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"Ask The Expert" is a service of the HCH Clinicians' Network intended as a resource for clinicians who work with people experiencing homelessness. We are unable to answer questions for individuals about their own health problems. There is useful patient information on numerous websites. Access WebMD for basic facts on any condition, it's straightforward and easy to use; MayoClinic.com features consumer-oriented info about both illnesses and drugs; and MEDLINEplus provides comprehensive background on all diseases, definitions of medical terms, and referrals to organizations that deal with specific illnesses.

Diabetes and Homelessness

 

Our Expert
 


Theresa Brehove , MD
Venice Family Clinic

Dr. Theresa Brehove is a family practice physician who works with the Venice Family Health project in Venice, California. She came to Venice Family Clinic after nine years in private practice and says that it's one of the best decisions she ever made. Dr. Brehove has been caring for homeless persons since 1996. She considers the HCH Clinicians' Network a useful resource in teaching clinicians how to better serve homeless patients, and she offers her services here on our website in hopes that she will be helpful to others.

Dr. Brehove was a major contributor to the HCH Clinicians' Network publication, Adapting your Practice: Diabetes and Homelessness, and she and her health care team participated in the Diabetes Collaborative developed by the Bureau of Primary Health Care.

Q: Many of my diabetic homeless clients have alcohol abuse issues. I’m never sure if their alcohol history is accurate. Do you use Metformin with these clients? Susan, Seattle, WA

When asking about alcohol use in clients for whom I am considering Metformin, first I explain why I am asking about their alcohol use. Then I tell them the serious consequences of lactic acidosis that can occur with the combination of alcohol and Metformin. I feel that clients are more likely to be honest with me when they understand the reason for my questions. I ask clients if they are willing and able to abstain from alcohol so they can receive the benefits of Metformin for their diabetes. I also check liver enzymes in addition to creatinine before I consider Metformin. I am less likely to consider it for clients I have only treated once or twice. For clients in recovery programs I would consider Metformin only after six months of sobriety, because early relapse is possible.


Q: It is difficult to get homeless people to collect 24-hour urine specimens. Should I even try doing this, if I already have them on an ACE or ARB treatment? Diana, Cleveland, OH

Fortunately, the American Diabetes Association (ADA) Standards of Care for Patients with Diabetes Mellitus (2002) give three acceptable methods for screening for microalbuminuria. These can be done once a routine dipstick UA for protein is negative:
  1. A random spot collection measurement of the albumin-to-creatinine ratio;
  2. A 24-hour collection with creatinine, allowing simultaneous measurement of creatinine clearance; or
  3. A timed collection (for example, 4-hour or overnight).

The last two methods are just about impossible for homeless clients either on the street or in shelters. I think the random spot collection is the most reasonable option for homeless persons.

The ADA Standards state, “The role of annual microalbumin screening is unclear after the diagnosis of microalbuminuria and institution of ACE inhibitor therapy and blood pressure control. Many experts recommend continued surveillance both to assess response of therapy and progression of disease.”

Since there are no established guidelines for use of micro albumin testing in this way, our clinic has decided not to use our scarce resources for screening only and we do not routinely test if the patient is already on an ACE or ARB. We do not routinely test if the patient is already receiving appropriate treatment, i.e., already on an ACE or ARB and already working on BP and glucose control.


Q: When homeless people have sporadic meal patterns (for example, infrequent breakfasts or no breakfasts), do you have them adjust their medications? Or should they wait until after lunch before they take insulin, or perhaps take pills with the first meal? Mark, Albuquerque, NM

First, I work with the clients and discuss strategies for avoiding this problem. I give the client information on community resources for getting food and start the referral process for shelter or housing (if the client is willing). I educate clients on risks of hypoglycemia and make such suggestions as reserving a portion of lunch or dinner for eating in the morning. When the client cannot eat, however, there needs to be a firm plan.

Goals for glycemic control need to be individualized to the client’s situation. For many diabetic homeless persons, the risk of severe hypoglycemia in the short term is the most immediate threat, rather than long-term complications. Loose gylcemic control may be safer for most homeless clients until their living situation is more stable.

Strategies for dealing with sporadic meals differ for Type 1 and Type 2 diabetes. Type 1 diabetics must have some basal insulin, even when not eating. One strategy for Type 1 diabetics is to have the client on basal insulin, such as Lantis or Ultralente for the morning and then Lispro or regular insulin before meals. This gives more flexibility, though some patients may balk and it may be difficult on the streets to have the appropriate time, place and sanitary conditions for as many as four injections daily. Some clinics also may not be able to obtain these insulins because they are expensive.

For clients on NPH/regular, consider having them take a smaller dose of NPH and delay the regular dose until the client can eat. It is not as crucial in Type 2 diabetics to have the basal insulin, so skipping the insulin when the client is unable to eat is not a problem in the short-term.

Many oral diabetic medications carry the risk of hypoglycemia if meals are missed. These medications can be delayed until the client can eat, or skipped altogether if the client cannot eat until afternoon. If available, consider short-acting medications that can be taken with each meal, such as Nateglinide (Starlix) or Repaglinide (Prandin). Metformin alone does not carry the risk of hypoglycemia, but is dosed with meals because food minimizes gastrointestinal side effects. If clients can tolerate Metformin on an empty stomach, they can take it at the regular time without food. Acarbose and glitazones also do not cause hypoglycemia if used alone.

Q: Do you know of a resource to help get therapeutic shoes for our homeless patients? Do you know if there is grant money, for example, that might be used for this purpose? Lita, Baltimore, MD

That old Nancy Sinatra song comes to mind, "These boots are made for walking . . ." Last year, Marianne received a small grant from the Marianite Sisters of the Holy Cross expressly for the purchase of quality shoes/winter work boots for the homeless. WalMart has helped provide shoes in some communities. Although they may not provide therapeutic shoes, perhaps they will help financially. Our HCH project in Portland, Maine, received assistance from the General Assistance Program to provide payment, and has also received donations of therapeutic footwear from local doctor's offices. Podiatrists have been helpful in a number of communities, providing resources as well as connections to individuals who may donate therapeutic footwear.

Our project in Salt Lake City had a runaway youth with a size 16 shoe size, and one of the Utah Jazz team members (NBA team) donated a slightly used pair of gym shoes. Ask podiatrists in your community to collect gently worn shoes once a year and to do a fundraising to purchase good shoes. Sponsor a community event to distribute the shoes in the fall. Naot does an annual distribution to Health Care for the Homeless through their local distributor. Check to see if this brand is available in your community. Since they are predominantly women's shoes, you may want to organize a "Pamper your feet" day for women clients. Offer podiatry, pedicures, snacks, toiletries, etc. Additional shoes collected but not distributed can be kept for later distribution.

Timberline has provided warm, sturdy boots and shoes for elders and other guests at Pine Street Inn in Boston, and Kenneth Cole does an exchange. Both companies are good leads to follow up on, although neither has provided therapeutic.

Q: Are there any particular problems with oral health that diabetic patients should be concerned with? Allen, Phoenix, AZ

Diabetic patients, and those patients who may not be diagnosed with diabetes but have it, are at particular risk for several oral health problems. According to colleague Judith L. Allen, DMD, Clinical Director, McMicken Dental Center, Health Care for the Homeless Dental Project, in Cincinnati, Ohio, the following conditions make it imperative for health care providers—medical and dental—to work in concert when treating diabetic patients.

First: Diet and maintaining proper blood sugar levels are primary concerns in diabetic patients. The best diet for a person with diabetes is one high in vegetable intake. Vegetables should be eaten crisply cooked for best nutritional value. One must have good teeth to eat vegetables this way. Most people with dentures have great difficulty eating hard-to-chew foods. They tend to cook them to a consistency that deletes all the food value, or turn to foods high in carbohydrates or sugar—both of which exacerbate their condition. In diabetic patients, keeping their natural teeth is paramount to keeping them healthy.

Second: If the patient’s teeth are in poor condition or if tooth decay or periodontal (gum) disease is present, they can be susceptible to serious infection. If this condition is left unattended, it can lead rapidly to infection that can spread to vital organs of the head or neck, or cause ketoacidosis—which can degenerate to coma and ultimately death. The incidence of periodontal disease is as much as three times higher in diabetic patients than in patients with normal blood sugar levels. Periodontal disease, the leading cause of tooth loss, may also have an important role in cardiac complications.

Third: High glucose levels in saliva caused by uncontrolled diabetes can lead to tooth decay, fungal infections, salivary dysfunction, or burning mouth syndrome. All of these conditions are very unpleasant and can lead to further deterioration of the patient’s condition by making eating and swallowing uncomfortable. Burning mouth syndrome has been identified as one of the diabetic neuropathies associated with uncontrolled diabetes and can be a precursor to detection in patients not otherwise diagnosed with the disease.

All of these conditions make it imperative for health care providers, medical and dental, to work in concert when treating diabetic patients.
DISCLAIMER: "Ask the Expert" is a communication service for those interested in providing health care to homeless people. The opinions expressed here are those of the authors and do not necessarily represent the views of the Health Care for the Homeless Clinicians' Network, the National Health Care for the Homeless Council, or the Health Resources and Services Administration.

© 2003 National Health Care for the Homeless Council

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