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	James L. Holly, M.D.

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Your Life Your Health - Less Initiative: SETMA's Initiative Confirmed by Medical Journals

James L. Holly,M.D.

March 22, 2005

Internal memo to SETMA Partners

Earlier today, I sent you summaries of three studies: "Differences in Insulin Resistance in nondiabetic Subjects with Isolated Impaired Glucose Tolerance or Isolated Impaired Fasting Glucose"; "Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) in Relation to the Incidence of Cardiovascular Disease"; "Insulin-Resistant Prediabetic Subjects Have More Atherogenic risk Factors Than Insulin-Sensitive prediabetic Subjects." The clinical take away of these studies, all of which come from Dr. Steven Haffner's lab at UTHSCSA in San Antonio, is:

Prediabetics have an atherogenic pattern of CV risk factors which are predominantly observed in prediabetics with increased HOMA IR and fasting insulin, i.e, insulin resistance.
Atherogenic changes in the prediabetic state are mainly seen in insulin-resistant subjects.
Strategies to prevent type 2 diabetes might focus on insulin-sensitizing interventions rather than interventions that increase insulin secretion because of potential effects on cardiovascular risk.
Nondiabetic individuals with isolated post challenge hyperglycemia (IGT) are more insulin resistant than individuals with isolated fasting hyperglycemia (IFG).
The risk factor pattern (including increased insulin resistance) seen in isolated IGT identifies a subgroup of nondiabetic individuals who are likely to benefit from early intervention.

At SETMA, part of every patient evaluation is:

LESS Initiative -- Loss Weight, Exercise, Stop Smoking; part of the LESS is the evaluation of every patient for their risk of developing diabetes.
Preventing Diabetes -- This provides screening criteria for "recommended" and "required" screening for impaired fasting glucose and for impaired glucose tolerance.
Predicting the Development of Diabetes -- This function utilizes the Diabetes Prediction Rule published February, 2005 in Diabetes Care to evaluate those patients who are at greatest risk for the development of diabetes. A score of 4 or higher means the patient should be aggressively treated to prevent the development of diabetes.
Screening for Insulin Resistance -- This is an algorithm which allows you to know whether the patient is at high risk or lower risk for having or developing insulin resistance.

In both the Diabetes and Metabolic Syndrome suite of templates, two surrogates, or markers, for Insulin Resistance are automatically calculated:

Triglycerides/HDL ratio -- a value above 2 is highly suggestive of Insulin Resistance
HOMA-IR which is an equation employing the values of a fasting glucose and a fasting insulin level -- a value above 2 represents insulin resistance.

On both the Metabolic Syndrome suite of templates treatment plan and on Preventing Diabetes template, there is a pop-up entitled Insulin Sensitivity. This gives you the steps of treating insulin insensitivity which are:

Life style -- weight loss and exercise
Pharmacotherapy -- TZD and Metaforim improve insulin sensitivity with some suggestions (not in the articles listed above) that R-Lipoic Acid, Chromium and Vanadium can improve insuliin sensitivity.

There is a strong relationship between all that we do in evaluating patients. With this material we can make a difference in their long-term well being. As more data is published, it will make all of this clearer and more definitive. Our patients can be "ahead of the game" by following the simple steps we recommend to them everyday.

James. L. Holly, MD CEO, SETMA, LLP

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