Weighing In On Diabetes

October 28, 2009
By Dr. Laurie Tom

Dr. Laurie Tom
Endocrinologist

How long have you been practicing?

I started my private practice at Queen’s in 1992. I practice general endocrinology and metabolism, but just by the nature of the specialty and diseases that it encompasses, people with diabetes are a significant portion of my practice because the disease is so prevalent. Here in Hawaii we have some of the highest rates of diabetes because of the high-risk ethnic groups, which include our Native Hawaiians and the other Pacific Island population, and even our Asian population. The high prevalence is in part related to the adoption of the Western diet, which is high in fat and calories. Basically, it is the obesity problem. Probably 80-90 percent of people with diabetes are overweight or obese.

Then there are more complicated socio-economic issues in terms of what’s affordable to eat. If you are struggling with the economy, you are going to eat the less expensive things like ramen and fast-food specials - not the healthiest of things to be eating. And then people struggling just to make ends meet by working two jobs don’t have the energy or time to exercise. So those are some of the challenges that people with diabetes are facing.

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Which diabetes patients would come to see you, rather than just their primary care physician?

There are not enough diabetes specialists. Probably about 90-95 percent of diabetes patients are managed by their primary care physician or family practitioner. The way I look at the world of diabetes is that prevention is so important. We have done prevention studies in the U.S. and across the world, and have proven that diabetes can be prevented through a healthier diet, exercise and weight loss. For those at high risk, you can at least control their blood glucose levels. Once someone is diagnosed with diabetes, those diet and lifestyle principles still need to be reinforced, but we usually have to start using medications. Again, most people are managed by their primary care physicians. However, those with a private insurance plan may seek a specialist on their own. Oftentimes when patients are referred to us, it is because their condition has become more complicated and they need to advance to insulin therapy.

As endocrinologists, we try to educate our primary care physicians how to manage their patients with diabetes even if they have to initiate insulin therapy. That can be done by the primary care physicians. The importance of managing and controlling diabetes is to prevent the long-term complications, which include blindness, kidney failure, nerve damage and more serious things like heart attacks and strokes.

How does REHAB Hospital help your patients?

Those with complications can receive skilled care at REHAB Hospital. Each year they serves approximately 1,500 patients in their hospital, and more than half are there as a result of a diabetes-related illness or injury. More than a quarter of their patients with diabetes are receiving specialized rehabilitation for stroke. Other conditions range from amputation made necessary by nerve damage, fractures, joint replacements, cardiac surgery, or non-traumatic spinal cord injury or traumatic brain injury.

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How common are amputations directly caused by diabetes?

Diabetes is the leading cause of non-traumatic limb amputations, and last year 111 REHAB Hospital patients received rehabilitation therapy to recover from an amputation. Very commonly, people with diabetes also have hypertension and high cholesterol, both also risk factors for peripheral artery disease that can lead to the risk for amputation, heart attacks and stroke. If you look at patients with diabetes and what they are at risk of dying from, 75 percent of patients will have a cardiovascular event, which is a stroke or heart attack.

For some people, whether it’s genetics or other factors, is it possible that such long-term complications would gradually happen anyway and prevention methods are used to delay the process?

The message is that poorly controlled diabetes can lead to these complications. Our goal is to prevent these complications. Through good control of diabetes and other risk factors such as hyper-tension, hyperlipedemia and smoking cessation, along with a healthy diet, exercise and medications, complications can be prevented or delayed. The problem with diabetes is often there are no symptoms, so a lot of people don’t take it seriously. Many times even if your sugar levels are high, you can walk around and be asymptomatic. So that’s why people don’t take it as seriously as they should. We’re asking people to change their behavior, which includes eating less and exercising. But the bottom line is that people need to know that these complications do not have to be inevitable. Now there’s so much access to information to learn about diabetes and how to take care of it. The message is that patients with diabetes should be able to live long, productive lives and diabetes should not get in the way of that.