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DIABETES

MELLITUS UPDATE
2014
Margarita Ochoa-Maya, MD
Advanced Health and Wellbeing, PC
Integrative and Functional Medicine
Endocrinology and Metabolism

THE FACTS ABOUT


DIABETES
Adapted from the CDC National Diabetes Facts: 2011
What is diabetes:
A group of diseases marked by high levels of blood

glucose
Results from deficits in
Insulin production
Insulin action
Both

Diabetes can lead to serious complications and

premature death
Diabetes is a lifestyle and can be controlled and
complications can be prevented

THE FACTS ABOUT


DIABETES
Adapted from the CDC National Diabetes Facts: 2011
The prevalence of Diabetes by type (Terminology):
Type 1:
Also called Insulin dependent juvenile onset
5% of all diagnosed cases of diabetes in adults
Type 2:

Also called non-insulin dependent or adult onset


90-95% of all diagnosed cases of diabetes in adults
Increasingly being diagnosed in children and adolescents

Gestational Diabetes:
2-10% of pregnancies
Women who have had GDM have a 35-60 % chance of
developing diabetes (mostly Type 2) in the next 10 20 years

THE FACTS ABOUT


DIABETES
Adapted from the CDC National Diabetes Facts: 2011
What is the prevalence of diabetes by gender?
13 million men have diabetes
11.8 % of all men ages 20 and older
12.6 million women have diabetes

10.8% of all women ages 20 and older

What is the prevalence of diabetes by age?


25.6 million Americans 20 or older have diabetes

11.3 % of this age group

10.9 million Americans 65 and older have diabetes


26.9 % of this age group

THE FACTS ABOUT


DIABETES
Adapted from the CDC National Diabetes Facts: 2011
What is the prevalence of diabetes in youth?
215,000 Americans younger than age 20 have diabetes
Most cases in children and adolescents are Type 1

What is the prevalence of diabetes by ethnicity?


Non-hispanic whites:15.7 million (10.2%)
African-Americans: 4.9 million (18.7 %)
Hispanics Latinos: 11.8 % (7.6% Cubans- 13.8% PR)
American Indians: 16.1% (5.5% AK -35.5% AZ)
Asian Americans: 8.4%

THE FACTS ABOUT


DIABETES
Adapted from the CDC National Diabetes

Facts: 2011
Compared to Non-Hispanic Whites, the
risk of diagnosed diabetes:
18% higher among Asian Americans
66% higher among Hispanics/ Latinos
77% higher among non-Hispanic Blacks

THE FACTS ABOUT


DIABETES
Adapted from the CDC National Diabetes Facts:

2011
How many deaths are linked to diabetes?
Diabetes is the 7th leading cause of death listed

on the US. Death certificate


Cardiovascular disease is the leading cause of
death among people with diabetes

68% die of heart attack or stroke

The risk of overall death among people

with diabetes is DOUBLE that of people


without diabetes

THE FACTS ABOUT


DIABETES
Adapted from the CDC National Diabetes Facts:

2011
How much does diabetes COST the Nation?
Total health care and related costs for the

treatment of diabetes runs about $174 BILLION


annually (per year)
Of this total:
DIRECT MEDICAL COSTS: (Hospitalizations, medical care,
treatment supplies, prescriptions):$116 BILLION / year
INDIRECT COSTS: (Disability, time lost from work, and
premature death): $58 BILLION / year

THE FACTS ABOUT


DIABETES
CRITERIA FOR DIAGNOSIS OF DIABETES:
HbA1c > 6.5%
Fasting Plasma glucose >126 mg/dL
2 hour plasma glucose after 75 g glucose challenge:
>200mg/dL
Random plasma glucose >200 mg/dL + Sx
CRITERIA FOR CARDIOMETABOLIC SYNDROME AND

PRE DIABETES:
Fasting plasma glucose 100- 125 mg/dL (IFG)
2 hour plasma glucose after 75 g glucose challenge:

140-199 mg/dL (IGT)


HbA1c 5-7%-6.4%

How many Americans have


Diabetes and the CardioMetabolic Syndrome?
25.8 million Americans have diabetes
8.3% of the U.S population

Of these: 7 million do not know they have diabetes

In 2010, about 1.9 million people ages 20 or older were

diagnosed with diabetes


The number of people diagnosed with diabetes:
In 1958: 1.5 million
In 2010: 18.8 million
IT IS AN EPIDEMIC!

It is estimated that 79 million adults aged 20 or older

have the Cardio-Metabolic Syndrome also named PreDiabetes

How many people have the


Cardio-Metabolic Syndrome?
How is the Cardio-Metabolic Syndrome

diagnosed?
Blood pressure equal or higher than 130/85

mmHg
Fasting blood glucose greater than 100 mg/dL
Large waist circumference
Men: 40 inches or more
Women: 35 inches or more

Low HDL cholesterol:


Men: Under 40 mg/dL
Women: under 50 mg/dL
Triglycerides equal or higher than 150mg/dL

THE STATE OF Cardiometabolic


RISK?
2 out of 3 Americans are overweight or obese
More than 70 million (nearly 1 in 4) Americans

have varying degrees of insulin resistance

There are an estimated 54 million (more than 1 in

6) Americans with prediabetes

Nearly 1 in 4 U.S. adults has high cholesterol


1 in 3 American adults has high blood pressure

CARDIOMETABOLIC RISK FACTORS


NON MODIFIABLE
Age
Race/ethnicity
Gender
Family history

MODIFIABLE
Overweight
Abnormal lipid
metabolism

Inflammation
Hypercoagulation
Hypertension
Smoking
Physical inactivity
Unhealthy diet
Insulin resistance

INSULIN RESISTANCE

FACTORS AFFECTING
INSULIN RESISTANCE
Overweight/ fat distribution
Age
Genetic predisposition
Activity level
Medications
Puberty
Pregnancy

CRITERIA FOR TESTING IN YOUTH


Overweight (BMI > 85th percentile for age and sex,

weight for height > 85th percentile, or weight


>120 percent of ideal for height) Plus any two of the
following:
Family history
Race/ethnicity
Signs of insulin resistance or conditions associated
with insulin resistance
Maternal history of diabetes or GDM

CRITERIA FOR TESTING IN ADULTS


Testing should be considered in all overweight
adults
(BMI 25 kg/m2*) and have additional risk
factors:

Physical inactivity
First-degree relative with diabetes
Members of a high-risk ethnic population
Women delivering baby weighing >9 lb or
were diagnosed with GDM
Hypertension (140/90 mmHg)

CRITERIA FOR TESTING IN ADULTS


Testing should be considered in all overweight
adults
(BMI 25 kg/m2*) and have additional risk
factors:

HDL cholesterol level <35 mg/dl (0.90


mmol/l) and/or a triglyceride level >250
mg/dl (2.82 mmol/l)
Women with polycystic ovarian syndrome
(PCOS)
IGT or IFG on previous testing
Other clinical conditions associated with
insulin resistance (e.g., severe obesity and

CRITERIA FOR TESTING IN ADULTS


Testing should be considered in all overweight
adults
(BMI 25 kg/m2*) and have additional risk
factors:
In the absence of the previous criteria, testing for

pre-diabetes and diabetes should begin at age 45


years

If results are normal, testing should be repeated

at least at 3-year intervals, with consideration of


more frequent testing depending on initial results
and risk status.

(n=943)

CHD mortality, per 1000

P<.01

29

30-50

51-72

73-114

115

Quintiles (pmol) of fasting plasma insulin


Insulin Sensitive
Fontbonne AM, et al. Diabetes Care. 1991;14:461-469.

Insulin Resistant

Cardiometabolic Risk
Insulin Sensitivity
Insulin Secretion
Associated Risk Factors
Hypertension
Dyslipidemia
Atherogenesis
Microvascular
Complications
Fasting Blood Glucose

tes
Diabe

Euglycemia

Impaired Fasting Glucose

Age (years)

Type 2 Diabetes

Cardiometabolic Risk
Factors
Overweight/obesity
Source: CDC , ADA

Abnormal lipid metabolism


High LDL cholesterol
Low HDL cholesterol
High triglycerides

Desired Goals for Healthy Patients


Prevention of overweight/obesity as measured by BMI
(normal = 18.524.9).
In those who are overweight/obese, the goal is to lose 5
7% of body weight.
Desirable levels are less than 100 mg/dL.
Desirable levels are greater than 40 mg/dL in men and
greater than 50 mg/dL in women.
Desirable levels are less than 150 mg/dL

Source: NHLBI, ATP III Guidelines, ADA

Hypertension
Source: NHLBI, JNC7

<140/90 mm/Hg or 130/80 mm/Hg for people with diabetes


(Ideal is less than 120/80 mm/Hg)

Fasting blood glucose

Below 100 mg/dL

Source: ADA

Physical inactivity Source: CDC

At least 30 minutes of moderate activity most days

Smoking Source: ADA

Quit or never start

Children

Maintain healthy weight for age, sex, and height.

Source: ADA

SCREENING FOR OBESITY


Measure BMI routinely at each regular check-up.
Classifications:
BMI 18.5-24.9 = normal
BMI 25-29.9 = overweight
BMI 30-39.9 = obesity
BMI 40 = extreme obesity

Measure waist circumference:


Large waist circumference (WC) can identify some at increased
risk over BMI alone

If BMI and other cardiometabolic risk factors are assessed,


currently there is insufficient evidence to:
Substitute WC for BMI
Measure WC in addition to BMI

RISK MANAGEMENT: OVERWEIGHT


Consider pharmacologic treatment
BMI 30 with no related risk factors or diseases,

or
BMI 27 with related risk factors or diseases
As part of a comprehensive weight loss program
incl. diet & physical activity

Consider surgery
BMI 40 or
BMI 35 with comorbid conditions
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and
Obesity in Adults: The Evidence Report. NIH Publication # 98-4083, September 1998,
National Institutes of Health. Diabetes Prevention Program (DPP) Diabetes Care 25:2165
2171, 2002. The Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure, NIH Publication No. 045230, August 2004

TOTAL CHOLESTEROL
GOALS
Desirable Less than 200 mg/dL
Borderline high risk 200239 mg/dL
High risk 240 mg/dL and over

ABNORMAL LIPID
METABOLISM
Increased:
Triglycerides
VLDL
LDL and small
dense LDL
ApoB

Decreased:
HDL
Apo A-I

CHOLESTEROL
MANAGEMENT
For patients >20 years of age, cholesterol

should be checked every 5 years

Ordering a fasting lipid panel is preferred to

gauge the patients total cholesterol, LDL-C,


HDL-C and triglycerides

Treatment priorities

LDL-C-lowering
Category of risk

LDL-C Goal

0-1 risk factor*

< 160 mg/dL or lower

Multiple (2+) risk factors*

< 130 mg/dL or lower

People with coronary heart < 100 mg/dL or lower


disease or risk equivalent
(e.g., diabetes)
Known CAD and DM

< 70 mg/dL or lower


may be ideal

3
2.5
Relative Risk

Women

Men
n=5,127

2
1.5
1
0.5
0
50

100

150

200

250

300

350

400

Triglyceride Level, mg/dL


Castelli WP. Epidemiology of triglycerides: a view from Framingham American Journal of Cardiology. 1992;70:3H-9H.

Mean Steady State


Plasma Glucose (mmol/L)
at Identical Plasma Insulin

12

(n=19)
(n=19)

10
8

(n=29)
(n=29)
(n=52)
(n=52)

6
4
2
0

A
Larger LDL particle
pattern

Intermediate
pattern

B
Small LDL particle
pattern

LDL-Size Phenotype
Reaven GM, et al. J Clin Invest. 1993;92:141-146.

Risk of CHD

-C
L
HD

L)
d
g/
(m

LDL-C (mg/dL)
Gordon T, Castelli WP, Hjortland MC, Kannel WB, Dawber TR. High density lipoprotein as a protective factor against
coronary heart disease. The Framingham Study. American Journal of Medicine. 1977;62:707-14.

ABNORMAL
CHOLESTEROL PX:
Pharmacologic treatment: primary goal is LDL
lowering

Without overt CVD: If over 40, statin therapy


recommended to achieve 30-40% LDL reduction

With overt CVD: All patients should receive


statin therapy to achieve 30-40% LDL reduction

Lowering triglycerides and raising HDL with a


fibrate is associated with fewer cardiovascular
events in patients with clinical CVD, low HDL,
and near-normal LDL

HYPERTENSION:
Evaluation and Screening
Persons without Diabetes
BP should bemeasured at each regular visit or

at least once every 2 years if BP <120/80 mmHg


BP measured seated after 5 min rest in office

Persons with Diabetes


BP should bemeasured at each regular visit
BP measured seated after 5 min rest in office
Patients with 130 or 80 mmHg should have
BP confirmed on a separate day

MANAGEMENT OF HYPERTENSION
Non-pharmacologic
DASH diet
Dietary

Approaches to Stop
Hypertension
High in whole grains, fruits, vegetables,
and low-fat dairy
Low in saturated and trans fat,
cholesterol
Physical Activity
Weight loss, if applicable

MANAGEMENT OF HYPERTENSION
Pharmacologic
Drug therapy indicated if BP 140/ 90
mm Hg
Combination therapy often necessary
Treatment should include ACE or ARB
Thiazide diuretic may be added to reach
goals
Monitor renal function and serum
potassium

COMPLICATIONS OF HYPERTENSION
Microvascular
Renal disease
Autonomic neuropathy
Eye disease (glaucoma, retinopathy with
potential blindness)
Macrovascular
Cardiac disease
Cerebrovascular disease
Reduced survival and recovery rates from stroke
Peripheral vascular disease

PHYSICAL ACTIVITY
35% of coronary heart disease deaths in

the US can be attributed to an inactive


lifestyle*
Consistent exercise can reduce CVD risk*
Exercise, combined with healthy diet and
weight loss, is proven to prevent/delay
onset of type 2 diabetes
* American Diabetes Association. Diabetes Care. 2007;30:S4-41.
Diabetes Prevention Program Diabetes Care 25:21652171, 2002.

PHYSICAL ACTIVITY
Benefits of Exercise
Increased insulin sensitivity
Improved lipid levels
Lower blood pressure
Weight control
Improved blood glucose control
Reduced risk of CVD
Prevent/delay onset of type 2 diabetes
American Diabetes Association. Diabetes Care. 2007;30:S4-41

PHYSICAL ACTIVITY: PRECAUTIONS


Peripheral neuropathy can cause loss of

sensation in feet; educate about preventive


care measures for foot protection
Pre-existing CVD can cause arrhythmias,
myocardial ischemia, or infarction during
exercise
In presence of PDR or severe NPDR, vigorous
exercise or resistance training may be
contraindicated because of risk of vitreous
hemorrhage or retinal detachment
American Diabetes Association. Diabetes Care. 2007;30:S4-41

Hazards Ratio (95% CI)


Never Smoked
Ex-Smoker
Current Smoker

1
1.08 (0.75 - 1.54)
1.58 (1.11 - 2.25)

R C Turner, H Millns, H A W Neil, I M Stratton, S E Manley, D R Matthews, and R R Holman. Risk factors for
coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes
study (UKPDS: 23) BMJ. 1998;316:823-828.

SMOKING:
Cessation Resources
Set a Plan
Offer counseling and referrals
Offer medication assistance
Offer combined pharmacologic and behavioral
intervention
Online guide to quitting: SmokeFree.gov

American Diabetes Association. Diabetes Care.

2004;27:S27:S74-S75

INFLAMMATION

INFLAMMATION +
HYPERCOAGULATION
Proinflammatory/prothrombotic factors

underlie cardiometabolic risk


Inflammation is a major component of
atherogenesis and other cardiometabolic
problems
Obesity is associated with inflammation
Ross R. Atherosclerosis: an inflammatory disease. N Engl J Med.
1999;340:115-126. Ballantyne CH, Nambi V. Markers of inflammation
and their clinical significance. Atherosclerosis suppl 2005; 6: 21-9.
McLaughlin T et al. Differentiation between obesity and insulin
resistance in the association with C-reactive protein. Circulation.
2002;106:2908-2912.

RISK MANAGEMENT:
INFLAMMATION
High-sensitivity CRP tests may be used to further
evaluate underlying risk

Relative risk categories


Low risk
Average risk
High risk

<1 mg/L
1-3 mg/L
>3 mg/L
Aspirin and statins reduce CRP levels
Unclear whether CRP should be a treatment target
Reduce weight
Ross R. Atherosclerosis: an inflammatory disease. N Engl J
Med.1999;340:115- 126. Ballantyne CH.

Fasting Plasma
Glucose

Any abnormality
must be repeated
and confirmed on
a separate day*

Diabetes Mellitus

2-hour Plasma
Glucose On OGTT
Diabetes Mellitus

126 mg/dL

100 mg/dL

Impaired Glucose
Tolerance

Impaired Fasting
Glucose

200 mg/dL

140 mg/dL

Normal

Normal

Pre-Diabetes
* One can also make the diagnosis of diabetes based on
unequivocal symptoms and a random glucose >200 mg/dL

Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.
Diabetes Care 2004; Supplement 1

40

Cumulative Incidence
of Diabetes (%)

Placebo
30

Metformin

20

Lifestyle

10

0
0

0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

Years
Knowler WC, et al. NEJM. 2002;346:393-403.

Medication

Behavior

Results of Recent Randomized Trials


Study

Subjects

Intervention

Relative Risk
Reduction

Finnish DPS

IGT

Lifestyle

58%

IGT

Lifestyle

58%

IGT
IGT

Metformin
Acarbose

31%
25%

US DPP
US DPP
STOPNIDDM
TRIPOD
XENDOS
DREAM

Troglitazone
Prior GDM
Orlistat
IGT
Rosiglitazone/Ramipril
IGT

55%
45%
61%/NS

WHAT SHOULD WE DO
LIFESTYLE
DIET
EXERCISE
SLEEP
MOOD

PRESCRIPTIONBLOOD SUGAR MONITORING


BEFORE AND 2 HOURS AFTER EATING
PX THAT AFFECT THE BRAIN
PX THAT AFFECT THE GASTROINSTEINAL TRACT
PX THAT AFFECT THE LIVER
PX THAT AFFECT THE PANCREAS
PX THAT AFFECT THE KIDNEYS

THANK YOU
Dr. Margarita Ochoa-Maya, MD
Advanced Health and Wellbeing, PC