ABC’s and…..P of Diabetes Eric L. Johnson, M.D. Assistant Professor Department of Family and...

ABC’s and…..P of Diabetes

Eric L. Johnson, M.D.Assistant Professor

Department of Family and Community MedicineUNDSMHS

Assistant Medical DirectorAltru Diabetes Center

Grand Forks, ND

Definitions

• Diabetes is a disorder of abmormal blood sugar levels

• Defect of insulin production or its use by the body

• Insulin is a hormone made by pancreas to regulate blood sugar

Definitions

• Type 1 diabetes: usually younger, go on insulin day of diagnosis

• Type 2 diabetes: usually older, usually treat with pills first

• They end up about the same in adulthood

U.S. Prevalence of Diabetes 2010

• Diagnosed: 26 million people—8.3% of population (90%+ have Type 2)

• Undiagnosed: 7 million people

• 79 million people have pre-diabetes

CDC 2011

Diabetes In The U.S. 2010• 8.3% of all Americans• 11.3% of adults age 20 and older• 27% of adults age 65 and older• 1.9 million diagnosed in 2010• Could be 33% by 2050• Prediabetes

35% of adults age 20 and older

50% of Americans 65 and older

CDC 2011

Estimated Prevalence and Cost of Diabetes in North

Dakota• ~6.7% of adults (~40,000 people)

• Medical cost of diabetes: $209,700,000

• Indirect Cost: $99,140,000

• Total Cost: $308,800,000

Estimated Prevalence and Cost of Diabetes in

Minnesota• ~6% (~300,000 people)

• Medical cost of diabetes: $1,750,000,000

• Indirect Cost: $929,000,000

• Total Cost: $2,679,000,000

Individual Diabetes Costs

• $8,000-$14,000/year for diabetes

• $3200-$3800/year for non-diabetes

• This study only looked at 18-65 y/o

Curr Med Res Opin. 2010 Aug;26(8):1827-34

Stop Diabetes

• Diabetes needs more urgency

• Diabetes is fatal

• People get cancer, they do everything to get better (and they should)

• People get diabetes, don’t always take it seriously

• Many cases of type 2 diabetes are preventable

Diagnosing DiabetesCategory Fasting blood sugar

Normal <100Impaired Fasting Glucose (IFG)100 – 125

(prediabetes)

Diabetes >126**

•OR A1C >6.5** On 2 separate occasions American Diabetes AssociationAmerican Diabetes Association

Risk Factors for Type 2 Diabetes

• Obesity/poor diet

• Family History

• Sedentary Lifestyle• Gestational Diabetes (diabetes of pregnancy)

• Smoking

• Increasing Age

Screening for Type 2 Diabetes

• 45 year old and older

• Risk factors like Family History, Ethnic, High Blood Pressure, Smoking

• History of Gestational Diabetes

• Any previously documented abnormal blood sugar (i.e., prediabetes)

Diabetes Complications• Eye disease/blindness• Kidney disease• Heart Disease (common)• Stroke (common)• Nerve damage• Liver disease• Amputation• Infection

• Scary stuff…..

• But…..

• Treatments are much better than 10 or 20 years ago

• This is not your father’s or mother’s diabetes!

• Many cases of type 2 diabetes are preventable

ABC’s….and P of Diabetes• A1C: Test relating to blood sugar

• Blood Pressure: Many adults with diabetes have high blood pressure

• Cholesterol: Many adults with diabetes have high cholesterol

• Prevention: Type 2 diabetes can be avoided/delayed

Avoid Complications of Diabetes

• Good blood sugar control

• Good blood pressure control

• Good cholesterol control

A1C

A1C/Blood Sugar Control

• A1C < 7 for most non-pregnant adults• Average daily blood sugar of 154• Recommend pre-meal blood sugar <130• Recommend 2 hours after meal blood sugar

<180• Many medications available, meal planning

and exercise are important

A1C ~ “Average Glucose”

American Diabetes Association

A1C eAG

% mg/dL mmol/L

6 126 7.0

6.5 140 7.8

7 154 8.6

7.5 169 9.4

8 183 10.1

8.5 197 10.9

9 212 11.8

9.5 226 12.6

Formula: 28.7 x A1C - 46.7 - eAG

Diabetes Medications

• Many new medications on the market in the last 10 years

• Three main categories of medication– Oral agents (pills)- many different kinds old and new

– Insulin- newer, more modern insulins

– Newer, non-insulin injectable medications

• Choices allow individualization of treatment plan

• Different medications, different indications, different situations

Diabetes Medications-Pills

• Sulfonylureas: Glyburide, Glipizide, Glimiperide

• Biguanides: Metformin

• TZD’s: Actos, Avandia

• DPP-IV: Januvia, Onglyza

• Others, i.e., Welchol

Diabetes Medications-Injected

• Non-insulin: Byetta, Victoza, Symlin

• Insulin:

-long acting: NPH, Lantus,Levemir

-short acting: R, Novolog, Humalog, Apidra

What Medication to Use?

• Type 1 always insulin

• Type 2 combination of pills, insulin, other injectable

Medication selection in type 2 depends on patient and “where they are at”

What Medication to Use?

• In type 2, metformin is almost always used in combination with another medication

• Nearly all patients with type 2 will eventually need to be on insulin, as the body makes less insulin with age

• Insulin!?!?!• No problem, nearly all come in easy to use pen

injectors

Blood Pressure

Blood Pressure

• Many adults with diabetes have high blood pressure

• High blood pressure increases risk for kidney disease, heart attack, and stroke

• Target blood pressure in diabetes

<130/<80

Blood Pressure Medications

• ACE Inhibitors (recommended)

Lisinopirl, Enalapril

• ARB alternative to ACE (usually)

Diovan, Cozaar, others

• Beta Blockers

Atenolol, Metoprolol

Blood Pressure Medications

• Calcium Channel Blockers

Diltiazem, Nifedipine, Amolidopine

• Diuretics (“water pills”)

HCTZ, Furosemide, others

Cholesterol

Cholesterol

• Often abnormal in adults with diabetes

• Increases risk for heart disease, stroke, amputation

Cholesterol Targets in Diabetes

• Total Cholesterol <200

• Triglycerides <150

• HDL (good)– >40 for males– >50 for females

• LDL (bad)– <100– <70 for high risk

Cholesterol Medications

• Statins

Simivastatin, atorvastatin, rosuvastatin• Fibrates

Tricor• Fish Oil (omega-3)• Niacin• Others, i.e., Zetia

Heart Disease and Stroke

• Don’t smoke

• Treat cholesterol to target

• Treat blood pressure to target

• Daily aspirin in many patients (>50 y/o)

Treating these risk factors effectively can lower risk by up to 40%

Prevention

Pre-Diabetes• Abnormal blood sugar

• Not abnormal enough to be classified as diabetes–Normal blood sugar fasting <100–Pre-diabetes blood sugar 100-125–Diabetes blood sugar >126–Usually obese

Pre-Diabetes

• Higher risk to develop type 2 diabetes

• Best prevention is lifestyle management

• May be a role for medication in certain patients or in the future

Pre-Diabetes• Lifestyle management can reduce risk of

diabetes by over 50%• Lifestyle management

–Meal plan–Activity plan–Stop smoking

• Diabetes medications to prevent diabetes not as effective (although this may change with newer meds)

Lifestyle Management/Prevention

• 30 minutes of activity 5 days a week• Portion control, “heart healthy” meal plans• 7% body weight reduction is associated

with lower risk of diabetes• Can improve blood pressure and

cholesterol• Talk with health care provider

Activity/Exercise

• Needs to be individualized- for example, if you have arthritis in knees/hips, walking may not be best

• Can be simple to start- for example, low weight dumbells while watching TV

• Be alert to opportunities to be active

Resources• American Diabetes Association (ADA)

www.diabetes.org• American Heart Association (AHA)

www.americanheart.org• Centers for Disease Control (CDC)

www.cdc.gov• Commercial programs- • Weight Watchers www.weightwatchers.com• Meal planning websites i.e., six o’clock

scramble thescramble.com

Summary• Diabetes is common• Diabetes is costly• Diabetes is fatal• Manage diabetes, blood pressure, cholesterol to

reduce risk

• Type 2 Diabetes can be prevented or delayed

• Pre-diabetes should be diagnosed and managed to prevent or delay Type 2 Diabetes and diabetes complications