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Prediabetes Diagnosis and Management

www.drsarma.in. Prediabetes Diagnosis and Management. Prof. Dr. Sarma VSN Rachakonda M.D., M.Sc., (Canada), FCGP, FIMSA, FRCP (Glasgow), FCCP (USA)., Senior Consultant Physician, Cardio-metabolic & Chest Specialist, Visiting Professor of Internal Medicine, SBMC, FLL, iDRF, Chennai.

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Prediabetes Diagnosis and Management

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  1. www.drsarma.in Prediabetes Diagnosis and Management Prof. Dr. Sarma VSN Rachakonda M.D., M.Sc., (Canada), FCGP, FIMSA, FRCP (Glasgow), FCCP (USA)., Senior Consultant Physician, Cardio-metabolic & Chest Specialist, Visiting Professor of Internal Medicine, SBMC, FLL, iDRF, Chennai

  2. The Outline of the Presentation

  3. How Big is the Problem? CDC. National Diabetes Fact Sheet: National estimates and general information on diabetes and Prediabetes in the United States, 2011.

  4. Natural History of T2D Obesity IGT* Diabetes Uncontrolled Hyperglycemia Post-meal Glucose Plasma Glucose Fasting Glucose 120 (mg/dL) Relative -Cell Function Insulin Resistance 100 (%) Insulin Level -20 -10 0 10 20 30 Years of T2DM Endocrinol Metab Clin North Am.1997;26:659-677;

  5. ADA Diagnostic Criteria for DiabetesClinical Practice Recommendations 2010 * In the absence of unequivocal hyperglycemia, criteria 1–3 should be confirmed by repeat testing

  6. Diagnostic Cut Points Category FPG (mg/dL) 2h 75g OGTT A1C Normal < 100 < 140 < 5.7 Prediabetes 100 -125 140 -199 5.7 - 6.4 Diabetes > 126** > 200 ** > 6.5 Or patients with classic hyperglycaemic symptoms with plasma glucose >200 Diabetes Care 34:Supplement 1, 2011

  7. How is Prediabetes Diagnosed ?Categories of increased risk for diabetes For all three tests, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at higher ends of the range.

  8. Gestational Diabetes (GDM) Overnight fast 75g OGTT • Fasting >92 mg/dl • 1 h post glucose>180 mg/dl • 2 h post glucose >153 mg/dl Any ONE abnormal value is adequate Diabetes Care 34:Supplement 1, 2011 Diabetes Care 2010; 33: 676–682

  9. Age 45 or older Overweight – BMI >25 Physical Inactivity Asian or African ethnicity Family H/o of Diabetes Excess abdominal fat HT and/or on Rx for HT Previous Prediabetes TG > 200, HDL < 35 Acanthosis Nigricans PCOS, IR, Waist Circum H/o GDM, CVD Had macrosomic baby Risk Factors for the Development of Prediabetes and Type 2 Diabetes

  10. Modifiable Risk Factors for T2DM • Obesity, Body fat distribution • Increased waist circumference • Physical inactivity • Elevated fasting and 2 hr glucose levels • Dyslipidemia and Hypertension • Smoking and Alcohol

  11. Physical Inactivity and TV watching 3.0 2.5 2.0 RR 1.5 1.0 <10.0 10.0-23.5 0.5 23.6-45.9 0 >15.0 Quartiles ofMET - hours per week 46.0 8.1-15.0 3.6-8.0 Quartiles of no. of hourswatching TV per week 3.5 Hu et al. Arch Intern Med. 2001;161:1542.

  12. Natural History of IGT IGT -after 10 years

  13. Does Prediabetes Predict Diabetes?Progression of IGT/IFG to DM in11year follow up Persons with IGT Persons with IFG Stephen Twigg. Pre diabetes Symposium ADS & ADEA Annual Scientific Meeting Sydney 2004

  14. Risk of Cardiovascular Disease is elevated prior to diagnosis of T2DM CVD Risk 3.2 higher adjusting for all CVD risk factors % with CVD Adapted from: Hu F, et al. Diabetes Care. 2002;25:1129-1134.

  15. Diabetes Mean body weight $ spent on fast food The Prevalence of T2DM & Obesity Prevalence of obesity, increased by 61% since 1991 65% of US adults are overweight BMI and weight gain major risk factors for diabetes (110) Prevalence (%) kg (70) Year JAMA.1999;282:1519-1522 & JAMA.2001;286:1195-1200.

  16. What are the Health Risks Associated with Prediabetes? Progression to diabetes: 11% of people with pre-diabetes develop T2DM each year (DPP) Other studies: majority with Prediabetes develop T2DM in 10 years Microvascular complications at onset of DM 50% higher risk of CVD, CAD and Stroke

  17. Feasibility of Preventing T2DM • There is a long period of glucose intolerance that precedes the development of diabetes • Screening tests can identify persons at high risk • Predicts high risk for development of diabetes • Predicts high risk for development of atherosclerotic vascular disease • There are safe, potentially effective interventions that can prevent the above modifiable risk factors such as lifestyle and pharmacologic interventions

  18. Diabetes Prevention Program DPPProgression to Type 2 Diabetes Average follow-up of 2.8 years  31%* Cases/100 person-years  58%* Placebo Metformin Intensive lifestyle *All pairwise comparisons significantly different by group; The Diabetes Prevention Program Research Group. N Eng. J Med. 2002;346:393.

  19. Mean Change in Physical Activity Lifestyle Metformin Placebo The DPP Research Group, NEJM 346:393-403,2002

  20. Mean Weight Change Placebo Metformin Lifestyle The DPP Research Group, NEJM 346:393-403, 2002

  21. Incidence of Diabetes in DPP Placebo (n=1082) Metformin (n=1073, p<0.001 vs. Placebo) Lifestyle (n=1079, p<0.001 vs. Metformin , p<0.001 vs. Placebo) Risk reduction 31% by metformin 58% by lifestyle The DPP Research Group, NEJM 346:393-403, 2002

  22. Mean Change in HbA1c Placebo Metformin Lifestyle The DPP Research Group, NEJM 346:393-403, 2002

  23. A Decade Later….DPPOSThe Lancet, Oct 2009 • At end of DPP: participants 16-session program of intensive TLC • Lifestyle group: 34% reduction in diabetes risk maintained • More favorable CV risk factors: BP and TG’s, despite fewer drugs • Benefits more pronounced in elderly: 50% reduction in age >60

  24. The Finnish Diabetes Prevention StudyLifestyle Modifications • 522 overweight individuals with IGT randomized to • Control: diet instruction at the onset of study • Individualized advice given 7 times in the first year and every 3 months thereafter with goals of • Weight loss 5% • Reducing fat intake to <30% of energy consumption • Increasing fiber intake to 15 g/1000 kcal • Exercising at a moderate level for 30 min/d • Primary end point: Prevention of diabetes, assessed by OGTT Tuomilehto et al. N Engl J Med. 2001;344:1343.

  25. Indian Diabetes Prevention Program Ramachandran et al, IDDP-1, Diabetologia (2006) 49: 289–297.

  26. Cumulative Incidence of Diabetes Low BMI High IR High incidence of DM Ramachandran et al, IDDP-1, Diabetologia (2006) 49: 289–297.

  27. The Finnish Diabetes Prevention StudyLifestyle Modifications (cont’d)  58% Incidence of diabetes (cases/1000 person-years) Tuomilehto et al. N Engl J Med. 2001;344:1343.

  28. Cumulative incidence of diabetes at 6 years Da Qing Chinese Study Data from: Pan et al, Diabetes Care, 1997; 20: 537-44

  29. NAVIGATOR StudyEffect of Nateglinide & Valsartan on Incidence of T2DM and CV Events - 9306 persons with IGT, CVD or CV riskfollowed for 5 years • Nateglinide: A postprandial glucose-lowering approach; incidence of diabetes 36% vs. 34%; composite CV outcome 14.2% vs. 15.2%; increased the risk of hypoglycemia • Valsartan: incidence of diabetes 33.1% vs. 36.8% (RR 14%); 38 fewer cases per 1000 pts treated for 5 years; no reduction in rate of CV events NEJM online, March 14, 2010

  30. Prevention Studies in People with IGT Downstream strategies • Lifestyle interventions • Da Qing : Diet and Exercise • Malmo study : Diet and exercise • Finish Diabetes Prevention Study Lifestyle • DPP (Diabetes Prevention Study) Lifestyle, MF (Glitazone) • Lifestyle interventions with pharmacological agents • FHS (Fasting Hyperglycaemia Study) Healthy Living & SU • EDIT (Early Diabetes Intervention Study): Acarbose and MF • STOP NIDDM : Acarbose

  31. Low Risk - 3 to 9 points Maintain healthy wt. Regular exercise Keep it up regularly High Risk 10+ points High risk for diabetes Medical evaluation Take steps to improve score How to Ascertain the Risk ?

  32. Framingham DM Risk ScorePrediction of Incident DM in Adults Wilson, P. W. F., J. B. Meigs, et al. (2007). Arch Intern Med 167(10): 1068-1074.

  33. Indian Diabetes Risk Score (IDRS)Based on CUREs study Chennai

  34. A1c Level and Future Risk of T2DM • Meta-analysis of 16 studies • 44,203 participants • Follow-up 5.6 years Zhang, X., E. W. Gregg, et al. (2010). Diabetes Care 33(7): 1665-73.

  35. Prediabetes and Risk of CVD • Meta-analysis of 18 studies • 175,152 participants Ford, E. S., G. Zhao, et al. (2010). J Am Coll Cardiol 55(13): 1310-7.

  36. ADA Consensus StatementPreventive treatment in high risk individuals with Prediabetes • In addition to lifestyle modification, the following individuals should be considered for treatment with metformin: • those who have both IFG and IGT, and • at least one additional risk factor (age < 60, BMI ≥35, F H/o of diabetes,  TGs,  HDL, or A1C > 6% Diabetes Care 2007

  37. Prevention of Diabetes Recommendations to reduce risk of type 2 diabetes • Regular physical activity • Interventions to reduce obesity • Waist circumference, • body weight and body mass index (BMI) • identify individuals for weight management program • Individuals at risk should have dietary intake assessed and receive individualised dietary advice and continued diet advice Evidence Based Guideline for the Prevention of Type 2 Diabetes. Australian Government NHMRC www.diabetesaustralia.com.au

  38. Prevention of Diabetes Recommendations to reduce risk of type 2 diabetes • Identification of women with GDM would allow: • Postnatal clinical interventions in those with diabetes • Option to use preventive methods to  the risk of DM • Diet and exercise education in children should include • Parental involvement • Behavioral techniques Evidence Based Guideline for the Prevention of Type 2 Diabetes. Australian Government NHMRC www.diabetesaustralia.com.au

  39. Prescription pad Prescription pad

  40. Thank you all

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