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