By Eileen B. Wyner, NP
Bulfinch Medical Group
Every year the multidisciplinary Professional Practice Committee of the American Diabetes Association (ADA) publishes a set of guidelines and recommendations on the diagnosis and treatment of diabetes for both adults and children. These standards guide us in how and when to screen for, diagnose and treat diabetes; how to monitor for complications; and how to educate patients in their self-management strategies.
These standards of care provide concrete data about goals of treatment, but they are not meant to be the only approach to care. Rather, they provide a guideline for the care of a person with diabetes; providers rely on their best clinical judgment for each individual they care for and adapt the guidelines as needed. Last year I did a review of the ADA Guidelines along with the specific updates published (you can refer to that post here). This year there were 12 revisions published which I will highlight this week and next. Please remember that these are guidelines— always review your personal health care plan with your health care provider(s).
Screening for Type 1 Diabetes
Type 1 Diabetes is generally diagnosed with an acute presentation of hyperglycemia and even ketoacidosis. There is no evidence that screening the general population for Type 1 Diabetes is helpful, but there is valid evidence that measuring islet autoantibodies in relatives of people with Type 1 Diabetes will identify at-risk individuals. Those identified can be referred to clinical studies where they can learn about their potential for developing Type 1 Diabetes and what symptoms to watch for. Lifestyle education would also be provided and more frequent screening instituted.
Prevention/Delay of Type 2 Diabetes
There are several random controlled studies showing that people at high risk for developing Type 2 Diabetes can decrease their rate of onset with certain interventions. These interventions may include lifestyle changes and even medication in some instances. ADA supports formal education for people with impaired glucose tolerance and an A1C between 5.7 and 6.4%. People who fall into this category also need to be monitored annually for their blood sugar values and assessed for cardiovascular risk factors (obesity, hypertension, and high cholesterol).
I think one of the most important things we do as diabetes providers is helping people learn how to monitor their blood sugars at home and follow these patterns for better control. However, there has been some discussion in the literature about the clinical utility and expense for self-monitoring of blood glucose (SMBG) in people who aren’t on aggressive insulin or not on insulin at all. ADA has approached this issue by stating that frequency and timing of SMBG should be decided on an individual basis based on the person’s needs and goals for treatment. People using MDI or an insulin pump need frequent SMBG to assess for control and monitor for hypoglycemia. People using less frequent insulin or non-insulin therapies may check SMBG on a more variable schedule that should be determined with the health care provider. It’s also important to review testing technique at times to be sure the results are accurate.
DSME and Support Groups
ADA has always advocated for education and support for people with diabetes, and now is supporting formal education for pre-diabetic patients. ADA supports third-party payer reimbursement for both these services.
Hypoglycemia awareness and management should be frequently reviewed with patients. The self-management plan should always be re-evaluated if there have been one (1) or more episodes of severe hypoglycemia (inability to handle the episode on your own). People with severe hypoglycemia or hypoglycemia unawareness may need the targets for glycemic control raised. People with declining cognition need to be assessed frequently for hypoglycemia by their providers and family members. Adjustments in their glycemic management plan will also need to be made.
To view the full set of Clinical Practice Recommendations for 2013, click here.