M&D Clinical Corner: National Diabetes Awareness Month

The Clinical Corner is a monthly feature that highlights a variety of important pharmacist topics that is written by Dr. Jesica Mills, PharmD, ND, MBA, RPh, BCES, BCLS, BCNP.

National Diabetes Awareness Month—Understanding, Screening, and Supporting Patients with Diabetes

November is recognized as National Diabetes Awareness Month, a time dedicated to raising awareness about diabetes and promoting the importance of understanding, preventing, and managing this chronic condition. The month-long observance aligns with World Diabetes Day on November 14th, commemorating the birthday of Sir Frederick Banting, who co-discovered insulin in 1921. This discovery revolutionized the treatment of diabetes, transforming it from a fatal disease into a manageable condition and marking a significant advancement in medical history.

A Brief History of Diabetes

The earliest records of diabetes date back to ancient Egypt around 1550 BCE, where it was described as a condition causing excessive urination and weight loss. In the 5th century BCE, Indian physicians identified the sweet taste of urine in diabetic patients, leading to the term “madhumeha,” meaning “honey urine.” The term “diabetes mellitus” combines the Greek word “diabetes” (to siphon or pass through) and the Latin word “mellitus” (honeyed or sweet). The pivotal moment in diabetes treatment came in 1921 when Sir Frederick Banting and Charles Best successfully isolated insulin at the University of Toronto. Insulin therapy became the cornerstone of diabetes management, saving countless lives. Over the years, advancements such as the development of synthetic insulin, insulin pumps, continuous glucose monitoring systems, and

Types of Diabetes

1. Type 1 Diabetes Mellitus: An autoimmune condition where the pancreas produces little
   to no insulin due to the destruction of insulin-producing beta cells.
2. Type 2 Diabetes Mellitus: A metabolic disorder characterized by insulin resistance and
   relative insulin deficiency, often associated with lifestyle factors.
3. Gestational Diabetes Mellitus (GDM): Glucose intolerance first recognized during
   pregnancy, which may resolve after childbirth but increases the risk of developing type 2
   diabetes later.
4. Prediabetes: A condition where blood glucose levels are higher than normal but not
   high enough for a diabetes diagnosis, indicating increased risk for developing type 2
   diabetes.
5. Maturity-Onset Diabetes of the Young (MODY): A group of monogenic diabetes forms
   caused by single-gene mutations affecting insulin production.
6. Neonatal Diabetes Mellitus: A rare form occurring in the first six months of life due to
   genetic mutations affecting insulin production.
7. Secondary Diabetes: Diabetes resulting from other medical conditions or treatments,
   such as pancreatic diseases or certain medications.
8. Latent Autoimmune Diabetes in Adults (LADA): A slow-progressing form of
   autoimmune diabetes occurring in adults, sharing features of both type 1 and type 2
   diabetes.

Testing and Screening for Diabetes

Early detection of diabetes is crucial for preventing complications. The American Diabetes Association (ADA) recommends the following screening guidelines:

• Adults Aged 45 and Over:
  • Should undergo initial screening with a fasting plasma glucose test, A1C test, or an oral glucose tolerance test (OGTT).
  • If results are normal, repeat testing every three years or more frequently depending on risk factors.
• Adults Under 45 with Risk Factors:
  • Overweight or obese individuals (BMI ≥25 kg/m² or ≥23 kg/m² in Asian Americans) with one or more additional risk factors should be screened.
  • Risk factors include:
    • Family history of diabetes.
    • Physical inactivity.
    • High blood pressure.
    • Abnormal cholesterol levels.
    • History of cardiovascular disease.
    • Women with polycystic ovary syndrome (PCOS) or who had gestational diabetes.
  • Testing should be repeated every 1–3 years depending on initial results and risk status.
• Children and Adolescents:
  • Overweight or obese youths with at least one risk factor should begin screening at age 10 or at the onset of puberty, whichever comes first.
  • Repeat testing every 3 years or more frequently if BMI increases.
• Pregnant Women:
  • Screening for gestational diabetes at 24–28 weeks of gestation.
  • Women with risk factors may be screened at the first prenatal visit.

Lifestyle Changes for Prevention and Management

Lifestyle modifications play a significant role in preventing type 2 diabetes and managing all types of diabetes:

• Healthy Eating:
  • Emphasize a balanced diet rich in whole grains, lean proteins, healthy fats, fruits, and non-starchy vegetables.
  • Limit intake of processed foods, sugary beverages, and excessive saturated fats.
• Regular Physical Activity:
  • Aim for at least 150 minutes of moderate-intensity aerobic exercise per week, such as brisk walking or cycling.
  • Incorporate strength training exercises 2–3 times per week to improve insulin sensitivity.
• Weight Management:
  • Achieve and maintain a healthy weight to reduce insulin resistance.
  • A modest weight loss of 5–7% of body weight can significantly reduce the risk of developing diabetes.
• Smoking Cessation:
  • Avoid tobacco use to improve cardiovascular health and insulin sensitivity.
• Stress Management:
  • Practice stress-reducing techniques like mindfulness, meditation, or yoga to help control blood glucose levels, since cortisol is the stress hormone and is a glucocorticoid that raises glucose in the blood.

Drug-Induced Nutrient Depletion: Metformin and Vitamin B12

Metformin is the first-line medication for type 2 diabetes due to its effectiveness and safety profile. However, long-term use of metformin has been associated with vitamin B12 deficiency.

• Mechanism:
  • Metformin may interfere with vitamin B12 absorption in the small intestine.
• Clinical Implications:
  • Vitamin B12 deficiency can lead to anemia and neuropathy, which may exacerbate diabetic neuropathy.
• Recommendations for Pharmacists:
  • Monitor patients on long-term metformin therapy for signs of vitamin B12 deficiency.
  • Consider periodic measurement of vitamin B12 levels.
  • Advise patients about dietary sources of vitamin B12 (e.g., meat, fish, dairy products) or recommend supplementation if necessary. Don’t overlook that intestinal absorption is why metformin can cause a deficiency, so B12 supplementation could be better as an injectable, topical patch, or sublingual form.

Goals Set in Guidelines

The ADA provides guidelines to optimize diabetes management and reduce the risk of complications:

• Glycemic Targets:
  • A1C Goal: Generally less than 7% for non-pregnant adults.
  • Preprandial Plasma Glucose: 80–130 mg/dL.
  • Peak Postprandial Plasma Glucose: Less than 180 mg/dL two hours after meals.
• Blood Pressure Control:
  • Target of less than 140/90 mmHg for most patients.
  • A lower target of 130/80 mmHg may be appropriate for individuals at higher cardiovascular risk.
• Lipid Management:
  • Statin Therapy: Recommended based on age and cardiovascular risk factors.
    • Moderate-intensity statin for patients aged 40–75 years without additional risk factors.
    • High-intensity statin for those with cardiovascular disease or higher risk.
• Regular Monitoring:
  • Eye Examinations: Annual dilated eye exams to detect retinopathy.
  • Foot Examinations: Regular foot checks to assess for neuropathy and prevent ulcers and amputations.
  • Kidney Function Tests: Annual assessment of urinary albumin and estimated glomerular filtration rate (eGFR).

Resources for Patients

• American Diabetes Association (ADA):www.diabetes.org
  • Offers education, support programs, and tools for managing diabetes.
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK):www.niddk.nih.gov
  • Provides comprehensive information on diabetes treatment and research.
• Centers for Disease Control and Prevention (CDC) Diabetes Division:www.cdc.gov/diabetes
  • Features resources on prevention, management, and statistics.
• Diabetes Self-Management Education and Support (DSMES):
  • Programs designed to help patients learn how to manage diabetes effectively.

Supplements, Diet, and Movement Recommendations

• Dietary Supplements:
  • Vitamin B12:
    • Recommended for patients on long-term metformin therapy.
    • Available as sublingual, topical patches, or injections.
    • Consider that diabetes is a metabolic disease, and methylation might be a challenge in the majority of diabetics. Opt for a b complex or methylated form that is bioavailable (methylcobalamin) rather than cyanocobalamin, as poor methylators on cyanocobalamin will produce homocysteine.
  • Vitamin D:
    • May improve insulin sensitivity and is involved in multiple metabolic processes.
    • Aim for a level above 40, and know the optimal level for diabetics is 80 nmol/L. ○ Magnesium:
    • Magnesium deficiency can lead to insulin resistance and the development of type 2 diabetes. It aids in glucose transport and utilization. Magnesium oxide is not the best form to increase sustained levels in the blood. Opt for Magnesium Chloride (Slo-Mag), or magnesium glycinate.
  • Omega-3 Fatty Acids:
    • Supports cardiovascular health; consume through diet (e.g., fatty fish) or supplements.
    • Consider all forms of omegas, including borage seed oil, black seed oil, and flax seed oil along with fish oil. A supplement with multiple forms of omegas can provide a balanced support of lowering inflammation.
  • Chromium:
    • Some evidence suggests it may aid glucose metabolism; as always, consult with their healthcare provider before use.
• Dietary Recommendations:
  • High-Fiber Foods:
    • Include whole grains, legumes, fruits, and vegetables to improve glycemic control.
  • Low Glycemic Index Foods:
    • Choose foods that have a slower impact on blood sugar levels.
    • Consider providing patients with a resource of low glycemic index foods, or creating a meal plan for them through planning tools like That Clean Life that can integrate with your software.
  • Healthy Fats:
    • Incorporate sources like avocados, nuts, seeds, and olive oil.
• Physical Activity:
  • Aerobic Exercise:
    • Engage in activities like walking, swimming, or cycling.
    • Walking 20 minutes after eating is a best practice, since the muscles will utilize the glucose and it won’t stay in the blood causing the release of insulin.
  • Strength Training:
    • Include resistance exercises to build muscle mass and improve insulin sensitivity. Resistance bands are a powerful and available tool to provide to patients, along with guides on how to use them.
  • Flexibility and Balance Exercises:
    • Practices like yoga or tai chi can enhance overall well-being.
    • Phone apps can be useful in reminding patients and guiding patients through exercises. An example of this is DDP Yoga, which has exercises for men and women at all levels of physical fitness, including chair exercises.
• Behavioral Support:
  • Set Realistic Goals:
    • Encourage small, achievable changes to build confidence.
    • As Pharmacists, we can be the guide for what their goals are, what they are trying to prevent, and what goals are important to the patient based on their lifestyle and values.
  • Monitoring Progress:
    • Use tools like glucose meters and activity trackers.
    • Providing patients with weight trackers, resistance bands, technology resources, and creating the space and time to meet with patients to educate and encourage and plan is essential for their continued progress.
  • Seek Support:
    • Join support groups or work with a diabetes educator.
    • Pharmacists can utilize technology like social media to create a community that celebrates their patients’ wins, and encourages them during setbacks. They can facilitate in-person events, and include glucose monitoring in all other health and wellness programs (like weight loss) they offer.

Conclusion

National Diabetes Awareness Month serves as a crucial reminder of the importance of understanding, preventing, and managing diabetes. Pharmacists play a vital role in patient education, medication management, and supporting lifestyle changes. By staying informed about the latest guidelines, recognizing potential medication-related nutrient depletions, and providing accessible resources, healthcare professionals can empower patients to take control of their health and improve their quality of life.

References

1. American Diabetes Association. Standards of Medical Care in Diabetes—2023. Diabetes Care. 2023;46(Suppl 1) –S291.
2. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2022. Available at: https://www.cdc.gov/diabetes/data/statistics-report/index.html
3. de Jager J, Kooy A, Lehert P, et al. Long-term treatment with metformin in type 2 diabetes and vitamin B12 deficiency: randomized placebo-controlled trial. BMJ. 2010;340.
4. Evert AB, Dennison M, Gardner CD, et al. Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report. Diabetes Care. 2019;42(5):731–754.
5. Pittas AG, Lau J, Hu FB, Dawson-Hughes B. The role of vitamin D and calcium in type 2 diabetes. A systematic review and meta-analysis. J Clin Endocrinol Metab. 2007;92(6):2017–2029.
6. American Diabetes Association. Diabetes Risk Factors. Available at: https://www.diabetes.org/diabetes-risk

Call to Action

As we observe National Diabetes Awareness Month, let’s commit to enhancing our efforts in diabetes education and management. Pharmacists are encouraged to engage with patients proactively, offer screenings that identify diabetics, educate and suggest lifestyle modifications, and medication management. Together, we can make a significant impact on the lives of those affected by diabetes.