standards of medical care in diabetes - 2008 jeri jennings mills, rd/ld, cde sami wood, rd/ld, cde...

Standards of Medical Care in Diabetes - 2008

Jeri Jennings Mills, RD/LD, CDESami 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 diabetesIn 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 auto-antibodies is not currently recommended

• Clinical studies are being done to test various methods of preventing type 1

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)

0%0%

1. Yes

2. No

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.

An A1C should be tested at least once yearly. (E)

0%0%

1. True

2. False

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

The ADA A1C goal for nonpregnant adults with diabetes is <7%. (A)

0%0%

1. True

2. False

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)

The ADA diabetic diet is the current recommendation for Medical NutritionTherapy (MNT). (A,E) 0%0%

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

Assessment of depression should be included in the medical management of diabetes. (E)

0%0%

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

Patients with type 2 DM should have a dilated eye exam within 5 years of diagnosis. (B)

1. True

2. False

0%0%

• 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

Individuals with diabetes should be started on statin therapy if they do not have CVD but are over age 40. (A) 0%0%

1. True2. 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

Smoking cessation counseling should be a treatment component of diabetes care. (B) 0%0%

1. True

2. False

SMOKING• Should be #1 intervention

• We have a smoking cessation counselor at OSUMC!!

In patients with type 2 DM, ACE’s and ARB’s have been shown to protect kidney function. (A) 0%0%

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)

A foot exam using a monofilament, tuning fork, palpation & visual exam should be done at least every 3 years. (B)

0%0%

1. True

2. False

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!