1. DIABETES Cameron VanTassell MS,RD,BC-ADM

2. HbA1c Definition-a stable glycoprotein formed when glucose binds to hemoglobin A in the blood in a concentration dependent process – Marker of glycemic control for the last 2-3 months More heavily weighted towards the last month (~50%) Good glycemic control – ADA- 7%, AACE- 6.5% HbA1c now recognized by ADA and AACE as a way to diagnose DM (>6.5%)

3. HbA1c Other factors besides glycemic control are known to alter HbA1c values (1) – Advanced kidney disease – Any illness characterized by hemolysis – Certain forms of dyslipidemia – Malignancies – Cirrhosis – Iron deficiency anemia (increases of 1-1.5 %) – Pregnancy – Unknown Genetic factors (high glycators (African Americans) vs low glycators (non-Hispanic whites)) – Age “Given the frequency with which subjects with diabetes have other medical illnesses, the likelihood that such factors may alter HbA1C is widely underestimated.” Dr. Zachary Bloomgarden

4. HbA1c  Usefulness  Inpatient- Only thing available to determine recent glycemic control but should be interpreted with the knowledge it can be misleading  Outpatient- Should not be used as the only tool to determine glycemic control. Home blood glucose results should also be used.

6. Post Open Heart Blood Glucose  Portland Protocol (2)  Every 4 hour subcutaneous insulin vs insulin drip Goal was less than 200 mg/dl for q 4 sub q Goal was 150-200 mg/dl for drip 50% decrease in mortality using drip Significant decrease in sternal wound infections  Portland Protocol “3-BG” (3)  3-BG an is average of all glucose values the day of surgery and days 1 and 2 post op Increase 3-BG was associated with deep sternal infections, hospital length of stay, blood transfusions, new onset atrial fibrillation, and low cardiac output syndrome.

7. Post Open Heart Blood Glucose  Lazar et al (4)  Used modified glucose-insulin-potassium (GIP) drip vs. sliding scale after 12 hours in the ICU the average glucose for GIP was 134 mg/dL vs 266 mg/dL ( p < 0.0001)for those receiving sliding scale Those receiving GIP had significantly shorter hospital stay vs sliding scale (6.5 days vs 9.2 days; p = 0.0003) After 5 year those receiving GIP had a significant survival advantage (p = 0.04), a significantly lower incidence of recurrent ischemia (p = 0.01) and wound infections (p = 0.03), and were able to maintain a lower angina class (p = 0.03).

8. What Does The Patient Need to Know?  Depends on  What type of DM  Oral vs insulin therapy  Previous Education  Socioeconomic factors  What daily choice do patients make that has the biggest impact on glycemia?

9. What Does The Patient Need to Know?  Indirect knowledge  DM education Carbohydrate counting  Direct knowledge  Testing with purpose If I eat x I can expect y to happen

10. Stages of Type 2 Diabetes Related to Beta-Cell Function 10 Adapted from Lebovitz HE. Diabetes Reviews. 1999;7(3). 2­12­2­10­6061014 Beta­Cell Function (%) 0 50 100 75 25 Type 2 Phase 1 IGT Years from Diagnosis Type 2 Phase 2 Type 2 Phase 3 Postprandial Hyperglycemia

11. Insulin Secretion in Type 2 Diabetes 11 Polonsky KS, et al. N Engl J Med. 1996 Mar 21;334(12):777-783. Normal Type 2 diabetes Time (24­hour clock) 060010001400180022000200 800 600 400 200 0 Insulin Secretion (pmol/min) Meal

12. Testing with purpose  I believe one major reason people fail to test their blood glucose is they see no purpose in it  Unable to interpret why/ patterns  No one in the medical community ever looks at the numbers  Some are discouraged to do so or told it is unimportant

13. Testing with purpose  One of the most effective ways to give patients immediate feedback on the choices they make is to test pre and post prandial blood glucose  Test right before meals and 1-2 hours post meal. What is the difference? Generally we would like to see no more than a 60 mg/dl rise