Diabetes Mellitus: Exploring the Evidence

Introduction
Diabetes Mellitus effects over 18 million Americans Almost 1/3 of those are undiagnosed Diabetes leads to over $130 Billion per year in total costs Diabetes is the 6th leading cause of death Risk of death is 2 times greater in diabetics than non-diabetics
Center for Disease Control and Prevention. National Diabetes Fact Sheet: general information and national estimates on diabetes in the United States, 2002. Atlanta, GA: US Department of Health and Human Services, Center for Disease Control and Prevention, 2003.

Objectives
Review the standards of current diabetic care

Review the evidence of why those standards exist

Explore prevention and screening

Standards of Diabetic Care

Glycemic control
A1C
Goal range Frequency, goals met Frequency, goals not met Preprandial glucose Peak postprandial glucose <7.0% (B)* 2x / year (E)* Quarterly (E)* 90-130 mg/dl <180 mg/dl

Self Monitored Glucose Testing

American Diabetes Association: Standards of Medical Care in Diabetes (Position Statement). Diabetes Care 28 (Suppl. 1): S4-36, 2005

* Level of Evidence Determination

Standards of Diabetic Care

Lifestyle Modifications
Nutritional Medical Therapy
Individualized, as needed (B)*

Low carbohydrate diets (<130gm/day) are not recommended (E)*

Weight loss for all overweight or obese individuals (BMI = or > 25%) (E)*
American Diabetes Association: Standards of Medical Care in Diabetes (Position Statement). Diabetes Care 28 (Suppl. 1): S4-36, 2005

* Level of Evidence Determination

Standards of Diabetic Care

Lifestyle Modifications
Physical Activity
Regular physical activity is recommended (B)*

American Diabetes Association: Standards of Medical Care in Diabetes (Position Statement). Diabetes Care 28 (Suppl. 1): S4-36, 2005 * Level of Evidence Determination

Standards of Diabetic Care

Blood Pressure Control
Systolic BP Diastolic BP <130 (C)* <80 (B)*

Multiple drug therapy usually required (B)* Initial therapy should be with a drug known to reduce CVD in diabetics (ACE-I, ARBs, Bblockers, diuretics, or CCBs) (A)* An ACE-I or an ARB should be used in all patients with DM and HTN who tolerate them (E)*
American Diabetes Association: Standards of Medical Care in Diabetes (Position Statement). Diabetes Care 28 (Suppl. 1): S4-36, 2005 * Level of Evidence Determination

Standards of Diabetic Care

Cardiovascular Protection
Lipid Goals
LDL (priority goal of pharmacological therapy)
For under 40 without overt CVD <100 For >40 w/o overt CVD and total chol >135 30-40 % reduction and <100 For those with CVD <70 (C)* (A)* (B)*

If LDL abnormal, initiate a statin

* Level of Evidence Determination

(A)*

American Diabetes Association: Standards of Medical Care in Diabetes (Position Statement). Diabetes Care 28 (Suppl. 1): S4-36, 2005

Standards of Diabetic Care

Cardiovascular Protection
Lipid Goals
Triglycerides HDL
in men In women

<150 (C)*
>40 (C)* >50 (C)*

Non-HDL-C
secondary goal when triglycerides are >200 Can be used as a surrogate for LDL-C Goal is 30 above goal LDL-C
American Diabetes Association: Standards of Medical Care in Diabetes (Position Statement). Diabetes Care 28 (Suppl. 1): S4-36, 2005 * Level of Evidence Determination

Standards of Diabetic Care

Cardiovascular Protection
Antiplatelet therapy
ASA (75-162mg/day) is recommended for secondary and primary prevention of vascular disease in Type 2 DM. (A)* ASA therapy is recommended for primary prevention in Type 1 Diabetics with additional risk factors for CVD. (C)* If ASA contraindicated, consider other anti-platelet agents as an alternative. (E)* No ASA if under age 21. (E)*

American Diabetes Association: Standards of Medical Care in Diabetes (Position Statement). Diabetes Care 28 (Suppl. 1): S436, 2005 * Level of Evidence Determination

Standards of Diabetic Care

Renal Protection
Annual Screening
Random, spot albumin to creatinine ratio 24-hr collection Timed (4hr or overnight) collection

(E)*

If positive, repeat test (at least 2 of 3 screening tests should be positive prior to diagnosis of microalbuminuria)
American Diabetes Association: Standards of Medical Care in Diabetes (Position Statement). Diabetes Care 28 (Suppl. 1): S4-36, 2005

* Level of Evidence Determination

Standards of Diabetic Care

Renal Protection
Treatment
Optimize glucose control (A)*

Optimize blood pressure control

ACE-I inhibitor and/or ARB Consider referral when GFR falls to <60

(A)*
(A)* (B)*

American Diabetes Association: Standards of Medical Care in Diabetes (Position Statement). Diabetes Care 28 (Suppl. 1): S4-36, 2005 * Level of Evidence Determination

Standards of Diabetic Care

Eye Protection
Optimal Glycemic control
Optimal Blood Pressure control Annual Screening

(A)*
(A)* (B)*

American Diabetes Association: Standards of Medical Care in Diabetes (Position Statement). Diabetes Care 28 (Suppl. 1): S4-36, 2005 * Level of Evidence Determination

Standards of Diabetic Care

Foot Protection
Periodic comprehensive foot exam (B)*

Refer high risk patients for surveillance and preventative care (C)* Screen for peripheral arterial disease, consider Ankle Brachial Index

(C)*

American Diabetes Association: Standards of Medical Care in Diabetes (Position Statement). Diabetes Care 28 (Suppl. 1): S436, 2005

* Level of Evidence Determination

Screening and Prevention

Screeningper the ADA
How?
Fasting glucose
2 hour glucose tolerance test

(B)*

American Diabetes Association: Standards of Medical Care in Diabetes (Position Statement). Diabetes Care 28 (Suppl. 1): S436, 2005 * Level of Evidence Determination

Screening and Prevention

Screeningper the ADA
Who? (E)*

Individuals age 45 and older, particularly if BMI > or equal to 25 Younger individuals if overweight and additional risk factors exist

American Diabetes Association: Standards of Medical Care in Diabetes (Position Statement). Diabetes Care 28 (Suppl. 1): S4-36, 2005 * Level of Evidence Determination

Screening and Prevention

Screening per USPSTF
Concludes the evidence is insufficient evidence to recommend for or against routinely screening asymptomatic adults for Type 2 DM, impaired glucose tolerance or impaired fasting glucose. I recommendation.
Recommends screening for type 2 DM in adults with HTN or HLP. B recommendation.
US Preventative Services Task Force: Screening for Type 2 Diabetes Mellitus in Adults (Recommendations and Rationale) .AHRQ Pub. No. 03-517A, 2003

Screening and Prevention

Prevention
Lifestyle modification (A)*
Initial counseling on the importance of modest weight loss and regular physical activity Follow-up counseling is important (B)* Can produce a relative reduction of up to 58%

American Diabetes Association. Prevention or Delay of Type 2 Diabetes (Position Statement). Diabetes Care. 27 (Suppl. 1): S47-54, 2004. *Level of Evidence Determination

Screening and Prevention

Prevention
Medications
Acarbose Metformin Troglitizone RRR of 32% RRR of 31% RRR of 56%

American Diabetes Association. Prevention or Delay of Type 2 Diabetes (Position Statement). Diabetes Care. 27 (Suppl. 1): S47-54, 2004.

*Level of Evidence Determination

Screening and Prevention

Prevention
Bottom line
Lifestyle changes were more effective than medication, safer than medication, less costly, and had additional health benefits. Therefore, drug therapy should not be routinely used until more data is available. (E)*

style
American Diabetes Association. Prevention or Delay of Type 2 Diabetes (Position Statement). Diabetes Care. 27 (Suppl. 1): S47-54, 2004. *Level of Evidence Determination

Conclusion
The ADA position statement Standards of Medical Care in Diabetes Review of the evidence Summary on Screening and Prevention of Diabetes