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  • Diabetes Mellitus in the US: Overview Diabetes is one of the most common chronic diseases affecting people in the United States. Data cited here are derived from the Third National Health and Nutrition Examination Survey (NHANES III) 1988-1994. NHANES III used procedures that were similar to those used by NHANES II (1976-1980) and the Hispanic Health and Nutrition Examination Survey (HHANES) to determine a diagnosis of diabetes. For example, a probability sample of 18,825 US adults 20 years of age or older were interviewed to determine whether they had received a diagnosis of diabetes, a subsample of 6,587 persons underwent fasting plasma glucose (FPG) measurements, and another subsample of 2,844 persons aged 40 to 74 years underwent oral glucose tolerance testing. The American Diabetes Association (ADA) 1997 criteria for FPG and the 1980-1985 World Health Organization (WHO) criteria for oral glucose tolerance testing were used to assess the prevalence of diabetes. It is estimated that approximately 798,000 new cases of diabetes are diagnosed each year. Many additional new cases probably go undiagnosed. Diabetes has a major impact on the health of the US population. It is the leading cause of new blindness, end-stage renal disease (ESRD), and nontraumatic amputations in adults. Care for diabetes and its complications consumes approximately 15% of the total healthcare expenditures in the country. That figure is out of proportion to the 6% prevalence of diabetes, reflecting the excess morbidity and medical care required by patients with diabetes. Data from the National Health Interview Survey (NHIS) indicate that ~93% of all people with diabetes have characteristics of type 2 diabetes. NIDDK. Diabetes Statistics. NIH Publication 98-3926. November 1997 (updated February 1998).
  • Prevalence of Diabetes in the United States The prevalence of diagnosed diabetes among US adults increased by 49% in a single decade, from 4.9% in 1990 to 7.3% in 2000. If undiagnosed diabetes is taken into account, it is likely that as many as 10% of US adults have the disease. Based on data obtained through the Behavioral Risk Factor Surveillance System (BRFSS), which conducted telephone interviews with 184,450 people aged 18 years and older in 50 states in 2000, the investigators calculated that approximately 15 million US adults (6.3 million men, 8.7 million women) had diagnosed diabetes in 2000. The prevalence of combined diabetes and obesity was 2.9% in 2000, compared with 1.4% in 1991. Mississippi had the highest rate (8.8%) of diagnosed diabetes in 2000, and Alaska had the lowest (4.4%). In 1990, only four states had diabetes rates of 6% or greater; in 2000, 43 of 50 states had this prevalence rate. Blacks had the highest rate (11.1%) of diagnosed diabetes in 2000, followed by Hispanics (8.9%), other races (6.7%), and whites (6.6%). Analysis of the 2000 data according to education showed that people with less than a high school education had the highest rate (12.9%) of diagnosed diabetes. Mokdad AH et al. JAMA . 2001;286:1195-1200.
  • Prevalence of Obesity in the United States The prevalence of obesity among US adults increased by 61% from 1991 to 2000, according to data obtained through the Behavioral Risk Factor Surveillance System (BRFSS), which conducted telephone interviews with 184,450 people aged 18 years and older in 50 states in 2000. According to BRFSS data, 38.8 million US adults (19.6 million men, 19.2 million women) were obese (body mass index [BMI]  30 kg/m 2 ) in the year 2000. The prevalence of obesity in the United States was estimated to be 19.8% in 2000 (12% in 1991), the prevalence of diagnosed diabetes was 7.3% (4.9% in 1990), and the prevalence of combined obesity and diabetes was 2.9% (1.4% in 1991). In addition, 56.4% of US adults were overweight (BMI  25 kg/m 2 ) in 2000 (45% in 1991), and 2.1% were extremely obese (BMI  40 kg/m 2 ), compared with 0.9% a decade ago. Of the states participating in the BRFSS survey, only four had obesity rates of 15% or greater in 1991, but in 2000, all 50 participating states had rates of 15% or greater. None of the states had obesity rates of 20% or greater in 1991, whereas in 2000, 22 did. Mississippi had the highest rate of obesity (24.3%) in 2000, and Colorado had the lowest (13.8%). The 2000 obesity rates by race in descending order were: blacks (29.3%), Hispanics (23.4%), whites (18.5%), and other races (12%). Mokdad AH et al. JAMA . 2001;286:1195-1200.
  • On the basis of current estimates, diabetes affects 15.6 million adults aged 20 years or older and 123,000 children and adolescents in the United States. The prevalence of diabetes in these two age groups is 8.2% and 0.16%, respectively. Notably, the prevalence of diabetes increases with age, such that 6.3 million people, or 18.4% of those aged 65 years or older, have this illness. Type 2 diabetes is increasingly prevalent among adolescents. For example, 10% to 33% of newly diagnosed cases among adolescents are type 2 diabetes. Most adolescent patients with type 2 diabetes are obese, and the stress of obesity combined with increased demand for insulin may explain the onset of type 2 diabetes in this age group. NIDDK. Diabetes Statistics . NIH Publication No. 99-3892. March 1999 (e-text posted September 1999). Rosenbloom AL, et al. Diabetes Care . 1999;22:345-354.
  • Powerpoint

    1. 1. Diabetes Management Thomas Donner, MD, Associate Professor Michelle Sheldon-Rubio, RN, Clinical Instructor University of Maryland School of Medicine Division of Endocrinology, Diabetes and Nutrition
    2. 2. What is Diabetes? <ul><li>A disease in which the body either fails to produce any insulin (type 1), or the insulin that it does produce is unable to adequately trigger the conversion of food into energy (type 2). </li></ul>
    3. 3. Insulin <ul><li>Insulin is a hormone which is produced by the pancreas in the abdomen. Insulin is released into the bloodstream to help a sugar (glucose) travel into cells of the body where it is used as energy. </li></ul>
    4. 5. Hyperglycemia <ul><li>When glucose is unable to enter cells in the body, glucose levels build up in the blood to cause hyperglycemia. The longer blood glucose levels are high and the higher these glucose levels remain, the more rapidly complications from diabetes can develop. </li></ul>
    5. 6. Symptoms of Diabetes <ul><li>Excessive thirst </li></ul><ul><li>Frequent urination </li></ul><ul><li>Weight loss </li></ul><ul><li>Blurred vision </li></ul><ul><li>Fatigue </li></ul><ul><li>Sometimes there are no symptoms (type 2) </li></ul>
    6. 7. Diabetes Mellitus in the US: Overview
    7. 8. Prevalence of Diabetes in the United States
    8. 9. Prevalence of Obesity in the United States
    9. 10. Prevalence of Diabetes in the United States According to Age and Sex
    10. 11. Risk Factors Associated with Central Obesity <ul><li>Diabetes </li></ul><ul><li>High triglycerides </li></ul><ul><li>Low HDL (good) cholesterol </li></ul><ul><li>Hypertension </li></ul><ul><li>Cardiovascular disease (heart attacks and strokes) </li></ul>
    11. 12. Most Patients with Diabetes Die of Cardiovascular Disease <ul><li>2- to 4-fold more likely to have heart disease </li></ul><ul><li>2- to 4-fold more likely to have a stroke </li></ul><ul><li>2- to 8-fold more likely to have heart failure </li></ul><ul><li>~ 70% of all diabetes-related deaths are associated with vascular disease </li></ul>
    12. 13. How can patients prevent the complications of diabetes? <ul><li>Regular check-ups with health care providers </li></ul><ul><li>Home blood sugar testing </li></ul><ul><li>Keep blood sugar levels close to normal </li></ul><ul><li>Keep blood pressure and cholesterol normal </li></ul>
    13. 14. How can blood sugar levels be kept normal? <ul><li>Diet and exercise </li></ul><ul><li>Weight loss in those who are overweight </li></ul><ul><li>Medications when needed </li></ul>
    14. 15. Nutrition Therapy, Exercise, Lifestyle Changes <ul><li>Nutrition therapy </li></ul><ul><ul><li>Decrease fat content and total calories </li></ul></ul><ul><ul><li>Weight reduction in obese patients </li></ul></ul><ul><ul><li>Decrease saturated fat </li></ul></ul><ul><ul><li>Increase fiber </li></ul></ul><ul><li>Exercise </li></ul><ul><ul><li>Increase energy expenditure with moderate-intensity exercise </li></ul></ul><ul><li>Smoking cessation to reduce cardiovascular risk factors </li></ul><ul><li>Training in self-management and SMBG </li></ul><ul><li>SMBG – self monitoring blood glucose </li></ul>IV.1
    15. 16. Benefits of Exercise <ul><li>Decreases insulin resistance which lowers blood sugar </li></ul><ul><li>Improves weight, blood pressure, LDL (bad) and HDL (good) cholesterol </li></ul><ul><li>May increase risk of low blood sugar in patients on insulin or pills which increase insulin release </li></ul><ul><li>Patients at risk should be pre-screened for coronary artery disease with a stress test </li></ul>
    16. 17. Benefits of Modest Weight Loss <ul><li> cardiovascular risk (heart attacks and strokes) </li></ul><ul><li> blood sugar levels </li></ul><ul><li> blood pressure </li></ul><ul><li> LDL and triglycerides (bad cholesterols) </li></ul><ul><li> HDL (good) cholesterol </li></ul><ul><li> severity of sleep apnea </li></ul><ul><li> symptoms of degenerative joint disease </li></ul>
    17. 18. How can blood sugar levels be kept normal? <ul><li>Medications </li></ul><ul><ul><li>Many different pills are now available which can be used in combination with diet and exercise </li></ul></ul><ul><ul><li>Insulin may be necessary in patients whose own bodies are not producing enough insulin </li></ul></ul>
    18. 19. Oral Pharmacologic Therapy <ul><li>Monotherapy </li></ul><ul><ul><li>Insulin secretogogues: sulfonylureas, nateglinide and repaglinide </li></ul></ul><ul><ul><li>Metformin (glucophage) </li></ul></ul><ul><ul><li>Alpha-glucosidase inhibitors (acarbose, miglitide) </li></ul></ul><ul><ul><li>Thiazolidinediones (actos and avandia) </li></ul></ul><ul><li>Combination therapy </li></ul>
    19. 20. GLUCOSE ABSORPTION GLUCOSE PRODUCTION Metformin (Thiazolidinediones) MUSCLE PERIPHERAL GLUCOSE UPTAKE Thiazolidinediones (Metformin) PANCREAS INSULIN Secretion Sulfonylureas Meglitinides Nateglinide Insulin Pramlintide ADIPOSE TISSUE LIVER alpha-glucosidase inhibitors Sonnenberg and Kotchen. Curr Opin Nephrol Hypertens 1998;7(5):551–5 INTESTINE Sites of Action by Therapeutic Options Presently Available to Treat Type 2 Diabetes
    20. 21. Cardiovascular Disease in Type 2 Diabetes
    21. 22. Treatment of HTN in Diabetes <ul><li>Goal BP is <130/80 </li></ul><ul><li>Specific blood pressure medications (ACE-inhibitors and ARBs) have been shown to be especially protective against kidney and cardiovascular disease) </li></ul>
    22. 23. 2005 ADA Cholesterol Recommendations <ul><li>Goals: </li></ul><ul><ul><li>Bad </li></ul></ul><ul><ul><li>LDL < 100 </li></ul></ul><ul><ul><li>Triglycerides < 150 </li></ul></ul><ul><ul><li>Good </li></ul></ul><ul><ul><li>HDL > 50 </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Initial lifestyle modification </li></ul></ul><ul><ul><ul><li>Weight loss, moderation of saturated fats and excessive carbohydrates, exercise </li></ul></ul></ul><ul><ul><li>Medications (especially statin drugs) are indicated if lifestyle modification does not get levels to goal </li></ul></ul>
    23. 24. Aspirin Therapy <ul><li>Has been shown to reduce the risk of cardiovascular events by 10-20% in patient with diabetes </li></ul><ul><li>Baby aspirin (81 mg) has most of the benefit of an adult-sized (325 mg) pill </li></ul><ul><li>Recommended in patients with diabetes over age 30 who have another heart disease risk factor or have known heart disease </li></ul>
    24. 25. Summary <ul><li>Diabetes is a common disease that can cause serious complications. </li></ul><ul><li>Control of blood sugar levels, blood pressure and cholesterol will dramatically reduce the risk of developing these complications. </li></ul><ul><li>Patient education about healthy lifestyle choices and diabetes management is an important feature of good diabetes control. </li></ul>