Prevention and Delay of Type 2 Diabetes in Children and Adults

D i a b e t e s
T r e a t m e n t
a l g o r i t h m s
Prevention and Delay of Type 2 Diabetes
in Children and Adults PREVENTION AND DELAY OF TYPE 2 DIABETES
Publication #45-11825
IN CHILDREN AND ADULTS
Screening1:
1. General population
OPTIONS FOR TESTING1,6,7,8:
Individuals >45 years with no risk factors
• Baseline and every 3 years
High risk population 18 years
• BMI >25 with one or more risk factors
• Baseline and yearly
Children and youth at risk
• Overweight with > two risk factors
o BMI >85th percentile for age and gender OR
o Weight for height >85th percentile OR
o Weight >120% of ideal for height
• Baseline at age 10 or at onset of puberty and every 3 years
Women with history of gestational diabetes2
• 6 to 12 weeks postpartum and yearly
•
2.
3.
4.
Risk Factors:
• 1st degree (and/or 2nd degree in children) relative
•
•
•
•
•
•
•
•
•
•
with diabetes
History of gestational diabetes or delivery of a baby
weighing >9 lbs
High-risk ethnic group
Hypertension
Dyslipidemia
Polycystic Ovary Syndrome
Metabolic3 and/or Insulin Resistance4 Syndromes
Vascular disease
Acanthosis nigricans
Physical inactivity
Periodontal disease5
• A1c
• FPG
• 2-hr OGTT (Glucose: Adults – 75 grams;
Children: 1.75g/kg to max of 75 grams)
If an abnormal initial screen, repeat using any of the
above options.
- FPG >100 and <126 mg/dL
and/or
NORMAL
A1c <5.7%
FPG <100 mg/dL;
2-hr OGTT <140 mg/dL
TYPE 2 DIABETES
• A1c
6.5%
and/or
• FPG >126 mg/dL
and/or
• 2-hr OGTT >200 mg/dL
• IGT (ICD-9: 790.22)
Manage modifiable risk factors
and institute appropriate
lifestyle interventions
Refer to Texas Diabetes
Council Algorithms
- 2-hr OGTT Glucose >140 and
<200 mg/dL
Initial Intervention: Lifestyle
9,10
Unsuccessful Outcome: Children
Abnormal A1c, FPG and/or 2-hr OGTT:
Continue Lifestyle Intervention and
Refer to Pediatric Endocrinologist or
Obesity Specialist
6 months
Unsuccessful Outcome: Adults
Abnormal A1c, FPG and/or 2-hr OGTT:
Consider Adding Drug Therapy11 to Lifestyle
Intervention
Metformin10,12
Contraindicated in
Renal Disease or
Renal Dysfunction
Orlistat13
Contraindicated in
Chronic Malabsorption,
Cholestasis
Acarbose14
Contraindicated in
Gastrointestinal
Disease
DRAFT
8/9/12 Revised 8/9/12
BMI—Body mass index (kg/m2)
FPG—Fasting plasma glucose
OGTT— Oral glucose tolerance test
PCP—Primary care provider
IFG – Impaired fasting glucose
IGT – Impaired glucose tolerance
A1c – Hemoglobin A1c
DIAGNOSIS
PREDIABETES
• A1c 5.7% – 6.4%
and/or
• IFG (ICD-9: 790.21)
Publication #45-11825
Weight Loss:
5–10% if BMI <40; 10–15% if BMI >40
Exercise/Physical Activity:
30–60 minutes per day
Hypocaloric Diet:
Deficit 250–1000 Kcal per day ± Meal Replacements
Behavior Modification:
Nutrition/Family Counseling
Regular Follow-up by PCP
6 months
Rescreen yearly or as
recommended based on
risk factors
Successful Outcome
Normal A1c, FPG and/or 2-hr OGTT
Continue Lifestyle Maintenance,
Physical Activity and
Weight Loss/Maintenance
Reassess yearly
A1c, FPG and/or 2-hr OGTT
Abnormal—
Consider
Drug
Therapy11
Normal—
Continue
Lifestyle
Intervention
Reassess A1c, FPG and/or 2-hr OGTT every 6 months
Abnormal—Re-evaluate Lifestyle and Medication Regimen
Normal—Continue Current Therapy
See web site (http://www.texasdiabetescouncil.org) for latest version and disclaimer. See reverse side for more information
1 of 2 – Prevention and Delay of Type 2 Diabetes in Children and Adults – Revised 8/9/12
See disclaimer at www.tdctoolkit.org/algorithms_and_guidelines.asp
D i a b e t e s
T r e a t m e n t
a l g o r i t h m s
Footnotes
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14.
American Diabetes Association. Standards of Medical Care in Diabetes - 2012. Diabetes Care. 2012;35(suppl 1):S11-63.
American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice. Postpartum screening for abnormal glucose tolerance in
women who had gestational diabetes mellitus. ACOG Committee Opinion No. 435, June 2009.
http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Postpartum_Screening_for_Abnormal_Glu
cose_Tolerance_in_Women_Who_Had_Gestational_Diabetes_Mellitus
National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment
Panel III). JAMA. 2001;285(19):2486–97.
American College of Endocrinology position statement on the insulin resistance syndrome. Endocr Pract. 2003;9(3):237-52.
Demmer RT, Jacobs DR, Desvarieux M. Periodontal disease and incident type 2 diabetes. Diabetes Care. 2008:31;1373-79.
American Diabetes Association: Clinical Practice Guidelines 2004. The prevention or delay of type 2 diabetes. Diabetes Care. 2004;27(suppl 1):S47-54;
Diabetes Care. 2005;28(suppl 1):S4-S36.
Edelstein SL, Knowler WC, Bain RP, et al. Predictors of progression from impaired glucose tolerance to NIDDM: an analysis of six prospective
studies. Diabetes. 1997;46(4):701-10.
Sinha R, Fisch G, Teague B, et al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. N Engl J Med.
2002;346(11):802-10. Erratum in: N Engl J Med. 2002;346(22):1756. Correction of dosage error in abstract.
See Texas Diabetes Council algorithms: Exercise Algorithm Type 2 Diabetes Prevention and Therapy, Diabetes Medical Nutrition Therapy and
Prevention Algorithm for Adults, Weight Loss Algorithm for Overweight and Obese Adults, Weight Management Algorithm for Overweight Children
and Adolescents.
Knowler WC, Barrett-Connor E, Fowler SE, et al. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with
lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403 (dose of metformin 850 mg twice daily).
No medication is currently FDA-approved for prevention of type 2 diabetes in adults, but a number of studies provide evidence for drug treatment.
Metformin is as effective as lifestyle intervention in individuals <age 45 or those with BMI >35; metformin is nearly ineffective in individuals >age 60
or those with BMI <30 (DPP evidence).
Torgerson JS, Hauptman J, Boldrin MN, et al. XENical in the prevention of diabetes in obese subjects (XENDOS) study: a randomized study of orlistat
as an adjunct to lifestyle changes for the prevention of type 2 diabetes in obese patients. Diabetes Care. 2004;27(1):155-61 (dose of orlistat 120 mg
three times daily with food).
Chiasson JL, Josse RG, Gomis R, et al. Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet.
2002;359(9323):2072-7 (dose of acarbose 100 mg three times daily with food).
2 of 2 – Prevention and Delay of Type 2 Diabetes in Children and Adults – Revised 8/9/12
See disclaimer at www.tdctoolkit.org/algorithms_and_guidelines.asp