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MELLITUS UPDATE
2014
Margarita Ochoa-Maya, MD
Advanced Health and Wellbeing, PC
Integrative and Functional Medicine
Endocrinology and Metabolism
glucose
Results from deficits in
Insulin production
Insulin action
Both
premature death
Diabetes is a lifestyle and can be controlled and
complications can be prevented
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
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
2011
How many deaths are linked to diabetes?
Diabetes is the 7th leading cause of death listed
2011
How much does diabetes COST the Nation?
Total health care and related costs for the
PRE DIABETES:
Fasting plasma glucose 100- 125 mg/dL (IFG)
2 hour plasma glucose after 75 g glucose challenge:
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
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
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)
(n=943)
P<.01
29
30-50
51-72
73-114
115
Insulin Resistant
Cardiometabolic Risk
Insulin Sensitivity
Insulin Secretion
Associated Risk Factors
Hypertension
Dyslipidemia
Atherogenesis
Microvascular
Complications
Fasting Blood Glucose
tes
Diabe
Euglycemia
Age (years)
Type 2 Diabetes
Cardiometabolic Risk
Factors
Overweight/obesity
Source: CDC , ADA
Hypertension
Source: NHLBI, JNC7
Source: ADA
Children
Source: ADA
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
Treatment priorities
LDL-C-lowering
Category of risk
LDL-C Goal
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
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
HYPERTENSION:
Evaluation and Screening
Persons without Diabetes
BP should bemeasured at each regular visit or
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
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
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
2004;27:S27:S74-S75
INFLAMMATION
INFLAMMATION +
HYPERCOAGULATION
Proinflammatory/prothrombotic factors
RISK MANAGEMENT:
INFLAMMATION
High-sensitivity CRP tests may be used to further
evaluate underlying 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
Years
Knowler WC, et al. NEJM. 2002;346:393-403.
Medication
Behavior
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
THANK YOU
Dr. Margarita Ochoa-Maya, MD
Advanced Health and Wellbeing, PC