2012 ADA Clinical Practice Recommendations

By Eileen B. Wyner, NP
Bulfinch Medical GroupEileen W

Every year the American Diabetes Association 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 Diabetes, how to diagnose, how to monitor for complications, how to treat Diabetes and how to educate patients in their self-management strategies. A large body of evidence-based data is reviewed by the experts annually to provide the best possible information.

These standards of care provide concrete data about goals of treatment, but they are not meant to be the only approach to care. Providers rely on their best clinical judgment for each individual they care for.  Although well controlled Diabetes may lessen the instance of complications across the lifespan, there may be associated adverse affects in the process.  Some patients simply can’t tolerate tight control for example; or medications have side affects, the most concerning of which is hypoglycemia (which can be life threatening). While we all fall back on these guidelines, we also have to adapt them as needed.

There are many aspects of these Guidelines, but I want to discuss a few points a little more closely. The ADA Standards not only addresses medical management but strongly emphasizes the importance of Diabetes self –management education, or DSME. The ADA supports all patients receiving education with diagnosis of disease and ongoing education as needed. Education and knowledge about this chronic disease has been shown to improve physical and emotional health.  People with Diabetes who have ongoing educational updates—either in a group or one-to-one—have better control of their disease, better ability to prevent/manage complications, and have better quality of life.

The Standards also identify some other medical conditions that occur in the Diabetic population more so than in the general population. This doesn’t mean that everyone will get these conditions, but it is important to be aware of them:

  • Hearing impairment is more common —this may be due to neuropathy
  • Sleep apnea, especially in obese men, is common and is a risk factor for cardiovascular disease
  • Low testosterone in men, especially if they are obese, is more prevalent in the Diabetic population and may present with symptoms of fatigue and decreased libido (routine screening isn’t done for this condition, but if you are having any concerns it’s a good idea to bring this up with your health care provider)
  • Gum disease is more serious (not necessarily more common)
  • Poor blood sugar control and noncompliance are real concerns
  • People with Diabetes have a higher risk of cognitive impairment (this is an area that needs to be studied more closely, but long-term hyperglycemia seems to be a factor)

A Note about Driving

This year the ADA added a section on Diabetes and driving.  Driving with Diabetes is a topic I try to bring up often with my patients, especially if they’re older, have known visual problems, or have had frequent hypoglycemia. While there is data to show a small increase in the risk of motor vehicle accidents due to hypoglycemia and hypoglycemia unawareness, it’s a much smaller risk than those associated with teenage male drivers. The ADA is against blanket restrictions for people with Diabetes and advises health care providers to make individual assessments as needed.  Everyone who has a license is expected to drive with caution and care; Diabetes doesn’t mean you can’t drive, but it may mean that you need to be a little more cautious.

I tell all of my patients to wear medical identification. I prefer it be a bracelet or necklace, something that hangs off the body and is easily seen— a wallet card can’t be easily accessed in an emergency. Hypoglycemia can resemble drunk driving and valuable time for your health will be lost if you are involved in a driving incident and not acting yourself.  First responders will not think “hypoglycemia”; they will think “cocktails”.

And here are some other considerations to be aware of:  You may have neuropathy, so feeling the brake and gas pedals may be difficult. That may mean you will have to stop driving. Retinopathy may diminish your nighttime or peripheral vision. You may need to curtail your driving from dusk to dawn or stop driving altogether. If you have experienced hypoglycemia frequently or to extremes, you should discuss it with your health care provider. You may need to develop a detailed plan for driving such as checking your blood sugar before you get in the car and checking frequently on the road. And, always be sure to have glucose tablets in the car.

I encourage you to think about your own circumstances.  Do you need a refresher on your self-management care?  Talk to your health care provider and see about education opportunities. Is driving a little more challenging (aside from the normal challenge of maneuvering Boston’s roads)? Set up an appointment to see the eye doctor. Use this New Year as a chance to give yourself good care. You deserve it.

To view the full standards, click here.