Helping Older Adults With Diabetes Overcome Barriers to Control
Suggestions for the home health care staff.
By Linda Pearce, RNC, BSN, MEd, CDE

Diabetes is common, costly, complex, serious, and frustrating. In fact, hyperglycemia is problematic even when diabetes is not the primary diagnosis.¹ Well-recognized barriers to diabetes control stem from the system, provider, patient, and society. Patients and health care professionals perceive barriers to diabetes care differently. According to research from Simmons et al,² professionals perceive motivation and system barriers as the two major impediments to care, with the influence of other health problems ranked tenth or lower in terms of importance. On the other hand, patients perceive the strictness of their treatment regimen, the influence of other health problems, and systems' barriers as the top three. For patients, knowledge is perceived as least important. In this article, patient barriers will be identified and suggestions will be made to help overcome those barriers.

The Visiting Nurses Association of America's (VNAA) Chronic Conditions Web site offers diabetes and heart disease information and resources for staff and patients at www.chronicconditions.org. Other chronic conditions are planned for future additions to the Web site.

DIABETES COMPLICATIONS ARE COSTLY
Diabetes affects approximately 30% of patients receiving home care.³ According to one report, diabetes was 8.1% of the primary diagnosis in this population, with more than 20% of the US population aged >65 years having diabetes. Therefore home care staff must be extremely well versed in diabetes care, especially as it affects the older adult.

Almost 50% of patients diagnosed with type 2 diabetes today already have complications—many have one or more comorbidities (Table 1). For example, 60% of older adults with diabetes also have hypertension, 35% have heart disease, and 30% also have dyslipidemia.⁴ The cost of treating diabetic complications averages $10,000 per patient per year, and it is estimated that patients pay $1,566 of that cost out-of-pocket.⁵

It is important to note that attitudes toward diabetes are costly as well. Diabetes is one of the few diseases where the victim is blamed for causing his/her diabetes. Beliefs about diabetes affect the way health care providers treat patients, and the way patients view the need or importance of learning to control their disease. Patients are influenced by their perception of how serious their condition is, their ability to affect short- or long-term outcomes, and the value of education.^6,7

When health professionals do not believe that diabetes is a serious disease or that the patient could have prevented their own disease, the patients are affected by such attitudes. One suggestion for helping professionals appreciate the seriousness of diabetes and the genetic and other factors related to the disease is through continuing medical education and programs for health care professionals and especially faculty involved in health professional education.

Forty-two percent of people with diabetes in the United States are aged >65 years, and by 2025 53% of the people with diabetes in this country will be aged >65 years. One important barrier is that about 50% of these patients with type 2 diabetes have no symptoms—therefore treatment comes with no relief. If there are symptoms, they likely include falls, urinary incontinence, fatigue, weight loss, and decreased cognition.^8,9 Unfortunately, many health professionals also have traditionally had negative attitudes about working with older adults, and continuing education programs along with establishing geriatric specialists could also eventually help with such attitudes.

DIAGNOSTIC CRITERIA MISSES MANY OLDER ADULTS WITH DIABETES
The 2009 American Diabetes Association (ADA) diagnostic criteria for nonpregnant adults consists of three recommendations. Any one may be used to diagnose diabetes, but must be repeated on another day unless symptoms of hyperglycemia are present. The three criteria are:¹⁰

• Fasting plasma glucose (FPG) >126 mg/dL.
• Casual blood glucose >200 mg/dL, with symptoms.
• On a 2-hour, 75-g oral glucose tolerance test, blood glucose >200 mg/dL.

It is clear, however, that the ADA diagnostic criteria misses elderly with diabetes.^11,12 The barrier is that, depending on FPG, to detect diabetes necessarily misses about 31% of people with type 2 diabetes. As already noted, older adults likely have complications of diabetes at diagnosis. This means additional screening should occur for that group. To overcome this barrier, one suggestion is that all elderly individuals should be screened at least annually for diabetes.

Diabetes care is complicated by the clinical and functional heterogenecity of the elderly. Care must be individualized, and health care providers must consider both functional abilities and chronological age.¹³

With regard to diabetes education, older adults typically prefer practical information about their diabetes that is focused on helping them maintain independence and quality of life. Therefore, information alone is not sufficient, patients also need confidence to manage their diabetes.¹⁴ Patients need to know that their health care providers consider their diabetes management important.

A useful mneumonic device has helped this author in remembering diabetes management topic areas that should be considered for each patient: MMM A CPR—medications, monitoring, meal planning; activity; coping, problem solving, and risk reduction or resources.¹⁵ Although the mneumonic is general, care must be individualized. To help patients achieve management goals, (1) assess for the individual patient's barriers in each of the areas of self-care related to MMM A CPR and (2) mutually consider with the patient, suggestions to help overcome identified barriers. Patient involvement with regard to prioritizing and setting mutual goals will enhance their involvement and acceptance of the complicated diabetes care regimen.

ADHERENCE VS COMPLIANCE
Compliance refers to when a patient's behavior matches medical advice. The flip side, noncompliance, implies that the patient willingly disobeys the practitioner and is somehow a diabetes patient "criminal." Compliance facilitates a negative attitude toward patients and sets the patient up as passive in their care.^16,17 Adherence is a voluntary, collaborative involvement of the patient in mutually acceptable course of behavior to produce therapeutic result. The role of the health care provider is more like that of a coach and mentor. Adherence rates for chronic illness regimens and lifestyle changes are estimated to be at about 50%. The concept of adherence recognizes that the patient has a choice and may choose to adhere to one part and not other parts of a very complex plan like diabetes management. The suggestion for health care professionals is to support patient decisions related to their self-care and encourage them to overcome any barriers that may be interfering with them making optimal informed decisions for their care.

To improve patients' adherence we as health care professionals must understand why individual patients make certain choices. Although many barriers are documented in the literature, each patient may see their barriers differently from our expectations. Health care providers must, after establishing trust and rapport, listen to what is important to the patient; assess the importance of diabetes control to the patient; and assess the patient's confidence that he/she can make the changes needed. The diabetes care provider should ask him or herself for each patient, "How can I empower this patient to make daily informed choices about diabetes self-care?"

To help patients overcome barriers, practitioners must understand that patients adhere to chronic disease recommendations¹⁶ when the treatment regimen makes sense and seems effective, when patients believe that the benefits exceed costs, when patients believe it is important, when patients have confidence they can succeed at the regimen, and when the patient's environment is supportive of regimen-related behaviors (especially family).

DIABETES STANDARDS OF CARE
At every visit with the health care provider (at least quarterly) the following measurements should be performed: blood glucose, blood pressure, weight, foot exams, physical activity, tobacco avoidance, aspirin use, and depression screening. Lipids, eye exam, kidney function, and influenza vaccine should be checked every year.

An important diabetes self-management basic principle: Share the level of evidence for each recommendation with your patients. Let them know that what gets paid for gets done, and teach them the value of control and what is paid for under their health plan, especially if they use Medicare.

Medicare provides coverage for diabetes supplies and services.¹⁸ A comprehensive list of resources is available at www.medicare.gov/Publications/Pubs/pdf/11022.pdf. Other useful information is available by calling the Medicare Covers hotline at 800-633-4227. Medicare covers self-testing equipment (meters, strips, lancets) for all Medicare recipients with diabetes (copay 20%) and patients can obtain special meters with medical reason (eg, low vision, decreased manual dexterity). Medicare also covers therapeutic shoes, shoe inserts (copay 20%), diabetes services (copay 20%, self-management training, medical nutrition therapy), flu and pneumococcal pneumonia vaccine, and glaucoma screening every 12 months.

Medicare puts some limits on monitoring supplies, and 46 states have insurance laws that require coverage of diabetes education, equipment, and supplies.

DIABETES CONTROL GOALS
Most older patients in generally good health can benefit from progressive treatment intensification to reach therapeutic goals. The American College of Endocrinology and American Association of Clinical Endocrinologists recommend advancing to more-intensified regimens if control goals are not reached in 2 to 3 months.^19,20 The "Road Map for Prevention and Treatment of Type 2 Diabetes" is a valuable resource available at: www.aace.com/meetings/consensus/odimplementation/roadmap.pdf.

What gets paid for gets done—and what gets monitored gets done. Lowering A1C has been associated with a reduction of microvascular and neuropathic complications of diabetes and possibly macrovascular disease.^21,22 The A1C goal for patients in general is <7%; however, 63% of patients with diabetes are not at goal.²³

Lower A1C saves patients money, therefore control is cost effective. When A1C is lowered 1% for 1 year there are fewer hospitalizations, fewer trips to the emergency department, and fewer doctor visits (average savings = $400+/yr).^24,25

In a survey of perceptions from Setter et al,²⁶ it was revealed that home care nurses do not teach patients about A1C. The survey found:

• Only 7% of patients report visiting nurse taught them about the A1C.
• Almost 35% of nurses never educate patients about their A1C.
• Most nurses never contacted the physician to obtain A1C results
• Fifty-eight percent of nurses could not identify the current A1C recommendation for patients.

For older adults with diabetes it is important to consider the costs versus benefits of A1C control. It takes 8 to 9 years of intensive glucose control to reduce microvascular complication risks, but it only takes 2 to 3 years of blood pressure control, plus aspirin therapy to reduce the risks of cardiovascular disease (CVD).²⁷

According to the ADA recommendation for older adults, "Patients who can be expected to live long enough to reap the benefits of long-term intensive diabetes management (10 years) and who are active, cognitively intact, and willing to undertake the responsibility of self-management should be encouraged to do so and be treated using the stated goals for younger adults with diabetes."²¹

It is important to teach each patient the value of recommendations for their "Diabetes ABCs" of A1C, blood pressure, and cholesterol (Table 2).

INDIVIDUALIZED CARE
Recognize that older patients need individualized diabetes care. The ADA recommends less-aggressive target goals for older patients with advanced complications, comorbid illness, cognitive, or functional impairment (FPG 140 mg/dL , vs 90–130 mg/dL and postprandial 200–220 mg/dL, vs <180 mg/dL).27 The American Geriatric Society (AGS) recommends less-stringent A1C goals if life expectancy is <5 years (A1C 8%, blood pressure 140/80 mm Hg), but A1C goal of 7% is reasonable if relatively healthy and good functional status exists.

Elderly patients with diabetes require individualized education. The care provider must listen to the patient and help facilitate such things as product selection based on the patient's manual dexterity, vision, hearing, memory, fears, and level of financial coverage. Note that providing information does not guarantee behavior change, therefore practitioners should teach problem solving skill and help patients to simplify their treatment regimen and use any means that will help the patient remember what is most important.

DIABETES IS ASSOCIATED WITH FUNCTIONAL LIMITATIONS
Research shows poor glycemic control contributes to functional decline in older people with diabetes.²⁸ Because functional decline is associated with disability, it is important for the health care provider to improve glycemic control in these patients and enhance quality of life through fewer physical symptoms. Disabilities associated with diabetes affect up to 50% of patients aged >70 years and include visual impairment, decreased manual dexterity, neuropathy, cognitive problems, and paralysis. Disabilities complicate and interfere with diabetes control.^29,30

Clinicians making home health visits can adapt for patients' hearing deficits by having one-on-one sessions, decreasing background noise and distractions (eg, television), enunciating clearly, and encouraging the patient wear a hearing aid if they have one.

Adaptations for vision loss can include the use of thick black markers, decreasing glare from glossy paper or colors that are more difficult to read, and providing adequate lighting and magnification for patients. Talking glucose monitors and other aids are available for patients with low vision, and are covered by Medicare if the patient's vision in the best eye is ≤20/200. Insulin use can be facilitated for those with visual impairments by putting a rubber band on the vial (eg, thick rubber band for one kind of insulin, thin for another, and no rubber band for a third kind). Insulin pens may be a good solution for low-vision patients.

To adapt educational messages for patients with cognitive changes, limit the amount of information and combine verbal and written instructions. Offer the patient concrete examples using factual information, short sentences, and frequent repetition. Be sure to obtain feedback from the patient and allow plenty of time for the consultation. Memory aids such as pill bottle alarms available from Independent Living Aids, Maxi Aids, e-pill and at some local pharmacies may be helpful.

Fall risks are increased for elderly with diabetes due to peripheral neuropathy, altered foot structure (Charcot foot), muscle weakness, orthostatic hypotension, decreased vision, the risk of hypo- and hyperglycemia, and the use of four or more medications.³¹ Diabetes increases the risk of osteoporosis, leading to increased risk for fractures when older adults with diabetes fall.

Osteoporosis is also a common comorbidity in this patient population. Osteoporosis contributes to a 6.9 to 12-fold increase in fracture risk among women with type 1 diabetes and 1.7 increased fracture risk in women with type 2 diabetes.³² This is caused by too little insulin leading to calcium loss through urine, and decreased absorption from food. The risk can be decreased by increasing exercise, not smoking, and avoiding alcohol. Therefore suggestions for older patients would definitely include physical activity and avoiding alcohol and cigarettes.

THE POWER OF EDUCATION
The most powerful therapy for diabetes control is education.³² Without education the risk of major diabetes complications increases four-fold.33 The 2003 AGS recommendations³⁴ suggest that patients keep an updated medication list. Package inserts use very small print and health literacy and language barriers adversely affect the patients' ability to read and understand medicine labels and inserts. Data show that 67% of patients do not understand the label and 39% cannot read labels. Nearly half of American adults have difficulty understanding health information, putting them at risk.³⁵ Some ways to improve health literacy include asking the patient to teach back or teach a family member or friend what they have learned about diabetes management, use picture-based materials, colored dots, audiotapes, and DVDs that patient can listen to or watch over and over.

Television can be used for education. DLifeTV on CNBC Sundays brings leading experts, timely medical information, inspirational stories, and recipes for healthy food to television. Health care providers must teach relationships among the various diabetes control factors (MMM A CPR). In other words don't just teach about meal planning, monitoring, medications, physical activity, and sick day care, etc. but teach how each of these factors affects the others.

MEDICATIONS
It is a fact that 50% of all prescriptions are taken incorrectly;³⁶ and 33% of prescriptions are never filled. Diabetes drug costs could rise 70% by the end of this year, and the use of diabetes drugs is expected to continue to rise 8% to 10% per year.

Diabetes is a polypharmacy disease. Often more than one medication is required to achieve treatment goals for glucose, cholesterol, blood pressure, heart disease, neuropathy, and pain. Polypharmacy in older adults is especially challenging, and every time you add another medication, you decrease the chance of the drugs being taken correctly. The average older adult takes seven medications. Generic pills complicate teaching the older adult about their medications because the same medication may come in different colors and shapes. Still, they need to know the name of their medications, when and how to take the medication, the reason for taking each one, and when to call the health care provider. A medication list is useful in teaching about medications. The patient's medication list should include both prescription and over-the-counter medicines, such as pain relievers, antacids, cold medicines, laxatives, eye drops, dietary supplements, vitamins, herbals, and topical medicines. The pharmacist should be enlisted to help check for potential food or medication interactions.

If patients can't open containers, they should ask their pharmacist for help. If pill swallowing is a problem, ask the pharmacist if a liquid is available or if the oral medication can be crushed or split.

ADA recommends aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes who have a history of CVD.²¹ Use aspirin therapy (75–162 mg/day) as a primary prevention strategy in those with type 2 diabetes at increased cardiovascular risk, including those who are aged >40 years or who have additional risk factors (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria).

FINANCIAL BARRIERS, INCONVENIENCE
Patients will skip medication to save money. Research shows that 11% of people with diabetes cut back on their medications and 28% do without food to pay for medications. Patients who are taking seven or more drugs are more likely to skip some of them. Patients not taking medications had worse blood glucose control, more symptoms, and worse physical and mental functioning.³⁷

About 70% of adults aged 70 to 85 years with diabetes also use some form of complementary or alternative medicine (CAM). Diabetes is an independent predictor of CAM use; and CAM is a widely used component of health self-management among rural older adults with diabetes.^38-40

The inconvenience and inflexibility of timing is a barrier to adequate control through medication. Additionally, the cost is an issue for many patients, as 64% of Medicare eligibles for Plan D had medication expenses in excess of $2,250 (Plan D "donut hole").^41,42 Many diabetes medications are associated with weight gain and fluid retention (especially when patient also has CVD), along with physical and emotional side effects that present barriers for patients. Fear of hypoglycemia (and the associated risk of falls and fractures) and the desire to avoid injections are also barriers.

To offer financial assistance to patients with their medications, consider splitting samples obtained from health care providers through pharmaceutical representatives (eg, Glucophage, Glucotrol, Glucovance, Glycet). Combination pills and medications in bulk supply can save costs for many patients, additionally discount drugs from Canada, Ireland, and the United Kingdom are available in several states. Information for people who need help with medication cost can be obtained from Pharmaceutical Assistance Programs (PAPS) at www.needymeds.com. Participating Wal-Mart stores and other local pharmacies offer a 30-day supply of generic medications for $4.00 and 90-day supplies for $10.00.43

NUTRITION
Meal planning, including carbohydrate counting and reading nutrition labels, are important educational aspects of diabetes care.²¹ Sucrose-containing foods can be substituted for other carbohydrates in the meal plan, but the total carbohydrates must be counted. Alcohol use can be a barrier to control for older adults. Aging changes that affect diabetes nutrition include taste, smell, and dentition. Chewing, and swallowing issues also affect older adults and must be considered in meal planning. A registered dietitian who is also a certified diabetes educator is an ideal resource for helping older adults with meal planning related issues (Table 3).

High blood glucose is associated with dementia in older women. In a study of 1,983 postmenopausal women (average age 67 years) the risk of developing mild mental difficulties or dementia was 40% greater for each 1% increase in A1C, when A1C was 7% at beginning of study.44 Available nutrition resources for older adults include such programs45 as community nutrition sites, food stamps, adult day care centers, county extension agents, grocery store delivery services, Meals-on-Wheels, commodity foods, in-home personal aids, centers on aging, and social services. Educational materials for older adults should include specific fluid recommendations and simple lists with tips (eg, low-cost protein sources, recipe alterations).

Some suggestions to overcome nutrition barriers in older adults include helping them to strengthen their willpower for behavior change, and to make small changes that can be built upon weekly. Home health care providers can communicate these changes to health care providers and encourage the providers to offer reinforcement. Some additional nutrition suggestions include encouraging patients to buy fewer sweets, read labels, provide hands on assistance in grocery store, increase water and fiber intake, decrease fat intake, switch to brown higher fiber breads, rice, and pastas; consider fresh or frozen vegetables instead of canned; and decrease portion sizes.

Obese older adults with diabetes may benefit from modest energy restriction and an increase in physical activity; because energy requirements may be less than for a younger individual of a similar weight.²¹ In the institutionalized elderly, undernutrition is likely and caution should be exercised when recommending weight-loss diets, according to the ADA. Weight-loss is seldom an appropriate goal for older adults with diabetes.

Low-income families often rely on cheaper, high-calorie (energy dense) foods to help stretch food budgets. Barriers to good nutrition in such an environment include the cost of food, difficulty with label reading, time constraints, family preferences, convenience, and knowledge deficits.46 Some suggested tips for enhancing nutrition education include emphasizing blood glucose control—not weight loss—and focusing on low-carbohydrate foods, portion controls, and total number of servings per meal. Physical activity should be encouraged especially following meals, and food records should include blood glucose monitoring data as well as an indication of the amount and intensity of physical activity. Exercise after meals helps with postmeal blood sugar control, so it is especially important if patient indulges a little extra at any meal.

MONITORING OF BLOOD GLUCOSE
Some predictors and barriers to self-monitoring of blood glucose (SMBG) nonadherence include longer duration of diabetes, less-intensive diabetes therapy, fewer medical visits, lower educational attainment, excessive alcohol consumption, male gender, older age, and ethnic minority. Others may include cost, pain, inconvenience, time, failure to understand control goals, and not knowing how to use the information obtained.^47,48

Many factors can affect blood glucose readings leading to inaccurate data, such as low or high hematocrit, dehydration, failure to code the meter, outdated strips, products not washed off hands, temperature, humidity, and altitude.

To encourage monitoring, suggest that patients use community services such as low-cost or free blood glucose monitoring clinics. Volunteering for clinical trials and attending meter swap programs at area pharmacies and health fairs are other ways to check blood sugar and save on test strip expense. Certain meters and lancing devices may be more convenient for older patients. Evaluation criteria available at www.childrenwithdiabetes.com/d_0i_000.htm#criteria can help identify user-friendly equipment.

Free testing strips do not improve glycemic control, according to an investigation.⁴⁹ Patients with type 2 diabetes not using insulin do not know how to use the information obtained from SMBG. Health care providers should look at the patient's log book with the patient at every visit and help the patient figure out reasons numbers are at or not at target, as well as patterns. To encourage SMBG try matching the meter to the patient. The best meter is one the patient can and will use, that is adequate for his or her needs based on level of visual acuity and dexterity, personal preferences, type of meter coding, expense of strips, and other issues such as heat, humidity, and altitude.

ACTIVITY
To improve glycemic control, assist with weight maintenance, and reduce risk of CVD, at least 150 min/week of moderate-intensity aerobic physical activity (50–70% of maximum heart rate) and/or at least 90 min/week of vigorous aerobic exercise (>70% of maximum heart rate) is recommended, according to ADA.²¹ The physical activity should be distributed over at least 3 days/week and no more than two 2 consecutive days without physical activity.

In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance exercise three times a week, targeting all major muscle groups, progressing to three sets of eight to 10 repetitions at a weight that cannot be lifted more than eight to 10 times.

Typical reasons people give for not exercising include embarrassment, lack of time, they forget, there is no safe place to exercise, they are afraid, its expensive, they don't like to, and limitations of the their physical health. To help older adults overcome barriers such as these and others they may identify, encourage them to identify personal benefits of exercising, such as to improve insulin sensitivity, decrease need for medication for glycemic control; reverse mild depression, increase muscle mass, strength and endurance, and reduce insomnia. Other benefits from physical activity include^50,51 reduced arthritis pain, improved longevity, diminished fall risk, improved functional status, improved quality of life, improved bone strength, and improved central nervous system functioning.

Pedometer use increases activity.^52,53 An additional suggestion is to request referral to a physicial therapist, occupational therapity or personal trainer as appropriate. Numerous handouts, tracker logs, and other information available at VNAA Chronic Care Clearinghouse.

COPING AND DEPRESSION
Older adults should be screened for depression. It has been shown that 64% of people aged >70 years have symptoms of depression, dementia, or disability,^54,55 and 53% have deficits in activities of daily living. Health care costs are 50% more when a patient is depressed, therefore practitioners must assess and refer if needed. Depression often upsets diabetes self-care.⁵⁶ Depressed people with diabetes are less likely to watch what they eat, to exercise, and to take their medications. Depression makes diabetes management more difficult and complicates the recognition of hyperglycemia, hypoglycemia, regular meal times, remembering medications, sleep patterns, and other important facets of control. When depression is suspected it is very important to find ways to enhance and encourage the patient's level of social support.

Depression screening is as simple as remembering to ask three questions: (1) Do you often feel sad or depressed? (2) During the past month, have you been bothered by feeling down, depressed, or hopeless? (3) During the past month, have you been bothered by little interest or pleasure in doing things?⁵⁷ If answers are yes, then further screening and possible referral is indicated.

Hypoglycemia recommendations. Glucose (15–20 g) is the preferred treatment for hypoglycemia, although any form of carbohydrate that contains glucose may be used, and treatment effects should be apparent in 15 minutes.21 Hypoglycemia may only be temporarily corrected; therefore, plasma glucose should be retested in 15 minutes, an hour, and frequently for the next 24 hours as additional treatment may be necessary.

Symptoms of hypoglycemia in adults when present are easily mistaken for Alzheimer's Disease or dementia. Care givers should teach patients to recognize their own symptoms, empower them to reach target goals, and encourage them to participate in active learning. Patients should wear diabetic identification, not just carry a card that may not be located in an emergency situation until too late.

Hyperglycemia recommendations. The mean age of onset for of hyperosmolar hyperglycemic nonketotic coma (HHNC) is 70 years.58 Because older adults dehydrate quickly, it is very important to make certain they know the importance of fluid intake, and to contact their primary care provider whenever their blood glucose meter reads "high" or >300 mg/dL. Individuals with type 2 diabetes usually have HHNC when they experience a coma from a high blood glucose but it is also possible for them to have diabetic ketoacidosis (DKA). Fluid intake as tolerated is important when the blood glucose levels are elevated. Typical reasons for DKA hospitalization in diabetes patients include stopped insulin59 (about ~50% said lacked money to purchase insulin), lack of transportation clinic, unaware of dose adjustments for sick days, and not monitoring for ketones when blood glucose is elevated. About 66% of these episodes are preventable with education and access to care. During acute illnesses, insulin and oral glucose-lowering medications should be continued, according to the ADA.

RISK REDUCTION
The phrase "Keep it SIMPLE" will help the patient remember the current ADA recommendations for diabetes care and what is most important to help prevent diabetes complication.21 S—smoking cessation; I—inspect feet daily, eyes yearly and teeth every 2 years; M—monitor blood sugar, A1C, and urine protein; P—lower blood pressure to <130/80 mm Hg; L—lose weight if needed; and E—exercise most days of the week for 30 minutes or more.

All patients should be counseled not to smoke (level A ADA management recommendations). About 25% of Americans currently smoke and smokers with diabetes have higher mortality.60 The reasons for this are that smoking narrows arteries, reduces blood flow legs thereby increasing risk of myocardial infarction (MI) and stroke. It also slows wound healing, making amputations more likely. Smoking increases risk of nerve damage and kidney disease, and smoking impairs the immune system, making smokers more susceptible to colds and respiratory infections.

To help patients stop smoking, several tools are listed at www.chronicconditions.org and a quit line is available (telephone support by each state) at 1-800-QUITNOW or 1-800-784-8669. It is never too late to stop smoking.

All patients should be screened for distal symmetric polyneuropathy (DPN) at diagnosis and at least annually thereafter, using simple clinical tests.21 Education of patients about self-care of the feet and referral for special shoes/inserts when indicated are also vital components of patient management.21 Up to 85% of amputations are preventable.61-63 Many diabetes patients make common foot care and foot wear errors. Approximately 28% wear inappropriate shoes and 31% go barefoot.Ên