GO! Diabetes Residency Train the Trainer Program

Diabetes: Early Detection and Lifestyle Monitoring

MAKING THE DIAGNOSIS A1C ≥6.5 percent. OR FPG ≥126 mg/dL. OR Two-hour (75 gm) plasma glucose ≥200 mg/dL during an OGTT. OR In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL. American Diabetes Association. Standards of Medical Care in Diabetes Care 2010; 33:S11. Copyright © 2010 American Diabetes Association.

Evolution of DM Insulin resistance results in hyperinsulinemia NOT hyperglycemia at first! Postprandial glucose is the next to climb Fasting glucose levels rise with progressive beta-cell dysfunction (Bergenstal, Mgmt Type 2 DM, 2001)

Etiology of Metabolic Syndrome Insulin resistance –Due to genetics and lifestyle factors –Insulin receptors no longer recognize insulin –Leads to Hyperglycemia and Hyperinsulinemia Pro-thrombotic state Pro-inflammatory state

Insulin Resistance Leads to… Increased fat storage in the abdomen May stimulate cancer cell growth Vascular changes in the endothelial lining leading to vasoconstriction: Lab abnormalities: elevated TG, small dense LDL-chol, and low HDL-chol Increased platelet adhesion Increased response to Angiotensin II Reduction in nitric oxide (a vasodilator)

Metabolic Syndrome Requires 3 or more: –Triglycerides > 150 –HDL < 40 –Waist size >40” men, >35” women –BP > 130/85 –Fasting glucose > 100 Caveat: Treatment counts for requirements… Grundy, Circulation, 2005

Metabolic Syndrome cont. The relevance? 1 in 4 adults meets diagnostic criteria (at least 3 factors) 4 out of 5 adults has at least one factor and is at risk (Ford, JAMA, 2002)

Metabolic Syndrome as a Risk Factor in the Incidence of Diabetes metabolic syndrome Impaired Glucose Tolerance % Yes No yes no

“Pre-Diabetes” Key Point: You have to predict the emergence of diabetes and head it off before it evolves in a patient Impaired Fasting Glucose –FBS mg/dL Impaired Glucose Tolerance –2-hr GTT of Which would catch a problem earlier?

Pre-Diabetes Definition FastingGTT or If FBG >100 there is a 10-15% risk of DM within 7 years…

Who and When to Screen? Family history Overweight (BMI>25) Dyslipidemia HTN High risk ethnicity Vascular disease Prior glucose elevation Hx or exam findings Starting at age 45, a fasting blood glucose every three years More frequent screening if:

How to Screen As mentioned before, fasting glucose and oral glucose tolerance tests are the standard Important note: HbA1c testing is not a screening tool due to lower sensitivities (think about the window period of hyperinsulinemia but normal glucose)

What if You Don’t Screen? Estimates show a 5-15% conversion to full diabetes from prediabetes per year

Benefits of Diagnosis Seven trials showed a reduction of % in relative risk from behavioral or pharmacologic interventions Numbers needed to treat were in the 4-14 range Cost/benefit analysis clearly favors early diagnosis and intervention. [Currently ~50 million prediabetics] (CDC)

Role of Obesity in Diabetes Obesity (specifically abdominal) has one of the highest associations with insulin resistance and glucose intolerance Numerous studies have tied weight loss to diabetes prevention

Obesity cont. A 5-10% weight loss yields a 58% reduction in the incidence of diabetes! –At the end of four years Diet and exercise regimens average a 4kg loss after two years Advice alone results in a 1kg gain (Franz, Journal American Diabetes Assoc., 2007)

Quantifying Obesity Easiest is by waist circumferences 40” males, 35” females Some variation by ethnicity (35” and 31” for Asians) Measured across iliac crest in the back and the umbilicus in the front

Activity Recommendations For general fitness: 30 min/day moderate activity (walking) five days a week To emphasize weight loss: 60 min/day For children: 60 min/day Vigorous exercise has more cardio benefits (achieves target heart rate) (DGAC, 2005)

“Fitness” A 1999 study published in the American Journal of Clinical Nutrition showed a distinction between “fitness” and body mass/obesity in risk reduction Relative risk reduction in all-cause mortality was the same regardless of body size/BMI – if physically fit (Lee, AJCN, 1999)

Healthcare Maintenance Latest ADA guidelines Lab surveillance Diabetic education Vaccinations/routine healthcare Smoking cessation Foot exams Eye exams

Reasons to Look at Feet Up to 70% of diabetics eventually develop a neuropathy. Up to 15%* develop foot ulcers. More than half of the foot ulcers become infected at some point. * The Semmes Weinstein Monofilament Exam as a screening tool for Diabetic peripheral neuropathy Journal of Vascular Surgery; Sept 2009;

The real morbidity… 10-20% of infected ulcers lead to amputation More than 50% of non traumatic lower limb amputations are due to diabetic foot ulcers. One amputation increases the likelihood of another 5-year mortality rates approach 80%

Foot Surveillance Examine the feet at every visit Annual comprehensive evaluation –Sensation –Pulses –Skin condition (ulcers, hair, nails) –Anatomic deformities –Shoe evaluation

Sensory Exam 10-gram monofilament –Patient should not watch –Three* sites per foot –Apply filament perpendicular to skin –Allow slight buckle of filament in one motion –Each site should take 1-2 sec –Do not apply to ulcers or calluses * The Semmes Weinstein Monofilament Exam as a screening tool for Diabetic peripheral neuropathy Journal of Vascular Surgery; Sept 2009;

Foot Exam Sites Fewer sites than 10 years ago…

Procedures/Billing Foot exams Protective footwear Nail trimming Debridement of corns and calluses

G Initial physician evaluation of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) which must include: 1. the diagnosis of LOPS; 2. a patient history; 3. a physical examination that consists of at least the following elements: –(a) visual inspection of the forefoot, hind foot, and toe web spaces, Diabetic Foot Examination

3.Exam cont: –(b) evaluation of a protective sensation, –(c) evaluation of foot structure and biomechanics, –(d) evaluation of vascular status and skin integrity, –(e) evaluation and recommendation of footwear, and 4. patient education Diabetic Foot Examination

G Follow-up evaluation of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include at least the following: 1. a patient history; 2. a physical examination that includes: –(a) visual inspection of the forefoot, hind foot, and toe web spaces, –(b) evaluation of protective sensation, –(c) evaluation of foot structure and biomechanics, –(d) evaluation of vascular status and skin integrity, –(e) evaluation and recommendation of footwear, and 3. patient education. Diabetic Foot Examination

G Routine foot care of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include if present, at least the following: –(1) local care of superficial wounds, –(2) debridement of corns and calluses, and –(3) trimming and debridement of nails. NOTE: Code G0247 must be billed on the same date of service with either G0245 or G0246 in order to be considered for payment.

Medicare Protective Footwear One pair of depth shoes and three pairs of inserts One pair of custom-molded shoes (including inserts) and two additional pairs of inserts

Eye Care Diabetic retinopathy is the leading preventable cause of blindness Prevalence of DR increases with duration of diabetes (100% Type 1, 60% Type 2 after 20 years) Of all recommendations, eye screening is the least likely to get done

Pathogenesis Increased circulating glucose leads to weakness of capillary walls Microaneurysms and leakage occurs causing eventual infarction of the nerve fiber layers (cotton wool spots) The localized hypoxia then leads to vasoproliferation Extension into the vitrea (+/- hemorrhage) leads to fibrosis and vision loss

Diabetic Retinopathy Normal Retina (left) contrasted with Proliferative Diabetic Retinopathy (right) Refer patients for ophthalmologist evaluation

Key Point Make the annual referral! Attempt screening on your own also – consider a pan-ophthalmoscope There are treatments available (laser)

Questions?