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Pre-Diabetes Dr. Sung T. Kim Inova Medical Group - Centreville

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Diabetes Facts – 2011

• Total prevalence of diabetes – 25.8 million, about 8.3% of population have diabetes

• 1.9 million new cases of diabetes diagnosed in age 20 and older in 2010.

• Men 13 million > Women 12.6 million

• Diabetes complications contributed to total of 231,404 deaths in year 2007.

• Pre-diabetes: 79 million people

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Pre-diabetes – what does it mean?

• Means that blood sugar is higher than normal, but it’s not yet high enough to be classified as type 2 diabetes.

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What is the problem?

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Why you have abnormally high glucose level?

• Body not using insulin properly – insulin resistance.

• Initially, pancreas makes extra insulin but over time, it’s not able to keep up and eventually can’t make enough insulin to keep up with blood glucose levels.

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Basics of pre-diabetes

• No clear symptoms, you may have it and not know it.

• Most of diagnosis are done when blood test is done to look at glucose level(i.e. physical exam, health screening).

• If you are diagnosed, should be screened for type 2 diabetes every year.

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How do we prevent Type 2 diabetes?

• Early treatment and lifestyle changes can return blood glucose levels to normal range.

• Research shows risk of type 2 diabetes lowers by 58% if you:

- loose 7% of you body weight(or 15 lbs. if you weight <200 lbs.)

- appropriate dietary plan

- exercise moderately 5 days a week, 30 minutes a day

(i.e. brisk walking, cardio)

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What are the complications?

• Long-term damage of diabetes especially to your heart and circulatory system may already be starting

• Adults with diabetes have 2-4 times higher risk of

heart disease related deaths as well as

2-4 times risk of stroke.

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What are the complications?

• 67 % of diabetics have high Blood Pressure >140/90 or use prescription medication for hypertension.

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What are the complications?

• Leading cause of new cases of blindness among adults.

• 4.2 million people with diabetes aged >40 had diabetic retinopathy, almost 0.7 million of them had advanced diabetic retinopathy that can lead to severe vision loss.

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What are the complications?

• Leading cause of kidney failure, responsible for 44% of new cases in 2008.

• In 2008, Total of 202,290 people were living on chronic dialysis or with kidney transplant in US due to diabetes.

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What are the complications?

• >60-70% of diabetics have some form of Nervous system damage

• 65k lower limb amputations were performed in people with diabetes in 2006.

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Diabetic foot exam

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Big picture... Goals…

• First things first – understanding disease process

- Educational material

- INOVA Diabetes education classes – free

• Lifestyle changes - diet and exercise

• Continued goal oriented visits with your doctor

• Patient-Centered Medical Home(PCMH) at INOVA

• Prevention, Prevention, Prevention!

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Pre-diabetic & diabetic patient benefits of weight loss Dr. Kajal Zalavadia

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Obesity and Diabetes

• Increased body weight = increased risk for impaired glucose tolerance/

type 2 diabetes

- Strong association with obesity and type 2 diabetes

- >80% of cases of type 2 diabetes can be attributed to obesity

• Nurses Health Study

- 100 fold increased risk for diabetes over 14 years in nurses with a

BMI >35 compared to BMI <22

• Excess weight induces insulin resistance, impairs insulin-mediated blood sugar uptake by the body

- Decreases beta cell sensitivity (cells in charge of insulin)

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Obesity and Diabetes

• Increased abdominal obesity raises the degree

of insulin resistance and risk of diabetes

- Waist circumference

- Waist-to-hip ratio

• Genes matter - diabetes risk significantly influenced by lifestyle factors positive and negative

- Sedentary lifestyle lowers energy expenditure, promotes weight gain

- Poor diet (i.e. sugar sweetened beverages)

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Weight Loss

• Weight loss can decrease risk of developing diabetes

- 5 - 10% loss of body weight and maintenance of weight can reduce risk

• For diabetic patients, weight-loss can improve glycemic control

• Lifestyle changes are not temporary

- Implement changes you can maintain forever

- Take control of your health!

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Basic Principles

• Accept responsibility

- Make your health your priority

- Nothing can happen without your participation

• Assess current health, habits and environment to identify changes you can make

- Health Status: My Health Advisor

- Diabetes Risk:

Pre-diabetes/Insulin resistance

Disease progression and multi-organ involvement

- Know your healthy weight range: BMI

- Home and workplace factors that affect your weight and health

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Surroundings

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Readiness Assessment

• Are you ready to control your health?

- Not ready for a change? Consider how change can benefit you

and your family

• Want to change, only later?

- What are your barriers?

• I want to start making a plan.

- Congrats! Start date ___. Spell out your plan.

• I have started making some changes already

- Good for you!

- OK to make mistakes, just get back on board!

• I have integrated these changes to my lifestyle (>6 months)

- Be proud!

- Track your efforts

- Sign yourself up for the next step! (Variation)

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Readiness

• A realistic and specific plan is a more achievable

- What is my goal (I am 50 lbs. over my desired weight)

• Setting goals:

- Changes are meant to be maintained forever

(LIFESTYLE CHANGES)

- Start small

• Be specific:

- Instead of “I will walk more” go with “I plan to walk 30 minutes after

lunch on M-F”

• Foresee Barriers

• Reward System

• Stay positive!

- When things don’t go as planned, just pick yourself up and get back on

track

• Next Goal!!!

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Track Progress

Start Tracking!!!

•Accountability and Motivation

- American Diabetes Association and My Food Advisor

- Phone Apps: My Fitness Pal

- Fitbit

•Food +drinks

•Physical activity

•Recognize patterns

•Emotions can influence eating

- Boredom, stress, emotional, and triggers

- Recognize when you’re hungry, and full/satisfied

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Food

• Education is the first (and important) step to control

- More nutritious option

- Whole grains, non-starchy veggies, lean proteins

- Carb counting

• Portions

- Cultural distortion

• Calorie Control (3500 cal. = 1-2 lbs.)

• Planning your meal - Preparation!

• Tools:

- Diabetic Education

- American Diabetes Association

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Fitness

• Diet gets weight off

• Exercise keeps it off

• Activity sensitizes cells to insulin so they work more efficiently

• Improves blood glucose and A1C, decreases need for pills/insulin

• Combination of aerobic and strength training is important for diabetes

- Aerobic helps body use insulin better

Aim for 30 minutes of moderate to intense aerobic activity, 5 days/ week

- Strength training sensitizes body to insulin and lowers blood glucose

More muscle = more calories you burn (even at rest).

Aim for 2-3 days/week. !

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Medical Treatments

• Inova Weight Loss Services

- Medical Management (conservative)

- Surgical Services

• More aggressive options BUT

- No short cuts - will NOT work if you don’t put in the time and effort

- Make your health a priority

• Medical Weight Loss Program

- Weekly structured sessions, strict regimen, dedication

- Team of healthcare professionals: obesity medicine physician,

dieticians, behavioral therapist, nurse navigator and fitness trainers

- Work with you to create a healthy lifestyle to follow long term

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Medical Treatments

• Weight Loss Surgery

• BMI>40 or

• BMI between 35-40 and with weight related medical conditions such as diabetes

• Still a TOOL and both dietary and fitness changes must take place for this to work successfully long term

• Center of Excellence for Bariatric Surgery at Inova Fair Oaks Hospital

• Surgical treatment in patients with diabetes has the largest range of sustained weight loss and thus improvement in blood glucose control

• Especially Rou-en-Y gastric bypass to follow long term

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Resources & Contact Info

Phone: 703.348.4716

Email: weightloss@inova.org

Web: inovaweightloss.org

FB: facebook.com/inovaweightloss

twitter: twitter.com/inovaweightloss

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Taking control of diabetes Dr. Shivam Champaneri Inova Medical Group Endocrinology

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Diabetes Diagnosis - AACE Guidelines

• Fasting plasma glucose of >126 mg/dl OR

• Plasma glucose concentration of > 200 mg/dl 2 hours after ingesting 75 g oral glucose load in the morning after an overnight fast of at least 8 hours or

• Symptoms of uncontrolled hyperglycemia (i.e. polyuria, polydipsia, polyphagia) & a random (casual, nonfasting) plasma glucose concentration of > 200 mg/dl OR

• A1C level of >6.5%

• Multiple tests are done or repeated to confirm the diagnosis

• Hemoglobin A1C - a blood test providing a cumulative average sugar measure over the past 3 months

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Hemoglobin A1C

A1c level Estimated average blood sugar

5 % 97 mg/dl

6 % 126 mg/dl

7 % 154 mg/dl

8 % 183 mg/dl

9 % 212 mg/dl

10 % 240 mg/dl

11 % 269 mg/dl

12 % 298 mg/dl

13 % 326 mg/dl

14 % 355 mg/dl

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Diabetes Symptoms

• Weight changes (may be related to diet/exercise/medication/degree of control)

• Excessive thirst, urination (nighttime)

• Blurred vision (eye complications),

• Numbness/tingling

(foot, nerve complications)

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Diabetes – Taking Control

• Blood sugar control - always bring a log of your sugars/meter to your doctor visits so appropriate medication adjustments can be made

• Certain medications impact morning fasting sugars while others work more on prandial sugars (mealtime)

• Insulin injections: inject in fat tissue to prevent pain, bruising, and improper insulin absorption

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Diabetes – Taking Control

• Diet:

- Watching carbohydrate intake has direct impact on blood sugars

- Dietary indiscretions - regular sodas, fruit juices, sweets, high

carbohydrate foods (rice, breads, potatoes, pastas)

- Visited diabetes educator/dietician?

• Exercise

• Weight has direct impact on blood sugars, cholesterol and blood pressure which affect cardiovascular health

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Diabetes – Low blood sugar

• How often is it happening and time of day ? Before or after meals? Overnight hours?

- Associated symptoms: shakes, sweats, nervousness, weakness,

confusion

• Medic alert bracelet/necklace?

• Carry sugar source with you?

• Glucagon emergency kit ?

(Particularly if on insulin).

• Check sugar before driving/bedtime/exercise

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Diabetes Complications

• Retinopathy: annual eye exam

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Diabetes Complications

• Nephropathy: urine microalbumin or urine total protein/creatinine ratio

• Often multiple tests are done or the test is repeated to confirm the diagnosis

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Diabetes Complications

• Gastroparesis: nausea, vomiting, bloating, early satiety

• Erectile dysfunction

• Cardiovascular:

- high blood pressure,

- high cholesterol

- heart attack/stroke

- peripheral artery disease

• Acanthosis Nigricans

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Diabetes – Check-up

• Exam:

- Blood pressure (<130/80)

- Weight; body mass index

- Thyroid examination; carotid arteries

- Skin examination (acanthosis/insulin injection sites)

- Comprehensive foot exam

• Labs:

- Hemoglobin A1C (checked every 3-6 months)

- Fasting lipid panel (goal LDL in diabetics <100; some say <70

- Comprehensive metabolic panel (includes markers for kidney and liver

function)

- Urine microalbumin/Cr or spot urine total protein/Cr

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Diabetes Foot Care

• Wash feet daily with warm water & soap - dry well, especially between toes.

• Check daily for blisters, cuts, sores, redness or swelling. Check between toes and use a mirror to check the bottom of your feet. Notify your doctor if you find something wrong.

• Cut your toenails straight across (to prevent ingrown toenails)

• Wear shoes that fit well and do not rub toes or heels

• See your podiatrist if you have a wound that is not healing

• Never walk barefoot indoors or outdoors

• Never use a knife or razor blade to cut your toenails or feet

• Never wear garters, tight socks or other clothing that cuts circulation to feet

• Don’t smoke!

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Correcting low blood sugar

• Check your sugar if you experience low blood sugar symptoms

• For glucose <70→ eat a 15-20 g carb snack → recheck glucose 15 min later → if still <70, eat another snack.

• 15-20 grams of carbs = 1/2 cup fruit juice or (not diet) soda; 1 cup milk; 5 pieces hard candy; 1 tbsp. sugar, 3 - 4 glucose tablets

• Friend /family member should administer

glucagon emergency kit & CALL 911 if you are

unresponsive, having a seizure, or can't take

a snack due to unconsciousness

• If your blood sugar is <100 mg/dL prior to exercise,

or at bedtime, eat a snack to prevent hypoglycemia

Inova Medical Group Diabetes Care Team

• Primary care physician

• Endocrinologist - a doctor who specializes in treating diabetes and other

diseases of the endocrine system

• Physician assistant/nurse practitioner

• Certified diabetes educator (CDE)/dietitian

• Ophthalmologist (annually)

• Podiatrist – foot specialist

• Mental health professional

• Dentist (every 6 months)

Inova Medical Group Endocrinology

Springfield Healthplex

6355 Walker Lane, Suite 405,

Alexandria, VA