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Standards of Medical Care in Diabetes

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Standards of Medical
Care in Diabetes - 2008
Jeri Jennings Mills, RD/LD, CDE
Sami Wood, RD/LD, CDE
OSUMC Diabetes Education
Types of Diabetes
• Type 1 diabetes
• IDDM
• juvenile onset
• type I
• Type 2 diabetes
• NIDDM
• adult onset
• type II
Gestational diabetes (GDM)
•
Others
– Genetic defects in beta cell function
– Genetic defects in insulin action
– Diseases of the pancreas (cystic fibrosis)
– Drug induced (AIDS Tx/organ transplantation)
– MODY
Some patients cannot be clearly
classified as type 1 or type 2
• LADA
• Type 1.5
How to diagnosis diabetes
• FPG is the preferred diagnostic test
• Use of the A1c for diagnosis is not
recommended at this time
Three diagnostic criteria:
• FPG > 125 mg/dL*, or
• “Casual” plasma glucose > 200 mg/dL
& sx’s of high blood sugar, or
• 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
“There is
no more
�screening’
for type 2”!
Screening for type 1 diabetes
• Screening asymptomatic individuals for autoantibodies is not currently recommended
• 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
“borderline” diabetes.
Joe has no
symptoms of
diabetes. Should he
be tested? (B)
Testing for type 2
• About 1/3 of all people with diabetes may
be undiagnosed
• Average dx is 7-10 years after onset
• Type 2 DM is frequently diagnosed after
complications appear
• So…who should be tested?
All adults with BMI >24 and a risk factor below…
• Physical inactivity
• 1st degree relative with DM
• High-risk ethnic group
• Women w/hx GDM and/or PCOS
• HTN
• HDL <35 or trig >250
• IGT or IFG on previous testing
• Acanthosis nigricans
• Hx of CVD
• Age 45 if none of the above apply & q 3 yrs…
“Type 2 diabetes has a long asymptomatic
phase and significant clinical risk markers.
Diabetes may be identified anywhere
along a spectrum of clinical scenarios”.
Prediabetes is NOT
“borderline diabetes”!
• Fasting: 100-125 – Impaired fasting
glucose (IFG)
• 2-hr glucose: 140-199 – 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 factors…
• Family hx in 1st or 2nd degree relative
• Race/ethnicity (African American, Native
American, Latino, Asian, Pacific Islander)
• Signs of insulin resistance (Acanthosis
nigricans, hypertension, dyslipidemia, or
PCOS)
• Maternal history of diabetes or GDM
When to test for type 2 diabetes in
children (Table 4 page S14)
• Age of initiation: 10 yrs or at onset of puberty
• Frequency: every 2 yrs
• Test: FPG preferred
Gestational Diabetes
(Table 5 Page S15)
If high risk factors present, screen for diabetes
ASAP after pregnancy confirmed.
• Marked obesity
• Hx of GDM
• Previous large-for-gestation-age infant
• Glycosuria
• PCOS or “insulin resistant”
• Fam Hx DM
Low risk factors for GDM
• Age <25 yrs
• Weight normal before pregnancy
• Member of ethnic group with low
prevalence of diabetes
• No known diabetes in first degree relative
• No history of abnormal OGTT or GDM
• 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
• Lifestyle modification counseling important
• Monitor for DM every 1-2 yrs
• Treat other CVD risk factors (tobacco use,
HTN, dyslipidemia)
• Consider metformin in addition to lifestyle
counseling
Reducing Diabetes Risk
Lifestyle modification was shown to have the
greatest effect in two well-controlled studies:
• Diabetes Prevention Program (DPP):
reduced risk of developing diabetes by 58%
• Finnish Diabetes Prevention Study
showed direct relationship between lifestyle
intervention and decrease in diabetes
Self monitoring of blood glucose
• 2-4x/day if on insulin
• If on oral agents or MNT, SMBG
is done to achieve glycemic control
• May include postprandial checks
• Routinely evaluate technique and
patient’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 “3 month average”
• should be checked at initial assessment then regularly…
• 2x/year in patients meeting tx goals,
• 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)
• A1c <7% (~ plasma glucose of 170 mg/dL)
• Pre-meal: 90-130 mg/dl
• Post-meal <180 (1-2 hrs post meal)
Glycemic control is fundamental to
the management of diabetes
• UKPDS demonstrated significant
reductions in microvascular and
neuropathic complications with intensive
therapy in type 2
• 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
“ADA diet”. Since
1994, the ADA has
not endorsed any
single meal plan. The
term “ADA diet”
should no longer be
used.
I think that
means it’s
extinct!!
Physical Activity –
Precautions
• EKG monitoring - should be
considered before starting
aerobic activity in the sedentary
patient
• Autonomic Neuropathy – can
decrease cardiac responsiveness in
exercise. Is strongly associated with
CVD in people with diabetes
Physical Activity
(precautions)
• Dilated Eye Exam: resistance training is
contraindicated if retinopathy is present (can
trigger vitreous hemorrhage or retinal
detachment)
• 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)
• Hyperglycemia – in type 1 DM: Avoid
exercise in presence of ketosis. Muscles
can’t use sugar if not enough insulin available
• Hypoglycemia – Exercise increases insulin
sensitivity. Low BS can result if pt on insulin
or sulfonylurea drugs
• 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
• Depression is greater in individuals with
diabetes
– Can impact self-care behaviors
– 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)
• Type 1 DM: dilated, comprehensive eye
exam within 3-5 yrs of diagnosis, then yearly
• Type 2 DM: dilated, comprehensive eye
exam shortly after diagnosis & then yearly
• 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
• Trigs <150
• HDL >40 in men
• HDL >50 in women
• LDL <100
– (consider statin therapy if LDL >100)
• LDL <70 in those with overt CVD
• BP Goal <130 systolic/< 80 diastolic
• Consider daily aspirin (75-162 mg/day)
– In people with diabetes between 30-40 years of
age in presence of CV risk factors
– Not recommended in anyone <21 yrs of age
due to risk of Reye’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
• Should be #1 intervention
• We have a smoking cessation
counselor at OSUMC!!
ls
e
0%
Fa
0%
Tr
ue
In patients with
type 2 DM,
ACE’s and
ARB’s have
been shown to
protect kidney
function. (A)
1. True
2. False
Complications: Kidney
• ACE’s &/or ARB’s have been shown to
delay nephropathy (contraindicated in pg)
• Screen annually for microalbuminuria:
– in type 1 DM, diagnosed > 5 yrs,
– in type 2 DM at diagnosis, and
– during pregnancy
• Screen annually for serum creatinine & GFR
Complications: Kidneys
• Dietary protein reduction may be
needed if CKD present
• 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
• Foot Exam Should Be Done:
– at diagnosis of type 2
– 5 yrs after diagnosis of type 1
– at least annually thereafter
Diabetes
Complications: FEET
• Includes use of monofilament, tuning
fork, palpation and visual inspection
• Initial screening for PAD (Doppler Study
or ABI – ankle brachial index)
Other Neuropathies:
Autonomic diabetic neuropathy
– Resting tachycardia
– Exercise intolerance
– Orthostatic hypotension
– Constipation
– Gastroparesis
– Erectile dysfunction
– Brittle diabetes
– Hypoglycemic unawareness
Immunizations – Page S24
• Flu vaccine annually >6 months of age
w/DM
• At least one lifetime pneumococcal
vaccine for adults with diabetes.
Diabetes Care:
Inpatient Setting
• Glucose goals for critically ill:
– 110 - <140 (A)
• Goals for non-critically ill:
–fasting <126 and
–random glucoses <180-200 (E)
Insulin in the
Inpatient Setting
• “Sliding scale” or “correction scale”
is NOT effective as monotherapy
and is NOT recommended
• What is recommended?
Meal-time coverage a “correction”
scale, and basal insulin
Diabetes Self
Management Education
(DSME)
• People with diabetes need education from
qualified health care providers with
professional training (CDE’s)
• Should be reimbursed by 3rd party payors
• Education should be on-going (yearly)
References
• You have been given an overview of
your printed Diabetes Care article.
• Over 200 references to access for
future lectures if needed
• Thank you for your time!
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