PREDIABETES

1 PREDIABETES PREDIABETES Strategies for Effective Screening, Intervention and Follow-up Learning Objectives Define PREDIABETES List risk factors and clinical signs in individuals at risk for type 2 diabetes Identify interventions to modify risk factors to preventing type 2 diabetes Develop a strategic management plan to proactively screen, assess, follow-up, and evaluate patients with PREDIABETES Discuss the benefits of a team-based approach to assist individuals with PREDIABETES to achieve their target goals and objectives Adapted from: American diabetes Association. diabetes Care.

2 2014;37 Suppl 1:S81-90. Normal diabetes Mellitus PREDIABETES Impaired Glucose Tolerance Fasting Plasma Glucose 126 mg/dL 2-hour Plasma Glucose On OGTT 200 mg/dL 140 mg/dL Any abnormality must be repeated and confirmed on a separate day The diagnosis of diabetes can also be made based on unequivocal symptoms and a random glucose >200 mg/dL 100 mg/dL PREDIABETES Impaired Fasting Glucose What is PREDIABETES ? Normal diabetes Mellitus Hemoglobin A1C PREDIABETES Normal diabetes Mellitus PREDIABETES An important risk factor for future diabetes and CV disease Risk for PREDIABETES is a continuum Important to identify early and begin intervention immediately Interventions can reduce the rate of progression from PREDIABETES to diabetes oHealthy diet oPhysical activity oWeight loss American diabetes Association.

3 diabetes Care. 2014:37 Suppl 1:S81-90. PREDIABETES Long-term consequences include oHypertension1 oCancer2 Risk increased by 15% Stomach/colorectal, liver, pancreas, breast, endometrium oAlzheimer s disease3 diabetes Association. diabetes Care. 2014:37 Suppl 1:S81-90. LD, et al. Arch Neurol. 2011;68:51-57. Y, et al. Diabetologia. 2014 Sep 11. [Epub ahead of print] Impaired Fasting Glucose and Impaired Glucose Tolerance Not clinical entities but rather risk factors for diabetes and cardiovascular disease Associated with: oPhysical inactivity oObesity (especially abdominal, or visceral) oDyslipidemia High triglycerides and/or low HDL cholesterol oHypertension American diabetes Association.

4 diabetes Care. 2014:37 Suppl 1:S81-90. PREDIABETES Centers for Disease Control, 2012 37% (86 million) adults aged 20 years or older have prediabetes1 oPercentage was similar by race o51% aged 65 years Only 11% were aware they had it2 In adolescents aged 12 to 19 years, prevalence of PREDIABETES and diabetes increased from 9% to 23%3 diabetes Statistics Report. Available at: MMWR Morb Mortal Wkly Rep. 2013;62:209-212. AL, et al. Pediatrics. 2012;129:1035 1041. Adapted from: Boyle JP, et al. Popul Health Metr. 2010;8:1-12. Projecting the Future diabetes Population: It Is Growing Determinants of PREDIABETES /Type 2 diabetes : A Call to Action Adapted from: Hill J.

5 O. et al. diabetes Care. 2013;36:2430-2439. There is an association between social and environmental factors and development of obesity and type 2 diabetes Better understanding needed oVariables that influence behaviors that lead to obesity, PREDIABETES , and diabetes oHow to modify these variables Perform research conducted on community-level interventions Identify individuals at risk PREDIABETES Process for Diagnosing S Screen A Assess and Advise F Follow-up E Evaluate progress S Screen A Assess and Advise F Follow-up E Evaluate progress Screening for diabetes Be proactive in an effort to improve outcomes Find who might have risk factors Ask patients to take the ADA diabetes Risk Test* Depending on results.

6 Invite them into the office to be tested If diagnosed with diabetes / PREDIABETES oAssess and advise oFollow-up oEvaluate * Available at: Criteria for Screening for PREDIABETES /Type 2 diabetes in Asymptomatic Adult Individuals Consider testing (screening) all adults with a BMI* 25 kg/m2 and additional risk factors oIf no risk factors, consider screening no later than age 45 years If normal results, repeat testing (screening) at 3-year intervals oMore frequently depending on initial test results and risk factors oTest 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 , 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.

7 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 Modifiable Risk Factors of diabetes / PREDIABETES for CV Disease American diabetes Association. diabetes Care. 2014:37:S14-80. Non-modifiable Age Race/Ethnicity Gender Family history Modifiable Physical inactivity Overweight/Obesity Hypertension Smoking Abnormal lipid metabolism High plasma glucose levels CHILDREN/ADOLESCENTS S Screen A Assess and Advise F Follow-up E Evaluate progress Prevalence of PREDIABETES in Children/Adolescents in the Li C, et al.

8 diabetes Care. 2009;32:342-347. Screening Children for PREDIABETES and diabetes Consider for all children who are overweight and have 2 of any of the following risk factors Family history of type 2 diabetes in first- or second-degree relative High-risk race/ethnicity Signs of insulin resistance or conditions associated with insulin resistance Maternal history of diabetes of GDM during child s gestation Begin screening at age 10 years or onset of puberty Screen every 3 years A1C test is recommended for diagnosis in children Adapted from: ADA. Testing for diabetes in Asymptomatic Patients.

9 diabetes Care. 2014;37(suppl 1):S17-18. GESTATIONAL diabetes (GDM) S Screen A Assess and Advise F Follow-up E Evaluate progress GDM Progression to PREDIABETES With GDM, the risks for abnormal glycemia can persist even after the early postpartum period Adapted from: Retnakaran R, et al. Obesity (Silver Spring). 2010;18:1323-1329. Risk factors included: 3-month postpartum glucose Leptin HDL-C LDL-C Triglycerides Adiponectin Risk of PREDIABETES in Adolescent Offspring of Mothers with GDM Adapted from: Holder T, et al. Diabetologia. 2014; DOI Obese adolescents with normal glucose tolerant (NGT) (N=255) No Exposure to GDM (n=210; ) Exposure to GDM (n=45; ) Approx times increase in risk; p <.

10 001 GDM Screening and Diagnosis ONE-STEP (IADPSG) Screening (at 24-28 weeks gestation) 75-g OGTT in the AM after an overnight fast of at least 8 hours; measure PG during fasting, at 1 hour, and at 2 hours Diagnosis Any of the following PG values are exceeded oFasting: 92 mg/dL ( mmol/L) o1 hr: 180 mg/dL ( mmol/L) o2 hr: 153 mg/dL ( mmol/L) TWO-STEP (NIH Consensus) Screening (at 24-28 weeks gestation) 50-gram non-fasting OGTT with PG measurement at 1 hour (Step 1) If PG level at 1 hour after load is 140 mg/dL* ( mmol/L), proceed to 100-gram fasting OGTT (Step 2) Diagnosis 3-hour post-test PG is 140 mg/dL* ( mmol/L) For women not previously diagnosed with overt diabetes : Use 1 of 2 methods Adapted from.