10th Annual Diabetes/Heart Disease and Stroke Prevention

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10th Annual Diabetes/Heart Disease and Stroke
Prevention Winter Symposium. Introducing
South Carolina Guidelines for Diabetes Care

• Gerald Wilson, MD Kathie Hermayer, MD, MS, FACE
• March 10, 2012

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Why do we need Diabetes Guidelines for South
Carolina ?

• High complications, disability, and burden,
  especially in minority populations
• Inconsistent adherence to guidelines

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Diabetes Advisory Council established in 2010

• DAC Mission to provide community input and
  statewide leadership to prevent and control
  diabetes, eliminate disparities, and reduce the
  impact of diabetes on South Carolinians.
• Diabetes Guidelines Sub-committee established by
  DAC By-laws and charged to develop evidence-based
  guidelines for diabetes care in SC
• Worked in collaboration with the Diabetes
  Initiative of SC (DSC)
• Guidelines released September 15, 2012 by MUSC
• www.musc.edu/diabetes

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• Disclosure Verification for
• Name Kathie L. Hermayer, MD, MS, FACE
• The presenter listed above
• ___ Does not have any significant financial
  relationships to disclose
• _x_ Has disclosed the following relationship
  with
• Sanofi-aventis, Eli Lilly, Novo Nordisk, Amylin,
  Boehringer Ingelheim
• _x_ Research Grants _x_ Speakers Bureau
  __ Ownership
• __ Consultant for fee __Stock/Bond Holding
  __ Employment
• __Partnership Other_________
• Was this activity Supported by an educational
  grant or received in-kind
• support?
• x Yes _ _ No

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Facts on Diabetes

• Of 311 million Americans, 26 million Americans
  have diabetes
• An estimated 79 million American adults have pre
  diabetes
• A condition that increases their risk of type 2
  diabetes, heart disease and stroke
• Diabetes more likely to affect older Americans
• Almost 27 of people age 65 years and older had
  diabetes in 2010
• Diabetes affects 8.3 of all Americans and 11.3
  of adults age 20 and older
• Some 27 of people with diabetes 7 million
  Americans do not know they have the disease

http//www.cdc.gov/Features/DiabetesFactSheet/.
Accessed 3/1/2012.
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Diabetes in South Carolina

• S.C. ranks 8th highest in the nation in the
  percent of population with diabetes
• Approximately 1 in 8 African-Americans in S.C.
  has diabetes
• The 21st highest rate of diabetes among
  African-Americans in the nation
• Diabetes is the seventh leading cause of death in
  S.C. after heart disease, cancer, accidents,
  stroke, chronic lower respiratory disease, and
  Alzheimers

http//www.scdhec.gov/diabetes. Accessed
3/1/2012.
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South Carolina Guidelines for Diabetes Care 2011
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South Carolina Guidelines for Diabetes Care 2011
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Case 1

• You perform a physical exam on a pleasant 48 year
  old female with no prior H/O T2DM, strong
  family history of DM. Her FBG 115, A1C 6.2,
  height 56, Weight 170 lbs, BMI 27.4, BP 120/70,
  chol 195, TG 115, HDL 52 and LDL 120, S creat
  0.7. What do you advise?
• Begin metformin 500 mg bid
• Begin Lantus 10 u sc hs
• Stress diet and exercise
• Refer to personal trainer
• Start glucotrol xL 5 mg qd

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Criteria for the Diagnosis of Diabetes
NGSP- National Glycohemoglobin Standardization
Program
Diabetes Care 2012 (Suppl 1) S11-S63.
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Overweight/Obesity
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Screening Overweight

• Measure BMI routinely at each regular check-up.
• Classifications
• BMI 18.5-24.9 normal
• BMI 25-29.9 overweight
• BMI 30-39.9 obesity
• BMI 40 extreme obesity

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.
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Hypertension
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Hypertension Evaluation and Screening

• Persons without Diabetes
• BP should be measured at each regular visit or at
  least once every 2 years if BP lt120/80 mmHg
• BP measured seated after 5 min rest in office

• Persons with Diabetes
• BP should be measured at each regular visit
• BP measured seated after 5 min rest in office
• Patients with 130 or 80 mmHg should have BP
  confirmed on a separate day

Preventing Cancer, Cardiovascular Disease, and
Diabetes A Common Agenda for the American Cancer
Society, the American Diabetes Association, and
the American Heart Association. Circulation.
20041093244-3255. American Diabetes
Association. Diabetes Care. 200730S4-41.
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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

The Dash Diet. http//dashdiet.org. American
Diabetes Association. Diabetes Care.
200730S4-41.
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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

The Dash Diet. http//dashdiet.org. American
Diabetes Association. Diabetes Care.
200730S4-41.
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Complications of Hypertension in Patients with
Diabetes

• 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

American Diabetes Association. Diabetes Care.
200730S4-41..
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Abnormal Lipid Metabolism
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Screening for Dyslipidemia

• Persons without Diabetes
• Test at least every 5 years, starting at age 20,
  including adults with low-risk values
• Persons with Diabetes
• In adults, test at least annually
• Lipoproteins measure at after initial blood
  glucose control is achieved as hyperglycemia may
  alter results

Preventing Cancer, Cardiovascular Disease, and
Diabetes A Common Agenda for The American Cancer
Society, the American Diabetes Association, and
the American Heart Association. Circulation.
20041093244-3255. American Diabetes
Association. Standards of Medical Care in
Diabetes 2007. Available at http//care.diabetesj
ournals.org/cgi/reprint/30/suppl_1/S4
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Cholesterol Management
LDL-C-lowering
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Cholesterol Management

• Improve glucose control if diabetes is present
• Weight loss if overweight
• Daily exercise
• Smoking cessation
• Dietary modifications including low saturated fat
  (fat intake less than 30 of total calories and
  saturated fat less than 7 of total calories),
  low cholesterol (no more than 200 mg daily) diet
• Pharmacologic treatment frequently necessary
• Risk factors include hypertension HDL lt 40
  family history of MI before age 55 male gt 45
  years old female gt 55 years old smoking.

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Healthy Lipid GoalsTargets for Patients Without
DM or CVD

Third Report of the National Cholesterol
Education Program (NCEP) Expert Panel on
Detection, Evaluation, and Treatment of High
Blood Cholesterol in Adults (Adult Treatment
Panel III) National Cholesterol Education
Program, National Heart, Lung, and Blood
Institute, National Institutes of Health. NIH
Publication No. 01-3670, May 2001
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Risk ManagementAbnormal Lipids

• Pharmacologic treatment primary goal is LDL
  lowering
• Without overt CVD If over 40, statin therapy
  recommended to achieve 30-40 LDL reduction
• With overt CVD All patients should receive
  statin therapy to achieve 30-40 LDL reduction
• Lowering triglycerides and raising HDL with a
  fibrate is associated with fewer cardiovascular
  events in patients with clinical CVD, low HDL,
  and near-normal LDL

American Diabetes Association. Diabetes Care.
200730S4-41.
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Nephropathy
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Aspirin
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Retinopathy
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Foot Care
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Self-Management Goals
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Case 2

• Mr. Jones is a 55 year old male with T2DM X 3
  years, on metformin 1000 mg po bid. A1C 6.9, BP
  120/80, stable CV exam, weight 220 lbs, 510
  and BMI 31.6. Chol 175, TG 150, HDL 45, LDL 100.
  Urine microalb neg, S. Creat 0.8. What would
  you advise next?
• Add glucotrol XL 5 mg qd.
• Add Januvia 100 mg qd
• Diet and exercise to lose 10 total body weight
• Add actos 15 mg qd
• No changes. Advise him to keep living his
  current lifestyle.

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Immunizations
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Smoking
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Neuropathy
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What Should We Do?