Diabetes Prevention Demonstration Project

1. Diabetes Prevention Demonstration Project Clinical Case Studies

2. Case #1 • A 49-year-old woman is recruited at a community event for participation in your DP Program. • Your program elects to do an OGT as the glycemic measure. • She comes to the lab for her 2 hr OGT using a 75gm glucola solution. • Her OGT results are: FBS129mg/dl 2 hr175mg/dl

3. Case #1, continued • What do you think of these results? • What would you do next? • A follow up FBS result is 138mg/dl • What do you need to do now? • What if the follow up FBS result is 117mg/dl?

4. Case #2 • A 53-year-old man asks about the DP Program while in Clinic and is referred to your program after talking to his FP. • Your program elects to do a FBG as the glycemic measure. • The results are: FBS98mg/dl

5. Case #2, continued • What do you think of these results? • What would you do next? • What if the results are: FBS105mg/dl OR 220mg/dl • What if your lab runs an A1c with the following results - 5.9% • What if the results are 6.3% OR 7.0%?

6. Diagnosis of Pre-DiabetesUsing OGT • OGTresults should be interpreted as follows: • Normal – fasting glucose <100; 2-hour glucose < 140 • Pre-Diabetes – fasting blood glucose = 100-125 (IFG) or 2-hour result =140-199mg/dl (IGT) • Diabetes(presumptive) – fasting glucose ≥126mg/dl or 2-hour result >200 DP Demonstration Project Screening and Eligibility Core Element

7. Other Glycemic Measures Useful in the Diagnosis of Pre-Diabetes • A1c -≥ 6.0% and < 6.5% - This remains an area of controversy - Current best evidence suggests this cut-off at this time • Casual BG - 140-199 mg/dl - A result in this range is NOT diagnostic for Pre-Diabetes, but requires another glycemic measurement for diagnosis DP Demonstration Project Screening and Eligibility Core Element

8. ADA Guidelines for Diagnosis of DM • The American Diabetes Association recommends three ways to diagnose diabetes in non-pregnant adults: 1.Fasting plasma glucose ≥126 mg/dLor 2.Symptoms of hyperglycemia and a casual plasma glucose concentration ≥200 mg/dL, or 3. 2-hour plasma glucose ≥200 mg/dL after a 75-gram oral glucose tolerance test 4. An A1c ≥ 6.5% for diagnosis remains controversial with science to support this cut-off, but no consensus has been reached. • In the absence of unequivocal hyperglycemia, these criteria should be confirmed by repeat testing on a different day. • Fasting plasma glucose is the preferred diagnostic test because of its ease of use, acceptability to patients, and lower cost. The use of A1c for diagnosis is still being reviewed by ADA, CDC and NIH and may be recommended in the near future. ADA Clinical Guidelines 2008

9. Case #3 • A 36-year-old woman comes to your program’s information booth at the Health Fair. She expresses interest in your DP Program and agrees to have a casual blood glucose done. The results are 99mg/dl. • 2 weeks later, you get a call from the same woman and she tells you she was just diagnosed with Metabolic Syndrome in Clinic and would like some information. • What do you do next?

10. Metabolic Syndrome • Metabolic Syndrome is defined as having at least 3 of these 5 conditions: 1. Abdominal Obesity (Waist circumference > 40 inches in men, > 35 inches in women) 2. Hypertension (Blood pressure ≥ 130/85 mm Hg) or on drug treatment for HTN 3. Low HDL Cholesterol (< 40 mg/dl in men, < 50 mg/dl in women) or on drug treatment for low HDL 4. High triglycerides (> 150 mg/dl) or on drug treatment for high TG 5. Elevated fasting plasma glucose (FBG ≥100 mg/dl NCEP ATP III

11. Case #4 • A 50-year-old woman is interested in your DP Program and her glycemic measurement reveals IGT. • She was recently diagnosed with Breast CA and underwent a lumpectomy. • She is currently undergoing radiation and chemotherapy treatment. • What would you need to know? • Is this individual eligible to participate in your program?

12. Exclusions • Exclude individuals from participation in this project with the following diagnoses/conditions: • Current diagnosis of pregnancy (reconsider participation 6 weeks after delivery, suspend participation if becomes pregnant during project) • Active alcohol or substance abuse that would affect successful participation (by provider judgment) • End Stage Renal Disease on dialysis • Previous diagnosis of diabetes (not eligible for diabetes prevention) • Current diagnosis of cancer undergoing treatment that prohibits participation – provider judgment • Any other significant or unusual condition or life situation that makes it likely that the participant will not be able to participate DP Demonstration Project Screening and Eligibility Core Element

13. Lessons Learned • Know the NEW Screening and Eligibility Core Element content • There are guidelines for chronic or pre-existing conditions available on the web site • Use the ADA/IHS Guidelines for Diagnosis of DM • The 75 gmglucola solution is the ONLY acceptable glucola for use in an OGT (if utilized) for non-pregnant individuals. • A glycemic measurement result in the Diabetes range requires a 2nd FBS test done on a separate day for the exclusion or diagnosis of DM.

14. I need a hug!