How to Treat a Diverse Disease
By Cary Estes
Stuart Frank (left) and Fernando Ovalle have opened two new multidisciplinary clinics for adult and adolescent diabetes. In one day, patients can see a team of specialists and receive a personalized treatment plan.
A diabetes patient could be a toddler or a senior citizen. Many are overweight, but not all. Some diabetics have kidney problems, while others experience problems with their eyes or feet. With such a range of symptoms and characteristics, type 1 and type 2 diabetes are actually “type many,” says Stuart Frank, M.D., director of UAB’s Division of Endocrinology, Diabetes, and Metabolism.
Consequently, patients usually must visit a variety of specialists to find the care they need. But as clinicians have observed, more specialists typically means more trips to the doctor or hospital—and more reasons for patients to not follow through on care.
Two new UAB clinics aim to solve that problem. The multidisciplinary diabetes clinic, directed by Fernando Ovalle, M.D., brings together in one place a wide range of specialty services tailored specifically for adult diabetic patients; a similar clinic is designed to help adolescent patients make the transition from pediatric to adult diabetes care.
“It’s kind of a one-stop shop,” says Frank. “On different days of the week we focus on different aspects of diabetes and have the patients consult with different specialists—eye doctors, foot experts, and so forth. On the day for adolescents, we’ll have pediatricians, endocrinologists, social workers, diabetes educators, and dieticians in the same clinic. Another day we’ll have a clinic that specializes in complications for adults with diabetes. Then we’ll have a day set aside for a pump clinic.”
The setup of the two clinics means patients can schedule visits with a wide range of specialists in a single day—a particular benefit for diabetic patients who cannot travel easily. “The patients arrive in the morning and have a battery of tests,” Frank explains. “They have lunch with the nutritionist and get a better feel for what we think constitutes good nutritional management of diabetes. Then they see the specialists in the afternoon.”
Once the tests are done, Frank says, the specialists develop a treatment plan for each patient and discuss it with him or her. “We schedule it so we don’t see very many patients each day,” Frank says. “That way we can take more time and be more thorough.”
The development of the adult and adolescent clinics, which opened in October, heralds “a very exciting time at UAB,” Frank adds. “A lot of things are coming together to crystallize the focus of the Comprehensive Diabetes Center. This is an area that is important for the university to target.”
Treatment to Go
Diabetes treatment options also have changed for children with the evolution—and rise in popularity—of insulin infusion pumps to replace multiple insulin shots each day. UAB pediatric endocrinologist Gail Mick, M.D., says approximately 800 of the 2,000 children being treated at Children’s Hospital for diabetes are using these pumps.
“If we can specifically transplant islets, then we will be accomplishing something. It’s an area of intense investigation.”
—Stuart Frank
“Pumps really help with quality of life,” Mick explains. “With shots, parents have to approach their young children with a syringe many times per day, and that can be traumatic. A pump is less stressful for everyone.”
It also provides flexibility. Today’s pumps are sophisticated, wearable, iPod-sized computers that can be programmed to deliver precise insulin injections at specific times. The amount of insulin to be injected can be adjusted throughout the day to allow for meals, physical activity, changing schedules, and other factors. “The pumps give patients infinite control over their insulin dosing 24/7,” Mick says. “This is especially important for active teenagers.
“They offer great precision and the ability to turn insulin infusion on and off rapidly,” she adds, “because they can regulate rates in increments as low as 0.025 units per hour. Moreover, new pump innovations allow wireless communication with a patient’s blood glucose meter—or even specialized continuous glucose monitoring devices that can measure minute-to-minute blood trends 24 hours a day.”
Insulin has improved along with its delivery systems. Some new insulins enter the bloodstream immediately, doing away with the traditional half-hour delay; others, designed to intentionally delay absorption, flow in steadily throughout the day. These “user-friendly” insulins not only offer more flexibility, but they also “enable us to more safely and more effectively control blood sugar,” Frank says.
Slimmer Chances
Jamy Ard, M.D., is looking for other ways to manage blood sugar, even before diabetes is diagnosed. “I know it sounds like the same old refrain, but the best way to prevent diabetes is with a healthy lifestyle,” says Ard, an assistant professor in UAB’s Department of Nutrition Sciences and medical director of UAB’s EatRight Weight Management Services.
Jamy Ard (above) and staff members at UAB’s EatRight Risk Reduction
Clinic tailor diet and exercise plans to help patients reduce obesity and
their chances of developing diabetes.
“It’s hard to say directly that being obese causes diabetes, but the evidence shows that more than 60 percent of the people with adult type 2 diabetes are obese,” Ard says. In addition, numerous research initiatives, including the recent National Institutes of Health Diabetes Prevention Program study, report that healthy eating habits and weight loss are the best tools for preventing type 2 diabetes, which accounts for 90 to 95 percent of all diabetes cases in the United States. In the three-year study, participants with impaired glucose tolerance who cut back on their fat and calorie intake and exercised approximately 20 minutes per day reduced their risk of developing diabetes by 58 percent.
Findings such as those encourage Ard and his colleagues as they help patients at high risk for type 2 diabetes, pre-diabetes, and other conditions through EatRight’s Risk Reduction Clinic. Patients receive counseling about lifestyle changes, including diet and exercise, along with a clear goal: “When you lose weight, your blood sugars get better and your diabetes—or your risk of it—improves,” Ard says.
Transplants on the Horizon
Naturally, the ideal treatment for diabetes would eliminate the need for insulin injections entirely. UAB clinicians are pursuing that goal as well; Frank says that one of the most promising new techniques, islet cell transplantation, has been at the forefront of UAB research for several years. In fact, UAB’s islet cell laboratory, directed by Devin Eckhoff, M.D., is one of only eight in the country that belong to the National Institutes of Health Islet Cell Resource Center Consortium.
“If we can specifically transplant islets—the little regions within the pancreas that harbor the beta cells that make the insulin—and if we can put them into the body so that they won’t be attacked by the immune system, then we will be accomplishing something,” Frank says. “It’s an area of intense investigation.
“The first hurdle is obtaining the islets,” he explains. “They can’t be donated. Cadavers are one source. The other possibility is growing islets in the fashion of tissue engineering. Or we could convert stem cells into islets.” Those techniques for replenishing the body’s beta cells “aren’t quite ready for prime time yet,” Frank adds, but he and other physicians view them as a promising path to the future of diabetes treatment.