Diabetes Update Laurel Mullally C-FNP

Diabetes Incidence 20.8 million US children and adults have diabetes (1/3 undiagnosed) 20.8 million US children and adults have diabetes (1/3 undiagnosed) 54 million Pre-diabetic (insulin resistance/impaired glucose tolerance) 54 million Pre-diabetic (insulin resistance/impaired glucose tolerance) 2 million adolescents (1 in 6 overweight adolescents) aged had pre-diabetes (2005) 2 million adolescents (1 in 6 overweight adolescents) aged had pre-diabetes (2005)

Burden of Diabetes If present trends continue 1 in 3 Americans (1 in 2 minority members) born in 2000 will develop diabetes in their lifetime If present trends continue 1 in 3 Americans (1 in 2 minority members) born in 2000 will develop diabetes in their lifetime Since 1987 the death rate related to diabetes has increased 45%, making diabetes the 5 th leading cause of death in the US Since 1987 the death rate related to diabetes has increased 45%, making diabetes the 5 th leading cause of death in the US Estimated annual cost of diabetic care was $132 Billion in 2002 (1 in 10 healthcare dollars spent in US) Estimated annual cost of diabetic care was $132 Billion in 2002 (1 in 10 healthcare dollars spent in US)

Type II Diabetes and Obesity Type II (formerly adult onset) diabetes accounts for 90-95% of all diabetes Type II (formerly adult onset) diabetes accounts for 90-95% of all diabetes A metabolic disorder resulting from insulin resistance and progressive decline in pancreatic Beta cell functions A metabolic disorder resulting from insulin resistance and progressive decline in pancreatic Beta cell functions Prevalence has doubled in middle-aged adults in past 30 years Prevalence has doubled in middle-aged adults in past 30 years No longer considered an adult condition: No longer considered an adult condition: Affects adolescents and some children.

Screening Children for Diabetes II Testing should be preformed on all children/adolescents (10 years and older) who are overweight (BMI>85%; weight-for- height > 85%) and have 2 of the following: Testing should be preformed on all children/adolescents (10 years and older) who are overweight (BMI>85%; weight-for- height > 85%) and have 2 of the following:

Family history diabeties in 1 st or 2 nd degree relative (I or II) Family history diabeties in 1 st or 2 nd degree relative (I or II) Native-, African-, Asian-American, Latino or Pacific Islander Native-, African-, Asian-American, Latino or Pacific Islander Signs of insulin resistance (acanthosis nigricans, hypertension, dyslipidemia or polycystic ovary syndrome) Signs of insulin resistance (acanthosis nigricans, hypertension, dyslipidemia or polycystic ovary syndrome) Maternal history gestational diabetes Maternal history gestational diabetes

Adolescent/Pediatric Diabetes testing Beginning at 10 years and every 2 years Beginning at 10 years and every 2 years Fasting glucose (FPG) Fasting glucose (FPG)

ADA Diagnostic Criteria DM II Symptoms of diabetes (polyuria, polydipsia, weight loss) PLUS Symptoms of diabetes (polyuria, polydipsia, weight loss) PLUS Random glucose >200 mg/dL ORRandom glucose >200 mg/dL OR Fasting Glucose >126 mg/dLFasting Glucose >126 mg/dL Or 2 hour (75 gm) glucose tolerance test (OGTT) >200 mg/dLOr 2 hour (75 gm) glucose tolerance test (OGTT) >200 mg/dL

ADA Diagnostic Criteria “Pre- Diabetes” Impaired fasting glucose: mg/dL Impaired fasting glucose: mg/dLAnd/or Impaired glucose tolerance 2-hour value mg/dL Impaired glucose tolerance 2-hour value mg/dL

Initial Workup after Diagnosis Hemoglobin A1C – goal <6; Hemoglobin A1C – goal <6; Glucose Glucose Lipids Lipids Urinalysis Urinalysis Serum creatinine/GFR Serum creatinine/GFR Thyroid function Thyroid function Educational need assessment Educational need assessment Follow-up every 3-6 months Follow-up every 3-6 months

Goal: Tight Glycemic Control GH A1C Goal < 6% GH A1C Goal < 6% ADA recommends A1C as close to normal as possible without hypoglycemic symptom episodes ADA recommends A1C as close to normal as possible without hypoglycemic symptom episodes (ADA recommends <7% for diabetic control) (ADA recommends <7% for diabetic control) NIH 2000 statistics show that 63% of diabetics have A1C levels >7% NIH 2000 statistics show that 63% of diabetics have A1C levels >7%

Benefits of Tight Control DCCT (Diabetic Control and Complications Trial) demonstrated that A1C values near normal (<6%) significantly decreased micro-, macro-vascular and neuropathic complications DCCT (Diabetic Control and Complications Trial) demonstrated that A1C values near normal (<6%) significantly decreased micro-, macro-vascular and neuropathic complications Macrovascular: reduction of MI, stroke and CVD death by 57% Macrovascular: reduction of MI, stroke and CVD death by 57%

1% A1C Reductions Produces 14% reduction MI 14% reduction MI 12% Stroke 12% Stroke 16% Heart Failure 16% Heart Failure 43% Peripheral Vascular Disease 43% Peripheral Vascular Disease

Metabolic Syndrome: 3 or more Waist Circumference (abdominal obesity) Waist Circumference (abdominal obesity) Men > 40 inches & Women > 35 inchesMen > 40 inches & Women > 35 inches Triglycerides >150 mg/dL Triglycerides >150 mg/dL High density lipoprotein cholesterol High density lipoprotein cholesterol Men < 40 mg/dL & Women <50 mg/dLMen < 40 mg/dL & Women <50 mg/dL Blood pressure > 130/85 mm Hg Blood pressure > 130/85 mm Hg Fasting glucose >100 mg/dL Fasting glucose >100 mg/dL

Treatment Strategy Moderate weight loss and physical Activity = lowered diabetes/CVD risk Moderate weight loss and physical Activity = lowered diabetes/CVD risk 5-10% body weight reduction through lifestyle modification decreases progression to DM II regardless of age, sex or ethnicity. 5-10% body weight reduction through lifestyle modification decreases progression to DM II regardless of age, sex or ethnicity. Successful weight loss and maintenance for more than 1 year: high levels of physical activity (1 hour/day) Plus low calorie, low fat diet Successful weight loss and maintenance for more than 1 year: high levels of physical activity (1 hour/day) Plus low calorie, low fat diet Eating breakfast regularly, self monitoring weight Eating breakfast regularly, self monitoring weight Maintaining consistent eating patterns (weekend and weekday) Maintaining consistent eating patterns (weekend and weekday)

Evidence-Based Practice Recommendation Include exercise as an intervention for all persons with type 2 diabetes because exercise significantly improves glycemic control and reduces visceral adipose tissue and plasma triglycerides (even in the absence of weight loss) Include exercise as an intervention for all persons with type 2 diabetes because exercise significantly improves glycemic control and reduces visceral adipose tissue and plasma triglycerides (even in the absence of weight loss)

General Dietary Recommendations 5-7 servings of fruits and vegetables/day 5-7 servings of fruits and vegetables/day 6 or more servings of whole grain products/day 6 or more servings of whole grain products/day <6 grams of salt/day <6 grams of salt/day grams of fiber/day grams of fiber/day <300 mg of cholesterol/day <300 mg of cholesterol/day 64 plus ounces of water/day 64 plus ounces of water/day

General Dietary Recommendations Fat free and low fat milk products, fish, legumes, skinless poultry and lean meats Fat free and low fat milk products, fish, legumes, skinless poultry and lean meats Fats/oils with 2 gms or less of saturated fat/tablespoon (canola, olive oil or margerine) Fats/oils with 2 gms or less of saturated fat/tablespoon (canola, olive oil or margerine) Limited intake of high calorie/low nutrition foods, such as soft drinks and candy Limited intake of high calorie/low nutrition foods, such as soft drinks and candy Limited intake of foods high in saturated fat or cholesterol Limited intake of foods high in saturated fat or cholesterol No more than one alcoholic drink/day No more than one alcoholic drink/day

Medication Tx DM II Recommendation for initial oral single agent or combined therapy Recommendation for initial oral single agent or combined therapy First Line: metformin monotherapy for overweight persons First Line: metformin monotherapy for overweight persons Add on SU Add on SU If target A1C not met (6-7%) consider third oral agent or Insulin If target A1C not met (6-7%) consider third oral agent or Insulin

Evidence Based Practice Recommendation Use First Line Metformin mono- therapy therapy for overweight /obese persons Use First Line Metformin mono- therapy therapy for overweight /obese persons Promotes significant benefit for glycemic control, weight control, Dyslipidemia & Diastolic blood pressure Promotes significant benefit for glycemic control, weight control, Dyslipidemia & Diastolic blood pressure

Insulin Therapy DM II Most Diabetic patients will need insulin therapy (progressive beta cell failure) Most Diabetic patients will need insulin therapy (progressive beta cell failure) Not a “failure” but a continuum of treatment Not a “failure” but a continuum of treatment