PREDIABETESJILL M ABELSETH MD FACE

DIRECTOR CRDEC

JILL.ABELSETH@SPHP.COM

LYNN SUTTON RD CDE

LYNN.SUTTON@SPHP.COM

HOW DO WE IDENTIFY PATIENTS AT

RISK.

When reviewing routing lab work, look for an elevated glucose, or A1c

the same way you would look for elevated lfts.

If a patient does not have routine lab work or there is no glucose

available, decide who needs to be screened.

WHO DO WE SCREEN FOR PREDIABETES/TYPE 2 DIABETES

IN ASYMPTOMATIC ADULT INDIVIDUALS

Consider testing (screening) all adults

with a BMI* ≥25 kg/m2 and additional risk

factors

If no risk factors, consider screening

no later than age 45 years

If normal results, repeat testing

(screening) at ≥3-year intervals

More frequently depending on initial

test results and risk factors

Test yearly if prediabetes

DIABETES RISK FACTORS

●Physical inactivity

●First-degree relative with diabetes

●High-risk race/ethnicity

●Women who delivered a baby weighing >9 lb or were diagnosed with GDM

●Hypertension (≥140/90 mmHg or on therapy for hypertension)

●HDL-C <35 mg/dL and/or a TG >250 mg/dL

●A1C ≥5.7%, IGT, or IFG on previous testing

●Other clinical conditions associated with insulin resistance, such as severe obesity, acanthosis nigricans, PCOS

●History of CVD

Adapted from: American Diabetes Association. Testing for Diabetes in Asymptomatic Patients.

Diabetes Care. 2014;37(suppl 1):S17; Table 4

*At-risk BMI may be lower in some ethnic groups

Fasting Plasma Glucose

Diabetes Mellitus

Prediabetes Impaired Fasting

Glucose

Normal

2-hour Plasma Glucose on

OGTT

Diabetes Mellitus

Prediabetes Impaired Glucose

Tolerance

Normal

Hemoglobin AIC

Diabetes Mellitus

Prediabetes

Normal

What is Prediabetes?

The diagnosis of diabetes can also be made based on unequivocal

symptoms and a random glucose >200 mg/dL (Adapted from Am

Diabetes Assn, Diabetes Care 2014)

100 mg/

dL

200 mg/

dL

140

mg/

dL

126 mg/

dL

P.S.

64 Y/O MALE

2/2016 INITIAL PCP VISIT MET W/ NP

HEIGHT: 70” WEIGHT: 315# BMI: 45.2

MEDICAL HX

BLADDER CA > 30 YRS (UROLOGY )

EPILEPSY STABLE ON MEDS NO

SEIZURES > 3YR

( NEUROLOGY)

HYPERLIPIDEMIA ( STATIN & NIACIN )

GERD ( OMEPRAZOLE )

OBESITY

Medications:

Divalproex ER 500mg

Lovastatin 20mg

Niacin 500 mg

Aspirin 325 mg

Omeprazole

FAMILY HX

Brother: Prostate CA, type 2 DM, Obese

Sister: GDM, Obese

Father: MI

Mother: CVA

11/2015 5/2016

FBG ------------ 105 FBG - ----------- 102

A1C ------------ NA A1C ------------ 6.4%

EAG ------------ NA EAG ----------- 137

TC ------------ 164 TC ------------ 185

TG ------------ 117 TG ------------ 160

LDL ------------- 96 LDL ------------- 96

VLDL ------------ 23 VLDL ------------ 23

HDL ------------- 45 HDL ------------ 44

ADA RECOMMENDATIONS

Follow-up counseling and maintenance programs should be offered for long term success. (B)

Such programs should be covered by third-party payers. (B)

At least annual monitoring in those with prediabetes should occur. (E)

Screening and treatment of modifiable risk factors for CVD is suggested. (B)

REFER TO DPP

No class for 3 months or no class geographically or time appropriate

Patient refuses to go to one more thing/doesn’t like classes

Nope, not going to do it

WHAT TO DO NEXT

Determine the most effective treatment or

treatments for the patient that can be

prescribed from your office.

It is very important that the seriousness of

this diagnosis be confirmed to the patient

and that a program is initiated immediately if

the patient is unwilling/unable to go to a DPP

FOLLOW UP VISIT WITH NP 5/23/2016

Weight 325# up 10# in 3 mo.

BMI @ 46.6 up from 45.2

“Morbid obesity- patient states that everyone has

just told him to back away from the food and just

stop eating so much, but he states that it's not that

simple. Will eat a large amount of food and then

afterwards feel guilty and wonder why he ate so

much. Knows that his weight is impacting many

different aspects of his life and if he could lose

some weight other things would get better.”

TREATMENT CHOICES

Lifestyle counseling similar to what would be

prescribed in the DPP, ie loss of 7% of body

weight and exercise 150 minutes per week

Medication

Lifestyle counseling and medication

Education: what is pre-DM and how to prevent

progression to DM.

Nutrition:

1800 calorie diet for significant weight loss

75 grams of fat ( less than 30%) greater than 80% from

mono & polyunsaturated fat choices.

Balance of CHO with 45g /meal & 15 g CHO for snacks,

eat lean protein for all meals.

WALK 15 MINUTES AFTER DINNER.

EMAIL CONTACT PROVIDED FOR QUESTIONS

F/U 7/2016 Wt 296# BMI @ 42.4

Wife accompanied as she does all the grocery shopping and food prep. Reviewed all from initial visit

Following dietary recommendations &

walking 3 miles everyday

F/U 8/2016 Wt 288# BMI @ 41.3

Continues diet

Continues walking daily

Discussed maneuvering celebrations, family gatherings

Feeling well, trying to encourage family members to do the same.

RD,CDE VISIT 10/2016

Wt 280# down a total of 45# in 5 months.

BMI @ 40.17 ( original 45.2)

A1C now 5.6% ( original 6.4% )

Continued weight loss advised

Understanding weight loss will slow

Continue activity, walking.

States motivation to continue weight loss

get A1C lower and …

HAVE HIS CLOTHES TAILORED

VISIT / CONTACT TIMELINE

5/2016 REFERRED TO RD,CDE

3 VISITS, ONCE MONTHLY FOR 3 MONTHS

4TH VISIT 6 WEEKS

5TH VISIT 6 WEEKS

THEN 3 MONTHS BETWEEN SUPPORT.

EMAIL, VOICEMAIL, SUPPORT

GROUPS.

PREVENTION OPTIONS

No DPP

available

Willing and

able to go

To a

Registered

Dietitian

Recommend

diet and

exercise

Refer to

RD,CDE

Such as @

CRDEC

No DPP

available

not able

or unwilling

to go to

Registered

Dietitian

Offer

“Back on

Track Plan” *

PREVENTING DIABETES

WE KNOW WHAT WORKS

INTERVIEW & ASSESS

What will they do?

Write your prescription!

PRESCRIBE SPECIFICS

1. Stop drinking all juice, milk and sugar sweetened beverages

2. Follow this diet plan

3. Walk 10 minutes after every meal

4. Check off

“PRESCRIBE” A SPECIFIC

DIET Before 9am

Breakfast: 1 slice toast with 1 TBL peanut butter, 1 egg & 1 orange

Before 2 pm,

Lunch: 2 slices bread, 3 oz. turkey breast, lettuce, tomato, onion, mustard

Carrots, celery, sugar snap peas, 2 TBL low fat salad dressing

Before 7 pm

Dinner: 3 – 6 oz. chicken or turkey breast, fish, tenderloin, 1 small potato, large salad, 2 TBL low-fat dressing, 2 cups cooked vegetables.

Before 9 pm

Snack: 1 apples and 10 nuts or

1 slice of toast w/ 1 TBL peanut butter

**Close Kitchen @ 9pm

EXERCISE

Walking after a meal

increases insulin

sensitivity and lowers

postprandial glucose.

Rynders CA, Weltman JY, Jiang B, et al. Effects of Exercise Intensity on Postprandial Improvement

in Glucose Disposal and Insulin Sensitivity in Prediabetic Adults. The Journal of Clinical Endocrinology

and Metabolism. 2014;99(1):220-228. doi:10.1210/jc.2013-2687.

DiPietro L, Gribok A, Stevens MS, Hamm LF, Rumpler W. Three 15-min bouts of moderate post-meal walking

significantly improves 24-h glycemic control in those at risk for impaired glucose tolerance.

Diabetes Care. 2013 Oct;36(10):3262-8. doi: 10.2337/dc13-0084. Epub 2013 Jun 11.

MONITOR PROGRESS

Best if patient monitors

what they are doing

Provider needs to

assess frequently

FOLLOW UP SUPPORT

TRACK PROGRESS: WEIGHT LOSS

5- 7% weight loss will

have a significant

effect on insulin

resistance.

IS THERE A WAY TO DETERMINE

INCREASED RISK?

METABOLOMICS

Is there a metabolic signature that would

identify the patients with prediabetes who

are at highest risk and need most

aggressive intervention?

IMPAIRED GLUCOSE TOLERPROGREANCE PRECEDES

TYPE 2 DIAGNOSIS

Schematic of β-cell failure andPROpR insulin resistance prior to diagnosis

β-cell failure

Endogenous Insulin

Insulin Resistance

Years4-7 years

Postprandial Blood Glucose

Fasting Blood Glucose Time of Diagnosis

Fasting >125mg/dLPostprandial >180mg/dL

Pre-diabetes Diabetes

Adapted from Ramlo-Halsted BA, Edelman SV. Prim Care. 1999;26(4):771-789

WHAT IS METABOLOMICS?

Genomics - A field of life science research that uses High Throughput (HT) technologies to identify and/or characterize all the genes in a given cell, tissue or organism (i.e. the genome).

Metabolomics - A field of life science research that uses High Throughput (HT) technologies to identify and/or characterize all the small molecules or metabolites in a given cell, tissue or organism (i.e. the metabolome).

THE PYRAMID OF LIFE

25,000 Genes

7500 Enzymes

8000

Chemicals

Metabolomics

Proteomics

Genomics

En

vir

on

me

nta

l In

flu

en

ce

METABOLISM IS “UNDERSTOOD”

METABOLOMICS IS MORE TIME

SENSITIVE THAN OTHER “OMICS”

Metabolomics

Proteomics

GenomicsR

es

po

ns

eR

es

po

ns

eR

es

po

ns

e

Time

METABOLOMICS IDENTIFIER FOR

PREDIABETES/DIABETES

Branched Chain Amino Acids ( leucine,

isoleucine, valine, probably early signals of

deterioration of glucemic control.

WHO IS MOST AT RISK?

Patients with a BMI >35kg/m2

Those aged >60years

Women with a previous history of GDM

For this group metformin therapy should be

considered. (level A evidence based

recommendation. )

METFORMIN

ESTABLISHED TREATMENT FOR DIABETES BUT

UNDERUTILIZED BY PRIMARY CARE

GOOD SAFETY PROFILE

4% OF PATIENTS IN CLINICAL TRIALS DISCONTINUED

DRUG BECAUSE OF GI INTOLERANCE

THIS CAN BE AVOIDED BY GRADUAL DOSAGE

TITRATION

DOES NOT CAUSE HYPOGLYCEMIA AS

MONOTHERAPY

LACTIC ACIDOSIS ONLY OCCURS IN SETTINGS OF

RENAL AND/OR HEPATIC FAILURE

METFORMIN RESULTS IN DIABETES

PREVENTION

Reduced the development of DM by 31% over 2.8

years and this has continued over 10 years of the

extension study.

Weight loss was 26% reached 5% weight loss but

this was durable over extension

Weight loss was related to medication adherence.

Over 80% adherence, higher weight loss

METFORMIN INITIATION

In study they used 850 mg q day for one

month then increased to final dose of 850mg

bid

Some European data that weight loss is

dose related.

I do 500mg ER for one week and then

increase by one pill every 1-3 weeks until at

4 pills at one meal.

Stop before dye study or surgery ,day before

and resume 2 days after.

D-CLIP RANDOMIZED CONTROL TRIAL

DIABETES CARE: 2016 VOLUME 39 PAGE: 1760

RCT LOOKING AT IMPACT OF ADDITION OF

METFORMIN

PATIENTS WITH PREDIABETES RANDOMIZED TO

STANDARD LIFESTYLE (CONTROL) VS DPP PROGRAM

WITH METFORMIN ADDED FOR THOSE JUDGED HIGH

RISK AT 4 MONTHS OF FOLLOWUP (IF STILL MET

CRITERIA FOR PREDIABETES)

RRR WAS 32%

76% OF PATIENTS WITH IFG REQUIRED METFORMIN

OTHER DRUGS?

PIOGLITAZONE PREVENTS DIABETES IN

PATIENTS WITH INSULIN RESISTANCE AND

CEREBROVASCULAR DISEASE, REDUCTION

OF PROGRESSION TO DM OF 52% OVER 4.8

YRS.

PIOGLITAZONE EFFECTIVE IN REDUCING

NASH

DON’T USE IN PATIENTS WITH CHF, BLADDER

CANCER AND OR LIVER DISEASE

OTHER DRUGS?

GLUCAGON LIKE PEPTIDE DRUGS OR GLP-1 ARE AGENTS THAT

LOWER GLUCOSE WITHOUT CAUSING HYPOGLYCEMIA AND ARE

ASSOCIATED WITH WEIGHT LOSS.

BLACK BOX WARNING FOR MTC AND INCREASED RISK FOR

PANCREATITIS

TRULICITY, BYDUREON, TANZEUM, BYETTA

OFF LABEL FOR PREDIABETES BUT VERY EFFECTIVE

THANK YOUQUESTIONS?