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A 42-year-old asymptomatic man with hypertension presents for his annual physical examination. His medications include atenolol combined with chlorthalidone.

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Presentation on theme: "A 42-year-old asymptomatic man with hypertension presents for his annual physical examination. His medications include atenolol combined with chlorthalidone."— Presentation transcript:

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2 A 42-year-old asymptomatic man with hypertension presents for his annual physical examination. His medications include atenolol combined with chlorthalidone (at doses of 50 mg and 25 mg per day Both parents had type 2 diabetes mellitus later in life.

3 He does not smoke cigarettes. His body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) is 32.3, and his blood pressure is 130/80 mm Hg. Would you screen the patient for diabetes, and if so, how?

4 American Diabetes Association Recommendations for the Screening of Asymptomatic Persons for Diabetes.*

5 Screen beginning at 45 yr of age, at least every 3 yr

6 Screen at any age and more frequently if the body-mass index is 25 or more and if the person has at least one additional risk factor

7 Family history of diabetes (first- degree relative)

8 High-risk race (e.g., black, Native American, Asian, and Pacific Islander) or ethnic group (Hispanic

9 Glycated hemoglobin level of 5.7% or more or impaired fasting glucose or impaired glucose tolerance on previous testing

10 History of gestational diabetes or delivery of a baby weighing more than 9 lb (4.1 kg)

11 The polycystic ovary syndrome

12 Hypertension (blood pressure ≥140/90 mm Hg; or therapy for hypertension

13 History of cardiovascular disease

14 HDL cholesterol level of less than 35 mg per deciliter, triglyceride level of more than 250 mg per deciliter or both

15 Physical inactivity Other clinical conditions associated with insulin resistance (e.g., severe obesity and acanthosis nigricans

16 Summary: Risk Factors for Type 2 Diabetes Age ↑ Family History / genetics ↑ Gestational Diabetes ↑ Obesity / fat distribution ↑ Physical Activity / fitness ↓ Smoking ↑ Very low birth weight ↑ Depression ↑ Antipsychotic medications ↑ Anti-Retrovial therapy ↑ Dietary Factors –Carbohydratess ↓ –Fats ↑↓ –Glycemic load ↑ –Cereal fiber / whole grain ↓ –Dairy products ↓ –High fructose corn syrup ↑ –Sugar-sweetened bevarages ↑ –Alcohol ↓ –Coffee ↓

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18 : AACE Diagnostic Criteria Glucose Testing and Interpretation

19 Criteria for the Diagnosis of Diabetes A1C ≥6.5% OR Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) OR 2-h plasma glucose ≥200 mg/dL (11.12 mmol/L) during an OGTT OR A random plasma glucose ≥200 mg/dL (11.1 mmol/L) ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 2.

20 Criteria for the Diagnosis of Diabetes Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) Fasting is defined as no caloric intake for at least 8 h * *In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing. ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 2.

21 Criteria for the Diagnosis of Diabetes 2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water * *In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing. ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 2.

22 Criteria for the Diagnosis of Diabetes In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL) ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 2.

23 Criteria for the Diagnosis of Diabetes A1C ≥6.5% The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay * *In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing. ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 2.

24 The diagnosis requires confirmation by the same or the other test.

25 Prediabetes: IFG, IGT, Increased A1C Categories of increased risk for diabetes (prediabetes) * FPG 100 – 125 mg/dL (5.6–6.9 mmol/L): IFG OR 2-h plasma glucose in the 75-g OGTT 140–199 mg/dL (7.8–11.0 mmol/L): IGT OR A1C 5.7–6.4% *For all three tests, risk is continuous, extending below the lower limit of a range and becoming disproportionately greater at higher ends of the range. ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 3.

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27 AACE Recommendations for A1C Testing A1C may be misleading in some clinical settings –Hemoglobinopathies –Iron deficiency –Hemolytic anemias –Thalassemias –Spherocytosis –Severe hepatic or renal disease AACE/ACE endorse the use of only standardized, validated assays for A1C testing AACE. Endocrine Pract. 2010;16:

28 AACE. Endocrine Pract. 2010;16: AACE Recommendations for A1C Testing A1C should be considered an additional optional diagnostic criterion, not the primary criterion for diagnosis of diabetes When feasible, AACE/ACE suggest using traditional glucose criteria for diagnosis of diabetes A1C is not recommended for diagnosing type 1 diabetes A1C is not recommended for diagnosing gestational diabetes 28

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30 , for every 25-32mg/dL in increase blood glucose levels, there is a 1% increase in HbA1c in patients But without any hematologic variants. 3 with patients who do have any hematologic disorders, this corresponding increase in HbA1c does not occur.

31 low values may occur in patients with certain hemoglobinopathies e.g., sickle cell disease and thalassemia) or who have increased red-cell turnover hemolytic anemiaand spherocytosis) or stage 4 or 5 chronic kidney disease, especially if the patient is receiving erythropoietin

32 In contrast, falsely high glycated hemoglobin levels have been reported in association with iron deficiency and other states of decreased red-cell turnover

33 Glycated hemoglobin Fasting not required, low biologic marker of long-term glycemia, stable during acute illness, sample stability in vial global, standardization, close association of results with complications variability,

34 A1C ~ “Average Glucose” American Diabetes Association A1C eAG % mg/dL mmol/L Formula: 28.7 x A1C eAG

35 A fasting glucose level of 100 to 125 mg is consistent with prediabetes; the range of glycated hemoglobin levels that are diagnostic of prediabetes is controversial, but the ADA recommends a range of 5.7 to 6.4%

36 Oral glucose-tolerance test Most sensitive test, earliest marker of glucose dysregulation

37 Fasting required, substantial biologic variability, poor reproducibility from day to day, lack of association of results with complications over time, sample instability in vial more time required, inconvenience,, higher cost, lack of global standardization of plasma glucose measurements

38 Advantage of GTT

39 Test allowed established whether has an n GTTor unkown type 2 diabetes It disclosed wheathera subject has prediabetes Approximately40%of subjects who will develo diabetes with the NGT OGTT detectsdiabetes more efficiently thanFBS

40 Sbject withFBS >100in GTT(60%)had 2hpg <140 Subject withFBS.140

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42 Testing of glycated hemoglobin or fasting plasma glucose appears to identify different groups of patients with diabetes and prediabetes, yet both tests identify patients at similar risk for adverse sequelae.

43 Longitudinal investigations have shown that persons categorized as being “impaired” by any of these definitions have approximately a 5 to 10% annualized risk of diabetes, a risk that is greater by a factor of approximately 5 to 10 than that normal glucose tolerance or normal fasting glucose.

44 Risks appear to be similar among persons with isolated impaired fasting glucose (i.e., without impaired glucose tolerance) and isolated impaired glucose tolerance (without impaired fasting glucose). However, the proportion of patients with impaired glucose tolerance tends to be greater than that with impaired fasting glucose in most populations

45 Persons with both impaired fasting glucose and impaired glucose tolerance have a higher risk of diabetes (approximately 10 to 15% per year) than those with only one abnormality. Whereas both prediabetic states are associated with increased total and cardiovascular mortality, impaired glucose tolerance tends to be a better predictor than impaired fasting glucose.

46 Persons with both impaired fasting glucose and impaired glucose tolerance have a higher risk of diabetes (approximately 10 to 15% per year) than those with only one abnormality. Whereas both prediabetic states are associated with increased total and cardiovascular mortality, impaired glucose tolerance tends to be a better predictor than impaired fasting glucose.1414

47 Type 2 Diabetes Screening in Children/Adolescents Overweight -BMI >85th percentile -weight for height >85 th percentile -weight >120% of ideal for height Plus any two of the following risk factors….

48 Type 2 Diabetes Screening in Children/Adolescents FH of type 2 diabetes in 1st or 2nd-degree relative Race/ethnicity (Native American, African American, Latino, Asian American,Pacific Islander) Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, PCOS, or small-for -gestational-age (SGA) birth weight) Maternal history of diabetes or GDM during gestation Diabetes Care 34:Supplement 1, 2011

49 Type 2 Diabetes Screening for Children/Adolescents Age of initiation: at-risk age 10 years or if younger onset puberty Screen every 3 years No screening recommended for Type 1 Diabetes in asymptomatic individuals outside of research protocols

50 Gestational Diabetes (GDM) Screen for type 2 diabetes first prenatal visit if risk factors Not known to have diabetes, screen for GDM at 24 –28 weeks of gestation Screen women with GDM for persistent diabetes 6–12 weeks postpartum Women with a history of GDM lifelong screening for diabetes or prediabetes at least every 3 years (up to 7x higher risk than non- GDM) Diabetes Care 34:Supplement 1, 2011 Diabetes Care 34:Supplement 1, 2011 Lancet, 2009, 373(9677): Diabetes Care 21(2):B161–B167, 1998 Diabetes Care 2010; 33: 676–682

51 Screening for and Diagnosis of GDM Perform a 75-g OGTT, with plasma glucose measurement fasting and at 1 and 2 h, at 24–28 weeks of gestation in women not previously diagnosed with overt diabetes Perform OGTT in the morning after an overnight fast of at least 8 h ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2013;36(suppl 1):S15; Table 6.

52 GDM diagnosis: when any of the following plasma glucose values are exceeded – Fasting ≥92 mg/dL (5.1 mmol/L) – 1 h ≥180 mg/dL (10.0 mmol/L) – 2 h ≥153 mg/dL (8.5 mmol/L)

53 Gestational Diabetes (GDM) Overnight fast, 75g OGTT Fasting >92 mg/dl 1 h >180 mg/dl 2 h >153 mg/dl Diabetes Care 34:Supplement 1, 2011 Diabetes Care 2010; 33: 676–682

54 Time of Sample Collection ACOG Levels**,4(mg/dL)**ADA Levels 3 (mg/dL) gram Glucose Drink 75-gram Glucose Drink Fasting, before drinking glucose 95 or above92 or above 1 hour after drinking glucose 180 or above 2 hours after drinking glucose 155 or above153 or above 3 hours after drinking glucose 140 or aboveNot used Requirements for Diagnosis TWO or more of the above levels must be met ONE or more of the above levels must be met OGTT Levels for Diagnosis of Gestational Diabetes **Carpenter and Coustan Conversion, some labs use different numbers.

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56 Classification of Diabetes Type 1 diabetes –β-cell destruction Type 2 diabetes –Progressive insulin secretory defect Other specific types of diabetes –Genetic defects in β-cell function, insulin action –Diseases of the exocrine pancreas –Drug- or chemical-induced Gestational diabetes mellitus (GDM) ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S11.

57 Classification of Diabetes Type 2 diabetes –Progressive insulin secretory defect Other specific types of diabetes –Genetic defects in β-cell function, insulin action –Diseases of the exocrine pancreas –Drug- or chemical-induced Gestational diabetes mellitus (GDM ) ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S11. Type 1 diabetes –β-cell destruction

58 Blood Pressure Done at every visit Target is <130/<80 ACE inhibitors typically first line American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

59 Children with DM Hypertension and Lipids Lipids: start screening in childhood if strong FH, or at age 10 Hypertension: BP >90 th percentile for height and weight or >130/>80 Consider medications (statins, ACE) if necessary American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

60 Lipids (Cholesterol) Fasting lipid panel at least annually Goals: Total cholesterol <200 Triglycerides <150 HDL >40 men, >50 women LDL <100 (<70, CVD or high risk) American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

61 Aspirin Men >50 years of age Women >60 years of age Younger if higher risk American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

62 Nephropathy (Kidney Disease) Screening Annual urine testing for micro- or macro- albuminuria Annual creatinine and GFR Start at diagnosis for type 2 Start 5 years after diagnosis type 1 Diabetes Care. 2011;34(suppl 1)

63 Retinopathy Screening Type 1 annual starting after age 10 or after 5 years post diagnosis Type 2 annual starting shortly after diagnosis Consider less frequent if one or more normal exams (not usually done) Diabetes Care. 2011;34(suppl 1)

64 Neuropathy Screening Screen at diagnosis and annual thereafter Filament testing Vibratory testing Reflexes American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

65 Celiac Disease Screening At diagnosis in Type 1 and periodic (?), pregnant Rescreen if GI symptoms, failure to thrive, glycemic control changes ~10% of type 1? Test: Tissue transglutaminase IgA and IgG Or Anti-endomysial antibiodies with serum IgA American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

66 Thyroid Screening Type 1 screen at diagnosis and every 1 to 2 years, pregnant At diagnosis, thyroid peroxidase and thyroglobulin antibodies TSH thereafter

67 Other Screening/Interventions Tobacco cessation Smoking contributes to poor glucose control and increased CVD risk Smokers should be directed to a cessation program, i.e., Quitline, Quitnet, Quitplan, 3 rd party payer, etc. Medication(if appropriate) Other routine screens (i.e.,cancer)

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75 All diabetes and IGT Total population (millions) Adult population (millions) (20-79 years) Diabetes prevalence (%) (20-79 years) Diabetes number (millions) (20-79 years) IGT prevalence (%) (20-79 years) IGT number (millions) (20-79 years) Type 1 diabetes (0-14 years) 2003 Child population (millions) Type 1 diabetes prevalence (%) 0.02 Type 1 diabetes number (thousands) 46.5

76 Diabetes Pyramid of Prevention Diabetes Very High Risk (A1c > 5.7%; IGT; GDM) Undiagnosed DM Moderate Risk Low Risk Adult Prevalence Goal / Intervention Tier 7.6% 2.6% ~ 12-15% ~ 15-20% ~57% Prevent Morbidity Detect Early High Risk (FPG > 100); Central Obesity; HTN, age What type of intervention for what level of risk?

77 Methods: Conducted in ,287 Iranian citizens included Sample size aged 15–64 years Results: 8.7% Diabetes 8.7% 26.6% Hypertension26.6% 22.3% Obesity22.3% 53.6% Central obesity53.6% Prevalence of Diabetes and its risk factors in Iran Esteghamati A, et al. Third national surveillance of risk factors of non-communicable diseases (SuRFNCD-2007) in Iran: methods and results on prevalence of diabetes, hypertension, obesity, central obesity, and dyslipidemia. BMC Public Health May 29;9: million Iranian

78 EpidemiologyPrevalence 2-3 million Incidence Blindness9500 Dialysis1000 Amputation5700 MI20000 CV25000 Hypertension62000 Death40000

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80 Complications Heart disease and stroke In 2004, heart disease was noted on 68% of diabetes-related death certificates among people aged 65 years or older. In 2004, stroke was noted on 16% of diabetes-related death certificates among people aged 65 years or older..

81 Adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes. The risk for stroke is 2 to 4 times higher among people with diabetes

82 Cardiac Complications

83 High blood pressure In , of adults aged 20 years or older with self-reported diabetes, 67% had blood pressure greater than or equal to 140/90 mmHg or used prescription medications for hypertension.

84 Systolic Blood Pressure 130 mm Hg 0.50%

85 Diastolic Blood Pressure 80 mm Hg

86 Retinopathy (in 1173 patients ) - Free 68.9 % - Back ground 22.6 % - Proliferative 9.5 %

87 Blindness Diabetes is the leading cause of new cases of blindness among adults aged 20–74 years. (28.5%) people with diabetes aged 40 years or older had diabetic retinopathy, and of these, almost 0.7 million (4.4% of those with diabetes) had advanced diabetic retinopathy that could lead to severe vision loss.

88 Kidney disease Diabetes is the leading cause of kidney failure, accounting for 44% of new cases in

89 Nervous system disease (Neuropathy) About 60% to 70% of people with diabetes have mild to severe forms of nervous system damage.

90 Amputation More than 60% of nontraumatic lower- limb amputations occur in people with diabetes..

91 Prevalence of foot complications 1- Fungus infection = Foot ulcers = 6.8 % 3- Evident Ischaemic changes = 9.7 % 4- Amputations = 3.0 % 5- Deformities = 1.0 %

92 Hospitalization: 3 times Mortality: 3-4 times Diabetes care costs: 2.5 times

93 Cost of Diabetes Updated March 6, 2013 $245 billion: Total costs of diagnosed diabetes in the United States in 2012 $176 billion for direct medical costs $69 billion in reduced productivity

94 Table: Prevalence, awareness, treatment, and control rate of hypertension, dyslipidaemia and diabetes: Isfahan Healthy Heart Programmed study Condition treatment % (% total) Hypertension 87.7 (35.3) Dyslipidaemia 49.7 (7.1) Diabetes mellitus 84.7 (46.2)

95 Table: Prevalence, awareness, treatment, and control rate of hypertension, dyslipidaemia and diabetes: Isfahan Healthy Heart Programmed study Condition awareness % Hypertension40.3 Dyslipidaemia14.4 Diabetes mellitus 54.6

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97 Post Prandial Hyperglycemia - Controlled < 160 mg/dl = 13.5 % - Accepted mg/dl = 7.9 % Total = 21.4 % - Uncontrolled ( >180 mg/dl ) = 78.6 % * Moderate -220 mg/dl = 17.4 % * Severe mg/dl = 16.0 % * Very Severe > 260 mg/dl = 45.2 %

98 120 mg/dl Hyperglycemia Fasting

99 How well are diabetic risk factors controlled in Iran? 6.4% 1.1% 25.7% NA HbA 1c Measured in the previous year Patients at goal Lipids Delaveri A.,Archives of Iranian Med 2009;12:

100 Lipid Control Serum Cholesterol 200 mg

101 Lipid Control Serum Triglycerides 150 mg

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107 Costs of Diabetes Indirect Direct ~2.3 times more than medical costs of people without diabetes 107 CDC. National diabetes fact sheet,

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