Standards of Medical Care in Diabetes - 2008 Jeri Jennings Mills, RD/LD, CDE Sami Wood, RD/LD, CDE OSUMC Diabetes Education Types of Diabetes вЂў Type 1 diabetes вЂў IDDM вЂў juvenile onset вЂў type I вЂў Type 2 diabetes вЂў NIDDM вЂў adult onset вЂў type II Gestational diabetes (GDM) вЂў Others вЂ“ Genetic defects in beta cell function вЂ“ Genetic defects in insulin action вЂ“ Diseases of the pancreas (cystic fibrosis) вЂ“ Drug induced (AIDS Tx/organ transplantation) вЂ“ MODY Some patients cannot be clearly classified as type 1 or type 2 вЂў LADA вЂў Type 1.5 How to diagnosis diabetes вЂў FPG is the preferred diagnostic test вЂў Use of the A1c for diagnosis is not recommended at this time Three diagnostic criteria: вЂў FPG > 125 mg/dL*, or вЂў вЂњCasualвЂќ plasma glucose > 200 mg/dL & sxвЂ™s of high blood sugar, or вЂў 2-h plasma glucose* > 200 mg/dl (during an 75 gram glucose OGTT) *needs repeat confirmation on different day Screening for diabetes In diabetes, the same tests used to screen for diabetes, also diagnose diabetes вЂњThere is no more вЂ�screeningвЂ™ for type 2вЂќ! Screening for type 1 diabetes вЂў Screening asymptomatic individuals for autoantibodies is not currently recommended вЂў Clinical studies are being done to test various methods of preventing type 1 1. Yes 2. No 0% o Ye s 0% N Joe is 30 years old with a BMI of 29. He does not exercise. His father has вЂњborderlineвЂќ diabetes. Joe has no symptoms of diabetes. Should he be tested? (B) Testing for type 2 вЂў About 1/3 of all people with diabetes may be undiagnosed вЂў Average dx is 7-10 years after onset вЂў Type 2 DM is frequently diagnosed after complications appear вЂў SoвЂ¦who should be tested? All adults with BMI >24 and a risk factor belowвЂ¦ вЂў Physical inactivity вЂў 1st degree relative with DM вЂў High-risk ethnic group вЂў Women w/hx GDM and/or PCOS вЂў HTN вЂў HDL <35 or trig >250 вЂў IGT or IFG on previous testing вЂў Acanthosis nigricans вЂў Hx of CVD вЂў Age 45 if none of the above apply & q 3 yrsвЂ¦ вЂњType 2 diabetes has a long asymptomatic phase and significant clinical risk markers. Diabetes may be identified anywhere along a spectrum of clinical scenariosвЂќ. Prediabetes is NOT вЂњborderline diabetesвЂќ! вЂў Fasting: 100-125 вЂ“ Impaired fasting glucose (IFG) вЂў 2-hr glucose: 140-199 вЂ“ Impaired glucose tolerance (IGT) Both IFG and IGT are considered risk factors for future diabetes & CVD and should be treated. Testing for type 2 diabetes in asymptomatic children (Table 4 page S14) BMI >85th percentile for age & sex, weight for height or weight >120% of ideal for height plus 2 of the following risk factorsвЂ¦ вЂў Family hx in 1st or 2nd degree relative вЂў Race/ethnicity (African American, Native American, Latino, Asian, Pacific Islander) вЂў Signs of insulin resistance (Acanthosis nigricans, hypertension, dyslipidemia, or PCOS) вЂў Maternal history of diabetes or GDM When to test for type 2 diabetes in children (Table 4 page S14) вЂў Age of initiation: 10 yrs or at onset of puberty вЂў Frequency: every 2 yrs вЂў Test: FPG preferred Gestational Diabetes (Table 5 Page S15) If high risk factors present, screen for diabetes ASAP after pregnancy confirmed. вЂў Marked obesity вЂў Hx of GDM вЂў Previous large-for-gestation-age infant вЂў Glycosuria вЂў PCOS or вЂњinsulin resistantвЂќ вЂў Fam Hx DM Low risk factors for GDM вЂў Age <25 yrs вЂў Weight normal before pregnancy вЂў Member of ethnic group with low prevalence of diabetes вЂў No known diabetes in first degree relative вЂў No history of abnormal OGTT or GDM вЂў No history of poor obstetric outcome Women with GDM should be tested for diabetes 6-12 weeks PP Prevention/delay of type 2 diabetes after GDM вЂў Lifestyle modification counseling important вЂў Monitor for DM every 1-2 yrs вЂў Treat other CVD risk factors (tobacco use, HTN, dyslipidemia) вЂў Consider metformin in addition to lifestyle counseling Reducing Diabetes Risk Lifestyle modification was shown to have the greatest effect in two well-controlled studies: вЂў Diabetes Prevention Program (DPP): reduced risk of developing diabetes by 58% вЂў Finnish Diabetes Prevention Study showed direct relationship between lifestyle intervention and decrease in diabetes Self monitoring of blood glucose вЂў 2-4x/day if on insulin вЂў If on oral agents or MNT, SMBG is done to achieve glycemic control вЂў May include postprandial checks вЂў Routinely evaluate technique and patientвЂ™s ability to use data to adjust food intake, exercise, & medications. 1. True 2. False An A1C should be tested at least once yearly. (E) ls e 0% Fa Tr ue 0% The A1C A вЂњ3 month averageвЂќ вЂў should be checked at initial assessment then regularlyвЂ¦ вЂў 2x/year in patients meeting tx goals, вЂў quarterly in patients who are not meeting tx goals 1. True 2. False The ADA A1C goal for nonpregnant adults with diabetes is <7%. (A) ls e 0% Fa Tr ue 0% ADA Glycemic Goals (Table 8, S18) вЂў A1c <7% (~ plasma glucose of 170 mg/dL) вЂў Pre-meal: 90-130 mg/dl вЂў Post-meal <180 (1-2 hrs post meal) Glycemic control is fundamental to the management of diabetes вЂў UKPDS demonstrated significant reductions in microvascular and neuropathic complications with intensive therapy in type 2 вЂў DCCT demonstrated similar findings in type 1 diabetes Relationship of A1C to Risk of Complications Medical Nutrition Therapy (MNT) Individuals who have pre-diabetes or diabetes should receive individualized MNT to achieve treatment goals, preferably by a registered dietitian & certified diabetes educator (RD/CDE) ls e 0% Fa 0% Tr ue The ADA diabetic diet is the current recommendation for Medical NutritionTherapy (MNT). (A,E) 1. True 2. False Hospital diets continue to be ordered by calorie levels based on the вЂњADA dietвЂќ. Since 1994, the ADA has not endorsed any single meal plan. The term вЂњADA dietвЂќ should no longer be used. I think that means itвЂ™s extinct!! Physical Activity вЂ“ Precautions вЂў EKG monitoring - should be considered before starting aerobic activity in the sedentary patient вЂў Autonomic Neuropathy вЂ“ can decrease cardiac responsiveness in exercise. Is strongly associated with CVD in people with diabetes Physical Activity (precautions) вЂў Dilated Eye Exam: resistance training is contraindicated if retinopathy is present (can trigger vitreous hemorrhage or retinal detachment) вЂў Foot Exam: Decreased pain sensation results in risk of skin breakdown, infection and of Charcot joint destruction. Consider non-weight bearing like swimming, bicycling, or arm exercises Physical Activity (precautions) вЂў Hyperglycemia вЂ“ in type 1 DM: Avoid exercise in presence of ketosis. Muscles canвЂ™t use sugar if not enough insulin available вЂў Hypoglycemia вЂ“ Exercise increases insulin sensitivity. Low BS can result if pt on insulin or sulfonylurea drugs вЂў Check BS prior to exercise, during and after ls e 0% Fa 0% Tr ue Assessment of depression should be included in the medical management of diabetes. (E) 1. True 2. False Psychosocial Assessment вЂў Depression is greater in individuals with diabetes вЂ“ Can impact self-care behaviors вЂ“ Screen for depression It is important to establish that emotional well-being is part of diabetes management. Main Complications of Diabetes 1. True 2. False 0% ls e Tr ue 0% Fa Patients with type 2 DM should have a dilated eye exam within 5 years of diagnosis. (B) вЂў Type 1 DM: dilated, comprehensive eye exam within 3-5 yrs of diagnosis, then yearly вЂў Type 2 DM: dilated, comprehensive eye exam shortly after diagnosis & then yearly вЂў Pregnant with pre-existing diabetes: eye exam in 1st trimester; f/u during pregnancy & for 1 year after ls e 0% Fa 0% Tr ue Individuals with diabetes should be started on statin therapy if they do not have CVD but are over age 40. (A) 1. True 2. False Recommendations for those without CVD and under age 40 вЂў Trigs <150 вЂў HDL >40 in men вЂў HDL >50 in women вЂў LDL <100 вЂ“ (consider statin therapy if LDL >100) вЂў LDL <70 in those with overt CVD вЂў BP Goal <130 systolic/< 80 diastolic вЂў Consider daily aspirin (75-162 mg/day) вЂ“ In people with diabetes between 30-40 years of age in presence of CV risk factors вЂ“ Not recommended in anyone <21 yrs of age due to risk of ReyeвЂ™s Syndrome ls e 0% Fa 0% Tr ue Smoking cessation counseling should be a treatment component of diabetes care. (B) 1. True 2. False SMOKING вЂў Should be #1 intervention вЂў We have a smoking cessation counselor at OSUMC!! ls e 0% Fa 0% Tr ue In patients with type 2 DM, ACEвЂ™s and ARBвЂ™s have been shown to protect kidney function. (A) 1. True 2. False Complications: Kidney вЂў ACEвЂ™s &/or ARBвЂ™s have been shown to delay nephropathy (contraindicated in pg) вЂў Screen annually for microalbuminuria: вЂ“ in type 1 DM, diagnosed > 5 yrs, вЂ“ in type 2 DM at diagnosis, and вЂ“ during pregnancy вЂў Screen annually for serum creatinine & GFR Complications: Kidneys вЂў Dietary protein reduction may be needed if CKD present вЂў Diabetic nephropathy is the single leading cause of ESRD (See Table 12 & 13 pg S30 for specific information) 1. True 2. False ls e 0% Fa 0% Tr ue A foot exam using a monofilament, tuning fork, palpation & visual exam should be done at least every 3 years. (B) Diabetes Complications: FEET вЂў Foot Exam Should Be Done: вЂ“ at diagnosis of type 2 вЂ“ 5 yrs after diagnosis of type 1 вЂ“ at least annually thereafter Diabetes Complications: FEET вЂў Includes use of monofilament, tuning fork, palpation and visual inspection вЂў Initial screening for PAD (Doppler Study or ABI вЂ“ ankle brachial index) Other Neuropathies: Autonomic diabetic neuropathy вЂ“ Resting tachycardia вЂ“ Exercise intolerance вЂ“ Orthostatic hypotension вЂ“ Constipation вЂ“ Gastroparesis вЂ“ Erectile dysfunction вЂ“ Brittle diabetes вЂ“ Hypoglycemic unawareness Immunizations вЂ“ Page S24 вЂў Flu vaccine annually >6 months of age w/DM вЂў At least one lifetime pneumococcal vaccine for adults with diabetes. Diabetes Care: Inpatient Setting вЂў Glucose goals for critically ill: вЂ“ 110 - <140 (A) вЂў Goals for non-critically ill: вЂ“fasting <126 and вЂ“random glucoses <180-200 (E) Insulin in the Inpatient Setting вЂў вЂњSliding scaleвЂќ or вЂњcorrection scaleвЂќ is NOT effective as monotherapy and is NOT recommended вЂў What is recommended? Meal-time coverage a вЂњcorrectionвЂќ scale, and basal insulin Diabetes Self Management Education (DSME) вЂў People with diabetes need education from qualified health care providers with professional training (CDEвЂ™s) вЂў Should be reimbursed by 3rd party payors вЂў Education should be on-going (yearly) References вЂў You have been given an overview of your printed Diabetes Care article. вЂў Over 200 references to access for future lectures if needed вЂў Thank you for your time!