The Many Faces of Diabetes
How a group of nurses, physicians, social workers and dietitians are changing the face of adult diabetes treatment at UF Health
By Morgan Sherburne
Scherwin Henry occasionally gets a craving for potato chips.
He normally eats a healthy diet. He jogs a few times a week, exercises both at a gym and with a personal trainer.
But sometimes, those chips just beckon.
So, he grabs a bag and sits down. But instead of devouring the whole bag as he used to do, he now counts out a handful — one serving — and enjoys a guilt-free snack.
In February, the 64-year-old Gainesville resident, a retired senior biological scientist for the UF Interdisciplinary Center for Biotechnology Research, went to an appointment with his primary care physician for leg pain. Over the course of pinning down the cause of that pain, his physician discovered something else: Henry has Type 2 diabetes. Shortly after his diagnosis, Henry was referred to the UF Health Diabetes Education Program, where he could begin to learn how to manage his disease.
Taking diabetes to task
The UF Health Diabetes Education Program is part of an effort across UF Health to address adult diabetes. On the second Wednesday of each month, the diabetes care task force meets to discuss and revise the way adult diabetes is managed in UF Health Shands Hospital.
During a recent meeting, the first order of business was to streamline the orders for insulin that nurses receive from hospital pharmacists in Epic, the electronic patient medical record used in hospital systems. Clarifying these orders makes it easier for nurses to administer the correct dosage of insulin to their patients at the correct time. Each patient’s diabetes can be as individualized as the patient — and the need to care for these patients is becoming more urgent by the year.
When Kenneth Cusi, M.D., chief of the division of endocrinology, diabetes and metabolism in the UF College of Medicine’s department of medicine, arrived at UF Health in 2011, he recognized the need to make diabetes care a priority in the hospital. So he started the diabetes care task force in 2013 with the goal of offering an integrated, state-of-the-art inpatient and outpatient program to all patients with diabetes.
In the five years since Cusi has been at UF Health, the number of visits of patients with diabetes in the hospital has exploded. Between 2011 and 2015, that number increased 10 fold, from 399 patients seen in 2011 to 4,098 so far in 2016.
These numbers can be explained in part by active work to expand diabetes care in the hospital and in UF Health outpatient clinics, but it’s also because of the explosion in the rate of people diagnosed with Type 2 diabetes. According to the American Diabetes Association, 21 million adults in the United States were diagnosed with the disease as of 2014. Another 8.1 million have the disease, but aren’t aware of their condition, and 1.4 million people are diagnosed every year.
In addition, 86 million people live with prediabetes, a condition that could develop into diabetes if certain precautions aren’t taken. Diabetes has become the seventh-leading cause of death for adults in the United States, and is one of the most pervasive diseases the country faces.
Each month, Cusi’s task force — a group of doctors, nurses, pharmacists, social workers and others — meets to discuss the care of adult patients with diabetes. They focus on those in the hospital and devise ways to encourage patients to return to UF Health clinics for follow-up care or or to learn how to better manage out-of-control diabetes.
In the hospital, there are about 800 adult patients with diabetes during any given month, with about 150 monthly diabetes education consult requests, according to diabetes nurse clinician Courtney Puentes, R.N., C.D.E., who leads the effort to work with hospitalized patients who have diabetes. Part of the task force’s goal is to ensure there is a diabetes research nurse available in most units of the hospital during as many shifts as possible, resulting in about 70 nurses trained to care and educate people with diabetes at any time.
About 30 percent of these patients have Type 1 diabetes, while the balance have Type 2. In Type 1 diabetes, the patient’s pancreas is unable to make insulin to break down sugar in the blood; in Type 2, the body produces insulin but is unable to use it. But both can cause systemwide complications, including high blood pressure, high cholesterol levels and heart disease.
“Sugars fluctuate a lot in the hospital. If patients are unable to eat, blood sugars may get low. Sometimes, sugars can increase because patients are ill or they’re getting other medications that increase sugars. Finding the right insulin dosing is challenging because there are many factor at play — sugars become very volatile in the hospital,” Cusi said. “The diabetes care task force is trying to coordinate all these teams so these patients have a very positive experience with diabetes.”
Diabetes: An all-systems disease
The disease also complicates how a patient is given anesthetic before surgery. Anesthesiologist Nelson Nicolas Algarra, M.D., needs to know a patient’s blood sugar levels before the patient has surgery. While patients’ blood sugar levels are always checked before surgery, Algarra’s role in the diabetes care task force has been to implement an alert in Epic for patients with diabetes who are slated to undergo surgery. The alert will notify the surgical and anesthesia teams well in advance of the surgery if the patient’s blood sugar needs to be managed before the procedure can take place.
Nurses are the first line of defense for patients whose blood sugar needs to be controlled. Puentes works with diabetes resource nurses who help teach patients about their disease.
When patients are newly diagnosed, diabetes resource nurses have about an hourlong consultation with the patients to teach them about their disease. Patients need extensive education, which they may be better prepared to hear as an outpatient with the UF Health Diabetes Education Program.
“When patients are here in the hospital, they’re not feeling well,” Puentes said. “When they don’t feel well, it is challenging to teach them complex subjects.”
That’s where the task force comes in as well, Puentes said.
“We’re trying to improve education in the hospital. We want to teach patients the essential tools to get them home safely, then bridge them into outpatient education.”
That outpatient education takes place at the UF Diabetes Education Program outpatient clinic at the UF Health Medical Plaza. In the American Diabetes Association-certified program, the diabetes educators meet one-on-one with patients to understand from them what they know about the disease, the medication they take for it and the way their food habits might need to change to help manage their illness.
At UF Health Endocrinology’s outpatient practice at the Medical Plaza, a team of 15 endocrinologists and four nurse practitioners and physician’s assistants see an estimated 13,000 outpatient visits take place annually — a four-fold increase from 2013.
“There is a significant challenge to provide comprehensive diabetes care in the real world for people with a disease that has reached epidemic proportions,” said Cusi, who set the active outpatient clinical program into motion. “The task can be even more formidable for patients with long-standing disease needing specialized care or after patients leave the hospital.”
Listening to the “food voices”
Kathryn Parker, R.D., L.D./N., does not want to take away your rice.
Parker, program manager of the Diabetes Self-Management Education and Nutrition Therapy Center, is helping to provide outpatient education to newly diagnosed patients.
The center’s approach is not to take food away from patients. Instead, Parker and the nurses and registered dietitians who work in the center want to teach patients how to eat the foods they like while still managing their diabetes.
“Food is beyond nourishment in this country. It’s comfort. The diabetes educator takes all of that into account,” Parker said. “People have ‘food voices’ — this is their childhood speaking. We do not take things away from people. We won’t do it; it doesn’t work.”
Instead, at each outpatient consult, a certified diabetes educator such as Ryan Sanders, R.D., L.D.N., C.D.E., talks with patients like Scherwin Henry to find out the patient’s level of knowledge of his or her disease as well as the types of food that person likes to eat. Then, depending on the patient’s comfort level, they talk about what makes sense for the patient’s meal plan, medication and goals for their disease. In the appointment, Sanders and fellow certified diabetes educator Amy Aponick, R.D.N., L.D.N., C.D.E., help patients determine individual carbohydrate guidelines for patients.
“We don’t want patients like Scherwin to walk around thinking they can’t eat a certain food,” Sanders said. “He may very well have family members that look at something he’s about to eat and say, ‘Should you really be eating that?’ Hopefully, he can come back and say, ‘I can eat whatever I want as long as I know how many carbohydrates are in it, and can construct my meal according to my plan.’”
Sanders and Aponick then recommend the newly diagnosed patients attend a pair of diabetes education classes where they learn about healthy eating, being active, monitoring their blood sugar, taking their medications appropriately, coping with their disease and reducing risk of complications.
This kind of education is also the goal of Peter Carek, M.D., chair of the department of community health and family medicine. The department oversees six outpatient clinics throughout Gainesville where physicians are implementing a separate initiative to help patients whose diabetes is not managed, as indicated by the patient’s blood-sugar levels.
A normal range of blood sugar before a person has eaten is about 70 to 99 milligrams per deciliter; the goal range for people with diabetes is between 70 and 130. Physicians also assess a person’s blood sugar by looking at his or her hemoglobin A1C, a measure of that person’s blood sugar levels over several months. Ideally, a person’s A1C number should be 7 percent or below.
“Our initiative is to identify patients who have an A1C greater than 9, and reduce the number of those folks with uncontrolled diabetes,” Carek said.
To help target these patients, the clinics are creating a patient care registry that tracks individuals with an A1C greater than 9.
“To help these patients, we’re taking a multifaceted approach, working with not only our physicians, but also our nurses, pharmacists, nutritionists and nurse educators to develop a medication regimen as well as talking with patients about their diet and physical activity,” Carek said. “We’re asking ourselves how we can best manage individual patients so they can get maximum benefit from this team approach.”
Carek’s initiative was implemented in July, so it’s too soon to measure the department’s efforts. He hopes the initiative will also take into account the patient’s overall care, including evaluating a person’s access to transportation so they can attend appointments as well as access to healthy food. This holistic approach includes working with social workers as well as HealthStreet, a UF program that aims to connect the community with health care and research.
“We’re trying to think outside the box,” Carek said. “We don’t want to assume that our physicians and nurses can address all the issues these patients have.”
Getting back to the basics
Controlling blood sugar in patients with diabetes is key, but what if UF researchers could address the disease at a more basic level?
Nishanth Sunny, Ph.D., an assistant professor in the UF College of Medicine’s division of endocrinology, diabetes and metabolism, is doing just that. His research examines how metabolic pathways — chemical reactions that take place within cells — in the liver work. Understanding these pathways will help him identify or develop medications for Type 2 diabetes and another disease that often plagues people with Type 2: nonalcoholic fatty liver disease.
In nonalcoholic fatty liver disease, the liver becomes unable to efficiently process fat, either because of a high-fat diet, obesity or diabetes. If a diet high in fat continuously delivers fat to the liver, mitochondria can become overworked.
In the case of these diseases, the metabolic pathways within mitochondria that process sugar, fat and protein are dysfunctional.
“If you stretch a rubber band hundreds and hundreds of times, eventually the rubber band can no longer come back to its original shape,” Sunny said. “That’s what happens with the liver.”
Malfunctioning metabolic pathways can result in inflammation and cell death.
Sunny uses tracer molecules to track metabolites — small particles produced by the process of metabolism — to understand how these metabolic pathways work. The tracers look chemically different from metabolites but go through the same processes in the body, so Sunny can track the function of the pathways that metabolize sugar, fatty acids or proteins from food after it’s eaten. Discovering how and where metabolism pathways break down could give Sunny and his fellow researchers places to target drug therapies.
Cusi, who works closely with Sunny, has already tested one such drug typically used for diabetes: pioglitazone. In a three-year landmark study, Cusi found the drug also works to halt the progression of fatty liver disease in nearly 60 percent of the study’s participants. In this trial and others, Sunny can evaluate how drugs are working in humans by giving the same drugs to mice and examining how the mice are affected by the drug.
Fernando Bril, M.D., a research assistant scientist in the division of endocrinology, diabetes and metabolism, studies medications to combat Type 2 diabetes and nonalcoholic fatty liver disease.
“In the last of couple years, we have learned that as fat accumulates in the liver, it promotes inflammation, and you are at risk of developing cirrhosis just because you are overweight or obese,” Bril said.
Bril expects cirrhosis caused by fatty liver disease, which is increasing at rates similar to diabetes, to overtake hepatitis C as the top reason people need liver transplants.
Currently, there is no FDA-approved medication to treat fatty liver disease, although Bril, Cusi and Sunny did have success in halting the disease using pioglitazone. Now, the team is examining how the drug paired with vitamin E affects people with the disorder.
“The importance of diet and exercise to Type 2 diabetes and fatty liver disease cannot be underestimated,” Cusi said. “But this alone is often not enough, which is why we need such an active patient care and clinical research program to find improved ways to treat both diseases.”
Scherwin Henry’s drive
Henry’s diagnosis came as a complete surprise to him. His grandmother, mother and brother had lived with the disease, but he considered himself to be in good shape.
“The first thing was getting over the initial shock of being diagnosed with diabetes,” Henry said. “The next thing was understanding what I needed to do to control it. That’s where the classes came in handy because I was able to be educated and gain knowledge about the disease.”
The first class helps participants understand the role of carbohydrates in their diet. By testing their blood sugar before and after meals, patients can get a better understanding of how many carbohydrates they can eat during each meal. Henry religiously follows his recommended plan. When he eats out at a favorite restaurant with his wife, he eats the chicken and saves part of the angel hair pasta for the next day. Or he orders broccoli instead of a baked potato, or cuts the baked potato in half.
The second class dives a little more deeply into how Type 1 and Type 2 diabetes affect the body, and what medications do to combat the diseases.
Henry is down 18 pounds since his February diagnosis, and takes only metformin, a medication that controls blood sugar. Controlling his diabetes through diet and exercise requires diligence, but Henry says it’s the only answer for him.
“You just have to take the long-term view. For me, I have grandchildren, and I know that if I don’t take care of myself, I possibly won’t be around long enough to see them grow up and become the young men or ladies they could be,” he said. “In other words, I can’t be selfish and just indulge myself in what I want to do. There are others I have to consider. That’s what drives me.”