B (4:13)

Excellent. Let's now move on to the standards themselves. First, can you discuss which tests are recommended for making the diagnosis of diabetes and some of the differences between using fasting glucose, A1C and the two hour oral glucose tolerance test?

C (4:29)

Well, as you mentioned the three tests, diabetes can be diagnosed using the plasma glucose criteria and that includes a fasting plasma glucose or a 2 hour plasma glucose after a 75 gram oral glucose tolerance test. Or the alternative would be an A1C being drawn. Now getting to the blood glucose approach to it. A fasting plasma glucose requires an individual that fasted for at least eight hours prior to testing. And the same thing also goes into play for the oral gtt. That said, if one has a fasting plasma glucose of greater than 126 milligrams per deciliter or your 2 hour GTT Plasma glucose is 200 milligrams or greater, that's diagnostic for diabetes. You get into this other Neverland where if you've got a plasma glucose between 100 milligrams and 125 milligrams per deciliter or your 2 hour GTT is 140 milligrams to 199, that could be an indication for prediabetes. As I mentioned, both of these tests do require the individual to fast for at least eight hours. And if you're doing the glucose tolerance test, it's more involved with having to get multiple blood draws. An A1C's got the advantage where one does not have to fast for it. An A1C value of greater than or equal to 6.5% would be diagnostic for diabete. Any value that falls between 5.7% and 6.4% could be consistent with prediabetes. Again, the A1C's got several advantages compared to the fasting plasma Glucose and the glucose tolerance test that include greater convenience. There's also greater pre analytical stability and then there's also less day to day changes due to stress or else illness. Now, the only caveat with the A1C would be that you have to take into account an individual's age, race, ethnicity and anemia, or any hemoglobinopathy because they could impact the results of your A1C test. If you do get an abnormal result, you should have it repeated to confirm the diagnosis. So that's the other caution that we throw in there for any of the three tests.

B (7:08)

Our next question is what are the recommendations for who should be screened for diabetes?

C (7:14)

Well, that's a great question. In asymptomatic people, one should really consider doing it in an adult of any age who's overweight or obese. And by definition that would be a bmi greater than 25. Or for Asian Americans, a BMI greater than or equal to 23 and who have one or more additional risk factors for diabetes. Additionally, all patients should begin testing at age 45 years. And if the tests are normal, they ought to be repeated once every three years or thereabouts. The other thing that's out there that people need to be considering is regarding children and adolescents. We're seeing an awful lot of prediabetes and type 2 diabetes in younger populations. So for that group, the children and adolescents who are overweight or obese, and we have two or more additional risk factors for diabetes, one should consider screening them.

B (8:24)

Can you explain for our listeners the category of increased risk for diabetes, often called prediabetes?

C (8:32)

Well, as I mentioned before, prediabetes really is a category for individuals who have not tested to definitely show they have diabetes, but yet they really don't have a fairly normal blood glucose or an A1C, they sort of have impaired fasting glucose or an impaired glucose tolerance and it's an increased risk for the development of diabetes. It's not an absolute guarantee that you're going to get it, but the probability is huge for that. And it's also associated with obesity. And also dyslipidemia and hypertension is what people have traditionally called the metabolic syndrome. Now people with prediabetes, they really need to be referred to an intensive diet and also physical activity behavioral counseling program. The ADA has got an incredible evidence based program called Diabetes Prevention Program where if one goes through that with a target to lose about 7% of body weight and if one can increase one's moderate intensity physical activity such as walking briskly to about 115 minutes per week. It will make a difference where the studies now show that consistently that if you go through that I lose that 7% of the body weight, increase your exercise, you nearly hit a 60% reduction in the rate of diabetes onset after three years. So it's something people can do to help themselves out and and also be healthier.

B (10:16)

The potential opportunity to utilize lifestyle modification in the treatment of prediabetes in order to prevent progression of diabetes really is impressive. Let's move on now to diabetes and can you discuss a critical issue which is setting A1C goals? A common misconception is that all patients with diabetes should have an A1C goal of less than 7%. What do the standards actually recommend with regard to A1C goal setting?

C (10:45)

Well, the thing that's the theme that seems to now be running through the standards of care is that one needs to individualize what one's goals are based upon the patient at hand. But a reasonable A1C goal for many non pregnant adults is at less than 7%. And like for some folks, even more stringent A1C goals at at around 6.5% or less might be appropriate for selected people, as long as you can achieve it without having significant hypoglycemia or other adverse effects of treatment. And those type of patients might include those who have had a short duration of diabetes, people with type 2 diabetes that's been treated with lifestyle changes or metformin by themselves, or people have a long life expectancy, or someone that doesn't have significant cardiovascular disease. On the other hand, a less stringent A1C goal, and this is in the ballpark of say less than 8% in the A1C test, would be appropriate for patients who've got a history of severe hypoglycemia or might have limited life expectancy, might have advanced microvascular or macrovascular complications, could have extensive comorbid conditions, or in folks with long standing diabetes in whom the general goal has been difficult to attain despite self management, education, glucose monitoring and effective doses of glucose lowering agents that would also include insulin. So again, this is something that you have to tailor to the situation that your patient is in and that's where you have the greatest amount of success to help them out.

B (12:36)

The 2016 standards include a new section on obesity management in type 2 diabetes. Can you tell us a bit about this new addition to the standards?

C (12:49)

Yeah, the committee recognized that weight management, obesity play a huge role in the management of diabetes, particularly type 2 diabetes. And there's pretty strong and consistent evidence that obesity management can delay the progression for folks from prediabetes to type 2 diabetes, and it could also be beneficial in the treatment of type 2 diabetes in overweight and obese people with type 2 diabetes. Modest and sustained weight loss has been really shown to improve glycemic control and really can reduce the need for people having to use glucose lowering medications. Also in addition to this, the committee felt that this section should address recommendations regarding diet, physical activity, behavioral therapy, pharmacotherapy, and also bariatric surgical approaches for addressing diabetes. Again, the thing here is trying to tailor what can work out best for your individual patient that's sitting in front of you so that you can both be successful in achieving the goals that you want to set.

B (14:03)

We won't take the time on today's podcast to discuss pharmacologic therapy for hyperglycemia other than to say the standards are in agreement with the position statement of the American Diabetes association and the EASD on the management of hyperglycemia and type 2 diabetes. That statement stresses an individualized, patient centered approach that takes into account patient preferences, cost, side effects, effect on body weight and hypoglycemic risk. Our audience is referred to both the statement itself, which is available from diabetesjournals.org and the podcast from last year with Dr. Anzutchi. Joe, can you discuss the importance that the standards now place on the recognition and management of hypoglycemia?

C (14:54)

Well, hypoglycemia prevention is really a critical component for diabetes management. The studies, both the ACCORD and the advanced trials, show that severe hypoglycemia is associated with mortality. Also, if you think about it, young children with type 1 diabetes and elderly individuals are particularly vulnerable to severe hypoglycemia because of their reduced ability to recognize diabetes, the symptoms for hypoglycemia, and sometimes their inability to communicate their needs to the people around them. So because of this individualized patient education, dietary interventions such as something like a bedtime snack to prevent the overnight hypoglycemia, exercise management, medication adjustments, glucose monitoring, and really routine clinical surveillance may improve the patient outcomes for this. But this is something that people have to pay attention to because it is a very dangerous situation potentially for our patients with diabetes.

B (15:59)

How about immunizations?

C (16:01)

Yeah, the ADA recommends providing all of the routine vaccinations that the CDC and the ACIP folks recommend for children and adults across the board, particularly those with diabetes. But to call out two separate issues, all people with IKE with diabetes 2 years of age and older should receive the pneumococcal polysaccharide vaccine 23. And then those that are over the age of 65 should have received both the PPSV 23 and the PCV 13 in a series, again because individuals with diabetes are particularly vulnerable to pneumococcal infections. And then the other vaccine that should be called out would be the administration of the hepatitis B vaccine to unvaccinated adults 19 years of age or older. That's another important vaccination to keep in mind.

B (17:03)

Cardiovascular disease is an important and far too common consequence of having diabetes. Control of cardiovascular risk factors is an essential component of the treatment of diabetes. There have been a number of changes over the last few years regarding blood pressure goals. Can you tell us about the current recommendation for systolic and diastolic blood pressure in patients with diabetes?

C (17:27)

Well, I'm glad to say that I think we're pretty consistent with what's out there within the literature. And the recommendation is that people with diabetes and hypertension should be treated to a systolic blood pressure of less than 140 millimeters and a diastolic blood pressure of less than 90 millimeters. You can go for lower systolic targets such as less than 130 and a lower diastolic target such as less than 80, which could be appropriate for certain individuals with diabetes. And this would be individuals that are younger patients, those that might have albuminuria, or those with hypertension who have also one or more atherosclerotic cardiovascular disease risk factors. But again, this shouldn't be pursued unless you can make sure that there's no undue treatment burden to the patient and you really want to lower the risk of side effects. You certainly don't want to be overly aggressive with senior citizens because if you bottom out, the blood pressure, they fall and they break their hip. You haven't gained much. In fact, you've probably done them harm that way. So that's what you got to keep in mind. Again, it's individualized.

B (18:48)

What are the current recommendations regarding lipid management?

C (18:52)

We recommend lifestyle modification that focuses on weight loss, reduction of saturated fat, and please get rid of trans fats and and manage your cholesterol intake. Also, people should consider increasing the intake of omega 3 fatty acids, use of viscous fiber and plant stanols and sterols. And also, of course, increased physical activity is incredibly helpful to improve the lipid profile and please stop smoking. That all said, for individuals with diabetes who had had an atherosclerotic cardiovascular event recommendation is that they should be on a high intensity statin therapy in addition to the lifestyle changes. And for individuals who are age 40 to 75 years of age without additional arteriosclerotic cardiovascular disease risk factors, you can consider using moderate intensity statin therapy in addition to lifestyle therapy. So those are the recommendations regarding lipid management.

B (20:05)

Excellent. And how about antiplatelet therapy?

C (20:08)

Well, use of aspirin as a secondary prevention strategy for those folks with diabetes and who've had a cardiovascular event. That's a huge must. I mean, that's true for anybody and we certainly endorsing strategy. You should consider aspirin therapy as a primary prevention strategy for those people with type 1 or type 2 diabetes who are at an increased cardiovascular risk, that being having a 10 year risk that's greater than 10%. And this would include most men or women who are at the age of 50 years or older who have had at least one additional risk factor, such as a family history of coronary artery disease or have hypertension, they smoke or have hyperlipidemia or else albuminuria, and of course, are not at increased risk of bleeding. But again, it shouldn't be used widely unless an individual falls into one of these categories.

B (21:13)

That's very helpful. Due to time constraints, we've had to be selective in going over the highlights and important changes in the standards care. The full standards contain recommendations on many other topics, including screening and management of neuropathy, nephropathy, retinopathy, management of diabetes during illness and inpatient admissions, medical nutrition, therapy and exercise, and many other aspects of care. For more details, again, let me refer our audience to diabetesjournals.org to download and read the full standards or now the abridged version version of the standards. Dr. Stankatis, thank you very much for everything you've gone over with us today. It was very helpful.

C (21:58)

My pleasure. It was really fantastic to have that opportunity.

B (22:02)

We covered a good deal of material today to recap for our listeners. We talked about screening for diabetes, identification and management of prediabetes, individualizing A1C goals, obesity and type 2 diabetes, hypoglycemia, management of blood pressure, cholesterol, and decisions about the use of antiplatelet agents for the American diabetes association. I'm Dr. Neal Skolnick. Thanks for listening.

C (22:40)

It.