Diabetes, Obesity, BMI: What are the limits?
Iris Thiele Isip Tan MD, FPCP, FPSEMClinical Associate Professor, UP College of Medicine
Section of Endocrinology, Diabetes & Metabolism
Department of Medicine, Philippine General Hospital
Type 1 diabetesabsolute insulin deficiency
Type 2 diabetesinsulin secretory defect +
insulin resistance
Gestational diabetes
Other specific types
http://www.flickr.com/photos/jill_a_brown/2629206224/
“Diabetes” by Jill A. Brown, 1 Jul 2008. Accessed 30 Oct 2010
http://www.flickr.com/photos/emagineart/4655345533/
“Pills 3” by eMagine-Art.com, 31 May 2010. Accessed 30 Oct 2010
Overweight* or obese with one or more risk factors
* BMI >25 kg/m2
Who should be tested for diabetes?
American Diabetes Association. Standards of Medical Care in Diabetes - 2010. Diabetes Care 2010;33(1):S11-61
Physical inactivity
First-degree relative with
diabetes
9 lb babyGDM
PCOS
♀ History of CVD
Hypertension (BP >140/90 or
on treatment)
HDL <35 mg/dL
or Trigly >250 mg/dL
A1c >5.7%IGT or IFG
on previous tests
Insulin resistance
(acanthosis nigricans, severe
obesity) American Diabetes Association. Standards of Medical Care in
Diabetes - 2010. Diabetes Care 2010;33(1):S11-61
Overweight* or obese with one or more risk factors
* BMI >25 kg/m2
Who should be tested for diabetes?
American Diabetes Association. Standards of Medical Care in Diabetes - 2010. Diabetes Care 2010;33(1):S11-61
In those without risk factors, testing should begin at 45 years.FBS is part of PEME “C” for serving seafarers >40 years old
To test for diabetes: A1c, FPG or 2-h 75-g OGTTRepeat testing at least q 3 years
Criteria for the Diagnosis of Diabetes
In the absence of unequivocal hyperglycemia, criteria 1-3 should be confirmed by repeat testing
A1c >6.5%
NGSP-certifiedStandardized to
DCCT assay
FPG >126 mg/dL (7.0 mmol/L)No caloric intake
for at least 8 h
2-h glucose >200 mg/dL (11.1 mmol/L)
during a 75-g OGTT
Random plasma glucose
>200 mg/dL (11.1 mmol/L)
with classic symptoms of
hyperglycemia
American Diabetes Association. Standards of Medical Care in Diabetes - 2010. Diabetes Care 2010;33(1):S11-61
1 3
2
4
AdvantagesFasting not required
Greater pre-analytical stability
Less perturbations during stress and illness
HbA1c
DisadvantagesGreater cost
Limited availability
Incomplete correlation with average glucose
When HbA1c can be misleading ...
Abnormal red cell turnoverAnemias from hemolysis and iron deficiency
HemoglobinopathiesSickle cell trait
Unique ethnic or geographic distributions
American Diabetes Association. Standards of Medical Care in Diabetes - 2010. Diabetes Care 2010;33(1):S11-61
Blood Cells by Andrew Mason, 13 June 2005. http://www.flickr.com/photos/a_mason/19191446/
Accessed 2 Nov 2010
Impaired Fasting Glucose
Impaired Glucose Tolerance
Prediabetes
FPG 100-125 mg/dL (5.6-6.9 mmol/L)
2h OGTT 140-199 mg/dL(7.8-11.0 mmol/L)
HbA1c 5.7-6.4%
American Diabetes Association. Standards of Medical Care in Diabetes - 2010. Diabetes Care 2010;33(1):S11-61
Toast 2, 3 & 4 by ba1969, 14 Dec 2008. http://www.sxc.hu Accessed 1 Nov 2010
25%
50%
25%
Diabetes Persistent IFG/IGT NGT
Evolution of Prediabetes to Diabetes
With longer observation, majority of individuals
develop diabetes
Observation period of 3-5 years
Nathan et al. Diabetes Care 2007,30(3):753-9
<180 mg/dL (10 mmol/L)
70-130 mg/dL (3.9-7.2 mmol/L)
Primary target
Individualized based on life expectancy and comorbid conditions
Peak postprandial capillary plasma glucose
Preprandial capillary plasma glucose
A1c <7%
American Diabetes Association. Standards of Medical Care in Diabetes - 2010. Diabetes Care 2010;33(1):S11-61
Insulin secretagogues: 1-2 wk intervals
Adjusting Drug Dose toward Glycemic Goal
Metformin: 1-2 wk intervals
α-glucosidase inhibitors: 2-4 wk intervals
TZD: maximum effect at 16-20 wkshalf the glucose reduction in 4 weeks
HbA1c
At least twice a year in those with stable
glycemic control
At least quarterly for those not meeting goals or when therapy
is changed
American Diabetes Association. Standards of Medical Care in Diabetes - 2010. Diabetes Care 2010;33(1):S11-61
Diabetes & Employment
Evaluate for
Hypoglycemia for those on insulin secretagogues
Hyperglycemia can cause long-term complications
American Diabetes Association. Diabetes and Employment. Diabetes Care 2010;33(1):S82-86
Obesity
Body mass index (BMI)measure of fatness
Waist circumferencemeasure of visceral fat
Full-figured man by Tobyotter, 15 Aug 2009. http://www.flickr.com/photos/78428166@N00/3872155588/
Accessed 1 Nov 2010
Body Mass Index= [weight (kg)/height (m) 2]
WHO ClassificationAsia Pacific Classification
Underweight <18.5 <18.5
Normal 18.5-24.9 18.5-22.9
Overweight 25-29.9 23-24.9
Obese Class I 30-34.9 25-29.9
Obese Class II 35-39.9 >30
Morbid obesity >40
= (weight (lb) x 703)/height (in)2
NHLBI, The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults (2000)
Measuring Tape Position for Waist Circumference
Horizontal plane around the abdomen at the level
of the iliac crest
Tape is snug but does not compress the skin;
is parallel to the floor
Measure at the end of normal expiration
NHLBI, The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults (2000)
Waist Circumference
Increased risk
♂ >90 cm (35 in)
♀ >80 cm (32 in)
High risk
♂ >102 cm (40 in)
♀ >88 cm (35 in)
Free Tape Measure Woman by D. Sharon Pruitt, 18 Jan 2009. http://www.flickr.com/photos/pinksherbet/3206805049/
Accessed 1 Nov 2010
BMI (kg/m2)
Obesity Class
Disease Risk*(Relative to Normal Weight and Waist Circumference)
Underweight
Normal ✝
Overweight
Obesity
Extreme Obesity
♂<40 in (<102 cm)
♀<35 in (<88 cm)<40 in (<102 cm)<35 in (<88 cm)
<18.5 - -18.5-24.9 - -25.0-29.9 Increased High
30.0-34.9 I High Very High35.0-39.9 II Very High Very High
>40 III Extremely High Extremely High
* Disease risk for type 2 diabetes, hypertension & CVD
✝ Increased waist circumference can also be a marker for increased risk even in persons of normal weight
NHLBI, The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults (2000)
!ank Y"http://www.endocrine-witch.net
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