This document discusses diabetes diagnosis, management, and complications. It begins by comparing the economic costs of diabetes to the War on Terror, finding them similar. It then examines screening guidelines and debates using A1c versus glucose. Management focuses on lifestyle, medications like metformin, insulin, and monitoring. Complications include microvascular issues, cardiovascular disease, and foot problems. The document emphasizes evidence-based prevention and management while acknowledging uncertainty and a patient-centered approach.

1. Diabetes 2011

2. Jonathan Ploudré, MD
North Cascade Family Physicians

3. What’s Bigger?
Diabetes or War on Terror?
In 2007 it’s a trick question: About the Same. $174 Billion/year.

4. Is Diabetes Destiny?
Samoa?
USA?
New Zealand

5. Ploudré Diabetes Index
USA NZ Samoa
BMI
Fasting
Glucose
WHO Noncommunicable Diseases Data. 1980 - 2010

6. Diabetes
• Diagnosing
• Managing
• Complication
Let’s narrow this down to a third of endocrinology

7. Diagnosis
?

8. Screening/Diagnosis
• Two fasting glucose > 126 mg/dl
• Random > 200

9. Who to screen?
• USPTF: Assymptomatic Adults with HTN
(B). All Adults (Insufficient).
• ADA: 18-45, Obese with Risk Factor. All
over 45.

10. Should we use the A1c?
Population Screening in 2010:
1/3 Elevated Fasting Glucose
1/3 Elevated A1c (>6.5)
1/3 Both Fasting Glucose & A1c
J Clin
Endocrinol
Metab 2010
Dec. 95:5289

11. Should we use the A1c?
Longitudinal Cohort Study,
Japan
Fasting Glucose: 6x Hazard Ratio
Elevated A1c: 6x Hazard Ratio
Both: 32x Hazard Ratio
Heianza Y et al.
Lancet, 2011

12. Screening Problem

13. Who to listen to?
• Metaguideline
• Guideline
• Review
• Study
• Preceptor’s Unsourced Opinion
• Google

14. Who to listen to?
• Metaguideline
• Guideline Putting evidence into practice requires
• Review
more guesswork and judgement than you
might think as a 3rd year. Less about
facts, more about hunches.
• Study
• Preceptor’s Unsourced Opinion
• Google

15. Diabetes
• Diagnosing
• Managing
• Complication

16. What works
?

17. • Exercise (1600s?)
• Diet change (1700s)
• Weight loss (Rationing, 1870s)
• Insulin (1921)
• Medications (Sulfonylurea, 1942, Oral in
1956)
• Glucose monitoring (1969)
• Secondary Screening (A1c, 1979)

18. Lifestyle Management
• Why does a chocolate chip cookie, with its
warm, sumptuous mounds of chocolate, have
such power over us?
— David Kessler

19. Guilt
• We probably react like rats here. Oral
glucose has measurable affects on
dopaminergic responses in the Amygdala
for 7 days. Gastric infusion doesn’t.
• Changing Diet is harder than giving the
advice.

20. Lifestyle Management
• Patient-centered: Motivational counseling
• Systems-approach: Reminders
• Support Group
• Group Visits

21. 3 month intervention, SMS
Messages
Patients with SMS messages had 1.16%
drop in A1c compared to controls.
Diabetes Res
Clin Pract. 2011
Aug

22. Medications
• Metformin (Even ER, $4/month)
• Glyburide ( $4/month)
• Contrast: Januvia ($200/month), Actos
($300/month)
Since I include the prices, here,
I’m guessing you have a hunch
about my opinion.
Only oral meds on WHOs Model List of Essential Meds: Metformin, Glyburide.

23. Insulin
• “The most dangerous drug I prescribe”
• Key to management: Matching patients
glucose patterns.
• Glargine, NPH, 70/30, Regular: It depends.

24. Glucose Monitoring
• Somewhere between continuously and
never.
• Test Strips are typically $1 each
• Testing in stable diabetics correlates with
depression (Unactionable result?)
• 10 years ago, I was taught 2x Daily. My
practice now trends toward 0x Daily.

25. Continuous Glucose

26. A1c
?

27. A1c in a tweet
• Your A1c is like a candy coating on your
blood cells. It gives an average of the sugar
in your blood over the 3 months blood
cells live.
• Or just use the estimated glucose instead?
~A1c x 29
As fundamental as A1c is, how
many patients don’t grasp it?

28. A1c Goal < 7.0
That’s right, um, isn’t it?

29. Diabetes
• Diagnosing
• Managing
• Complication

31. Hospital DM
• DKA (Type 1)
• Hyperosmolar Hyperglycemia (Type 2)
• Contrast-induced Kidney Failure
• Secondary Healing Issues
• 2 am Calls (Sugar is 500. Sugar is 25)

32. Grouping
Complications
• Microvascular: Retinopathy, Nephropathy,
Neuropathy
• Macrovascular: MI/CAD, Stroke

33. Diabetes
• Diagnosing
• Managing
• Complication

34. Secondary Prevention
• Retinopathy Exam
• Routine Foot Exam
• Screening Microalbuminuria
• Screening for CVD

35. Reducing CVD
• Aspirin
• BP Control (Especially ACEi)
• Dyslipidemia
• Smoking Cessation

36. UKPDS, 1998

37. UKPDS, 1998

38. Metabolic Syndrome
• With Diabetes, the risk of CVD doubles.

39. 35,000 patients (mean age, 62) received
either intensive or
standard glucose-lowering treatment.
After a mean follow-up of 5 years,
intensive glucose lowering was not
associated with lower risks for
all-cause mortality and CV death
BMJ 2011 Jul

40. Statins effective in CVD
prevention
20-30% reduction in major coronary
events, strokes, revascularizations with
simvastatin.
Lancet 2003.

41. Medication Cage Match
in
rm
fo
et
M
Vs.
in
at
st
va
Sim

42. UKPDS, 1998

43. Intensive BP Therapy: Non-significant
Change in Major CV Risk.
ACCORD BP,
2010

44. Anti-hypertensive?
ACCOMPLISH
ALLHAT
SANDS
ADVANCE
UKPDS

45. Do DM Goals Help?
• A1c < 7.0
• LDL < 70
• SBP < 130, DBP < 85
• Microalbumin < 30
• Monofilament > ....

46. Let’s not get too
Doctor-centered
• Medication adherence probably matters
more for reducing CVD. Apparently, the
statin only works if the patient swallows it
regularly.
• Cost is still a major factor for patients.
• Wouldn’t we get more bang from getting at
the 1 out of 3 diabetics that isn’t
diagnosed?

47. The future of Diabetes
Low Agency High Agency
Diabetes is our Map for treating
Certain
destiny diabetes
Who knows what Let’s build the
Uncertain
we’ll do someday future of diabetes

49. Thanks Flickr, Creative
Commons.
• McDiabetes: http://www.flickr.com/photos/hertzen/5594880296/sizes/l/in/
photostream/
• Diabetes Syringe: http://www.flickr.com/photos/jill_a_brown/2629206800/
sizes/z/in/photostream/
• Iraq: http://www.flickr.com/photos/imcomkorea/3046373113/
• Maria's World Map: http://www.flickr.com/photos/mrsdkrebs/5967890349/
• Breakfast: http://www.flickr.com/photos/k9/46829792/sizes/l/in/photostream/

50. Want the slides?
unchart.com/2011/diabetes/