PCore Diabetes Flashcards
Who to screen for diabetes and prediabetes
ppl age 45 and above
esp if bmi >= 25 (obese)*
may not be true for all ethnic groups PCOS (polycystic ovarian syndrome)
Diabetes fasting glucose
126 mg/dL
Screening people < 45 if one or more additional risk factor
- habitually physically inactive
- part of high risk ethnic group (african americans, latino, Native American, asian american, Pacific Islander)
- had baby weighing > 9 pounds or dx with gestational diabetes mellitus
- had impaired fasting glucose or impaired glucose tolerance on previous testing
- other clinical conditions assoc w insulin resistance acanthosis nigricans
- family hx (1st degree relative)
- PCOS
- HDL < 35 mg/dL or triglycerides > 250 mg/dL
- hx of vascular dz
- hypertensive (>= 140/90)
Diagnosing diabetes based on Hg A1c
dx can be made based on elevated value
–> comparable in screening utility to fasting glucose and 2-hr 75 g glucose tolerance testing
a1c >= 6.5% : diagnostic for diabetes; test result must be repeated on subsequent day to rule out lab error, unless dx is evident on clinical grounds (hyperglycemia crisis for ex)
a1c 5.7-6.4% : diagnostic for pre-diabetes; test must also be repeated
Pros and cons of using A1c to dx diabetes
pros: convenience over fasting glucose testing and 2 hr oral glucose tolerance test; no need to fast; less subject to daily fluctuations during periods of stress or illness;
cons: cost, limited availability in certain parts of world, race and age variability, inability to use in pts w certain anemias and hemoglobinopathies (eg sickle cell dz)
Fasting plasma glucose to dx diabetes
- children and non pregnant adults
pros: easier to admin, acceptable to pts, costs less than oral glucose tolerance test
fasting: no calorie intake for >= 8 hrs
diabetes: fgp >= 126 mg/dL dx pts with diabetes!
pre-diabetes: >= 100 and < 126 ; impaired fasting glucose = elevated fasting plasma glucose
dx of prediabetes or diabetes must be repeated and confirmed on sepearate day unless sx of diabetes present
Oral glucose tolerance test (OGTT)
75 g oral glucose tolerance test more sensitive, slightly more specific than FPG
cons: poorly reproducible, more $$$, inconvenient for patients, rarely used in clinical practice
diabetes: plasma glucose >= 200 mg/dL drawn 2 hrs post OGTT
pre-diabetes: *impaired glucose tolerance >= 140 and < 200 mg/dL) after 75 g oral glucose load on ogtt in presence of fpg concentration < 126 mg/dL
Random / casual plasma glucose dx diabetes
+
any time of day regardless of last meal
if > 200 mg/dL + classic symptoms of diabetes (polyuria, polydipsia, unexplained weight loss) makes dx and does not need to be repeated on subsequent day!
Confirming dx with multiple screening tests in same person
- use same screening test in same person for confirmation
- if two diff screening tests used in same pt: if both tests reach diagnostic threshold, then dx can be confirmed at that time (even if both are initial screens)
- if 2 tests discordant, the test that is above threshold should be repeated and dx made based on confirmed test
Criteria to test children for t2dm
initiate age 10 yrs or at onset of puberty (if puberty occurs at younger age);
repeat every 2 yrs
test used: fasting plasma glucose
overweight (bmi > 85th percentile for age and sex; weight for height > 85th percentile, or weight > 120 % of ideal for height)
+
any 2 of following risk factors:
- fam hx t2dm in 1st or 2nd degree relative
- race/ethnicity (Native American, african american, latino, asian american, Pacific Islander)
- signs of insulin resistance or conditions associated w insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, or PCOS)
- maternal hx diabetes or gdm
When to screen women postpartum with gdm
6 wks - 12 wks postpartum
should be followed up with subsequent screening for devt of diabetes or pre-diabetes
Preventing diabetes progression in ppl at high risk or those with pre-diabetes
insulin secretion may be adequeate to maintain fasting blood glucose levels < 126 mg/dL but process of insulin resistance already present
modest weight loss and increasing phyiscal activity can reduce risk of diabetes by 50%
Patients with IFG and IGT prediabetes and any of the following…
< 60 yrs age bmi >= 35 kg/m2 fam hx diabetes in 1st deg relative elevated triglycerides, reduced hdl htn a1c > 6%
in addition to lifestyle modification: metformin (850 mg 2x/day)
no other meds recommended for this group yet
Prevention in pts with IFG or IGT prediabetes (ADA recommendations) and no other significant risks or categorizations (in another slide)
- lifestyle modification (5-10% weight loss and moderate intensity physical activity about 30 min/day)
2.
Followup in pts with ifg/igt being treated with metformin
a1c: semi annually in ppl with ifg/igt being treated with metformin
assess and treat for other cardiovascular risk factors (hyperlipidemia, htn, tobacco use)
counsel for lifestyle modification
follow up pts with ifg/igt not being treated with metformin
a1c: annually screen
assess and treat for other cardiovascular risk factors: hyperlipidemia, htn, tobacco use)
counsel for lifestyle modification
Signs and symtpoms undiagnosed diabetes
most are asymptomatic!!!!
undiagnosed gluocse intolerance and perisistent hyperglycemia can eventually –> classic polydipsia, polyuria, fatigue, weight loss, blurry vision
other signs: obesity, evidence of metabolic syndrome or cardiovascular dz
Assess risk factors for atherosclerosis
smoking, htn, obesity, dyslipidemia, fam hx
Laboratory evaluation patients with diabetes risk or diabetes
a1c
fasting lipid profile: total cholesterol, hdl, triglycerides, LDL
microalbuminuria in t1dm pts who had diabetes for >= 5 yrs and in all patients with t2dm (some advocate testing pubertal children sooner than 5 yrs of diabetes)
serum creatinine in adults (children if proteinuria present)
TSH in all t1dm; t2dm if indicated
ekg in adults if clinically indicated
urinalysis for ketones, protein, sediment
REcommendations to diabetic patients in managing brief illnesses (viral syndromes)
- continue taking medications
- check sugars more frequently (every 2-4 hrs)
- check ketones (every 4 hrs)
- drink lots of non-caffeinated fluids
call dr if cant hold down fluids or carb intake for > 6 hrs, cant eat regular food for one day, develop intractable heavy vomiting or diarrhea, drowsiness or recurrent hypoglycemia
Complications in diabetes: Hypoglycemia
symptoms and plan
causes: taking too much diabetes medicine, missing a meal or snack, exercising too much, drinking alcohol
signs: feeling weak or dizzy; nervous, shaky, or confused; irritability; sweating more; noticing sudden changes in heartbeat; feeling very hungry; losing consciousness; develop seizures
plan: test blood glucose; if <= 70 mg/dL, eat one of the following right away:
2-3 glucose tablets; 1/2 cup (4 oz) any fruit juice, 1/2 cup regular non diet soft drink; 1 cup milk; 5-6 pieces hard candy; 1-2 teaspoons of sugar or honey
check blood glucose again 15 minutes after glucose intake
Complications in diabetes: hyperglycemia
symptoms
causes: forgetting to take medicine on time, eating too much and getting too little exercise; being ill can also raise blood glucose levels
symptoms: frequent hunger; frequent thirst; frequent urination; blurred vision; fatigue; weight loss; poor wound healing
Risk factors for depression in diabetic patients include
age >65; previous hx depression; unmarried; female; poor physical health; poor mental health
Diabetes self-mgmt education programs (dsme)
diabetes care; skill based; pt centered; longitudinal
better outcomes
When to test glucose if pt is NOT on insulin if pt has new dx of diabetes, recent therapy adjustment, or glucose level outside of target
3x/day:
- before breakfast
- before main meal of day
- 2 hrs after start of main meal
When to test glucose if pt is NOT on insulin and glucose in target range
3x/day every 3rd day
When to test glucose if ON insulin
–> taking basal and bolus (meal-associated) insulin
test 4x/day:
- before breakfast
- mid-morning
- mid to late afternoon
- mid evening
When to test glucose if ON insulin
–> taking basal insulin only
test fasting glucose daily and perform other pre and post meal tests intermittently
In all diabetic pts takiing or not taking insulin, test:
- whenever suspecting hypoglycemia
- before driving if having trouble sensing hypoglycemia
dont forget to reassess self-monitored blood glucose skills periodically (esp if glucometer #s dont correspond to hga1c levels)
Hemoglobin A1c
patients average glycemic levels over past 2-3 months
without diabetes: 4-6% (4-6% of a non diabetic persons hemoglobin has nonenzymatically attached glucose)
HOw often to check A1c
patients whose therapy has changed recently: quarterly
patients not meeting glycemic control: quarterly
patients at glycemic control: 2x/yr
Effects of Lowering A1c levels in diabetes…
reduce neuropathic and microvascular complications
ADA recommendations to target goals for A1c and self-monitored blood glucose levels
hga1c for diabetic patients: < 180 mg/dL
Glycemic target goals american assoc clin endocrinologists
hgba1c: < 6.5%
premeal glucose < 110
postmeal glucose 140 mg/dL (2 hours)
Glycemic target goals international diabetes center
Hgba1c < 7%
premeal glucose 70-140
postmeal glucose <160 mg/dL (2 hrs)
Glycemic target goals american diabetes association
Hgba1c < 7%
premeal glucose 90-130 mg/dL
postmeal glucose < 180 mg/dL (1-2 hrs)
Medical nutrition therapy with registered nutritionist
can reduce a1c in newly diagnosed t2dm by 2% and by 1% with t2dm for 4 or more years
overall goals:
- prevent and manage chronic complications
- improve gneeral overall health thru food choices and physical activity
- achieve and maintain optimal metabolic outcomes
- address individual needs
focus: wt mgmt, carb counting, reduced dietary fat
Weight mgmt
strong link bw obese or overweight status and diabetes
obesity: independent risk factor for hyperlipidemia, htn, and cardiovascular dz
ADA recommendations of weight mgmt
- decrease in 500-1000 kcal/day will allow slow progressive wt loss of 1-2 lbs/week
- wt loss diets should supply 1000-1200 kcal/day for women and 1200-1600 kcal/day for men
- drug therapy for obesity may be appropriate to reduce wt in selected patients but lifestyle modifications still important
- severely obese pts: gastric bypass or gastroplasty may be appropriate alternative and can –> reduce doses or discontinuation of diabetes meds
Carb counting possible benefits
limit hyperglycemia
improve weight loss
reduce insulin resistance
prevent complications of diabetes
15 carbs = 1 carb “choice”
c””
International diabetes center recommended food plan
women
weight loss: 2-3 choices/meal
maintain wt: 3-4 choices/meal
for v active person: 4-5 choices/meal
men
weight loss: 3-4 choices/meal
maintain wt: 4-5 choices/meal
v active person: 4-6 choices/meal
Low carb diets not recommended for diabetic patients!
restricting carbs <130 grams/day may be below brain, nervous system, and other metabolic requirements
Dietary fat
total fat :
25-35% of total calories
saturated and tras fatty acids = principal dietary factors of LDL cholesterol (a major factor in cardiovascular dz)
Alcohol
not recommended but those who drink:
women: 1 or less/day
men: 2 or less/day
drink = 12 oz beer, 5 oz wine, 1.5 oz distilled spirits
PHysical activity benefits
reduce risk of cardiovascular dz, reduce insulin resistance, assist in wt reduction, assist in wt mgmt
Aerobic activity
moderate intensity: achieve 50-70% maximum heartrate
vigorous aerobic exercise: > 70% max heartrate
