Comprehensive, Patient-Centric DM Care Challenges & Solutions

Paul Aoun, D.O., Ph.D. Clinical Endocrinologist, PBDES

Affiliate Assistant Prof, Univ of Miami

Disclosure

• I do not have any financial relationships relative to the content of this program

• Today in the U.S., ________ will be diagnosed with diabetes. This is equivalent to about _______ per minute

ADA

4,660

3

Prevalence of Diabetes and

Prediabetes in the United States

4

1. CDC. National diabetes fact sheet, 2008. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2008.pdf.

2. CDC. National diabetes fact sheet, 2011. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf.

3. CDC. National diabetes statistics report, 2014. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf

Prediabetes

37% of US population

Diabetes

9.1% of US population

57

79 86

17.9

18.8 21.0

5.7

7

8.1

0

20

40

60

80

100

120

140

2007 2011 2014

Pers

on

s (

millio

ns)

Undiagnosed DM

Diagnosed DM

Prediabetes

1 2 3

HOW ARE WE DOING?

The Good

Improving Survival

Reducing complications

New discoveries

Novel technologies

8

Ali MK,et al. Achievement of goals in U.S. diabetes care, 1999-2010. N Engl J Med. 2013;368:1613-1624.

The Bad

WHY?

PHYSICIAN

E

M

L

E

G

S

L

A

T

I

O

N

S

EB

V

A

L

U

S E

M

E

FO D SUPPLY

RE EARCH MONEY

OBJECTIVES

• PATIENT-PHYSICIAN RELATIONSHIP

– 4 Challenges

– 4 Potential Solutions

• GLOBAL CHALLENGES

OBJECTIVES

• PATIENT-PHYSICIAN RELATIONSHIP

– 4 Challenges

– 4 Potential Solutions

• GLOBAL CHALLENGES

COMPLIANCE

CHALLENGES

OBJECTIVES

http://www.patientresource.com

COMPLIANCE

CHALLENGES SOLUTIONS

OBJECTIVES

COMPREHENSION

COMPREHENSION

Physician Patient

-Values & Preferences

-DM Distress & Burden

-Occupation

-Living Conditions

-Socioeconomic status

-Psychosocial barriers

COMPREHENSION

Patient Condition

-Diabetes

-Treatments:

-Dietary Choices

-Physical Activity

-Medications

Physician Patient

-Values & Preferences

-DM Distress & Burden

-Occupation

-Living Conditions

-Socioeconomic status

-Psychosocial barriers

COMPREHENSION

CONDITION(S):

-Diabetes

-Treatments:

-Dietary Choices

-Physical Activity

-Medications

Physician Patient

-Values & Preferences

-DM Distress & Burden

-Occupation

-Living Conditions

-Socioeconomic status

-Psychosocial barriers

Why do you think you

developed (type II) diabetes?

The genes set the stage,

the behavior tells the tale…

COMPREHENSION

CONDITION(S):

-Diabetes

-Treatments:

-Dietary Choices

-Physical Activity

-Medications

Physician Patient

-Values & Preferences

-DM Distress & Burden

-Occupation

-Living Conditions

-Socioeconomic status

-Psychosocial barriers

One quarter of what you eat keeps you alive;

The other three-quarters keep your doctor alive

(Ancient Egyptian Proverb)

25

26

LOW FAT LOW CARB

Juixing.com

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjp_arv_tTWAhWGi1QKHSl1A-4QjRwIBw&url=https://draxe.com/charts-american-diet/&psig=AOvVaw3-z3cF3oeo9hEEd0gTDbbv&ust=1507138525829126

Zuker CS. Cell 161:9-11; 2015

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiPp8Cj78PMAhWGPB4KHce1CUkQjRwIBw&url=http://www.sfgate.com/health/article/Sugar-coated-We-re-drowning-in-high-fructose-2794906.php&psig=AFQjCNHrYcf3wiEQu9u4Hf7vyHNUNpUQ9Q&ust=1462569745646850

Zuker CS. Cell 161:9-11; 2015

Sanz Y. Nature 77(1); 2015

How did we attempt to fix the

problem?

Artificial sweeteners

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjEz9yBlpnMAhVGRiYKHS-SBdEQjRwIBw&url=http://www.marketsandmarkets.com/PressReleases/global-market-for-weight-loss-worth-$726-billion-by-2014.asp&psig=AFQjCNECLIpTtCIKHCiD2T6vOUeVNUxr5g&ust=1461102738154469

Fact of the matter…

Almost all diets (and diet pills) work initially

Almost all diets (and diet pills) fail eventually

As A Medical Community:

We Must Aim for

Long-Lasting SUSTAINABLE Results

BUT, How to market it?

We cannot change the behavior

without altering the belief

Patient: When I eat, I eat

Me: Two options:

1) when you eat, eat better and don’t eat as much;

2)start a new medication

Patient: Is the medication expensive?

PORTION

PROPORTION

200 calories

WiseGeek.com

Incentive

DON’T: You need to lose weight

DO: You are very likely _____ lbs away from coming off _________

Aoun, P.

MOT ON

PORTION

PROPORTION

Physical Activity Altering the perception

Physical Activity Exercise

• Exercise: a structured form of activity for

a defined purpose, often to compete in a

sport or strength-training to maintain a

certain fitness level.

• Physical activity: Any bodily movement

that involves muscle contraction.

James A .Levine, 2007

James A .Levine, 2007

COMPREHENSION

CONDITION(S):

-Diabetes

-Treatments:

-Dietary Choices

-Physical Activity

-Medications

Physician Patient

-Values & Preferences

-DM Distress & Burden

-Occupation

-Living Conditions

-Socioeconomic status

-Psychosocial barriers

Real-World Severe Hypoglycemia in

Diabetics Exceeds Trial Rates

Gao J et al. Biomedical Reports. 2015:3(3)

gLOWmeperide

gLOWbyride

gLOWpizide

COMPLIANCE

COST

COMPLEXITY

CHALLENGES SOLUTIONS

COMPREHENSION

58

Ways to reduce insulin requirements?

• 72 y.o. F Medically-complicated obesity (BMI 36); DM-2 since 1982; HTN; Dyslipidemia, CKD (eGFR-60s)

• INITIAL CONSULT: A1C-8.6%; Glu-180 Cr-1.0 (eGFR-70s)

• On Glargine 34 HS; Lispro up to 28 ac TID

• Lives w/ husband who assists with insulin administration & treatment of hypoglycemia

• “frustrated” w/ BG variability and hypos

Clinical case

A1C-8.6%

Wt: 188 lbs A1C-6.5%

Wt: 164 lbs

• B cell failure:

– Dysfunction (“stunned”)

– De-differentiation

– Death?

Halban PA et al. JCEM 2014

Effects of Wt loss on B-cell parameters

Insulin Sensitivity Insulin Secretion

Obese Diabetics

Kelley DE et al, JCEM 1993

Ferrannini E et al, Diabetes 2004

Robertson SP et al, Diabetes 2004

• “Interestingly, the greatest HbA1c reduction

was the fall of 2% during the first 3 months

with intensive diet and 5% weight loss”

R. Holman, Oxford, U.K

(Chief Investigator-UKPDS)

If insulin indicated,

Simplicity Improves Adherence

…AND OFTEN SAFETY

Gao J et al. Biomedical Reports. 2015:3(3)

FDA & Metformin

Ask your doctor if Metformin is again right for you

RRR 16%

ARR 2.1%

NNT 49

NS PIOGLITAZONE

Dormandy JA et al.

RRI 38%

ARI 3%

NNH 33

• Judicious use of Pioglitazone:

– Low dose 15 mg

– Cautious use if pt on high dose insulin BUT could consider low dose pioglitazone to help reduce insulin requirements ($)

– Avoid in those w pre-existing CHF and/or high risk Fx

– Avoid if h/o bladder cancer (risk w long term/high dose pioglitazone use)

COMPLIANCE

COST

COMPLEXITY

CHALLENGES SOLUTIONS

COMPREHENSION

COST-EFFECTIVE

CONVENIENCE

COMPLIANCE

COST

COMPLEXITY

CONCERNS

CHALLENGES SOLUTIONS

COMPREHENSION

COST-EFFECTIVE

CONVENIENCE

CONOTATION

OBJECTIVES

• PATIENT-PHYSICIAN RELATIONSHIP

– 4 Challenges

– 4 Potential Solutions

• GLOBAL CHALLENGES

– Research $

– Food Supply

– Insurance coverage & Legislations

Reconcile

Research with

Reality

DM trials

Purpose: 75% therapeutic; 10% preventative

Funding: 51% Industry; 25% industry-funded multicenter

Interventions: 64% Drugs; 12% Behavioral

Size: 91% <500

Mean time to completion: 1.8 years

>65 y.o excluded: 30%

>75 y.o. excluded: >90%

Trials targeting >65 y.o.: 0.6%

Present & Future

of

Food Supply

Reconcile

Guidelines

with

Insurance coverage

The new and best diabetes drugs

…..money can(not) buy

Legislative

Efforts

1 in 3 MEDICARE $

People with Diagnosed Diabetes

ADA

AACE

Nat’l Clinical Care Commission Act

(H.R. 309/S. 920)

Public Law 115-80

It is not what you look at that matters,

it’s what you see

Henry D. Thoreau

THANK

YOU