Diabetes Mellitus - Document List
Challenging Sociocultural Health Disparities: A Collaborative Interdisciplinary Model Podogeriatric Teaching Module
Chapter VII: Type 2 Diabetes Mellitus in the Elderly
Rationale
Type 2 diabetes mellitus is an increasingly common chronic medical condition in the elderly associated with great morbidity and diminished quality of life. It is the leading cause of new blindness in people age 20-74 years, the leading cause of end-stage renal disease, and the most frequent cause of non-traumatic lower limb amputations. It is also a major risk factor for coronary artery disease and stroke. Comorbid conditions such as hypertension, hyperlipidemia, disability, depression and cognitive impairment are seen more commonly in those with type 2 diabetes. These potentially devastating complications may be prevented or delayed with early diagnosis and proper management, using multiple members of the health care team. As such, it is essential for anyone caring for an elderly person with type 2 diabetes to understand the disease, its manifestations, and proper management.
Goals and Objectives
Goal #1 - Properly make the diagnosis of type 2 diabetes mellitus.
• Identify the signs and symptoms suggestive of diabetes mellitus.
• Compare and contrast type 1 and type 2 diabetes mellitus.
• List the 3 ways diabetes mellitus can be diagnosed, citing the pros and cons of each method.
Goal #2 - Develop the necessary knowledge, skills and attitudes to recognize, comfortably manage, and appropriately refer when necessary, the potential complications of type 2 diabetes mellitus.
• As outlined by the American Diabetes Association, describe the presentation, initial evaluation, management and appropriate follow-up of patients who have the following major chronic complications of type 2 diabetes mellitus:
• coronary artery disease
• retinopathy
• nephropathy
• neuropathy
• diabetic foot
• Describe the major treatment modalities for managing type 2 diabetes mellitus, including the role of patient education, medical nutrition therapy, physical activity, and medications.
Goal #2
• Master the following psychomotor skills:
• vascular examination of the lower extremity, including examination of pulses, listening for bruits, and checking for capillary refill;
• neurological examination of the lower extremity checking for peripheral neuropathy using the nylon monofilament test;
• close examination of the foot, identifying deformities that may potentially lead to ulcerations.
Goal #3 - Provide comprehensive health care services aimed at preventing health problems in the elderly with type 2 diabetes mellitus.
• Outline the standards of care established by the American Diabetes Association for those with type 2 diabetes mellitus, and identify resources by which one can remain current with those standards.
• Identify the essential components of the FOCUSed examination for each visit with the patient with type 2 diabetes mellitus.
Goal #4 - Demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients and their families, and professional associates.
• Effectively and compassionately communicate with patients, their families, and significant others, being sensitive to multicultural beliefs and habits.
• Identify the various members of the health care team that are essential in providing optimal care to the elderly patient with type 2 diabetes mellitus.
Illustrative Case
Mr. P, a 70 year-old man originally from the Philippines, was diagnosed with type 2 diabetes mellitus in 1972. He was initially treated with diet and a sulfonylurea. In 1976 he quit his two pack-per-day cigarette smoking habit. Through the years his lipid profile has been slightly abnormal with a cholesterol of 226 mg/dl, HDL of 30 mg/dl, and triglycerides of 280 mg/dl, and his blood pressure slightly elevated at 152/94 mg/dl. During the 1970’s and 1980’s, he had poor glucose control, with his glucose averaging 280-400 mg/dl and a glycosylated hemoglobin average of 12.8%. During this time he developed cholecystitis, peripheral neuropathy, and erectile dysfunction. In 1990 he was started on insulin with a bit better control of his glucose (average now less than 200 mg/dl), but the glycosylated hemoglobin remained high at 10.7%. During the 1990’s he developed proteinuria, cataracts which required surgery, and diabetic retinopathy. He also suffered a right-sided cerebrovascular accident with residual left-sided weakness. During the past year his proteinuria has worsened. You are now seeing him in the office for the first time, presenting a complaint of right foot pain with discoloration of his toes. As you examine his diabetic foot (Figure 1), you ponder how all of this could have been prevented, and what you should do now to minimize any further damage.
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Definition of Diabetes Mellitus
Diabetes mellitus is a group of metabolic disorders associated with abnormalities in carbohydrate, lipid, and protein metabolism.1, 2 The common feature of this disorder, hyperglycemia, is due to defects in insulin secretion, insulin action, or both, with resulting long-term damage to various organs and diminished quality of life.
Diagnosis and Classification
The upper limit of normal fasting plasma glucose is 109 mg/dl. Although this number is somewhat arbitrary, values above this level are associated with a progressively greater risk of developing the micro- and macrovascular complications associated with diabetes. According to the American Diabetes Association’s (ADA) Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, the diagnosis of diabetes can be made in one of three ways (Table 1).2,3 Each method must be confirmed, on a subsequent day, by any of these three methods. For example, you see a 67 year-old woman in the office who has a two-week history of increased thirst and urination. Although she had just eaten an hour before the appointment, you obtain a plasma glucose, which returns elevated at 215 mg/dl. Before you can tell her for certain that she has diabetes mellitus, you must confirm the diagnosis, which you do the following week when her fasting plasma glucose returns at 156 mg/dl. Due to increased costs and patient inconvenience, the 75-gram oral glucose tolerance test normally is reserved for research purposes and is not recommended for routine clinical practice.
Glycated hemoglobin (Hemoglobin A1c, HbA1c) is a laboratory test strongly correlated with the mean level of blood glucose over the previous one to three months.3-5 Although useful in monitoring the effectiveness of treating diabetes mellitus, the ADA at this time does not recommend its use for diagnostic purposes due to a lack of standardization in our national laboratories. However, some investigators are advocating its use in diagnosing diabetes mellitus, especially when done in centers where the test is standardized.3
There are two major types of diabetes mellitus in the elderly, which are accompanied by a host of several distinct, but rare, conditions. The classification system used by the ADA is based on the pathogenesis of the disease, not on the treatment required for its management.2 Type 1 diabetes mellitus, formerly known as “juvenile-onset” and “insulin-dependent” (IDDM) diabetes, is normally due to an autoimmune destruction of the ß-cells within the pancreas, leading to an absolute deficiency of insulin. These individuals require insulin for survival - without it they would normally go into diabetic ketoacidosis and die. Although this type usually occurs in children and adolescents, it can occur at any age, even up to the 9th decade of life.2 Its diagnosis can be confirmed by a low or undetectable level of plasma C-peptide
Type 2 diabetes mellitus, formerly known as “adult-onset” and “non-insulin-dependent” (NIDDM) diabetes, is due to insulin resistance with a relative, rather than an absolute, deficiency of insulin.6 The majority, up to 95%, of all elderly patients with diabetes have this type. These individuals may need insulin to help control hyperglycemia, but they rarely need it for survival. Type 2 diabetes normally begins with insulin resistance.6, 7 The pancreas is initially able to compensate for this resistance by increasing its insulin production (hyperinsulinemia). However, in time the insulin secretion diminishes, resulting in hyperglycemia. The risk of developing type 2 diabetes increases with age, obesity, and lack of physical activity.
Impaired glucose tolerance
This is also known as “pre-diabetes”, and is defined as having an elevated fasting plasma glucose between 110 mg/dl and 125 mg/dl. Nearly 16 million Americans have this condition, which substantially increases their risk for developing type 2 diabetes within 10 years and a 50% greater likelihood of having cardiovascular disease.8, 9 Studies have shown that modest weight loss coupled with moderate exercise can prevent the onset of diabetes in these individuals.10-13
Type 2 diabetes mellitus often goes undiagnosed for years as the classic symptoms of diabetes (polydipsia, polyuria, weight loss, and visual changes) normally do not occur until marked hyperglycemia is present. Because individuals during this time are at increased risk for developing the chronic complications of diabetes, early detection with intervention is warranted. The ADA advises screening individuals at high risk for type 2 diabetes (Table 2) at 3-year intervals beginning at age 45, especially those who are overweight.14 Depending on the number of risk factors, screening may occur more frequently.
Epidemiology of Type 2 Diabetes
Nearly 16 million Americans have diabetes, with a prevalence of 5-7% among all adults, which increases to over 18% among the elderly.1, 9 Diabetes is the 6th leading cause of death, with an associated loss of life of up to 15 years, and is a major cause of morbidity and diminished quality of life.1 As previously stated, it is the leading cause of new blindness in people age 20-74 years (retinopathy), the leading cause of end-stage renal disease (nephropathy), and the most frequent cause of non-traumatic lower limp amputations (neuropathy and peripheral vascular disease).15-17 It is also a major risk factor for coronary artery disease and stroke.18 Comorbid conditions such as hypertension, hyperlipidemia, disability, depression and cognitive impairment are seen more commonly in those with DM.17
The impact of diabetes is quite costly, accounting for 14% of all health care expenditures, and 25% of all Medicare costs.1, 17 Indirect and direct health care costs approach $100 billion each year in the United States. The majority of these health care dollars are used for hospitalization and the care of the diabetic complications. Increased costs are associated with poor control of diabetes. In a 1995 study of 3000 adults with diabetes in a large health-maintenance organization, for every 1% increase in the HbA1c above 6%, annual health care expenditures rose 4%, 10%, 20% and 30% respectively.19
Health Care Disparities in Type 2 Diabetes
Diabetes is particularly more common in African-Americans, Latinos, and Native Americans than in the non-Hispanic, Caucasian population.1, 17, 20-22 Poor glycemic control and a higher risk of diabetes-related complications and mortality are particularly high in African-Americans 20, 21, 23-25 and in those in a lower socioeconomic status.26-28 A recently published article suggested that targeting diabetes mellitus would have one of the greatest effects on reducing racial disparity in mortality rates.29 Because of this perceived disparity in diabetes care, the National Institutes of Health has included type 2 diabetes as one of its areas of focus in their Strategic Research Plan to Reduce and Ultimately Eliminate Health Disparities.30
Major Complications of Type 2 Diabetes
Type 2 diabetes is associated with both acute and chronic complications (Table 3).15, 16 Diabetic ketoacidosis (DKA) typically occurs in those with type 1 diabetes, but may sometimes occur in the elderly who have type 2 diabetes.31-33 The hallmark of DKA is extreme hyperglycemia, often above 1,000 mg/dl, associated with an anion-gap, metabolic acidosis, severe dehydration, and hypokalemia. The mortality rate is usually less than 5%, but is higher when it occurs in the elderly. In contrast, hyperglycemic hyperosmolar nonketotic syndrome (HHNS), typically occurs in those over the age of 65 who have type 2 diabetes.31-33 Individuals with HHNS have marked hyperglycemia, hyperosmolarity, dehydration, and often altered mental status, but normally do not have ketones nor metabolic acidosis. The mortality rate, depending upon other comorbid conditions, may be as high as 40% to 50%. In both hyperglycemic conditions, infection is the most common precipitating factor.
Hypoglycemia is occurring more frequently as the standards for treatment call for tighter glucose control.34-36 Individuals usually develop warning signs such as hunger, tachycardia, diaphoresis, shakiness, and anxiety. Eating rapidly absorbed carbohydrates at this stage often alleviates the symptoms and prevents further fall in the glucose levels. However, some elderly individuals may not experience or recognize these symptoms. If the glucose continues to fall, these individuals may develop altered mental status, with eventual loss of consciousness or seizure. Severe hypoglycemic reactions may also precipitate a myocardial infarction in those elderly patients with cardiovascular disease.
The elderly with type 2 DM are more prone to infections due to abnormalities in their immune function (Table 3). It is important to recognize and treat these infections as they may precipitate a hyperglycemic crisis. Since those elderly patients with type 2 DM are four times more likely to die from influenza and pneumonia, they should be current on their influenza and pneumococcal vaccinations.37
Coronary artery disease is the leading cause of death in those with type 2 diabetes, accounting for up to 70% of the mortality.18, 38 Type 2 diabetes is associated with a two- to four-fold excess risk of myocardial infarction, congestive heart failure, and sudden death.39 Typically, atherosclerosis is advanced, occurring earlier in life and involving more vessels in a diffuse manner. In addition, women with type 2 diabetes have the same risk, if not greater, than men for coronary heart disease. Because of the often-accompanying autonomic neuropathy, silent ischemia is more common. Instead of typical angina symptoms, the elderly having a myocardial infarction will often complain of increased dyspnea or fatigue. A high index of suspicion is needed in these individuals to prevent further complications.
Up to 65% of those with type 2 diabetes will have at least one other modifiable risk factor for coronary artery disease (Table 4). Hypertension is a very common comorbid condition, occurring in up to two-thirds of those with type 2 DM.40 The U.K. Prospective Diabetes Study (UKPDS), demonstrated that lowering blood pressure below 150/85 mmHg in those with type 2 DM achieved a clinically important reduction in the risk of death due to coronary heart disease and diabetes, progression of retinopathy and nephropathy.41 The American Diabetes Association recommends even tighter blood pressure control, with a goal of < 130/80 mmHg.40 In addition to weight reduction and exercise, medications should be considered if the goal is not achieved within three months. Although any antihypertensive may be used, some drug classes such as Angiotensin Converting Enzyme (ACE) inhibitors, ß-blockers, and diuretics are often the preferred drugs for initial therapy.42 Sometimes two or three different antihypertensives are needed to achieve the target blood pressure goals.42, 43
Dyslipidemia is another commonly encountered comorbid condition seen in those with type 2 diabetes. The most common lipid pattern seen is high triglycerides with a low HDL cholesterol.39, 44 In addition to exercise, good medical nutrition, and glucose control, medications are often needed to achieve the desired lipid goals.
Cigarette smoking is associated with an increased risk of worsening microvascular complications and premature death in those with type 2 diabetes.45 Elderly patients should be asked whether or not they smoke. Every smoker should be advised to quit, using a clear, strong and personalized message. As many elderly patients have been smoking for over 30-40 years, assistance is often needed, including pharmacologic supplements and behavioral modification. Close follow-up is required to assist the smoker in quitting.
In addition to modifying the above risk factors, aspirin therapy should be considered in all those who have type 2 DM, especially if they already have documented coronary heart disease.46, 47 If used, enteric-coated aspirin in doses of 81-325 mg per day are recommended. Contraindications include those with an aspiring allergy, bleeding tendency, on anticoagulant therapy, recent gastrointestinal bleeding, and clinically active hepatitis.46
Peripheral arterial occlusive disease is four times more common in those with type 2 DM.48 Vessels typically involved are the tibial and peroneal arteries (with sparing of the dorsalis pedis artery). Individuals with lower extremity ischemia often will have signs and symptoms such as intermittent claudication, pain occurring in the arch or forefoot at rest or during the night, diminished femoral, popliteal, posterior tibial and dorsalis pedis pulses, and femoral bruits. The extremities should be inspected. Typically those with vascular disease have thin and shiny skin, with absence of hair on the lower let and foot. (Figure 2)
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Capillary filling time is normally 1.0 to 1.5 seconds; however, those with moderate vascular disease have a filling time of 1.5 to 2.5 seconds, while those with very severe disease have a filling time greater than 4.0 seconds. Non-invasive testing in the vascular lab include the measurement of the ankle-brachial index. For those with suspected lower extremity ischemia, imaging studies such as arteriography should be preformed.
At the time of diagnosis, 15% to 20% of those with type 2 diabetes will have some form of diabetic retinopathy, which increases to 60% after having the disease for 20 years.49 Diabetes affects every part of the eye (e.g., corneal disease, cataracts, glaucoma, and retinopathy), and is the leading cause of new cases of blindness among adults aged 20-74 years. Diminished vision also impacts negatively on the elderly patients’ ability to properly examine their feet. Prevention of diabetic retinopathy is possible through tight blood pressure and glucose control.41, 50 It is essential to detect the early forms of diabetic retinopathy at once. As proliferative retinopathy develops, the risk of severe visual loss within two years is up to 50% unless laser photocoagulation is performed. To detect the early stages of diabetic retinopathy which are often asymptomatic, all patients with type 2 DM should undergo an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of initial diagnosis, and yearly thereafter.
Diabetic nephropathy is a clinical syndrome characterized by albuminuria (> 500 mg/day), hypertension, and progressive, relentless and self-destructive renal failure.51, 52 It is the single most common cause of end-stage renal disease (ESRD) in the U.S. Annual screening for microalbuminuria is important since diabetic nephropathy is usually asymptomatic until ESRD develops. Prevention of diabetic nephropathy is possible through tight blood pressure and glucose control.41, 50 The use of ACE inhibitors and Angiotensin Receptor Blockers (ARBs) slow the rate of progression of nephropathy. A nephrologist should be consulted once proteinuria develops and the creatinine begins to rise.
The prevalence of diabetic neuropathy depends upon glycemic control - those in better control have less problems with this compared to those with worse control.53 Distal symmetric polyneuropathy is the most common form of diabetic neuropathy. It typically involves the lower extremities and is a major cause of lower extremity amputations. Symptoms include numbness, paresthesias, and severe pain. Typically patients have decreased vibratory sensation, decreased light touch (as measured by the nylon monofilament test - see below), and decreased ankle reflexes (which subsequently may lead to tendon shortening and foot deformities). Good glucose and blood pressure control prevents the progression of the neuropathy. 41, 50 Once it develops, the treatment for the pain is often challenging, although gabapentin at doses of 900 to 3600 mg per day appears to be efficacious in pain relief.54
In addition, autonomic neuropathy can occur, resulting in a diminished quality of life for those with type 2 diabetes. Typical complications involve the skin (anhydrosis), the gastrointestinal system (gastroparesis, diabetic diarrhea), genitourinary system (neurogenic bladder, sexual dysfunction), and cardiac system (orthostatic hypotension, resting tachycardia, and silent ischemia).
Complications of the diabetic foot are the most common cause of nontraumatic lower extremity amputations (35-40,000 occur each year) and the most frequent reason for hospitalization in patients with type 2 diabetes.55 (Figurs 3,4) Early detection and appropriate treatment of diabetic foot ulcers may prevent up to 85% of these amputations. Foot-related risk conditions associated with an increased risk of amputation include peripheral neuropathy with loss of protective sensation, altered biomechanics through foot deformities and callus formation, peripheral arterial occlusive disease, and autonomic neuropathy causing decreased sweating and dry, fissured skin.56 Complicating these factors are impaired vision of the elderly, which prevents adequate examination of the feet, and poor glucose control leading to poor wound healing.
[pic]
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Prevention of ulcer formation requires meticulous attention to foot care and proper management of minor foot injuries. (Table 5) Patients (or their caregivers if they lack sufficient visual acuity or mobility to perform the exam) must examine their feet daily, and should promptly seek medical attention should foot problems occur. Health care providers must carefully examine the feet, preferably at every office visit, looking between the toes and unroofing calluses which may hide ulcerations. The shoes should also be inspected for areas of inadequate support or improper fit. If ulcerations are discovered, aggressive treatment requires adequate debridement, often under the care of a podiatrist.
Management of Diabetes Mellitus
Proven benefits of lowering the blood glucose levels to or near normal include diminished symptoms (polyuria, polydipsia, fatigue, weight loss. blurred vision, vaginitis or balanitis), reduced risk of acute hyperglycemic crises such as HHNS or DKA, and a decrease risk of developing or worsening of diabetic retinopathy, nephropathy, and neuropathy.57 Two landmark studies have shown that good glycemic control in those with diabetes can prevent or delay these diabetic complications. The Diabetes Control and Complications Trial (DCCT) showed that tight control in those with type 1 diabetes can reduce the development and progression of retinopathy, nephropathy and neuropathy.50 Likewise, the United Kingdom Prospective Diabetes Study (UKPDS) found that controlling hyperglycemia in those with type 2 DM reduces the risk of microvascular (retinopathy, nephropathy, and neuropathy) complications.58 For every percentage point decrease in HbA1c, there was a 35% reduction in the risk of microvascular complications, a 25% reduction in diabetes-related deaths, a 7% reduction in all-cause mortality, and an 18% reduction in combined fatal and nonfatal myocardial infarctions. Good glycemic control also decreases health care costs.59, 60
The key to good control of the diabetes involves individualization of therapy (there are no “cookbook” formulas) and patient self-management. Often this care requires negotiation - individualized and acceptable management goals. The patient should and must participate in the decision-making process. Patients need to be empowered to make informed decisions about their own care. To effectively do this, they need to have the knowledge and skills to make ongoing decisions and modifications in an appropriate fashion.61 The lack of open communication has been a significant obstacle to good diabetes care for many years. Open dialogue with the patient is important - this will move the management of type 2 diabetes away from the frustration of blaming patients for failed treatment, and towards helping patients make adequate and appropriate management choices. It is essential to take the time to better understand the patients and their behaviors, and through open and honest communication develop a shared problem-solving approach to diabetes care (Table 6)
The staged approach in the management of diabetes includes: 1) patient education, medical nutrition therapy, and physical activity, 2) oral medications, and 3) insulin for those who fail these treatments. Try to keep it simple. The foundation for managing type 2 DM includes patient education (Table 7), medical nutrition therapy (Table 8)62, and physical activity (Table 9).63 When these don’t fully result in good glucose control, oral medications should be tried. By better understanding the pathogenesis of type 2 diabetes, one is able to logically select the appropriate medicines for its treatment. There are currently five classes of oral drugs available in the United States for treating type 2 DM (Table 10).64-69 Sulfonylureas are “hypoglycemics” while the newer treatment options are “anti-hyperglycemics” which are less likely to cause hypoglycemia.
These medicines can also be used in combination to better control diabetes. The majority of patients eventually need multiple therapies to attain good glycemic control levels. 70 If the patient does not respond to the first line agent, a second drug should be added - not substituted since no currently available oral medication appears to be superior when used as monotherapy. For those on insulin who have weight gain, the addition of metformin, acarbose, or the thiazolidinediones may allow the insulin dose to be decreased and may aid in weight loss. Currently, no consensus exists regarding when and how various pharmacological modalities should be started. Clinicians must use their own clinical judgment to determine which therapy is appropriate for a particular patient.
About 30%-40% of patients with type 2 diabetes use insulin to help control their hyperglycemia. Various types of insulin exist (Table 16). For an excellent overview of properly administering insulin, please see the ADA’s consensus statement.71 Potential problems using insulin in type 2 diabetics include hypoglycemia (which may precipitate a coronary event), weight gain (up to 5-10 kg the first year while on insulin), hyperinsulinemia and insulin resistance which may be associated with an increased risk of hypertension, coronary artery disease and stroke (insulin may be atherogenic), and increased resource utilization (more patient visits, more lab tests, more self-glucose monitoring).
The ADA has established standards of care for those with type 2 diabetes which is updated annually.72 These standards emphasize that patients play a central role in diabetes care and that health care professionals must thoroughly train patients in self-management. The standards emphasize diabetes management through dietary modification, physical activity and weight reduction, supplemented as needed by glucose lowering agents and/or insulin.
To decrease symptoms while lowering the risk of chronic complications, the ADA has also established target goals for glucose and HbA1c values (Table 17). To achieve those goals, the ADA recommends that patients consider self-monitoring of their blood glucose (SMBG).4 The frequency depends on the stability of their glucose values, and whether the results will be used to make a change in their treatment regimen. SMBG is recommended for all insulin-treated patients with diabetes; it may be desirable in patients treated with sulfonylureas and in all patients not achieving glycemic goals. In addition, the hemoglobin A1c (HbA1c) provides information about the mean serum glucose level during the past 2-3 months, and is a useful way to monitor glucose control. One formula which allows the HbA1c value to be converted to the mean glucose is: (HbA1c x 33.3) - 84 = average glucose over 2-3 months (mg/dl).
The ADA standards are comprehensive, and require a diabetes flow sheet in each medical record to keep track of the various tasks that should be completed. For a busy clinician, it makes sense to focus on the areas listed in Table 18 during each visit. A simple mnemonic highlighting these issues is to perform a FOCUSed examination: F (feet), O (ocular, eyes), C (cardiovascular), U (urinary tract, renal disease), and S (sensory).
Table 19 highlights the performance guidelines by which these standards of care are measured. It is important to emphasize that no one clinician can provide all of the required care for the elderly person with type 2 diabetes, especially considering the concomitant comorbid conditions. As such, it takes a health care team, which includes the patient and his/her family, the primary care physician, a registered dietician, a certified diabetes educator, an eye specialist, a podiatrist, and other specialists as required.
Table 1. Diagnosis of Diabetes Mellitus.
|Diabetes mellitus can be made by one of these three methods. In the absence of acute metabolic decompensation, the diagnosis should be |
|confirmed on a subsequent day using any of these three methods. |
|Fasting plasma glucose ≥ 126 mg/dl.* |
|Classic symptoms of diabetes with a casual plasma glucose ≥ 200 mg/dl.** |
|75-gram Oral Glucose Tolerance Test - two-hour fasting plasma glucose ≥ 200 mg/dl. |
* fasting is defined as no caloric intake for at least 8 hours
** classic symptoms include polyuria, polydipsia, unexplained weight loss, visual changes; casual means any time of the day without regard to time since the last meal.
Table 2. Major Risk Factors for Developing Type 2 Diabetes.
|Previously identified with prediabetes (impaired glucose intolerance) |
|Age ≥ 45 years |
|First-degree relative with diabetes (parents, siblings) |
|Minority group (African-American, American Indian, Hispanic American/Latino, Asian Americans, Pacific Islanders) |
|Overweight, with a body mass index (BMI) ≥ 25 kg/m2 |
|Physical inactivity |
|History of gestational diabetes or giving birth to a baby weighing more than 9 pounds |
|Hypertension (≥ 140/90 mmHg) |
|HDL cholesterol ≤ 35 mg/dl and/or triglyceride level ≥ 250 mg/dl |
|Polycystic ovary disease |
Table 3. Major Complications of Type 2 Diabetes.
|Acute Complications |
|Diabetic ketoacidosis (rare, except under extreme distress) |
|Hyperglycemic hyperosmolar nonketotic syndrome |
|Hypoglycemia |
|Infections |
|Urinary tract - emphysematous cystitis, acute pyelonephritis, papillary necrosis |
|Influenza |
|Community acquired pneumonia |
|Sinusitis |
|Cholecystitis |
|Cellulitis |
|Genital candidiasis |
|Chronic Complications |
|Macrovascular diseases |
|Accelerated atherosclerosis - coronary artery disease, peripheral arterial occlusive disease, cerebrovascular disease |
|Microvascular diseases |
|Retinopathy |
|Nephropathy |
|Neuropathic conditions |
|Distal symmetric polyneuropathy |
|Autonomic neuropathy |
|Mixed Vascular and Neuropathic Conditions |
|Diabetic foot |
Table 4. Major Modifiable Risk Factors for Coronary Heart Disease in Type 2 Diabetes.
|Risk Factor |ADA Goals |Method |
|Sedentary lifestyle |30 minutes of moderate physical activity on most |Walking, swimming, bicycling, chair exercises, arm |
| |days of the week |exercises* |
|Hypertension |systolic < 130 mmHg |weight reduction |
|(BP ≥ 140/90 mmHg) |diastolic < 80 mmHg |exercise |
| | |antihypertensive |
| | |(ACE inhibitor, ARB, ß-blocker, diuretic) |
|Dyslipidemia |LDL < 100 mg/dl |medical nutrition therapy |
| |HDL > 40 mg/dl |exercise |
| |triglycerides < 150 mg/dl |glucose control |
| | |medication |
| | |(HMG CoA reductase inhibitor, fenofibrate) |
|Cigarette smoking |Cessation |Ask, Advise, Assist |
* prior to writing an exercise prescription, it may be wise to first perform a graded exercise test.
Table 5. Treatment-Based Classification System for the Diabetic Foot.
|Risk Category | | |
| |Symptoms |Treatment |
| | | |
|0 |No pathology - normal monofilament test; no evidence of peripheral |Daily foot exam by the patient or caretaker; foot examination|
| |arterial occlusive disease; no history of ulcer |by the physician 2-3 times each year |
|1 |Neuropathy with an abnormal monofilament test |Same as for category 0, plus protective footwear |
|2 |Neuropathy with abnormal monofilament test and foot deformity |Same as for category 1, plus consider podiatrist consultation|
| | |for custom shoe or prophylactic surgery to correct deformity |
|3 |History of a foot ulcer, but no evidence of peripheral arterial |Same as for category 2, plus more frequent visits to evaluate|
| |occlusive disease |feet and shoes |
|4A |Foot ulcer present, but no evidence of peripheral arterial occlusive |Same as for category 3, plus debridement of ulcer and use of |
| |disease; no evidence of infection |appropriate wound dressings. |
|4B |Plain-film radiographs show joint degeneration suggestive of |Same as for category 3, plus periodic thermometric and |
| |Charcot’s joint formation |radiographic monitoring to assess for joint deterioration |
|5: |Infected ulcer, but no evidence of peripheral arterial occlusive |Debridement, wound probe, plain films, bone scan to rule out |
| |disease |osteomyelitis; antibiotic therapy; hospitalization if |
| | |outpatient treatment is unsuccessful or the infection is |
| | |limb-threatening |
|6 |Evidence of peripheral arterial occlusive disease by abnormal |Same as for category 4A if ulcer is present and same for |
| |ankle-brachial index, transcutaneous oxygen requirement or absolute |category 5 if infection is present, plus consider vascular |
| |toe systolic pressure |surgery consultation if disease is severe (ankle-brachial |
| | |index of less than 0.45) or if the foot fails to heal with |
| | |usual ulcer/infection treatment measures |
Adapted from Armstrong DG, Lavery LA: Diabetic foot ulcers: Prevention, diagnosis and classification. Am Fam Phys 1998; 57:1325-32
Table 6. Exploratory Questions to Ask Patients Who Have Type 2 Diabetes.
|Theme |Questions |Probes |
|Diet |• What do you think would be an ideal diet for a person with |• Are there foods or drinks you think you should stay away from? |
| |diabetes? |Why? |
| |• Are there times when you really can’t or don’t eat the way |• What do you eat and drink then? Why? Do you think that is a |
| |you’re supposed to for your diabetes? Tell me about that. |pretty good choice? Why? |
|Physical Activity |• What types of physical activity do you do, and how often? |• What is keeping you from exercising more frequently? |
|Medications |• Do you always take your (pills or insulin) exactly as you |• Why change it? In what way do you change it? Why change it in |
| |were told to take them, or are there times that you change that|that way? What effect does doing it that way have? |
| |somewhat? |• Have you heard of any dangers or benefits in taking insulin? |
| |• What do you think about taking insulin? Have you ever, or do|What do you think of that? |
| |you think you might ever be asked to take it? What do you | |
| |think about that? | |
|Symptoms |• Can you tell by the way you feel whether your blood glucose |• What does it feel like when it’s (high/low)? How often does |
| |is high or low? |that happen? What brings it on? |
| |• (If distressing symptoms are mentioned:) What do you do when |• Do you ever change what you’re eating or how you’re taking your |
| |that happens?: Is there anything you can do to feel better? |medicine to try to feel better? Tell me about that. |
Adapted from: Hunt LM, Pugh J, Valenzuela M: How patients adapt diabetes self-care recommendations in everyday life. J Fam Pract 1998; 46:207-15
Table 7. The Role of Patient Education in Managing Type 2 Diabetes Mellitus.
|Patients with diabetes should have a thorough knowledge of: |
|the disease and its complications, |
|the importance of good nutrition, physical activity, and medicines, and |
|proper foot care. |
|Education requires a time commitment from both the physician and the patient. The family should be involved in the education and management. |
|Diabetes education classes and support groups are beneficial, Further information about the importance of patient education can be found on |
|the home pages of the: |
|the American Diabetes Association () and |
|the American Association of Diabetes Educators (AADE) (). |
Table 8. The Role of Medical Nutrition Therapy in Managing Type 2 Diabetes Mellitus
Medical Nutrition Therapy (MNT) is integral to total diabetes care and management; it is also one of the most challenging aspects of diabetes care. It is estimated that 80 % of those with Type 2 DM could have good glucose control with diet alone; however, 60% neither understand nor follow their diets! It requires a team effort—the person with diabetes is at the center (most responsible), along with a registered dietician who is knowledgeable and skilled in implementing diabetes MNT. MNT should be individualized – there is no longer one “ADA” diet.
For those with type 2 diabetes, the overall goal of MNT is to assist individuals in making changes in nutrition and exercise habits, leading to improved metabolic control. Goals include near-normal blood glucose, lipid, and blood pressure levels. A reasonable weight should be attained ( the weight an individual health care provider acknowledge as achievable and maintainable, both short and long term, which may not be as the traditionally defined ideal body weight). Further details about MNT can be found by visiting the ADA’s website (), or by reviewing their recently published standards.
Table 9. The Role of Physical Activity in Managing Type 2 Diabetes Mellitus.
The benefits of exercise include diminished glucose, triglycerides, LDL and total cholesterol, blood pressure, increased HDL cholesterol and collateral circulation, and improved self-esteem. However, there are risks, especially if done without caution, including exacerbation of foot or soft tissue injuries, worsening of proliferative retinopathy, development of hypoglycemia, and the onset of cardiovascular event. Before beginning an exercise program, the elderly patient with Type 2 DM should undergo a thorough medical evaluation with appropriate diagnostic studies, including a cardiovascular examination. A graded exercise test should be done if they are about to embark on a moderate to high-intensity exercise program,especially if the had previously been sedentary.
Elderly patients should properly warm-up with a 5-10 minute aerobic activity (e.g. walking)at a low-intensity level, followed by gentle muscle stretching for another 5-10 minutes. Health care providers should be able to write an exercise prescription, which consists of the type of the physical activity (patients should choose ones they find enjoyable), the duration (typically 20-30 minutes), the frequency (most if not all days of the week), intensity (65-85% of their maximum hearth rate), and to progress as tolerated. Afterwards, the should have a proper cool down of 5-10 minutes.
When prescribing physical activity, one needs to take precaution for those exercises which involve the feet (e.g. walking, jogging). The use of silica gel or air midsoles as well as polyester or blend (cotton-polyester) socks to prevent blisters and keep the feet dry, helps to minimize trauma to the feet. Individuals must monitor closely for the development of blisters and other potential damage to their feet, both before and after exercise. A diabetes identification bracelet should be clearly visible when exercising. Proper hydration is essential, especially in hot or cold environments. Moderate weight training using light weights and high repetitions helps maintain and enhance upper body strength.
Table 10. Oral Medications for the Treatment of Type 2 Diabetes Mellitus - 2003.
| | | |Usual Daily Dose |
|Class |Mechanism of Action |Drug | |
| | | | |
|Sulfonylurea |Increases ß-cell insulin secretion, increases|First Generation | |
|[Table 11] |target cell sensitivity |Acetohexamide |500-750 mg |
| | | | |
| | |Chlorpropamide |250-375 mg |
| | | | |
| | |Tolazamide |250-500 mg |
| | | | |
| | |Tolbutamide |1000-2000 mg |
| | | | |
| | |Second Generation | |
| | |Glimepiride (Amaryl) |1-4 mg |
| | | | |
| | |Glipizide (Glucotrol) |10-20 mg |
| | |(Glucotrol XL) |5-20 mg |
| | | | |
| | |Glyburide |5-20 mg |
| | |(Diabeta, Micronase) | |
| | | | |
| | |Glyburide micronized |3-12 mg |
| | |(Glynase) | |
| | | | |
|Biguanide |Suppresses hepatic glucose output; enhances |Metformin |1500-2550 mg |
|[Table 12] |insulin- and non-insulin mediated glucose |(Glucophage) | |
| |uptake | | |
| | |(Glucophage XR) |1500-2000 mg |
| | | | |
|Alpha-Glucosidase Inhibitor |Inhibits intestinal alpha-glucosidase enzymes|Acarbose (Precose) |50-100 mg tid |
|[Table 13] |with resultant reduction in glucose | |(with meals) |
| |absorption - decreases postprandial | | |
| |hyperglycemia; does not affect fasting | | |
| |glucose levels |Miglitol (Glyset) |50-100 mg tid |
| | | |(with meals) |
| | | | |
|Thiazolidinedione |Decreases insulin resistance, |Rosiglitazone |4-8 mg |
|[Table 14] |gluconeogenesis, glucose output and |(Avandia) | |
| |triglyceride synthesis in the liver; | | |
| |increases glucose uptake and use in both |Pioglitazone |15-45 mg |
| |skeletal muscle and adipose tissue |(Actos) | |
| | | | |
|Meglitinide |Although structurally different than |Repaglinide |1-4 mg tid |
|[Table 15] |sulfonylureas, it increases early insulin |(Prandin) |(before meals) |
| |secretion and decreases prandial and | | |
| |post-prandial hyperglycemia | | |
| | |Nateglinide |60-120 mg tid |
| | |(Starlix) |(before meals) |
Table 11. The Use of Sulfonylureas in Managing Type 2 Diabetes Mellitus.
|Sulfonylureas are indicated for the patient with type 2 diabetes who has some remaining pancreatic function and whose plasma glucose can no |
|longer be controlled by diet and exercise. Over 60% of all type 2 diabetics will initially respond to sulfonylureas. Available sulfonylureas |
|include “first-generation” (tolbutamide, acetohexamide, tolazamide, and chlorpropamide) and “second-generation” (glyburide, glipizide, |
|glimepiride). All are equally efficacious and no single drug is clearly superior to another. The advantage of the second-generation |
|sulfonylureas is that they are 100 times more potent on a weight basis than the first-generation, but are not necessarily more effective. |
|Factors that may predict a favorable response to sulfonylureas include diagnosis within the past 5 years, age > 40 at diagnosis, obesity |
|(actual weight between 110 - 160% of ideal body weight), poor glycemic control with diet and exercise alone, have never required insulin or |
|are controlled on < 40 U/day, and fasting blood glucose < 200 mg/dl. |
| |
|Sulfonylureas should be taken 30 min before breakfast for maximum absorption. They are highly bound to albumin and are displaced by other |
|highly bound drugs, thus producing hypoglycemia. Potential side effects include hypoglycemia (most common), skin conditions (3% - pruritus, |
|rash, Stevens-Johnson syndrome, erythema nodosum, erythema multiforme, exfoliative dermatitis, purpura, photosensitivity), and |
|gastrointestinal symptoms (2-3% - nausea, vomiting, heartburn, abnormal liver function tests, hepatitis, cholestatic jaundice). Sulfonylureas|
|interact with other drugs such as trimethoprim, cimetidine, alcohol, and anticoagulants, all which increase the risk for hypoglycemia. |
| |
|Of those who initially respond to sulfonylureas, 5-20% will have secondary failure, mainly due to reluctance to follow a prescribed diet and |
|exercise regimen. Within 5 years after starting treatment, about half of type 2 diabetics will eventually need other medicines for control of|
|hyperglycemia. Treatment with second-generation sulfonylurea agents for patients with type 2 diabetes following onset of secondary failure to|
|first-generation sulfonylurea drugs achieves no better metabolic control than treatment with first-generation agents. |
Table 12. The Use of Metformin in the Management of Type 2 Diabetes Mellitus.
|Metformin, a biguanide, acts by directly decreasing hepatic glucose output and by increasing peripheral glucose utilization by improving |
|glucose transport across the cell membrane and increasing the number of glucose transporters in skeletal muscle. The patient must have insulin|
|for it to be effective (thus, not indicated in type 1 diabetics). Advantages to metformin are that it is effective in lowering fasting |
|glucose, it usually does not cause weight gain, and it has a favorable action on lipids. Although effective in all type 2 diabetics, it |
|appears to be most effective in those who are obese. Metformin in combination with sulfonylureas improved glycemic control in adults |
|refractory to sulfonylureas alone; the combination therapy improves glucose uptake. It is best used in otherwise healthy individuals under |
|the age of 80 years. |
| |
|The initial dose should be 500-850 mg once daily, and slowly increased every 4-6 weeks as needed for glucose control up to 2550 mg per day in |
|three divided doses. Metformin should be taken with meals or soon after a meal to decrease the possible gastrointestinal side effects. Side |
|effects are usually self-limited and can be avoided if metformin is started at an initial low dose and increased gradually. Potential adverse|
|effects include decreased appetite (anorexia and nausea, which results in weight loss), a metallic taste, diarrhea (5%), abdominal discomfort |
|( 1.5 mg/dl in men, > 1.4 mg/dl in |
|women); liver disease or those with a history of alcohol abuse; history of lactic acidosis; cardiac or respiratory insufficiency likely to |
|cause central hypoxia, including congestive heart failure; age over 80 years (unless creatinine is normal); hospitalization; sepsis; and |
|within 48 hours prior to and after procedures using IV radiographic contrast agents or general anesthesia. |
Table 13. The Use of Alpha-Glucosidase Inhibitors in the Management of Type 2 Diabetes Mellitus.
|Acarbose and miglitol are reversible inhibitors of alpha-glucosidases in the brush border of the small intestine. By delaying glucose |
|absorption, they reduce postprandial serum glucose and insulin responses and subsequently decrease postprandial hyperglycemia. They usually |
|do not affect the fasting serum glucose, but when used in combination with sulfonylurea or insulin, may increase the risk. If hypoglycemia |
|does occur, glucose tablets or liquids or glucagon injection should be used (complex carbohydrates are blocked). They are not that effective |
|when used as monotherapy. Although there are no published studies comparing acarbose with miglitol, results of placebo-controlled trials |
|suggest that their effects on HbA1c and one-hour postprandial glucose concentrations are similar. |
| |
|The side effects are quite annoying and occur in 37-97% of patients (depending on dosage). Gastrointestinal side effects are due to the |
|undigested sugars that are metabolized in the large intestine and include flatulence, cramps, abdominal distension, and diarrhea - these |
|usually diminish over time. These drugs also can interfere with iron absorption with the development of anemia. Caution should be used in |
|those with renal dysfunction (creatinine > 2.0), and their use is contraindicated in those with inflammatory bowel disease and other diseases |
|of the large intestine. Acarbose has been associated with hepatic toxicity; liver function tests should be checked every 3 months. Miglitol |
|has had no reported hepatic toxicity and there are no manufacturer recommendations for periodic liver function tests. Both drugs should be |
|started at a dosage of 25 mg tid (at the first bite of each meal), and slowly increased as needed for glycemic control at 4-8 week intervals |
|up to 100 mg tid. |
Table 14. The Use of Thiazolidinediones in the Management of Type 2 Diabetes Mellitus.
|There are currently two thiazolidinediones (glitazones) available in the U.S. - rosiglitazone and pioglitazone. These agents work by |
|stimulating the peroxisome proliferator-activated receptor-gamma (PPAR-gamma). These receptors are found in fat, skeletal muscle, and liver. |
|They control glucose production, transport, and utilization. Stimulation of PPAR-gamma increases insulin sensitivity (and thus decreases |
|insulin resistance). |
| |
|These two drugs are well tolerated; known side effects include a mild increase in headaches, mild anemia, diarrhea and edema. They may |
|diminish the effectiveness of oral contraceptives. There have been no reported cases of drug-related jaundice or liver failure in any of the |
|clinical trials of these two drugs. However, although there was no evidence of liver toxicity with these two agents, the FDA still recommends|
|that these two agents carry a label warning about potential liver problems. In addition, the FDA recommends checking baseline liver function |
|tests (ALT), and repeat ALT every two months during the first year of therapy. Avoid these drugs if the ALT is > 2.5 times the upper limit of |
|normal. Both drugs have been approved for monotherapy or in combination with metformin, sulfonylureas, or insulin. These drugs should be |
|used with caution in those with class III or IV congestive heart failure. |
Table 15. The Use of Meglitinides in the Management of Type 2 Diabetes Mellitus.
|The meglitinides (repaglinide and nateglinide) augment early insulin response and decrease excess prandial and postprandial glucose |
|elevations. They are chemically different from the sulfonylurea class, but their action is similar - they stimulate the pancreas to secrete |
|insulin. They have a rapid onset (15 minutes) and short duration (< 4 hours). They can be used as monotherapy, or in combination with |
|metformin or troglitazone. Their use can result in hypoglycemia, but less often than with sulfonylureas. Otherwise, they appear to have very|
|little side effects. Use cautiously in those with diminished hepatic function. It is too early to determine the exact role of this class, |
|but it does appear effective for those who skip meals or who don’t eat “regularly.” |
Table 16. Commonly Prescribed Insulin Products.
|Forms of Insulin |Onset |Peak |Duration |
|Short Acting | | | |
| Regular (Humilin R, Novolin R) |30 - 60 min |1 - 2 hr |5 - 12 hr |
| Rapid Acting |10 - 30 min |30 - 60 min |3 - 5 hr |
|Insulin aspart (Novolog) | | | |
|Insulin lispro (Humalog) | | | |
|Intermediate-Acting |1 - 2 hr |4 - 8 hr |10 - 20 hr |
|NPH (Humilin N, Novolin N) | | | |
|Lente (Humilin L, Novolin L) | | | |
|Long-Acting | | | |
|Ultralente (Humulin U) |2 - 4 hrs |8 - 20 hrs |16 - 24 hrs |
|Glargine (Lantus) |1 - 2 hrs |no peak |24 hrs |
Table 17. Target Glucose Goals as Established by the ADA.72
|Biochemical Index |Normal |Diabetic Goal |Action Suggested |
| | | | |
|Pre-prandial glucose (mg/dl) |< 110 |80 - 120 |< 80 or > 140 |
| | | | |
|Post-prandial glucose (mg/dl) |< 140 |< 180 |< 80 or > 140 |
| | | | |
|Bedtime glucose (mg/dl) |< 120 |100 - 140 |< 100 or > 160 |
| | | | |
|Hemoglobin A1c (%) |< 6.0 |< 7.0 |> 8.0 |
Table 18. Areas of Focus While Examining a Patient with Type 2 Diabetes.
|Assess for cardiovascular risks - family history of premature coronary heart disease, use of tobacco, physical activity, weight and blood |
|pressure measurements, symptoms suggestive of coronary heart disease, use of prophylactic aspirin, and annual lipid panel to assess for |
|dyslipidemia. |
|Assess for diabetic renal disease - annually screen for microalbuminuria and serum creatinine, and consider instituting ACE inhibitor or ARB |
|therapy for prevention. |
|Assess for diabetic eye disease - ask about visual problems, and ensure an ophthalmologist or optometrist sees them each year for a dilated |
|and comprehensive eye exam. |
|Assess for peripheral vascular disease - visually inspect the patient’s feet, with socks off, and providing specific patient education about |
|potential diabetic foot problems. |
|Monitor glycemic control - review the results of the patient’s self-monitoring of blood glucose (SMBG) and the glycated hemoglobin (HbA1c). |
|Provide patient education regarding medical nutrition, physical activity, and self-management of diabetes, |
|Inquire about psychosocial issues such as their quality of life, family function, depressive symptoms, and issues that may affect their |
|compliance with their treatment regimen. |
Table 19. Performance Measure Guidelines.72
|The following are performance measure guidelines for those with type 2 diabetes, as established by the Standard of Medical Care by the |
|American Diabetes Association. |
|HgbA1c measurement four times a year, or 2 times per year in patients who are meeting treatment goals and have stable glycemic control; |
|Most recent HgbA1c value of < 7% (goal); |
|Annual lipid analysis unless values are normal, and then every 2 years; |
|Most recent LDL < 100 mg/dl, triglycerides < 200 mg/dl, and HDL > 45 mg/dl in men and > 55 mg/dl in women; |
|Annual test for microalbuminuria (spot collection for albumin-to-creatinine ratio, 24 hour urine collection, or timed collection); |
|Blood pressure measurement at each visit with a goal of < 130/85 mm Hg; |
|Use of an ACE-inhibitor or ARB for those patients with microalbuminuria and meeting ADA criteria (definite in hypertensive patients, less |
|well-defined in those with normal blood pressure); |
|Annual influenza vaccination (unless contraindicated); |
|Pneumococcal vaccination as per guidelines - for those aged 65 years and older, a 2nd vaccination should be given if they have received the |
|vaccine greater than 5 years previously and were aged less than 65 years at the time of primary vaccination. Elderly persons with unknown |
|vaccination status should have received at least one dose of the vaccine; |
|Annual eye examination by an optometrist or ophthalmologist; |
|Annual foot examination unless peripheral neuropathy is present - then visual examination at each visit; |
|Evidence of patient education performed at least annually; |
|Office visit frequency - at least quarterly, unless the patient has well-controlled type 2 diabetes, at which they should be seen at least |
|semi-annually. For this assessment, two or more visits annually will be used as the standard. |
Resources for the Health Care Provider and Patients with Type 2 Diabetes
The following are internet addresses of organizations that will allow you and your patients to keep up with the latest information on diabetes management.
|Organization |Internet Address |
|• American Association of Diabetes Educators |• |
|• American Diabetes Association |• |
|• Centers for Disease Control and Prevention |• |
|• Department of Veterans Affairs |• |
|• Juvenile Diabetes Foundation International |• |
|• National Institute of Diabetes and Digestive and Kidney Disease of the |• |
|National Institutes of Health | |
Test Your Knowledge
1. All of the following are common features of type 2 diabetes mellitus EXCEPT:
A. Hyperglycemia
B. Diabetic ketoacidosis
C. Hypertension
D. Dyslipidemia
E. Insulin resistance
Answer: B
Diabetic ketoacidosis, due to an absolute deficiency of insulin, is a common feature of type 1 diabetes mellitus, but not type 2. The hallmark of type 2 diabetes mellitus is insulin resistance, which results in hyperglycemia and is often accompanied by hypertension and dyslipidemia.
2. Which of the following is the preferred method for diagnosing diabetes mellitus?
A. Two-hour glucose tolerance test
B. Three-hour glucose tolerance test
C. Glycolated hemoglobin (HbA1c)
D. Fasting glucose
E. Random glucose
Answer: D
Because of its simplicity and low cost, a fasting glucose greater than 125 mg/dl is the preferred method for diagnosing diabetes mellitus. The other two methods recommended by the American Diabetes Association includes a 75-gram two-hour glucose tolerance test (two-hour glucose level greater than 199 mg/dl) and a random glucose greater than 199 mg/dl accompanied by the classic symptoms of polyuria, polydipsia, unexplained weight loss, and visual changes. With each of these three methods, the diagnosis should be confirmed on a subsequent day using any of these methods. The three-hour glucose tolerance test is used to confirm gestational diabetes. Lack of national laboratory standardization has prevented the glycolated hemoglobin value from becoming a recommended test for diagnosis.
3. All of the following are false statements about the types of diabetes mellitus EXCEPT:
A. Individuals with type 2 diabetes almost always require insulin injections for survival.
B. The hallmark of type 1 diabetes is insulin resistance.
C. The major chronic complications are different in type 1 diabetes mellitus compared to type 2.
D. Type 1 is the most common type of diabetes mellitus in the United States.
E. Coronary artery disease is the most common cause of death in those with type 2 diabetes.
Answer: E
Type 2 diabetes, due to insulin resistance, is by far and away the most common type of diabetes found in the United States, accounting for over 90% of all cases. The hallmark of type 2 diabetes is insulin resistance. Although insulin injections may be used in those with type 2 diabetes to help manage their glucose levels, it is not required for survival. In contrast, those with type 1 diabetes, marked by absolute insulin deficiency, require insulin to live. Since hyperglycemia is a common manifestation of both types, the chronic complications are similar. Because of the often accompanying comorbid conditions such as hypertension and dyslipidemia seen in those with type 2 diabetes, coronary artery disease is the most common cause of death.
4. Which of the following individuals is at risk for developing diabetes mellitus?
A. A 38 year-old woman who is sedentary and weighs 276 pounds (BMI 50 kg/m2)
B. A 62 year-old Latino man with hypertension.
C. A 45 year-old woman who in the past gave birth to a baby weighing more than 9 pounds.
D. A 55 year-old African-American man who has a sister with diabetes.
E. All of the above.
Answer: E
All of the individuals listed are at increased risk for developing diabetes mellitus, and, according to the American Diabetes Association, should undergo routine screening for diabetes.
5. All of the following are potential complications of type 2 diabetes mellitus EXCEPT:
A. End-stage renal disease.
B. Infertility.
C. Blindness.
D. Depression.
E. Lower extremity amputation.
Answer: B
Diabetes mellitus is the leading cause of new blindness in people age 20-74 years (retinopathy), the leading cause of end-stage renal disease (nephropathy), and the most frequent cause of non-traumatic lower limp amputations (neuropathy and peripheral vascular disease). It is also a major risk factor for coronary artery disease and stroke. Comorbid conditions such as hypertension, hyperlipidemia, disability, depression and cognitive impairment are seen more commonly in those with DM. Although women with type 1 diabetes mellitus are at risk for having a complicated pregnancy, there is no increased risk of infertility.
6. All of the following are true statements about coronary artery disease in diabetes EXCEPT:
A. Almost all individuals with diabetes suffering from a myocardial infarction will have typical angina or chest pain.
B. Women with diabetes have the same risk, perhaps even greater risk, than men for developing diabetes.
C. Atherosclerosis is typically advanced, involving more coronary vessels in a diffuse manner.
D. Controlling comorbid conditions such as hypertension and dyslipidemia is essential in preventing coronary artery disease in those with diabetes.
E. Aspirin should be considered as preventive therapy in those who have type 2 diabetes.
Answer: A
Coronary artery disease is the leading cause of death in those with type 2 diabetes, accounting for up to 70% of the mortality. All statements are true except for “a.” Because of the often-accompanying autonomic neuropathy, silent ischemia is more common. Instead of typical angina symptoms, the elderly having a myocardial infarction will often complain of increased dyspnea or fatigue. A high index of suspicion is needed in these individuals to prevent further complications.
7. All of the following are true statements about the impact of diabetes mellitus on the eye EXCEPT:
A. Diabetes affects every part of the eye.
B. Eye pain is a common symptom of early proliferative retinopathy.
C. All patients with type 2 diabetes mellitus should undergo a yearly eye exam by an ophthalmologist or optometrist.
D. Prevention of diabetic retinopathy is possible through tight blood pressure and glucose control.
E. Once proliferative retinopathy develops, the risk of severe visual loss within two years I up to 50% unless laser photocoagulation is performed.
Answer: B
All of the above are true except for “B” - the early stages of diabetic retinopathy are often asymptomatic, and eye pain is rare. Because of this, it is important for all patients with type 2 diabetes to undergo an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of initial diagnosis, and yearly thereafter.
8. All of the following are true statements about diabetic nephropathy EXCEPT:
A. Diabetic nephropathy is characterized by albuminuria, hypertension, and progressive renal failure.
B. Annual screening for microalbuminuria is important to detect early nephropathy.
C. Prevention of diabetic nephropathy is possible through tight blood pressure and glucose control.
D. Hematuria is a common manifestation of early diabetic nephropathy.
E. The use of angiotensin-converting-enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) slow the rate of progression of nephropathy.
Answer: D
All of the following are true except “D” – in the early stages diabetic nephropathy is asymptomatic. Hematuria is rarely a manifestation of nephropathy and other causes should be sought.
9. All of the following are signs and symptoms of distal symmetric polyneuropathy EXCEPT:
A. Increased vibratory sensation.
B. Numbness.
C. Severe pain.
D. Paresthesias.
E. Decreased light touch.
Answer: A
Distal symmetric polyneuropathy is the most common form of diabetic neuropathy. It typically involving the lower extremities and is a major cause of lower extremity amputations. All of the above are signs and symptoms except for “A” – diabetic neuropathy results in a decreased vibratory sensation.
10. All of the following are risk factors for a patient with a diabetic foot to undergo an amputation Except:
A. Peripheral neuropathy with loss of protective sensation.
B. Altered biomechanics through foot deformities and callus formation.
C. Peripheral arterial occlusive disease.
D. Autonomic neuropathy causing decreased sweating and dry, fissured skin.
E. Good glycemic control.
Answer: E
Complications of the diabetic foot are the most common cause of nontraumatic lower extremity amputations (35-40,000 occur each year) and the most frequent reason for hospitalization in patients with type 2 diabetes. All of the factors listed increase the risk for amputation, except for “E” - good glycemic control decreases the risk for diabetic foot and its complications.
11. Which of the following statements about the diabetic foot is true?
A. Good foot care can prevent most amputations in those with diabetes.
B. Patients should examine their feet daily.
C. Shoes should be inspected for inadequate support or improper fit.
D. Ulcerations should be aggressively treated.
E. All of the above are true.
Answer: E
Prevention of ulcer formation requires meticulous attention to foot care and proper management of minor foot injuries. All of the statements listed are true.
12. All of the following are major goals for managing diabetes Except
A. Eliminating the symptoms of diabetes.
B. Improving the sense of well-being
C. Minimizing the cost of care.
D. Improving the quality of life in those with diabetes.
E. Preventing both acute and chronic complications.
]Answer: C
Although controlling the cost of care is important, it is not one of the major goals in managing diabetes. All of the others listed are major goals.
13. All of the following statements are true regarding diabetes management Except
A. Patient self-management is an important aspect of therapy.
B. One standard formula for management exists that is best for all patients.
C. Patients should be empowered to make informed decisions about their own care.
D. Patients should have the knowledge and skills to make ongoing decisions.
E. Open dialogue between the patient and provider is important for good glucose control.
Answer: B
The key to good control of the diabetes involves individualization of therapy - there are no “cookbook” formulas for care. Patient self-management is key, and involves empowering the patient to make informed decisions about their own care. To do this, patients must have the knowledge and skills to make these decisions. Open dialogue between the patient and provider is an important aspect of managing diabetes.
14. The foundation for control of type 2 diabetes includes all of the following Except
A. Patient education.
B. Medical nutrition therapy.
C. Physical activity.
D. A simple management plan.
E. Insulin for those with a glucose over 200 mg/dl.
Answer: E
The staged approach in the management of diabetes includes: 1) patient education, medical nutrition therapy, and physical activity, 2) oral medications, and 3) insulin for those who fail these treatments. Try to keep it simple. The foundation for managing type 2 diabetes includes patient education, medical nutrition therapy, and physical activity. When these don’t fully result in good glucose control, oral medications should be tried. Insulin is normally reserved for those who failed these treatments.
15. Which one of the following class of oral medications for type 2 diabetes is superior to the others and should be considered as the first drug of choice?
A. Sulfonylureas.
B. Metformin.
C. Thiazolidinediones.
D. Meglitinides.
E. None of the above.
Answer: E
No currently available oral medication for type 2 diabetes appears to be superior when used as monotherapy. Currently, no consensus exists regarding when and how various pharmacological modalities should be started. Clinicians must use their own clinical judgment to determine which therapy is appropriate for a particular patient.
16. All of the following statements are true regarding the oral medication treatment for type 2 diabetes EXCEPT:
A. The majority of individuals with type 2 diabetes can be controlled with just one oral medication.
B. Metformin suppresses hepatic glucose output and appears to be effective in obese patients.
C. The most common side effect of sulfonlyureas is hypoglycemia.
D. Thiazolidinediones are effective because they decrease insulin resistance but should be avoided in those with Class III and IV congestive heart failure.
E. Meglitinides have a rapid onset of action and short duration of action, making it preferable for those who skip meals or don’t eat regularly.
Answer: A
These medicines can be used in combination to better control diabetes. The majority of patients eventually need multiple therapies to attain good glycemic control levels. If the patient does not respond to the first line agent, a second drug should be added - not substituted since no currently available oral medication appears to be superior when used as monotherapy.
17. All of the following are potential problems using insulin in those with type 2 diabetes EXCEPT:
A. Hypoglycemia.
B. Weight gain.
C. Infection at the injection site.
D. Hyperinsulinemia.
E. Increased cost.
Answer: C
Potential problems using insulin in type 2 diabetics include hypoglycemia (which may precipitate a coronary event), weight gain (up to 5-10 kg the first year while on insulin), hyperinsulinemia and insulin resistance which may be associated with an increased risk of hypertension, coronary artery disease and stroke (insulin may be atherogenic), and increased resource utilization (more patient visits, more lab tests, more self-glucose monitoring). Infections at the injection site are extremely rare.
18. All of the following are target goals established by the American Diabetes Association for those with type 2 diabetes EXCEPT:
A. Pre-prandial glucose between 80 and 120 mg/dl.
B. Post-prandial glucose less than 180 mg/dl.
C. Bedtime glucose between 100 and 140 mg/dl.
D. Hemoglobin A1c less than 9.0%.
E. Systolic blood pressure less than 130 mmHg and diastolic blood pressure less than 80 mmHg.
Answer: D
All of the choices listed are target goals established by the American Diabetes Association except for “D” - the ADA recommends that the hemoglobin A1c should be less than 7%.
19. All of the following are areas of focus while examining a patient with type 2 diabetes EXCEPT:
A. Assess and manage cardiovascular risks.
B. A thorough eye examination every four years.
C. Visually inspect the patient’s feet, with socks off, and provide specific patient education about potential diabetic foot problems.
D. Provide patient education regarding medical nutrition, physical activity, and self-management of diabetes.
E. Inquire about psychosocial issues such as quality of life, family function, depressive symptoms, and issues that may affect compliance with their treatment regimen.
Answer: B
All of the above listed areas are important to assess. However, a thorough eye examination performed by an ophthalmologist or optometrist should be performed annually.
20. All of the following are true regarding the management of type 2 diabetes EXCEPT:
A. The American Diabetes Association has established standards which are updated annually.
B. Self-monitoring of blood glucose (SMBG) is recommended for all insulin-treated patients with diabetes, and is desirable for those not achieving glycemic controls.
C. A hemoglobin A1c provides important information about the mean serum glucose and should be done monthly.
D. Use of a diabetes flow sheet assists the clinician in managing the patient with diabetes.
E. A team approach is needed for proper diabetes management.
Answer: B
The hemoglobin A1c provides important information about the mean serum glucose level during the past 2-3 months, and is a useful way to monitor glucose control. It should be performed every 3-6 months, depending upon how well glycemic control is achieved. All of the other statements are true regarding the management of type 2 diabetes.
References
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Challenging Sociocultural Health Disparities:
A Collaborative Interdisciplinary Model Podogeriatric Curriculum Plan
Podogeriatric Module Evaluation
Chapter VII: Type 2 Diabetes Mellitus in the Elderly
Name:___________________________________________Date:______________________
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Status: PGY-11 PGY-22 PGY-33 Faculty Other__________________________
Discipline: Allopathic Osteopathic Podiatric Medicine Podiatric Surgery
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By way of clarification for PODIATRY RESIDENTS:
[1] PGY 1=PPMR, POR, RPR
2 PGY 2=PSR12 (Preceded by one of the above)
2 PGY 2=PSR24 (If preceded by 1 year)
3 PGY 3=PSR24 (If preceded by 2 years)
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A fasting glucose ≥ 126 mg/dl is abnormal
The diagnosis of diabetes can be made in 1 of 3 ways.
Type 2 is the most common type of DM found in the elderly.
Increased thirst and urination, decreased weight, and visual changes are common diabetic symptoms.
Nearly 1 in 5 elderly patients will have diabetes.
Minorities are at increased risk for diabetes and its complications.
Influenza and pneumococcal vaccinations are important.
Coronary artery disease is the #1 killer in those with type 2 DM.
Yearly eye exams are important!
Control cardiac risk factors in those with type 2 DM!
Good glucose and blood pressure control can lower the risk of retinopathy, nephropathy and neuropathy.
Good foot care can prevent most amputations in diabetics.
Major goals include eliminating symptoms, improving sense of well-being and quality of life, and preventing complications.
Patient self-management is key!
Standards of medical care exist for those with type 2 DM.
A team approach is needed for proper diabetes management.
Figure 1. Diabetic foot. Notice the vascular changes and gangrene.
Figure 2. Peripheral arterial occlusive disease in a patient with diabetes mellitus.
Figure 3. Feet of a diabetic patient. Notice the missing toes and the gangrenous second digit of the left foot, and the callous formation of the right foot.
Figure 4. Diabetic foot. Notice the dry skin that is commonly found due to autonomic neuropathy, and the dry gangrenous toe.
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