Presentation on theme: "DIABETES Cameron VanTassell MS,RD,BC-ADM. HbA1c Definition-a stable glycoprotein formed when glucose binds to hemoglobin A in the blood in a concentration."— Presentation transcript:
HbA1c Definition-a stable glycoprotein formed when glucose binds to hemoglobin A in the blood in a concentration dependent process – Marker of glycemic control for the last 2-3 months More heavily weighted towards the last month (~50%) Good glycemic control – ADA- 7%, AACE- 6.5% HbA1c now recognized by ADA and AACE as a way to diagnose DM (>6.5%)
HbA1c Other factors besides glycemic control are known to alter HbA1c values (1) – Advanced kidney disease – Any illness characterized by hemolysis – Certain forms of dyslipidemia – Malignancies – Cirrhosis – Iron deficiency anemia (increases of 1-1.5 %) – Pregnancy – Unknown Genetic factors (high glycators (African Americans) vs low glycators (non-Hispanic whites)) – Age “Given the frequency with which subjects with diabetes have other medical illnesses, the likelihood that such factors may alter HbA1C is widely underestimated.” Dr. Zachary Bloomgarden
HbA1c Usefulness Inpatient- Only thing available to determine recent glycemic control but should be interpreted with the knowledge it can be misleading Outpatient- Should not be used as the only tool to determine glycemic control. Home blood glucose results should also be used.
Post Open Heart Blood Glucose Portland Protocol (2) Every 4 hour subcutaneous insulin vs insulin drip Goal was less than 200 mg/dl for q 4 sub q Goal was 150-200 mg/dl for drip 50% decrease in mortality using drip Significant decrease in sternal wound infections Portland Protocol “3-BG” (3) 3-BG an is average of all glucose values the day of surgery and days 1 and 2 post op Increase 3-BG was associated with deep sternal infections, hospital length of stay, blood transfusions, new onset atrial fibrillation, and low cardiac output syndrome.
Post Open Heart Blood Glucose Lazar et al (4) Used modified glucose-insulin-potassium (GIP) drip vs. sliding scale after 12 hours in the ICU the average glucose for GIP was 134 mg/dL vs 266 mg/dL ( p < 0.0001)for those receiving sliding scale Those receiving GIP had significantly shorter hospital stay vs sliding scale (6.5 days vs 9.2 days; p = 0.0003) After 5 year those receiving GIP had a significant survival advantage (p = 0.04), a significantly lower incidence of recurrent ischemia (p = 0.01) and wound infections (p = 0.03), and were able to maintain a lower angina class (p = 0.03).
What Does The Patient Need to Know? Depends on What type of DM Oral vs insulin therapy Previous Education Socioeconomic factors What daily choice do patients make that has the biggest impact on glycemia?
What Does The Patient Need to Know? Indirect knowledge DM education Carbohydrate counting Direct knowledge Testing with purpose If I eat x I can expect y to happen
Stages of Type 2 Diabetes Related to Beta-Cell Function 10 Adapted from Lebovitz HE. Diabetes Reviews. 1999;7(3). 2122106061014 BetaCell Function (%) 0 50 100 75 25 Type 2 Phase 1 IGT Years from Diagnosis Type 2 Phase 2 Type 2 Phase 3 Postprandial Hyperglycemia
Insulin Secretion in Type 2 Diabetes 11 Polonsky KS, et al. N Engl J Med. 1996 Mar 21;334(12):777-783. Normal Type 2 diabetes Time (24hour clock) 060010001400180022000200 800 600 400 200 0 Insulin Secretion (pmol/min) Meal
Testing with purpose I believe one major reason people fail to test their blood glucose is they see no purpose in it Unable to interpret why/ patterns No one in the medical community ever looks at the numbers Some are discouraged to do so or told it is unimportant
Testing with purpose One of the most effective ways to give patients immediate feedback on the choices they make is to test pre and post prandial blood glucose Test right before meals and 1-2 hours post meal. What is the difference? Generally we would like to see no more than a 60 mg/dl rise