(ADA Diabetes Care Vol. 36, Supp. 1 2013)
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 >50 years of age or women >60 years of age who have at least one additional major risk factor (family history of CVD, hypertension, tobacco, dyslipidemia or albuminuria. Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk (10-year CVD risk <5%, such as in men <50 years of age and women <60 years of age, with no major additional CVD risk factors), since the potential adverse effects from bleeding likely offset the potential benefits. In patients in these age-groups with multiple other risk factors (e.g. 10-year risk 5% to10%), clinical judgment is required. Use aspirin therapy (75-162 mg/day) as a secondary prevention strategy in those with diabetes with a history of CVD. For patients with CVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used. Combination therapy with aspirin (75-162 mg/day) and clopidogrel (75 mg/day) is reasonable for up to a year after an acute coronary syndrome.
Monitoring Blood Glucose Control
Blood glucose testing and recording of results give individuals an active role in their health care and encourage responsibility. Self-blood glucose monitoring is essential to management of diabetes and must be emphasized as such. The monitoring system must be easy to use, easily portable, accurate and reliable. The frequency and timing of testing varies depending on the treatment regimen. The patient who is treated with dietary changes and exercise can use blood glucose test results as immediate feedback regarding the effects of their efforts. Positive feedback can reinforce those efforts and increase self-motivation. Patients should be given goals in writing for the blood glucose results. Recording of the results should be documented in a patient record book to enable the patient and health care provider to look at trends, recognize successes and assess the effectiveness of the medication changes. Patients should understand the use of A1C monitoring and the specific goal in diabetes management. They should know their A1C goal and current results.
Body Weight Management
Weight loss is recommended for all overweight or obese individuals who have or are at risk for diabetes. Most people newly diagnosed with Type 2 diabetes are overweight. Excess weight, particularly in the abdomen, makes it difficult for cells to respond to insulin, resulting in high blood glucose. Often, people with Type 2 diabetes are able to lower their blood glucose by losing weight and increasing physical activity. Losing weight also helps lower the risk for other health problems that especially affect people with diabetes, such as cardiovascular disease. A large study, called the Diabetes Prevention Program, showed that people at high risk for diabetes can prevent or delay the onset of the disease by losing 5% to 7%of their weight, if they are overweight — that’s 10 to 14 pounds for a 200-pound person.
Body Mass Index (BMI) should be used as a screening tool to identify weight status in adults. Body Mass Index (BMI) is a number calculated from a person’s weight and height. BMI is a fairly reliable indicator of body fatness for most people. BMI does not measure body fat directly, but research has shown that BMI correlates to direct measures of body fat, such as underwater weighing and dual energy x-ray absorptiometry (DXA). BMI can be considered an alternative for direct measures of body fat.
The standard weight status categories associated with BMI ranges for adults are shown in the following table.
18.5 – 24.9
25.0 – 29.9
30.0 and Above
In addition to BMI, measuring waist circumference is a useful tool to screen for possible health risks associated with overweight and obesity. Abdominal fat is associated with a greater risk for heart disease and Type 2 diabetes. Risk increased for women with a waist size greater than 35 inches and 40 inches for men.
For weight loss, either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term – up to two years. For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and protein intake (in those with nephropathy), and adjust hypoglycemic therapy as needed. Physical activity and behavior modification are important components of weight loss programs and are most helpful in maintenance of weight loss.
Diabetes patients must maintain a rigorous oral self-care regimen to minimize oral health problems that may complicate glycemic control since the mouth is the first part of the digestive process. Regular visits (generally twice a year) to their dentist for a dental examination and dental prophylaxis and necessary radiographs are recommended to achieve an optimal oral health status. This rate of dental visitation is dependent on the patient’s oral health status. Regular brushing and flossing are essential to keep the teeth and gums healthy. Denture cleaning tablets should be used daily or dentures should be soaked nightly in diluted bleach (1 ounce of bleach in 4 cups of water). A history of stroke or musculoskeletal disorders might necessitate the use of other mechanical or electric dental devices to accomplish optimal goals of oral health.
Cardiovascular disease is the major cause of morbidity and mortality for persons with diabetes. Hypertension and dyslipidemia are risk factors for cardiovascular disease and diabetes itself is an independent risk factor.
Patients should be educated in lipid management to prevent/manage CVD. A discussion of risk factors and symptomology of CVAs and MIs should be included. An annual fasting lipid panel is recommended and may be repeated upon MD recommendations. Goals for lipid management should be taught in education classes and at clinic visits. Baseline EKG/cardiac stress testing may be recommended.
Statins are the preferred drug of choice for elevated LDL levels in adults, unless contraindicated. Hypertriglyceridemia may warrant therapy with lifestyle and pharmacologic therapy such as fibric acid derivatives or niacin. Aspirin therapy should be considered as a primary prevention strategy for those at increased risk for CVD. A discussion of medication actions and side effects should be presented with education.
Lifestyle modifications would focus on healthy eating guidelines, moderation of alcohol intake, regular physical activity, tobacco cessation and weight reduction.
Back to topEye Care
Early detection and treatment of diabetic retinopathy is essential to preventing blindness in persons with diabetes. Diabetic retinopathy is the most frequent cause of new cases of blindness among adults ages 20 to 74 years. The longer a person has diabetes, the more likely they are to develop diabetic retinopathy, particularly if the diabetes is poorly controlled.
Knowledge of the presence of retinopathy is one more piece of evidence for the Primary Care Physician to utilize in the overall management of the diabetic patient.
The American Diabetes Association (ADA) recommends a dilated retinal eye examination by an ophthalmologist or optometrist as an annual standard of care for persons with diabetes. The ADA (2010) states that that high-quality mydriactic fundus photographs can detect most, but not all, clinically significant diabetic retinopathy if performed by a trained ophthalmic photographer and interpreted by a trained eye care provider. While retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam, which should be performed at least initially and at intervals thereafter as recommended by an eye care professional.
Screening for Adults
Type 1: ADA (2009-10) - Initial dilated and comprehensive exam within five years after onset with annual follow-up dilated exams. American Academy of Ophthalmology - Five years after onset and annually thereafter.
Type 2: ADA (2010) - Initial exam at the time of diagnosis, with annual follow-up dilated exams.
Screening for Children
American Diabetes Association Recommendations: The first ophthalmologic examination (ADA, 2010) should be obtained once the child is ≥ 10 years of age and has had diabetes for three to five years. The examination should include a dilated fundus examination. After the initial examination, annual routine follow-up is generally recommended. Less frequent examinations may be acceptable on the advice of an eye care professional. Although retinopathy most commonly occurs after the onset of puberty and after five to 10 years of diabetes duration, it has been reported in prepubertal children and with diabetes duration of only one to two years. Referrals should be made to eye care professionals with expertise in diabetic retinopathy, an understanding of the risk for retinopathy in the pediatric population, and experience of counseling the pediatric patient and family on the importance of early prevention/intervention.
American Academy of Pediatrics Recommendations: Screening in children three to five years after diagnosis if less than nine years old and annually thereafter.
Pediatric Endocrinologist Recommendations: Screening in children with a dilated retinal exam the first year after diagnosis, and not annually until adolescence or after puberty, but based on clinical judgment for each individual.
Further studies are warranted in the area of screening for youth. The frequency of exams may be determined based on the mutual findings of the primary care physician and eye care provider.
More frequent exams (than above recommendations) for both adults and children may be necessary based upon clinical findings. Regular eye examinations also allow for early diagnosis and treatment of other conditions affecting those with diabetes.
The goal of instructing a patient in daily foot care is the identification and prevention of foot problems that could lead to amputation. Most important is the daily inspection for problems and when to seek help from a health care professional. Other topics include appropriate footwear, management of minor foot problems, benefits of extra depth shoes, and the dangers of soaking feet, hot water bottles and heating pads. Additional information includes the avoidance of foot trauma and tobacco use cessation. Presence and degree of neuropathy, presence of peripheral vascular disease, and the implications for foot care. They should be instructed to remove their shoes and stockings and have their feet examined at each visit.
See also: Foot Exam Form (PDF)
(ADA Diabetes Care Vol. 36, Supp. 1 2013)
For all adults with diabetes aged 19 through 59 years who have diabetes, it is recommended they be vaccinated against the hepatitis B virus (HBV) as soon as possible after a diagnosis of diabetes is made and that vaccination should be considered for those aged >60 years, after assessing risk and likelihood of an adequate immune response. HBV is highly transmissible and stable for long periods of time on surfaces such as lancing devices and blood glucose meters, even when no blood is visible. Blood sufficient to transmit the virus has also been found in the reservoirs of insulin pens, resulting in warnings against sharing such devices between patients.
Hypertension (High Blood Pressure)
Blood pressure should be measured at every diabetes-related visit. Hypertension (blood pressure at or above 140/90) affects the majority of patients with diabetes. Hypertension is a major risk factor for heart attack and stroke, as well as diabetic complications such as retinopathy and nephropathy. Randomized clinical trials have demonstrated reduced risk for these conditions when the blood pressure is lowered below 140/80. Many different medications may be used to treat hypertension. Most patients with diabetes will need to take at least two medications in order to achieve blood pressures below 140/80. Almost all patients with diabetes and hypertension should be treated with a medication regimen that includes either an angiotension-converting enzyme inhibitor (“ACE”) or an angiotensin receptor blocker (“ARB”), as these agents have been shown to reduce the risk of complications more than other classes of medications. ACE inhibitors and ARBs are contraindicated during pregnancy. Diuretics, beta-blockers, and calcium channel blockers are also beneficial for patients with diabetes and hypertension. In addition to medications, lifestyle modifications can help lower blood pressure. These modifications include increased consumption of fruits, vegetables, and low-fat dairy products; DASH diet; reduced intake of sodium and alcohol; increased physical activity; weight loss (when indicated); and quitting tobacco use.
Instruction about hypoglycemia includes recognition of symptoms, level of blood glucose, treatment and prevention. Symptoms of hypoglycemia vary between individuals; patients should use blood glucose testing to determine the actual meaning of symptoms. The plan for treatment should include options for the fast-acting sugar source and the follow-up snacks, what to carry with them and how to prevent hypoglycemia (i.e., regular meals and snacks, testing as often as needed, particularly before exercise, or increased physical activity). Patients’ family and friends should be taught the symptoms to look for and how to recognize when the person needs assistance. Hypoglycemia unawareness can be a complication of the body’s response to chronic low blood sugar levels. People who develop hypoglycemia may not recognize its signs or symptoms. Frequency and severity of low blood glucose episodes should be monitored and treatment should not be delayed. Patients on insulin need to have glucagon injections available and their families and friends should be taught to administer the drug when necessary. Schools should provide for administration of glucagon in the event of severe hypoglycemia at school. Instruction should include effects of beta-blockers on symptoms of hypoglycemia.
A number of lifestyle behaviors and situations including tobacco use, use of alcohol and street drugs, stress, depression and unplanned pregnancies can affect immediate and long-term outcomes of diabetes. Patients should be instructed regarding tobacco use prevention and cessation, effects and risks of alcohol and/or street drugs, and the effects and management of stress/depression. Women of childbearing age from adolescence to menopause must be adequately informed of pre-pregnancy planning with optimum control of blood glucose before and during pregnancy. This would include instruction regarding options for birth control.
Instruction includes the action and side effects of insulin and diabetes medications. The exact dosage and administration schedule should be written out clearly and provided as a resource for the patient. The administration schedule should be tailored to the patient’s daily work hours, and school, exercise and meal schedules. Instruction in insulin administration includes accuracy in the technique of drawing up and injecting the dose, rotation of injection sites, rotation of injection areas (i.e., abdomen to thigh) and storage of insulin at home and away. Any use of insulin adjustment schedules should be carefully explained and written out for the patient. Patients should be taught to record the doses of both insulin and oral agents in the blood glucose record book. Metformin should be considered as the first line drug of choice used with children and adults that have Type 2 diabetes, unless contraindicated. There is an acceptable liquid formation of Metformin (Riomet) available. (Ref. Diabetes Care, Volume 33, Supplement 1, January 2010, p. S20.) (For a list of currently approved diabetes medications, see Working Together to Manage Diabetes: Diabetes Medications Supplement, 2007 by the National Diabetes Education Program at http://ndep.nih.gov/
Diabetic nephropathy occurs in 20%-40% of patients with diabetes and is the single leading cause of End Stage Renal Disease. Annual screening for microalbuminuria is recommended. Either a spot urine for microalbumin/creatinine ratio or a 24-hour urine test for microalbumin is acceptable. Treatment with an Angiotensin Converting Enzyme (ACE) Inhibitor should be considered for Type 1 patients with any degree of microalbuminuria and for Type 2 patients with microalbuminuria. ARB's (angiotensin receptor blocker) may be used alternatively where the patient experiences intolerance to or hyperkalemia from ACE-I therapy. Annual testing should be continued after ACE or ARB therapy in order to monitor effectiveness and titrate dosage of medication. Patients with Glomerular Filtration Rate of <60 ml/min should be referred to a nephrologist. Measure serum creatine at least annually in all adults with diabetes regardless of the degree of urine albumin excretion. The serum creatine should be used to estimate GFR and stage the level of chronic kidney disease (CKD), if present.
A consultation with a dietitian is the most effective method of promoting good nutrition in the management of diabetes. Individualized nutrition recommendations and instruction must take into consideration lifestyle, ethnic differences, metabolic needs and metabolic control (lipids, blood glucose, and weight management). The nutrition plan must be integrated into the overall diabetes management plan through a multi-disciplinary approach. There are numerous strategies and teaching or education tools that can be used to implement the plan and achieve the glucose, lipid and nutrition goals. An individualized approach is recommended.
The 2010 Dietary Guidelines for Americans recommends two overarching concepts which apply to the nutrition management of diabetes: 1) maintain calorie balance over time to achieve and sustain a healthy weight, and 2) focus on consuming nutrient-dense foods and beverages. Monitoring carbohydrates, whether by carbohydrate counting, choices, or experience-based estimation, remains a key strategy in achieving glycemic control. Eating smaller portions and limiting foods high in added sugars – cakes, candy, cookies, fruit-flavored drinks, soda), saturated fats and trans fats – fried foods, fatty cuts of meat, whole milk/dairy products, solid fats – is recommended.
A healthy eating pattern for those with diabetes includes eating a variety of fruits and vegetables every day, especially dark green and orange veggies, and beans and peas – lentils, black beans, pinto beans – fat-free or low fat milk/milk products, whole grains, and lean meats. The mix of carbohydrate, protein, and fat may be adjusted to meet the metabolic goals and individual preferences of the person with diabetes. An eating plan, such as Dietary Approaches to Stop Hypertension (DASH) is recommended to lower high blood pressure. If adults with diabetes choose to use alcohol, they should limit intake to a moderate amount – one drink per day or less for adult women and two drinks per day or less for adult men – and should take extra precautions to prevent hypoglycemia.
Nutrition management should also include a consultation with a dietitian for the most effective method of promoting good nutrition in the management of diabetes. Individualized nutrition recommendations and instruction must take into consideration lifestyle, ethnic differences, metabolic needs and metabolic control – lipids, blood glucose, and weight management. The nutrition plan must be integrated into the overall diabetes management plan through a multi-disciplinary approach. There are numerous strategies and teaching or education tools that can be used to implement the plan and achieve the glucose, lipid and nutrition goals. An individualized approach is recommended.
Physical activity has a key role in the management of diabetes and must be integrated into the overall plan of care. Physical activity has important physiologic and metabolic benefits for people with both Type 1 and Type 2 diabetes. Cardiovascular fitness and psychological well-being also improve with increased physical activity. In persons with Type 2 diabetes and insulin resistance, physical activity will increase sensitivity to insulin. People with diabetes should be advised to perform at least 150 minutes a week of moderate intensity aerobic physical activity (50%-70% of maximum heart rate). In the absence of contraindications, they should also be encouraged to perform resistance training three times per week. Self-monitoring of blood glucose is essential to avoid hypoglycemia as well as a motivator for continuing the effort. Special attention is needed to design an exercise program that takes into consideration the person’s special needs and the type of exercise that is practical for that individual. Prior to starting an exercise program, patients should have an assessment of cardiovascular risk and evaluation for previously undiagnosed hypertension, retinopathy, neuropathy, nephropathy and lower extremity pathology. Patients should be taught how to recognize symptoms that indicate they should stop exercising and/or consult a health care provider.
(ADA Diabetes Care Vol. 36, Supp. 1 2013)
Hyperglycemia not sufficient to meet the diagnostic criteria for diabetes is categorized as either impaired fasting glucose (IFG) or impaired glucose tolerance (IGT), depending on whether it is identified through the fasting plasma glucose (FPG) or the oral glucose tolerance test (OGTT):
- IFG = FPG 100 mg/dl (5.6 mmol/l) to 125 mg/dl (6.9 mmol/l)
- IGT = 2-h plasma glucose 140 mg/dl (7.8 mmol/l) to 199 mg/dl (11.0 mmol/l)
- A1C = 5.7 – 6.4%
IFG and IGT are categories of increased risk for diabetes. Both categories are risk factors for future diabetes and for cardiovascular disease (CVD).
Prevention/delay of Type 2 diabetes:
- Patients with IGT or IFG should be given counseling on weight loss of 5% to 10% of body weight, as well as on increasing physical activity to at least 150 minutes per week of moderate activity such as walking.
- Follow-up counseling appears to be important for success.
- Based on potential cost savings of diabetes prevention, such counseling should be covered by third-party payers.
- In addition to lifestyle counseling, metformin may be considered in those who are at very high risk (combined IFG and IGT plus other risk factors) and who are obese and under 60 years of age. Monitoring for the development of diabetes in those with pre-diabetes should be performed every year.
Patients need to know how to manage their diabetes during an episodic illness to prevent extreme hyperglycemia and maintain hydration and nutrition. Patients with Type 1 diabetes should be instructed on how to prevent or detect ketoacidosis with frequent blood glucose monitoring and urine ketone testing. Some people benefit from instruction on how to give additional insulin when blood glucose levels are increasing to prevent hospitalization and when it is appropriate to their care. All people with diabetes should be taught when to call their health care provider during an illness and when to go to the emergency department.
Patients should be instructed regarding tobacco use and cessation using the five A’s Method of Ask, Advise, Access, Assist and Arrange.
- ASK – about their tobacco use
- ADVISE – users to quit
- ASSESS – readiness to quit
- ASSIST – patients in making a quit plan including 1-800-QuitNow, Nebraska’s toll free, 24-hour tobacco cessation Quitline.
- ARRANGE – follow-up; Examples: If the patient shows readiness to quit health care provider faxes referral to the Quitline: www.dhhs.ne.gov/tfn/ces/hcp.htm
OR: Refers to a community cessation programs, where available
Dental Care Guidelines
Diabetes patients must maintain a rigorous oral self-care regimen to minimize oral health problems that may complicate glycemic control since the mouth is the first part of the digestive process. Regular visits (generally twice a year) to their dentist for a dental examination and dental prophylaxis and necessary radiographs are recommended to achieve an optimal oral health status. This rate of dental visitation is dependent on the patient’s oral health status. Regular brushing and flossing are essential to keep the teeth and gums healthy. A history of stroke or musculoskeletal disorders might necessitate the use of other mechanical or electric dental devices to accomplish optimal goals of oral health.
The major oral health complications of diabetes are: periodontal disease, salivary gland disorders, oral soft tissue infections, and possibly caries (dental decay). The quality and extent of these problems are largely dependent on the level of glycemic control, the age of the patient, prior history and length of time of medical or dental problems, and the dental IQ or self-efficacy of the patient. Furthermore, medications may by themselves cause oral health problems such as gingival hyperplasia and xerostomia. Aggressive management of these dental problems and optimal oral self-care by the patient is necessary to minimize the impact on glycemic control and the patient’s quality of life.
Bone, thyroid, gastrointestinal, musculoskeletal, cognitive, and psychosocial complications and some of the therapeutic regimens all have varying oral health implications. Both bone and thyroid metabolic disturbances have oral health implications. Gastrointestinal problems such as GERD may cause enamel erosion. Musculoskeletal changes and tooth loss will affect the ability to masticate and patients will shift their diets to softer foods. Cognitive problems will influence the ability of the patient to comprehend the caregiver’s instructions and provide self-care. Bulimia will cause enamel erosion and dental decay. These problems have been shown to worsen the oral condition. Patients with these conditions should be asked about their oral health status and encouraged to seek dental preventative care.
Many patients that wear dentures feel that once their teeth are gone there is no need to seek further dental care. This could not be further from the truth. Individuals with dentures normally lose chewing function by over 50%. These patients need yearly oral examinations. This includes evaluating the oral structures for soft tissue infections, denture sores, and an oral cancer screening examination. Members of the Diabetes Care Team should ask these patients to remove their dentures to assess fit and function and whether prompt dental referral is needed. Debris, calculus, broken teeth or acrylic base cracks are some indicators that there is a problem. Worn or loose dentures or those that are over five years old should be replaced. Some loose dentures can be relined or rebased to improve the fit if the teeth if they are in good shape. A self-care regimen of daily tissue scrubs using a washcloth and toothpaste maintains the underlying gum tissue in good health. The dentures should be removed nightly, cleaned using a denture brush and toothpaste, and stored in water. Denture cleaning tablets should be used daily or dentures should be soaked nightly in diluted bleach (1 ounce of bleach in 4 cups of water) to disinfect dentures. Denture cleaning tablets may be used 2-3 times a week. Coffee, tea, and tobacco use tend to heavily stain a denture. Dentures can also accumulate plaque and calculus. Candida infections may be due to a combination of a poor fitting prosthesis or poor host immune response. Treatment of Candida involving a prosthesis should include soaking the prosthesis in Nystatin solution daily and the use of the rinse orally (swish and swallow) or if it persists utilize Diflucan. Ensuring that a denture has an optimal fit and comfort will help the patient improve glycemic control and achieve the goals of medical nutrition therapy.
Diabetes Prevention and Control Program
Nebraska Department of Health and Human Services
P.O. Box 95026
Lincoln, NE 68509-5026
Phone: (402) 471-4411
1-800-745-9311 (ask for Diabetes Section)