Baskets of Care Diabetes Subcommittee

Transcription

1 Baskets of Care Diabetes Subcommittee Disclaimer: This background information is not intended to be a comprehensive scientific discussion of the topic, but rather an attempt to provide a baseline level of information for anyone unfamiliar with the subject matter. Background: Diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. The cause of diabetes continues to be a mystery, although both genetics and environmental factors such as obesity and lack of exercise appear to play roles. There are 23.6 million children and adults in the United States, or 7.8% of the population, who have diabetes. While an estimated 17.9 million have been diagnosed with diabetes, unfortunately, 5.7 million people (or nearly one quarter) are unaware that they have the disease. In order to determine whether or not a patient has pre-diabetes or diabetes, health care providers conduct a Fasting Plasma Glucose Test (FPG) or an Oral Glucose Tolerance Test (OGTT). Either test can be used to diagnose pre-diabetes or diabetes. The American Diabetes Association recommends the FPG because it is easier, faster, and less expensive to perform. With the FPG test, a fasting blood glucose level between 100 and 125 mg/dl signals prediabetes. A person with a fasting blood glucose level of 126 mg/dl x 2 or higher or a single blood glucose of 200 mgm% or greater has diabetes. In the OGTT test, a person's blood glucose level is measured after a fast and two hours after drinking a glucose-rich beverage. If the two-hour blood glucose level is between 140 and 199 mg/dl, the person tested has pre-diabetes. If the two-hour blood glucose level is at 200 mg/dl or higher, the person tested has diabetes. Diabetes can be categorized into four major types: Type 1 diabetes - Results from the body's failure to produce insulin, the hormone that "unlocks" the cells of the body, allowing glucose to enter and fuel them. It is estimated that 5-10% of Americans who are diagnosed with diabetes have type 1 diabetes. Type 2 diabetes - Results from insulin resistance (a condition in which the body fails to properly use insulin), combined with relative insulin deficiency. Most Americans who are diagnosed with diabetes have type 2 diabetes. Gestational diabetes - Immediately after pregnancy, 5% to 10% of women with gestational diabetes are found to have diabetes, usually, type 2.

2 Pre-diabetes - Pre-diabetes is a condition that occurs when a person's blood glucose levels are higher than normal but not high enough for a diagnosis of type 2 diabetes. There are 57 million Americans who have pre-diabetes, in addition to the 23.6 million with diabetes. Diabetes Complications Patients with diabetes are at risk for many serious complications, including the following: Heart Disease and Stroke - People with diabetes have extra reason to be mindful of heart and blood vessel disease. Diabetes carries an increased risk for heart attack, stroke, and complications related to poor circulation. Kidney Disease - Diabetes can damage the kidneys, which not only can cause them to fail, but can also make them lose their ability to filter out waste products. Eye Complications - Diabetes can cause eye problems and may lead to blindness. People with diabetes do have a higher risk of blindness than people without diabetes. Early detection and treatment of eye problems can save sight. Diabetes, Oral Health and Hygiene - There are many bacteria in the mouth. If those germs settle into the gums, gum disease can develop. Diabetic Neuropathy and Nerve Damage - One of the most common complications of diabetes is diabetic neuropathy. Neuropathy means damage to the nerves that run throughout the body, connecting the spinal cord to muscles, skin, blood vessels, and other organs. Foot Complications - People with diabetes can develop many different foot problems. Foot problems most often happen when there is nerve damage in the feet or when blood flow is poor. Skin Complications - As many as one-third of people with diabetes will have a skin disorder caused or affected by diabetes at some time in their lives. In fact, such problems are sometimes the first sign that a person has diabetes. Fortunately, most skin conditions can be prevented or easily treated if caught early. Gastroparesis and Diabetes - Gastroparesis is a disorder that affects people with both type 1 and type 2 diabetes. Depression - Feeling down once in a while is normal. But some people feel a sadness that just won't go away. Life seems hopeless. Feeling this way most of the day for two weeks or more is a sign of serious depression.

3 Diabetes Management The management of diabetes includes nutrition therapy, physical activity, selfmanagement strategies, and pharmacologic therapy recommendations, as well as the prevention and diagnosis of diabetes-associated complications and risk factors. Nutrition Therapy Medical nutrition therapy for diabetes emphasizes improving metabolic outcomes. Major goals are to attain and maintain in the normal or as close to normal range as is safely possible blood glucose, blood pressure and lipid/lipoprotein levels. These goals help reduce the risk for chronic complications of diabetes and macro- and microvascular disease. Weight loss is also an important goal because it improves insulin resistance, glycemic control, blood pressure and lipid profiles. Moderate weight loss (5% of body weight) can improve fasting blood glucose in many overweight or obese. Physical Activity The positive benefits of physical activity include improved blood pressure values, improved lipid profile, improved cardiac status, increased insulin sensitivity, more effective weight management and improved glycemic control, and it helps in the management of depressive symptoms. Because the positive effects of increased physical activity diminish within days of the cessation of exercise, regular activity is recommended. Weight Management Weight loss is also an important goal because it improves insulin resistance, glycemic control, blood pressure and lipid profiles. Education for Self-Management Adequate self-management support for patients requires integration of available self-management education and support resources into routine care. Appropriate education may require the expertise of the diabetes educator. Foot Care Education should be tailored to patient s current knowledge, individual need and risk factors. Patient s should be aware of their risk factors and appropriate measures to avoid complications.

4 Pharmacologic Therapy Medical nutrition therapy may be all that is required to treat diabetes, especially for the patient with early mild symptomatic disease. Medical nutrition therapy should be maintained throughout the course of the disease, even as pharmacologic agents are used. Oral agent medications are generally used if medical nutrition therapy alone does not succeed in obtaining patients' goals within a reasonable time frame, usually no longer than two to three months. At the time of diagnosis, if patients have severe symptomatic disease, insulin should be initiated. With appropriate educational support and care, the risks of insulin may not differ from many oral agents. In some circumstances when glucose intolerance is significant and the patient is unwilling to consider insulin or it is not felt to be appropriate, the initiation of combinations of oral agents can be appropriate. Insulin is indicated when there is a failure to achieve treatment goals with oral agents. It is important to remember that patients may move off of specific pharmacologic therapies as lifestyle changes are made that improve glycemic control. Diabetes is a progressive disease, however, and the use of pharmacologic agents will likely become necessary in the majority of patients, even if they are able to follow through with nutrition and physical activity recommendations. Supporting Evidence: A. Institute for Clinical Systems Improvement Guideline: Diabetes Mellitus in Adults, Type 2; Diagnosis & Management of. Evidence based guideline, which provides a comprehensive approach to the diagnosis and management of prediabetes and type 2 diabetes mellitus in adults. Management includes nutrition therapy, physical activity, weight management, self-management strategies, and pharmacologic therapy recommendations, as well as the prevention and diagnosis of diabetes-associated complications and risk factors. B. American Diabetes Association Clinical Practice Recommendations 2009, found at: Summary of current recommendations for medical care in diabetes. C. Standards of medical care in diabetes. V. Diabetes care. American Diabetes Association - Professional Association (revised 2008 Jan). 8 pages. NGC: Guideline to provide evidence based principles and recommendations for diabetes management and to provide clinicians, patients, researchers, payers, and other

5 interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care; target population includes: adults and children with type 1 diabetes, adults and children with type 2 diabetes, pregnant and lactating women with diabetes and older adults with diabetes. D. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of Microvascular complications. American Association of Clinical Endocrinologists - Medical Specialty Society (revised 2007). 6 pages. NGC: Guideline to provide clinicians with clear and accessible guidelines to care for patients with diabetes mellitus including a target population of children, adolescents, and adults with or at risk of developing E. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of Screening and diagnosis. American Association of Clinical Endocrinologists - Medical Specialty Society (revised 2007). 3 pages. NGC: Guideline to provide clinicians with clear and accessible guidelines to care for patients with diabetes mellitus including a target population of children, adolescents, and adults with or at risk of developing F. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of Prevention of type 2 diabetes mellitus. American Association of Clinical Endocrinologists - Medical Specialty Society (revised 2007). 4 pages. NGC: Guideline to provide clinicians with clear and accessible guidelines to care for patients with diabetes mellitus including a target population of children, adolescents, and adults with or at risk of developing G. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of Glycemic management. American Association of Clinical Endocrinologists - Medical Specialty Society (revised 2007). 19 pages. NGC: Guideline to provide clinicians with clear and accessible guidelines to care for patients with diabetes mellitus including a target population of children, adolescents, and adults with or at risk of developing H. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of Nutrition and diabetes. American Association of Clinical Endocrinologists - Medical Specialty Society

6 (revised 2007). 4 pages. NGC: Guideline to provide clinicians with clear and accessible guidelines to care for patients with diabetes mellitus including a target population of children, adolescents, and adults with or at risk of developing I. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of Hypertension management. American Association of Clinical Endocrinologists - Medical Specialty Society (revised 2007). 6 pages. NGC: Guideline to provide clinicians with clear and accessible guidelines to care for patients with diabetes mellitus including a target population of children, adolescents, and adults with or at risk of developing J. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of Lipid management. American Association of Clinical Endocrinologists - Medical Specialty Society (revised 2007). 8 pages. NGC: Guideline to provide clinicians with clear and accessible guidelines to care for patients with diabetes mellitus including a target population of children, adolescents, and adults with or at risk of developing Areas of Current Clinical Review and Discussion: Statin Use Goals for BP Aspirin Use Treatment with ACE Inhibitors or ARBs Thiazide Diuretics A1c Management Prediabetes Basket of Care Scope samples: Management of prediabetes in adults. Management of type 2 diabetes mellitus in adults Management of type 2 diabetes mellitus, including risk reduction strategies for hypertension and hyperlipidemia, in adults without other existing comorbidities