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April 2005: 20 million Americans have diabetes, but 41 million have "pre-diabetes", which leads to diabetes if left
untreated. AACE and ACE sponsored the Implementation Conference for Outpatient Diabetes Mellitus:
1. Detect and treat impaired glucose tolerance (IGT) for the purpose of preventing type 2 diabetes and potentially reducing cardiovascular disease.
Utilize currently recognized profiles to identify patients at risk for type 2 diabetes and perform a 2 hour oral
glucose tolerance test (OGTT).
Promoptly start education and treatment for risk reduction.
2. Adopt an uncompromising "treat-to-target" approach to achieve and maintain glycemic goals in patients with
diabetes.
Initiate early treament and prsistent titration to safely achieve and maintain glycemic targets.
Address postprandial glucose as well as fasting glucose levels to safely achieve target A1c levels.
3. Promote the tools for self-management
Use self monitoring of blood gludose
Advocate system redsign to support a chronic care model in the treatment of diabetes.
A1C <6.5%
Fasting/Preprandial <110 mg/dL
2-hr Postprandial <140 mg/dL
Lower screening age from 45 to 30 for high risk groups
November 1 2003 • Volume 36 • Number 21
Adults aged 45-74 years
Prediabetes Screening Likely to Be Cost Effective
Miriam E. Tucker
PARIS — Screening for and treating prediabetes in adults aged 45-74 years is likely to be cost effective, Ping Zhang, Ph.D., said at the 18th International Diabetes Federation Congress.
Most currently available screening methods could identify a case of prediabetes or undiagnosed diabetes for less than $200 in direct medical costs, and for less than $300 in total costs (including direct medical and nonmedical costs, plus indirect costs). Costs would be even lower if screening were limited to overweight patients, said Dr. Zhang of the division of diabetes translation at the Centers for Disease Control and Prevention, Atlanta.
His analysis included five prediabetes screening methods: a 2-hour oral glucose tolerance test (OGTT), a fasting plasma glucose test, hemoglobin A1c (HbA1c), capillary blood glucose (CBG) test, and a risk assessment questionnaire.
From population estimates, the direct medical costs per case identified ranged from $176 for CBG with a cutoff value of 100 mg/dL or above, to $236 for a HbA1c test with a cutoff of 5% or above, the only method costing more than $200. Inclusion of direct nonmedical costs such as time and transportation and loss in productivity raised the cost per case detected to $247 for CBG up to $332 for HbA1c.
If screening were carried out only in the 37.4 million eligible adults who had a BMI of 25 kg/m2 or greater—of whom 9.6 million would have prediabetes and 4.7 undiagnosed diabetes—the cost would be lower, ranging from $153 (both CBG and risk-assessment questionnaire) to $200 (HbA1c) in direct medical costs, and from $215 to $282 in total costs, Dr. Zhang reported.
Testing everyone with an OGTT would identify 100% of diabetics and prediabetics, but at a higher cost—particularly in terms of time and lost productivity—than some of the other methods. On the other hand, CBG testing and screening for risk factors via questionnaire detect fewer cases (70% and 69%, respectively), but they give the greatest bang for the buck.
The results were published shortly after the meeting (Diabetes Care 26[9]:2536-42, 2003).
November 1 2003 • Volume 36 • Number 21
Lower postprandial glucose
Acarbose Cuts CV Events In Glucose Intolerance
Event rate was 2.3% at 3.3 years, vs. 5.7%.
Mitchel L. Zoler
Philadelphia Bureau
VIENNA — Treatment of patients with impaired glucose tolerance with acarbose led to a substantial drop in the incidence of cardiovascular events during 3.3 years of follow-up in a controlled study with about 1,400 patients.
“This is the first prospective, randomized study to confirm the hypothesis that high postprandial glucose levels contribute to cardiovascular disease,” Dr. Uwe Zeymer said at the annual congress of the European Society for Cardiology. Acarbose (Precose) delays glucose release from carbohydrates, thereby limiting postprandial spikes in blood glucose levels. The study was sponsored by Bayer, the company that makes acarbose.
The report by Dr. Zeymer focused on a secondary end point of the STOP-NIDDM (Study to Prevent Non-Insulin-Dependent Diabetes Mellitus) trial. The study's primary end point was the reduction of new cases of type 2 diabetes. A prior report from the study showed that a regimen of 100 mg of acarbose t.i.d was associated with a 32% incidence of new-onset diabetes, compared with a 42% incidence in the placebo group, which was a statistically significant difference (Lancet 359[9323]:2072-77, 2002).
The study enrolled people who did not have diabetes but had evidence of glucose intolerance based on a blood-glucose level of 140-200 mg/dL 2 hours after undergoing an oral glucose challenge. Eligible participants also had fasting levels of blood glucose of 100-140 mg/dL and no recent cardiovascular events.
After 3.3 years of treatment, the 682 evaluable people who received acarbose had 16 cardiovascular events (2.3%), compared with 39 events (5.7%) among the 686 evaluable people treated with placebo, a statistically significant difference, reported Dr. Zeymer, a cardiologist at the Ludwigshafen (Germany) Clinic.
Analysis of the results showed that treating 29 people with impaired glucose tolerance with acarbose for 3.3 years would be expected to prevent one cardiovascular event.
The most common cardiovascular event was MI. The people treated with acarbose had two MIs—one clinically apparent and one silent (identified only by ECG changes)—during the study. Those treated with placebo had 19 MIs—12 clinically apparent and 7 silent. This difference also was statistically significant.
The mechanism by which elevations in postprandial glucose cause cardiovascular events is not known. Experts hypothesize that postprandial hyperglycemia raises thrombin levels, increases adhesion molecules on blood cells, increases endothelin levels, and boosts serum levels of low-density lipoprotein cholesterol, Dr. Zeymer said.
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July 30, 2002 |
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Blood tests may help identify people at risk for developing diabetes. (PhotoDisc) |
Pre-Diabetes: Are You at Risk?
Interventions Can Keep Those with Pre-Diabetes From Developing Full Disease
July 30 — Is diabetes knocking at your door? It is for millions of Americans. In fact, it's the fourth-leading killer in the country. But with proper identification of those with a condition dubbed "pre-diabetes," the full-blown version of the illness can be turned away. | 
An estimated 16 million Americans have pre-diabetes, on top of the 17 million estimated to have already developed diabetes. Pre-diabetes, a term coined earlier this year as part of an ongoing prevention campaign, describes a condition previously known as impaired glucose tolerance.
Those with the condition have blood glucose levels higher than they should be but are not yet high enough to be classified as diabetes. The higher levels put them at greater risk of developing not only diabetes, but also stroke and heart disease.
While pre-diabetes has been around for years under a different moniker, a growing body of research uncovering its considerable threat encouraged health officials to push for greater awareness and recognition.
"If you tell people that they don't have diabetes yet, they think 'Oh good.' They take that loophole," says Anne Daly, past-president of health care and education for the American Diabetes Association, based in Alexandria, Va. "We don't want people to take that loophole."
Who Is at Risk?
The good news is that with quick intervention a future full of insulin shots can be avoided. Among those at the greatest risk of developing pre-diabetes, and full-blown diabetes, include:
 Those with a family history of diabetes, as well as those who have had high blood sugar while pregnant — a condition known as gestational diabetes.
Those who belong to minority groups that are disproportionately affected by diabetes, including African Americans, Native Americans, Latinos and Pacific Islanders.
Those who are overweight or obese.
Those with high blood pressure or blood fats.
Those who are sedentary or inactive.
To ward off the the disease, health officials recommended specifically that overweight people over the age of 45 be screened for pre-diabetes.
Keeping Diabetes at Bay
A major message of the government-backed campaign, however, is that diabetes need not be an inevitable conclusion after a pre-diabetes diagnosis.
"Progression to type 2 diabetes can be prevented by lifestyle modification," says Dr. Joann E. Manson, chief of the division of preventive medicine at Brigham and Women's Hospital in Boston, Mass. "Most importantly, lose weight and become physically active."
Medications, such as metformin, may be used in some instances to lower blood sugar. But some experts emphasize the importance of diet and exercise over medical intervention.
"We know that losing weight is effective," says Daly. "In order to create a calorie deficit, which is how you lose weight, you've got to decrease what's coming in the door and increase what's going out the door. You need to work on both sides of that energy equation. You can try to be a couch potato and eat like a bird, but it isn't going to work."
For those who are baffled about getting started on an effective diet and exercise program, Daly recommends consulting a dietitian or other health-care professional for help.
Adds Daly, "If we identify more people with pre-diabetes, it is likely we can prevent heart attacks and strokes by the bucket full, by implementing lifestyle change to decrease medical risk factors that are an accident looking for an place to happen."
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Women and Diabetes
Some statistics suggest that women may need to pay even closer attention to their blood sugar and have added incentive to ward off developing diabetes. Here are some of the reasons why:
- Diabetes is taking an increasingly harsh toll on women: More than 2.5 million American women are unknowingly affected by diabetes, while millions more have also undetected "pre-diabetes."
- Women currently make up 60 percent of diabetics and the gender gap is expected to widen as the population ages and becomes more ethnically diverse. American Indian, Alaskan Native, African American and Hispanic women are at much greater risk of diabetes than white women.
- What's more, for unexplained reasons, diabetes runs a more severe course in women than in men. For example, women are at greater risk for diabetes-associated heart disease and blindness compared with men.
- Belgium researchers recently conducted the largest study ever on the sex lives of women with diabetes and found that significantly more women with diabetes, 27 percent versus 15 percent of men, reported sexual dysfunction. The study and editorial were published in the April issue of Diabetes Care. These problems were primarily a result of the psychological, rather than physiological, impact of diabetes. Women with sexual dysfunction tended to be frustrated with their diabetes treatment and were also more apt to be depressed.
- An estimated 45 percent of women with diabetes have heart disease compared with less than 39 percent of diabetic men.
- There are a slew of other ways in which diabetes disproportionately affects women. Diabetes-associated coma, stroke, nerve damage, urinary tract infections and hypertension have all been shown to occur more frequently among women.
Facts provided by Sophia Cariati of the Society for Women's Health Research. | |
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