1. Special Diabetes Program for Indians Competitive Grant Program SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program Clinical Goals for the Healthy Heart Project

2. Case Management Core Element Treatment Goals and Strategies located here Goals based on current IHS and ADA recommendations and clinical guidelines from the JNC 7 (The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure– published in 2003) and ATP III (Detection, Evaluation, and Treatment of High Blood and Cholesterol in Adults (Adult Treatment Panel III) – 2004) Both can be found at: www.nhlbi.nih.gov SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program

3. Clinical Treatment Goals Intention is to reduce Cardiovascular Disease (CVD) Risk in patients with Diabetes Cardiovascular Disease events include: 1. Myocardial Infarction (MI) 2. Cerebral Vascular Accident (Stroke) 3. Peripheral Artery Disease (PAD) SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program

4. Blood Pressure Goals In patients with DM: BP goal is < 130/80 The risk of CVD doubles with each increment of Systolic BP elevation of 20mm Hg and Diastolic BP elevation of 10mm HG above 115/75. - in other words, for a patient with DM who has BP of 140/90 their risk of CVD increases ~ 4 fold SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program

5. Lipid Treatment Goals Based on ATP III and other clinical recommendations Diabetes is identified as being a CHD risk equivalent – in other words, a patient with Diabetes and no other risk factors would still be considered at highest risk (10 year risk > 20%) for a cardiac event and necessitates treatment for dyslipidemia. Lipid testing is done after a 9 – 12 hour fast Fasting samples are preferred and recommended for diagnosis SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program

6. LDL-C Treatment Goals LDL-C should be treated to reach a level of < 100 mg/dl for most patients with DM Treatment goal is < 70 mg/dl for those patients at highest risk (hx of cardiac event, other significant risk factors) Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults, JAMA, 2001; 285: 2486-2497. Grundy, SM, et al. Circulation 2004; 110:227-239. SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program

7. HDL-C Treatment Goals Based on ATP III and other clinical recommendations First reach LDL goal, then intensify weight management and  physical activity HDL goal is > 40mg/dl in men and > 50 mg/dl in women SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program

8. Triglyceride Treatment Goals First reach LDL goal, then intensify weight management and  physical activity IF triglycerides (TG) remain elevated, specific TG lowering medications should be added TG goal is < 150mg/dl SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program

9. HgA1C Treatment Goals Based on IHS Standards of Care 2006 The A1C test is a “weighted” test measuring blood glucose control over the preceding 120 days Lowering A1C is associated with reducing complications of DM A1C goal is < 7.0% The A1C level reflects a blood glucose average that can roughly correspond to the following blood glucose levels: SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program

10. HgA1C(%)Plasma Glucose (mg/dl) 6 135 7 170 8 205 9 240 10 275 11 310 12 345 SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program

11. SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program

12. Lifestyle Treatment Goals Based on IHS, ADA Standards of Care Weight Loss – individualize. Contributes to improved blood glucose control, improved lipid results. Goal is loss of 7% of body weight or BMI < 30. Physical Activity – at least 150 minutes per week; aerobic in nature (walking, swimming, cycling, etc. An increase in activity will result in an  increase in caloric expenditure = weight loss. Screening for cardiac conditions prior to initiating exercise is necessary. Waist Circumference < 40 inches in men and < 35 inches in women SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program

13. Lifestyle Treatment Goals Improved Nutrition with: Dietary Sodium Reduction – reduce intake to no more than 2.4 g sodium or 6 g sodium chloride per day DASH Eating Plan – consume a diet rich in fruits, vegetables and low fat dairy with reduced saturated and total fat Moderation of Alcohol Consumption – Limit alcohol to no more than 2 drinks per day for most men and to no more than 1 drink per day for most women and lighter weight persons (a drink = 1 oz or 30mL of alcohol, e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey). Total saturated fat should be < 7% of daily calories Cholesterol should be < 200mg/day SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program

14. Lifestyle Treatment Goals Smoking Cessation Aspirin (anti-platelet) Therapy – ASA doses of 75-325mg per day are recommended for adults with DM who have evidence of large vessel disease. Plavix® has been shown to be just as effective and can be used in those with true ASA allergy or severe GI side effects. SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program

15. SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program