Wilma J. Wooten, M.D., MPH

The management and treatment of type 2 diabetes, from the basics through the latest guidelines and therapies, were covered Saturday in a 5.5-hour "Diabetes Management Symposium and Certification Workshop" featuring 15 speakers.

Presentations began with "Diabetes 101" and quickly moved on to the natural history of the disease, prevention, treatment options, dealing with complications, using a team approach for treatment, nutrition and exercise, and how management and treatment can change throughout the lifespan of a patient.

In the past two decades, the prevalence of children who are obese has doubled, while the number of adolescents who are obese has tripled.

"Because of the obesity epidemic, we are seeing more type 2 diabetes in adolescents. It is important for the primary care provider to know how to manage it," said Wilma J. Wooten, M.D., MPH, the symposium moderator and a presenter.

"Diabetes is also increasing in the adult population. As of 2007, national statistics show an increase in diabetes from 21 million to 24 million people, and one-fourth of those people do not know they have it," said Dr. Wooten, public health officer for the county of San Diego and the principal investigator for NMA Diabetes Education Program, funded by the Centers for Disease Control.

Update on treatment options
Changes in treatment options were reviewed by Oluwaranti Akiyode, Pharm.D, BCPS, BC-ADM, in her presentation, "Update on Treatment Options." A key is the measurement of hemoglobin A1c blood levels, which has become the prime marker for treatment options in the past few years. Hemoglobin A1c represents the percentage of glucose that binds to hemoglobin in red blood cells, which is an indicator of a patient's overall glucose control.

"A1c drives our decision of what to use and when; it is one of the markers we use for glycemic control. The American Diabetes Association's (ADA) goal for A1c is to have it be less than 7 percent," said Akiyode, associate professor at the Howard University School of Pharmacy and a clinical pharmacist at the Howard University Hospital Diabetes Treatment Center.

If the A1c level is between 7 percent and 8.5 percent, older oral therapies, such as sulfonylureas, biguanides and thiazolidinediones can be effective, she said.

Still, these therapies can only lower A1c levels by 1-2 percent, so if the level is 8.5 percent or higher, a patient needs insulin, Akiyode said.

"A lot of times, physicians tend to wait a while before they initiate insulin therapy. Usually, a lot of damage is taking place in those cells, so early initiation of insulin is necessary for effectiveness for glycemic control," she said, adding that data from the Diabetes Control and Complications Trial-Epidemiology of Diabetes Interventions and Complications (DCCT-EDIC) and follow-up study to the United Kingdom Prospective Diabetes Study (post-UKPDS) trials demonstrate the benefit of early glycemic control in the reduction of long-term complications.

"The key is that all the data show patient glycemic control needs to be attained as early as possible, and that is not being done. The fact is that the earlier a patient reaches glycemic control, the better long-term quality of life, not only in clinical outcomes but also in economic outcomes," Akiyode said.

These treatment guidelines are supported by two treatment guidelines developed by the ADA and the European Association for the Study of Diabetes, which was updated in January, and the American College of Endocrinology and the American Association of Clinical Endocrinologists.

Team approach to diabetes management
Dr. Wooten discussed the effectiveness of using a team of health-care professionals in diabetes management, an approach based on the medical home principle for patients with chronic disease.

"That model takes a team approach, so just a physician is not needed in management," Dr. Wooten said. "The patient is an integral part of this. This looks at several constructs and how they speak to the success of the management of chronic diseases. We are trying to drive home the fact that doing that will provide the best patient outcomes."

The symposium reflected this team approach, with an endocrinologist, internal medicine doctor and OB-GYN discussing gestational diabetes, neuropathy, mental health and erectile dysfunction, she said.

"This chronic care model has been around for a while. It also takes into account that in your office you will have an electronic health record (EHR)," Dr. Wooten said. "This is important given the fact that the federal government is encouraging all providers to have some type of electronic medical records by 2014. Studies show that when you have EHR, there are decreased errors and your practice is more efficient."

Pediatrics
Type 2 diabetes is also on the increase among adolescents because of the increase in obesity, said Tanya Pagan Raggio-Ashley, M.D., MPH, director of the Office of Minority Health and Health Disparities and chief medical officer for the Health Resources and Services Administration.

In her presentation, Dr. Raggio-Ashley addressed the basics of introducing teens to living with diabetes, how physicians should talk to adolescents about the disease and how to treat both type 1 and type 2 diabetes.

"The epidemic of obesity is related to diabetes, and even though many of these patients can be treated with oral medications, we need to try to prevent complications with lifestyle modifications, such as a better diet and an increase in aerobic activity," she said.