ABC’s and…..P
of Diabetes
Eric L. Johnson, M.D.
Assistant Professor
Department of Family and Community Medicine
UNDSMHS
Assistant Medical Director
Altru 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
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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
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~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
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~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 Diabetes
Category
Fasting blood sugar
Normal
<100
Impaired Fasting Glucose (IFG)100 – 125
(prediabetes)
Diabetes
>126**
•OR A1C >6.5
** On 2 separate occasions
American Diabetes Association
Risk Factors for
Type 2 Diabetes
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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
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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
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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”
A1C
%
6
6.5
7
7.5
8
8.5
9
9.5
eAG
mg/dL
126
140
154
169
183
197
212
226
mmol/L
7.0
7.8
8.6
9.4
10.1
10.9
11.8
12.6
Formula: 28.7 x A1C - 46.7 - eAG
American Diabetes Association
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
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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