular disease. www.ndep.nih.gov/media/ CVD_FactSheet.pdf.

Centers for Disease Control and Prevention. (2012). Adult obesity facts. www.cdc.gov/obesity/data/adult.html.

Solano, M. P., & Goldberg, R. B. (2006). Lipid management in type 2 diabetes. Clinical Diabetes, 24(1), 27–32. [Available at http://clinical.diabetesjournals.org/content/ 24/1/27.full.pdf+html]

American Diabetes Association. (2003). Treatment of hypertension in adults with diabetes. Diabetes Care, 26(1), s80–s82. [Available at http://care.diabetesjournals.org/ content/26/suppl_1/s80.full]

Brignole, M., Alboni, P., Benditt, D. G., Bergfeldt, L., Blanc, J. J., Bloch, T., . . . Weiling, W. (2004). Guidelines on management (diagnosis and treatment) of syncope–update 2004. Europace, 6(6), 467–537. [Available at www.ncbi.nlm.nih.gov/pubmed/15519256]

Haffner, S. M., Lehto, S., Rönnemaa, T., Pyörälä, K., & Laakso, M. (1998). Mortality from coronary heart disease in

subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. New England Journal of Medicine, 339, 229–234. [Available at www.nejm.org/doi/full/10.1056/ NEJM199807233390404] 11

National Diabetes Information Clearinghouse, National Institute of Diabetes and Digestive and Kidney Disorders, National Institutes of Health, U.S. Department of Health and Human Services. (2011). Diabetes, heart disease, and stroke. www.diabetes.niddk.nih.gov/dm/pubs/stroke.

Laakso, M., & Lehto, S. (1997). Epidemiology of macrovascular disease in diabetes. Diabetes Reviews, 5, 294–315.

American Diabetes Association. (2013). Peripheral arterial disease (PAD). www.diabetes.org/living-with-diabetes/ complications/peripheral-arterial-disease.html.

Feldman, H. A., Goldstein, I., Hatzichristou, D. G., Krane, R. J., & McKinlay, J. B. (1994). Impotence and its medical and psychological correlates: Results of the Massachusetts Male Aging Study. Journal of Urology, 151, 54–61. [Available at www.ncbi.nlm.nih.gov/pubmed/8254833] Turek, S. (2012, June). Presentation at the 72nd Scientific Sessions of the American Diabetes Association (ADA), Philadelphia, PA. Young, L. H., Wackers, F. J., Chyun, D. A, Davey, J. A., Barrett, E. J., Taillefer, R., . . . Inzucchi, S. E. (2009). Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes, the DIAD Study: A randomized controlled trial. Journal of the American Medical Association, 301(15), 1547–1555. [Available at http://jama.jamanetwork.com/article.aspx? articleid=183751] Dublin, S., Glazer, N. L., Smith, N. L., Psaty, B. M., Lumley, T., Wiggins, K. L., . . . Heckbert, S. R. (2010). Diabetes mellitus, glycemic control, and risk of atrial fibrillation. Journal of General Internal Medicine, 25(8), 853–858. [Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2896589] Kannel, W. B., Hjortland, M., & Castelli, W. P. (1974). Role of diabetes in congestive heart failure: The Framingham study. The American Journal of Cardiology, 34, 29–34. [Available at www.ajconline.org/article/0002-9149 (74)90089-7/abstract]

Boudina, S., & Abel, E. D. (2007). Diabetic cardiomyopathy revisited. Circulation, 115, 3213. [Available at http://circ. ahajournals.org/content/115/25/3213.abstract]

Eeg-Olofsson, K., Eliasson, B., Zethelius, B., Svensson, A., Gudbjörnsdottir, S., & Cederholm, J. (2012, June). HbA1c

reduction and risk of cardiovascular diseases in type 2 diabetes: An observational study from the Swedish NDR. Data presented at the 72nd Scientific Sessions of the American Diabetes Association. Meeting abstract no. 415-P. 21

Nathan, D. M., Cleary, P. A., Backlund, J. Y., Genuth, S. M., Lachin, J. M., Orchard, T. J., . . . Zinman, B. (2005). Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. New England Journal of Medicine, 353(25), 2643–2653. [Available at www.ncbi.nlm.nih.gov/ pubmed/16371630]

The Action to Control Cardiovascular Risk in Diabetes Study Group (ACCORD). (2008). Effects of intensive glucose lowering in type 2 diabetes. New England Journal of Medicine, 358, 2545–2559. [Available at www.nejm.org/doi/full/10.1056/ NEJMoa0802743]

National Diabetes Information Clearinghouse, National Institute of Diabetes and Digestive and Kidney Disorders, National Institutes of Health, U.S. Department of Health and Human Services. (2011). National diabetes statistics. www.diabetes.niddk.nih.gov/dm/pubs/statistics.

Minder, C. M., Santos, R. D., & Blumenthal, R. S. (2012). Statins and diabetes: Rethinking the data [Editorial]. American College of Cardiology/CardioSource. [Available with free registration at www.cardiosource.org]

Farkouh, M. E., Domanski, M., Sleeper, L. A., Siami, F. S., Dangas, G., Mack, M., . . . Fuster, V. (2012). Strategies for multivessel revascularization in patients with diabetes. New England Journal of Medicine, 367, 2375–2384. [Available at www.nejm.org/doi/full/10.1056/NEJMoa1211585]

Garber, C. E., Blissmer, B., & Deschenes, M. R. (2012). Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Medicine & Science in Sports & Exercise, 43(7), 1334–1359. [Available at www.ncbi.nlm.nih.gov/pubmed/ 21694556]

The Look AHEAD (Action for Health in Diabetes) Research Group. (2010). Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus. Archives of Internal Medicine, 170(17), 1566–1575. [Available at www.ncbi.nlm.nih.gov/ pubmed/20876408]

theheart.org. (2012, October 19). Look AHEAD halted: Lifestyle management fails to reduce hard CV outcomes in diabetics. [Available at www.theheart.org/article/ 1458351.do]

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General Approach to the

TYPE 2 DIABETIC PATIENT By Stephen H. Sherry, MD Successful care of the type 2 diabetic patient requires an organized multisystem and multispecialty approach to decrease the risk of complications and comorbidities. Complications arise because of cumulative injury to organ systems, related to hyperglycemia, hyperlipidemia and hypertension, among other factors. The consequences are traumatic: Diabetes is the leading cause of blindness in working-age adults in the United States, the leading cause of new cases of kidney failure and the leading cause of nontraumatic amputations, and this disease at least doubles the risk of myocardial and cerebrovascular infarction. Given the severity of potential problems, proper care of the type 2 diabetic patient requires a meticulous approach to improve outcomes. Involvement of the patient in his or her care is also vital because many of the necessary interventions require the patientâ&#x20AC;&#x2122;s cooperation. Health professionals caring for type 2 diabetics should familiarize themselves with the standards of medical care for diabetes that are published annually in a January 1 supplement to Diabetes Care. Adhering to these basic standards has a direct and measurable effect on the outcome of this complex disease. STUDY RESULTS LOOK POSITIVE Studies have documented a decreased risk of microvascular complications, such as diabetic retinopathy and nephropathy, with control of blood sugars.2 There are less data to document decreased risk of macrovascular diseases such as coronary artery disease, cerebrovascular disease and peripheral vascular disease, although an analysis of several trials showed a 9 percent reduction in major cardiovascular events, but no effect on all-cause mortality.3 The Steno 2 study shows that a coordinated program addressing nutrition, exercise, smoking behavior, blood sugar, cholesterol and blood pressure abnormalities decreases mortality from cardiovascular causes and cardiovascular events.4 Overweight type 2 diabetic patients assigned to metformin therapy versus conventional therapy experienced risk reductions of 32 percent for any diabetes-related endpoint, 42 percent for deaths due to diabetes and 36 percent for all-cause mortality.5

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CLINICAL PRACTICE RECOMMENDATIONS Selected clinical practice recommendations from the American Diabetes Association1 are summarized as follows: Nutrition treatment is a vital part of any diabetes care plan. Although professional counseling by a certified diabetes educator is important, the implementation of a nutritional plan is the day-to-day, ongoing responsibility of the patient. The nutrition management plan should focus on eliminating concentrated carbohydrates (such as simple sugars), reaching and maintaining optimal weight and achieving a proper balance of carbohydrates, protein and fats. For patients on basal/bolus insulin programs, carbohydrate counting is useful. Physical activity is necessary to promote weight loss and cardiovascular conditioning. A program that the patient enjoys and is capable of following should include aerobic exercise for at least 150 minutes weekly and biweekly sessions of resistance training. Collaboration with the patient is important to develop a plan that is achievable and sustainable. Smoking cessation counseling is vital because macrovascular complications are an important cause of comorbidity in diabetics. The particular hazards of smoking in the diabetic should be emphasized, and multiple strategies are often needed to attain abstinence. Nicotine patches, Wellbutrin, nicotine gum, Chantix (varenicline), alternative medicine treatments and behavior modification therapy may each have a role. Lipid management goals must be targeted. The first goal is to achieve a low-density lipoprotein (LDL) cholesterol of less than 100 mg/dL, with an optional target of <70 mg/dL in tobacco users or patients with known cardiovascular disease. The Heart Protection Study, performed with 5,963 diabetic patients over the age of 40 treated with simvastatin 40 mg daily showed an approximately 25 percent reduction in occurrence of first major vascular event, even in 2,426 diabetics whose LDL cholesterol at entry was less than 116 6 mg/dL. Therefore, diabetics should be treated with statin therapy if they have obvious cardiovascular disease, if they are over age 40 and have additional cardiovascular risk factors or if they donâ&#x20AC;&#x2122;t achieve appropriate LDL goals with diet and exercise interventions.

MAJOR SECOND-TIER TREATMENT OPTIONS

Secondary goals in lipid management include attaining triglyceride levels less than 150 mg/dL and high-density lipoprotein (HDL) cholesterol levels greater than 40 mg/dL (in men) or 50 mg/dL (in women). After statin therapy is implemented, additional drugs can be added, although the clinical benefit is unclear. Nicotinic acid is the most effective drug for lowering triglycerides and raising HDL, but using it is complicated by gastrointestinal side effects, flushing and hyperglycemia. Additionally, fibric acids are effective, as are fish oils. Control of hypertension to appropriate targets should be initiated with an angiotensin-converting enzyme inhibitor or an angiotensin-converting enzyme receptor blocker. In the absence of renal disease, as manifested by the presence of microalbuminuria, blood pressures can be maintained at <130/<80.7 (Recently, some organizations have loosened this recommendation to <140/<80.) Diabetic nephropathy screening is important for early detection of injury. Pharmacologic treatment with angiotensin-converting enzyme inhibitors or angiotensionconverting receptor blockers is appropriate if screening for diabetic nephropathy shows early injury. Dilated eye examinations by a qualified eye professional are an important part of routine care. These exams should begin immediately at the time of diagnosis and be repeated at appropriate intervals. Annual examination of the feet is indicated, and patients should be educated on foot self-examination. Pharmacologic management of glucose in type 2 diabetics focuses on individualized targets and treatments. For many non-pregnant adult diabetics, the hemoglobin A1c target is <7.0 percent, the preprandial glucose target is 70-130, and the peak postprandial capillary plasma glucose target is <180 mg/dL. Treatment should be intensified at three-month intervals if appropriate glucose control is not achieved.8 Pharmacologic treatment begins with metformin, unless the patient is ineligible due to allergy, intolerance, inadequate renal function or disqualifying comorbid conditions. At this point, the current treatment algorithm further diverges from the past and lists many second-tier choices, with the pluses and minuses of each.

Second-tier treatment options include sulfonylureas, pioglitazone, glucagon-like peptide-1 (GLP-1) receptor agonists, dipeptylpeptidase 4 inhibitors and basal insulin. Triple-drug therapy is also discussed, and the fourth tier of treatment is basal/bolus insulin therapy. The advantages and disadvantages of each type of treatment are presented in the Position Statement of the American Diabetes Associa8 tion and the European Association for the Study of Diabetes and are listed in the current American Diabetes Association Clinical Practice Recommendations.1 Sulfonylureas are inexpensive, effective hypoglycemics that are generally well tolerated. However, use of sulfonylurea drugs is limited by hypoglycemia, weight gain, secondary treatment failures and the need to tailor treatment to the individual in the face of liver or kidney impairment. Pioglitazone does not cause hypoglycemia, and raises HDL cholesterol and lowers triglycerides. However, it is associated with weight gain, bone fractures and edema up to and including heart failure. Pioglitazone increases the risk of bladder cancer, and therefore should not be used in patients with bladder cancer or with a family history of bladder cancer. GLP-1 receptor agonists do not cause hypoglycemia by themselves, are associated with weight reduction and might improve beta-cell mass/function. Disadvantages include gastrointestinal symptoms such as nausea, vomiting, diarrhea and the need for injections. Use may cause acute pancreatitis, and long-acting GLP-1 receptor agonists cause thyroid C-cell hyperplasia and medullary thyroid tumors in animals; however, these problems have never been reported in humans. Dipeptylpeptidase 4 inhibitors do not cause hypoglycemia and are weight neutral. However, they are occasionally associated with allergic reactions and pancreatitis. Basal insulin (Lantus or Levemir) is well studied in the management of diabetes. Although there is no significant effect on postprandial glucose with the use of basal insulin, there is associated weight gain, hypoglycemia and a requirement for medication injection. Basal/bolus insulin (Humalog, NovoLog or Apidra) therapy is appropriate in addition to basal insulin if previous treatments are ineffective in reaching targeted goals. (Other hypoglycemic agents are available in the United States but are used less often.) Vaccines are recommended for diabetes management. Influenza vaccine should be given annually. Pneumococcal polysaccharide vaccine should be administered once and repeated after age 64 if the previous vaccination was given 9 more than five years earlier. In 2011, the Advisory Committee

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American Diabetes Association. (2012). Clinical practice recommendations 2012. Diabetes Care, 35(Supplement 1).

UK Prospective Diabetes Study Group. (1998). Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet, 352(9131), 837–853.

Turnbull, F. M., Abraira, C., Anderson, R. J., Byington, R. P., Chalmers, J. P., Duckworth, W. C., . . . Woodward, M. (2009). Control group: Intensive glucose control and macrovascular outcomes in type 2 diabetes. Diabetologia, 52, 2288–2298.

Gaede, M., Lund-Anderson, H., Parving, H. H., & Pederson, O. (2008). Effect of a multifactorial intervention on mortality in type 2 diabetes. New England Journal of Medicine, 358, 580–591.

UK Prospective Diabetes Study Group. (1998). Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes. Lancet, 352(9131), 854-865.

Heart Protection Study Collaborative Group. (2003). MRC/ BHF heart protection study of cholesterol-lowering with simvastatin in 5963 people with diabetes: A randomised placebo-controlled trial. Lancet, 361(9374), 2005–2016.

Chobanian, A. V., Bakris, G. L., Black, H. R., Cushman, W. C., Green, L. A., Izzo, J. L., . . . the National High Blood Pressure Education Program Coordinating Committee. (2003, May 21). National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Journal of the American Medical Association, 289(19), 2560–2572.

Inzucchi, S. E., Bergenstal, R. M., Buse, J. B., Diamant, M., Ferrannini, E., Nauck, M., . . . Matthews, D. R. (2012). Management of hyperglycemia in type 2 diabetes: A patient-centered approach. Position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care, 35(6), 1364–1379.

Centers for Disease Control and Prevention. (2012, May 31 [updated]). Immunization schedules. www.cdc.gov/ vaccines/schedules.

Sawyer, M. H., Hoerger, T. J., Murphy, T. V., Schillie, S. F., Hu, D., Spradling, P. R., . . . Zhou, F. (2011). Use of Hepatitis B vaccination for adults with diabetes mellitus: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 60(50), 1709–1711.

on Immunization Practice added a recommendation for 10 Hepatitis B vaccination for diabetics ages 19 to 59. THE HEALTHCARE PROVIDER’S CHALLENGE There is no doubt that the management of diabetes and of the diabetic patient is a complex and multi-faceted process. Keeping in mind the standards of care outlined by the American Diabetes Association is the first step in decreasing the risk of complications and comorbidities that too often cause long-term, life-altering medical problems and even death for these patients. Stephen H. Sherry, MD, is a practicing endocrinologist at Montclair Endocrine Associates in Montclair, New Jersey.

“A program that the patient enjoys and is capable of following should include aerobic exercise for at least 150 minutes weekly”

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Stay Hungry TWO CASE STUDIES

– FOR

KNOWLEDGE

As a physician, you are inundated with information,1 so, a valid question is this: Is it fair to expect you to stay current on developments in your specialty? Moreover, is it required that you stay up to date in your field, if you are to have and employ the “knowledge and skill” that the law expects of the average practitioner in your field? The legal answer to both questions is “yes.” The question of how to stay current about all the changes in your area of medicine is beyond the scope of this article. However, perhaps by vicariously feeling the pain of a “failure to know” through the experiences recounted in the two given case studies, you will be motivated (without actually causing harm to your patients or expense and angst to yourself) to do whatever you must to stay current with developments that may impact the patients you serve. Certainly, there was a time in your career when you had to know all the latest developments because obtaining your medical license (or getting your board certification) depended upon it. Hopefully, despite the many demands in your personal and professional lives, the following two case studies that illustrate the consequences of the failure to stay current in the practice of medicine will inspire you to reignite an interest in real continuing medical education, such that you will be as hungry for current information as you were at the start of your career.

By Robert E. Paarz, Esq.

CASE 1:

GENERAL SURGEON MISSES A RARE BUT WELL-KNOWN COMPLICATION The ongoing national epidemic of obesity has seen a concomitant increase in type 2 diabetes. Interestingly, weight-loss surgery had its origins as a last-ditch effort to combat this problem. Recent studies suggest that bariatric surgery may improve the glycemic control essential to management of the disease and does so more effectively than medical therapy alone.2 In addition, a limited study reported the effectiveness of bariatric surgery in actually preventing the onset of diabetes.3 The validity of these reports, as well as the larger questions of long-term outcome, adverse effects and cost factors, remains to be settled. However, such surgery has been and will continue to be performed in many patients. The legal requirement of “knowledge” of developments in specialized surgery by all physicians was illustrated recently in a case involving a general surgeon who was taking call in an emergency department in a community hospital. The patient was an otherwise-healthy 52-year-old woman presenting with a history of gastric bypass surgery (GBS) (three years earlier) and a primary complaint of seven to ten out of tenlevel abdominal pain for approximately eight hours. The abdominal exam was relatively benign (except for “diffuse crampy abdominal pain”), and there was leukocytosis (white blood count = 16.4). Her plain films of the abdomen (KUB) reportedly showed no bowel obstruction. The patient had been on amoxicillin for four days secondary to an upper-respiratory infection. She reportedly had some nausea with diarrhea (non-bloody). A decision was made to admit her to the service of the hospitalist on call. At 2 a.m., the hospitalist ordered a computed tomography (CT) scan and a surgical consult in the morning. Approximately 11 hours after the patient’s presentation to the hospital, she was first seen by the general surgeon at 9

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TWO CASE STUDIES “The real issue in the case was whether a general surgeon has a duty to be aware of literature that addresses the issue of potential complications following gastric bypass surgery even though he or she does not perform GBS.”

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a.m. In the interval between admission and evaluation, the patient had received a total of 5 milligrams of Dilaudid for pain (intravenously at 1 to 2 milligrams each, at approximately 2to 2½-hour intervals). The surgeon recorded that the patient “appears comfortable resting in bed in no apparent distress. Alert and oriented x3. Abdomen: soft with minimal distention. Minimal tenderness in the lower abdomen but certainly no rebound guarding and there are positive normo-active bowel sounds present.” He acknowledged that a CT was pending. With that, he went to his office and did not return until 6 p.m. When the surgeon returned, he read the CT as showing a complete small bowel obstruction but decided to wait for the process that was causing the pain to either resolve or further declare itself. When the patient’s condition deteriorated further, he decided to operate at 10:30 p.m. that evening. In surgery, he found no sign of perforation, but bowel ischemia was clearly present. There was an internal hernia underneath the roux limb, extending from the gastric pouch to the Roux-en-Y anastomosis. The small bowel had volvulized (twisted and strangulated) twice under the point of herniation. He untwisted the bowel, and the affected portion of the bowel appeared to warm immediately. The defunctionalized portion of the stomach, the entire duodenum and approximately two feet of the jejunum appeared to be viable and healthy. The remainder of the bowel appeared to have “patchy” ischemia that was slowly responding to reperfusion. Doppler study showed flow within the mesenteric vessels. The small bowel was then returned to the abdominal

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cavity while the surgeon planned a “second look” operation within 12 to 24 hours. Unfortunately, the bowel became necrotic, and the patient died. It should not be surprising that a risk of gastric bypass surgery (GBS) is the development of an internal hernia. The operation is performed by creating a tunnel through which the roux limb is passed upwards to the stomach pouch. In the process, a hernia is created. In addition, the extensive weight loss following a GBS exacerbates the conditions that may create an internal hernia, leading to bowel strangulation and possibly bowel death. It matters not whether the GBS is done via an “open” procedure or laparoscopically. Both approaches increase the risk of an internal hernia compared to the risk of an internal hernia in the general population without GBS. A general surgeon must have and employ the knowledge of this increased risk when evaluating a patient presenting with severe pain out of proportion to the abdominal exam and leukocytosis. Furthermore, given the potentially fatal consequence of an internal hernia causing ischemic injury to the bowel, there must be a very high index of suspicion for this complication and a low threshold for the performance of an exploratory procedure. There is a substantial amount of literature that discusses the indications for the performance of gastric bypass surgery, the techniques and complications. In this case, the surgeon did not perform gastric bypass surgery as a part of his practice and, therefore, acknowledged he did not read about it. He did not suspect an internal hernia allegedly because he did not know that there is an increase in the incidence of internal hernia following GBS. When the surgeon was asked at his deposition what he would have done differently had he known that there was an increase in the incidence of internal hernia after GBS, he said that he would have upgraded the pending CT to “STAT,” and given the results of the CT scan (a highgrade obstruction), he would have urgently explored the abdomen. Under that scenario, the patient would have had exploratory surgery at least 12 hours earlier. In the case of an ischemic bowel, it was determined that a 12-hour delay in performing surgery deprived the patient of a chance at a substantially better outcome. The real issue in the case was whether a general surgeon has a duty to be aware of literature that addresses the issue of potential complications following gastric

TWO CASE STUDIES â&#x20AC;&#x153;if this general surgeon had kept up to date on his knowledge and skill in his field of medicine, this patient might not have diedâ&#x20AC;?

bypass surgery even though he or she does not perform GBS. The general surgeon admitted that publications addressed primarily to bariatric surgeons had many articles on the subject, but his defense was that in publications addressed primarily to general surgeons there were very few articles on the subject. However, the surgeon admitted that there were probably patients in the area serviced by the hospital (where he practiced and this happened) who had had GBS and that they might experience complications from that procedure. Therefore, the critical issue in the case was whether the standard of care required the surgeon to know that patients who have undergone GBS surgery are at increased risk (compared to the general population) for the complication of internal hernia, bowel strangulation and even death. The quantity of published medical literature is admittedly overwhelming. No one can study everything. Therefore, was it a reasonable expectation to say that the general surgeon in this case should have been aware of the potential for an internal hernia as a complication of a type of surgery he did not perform but might encounter in postoperative consultation? The expert testimony was divided. The attorney for the patient had a general surgeon from an Ivy League school on her side, and the attorney for the defendant surgeon had an expert from a community hospital on his side of the issue. Perhaps it is useful to acknowledge that GBS, while not usually published in the major general surgery literature, was the subject of several articles in publications addressed to general surgeons, including a journal

that published an article written by the defense expert. In addition, GBS was the subject of a question published in 4 SESAP only two years before the date of this incident. Therefore, it was believed that the general surgeon had a duty to have and employ knowledge of the complications of GBS surgery, including an understanding that severe abdominal pain out of proportion to the abdominal exam findings could be the result of an internal hernia causing bowel ischemia, a potentially life-threatening complication. The case settled before trial for a substantial amount of money. Perhaps the decision to settle was driven, in part, by the fact that the doctor admitted when he was deposed that the circumstances of this case (that people who had GBS were in the patient base he was obliged to treat) required that he know the potential complications following GBS. A related concern was that a reasonable jury would find that it was not too much to ask that a doctor stay current about signs and symptoms of potentially life-threatening conditions that could arise in patients he might see following the relatively new development of GBS surgery or following other changes in the evolution of medical and surgical practice. Undoubtedly, some observers will never be convinced that the surgeon had an obligation in this case to be aware of that potential complication; others will maintain he did have that duty. Still others will argue that the issue of the knowledge of the surgeon regarding the increased risk of an internal hernia associated with GBS is irrelevant because any general surgeon should recognize that a patient presenting with severe and unremitting pain unresponsive to narcotics with an elevated WBC and an abnormal CT that diagnosed an obstruction required urgent surgical exploration in any event. Regardless of oneâ&#x20AC;&#x2122;s personal opinion about this case, the fact remains that if this general surgeon had kept up to date on his knowledge and skill in his field of medicine, this patient might not have died, and he would not have faced such a difficult court case.

CASE STUDY #2

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TWO CASE STUDIES “the patient does not have to prove the omitted test would have resulted in avoiding the harm–only that it might have.”

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CASE 2:

SPECIALIST MISSES CHANGE IN PRACTICE REGARDING GENETIC TEST Wrongful birth cases are actions based upon the failure of the physician to give a patient the information regarding the risks, benefits and alternatives that a reasonable patient would deem “material” to making an informed decision about continuing a pregnancy. The damages that are potentially recoverable in a wrongful birth case include the extraordinary costs associated with raising a child who has special needs and those awarded for the parents’ emotional distress. The medical expenses for maintaining a special needs child with a normal life expectancy in excess of 75 years often run into the tens of millions of dollars. These cases are very expensive if there is liability and provide at least one of the reasons for increasing malpractice insurance premiums in “high-risk” specialties such as obstetrics. Generally, there are three antenatal diagnostic tests available that are used to determine with reasonable medical certainty if the fetus has a chromosomal or other defect: 1) chorionic villus sampling (CVS), 2) amniocentesis and 3) cordocentesis (percutaneous umbilical cord blood sampling [PUBS]). If any of the tests are a viable option, a patient has the right to be told about them. If she is not informed and delivers a baby with a chromosomal defect that may have been discovered had a test been performed, then the mother may have a cause of action for the loss of her legal right to terminate a pregnancy. In fact, under current New Jersey law, where the alleged malpractice is a failure of the defendant physician to perform a diagnostic test, the patient does not have to prove the omitted test would have resulted in avoiding

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the harm–only that the test might have. The patient can demonstrate the failure to perform the diagnostic test increased the risk of harm from the undetected preexisting condition, even if such tests are helpful in a small proportion of cases. The defendant physician may offer evidence that the omitted test would not have revealed an abnor5 mality or would not have prevented the injury at issue. When the CVS test first became available, it was generally an option offered to patients at 10–12 weeks of the pregnancy. However, the testing window was expanded to include at least the 13th week as early as 2001, according to Williams Obstetrics.6 In 2008, a patient who was at risk of having a baby with Down syndrome (trisomy 21 chromosomal defect) because of her advanced maternal age was referred to a maternal-fetal medicine (MFM) specialist by her general obstetrician. The purpose of the referral was to provide the patient with necessary information so that she could make an informed decision about whether to continue the pregnancy or abort. Unfortunately, although the patient saw her general obstetrician in the 8th week of her pregnancy, she was not seen by the MFM specialist until she was in the middle of the 13th week of gestation. The MFM specialist was trained in the late 1980s, and he did not know that CVS testing was available in the 13th week of pregnancy, and therefore, he did not offer it to the patient. He relied on his training of some 20 years earlier that had taught him that CVS could not be performed later than the end of the 12th week (i.e., not later than 11 weeks 6 days). Therefore, he counseled her to consider amniocentesis because it could be done at 15–20 weeks gestation. However, the MFM specialist did not have the patient return until she was into her 20th week of gestation. For extraneous reasons, the patient did not elect to have an amniocentesis until she was into her 24th week. That test was positive according to preliminary fluorescence in situ hybridization (FISH) analysis, but the full test result did not come back until it was deemed too late to abort the pregnancy. Communication between the patient and the MFM specialist broke down, and the patient consulted an attorney. When the patient learned that an available diagnostic test would have told her at 11–12 weeks that the fetus had Down syndrome, she was very angry and after delivery filed a wrongful birth suit. The MFM doctor’s defense was that he did not know

TWO CASE STUDIES “Increasing your awareness of relevant medical information improves the chances of a good outcome for your patient and greater satisfaction in your practice of medicine.”

that the CVS testing window had expanded such that the patient could have undergone CVS testing when he first evaluated her, notwithstanding that the change in the testing window was well documented in the literature. The MFM expert retained on behalf of the doctor had to concede that the defendant should have known about this clinically important development in prenatal screening of patients. The defendant doctor could have avoided a lawsuit if he had stayed current on the developments relevant to clinical decision-making in his field. Even if he was not comfortable performing CVS in the 13th week, he could have referred her to other doctors in the area who would perform the test. Just as importantly, the MFM doctor compounded that “missed opportunity” by failing to ensure that the amniocentesis testing was performed early enough in the pregnancy to allow for termination if elected by the mother. Wrongful birth cases are essentially “informed consent” cases in which the doctor is obligated to inform his or her patient about information a reasonable patient would consider important in making healthcare choices. Here, the MFM doctor’s admitted lack of knowledge deprived the patient of timely testing that would have allowed the mother to exercise her legal right to terminate the pregnancy. LESSONS LEARNED The lesson to be learned from both case studies is that it is essential that you stay current on developments that affect your practice. The development of new technologies and the exponential growth of relevant medical information have created the

concomitant challenge of keeping up with it all, but keep up you must. Speak with respected practitioners and develop a system of regular literature review, CME and other methods to stay current in your field. What you don’t know may hurt you and your patients. Staying as hungry as you were for medical knowledge when you first entered the practice of medicine decreases the chances that you or your patient will suffer harm due to a knowledge deficit. Increasing your awareness of relevant medical information improves the chances of a good outcome for your patient and greater satisfaction in your practice of medicine. Robert E. Paarz, Esq., is a Principal of the law firm Weiss & Paarz, PC. 1

For example, as of April 2009, PubMed contained information on almost 19 million citations in the medical literature, while adding more than 670,000 new entries per year.

Schauer, P. (2012, April 26). Bariatric surgery versus intensive medical therapy in obese patients with diabetes. New England Journal of Medicine, 366, 1567–1776; see also Schauer, P., Kashyap, S., Wolski, K., Brethauer, S., Kirwan, J., Pothier, C., …Bhatt, D. (2012, April 26). Bariatric surgery versus conventional medical therapy for type 2 diabetes. New England Journal of Medicine, 366, 1577–1585.

Carlson, L., Peltonen, M., Ahlin, S., Anveden, A., Bouchard, C., Carlsson, B., … Sjostrom, L. (2012, Aug. 23). Bariatric surgery and prevention of type 2 diabetes in Swedish obese patients. New England Journal of Medicine, 367, 695–704.

SESAP (Self-Education and Self-Assessment Program) is a product prepared under the auspices of the American College of Surgeons to prepare candidates for board certification and the recertifying process.

Gardner v. Pawliw, 150 N.J. 359 (1997).

Cunningham, F. G., Gant, N. F., Leveno, K. J., Gilstrap, L. C., Hauth, J. C., & Wenstrom, K. D. (2001). Williams obstetrics (21st ed.). New York, NY: McGraw-Hill.

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A Y O U N G A D U LT ’ S P E R S P E C T I V E :

“the physical and emotional nature of diabetes has its

An Encouraging Story for

highs and lows

Young Diabetics

every day, like my

”

blood sugar.

By Carson Scott Before I take the field, my pregame routine ends a little differently from that of most high school lacrosse players. Some guys sit and pray, and others listen to music. I, however, test my blood sugar. My name is Carson Scott. I am 18 years old, and I have type 1 diabetes. I was diagnosed when I was three years old and have experienced many of the consequences that come with this disease. I certainly know that the physical and emotional nature of diabetes has highs and lows every day, like my blood sugar. It’s a constant battle, but I encourage my fellow type 1 diabetics to fight and win that battle. There are plenty of ways to turn the bad days into good ones. Exercise and eat a healthy diet. Get the support of other diabetics because having someone to relate to and who will motivate you is therapeutic. Knowing that there is someone else out there the same age as you, battling the same issues as you, can be comforting because not everyone understands what you’re going through with this disease. Don’t feel restrained by the disease; the only thing restraining you is fear. Live your life and participate in activities that make you happy. Turn this disadvantage

into an advantage. Listen to your doctors. They aren’t there to yell at you and tell you what an irresponsible diabetic you are; they are there to help you live your life and make it easier for you to cope with the disease. I have found through my own success of winning two lacrosse state championships that I can be a leader on my team. I attribute this team and personal success to my management of my diabetes. Keeping my blood sugar in its optimum range becomes addicting, like winning. With lacrosse, I know what I need to do physically and mentally every day to win the big games. With diabetes, I know what my numbers have to be every day to be successful. I don’t let my diabetes control me; I control my diabetes. I am going to continue reaching for my goal by attending the University of Delaware next year on a D1 lacrosse scholarship. My goal is to compete and win the national championship and continue to manage my diabetes. I encourage you to do the same. Whatever you are passionate about or want to achieve, use your success with managing your diabetes to reach that goal. Carson Scott of Berwyn, PA, is a lacrosse player who plans to attend the University of Delaware.

“Keeping my blood sugar in its optimum range becomes *Healthcare providers are encouraged to copy and share this article with their young adult patients with diabetes.

addicting,

”

like winning. E42

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“‘With the elderly,’ says Dr. Giangola,

Talking About Diabetes

‘you have to keep things very simple and concrete.’”

“Communicating with young children

By Steve Adubato, PhD

is easy because Mom and Dad are there, so you rely heavily on the parents.”

There are many unique challenges facing physicians and medical professionals when it comes to communicating with patients and their families about diabetes care. This is particularly so when talking about blood sugar and insulin management because communicating with patients in a way that is direct and clear is critical to ensuring that they understand how to test, when to test and how to maintain control of their levels. I recently had the opportunity to learn more about the most challenging aspects of communicating with patients about diabetes from one of the leading experts in diabetes management, Joseph Giangola, MD. Dr. Giangola is the Medical Director for Hackensack University Medical Center’s MOLLY Diabetes Center, whose mission is to provide cutting-edge medical treatment while meeting the emotional needs of patients and their families. According to Dr. Giangola, when it comes to speaking with patients whose lives are impacted by diabetes, the way you talk to patients differs depending on their age and level of self-care. COMMUNICATING WITH THE ELDERLY “With the elderly,” says Dr. Giangola, “you have to keep things very simple and concrete. It also helps to provide written instructions. Additionally, it is of tremendous help to talk when they have someone with them, such as a daughter, a son or a caretaker, who can be a source of support and to whom you can explain things.” Dr. Giangola says that when he talks with patients about monitoring blood sugar levels and about sugar and insulin intake, he takes the time to write down spe-

cific instructions. He says that studies have shown that although pharmaceutical companies have detailed printed materials, people have a tendency to put those pamphlets in a drawer and never refer back to them. He compares his instructions to a holiday card that has a handwritten note. People are more reluctant to discard a personalized card compared to a generic one. Dr. Giangola shares another important reason for writing down instructions for adult or elderly patients: “Adults with diabetes may have mild cognitive impairment that hinders the learning process. Simply put, these adults don’t learn as well. We’ve known that for a while, and as a result, I’ve learned through the years to make my communication as concrete and clear as possible.” COMMUNICATING WITH YOUNG ADULTS There is also a unique set of challenges when communicating to younger patients, in particular, “emerging adults,” whom Dr. Giangola defines as those in the 18- to 22-year-old range. Says Dr. Giangola, “Communicating with young children is easy because Mom and Dad are there, so you rely heavily on the parents. But it is the emerging adults who are most challenging, as they have to manage their levels themselves. Sometimes, we baby kids too much before that age, so we haven’t started early enough teaching them to be independent.” According to Dr. Giangola, a team approach is key to working with this age group. It is helpful to have a nurse experienced in diabetes treatment, as well as input from social workers or case managers. Says Dr. Giangola, “Sometimes there are underlying issues in the family unit, so

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“try an open-ended question such as …’What is your target blood sugar number?’” social workers can help to identify how many times these emerging adults are checking their blood sugar and if they are exercising and eating properly. Add that level of monitoring with guidance from an APN, RN or RD who is also a Certified Diabetes Educator, and you have an invaluable team treating the patient. As a physician, you can’t do it all yourself.” Another source of information and support for emerging adults is other diabetics in this same age group. I encourage any physician treating young adult diabetics to copy and share the article in this issue of MDAdvisor entitled “A Young Adult’s Perspective: An Encouraging Story for Young Diabetics” by Carson Scott of Berwyn, PA. Carson’s story offers his peers a view of how one young man’s positive attitude has helped him proactively take control of his diabetes. See page E42

THE VALUE OF OPEN-ENDED QUESTIONS Regardless of the age of the patient with whom you are communicating, using open-ended questions can help to ensure that the message sent equals the message received. As a physician, after you have gone through a series of instructions and taken Giangola’s advice about writing them down, simply asking the patient, “Do you understand?” will most often get a simple “yes” answer. Instead, try an open-ended question such as, “Based on what we just discussed, what is your understanding of how often you should test your blood every day?” Or “What is your target blood sugar number?” Only then can you be sure that you and your patients are communicating on the same page, which will help them to better manage their own care–and this knowledgeable self-care is a key factor in successful diabetes management. Steve Adubato, PhD, is a four-time Emmy Awardwinning anchor for Thirteen/WNET (PBS) and is a media analyst for MSNBC. He is a motivational speaker and Star-Ledger columnist who has written extensively on doctor-patient communication.

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