Monday, August 20, 2012

How can I delete this ? update final version

Yipes! This  was published by accident . It is an a  outline draft of my initial thoughts for a talk I am giving to a local American Diabetes association group . Initially i spent time trying to delete it and then decided to leave it because it may produce a comment or two. Remember this is an outline and not complete.    Dr Calder

         Who is responsible for your health care ?
                                  answer.           I am.

What is your greatest fear ?Blindness  ?kidney disease ? amputation ? neuropathy  
What is the most common cause of death and disability ?
Heart disease & stroke is the most common cause for death and disability in patients with diabetes
                        You may say diabetes is to complicated .
                                          I will let my doctor worry about it 
               Diabetes is not complicated
              It is just a game of numbers
              It is a game you can win

The tools to correct these numbers is available today in your doctors office . Getting those tools into your hands is not difficult.  
* Know what the risk factors are ( just numbers)
* Know the target goals for these numbers that will reduce your risk of complications 

You do not have to understand the test , that will come with time and repetition.
* Have your doctor help you set treatment goals because one size does not fit all

* Follow and record your lab test
 *Any number that is not at your selected target is a reason to talk with your doctor.

                      Just ask the right question  .
                       Doc, can you help me reach my goal ?

                                Diabetes is just a game of numbers.  
                             It is a game that allow you to be less than perfect and still win
                              The Big 3 

               Fix the numbers and you will preserve your good health
                        What if you fix one?     What if you fix more  ? 

# 1 Fix  A1c   -   Effects
                            Small vessel disease _YES  
                            Cardiovascular disease _  ? maybe
There is good evidence that lowering your A1c by 1 % point ( with a target goal of 7 ) will significantly reduce the risk of developing small vessel  disease by about 25 to 30 %

There is also evidence that trying to achieve a near normal A1c of < 6 shows further improvement but is associated with higher mortality and hypoglycemia. ACCORD

 Higher sugars especially post prandial are associated with with increased CV risk
 Producing evidence that glucose control prevents CVD is limited. 
 UKPDS Ns reduction in risk of CV disease except in pts. taking meformin
    10 year followup intensive care pts, had a 15 to 33% reduction in the risk of MI
  DCCT 17 year followup 42 % reduction in CV events and 57 % reduction in stroke

We do not have to be perfect to win . Small changes have a big effect
 How close do you have to get to 7 to show benefit ? 
  Mean A1c in UKPDS 7.4          Steno-2 study 7.8            DCCT 7.4

  #2 Fix Lipids especially LDL  -    Effects 
                                                           Small Vessel Disease ? maybe
                                                           CVD__  YES
 reduce LDL
          CARDS Baseline 129  mg/dl  lipitor 10 -Prevents 1 CV event /37 pts./1000 treated for 4 years
                           stroke reduced 48% , coronary Bypass graft 31% acute MI 36%

            LDL mean in 75% was 93  mg/dl    25% was 64

           Heart Protection Study 
           40 mg zocor will lower LDL by about 38 mg/dl  to 58 mg/dl and reduce the risk of developing
           CVD by about 25% regardless of age , sex or initial LDL level . 

When the data was corrected
           for other variables , zocor reduced the risk compared to controls  by about 1/3 rd. treatment for 5
           years will prevent 70 to 100/1000 from having a CV event
   #3 Fix Blood Pressure -Effects
                                            Small vessel disease _ yes
               reduce BP 154/87  to  144/82 
               24 % reduction in all risk
               44% reduction in stroke
              data supports that lowering S  BP below  140 is beneficial and there is no 
              incremental benefit in reducing BP beolw 120

                        Fix all 3
      Treating multiple risk factors is additive!

          Results  50% reduction in relative risk or a 20 % reduction in absolute risk
        Steno-2 study  
               goals                at 7.8 years achieved
       A1c    <6.5                   7.9 vs 9
       SBP <130/80              131
       LDL chol                      83 vs 126
What about the other six ? residual risk Raise HDL , decrease triglycerides , lose weight, reduce waist , circumference exercise

               The Sleeper       sleep apnea

     who snores or has a bed partner that snores
     37 % of type 2  have sleep apnea
     10 % of type1    ''

Diabetes management is more than just glucose control

- Risk factor management can prevent heart disease and stroke  and small vessel disease 
- set goals  for lab test with your doctor 
-record those goals track your own lab 
-Any test not reaching your agreed goal is a reason to talk to your doctor
-you do not have to understand the test initially 
- understanding will come with repetition and time


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Your comments and questions are appreciated. David Calder,MD