Diabetes Mellitus 2014
By Shahid Athar, MD, FACE, FACP
Endocrinologist, St. Vincent Medical Group
According to the CDC, 25.8 million Americans have diabetes but 7 million do not know they suffer from the disease. About 79 million adults have pre Diabetes (or Metabolic Syndrome X). Type II Diabetes Mellitus is becoming more common in children and teens, especially in minority groups. About 26.9 million Americans of 65 years or older have Diabetes Mellitus . High Blood Glucose is not always Diabetes as high blood glucose is seen with other medical conditions such as hyperthyroidism, Cushing’s and steroid use.
Diabetes Mellitus is a chronic disease with persistent hyperglycemia. If not controlled it may lead to many chronic complications such as coronary artery disease, nerve, kidney or retinal damage
Diagnosis of Diabetes Mellitus
Fasting blood glucose levels of >126 mg/dl, 2 hr after meal glucose levels of >200 and or A1C of >6.5%. Pre Diabetes is fasting blood glucose levels of 100-125, 2 hr after meal blood glucose levels of 140-199 and A1C of 5.7%-6.4%.
Type I: The pancreas does not produce insulin. This usually occurs in younger patients and requires insulin as treatment. Patients are symptomatic with increased thirst, urination, and weight loss and are prone to diabetic coma
Type II: Usually occurs in the older group and has multiple factors such as slow insulin release, insulin resistance and high glucagon levels. Early symptoms include fatigue, weight loss, slow healing of sores and blurred vision.
The current surge in the incidence of Diabetes Mellitus Type 2 is due to many factors such as heredity, sedentary lifestyle, obesity (30% Americans are overweight) and consumption of fast food. Anyone with a BMI (body mass index) of >25, first degree relatives, certain ethnicities (African American, Latino, Asian Americans and Native American), women who have had babies weighing over 9 lb, anyone with hypertension, hypercholesterolemia, PCOS, insulin resistance, acanthosis nigricans, or history of gestational diabetes should be tested for Diabetes or Metabolic Syndrome.
Can Diabetes Mellitus be prevented? Lifestyle modifications such as balanced diet and exercise have shown 58% reduction. Metformin and Rosiglitazone reported 31% reduction shown in DPP and DREAM trials.
Treatment of Diabetes is a team work with the patient being the team leader, along with care providers (physicians, dietitians, and educators) and family members. Diabetes is a disciplinary disease. In the process of controlling blood sugars, one may be able to control cholesterol, weight and blood pressure, thus delaying the chronic complications.
The 2014 ADA and AACE goals of diabetes control are A1C (three month average blood glucose) of <6.5% for healthy patients with low risk of hypoglycemia and 6.5%-7% in older patients with concurrent illness and risk for hypoglycemia. Self glucose monitoring and balanced nutrition are the cornerstone of treatment. Stress management and regular exercise are also needed.
For Type I diabetics, insulin (basal/bolus regimen or insulin pump) is the best treatment. Symlin (Pramlintide) can be added to an unstable type 1 diabetic. For Type II diabetics, in addition to the diet and lifestyle modifications, many oral agents as well as GLPI Receptor Agonists ( Byetta and Victoza) are available. One can start with diet and Metformin, and then add Sulphonylurea, DPP4 inhibitor (such as Januvia). Usually combination therapy is needed and sometimes insulin may also need to be added. There are newer agents SGLT2 inhibitors (Invokana and Farxiga) available to control hyperglycemia.
The goal is prevention of acute and long-term complications of both high and low blood glucose. For unstable difficult to control patients, consultation with an Endocrinologist may be considered. For obese Type II diabetics (BMI >35) bariatric surgery may cause reversal of diabetes mellitus or at least marked reduction in the dose of insulin. While treating diabetes mellitus, one must pay full attention to the co-morbid conditions including hypertension, hypercholesterolemia and worsening of renal function.
(Dr Athar is an Endocrinologist with St. Vincent Medical Group. His office is located at 12400 N. Meridian, Suite 100, Carmel, IN 46032. Phone (317)582-8900, Email: Shahid.Athar@stvincent.org)