Appendix B

APPENDIX B: ADDITIONAL SCREENING REFERENCES

Helping Obese Women Improve Their Health

Insulin Resistance and The Glycemic Index

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American Diabetes Association Recommendations

Common Laboratory Screening Measures

DIABETES MELLITUS

FERTILITY LABWORK

HEMOGLOBIN A 1 C

LIPID SCREENING

Common Obesity Measures

FAO/WHO Carbohydrate Recommendations

Research methods to detect Insulin Resistance

Syndrome X

Web Sites: Health Care Sites for Consumers

Web Sites: Major Organizations

ADA Dietary Recommendations:

Available: http://www.diabetes.org/virtualgrocery/mealplanning.asp

1. Eat a variety of foods

2. Follow the diabetes food guide pyramid for guidelines on what and how much to eat. People with diabetes have the same food needs as people without diabetes.

3. The diabetes food guide pyramid is similar to the one commonly seen on cereal and bread products. There are two major differences; starchy vegetables like green peas, corn and potatoes were moved out of the Vegetable Group and put into the Grains/Beans and Starchy Vegetables group. The other major change is that cheese was moved out of the Milk Group and is now in the Meat & Others Group.

4. The amounts needed from each of the food groups is as follows:

Grains, Beans, and Starchy Vegetables - 6 or more servings per day

Fruits - 3-4 servings per day

Vegetables - 3-5 servings per day

Meat & Others - 2-3 servings per day

Milk - 2-3 servings per day

Fats and Oils - only in small amounts

Sweets - only once in a while

5. Keeping a food record for a day or two, and then comparing the number of servings you eat to the number recommended by the diabetes food guide pyramid will tell you whether you are eating too much or too little of any of the food groups.

6. Also, remember that the recommended number of servings is for the whole day, so you might want to divide the total number by 3 to see the amount needed per meal. For example, 3-4 servings of fruit per day means 1 per meal or snack, spread throughout the day.

7. 'Control carbohydrates'

8. Carbohydrates include both starches and sugars. The total amount of carbohydrate is more important than the source of carbohydrate. Carbohydrates can be either refined and processed such as in soft drinks and candy, occur naturally such as in milk and fruit, and can be found in pasta, bread, rice, dried beans and peas, and starchy vegetables such as potatoes, corn or green peas.

9. In other words, carbohydrate in the form of cookies doesn't affect your blood sugar any differently than carbohydrate from rice. However, carbohydrate foods in the form of grains, fruits or milk have vitamins, minerals and fiber, while sugary foods such as cookies have little nutritional value and are often high in fat.

Therefore, the majority of carbohydrate you consume should come from the grains, fruit or milk groups. It's okay to eat high-sugar foods, but they must be substituted for other carbohydrates, rather than just added to your meal plan. One serving of grains, fruit or milk provides about 15 grams of carbohydrate and is often referred to as 1 carbohydrate choice. For most people, 45-75 grams of carbohydrate per meal, and no more than 15-30 grams of carbohydrate per snack is a reasonable goal. However, your meal plan should be individualized to meet your specific needs, preferably by a registered dietitian.

Common Laboratory Screening Measures

CRITERIA FOR THE DIAGNOSIS OF DIABETES MELLITUS

Normoglycemia	IGF or IGT	Diabetes Mellitus
	Impaired Glucose Tolerance
FPG < 110mg/dl	FPG > 110 and < 126 mg/dl (IFG)	FPG >126 mg/dl
2 hr PG <140mg/dl	2 hr PG >140 and < 200 mg/dl (IGT)	2hr PG >200 mg/dl
		Symptoms of DM and random plasma glucose concentration > 200 mg/dl

Sources

http://www.fpnotebook.com/END7.htm

Tight Diabetes Control

http://www.diabetes.org/main/type1/medical/blood_sugar/default3.jsp

HEMOGLOBIN A 1 C

Source: http://www.mydiabetes.com/

[Articles Section: How Food Affects Blood Glucose Levels

What is it ?

http://medweb.bham.ac.uk/easdec/prevention/what_is_the_hba1c.htm

http://www.diabetes.org/main/type1/medical/blood_sugar/glyc_hemoglobin.jsp

http://www.geocities.com/diabeteschart/hba1ctest.html

Comparison Charts

http://www.geocities.com/diabeteschart/bloodsugarchart.html

http://www.pharmacie.de/info/blutwerte/hbac1c.html

COMMON LIPID SCREENING

Lipid Screening: Cholesterol and HDL Levels

Total cholesterol

<200 mg/dL = Desirable blood cholesterol

200 to 239 mg/dL =Borderline-high blood cholesterol

240 mg/dL and over =High blood cholesterol

HDL cholesterol

< 35 mg/dL = Low HDL cholesterol

Source American Heart Association: http://www.americanheart.org/presenter.jhtml?identifier=1200000

http://216.185.112.5/presenter.jhtml?identifier=548

http://216.185.112.5/presenter.jhtml?identifier=183

**Lipid Screening: Triglycerides**
Normal triglycerides	Less than 200 mg/dL
Borderline-high triglycerides	200 to 400 mg/dL
High triglycerides	400 to 1000 mg/dL
Very high triglycerides	Greater than 1000 mg/dL
These are based on fasting plasma triglyceride levels.

http://216.185.112.5/presenter.jhtml?identifier=4778

Source American Heart Association: http://www.americanheart.org/presenter.jhtml?identifier=1200000

Common Obesity Measures

Body Mass Index and Physical Obesity Measures

BMI and Truncal Obesity

The BMI is a measurement of height and weight considered highly accurate and easily obtained. during a routine office visit. The BMI has been proven useful for epidemiological research, and individuals can determine their BMI by doing their own measurements and calculations. The American Obesity Association provides a useful tool: [http://nutrition.ucdavis.edu/www/bmi.htm]

The formula for calculating the BMI (also called the Quetlet index) is: weight in kg divided by the quare of the height in meters.

Classification	BMI
Underweight	<18.5
Healthy Weight	18.5 to 24.9
Overweight	25.0 to 29.9
Class I obesity	30.0 to 34.9
Class II obesity	35 to 39.9
Class III obesity	40.0 or higher.

A BMI of approximately 25 kg/m² corresponds to about 10 percent over ideal body weight. http://www.americanheart.org/Heart_and_Stroke_A_Z_Guide/body.html, and Willett, Dietz, Colditz, (1999)

Truncal (or abdominal) is a convenient way for clinicians to identify IR (Bernstein (1997, p 375) identifies truncal obesity (also called central or visceral obesity) as a form of obesity, in which the circumference of the waist is greater than the circumference of the hips (in males) or greater than 80% of the hip circumference in females. Truncal obesity is associated with hyperinsulinemia and metabolic syndrome X. (Bernstein, p 375).

Two different measurements can be taken:

Waist circumference alone has been associated with abnormal metabolic health indicators. "A waist circumference > 35 inches in a woman is a critical threshold leading to metabolic complications. ACCEA/ACE Obesity Position Statement, 1998, p 308).

The Waist-to-Hip Ratio (WHR) is an extension of that, using the same measurements

**How to determine your waist/hip ratio**
a. Measure around the smallest part of your waistline – don't pull in, just stand relaxed.
b. Next, measure your hips at the largest point.
c. Then, divide the waist measurement by the hip measurement.

Available AHA Web Site: http://www.americanheart.org/Whats_News/AHA_News_Releases/obesitytips.html

Tips on finding a Healthy Weight for You."

FAO/WHO Carbohydrate recommendations

Some Dietary Recommendations. Source: FOA/WHO Joint Expert Consultation. (1997). Carbohydrates in Human Nutrition. Available: www.fao.org/es/esn/carboweb/carbo.htm. Page 107
Components of dietary energy	saturated fatty acids, <10% of total energy Omega 6 polyunsaturated fatty acids, <10 % of total energy Protein, 10-20% of total energy Carbohydrate and cist-monounsaturated fatty acids, for the remainder
Carbohydrate Issues	Low glycemic index foods and those rich in soluble fiber recommended Vegetables, fruits, pulses and cereal-derived foods preferred Sucrose <10% total energy acceptable in certain circumstances Timing of intake essential for those on insulin
Special 'diabetic' and 'dietetic' foods	Non-alcoholic beverages sweetened with non-nutritive sweeteners are useful Other special foods not encouraged No particular need of fructose and other 'special' nutritive sweeteners over sucrose

Commonly Used Research methods to detect IR

a.)Euglycemic insulin clamp:

One of the most widely accepted research method or 'gold standard' in the review articles available is the euglycemic insulin clamp technique. "Exogenous insulin is infused, to maintain a constant plasma insulin level above fasting, while glucose is fixed at a basal level by infusing glucose at varying rates" The glucose infusion rate is increased when the plasma glucose level falls, and the rate is rebalanced to return the plasma glucose levels to basal levels. The description continues:

The total amount of glucose infused over time (M value) is an index of insulin action on glucose metabolism. The more glucose that has to be infused per unit time, then the more sensitive the patient is to insulin. Conversely, the insulin-resistant patient requires much less glucose to maintain basal plasma glucose levels.

The advantages to this test are that the effect of insulin on fuel metabolism can be found without the confounding effects of c hypoglycemia or hyperglycemia, or endogenous insulin secretion.. Other events can be studied, such as the regulation of glucose and glucose uptake, inhibition of lipolysis, and changes in protein metabolism.. Limitations of this method are: several doses of insulin might be needed, and a steady state must be achieved for each dose. Complexity and cost in addition to the inability to reproduce physiological conditions limit usability of this test. The test is much too involved for use by clinicians in workplace. http://journal.diabetes.org/FullText/Diabetes%20Care/1999-02ft/pg262.htm

b.) The Minimal Model

Bergman developed the minimal model to develop a more practical method for measuring insulin resistance. Glucose and insulin are sampled frequently during an intravenous Glucose Tolerance Test (GTT), and a computer generated value becomes the index of insulin sensitivity ((called S_i ) The acute insulin release (AIR), in response to glucose can also be determined. The test appears to correlate well with the euglycemic insulin clamp in nondiabetic subjects, but the accuracy deteriorates in diabetes, as it is proposed the immediate plasma insulin response is diminished. "The procedure focuses on glucose, and not other insulin-sensitive fuels and only looks at net effects on glucose metabolism. The individual roles of peripheral and hepatic glucose metabolism are not separated" The viewpoint on this test is that it is not useful for the clinician, because of the cost, time involved, and the complexity of the sampling procedure.

Source: http://www.diabetes.org/DiabetesCare/1998-02/pg310.htm

c.)Fasting Plasma Insulin Levels:

"One limitation in the measurement of fasting insulin is an overlap between insulin resistant individuals and normal individuals. Another limitation of this test is the lack of standardization and differences between labs.

If the assay for fasting insulin was reliable, it would be useful to detect insulin resistance early…before clinical disease appears….we do not recommend routine screening of patients using fasting insulin measurements because of the following liabilities: the problems with assay procedures, the inability of the measurement to accurately indicate the presence of insulin resistance, the lack of a well-defined cut point differentiating normal from abnormal, and the lack of data establishing whether modification of insulin resistance has an impact on outcomes. Available: http://www.diabetes.org/DiabetesCare/1998-02/pg310.htm

d.)Fasting Proinsulin Concentration

This assay appears to have a high correlation with the prediction of diabetes and other related conditions. This specific assay allows for the different molecules in proinsulin to be measured separately, and is named the 32,33 Split Proinsulin. A study of this prohormone was a population-based-longitudinal cohort study conducted in England. Initially, .1,122 individuals were screening with a 75-g oral glucose tolerance test (OGTT). At the 4.5-year follow-up study, repeat OGTTs were performed on 937 of the cohort of 1,071 individuals who had been nondiabetic at baseline. The authors (15) cite the following results of their research:

A total of 26 people progressed to diabetes as determined by the OGTTs. The risk of progression was strongly related to the fasting glucose concentration (relative risk [RR] comparing top with bottom quartile 17.6 [95% CI 2.4–130.4]) and fasting 32,33 split proinsulin (RR 16.4 [2.2–121.9]), but less strongly to the fasting insulin (RR 4.41 [1.5–12.9]) or intact proinsulin (RR 5.2 [1.5–17.3]). In multivariate analyses, these associations were independent of age, sex, BMI, and baseline glucose tolerance category. Subjects in the top quartile for fasting glucose and total proinsulin with a family history of diabetes were a high-risk subgroup (incidence 65.8 per 1,000 person-years of follow-up [pyfu]); 30% of them progressed to diabetes at follow-up.

Proinsulin is a connecting peptide, and considered a prohormone to insulin. It contains a connecting peptide or C-peptide, composed of 31 amino acids with an additional amino acid at either end linked to the alpha and beta chains. As is the case with other prohormones, the connecting peptide of proinsulin is cleaved off before insulin is released into the circulation Available: http://www.britannica.com/bcom/eb/article/6/0,5716,108526+2,00.html

asting 32,33 split proinsulin independently predicts the development of diabetes. This prediction was better than that observed for either the insulin or intact proinsulin concentrations. The combination of family history, fasting glucose, and total proinsulin identified a subgroup of individuals at high risk of progression who might benefit from targeted interventions. More information about Proinsulin can be found at: http://journal.diabetes.org/FullText/Diabetes%20Care/1999-02ft/pg262.htm

Syndrome X

Available: http://www.americanheart.org/Heart_and_Stroke_A_Z_Guide/syndx.html

Syndrome X has been observed in people who are insulin resistant. One such group is people with diabetes , who have a defect in insulin action and are unable to maintain a proper level of glucose in their blood. Another is people, primarily hypertensives (those with high blood pressure), who are nondiabetic and insulin resistant but compensate by secreting large amounts of insulin. This condition is known as hyperinsulinemia . A third group is heart attack survivors who, unlike hypertensives, have hyperinsulinemia without having abnormal glucose levels. The term "Syndrome X" also refers to a heart condition where chest pain, and electrocardiographic changes that suggest ischemic heart disease, are present, but where there are no angiographic findings of coronary disease. Some research has shown that people with cardiac Syndrome X also have lipid abnormalities, suggesting that the two syndromes may be the same.

Risk Factors include: central obesity (excessive fat tissue in the abdominal region), glucose intolerance hyperlipidemia - primarily high triglycerides and low HDL cholesterol and high blood pressure Many scientists think that it is genetically based. The underlying cause is not fully understood. People with Syndrome X are at increased risk of coronary artery disease.

The following are recommendations from the AHA

[American Heart Association]

Monitor blood glucose, lipoproteins and blood pressure.

Achieve ideal body weight and increase physical activity - both are time-tested methods of improving insulin sensitivity, blood pressure and lipoprotein levels.

Treat diabetes and hyperlipidemia according to established guidelines.

Choose drug therapy for hypertensives with care since different agents have different effects on insulin sensitivity.

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Contact: webmidwife1@attbi.com
Pat Sonnenstuhl, ARNP, CNM	Revised: 11/08/2007