Role of the Primary Care Physician in Diabetes Treatment

with Brian Hirano, M.D., Internal Medicine, Columbia St. Mary’s

Posted: Nov. 1, 2004

If Dr. Brian Hirano had to sum up the most important piece of medical advice he could offer his patients with diabetes, it would sound something like this:

“Be educated about the disease, motivated about managing the disease and monitor for complications of the disease,” he said.

Dr. Hirano estimates that approximately 10 percent of his patients have diabetes. That number is likely to increase in the coming years. In 2002, more than 18 million Americans had Type 1 or Type 2 diabetes; people born that year have a one in three chance of developing the disease during their lifetime.

Brian Hirano, M.D., Internal Medicine, Columbia St. Mary’s "If you ask any primary care physician, they’d tell you they see someone with diabetes every day."

The majority of Dr. Hirano’s patients with diabetes have Type 2, which accounts for between 90 and 95 percent of all diagnosed cases of the disease. Type 2, in which the pancreas gradually loses its ability to produce insulin, is more commonly associated with obesity.

The exact cause of Type 1 diabetes is unknown; it occurs when the immune system destroys the only cells in the body capable of producing insulin.

“I have some older Type 1 patients who are pretty stable, and I follow them along, but newly diagnosed Type 1 patients will usually end up seeing an endocrinologist,” Dr. Hirano said.

Type 2 diabetes, though, has become so prevalent that it’s routine for primary care doctors to follow a patient from diagnosis and stabilization through regular monitoring.

“If you ask any primary care physician,” he said, “they’d tell you they see someone with diabetes every day.”

Making a diagnosis
Many of Dr. Hirano’s Type 2 patients discover they have diabetes as the result of a routine physical examination, when a blood glucose screening shows elevated levels of sugar in the bloodstream. Those who make an appointment because they’re experiencing the symptoms of diabetes — frequent urination, excessive thirst, extreme hunger, unusual weight loss, increased fatigue, irritability and blurry vision — are more unusual.

With any newly diagnosed patient, Dr. Hirano orders a battery of tests. One of the tests ordered is known as the A1c, which reflects the average blood sugar level for the past three months.

He also assesses the patient for heart disease by performing blood pressure and lipid panel tests because patients with diabetes are much more likely to have heart disease. Until recently, the recommended level for LDL (bad) cholesterol in people with diabetes was 100, it is now 70.

Dr. Hirano also talks about the association with diabetes and vascular disease, particularly with patients who smoke cigarettes. While most of his patients with Type 2 diabetes are overweight, there are those of normal weight whose family history is the main factor in their developing the disease.

His initial recommendation for any patient diagnosed with diabetes is to begin — if they haven’t already established one — a regular exercise routine. He does so, however, with the advice to begin slowly. If a patient has risk factors for heart disease, he orders a cardiac stress test before advising patients to start an exercise program.

Once he’s determined the severity of the disease, Dr. Hirano prescribes pills or a combination of pills and injectable insulin. He also refers them to Columbia St. Mary’s Diabetes Treatment Center.

Specialized care at Diabetes Treatment Center
The Diabetes Treatment Center at Columbia St. Mary's is part of a nationwide network of programs specializing in the treatment of diabetes, Dr. Hirano said, which have the ability to provide a range of services that he doesn’t.

“They can sit down with a patient and go through all the different things the patient needs to know,” he said. Physicians referring their patients to the Center can choose from a range of specific services, selecting the ones the patient needs.

Services include nutrition counseling, exercise program instruction, how to monitor blood glucose levels and learning to be aware of symptoms that may indicate complications. There are also psychologists on staff, because, as Dr. Hirano put it, “the diagnosis can be overwhelming to deal with.”

Once their symptoms are under control, he sees his patients with diabetes every three months. After making sure their heart, blood pressure and blood glucose levels are within normal range, he checks their feet for calluses or sores. These can lead to non-healing skin ulcers. He also checks feet and nails for fungus, and assesses if they have any numbness or tingling in their lower legs or feet. He examines their eyes and makes sure they’re seeing an ophthalmologist for a yearly exam.

Taking control reduces complications
While Dr. Hirano has many patients who he described as motivated and conscientious about keeping their diabetes under control, for some, making important lifestyle changes is very difficult. He helps those with diabetes understand what they need to do to remain healthy as well as the possible consequences of unhealthy choices. Poorly controlled diabetes can result in kidney failure, blindness and amputation.

Dr. Hirano is aware of and sympathetic to the challenge that many of his patients face.

“A lot of people have diabetes because of lifelong habits,” he said, “and they’re not going to change that overnight.”

But, he added, making the necessary changes — changing their diets, making time for exercise, doing a daily foot exam and taking care of their eyes — can make a big difference.

“Probably 95 percent of patients I see with Type 2 diabetes are overweight,” he said, “and I’ve had a couple actually get off their medication by losing 50 pounds, which was pretty impressive.” With proper care, education and motivation, people with diabetes can significantly reduce the risk of complications of the disease.

We Have Answers Do you have medical questions or need help finding a doctor? The experts at Columbia St. Mary's and Advanced Healthcare can help. Click here.