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The 4 B's of Prevention in Diabetes

Prevention of complications is one of the many challenges associated with a diagnosis of diabetes. Type 1 and Type 2 diabetes are associated with an increased risk of microvascular (small vessel) and macrovascular (large vessel) disease. Microvascular complications include eye disease, kidney disease and nerve disease. Macrovascular complications include heart disease, strokes and peripheral vascular disease. An in-depth discussion of complication risks and prevention strategies is beyond the scope of this article. Nonetheless, I’d like to propose the 4 B's as a simple mnemonic to learn how you can greatly reduce your risk of developing each complication. The 4 B’s of prevention are Blood glucose, Blood pressure, Blood lipids and Be proactive.

Blood Glucose Control
Blood glucose control is most important in the prevention of the microvascular complications associated with diabetes. In Type 1 and Type 2 diabetes, a 1% reduction in the HA1c is associated with a 30% reduction in the risk of development of, or progression of, diabetes related eye disease (retinopathy). Similar improvements are seen in the risk of development of diabetes related kidney disease as glucose control is improved. Benefits have been reported in short and long-term studies. Small studies suggest a similar benefit in reducing the risk of progression of kidney disease that is already present. Benefits have also been reported in the prevention of nerve disease associated with diabetes (neuropathy). The benefits appear to be most significant in people with Type 1 diabetes. AACE guidelines recommend a fasting plasma glucose target of < 110 mg/dl, 2 hour after meal glucoses <140 mg/dl and an HA1c of 6.5% or less. Individualization of goals is emphasized with respect to age, duration of diabetes and associated medical conditions. ADA guidelines for glycemic control are less strict. They include a fasting plasma glucose goal of 80-130 mg/dl, 2 hour after meal glucose levels <180 mg/dl and an HA1c <7%. The ADA also emphasizes the importance of individualizing glucose and HA1c goals. An HA1c goal of <8% is recommended in people with a history of severe hypoglycemia, a limited life expectancy, the presence of advanced diabetes complications and/or mutliple associated medical problems.

Blood Pressure Control
Blood pressure control is important in the prevention of both microvascular and microvascular disease. Althought exact blood pressure goals in people with diabetes are a source of continued study and controversy, in general, you should strive for a blood pressure of <140/90. Multiple well designed trials have reported a reduced risk of heart-related complications, strokes and kidney disease in people with diabetes who maintain this level of blood pressure control. Eye related complications may also improve. Although most blood pressure medications are effective, the ACE inhibitors and ARB’s are most frequently considered “first line” options. Examples of typically prescribed medications in these classes include Quinapril (ACE inhibitor) and Losartan (ARB). More aggressive BP goals (to <130/80) may be appropriate in younger people, and in those with additional heart risks.

Blood Lipid Control
Blood lipid management is most important in the prevention of macrovascular complications. The ADA recommends moderate or high dose statin therapy for people with diabetes who are 40 years or older. High dose therapy (atorvastatin 40-80 mg, rosuvastatin 20-40 mg) is reserved for people with additional heart disease risks and/or the presence of documented heart disease Since people with Type 1 diabetes have exhibited similar benefits, albeit in smaller studies, recommendations regarding therapy are the same. Lipid control also appears to reduce the risk of progression of diabetes related eye disease.

Be Proactive
In addition to working towards blood glucose, blood lipid, and blood pressure goals, people with diabetes have to be proactive regarding lifestyle, risk screening, and education. Initiate appropriate lifestyle changes. Don’t smoke, limit your alcohol intake, exercise carefully, reduce your red meat and saturated fat intake. Maintain a regular screening schedule to include dilated eye exams and spot urinary microablumin collections. It's recommended that people with Type 2 diabetes have a dilated eye exam by an optometrist or opthamologist at the time of diagnosis. People with Type 1 diabetes should be evaluated within 5 years of onset. If there is no evidence of diabetes related eye complications on consecutive yearly visits, some studies support reducing visits to every other year. This should only be done after an in-depth discussion with your opthamologist.  If diabetes related eye disease is present, you should see your opthamolgist at least yearly.  Follow-up of the eyes during pregnancy is more frequent, and should be discussed with your physicians. Urinary microablumin levels should be obtained via a spot microbalbumin sample every year. If your levels are high (>30 mg/day), obtain 2 more samples. Exercise, infection, high sugars. blood and fevers can transiently raise microalbumin secretion. Remember that a random urinalysis protein test is not senstive enough to detect small increases in urinary protein secretion. Always remember to include a urine creatine in the final calculation. If your urine microalbumin/cre levels are consistenly more than 30  mg/day, discuss initiation of an ACE or ARB with your physician, even if your blood pressure is normal. Understand the causes of diabetes related complications. Understand the rationale for screening and treatment recommendations. Keep up with ADA recommendations, as well as those of the AHA. Don’t listen to anyone who tells you complications are inevitable. They’re wrong. Take an active role in your management. Make a positive difference in your life.