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HomemistoryTaking Control of Diabetic Eye Disease

Taking Control of Diabetic Eye Disease

Diabetes is now considered a global ‘pandemic’ by leading epidemiologists. Multiple associated complications – including diabetic eye disease – severely impact quality of life in our working age population and cost the economy billions of dollars, making this a disease to be tackled by Government, patient organisations, clinicians, industry and the wider community.

Diabetes is the fastest growing chronic condition in Australia and is projected to become the number one burden of disease in Australia in the next five years.

According to Amelia Lake, Deakin University PhD Candidate and Associate Research Fellow at The Australian Centre for Behavioural Research in Diabetes, the best estimate is that at least 1.5 million Australians have diabetes, with Type 2 diabetes (T2D) accounting for 85–90 per cent of all cases.1 A frightening fact is that approximately 280 Australians are diagnosed with diabetes every single day and it is estimated that there a further 500,000 undiagnosed type 2 diabetes.

Frightening also is the financial cost associated with diabetic eye disease; a common complication of diabetes and the leading cause of blindness among working age adults in Australia.

…diabetic eye disease; a common complication of diabetes and the leading cause of blindness among working age adults in Australia…

According to Professor Paul Mitchell, “almost everyone with type 1 diabetes will develop some form of diabetic eye disease within 20 years of diagnosis. Of particular concern, however, is that many people with the more common type 2 diabetes will have already had the disease for many years by the time they are diagnosed. A large proportion of these people will develop potentially blinding diabetic retinopathy within five to 10 years of their diabetes diagnosis.”

A Deloitte Access Economics report estimated that 72,000 Australians are living with diabetic macular edema (DME).2 Additionally it identified that the number of people at risk of blindness from DME will increase by 42 per cent to 102,000 people in the next 15 years.

The entire indirect financial and wellbeing costs associated with DME are set to amount to approximately $2.07 billion in 2015. Of this approximately $570 million is due to productivity losses from lower workforce participation, absenteeism and premature death.

Why?

Although public health campaigns have increased awareness of diabetes, Amelia Lake believes the increase in its incidence is mainly due to an increase in the risk factors for development of the T2D. “These include overweight or obesity, which affects around 27 per cent of Australian adults,3 lack of physical activity, sedentary behaviour, ethnicity, family history and longer life span,” she said.4

Ms. Lake said most people with diabetes have some level of awareness of diabetes-associated complications such as vision loss.

“The Melbourne Visual Awareness Project asked 445 Victorians with diabetes from metropolitan and rural locations about their knowledge of complications,” said Ms. Lake.5 “Overall, 62 per cent of rural and 57 per cent of metropolitan participants were aware of at least one diabetes complication. Of those, eye complications were the most commonly cited (37 per cent of respondents were aware of complications), with no difference between rural and metropolitan respondents.”

Prevention Better than Cure

Of course prevention is always better than a cure, and this is something Ms. Lake says optometrists can make a significant contribution towards.

“Diabetes is now considered a global ‘pandemic’ by leading epidemiologists.6 So, to reduce the incidence of diabetes, you need to adopt a big picture approach and focus on reducing the behavioural risk factors common to diabetes and many other chronic conditions: smoking, physical inactivity, poor nutrition and harmful use of alcohol.7

“People are already aware of many of these key messages, so it’s clear that knowledge isn’t enough. Initiating and sustaining healthy lifestyle changes can be very difficult. We need to look at systematic changes that can support individual efforts to prevent chronic disease. These can include increasing the availability of healthy and affordable food options, and increasing active transport options in our city and suburbs.

We can also look at the cognitive and psychological barriers that may impede uptake of positive health behaviours. Once the barriers and facilitators to a target behaviour are understood, messages and strategies can be developed to target or address them.

Case Study: Jason Hewens

Former Tasmanian truck driver Jason Hewens grew up thinking he’d have to watch his heart health because he’d witnessed his father and his father’s two brothers die from heart disease within 13 months of each other when they were in their late 50s. Little did he know that diabetes would be the disease that had the greatest impact on his life.

Jason was diagnosed with Type 1 diabetes when he was 25. It came on very quickly.

“I was at work one day and it was cold. All of a sudden I broke into a real sweat from head to toe; I was saturated. I told my boss I didn’t feel well and I went home. I had a cold shower to cool down, then collapsed onto my bed.”

“Finding out I had diabetes was a real shock, it took me a while to come to terms with it. In the early days, my biggest fear was having to give myself injections four times a day, but it turns out they’re tiny and you don’t feel them. That was a load off my mind.

“Then the doctors told me about the complications associated with diabetes – about how it could affect my feet, my kidneys and my eyes and that really worried me. I was afraid I’d die early. So right from the start I wanted to do the right thing to make sure nothing like that happened.”

Despite his best efforts, a few years ago the complications began to occur. Last year, in October, failing kidneys created a problem with fluid retention, which in turn affected Jason’s vision.

With his vision significantly deteriorated, Jason’s commercial driver’s licence had to be revoked. “I had enough vision for my car licence but not my commercial licence. It was a big shock. I ended up being out of work, not getting paid, worried about losing my job and going nuts – all I wanted to do was get out there on the road.”

Fortunately Jason’s employer at the time, DeBruyns Transport, was fully supportive of his condition and held his job open for the three months it took to get his sight under control.

The treatment Jason continues to receive to maintain his vision is relentless, requiring visits to the Dr. Nitin Verma for injection and laser therapy every two weeks. However he says, it’s absolutely worthwhile because, “at the end of the day if you want quality of life you’ve got to be prepared to make sacrifices… if I
get to see for another 10 or 15 years, that’s a whole lot better than doing nothing and going blind.”

“Dr Verma has been incredible, but even so, I do have my down times. Sometimes the treatment seems too much and I want to give up, but with support from my wife, my sister, mother and in-laws, I’m getting through. We support each other.”

“Eye health professionals have a role in this and can assist by providing basic health education during consultations, emphasising the importance of diet, activity and regular screening activities,” said Ms. Lake.

Macular Disease Foundation Australia CEO Julie Heraghty believes a coordinated national partnership approach between Government, patient organisations, clinicians, industry and the community is needed to encourage early screening. This would support early diagnosis of diabetic eye disease, leading to early treatment and improved continuum of care.

“Many Australians with diabetes don’t recognise they are at risk of blindness or the importance of maintaining regular eye tests when their risk actually increases over time – even if they are managing their diabetes well.

“The Deloittes report has identified that approximately one in two people with diabetes do not have their eyes examined within the recommended timeframe,” Ms. Heraghty said.

Of course early detection of diabetic eye disease means that treatment can be commenced before vision is lost, enabling people to maintain their place in the workplace and enjoy quality of life for as long as possible. With the inclusion of ranibizumab (Lucentis) on the Pharmaceutical Benefits Scheme early in 2015 and aflibercept (Eylea) listed on 1 October, registered treatment is now more accessible and affordable than ever before.

Diabetes Classifications

Type 1 Diabetes
This is one of the most common chronic childhood diseases in developed nations. It occurs when
the pancreas is no longer able to produce the insulin needed. Daily insulin injections or an insulin pump, and regular blood glucose level tests are required.

Type 2 Diabetes
Type 2 represents 85–90 per cent of all cases of diabetes. It occurs when the pancreas is not producing enough insulin and the insulin is not working effectively. Type 2 diabetes is managed by regular physical activity and healthy eating. Blood glucose-lowering tablets and/or insulin injections may also be required.

Pre-diabetes
Pre-diabetes is present when blood glucose levels are higher than normal but not yet high enough to be diagnosed as Type 2 diabetes. This condition can develop into type 2 diabetes within five to 10 years if
left untreated.

Gestational Diabetes
This can occur in pregnancy and usually disappears after the birth. It is managed with lifestyle and medications, such as blood-glucose-lowering tablets or insulin. Women who develop gestational diabetes are at increased risk of developing Type 2 diabetes later in life, with a 30–50 per cent chance of developing it within 15 years after pregnancy.

Reference

diabetes.nsw.com.au

“If two thirds of all people living with DME who had visual impairment were treated with anti-VEGF therapy, the financial benefits potentially associated with improvement in vision and wellbeing would have amounted to $353.13 million in 2015 alone,” Ms. Heraghty said.

Why Not?

Even armed with knowledge, the evidence would suggest that people with diabetes are not taking the risk of associated complications, like diabetic eye disease, seriously enough.

Ms. Lake suggests it is more than that.

“Managing diabetes is unrelenting and onerous. Often people are asked to make lifestyle changes such as increasing physical activity and being mindful of their diet. There is the daily reality of blood glucose checking and for many, medications and/or insulin,” she said.

“In addition to the practical demands, people with diabetes are vulnerable to diabetes-related distress, depression, stigma, anxiety and fear of complications which can result in diabetes burnout.8 Many of these psychological concerns are negatively associated with glycaemic control, self-care activities, increased risk of complications and mortality.”

Ms. Lake said this makes patient communication critical to the management of diabetes and diabetic eye disease.

“It is very important for health professionals to be sensitive to the language used when discussing diabetes management with their patient.

“The Australian Centre for Behavioural Research in Diabetes (ACBRD) has conducted extensive research with people living with diabetes9,10 and found that people with T1D and T2D feel stigmatised by their condition, particularly with respect to overweight and obesity.11

“Perceptions of stigma and negative judgement impacts an individual’s social identity, emotional well-being and diabetes management. In order to assist all healthcare professionals in their communication with patients, the ACBRD and Diabetes Australia developed a language position statement,12 which provides a clear explanation of the impact of negative language and suggestions on words to use and the
ones to avoid.”

Ms. Lake said it is important to be non-judgmental; and supportive of the client, re-iterating key chronic condition management messages which focus on lifestyle improvement, taking medication as prescribed and preventative screening.

Having worked with patients since 1983, Associate Clinical Professor Nitin Verma has had plenty of experience talking through the issues and encouraging treatment compliance. He says engaging the patient in their own eye health management is an invaluable strategy. “The important thing is this is not a one sided show – the patients have an important role to play. In the case of diabetic eye disease, the patient needs to get their blood sugar levels and blood pressure down; they need to get their lipids in order. I tell them I’m going to write to their endocrinologist and their GP, and I remind them that they are as important as I am. When I do that they feel there is a light at the end of the tunnel.

“I’ve seen patients start to check their blood pressure, quit smoking and start to exercise… The main thing is to engage, to make them part of the solution, to take photos of the back of their eye every time they come in so they can see what’s changed and what we are able to do – so they feel like they are part of the management process,” said Associate Clinical Professor Verma.

Six Steps for Managing a Patient with Diabetes

Consultant vitreoretinal surgeon Associate Professor Lawrence Lee presents the following important steps to take when managing a patient at risk of diabetic eye disease.

1. Benchmark and Monitor
Ask the patient who is managing their diabetes how well controlled their disease is. Note their HbA1C levels, because it is good to have a target figure to aim for. Around 6-7 is very good; 7-8 is OK but there is room for improvement and a level of 8 or more really needs work.

2. Check on Access to Support
Ask your patient about any ancillary support they have accessed, such as
a dietician or exercise specialist.

Advise them about other support groups available such as Diabetes Australia and Macular Disease Foundation Australia.

3. Offer Evidence Based Information
In patient friendly terms, advise them about relevant studies on diabetes and diabetic eye disease. For example, you could provide your patient with an article presenting evidence based
data that shows good muscular exercise, as well as weight loss, can reduce blood sugar levels.

4. Provide Encouragement
Encourage your patient to keep working on controlling their diabetes. Remind them that change occurs
slowly but they will need to persist and not give up.

5. Offer Hope
Diabetes, and all of its associated complications, is overwhelming for the majority of patients. Advise your patient that with good control of their diabetes and regular monitoring the risk of complications can be reduced. Remind them of the promise of new treatments under development – such as new insulin pumps and in the future, stem cell treatments – that will improve quality of life. With current new treatments (anti-vegf, and intravitreal triamcinolone) there are now effective ways to improve vision loss caused by diabetic maculopathy.

6. Reinforce the Importance of Follow Up
Remind your patients that regular endocrinology reviews, in conjunction with their GP, optometrist and ophthalmologist visits, are important to identify change and to maintain better control. Reinforce that regular eye tests are essential to save sight.

Sensitivity Required

Ms. Lake said , “It is also important for optometrists and other eye health professionals to be aware of the potential for depression and distress when caring for a client with diabetes, particularly if a diagnosis of diabetic eye disease is forthcoming. Vision loss and blindness is one of the most feared complications of diabetes13 and onset of any complications is a known ‘critical period of psychological risk’.14 This,combined with the already two-fold increase in risk of depression,15 could be very challenging for a patient to accept.

“This doesn’t mean that eye health professionals shouldn’t tell patients that they have diabetic eye disease (in fact emerging research suggests that the feedback on retinal images can motivate health behaviour change for people with diabetes, significantly improving HbA1c levels at three-month follow up.16 Rather, approaching the issues with sensitivity and clear communication as opposed to negative judgement and fear appears to be the best way to address both diagnosis of complications and advice on lifestyle management.”

References

1. Zimmet P, Alberti KGMM, and Shaw J, Global and societal implications of the diabetes epidemic, in Nature. 2001. p. 782–787.

2. Deloitte Access Economics Pty Ltd, 2015. The Economic Impact of Diabetic Macular Oedema in Australia

3. Tanamas SK, et al.: The Australian Diabetes, Obesity and Lifestyle Study. Melbourne; 2012.

4. Whiting DR, et al. IDF Diabetes Atlas: Global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract 2011. 94(3): 311–321.

5. Livingston PM, et al. Awareness of diabetic retinopathy among people who attended a diabetic retinopathy screening program. Medical Journal of Australia 1998. 169(2): 117.

6. Zimmet P, et al. Diabetes: a 21st century challenge. The Lancet Diabetes & Endocrinology 2014. 2(1): 56–64.

7. Australian Institute of Health and Welfare (AIHW): Australia’s health 2014. Cat. no. AUS 178. AIHW; 2014.

8. Stoeckel M and Duke D. Diabetes and behavioral learning principles: often neglected yet well-known and empirically validated means of optimizing diabetes care behavior. Current Diabetes Reports 2015. 15(7): 39–46.

9. Browne JL, et al. ‘I’m not a druggie, I’m just a diabetic’: a qualitative study of stigma from the perspective of adults with type 1 diabetes. BMJ Open 2014. 4: 11.

10. Browne JL, et al. ‘I call it the blame and shame disease’: a qualitative study about perceptions of social stigma surrounding type 2 diabetes. BMJ Open 2013. 3(11): e003384.

11. Browne JL, Zimmet P, and Speight J. Individual responsibility for reducing obesity: the unintended consequences of well intended messages. Med J Aust 2011. 195(7): 386–386.

12. Available at: static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/9864613f-6bc0-4773-9337-751e953777cd.pdf [accessed 8 September 2015].

13. Quandt SA, et al. Older Adults’ Fears About Diabetes: Using Common Sense Models of Disease to Understand Fear Origins and Implications for Self-Management. Journal of Applied Gerontology 2012. 32(7): 783–803.

14. Rubin RR and Peyrot M, Psychosocial adjustment to diabetes and critical periods of psychological risk, Chapter 13 in, Y. Hyman, Editor. 2013.

15. De Groot M, et al. Association of depression and diabetes complications: a meta analysis. Psychosomatic Medicine 2001. 63: 12.

16. Rees G, et al. Feedback of personal retinal images appears to have a motivational impact in people with non-proliferative diabetic retinopathy and suboptimal HbA1c: findings of a pilot study. Diabetic Medicine 2013. 30(9): 1122–1125.