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Diabetes Mellitus – An Overview For Family Physicians
By Dr N P Singh, Professor, Deptt of Medicine, MAMC and Dr Didar Singh, Resident, MAMC

Diabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. Type 2 DM forms more than 95 % of cases. In the last two decades, type 2 DM is on the rise, degree of which varies in different countries. The world health organization (WHO) has projected that global prevalence of type2 DM will more than double –from 135 million in 1995 to 300 million by 2025. Today, India has primary position in the global diabetes epidemiology map as it is the home of nearly 32 million diabetics. which is the highest number in the world and this is expected to increase to 80 million by 2030.The National Urban Diabetes Survey in India has shown standardized prevalence of diabetes and IGT to be 12.4%and 14% respectively with no gender difference .Subjects under 40 years of age had higher prevalence of IGT than diabetes(12.8 vs 4.6 :p <0.001). So India has garnered the notoriety of being the diabetic capital of the world.

Classification And Diagnosis

Classification

In 1997, the ADA issued new diagnostic and classification criteria (1); in 2003, modifications were made regarding the diagnosis of impaired fasting glucose (IFG)(2) . The classification of diabetes includes four clinical classes:

• Type 1 diabetes (results from ß-cell destruction, usually leading to absolute insulin deficiency).
• Type 2 diabetes (results from a progressive insulin secretory defect on the background of insulin resistance).
• Other specific types of diabetes (due to other causes, e.g., genetic defects in ß-cell function, genetic defects in insulin action, diseases of the exocrine pancreas, and drug or chemical induced).
• Gestational diabetes mellitus (GDM) (diagnosed during pregnancy).

Diagnosis

Three ways to diagnose diabetes are available, and each must be confirmed on a subsequent day unless unequivocal symptoms of hyperglycemia are present. Although the 75-g oral glucose tolerance test (OGTT) is more sensitive and modestly more specific than fasting plasma glucose (FPG) to diagnose diabetes, it is poorly reproducible and rarely performed in practice. Because of ease of use, acceptability to patients, and lower cost, the FPG is the preferred diagnostic test. It should be noted that the vast majority of people who meet diagnostic criteria for diabetes by OGTT, but not by FPG, will have an A1C value >7.0%. The use of the A1C for the diagnosis of diabetes is not recommended at this time. Criteria for the diagnosis of diabetes in non pregnant adults are shown in Table 1.

Table 1— Criteria for the diagnosis of diabetes

• Symptoms of diabetes and a casual plasma glucose 200 mg/dl (11.1 mmol/l). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss.
  or
• FPG 126 mg/dl (7. 0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.
  or
• 2-h plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.

In the absence of unequivocal hyperglycemia, these criteria should be confirmed by repeat testing on a different day. The OGTT is not recommended for routine clinical use, but may be required in the evaluation of patients with IFG or when diabetes is still suspected despite a normal FPG as with the postpartum evaluation of women with GDM.

Hyperglycemia not sufficient to meet the diagnostic criteria for diabetes is categorized as either IFG or impaired glucose tolerance (IGT), depending on whether it is identified through a FPG or an OGTT:

• IFG = FPG 100 mg/dl (5.6 mmol/l) to 125 mg/dl (6.9 mmol/l)
• IGT = 2-h plasma glucose 140 mg/dl (7.8 mmol/l) to 199 mg/dl (11.0 mmol/l

Recently, IFG and IGT have been officially termed "pre-diabetes." Both categories, IFG and IGT, are risk factors for future diabetes and cardiovascular disease (CVD). What is being recognized now is that raised blood glucose level even below the threshold to diagnose diabetes or even impaired glucose tolerance is also associated with an increased risk of cardiovascular disease. Thus there seems to be a continuous relation between the risk of CVD and raised postprandial glucose levels that extends from barely elevated levels right into the diabetic range. The postprandial glucose levels above which the patients are at an increased risk for CVD is not defined but it may be as low as 98mg/dl.In a recent review the ADA has proposed further lowering of the cut off value for the diagnosis of IFG as 100mg/dl.(&).

Screening For Diabetes

There is a major distinction between diagnostic testing and screening. When an individual exhibits symptoms or signs of the disease, diagnostic tests are performed, and such tests do not represent screening. Some times during daily family practice , we commonly encounter a situation in which a healthy adult comes to the clinic and inquires about his chances of getting DM in future as some his close relative is a diabetic. His /her chances of becoming a diabetic are as follows depending upon his position in the family tree :

Table 2 : Predicting Risk For Type 2 DM

Table 3 : Predicting Risk For Type 1 DM

Type 1 diabetes

Generally, people with type 1 diabetes present with acute symptoms of diabetes and markedly elevated blood glucose levels. Because of the acute onset of symptoms, most cases of type 1 diabetes are detected soon after symptoms develop. Widespread clinical testing of asymptomatic individuals for the presence of autoantibodies related to type 1 diabetes cannot be recommended at this time as a means to identify individuals at risk.
The prominent reasons for not recommending widespread screening for these markers are :

• The cut off values for some of the immune marker assays have not been completely established in clinical settings.
• There is no consensus as to what action should be taken when a positive autoantibody test result is obtained.
• The incidence of type 1 diabetes is low, testing of healthy children will identify only a very small number (<0.5%) who at that moment may be "pre-diabetic."

Type 2 diabetes

Type 2 diabetes is frequently not diagnosed until complications appear, and approximately one-third of all people with diabetes may be undiagnosed. Individuals at high risk should be screened for diabetes and pre-diabetes. So there is inordinate amount of time before this disease manifests in a full blown picture . It passes through various stages as shown in the graph. Given the enormous risk of cardiovascular disease and such a protracted natural history, dysglycemia really warrants early detection in high risk groups.

For the screening process to be really sensitive enough so that it picks up most susceptible individual, following set of risk factors have been proposed for screening in the community.

Table 4 Criteria for testing for diabetes in asymptomatic adult individuals

May not be correct for all ethnic groups. PCOS, polycystic ovary syndrome.

Additional indicators of high risk for DM in Indians are

• Raised waist-hip ratio (men >0.9. women>0.85)
• Tuberculosis especially atypical presentation or non healing
• Any other recurrent infection or ulcer
• Premature atherosclerosis
• Stress hyperglycemia

Screening should be carried out within the health care setting. Either a FPG test or 2-h OGTT (75-g glucose load) is appropriate. The 2-h OGTT identifies people with IGT, and thus more people who at increased risk for the development of diabetes and CVD. It should be noted that the two tests do not necessarily detect the same individuals (3). The FPG test is more convenient to patients, more reproducible, less costly, and easier to administer than the 2-h OGTT (1,2). Therefore, the recommended initial screening test for nonpregnant adults is the FPG.

The incidence of type 2 diabetes in children and adolescents has increased dramatically in the last decade. Consistent with screening recommendations for adults, only children and youth at increased risk for the presence or the development of type 2 diabetes should be tested (4) (Table 4).

Table 5 Testing for type 2 diabetes in children

Criteria :

• Overweight (BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% of ideal for height)

Plus

• Any two of the following risk factors :
• Family history of type 2 diabetes in first- or second-degree relative
• Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander)
• Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, or PCOS)

Age of initiation: age 10 years or at onset of puberty, if puberty occurs at a younger age
Frequency: every 2 year
Test : FPG preferred

Clinical judgment should be used to test for for diabetes in high-risk patients who do not meet these criteria. PCOS, polycystic ovary syndrome

Detection And Diagnosis Of Gestational Diabetes Mellitus (Gdm)

Risk assessment for GDM should be undertaken at the first prenatal visit. Women with clinical characteristics consistent with a high risk for GDM (those with marked obesity, personal history of GDM, glycosuria, or a strong family history of diabetes) should undergo glucose testing as soon as possible (5). An FPG 126 mg/dl or a casual plasma glucose 200 mg/dl meets the threshold for the diagnosis of diabetes and needs to be confirmed on a subsequent day unless unequivocal symptoms of hyperglycemia are present. High-risk women not found to have GDM at the initial screening and average-risk women should be tested between 24 and 28 weeks of gestation. Testing should follow one of two approaches:

• One-step approach: perform a diagnostic 100-g OGTT
• Two-step approach: perform an initial screening by measuring the plasma or serum glucose concentration 1 h after a 50-g oral glucose load (glucose challenge test [GCT]) and perform a diagnostic 100-g OGTT on that subset of women exceeding the glucose threshold value on the GCT. When the two-step approach is used, a glucose threshold value 140 mg/dl identifies 80% of women with GDM, and the yield is further increased to 90% by using a cutoff of 130 mg/dl.

Diagnostic criteria for the 100-g OGTT

• Fasting plasma glucose > 95mg/dl
• Plasma glucose at 1 hr > 180mg/dl
• Plasma glucose at 2hr > 155mg/dl
• Plasma glucose at 3hr > 140mg/dl

Two or more of the plasma glucose values must be met or exceeded for a positive diagnosis. The test should be done in the morning after an overnight fast of 8–14 h. The diagnosis can be made using a 75-g glucose load, but that test is not as well validated for detection of at-risk infants or mothers as the 100-g OGTT.

Low-risk status requires no glucose testing, but this category is limited to those women meeting all of the following characteristics :

• Age < 25 years.
• Weight normal before pregnancy.
• Member of an ethnic group with a low prevalence of GDM.
• No known diabetes in first-degree relatives.
• No history of abnormal glucose tolerance.
• No history of poor obstetric outcome.

Women with gestational diabetes should be screened for diabetes 6 weeks postpartum and should be followed up with subsequent screening for the development of diabetes or pre-diabetes.

Diabetes Care

Initial evaluation

A complete medical evaluation should be performed to classify the patient, detect the presence or absence of diabetes complications, assist in formulating a management plan, and provide a basis for continuing care. If the diagnosis of diabetes has already been made, the evaluation should review the previous treatment and the past and present degrees of glycemic control. Laboratory tests appropriate to the evaluation of each patient’s general medical condition should be performed. A focus on the components of comprehensive care (Table 5) will assist the health care team to ensure optimal management of the patient with diabetes.

Table 6 Components of the comprehensive diabetes evaluation

Medical history

• Symptoms, results of laboratory tests, and special examination results related to the diagnosis of diabetes
• Prior A1C records
• Eating patterns, nutritional status, and weight history; growth and development in children and adolescents
• Details of previous treatment programs, including nutrition and diabetes self-management education, attitudes, and health beliefs
• Current treatment of diabetes, including medications, meal plan, and results of glucose monitoring and patients’ use of data
• Exercise history
• Frequency, severity, and cause of acute complications such as ketoacidosis and hypoglycemia
• Prior or current infections, particularly skin, foot, dental, and genitourinary infections
• Symptoms and treatment of chronic eye; kidney; nerve; genitourinary (including sexual), bladder, and gastrointestinal function (including symptoms of celiac disease in type 1 diabetic patients); heart; peripheral vascular; foot; and cerebrovascular complications associated with diabetes
• Other medications that may affect blood glucose levels
• Risk factors for atherosclerosis: smoking, hypertension, obesity, dyslipidemia, and family history
• History and treatment of other conditions, including endocrine and eating disorders
• Assessment for mood disorder
• Family history of diabetes and other endocrine disorders
• Lifestyle, cultural, psychosocial, educational, and economic factors that might influence the management of diabetes
• Tobacco, alcohol, and/or controlled substance use
• Contraception and reproductive and sexual history

Physical examination

• Height and weight measurement (and comparison to norms in children and adolescents)
• Sexual maturation staging (during pubertal period)
• Blood pressure determination, including orthostatic measurements when indicated, and comparison to age-related norms
• Fundoscopic examination
• Oral examination
• Thyroid palpation
• Cardiac examination
• Abdominal examination (e.g., for hepatomegaly)
• Evaluation of pulses by palpation and with auscultation
• Hand/finger examination
• Foot examination
• Skin examination (for acanthosis nigricans and insulin-injection sites)
• Neurological examination
• Signs of diseases that can cause secondary diabetes (e.g., hemochromatosis, pancreatic disease)

Laboratory evaluation

• A1C
• Fasting lipid profile, including total cholesterol, HDL cholesterol, triglycerides, and LDL cholesterol
• Test for microalbuminuria in type 1 diabetic patients who have had diabetes for at least 5 years and in all patients with type 2 diabetes; some advocate beginning screening of pubertal children before 5 years of diabetes
• Serum creatinine in adults (in children if proteinuria is present)
• Thyroid-stimulating hormone in all type 1 diabetic patients; in type 2 if clinically indicated
• Electrocardiogram in adults, if clinically indicated
• Urinalysis for ketones, protein, sediment

Referrals

• Eye exam, if indicated
• Family planning for women of reproductive age
• MNT, as indicated
• Diabetes educator, if not provided by physician or practice staff
• Behavioral specialist, as indicated
• Foot specialist, as indicated
• Other specialties and services as appropriate

Management

People with diabetes should receive medical care from a physician-coordinated team. Such teams may include, but are not limited to, physicians, nurse practitioners, physician’s assistants, nurses, dietitians, pharmacists, and mental health professionals with expertise and a special interest in diabetes. It is essential in this collaborative and integrated team approach that individuals with diabetes assume an active role in their care.

The management plan should be formulated as an individualized therapeutic alliance among the patient and family, the physician, and other members of the health care team. Any plan should recognize diabetes self-management education (DSME) as an integral component of care. In developing the plan, consideration should be given to the patient’s age, school or work schedule and conditions, physical activity, eating patterns, social situation and personality, cultural factors, and presence of complications of diabetes or other medical conditions.It stated that in good DSME the patient himself should become “Professor of Diabetes”.So before assessing glycemic control as a part of efficacy of good diabetic manangement even a word with the patient about diabetes can tell you volumes about the diabetes management being administered to the patient. A variety of strategies and techniques should be used to provide adequate education and development of problem-solving skills in the various aspects of diabetes management. Implementation of the management plan requires that each aspect is understood and agreed on by the patient and the care providers and that the goals and treatment plan are reasonable. Following algorithm depicts the step wise approach the management of type 2 diabetes.

The drugs used to treat diabetes can be classified as follows with their respective mechanism of action :

• Sulfonylureas – they increase endogenous insulin secretion by stimulating beta cells in pancreas .Commonly used drugs in this category are; Glimepride, Glipzide, Glicalzide
• Biguanides –they reduce hepatic glucose production. Example Metformin. Initial drug of choice in obese type 2 diabetic.
• Meglitinide analogs- they also act insulin secretagouges . Example Repagilinide, Nateglinide
• Alpha glucosidase inhibitors- they reduce glucose absorption.Example Acarbose
• Thiazolidindiones- they act as insulin sensitizers. Example Rosiglitazone , Pioglitazone

Type 1 diabetes needs insulin therapy in beginning as an essential part of the management while type 2 diabetes patient needs it sometime later in the management as depicted in the algorithm .But in significant change in the paradigm of treatment of type2 diabtetes, early insulin therapy holds place in the management. Recent studies have shown that if insulin therapy is initiated early it prevents further beta cell destruction.Insulin should be the initial therapy in type2 diabetic particularly in :

• Lean individual or those with severe weight loss
• In individuals with renal or hepatic disease that precludes the use of oral glucose lowering agents
• In hospitalized or acutely ill patients
• In pregnant patient
• Severe hypoglycemia at presentation 250 – 300mg/dl

Following types of insulins are used routinely in the management of diabetes.

• Short acting - regular, lispro, aspart
• Intermediate acting - NPH, Lente
• Long acting - Glargine (without any peak activity, has sustained action for 24 hours.)

There is no clear guideline for institution of insulin therapy in type 2 DM but a commonly insulin is started at dose of 0.4u/kg and dose is slowly escalated by following glycemic trends. The level of hyperglycemia should influence the intial therapy of choice. Life style modification should be tried in appropriate group of patients which includes diet therapy and physical activity. In patients with mild to moderate hyperglycemia (200 to 250 mg/dl) single oral agent achieves glycemic goals.In patients with more severe hyperglycemia >250mg.dl two oral agents should be combined which should be from the different group, there is no use of adding two agents from the same class, which common mistake made in clinical pratice. In patients with severe hyperglycemia 250 – 300 mg/dl insulin therapy should be started preferably after counseling the patient because patient do not accept this as welcome therapy because of undue apprehensions so every effort should be made to relieve these worries and encourage the patient to take insulin. Recent trend has been the use of insulin with oral agents and it is popularly known as BIDS regimen, the acronym stands for bed time insulin and day time sulfonylurea. The rational for this therapy is that sulfonylurea takes care of daytime excursions of glucose levels while at night exogenous insulin puts the pancreatic beta cells to rest and preserving their function for a longer period and thus reducing the chances of secondary failure of oral agents. Commonly used insulin in this combination is either NPH (intermediate ) insulin or Glargine.

Glycemic control

Assessment of glycemic control

Two Techniques are available for health providers and patients to assess the effectiveness of the management plan on glycemic control. One of these techniques is self monitoring of blood glucose (SMBG) in which patient himself measures his/her blood sugar during the day and prepares a chart which can be readly followed by the concerned physician to make commensurate amendments in the therapy of patient as regards the case of patients on insulin regimens. This method of assessing the glycemic control gives somewhat like real picture of the glycemic trends hence it is more representative of prevailing diabetic state . The method of assessing glycemic control is by measuring HbA1c , which reflects prevailing average blood sugar in previous two to three months.

Self-monitoring of blood glucose.(SMBG)

SMBG allows patients to evaluate their individual response to therapy and assess whether glycemic targets are being achieved. Clinical trials using insulin that have demonstrated the value of tight glycemic control have used SMBG as an integral part of the management strategy Results of SMBG can be useful in preventing hypoglycemia and adjusting medications, medical nutrition therapy (MNT), and physical activity. The frequency and timing of SMBG should be dictated by the particular needs and goals of the patients For most patients with type 1 diabetes and pregnant women taking insulin, SMBG is recommended three or more times daily. The optimal frequency and timing of SMBG for patients with type 2 diabetes on oral agent therapy is not known but should be sufficient to facilitate reaching glucose goals. Patients with type 2 diabetes on insulin typically need to perform SMBG more frequently than those not using insulin. When adding to or modifying therapy, type 1 and type 2 diabetic patients should test more often than usual. The role of SMBG in stable diet-treated patients with type 2 diabetes is not known.

Because the accuracy of SMBG is instrument- and user-dependent (6), it is important for health care providers to evaluate each patient’s monitoring technique, both initially and at regular intervals thereafter. Health professionals should evaluate at regular intervals the patient’s ability to use SMBG data to guide treatment.

A1C

By performing an A1C test, health providers can measure a patient’s average glycemia over the preceding 2–3 months (6) and, thus, assess treatment efficacy. A1C testing should be performed routinely in all patients with diabetes, first to document the degree of glycemic control at initial assessment and then as part of continuing care. Since the A1C test reflects mean glycemia over the preceding 2–3 months, measurement approximately every 3 months is required to determine whether a patient’s metabolic control has been reached and maintained within the target range.ability to use data to adjust therapy.

Table 7 Summary of recommendations for adults with diabetes

Glycemic control

Key concepts in setting glycemic goals :

• A1C is the primary target for glycemic control
• Goals should be individualized
• Certain populations (children, pregnant women, and elderly) require special considerations
• Less intensive glycemic goals may be indicated in patients with severe or frequent hypoglycemia
• More stringent glycemic goals (i.e. a normal A1C, <6%) may further reduce complications at the cost of increased risk of hypoglycemia (particularly in those with type 1 diabetes)
• Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals

* Referenced to a nondiabetic range of 4.0–6.0% using a DCCT-based assay.

Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes.

Current NCEP/ATP III guidelines suggest that in patients with triglycerides 200 mg/dl, the "non-HDL cholesterol" (total cholesterol minus HDL) be used. The goal is 130 mg/dl (31).

For women, it has been suggested that the HDL goal be increased by 10 mg/dl.

As a part of good diabetic manangement plan it is recommended that HBA1c should be performed at least two times in a year in a patient who who meets treatment goal(and who have stable glycemic control).The frequency of administering HbA1c needs to be increased to four times in a year in patients whose therapy has changed or who are not meeting glycemic goals.

Glycemic goals

Glycemic control is fundamental to the management of diabetes. Prospective randomized clinical trials such as the DCCT (7) and the U.K. Prospective Diabetes Study (UKPDS) (8,9) have shown that improved glycemic control is associated with sustained decreased rates of retinopathy, nephropathy, and neuropathy (10).Lowering A1C has been associated with a reduction of microvascular and neuropathic complications of diabetes. So it is strongly recommended that diabetic management plan should be appropriate to achieve normal or near-normal glycemia with an A1C goal of <7%. Furthermore the goal of glycemic control should be more stringent (i.e., a normal A1C, <6%) in individual patients and in pregnancy. Hyperglycemia and insulin resistance are common in critically ill patients, even if there is no previous history of diabetes. Landmark study by Vanden Bergh et al showed that intensive insulin therapy (maintenance of blood glucose level between 80-110mg/dl) significantly reduced the mortality. Aggressive glycemic management with insulin may reduce morbidity in patients with severe acute illness, perioperatively, following myocardial infarction and in pregnancy. So glycemic control determines mortality and morbidity not only in apparently healthy subjects but also in critically ill patients. Such stringent treatment goals may not be appropriate for patients with a history of severe hypoglycemia, patients with limited life expectancies, very young children or older adults, and individuals with comorbid conditions.

Medical Nutrition Therapy(MNT)

MNT is an integral component of diabetes management and DSME. People with diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT. Goals of MNT that apply to all individuals with diabetes are as follows:

• Attain and maintain recommended metabolic outcomes, including glucose and A1C levels, LDL cholesterol, HDL cholesterol, triglyceride levels, blood pressure, and body weight (Table 6).
• Prevent and treat the chronic complications and comorbidities of diabetes. Modify nutrient intake and lifestyle as appropriate for the prevention and treatment of obesity, dyslipidemia CVD, hypertension, and nephropathy.
• Improve health through healthy food choices and physical activity.
• Address individual nutritional needs, taking into consideration personal and cultural preferences and lifestyle, while respecting the individual’s wishes and willingness to change.

Goals of MNT that apply to specific situations include the following :

• For youth with type 1 diabetes (11), provide adequate energy to ensure normal growth and development; integrate insulin regimens into usual eating and physical activity habits.
• For youth with type 2 diabetes, who are often overweight/obese, facilitate appropriate changes in eating and physical activity habits.
• For pregnant and lactating women, provide adequate energy and nutrients needed for optimal outcomes. In pregnancy, counting and recording carbohydrate intake contributes to optimal glycemic control.
• For older adults, provide for the nutritional and psychosocial needs of an aging individual.
• For individuals treated with insulin or insulin secretagogues, provide self-management education for treatment (and prevention) of hypoglycemia, acute illnesses, and exercise-related blood glucose problems.
• For individuals at risk for diabetes, decrease risk by encouraging physical activity and promoting foods

Recommendations

• People with diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT. (B)
• Both the amount (grams) of carbohydrate as well as the type of carbohydrate in a food influence blood glucose level. Monitoring total grams of carbohydrate, whether by use of exchanges or carbohydrate counting, remains a key strategy in achieving glycemic control. The use of the glycemic index/glycemic load can provide an additional benefit over that observed when total carbohydrate is considered alone. (B)
• Low carbohydrate diets (restricting total carbohydrate to <130 g/day) are not recommended in the management of diabetes. (E)
• Weight loss is recommended for all overweight (BMI 25.0–29.9 kg/m2) or obese (BMI 30.0 kg/m2) adults, who have, or who are at risk for developing, type 2 diabetes. (E)
• The primary approach for achieving weight loss is therapeutic lifestyle change, which includes a reduction in energy intake and/or an increase in physical activity. A moderate decrease in caloric balance (500–1,000 kcal/day) will result in a slow but progressive weight loss (1–2 lb/week). For most patients, weight loss diets should supply at least 1,000–1,200 kcal/day for women and 1,200–1,600 kcal/day for men. (E)
• Initial physical activity recommendations should be modest, based on the patient’s willingness and ability, gradually increasing the duration and frequency to 30–45 min of moderate aerobic activity 3–5 days per week, when possible. Greater activity levels of at least 1 h/day of moderate (walking) or 30 min/day of vigorous (jogging) activity may be needed to achieve successful long-term weight loss. (E)

Prevention And Management Of Diabetes Complications

Diabetes is multisystem disorder which has wide ranging impact on major systems of the body which are characterized by myriad manifestations of ths disease in each of these systems. Major impact of diabetes is borne by cardiovascular and renal

System followed by nervous and extremities

CVD

CVD is the major cause of mortality for individuals with diabetes. It is also a major contributor to morbidity and direct and indirect costs of diabetes. Type 2 diabetes is an independent risk factor for macrovascular disease, and its common coexisting conditions (e.g., hypertension and dyslipidemia) are also risk factors.A very interesting outcome of recent studies has brought an important risk factor in the setting of diabetes mellitus to the forefront mandating screening, which is proteinuria. It has been seen that presence of proteinuria increases mortality from cardiovascular . There are a number of risk factors for coronary artery disease in diabetes mellitus which can classified as modifiable and non modifiable risk factors . Patient age , male sex , family history of coronary artery disease constitute nonmodifiable risk factors . Amongst modifiable risk factors are :

• Elevated LDL
• Low HDL
• Elevated TG
• High blood pressure
• Diet
• Tobacco smoking
• Excessive alcohol consumption
• Physical inactivity
• Obesity
• Thrombogenic factors
• Thrombogenic factors
• PAI
• Fibrinogen
• CRP

Emphasis should be placed on reducing cardiovascular risk factors, when possible, and clinicians should be alert for signs and symptoms of atherosclerosis.

Hypertension/blood pressure control.

HTN is a major risk factor for CVD and microvascular complications such as retinopathy and nephropathy. In type 1 diabetes, HTN is often the result of underlying nephropathy. In type 2 diabetes, HTN may be present as part of the metabolic syndrome (i.e., obesity, hyperglycemia, and dyslipidemia) that is accompanied by high rates of CVD. Randomized clinical trials have demonstrated the benefit (reduction of CHD events, stroke, and nephropathy) of lowering blood pressure to <130 mmHg systolic and <80 mmHg diastolic in individuals with diabetes (12–15). Epidemiologic analyses show that blood pressure>115/75 mmHg is associated with increased cardiovascular event rates and mortality in individuals with diabetes (12,16,17). Therefore, a target blood pressure goal of <130/80 mmHg is reasonable if it can be safely achieved.

Blood pressure should be measured at every routine diabetes visit. Before beginning treatment, patients with elevated blood pressures should have their blood pressure reexamined within 1 month to confirm the presence of HTN. Systolic blood pressure&160 mmHg or diastolic blood pressure 100 mmHg, however, mandates that immediate pharmacological therapy be initiated. In these patients, other cardiovascular risk factors, including obesity, hyperlipidemia, smoking, presence of microalbuminuria (assessed before initiation of treatment), and glycemic control, should be carefully assessed and treated. Many patients will require three or more drugs to reach target goals. Patients with hypertension (systolic blood pressure 140 mmHg or diastolic blood pressure 90 mmHg) should receive drug therapy in addition to lifestyle and behavioral therapy. Patients with a systolic blood pressure of 130–139 mmHg or a diastolic blood pressure of 80–89 mmHg should be given lifestyle and behavioral therapy alone for a maximum of 3 months and then, if targets are not achieved, in addition, be treated with pharmacological agents that block the renin-angiotensin system. Initial drug therapy should be with a drug class demonstrated to reduce CVD events in patients with diabetes (ACE inhibitors, ARBs, ß-blockers, diuretics, and calcium channel blockers). All patients with diabetes and hypertension should be treated with a regimen that includes either an ACE inhibitor or an ARB. If one class is not tolerated, the other should be substituted. If needed to achieve blood pressure targets, a thiazide diuretic should be added. In patients with type 1 diabetes, with hypertension and any degree of albuminuria, ACE inhibitors have been shown to delay the progression of nephropathy so they should be preferred as intial therapy. In patients with type 2 diabetes, hypertension, and microalbuminuria, ACE inhibitors and ARBs have been shown to delay the progression to macroalbuminuria. In those with type 2 diabetes, hypertension, macroalbuminuria, and renal insufficiency, ARBs have been shown to delay the progression of nephropathy. Beta blockers should be used especially in patients with coronary heart disease .Non dihydropyridine calcium channel blockers (Diltiazem,Verapamil) can be used in patients wit contraindications to beta blockers.

During pregnancy in diabetic women with chronic HTN, target blood pressure goals of systolic blood pressure 110–129 mmHg and diastolic blood pressure 65–79 mmHg are reasonable as they may contribute to long-term maternal health. Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, labatolol, diltiazem, clonidine, and prazosin. ACE inhibitors and ARBs are contraindicated during pregnancy

Dyslipidemia/lipid management

Patients with type 2 diabetes have an increased prevalence of lipid abnormalities that contributes to higher rates of CVD.The commonest lipid abnormality in diabetics is high TG, low HDL and normal LDL. Lowering triglycerides and increasing HDL cholesterol is associated with a reduction in cardiovascular events in patients with clinical CVD, low HDL, and near-normal levels of LDL reduction in cardiovascular events in patients with clinical CVD, low HDL, and near-normal levels of LDL.In adult patients, test for lipid disorders should be done at least annually and more often if needed to achieve goals. In adults with low-risk lipid values (LDL <100 mg/dl, HDL >50 mg/dl, and triglycerides <150 mg/dl), lipid assessments may be repeated every 2 years. Lower triglycerides to <150 mg/dl (1.7 mmol/l) and raise HDL cholesterol to >40 mg/dl (1.15 mmol/l). In women, an HDL goal 10 mg/dl higher (>50 mg/dl) should be considered A lower LDL cholesterol goal of <70 mg/dl (1.8 mmol/l), using a high dose of a statin, is an option in high risk patients with diabetes and overt CVD. Lifestyle intervention including MNT, increased physical activity, weight loss, and smoking cessation should allow some patients to reach these lipid levels. Glycemic control can also beneficially modify plasma lipid levels. Pharmacological treatment is indicated if there is an inadequate response to lifestyle modifications and improved glucose control. However, in patients with clinical CVD and LDL >100 mg/dl, pharmacological therapy should be initiated at the same time that lifestyle intervention is started. The first priority of pharmacological therapy is to lower LDL cholesterol to a target goal of <100 mg/dl (2.60 mmol/l) or therapy to achieve a reduction in LDL of 30–40%. For LDL lowering, statins are the drugs of choice If the HDL is <40 mg/dl and the LDL is between 100 and 129 mg/dl, a fibric acid derivative or niacin might be used. Niacin is the most effective drug for raising HDL but can significantly increase blood glucose at high doses. More recent studies demonstrate that at modest doses (750–2,000 mg/day), significant benefit with regards to LDL, HDL, and triglyceride levels are accompanied by only modest changes in glucose that are generally amenable to adjustment of diabetes therapy (18,19).

Combination therapy, with a statin and a fibrate or statin and niacin, may be efficacious for patients needing treatment for all three lipid fractions, but this combination is associated with an increased risk for abnormal transaminase levels, myositis, or rhabdomyolysis. The risk of rhabdomyolysis seems to be lower when statins are combined with fenofibrate than gemfibrozil.

There is also a risk of a rise in plasma creatinine, particularly with fenofibrate.

Anti-platelet agents

One large meta-analysis and several clinical trials demonstrate the efficacy of using aspirin as a preventive measure for cardiovascular events, including stroke and myocardial infarction. Many trials have shown an 30% decrease in myocardial infarction and a 20% decrease in stroke in a wide range of patients, including young and middle-aged patients, patients with and without a history of CVD, males and females, and patients with hypertension.

Dosages used in most clinical trials ranged from 75 to 325 mg/day. There is no evidence to support any specific dose, but using the lowest possible dosage may help reduce side effects. There is no evidence for a specific age at which to start aspirin, but at ages <30 years, aspirin has not been studied. So aspirin therapy should be used as secondary prevention strategy in diabetics with :

• History of myocardial infarction
• Patients who have undergone vascular bypass procedure
• History of stroke or transient ischemic attack
• History of peripheral vascular disease
• History of claudication and or angina

Use of aspirin therapy (75–162 mg/day) as a primary prevention strategy should be made in those with type 2 diabetes and type 1 diabetes who are at increased cardiovascular risk,

• who are >40 years of age or
• who have additional risk factors (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria).

People with aspirin allergy, bleeding tendency, receiving anticoagulant therapy, recent gastrointestinal bleeding, and clinically active hepatic disease are not candidates for aspirin therapy. Other anti-platelet agents may be a reasonable alternative for patients with high risk. Aspirin therapy should not be recommended for patients under the age of 21 years because of the increased risk of Reye’s syndrome associated with aspirin use in this population. Aspirin therapy does not prevent retinopathy or increase the risks of hemorrhage.

Smoking cessation

• Nicotine gum
• Support group
• Bupriopion

CHD screening and treatment.

To identify the presence of CHD in diabetic patients without clear or suggestive symptoms of CAD, a risk factor-based approach to the initial diagnostic evaluation and subsequent follow-up is recommended. At least annually, cardiovascular risk factors should be assessed. These risk factors include dyslipidemia, hypertension, smoking, a positive family history of premature coronary disease, and the presence of micro- or macroalbuminuria.

Candidates for a diagnostic cardiac stress test include those with:

• Typical or atypical cardiac symptoms
• An abnormal resting electrocardiogram (ECG).

Candidates for a screening cardiac stress test include those with:

• a history of peripheral or carotid occlusive disease
• sedentary lifestyle, age >35 years, and plans to begin a vigorous exercise program
• two or more of the risk factors noted above

Keeping in view the beneficial role ACE inhibitors in reducing cardiovascular mortality and morbidity it is recommended that in patients >55 years of age, with or without hypertension but with another cardiovascular risk factor (history of CVD, dyslipidemia, microalbuminuria, or smoking), an ACE inhibitor (if not contraindicated) should be considered to reduce the risk of cardiovascular events. In patients with a prior myocardial infarction or in patients undergoing major surgery, ß-blockers, in addition, should be considered to reduce mortality. In patients with treated CHF, metformin use is contraindicated. The thiazolidinediones are associated with fluid retention, and their use can be complicated by the development of CHF. Caution in prescribing thiazolidinediones in the setting of known CHF or other heart diseases as well as in patients with preexisting edema or concurrent insulin therapy is required.

Nephropathy screening and treatment

Diabetic nephropathy occurs in 20–40% of patients with diabetes and is the single leading cause of end-stage renal disease (ESRD). Persistent albuminuria in the range of 30–299 mg/24 h (microalbuminuria) has been shown to be the earliest stage of diabetic nephropathy in type 1 diabetes and a marker for development of nephropathy in type 2 diabetes. Microalbuminuria is also a well-established marker of increased CVD risk (20,21). Patients with microalbuminuria who progress to macroalbuminuria ( 300 mg/24 h) are likely to progress to ESRD over a period of years (22,23) . So testing for microalbumunuria should be performed annualy for the presence of microalbuminuria in type 1 diabetic patients with diabetes duration of 5 years and in all type 2 diabetic patients, starting at diagnosis and during pregnancy.. In a cohort study designed to identify the risk factors for the development of diabetic nephropathy 176 patients with non-insulin-dependent diabetes mellitus (NIDDM) were followed for 5.8 years(Gall, 1997).The 5-year incidence of incipient or overt nephropathy was 23 percent. Following risk factors were identified :

• Increased urinary albumin excretion
• Male sex
• The presence of retinopathy
• Increased cholesterol level
• Elevated HbA1c.

Keeping in view that diabetic nephropathy contributes considerably to morbidity and mortality in a diabetic it constitutes a very important part of management of a diabetic. The interventions suggested to reduce the incidence of diabetic nephropathy are: tight glycemic control, blood pressure control, renin-angiotensin-aldosterone system blockade and protein restriction.

Treatment

In the treatment of both micro- and macroalbuminuria, either ACE inhibitors or ARBs should be used except during pregnancy. While there are no adequate head-to-head comparisons of ACE inhibitors and ARBs, there is clinical trial support for each of the following statements:

• In patients with type 1 diabetes, with hypertension and any degree of albuminuria, ACE inhibitors have been shown to delay the progression of nephropathy.
• In patients with type 2 diabetes, hypertension, and microalbuminuria, ACE inhibitors and ARBs have been shown to delay the progression to macroalbuminuria.
• In patients with type 2 diabetes, hypertension, macroalbuminuria, and renal insufficiency (serum creatinine >1.5 mg/dl), ARBs have been shown to delay the progression of nephropathy.

With presence of nephropathy, initiate protein restriction to 0.8 g · kg–1 body wt–1 · day–1 ( 10% of daily calories), the current adult-recommended dietary allowance for protein. Further restriction may be useful in slowing the decline of GFR in selected patients.In the setting of albuminuria or nephropathy, in patients unable to tolerate ACE inhibitors and/or ARBs, consider the use of non-DCCBs, ß-blockers, or diuretics for the management of blood pressure. Use of non-DCCBs may reduce albuminuria in diabetic patients, including during pregnancy. Consider referral to a physician experienced in the care of diabetic renal disease when the eGFR has fallen to <60 ml · min–1 · 1.73 m–2 or if difficulties occur in the management of hypertension or hyperkalemia.

Retinopathy screening and treatment

Diabetic retinopathy is a highly specific vascular complication of both type 1 and type 2 diabetes. The prevalence of retinopathy is strongly related to the duration of diabetes. Intensive diabetes management with the goal of achieving near normoglycemia has been shown in large prospective randomized studies to prevent and/or delay the onset of diabetic retinopathy (24–26). In addition to glycemic control, severa other factors seem to increase the risk of retinopathy. The presence of nephropathy is associated with retinopathy. High blood pressure is an established risk factor for the development of macular edema and is associated with the presence of proliferative diabetic retinopathy (PDR). Lowering blood pressure, as demonstrated by the UKPDS, has been shown to decrease the progression of retinopathy.

Patients with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes. Subsequent examinations for type 1 and type 2 diabetic patients should be repeated annually by an ophthalmologist or optometrist who is knowledgeable and experienced in diagnosing the presence of diabetic retinopathy and is aware of its management.Following set of fundoscopic pictures showing various stages of diabetic retinopathy should help the physician in making a timely decision. When planning pregnancy, women with preexisting diabetes should have a comprehensive eye examination and should be counseled on the risk of development and/or progression of diabetic retinopathy. Women with diabetes who become pregnant should have a comprehensive eye examination in the first trimester and close follow-up throughout pregnancy and for 1-year postpartum. This guideline does not apply to women who develop GDM because such individuals are not at increased risk for diabetic retinopathy.

Stages of diabetic retinopathy

• Back diabetic retinopathy
• Diabbetic maculopathy
• Preproliferative diabetic retinopathy
• Proliferative diabetic retinopthy
• Advanced eye disease

Figure 1: Back Ground Retinopthy With Intraretinal Hemorrhag

Figure 2 : Proliferative Diabetic Retinopathy Along Vascular Cascade

Figure 3 : Proliferative Diabetic Retinopathy On Optic Dis

Figure 4 : Vitreous Hemorrhage

Treatment

• Laser therapy can reduce the risk of vision loss in patients with HRCs.
• Promptly refer patients with any level of macular edema, severe NPDR, or any PDR to an ophthalmologist who is knowledgeable and experienced in the management and treatment of diabetic retinopathy.

Remember...

In a diabetic, get a comprehensive dilated eye exam at least once a year.

• Proliferative retinopathy can develop without symptoms. At this advanced stage, patients are at high risk for vision loss.
• Macular edema can develop without symptoms at any of the four stages of diabetic retinopathy.
• Patient can develop both proliferative retinopathy and macular edema and still see fine. However, he/she is at high risk for vision loss.

Foot care

Amputation and foot ulceration are the most common consequences of diabetic neuropathy and major causes of morbidity and disability in people with diabetes. Early recognition and management of independent risk factors can prevent or delay adverse outcomes.

The risk of ulcers or amputations is increased in people who have had diabetes >10 years, are male, have poor glucose control, or have cardiovascular, retinal, or renal complications

The following foot-related risk conditions are associated with an increased risk of amputation:

• Peripheral neuropathy with loss of protective sensation.
• Altered biomechanics (in the presence of neuropathy).
• Evidence of increased pressure (erythema, hemorrhage under a callus).
• Bony deformity.
• Peripheral vascular disease (decreased or absent pedal pulses).
• A history of ulcers or amputation.
• Severe nail pathology.

How should sensation be tested with a monofilament ?

It is worthwhile making sure that the monofilament that is used is a 10 gm one. Different people test different sites. It is tested at two sites on the bottom of the feet. If the monofilament cannot be felt at one or both of the sites, then the loss of sensation is considered to be significant hence a risk factor for developing ulcer.

Foot care for those at high risk of developing a foot ulcer

Every person with diabetes needs to be careful about the feet. However, if the risk is high because of neuropathy or peripheral vascular disease or other factors then particular attention is needed. Daily foot care should include: Look at your feet - every day. Look at the top and bottom of your foot. Look and feel in between your toes and around the heel area.

What to look for :

• Bruises
• Cracks/breaks in skin
• Soggy skin
• Dry skin
• Swellings/swelling in only one foot or leg
• Corns and calluses
• Ingrown toenails
• Blisters
• Sharp toe nails
• Hot/cold spots
• Discolouration
• Anything that is not normal or that was not there yesterday

If you are unable to see your feet use a mirror or ask someone to help you if you cannot manage to examine your own feet.

Prevention or Delay of Type 2 Diabetes

Our knowledge of the early stages of hyperglycemia that portend the diagnosis of diabetes, and the recent success of major intervention trials, clearly show that individuals at high risk can be identified and diabetes delayed, if not prevented. The strategies shown to be effective in preventing diabetes relied on lifestyle modification or glucose-lowering drugs that have been approved for treating diabetes.

Lifestyle modification

In well-controlled studies that included a lifestyle intervention arm, substantial efforts were necessary to achieve only modest changes in weight and exercise, but those changes were sufficient to achieve an important reduction in the incidence of diabetes. In the Finnish Diabetes Prevention Study, weight loss averaged 9.2 lb at 1 year, 7.7 lb after 2 years, and 4.6 lb after 5 years (27); "moderate exercise," such as brisk walking, for 30 min/day was suggested. In the Finnish study, there was a direct relationship between adherence with the lifestyle intervention and the reduced incidence of diabetes.

In the DPP (28), the lifestyle group lost 12 lb at 2 years and 9 lb at 3 years (mean weight loss for the study duration was 12 lb or 6% of initial body weight). In both of these studies, most of the participants were obese (BMI >30 kg/m2).

A low-fat (<25% fat) intake was recommended; if reducing fat did not produce weight loss to goal, calorie restriction was also recommended. Participants weighing 120–174 lb (54–78 kg) at baseline were instructed to follow a 1,200-kcal/day diet (33 g fat); participants weighing 175–219 lb (79–99 kg) were instructed to follow a 1,500-kcal/day diet (42 g fat); those 220–249 lb (100–113 kg) were instructed to follow an 1,800-kcal/day diet (50 g fat); and those >250 lb (114 kg) were instructed to follow a 2000-kcal/day diet (55 g fat).

Pharmacological interventions

Three diabetes prevention trials used pharmacological therapy, and all have reported a significant lowering of the incidence of diabetes. The biguanide metformin reduced the risk of diabetes by 31% in the DPP (28), the -glucosidase inhibitor acarbose reduced the risk by 32% in the STOP-NIDDM trial (29), and the thiazolidinedione troglitazone reduced the risk by 56% in the TRIPOD study (30).

• Lifestyle or medication?
  The DPP is the only study in which a comparison of the two was made, and lifestyle modification was nearly twice as effective in preventing diabetes (58 vs. 31% relative reductions, respectively). The greater benefit of weight loss and physical activity strongly suggests that lifestyle modification should be the first choice to prevent or delay diabetes. Modest weight loss (5–10% of body weight) and modest physical activity (30 min daily) are the recommended goalsIndividuals at high risk for developing diabetes need to become aware of the benefits of modest weight loss and participating in regular physical activity. Patients with IGT should be given counseling on weight loss as well as instruction for increasing physical activity. Follow-up counseling appears important for success. Close attention should be given to, and appropriate treatment given for, other CVD risk factors (e.g., tobacco use, hypertension, dyslipidemia). Monitoring for the development of diabetes should be performed every 1–2 years.

Self Assessment Questionaire

Following set of questions will help you to grasp the relevant facts in this chapter and help you to serve your patients in a better way. These multiple choice questions have four choices, choose only one.

1. The diagnosis of diabetes mellitus can be made in an individual if his random plasma glucose level is :
a) 200mg/dl with or without symptoms
b) 126mg/dl
c) 200mg/dl with polyuria, polydipsia
d) 140mg/dl

2. The diagnosis of diabetes mellitus can be made in an individual with a fasting plasma glucose level more than 126mg/dl after he is fasting for :
a) 8hrs
b)10hrs
c)12hrs
d)6hrs

3. Oral Glucose Tolerance Test (OGTT) is not recommended for routine clinical use, but it has some value in following settings:
a) in cases of Gestational diabetes mellitus(GDM) performed with 100g glucose
b) in cases postpartum evaluation of females with GDM with normal fasting plasma glucose(FPG), performed with 75g glucose
c) in cases postpartum evaluation of females with GDM with normal fasting plasma glucose, performed with 100g glucose
d) both a &b
e) both a &c

4. What is pre diabetes ?
a) FPG =110mg/dl-125mg/dl
b) 2hr OGTT -75g plasma glucose level =140mg/dl-199mg/dl
b) both of these
b) there is no such entity

5. Assertion :The wide spread screening for immunological markers type 1 diabetes is recommended .
Reason : The incidence of type 1 DM is rising(.0.5%),so appropriate action can be taken when a positive autoantibody test result is obtained.
a) both assertion and reason are true and are complementary
b) both assertion and reason are true and are not complementary
c) both assertion and reason are false and are complementary
d) both assertion and reason are false and are not complementary

6. Which of the following individuals should be screened for diabetes:
Ram singh -47y old male weighing 70 kg who is an executive and smokes cigar.(a)
Shalu -18y old female weighing 68 kg, with abnormal hair growth and irregular periods, hoarse voice.(b)
Shayam sunder -35y old male hypertensive,jeweler by profession who had normal results on screening for DM three years ago, his 42y old brother had myocardial infarction.(c)
a) only b
b) only c
c) all of them
d) none of them

7. What is the most appropriate time to screen for DM in a 20 week pregnant female who was not found to have DM when screened at 12 weeks . She delivered male baby weighing 4 kg four years ago
a) at 24 – 28 week of gestation
b) 6 weeks postartum
c) after 3 years
d) not really required

8. A 20y old male diabetic come to your clinic who was found to have diabetes recently . he is taking insulin injections, what all investigations you would like to perform in his case. CHOOSE which ever is appropriate;
a) Fundoscopic examination
b) Test for urinary protein
c) Electrocardiogram
d) TSH
e) HbA1c
f) skin examination
g) foot examination
h) referral to a behavioral specialist

9. IF YOU WERE to advise self monitoring of blood glucose to your patients as an indispensable part of the management which of these patients you will choose
a) a pregnant diabetic female
b) a type 1 diabetic
c) a type 2 diabetis on bedtime insulin
d) a type 2 diabetic on diet therapy

10. How many times in day should SMBG BE DONE ?
a) twice
b) thrice
c) 6-8 times
d) atleast once

11. What is treatment goal for HbA1c?
a) 6%
b) 7%
c) 7.5%
d) 6.5%

12.while treating dyslipidemia in a diabetic, each component of lipid profile is assigned appropriate importance . Which of the following choices best describes the above statement?
a) HDL>LDL>TG
b) LDL>HDL>TG
c) TG>LDL>HDL
d) HDL>TG>LDL

13. What is the goal for blood pressure control in DM?
a) 130/80 with protienuria
b) 125/75 with proteinuria
c) 140 /90 without proteinuria
d) 135/ 85 without proteinuria

14. What is the drug of choice for 45 old male hypertensive with type2 DM , 4+ protein on urinary stick test ?
a) ACE
b) ARB
c) either of these
d) Calcium channel blockers

15.
a) not required in asymptomatic cases
b) essentially required

16. Which of the following measures have been shown to delay the progression of prediabetes to diabetes ?
a) life style modification
b) metformin
c) acarbose
d) thizolidinediones
e) all of the above

17. A young male whose mother has type2 diabetes for last 12 years, is very anxious and asks you about the chances that he will have diabetes in his life time :
a) 19%
b) 14%
c) 2%
d) 5%

18. In National Urban Diabetes Survey in India what is the prevalence of IGT?
a) 12%
b) 14%
c) 6.8
d) 13%

19. What constitutes BIDS regimen?
a) Biguanide +Insulin+Diet+Sulfonylurea
b) Biguanide + Sulfonylurea
c) NPH/Glargine insulin + glimepiride
d) Bedtime Insulin +Diet + Glimepiride

References

• Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 20:1183–1197, 1997.
• Expert Committee on the Diagnosis and Classification of Diabetes Mellitus Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 26:3160–3167, 2003.
• Gabir MM, Hanson RL, Dabelea D, Imperatore G, Roumain J, Bennett PH, Knowler WC: The 1997 American Diabetes Association and 1999 World Health Organization criteria for hyperglycemia in the diagnosis and prediction of diabetes. Diabetes Care 23:1108–1112, 2000.
• American Diabetes Association: Type 2 diabetes in children and adolescents (Consensus Statement). Diabetes Care 23:381–389, 2000
• American Diabetes Association: Gestational diabetes mellitus (Position Statement). Diabetes Care 27 (Suppl. 1):S88–S90, 2004
• Sacks DB, Bruns DE, Goldstein DE, Maclaren NK, McDonald JM, Parrott M: Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Clin Chem 48:436–472, 2002
• The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977–986, 1993
• UK Prospective Diabetes Study (UKPDS) Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352:837–853, 1998
• UK Prospective Diabetes Study (UKPDS) Group: Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 352:854–865, 1998
• Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT-EDIC) Research Group: Retinopathy and nephropathy in patients with type 1 diabetes four years after a trial of intensive therapy. N Engl J Med 342:381–389, 2000
• Silverstein J, Klingensmith G, Copeland K, Plotnick L, Kaufman F, Laffel L, Deeb L, Grey M, Anderson B, Holzmeister LA, Clark N: Care of children and adolescents with type 1 diabetes: a statement of the American Diabetes Association (ADA Statement). Diabetes Care 28:186–212, 2005
• Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 289:2560–2572, 2003
• UK Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 317:703–713, 1998
• Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, Menard J, Rahn KH, Wedel H, Westerling S: Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial: the HOT Study Group. Lancet 351:1755–1762, 1998
• Adler AI, Stratton IM, Neil HA, Yudkin JS, Matthews DR, Cull CA, Wright AD, Turner RC, Holman RR: Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ 321:412–419, 2000
• Lewington S, Clarke R, Qizilbash N, Peto R, Collins R: Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 360:1903–1913, 2002
• Stamler J, Vaccaro O, Neaton JD, Wentworth D: Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care 16:434–444, 1997
• Elam MB, Hunninghake DB, Davis KB, Garg R, Johnson C, Egan D, Kostis JB, Sheps DS, Brinton EA: Effect of niacin on lipid and lipoprotein levels and glycemic control in patients with diabetes and peripheral arterial disease: the ADMIT study: a randomized trial: Arterial Disease Multiple Intervention Trial. JAMA 284:1263–1270, 2000
• Grundy SM, Vega GL, McGovern ME, Tulloch BR, Kendall DM, Fitz-Patrick D, Ganda OP, Rosenson RS, Buse JB, Robertson DD, Sheehan JP: Efficacy, safety, and tolerability of once-daily niacin for the treatment of dyslipidemia associated with type 2 diabetes: results of the Assessment of Diabetes Control and Evaluation of the Efficacy of Niaspan trial. Arch Intern Med 162:1568–1576, 2002
• Garg JP, Bakris GL: Microalbuminuria: marker of vascular dysfunction, risk factor for cardiovascular disease. Vasc Med 7:35–43, 2002
• Klausen K, Borch-Johnsen K, Feldt-Rasmussen B, Jensen G, Clausen P, Scharling H, Appleyard M, Jensen JS: Very low levels of microalbuminuria are associated with increased risk of coronary heart disease and death independently of renal function, hypertension, and diabetes. Circulation 110:32–35, 2004
• Gall MA, Hougaard P, Borch-Johnsen K, Parving HH: Risk factors for development of incipient and overt diabetic nephropathy in patients with non-insulin dependent diabetes mellitus: prospective, observational study. BMJ 314:783–788, 1997
• Ravid M, Lang R, Rachmani R, Lishner M: Long-term renoprotective effect of angiotensin-converting enzyme inhibition in non-insulin-dependent diabetes mellitus: a 7-year follow-up study. Arch Intern Med 156:286–289, 1996
• The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977–986, 1993
• UK Prospective Diabetes Study (UKPDS) Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352:837–853, 1998
• UK Prospective Diabetes Study (UKPDS) Group: Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 352:854–865, 1998
• Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, Keinanen-Kiukaanniemi S, Laakso M, Louheranta A, Rastas M, Salminen V, Uusitupa M: Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 344:1343–1350, 2001
• Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346:393–403, 2002
• Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M: Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet 359:2072–2077, 2002
• Buchanan TA, Xiang AH, Peters RK, Kjos SL, Marroquin A, Goico J, Ochoa C, Tan S, Berkowitz K, Hodis HN, Azen SP: Preservation of pancreatic ß-cell function and prevention of type 2 diabetes by pharmacological treatment of insulin resistance in high-risk hispanic women. Diabetes 51:2796–2803, 2002 Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M: Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet 359:2072–2077, 2002 & The expert committee on the diagnosis and classification of Diabetes Mellitus:Follow up on the diagnosis of Diabetes Mellitus .Diabetes care 2003;26:3160-67

Answers

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