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