Diabetes, Obesity, BMI, what are the limits?

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?


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


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


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%


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%


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


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


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


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Diabetes, Obesity, BMI, what are the limits?

Health & Medicine

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