Diabetes Outreach Network
QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS
Chapter
19
Chronic
Complications of Diabetes
Chronic complications of diabetes include cardiovascular disease, neuropathy, nephropathy, retinopathy, periodontal disease, as well as complications from flu and pneumonia.
Research
Studies
Striving for optimal glycemic control is the cornerstone in the prevention
of diabetes complications. The Diabetes Control and Complications Trial
(DCCT) compared intensive vs. conventional control in persons with type
1 diabetes. Intensive diabetes care reduced the risk of:
- Retinopathy 76%
- Neuropathy 60%
- Nephropathy 50% and
- Cardiovascular disease 35%.
Most participants were then enrolled in the Epidemiology of Diabetes Interventions and Complications (EDIC), an 8 year observation study. It showed further risk reduction in:
- Heart and blood vessel disease by 42%
- Heart attack, stroke, or heart and blood vessel disease-related death by 57%.
Similarly, the United Kingdom Prospective Diabetes Study (UKPDS) showed that improved blood glucose control in those with type 2 diabetes reduced risk of:
- Retinopathy by 21%
- Nephropathy by 33%.
The UKPDS also showed that improved blood pressure control reduced incidence of stroke and microvascular complications.
However, in light of recommended treatment goals, only:
- 37% of adults with diagnosed diabetes achieved an A1C of <7%
- 36% had a blood pressure <130/80 mmHg
- 48% had a cholesterol <200 mg/dl
- 7.3% met all three above goals.
Cardiovascular Disease (CVD), the number one killer in those with diabetes, includes coronary artery disease, myocardial infarction, peripheral vascular disease and cerebral vascular disease. Risk factors for CVD include duration of diabetes, age, genetics, race and gender, along with modifiable risk factors listed in the table below.
Guidelines for Reducing Risk of CVD
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* Current NCEP/ATP III guidelines suggest that "non-HDL cholesterol" (total cholesterol minus HDL) be utilized in those with triglycerides 200 mg/dl. Lower
Extremity Complications and Neuropathies An annual comprehensive foot exam including a 5.07 monofilament test is recommended to screen for neuropathy. Suggested sites for monofilament testing are shown below. |
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 |
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- Genitourinary: problems with bladder, erectile dysfunction.
- Gastrointestinal: gastroparesis, diarrhea, constipation
- Cardiovascular:
orthostatic hypotension, silent heart attack
Impaired insulin counter-regulation: hypoglycemia unawareness - Sudomotor: abnormal sweating
- Pupillary: difficulty seeing in the dark.
Persons with diabetes should be taught to examine their feet daily and report changes to their health care provider, including redness, swelling, ulcers, temperature change or structural changes. Reducing risk for lower extremity complications includes smoking cessation, controlling blood lipids, blood pressure and blood glucose, weight management and being physically active.
Autonomic neuropathy affects blood flow, perspiration and skin hydration. This can lead to dry, cracking skin and calluses. It may also impair one’s ability to fight infection. Autonomic neuropathy can also affect other body systems:
Nephropathy
Diabetic nephropathy occurs in 20-40% of those with diabetes. Risk factors
are listed below.
|
A family history of high blood pressure and/or the presence of hypertension increase the risk to develop kidney disease and hypertension speeds the progress of kidney disease when it already exists.
Guidelines for reducing one’s risk of Kidney Disease
| Goal | |
| Blood Pressure |
|
| Cigarette Smoking |
|
| Diabetes |
|
| Diet |
|
| Lipids |
|
| Lab Testing |
|
| Weight management |
|
* For GFR calculator: go to www.nkdep.nih.gov/professionals/gfr_calculators/
Retinopathy
Diabetes is the leading
cause of blindness in the US among those aged 20-74. Eye disease is 25
times more common among persons with diabetes than the general population.
Listed below are common eye problems in persons with diabetes.
| Functional losses | Treatment | Prevention | |
| Cataracts (clouding of the lens of the eye) | Blurry vision Reduced night vision Problems with glare Fading of colors |
Surgery to replace the lens | BG control Annual eye exam |
| Glaucoma (group of eye diseases that damage the optic nerve) | None in early
stages Loss of peripheral vision Difficulty with night or low vision |
Lower eye pressure
(eye drops or surgery) |
Annual eyeball pressure check |
| Retinopathy (microvascular disease of the retina) | None in early
stages Later: blurry vision, floaters, flashing lights, sudden vision loss |
Dependent on
severity |
Annual dilated
eye exam Strive for optimal blood pressure, lipid and glycemic control Smoking cessation |
Periodontal
Disease
Periodontal disease is the most common oral complication of diabetes.
It is more prevalent in those with poorly controlled diabetes. Prevention
of periodontal disease involves striving for optimal glycemic control,
good oral hygiene (regular brushing and flossing of teeth) and follow-up
every 6 months with a dental professional.
Flu
and Pneumonia
Influenza and pneumonia are common, preventable infectious diseases associated
with high mortality and morbidity in those with chronic diseases. Vaccination
guidelines are listed below.
Influenza: annual to all with diabetes 6 months of age.
Pneumonia: one lifetime vaccine for adults with diabetes. A one-time revaccination
is recommended for those >65 years of age previously immunized when
they were <65 years of age if the vaccine was administered >5 years
ago.
References:
Franz MJ et al. (2003). A Core Curriculum for Diabetes Educators, 5th
Ed., Diabetes Complications. American Association of Diabetes Educators,
Chicago.
Saydah
SH, Fradkin J, Cowie CC: Poor control of risk factors for vascular disease
among adults with previously diagnosed diabetes. JAMA 291:335–342,
2004.
American Diabetes Association (2006). Clinical Practice Recommendations. Diabetes Care. Supplement. Vol 29.
| Independent
Study Modules |
