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MODULE 3: TREATMENT OF
TYPE 2 DIABETES
TABLE OF CONTENTS
INTRODUCTION.................................................................................................................................................................... 1
MODULE SUMMARY...........................................................................................................................................................49
GLOSSARY..........................................................................................................................................................................53
REFERENCES .....................................................................................................................................................................55
INTRODUCTION
Diabetes is a chronic illness that requires continual medical care and educated patient
participation to help maintain glucose control, blood pressure (BP), and cholesterol, and
thereby reduce the risk of acute and long-term complications. This is often referred to as
treating the ABCs of diabetes:
Data from numerous clinical studies indicate that treating the ABCs of diabetes reduces
the risk for developing many of the long-term complications of diabetes.
Module 3: The Treatment of Type 2 Diabetes will review the results of several of these
clinical studies, which provide the scientific basis for currently recommended diabetes
treatment guidelines. It also will review the current therapeutic options for the treatment
of type 2 diabetes. Specific topics in this module include the following:
Chapter 1 describes some of the landmark clinical trials conducted in patients with
diabetes. Chapter 1 also reviews some more recent trials that compare intensive
glucose-lowering therapy with standard glucose-lowering therapy. It will describe how
the results from recent trials differ from the landmark trials and introduce possible
reasons for these differences. Finally, the results of studies and subgroup analyses
that provide evidence for the treatment of blood pressure and lipid levels in patients
with type 2 diabetes will also be presented.
Chapter 2 discusses the therapeutic options that are available for the treatment of
type 2 diabetes, including recommended nonpharmacologic options and currently
available pharmacologic treatments.
Throughout the text, medical terms are defined in the margin. The module concludes
with a summary, a glossary, and a bibliography.
LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
1. Discuss several landmark trials that demonstrate the benefits of lowering blood
glucose levels.
2. Discuss several studies that emphasize the benefits of tight glucose control.
3. Describe the differences in cardiovascular outcomes between landmark trials and
more recent trials.
4. Discuss the possible reasons for the different outcomes seen between landmark and
more recent studies.
5. Discuss the results of studies and subgroup analyses that show benefits associated
with treatment of blood pressure and lipid levels.
The following paragraphs discuss several landmark studies that emphasize the
importance of tight glucose control:
Kumamoto study
This chapter also discusses several more recent trials that compared intensive
glucose-lowering therapy with standard glucose-lowering therapy:
It is important to note that despite the data provided by these trials and the availability
of multiple medication options, patients still have a very difficult time achieving and
maintaining their glycosylated hemoglobin (A1C) goal. For example, as shown in glycosylated hemoglobin (A1C):
(glahy-KOS-uhl-ahyt-ed HEE-muh-
Figure 1, in the UKPDS, A1C continued to deteriorate (that is, increase) in all 3 treatment gloh-bin) the amount of hemoglobin
groups over 6 years, even with intensive insulin or oral antidiabetic medication therapy. within red blood cells with glucose
attached; provides an estimate of
blood sugar control for the previous
2 to 3 months
The proportion of patients with complications also continued to rise throughout the trial.
These results emphasized the need for new approaches for diabetes treatment.
The goal of the DCCT was to determine whether diabetes management with a more
intensive insulin regimen compared to a standard insulin regimen could prevent or delay
the progression of complications in patients. The intensive insulin regimen was designed
to achieve as near normal glucose levels as possible by using 3 or more insulin injections
per day or treatment with an insulin pump. The standard regimen consisted of 1 or 2
insulin injections per day. A more intensive insulin regimen would likely result in better
glucose controlthus, the DCCT was designed to evaluate whether lowering glucose
would prevent or delay complications. The trial evaluated 2 groups of patients:
The primary endpoint was the development and progression of retinopathy, but renal, retinopathy (ret-n-OP-uh-thee):
damage to the retina of the eye;
neurologic, and cardiovascular complications were also studied. The results of DCCT can lead to blindness
are described in the following table.
The primary endpoint in EDIC was the time to the first cardiovascular event, including any
of the following: nonfatal myocardial infarction (MI) or stroke, death due to cardiovascular
disease, subclinical MI, angina, or the need for coronary artery revascularization. The
results of the study showed that the intensive therapy group had a 42% reduction in the
relative risk of any cardiovascular event (P = 0.02) and a 57% risk reduction for nonfatal
MI, stroke, or death from cardiovascular disease (P = 0.02). Since patients in the intensive
and conventional treatment groups received similar treatment during the EDIC study,
these results indicated that approximately 6.5 years of intensive diabetes therapy had
a long-term effect on the risk for developing diabetes complications.
More recently, the results from the DCCT/EDIC study were compared with results from a
subset of patients in the Pittsburgh Epidemiology of Diabetes Complications (EDC) study,
a population-based observational study conducted during an overlapping time frame with
the DCCT/EDIC study. The 2 studies used similar methods of data collection and patients
in the EDC cohort had similar patient characteristics as those enrolled in the DCCT.
Patients who received conventional treatment in the DCCT and those enrolled in the
EDC had similar incidences of proliferative retinopathy (50% versus 47%, respectively),
nephropathy (25% versus 17%, respectively), and cardiovascular disease (14% for both
cohorts). Patients who received intensive treatment in the DCCT had substantially lower
incidences of proliferative retinopathy, nephropathy, and cardiovascular disease (21%,
9%, and 9%, respectively). The authors concluded that serious complications from
type 1 diabetes are lower than reported historically, particularly in patients who receive
intensive treatment.
Kumamoto Study
This study, which was conducted at Kumamoto University in Japan, was a milestone
study of intensive glucose control conducted in patients with type 2 diabetes. Patients
received insulin therapy, and the goal was to compare the effect of an intensive insulin
regimen with a standard insulin regimen on the development and/or progression of
complications of type 2 diabetes. Intensive insulin therapy, including 3 or more insulin
injections per day, was used to achieve as normal glucose values as possible.
Standard therapy consisted of 1 or 2 injections of intermediate-acting insulin per day.
Similar to the DCCT, this study evaluated 2 groups of patients:
Patients were followed for 6 years. The following table summarizes key results of the
Kumamoto Study.
For the primary prevention group, intensive glucose control significantly reduced:
The risk of development of retinopathy (P = 0.039)
The risk of developing nephropathy (P = 0.032)
For the secondary prevention group, intensive glucose control significantly
reduced:
The risk of progression of retinopathy (P = 0.049)
The risk of progression of nephropathy (P = 0.044)
For the combined group, intensive glucose control significantly reduced the risk
of neuropathy (P < 0.05)
postprandial As A1C, FPG, and postprandial blood glucose concentrations increased
(pohst-PRAN-dee-uhl): after a meal
(i.e., glucose control worsened), the risk of worsening complications such as
retinopathy and nephropathy also increased
At the end of the Kumamoto Study, patients were informed of the superiority of intensive
therapy and were allowed to choose their own insulin regimen. Two patients elected to switch
to intensive therapy while the remainder chose to continue their current treatment regimen.
After 8 years of treatment, patients in the primary treatment group who received intensive
therapy had significantly lower cumulative incidences of retinopathy and nephropathy
compared with patients receiving standard therapy:
After 8 years of treatment, patients in the secondary treatment group who received
intensive therapy had significantly lower cumulative incidences of retinopathy and
nephropathy compared with patients receiving standard therapy:
After 8 years, patients in either study cohort who received intensive therapy demonstrated
significant improvement in nerve conduction (P < 0.05), while those who received
standard therapy experienced significant decreases in nerve conduction (P < 0.05).
UKPDS
The United Kingdom Prospective Diabetes Study (UKPDS) is a landmark trial that
has studied the importance of tight glucose control on reducing the development of
complications in patients with newly diagnosed type 2 diabetes. Unlike the Kumamoto
Study, which used intensive insulin therapy, in UKPDS, patients with type 2 diabetes
were treated with a variety of oral antidiabetic agents, insulin, or diet.
This study began in 1977. Physicians from participating hospitals referred newly
diagnosed patients between the ages of 25 and 65 to the study, of which 5102 were
recruited. Patients followed an established diet for 3 months (overweight patients were
advised to reduce calorie intake) and then their FPG was measured. Patients were then
separated into 2 groups (overweight and not overweight) and randomized to various
treatment regimens.
Many articles related to UKPDS have been and continue to be published. Here, we will
review some key UKPDS publications related to glucose control:
UKPDS 33
UKPDS 34
UKPDS 35
UKPDS 33: UKPDS 33 compared the effects of intensive blood glucose control to
conventional treatment with diet on the risk of microvascular and macrovascular
disease. The 2 groups were defined as:
Patients were followed for a median of 10 years for endpoint analysis. There were 21
clinical endpoints in the study. Compared with conventional treatment, intensive therapy
resulted in a:
Significant reduction in A1C (P < 0.0001), although A1C increased in both groups
over the length of the trial
Following completion of the trial, patients were seen annually at UKPDS clinics for 5
years; however, they were not required to maintain their previously assigned therapies.
Annual questionnaires were provided to patients unable to attend the clinic for the
additional 5-year period. All patients were assessed via annual questionnaire from Year 6
to Year 10.
Additionally, during post-trial follow-up, significant reductions in risk were observed for:
UKPDS 34: UKPDS 34 studied a group of overweight patients and the effect of intensive
treatment on the risk of complications of type 2 diabetes. The primary goal was to compare
411 patients assigned to a conventional treatment of diet with 342 patients assigned to an
intensive treatment with metformin, a drug that reduces glucose production and absorption.
As noted previously, intensive therapy was defined as a treatment program in which the
medication (metformin) was adjusted in order to achieve near-normal glucose levels.
The median follow-up time was 10.7 years.
UKPDS 35: UKPDS 35 was designed to determine the relationship between exposure
to high blood glucose levels over time and the risk of macrovascular or microvascular
complications. This study involved 3867 patients randomized to receive conventional
treatment, primarily with diet, or intensive therapy with insulin or a sulfonylurea. As noted
previously, intensive therapy is defined as aiming to achieve near-normal FPG levels.
The rates of macrovascular and microvascular complications were compared to correlated
blood glucose levels as indicated by A1C concentrations.
The results of UKPDS 35 included that for every 1% reduction in A1C, there was a:
Significant 37% decrease in the risk for microvascular endpoints (P < 0.0001)
Significant 14% decrease in the risk for fatal or nonfatal heart attack (P < 0.0001)
A1C was a mean of 6.5% in the intensive therapy group and 7.3% in the standard
therapy group
In December 2007, after a mean treatment period of 3.5 years, it was decided to
discontinue the intensive treatment regimen of the glycemia trial due to an increased
rate of all-cause mortality in the intensive therapy group: 5.0% versus 4.0%; (HR 1.22;
95% CI, 1.01 to 1.04, P = 0.04). Other findings included:
Stable median A1C levels were 6.4% in the intensive therapy group and 7.5% in the
standard group
The rate of the primary outcome (nonfatal MI, nonfatal stroke, or death from
cardiovascular causes) was not significantly different in the 2 groups (2.11%/year
for intensive therapy and 2.29%/year for standard therapy)
In February 2008, patients were informed of the decision to discontinue the intensive
treatment arm. Since patients had been assigned to receive treatment for either control
blood pressure or lipid levels, they were switched to standard therapy and continued to lipid (LIP-id): fat; found almost
be monitored through the end of the study. exclusively in foods of animal
origin and continuously synthesized
in the body
After 5-years of follow-up (at study end), compared with patients who received standard
glycemic therapy, patients randomized to 3.7 years of intensive glycemic control:
Experienced an increased rate of death from cardiovascular causes (0.74 versus 0.57;
hazard ratio, 1.29; 95% CI, 1.04 to 1.60; P = 0.02)
Were 19% more likely to experience death from any cause (1.53 versus 1.27; 95% CI,
1.03 to 1.38; P = 0.02)
Studies such as ACCORD, ADVANCE, and VADT were designed to further clarify the
effects of intensive glycemic control versus standard glycemic control on cardiovascular
outcomes in patients with type 2 diabetes. As reviewed earlier, neither the ADVANCE
study nor VADT showed significant reduction in cardiovascular events in patients who
received intensive glycemic treatment compared with those who received standard
treatment. In the ACCORD study, intensive glycemic control significantly increased
all-cause mortality and CVD-related deaths. Although a cause could not be identified for
the increase in mortality in the ACCORD trial, it has been theorized that hypoglycemia,
weight gain, unmeasured drug effects or interactions, or the intensity of treatment used to
achieve intensive glycemic control (as opposed to the target A1C) could be responsible.
It has been hypothesized that ACCORD, ADVANCE, and VADT did not show CVD
benefits from intensive glycemic control that were seen in DCCT/EDIC, UKDPS, and
other studies because:
Patients enrolled in ACCORD, ADVANCE, and VADT received treatment for other
CVD risk factors and the overall rate of CVD was lower than predicted in the standard-
treatment arms of all three trials. In patients with type 2 diabetes, the benefits of
glucose lowering on CVD are probably modest and incremental to the treatment of
other risk factors for CVD. Larger and/or longer trials might be needed to demonstrate
additive benefits from intensive glucose control.
Importantly, the results from ACCORD, ADVANCE, and VADT do not indicate a need to
change glycemic control targets. Instead, they confirm the need to individualize treatment
goals based on a patients desires and individual requirements.
Recall that both the ADA and AACE recommend a blood pressure goal of
<130/80 mm Hg for most patients with diabetes. Higher or lower blood pressure
targets may be appropriate for some patients. A number of pharmacologic treatments
are available to help patients achieve these blood pressure goals (see Table 3).
Evidence-Based Therapies
Renin-angiotensin-aldosterone system blockers
Angiotensin-converting enzyme inhibitors
Angiotensin II receptor blockers
Calcium channel blockers
Thiazide diuretic
Beta-adrenergic blockers
Additional Therapies
Aldosterone receptor blockers
Direct renin inhibitor
Selective alpha1-adrenergic blockers
Central alpha2 agonists
Direct vasodilators
Data from one of the UKPDS trials demonstrate that lowering blood pressure reduces
the risk of endpoints related to diabetes.
UKPDS 38
UKPDS 38 examined whether tight control of blood pressure reduces microvascular and
macrovascular diseases compared to less tight control of blood pressure in patients with
type 2 diabetes and hypertension. Patients allocated to tight control of blood pressure
and patients allocated to less tight control received different antihypertensive regimens.
Less tight control of BP was defined as <180/105 mm Hg, and tight control of blood
pressure was defined as BP <150/85 mm Hg. Please note that the goal BP level for
patients with diabetes is now much lower than when this trial conducted; the BP goal
for patients with diabetes is now <130/80 mm Hg.
Results from UKPDS 38 demonstrated that tight blood pressure control resulted in a:
As you learned previously, the UKPDS included a long-term follow-up period in which
patients visited a UKPDS clinic annually for 5 years and then continued to be monitored
via questionnaires from Year 6 to Year 10.
Between-group differences in blood pressure were no longer seen within 2 years of the
end of the trial. The significant relative risk reductions that were observed during the trial
(any diabetes-related endpoint, diabetes-related death, microvascular disease, and
stroke) were not maintained during the follow-up period. However, a relative risk reduction
for peripheral vascular disease became significant during the follow-up period (P = 0.02).
There were no relative risk reductions for MI and death from any cause during the study
or during the follow-up period. The authors concluded that good blood pressure control
must be maintained to continue to see the benefits associated with tight control.
ACCORD
A subset of patients in the ACCORD trial were also randomly selected to undergo
intensive versus standard therapy for lowering blood pressure. The blood pressure
goal for the intensive therapy group (n = 2362) was <120 mm Hg, while the goal for
the standard therapy group (n = 2371) was <140 mm Hg. The primary outcome was
the same as for the overall studythe first occurrence of nonfatal MI, nonfatal stroke,
or cardiovascular death. Key results include:
Diastolic BP was also reduced in the intensive therapy group: 64.4 mm Hg versus
70.5 mm Hg, with an average difference of 6.1 mm Hg (95% CI, 5.7 to 6.5)
The rate of the primary outcome was not significantly different between the 2 groups,
with a rate of 1.87% in the intensive therapy group and 2.09% in the standard therapy
group (HR = 0.88, 95% CI 0.73 to 1.06, P = 0.20)
Patients in the intensive therapy group were on more antihypertensive agents than
the standard therapy group (means of 3.4 drugs versus 2.1 drugs) and experienced
significantly more serious adverse events attributable to antihypertensive treatment,
hypokalemia as well as rates of hypokalemia and elevated serum creatinine levels
(hahy-poh-key-LEE-mee-uh):
abnormally low level of potassium
ions in the blood
A significant 27% reduction in the relative risk for major coronary artery events
(nonfatal myocardial infarction or coronary death) (P < 0.0001)
A significant 25% reduction in the relative risk for fatal or nonfatal stroke (P < 0.0001)
Conventional therapy (n = 80), which had less intense risk factor goals; patients
were seen by their general practitioner with the possibility of referral to a specialist
The primary endpoint was a composite of death from cardiovascular causes, nonfatal MI,
coronary artery bypass grafting, percutaneous coronary intervention, nonfatal stroke,
amputation as a result of ischemia, or vascular surgery for peripheral arterial disease.
After a mean follow-up of 7.8 years, the primary endpoint was significantly reduced in
the intensive therapy group compared with the conventional therapy group: HR 0.47
(95% CI 0.24 to 0.73) (P = 0.008).
You have learned that tight control of blood pressure with antihypertensive drugs can
reduce the development of complications of diabetes. In addition, the use of 2 classes
of antihypertensive agents, independent of their effects on blood pressure control,
has shown beneficial effects on delaying or preventing ESRD; these agents are:
Guidelines recommend the use of ACE inhibitors or ARBs in nonpregnant patients with
diabetes and microalbuminuria or macroalbuminuria.
SUMMARY
The following table summarizes the information presented in this chapter on evaluating glucose, blood pressure, and lipid
control in diabetes.
(cont.)
SELF-ASSESSMENT QUESTIONS
1. Which of the following statements about the Kumamoto Study is (are) true?
_____ A. Intensive glucose control significantly reduced the risk of developing neuropathy in all patients.
_____ C. The study population included only patients with type 1 diabetes.
_____ D. Only patients who had no complications of diabetes at the outset of the study were included.
2. The effects of tight control of blood pressure on microvascular and macrovascular diseases were studied in:
4. Subgroup analyses from the ACCORD, ADVANCE, and VADT trials suggest that intensive glucose control may
provide increased cardiovascular benefits in type 2 diabetes patients who:
5. True or false? Long-term follow-up of the UKPDS has demonstrated that a reduced rate of complications is
maintained even when intensive therapy is discontinued.
_____ A. true
_____ B. false
SELF-ASSESSMENT QUESTIONSANSWERS
1. A, B
2. C
4. C, D
5. True
LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
1. Describe a patient-centered approach to the treatment of type 2 diabetes.
2. List recommended lifestyle modifications and explain their limitations.
3. List the main available classes of antidiabetic medications and give examples
of each.
4. Describe the role of insulin in the management of type 2 diabetes.
In patient-centered care, the patient and healthcare provider work together to determine
a therapeutic regimen that is consistent with the patients desired level of involvement.
The guidelines note that multifactorial risk reduction is likely to provide greater benefits
for the patient, but recommendations contained within the guidelines need to be
individualized based upon the patients needs, desires, and tolerances (see Figure 6).
Evidence supports that engaging patients in health care decisions is effective and
may increase adherence to therapy.
Factors such as a patients life expectancy, attitude and motivation, and comorbidities should be
considered when setting glycemic goals. The ADA recommends an A1C goal of 7%. However,
for patients with the characteristics shown at the left of the scale (e.g., less motivated, short life
expectancy), a less stringent goal (e.g., 7.5% or 8%) might be appropriate. Conversely, for patients
who have characteristics shown at the right of the scale (e.g., newly diagnosed, no comorbidities),
an A1C goal of 6% or 6.5% might be appropriate. Whenever possible, patients should participate
in setting their glycemic goals to ensure the goals are consistent with their needs, values,
and preferences.
Adapted from: Inzucchi SE, Nauck M, Bergenstal RM, et al. Diabetes Care. 2012;35:13641379.
Lets review some of the general treatment recommendations for patients with type 2
diabetes.
LIFESTYLE MODIFICATIONS
Guidelines note that changing patterns of eating and physical activity may help reduce
the risk of many of the complications associated with diabetes. This chapter discusses
recommendations for nutrition and exercise. This chapter also features case studies that
illustrate key concepts relating to lifestyle modifications in the treatment of diabetes.
Nutrition
Nutrition therapy is an integral component of diabetes management, and patients
should receive individualized nutrition counseling and planning to achieve treatment
goals. Registered dietitians are important members of the healthcare team for patients
with diabetes.
Nutrition therapy has the following goals for patients with diabetes:
Help to promote weight loss (for patients who are overweight or obese)
Address individual nutrition needs, taking into account personal and cultural
preferences and willingness to change
Maintain the pleasure of eating by not limiting food choices unless indicated
by scientific evidence
Ongoing nutritional consultation about diet and eating habits needs to be available for
patients with diabetes. The following case study illustrates how nutrition therapy can be
used as part of a patients diabetes treatment plan.
Exercise
Guidelines recommend that patients with diabetes exercise regularly, because regular
exercise can improve blood glucose, reduce cardiovascular risk factors, and contribute
to weight loss. Exercise may help prevent type 2 diabetes in high-risk individuals.
Before beginning any physical activity program, patients should be screened for any
underlying complications that could be exacerbated by certain types of exercise, including
uncontrolled hypertension, severe autonomic or peripheral neuropathy, history of foot
lesions, and unstable proliferative retinopathy.
An exercise program should be individualized to the patient; the guidelines list specific
considerations for activity limitation in patients with diabetes complications or using
insulin. For example, in patients with some forms of retinopathy, the guidelines note
that strenuous activities, like weight lifting or jogging, are not appropriate because
the strain may cause hemorrhage in the eye or retinal detachment.
The following case study illustrates how exercise can play a role in a patients diabetes
management; it also illustrates that patients may find it difficult to follow exercise
recommendations.
Lifestyle Modifications
Guidelines recommend that all patients with diabetes modify nutrient intake and
lifestyle to reach recommended metabolic outcomes and prevent and treat obesity,
dyslipidemia, cardiovascular disease, hypertension, and nephropathy
Goals of nutrition therapy
Achieve and maintain blood glucose levels in the normal range
Reduce cardiovascular risk factors, including dyslipidemia and hypertension
Provide a balanced, nutritional diet
Lose weight
Prevent or slow the development of the chronic complications of diabetes
Address individual nutrition needs, taking into account personal & cultural
preferences and willingness to change
Maintain the pleasure of eating by not limiting food choices unless indicated
by scientific evidence
Regular exercise can improve blood glucose, reduce cardiovascular risk
factors, contribute to weight loss, and may even help prevent type 2 diabetes
in high-risk individuals
Exercise program should be individualized to the patient
Patients may have difficulty maintaining lifestyle modifications and their
beneficial effects
TREATMENT OPTIONS
While lifestyle modifications are an important component of the treatment of diabetes,
many patients with type 2 diabetes will require pharmacologic treatment. A number of
different oral and injectable pharmacologic options, as well as insulin, are available for
glucose control, and this chapter briefly introduces them. The following modules will
discuss them in greater detail.
Pharmacologic Options
The following table provides an overview of the pharmacologic options for type 2 diabetes
that have been approved by the US Food and Drug Administration.
(cont.)
Some patients receive 2 separate agents, but there are also a few products that combine
2 agents in one formulation.
Prandial insulins: These rapid-acting insulin analogues are designed to target prandial
glucose levels and are thus injected shortly before a meal
Basal insulins: These long-acting insulin analogues are slowly released into the
circulation up to 24 hours after an injection and are designed to supply the basal
level of insulin required by the body
Patients with type 2 diabetes usually initiate treatment with a basal, or long-acting,
insulin analogue. Basal insulins reduce blood glucose levels by suppressing hepatic
insulin production between meals and while the individual sleeps. While most patients
with type 2 diabetes can be adequately treated with basal insulin alone, some individuals
will require treatment with prandial, or rapid-acting, insulin analogues. Prandial insulins
are administered just before the patient eats to improve postprandial glucose control.
SUMMARY
The following table summarizes the information presented in this chapter on treatment options for type 2 diabetes.
Treatment Options
Patient-Centered Care
Patient-centered care is defined as providing care that is respectful of and responsive to individual patient
preferences, needs, and values and ensuring that patient values guide all clinical decisions
In patient-centered care, the patient and healthcare provider work together to determine a therapeutic regimen that
is individualized based upon the patients needs, desires, and tolerances
Lifestyle Modifications
Nutrition therapy is an integral component of diabetes management, and patients should receive individualized
nutrition counseling and planning to achieve treatment goals; registered dietitians are important members of the
healthcare team for patients with diabetes
Nutrition therapy has the following goals for patients with diabetes:
Achieve and maintain blood glucose levels in the normal range
Reduce cardiovascular risk factors, including dyslipidemia and hypertension
Provide a balanced, nutritional diet
Help to promote weight loss (for patients who are overweight or obese)
Prevent or slow the development of the chronic complications of diabetes
Address individual nutrition needs, taking into account personal and cultural preferences and willingness
to change
Maintain the pleasure of eating by not limiting food choices unless indicated by scientific evidence
Guidelines recommend that patients with diabetes exercise regularly as regular exercise can improve blood
glucose, reduce cardiovascular risk factors, and contribute to weight loss; exercise may help prevent type 2
diabetes in high-risk individuals
Before beginning any physical activity program, patients should be screened for any underlying complications
that could be exacerbated by certain types of exercise; for example, in patients with some forms of retinopathy,
strenuous aerobic or weight-training exercise might be contraindicated because of a risk for hemorrhage or
retinal detachment
(cont.)
SELF-ASSESMENT QUESTIONS
There may be more than one correct answer for each question.
1. A patient-centered approach type 2 diabetes might take into effect factors such as:
3. The plate method recommends that _______ should fill the majority of a persons plate at a meal.
_____ B. fish
5. Which of the following statements about the use of insulin therapy in type 2 diabetes is (are) true?
_____ B. Patients with type 2 diabetes are generally not dependent on insulin therapy for survival.
SELF-ASSESSMENT QUESTIONSANSWERS
1. A, B, C, D
2. A, B, C, D
3. C
4. D
5. B, C
MODULE SUMMARY
1) Glucose control, or the reduction of glucose levels to meet certain goals, is a major
factor in decreasing the morbidity and mortality associated with this disease.
However, glucose control is challenging for most patients even with commonly
used therapies, and most patients find it difficult to reach their A1C goal.
Clinical trials have demonstrated that intensive glucose control and lowering A1C
provides benefits, including:
Reduction of risk for complications of diabetes
Decreased progression of the microvascular and macrovascular diseases
associated with diabetes
Reduction of risk for death related to diabetes
More recent studies evaluating the effects of intensive glucose control, providing
mixed results on effects on cardiovascular events and mortality, include:
Action in Diabetes and Vascular Disease (ADVANCE) trial
Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial
Veterans Affairs Diabetes Trial (VADT)
Landmark studies such as the DCCT/EDIC and UKDPS suggest that intensive
glycemic control reduces the risk for cardiovascular disease compared with standard
glucose control; however, recent studies such as ADVANCE and VADT have not
demonstrated cardiovascular benefits from intensive glucose control compared with
standard glucose treatment. In the ACCORD study, patients receiving intensive
glucose control had significantly higher rates of all-cause mortality compared with
those randomized to standard glucose control.
Hypertension is common in patients with diabetes, and it is also a risk factor for
cardiovascular disease. In UKPDS, controlling blood pressure significantly reduced
the risk of diabetes-associated complications and mortality. In ACCORD, no
significant reduction cardiovascular events or death was found with intensive
blood pressure therapy.
Patients with type 2 diabetes have an increased prevalence of lipid abnormalities that
contribute to higher rates of cardiovascular disease. Lifestyle modification has been
shown to improve the lipid profile in patients with diabetes, but pharmacologic therapy
is recommended for patients who do not meet the LDL-C goal. For patients without
CVD, ADA recommends an LDL-C goal of <100 mg/dL. The ADA notes that
achieving an LDC-C <70 mg/dL is an optional goal for very high-risk patients.
In HPS, the LDL-cholesterol reduction from baseline with simvastatin treatment was
associated with a reduction in the risk for major coronary artery events and stroke.
In CARDS, 10 mg daily of atorvastatin, a lipid-lowering drug, was found to reduce
the risk of major cardiovascular events in patients with type 2 diabetes.
In the Steno-2 trial, intensive therapy addressing multiple risk factors (blood pressure,
lipids, glucose levels) in patients with diabetes resulted in significant reductions in the
occurrence of cardiovascular events and interventions.
2) Guidelines recommend that all patients with diabetes modify nutrient intake and
lifestyle to reach recommended metabolic outcomes and prevent and treat obesity,
dyslipidemia, cardiovascular disease, hypertension, and nephropathy.
Regular exercise can improve blood glucose, reduce cardiovascular risk factors,
contribute to weight loss, and may even help prevent type 2 diabetes in high-risk
individuals. An exercise program should be individualized to the patient. Patients
may have difficulty maintaining lifestyle modifications and their beneficial effects.
Patients with type 1 diabetes require insulin therapy, because they produce little or
no insulin and must depend on exogenous insulin for survival. Patients with type 2
diabetes are generally not dependent on insulin therapy for survival, but a substantial
number of patients with type 2 diabetes will require insulin.
GLOSSARY
body mass index (BMI): calculated value used to describe an individuals weight relative to height; calculated using
the following formula: BMI = kg/m2
creatinine: a waste product filtered from the blood and excreted in the urine
fasting plasma glucose (FPG): test of blood glucose levels; measured when the patient has not eaten for at least 8 hours
glucagon-like peptide 1 (GLP-1): a hormone in the gut that is released in response to food ingestion; during hyperglycemia,
GLP-1 stimulates insulin secretion, suppresses glucagon secretion, and decreases the rate of gastric emptying
glycosylated hemoglobin (A1C): the amount of hemoglobin within red blood cells with glucose attached; provides an
estimate of blood sugar control for the previous 2 to 3 months
high-density lipoprotein (HDL) cholesterol: good cholesterol; transports excess cholesterol to the liver for elimination
incretin: class of insulinotropic substances that are released in the gastrointestinal tract in response to food ingestion
insulin: hormone secreted by the beta-cells of the pancreas that is the key regulator of the metabolism of glucose
and processes necessary for metabolism of fats, carbohydrates, and proteins; opposes the action of glucagon
lipid: fat; found almost exclusively in foods of animal origin and continuously synthesized in the body
low-density lipoprotein (LDL) cholesterol: bad cholesterol; transports most cholesterol in the blood; when present
in high amounts, deposits cholesterol in the walls of arteries, forming lipid plaques
macroalbuminuria: the leakage of large amounts of albumin into the urine; defined as >200 mcg/min
microalbuminuria: the leakage of a small amount of albumin into the urine, defined as 20 mcg/min to 200 mcg/min
neuropathy: nerve damage, primarily peripheral neuropathy (in which the peripheral nerves in the extremities are
affected); can result in loss of sensation, which may result in serious infection, gangrene, and the need for amputation
triglycerides: lipid molecules containing 3 fatty acids bound to glycerol; the primary fat in the diet and the primary
molecule used for fuel storage
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