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January 7, 2014 Issue

Clinical Practice Points



Patient Care
Medical Knowledge

Prevention of Diabetes With Mediterranean Diets. A Subgroup Analysis of a Randomized Trial

This trial found that fewer participants assigned to a Mediterranean diet supplemented with either extra-virgin olive oil or mixed nuts developed diabetes over 4 years than those assigned to a low-fat control diet. Changes in dietary patterns that do not necessarily lead to weight loss or include energy restrictions could help prevent diabetes in some older adults.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Discuss who is at risk for diabetes. What interventions are known to prevent diabetes? The Prevention section of ACP Smart Medicine’s Diabetes Mellitus, Type 2 has these answers.
  • Ask what a Mediterranean diet involves. How do the results of this randomized, controlled trial complement results from observational studies (such as from the Nurses’ Health Study finding that better diet quality at midlife seems to be strongly linked to greater health and well-being later in life)?

Patient Care
Medical Knowledge

General Internists’ Preferences and Knowledge About the Care of Adult Survivors of Childhood Cancer. A Cross-Sectional Survey

This survey of general internists found that although most report providing care to adult survivors of childhood cancer, many general internists seem unfamiliar with available surveillance guidelines and would prefer to follow patients in collaboration with a cancer center.

Use this study to:

  • Discuss what an internist needs to know about the special risks faced by adult survivors of childhood cancers.
  • Ask what they need to know about the treatment received for cancer and why.
  • Are there special considerations regarding cognitive function, bone health, pulmonary, cardiac or any other conditions in these patients? The answers to these questions are presented in In The Clinic: Care of the Adult Cancer Survivor. You can use some of the already prepared teaching slides to help teach. There are also multiple-choice questions at the end; use them to prompt discussion. Log on to get CME credit for yourself.

Health Care Delivery


Systems-based Practice
Patient Care

Fostering Sustainable, Integrated Medical and Behavioral Health Services in Medical Settings

Patients with behavioral health conditions often have chronic medical conditions and high rates of early death. Efforts to better integrate behavioral health and primary care services include cross-referral or bidirectional efforts to add some features of primary care to specialty behavioral health care settings or vice versa. The authors propose a third full-service and financial integration and discuss how it differs from the other models.

Use this article to:

  • Discuss whether it is easy to obtain behavioral health services for your patients. Is the communication between providers of primary and behavioral care adequate?
  • What are the barriers?
  • Invite members of your institution’s behavioral health care team to join the discussion.
  • Do you think these authors’ proposals could be implemented?

Medical Knowledge
In the Clinic

Stable Ischemic Heart Disease

This concise review is organized around answering key clinical questions occurring when evaluating and treating patients with stable ischemic heart disease.

Use this review to:

  • Ask your learners why it matters to differentiate between stable ischemic heart disease and unstable angina. Why does it matter to differentiate the probability of disease from mortality risk?
  • See how long of a list of reasonable alternative diagnoses to angina your team can come up with for patients with chest discomfort.
  • Use the already prepared teaching slides.
  • Quiz your learners with the 4 multiple-choice questions provided at the end (and get CME credit for yourself by logging on and entering your answers).

MKSAP 15 Question: Diabetes Prevention

A 68-year-old woman is re-evaluated after laboratory studies show a fasting plasma glucose level of 113 mg/dL (6.3 mmol/L). She has a maternal family history of type 2 diabetes mellitus.

On physical examination, blood pressure is 142/88 mm Hg and BMI is 29. Other vital signs and examination findings are normal.

She undergoes an oral glucose tolerance test, during which her 2-hour plasma glucose level increases to 135 mg/dL (7.5 mmol/L).

Additional laboratory studies:

Hemoglobin A1c 5.8%
LDL-cholesterol 110 mg/dL (2.85 mmol/L)
HDL-cholesterol 48 mg/dL (1.24 mmol/L)
Triglyceride 172 mg/dL (1.94 mmol/L)

Which of the following is the most appropriate treatment recommendation to control her glucose level?

A. Acarbose administration
B. Diet and exercise
C. Metformin administration
D. Ramipril administration
E. Rosiglitazone administration

Correct Answer: B. Diet and exercise

Educational Objective: Treat prediabetes to prevent development of type 2 diabetes mellitus.

Key Point: Patients with prediabetes should be advised to adopt a program of lifestyle change to prevent progression to type 2 diabetes mellitus.

This patient with impaired fasting glucose (IFG), defined as a fasting plasma glucose level in the range of 100 to 125 mg/dL (5.6 to 6.9 mmol/L), should begin a program of intensive lifestyle change, including 30 minutes of exercise most days of the week and a calorie-restricted diet, to achieve weight reduction on the order of 7% of body weight.

According to a consensus statement on the prevention of diabetes from the American Diabetes Association and the European Association for the Study of Diabetes, diet and exercise is the recommended approach for patients with either IFG or impaired glucose tolerance (IGT), the prediabetic states. In the Diabetes Prevention Program (DPP), the relative risk reduction (RRR) in the incidence of diabetes in patients with IGT who were assigned to intensive lifestyle change was 58%.

Pharmacologic therapy with glucose-lowering drugs is not indicated for this patient with isolated IFG. In pharmacologic studies of diabetes prevention, acarbose therapy resulted in only a 25% RRR, which is inferior to that obtained with diet and exercise.

Metformin therapy is associated with a RRR of 31%, which is also inferior to the 58% RRR obtained with diet and exercise. The consensus panel has recommended that metformin therapy be considered in patients with both IFG and IGT, who constitute a higher risk group. This patient does not have IGT (fasting plasma glucose level of 140 to 199 mg/dL [7.7 to 11.0 mmol/L] at the 2-hour mark of an oral glucose tolerance test) and so should not receive metformin.

Modulators of the renin-angiotensin axis, such as ramipril and other angiotensin-converting enzyme inhibitors, were once thought to contribute to diabetes prevention, but the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) study disproved this.

Rosiglitazone and pioglitazone have been associated, respectively, with 62% and 81% RRRs in the incidence of diabetes. However, the consensus panel has not endorsed their routine pharmacologic use in patients with prediabetes because of their costs and adverse effects, including edema, increased fracture risk in women, and possible increased cardiovascular morbidity.

Bibliography
Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403. [PMID:11832527] - See PubMed


From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.

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