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www.diabetes.org 1-800-DIABETES

1

Diabetes in the Latino Population:A Case-based Approach to Optimal Management


2

Upon completion, attendees should be able to:• List the medical, social, and economic ways in which diabetes

impacts the Latino population;• Describe strategies to overcome barriers to improving diabetes

outcomes in the Latino population;• Utilize current standards of care for the detection of diabetes and

the monitoring of complications of diabetes in the Latino patient;• Assess current treatment options to maximize glycemic control

in order to minimize the complications of diabetes in the Latino population;

• Access appropriate national and local resources available to assist in caring for the Latino patient with diabetes.

Learner Objectives


3

Why are We Concerned about Diabetes?

Every 24 hours...

• 3,600 new cases of diabetes are diagnosed• 580 people die of diabetes-related complications• 225 people have a diabetes-related amputation• 120 people with diabetes progress to end-stage renal disease• 55 people with diabetes become blind


4

Why Are We Concerned about Diabetes Among Latinos?

• Prevalence of type 2 diabetes is 1.5 times higher than in non-Hispanic whites.

• 2 million Latinos 20 years or older have diabetes.

• Latinos have a greater number of risk factors for diabetes.

• Increased prevalence of retinopathy, nephropathy, and peripheral vascular disease in Mexican Americans.

National Diabetes Information Clearinghouse, NIDDK 2002


5

A Constellation of Complications

GastropathGastropathyy

Autonomic Autonomic NeuropathyNeuropathy

Renal Renal DiseaseDisease

Peripheral Peripheral NeuropathyNeuropathy

Retinopathy/ Retinopathy/ Macular Macular

EdemaEdema

HypertensionHypertensionCardiovascular Cardiovascular

DiseaseDisease

DyslipidemiaDyslipidemia

Peripheral Peripheral

Vascular Vascular DiseaseDisease

Erectile Erectile DysfunctionDysfunction

DiabetesDiabetes


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Diabetes Care in the U.S. Improvements NeededGoal Percent at Goal

A1C < 7.0 43% (18% at > 9.5)

LDL < 100 11% (58% at > 130)

BP < 140/90(ADA goal is 130/80)

66%

Dilated Eye Exam 63%

Foot Exam 55%

NHANES III and Behavioral Risk Factors Surveillance Study


7

Projected Increase in the US Population with Diagnosed Diabetes by 2020 by Ethnicity

0

20

40

60

80

100

120

Non Latino Whites Non Latino Blacks Latinos

Proj

ecte

d In

crea

se (%

)

Adapted from American Diabetes Association. Diabetes Care. 2003;26:917-932


8

Geographic Distribution of Latino Americans

Puerto Rican: 1.6 million

Cuban American: 130,000

Mexican American1 million

Puerto Rican: 500,000Cuban American:

830,000

Mexican American8.4 million

Adapted from U.S. Census Bureau, Current Population Survey, March 2000.

Mexican American5 million

Mexican American1.1 million


9

Clinical Discussion• Prevalence of diabetes• Prevalence of complications• Pathophysiology

- obesity- insulin resistance- metabolic syndrome

• Treatment- nonpharmacologic- medications


10

Prevalence of Type 2 Diabetes

10

8

6

4

2

0

Age

-adj

uste

d pr

eval

ence

(%

)

Non-Latino African Mexican Non-Latino African Mexican White American American White American American

Harris MI et al. Diabetes Care. 1998;21:518-524.

Previously undiagnosed diabetes Physician-diagnosed diabetes


11

Trends in Diabetes Prevalence (1990-1998)

30-39 40-49 50-59 Non-Latino African Mexican White American American

50

40

30

20

10

0

80

70

60

50

40

30

20

10

0

• Prevalence of type 2 diabetes is 2-3 times higher in Latinos than Caucasians

• Highly correlated with prevalence of obesity (r = 0.64, P < 0.001)

% I

n cre

ase

% I

ncre

ase

Age (years) Ethnicity

American Diabetes Association. Facts and Figures. Mokdad et al. Diabetes Care. 2000;23:1278.


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Complications of type 2 diabetes in Minorities

• Disparate and Disproportionate prevalence of longterm complications of type 2 diabetes in minorities vs Whites– lower leg amputations 2-4x

– retinopathy and blindness 2-4x

– stroke 2x

– ESRD 4-6x

Caballero AE. Diabetes in minority populations.

In: Joslin’s Diabetes Mellitus. LW & W; 2005. 14th Ed. p 505-524


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Klein et al. In: Harris et al, eds. Diabetes in America, 2nd ed. 1995. Reiber et al. In: Harris et al, eds. Diabetes in America, 2nd ed. 1995. USRDS. Am J Kidney Dis. 1994;24:879.

Caucasian African-American Mexican-American

Prevalence of Complications in Type 2 Diabetes

40–59 years 60 years

0

20

40

Pat

ien

ts (

%)

New Cases of End-Stage Renal Disease

100

200

300

(per

mil

lion

/pop

ula

tion

)

0

Prevalence of Retinopathy in Type 2 Diabetes

Age Range of Amputations per 10,000 DM patients

0

40

80

120

160

200


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• Latinos- more insulin resistance/diabetes but no higher rates for CAD when compared to Whites

• A true Hispanic paradox?• Data are not conclusive - some studies may be

influenced by changes in the population due to migration factors

Lerman-Garber I, Villa A.R, Caballero AE.. Diabetes and Cardiovascular Disease. Is there a true Hispanic Paradox? Rev Invest Clinic. 2004; 56 (3): 282-296 Available at: www.imbiomed.com.mx

Cardiovascular Disease in Latinos with Diabetes


15Hamman RF et al. Diabetes. 1989; 38;1231. Hamman RF et al. Diabetes Care. 1991;14(suppl 3):655.

No Difference In Complications When Good Control Is Achieved

San Luis Valley Study Caucasian and Latino (n=279)

- Similar glucose control in both study groups

- Similar severity of retinopathy, nephropathy and diabetic neuropathy


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Normal Normal -cell -cell functionfunction

CompensatoryCompensatoryhyperinsulinemiahyperinsulinemia

NormoglycemiaNormoglycemia

Relative insulin deficiencyRelative insulin deficiency

HyperglycemiaHyperglycemia

Type 2 diabetesType 2 diabetes

Abnormal Abnormal -cell -cell functionfunction

Diabetes: Dual ImpairmentInsulin Resistance and Impaired b-Cell Function

InsulinInsulinresistanceresistance


17

Insulin Resistance

• Genetic• Acquired

Central obesity Medications

• In 80-90% of type 2 patients• Clusters with metabolic disease syndrome• Associated with increased macrovascular disease


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Increased Visceral Fat

InsulinResistance

Endothelial Dysfunction

Modified from Caballero AE. Current Diabetes Reports 2004; 4: 237- 246

Visceral Fat, Insulin Resistance and Endothelial Dysfunction

Cytokines, SubstratesHormones

HyperglycemiaHypertensionDyslipidemia

IL1, IL6, TNF- , FFA,, PAI-1, RAS,

leptin, resistin Adiponectin

GenesGenesGenesGenes


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Insulin Sensitivity in Healthy Subjects in Various Ethnic Groups

0

1

2

3

4

5

6

7

NH White African Am Asian Am Mexican AmN=34 N=9N=9 N=18 N=16

Insu

lin

Sen

siti

vity

Ind

ex

(m

ol•

L-1•

m-2•

min

-1•

pmol

-1•

L-1)†

*P =0.0023 vs. Caucasians. †Data are geometric means. Adapted from: Chiu KC, et al. Diabetes Care. 2000;23(9):1353-1358.

**** **


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Prevalence of the Insulin Resistance Syndrome in the US Population

0

5

10

15

20

25

30

35

40

Men Women

White

African American

Mexican American

Other

*Age adjusted ≥ 20 years of age

Pre

vale

nce

(% o

f ad

ults

)

Ford ES et al. JAMA. 2002;287:356-359


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Progressive Nature of Type 2 Diabetes Progressive Nature of Type 2 Diabetes

Endogenous InsulinEndogenous Insulin

Fasting Blood Glucose

Fasting Blood Glucose

Postprandial Blood Glucose

Postprandial Blood Glucose

Normal Blood Glucose

Normal Blood Glucose

Normal Normal

YearsYears

IGTIGT DiabetesDiabetes

Avg Dx

9-12 yrs*

Avg Dx

9-12 yrs*

Insulin ResistanceInsulin Resistance


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UKPDS: Glucose Control Study Results

Change in risk P value

Any diabetes-related endpoint 12% 0.029 Diabetes-related deaths 10% NSMyocardial infarction 16% 0.052Microvascular disease 25% 0.0099Stroke 14% NS

Adapted from UKPDS Group. Lancet. 1998; 352:837-853.

Intensive Blood- Glucose Control


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Effect of Each 1% Rise in A1C on Risk of Developing Complications

Incidence of retinopathy

Progression of retinopathy

Progression to PDR

Visual loss

Proteinuria

Amputation

Ischemic heart death

0.5 1 1.5 2 2.5

Risk Ratio and 95% CIKlein. Diabetes Care 18:258-268, 1995

10-Year follow-up in older-onset patients


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Why Aren’t Patients Achieving Blood Glucose Goals?

• Physicians not setting appropriate glycemic targets• Type 2 diabetes is progressive - what works now

may not work in the future• Type of medications used and/or doses not

appropriate• Insulin therapy only used as a “threat”


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American Diabetes Association

Standards of Care

Clinical Practice Recommendations 2004. Diabetes Care, 27(Suppl1):S15-36.


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Diagnosing Diabetes

Fasting Plasma Casual Plasma Oral Glucose Test Glucose (FPG)* Glucose * Tolerance Test*

(Preferred Test) Stage

Diabetes FPG >126 mg/dl Casual plasma Two-hour plasma glucose >200 mg/dl glucose (2hPG)

(plus symptoms >200 mg/dl Impaired Impaired Fasting Impaired Glucose Glucose Glucose (IFG)=FPG Tolerance (IGT) = Homeostasis >100 and <126 mg/dl 2hPG >140 and

<200 mg/dl

Normal FPG <100 mg/dl 2hPG <140 mg/dl

*In the absence of unequivocal hyperglycemia, these need to be repeated on the second day


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Goals for Glycemic Control

A1C* < 7.0% 43% achieve goal

Pre- Prandial glucose 90-130 mg/dl

Postprandial plasma glucose

< 180 mg/dl

*For non-pregnant individuals

Diabetes Care, 27: Supp.1.S19, 2004


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Goals for Blood Pressure, Lipids and Microalbumin

Blood Pressure <130/80mmHg 66% achieve goal

Lipids (mg/dl)LDL-C <100 (<70) 11% achieve goal

HDL C <40 (male) HDL-C >50 (female) Triglycerides <150

Microalbumin <30 (mg/g creatinine)

Diabetes Care, 27: Sup 1. S19, 2004


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Monitoring Parameters for Control of Complications

Every visit Blood PressureFoot Exam (55% achieve goal)

______________________________________________

3-6 months A1C- Every 3 months if treatment changes or not meeting goals- Every 6 months if stable

_______________________________________________

Annual Dilated Eye Examination (63% achieve goal)Lipid Levels*Microalbumin

_______________________________________________________________*Every 2 years if levels fall in lower risk categories


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Goals of Medical Nutrition Therapy

• Achieve blood glucose goals

• Achieve optimal lipid levels

• Provide appropriate calories for:- Reasonable weight

- Normal growth and development

- Pregnancy and lactation

• Prevent, delay or treat nutrition-related complications

• Improve health through optimal nutrition

Diabetes Care 22(1):S42-S45,1999


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Non-pharmacological Medical Therapy for Type 2 Diabetes

Optimize BG Control Improve blood lipids Control blood pressure

Consistent carbohydrate intake

Monitor blood glucose to adjust therapy

Moderate weight loss

Increase physical activity

Space meals

Modify fat and calorie content


32

ADA Nutrition Recommendations

Total Daily Energy Intake

• Carbohydrate – 60-70%

• Protein – 15-20%

• Fat- 10% from polyunsaturated fats

- < 10% from saturated fats


33

Preventing or Delaying Type 2 Diabetes

• Exercise can lower risk, delay or prevent, type 2 diabetes

• Important for individuals with risk factors- Obesity

- Sedentary lifestyle

- Family history of type 2 diabetes

- Native American, Hispanic, African American, Asian American, Pacific Islander


34

Effects of Exercise

• Increased insulin sensitivity

• Improved lipids

• Lower blood pressure

• Weight control

• Improved blood glucose control in type 2 diabetes


35

Exercise Precautions for Type 2 Diabetes

• Check with referral source for medical clearance

• Lower VO2max may require a gradual training program

• Autonomic neuropathy or blood pressure meds do not allow for increased heart rate perceived exertion important

• Blood pressure may go higher, avoid exercise if systolic BP >180-200


36

Exercise Precautions Related to Complications of Diabetes

• Peripheral neuropathy can cause loss of sensation in feet

• Pre-existing CVD can cause arrhythmias, myocardial ischemia, or infarction during exercise

• Proliferative retinopathy does not increase risk for retinal or vitreous hemorrhage with exercise


37

Treatment of Type 2 Diabetes


38

Principles of Diabetes Treatment

• Define target goal

• Diabetes education is essential

• Monitoring glycemic control is necessary

• Lifestyle modification

• Stepwise and combination pharmacologic therapy


39

ADA Recommendations • Glycemic goals should be individualized

• Certain populations (children, pregnant women, and elderly) require special

considerations

• Less intensive glycemic goals may be indicated in patients with severe or

frequent hypoglycemia

• More stringent glycemic goals (i.e. a normal A1C, 6%) may further reduce

complications at the cost of increased risk of hypoglycemia.

• Postprandial glucose may be targeted if A1C goals are not met despite

reaching pre-prandial glucose goals.


40

Targeted Glucose Control

• Therapy based on glycemic goals

• Monotherapy usually not effective long-term

• Step-wise approach

• Whatever therapy is necessary to achieve glycemic goals


41

Pharmacologic Therapy

Selection of therapy should be

individualized based upon potential

side effects.


42

Therapeutic Agents for Type 2 Diabetes

Mechanism of Action Agent

1. Sensitize the body to insulin Thiazolidinediones, Biguanides

2. Control hepatic glucose production Biguanides, Thiazolidnediones

3. Stimulate the pancreas to Sulfonylureas

make more insulin Meglitinides

4. Slow the absorption of starches Alpha-glucosidase

inhibitors

5. Decreases hepatic glucose Insulin

production and increases

peripheral glucose uptake


43

Impact of Therapies on A1C Levels

Therapy A1C Reduction

Diet and Exercise 0.5 - 2.0% Sulfonylureas and Glitinides 1.0 - 2.0% Metformin 1.0 - 2.0% -Glycosidase Inhibitors 0.5 - 1.0 % Thiazolidinedione 0.5- 1.0% Insulin >5.0%

Nathan, D. Oct 2002. N Engl J Med, Vol. 347, No.17


44

Biguanides

Decrease hepatic glucose production and secondarily may increase insulin-mediated peripheral glucose uptake

• Efficacy- decrease blood glucose ~ 60 mg/dl- reduce HbA1c 1.0 - 2.0%- cause small decrease in LDL-C and triglycerides- no specific effect on blood pressure- no weight gain

• Other Effects- diarrhea and abdominal discomfort- lactic acidosis if inappropriately prescribed- contraindicated in patients with impaired renal function


45

Sulfonylureas

Increase endogenous insulin secretion• Efficacy

- decrease blood glucose ~ 60 mg/dl- reduce HbA1c 1.0 - 2.0 %- no specific effect on plasma lipids or

blood pressure

• Other Effects- hypoglycemia- weight gain


46

Thiazolidinediones

Potentiate insulin action on muscle and adipose tissue• Efficacy

- decrease FPG ~ 25 - 40 mg/dl- reduce HbA1c ~ 0.5 - 1%- combined with sulfonylureas reduce HbA1c ~ 0.8 - 1.0 %

- combined with insulin reduce HbA1C by 0.8 - 1.4% - Beneficial effect on lipids - Possible cardiovascular effects

• Other Effects- contraindicated with abnormal liver function- weight gain, edema


47

MeglitinidesNon-sulfonylurea insulin releasing agent; taken before each meal

Rapid onset of action with a duration of action of several hours

• Efficacy- decrease peak postprandial glucose

- decrease blood glucose 60 - 70 mg/dl

- reduce HbA1c 1.0 - 2.0 %

• Other Effects- hypoglycemia

- weight gain

- safe at higher levels of creatinine than sulfonylureas


48

Alpha-Glucosidase InhibitorsCompetitive inhibitor of alpha glucosidase enzymes in small intestines; taken

before meals

• Efficacy- decrease fasting plasma glucose 20-30 mg/dl

- decrease peak postprandial glucose 40-50 mg/dl

- no specific effect on lipids or blood pressure

- reduce HbA1c 0.5-1.0%

• Other Effects- abdominal discomfort and flatulence

- contraindicated with inflammatory bowel disease or cirrhosis


49

Insulin

Decreases hepatic glucose production and increases uptake and use of glucose by muscle and adipose tissue

• Efficacy- can lower plasma glucose to any level - reduces HbA1c > 5.0%- limited by hypoglycemia

• Other Effects- hypoglycemia- weight gain


50

Anticipated Response to Treatment

Agent Time to Response SMBG Indicator

Secretatogogues Long-acting Rapid-acting

7 – 10 days Immediate

Fasting Postprandial

Metformin 2 – 3 weeks Fasting

Glitazones 6 – 8 weeks AGIs Immediate Postprandial

Insulin Rapid Acting Long-acting

Immediate Immediate

Postprandial Fasting


51

Insulin Therapy in Type 2 Diabetes

• Most patients with type 2 diabetes will eventually

need insulin.

• As insulin deficiency progresses, a more physiologic

multi-component insulin regimen will be required to

adequately replace normal insulin secretion.

- Basal insulin

- Meal-Related (prandial, bolus) insulin


52

Indications for Insulin Therapy in Type 2 Diabetes

• Severe hyperglycemia at glucose toxicity

• To meet glycemic goals

• Hyperglycemia despite maximum doses of oral

agents

• Most patients with type 2 diabetes will

eventually need insulin


53

Insulin Action Comparison Insulins Onset Peak Duration

Lispro* orAspart ~15 minutes 1– 2 hours 4 – 6 hours

Human Regular 30 – 60 minutes 2 – 4 hours 6 – 10 hours

Human

NPH or Lente 2 – 4 hours 6 – 12 hours 12 – 20 hours

HumanUltralente 4 – 6 hours Unpredictable 18 – 24 hours

Glargine* 2– 4 hours Peakless 20 – 26 hours*Insulin analogs


54

Profiles of Human Insulins and Analogs

0 2 4 6 8 10 12 14 16 18 20 22 24

Plas

ma

insu

lin

leve

ls

Regular (6–10 hours)

NPH (12–20 hours)

Ultralente (18–24 hours)

Hours

Glargine (20-26 hours)

Aspart, lispro (4–6 hours)


55

STEP 1• Add metformin or insulin secretagogue

STEP 2• If on metformin, add insulin secretagogue• If on insulin secretagogue, add metformin

continued

Pharmacologic TherapyPossible Treatment StepsPharmacologic TherapyPossible Treatment Steps


56

STEP 3

• Add insulin

• Switch to insulin

• Add a thiazolidinedione

STEP 4

• Add an oral drug to insulin

• Use multiple component insulin therapy

Pharmacologic TherapyPossible Treatment StepsPharmacologic TherapyPossible Treatment Steps


57

Studies Aimed at Prevention of Type 2 DMLifestyle Modification Studies DPP (Diabetes Prevention Program) DPS (Diabetes Prevention Study, Finnish

Study) Da Qing (Chinese Study) Malmo Study (Males, Sweden)

Drug Intervention Studies DPP Stop-NIDDM (Acarbose) - Prevention Evaluation

(Ramipril) TRIPOD Study (Troglitazone) DREAm Study (Rosiglitazone

Ramipril)* Navigator Study (Nateglinide,

Valsartan) Xendos trial (Orlistat)* Sibutramine Study*

*Trial still underway


58

Summary

• The Latino Population is the largest minority group in the country

• The prevalence of diabetes and its complications is higher in Latinos when compared to the non-Latino White group

• Genetic and environmental factors influence the development of obesity, metabolic syndrome and type 2 diabetes in Latinos

continued


59

Summary

• Multiple cultural factors influence diabetes care in Latinos

• Goals for glycemic control, BP, weight, lipids and smoking cessation need to be established

• Aggressive Management to reach these goals is important

• Early use of available pharmacologic treatment tools needs to be considered

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