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Cardiometabolic Risk : Evaluation & Treatment in Your Patient Population. --Insert Here— Speaker Title and Affiliation. Why Focus on Cardiometabolic Risk? . A comprehensive approach to patient care; Multiple disease pathways and risk factors are considered to facilitate earlier intervention

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cardiometabolic risk evaluation treatment in your patient population
Cardiometabolic Risk:Evaluation & Treatment in Your Patient Population

--Insert Here—

Speaker Title

and Affiliation

why focus on cardiometabolic risk
Why Focus on Cardiometabolic Risk?
  • A comprehensive approach to patient care; Multiple disease pathways and risk factors are considered to facilitate earlier intervention
  • Early assessment and targeted intervention are needed to treat and prevent all risk factors associated with CVD and diabetes
cardiometabolic risk
Cardiometabolic Risk
  • Gives a comprehensive picture of a patient’s health and potential risk for future disease and complications
  • Is inclusive of all risks related to metabolic changes associated with CVD
  • Accommodates emerging risk factors as useful predictive tools
  • Focuses clinical attention to the value of systematic evaluation, education, disease prevention and treatment
  • Supports an integrated approach to care

Kahn, et al. The Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement From the American

Diabetes Association and the European Association for the Study of Diabetes Diabetes Care. 2005;28 (9)2289-2304.

the state of risk
The State of 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
direct and indirect cost of cvd and diabetes
Direct and Indirect Cost of CVD and Diabetes

Estimated Indirect Costs

(disability, work loss,

premature mortality)

Estimated Direct

Medical Costs

*Note: these figures may not account for potential overlap.

Sources: 2008 statistics from the American Diabetes Association and American Heart Association.

cardiometabolic risk graphic

Age

Genetics

Insulin Resistance

?

Insulin Resistance Syndrome

Glucose

BP

 Lipids

Age, Race, Gender,

Family History

Overweight / Obesity

  • Abnormal Lipid Metabolism
    • LDL 
    • ApoB 
    • HDL 
    • Trigly. 

Cardiometabolic Risk - Graphic

Cardiometabolic Risk

Global Diabetes / CVD Risk

Smoking

Physical Inactivity

Unhealthy Eating

Inflammation Hypercoagulation

Hypertension

non modifiable

Cardiometabolic Risk Factors

Age

Race/ethnicity

Gender

Family history

Overweight

Abnormal lipid metabolism

Inflammation, hypercoagulation

Hypertension

Smoking

Physical inactivity

Unhealthy diet

Insulin resistance

Non-modifiable

Modifiable

case mr martin
Case - Mr. Martin
  • 47-year-old African American man, hasn’t seen doctor in years
  • Works as a truck driver, eats mostly fast food
  • Smokes 1 pack per day
  • At health fair found to have BP = 146/86, total cholesterol = 210
  • Weight = 230 lbs; BMI = 29 kg/m²
  • Family history of HTN and diabetes
what s mr martin s cardiometabolic risk
What’s Mr. Martin’s Cardiometabolic Risk?
  • Age 47
  • Race/ethnicity African American
  • Gender Male
  • Family history HTN and diabetes
  • Overweight/obesity BMI = 29
  • Abnormal lipid metab TC = 210
  • Hypertension BP = 146/86
  • Smoking 1 pack per day
  • Physical Inactivity Yes
  • Unhealthy diet Fast food diet
est new diabetes diagnoses by age 2005

800,000

600,000

400,000

200,000

0

Est. New Diabetes Diagnoses by Age, 2005

Number

60+

40-59

20-39

Age Group

Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national

estimates on diabetes in the United States, 2005. Atlanta, GA: U.S. Department of Health and Human Services,

Centers for Disease Control and Prevention, 2005.

cardiovascular risk factor trends among u s adults aged 20 74
Cardiovascular Risk Factor Trends Among U.S. Adults Aged 20-74

39.2

30.8

36.0

33.6

33.1

1960-1962

28.2

29.3

1971-1975

27.2

26.3

26.4

1976-1980

1988-1994

19.0

1999-2000

14.8

17.0

14.9

5.0

4.6

3.5

3.4

1.8

High Blood

Pressure

High Total

Cholesterol

Smoking

Diagnosed

Diabetes

Centers for Disease Control & Prevention, Division for Heart Disease and

Stroke Prevention, "Addressing the Nation's Leading Killers: At A Glance 2007

slide13

American Indians/

Alaska Natives

Non-Hispanic Blacks

Hispanic/Latino Americans

Non-Hispanic Whites

0

2

4

6

8

10

12

14

16

18

20

Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national

estimates on diabetes in the United States, 2005. Atlanta, GA: U.S. Department of Health and Human Services,

Centers for Disease Control and Prevention, 2005.

factors affecting insulin resistance
Factors affectinginsulin resistance
  • Overweight/ fat distribution
  • Age
  • Genetic predisposition
  • Activity level
  • Medications
  • Puberty
  • Pregnancy
ifg and igt
IFG and IGT
  • Impaired Fasting Glucose (IFG): a condition in which the blood glucose level is between 100 mg/dL to 125mg/dL after an 8- to 12-hour fast.
  • Impaired Glucose Tolerance (IGT): a condition in which the blood glucose level is between 140 and 199 mg/dL at 2 hours during an oral glucose tolerance test (OGTT).
interpreting blood glucose levels
Interpreting BloodGlucose Levels

Healthy BG FPG < 100 mg/dL

Pre-diabetes FPG 100–125 mg/dL

Diabetes FPG ≥126 mg/dL

criteria for testing for type 2 diabetes in asymptomatic children50
Criteria for testing for type 2 diabetesin asymptomatic children50
  • 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 for diabetes in asymptomatic adult individuals50
Criteria for testing for diabetes in asymptomatic adult individuals50
  • 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)

Continued

criteria for testing for diabetes in asymptomatic adult individuals5020
Criteria for testing for diabetes in asymptomatic adult individuals50
  • 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 acanthosis nigricans)
  • History of CVD
criteria for testing for diabetes in asymptomatic adult individuals5021
Criteria for testing for diabetes in asymptomatic adult individuals50

2. In the absence of the above criteria, testing for pre-diabetes and diabetes should begin at age 45 years

3. 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.

*At-risk BMI may be lower in some ethnic groups.

insulin resistance and chd mortality paris prospective study
Insulin Resistance and CHD Mortality Paris Prospective Study

(n=943)

3

P<.01

2

CHD mortality, per 1000

1

0

29 30-50 51-72 73-114 115

Quintiles (pmol) of fasting plasma insulin

Insulin Sensitive Insulin Resistant

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

proposed metabolic observations in the natural history of type 2 diabetes

Cardiometabolic Risk

Diabetes

Impaired Fasting Glucose

Euglycemia

Proposed Metabolic Observations in the Natural History of Type 2 Diabetes

InsulinSensitivity

Insulin Secretion

Associated Risk Factors

  • Hypertension
  • Dyslipidemia

Atherogenesis

Microvascular

Complications

FastingBlood Glucose

Type 2 Diabetes

Age (years)

screening overweight
Screening: Overweight
  • 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

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.

measuring waist circumference
Measuring 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

Klein, et al. Waist Circumference and Cardiometabolic Risk. Diabetes Care. 2007 0: dc07-9921v1-0.

multiple factors associated with obesity give rise to increased risk of cvd

Insulin

Resistance

Hypertension

Dyslipidemia

Atherosclerosis

Hypercoagulability

Hyperglycemia

  • Coronary arteries
  • Carotid arteries
  • Cerebral arteries
  • Aorta
  • Peripheral arteries

Hyperinsulinemia

Inflammation

Impaired

Fibrinolysis

Endothelial

Dysfunction

Multiple Factors Associated With Obesity Give Rise to Increased Risk of CVD

Primary

Metabolic

Disturbance

Intermediate Vascular Disease Risk Factor

Intravascular

Pathology

Clinical

Event

Overnutrition

CVD

Despres JP, et al. Abdominal obesity and metabolic syndrome.Nature. 2006;444:881-887.

body weight and cvd
Body Weight and CVD

Men

Women

300

267

250

200

200

Incidence of CVD

per 1,000

128

150

125

121

105

100

50

0

<100 110-129 130+ <110 110-129 130+

n=56 n=75 n=30 n=191 n=199 n=78

*Metropolitan Relative Weight percent

(percentage of desirable weight)

Hubert HB et al. Circulation. 1983;67:968-977

risk management overweight
Risk ManagementOverweight
  • Lifestyle modification
    • Reduce caloric intake by 500-1000 kcal/day (depending on starting weight)
    • Target 1-2 pound/week weight loss
    • Increase physical activity
    • Healthy diet
      • Diabetes Prevention Program
      • DASH diet

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. 04-5230, August 2004

risk management cont overweight
Risk Management, cont. 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

total cholesterol goals34
Total Cholesterol Goals34
  • Desirable — Less than 200 mg/dL
  • Borderline high risk — 200–239 mg/dL
  • High risk — 240 mg/dL and over

American Diabetes Association. Understanding Cardiometabolic Risk: Broadening Risk Assessment and Management, Dyslipidemia Richard M Bergenstal, MD International Diabetes Center

abnormal lipid metabolism34
Increased:

Triglycerides

VLDL

LDL and small dense LDL

ApoB

Decreased:

HDL

Apo A-I

Abnormal Lipid Metabolism

American Diabetes Association. Diabetes Care. 2007;30:S4-41.

major risk factors affecting lipid goals36
Major Risk FactorsAffecting Lipid Goals36
  • Cigarette smoking
  • Hypertension (≥140/90 mm Hg or on antihypertensive medication)
  • Low HDL-C (<40 mg/dL)
  • Family history of early heart disease
  • Age (men ≥45 years; women ≥55 years)
slide36
Statins (also called HMG-CoA reductase inhibitors) work by increasing hepatic LDL-C removal from the blood.
  • Resins (also called bile acid sequestrants) bind to bile acids in the intestines and prevent their reabsorption, leading to increased hepatic LDL-C removal from the blood.
  • Cholesterol absorption inhibitors help lower LDL-C by reducing the amount of cholesterol absorbed in the intestines; increases LDL receptor activity.
slide37
Fibrates (also called fibric acid derivatives) activate an enzyme that speeds the breakdown of triglyceriderich lipoproteins while also increasing HDL-C.
  • Niacin (also called nicotinic acid) reduces the liver’s ability to produce VLDL. When given at high doses, it can also increase HDL-C.

American Diabetes Association. Understanding Cardiometabolic risk: Broadening risk Assessment and Management, Dyslipidemia Richard M Bergenstal, MD International Diabetes Center

cholesterol management
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 patient’s total cholesterol, LDL-C, HDL-C and triglycerides
  • Treatment priorities
cholesterol management40
Cholesterol Management
  • Improve glucose control if diabetes is present
  • Weight loss if overweight
  • Daily exercise
  • Smoking cessation
  • Dietary modifications including low saturated fat (fat intake less than 30% of total calories and saturated fat less than 7% of total calories), low cholesterol (no more than 200 mg daily) diet
  • Pharmacologic treatment frequently necessary
  • Risk factors include hypertension; HDL < 40; family history of MI before age 55; male > 45 years old; female > 55 years old; smoking.
risk of chd by triglyceride level the framingham heart study
Risk of CHD by Triglyceride Level:The Framingham Heart Study

3

Women

Men

2.5

n=5,127

2

1.5

Relative Risk

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.

association between small dense ldl and insulin resistance
Association Between Small, Dense LDL and Insulin Resistance

12

(n=19)

10

(n=29)

8

(n=52)

Mean Steady State

Plasma Glucose (mmol/L)

at Identical Plasma Insulin

6

4

2

0

A

Larger LDL particle

pattern

B

Small LDL particle

pattern

Intermediate

pattern

LDL-Size Phenotype

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

low hdl c independent predictor of chd risk even when ldl c is low
Low HDL-C: Independent Predictor of CHD Risk, Even When LDL-C is Low

Risk of CHD

HDL-C (mg/dL)

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.

.

screening for dyslipidemia
Screening for Dyslipidemia

Persons without Diabetes

  • Test at least every 5 years, starting at age 20, including adults with low-risk values

Persons with Diabetes

  • In adults, test at least annually
  • Lipoproteins: measure at after initial blood glucose control is achieved as hyperglycemia may alter results

Preventing Cancer, Cardiovascular Disease, and Diabetes: A Common Agenda for The American Cancer Society, the American Diabetes Association, and the American Heart Association. Circulation. 2004;109:3244-3255. American Diabetes Association. Standards of Medical Care in Diabetes 2007. Available at: http://care.diabetesjournals.org/cgi/reprint/30/suppl_1/S4

healthy lipid goals targets for patients without dm or cvd
Healthy Lipid GoalsTargets for Patients Without DM or CVD

Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III); National Cholesterol Education Program, National Heart, Lung, and Blood Institute, National Institutes of Health. NIH Publication No. 01-3670, May 2001

risk management abnormal lipids
Risk ManagementAbnormal Lipids
  • Lifestyle modification
    • Increased physical activity
    • Diet: reduced saturated fat, trans fat, and cholesterol
    • Weight loss, if indicated
  • American Diabetes Association. Diabetes Care. 2007;30:S4-41.
risk management abnormal lipids47
Risk ManagementAbnormal Lipids
  • 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
  • American Diabetes Association. Diabetes Care. 2007;30:S4-41.
hypertension evaluation and screening
Persons without Diabetes

BP should be measured 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 be measured 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

Hypertension: Evaluation and Screening

Preventing Cancer, Cardiovascular Disease, and Diabetes A Common Agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association. Circulation. 2004;109:3244-3255. American Diabetes Association. Diabetes Care. 2007;30:S4-41.

management of hypertension
Non-pharmacologic

DASHdiet

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

The Dash Diet. http://dashdiet.org. American Diabetes Association. Diabetes Care. 2007;30:S4-41.

management of hypertension51
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

Management of Hypertension

The Dash Diet. http://dashdiet.org. American Diabetes Association. Diabetes Care. 2007;30:S4-41.

complications of hypertension in patients with diabetes
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

Complications of Hypertension in Patients with Diabetes

American Diabetes Association. Diabetes Care. 2007;30:S4-41..

physical activity
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 25:2165–2171, 2002.

physical activity55
Physical Activity

Guidelines

  • Fit into daily routine
  • Aim for at least 150 minutes/week of moderate aerobic exercise
  • Start slowly and gradually build intensity
  • Wear a pedometer (10,000 steps)
  • Encourage patients to take stairs, park further away or walk to another bus stop, etc.
  • American Diabetes Association. Diabetes Care. 2007;30:S4-41.
physical activity56
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.
exercise precautions related to complications of diabetes
Exercise Precautions Related to Complications of Diabetes
  • 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.
impact of baseline smoking on mi in type 2 diabetes ukpds
Impact of Baseline Smoking on MI in Type 2 Diabetes: UKPDS

Hazards Ratio (95% CI)

Never Smoked 1

Ex-Smoker 1.08 (0.75 - 1.54)

Current Smoker 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 screening and intervention
Smoking – Screening and Intervention
  • Obtain documentation of history of tobacco use
  • Ask whether smoker is willing to quit
    • If no, initiate brief, motivational discussion regarding:
      • the need to stop using tobacco
      • risks of continued use
      • encouragement to quit, as well as support when ready
    • If yes, assess preference for and initiate either minimal, brief, or intensive cessation counseling.
  • American Diabetes Association. Diabetes Care. 2004;27:S27:S74-S75.
provide smoking cessation resources
Provide 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 hypercoagulation
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
Risk Management: Inflammation
  • High-sensitivity CRP tests may be used to further evaluate underlying risk

Relative risk categories

      • Low risk <1 mg/L
      • Average risk 1-3 mg/L
      • High risk >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.

pre diabetes
Pre-Diabetes
  • Pre-diabetes is an important risk factor for future diabetes and cardiovascular disease
  • Recent studies have shown that lifestyle modification can reduce the rate of progression from pre-diabetes to diabetes

American Diabetes Association, Diabetes Care. 2007:30:S4-41..

glucose tolerance categories
Glucose Tolerance Categories

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

Fasting Plasma

Glucose

2-hour Plasma Glucose On OGTT

Diabetes Mellitus

Diabetes Mellitus

126 mg/dL

200 mg/dL

Impaired Glucose

Impaired Fasting

Tolerance

Glucose

100 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

ada consensus conference on ifg and igt implications for diabetes care october 16 18 2006
ADA Consensus Conference on IFG and IGT: Implications for Diabetes Care October 16-18, 2006

Results:

  • Treat IFG and IGT with aggressive lifestyle modification
  • For certain patients with both IFG and IGT consider metformin

Nathan D, et al. Impaired Fasting Glucose and Impaired Glucose Tolerance: Implications for Care. Diabetes Care. 2007 30: 753-759.

slide69

40

Placebo

30

Metformin

Cumulative Incidenceof Diabetes (%)

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.

slide70

Study

Subjects

Intervention

Relative RiskReduction

Finnish DPS

US DPP

IGT

IGT

Lifestyle

Lifestyle

58%

58%

US DPP

STOP-NIDDM

TRIPOD

XENDOS

DREAM

IGT

IGT

Prior GDM

IGT

IGT

Metformin

Acarbose

Troglitazone

Orlistat

Rosiglitazone/Ramipril

31%

25%

55%

45%

61%/NS

Results of Recent Randomized Trials

Behavior

Medication

goals for glycemic control
Goals for Glycemic Control

A1C*†

<7.0%

Preprandial glucose

90-130 mg/dL

Postprandial plasma glucose

<180 mg/dL

* For non-pregnant individuals

† As close to normal (<6%) as possible without significant hypoglycemia

American Diabetes Association. Diabetes Care. 2007:30:S4-41..

screening for diabetes
Screening For Diabetes
  • Fasting plasma glucose at least every 3 yrs starting at age 45
  • Consider at younger age, or more frequently, if patient is overweight and has one or more of the following risk factors (or two if not overweight):
    • Family history of diabetes
    • Overweight (BMI 25 kg/m2)
    • Habitual physical inactivity

(continued)

American Diabetes Association. Diabetes Care. 2007:30:S4-41..

screening for diabetes73
Screening For Diabetes

Additional risk factors:

  • Race/ethnicity (e.g., African-Americans, Hispanic-Americans, Native Americans, Asian-Americans, and Pacific Islanders)
  • Previously identified IFG or IGT
  • Hypertension (140/90 mmHg in adults)
  • HDL cholesterol (35 mg/dl [0.90 mmol/l] and/or a triglyceride level 250 mg/dl [2.82 mmol/l])
  • History of GDM or delivering baby weighing >9 lbs
  • Polycystic ovary syndrome (PCOS)

American Diabetes Association. Diabetes Care. 2007:30:S4-41..

slide74
Age 47
  • Race/ethnicity African American
  • Gender Male
  • Family history HTN and diabetes
  • Overweight/obesity BMI = 29
  • Abnormal lipid metab TC = 210
  • Hypertension BP = 146/86
  • Smoking 1 pack per day
  • Physical Inactivity Sedentary
  • Unhealthy diet Fast food diet
slide75
Identify at-risk patients by evaluating a spectrum of predisposing risk factors
  • The existence of any one risk factor is an alert to evaluate patient for others
  • Integrate evidence-based risk management strategies to target modifiable risk factors

Kahn, et al. The Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement From the American

Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2005;28 (9)2289-2304.