Diabetes in the Latino Population:
A Case-based Approach
to Optimal Management
1
www.diabetes.org
1-800-DIABETES
Learner Objectives
Upon completion, attendees should be able to:
• List the medical, social, and economic ways in which diabetes
impacts the Latino population;
• Describe strategies to overcome barriers to improving diabetes
outcomes in the Latino population;
• Utilize current standards of care for the detection of diabetes and
the monitoring of complications of diabetes in the Latino patient;
• Assess current treatment options to maximize glycemic control in
order to minimize the complications of diabetes in the Latino
population;
• Access appropriate national and local resources available to
assist in caring for the Latino patient with diabetes.
2
www.diabetes.org
1-800-DIABETES
Why are We Concerned about Diabetes?
Every 24 hours...
•
•
•
•
•
3,600 new cases of diabetes are diagnosed
580 people die of diabetes-related complications
225 people have a diabetes-related amputation
120 people with diabetes progress to end-stage renal disease
55 people with diabetes become blind
3
www.diabetes.org
1-800-DIABETES
Why Are We Concerned about Diabetes
Among Latinos?
• Prevalence of type 2 diabetes is 1.5 times higher than in nonHispanic whites.
• 2 million Latinos 20 years or older have diabetes.
• Latinos have a greater number of risk factors for diabetes.
• Increased prevalence of retinopathy, nephropathy, and
peripheral vascular disease in Mexican Americans.
National Diabetes Information Clearinghouse, NIDDK 2002
www.diabetes.org
4
1-800-DIABETES
A Constellation of Complications
Erectile
Dysfunction
Renal
Disease
Peripheral
Vascular
Disease
Diabetes
Gastropathy
Dyslipidemia
Cardiovascular
Disease
www.diabetes.org
Peripheral
Neuropathy
Retinopathy/
Macular Edema
Autonomic
Neuropathy
Hypertension
5
1-800-DIABETES
Diabetes Care in the U.S. Improvements Needed
Goal
Percent at Goal
A1C < 7.0
43% (18% at > 9.5)
LDL < 100
11% (58% at > 130)
BP < 140/90
66%
(ADA goal is 130/80)
Dilated Eye Exam
63%
Foot Exam
55%
NHANES III and Behavioral Risk Factors Surveillance Study
www.diabetes.org
6
1-800-DIABETES
Projected Increase in the US Population with
Diagnosed Diabetes by 2020 by Ethnicity
Projected Increase (%)
120
100
80
60
40
20
0
Non Latino Whites Non Latino Blacks
Latinos
Adapted from American Diabetes Association. Diabetes Care. 2003;26:917-932
www.diabetes.org
7
1-800-DIABETES
Geographic Distribution of Latino Americans
Puerto Rican:
1.6 million
Cuban American:
130,000
Mexican American
1.1 million
Mexican American
8.4 million
Mexican American
1 million
Puerto Rican: 500,000
Cuban American:
830,000
Mexican American
5 million
Adapted from U.S. Census Bureau, Current Population Survey, March 2000.
www.diabetes.org
8
1-800-DIABETES
Clinical Discussion
• Prevalence of diabetes
• Prevalence of complications
• Pathophysiology
- obesity
- insulin resistance
- metabolic syndrome
• Treatment
- nonpharmacologic
- medications
9
www.diabetes.org
1-800-DIABETES
Prevalence of Type 2 Diabetes
Age-adjusted prevalence (%)
Physician-diagnosed diabetes
Previously undiagnosed diabetes
10
8
6
4
2
0
Non-Latino African
White
American
Mexican
American
Harris MI et al. Diabetes Care. 1998;21:518-524.
www.diabetes.org
Non-Latino
White
African
American
Mexican
American
10
1-800-DIABETES
Trends in Diabetes Prevalence (1990-1998)
Age (years)
Ethnicity
50
80
70
40
60
50
30
40
20
30
20
10
0
10
30-39
40-49
50-59
0
Non-Latino
White
African
American
Mexican
American
• Prevalence of type 2 diabetes is 2-3 times higher in Latinos than Caucasians
• Highly correlated with prevalence of obesity (r = 0.64, P < 0.001)
American Diabetes Association. Facts and Figures. Mokdad et al. Diabetes Care. 2000;23:1278.
www.diabetes.org
11
1-800-DIABETES
Complications of type 2 diabetes in Minorities
• Disparate and Disproportionate prevalence of
longterm complications of type 2 diabetes in
minorities vs Whites
–
–
–
–
lower leg amputations 2-4x
retinopathy and blindness 2-4x
stroke 2x
ESRD 4-6x
Caballero AE. Diabetes in minority populations.
In: Joslin’s Diabetes Mellitus. LW & W; 2005. 14th Ed. p 505-524
www.diabetes.org
12
1-800-DIABETES
Prevalence of Complications in Type 2 Diabetes
Prevalence of Retinopathy in
Type 2 Diabetes
New Cases of End-Stage
Renal Disease
Age Range of Amputations
per 10,000 DM patients
(per million/population)
200
Patients (%)
40
20
0
40–59 years
300
160
200
120
80
100
40
0
0
60 years
Caucasian
African-American
Mexican-American
Klein et al. In: Harris et al, eds. Diabetes in America, 2nd ed. 1995. Reiber et al.
In: Harris et al, eds. Diabetes in America, 2nd ed. 1995. USRDS. Am J Kidney Dis. 1994;24:879.13
www.diabetes.org
1-800-DIABETES
Cardiovascular Disease in Latinos
with Diabetes
• Latinos- more insulin resistance/diabetes but no
higher rates for CAD when compared to Whites
• A true Hispanic paradox?
• Data are not conclusive - some studies may be
influenced by changes in the population due to
migration factors
Lerman-Garber I, Villa A.R, Caballero AE.. Diabetes and Cardiovascular Disease. Is there a true
Hispanic Paradox? Rev Invest Clinic. 2004; 56 (3): 282-296
14
Available at: www.imbiomed.com.mx
www.diabetes.org
1-800-DIABETES
No Difference In Complications
When Good Control Is Achieved
San Luis Valley Study
Caucasian and Latino (n=279)
- Similar glucose control in both study
groups
- Similar severity of retinopathy, nephropathy and
diabetic neuropathy
Hamman RF et al. Diabetes. 1989; 38;1231. Hamman RF et al. Diabetes Care. 1991;14
(suppl 3):655.
www.diabetes.org
15
1-800-DIABETES
Diabetes: Dual Impairment
Insulin Resistance and Impaired b-Cell Function
Normal -cell
function
Insulin
resistance
Abnormal -cell
function
Relative insulin deficiency
Compensatory
hyperinsulinemia
Normoglycemia
Hyperglycemia
Type 2 diabetes
16
www.diabetes.org
1-800-DIABETES
Insulin Resistance
• Genetic
• Acquired
 Central obesity
 Medications
• In 80-90% of type 2 patients
• Clusters with metabolic disease syndrome
• Associated with increased macrovascular disease
17
www.diabetes.org
1-800-DIABETES
Visceral Fat, Insulin Resistance and Endothelial Dysfunction
IL1, IL6, TNF- ,
FFA,, PAI-1, RAS,
leptin, resistin
Adiponectin
Increased
Visceral Fat
Genes
Cytokines,
Substrates
Hormones
Insulin
Resistance
Hyperglycemia
Hypertension
Dyslipidemia
Modified from Caballero AE. Current Diabetes Reports 2004; 4: 237- 246
www.diabetes.org
Genes
Endothelial
Dysfunction
18
1-800-DIABETES
Insulin Sensitivity in Healthy Subjects in
Various Ethnic Groups
(mol• L-1• m-2• min-1• pmol-1• L-1)†
Insulin Sensitivity Index
7
*
6
*
5
*
4
3
2
1
0
NH White
N=34
African Am
N=9
Asian Am
N=18
Mexican Am
N=16
*P =0.0023 vs. Caucasians.
†Data are geometric means. Adapted from: Chiu KC, et al. Diabetes Care. 2000;23(9):1353-1358.19
www.diabetes.org
1-800-DIABETES
Prevalence of the Insulin Resistance
Syndrome in the US Population
Prevalence (% of adults)
40
35
30
White
African American
Mexican American
Other
25
20
15
10
5
0
Men
Women
*Age adjusted ≥ 20 years of age
Ford ES et al. JAMA. 2002;287:356-359
www.diabetes.org
20
1-800-DIABETES
Progressive Nature of Type 2 Diabetes
IGT
Diabetes
Endogenous Insulin
Normal
Insulin Resistance
Postprandial Blood
Glucose
Normal Blood
Glucose
Years
www.diabetes.org
Avg
Dx
9-12 yrs*
21
1-800-DIABETES
UKPDS: Glucose Control Study Results
Intensive Blood- Glucose Control
Change in risk
Any diabetes-related endpoint
Diabetes-related deaths
Myocardial infarction
Microvascular disease
Stroke
12%
10%
16%
25%
14%
Adapted from UKPDS Group. Lancet. 1998; 352:837-853.
www.diabetes.org
P value
0.029
NS
0.052
0.0099
NS
22
1-800-DIABETES
Effect of Each 1% Rise in A1C on Risk of Developing Complications
10-Year follow-up in older-onset patients
Incidence of retinopathy
Progression of retinopathy
Progression to PDR
Visual loss
Proteinuria
Amputation
Ischemic heart death
0.5
1
1.5
Risk Ratio and 95% CI
Klein. Diabetes Care 18:258-268, 1995
www.diabetes.org
2
2.5
23
1-800-DIABETES
Why Aren’t Patients Achieving
Blood Glucose Goals?
• Physicians not setting appropriate glycemic targets
• Type 2 diabetes is progressive - what works now
may not work in the future
• Type of medications used and/or doses not
appropriate
• Insulin therapy only used as a “threat”
24
www.diabetes.org
1-800-DIABETES
American Diabetes Association
Standards of Care
Clinical Practice Recommendations 2004. Diabetes Care, 27(Suppl1):S15-36.
www.diabetes.org
25
1-800-DIABETES
Diagnosing Diabetes
Test
Fasting Plasma
Glucose (FPG)*
(Preferred Test)
Casual Plasma
Glucose *
Oral Glucose
Tolerance Test*
Casual plasma
glucose >200 mg/dl
(plus symptoms
Two-hour plasma
glucose (2hPG)
>200 mg/dl
Stage
Diabetes
FPG >126 mg/dl
Impaired
Glucose
Homeostasis
Impaired Fasting
Glucose (IFG)=FPG
>100 and <126 mg/dl
Impaired Glucose
Tolerance (IGT) =
2hPG >140 and
<200 mg/dl
Normal
FPG <100 mg/dl
2hPG <140 mg/dl
*In the absence of unequivocal hyperglycemia, these need to be repeated on the second day
www.diabetes.org
26
1-800-DIABETES
Goals for Glycemic Control
A1C*
< 7.0%
43% achieve goal
Pre- Prandial glucose 90-130 mg/dl
Postprandial plasma
glucose
< 180 mg/dl
*For non-pregnant individuals
Diabetes Care, 27: Supp.1.S19, 2004
www.diabetes.org
27
1-800-DIABETES
Goals for Blood Pressure, Lipids
and Microalbumin
Blood Pressure
<130/80mmHg
66% achieve goal
Lipids (mg/dl)
LDL-C
HDL C
HDL-C
Triglycerides
<100 (<70)
<40 (male)
>50 (female)
<150
11% achieve goal
Microalbumin <30 (mg/g creatinine)
Diabetes Care, 27: Sup 1. S19, 2004
www.diabetes.org
28
1-800-DIABETES
Monitoring Parameters for
Control of Complications
Every visit
Blood Pressure
Foot Exam (55% achieve goal)
______________________________________________
3-6 months
A1C
- Every 3 months if treatment changes or
not meeting goals
- Every 6 months if stable
_______________________________________________
Annual
Dilated Eye Examination (63% achieve goal)
Lipid Levels*
Microalbumin
_______________________________________________________________
*Every 2 years if levels fall in lower risk categories
29
www.diabetes.org
1-800-DIABETES
Goals of Medical Nutrition Therapy
• Achieve blood glucose goals
• Achieve optimal lipid levels
• Provide appropriate calories for:
- Reasonable weight
- Normal growth and development
- Pregnancy and lactation
• Prevent, delay or treat nutrition-related complications
• Improve health through optimal nutrition
Diabetes Care 22(1):S42-S45,1999
www.diabetes.org
30
1-800-DIABETES
Non-pharmacological Medical Therapy
for Type 2 Diabetes
Consistent carbohydrate intake
Monitor blood glucose to
adjust therapy
Modify fat and
calorie content
Optimize BG Control
Improve blood lipids
Control blood pressure
Moderate weight loss
Space meals
Increase physical activity
31
www.diabetes.org
1-800-DIABETES
ADA Nutrition Recommendations
Total Daily Energy Intake
• Carbohydrate – 60-70%
• Protein – 15-20%
• Fat
- 10% from polyunsaturated fats
- < 10% from saturated fats
32
www.diabetes.org
1-800-DIABETES
Preventing or Delaying Type 2 Diabetes
• Exercise can lower risk, delay or prevent,
type 2 diabetes
• Important for individuals with risk factors
- Obesity
- Sedentary lifestyle
- Family history of type 2 diabetes
- Native American, Hispanic, African American,
Asian American, Pacific Islander
33
www.diabetes.org
1-800-DIABETES
Effects of Exercise
• Increased insulin sensitivity
• Improved lipids
• Lower blood pressure
• Weight control
• Improved blood glucose control in type 2
diabetes
34
www.diabetes.org
1-800-DIABETES
Exercise Precautions for Type 2 Diabetes
• Check with referral source for medical clearance
• Lower VO2max may require a gradual training
program
• Autonomic neuropathy or blood pressure meds do
not allow for increased heart rate perceived
exertion important
• Blood pressure may go higher, avoid exercise if
systolic BP >180-200
35
www.diabetes.org
1-800-DIABETES
Exercise Precautions Related to
Complications of Diabetes
• Peripheral neuropathy can cause loss of sensation
in feet
• Pre-existing CVD can cause arrhythmias,
myocardial ischemia, or infarction during exercise
• Proliferative retinopathy does not increase risk for
retinal or vitreous hemorrhage with exercise
36
www.diabetes.org
1-800-DIABETES
Treatment of Type 2 Diabetes
37
www.diabetes.org
1-800-DIABETES
Principles of Diabetes Treatment
• Define target goal
• Diabetes education is essential
• Monitoring glycemic control is necessary
• Lifestyle modification
• Stepwise and combination pharmacologic therapy
38
www.diabetes.org
1-800-DIABETES
ADA Recommendations
• Glycemic goals should be individualized
• Certain populations (children, pregnant women, and elderly) require special
considerations
• Less intensive glycemic goals may be indicated in patients with severe or
frequent hypoglycemia
• More stringent glycemic goals (i.e. a normal A1C, 6%) may further reduce
complications at the cost of increased risk of hypoglycemia.
• Postprandial glucose may be targeted if A1C goals are not met despite
reaching pre-prandial glucose goals.
39
www.diabetes.org
1-800-DIABETES
Targeted Glucose Control
• Therapy based on glycemic goals
• Monotherapy usually not effective long-term
• Step-wise approach
• Whatever therapy is necessary to achieve glycemic
goals
40
www.diabetes.org
1-800-DIABETES
Pharmacologic Therapy
Selection of therapy should be
individualized based upon potential
side effects.
41
www.diabetes.org
1-800-DIABETES
Therapeutic Agents for
Type 2 Diabetes
Mechanism of Action
1. Sensitize the body to insulin

2. Control hepatic glucose production

3. Stimulate the pancreas to
make more insulin
4. Slow the absorption of starches

5. Decreases hepatic glucose
production and increases
peripheral glucose uptake
www.diabetes.org


Agent
Thiazolidinediones,
Biguanides
Biguanides,
Thiazolidnediones
Sulfonylureas
Meglitinides
Alpha-glucosidase
inhibitors
Insulin
42
1-800-DIABETES
Impact of Therapies on A1C Levels
Therapy






A1C Reduction
Diet and Exercise
Sulfonylureas and Glitinides
Metformin
-Glycosidase Inhibitors
Thiazolidinedione
Insulin
0.5 - 2.0%
1.0 - 2.0%
1.0 - 2.0%
0.5 - 1.0 %
0.5- 1.0%
>5.0%
Nathan, D. Oct 2002. N Engl J Med, Vol. 347, No.17
43
www.diabetes.org
1-800-DIABETES
Biguanides
Decrease hepatic glucose production and secondarily may
increase insulin-mediated peripheral glucose uptake
• Efficacy
- decrease blood glucose ~ 60 mg/dl
- reduce HbA1c 1.0 - 2.0%
- cause small decrease in LDL-C and triglycerides
- no specific effect on blood pressure
- no weight gain
• Other Effects
- diarrhea and abdominal discomfort
- lactic acidosis if inappropriately prescribed
- contraindicated in patients with impaired renal function
44
www.diabetes.org
1-800-DIABETES
Sulfonylureas
Increase endogenous insulin secretion
• Efficacy
- decrease blood glucose ~ 60 mg/dl
- reduce HbA1c 1.0 - 2.0 %
- no specific effect on plasma lipids or
blood pressure
• Other Effects
- hypoglycemia
- weight gain
45
www.diabetes.org
1-800-DIABETES
Thiazolidinediones
Potentiate insulin action on muscle and adipose tissue
• Efficacy
- decrease FPG ~ 25 - 40 mg/dl
- reduce HbA1c ~ 0.5 - 1%
- combined with sulfonylureas reduce HbA1c ~ 0.8 - 1.0 %
- combined with insulin reduce HbA1C by 0.8 1.4%
- Beneficial effect on lipids
- Possible cardiovascular effects
• Other Effects
- contraindicated with abnormal liver function
- weight gain, edema
www.diabetes.org
46
1-800-DIABETES
Meglitinides
Non-sulfonylurea insulin releasing agent; taken before each meal
Rapid onset of action with a duration of action of several hours
• Efficacy
- decrease peak postprandial glucose
- decrease blood glucose 60 - 70 mg/dl
- reduce HbA1c 1.0 - 2.0 %
• Other Effects
- hypoglycemia
- weight gain
- safe at higher levels of creatinine than sulfonylureas
47
www.diabetes.org
1-800-DIABETES
Alpha-Glucosidase Inhibitors
Competitive inhibitor of alpha glucosidase enzymes in small intestines; taken
before meals
• Efficacy
- decrease fasting plasma glucose 20-30 mg/dl
- decrease peak postprandial glucose
40-50 mg/dl
- no specific effect on lipids or blood pressure
- reduce HbA1c 0.5-1.0%
• Other Effects
- abdominal discomfort and flatulence
- contraindicated with inflammatory bowel disease or cirrhosis
48
www.diabetes.org
1-800-DIABETES
Insulin
Decreases hepatic glucose production and increases uptake
and use of glucose by muscle and adipose tissue
• Efficacy
- can lower plasma glucose to any level
- reduces HbA1c > 5.0%
- limited by hypoglycemia
• Other Effects
- hypoglycemia
- weight gain
49
www.diabetes.org
1-800-DIABETES
Anticipated Response to Treatment
Agent
Time to Response
SMBG Indicator
Secretatogogues
Long-acting
Rapid-acting
7 – 10 days
Immediate
Fasting
Postprandial
Metformin
2 – 3 weeks
Fasting
Glitazones
AGIs
Insulin
Rapid Acting
Long-acting
6 – 8 weeks
Immediate
Postprandial
Immediate
Immediate
Postprandial
Fasting
50
www.diabetes.org
1-800-DIABETES
Insulin Therapy in Type 2 Diabetes
• Most patients with type 2 diabetes will eventually
need insulin.
• As insulin deficiency progresses, a more physiologic
multi-component insulin regimen will be required to
adequately replace normal insulin secretion.
- Basal insulin
- Meal-Related (prandial, bolus) insulin
51
www.diabetes.org
1-800-DIABETES
Indications for Insulin Therapy
in Type 2 Diabetes
• Severe hyperglycemia at glucose toxicity
• To meet glycemic goals
• Hyperglycemia despite maximum doses of oral
agents
• Most patients with type 2 diabetes will
eventually need insulin
52
www.diabetes.org
1-800-DIABETES
Insulin Action Comparison
Insulins
Onset
Peak
Duration
Lispro* or
Aspart
~15 minutes
1– 2 hours
4 – 6 hours
Human
Regular
30 – 60 minutes
2 – 4 hours
6 – 10 hours
6 – 12 hours
12 – 20 hours
Human
NPH or Lente
2 – 4 hours
Human
Ultralente
4 – 6 hours
Unpredictable
18 – 24 hours
Glargine*
2– 4 hours
Peakless
20 – 26 hours
*Insulin analogs
53
www.diabetes.org
1-800-DIABETES
Profiles of Human Insulins and Analogs
Aspart, lispro (4–6 hours)
Regular (6–10 hours)
Plasma insulin levels
NPH (12–20 hours)
Ultralente (18–24 hours)
Glargine (20-26 hours)
0
2
4
6
8
10
12
Hours
www.diabetes.org
14
16
18
20
22
24
54
1-800-DIABETES
Pharmacologic Therapy
Possible Treatment Steps
STEP 1
• Add metformin or insulin secretagogue
STEP 2
• If on metformin, add insulin secretagogue
• If on insulin secretagogue, add metformin
continued
55
www.diabetes.org
1-800-DIABETES
Pharmacologic Therapy
Possible Treatment Steps
STEP 3
• Add insulin
• Switch to insulin
• Add a thiazolidinedione
STEP 4
• Add an oral drug to insulin
• Use multiple component insulin therapy
56
www.diabetes.org
1-800-DIABETES
Studies Aimed at Prevention of Type 2 DM
Lifestyle Modification Studies
 DPP (Diabetes Prevention Program)
 DPS (Diabetes Prevention Study, Finnish
Study)
 Da Qing (Chinese Study)
 Malmo Study (Males, Sweden)
Drug Intervention Studies
 DPP
 Stop-NIDDM (Acarbose)

- Prevention Evaluation
(Ramipril)
 TRIPOD Study (Troglitazone)
 DREAm Study (Rosiglitazone
Ramipril)*
 Navigator Study (Nateglinide,
Valsartan)
 Xendos trial (Orlistat)*
 Sibutramine Study*
*Trial still underway57
www.diabetes.org
1-800-DIABETES
Summary
• The Latino Population is the largest minority group in
the country
• The prevalence of diabetes and its complications is
higher in Latinos when compared to the non-Latino
White group
• Genetic and environmental factors influence the
development of obesity, metabolic syndrome and type
2 diabetes in Latinos
continued
58
www.diabetes.org
1-800-DIABETES
Summary
• Multiple cultural factors influence diabetes care in
Latinos
• Goals for glycemic control, BP, weight, lipids and
smoking cessation need to be established
• Aggressive Management to reach these goals is
important
• Early use of available pharmacologic treatment
tools needs to be considered
59
www.diabetes.org
1-800-DIABETES