ADA Diabetes Guidelines 2016

ADA Diabetes Guidelines 2016
Wendy Langen

DM guidelines We are doing the ADA There are others.
WHO is similar, without HgA1c or RGT, FPG and OGTT are the same AACE is similar, without HgA1C, FPG and OGTT are the same

http://care. diabetesjournals. org/site/misc/2016-Standards-of-Care
“Standards of Medical Care in Diabetes—2014” comprises all of the current and key clinical practice recommendations of the American Diabetes Association (ADA) These Standards of Care are revised annually by the ADA’s multidisciplinary Professional Practice Committee (PPC) For the current revision, PPC members systematically searched Medline for human studies related to each subsection and published since 1 January 2013 Recommendations were revised based on new evidence or, in some cases, to clarify the prior recommendations or match the strength of the word to the strength of the evident A table linking the changes in the recommendations to new evidence can be reviewed at As for all position statements, the Standards of Care were reviewed and approved by the Executive Committee of ADA’s Board of Directors, which includes health care professionals, scientists, and lay people Feedback from the larger clinical community was valuable for the 2014 revision of the Standards of Care; readers who wish to comment on the “Standards of Medical Care in Diabetes—2014” are invited to do so at ADA funds development of the Standards of Care and all ADA position statements out of its general revenues and does not use industry support for these purposes The slides are organized to correspond with sections within the “Standards of Medical Care in Diabetes—2014” While not every section in the document is represented, these slides do incorporate the most salient points from the Position Statement

New in 2016 No one test is better than another
fasting plasma glucose, 2-h plasma glucose after a 75-g oral glucose tolerance test, and A1C criteria New Obesity Management section for the Treatment of Type 2 Diabetes “Atherosclerotic cardiovascular disease” (ASCVD) has replaced the former term “cardiovascular disease” (CVD), as ASCVD is a more specific term.

New in 2016 consider aspirin therapy in women aged >60 years has been changed to include women aged >50 years. A recommendation was also added to address antiplatelet use in patients aged >50 years with multiple risk factors. Inpatient diabetes care section

ADA Evidence Grading System for Clinical Recommendations
Level of Evidence Description A Clear or supportive evidence from adequately powered well- conducted, generalizable, randomized controlled trials Compelling nonexperimental evidence B Supportive evidence from well-conducted cohort studies or case-control study C Supportive evidence from poorly controlled or uncontrolled studies Conflicting evidence with the weight of evidence supporting the recommendation E Expert consensus or clinical experience The American Diabetes Association has developed a grading system for clinical recommendations (Table 1) This grading system was used to clarify and codify evidence that forms the basis for each of the recommendations in the “Standards of Medical Care in Diabetes—2012” The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E This slide summarizes the description for each of these levels of evidence ADA. Diabetes Care 2012;35(suppl 1):S12. Table 1. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S11-S12. Table 1.

Criteria for the Diagnosis of Diabetes
A1C ≥6.5% OR Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) 2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT A random plasma glucose ≥200 mg/dL (11.1 mmol/L) Table 2, current diagnostic criteria for the diagnosis of diabetes, is divided into five slides On this slide, all four criteria are included: A1C ≥6.5% OR Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) 2-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT A random plasma glucose ≥200 mg/dL (11.1 mmol/L), in patients with classic symptoms of hyperglycemia or hyperglycemic crisis The subsequent four slides examine each of the four criteria in greater detail ADA. I. Classification and Diagnosis. Diabetes Care 2014;37(suppl 1):S15; Table 2 Reference American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S15; Table 2

Criteria described FPG≥126 mg/dL Fasting is no caloric intake for 8 hours 2-h plasma during an OGTT glucose ≥200 mg/dL OGTT is according to WHO: with 75 grams anhydrous glucose load dissolved in water RPG ≥200 mg/dL in a person with classic diabetic symptoms

Classification of Diabetes
Type 1 diabetes β-cell destruction Type 2 diabetes Progressive insulin secretory defect Other specific types of diabetes Genetic defects in β-cell function, insulin action Diseases of the exocrine pancreas Drug- or chemical-induced Gestational diabetes mellitus (GDM) The classification of diabetes includes four clinical categories Type 1 diabetes (due to β-cell destruction, usually leading to absolute insulin deficiency) Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) Other specific types of diabetes due to other causes; e.g., genetic defects in β-cell function, genetic defects in insulin action, diseases of the exocrine pancreas (such as cystic fibrosis), and drug- or chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation) Gestational diabetes mellitus (GDM)(diabetes diagnosed during pregnancy that is not clearly overt diabetes) Some patients cannot be clearly classified as having type 1 or type 2 diabetes Clinical presentation and disease progression vary considerably in both types of diabetes Occasionally, patients who otherwise have type 2 diabetes may present with ketoacidosis Children with type 1 diabetes typically present with the hallmark symptoms of polyuria/polydipsia and occasionally with diabetic ketoacidosis (DKA) However, difficulties in diagnosis may occur in children, adolescents, and adults, with the true diagnosis becoming more obvious over time ADA. I. Classification and Diagnosis. Diabetes Care 2014;37(suppl 1):S14 Reference American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S14

Testing guidelines Testing to detect type 2 diabetes and assess risk for future diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI ≥25 kg/m2) and who have one or more additional risk factors for diabetes. In those without these risk factors, testing should begin at age 45 years. (B)

Testing guidelines If tests are normal, repeat testing should be carried out at least at 3-year intervals. (E) To test for diabetes or to assess risk of future diabetes, A1C, FPG, or 2-h 75-g OGTT are appropriate. (B) In those identified with increased risk for future diabetes, identify and, if appropriate, treat other cardiovascular disease (CVD) risk factors. (B)

Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (1)
1. Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2*) and who have one or more additional risk factors: Physical inactivity First-degree relative with diabetes High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) Women who delivered a baby weighing >9 lb or were diagnosed with GDM Hypertension (≥140/90 mmHg or on therapy for hypertension) HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L) Women with polycystic ovarian syndrome (PCOS) A1C ≥5.7%, IGT, or IFG on previous testing Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) History of CVD The three primary criteria for testing for diabetes in asymptomatic adult individuals (Table 4) are summarized on two slides; this slide (Slide 1 of 2) includes: Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2) and have additional risk factors1 Testing should be considered in adults of any age with BMI ≥25 kg/m2 and one or more of the known risk factors listed on this slide1 There is compelling evidence that lower BMI cut-points suggest diabetes risk in some racial and ethnic groups1 In a large multiethnic cohort study, for an equivalent incidence rate of diabetes conferred by a BMI of 30 kg/m2 in whites, the BMI cutoff value was 24 kg/m2 in South Asians, 25 mg/m2 in Chinese persons, and 26 kg/m2 in African-Americans2 *At-risk BMI may be lower in some ethnic groups. ADA. Testing in Asymptomatic Patients. Diabetes Care 2012;35(suppl 1):S14. Table 4. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S14. Table 4. Chiu M, Austin PC, Manuel DG, Shah BR, Tu JV. Deriving ethnic-specific BMI cutoff points for assessing diabetes risk. Diabetes Care 2011;34:

Which of the following labs makes for a diagnosis of diabetes, according to the ADA?
HgA1C>6.5 FPG ≥126 mg/dl OGTT≥200 mg/dl Random glucose ≥200 mg/dl with Sx

A1C ≥6.5% or Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) 2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT A random plasma glucose ≥200 mg/dL (11.1 mmol/L)

2-hour Plasma Glucose On OGTT
What is Prediabetes? Fasting Plasma Glucose 2-hour Plasma Glucose On OGTT Hemoglobin A1C Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus 126 mg/dL Prediabetes Impaired Fasting Glucose Prediabetes Impaired Glucose Tolerance 200 mg/dL 6.5% Prediabetes 100 mg/dL 140 mg/dL 5.7% Normal Normal Normal WHAT IS PREDIABETES? ANIMATION SLIDE Prediabetes is when an individual’s plasma glucose level is higher than normal, but not yet high enough to be diagnostic of having diabetes. This is based upon an impaired fasting glucose, impaired glucose tolerance, and/or an elevated hemoglobin A1C (A1C). Individuals with IFG, IGT and/or and elevated A1C have been referred to as having prediabetes, indicating the relatively high risk for the future development of diabetes. CLICK … By definition, IFG is a condition in which FPG levels range between 100 mg/dL (5.6 mmol/L) and 125 mg/dL (6.9 mmol/L) after an 8 to 12 hour fast. CLICK … IGT is defined as having 2-hour plasma glucose values from an OGTT of 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0 mmol/L). Levels above this, or if a 2-hour blood glucose rises to 200 mg/dl or above, a person has diabetes. CLICK … The American Diabetes Association’s Standards of Care also state that it is reasonable to consider an A1C range of 5.7–6.4% as having prediabetes. CLICK … Any abnormality must be repeated and confirmed on a different day than the original test. Although the above results can be used to diagnose diabetes, diagnosis can also be made based on unequivocal symptoms and a random glucose >200 mg/dL. Recommended Reference(s): Bullard KM, Saydah SH, Imperatore G, et al. Secular changes in U.S. Prediabetes prevalence defined by hemoglobin A1c and fasting plasma glucose: National Health and Nutrition Examination Surveys, Diabetes Care. 2013;36: American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2014;37 Suppl 1:S81-90. American Diabetes Association. Standards of Medical Care in Diabetes—2014 Diabetes Care. 2014;37:S14-S80. Any abnormality must be repeated and confirmed on a separate day The diagnosis of diabetes can also be made based on unequivocal symptoms and a random glucose >200 mg/dL Adapted from: American Diabetes Association. Diabetes Care. 2014;37 Suppl 1:S81-90. 19

Impaired Fasting Glucose and Impaired Glucose Tolerance
Not clinical entities but rather risk factors for diabetes and cardiovascular disease Associated with: Physical inactivity Obesity (especially abdominal, or visceral) Dyslipidemia High triglycerides and/or low HDL cholesterol Hypertension IMPAIRED FASTING GLUCOSE AND IMPAIRED GLUCOSE TOLERANCE These plasma glucose levels do not meet the criteria for diabetes, but are considered too high to be considered normal. IFG and IGT should not be viewed as clinical entities in their own right but rather risk factors for diabetes and cardiovascular disease (CVD). IFG and IGT are associated with physical inactivity, obesity (especially abdominal obesity), dyslipidemia with high triglycerides and/or low HDL cholesterol, and hypertension. Recommended Reference(s): American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2014;37 Suppl 1:S81-90. American Diabetes Association. Diabetes Care. 2014:37 Suppl 1:S81-90. 20

Prediabetes: IFG, IGT, Increased A1C
Categories of increased risk for diabetes (prediabetes)* FPG 100–125 mg/dL (5.6–6.9 mmol/L): IFG (impaired fasting glucose) OR 2-h plasma glucose in the 75-g OGTT 140–199 mg/dL (7.8–11.0 mmol/L): IGT (impaired glucose tolerance) A1C 5.7–6.4% *The World Health Organization (WHO) and a number of other diabetes organizations define the cutoff for IFG at 110 mg/dL (6.1 mmol/L) *For all three tests, risk is continuous, extending ADA. I. Classification and Diagnosis. Diabetes Care 2012;35(suppl 1):S13. Table 3. References Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20: Genuth S, Alberti KG, Bennett P, et al., for the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 2003;26: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S13. Table 3.

Prediabetes Process for Diagnosing
Screen A Assess and Advise F Follow-up E Evaluate progress Develop a process within your office to make it easier to diagnose patients who may have prediabetes. The acronym SAFE can be used to Screen Assess and advise about the treatment management if warranted Follow-up Evaluate the patient’s progress Let’s discuss each of these steps and how to incorporate them into diagnosing and monitoring your patients with prediabetes. 23

Primary prevention of diabetes
Among individuals at high risk for developing type 2 diabetes, structured programs emphasizing lifestyle changes including moderate weight loss (7% body weight) and regular physical activity (150 min/week), with dietary strategies including reduced calories and reduced intake of dietary fat, can reduce the risk for developing diabetes and are therefore recommended. (A)

Individuals at high risk for type 2 diabetes should be encouraged to achieve the U.S. Department of Agriculture (USDA) recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake). (B)

Patients with IGT (A), IFG (E), or an A1C of 5.7–6.4% (E) should be referred to an effective ongoing support program for weight loss of 5–10% of body weight and increase in physical activity to at least 150 min/week of moderate activity such as walking. Monitoring for the development of diabetes in those with pre-diabetes should be performed every year. (E)

In addition to lifestyle counseling, metformin may be considered in those who are at very high risk for developing diabetes (combined IFG and IGT plus other risk factors such as A1C >6%, hypertension, low HDL cholesterol, elevated triglycerides, or family history of diabetes in a first-degree relative) and who are obese and under 60 years of age. (E)

Activity Your patient has the following Labs: FPG= 120 GTT= 178
Ha1c= 6 Turn to your Patient and tell them what they should do.

Management of diabetes

Yale Diabetes Center Mnemonic Glucose bad
G lycemic control. Review glucose log, assess hypo/hyperglycemic symptoms. Check HbA1c Q 3-6 mo with a target <7.0% understanding that individualization is important. L ipids. Order complete lipid profile once or multiple depending on patient’s risk factors and target goal. Consider statins in all diabetic patients >40 y/o with at least one other CVD risk factor, unless contraindicated. U rine. Screen for microalbuminuria , check serum Cr and UA yearly in all type II; after five years in type I. If spot albumin : Cr ratio >30ug/mg consider ACE or ARB, even if normotensive.

C iggaretts. Assess smoking habits; counsel: consider referral, nicotine patch/gum, medications, etc. O pthalmological. Monitor retina status via eye care professional or with retinal photography once yearly in type II. S ex-Related Topics. Men: inquire about erectile dysfunction; treat/refer as indicated. Women: birth control in those not in good glycemic control. Extremeties. Inspect feet at each visit: neuropathy, vascular disease (check pulses), calluses bony deformities, incipient ulcerations, nail/foot fungus. Review foot care. Refer to podiatrist as indicated. Refer to vascular surgeon if claudication or ulceration + abnormal pulses.

B lood pressure. Check at each visit; treat aggressively. Consider ACEI or ARB as first-line therapy unless contraindicated. Target is generally < 130/80 A spirin. Use aspirin for secondary prevention in any patient with established CVD, per routine guidelines. Consider aspirin ( mg) for primary prevention in adults with diabetes at 10-year risk of CVD events>10% (ie men>age 50 and women > age 60 with at least one other major CVD risk factor (family history, hypertension, dyslipidemia, albuminuria, or smoking). D ental. Recommend Q6 mo dental visits for cleanings and aggressive treatment of periodontal disease.

Glucose monitoring Self-monitoring of blood glucose (SMBG) should be carried out three or more times daily for patients using multiple insulin injections or insulin pump therapy. (A) For patients using less frequent insulin injections, noninsulin therapies, or medical nutrition therapy (MNT) alone, SMBG may be useful as a guide to the success of therapy. (E) To achieve postprandial glucose targets, postprandial SMBG may be appropriate. (E)

A1C monitoring in diabetics
Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). (E) Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals. (E)

How often should you test HgA1C in a diabetic not meeting goals?
It is not necessary Yearly Twice per year Quarterly

Glycemic goals Even lower for some= A1C<7
for selected individual patients, providers might reasonably suggest even lower A1C goals than the general goal of <7%, if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Such patients might include those with short duration of diabetes, long life expectancy, and no significant CVD. (B) Is this the same as the criteria for diagnosis of DM?

Glycemic goals Higher for others
Conversely, less stringent A1C goals than the general goal of <7% may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, or extensive comorbid conditions and those with longstanding diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin. (C)

Pharmacologic treatment
Start with lifestyle change And Metformin Add others as needed GLP-1 RA Sulfonynuria Thiazolidin DPP-4 inhibitors SGLT2 inhibitor Do not delay insulin therapy if not at goal

L= Lipids

Lipid screening in DM fasting lipid profile at diagnosis, then every 5 years if normal- ADA guideline AHA/ACC cholesterol guideline- Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients: with overt CVD. (A) Moderate intensity for risk <7.5% High intensity for risk > 7.5%

Lipid reality in DM In reality, most diabetics are on a statin, so they get yearly fasting lipid panels It would be hard to test you on something that has conflicting guidelines from ADA (screen diabetics Q 5 years) and AHA/ACC (diabetics years with levels should be on a statin)

No ASCVD, and DM Ages 40-75: If LDC-C is , and DM, then moderate intensity statin (unless ASCVD, or risk >7.5% then high intensity) If <40 or >75, maybe statin

How often do you monitor lipids in a diabetic?
Monthly Twice per year Yearly Every 3 years Every 5 years if normal Every 5 years if normal

U= Urine

Routine urinalysis Perform an annual test to assess urine albumin excretion in type 1 diabetic patients with diabetes duration of ≥5 years and in all type 2 diabetic patients starting at diagnosis. (E) Measure serum creatinine at least annually in all adults with diabetes regardless of the degree of urine albumin excretion. The serum creatinine should be used to estimate GFR and stage the level of chronic kidney disease (CKD), if present. (E)

How often should a controlled diabetic have their creatinine checked?
Daily Quarterly Yearly Every 3 years Annually

Prevent nephropathy To reduce the risk or slow the progression of nephropathy, optimize glucose control. (A) To reduce the risk or slow the progression of nephropathy, optimize blood pressure control. (A) In the treatment of the nonpregnant patient with micro- or macroalbuminuria, either ACE inhibitors or ARBs should be used. (A)

Prevent nephropathy If one class is not tolerated, the other should be substituted. (E) When ACE inhibitors, ARBs, or diuretics are used, monitor serum creatinine and potassium levels for the development of acute kidney disease and hyperkalemia. (E)

Prevent nephropathy Reduce protein intake in some individuals.
Protein intake to 0.8–1.0 g · kg body wt–1 · day–1 in individuals with diabetes and the earlier stages of CKD and to 0.8 g · kg body wt–1 · day–1 in the later stages of CKD may improve measures of renal function (urine albumin excretion rate, GFR) and is recommended. (B)

A 55 year old female with DM 2 and CAD has microalbuminuria and a serum creatinine of 2. What medication will help nephropathy most? BB Statin ACE ASA

C= cigarettes Stop smoking Encourage abstinence
In any former smoker, no matter how remote

O= Opthalmology Eye screenings
Adults and children aged 10 years or older with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. (B) Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes. (B)

Eye screenings Subsequent examinations for type 1 and type 2 diabetic patients should be repeated annually by an ophthalmologist or optometrist. Less-frequent exams (every 2–3 years) may be considered following one or more normal eye exams. Examinations will be required more frequently if retinopathy is progressing. (B) Photos may help

S= Sex Screen for erectile dysfunction, a vascular disease, and a good reason to keep glucose at goal Inquire about birth control, assess for GDM

E= extremities

Screen for DPN All patients should be screened for distal symmetric polyneuropathy (DPN) at diagnosis and at least annually thereafter, using simple clinical tests. (B) What are those tests?

Foot care For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations. The foot examination should include inspection, assessment of foot pulses, and testing for loss of protective sensation (10-g monofilament plus testing any one of: vibration using 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold). (B)

Foot care Provide general foot self-care education to all patients with diabetes. (B) A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet, especially those with a history of prior ulcer or amputation. (B) For PD and SOAP notes, look at all diabetics’ feet every time (and document)!

BP = Blood pressure Patients with diabetes should be treated to a systolic blood pressure <140 And to a diastolic blood pressure <90 mmHg. (B) Patients with a systolic blood pressure of 130–139 mmHg or a diastolic blood pressure of 80–89 mmHg may be given lifestyle therapy alone for a maximum of 3 months, and then if targets are not achieved, be treated with addition of pharmacological agents. (E) Patients with more severe hypertension (systolic blood pressure ≥140 or diastolic blood pressure ≥90 mmHg) at diagnosis or follow-up should receive pharmacologic therapy in addition to lifestyle therapy. (A)

BP in diabetics Include DASH ACE or ARB and if needed,
Thiazide diuretic if GFR≥30 ml/min per 1.73 m2 Loop diuretic if GFR <30 If ACE inhibitors, ARBs, or diuretics are used, kidney function and serum potassium levels should be closely monitored. (E)

A= aspirin, ASA in DM Consider aspirin therapy (75–162 mg/day) as a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk (10-year risk >10%). This includes most men (and now women) >50 years of age who have at least one additional major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria). (C)

Which of the following should be used in a diabetic with heart disease?
Aspirin ACE inhibitor Statin Beta carotene Chromium Vitamin E ASA, ACE, Statin NOT the others

D= Dental care Everyone should brush and floss
Patients with A1C>9% get 3 times more periodontitis, 33% diabetics have severe periodontitis, resulting in tooth and jaw loss Treating periodontitis can reduce A1C by 1% Annual dental exam for diabetics (CDC) Cleaning and check every 6 months (CDC) For PD and SOAP notes, look at all diabetics’ mouths every time (and document)!

Still more DM recommendations
Advise all patients not to smoke. (A) In patients with known CVD, ACE inhibitor (C) and aspirin and statin therapy (A) (if not contraindicated) should be used to reduce the risk of cardiovascular events. In patients with a prior myocardial infarction, B-blockers should be continued for at least 2 years after the event. (B)

Medical Nutrition Therapy (MNT)
Individuals who have pre-diabetes or diabetes should receive individualized medical nutrition therapy (MNT) as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT. (A) Because MNT can result in cost-savings and improved outcomes (B), MNT should be covered by insurance and other payors. (E)

Weight loss In overweight and obese insulin-resistant individuals, modest weight loss has been shown to reduce insulin resistance. Thus, weight loss is recommended for all overweight or obese individuals who have or are at risk for diabetes. (A) For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short-term (up to 1 year). (A)

Weight loss For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and protein intake (in those with nephropathy) and adjust hypoglycemic therapy as needed. (E) Physical activity and behavior modification are important components of weight loss programs and are most helpful in maintenance of weight loss. (B)

Nutrition recommendations
Sugar alcohols and nonnutritive sweeteners are safe when consumed within the acceptable daily intake levels established by the Food and Drug Administration (FDA). (A) If adults with diabetes choose to use alcohol, daily intake should be limited to a moderate amount (one drink per day or less for adult women and two drinks per day or less for adult men). (E)

Nutrition recommendations
Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety. (A) Benefit from chromium supplementation in people with diabetes or obesity has not been conclusively demonstrated and, therefore, cannot be recommended. (C) Individualized meal planning should include optimization of food choices to meet recommended dietary allowances (RDAs)/dietary reference intakes (DRIs) for all micronutrients. (E)

Bariatric surgery Bariatric surgery should be considered for adults with BMI >35 kg/m2 and type 2 diabetes, especially if the diabetes or associated comorbidities are difficult to control with lifestyle and pharmacologic therapy. (B) Patients with type 2 diabetes who have undergone bariatric surgery need life-long lifestyle support and medical monitoring. (E) New article, JAMA

Diabetes self-management Education
People with diabetes should receive diabetes self-management education (DSME) according to national standards when their diabetes is diagnosed and as needed thereafter. (B)

Physical Activity People with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (50–70% of maximum heart rate). (A) In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance training three times per week. (A)

Which of the following meets the ADA guidelines for moderate aerobic activity in a diabetic?
25 minutes, 6 days per week 30 minutes, 5 days per week Two and a half hours per week 90 minutes per day 150 minutes per week, the first 2

Psychosocial assessment
Assessment of psychological and social situation should be included as an ongoing part of the medical management of diabetes. (E) Screen for psychosocial problems such as depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment when self-management is poor. (C)

Hypoglycemia Glucose (15–20 g) PO is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. If SMBG 15 min after treatment shows continued hypoglycemia, the treatment should be repeated. Once SMBG glucose returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. (E)

Hypoglycemia Glucogon may be prescribed and used.
Individuals with hypoglycemia unawareness or one or more episodes of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks, to partially reverse hypoglycemia unawareness and reduce risk of future episodes. (B)

A 55 year old diabetic patient presents to the ER confused
A 55 year old diabetic patient presents to the ER confused. He is speaking OK. Accucheck shows glucose of 50. What do you do?

Accucheck 50 and confusion, speaking OK
Give 10 units of insulin Give Glucose IV Give 20 units of insulin Give oral glucose 10 grams Oral glucose to conscious patient with hypoglycemia

A 55 year old diabetic patient presents to the ER confused
A 55 year old diabetic patient presents to the ER confused. He is speaking OK. Accucheck shows glucose of 400. What do you do?

Accucheck 400 and confusion, speaking OK
Give IV Glucose Give SQ insulin Give oral glucose 10 grams SQ insulin for hyper glycemia

Do no Harm What if you don’t know what the sugar is?
If at all possible, check. Giving sugar to a diabetic with hyperglycemia is better than giving insulin to a hypoglycemic diabetic. Why?

Vaccines Influenza yearly Pneumovac “routinely”
Hep B for all diabetics

Immunize Annually provide an influenza vaccine to all diabetic patients 6 months of age. (C) Administer pneumococcal polysaccharide vaccine to all diabetic patients ≥2 years of age. A one-time revaccination is recommended for individuals >64 years of age previously immunized when they were <65 years of age if the vaccine was administered >5 years ago. Other indications for repeat vaccination include nephrotic syndrome, chronic renal disease, and other immunocompromised states, such as after transplantation. (C)

A1C ≥6.5% or Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) 2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT A random plasma glucose ≥200 mg/dL (11.1 mmol/L)

Prediabetes: IFG, IGT, Increased A1C
Categories of increased risk for diabetes (prediabetes)* FPG 100–125 mg/dL (5.6–6.9 mmol/L): IFG (impaired fasting glucose) OR 2-h plasma glucose in the 75-g OGTT 140–199 mg/dL (7.8–11.0 mmol/L): IGT (impaired glucose tolerance) A1C 5.7–6.4% In 1997 and 203, The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus1,2 recognized an intermediate group of individuals whose glucose levels, although not meeting criteria for diabetes, are nevertheless too high to be considered normal This group was defined as having impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) IFG: fasting plasma glucose (FPG) of 100–125 mg/dL (5.6–5.9 mmol/L)* IGT: 2-hour plasma glucose (2-h PG) on the 75-g oral glucose tolerance test (OGTT) of 140–199 mg/dL (7.8–11.0 mmol/L) Individuals with IFG and/or IGT have been referred to as having prediabetes, indicating a relatively high risk for future development of diabetes IFG and IGT should not be viewed as clinical entities in their own right but rather risk factors for diabetes as well as cardiovascular disease (CVD) IFG and IGT are associated with obesity (especially abdominal or visceral obesity), dyslipidemia with high triglycerides and/or low HDL cholesterol, and hypertension Individuals with an A1C of 5.7–6.4% should be informed of their increased risk for diabetes as well as CVD and counseled about effective strategies to lower their risks (see Section IV. Prevention/Delay of Type 2 Diabetes) *The World Health Organization (WHO) and a number of other diabetes organizations define the cutoff for IFG at 110 mg/dL (6.1 mmol/L) *For all three tests, risk is continuous, extending ADA. I. Classification and Diagnosis. Diabetes Care 2012;35(suppl 1):S13. Table 3. References Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20: Genuth S, Alberti KG, Bennett P, et al., for the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 2003;26: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S13. Table 3.

Case Woman aged 68 without complaint is obese.
Denies PMHx, Takes no medications “Normal” vaccines of childhood in US. Never had a flu vaccine. PE is negative FBS 156 an Ha1c 7.5. Does she have DM? Yes

New onset DM What do you do?
Make sure the foot and eye exams are documented well. UA, serum creatinine, Lipid panel

Educate patient Start Metformin Start ASA Which vaccines? flu

Flu Pneumovac Hep B

Specialists Ophthalmologist yearly Nutritionist for MNT
Dentist Q 12 months, cleaning Q 6 months Podiatrist as needed

Questions What’s on the test?
Cases, like here is a patient… Do they have DM? Or PreDM? What to do? Do you like the blue slides or black and white? Do you like the case questions even if there is no respnseware?

References

ADA Diabetes Guidelines 2016

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ADA Diabetes Guidelines 2016

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Presentation on theme: "ADA Diabetes Guidelines 2016"— Presentation transcript:

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About project

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