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Question #817

(Continued from Question #816)

Mrs. O’Doole is a 34-year-old of Irish descent. She works as a florist and is married with three children. She arrives at your clinic for her annual wellness exam. Her blood pressure is 130/84 mmHg, pulse 65, BMI 24 kg/m2 and her physical exam is notable for acne and mild hirsutism. Her only current medication is oral birth control pills. She recalls starting OCP, 15 years prior, due to irregular menses.

Based upon her medical history and physical, you believe it would be prudent to screen Mrs. O’Doole for type 2 diabetes. You discuss your recommendations with her and she agrees be tested. The lab returns a fasting plasma glucose (FBG) of 112 mg/dL. You share these results with your patient and inform her that, while only mildly elevated, she has impaired fasting glucose.

What is the best choice for initial management of Mrs. O’Doole’s prediabetes?

Correct

Answer. D. Lifestyle modifications (dietary modifications, weight loss and exercise)

Mrs. O’Doole’s FPG 112 mg mg/dL is indicative of impaired fasting glucose and she is considered to have prediabetes. The ADA recommends patients with IGT, IFG or A1C 5.7-6.4% should target a 7% weight loss and at least 150 minutes/week of moderate activity. Dietary modifications (reduced calories/low fat/high fiber/limited use of sugar-sweetened beverages) have been part of lifestyle interventions that prevent diabetes. Findings from the Da Qing study, the Finnish Diabetes Prevention study and the U.S. Diabetes Prevention Program Outcomes study showed lifestyle interventions to be highly effective in reducing the conversion rate from prediabetes to diabetes. These studies also showed that lifestyle interventions were more effective than metformin in preventing diabetes development, except in very-high risk individuals (BMI?35 kg/m2, history of GDM and/or more sever or progressive hyperglycemia). Given her impaired fasting glucose, it would reasonable to recommend lifestyle modifications and provide follow-up counseling and support. For patients with prediabetes, monitoring for the development of diabetes should occur, at a minimum, annually.

Reference(s):

American Diabetes Association. Standards of medical care in Diabetes – 2013. Diabetes Care. January 2013; 36(Suppl. 1):S11-S66. Available at http://care.diabetesjournals.org/content/36/Supplement_1/S11.full. Accessed Jan. 11, 2013.

Li G, Zhang P, Wang J, et al. The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study. Lancet. 2008; 371:1783–1789.

Lindström J, Ilanne-Parikka P, Peltonen M, et al. Finnish Diabetes Prevention Study Group. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: Follow-up of the Finnish Diabetes Prevention Study. Lancet. 2006; 368:1673–1679.

Knowler WC, Fowler SE, Hamman RF, et al. Diabetes Prevention Program Research Group. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009; 374:1677–1686.

Herman WH, Hoerger TJ, Brandle M, et al. Diabetes Prevention Program Research Group. The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance. Ann Intern Med. 2005;142:323–332.

Diabetes Prevention Program Research Group. The 10-year cost-effectiveness of lifestyle intervention or metformin for diabetes prevention: an intent-to-treat analysis of the DPP/DPPOS. Diabetes Care. 2012; 35:723–730.

Diabetes Prevention Program Research Group. Long-term safety, tolerability, and weight loss associated with metformin in the Diabetes Prevention Program Outcomes Study. Diabetes Care. 2012; 35:731–737.

Incorrect