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November 14, 2007

Diabetes dilemma: Study shows that people with diabetes face a heavy burden from co-existing health conditions

U-M/VA researchers find that severity, not just number, of simultaneous chronic conditions matters -- so doctors need to treat the whole person

ANN ARBOR, MI – As if diabetes weren’t enough to handle, a new study shows that 92 percent of older people with the disease have at least one other major chronic medical condition – and that nearly half have three or more major diseases besides their diabetes.

Eve Kerr, M.D., MPHThe sheer number, and the severity, of these other conditions appears to decrease patients’ ability to manage their diabetes. The type of co-existing condition also matters, as diabetes self-care lags most among patients with conditions that they think aren’t related to their diabetes.

The new findings make it more important than ever, the researchers say, for doctors to “treat the whole person” by helping diabetes patients learn how to deal with their other conditions in ways that will also allow them to control their diabetes.

The study, published online ahead of print in the December issue of the Journal of General Internal Medicine, uses data from a nationally representative sample of 1,901 adults with diabetes who were age 55 or older in 2002.

The researchers, from the University of Michigan Health System and the VA Ann Arbor Healthcare System, looked at the influence that a range of medical conditions had on the participants’ ability to manage their diabetes, whether or not those conditions were physically linked to diabetes. For one condition, heart failure, they also assessed how the severity of another condition affected diabetes management.

The data were drawn from the Health and Retirement Study, a major study of older Americans based at the U-M Institute for Social Research and funded by the National Institutes of Health. The current research was funded by VA and NIH.

“Patients are dealing with these issues day to day, and they’re affecting the way people prioritize and manage their own self-care,” says first author Eve Kerr, M.D., MPH, of the VA and UMHS. “Meanwhile, we physicians talk to patients about their diabetes, but not about how their heart failure or their hypertension is affecting how they manage their diabetes. These results show that we need to be treating the whole patient, but we don’t yet have systems designed to do that.”

The competing demands of simultaneous chronic diseases may lead people to neglect the self-care steps that will have the biggest impact over the long run, Kerr says. For instance, if a person with diabetes also has arthritis pain, or shortness of breath from heart failure, and these aren’t fully addressed, the person may refrain from physical activity. And that in turn means they’ll struggle to control their blood sugar or blood pressure – which is important to prevent future issues such as stroke.

In general, the more diseases a person had along with their diabetes, the more likely they were to report they were putting priority on conditions other than their diabetes, and the worse they reported they were doing at managing their diabetes through five key self-care steps. Severity also mattered: For the one condition for which the researchers had severity data — heart failure — diabetes self-care was not diminished among patients in the early, less symptomatic stages, but it was among those in later stages.

Also important, the study found, is whether patients perceive that their other conditions are related to their diabetes. For instance, many people with diabetes still don’t realize that their disease puts them at much higher risk of heart disease and stroke. That lack of awareness may mean that they don’t put as much emphasis on their blood pressure or cholesterol, when in fact controlling those risk factors can greatly influence the health of a person with diabetes. And indeed, in the current study, diabetes self-care was worse among people who had both diabetes and heart disease.

John Piette, Ph.D.That’s why a whole-person approach to care is so important, says Kerr, who is an associate professor of internal medicine at the U-M Medical School and associate director of the VA Health Services Research & Development’s Center for Clinical Management Research. So much is known about how to prevent long-term diabetes complications, and how to detect them early when they can still be treated, that the “return on investment” for good diabetes self-care is high.

Kerr co-directs Quality Improvement for Complex Chronic Conditions, a joint U-M/VA research program directed by John Piette, Ph.D., senior author of the new paper. Together with other U-M and VA researchers, they are studying the issues that face patients who have multiple conditions, and their caregivers. They’re also devising tools to help assess and improve care for such patients.

The new study was performed to get a representative picture of how many older people with diabetes also have multiple other conditions, and how those other conditions affect them. Thirty percent of the study participants were aged 55 to 64 when the study began; the rest were age 65 or older. Nineteen percent were African-American; 53 percent were women. One-quarter used insulin.

In all, the researchers found that 39 percent had at least one condition that resulted from the damage that diabetes can cause to tiny blood vessels and therefore to nerves, eyes and kidneys. These “microvascular” conditions are often emphasized in diabetes management plans.

Meanwhile, 81 percent had at least one of the “macrovascular” problems that are aggravated or triggered in part by diabetes, including high blood pressure, coronary artery disease, a history of stroke or mini-stroke, or heart failure. The researchers also looked at three unrelated diseases. Ten percent also had a lung disease, 14 percent also had cancer, and 55 percent also had arthritis.

The new results show that doctors need to work closely with diabetes patients who have other chronic conditions, to set the priorities for self-care at home. This includes diabetes-related tasks such as taking medications and checking blood glucose levels regularly and on schedule, exercising, following a diabetes-friendly diet and performing self-checks of the feet to look for sores that might not be healing or causing pain due to diabetes-related circulation and nerve problems.

But self-care for other chronic conditions can include taking drugs for cholesterol, blood pressure, lung disease and pain; avoiding salt that can aggravate hypertension and heart failure; regular weigh-ins for heart failure patients to monitor fluid retention; regular blood pressure checks; and more. Helping patients manage other chronic conditions may be as important as helping them manage their diabetes.

Programs that are designed to help support patients with several conditions are needed, beyond the single-disease management programs that have become popular for doctors to refer their patients to, the authors say. “Right now, disease management does one disease at a time — but few older patients come with just one,” says Piette. “If we want to really improve quality of life for these patients we need to be treating more than one at a time and help patients set their own priorities.”

In addition to Kerr and Piette, the study’s authors are Michele Heisler, M.D., MPA, Sarah L. Krein, Ph.D., RN, Mohammed Kabeto, M.S., Kenneth M. Langa, M.D., Ph.D., and David Weir, Ph.D.

Reference: JGIM, DOI 10.1007/s11606-007-0313-2 .

Written by Kara Gavin

 

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