WHS PR Symposium - Diabetes melitus update 2014

8/10/2019 WHS PR Symposium - Diabetes melitus update 2014

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DIABETESMELLITUS UPDATE

2014Margarita Ochoa-Maya, MDAdvanced Health and Wellbeing, PC

Integrative and Functional Medicine

Endocrinology and Metabolis


2/50

!HE FAC!" A#O$!

DIA#E!E"Ada%ted &ro the CDC 'ational Diabetes Facts( )*++

What is diabetes(A grou% o& diseases ared by high levels o& blood

glucoseesults &ro de.cits in

Insulin %roduction Insulin action #oth

Diabetes can lead to serious co%lications and%reature death

Diabetes is a lifestyle and can be controlled andcomlications can be re!ented


3/50

!HE FAC!" A#O$!

DIA#E!E"Ada%ted &ro the CDC 'ational Diabetes Facts( )*++!he %revalence o& Diabetes by ty%e /!erinology0(

Tye 1"

Also called Insulin de%endent 1 2uvenile onset 34 o& all diagnosed cases o& diabetes in adults

Tye 2" Also called non-insulin de%endent or adult onset 5*-534 o& all diagnosed cases o& diabetes in adults

Increasingly being diagnosed in children and adolescents#estational Diabetes"

)-+*4 o& %regnancies Woen 6ho have had 7DM have a 83-9* 4 chance o&

develo%ing diabetes /ostly !y%e )0 in the ne:t +* 1 )* years


4/50

!HE FAC!" A#O$!

DIA#E!E"Ada%ted &ro the CDC 'ational Diabetes Facts( )*++$%at is t%e re!alence of diabetes by &ender'

+8 illion en have diabetes ++;< 4 o& all en ages )* and older

+);9 illion 6oen have diabetes +*;


5/50

!HE FAC!" A#O$!

DIA#E!E"Ada%ted &ro the CDC 'ational Diabetes Facts( )*++$%at is t%e re!alence of diabetes in yo(t%'

)+3,*** Aericans younger than age )* have diabetes

Most cases in children and adolescents are !y%e +

$%at is t%e re!alence of diabetes by et%nicity''on-his%anic 6hites(+3;= illion /+*;)40

A&rican-Aericans( >;5 illion /+


6/50

!HE FAC!" A#O$!

DIA#E!E"Ada%ted &ro the CDC 'ational Diabetes

Facts( )*++

)omared to *on+,isanic $%ites- t%eris. of dia&nosed diabetes"+


7/50

!HE FAC!" A#O$!

DIA#E!E"Ada%ted &ro the CDC 'ational Diabetes Facts(

)*++

,o/ many deat%s are lin.ed to diabetes'Diabetes is the =thleading cause o& death listed

on the $"; Death certi.cate

Cardiovascular disease is the leading cause o&death aong %eo%le 6ith diabetes 9


8/50

!HE FAC!" A#O$!

DIA#E!E"Ada%ted &ro the CDC 'ational Diabetes Facts()*++

,o/ m(c% does diabetes )ST t%e *ation'!otal health care and related costs &or the

treatent o& diabetes runs about +=> #I??IO'annually /%er year0

O& this total(

DIEC! MEDICA? CO"!"( /Hos%italiations, edical care,treatent su%%lies, %rescri%tions0(++9 #I??IO' B year

I'DIEC! CO"!"( /Disability, tie lost &ro 6or, and%reature death0( 3< #I??IO' B year


9/50

!HE FAC!" A#O$!

DIA#E!E"CI!EIA FO DIA7'O"I" OF DIA#E!E"(HbA+c 9;34

Fasting Plasa glucose +)9 gBd?

) hour %lasa glucose a&ter =3 g glucose challenge()**gBd?

ando %lasa glucose )** gBd? ":

CI!EIA FO CADIOME!A#O?IC "G'DOME A'D

PE DIA#E!E"(Fasting %lasa glucose +**- +)3 gBd? /IF70) hour %lasa glucose a&ter =3 g glucose challenge(

+>*-+55 gBd? /I7!0

HbA+c 3-=4-9;>4


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Ho6 any Aericans haveDiabetes and the Cardio-

Metabolic "yndroe)3;< illion Aericans have diabetes


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Ho6 any %eo%le have the

Cardio-Metabolic "yndroeHo6 is the Cardio-Metabolic "yndroe

diagnosed#lood %ressure eual or higher than +8*B* inches or ore

Woen( 83 inches or ore

?o6 HD? cholesterol( Men( $nder >* gBd?

Woen( under 3* gBd?

!riglycerides eual or higher than +3*gBd?


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!HE "!A!E OF Cardioetabolic

I"@ ) out o& 8 Aericans are over6eight or obese

More than =* illion /nearly + in >0 Aericans

have varying degrees o& insulin resistance

!here are an estiated 3> illion /ore than + in90 Aericans 6ith %rediabetes

'early + in > $;"; adults has high cholesterol

+ in 8 Aerican adults has high blood %ressure


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CADIOME!A#O?IC I"@ FAC!O" ** MDI5IABLE Age

aceBethnicity7ender Faily history

MDI5IABLEOver6eight Abnoral li%id

etabolis

InJaation Hy%ercoagulation Hy%ertension

"oing Physical inactivity $nhealthy diet Insulin resistance


15/50

I'"$?I' E"I"!A'CE


16/50

FAC!O" AFFEC!I'7

I'"$?I' E"I"!A'CEOver6eightB &at distribution

Age

7enetic %redis%ositionActivity level

Medications

Puberty

Pregnancy


17/50

CI!EIA FO !E"!I'7 I' GO$!H Over6eight /#MI


18/50

CI!EIA FO !E"!I'7 I' AD$?!"Testin& s%o(ld be considered in all o!er/ei&%tad(lts

6BMI 72 .&8m29: and %a!e additional ris.

factors"

Physical inactivity

First-degree relative 6ith diabetes

Mebers o& a high-ris ethnic %o%ulation Woen delivering baby 6eighing 5 lb or

6ere diagnosed 6ith 7DM

Hy%ertension /K+>*B5* Hg0


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factors"

HD? cholesterol level L83 gBdl /*;5*olBl0 andBor a triglyceride level )3*

gBdl /);


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factors"

In the absence o& the %revious criteria, testing &or%re-diabetes and diabetes should begin at age >3

yearsI& results are noral, testing should be re%eated

at least at 8-year intervals, 6ith consideration o&ore &reuent testing de%ending on initial results

and ris status;


21/50

00

11

22

33

C

HDmortality,per1000

CHDmortality,per1000

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

Quintiles (pmol) of fasting plasma insulinQuintiles (pmol) of fasting plasma insulin

P


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Insulin SensitiityInsulinSensitiity

Insulin SeretionInsulin Seretion

ssoiate* !is+ atorsssoiate* !is+ ators Hypertension Hypertension Dyslipi*emia Dyslipi*emia

t-erogenesist-erogenesis

iroasulariroasular

CompliationsCompliations

/ype 2 Diaetes/ype 2 Diaetesge (years)ge (years)

asting loo* luoseastingloo* luose

Cardiometabolic Risk Cardiometabolic Risk

Diabetes

ImpairedFastingGlucoseEuglycemia


23/50

Car*iometaoli !is+ators

Desire* oals for Healt-y atients

4er5eig-t6oesitySource: CDC , ADA

reention of oer5eig-t6oesity as measure* y I

(normal " 17.&82$.#).

In t-ose 5-o are oer5eig-t6oese, t-e goal is to lose &8'9 of o*y 5eig-t.

normal lipi* metaolismHig- :D: -olesterol

:o5 HD: -olesterol

Hig- triglyeri*es

Source: NHLBI, A! III "u#$el#ne%, ADA

Desirale leels are less t-an 100 mg6*:.

Desirale leels are greater t-an $0 mg6*: in men an*

greater t-an &0 mg6*: in 5omen.

Desirale leels are less t-an 1&0 mg6*:

HypertensionSource: NHLBI, &NC'


24/50

"CEE'I'7 FO O#E"I!GMeasure #MI routinely at each regular chec-u%; Classi.cations( #MI +;5 noral #MI )3-)5;5 over6eight #MI 8*-85;5 obesity #MI K>* e:tree obesity

Measure 6aist circu&erence( ?arge 6aist circu&erence /WC0 can identi&y soe at increased

ris over #MI alone I& #MI and other cardioetabolic ris &actors are assessed,

currently there is insucient evidence to("ubstitute WC &or #MI

Measure WC in addition to #MI


25/50

I"@ MA'A7EME'!( OEWEI7H! Consider %haracologic treatent #MI 8* 6ith no related ris &actors or diseases,

or

#MI )= 6ith related ris &actors or diseases As %art o& a co%rehensive 6eight loss %rogra

incl; diet Q %hysical activity

Consider surgery #MI >* or #MI 83 6ith coorbid conditions

Clinical 7uidelines on the Identi.cation, Evaluation, and !reatent o& Over6eight andObesity in Adults( !he Evidence e%ort; 'IH Publication R 5*


26/50

!O!A? CHO?E"!EO?

7OA?"Desirable T ?ess than )** gBd?#orderline high ris T )**1)85 gBd?

High ris T )>* gBd? and over


27/50

A#'OMA? ?IPID

ME!A#O?I"MIncreased(

!riglycerides

?D? ?D? and sall

dense ?D?

A%o# Decreased(

HD?

A%o A-I


28/50

CHO?E"!EO?

MA'A7EME'! For %atients )* years o& age, cholesterolshould be checed every 3 years

Ordering a &asting li%id %anel is %re&erred togauge the %atientUs total cholesterol, ?D?-C,HD?-C and triglycerides

!reatent %riorities


29/50

Category of ris+ :D:%C oal

0%1 ris+ fator < 1=0 mg6*: or lo5er

ultiple (2>) ris+ fators < 130 mg6*: or lo5er

eople 5it- oronary -eart

*isease or ris+ e?uialent(e.g., *iaetes)

< 100 mg6*: or lo5er

@no5n CD an* D < '0 mg6*: or lo5ermay e i*eal

?D?-C-lo6ering?D?-C-lo6ering


30/50

enen AomenAomen

n"&,12'n"&,12'

/riglyeri*e :eel, mg6*:/riglyeri*e :eel, mg6*:

&0&0 100100 1&01&0 200200 2&02&0 300300 3&03&0 $00$00

!elatie!is

+

!elatie!is

+

00

0.&0.&

11

1.&1.&

22

2.&2.&

33

Ca%tell# (!. )*#$e+#olo o tr#lcer#$e%: a /#e0 ro+ Fra+#na+ American Journal of Cardiology.1992;'3:H-9H.


31/50

5ea/en "M, et al. J Clin Invest. 199;92:141-146.

.eanStea*

yState

3lasma2luos

e(mmol6:)

at

I*ential3las

maInsulin

.eanStea*

yState

3lasma2luos

e(mmol6:)

at

I*ential3las

maInsulin

:arger :D: partile

pattern

:arger :D: partile

pattern

Interme*iate

pattern

Interme*iate

pattern

Small :D: partile

pattern

Small :D: partile

pattern

0

2

=

10

12

7

$

:D:%SiBe -enotype:D:%SiBe -enotype

(n"&2)(n"&2)

(n"1#)(n"1#)

(n"2#)(n"2#)


32/50

:D:%C (mg6*:):D:%C (mg6*:)

HD:%C(m

g6*:)

HD:%C(m

g6*:)

!is+ofCHD

!is+ofCHD

"or$on , Ca%tell# (!, Hortlan$ MC, 7annel (B, Da0ber 5. H# $en%#t l#*o*rote#n a% a *rotect#/e actor aa#n%tcoronar eart $#%ea%e. e Fra+#na+ Stu$.American Journal of Medicine. 19'';62:'3'-14.


33/50

A#'OMA?

CHO?E"!EO? PV( Pharacologic treatent( %riary goal is ?D?lo6ering

Without overt CD( I& over >*, statin thera%yrecoended to achieve 8*->*4 ?D? reduction

With overt CD( All %atients should receivestatin thera%y to achieve 8*->*4 ?D? reduction

?o6ering triglycerides and raising HD? 6ith a.brate is associated 6ith &e6er cardiovascularevents in %atients 6ith clinical CD, lo6 HD?,and near-noral ?D?


34/50

HGPE!E'"IO'(

Evaluation and "creeningPersons /it%o(t Diabetes

#P should be easured at each regular visit orat least once every ) years i& #P L+)*B


35/50

MA'A7EME'! OF HGPE!E'"IO'*on+%armacolo&ic DA"H diet

Dietary A%%roaches to Sto%,y%ertensionHigh in 6hole grains, &ruits, vegetables,

and lo6-&at dairy?o6 in saturated and trans&at,

cholesterol Physical Activity Weight loss, i& a%%licable


36/50

MA'A7EME'! OF HGPE!E'"IO'P%armacolo&ic

Drug thera%y indicated i& #P K+>*B K5*

Hg Cobination thera%y o&ten necessary

!reatent should include ACE or A#

!hiaide diuretic ay be added to reachgoals

Monitor renal &unction and seru%otassiu


37/50

COMP?ICA!IO'" OF HGPE!E'"IO'Micro!asc(lar

enal diseaseAutonoic neuro%athy Eye disease /glaucoa, retino%athy 6ith

%otential blindness0

Macro!asc(lar

Cardiac diseaseCerebrovascular diseaseeduced survival and recovery rates &ro stroe Peri%heral vascular disease


38/50

PHG"ICA? AC!II!G 834 o& coronary heart disease deaths inthe $" can be attributed to an inactiveli&estyleN

Consistent e:ercise can reduce CD risN E:ercise, cobined 6ith healthy diet and

6eight loss, is %roven to %reventBdelay

onset o& ty%e ) diabetes

N Aerican Diabetes Association; Diabetes Care. )**=X8*(">->+;

Diabetes Prevention Progra Diabetes Care )3()+931)+=+, )**);


39/50

PHG"ICA? AC!II!GBene;ts of E


40/50

PHG"ICA? AC!II!G( PECA$!IO'" Peri%heral neuro%athy can cause loss o&

sensation in &eetX educate about %reventivecare easures &or &oot %rotection

Pre-e:isting CD can cause arrhythias,yocardial ischeia, or in&arction duringe:ercise

In %resence o& PD or severe 'PD, vigorouse:ercise or resistance training ay be

contraindicated because o& ris o& vitreousheorrhage or retinal detachentAerican Diabetes Association; Diabetes Care. )**=X8*(">->+


41/50

5 C urner, H M#lln%, H A ( Ne#l, I M Stratton, S ) Manle, D 5 Matte0%, an$ 5 5 Hol+an. 5#%8 actor% or

coronar arter $#%ea%e #n non-#n%ul#n $e*en$ent $#abete% +ell#tu%: n#te$ 7#n$o+ *ro%*ect#/e $#abete%

%tu$ 7!DS: 2 BMJ. 199 - 1.>4

Current S+o8er 1.>< 1.11 - 2.2>


42/50

"MO@I'7(

Cessation esources "et a Plan OYer counseling and re&errals

OYer edication assistance

OYer cobined %haracologic and behavioralintervention

Online guide to uitting( "oeFree;govAerican Diabetes Association; Diabetes Care;

)**>X)=(")=("=>-"=3


43/50

I'F?AMMA!IO'


44/50

I'F?AMMA!IO'

HGPECOA7$?A!IO' ProinJaatoryB%rothrobotic &actors

underlie cardioetabolic ris

InJaation is a a2or co%onent o&atherogenesis and other cardioetabolic%robles

Obesity is associated 6ith inJaation oss ; Atherosclerosis( an inJaatory disease; ' Engl S Med;

+555X8>*(++3-+)9; #allantyne CH, 'abi ; Marers o& inJaationand their clinical signi.cance; Atherosclerosis su%%l )**3X 9( )+-5;Mc?aughlin ! et al; DiYerentiation bet6een obesity and insulinresistance in the association 6ith C-reactive %rotein; Circulation;)**)X+*9()5*


45/50

I"@ MA'A7EME'!(

I'F?AMMA!IO' High-sensitivity CP tests ay be used to &urtherevaluate underlying ris

elative ris categories?o6 ris L+ gB?Average ris +-8 gB?High ris 8 gB?

As%irin and statins reduce CP levels

$nclear 6hether CP should be a treatent target educe 6eight oss ; Atherosclerosis( an inJaatory disease; ' Engl S

Med;+555X8>*(++3- +)9; #allantyne CH;


46/50

A$a*te$ ro+ e )@*ert Co++#ttee on te D#ano%#% an$ Cla%%##cat#on o D#abete% Mell#tu%.Diabetes Care2334; Su**le+ent 1

asting lasma

luose

asting lasma

luose

12= mg6*:12= mg6*:

ormal

2%-our lasma

luose 4n 4//

2%-our lasma

luose 4n 4//

200 mg6*:200 mg6*:

1$0 mg6*:1$0 mg6*:

Diaetes ellitus

Impaire* luose/olerane

ormal

Diaetes ellitus

ny anormality

must e repeate*

an* onfirme* ona separate *ay

ny anormality

must e repeate*

an* onfirme* ona separate *ay

4ne an also ma+e t-e *iagnosis of *iaetes ase* on

une?uioal symptoms an* a ran*om gluose 200 mg6*:

4ne an also ma+e t-e *iagnosis of *iaetes ase* on

une?uioal symptoms an* a ran*om gluose 200 mg6*:

Ere%DiaetesF

100 mg6*:100 mg6*:

Impaire* astingluose


47/50

CumulatieIni*ene

ofDiaetes

(9)

CumulatieIni*ene

ofDiaetes(9)

GearsGears

$0$0

3030

2020

1010

00

00 0.&0.& 1.01.0 1.&1.& 2.02.0 2.&2.& 3.03.0 3.&3.& $.0$.0

laeolaeo

etforminetformin

:ifestyle:ifestyle

7no0ler (C, et al. EJM. 2332;46:9-43.


48/50

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etformin

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rior D

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5e$uct#onInter/ent#onInter/ent#onSubect%Subect%Stu$Stu$


49/50

WHA! "HO$?D WE DO?IFE"!G?EDIE!

EVECI"E

"?EEP

MOOD

PE"CIP!IO'-#?OOD "$7A MO'I!OI'7

#EFOE A'D ) HO$" AF!E EA!I'7

PV !HA! AFFEC! !HE #AI'PV !HA! AFFEC! !HE 7A"!OI'"!EI'A? !AC!

PV !HA! AFFEC! !HE ?IE

PV !HA! AFFEC! !HE PA'CEA"

PV !HA! AFFEC! !HE @ID'EG"


50/50

!HA'@ GO$

Dr; Margarita Ochoa-Maya, MD

Advanced Health and Wellbeing, PC

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WHS PR Symposium - Diabetes melitus update 2014

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