Diabetes Management and Prevention Overview

Goals of Treatment for Diabetes Mellitus

• The goals of treatment for type 2 diabetes mellitus (T2DM) are multifaceted and include landmark studies, cardiorenal benefits of SGLT-2 inhibitors and GLP-1 agonists, and hypertension and lipid management.

Learning Outcomes

• Review landmark studies in the understanding of T2DM.
• Describe the goals of treatment for Diabetes Mellitus.
• Recognize the cardiorenal benefits of SGLT-2 inhibitors and GLP-1 agonists.
• Define hypertension treatment goals in patients with diabetes and the management approach.
• Identify recommendations for lipid lowering therapy in patients with diabetes.

Fatima (Clinical Case Scenario)

• 40-year-old female with type 2 diabetes diagnosed 2 years prior.
• Hypertension and a family history of hyperlipidemia.
• Previous gestational diabetes.

Fatima (Clinical Case Scenario) - Further Details

• Blood pressure: 154/78 mmHg
• HbA1C: 8.2%
• Cholesterol: 6.2 mmol/L (240 mg/dL), HDL 1.03 mmol/L (40 mg/dL), LDL 5.4 mmol/L (210 mg/dL)
• Creatinine: 64 µmol/L (0.74 mg/dL), eGFR 95 ml/min/1.73 m²
• Weight: 84 kg, BMI 31.7 kg/m²
• Current Medications: Metformin 1000 mg daily, Perindopril 5 mg daily, Aspirin 75 mg daily

What is Diabetes?

• Diabetes mellitus (DM) is a group of diseases characterized by hyperglycemia.
• Type 2 diabetes mellitus (T2DM) is a metabolic disorder with multiple causes, characterized by chronic hyperglycemia, affecting carbohydrate, fat, and protein metabolism. Defects in insulin secretion, insulin action, and other pathophysiological factors are involved.
• DM can lead to long-term damage, dysfunction, and failure of various organs.

Diagnosis

• Fasting plasma glucose: ≥ 7.0 mmol/L (126 mg/dL)
• Two-hour plasma glucose: ≥ 11.1 mmol/L (200 mg/dL) after a 75g oral glucose load.
• HbA1c: ≥ 48 mmol/mol (equivalent to 6.5%)
• Random plasma glucose: ≥ 11.1 mmol/L (200 mg/dL) in the presence of symptoms of hyperglycemia.

Treatment Goals in Diabetes Mellitus - A Multifaceted Approach

• Exercise
• Diet
• Cholesterol management
• Blood pressure management
• A1c / Anti-platelets

Overview of Type 2 Diabetes Prevention Trials: Lifestyle Modification Intervention

• Studies on lifestyle modification for type 2 diabetes prevention show varying results, with different follow-up periods and participant numbers.

Diabetes Prevention Program (DPP): 7 kg Loss ↓ Risk of Type 2 Diabetes

• The DPP highlights the relationship between weight loss and the risk of type 2 diabetes.

Lifestyle Modification

• Encompasses diet, physical activity, and behavioral change.
• Reduced calorie diet (500-750 kcal/day deficit).
• Physical activity (typically aerobic, ≥ 150 min/week).
• Behavioral therapy (structured program).

Cardiovascular Disease & DM

• Patients with T2D are 2-4x more likely to develop CVD (cardiovascular disease) and CAD (coronary artery disease) compared to those without diabetes.
• Greater risk of hospitalizations amongst those with diabetes.
• Deaths among T2D patients are often due to cardiovascular complications.

Prevalence of ASCVD (PACT-MEA Study)

• This study presents prevalence data for established atherosclerotic cardiovascular disease (ASCVD) in various countries with high diabetes prevalence.

Several Risk Factors in Patients with T2DM

• Elevated glycated hemoglobin levels.
• Elevated blood pressure.
• Albuminuria (presence of microalbuminuria or macroalbuminuria).
• Smoking.
• Elevated LDL-C level.

Diabetes Control and Complications Trial (DCCT)

• 1441 teenagers and young adults with type 1 diabetes participated, randomly assigned to two groups:
• Conventional Care (one or two insulin injections daily, routine three-month follow-up visits).
• Intensive Treatment (initial hospitalization for education and stabilization, four or more blood sugar tests daily, use of insulin pump or multiple daily insulin injections, monthly office visits, and frequent weekly phone calls).

DCCT Summary: Intensive Therapy Significantly Reduced

• Retinopathy: 76% reduction
• Nephropathy: 50% reduction
• Neuropathy: 60% reduction

Patients with T2DM Often Have Multiple Comorbidities

• High rates of hypertension, obesity, and dyslipidemia exist in patients with type 2 diabetes.
• Patients with diabetes have a substantial risk of developing chronic kidney disease and coronary artery disease.

Cardiovascular Disease & Risk Management

• Multifactorial approach to reduction in risk of diabetes complications, incorporating lifestyle modification.

Use of Glucose-Lowering Medications in the Management of Type 2 Diabetes

• Guidelines for using different glucose-lowering medications, considering specific factors such as CVD, Heart Failure (HF), Chronic Kidney Disease (CKD), and individual patient needs.

Adam: 66-Year-Old Man with T2M

• Detailed timeline of complications (ACS, MI, PAD, retinopathy, CKD, neuropathy, ischemic toes amputation, stroke) in a 66-year old man with type 2 diabetes.

Complications of DM

• Macrovascular: CAD, ACS, MI, stroke, peripheral arterial disease (including ischemic toes amputation).
• Microvascular: Chronic Kidney Disease (CKD), neuropathy, retinopathy.

Blood Pressure Targets in T2DM

• Hypertension confirmation required with multiple blood pressure readings, confirming systolic >130 mmHg or diastolic >80 mmHg. Treatment initiated if confirmed as hypertension.
• BP >180/110 and known CVD—hypertension diagnosis is possible with one reading.
• BP > 120/80 monitoring—weight management, decreased sodium intake, decreased alcohol intake, increased physical activity should be considered.
• Separate guidelines for initial BP <160/100 and initial BP ≥160/100, focusing on adding drugs to therapy depending on comorbid conditions.

Lipid Targets in T2DM

• Primary Prevention: Moderate-intensity statins are recommended for adults aged 20–39 with other CVD risk factors. Moderate intensity statins for T2DM adults aged 40-75 without CVD. High-intensity statins for adults aged 40-75 with existing CVD, particularly those with LDL >1.8 mmol/L. Moderate-intensity statins for those >75.
• Secondary Prevention: High-intensity statins are recommended for T2DM patients with a diagnosis of atherosclerotic disease, especially those with high LDL levels (LDL >1.4 mmol/L) despite statin therapy.

Anti-Platelets and T2DM

• Secondary Prevention: Aspirin (75mg) or clopidogrel (if aspirin allergy) are possible for long-term use in high-risk patients. Low dose rivaroxaban and aspirin—may be indicated in patients with stable coronary or peripheral arterial disease.
• Primary Prevention: Controversial use for T2DM patients aged 50—70 with other risk factors.

Weight Management in T2DM

• Obesity is a chronic disease requiring specific management.
• Weight loss of >5% improves metabolic and cardiovascular risk factors. 10% weight loss may lead to T2D remission.
• Structured weight management programs are recommended, with long-term follow-up.
• Consider short-term very low-calorie diets (VLCDs) in specialist settings.
• Evidence-based pharmacotherapy for obesity (e.g., semaglutide, orlistat) may be considered.

Medical Nutrition Therapy (MNT)

• MNT focuses on nutrition assessment, therapy, and counseling for chronic disease management, tailored to the individual.

Patient-Centered Collaborative Care

• Collaborative approach focusing on eye care, registered dietitian, diabetes self management, dental exams, mental health professionals, and podiatry services are necessary to manage diabetes and comorbidities.

Test your knowledge on lifestyle interventions and treatment goals for diabetes management. This quiz covers key studies, risk reductions, and specific medication classes that benefit diabetes patients. Assess your understanding of important concepts related to Type 2 diabetes.