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GO! Diabetes Train the Trainer Program

GO! Diabetes Train the Trainer Program. Goals For Today. Review evidence based guidelines and equip you to deliver state of the art care to your diabetic patients Empower you to become agents of change within your practices Introduce the role of a diabetes educator

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GO! Diabetes Train the Trainer Program

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  1. GO! DiabetesTrain the Trainer Program

  2. Goals For Today • Review evidence based guidelines and equip you to deliver state of the art care to your diabetic patients • Empower you to become agents of change within your practices • Introduce the role of a diabetes educator • Understand tools that support practice performance and improvement

  3. Type 2 Diabetes - An Epidemic Is Here

  4. Diabetes and Gestational Diabetes Trends Among Adults in the U.S., BRFSS 1990 No Data Less than 4% 4% to 6% Above 6% Mokdad et al. Diabetes Care 2000;23:1278 Behavioral Risk Factors Surveillance System

  5. Diabetes and Gestational Diabetes Trends Among Adults in the U.S., BRFSS 2000 No Data Less than 4% 4% to 6% Above 6% Mokdad et al. J Am Med Assoc 2001;286(10)

  6. Diabetes and Gestational Diabetes Trends Among Adults in the U.S., Estimate For 2010 No Data Less than 4% 4% to 6% Above 6% Above 10% www.diabetes.org

  7. (In)Adequacy of Care • US NHANES Databases 1988 – 2002 • Glycemic control improved minimally • Blood pressure distribution unchanged • Improvements in lipids, ASA use, vaccinations • Why such slow improvement • Clinical inertia • Chronic illness • Lack of team approach • Reactive vs. proactive care

  8. Control of CV Risk Factors in Diabetic Hypertensive Patients in Academic Medical Centers • A1C <7% • 27% • LDL <100 • 36% • BP <130/85 mmHg • 27% • Daily Aspirin (ASA) Use • 46% • BP, Lipids and A1C • 3% • BP, Lipids, A1C + ASA • 2% McFarlane SI. DiabetesCare 2002;25:718

  9. Who Should Care for Diabetics? • 90 percent of diabetics receive care from generalist • Mortality rates and functional status no better for endocrinologists vs. FPs1 • Specialty clinics better at complying with eye exams and HgbA1C2 • JAMA 1995 Nov 8;274(18):1436-44 • Diabetes Care 1997 Apr;20(4):472-5

  10. Glycemic Control • Does glycemic control matter? • Diabetes Complications and Control Trial (DCCT) • 1441 type 1 diabetics randomized into two groups • Conventional treatment (HgbA1C =9%) • Intensive treatment (HgbA1C = 7%) • Epidemiology of Diabetes and Complications (EDIC) • Continuation of DCCT in which groups were intensively managed • Previous intensive group had reduced macrovascular events Diabetes Complications and Control Trial (DCCT) N Engl J Med; 1993; 329: 977-986.

  11. Effect of Tighter Glycemic Control on Progression of Retinopathy DCCT

  12. Effect of Intense Glycemic Control on Nephropathy from DCCT

  13. United Kingdom Prospective Diabetes Study • Study summary – 10 years • Type 2 diabetics – convention vs. intense control • Glycemic control – 7.0 vs. 7.9 • Hypertension control – 144/82 vs. 154/87 • Glycemic control • metformin, sulfonylureas, and insulin • Hypertension • captopril, atenolol

  14. UKPDS Blood Pressure Study:Tight vs. Less Tight Control • 1148 type 2 patients • BP lowered to avg. 144/82 (controls-154/87); 9 yr follow-up Endpoint Risk Reduction(%) P Value______ Any diabetes related endpoint 24 0.0046 Diabetes related deaths 32 0.019 Heart failure 56 0.0043 Stroke 44 0.013 Myocardial infarction 21 NS Microvascular disease 37 0.0092 UKPDS. BMJ. 317: 703-713. 1998.

  15. Glycemic Difference in UKPDS • Difference obtained • Not as substantial as DCCT • Both groups worsened over time

  16. Reduction in Type 2 DM EndpointsIntense Glycemic Control (UKPDS) • 12% reduction over 10 years • NNT = 19 at 10 years • Not nearly as impressive as BP outcomes

  17. Reduced Microvascular End PointsIntense Glycemic Control (UKPDS) • Microvascular End Points reduced 25% in intense glycemic group • Renal failure • Death from renal failure • Retinal photocoagulation • Vitreous hemorrhage

  18. Glycemic Control Reduces Complications Diabetes Control and Complications Trial (DCCT) Research Group. N Engl J Med 1893:329:977-988 UK Prospective Diabetes Study (UKPDS) Group. Lancet 1993; 352:837-853.

  19. ABCs Of Diabetes Management Diabetes Care 2007;30:S4-41

  20. Recommendations for Adults with Diabetes Mellitus • Goals should be individualized • Certain populations (children, pregnant females and elderly) require special considerations • Set less intensive goals in patients with severe or frequent hypoglycemia • Most patients should target their HgbA1C to be less than 7%. The ACCORD trial has suggested more stringent targets aren’t beneficial and may be harmful

  21. February 7, 2008 Diabetes Study Partially Halted After Deaths

  22. Diabetes Questions Making the Diagnosis Type 1 vs. Type 2 Glycemic Crisis Management

  23. Type 1 Vs Type 2:How To Tell Them Apart

  24. Case Study #1 • 28 year-old Mexican American female was noted to have a random glucose of 125 mg/dL on a “chemistry panel” obtained as part of an annual health fair by her employer. No symptoms or prior history of abnormal glucose (screening OGTT during pregnancy 4 years ago was negative) • PMH • Negative • Medications • None • FHx • Mother and brother have type 2 diabetes • Mother has a history of retinal laser treatments, proteinuria and foot ulcer

  25. Case Study #1 • Social Hx • She has smoked 1ppd since age 19 years • She and her husband own a convenience store • They have two children, ages 4 and 6 years • ROS • Frequent yeast infections • PE • Height 64" • Weight 200 lb • BP 142/92, 92 • Waist 38" • Skin tags • Trace edema • Further exam normal • Labs • A1C 6.3% (normal 4-6%) • 1-hour postprandial glucose 133 mg/dL • Questions Diabetic? How would you counsel her?

  26. Case Study #2 • 32 year-old Caucasian female with a history of gestational diabetes presents for confirmation of pregnancy (LMP 10 weeks ago). Recent home pregnancy test was positive. Asymptomatic except for nocturia without dysuria or fatigue • PMH • She has two children, ages 3 years and 26 months • Previous gestational diabetes requiring insulin therapy during both previous pregnancies • Glucose tolerance test 6 weeks post-partum “normal” • FHx • No diabetes or vascular disease

  27. Case Study #2 • Social Hx • No tobacco or EtOH • Power-walks 30 minutes 5-7 days a week • Follows standard nutritional guidelines • Weight stable for past 4 years • PE • Height 64" • Weight 110 lb • BP 110/62, 66 • Afebrile • Further exam negative • Labs • Urine beta-HCG positive • A1C 9.4% • Glucose 277 mg/dL (3 hr pc); yesterday at PCP 295 mg/dL (4h pc) • Questions Diabetic? Type 1 or Type 2?

  28. Case Study #3 • 78 year-old nursing home resident presents for evaluation of recurrent episodes of severe hypoglycemia. Diabetes diagnosed at age 65 years during routine insurance exam • Current treatment includes insulin 70/30 14 units qam; glargine 10 units qhs and sulfonylurea • Fingerstick glucose logs (4-6 readings per day) reveal levels from 30’s to mid 500’s for past two weeks • Severe hypoglycemia usually occurs during the afternoon or early morning • The average measurement is 196 mg/dL (SD 130 mg/dL) • PMH • Otherwise unremarkable • FHx • No vascular disease

  29. Case Study #3 • Social Hx • Denies tobacco or EtOH use • PE • Height 61" • Weight 98 lb • BP 138/66, 82 • Further exam normal • Labs • A1C 8.6% • Creatinine 1.3 • Total Cholesterol 150 mg/dL • HDL 70 mg/dL • LDL 70 mg/dL • Triglycerides 50 mg/dL • QuestionsDiabetic? Type 1 or Type 2?

  30. Case Study #4 • 32 year-old African American male presents for evaluation of poorly controlled diabetes. His diabetes was diagnosed after presenting with DKA at age 22 years during rehabilitation from a MVA with spinal cord injury that ended football career • Current medications include insulin 70/30 65 units bid • Glucose levels are generally in the mid 200’s • Glucometer download reveals average 3.1 readings per day and mean glucose 246 mg/dL (SD 55 mg/dL) • Recent implementation of MNT, though states “it doesn’t seem to make a difference” • Not currently exercising • PMH Full recovery from spinal cord injury • FHx Early vascular disease

  31. Case Study #4 • Social Hx • No EtOH • Smokes 1 ppd • Works as a dispatcher for a trucking firm • Married and has 3 children • ROS • Nocturia • Feet always cold • Blurred vision • Denies numbness and dysesthesias • PE • Height 70" • Weight 245 lb • BP 162/92, 102 • Waist 44" • Chest/cor normal • Hypertrophic • Normal pulses • Skin tags present diffusely • Hyperpigmented rash on nape of neck • Questions Diabetes? Type 1 or Type 2?

  32. The threshold fasting plasma glucose level recommended for confirming the diagnosis of diabetes mellitus is __________ mg/dL

  33. Which of the following medications can cause hyperglycemia? (Mark all that are true.)A) Nicotinic acidB) Clozapine (Clozaril)C) PrednisoneD) SpironolactoneE) Ramipril (Altace)

  34. Which of the following lipid-lowering agents can worsen glycemic control?(Mark all that are true.)A) Colestipol (Colestid)B) Ezetimibe (Zetia)C) Gemfibrozil (Lopid)D) Nicotinic acid (Niacin)E) Atorvastatin (Lipitor)

  35. Endocrinopathies associated with diabetes mellitus include which of the following? (Mark all that are true.)A) Cushing's syndromeB) AcromegalyC) PheochromocytomaD) HyperparathyroidismE) Glucagonoma

  36. Mark all options below that are true regarding diabetes screening, according to current American Diabetes Association guidelines.A) A 2-hour glucose challenge test is the recommended screenB) Screening at 3-year intervals is recommended in individuals with a BMI > 25.0 kg/m2, beginning at age 45C) Screening should be considered in all women who have delivered a baby weighing over 9 lbD) Community screening for diabetes is felt to be valuable and cost-effectiveE) Measurement of hemoglobin A1c has no role in screening for diabetes

  37. List three conditions included in the differential diagnosis of a high anion gap metabolic acidosis:1. _______________2. _______________3. _______________

  38. A 16-year-old male has a 1-week history of polyuria, polydipsia, and polyphagia. On laboratory evaluation he is found to have a serum glucose level of 270 mg/dL, a serum bicarbonate level of 9 mEq/L (N 22–26), a serum pH of 7.0, and a serum potassium level of 4.0 mmol/L (N3.5–5.0).Which one of the following most accurately describes this patient's total body potassium?A) Mild total body potassium excessB) Normal total body potassium storesC) Mild total body potassium deficiencyD) Severe total body potassium deficiency

  39. A 58-year-old obese male comes to your office with a 2-week history of fatigue associated with polyuria, polydipsia, and weight loss. You suspect he has type 2 diabetes. This diagnosis would be corroborated by a random glucose level greater than or equal to ________ mg/dL

  40. A 63-year-old handyman is brought to the emergency department unconscious. His temperature is 38.1° C (100.6°F) rectally, bloodpressure 90/70 mmHg, pulse 128 beats/min, and respirations 13/min. The examination is otherwise unremarkable except for very dry skin and mucous membranes.Laboratory Findings:Serum sodium............................. 150 mmol/L (N 135-145)Serum potassium ........................... 3.2 mmol/L (N 3.5-5.0)Serum chloride ............................ 107 mmol/L (N100-108)CO2 ................................................. 22 mmol/L (N 24-30)Serum glucose ............................................... 1080 mg/dLSerum creatinine ............................. 4.0 mg/dL (N 0.6-1.5)BUN .................................................... 70 mg/dL (N 8-25)Serum ketones ................................. small amount presentAdjusting for the hyperglycemia, what is the patient's corrected serum sodium level? ____________ mmol/L

  41. A 16-year-old female is admitted to the hospital with a 1-week history of polyuria, polydipsia, and polyphagia. Examination reveals a lethargic, volume-depleted female with the smell of acetone on her breath. Her blood pressure is 96/70 mm Hg, her pulse rate is 120 beats/min, and she has Kussmaul respirations at a rate of 32/min.Laboratory FindingsSerum glucose ................................................ 525 mg/dLSerum sodium .............................. 122 mEq/L (N 135–145)Serum potassium ........................... 3.1 mmol/L (N 3.5–5.0)Chloride ....................................... 95 mmol/L (N 100–108)CO2 ................................................... 7 mmol/L (N 24–30)Arterial blood gasespH ................................................... 7.10 (N 7.35–7.45)pCO2 ............................................. 15 mm Hg (N 35–45)pO2 .............................................. 98 mm Hg (N 80–100)After initiation of intravenous fluid therapy, which one of the following should be done next?A) Initiation of insulin therapyB) Potassium replacementC) Bicarbonate therapyD) Phosphate therapyE) Dexamethasone therapy

  42. Questions?

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