2011-11 October 2011 Triangle Physician cover article

Cary Internal Medicine & The Diabetes Center Excellence in Diabetes, Heart and Stroke Care

T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S

Cary Internal Medicine & The Diabetes Center Excellence in Diabetes, Heart and Stroke Care C

ary Internal Medicine & The Diabetes

physicians in Wake County to be recognized

diabetes to reduce complications has always

Center is a full-service internal medicine

by the National Committee for Quality

been central to our practice,” says Dr. Patel.

practice, specializing in the treatment and

Assurance for meeting the highest standard

management of diabetes, heart disease,

in diabetes care in 2004. They also earned

Drs. Patel and Juneja acquired Cary Internal

stroke and women’s health.

NCQA recognition for excellence in heart/

Medicine & The Diabetes Center at 103

stroke care.

Baines Court, after its founder, Fred C.

Leading the practice are Prashant K. Patel,

Oliver, M.D., retired in 2000. Having been “Diabetes is, as yet, incurable, but it is

established in 1979, the medical practice is

who have long recognized the connection

manageable with aggressive lifestyle changes

the oldest in Cary. Amrita Parikh, M.D., joined

between diabetes and complications that

and medication. Because diabetes and pre-

the practice in 2006. All three physicians are

can lead to heart disease and stroke. Through

diabetes are associated with the myriad

certified with the American Board of Internal

their proactive, patient-centered approach to

health problems that internists treat, helping

Medicine and members of the American

diabetes management, they became the first

patients effectively manage diabetes and pre-

College of Physicians.

PHOTO BY JIM SHAW PHOTOGRAPHY

M.D., F.A.C.P., and Vijay K. Juneja, M.D.,

Dr. Amrita Parikh (left) answers patient Joti Pallan’s women’s health questions.

Reprinted from The Triangle Physician

www.car yinternalmedicine.com

Cary Internal Medicine offers a full range of

third is undiagnosed and untreated.)

medical services, including routine physical

•T ype 2 diabetes accounts for 95

and gynecologic examinations. Patients

percent of all diabetes cases.

have in-office access to the latest diagnostic

vascular) complications. Unlike patients with type 1 diabetes, the majority of patients with type 2 do not need insulin to survive.

•A pproximately 20.6 million Americans

tests and treatments, such as: • Cardiovascular risk assessment, using treadmill stress testing,

age 20 and older, or 9.6 percent of the

According

population, have diabetes.

Education Program, heart disease and stroke

•A mong those age 65 and older 10.9

electrocardiograms and lipid profiles; • Pulmonary function testing, using spirometry, and nebulizer treatments; skin tag, wart and mole removal, biopsies and laceration repairs;

the

National

Diabetes

accounted for about 65 percent of deaths in

million, or 26.9 percent are diagnosed

people with diabetes in 2002. Adults with

with diabetes.

diabetes had heart disease death rates two

•O f those younger than 20,

• Minor surgical procedures, such as

to

to four times higher than adults without

approximately 215,000 have diabetes

diabetes. Their risk for stroke also was two to

(type 1 or type 2).

four times higher.

•A bout 79 million Americans over age

• Bone density testing; and

20 (50 percent of adults age 65 and

Obesity and age are major risk factors for

• Vision testing.

older) have pre-diabetes.

diabetes. Abdominal obesity is an indicator of insulin resistance. The abdominal fat is

Medical care is expedited and convenience

Type 1 diabetes can occur at any age, most

thought to prohibit insulin from converting

is enhanced by onsite laboratory services.

commonly in juveniles but also in adults,

sugar, starches and other food into energy needed for daily life.

“Diabetes is, as yet, incurable, but it is manageable with aggressive lifestyle changes and medication. Because diabetes and prediabetes are associated with the myriad health problems that internists treat, helping patients effectively manage diabetes and pre-diabetes to reduce complications has always been central to our practice.” – Prashant Patel, M.D., F.A.C.P.

“The epidemic of obesity in America and our aging population, coupled with lack of awareness, assure the incidence of diabetes will increase,” says Dr. Patel. NDEP estimates the total number of people with diabetes in the United States will be 30.3 million in 2030, which will place the United States third in global prevalence, after India and China.

“If recent trends in diabetes and pre-diabetes prevalence rates continue linearly over the next 50 years, future changes in the size and demographic characteristics of the U.S.

State of Diabetes in Nation a Concern

especially in their late 30s and early 40s.

population will lead to dramatic increases

Unlike people with type 2 diabetes, those

in the number of Americans with, or at risk

The statistics for diabetes are grim. Diabetes

with type 1 generally are not obese. The

for, diabetes,” says Dr. Juneja. “The current

– a group of diseases marked by high levels

distinguishing characteristic of a patient with

increase in the number of new cases in

of blood glucose resulting from defects in

type 1 diabetes is that ketosis and eventually

people age 40 to 59 raises the need for

insulin production, insulin action or both –

ketoacidosis develop if insulin is withdrawn.

interventions focused on this segment of the

ranks seventh as the leading cause of death

Therefore, these patients are dependent on

population.”

by disease in the United States. According

exogenous insulin.

to the Centers for Disease Control and

NDEP estimated the cost of diabetes in 2010

Prevention, the risk for death among people

Type 2 diabetes comprises an array of

at $174 billion. The total includes direct

with diabetes is about twice that of people of

dysfunctions resulting from the combination

medical costs ($116 billion) and indirect

similar age who do not have diabetes.

of

and

costs ($58 billion), those associated with

inadequate insulin secretion. Its disorders

loss of work, disability and premature

are

hyperglycemia

death. After adjusting for population age

• Diabetes affects 25.8 million people in

and associated with microvascular (i.e.,

and gender differences, the average medical

the United States, or 8.3 percent of the

retinal, renal, possibly neuropathic) and

expenditures among people with diagnosed

population. (Of that total, about one-

macrovascular (i.e., coronary, peripheral

diabetes were 2.3 times higher than what

Its 2011 fact sheet also reports:

www.car yinternalmedicine.com

resistance

to

characterized

insulin by

action

Reprinted from The Triangle Physician

over time), blood pressure and low-density lipoprotein cholesterol values – collectively known as the “ABCs” of diabetes.

A1c values and self-monitoring of blood glucose (SMBG) guide therapy for achieving glycemic targets and minimizing the risk of complications. The self-care plan takes into consideration the patient’s age, school or work schedule, physical activity, eating patterns, social situation and cultural factors, and presence of complications of diabetes or other medical conditions.

While

a

National

Diabetes

Education

Program (NDEP) study in 2007 found an acceptance of the importance of maintaining individual ABC goals among physicians, a significant number of them recognized their patients were not reaching their goals.

Successful

management

goes

beyond

teaching the ABCs, says Dr. Patel. “The didactic approach is to teach the relevant information about the ABCs and provide recommendations to patient care. The approach that empowers patients with knowledge and understanding of the ABCs within the context of personalized goalsetting, skill-building and one’s daily roles is Dr. Prashant Patel (right) explains the features of an insulin pump with patient Ronald Herschkorn.

the most effective,” he says.

expenditures would be in the absence of

individualized care for patients with pre-

At The Diabetes Center, patients have an

diabetes.

diabetes and diabetes is based on proven

integrated health care team that includes

models and backed by years of experience,

a certified diabetes educator, a dietician,

“Treatment costs for people with diabetes are

says Dr. Patel. “Our practice is uniquely

the referring physician and other health

more than double those for people without

positioned to meet the growing need.”

care providers, as necessary. The team is

diabetes, mainly because of the high costs associated with complications,” says Dr. Juneja. Cardiovascular disease remains the most costly complication of type 2 diabetes.

coordinated by Drs. Patel and Juneja.

Diabetes Management Is Patient-Centered and Goal-Oriented The

foundation

for

effective

“The therapeutic alliance works closely with the patient to develop attainable goals diabetes

for metabolic control, improved lipid levels

The positive news is that diabetes can be

management is patient understanding and

and reduced blood pressure,” says Dr. Patel.

prevented or delayed. “Lifestyle changes

self-care practices that empower him or her

“It is a collaborative process in which the

and ongoing management of both type 1

to make day-to-day and often hour-to-hour

diabetes educator helps the patients gain the

and type 2 diabetes can also prevent many

decisions.

knowledge and problem-solving and coping

complications associated with the disease,”

skills needed to successfully self-manage the Patients must have a working knowledge of

says Dr. Juneja.

disease and its related conditions.”

the three key metabolic markers: hemoglobin The

Diabetes

Center’s

comprehensive,

Reprinted from The Triangle Physician

A1c (a measure of average blood sugar levels

“Our practice is unique in that we effectively www.car yinternalmedicine.com

“Primary prevention remains an important area of focus for us. There needs to be more communication about pre-diabetes and the power of diabetes prevention with patients, as well as other health care professionals.” – Prashant Patel, M.D., F.A.C.P. manage diabetes in adults from A to Z,

month. Now my readings are consistently

beginning with diagnosis,” says Dr. Juneja.

between 100 to 130. I wish I had been referred sooner!”

Patient Frankie Lemons was referred by her serious hypoglycemic episodes resulting in

Medication Management and Monitoring

Oral diabetes medication is often prescribed

hospitalization. “When I was diagnosed with

The Diabetes Center physicians have the

for type 2 patients whose bodies still

type 2 diabetes, I believed oral medication

specialized understanding to prescribe

produce some insulin. When beta-cell failure

would be enough to manage my blood sugar

injectable insulin, oral pills and medication

develops, insulin injections are required

swings. Now, I have a better understanding

for

and prescribed either in combination with

of the impact of diet and lifestyle on my

weight control, as needed and to best

diabetes. I have focused on the proper

suit the patient. “There are many forms of

adjustments and haven’t been to the hospital

medication, and the type selected is based

Advanced care using a continuous glucose

since. I feel I have gotten my life back, and I

on a body’s response to it and the patient’s

monitoring system is prescribed for patients

am so grateful.”

ability to monitor and self-administer,” says

with diabetes that is difficult to control.

Dr. Patel.

“Studies have shown the benefits of using

internist to The Diabetes Center after several

blood

pressure,

cholesterol

and

diabetes pills or alone.

a CGM (continuous glucose monitor), even

“I was referred by my family physician to The Diabetes Center because of wide variations

Insulin is the only medication that can be

in people with good blood sugar control,”

in my glucose levels, from the 40s to 500s,”

used to control the increases in blood sugar

says Dr. Patel. “The patients spent more time

says Ronald Hershkorn, a patient with type

that occur with type 1 diabetes. For those

every day within their target glucose range,

2 diabetes. “The staff and physicians helped

with type 2, insulin may be used alone or

had lower A1c levels and fewer low blood

me get started on the insulin pump, and

in combination with diabetes pills or other

sugar emergencies.”

I have had amazing results in less than a

medications.

New CGM technology has enhanced comfort and convenience, minimizing user error in calculations and leading to greater patient compliance. Since continuous monitors are not as accurate as the standard meters, patients are advised to use a standard meter one or two times a day to confirm their CGM reading.

Lifestyle Changes and Weight Loss The Diabetes Prevention Program, a large study of people at high risk for diabetes funded by the National Institute of Diabetes and Digestive and Kidney Diseases, showed lifestyle intervention to lose weight and increased physical activity reduced diabetes www.car yinternalmedicine.com

Reprinted from The Triangle Physician

“If recent trends in diabetes and pre-diabetes prevalence rates continue linearly over the next 50 years, future changes in the size and demographic characteristics of the U.S. population will lead to dramatic increases in the number of Americans with, or at risk for, diabetes.” – Vijay Juneja, M.D.

Before people develop type 2 diabetes, they almost always have pre-diabetes – blood glucose levels that are higher than normal, but not yet high enough to be diagnosed as diabetes. In studies, the rate of progression has ranged from an average of three years to 10 years.

NDEP reported in 2008 that a survey found only 25 percent of those at high risk for diabetes believed they were at risk. In addition, only a small percentage (9 percent) of the population at risk for developing diabetes had been told by their physician.

incidence, especially among adults age 60

problems, says Dr. Patel. The combination

and older. It also found lifestyle intervention

of conditions in metabolic syndrome – high

It is estimated that about one-third of the U.S.

to be more cost effective than medications in

blood pressure, elevated insulin levels,

population has pre-diabetes, but is unaware

people with type 2 diabetes.

excess body fat around the waist and

of it. Symptoms can be subtle – such as

abnormal cholesterol levels – increase the

excessive urination, thirst, itching, difficulties

risk of heart disease, stroke and diabetes.

concentrating, weight loss – or absent.

Early Intervention Can Turn Back the Clock

Statistics show that people with pre-diabetes

the support of a network of health care professionals, have the greatest effect

“Primary prevention remains an important

compared to people with normal blood

managing their diabetes,” says Dr. Patel.

area of focus for us,” says Dr. Patel, “There

glucose. “Those with pre-diabetes may

“Those who pursue aggressive lifestyle changes, such as losing weight, exercising and quitting smoking, in addition to

have a 1.5-fold risk of cardiovascular disease

needs to be more communication about

already be experiencing long-term damage

This treatment approach also can delay

pre-diabetes and the power of diabetes

to the body, especially the heart and

or prevent the development of metabolic

prevention with patients, as well as other

circulatory system,” says Dr. Patel.

syndrome

health care professionals.”

and

further

serious

health

Dr. Vijay Juneja and patient Frankie Lemons review the results of her continuous glucose monitoring.

Reprinted from The Triangle Physician

www.car yinternalmedicine.com

than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting and back or jaw pain,” says Dr. Parikh.

Cary Internal Medicine physicians also monitor women for diabetes after they have experienced gestational diabetes.

“Blood sugar usually returns to normal soon after delivery for most women with gestational diabetes, but the risk of developing type 2 diabetes in the future remains,” says Dr. Parikh. “It is estimated that half of women with gestational diabetes will develop diabetes within 10 to 15 years.”

Advocate for Patients and Physicians pre-diabetes,

“As with men, women’s most common heart

Dr. Patel has embraced a mission of patient

intervening early can actually turn back

attack symptom is chest pain or discomfort.

advocacy and medical stewardship.

the clock and return elevated blood

But women are somewhat more likely

“For

some

people

with

glucose levels to the normal range,” says Dr. Patel. Studies have shown that those

1

with pre-diabetes can prevent or delay the

2

development of type 2 diabetes by up to 58 percent through changes to their lifestyle that include modest weight loss and regular exercise.

5

Dr. Patel advises that testing for pre-diabetes

3

in patients with risk factors for diabetes begin at age 12 in children who are overweight and be repeated every three years.

Women’s Health, Heart and Diabetes The physicians with Cary Internal Medicine & The Diabetes Center are keenly aware of the issues surrounding women’s health,

4

particularly cardiovascular disease, the leading cause of death in women.

Although heart disease is sometimes thought of as a “man’s disease,” it kills about the same number of women and men each year in the U. S. Unfortunately, 36 percent of women in a 2005 Centers for Disease Control and Prevention survey did not perceive themselves to be at risk for heart disease. www.car yinternalmedicine.com

1. This 90°, soft cannula infusion set combines ease of use with maximum comfort. The Quick-serter® may be used to easily and comfortably insert the cannula under your skin.

2. The Quick-serter is the insertion device for the Quick-set. The Quick-serter insertion device makes insertions quick, easy, and virtually painless.

3. The Paradigm Revel Insulin Pump lets you customize your insulin delivery to fit your lifestyle and leave the hassle of insulin injections behind. The Revel Insulin Pump comes CGM ready, so when you want to add a transmitter and glucose sensor to your Revel Insulin Pump, you can have the added protection from lows and highs 4. CareLink® USB upload device wirelessly sends data from your MiniMed Paradigm® Insulin Pump to CareLink® Personal software.

5. A compatible glucose meter is included with all new insulin pump orders which automatically sends your test results wirelessly to your Paradigm® Revel™ Insulin Pump. This helps reduce the number of button pushes and data entry mistakes, making insulin pump therapy more convenient and accurate.

Reprinted from The Triangle Physician

From left, Angela Allen, Dawn Howdyshell and April Richardson are medical assistants at Cary Internal Medicine & The Diabetes Center.

He is frequently featured in the local media to help

North

raise awareness of diabetes prevention and early

Wainwright to the Quality, Access, Value Committee

detection. He has been involved in guiding health

and most recently the Acute Care Services Committee,

care policy in Washington, D.C., as a member of the

also referred to as the CON committee. In the fall of

Leadership Council for Improving Cardiovascular

2009, he was invited to serve on the Legislative Cabinet

Care, and in North Carolina, as a member of American

of the North Carolina Medical Society.

Carolina

House

Representative

William

Diabetes Association Leadership Council. He also served on the physician’s advisory board of a major

This year, Dr. Patel was honored to be selected for the

North Carolina health insurance company.

“Physician Profile” by the editorial board of The Wake

Dr. Prashant K. Patel

County Physician magazine. He also was selected as Dr. Patel is a founding member of the Triangle Indian-

a 2012 scholar of the North Carolina Medical Society

American Physicians Society (TIPS), which began

Leadership College.

in 2006, and of the North Carolina Indian-American Political Action Committee.

Physician Consultation and Referral Cary Internal Medicine & The Diabetes Center offers

In these capacities, he led a team of 10 physicians to

consultation services on diabetes for physicians who

the halls of Congress Oct. 8, 2009, when they met with

are in a position to detect diabetes early – namely

six North Carolina congressional leaders in the House

family physicians, pediatricians and primary care

and Senate about health care reform. In particular, they

physicians, such as internists and gynecologists.

Dr. Vijay K. Juneja

discussed a permanent fix to the flawed sustainable growth rate formula and effective tort reform.

Referrals also are welcome.

On Jan. 1, 2010, Dr. Patel was awarded a fellowship

Contact Cary Internal Medicine & The Diabetes Center

by the American College of Physicians. On March 1,

at (919) 467-6125 or visit www.caryinternalmedicine.

2010, he was appointed by Gov. Beverly Perdue to the

com. Dr. Patel also suggests the website

State Health Coordinating Council (SHCC). He was

betterdiabetescare.nigh.gov for more information.

then appointed by SHCC Chairman and the honorable Reprinted from The Triangle Physician

Dr. Amrita Parikh www.car yinternalmedicine.com