Management of common comorbidities in diabetes
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Management of Common Comorbidities in Diabetes. Management of Common Comorbidities in Diabetes. Obesity. Prevalence of Obesity in Type 2 Diabetes. NHANES 1999-2004 (N=984). Normal (BMI <25). 12%. Overweight (BMI 25-29). 27%. T2DM Patients (%). Obese (BMI ≥30). 61%.

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Management of Common Comorbidities in Diabetes

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Management of common comorbidities in diabetes

Management of Common Comorbidities in Diabetes


Management of common comorbidities in diabetes1

Management of Common Comorbidities in Diabetes

Obesity


Prevalence of obesity in type 2 diabetes

Prevalence of Obesity inType 2 Diabetes

NHANES 1999-2004

(N=984)

Normal (BMI <25)

12%

Overweight(BMI 25-29)

27%

T2DM Patients (%)

Obese(BMI ≥30)

61%

BMI, body mass index, in kg/m2.

SuhDC, et al. J Diabetes Complications. 2010;24:382-391.


Consequences of obesity in diabetes

Consequences of Obesity in Diabetes

  • Increases risk of cardiovascular comorbidities

    • Hypertension

    • Dyslipidemia

    • Atherosclerosis

  • May limit ability to engage in physical activity

  • Increases insulin resistance

    • Worsens glucose tolerance

    • Necessitates higher exogenous insulin doses

  • Changes neuroendocrine signaling and metabolism

  • Reduces quality of life

Goal: 5% to 10% weight loss

Handelsman Y, et al. EndocrPract. 2011;17(suppl 2):1-53.


Energy homeostasis

Energy Homeostasis

Body Weight

Increase Decrease

Energy intake

Ingestion of:

Proteins

Fats

Carbohydrates

Energy expenditure

Physical activity

Diet-induced thermogenesis

Basal metabolic rate


Multihormonal control of body weight fat gut and islet derived signals

Vagal afferents

Hypothalamus

GI tract

Adipose tissue

Ghrelin

Hindbrain

CCK

Leptin

PYY3-36

Insulin

GLP-1

Amylin

Resistin

Visfatin

OXM

Adiponectin

GIP

Pancreatic islets

PP

Multihormonal Control of Body Weight: Fat-, Gut-, and Islet-Derived Signals

Badman MK, et al. Science. 2005;307(5717):1909-1914.


Small amounts of weight gain or loss have important effects on chd risk

Small Amounts of Weight Gain or Loss Have Important Effects on CHD Risk

Framingham Offspring Study 16-year Follow-up*

**

**

Change in Risk Factor Sum (%)

**

**

*Patients with Low HDL-C, high cholesterol, high BMI, high systolic BP, high triglyceride, high glucose.

**P <0.002 vs baseline.

Wilson PW, et al. Arch Intern Med. 1999;159:1104-1109.


Abdominal obesity and increased risk of cardiovascular events

Abdominal Obesity and Increased Risk of Cardiovascular Events

The HOPE Study

Waist Circumference (cm)

MenWomen

Tertile 1<95<87

Tertile 295-10387-98

Tertile 3>103>98

*Adjusted for BMI, age, smoking, sex, CVD disease, DM, HDL-cholesterol, total-C; CVD: cardiovascular disease; MI: myocardial infarction; BMI: body mass index; DM: diabetes mellitus; HDL: high-density lipoprotein cholesterol.

Dagenais GR, et al. Am Heart J.  2005;149:54-60.


Medical complications of obesity

Medical Complications of Obesity

Pulmonary disease

Abnormal function

Obstructive sleep apnea

Hypoventilation syndrome

Idiopathic intracranial hypertension

Stroke

Cataracts

Nonalcoholic fatty liver disease

Steatohepatitis

Cirrhosis

Coronary heart disease

Diabetes

Dyslipidemia

Hypertension

Gall bladder disease

Severe pancreatitis

Gynecologic abnormalities

Abnormal menses

Infertility

Polycystic ovary syndrome (PCOS)

Cancer

Breast, uterus, cervix, colon, esophagus, kidney, pancreas, prostate

Phlebitis

Venous stasis

Osteoarthritis

Skin

Gout


Health effects of weight change in t2dm

Health Effects of Weight Change in T2DM

  • Weight loss

    • Every kg of weight loss is associated with 3-4 months of improved survival1

    • In a prospective analysis of 5000 people with type 2 diabetes, 35% reported intentional weight loss; this subgroup experienced a 25% reduction in mortality over 12 years2

  • Weight gain

    • A 5-kg weight gain increases CHD risk by 30%3

1. Lean ME, et al. Diabet Med. 1990;7:228-233.

2. Williamson DF, et al. Diabetes Care. 2000;23:1499-1503. 3. Anderson JW, et al. J Am CollNutr. 2003;22:331-339.


Aace healthful eating recommendations

AACE Healthful Eating Recommendations

Handelsman Y, et al. EndocrPract. 2011;17(suppl 2):1-53.


Aace physical activity recommendations

AACE Physical Activity Recommendations

  • Evaluate for contraindications and/or limitations to increased physical activity before patient begins or intensifies exercise program

  • Develop exercise recommendations according to individual goals and limitations

  • ≥150 minutes per week of moderate-intensity exercise

    • Flexibility and strength training

    • Aerobic exercise (eg, brisk walking)

  • Start slowly and build up gradually

Handelsman Y, et al. EndocrPract. 2011;17(suppl 2):1-53.


Antidiabetic agents and weight gain loss potential

Antidiabetic Agents and Weight Gain/Loss Potential

Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.

RodbardHW, et al. EndocrPract. 2009;15:540-559.


Management of common comorbidities in diabetes2

Management of Common Comorbidities in Diabetes

Dyslipidemia


Prevalence of hyperlipidemia in t2dm

Prevalence of Hyperlipidemia in T2DM

Retrospective Medical Database Study, T2DM

(N=125,464)

NHANEST2DM Patients With Hyperlipidemia*

1%, No need for treatment

63%

Receiving statin

35%

Eligible for lipid-lowering therapy but untreated

*LDL-C ≥100 mg/dL, TC≥200 mg/dL, or TG≥150 mg/dL (treatment not assessed).

Fu AZ, et al. Curr Med Res Opin. 2011;27:1035-1040.

SuhDC, et al. J Diabetes Complications. 2010;24:382-391.


Atherogenic dyslipidemia

Atherogenic Dyslipidemia

  • Common in T2DM and the insulin resistance syndrome

  • Features

    • Elevated triglycerides

    • Decreased HDL-C

    • Small, dense LDL particles

    • Postprandial increase in triglyceride-rich lipoproteins

HDL-C, high-density lipoprotein cholesterol;LDL, low-density lipoprotein.

JellingerPS, et al. EndocrPract. 2012;18(suppl 1):1-78.


Dyslipidemia treatment options

Dyslipidemia Treatment Options

HDL-C, high-density lipoprotein cholesterol;LDL, low-density lipoprotein.

JellingerPS, et al. EndocrPract. 2012;18(suppl 1):1-78.


Benefits of aggressive ldl c lowering in diabetes

Benefits of Aggressive LDL-C Lowering in Diabetes

Primary event rate (%)

Aggressive lipid-loweringbetter

Aggressive lipid-lowering worse

Difference in LDL-C(mg/dL)

Treatment

Control

P

TNT Diabetes, CHD

ASCOT-LLA Diabetes, HTN

CARDS

Diabetes, no CVD

HPS

All diabetes

Diabetes, no CVD

13.8

9.2

5.8

9.4

9.3

17.9

11.9

9.0

12.6

13.5

0.026

0.036

0.001

<0.0001

0.0003

22*

35†

46†

39†

39†

0.75

0.77

0.63

0.73

0.67

0.5

0.7

0.9

1

1.7

*Atorvastatin 10 vs 80 mg/day

†Statin vs placebo

Relative risk

Shepherd J, et al. Diabetes Care. 2006;29:1220-1226. Sever PS, et al. Diabetes Care. 2005;28:1151-1157.ColhounHM, et al. Lancet.2004;364:685-696. HPS Collaborative Group. Lancet. 2003;361:2005-2016.


Randomized trials of statins a meta analysis of cv events

Randomized Trials of Statins: A Meta-Analysis of CV Events

Patients with Diabetes

(N=18,686; 14 RCTs)

Risk Reduction in Major Vascular Events per mmol/L Decrease in LDL-C

Cholesterol Treatment Trialists’Collaborators. Lancet. 2008;371:117-125.


Treat patients with the greatest absolute risk the most aggressively

Treat Patients With the Greatest Absolute Risk the Most Aggressively

Robinson JG, et al. Am J Cardiol. 2006;98:1405-1408.


Residual cardiovascular risk in major statin trials

Residual Cardiovascular Risk in Major Statin Trials

CHD events still occur in patients treated with statins

Secondary

Primary

LIPID

CARE

HPS

CARDS

TotalPopulation(%)

N =9014415920,5362841

 LDL-C-25%-28%-29%-40%

Patients with Diabetes(%)

N =78258659632841

LIPID Study Group. N Engl J Med. 1998;339:1349-1357. Sacks FM, et al. N Engl J Med. 1996;335:1001-1009.HPS Collaborative Group. Lancet. 2002;360:7-22. Colhoun HM, et al. Lancet. 2004:364:685-696.


Lipid effects of adding a fenofibrate to a statin in patients with t2dm

Lipid Effects of Adding a Fenofibrate to a Statin in Patients With T2DM

Action to Control Cardiovascular Risk in Diabetes

(N=5518)

ACCORD Study Group. N Engl J Med. 2010;362:1563-1574.


Effects of adding a fenofibrate to a statin on cv events in patients with t2dm

Effects of Adding a Fenofibrate to a Statin on CV Events in Patients With T2DM

Action to Control Cardiovascular Risk in Diabetes

(N=5518)

ACCORD Study Group. N Engl J Med. 2010;362:1563-1574.


Adding a fenofibrate to a statin in patients with t2dm subgroup analyses

Adding a Fenofibrate to a Statin in Patients With T2DM: Subgroup Analyses

Action to Control Cardiovascular Risk in Diabetes

(N=5518)

ACCORD Study Group. N Engl J Med. 2010;362:1563-1574.


Effect of fenofibrate on progression of coronary atherosclerosis in patients with type 2 diabetes

Effect of Fenofibrateon Progression of Coronary Atherosclerosis in Patients With Type 2 Diabetes

Diabetes Atherosclerosis Intervention Study

*

Change in Stenosis (%)

(n=207)

(n=211)

*P=0.02 vs placebo

Diabetes Atherosclerosis Intervention Study. Lancet. 2001;357:905-910.


Coronary drug project 15 year follow up

Coronary Drug Project:15-Year Follow-up

11% Reduction

P =0.0004

Event Rate (%)

12% Reduction

P <0.05

Canner PL, et al. J Am CollCardiol. 1986;8:1245-1255. Canner PL, et al. J Am CollCardiol. 2005;95:254-257.


Dyslipidemia summary

Dyslipidemia Summary

  • Patients with diabetes and insulin resistance syndrome have atherogenic dyslipidemia and an increased risk for CVD

  • Although statin therapy is effective in lowering LDL-C, residual CVD risk remains after statin therapy

  • To reduce residual CVD risk, lipid abnormalities beyond LDL-C (non–HDL-C, triglycerides,HDL-C) should be intensively treated

CVD, cardiovascular disease; HDL-C, high-density lipoprotein cholesterol;LDL-C, low-density lipoprotein cholesterol.

JellingerPS, et al. EndocrPract. 2012;18(suppl 1):1-78.


Management of common comorbidities in diabetes3

Management of Common Comorbidities in Diabetes

Hypertension


Meta regression analysis of major cv events and bp reduction

Meta-Regression Analysis of Major CV Events and BP Reduction

2.0

1.0

Relative Risk

0.5

Reduction in risk per 5 mm Hg reduction in SBP

Age <65: 11.9% (5.3% to 18.0%)

Age >65: 9.1% (3.6% to 14.3%)

Pfor heterogeneity of slopes = 0.38

0.25

-15-12- 9-6-3036

Difference in reduction in systolic BP (mm Hg)

BPLTTC. BMJ. 2008;336:1121-1123.


Bp reduction and effect on cv mortality at 4 years

BP Reduction and Effect on CV Mortality at 4 Years

Hypertension Optimal Treatment Trial

The lower the target BP in patients with diabetes,the lower the rates of CV events and CV deaths

Major CV Events

CV Deaths

DBP ≤ 90

DBP ≤85

DBP ≤ 80

  • P=0.005

  • P=0.016

51%

Events per

1000 Patient-years

Events per

1000 Patient-years

  • P=0.50

67%

  • P=0.49

n=18,790

n=1501

n=18,790

n=1501

DBP, diastolic blood pressure, in mmHg.

Hansson L, et al. Lancet. 1998;351:1755-1762.


Blood pressure and diabetic complications

Blood Pressure and Diabetic Complications

United Kingdom Prospective Diabetes Study

10

10

P<0.0001

P<0.0001

Myocardial InfarctionHazard Ratio

Microvascular ComplicationsHazard Ratio

12% Decreaseper 10 mmHg reduction in SBP

13% Decreaseper 10 mmHg reduction in SBP

1

1

0.5

0.5

Updated Mean A1C

Updated Mean A1C

140

140

110

110

120

120

130

130

150

150

160

160

170

170

Adler Al, et al. BMJ. 2000;321:412-419.


Bp reductions and risk of micro and macrovascular complications in t2dm

BP Reductions and Risk of Micro- and Macrovascular Complications in T2DM

United Kingdom Prospective Diabetes Study

Benefits of 144/82 vs. 154/87 mm Hg (N=1148)

Any diabetes-related endpoint

Vision deterior-ation

Diabetes-related death

Renal failure

Heart failure

Myocardial infarction

Stroke

Retinopathy

P=0.13

Risk Reduction (%)

P=0.005

P=0.019

P=0.004

P=0.29

P=0.013

P=0.004

P=0.004

UKPDS Group. BMJ. 1998;317:703-713.


Effect of intensive blood pressure control on cv outcomes and death in t2dm

Effect of Intensive Blood-Pressure Control on CV Outcomes and Death in T2DM

Action to Control Cardiovascular Risk in Diabetes

(N=4733)

ACCORD Study Group. N Engl J Med. 2010;362:1575-1585.


Long term follow up after tight control of blood pressure in t2dm

Long-Term Follow-up After Tight Control of Blood Pressure in T2DM

UKPDS Post-monitoring Study

  • BP became similar within 2 years of trial termination (mainly due to increased BP in tight control group)

  • Relative risk reductions achieved with tight BP control during the trial were not sustained for:

    • Any diabetes-related end point

    • Diabetes-related death

    • Microvascular disease

    • Stroke

  • Peripheral vascular disease risk reduction became significant during the follow-up (P = 0.02)

Good BP control must be continued if benefits are to be maintained

Any Diabetes-related Endpoint

Holman RR, et al. N Engl J Med. 2008;359;1565-1576.


Intensive blood pressure control in t2dm

Intensive Blood Pressure Control in T2DM

Action to Control Cardiovascular Risk in Diabetes

(N=4733)

ACCORD Study Group. N Engl J Med. 2010;362:1575-1585.


Multiple antihypertensive agents are usually required to achieve bp control

Multiple Antihypertensive Agents Are Usually Required to Achieve BP Control

ABCD, Appropriate Blood pressure Control in Diabetes trial; DBP, diastolic blood pressure, in mm Hg; HOT, Hypertension Optimal Treatment trial; IDNT, Irbesartan in Diabetic Nephropathy trial; IRMA-2, IrbesartanMicroalbuminuria Type 2 Diabetes in Hypertensive Patients trial; RENAAL, Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan study; UKPDS, United Kingdom Prospective Diabetes Study.

Bakris G, et al. Am J Kidney Dis. 2000;36:646-661.


Compelling indications for individual drug classes

Compelling Indications for Individual Drug Classes

Aldo ANT = aldosterone antagonist.

Chobanian AV, et al. Hypertension. 2003;42:1206-1252.


The renin angiotensin system ace inhibition

Bradykinin

AT1

NO, PGI2

AT2

The Renin Angiotensin System: ACE Inhibition

ACEI

Angiotensin I

ACE-independent

formation of ANG II

ACE

Angiotensin II

B2

Vasoconstriction

Proliferation

Aldosterone

Sympathetic NS

NaCl retention

Inflammation

Apoptosis

Antiproliferation

Differentiation

Regeneration

Anti-inflammation

Apoptosis?

Vasodilation, etc

NO

Vasodilation

Tissue protection

Unger T, et al. Am J Cardiol. 2007;100:25J-31J.


The renin angiotensin system at 1 blockade

AT1

NO, PGI2

AT2

The Renin Angiotensin System: AT1 Blockade

Angiotensin I

ARB

ACE

Angiotensin II

B2

Vasoconstriction

Proliferation

Aldosterone

Sympathetic NS

NaCl retention

Inflammation

Apoptosis

Antiproliferation

Differentiation

Regeneration

Anti-inflammation

Apoptosis?

Vasodilation, etc

NO

Vasodilation

Tissue protection

Unger T, et al. Am J Cardiol. 2007;100:25J-31J.


Mi risk with aceis and arbs

MI Risk With ACEIs and ARBs

0.51.02.0

favors 2nd listed

favors 1st listed

Odds Ratio

Volpe M, et al. J Hypertension. 2009;27:941-946.


Hypertension summary

Hypertension Summary

  • In T2DM, blood pressure lowering has the greatest and most immediate effect on morbidity and morality

  • The recommended BP target for patients with diabetes is 130/80 mm Hg

  • Multiple agents are usually required to achieve target BP

  • BP treatment must be continued for benefits to be maintained

  • An ACE inhibitor or ARB should be included in the BP-control regimens of patients with diabetes because of beneficial effects on the renin-angiotensin system

Torre JJ, et al. EndocrPract.2006;12:193-222.


Management of common comorbidities in diabetes4

Management of Common Comorbidities in Diabetes

Chronic Kidney Disease


Reducing a1c reduces nephropathy risk in t2dm

Reducing A1C Reduces Nephropathy Riskin T2DM

*Intensive vs standard glucose control.

UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837-853.ADVANCE Collaborative Group. N Engl J Med. 2008;358:2560-2572.Ismail-BeigiF, et al. Lancet. 2010;376:419-430.


Prevalence of ckd in diagnosed diabetes

Prevalence of CKD in Diagnosed Diabetes

Diabetic Kidney Disease Is the Leading Cause of Kidney Failure in the United States

*Pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies.

ESRD, end-stage renal disease; GFR, glomerular filtration rate (mL/min/1.73 m2); NKF, National Kidney Foundation.

CDC. National diabetes fact sheet, 2011. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf.

PlantingaLC, et al. Clin J Am SocNephrol. 2010;5:673-682.


Cardiovascular outcomes worsen with ckd progression

Cardiovascular Outcomes Worsen With CKD Progression

Valsartan in Acute Myocardial Infarction Trial

(N=14,527*)

eGFR (mL/min/1.73 m2)

75

60-74

45-59

<45

*23% of patients had diabetes.†P<0.001 vs GFR ≥75 by Cox model.

CHF, congestive heart failure; CV, cardiovascular.

AnavekarNS, et al. N Engl J Med. 2004;351:1285-1295.


Cv risk increases with comorbid diabetes and ckd

x 2.8

x 2.0

x 2.1

x 1.7

x 2.5

x 2.3

CV Risk Increases With Comorbid Diabetes and CKD

CHF, congestive heart failure; AMI, acute myocardial infarction; CVA/TIA, cerebrovascular accident/transient ischemic attack; PVD, peripheral vascular disease; ASVD, atherosclerotic vascular disease.

*ASVD was defined as the first occurrence of AMI, CVA/TIA, or PVD.

Foley RN, et al. J Am SocNephrol. 2005;16:489-495.


Appropriate staging and management of c kd

Appropriate Staging and Management of CKD

CKD, chronic kidney disease.

*Includesactions from preceding stages.

†Pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies.

National Kidney Foundation. Am J Kidney Dis. 2002;49(suppl1):S1-S266.


Kdigo ckd classification by relative risk

KDIGO CKD Classification by Relative Risk

Levey AS, et al. Kidney Int. 2011;80:17-28.


Dkd risk factor management

DKD Risk Factor Management

Handelsman Y, et al. EndocrPract. 2011;17(suppl 2):1-53.

National Kidney Foundation. Am J Kidney Dis. 2007;49(suppl 2):S1-S179.


Dietary guidelines for dkd

Dietary Guidelines for DKD

Handelsman Y, et al. EndocrPract. 2011;17(suppl 2):1-53.

National Kidney Foundation. Am J Kidney Dis. 2007;49(suppl 2):S1-S179.


Use of noninsulin antidiabetic therapies in patients with kidney disease

Use of Noninsulin Antidiabetic Therapies in Patients With Kidney Disease

Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.

HandelsmanY, et al. EndocrPract. 2011;17(suppl 2):1-53.

National Kidney Foundation. Am J Kidney Dis. 2007;49(suppl 2):S1-S179.


Management of common comorbidities in diabetes5

Management of Common Comorbidities in Diabetes

Cardiovascular Disease


Coincidence of cv comorbidities in t2dm

Coincidence of CV Comorbidities in T2DM

NHANES 1999-2004

(N=984)

Hypertension

(BP ≥140/90 mm Hg or taking antihypertensive medication)

16.9%

17.7%

12.2%

20.6%

Obesity

(BMI ≥30 kg/m2)

  • Hyperlipidemia

  • (LDL-C ≥100 mg/dL,TC ≥200 mg/dL, orTG ≥150 mg/dL)

5.9%

  • 5.0%

7.4%

Suh DC, et al. J Diabetes Complications. 2010;24:382-391.


Cardiovascular disease risk factors

Cardiovascular Disease Risk Factors

Apo, apolipoprotein; CAD, coronary artery disease; HDL-C, high-density lipoprotein cholesterol;hs-CRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol;Lp-PLA2, lipoprotein-associated phospholipase A2; PCOS, polycystic ovary syndrome.

JellingerPS, et al. EndocrPract. 2012;18(suppl 1):1-78.


Coronary artery disease risk categories

Coronary Artery Disease Risk Categories

CHD, coronary heart disease.

Jellinger PS, et al. EndocrPract. 2012;18(suppl 1):1-78.


Diabetes is a cardiovascular disease risk equivalent

Diabetes Is a Cardiovascular Disease Risk Equivalent

7-Year Incidence of MI (%)

P<0.001

P<0.001

No prior MI

Prior MI

No prior MI

Prior MI

Nondiabetic

(n=1373)

Diabetic

(n=1059)

MI, myocardial infarction.

Grundy SM, et al. Circulation. 2004;110:227-239.HaffnerSM, et al. N Engl J Med. 1998;339:229-234.


Cvd risk factors aace targets

CVD Risk Factors:AACE Targets

Handelsman Y, et al. EndocrPract. 2011;17(suppl 2):1-53.

JellingerPS, et al. EndocrPract. 2012;18(suppl 1):1-78.


Management of common comorbidities in diabetes6

Management of Common Comorbidities in Diabetes

Depression


Prevalence of comorbid depression and diabetes

Major Depressive Disorder

Likely Depression

Prevalence of Comorbid Depression and Diabetes

Meta-analysis

Diverse, Community Sample

P=0.5

1.9OR2.1

% Population

% Population

Diagnostic Interview

Self-report Scale

Fisher L, et al. Diabetes Care. 2007;30:542-548; Anderson RJ, et al. Diabetes Care. 2001;24:1069-1078


Depression and adherence to diabetes self management

Depression and Adherence to Diabetes Self-management

2.3-Fold increased risk of missing 1 or more prescribed medications over previous week with major depression

(HANDS score <9)

(HANDS score ≥9)

P<0.001

P=0.006

P=0.348

P<0.001

P=0.001

Mean Adherent Days/Week

P<0.001

P=0.241

Generaldiet

Carbo-hydrates

Exercise

Glucose monitoring

Fruitsand vegetables

High fat foods

Foot care

HANDS, Harvard Department of Psychiatry/National Depression Screening Day Scale.

Gonzales JS, et al. Diabetes Care. 2007;30:2222-2227.


Mental health referral for patients with diabetes

Mental Health Referral for Patients With Diabetes

  • Establish emotional well-being as a part of diabetes management

  • Include psychological assessment and treatment in routine care

    • Do not wait for deterioration in psychological status

    • Utilize patient-provider relationship as a foundation for psychological management

  • Indications for referral

    • Gross noncompliance with medical regimen

    • Depression with the possibility of self-harm

    • Debilitating anxiety (alone or with depression)

    • Eating disorder

    • Cognitive functioning that significantly impairs judgment

  • Always refer to mental health specialist familiar with diabetes management

Handelsman Y, et al. EndocrPract. 2011;17(suppl 2):1-53.

ADA. Diabetes Care. 2013;36(suppl 1):S11-S66.


Management of common comorbidities in diabetes7

Management of Common Comorbidities in Diabetes

Sleep Apnea


Sleep apnea

Sleep Apnea

Obstructive

  • Caused by relaxation of muscles supporting palate

  • Risk factors

    • Obesity

    • Hypertension

    • Male gender

    • Neck circumference >44 cm

    • Narrowed airway

    • Age

    • Family history

    • Alcohol, sedative use

    • Smoking

Central

  • Caused by neural signaling failure between brain and muscles surrounding lungs

  • Risk factors

    • CHF

    • Atrial fibrillation

    • Cerebrovascular disease

    • Brain tumor

Epstein LJ, et al. J Clin Sleep Med. 2009;5:263-276.

NHLBI Working Group on Sleep Apnea. Am Fam Physician. 1996;53:247-253.


Obstructive sleep apnea and insulin resistance

Obstructive Sleep Apnea and Insulin Resistance

EDS fatigue

Sleep apneaSleep fragmentationSleep debt

  • Depression of ventilation

  • Diaphragm mobility

  • Soft tissue edema

  • Stress hormonesInterleukin-6

  • Inflammatory cytokines

  • Visceral fatInsulin resistance

Vgontzas AN, et al. J Intern Med. 2003;254:32-44 .


Prevalence of sleep apnea in t2dm

Prevalence of Sleep Apneain T2DM

Sleep AHEAD Study

Obese Patients With T2DM

(N=305)

OSA, obstructive sleep apnea.

Foster GD, et al. Diabetes Care. 2009;32:1017-1019.


Treatment for sleep apnea

Obstructive Sleep Apnea

Continuous positive airway pressure (CPAP)

Adjustable airway pressure devices

Oral appliances

Surgery

Uvulopalatopharyngoplasty (UPPP)

Maxillomandibular advancement

Tracheostomy

Central and Mixed Sleep Apnea

Optimize therapy for associated conditions

Supplemental oxygen

CPAP

Bilevel positive airway pressure (BiPAP)

Adaptive servo-ventilation (ASV)

Treatment for Sleep Apnea

Aurora RN, et al. Sleep. 2012;35:17-40.

Epstein LJ, et al. J Clin Sleep Med. 2009;5:263-276.


Management of common comorbidities in diabetes8

Management of Common Comorbidities in Diabetes

Cancer


Diabetes and cancer risk

Diabetes and Cancer Risk

  • Diabetes (especially T2DM) may:

    • ↑ Cancer risk

      • Liver

      • Pancreas

      • Endometrium

      • Colon and rectum

      • Breast

      • Bladder

    • ↓ Cancer risk: prostate

  • Hyperinsulinemia, hyperglycemia, and inflammation may directly increase cancer risk

  • Shared risk factors

    • Aging

    • Obesity

    • Diet

    • Physical inactivity

Giovannucci E, et al. Diabetes Care. 2010;33:1674-1685.


Insulin and cancer risk

Insulin and Cancer Risk

Gerstein HC, et al. N Engl J Med. 2012;367:319-328. Kirkman MS, et al. Presented at the American Diabetes Association 72nd Scientific Sessions. June 11, 2012. Session CT-SY13. Philadelphia, PA.


Diabetes and cancer risk management

Diabetes and Cancer Risk Management

  • Conduct cancer screenings as recommended for age and sex

  • Encourage healthful diet, physical activity, and weight management

  • Evidence is inconclusive on effects of specific drugs on cancer risk due to limited data and confounding factors

  • Cancer risk should not be a major factor in the choice of antidiabetic agent unless the patient has a very high risk of cancer occurrence or recurrence

Giovannucci E, et al. Diabetes Care. 2010;33:1674-1685.


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