CME Supplements

Managing Type 2 Diabetes in Men

June 2012 · Vol. 61, No. 06 Suppl: S16-S21

References

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9. Nanri A, Mizoue T, Noda M, et al. Fish intake and type 2 diabetes in Japanese men and women: the Japan Public Health Center-based Prospective Study. Am J Clin Nutr. 2011;94(3):884-891.

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18. Avogaro A, Giorda C, Maggini M, et al. Incidence of coronary heart disease in type 2 diabetic men and women: impact of microvascular complications, treatment, and geographic location. Diabetes Care. 2007;30(5):1241-1247.

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Results of the Health Professionals Follow-up Study provide evidence of benefit in lowering the risk of T2DM in men who consume high amounts of low-fat dairy products, whole grains, and magnesium ( TABLE 1 ). With respect to dairy food consumption, after 12 years of follow-up involving 1243 incident cases of T2DM, the relative risk (RR) of developing T2DM in men in the top quintile of dairy intake was 0.77 compared with those in the lowest quintile (P = .003 for trend).¹⁰ Men in the highest quintile consumed 4.1 servings of dairy food per day compared with 0.5 servings per day in the lowest quintile. Each serving-per-day increase in total dairy intake was associated with a 9% lower risk for T2DM, with a lower risk seen with consumption of low-fat vs high-fat dairy food. With respect to whole-grain intake, the RR of developing T2DM was 0.58 in men in the upper vs lower quintiles (3.2 vs 0.4 servings/d), although the effect was attenuated with BMI (P = .0006 for trend).¹¹ Similar observations were made with respect to magnesium consumption; a RR of 0.76 for T2DM was observed in men with a median magnesium consumption of 457 mg/d compared with those who consumed 270 mg/d.¹²

TABLE 1

Suggestions for Men Who Are at Risk of or Have Been Diagnosed with Type 2 Diabetes Mellitus (T2DM)*

For men who are at risk: Key targets -Systolic BP -Smoking cessation -Alcohol consumption (moderate) Promote healthy diet -Fish/seafood -Low-fat dairy products -Whole grains -Magnesium
For men who have been diagnosed: Key targets -BP -Blood glucose -HDL-C Emphasize the importance of self-management Provide ongoing education/information regarding the progressive nature of T2DM and the need to adjust treatment over time, potentially adding both oral and injectable therapies Recommend a diabetes support group
BP, blood pressure; HDL-C, high-density lipoprotein cholesterol. *These suggestions are in addition to developing and fostering a collaborative, patient-centered approach.

JW has the following risk factors for T2DM:

Overweight with central adiposity
Physical inactivity
First-degree relative with T2DM
Possible cardiovascular disease (CVD; hypertension, smoking)
High daily alcohol intake (10 to 20 g alcohol/beer x 2-3 beers/d = 20 to 60 g alcohol/d)
Poor nutrition
Lives alone

Plan:

Discuss above risk factors with JW
Repeat BP measurement at next visit; implement treatment if BP >140/90 mm Hg (130/80 mm Hg if T2DM is diagnosed)
Consider evaluation for alcohol/substance abuse
Evaluate for smoking cessation program
Nutrition referral for lifestyle and dietary management intervention

Working with men to avoid the development of T2DM is an important objective for family physicians. It is essential to identify men who are at increased risk, including those with prediabetes, provide education about the disease and its risk factors, and implement appropriate risk reduction strategies. Risk reduction strategies should focus on modifiable factors, such as body weight, physical activity, BP, blood lipids, blood glucose, and smoking. With JW, his motivation to “get back into shape” will help move the conversation toward achievable goals that can be set and modified over time. Other strategies that may be helpful in reducing the risk of developing T2DM in men include a moderate daily alcohol intake and a diet high in fish and seafood, low-fat dairy products, whole grains, and magnesium ( TABLE 1 ).

Once diagnosed with T2DM, there are risk management strategies that can be particularly helpful in men. These include strategies that target cardiovascular health, as well as those that consider the psychosocial and coping behaviors of men.

Risk of Complications in Men With Type 2 Diabetes Mellitus

MR is a 57-year-old African American male diagnosed with hypertension 5 years ago and T2DM 3 years ago (A1C, 8.2%). Treatment with lifestyle modification and metformin 1000 mg twice daily had lowered his A1C to between 6.8% and 7.1%. However, 9 months ago, MR hurt his knee, which prevents him from walking his usual 1 to 1.5 miles several days a week and doing yard work on the weekends.

Physical examination: BP, 126/78 mm Hg; body weight, 183 pounds (a 13 to 17 pound increase since the knee injury); waist circumference, 38” (BMI, 28 kg/m²); grade 1 retinopathy bilaterally; neurologic exam normal.

Laboratory: A1C, 7.8%; lipids normal except triglyceride level, 219 mg/dL; creatinine clearance (calculated), 69 mL/min; urine, 45 mg albumin/g creatinine.

MR’s self-measured fasting plasma glucose (FPG) has ranged from 121 to 143 mg/dL over the past month; isolated postprandial glucose (PPG) measurements show 194 to 258 mg/dL.

MR works as a vocational teacher at the local high school, and he teaches driver education after school. Review of his pharmacy records suggests his adherence over the past year has been: metformin (88%), hydrochlorothiazide (72%), and lisinopril (72%).

Assessment:

A1C level of 7.8% indicates an estimated average glucose (eAG) of 177 mg/dL¹³
- –Mildly elevated FPG and PPG
- –Evidence of microvascular disease (retinopathy, nephropathy)
- –Creatinine clearance 69 mL/min and microalbuminuria indicate stage 2 chronic kidney disease¹⁴

In addition to referring MR for physical rehabilitation of his knee, you discuss with MR the need and options for intensifying his diabetes therapy.

Does the fact that MR is male affect your management plan?