NOSSCR Spring 2010Social Security Disability Law Conference

Suzanne Villalón Hinojosa1-800-481-0302

www.southtexasdisabilitylawyer.com

Why Diabetes?23.6 million people—7.8 percent of the population—

have diabetes.

Diagnosed: 17.9 million people Undiagnosed: 5.7 million people

57 million people—pre-diabetics

By 2025, it is estimated that 50 million people will be living with diabetes.

http://www.cdc.gov/diabetes/pubs/factsheet07.htm

Why now?• New Proposed rules

– We believe that, with one exception, we should no longer have listings in sections 9.00 and 109.00 based on endocrine disorders alone, and we are proposing to remove all such current endocrine listings.

• Revised Medical Criteria for Evaluating Endocrine Disorders – 12/14/09

• Current rules will expire 7/1/10 (if not extended)

Why is SSA eliminating the Current listings for Diabetes?• Since 1985, medical science has made

significant advances in detecting endocrine disorders at earlier stages…• and newer treatments have resulted in better

management of these conditions.

• Adequate glucose regulation is achievable…• with improved treatment options…

– 74 Fed. Reg. 66070

History of Diabetes treatment• Prior to 1920s

– diagnosis of diabetes was a death sentence, although doctors experimented with restrictive diets

• 1921 – discovery of insulin

• 1942 – first “anti-diabetes” drug: sulphonylurea

(Glimepiride)• 1994

– Metformin marketed in US• Late 1990s

– more medication therapy: thiazolidinedione (Avandia, Actos, Resulin)

Medical advances have not reduced the incidences and prevalence of Diabetes Better management of diabetes has not been

achieved.It requires a team approach and not all

diabetics have access to team members.

Medication management is not the panacea as suggested by SSA.The ADA frowns on the use of medications to

treat and prevent diabetes. ADA, Standards of Care, 1/2010 p. S16

Effect of new proposed rulesAdjudicators will view the proposed listing

changes as a more stringent standard at both Step 3 and Step 5.

Hypothetical question to VE must include all impairments found by the ALJ.

Maldonado v. Astrue, No. SA-08-CV-0503 NN, 2009 WL 398748, at *6 (W.D. Tex. Feb. 18, 2009).

Two Types of DiabetesType 1 Diabetes Type 2 Diabetes

Old name: insulin-dependent

diabetes mellitus (IDDM) or juvenile-onset diabetes

To survive:people with type 1

diabetes must have insulin delivered by injection or a pump.

Old name:non–insulin-dependent

diabetes mellitus (NIDDM) or adult onset diabetes

In adults: 90% to 95% of all

diagnosed cases of diabetes.

Among adults with diagnosed diabetes (type 1 or type 2), 14% take insulin only, 13% take both insulin and oral medication, 57% take oral medication only, and 16% do not take either insulin or oral medication.

Forms of Diabetic Neuropathy• Peripheral neuropathy

– pain or loss of feeling in the toes, feet, legs, hands, and arms.• Autonomic neuropathy

– changes in digestion, bowel and bladder function, sexual response, and perspiration. It can also affect the nerves that serve the heart and control blood pressure, as well as nerves in the lungs and eyes. Autonomic neuropathy can also cause hypoglycemia unawareness, a condition in which people no longer experience the warning symptoms of low blood glucose levels.

• Proximal neuropathy – pain in the thighs, hips, or buttocks and leads to weakness in

the legs.• Focal neuropathy

– Sudden muscle weakness or pain one nerve or group of nerves (Bells palsy, chest pain can be mistaken for heart attack).

About 60 to 70 percent of people with diabetes have some form of neuropathyhttp://diabetes.niddk.nih.gov/DM/pubs/neuropathies/

• Peripheral neuropathy affects– toes– feet– legs– hands– arms

• Most common

• Autonomic neuropathy affects– heart and blood

vessels– digestive system– urinary tract– sex organs– sweat glands– eyes– lungs

• More deadly

Autonomic neuropathy may be disabling

• Symptoms of autonomic neuropathy may be intermittent [but]…are responsible for…the most troublesome and disabling problems of diabetic neuropathy.– urinary incontinence– syncopal episodes– gastropathy can result in vicious cycles of glycemic

control problems, poor nutritional status, and advanced gastrointestinal complications.• http://journal.diabetes.org/diabetesspectrum/98v11n4/

pg224.htm– Due to strong association with CVD, ADA against

vigorous exercise. • http://care.diabetesjournals.org/content/33/Supplement_1/

S11.full.pdf+html

Foot damageFive simple clinical tests are

considered useful in the diagnosis of loss of protective sensation (LOPS) an indicator of risk of ulcers and amputation.10-g monofilamentVibration testing using a 128-Hz

tuning forkTests of pinprick sensationAnkle reflex assessmentTesting vibration perception

threshold with a biothesiometer ADA, Diabetes Care, Volume 33,

Supplement 1, January 2010Nerve conduction studies add little.

J Neurol Neurosurg Psychiatry 2003; 74 (Suppl II)ii15-ii19

Amputation and foot ulceration are the most common consequences of diabetic neuropathy and major causes of morbidity and disability in people with diabetes.

ADA, Diabetes Care, Volume 28, Supplement 1, January 2005

Distal symmetric polyneuropathy (DPN) with autonomic neuropathy1. Up to 50% of DPN may be asymptomatic2. Autonomic function tests show abnormalities in 97% of

patients with DSNP3. Autonomic neuropathy may involve every system in the

body4. Cardiovascular autonomic neuropathy causes substantial

morbidity and mortality.5. Specific treatment for nerve damage is not available

other than improved glycemic control, which may slow progression but not reverse neuronal loss.

6. Strict glucose control provides no clinically significant improvement from the patient’s perspective, despite modest improvement in vibration threshold and nerve conduction studies.

ADA Diabetes Care, Volume 33, Supplement 1, January 2010 & J Neurol Neurosurg Psychiatry 2003; 74 (Suppl II)ii15-ii19

Eye damage

Diabetic retinopathy is estimated to be the most frequent cause of new cases of blindness among adults aged 20-75 years.

ADA, Diabetes Care, Volume 28, Supplement 1, January 2005

Stages of retinopathy• Mild non-proliferative retinopathy

– small areas of balloon-like swelling occur in the retina's tiny blood vessels.

• Moderate non-proliferative retinopathy– some blood vessels that nourish the retina become blocked.

• Severe non-proliferative retinopathy– The damaged retina signals the body to produce new blood

vessels.• Proliferative retinopathy

– New blood vessels are abnormal, they can rupture and bleed, causing hemorrhages in the retina or vitreous.

– Scar tissue can develop and can tug at the retina, causing further damage or even retinal detachment.• http://www.nei.nih.gov/health/diabetic/retinopathy.asp

Symptoms of diabetic retinopathyBlurred or double visionFlashing lights, which can indicate a retinal

detachmentA veil, cloud, or streaks of red in the field of

vision, or dark or floating spots in one or both eyes, which can indicate bleeding

Blind or blank spots in the field of visionhttp://www.visionaware.org/how-diabetes-

affects-eyes-and-vision

Functional effects of retinopathy• Fluctuating vision in response to changing blood

glucose levels; vision can change from day-to-day, or from morning to evening

• Blurred central vision from macular edema can interfere with reading

• Decreased visual acuity can interfere with seeing the markings on an insulin syringe or the display on a standard blood glucose monitor

• Irregular patches of vision loss or "blind spots" can make it difficult to judge the size of food portions on a plate.

• Decreased depth perception, in combination with decreased visual acuity, can make it difficult to see curbs and steps, or walk to the diabetes clinic.

Type 2 diabetes is difficult to controlOnly 37% of adults with diagnosed diabetes

achieved an A1C of <7%, only 36% had a blood pressure <130/80 and just 48% had a cholesterol level <200 mg/dl.

Only 7.3% of diabetes subjects achieved all three treatment goals.

Saydah SH, Fradkin J, Cowie CC: Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA 291:335-342, 2004.

Risk Factors for Type 2 DiabetesYou can control

Habits & LifestyleBeing overweight

defined as a body mass index (BMI) over 25.

Abnormal cholesterol and blood fats such as good cholesterol

(HDL) lower than 35 mg/dL or a triglyceride level over 250 mg/dL.

High blood pressure greater than 140 /90 in

adults.Sedentary lifestyle

You can’t control

Race or ethnicityHispanicsBlacksNative AmericansAsians

Family history of diabetes Having a parent or

sibling with diabetes Age

Being 45 and older Gender

Women with Polycystic ovary syndrome

Causative FactorsAt least 50% of any patient’s insulin

resistance is due to genetic factors.Insulin resistance is worsened by:

Aging,Inactivity leading to a loss of muscle mass, And the development of obesity.

AACE Diabetes Guidelines, 2002

ADA Treatment Guidelines Initial referral to a diabetes educator with an annual follow

up. http://www.diabeteseducator.org

Quarterly check-up Blood work (AIC quarterly if uncontrolled, 2 times a year if under

control)

Annual examinationsUrine test (screening for microalbuminuria)Eye exam (opthalmologist or optometrist)Foot exam with nerve testing (Semmes-Weinstein

monofilament & tuning fork )Cardiovascular exam (with cholesterol and triglyceride

profile)Influenza vaccine

Diabetes ManagementPeople with diabetes should receive medical

care from a physician-coordinated team:PhysiciansNurse practitionersPhysician’s assistantsNursesDietitianPharmacistsMental health professionals with expertise and

a special interest in diabetes.ADA Standards of Care, 1, 2010

Different types of insulin

Different types of oral medication

The choices of oral drug therapy for type 2 diabetes have become extremely complex. AACE Diabetes Guidelines, 2002

State Diabetes Coverage Requirements within Private Insurance

http://www.ncsl.org/IssuesResearch/Health/DiabetesHealthCoverageStateLawsandPrograms/tabid/14504/Default.aspx#StateMap

ADA accommodations“tight control”

a private area to test blood sugar levels or to take insulin

a place to rest until blood sugar levels become normal

breaks to eat or drink, take medication, or test blood sugar levels

leave for treatment, recuperation, or training on managing

diabetes

modified work schedule or shift changeallow a person with diabetic neuropathy to use a

stool.