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Diabetes

Screening for diabetes is absolutely the most important thing that people on the front lines can do, and then we will talk about treatment for the rest of the time, focusing on the oral agents in particular, and I am talking about type II diabetes, type I diabetes is something that I think, first of all it’s the minority of diabetes and most people will feel more comfortable sending those people to internists or endocrinologists. We will focus on the definition of diabetes because they actually have changed over the last couple of years, the recommendations for screening which are also relatively new.

First to tell you why screening is so important, I don’t have to tell you that diabetes is a terrible disease, it causes a lot of problems, but just to give you some numbers, it causes 30 times the rate of blindness and is the most preventable cause of blindness in this country, one of the most preventable causes, twice at least the rate of heart disease, these are people who are dying of heart disease and stroke at a huge rate over the general or nondiabetic population, 17 times the rate of renal failure and a huge increase in the rate of amputations and it’s the leading cause of nontraumatic amputations.

There is also a category of people who doesn’t get talked about very much and these are people who have impaired fasting glucose, also related to a category called impaired glucose tolerance, some people call that a prediabetic state, it’s certainly a risk factor for getting diabetes but more importantly, this is a group of people who die from heart disease and stroke at least two times the rate of the general population. So they have the same risk for heart disease and stroke which is nearly equal.

These are the current recommendations for screening and these are very aggressive, I don’t think that we are close at all to implementing these in primary care. Basically my bottom line on this is that you look for any excuse to screen someone for diabetes. Age itself is a risk factor. The incidence of diabetes goes up sharply with age. So anyone over the age of 45 regardless of any other risk factors should be screened at least every three years with a fasting blood sugar, because it’s a very easy and cheap test to do. Then you look for any other reason, obesity, greater than 20% above the ideal body weight.

These are the high risk ethnic groups just to give you some numbers here; African Americans have at least twice the rate of diabetes as whites, Mexican and Puerto Ricans have 2 ½ times the risk and Native Americans have up to five times the risk, this is an enormously increased risk group. I have actually been surprised at the number of Native Americans that you might find in your clinic who don’t look at all Native American, who don’t live on a reservation in Minnesota or Arizona, but have Native American ancestry and those people have a much higher risk for diabetes than you might imagine.

There is another group not on here which are the Pacific Islanders or Asians who have moved here. Japanese people have a much higher risk of diabetes once they have lived here for some time at much lower body mass index than we have partly because they have an abdominal distribution of the way they carry their fat and that fat happens to me a little more metabolically active and predisposes people to cholesterol abnormalities and risk factors for diabetes. These are the targets for glycemic control once you are treating a diabetic, and you will notice they are very similar to the numbers we use for screening.