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A Team Approach

The cornerstone of Joslin care is a multi-disciplinary team approach that addresses all the needs of adult and pediatric patients under one roof. Located on the sixth floor of the medical center, Joslin has nine physicians who specialize in diabetes, as well as dietitians, an exercise physiologist, nurse diabetes educators, a podiatrist, an ophthalmologist, a social worker, and a psychologist. Team members work together to help patients create their own plan to manage their blood glucose levels. Patients learn to take steps to manage their illness and prevent the complications of diabetes.
This is not always an easy task. Frequently, patients are reluctant to make necessary changes in their lives. This is why education is so important. Patients must learn about their diabetes medications, how to take them, and what side effects they might expect.

Educators and dietitians teach about healthy food choices, portion control, and scheduling of meals.

Many diabetic patients need to lose weight. Exercise is an important part of that effort. But many patients resist the need to begin an exercise program; so an exercise physiologist works with them step by step.

The social worker and psychologist on the Joslin team are equipped to deal with the psychological issues that confront patients with chronic diseases. And specialists such as the podiatrist and ophthalmologist are always vigilant for signs of serious diabetics complications that can lead to loss of sight and limbs.
All of these health care professionals collaborate on the patient’s care, and create an individualized plan of therapy, with the idea that the patient is the most important team member of all. They must take charge of their own health. As Romaine Chase-Bobbitt puts it, "You deal with the total picture. Everybody’s coming together as you establish your own goals and they’re helping you get there."

The medical director of the University of Maryland Joslin Center is Alan Shuldiner, MD, a Harvard-trained endocrinologist and one of the nation’s leading authorities on diabetes and obesity. He says the Joslin Center is equipped to handle patients’ care in a way that individual internists and family physicians cannot. "Care of patients with diabetes can be a very labor intensive process that requires several health care professionals who interact to coordinate all aspects of a patient’s care. Up until now, Baltimore and the Mid-Atlantic region did not have a comprehensive diabetes center like the Joslin Center. Now patients who come here can receive state-of-the-art care." Dr. Shuldiner hopes area physicians will come to rely on the Joslin Center as a valuable resource for their patients with diabetes.

Diabetes is an increasingly common illness. Sixteen million people in this country have the disease, and one-third to one-half of those don’t even know it. The growing number of cases is due to many causes: our population is becoming older, more overweight, and less active. These are all risk factors for diabetes. Ethnic groups, such as African Americans and Hispanic Americans, are also more likely to get diabetes, as are those with a family history of the disease. Finally, women who have a history of gestational diabetes, or have given birth to babies weighing over nine pounds have a higher risk as well.

Research is leading to new treatments for diabetes. Three new oral medications have been approved for use in the last several years. There is also a new kind of insulin, Humalog, which is absorbed by the body more quickly. Patients who use it no longer have to wait thirty minutes after their injection to eat. The wait has been cut to five minutes.
But there is more work to be done, and Maryland’s Joslin Center is at the forefront of that work. Its active research program spans from the bench to the bedside. Dr. Shuldiner believes, in coming years, Joslin’s research programs will play a large part in the advances he expects to see in diabetes care.

Dr. Shuldiner, who is also a professor of medicine in the School of Medicine, is actively involved in some of those research programs himself. He specializes in the area of heredity and genetics in the development of Type II diabetes and obesity. One of his research programs has centered on the Amish in Lancaster County, Pennsylvania. He says, “The Amish are excellent for genetic studies because they are genetically homogeneous, and have large families with essentially complete genealogies dating back to the early 1700s.”

Dr. Shuldiner and his colleagues have recruited 1400 Amish volunteers from a single twelve generation pedigree. They have done a genome-wide search for diabetes susceptibility genes. They have tested four hundred different genetic markers on every chromosome to look for regions of chromosomes that are inherited more often in diabetic family members than would be expected by chance. Their studies suggest there may be such genes in specific regions of chromosomes one, two, 14, and 18. Once they identify the chromosomal regions that are inherited more often in diabetic family members, they will use molecular genetic techniques to identify specific genes and mutations in these genes that render individuals susceptible to diabetes.

Researchers know that lifestyle, as well as genes are factors in the development of diabetes. But if the particular genes responsible can be discovered, this could help predict who is susceptible to the disease and would allow for early intervention and prevention. It could also lead to the development of new medicines.

Genetics is only one of many active areas of diabetes research at the School of Medicine. Another provides an exciting possible alternative to pancreas transplants in diabetic patients who have severe complications such as kidney failure and vision loss. Work is underway to determine how to successfully transplant the insulin-producing islet cells of the pancreas instead of the whole organ. This work is still investigational, but the Joslin Center’s Associate Medical Director, Thomas Donner, MD, says there’s a lot of hope that this procedure may someday help cure diabetes.

The University of Maryland Medical Center, where the state’s first successful pancreas/kidney and pancreas-only transplants were performed, now has the second largest pancreas transplant program in the country. The program is directed by Stephen Bartlett, MD, professor of surgery and medicine at the University of Maryland School of Medicine. Most pancreas transplants are performed in conjunction with a kidney transplant, in patients whose diabetes has led to kidney failure. But with better methods of detecting early rejection episodes in pancreas-only transplants, more patients now have the opportunity to halt their diabetes before the onset of kidney failure.

Research is also underway at the University of Maryland that could help prevent many cases of diabetes altogether. In 1997, the National Institutes of Health awarded a $1 million grant to examine whether weight loss and other lifestyle changes can prevent the development of adult-onset or Type II diabetes in obese African-American children. The study is enrolling about 200 children. They and their parents are learning about healthy food choices, exercises they can do, and other behavior modifications. The youngsters are divided into three groups, and each receives a different intensity of intervention.
Sadly, there is a growing number of teenagers who are being diagnosed with Type II diabetes. According to Malinda Duke, a Joslin Center Certified Pediatric Nurse Practitioner, more and more teens are becoming overweight. The onset of puberty, or even a viral illness, can trigger diabetes in these overweight children. These young patients have a particularly difficult time coping with their illness. Some suffer from depression. The Joslin Center is equipped to deal with these problems. And its health care professionals are especially vigilant when it comes to monitoring the progress of these young patients. Additional attention is often a key to helping a teen who is resistant to taking the steps he or she must take in their own diabetes care.

The Joslin Center has started a teen group which meets monthly. The aim is to plan activities that are educational, but also fun. At one meeting, the kids went on a walk to Baltimore’s Inner Harbor, where they learned about healthy snacks they can choose when they make such outings with their friends.

The Joslin Center has also raised money to send younger children to a summer diabetes camp run by the American Diabetes Association. Youngsters have a wonderful time enjoying recreational activities with other kids just like them, who must eat the same foods, regularly test their blood glucose levels, and receive insulin. While at the camp, they learn more about their diabetes, and are taught skills that will help them in their diabetes care.

Children with Type I diabetes, like nine-year-old Amber Parker, face different issues from older children, and the Joslin Center’s professionals are experts in dealing with these problems, too. When Amber was diagnosed several years ago, she suddenly faced a future without some of her favorite things: candy, ice cream, and regular soda. At such a young age, she had to adjust to blood glucose testing four times a day, and insulin injections two to three times daily. She has learned to count carbohydrates, remember which foods she can and cannot have, and in what quantities.
All of these restrictions and responsibilities can leave children feeling deprived, confused, and different from their friends. So, the Joslin Center’s educator, social worker, and psychologist play a meaningful role. At one time, Amber was having a lot of trouble in school. Because of fluctuations in her blood sugar, she sometimes felt too ill to go to class. Her mom, Terri Parker, talked with the professionals at Joslin, who recommended a different school, where a full-time nurse now helps Amber manage her blood sugar levels. Mrs. Parker says, <i>"Whatever situation arises, there is someone at the Joslin Center I can turn to."</i>

Physicians at the Joslin Center say that doctors in private practice are important partners with them in their efforts to identify and treat patients with diabetes. Internists and family physicians are the ones who see patients regularly and can provide regular screenings for the disease. The American Diabetes Association recommends a fasting blood sugar screening every three years for patients over the age of 40. Patients who are diagnosed with diabetes also need to be monitored to prevent complications of the disease. Cholesterol must be kept in check; LDL should be under 130. Blood pressure should be under 140 over 85. Dr. Shuldiner recommends an annual eye exam as well as a kidney screening to check for early signs of kidney damage. Diabetes remains the leading cause of blindness and kidney failure in the United States. Most of these cases are preventable.

The Joslin Center is an important referral resource for community physicians. The Center provides comprehensive care for patients with diabetes, but is flexible in working in partnership with each patient’s family physician to coordinate care. In some cases, patients are referred only for an evaluation and recommendations. Others might come only for consultations with a nurse educator or dietitian. The center also offers many education programs for health care professionals, to help improve the quality of diabetes care throughout the region.

More and more patients in this area are able to use Joslin’s resources, even if they don’t live in Baltimore. A satellite Center has opened in Shipley’s Choice in Anne Arundel County, and negotiations are underway to bring two more satellite centers to Maryland and Delaware.
The high quality of the faculty at the University of Maryland School of Medicine and the Medical Center’s history of excellent patient care were factors in the decision by the Joslin Center in Boston to locate an affiliate here. Although there is still no cure for diabetes, Deborah Counts, MD who heads the pediatric diabetes team at the Joslin Center believes that within our lifetime there will be a cure. In the meantime, Joslin doctors carry on the vision of Elliott Joslin from a century ago, improving treatments and helping patients lead a longer and more healthy life. That progress can be seen in patients like Romaine Chase-Bobbitt whose blood glucose level was nearly 600 when she first went to the Joslin Center, and is now in a target range of about 116. She says, "The Joslin Center literally gave me my life back."

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