Diabetes Guidelines

Kevin H McKinney MD
University of Texas Medical Branch at Galveston
Division of Endocrinology/Stark Diabetes Center
 DIABETES MELLITUS
•Inability of the body to metabolize
blood sugar
•A disease of inadequate insulin
secretion and action
•Hyperglycemia is the main
manifestation
 COMPLICATIONS

Chronic hyperglycemia may cause:

–retinal damage
–chronic kidney disease
–nerve damage
–vascular disease
 COMPLICATIONS (cont.)

•Blindness
•Dialysis
•Lower Limb Amputation
•Stroke
•Myocardial infarction
•Claudication
 PRIMARY CLASSES OF
DIABETES MELLITUS
•Type 1
–Autoimmune destruction of islets
–No insulin secretion

•Type 2 Diabetes
–Insulin resistance with progressive insulin
secretory defect
–90% are obese
PREVALENCE OF TYPE 1
DIABETES IN THE US

• 1 million people

• Caucasians constitute the majority of

type 1 diabetics

• Most prominent during childhood

 PREVALENCE OF TYPE 2
DIABETES IN THE US
• Most common type of diabetes among
all ethnic groups

• 17 million patients with known diabetes

• 45% of children and teens with new

diagnoses
 PREVALENCE OF TYPE 2
DIABETES IN THE US
• Caucasian women experience higher
prevalence rates than men (57% vs. 26%)

• By age 70, African American prevalence

rates increase to 42% of the population
 METABOLIC SYNDROME
• Insulin resistance (type 2 diabetes)
• Hypertension
• Dyslipidemia
• Polycystic ovary syndrome
• Hyperuricemia
• Hypercoagulability
PREVALENCE OF METABOLIC
SYNDROME IN THE US

•Third NHANES Study (Prevalence Rates)

–21.6% African American Adults

–31.9% Mexican American Adults

–23.8% Caucasian Adults

 OBESITY—A PUBLIC HEALTH
PROBLEM

Rise in metabolic syndrome is related to

increasing prevalence of obesity

Multifactorial causes for obesity including

– A sedentary lifestyle
– Decline in exercise
– Increased access to unhealthy foods
– Greater food portions
 GESTATIONAL DIABETES
• Occurs after the onset of pregnancy

• Is secondary to the production of human

placental lactogen and other hormones
needed to sustain pregnancy

• Most common in people of color

 GESTATIONAL DIABETES
•If untreated, may result in fetal macrosomia
•Fetal macrosomia may lead to
–Cesarean section
–Shoulder dystocia
–Fetal hypoglycemia
•High risk women should be screened at first prenatal
visit
•Low-risk women should be screened from 24 to 28
weeks of gestation
 Hospitalization Costs for Chronic
Complications of Diabetes in the US
Ophthalmic Others Neurologic
disease disease  Total costs
Peripheral 12 billion
Renal
vascular
disease US $
disease

 CVD
accounts for
Cardiovascular 64% of total
disease
costs

American Diabetes Association. Economic Consequences of Diabetes Mellitus

in the US in 1997. Alexandria, VA: American Diabetes Association, 1998:1-14.
 DISPARITIES IN DIABETES
COMPLICATIONS IN AFRICAN AMERICANS

• Contributing factors
–Average delay in diagnosis of 4-7 years
–Longer duration of poorly controlled type 2
diabetes
–Development of equally devastating
complications
MICROVASCULAR COMPLICATIONS OF
DIABETES

•Diabetic retinopathy
–46% higher in African Americans and 86% higher
in Mexican Americans than in Caucasians

•Diabetic Nephropathy
–African Americans, Latinos, and Native Americans
have 3-4 times higher rates of renal failure than
Caucasians
 DIABETIC NEUROPATHY

•Primary contributor to the loss of limb protection

through the diminution or absence of pain and
sensory perception.

•Diminution or absence of pain and sensory

perception leads to limb trauma, open ulcers and
polymicrobial foot infections often culminating in
gangrene that is treated by limb amputation.

•Lower extremity limb amputation is 2-3 times higher

in African Americans and Mexican Americans than in
Caucasians.
 MACROVASCULAR
RISKS OF DIABETES
• Risk of stroke, coronary artery disease, and
peripheral vascular disease is increased 2-4
times in all patients with diabetes.

• The presence of diabetes is viewed as an

independent risk factor for first acute
myocardial infarction compared to those with
recurrent myocardial infarction without
diabetes.
 MACROVASCULAR
RISKS OF DIABETES
• The rates for myocardial infarction and stroke
among African Americans, Asian Americans and
Hispanic Americans are the same or lower than
in Caucasians; however, the mortality from CAD
is disproportionately high in minorities.

• Cardiovascular disease (CVD) remains the

leading cause of death in individuals with
diabetes, up to 70% of type 2 diabetes patients.
 RISK REDUCTION OF
MACROVASCULAR
COMPLICATIONS

–Glycemic Control
–Smoking Cessation
–Blood Pressure Control
–Lipoprotein Management
–Prothrombotic State Improvement
 SCREENING GUIDELINES
• Adults 45 years of age and older esp with BMI > 25
– Fasting Plasma Glucose at 3 year intervals

• Overweight or obese individuals with risk factors for

diabetes, African Americans, Latinos
– Fasting Plasma Glucose screened at an earlier age
and more frequently

• Children with BMI > 85th percentile

– Screened at age 10 and every 2 years thereafter
 DIAGNOSTIC CRITERIA
• Fasting Plasma Glucose > 126 mg/dL

• Casual Blood Sugar > 200 mg/dL or

greater as with diabetic symptoms

• 2-hour postprandial serum glucose of

200 mg/dL as stimulated by a glucose
tolerance test

• Test reconfirmation required

 PRE-DIABETIC STATES
• Impaired glucose tolerance (IGT)
– 2-hour glucose between 140 and 199

• Impaired fasting glucose (IFG)

– Fasting glucose beteween 100 and 125

• Above are risk factors for future

diabetes and cardiovascular disease
 Diabetes Prevention Program
Screened 158,177

OGTT, then randomize

3819 randomized

Lifestyle Metformin Placebo Thiazolidinedione

1079 1073 1082 585

5% Wt loss 3% Wt loss ~10 month followup

58 % 31% Diabetes Rate 23 %

Risk Reduction Risk Reduction 11 % per year Risk Reduction

Diabetes Prevention Program Research Gp,

NEJM 346(6): 393 -403, 2002.
 TREATMENT GOALS FOR
DIABETES MELLITUS
Maintaining:
• Pre-meal blood glucose in the range of
90 mg/dL to 130 mg/dL

• Bedtime blood glucose in the range of

100 mg/dL to 140 mg/dL

• A hemoglobin A1c value from 6.5% to 7%

over 3 months
 Increased A1c Raises Vascular
Event Risk
80

60 Microvascular
Adjusted Incidence per
1000 Patient-Years (%)

Complications

40 Myocardial
Infarction

20

0
0 5 6 7 8 9 10 11
Updated Mean A1c (%)*
* Updated mean A1c is adjusted for age, sex, and ethnic group, expressed for white men aged 50-54 years at diagnosis and
with mean duration of diabetes of 10 years.
Stratton IM et al. BMJ. 2000;321:405-412.
 Established Modifiable Cardiovascular
Risk Factors In Type 2 Diabetes
UKPDS 23
•Position
in Model Variable P Value*
•First Low-density lipoprotein cholesterol <.0001

•Second High-density lipoprotein cholesterol .0001

•Third Hemoglobin A1c .0022

•Fourth Systolic blood pressure .0065

•Fifth Smoking .056

* Significant for CAD (n = 280). P values are significance of risk factors after controlling for all other risk factors in model.
Adjusted for age and sex in 2693 white patients with type 2 diabetes with dependent variable as time to first event.
Turner RC et al. BMJ. 1998;316:823-828.
 TREATMENT GOALS FOR
DIABETES MELLITUS (Cont.)

Maintaining:
• Blood pressure < 130/80 mm Hg
• LDL Cholesterol < 100 mg/dL,
triglycerides < 150 mg/dL, and HDL
cholesterol > 40 mg/dL in men (> 50
mg/dL in women)
• High risk cardiovascular patients should
aim for LDL cholesterol < 70 mg/dL
 MANAGEMENT PLAN
• Must be individualized for each individual
patient
• Diabetes education: initial and subsequent
• Lifestyle modifications
– Diet (improve your nutrition)
– Exercise (increase your activity)
• Home blood glucose monitoring
– At least once/day for oral medications
– Three times daily for insulin users
• Medications
 FOLLOW-UP CARE
• Annual eye exam
• Physician visits every 3 months, more
frequently for poor control
– Fundoscopic exam
– Foot exam
• HbA1c quarterly for poor control, every
biannually for good control
• Lipogram yearly
• Microalbumin yearly
 Natural History of Type 2 Diabetes
Obesity IGT * Diabetes Uncontrolled
Hyperglycemia

Post-Meal
Plasma Glucose
Glucose
Fasting Glucose
120 (mg/dL)

Relative  -Cell Insulin Resistance

Function
100 (%)
Insulin Secretion

-20 -10 0 10 20 30
Years of
Diabetes *IGT = impaired glucose
tolerance.
Adapted from International Diabetes Center (IDC), Minneapolis, M innes ota.
 MEDICAL NUTRITIONAL
THERAPY
• Must be individualized for each patient
– Children must be allowed enough calories
for growth, development, and activity
– Pregnant women, elderly also deserve
special consideration
• Permanent low-carbohydrate diets not
recommended
– “carbohydrate counting” can be done with
insulin users
 MEDICAL NUTRITIONAL
THERAPY (cont)
• Weight management
– One should aim for 500-1000 Calorie reduction in
intake per day
– 1000-1200 Calories/day for women, 1200-1600
Calories/day for men for weight reduction
– Bariatrics?
• Activity should consist of 3-5 sessions per
week
– 30-45 minutes for health
– Weight loss: 1 hour of walking, 30 minutes of
vigorous exercise
 ORAL MEDICAL THERAPY
• First line: metformin useful except
where contraindicated
• Sulfonylureas or meglitinides also
frequently used
• Second line: thiazolidinediones
• Used uncommonly: acarbose
 INSULIN
• Traditional regimens
– Type 1: Basal insulin (NPH, glargine) with
bolus regular or short-acting insulin
(lispro, aspart, glulisine) by sliding scale;
split-mix regimen; insulin pump
– Type 2: split-mix regimen; fixed
combination (70/30, 50/50, 75/25); basal-
bolus
• Transitional type 2 insulin regimens:
oral agents with bedtime NPH or
glargine
 ADJUNCTS
• Cardiovascular
– Aspirin
• Renal
– ACE inhibitor/Angiotensin receptor
blocker
• Hypertension
– Diuretics
• Cholesterol
– Statins
 WHEN TO REFER
• Poor control for 6 months despite
patient adherence and physician
manipulation (HbA1c >10%)
• Multiple episodes of decompensation
(DKA, HONK)
• Frequent hypoglycæmic episodes
 Reference
• American Diabetes Association.
Diabetes Care 28:S4, 2005 Jan.
• American Association of Clinical
Endocrinologists. Endocrine Practice
8:S40, 2002 Jan/Feb.