Standards Of Medical Care In Diabetes - 2017
Standards of Medical Carein Diabetes - 2017
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Standards of Care Funded out Association’s general revenues anddoes not use industry support. Slides correspond with sections within theStandards of Medical Care in Diabetes - 2017. Reviewed and approved by the Association’sBoard of Directors.
Process ADA’s Professional Practice Committee (PPC)conducts annual review & revision. Searched Medline for human studies related to eachsubsection and published since January 1, 2016. Recommendations revised per new evidence, forclarity, or to better match text to strength ofevidence.Professional.diabetes.org/SOC
Professional Practice CommitteeMembers of the PPC William H. Herman, MD, MPH (Co-Chair) Rita R. Kalyani, MD, MHS, FACP (Co-Chair) Andrea L. Cherrington, MD, MPH Donald R. Coustan, MD Ian de Boer, MD, MS Robert James Dudl, MD Hope Feldman, CRNP, FNP-BC Hermes J. Florez, MD, PhD, MPH Suneil Koliwad, MD, PhD Melinda Maryniuk, MEd, RD, CDE Joshua J. Neumiller, PharmD, CDE, FASCP Joseph Wolfsdorf, MB, BChADA Staff Erika Gebel Berg, PhD Sheri Colberg-Ochs, PhD Alicia H. McAuliffe-Fogarty, PhD, CPsycol Sacha Uelmen, RDN, CDE Robert E. Ratner, MD, FACP, FACE
Evidence Grading System
1.Promoting Health and ReducingDisparities in Populations
Key Recommendations Treatment decisions should be timely and basedon evidence-based guidelines that are tailored topatient preferences, prognoses, andcomorbidities. B Providers should consider the burden oftreatment and self-efficacy of patients whenrecommending treatments. EAmerican Diabetes Association Standards of Medical Care in Diabetes.Promoting Health and Reducing Disparities in Populations. Diabetes Care 2017; 40 (Suppl. 1): S6-S10
Key Recommendations (2) Treatment plans should align with Chronic CareModel, emphasizing productive interactionsbetween a prepared proactive practice team andan informed activated patient. A When feasible, care systems should supportteam-based care, community involvement,patient registries, and decision support tools tomeet patient needs. BAmerican Diabetes Association Standards of Medical Care in Diabetes.Promoting Health and Reducing Disparities in Populations. Diabetes Care 2017; 40 (Suppl. 1): S6-S10
Care Delivery Systems 33-49% of patients still do not meet targets for A1C,blood pressure, or lipids. 14% meet targets for all A1C, BP, lipids, and nonsmokingstatus. Progress in CVD risk factor control is slowing. Substantial system-level improvements are needed. Delivery system is fragmented, lacks clinical informationcapabilities, duplicates services & is poorly designed.American Diabetes Association Standards of Medical Care in Diabetes.Promoting Health and Reducing Disparities in Populations. Diabetes Care 2017; 40 (Suppl. 1): S6-S10
Chronic Care ModelSix Core Elements:1.Delivery system design2.Self-management support3.Decision support4.Clinical information systems5.Community resources & policies6.Health systemsAmerican Diabetes Association Standards of Medical Care in Diabetes.Promoting Health and Reducing Disparities in Populations. Diabetes Care 2017; 40 (Suppl. 1): S6-S10
Strategies for System-Level Improvementwww.BetterDiabetesCare.nih.govThree Key Objectives1.Optimize Provider and Team Behavior2.Support Patient Self-Management3.Change the Care SystemAmerican Diabetes Association Standards of Medical Care in Diabetes.Promoting Health and Reducing Disparities in Populations. Diabetes Care 2017; 40 (Suppl. 1): S6-S10
Objective 1: Optimize Provider and Team Behavior For patients who have not achieved beneficial levels of controlin blood pressure, lipids, or glucose, the care team shouldprioritize timely & appropriate intensification of lifestyle and/orpharmaceutical therapy. Strategies include:– Explicit goal setting with patients– Identifying and addressing language, numeracy, and/or culturalbarriers to care– Integrating evidence-based guidelines– Incorporating care management teamsAmerican Diabetes Association Standards of Medical Care in Diabetes.Promoting Health and Reducing Disparities in Populations. Diabetes Care 2017; 40 (Suppl. 1): S6-S10
Objective 2: Support Patient Self-management Implement a systematic approach to supportpatient behavior change efforts, including:– Healthy lifestyle– Disease self-management– Prevention of diabetes complications– Identification of self-management problems anddevelopment of strategies to solve those problemsAmerican Diabetes Association Standards of Medical Care in Diabetes.Promoting Health and Reducing Disparities in Populations. Diabetes Care 2017; 40 (Suppl. 1): S6-S10
Objective 3: Change the Care SystemSuccessful practices prioritize providing a high qualityof care. Changes that have been shown to increasequality of care include:1. Basing care on evidence-based guidelines2. Expanding the role of teams to implement more intensivedisease management strategies3. Redesigning the care process4. Implementing electronic health record tools5. Activating and educating patientsAmerican Diabetes Association Standards of Medical Care in Diabetes.Promoting Health and Reducing Disparities in Populations. Diabetes Care 2017; 40 (Suppl. 1): S6-S10
Objective 3: Change the Care System (2)Successful practices prioritize providing a high quality ofcare. Changes that have been shown to increase quality ofcare include:6. Removing financial barriers and reducing patient out-of-pocketcosts7. Identifying community resources and public policy that supportshealthy lifestyles8. Coordinated primary care, e.g., through Patient-CenteredMedical Home9. Changes to reimbursement structureAmerican Diabetes Association Standards of Medical Care in Diabetes.Promoting Health and Reducing Disparities in Populations. Diabetes Care 2017; 40 (Suppl. 1): S6-S10
Tailoring Treatment to Reduce DisparitiesKey Recommendation Providers should assess social context, includingpotential food insecurity, housing stability, andfinancial barriers, and apply that information totreatment decisions. AAmerican Diabetes Association Standards of Medical Care in Diabetes.Promoting Health and Reducing Disparities in Populations. Diabetes Care 2017; 40 (Suppl. 1): S6-S10
Health Disparities Ethnic/Cultural/Sex Differences Access to Health Care– Lack of Health Insurance Food Insecurity Language Barriers HomelessnessAmerican Diabetes Association Standards of Medical Care in Diabetes.Promoting Health and Reducing Disparities in Populations. Diabetes Care 2017; 40 (Suppl. 1): S6-S10
System-Level InterventionsKey Recommendations Patients should be referred to local communityresources when available. B Patients should be provided with selfmanagement support from lay health coaches,navigators, or community health workers whenavailable. AAmerican Diabetes Association Standards of Medical Care in Diabetes.Promoting Health and Reducing Disparities in Populations. Diabetes Care 2017; 40 (Suppl. 1): S6-S10
2.ClassificationandDiagnosis of Diabetes
Classification & Diagnosis ClassificationDiagnostic Tests for DiabetesPrediabetesType 1 DiabetesType 2 DiabetesGestational DiabetesMonogenic Diabetes SyndromesCystic Fibrosis-Related DiabetesAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Classification of Diabetes1. Type 1 diabetes– β-cell destruction2. Type 2 diabetes– Progressive insulin secretory defect3. Gestational Diabetes Mellitus (GDM)4. Other specific types of diabetes– Monogenic diabetes syndromes– Diseases of the exocrine pancreas, e.g., cystic fibrosis– Drug- or chemical-induced diabetesAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Staging of Type 1 DiabetesAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Criteria for the Diagnosis of DiabetesFasting plasma glucose (FPG) 126 mg/dL (7.0 mmol/L)OR2-h plasma glucose 200 mg/dL(11.1 mmol/L) during an OGTTORA1C 6.5%ORClassic diabetes symptoms random plasma glucose 200 mg/dL (11.1 mmol/L)American Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Recommendations: Type 1 Diabetes Blood glucose rather than A1C should be used to dxtype 1 diabetes in symptomatic individuals. E Screening for type 1 diabetes with an antibody panelis recommended only in the setting of a clinicalresearch study or in a first-degree family membersof a proband with type 1 diabetes. Bwww.DiabetesTrialNet.orgAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Recommendations: Prediabetes Screening for prediabetes with an informal assessmentof risk factors or validated tools should be considered inasymptomatic adults. B Testing should begin at age 45 for all people. B Consider testing for prediabetes in asymptomatic adultsof any age w/ BMI 25 kg/m2 or 23 kg/m2 (in AsianAmericans) who have 1 or more add’l risk factors fordiabetes. B If tests are normal, repeat at a minimum of 3-yearintervals. CAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Recommendations: Prediabetes (2) FPG, 2-h PG after 75-g OGTT, and A1C, areequally appropriate for prediabetes testing. B In patients with prediabetes, identify and, ifappropriate, treat other CVD risk factors. B Consider prediabetes testing inoverweight/obese children and adolescents with2 or more add’l diabetes risk factors. EAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Prediabetes*FPG 100–125 mg/dL(5.6–6.9 mmol/L): IFGOR2-h plasma glucose 140–199 mg/dL (7.8–11.0mmol/L): IGTORA1C 5.7–6.4%* For all three tests, risk is continuous, extending below the lower limit of arange and becoming disproportionately greater at higher ends of the range.American Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Recommendations: Testing for Type 2 Diabetes Screening for type 2 diabetes with an informalassessment of risk factors or validated tools should beconsidered in asymptomatic adults. B Consider testing in asymptomatic adults of any age withBMI 25 kg/m2 or 23 kg/m2 in Asian Americans whohave 1 or more add’l dm risk factors. B For all patients, testing should begin at age 45 years. B If tests are normal, repeat testing carried out at aminimum of 3-year intervals is reasonable. CAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Recommendations: Screening for Type 2 Diabetes (2) FPG, 2-h PG after 75-g OGTT, and the A1C areequally appropriate. B In patients with diabetes, identify and, ifappropriate, treat other CVD risk factors. B Consider testing for T2DM in overweight/obesechildren and adolescents with 2 or more add’ldiabetes risk factors. EAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Risk factors for Prediabetes and T2Dwww.diabetes.org/are-you-at-riskAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Criteria for Testing for T2DM in Children & Adolescents Overweight plus any 2 :– Family history of type 2 diabetes in 1st or 2nd degree relative– Race/ethnicity– Signs of insulin resistance or conditions associated withinsulin resistance– Maternal history of diabetes or GDM Age of initiation 10 years or at onset of puberty Frequency: every 3 years Test with FPG, OGTT, or A1CAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Recommendations: Detection and Diagnosis of GDM Test for undiagnosed T2DM at the 1st prenatalvisit in those with risk factors. B Test for GDM at 24–28 weeks of gestation inwomen not previously known to have diabetes. A Screen women with GDM for persistent diabetesat 4–12 weeks postpartum, using the OGTT. EAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Recommendations: Detection and Diagnosis of GDM (2) Women with GDM history should have lifelongscreening for development of diabetes orprediabetes at least every 3 years. B Women with GDM history found to haveprediabetes should receive lifestyle interventionsor metformin to prevent diabetes. AAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Screening for& Diagnosis of GDM
One-Step Strategy At 24-28 weeks gestation in women not previouslydx’d with overt diabetes 75-g OGTT; Measure plasma glucose at fasting andat 1 and 2 hours. GDM dx’d when plasma glucose exceeds:– Fasting: 92 mg/dL (5.1 mmol/L)– 1 h: 180 mg/dL (10.0 mmol/L)– 2 h: 153 mg/dL (8.5 mmol/L)American Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Two-Step StrategyStep 1: In women not previously dx’d with overt diabetes,perform 50-g GLT (nonfasting); Measure plasmaglucose at 1 hour. If 1 hour plasma glucose level is 140 mg/dL*(7.8 mmol/L), proceed to step 2.*ACOG recommends either 135 mg/dL or 140 mg/dL in high-riskethnic minorities with higher prevalence of GDM.American Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Two-Step Strategy (2)Step 2:100-g OGTT is performed while patient is fasting.The diagnosis of GDM is made if 2 or more of thefollowing plasma glucose levels are met or exceeded:Carpenter/CoustanorNDDGFasting1h95 mg/dL (5.3 mmol/L)180 md/dL (10.0 mmol/L)105 mg/dL (5.8 mmol/L)190 mg/dL (10.6 mmol/L)2h3h155 mg/dL (8.6 mmol/L)140 mg/dL (7.8 mmol/L)165 mg/dL (9.2 mmol/L)145 mg/dL (8.0 mmol/L)American Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Recommendations: Monogenic Diabetes Syndromes All children diagnosed with diabetes in the first 6months of life should have genetic testing forneonatal diabetes. A Children and adults, diagnosed in early adulthood, whohave diabetes not characteristic of T1D or T2D thatoccurs in successive generations should have genetictesting for MODY. A In both instances, consultation with a center specializing indiabetes genetics is recommended. EAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Recommendations: Cystic Fibrosis–Related Diabetes (CFRD) Annual screening for CFRD with OGTT shouldbegin by age 10 years in all patients with cysticfibrosis not previously diagnosed with CFRD. B A1C is not recommended as a screening test forCFRD. BAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Recommendations: Cystic Fibrosis–Related Diabetes (CFRD) (2) Patients with CFRD should be treated withinsulin to attain individualized glycemic goals. A Annual monitoring for complications of diabetesis recommended, starting 5 years after CFRDdiagnosis. E See also: “Clinical Care Guidelines for CysticFibrosis–Related Diabetes” atCare.Diabetes.org.American Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
3.ComprehensiveMedical Evaluationand Assessment ofComorbidities
Patient-Centered Collaborative Care A patient-centered communication style thatuses active listening, elicits patient preferences,and assesses literacy, numeracy, and potentialbarriers to care should be used to optimizepatient health outcomes and health-relatedquality of life. BAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Comprehensive Medical EvaluationA complete medical evaluation should beperformed at the initial visit to: Confirm & classify diagnosis B Detect complications & potential comorbidconditions E Review prior treatment & risk factor control E Begin formulation of care management plan B Develop a continuing care plan BAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Components of the Comprehensive Diabetes EvaluationMedical history: Age and characteristics of onset of diabetes Eating patterns, nutritional status, weight history, sleepbehaviors, physical activity habits, nutrition education Presence of common comorbidities and dental disease Screen for psychosocial problems and other barriers toself-management History of tobacco use, alcohol consumption, andsubstance useAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Components of the Comprehensive Diabetes Evaluation (2)Medical History (2): Diabetes education, self-management, and supporthistory & needs Previous treatment regimens and response to therapy(A1C records) Results of glucose monitoring and patient’s use of data DKA frequency, severity, and cause Hypoglycemia episodes, awareness, frequency & causes Assess medication-taking behaviors/barriers to adherenceAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Components of the Comprehensive Diabetes Evaluation (3)Medical History (3): History of increased blood pressure, abnormal lipids Microvascular: retinopathy, nephropathy, and neuropathy(sensory, including history of foot lesions; autonomic,including sexual dysfunction and gastroparesis) Macrovascular: coronary heart disease, cerebrovasculardisease, and peripheral arterial disease For women with childbearing capacity, reviewcontraception and preconception planningAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Components of the Comprehensive Diabetes Evaluation (4)Physical Examination: Height, weight, and BMI; growth and pubertal developmentin children and adolescents Blood pressure determination, including orthostaticmeasurements when indicated Fundoscopic examination Thyroid palpation Skin examination Comprehensive foot examinationAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Components of the Comprehensive Diabetes Evaluation (5)Laboratory Evaluation A1C, if results not available within past 3 months If not performed/available within past year:–––––Fasting lipid profileLiver function testsSpot urinary albumin-to-creatinine ratioSerum creatinine and eGFRThyroid-stimulating hormone in patients with type 1 diabetesAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Recommendations: Immunizations Provide routine vaccinations for children and adultswith diabetes per age-specific CDCrecommendations. CCDC.gov/vaccines Administer hepatitis B vaccine to unvaccinatedadults with diabetes aged 19-59 years. C Consider administering hepatitis B vaccine tounvaccinated adults with diabetes 60 years old. CAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Common Comorbidities Autoimmune Diseases(T1D) Hearing Impairment HIV Cancer Low Testosterone (Men) Cognitive ImpairmentDementia Obstructive Sleep Apnea Periodontal Disease Psychosocial Disorders Fatty Liver Disease FracturesAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Recommendation: Autoimmune Disease Consider screening patients with type 1diabetes for autoimmune thyroid disease andceliac disease soon after diagnosis. EAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Recommendation: Cognitive Dysfunction In people with cognitive impairment/dementia,intensive glucose control cannot be expected toremediate deficits. Treatment should be tailoredto avoid significant hypoglycemia. BAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Human Immunodeficiency Virus (HIV) Patients with HIV should be screened for diabetesand prediabetes with a fasting glucose level every6–12 months before starting antiretroviral therapyand 3 months after starting or changing antiretroviraltherapy. E If initial screening results are normal, checkingfasting glucose every year is advised. E If prediabetes is detected, continue to measurefasting glucose levels every 3–6 months to monitorfor progression to diabetes. EAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Anxiety Disorders Consider screening for anxiety in people exhibitinganxiety or worries regarding diabetes complications,insulin injections or infusion, taking medications,and/or hypoglycemia that interfere with selfmanagement behaviors. Refer for treatment ifanxiety is present. B Persons with hypoglycemic unawareness, which canco-occur with fear of hypoglycemia, should betreated using blood glucose awareness training (orother evidence-based similar intervention) to helpre-establish awareness of hypoglycemia and reducefear of hypoglycemia. AAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Depression Consider annual screening with age-appropriatedepression screening measures. B Beginning at dx of complications or when thereare significant changes in medical status,consider assessment for depression. B Referrals for treatment of depression should bemade to mental health providers with experienceusing evidence-based treatment approaches. AAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Disordered Eating Behavior Consider reevaluating the treatment regimen inpeople with diabetes who present withsymptoms of disordered eating. B Consider screening for disordered eating usingvalidated screening measures whenhyperglycemia and weight loss are unexplainedbased on self-reported behaviors. BAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
Serious Mental Illness Annually screen people who are prescribed atypicalantipsychotic medications for prediabetes ordiabetes. B If a second-generation antipsychotic medication isprescribed, changes in weight, glycemic control, andcholesterol levels should be carefully monitored. C Incorporate monitoring of diabetes self-careactivities into treatment goals in people withdiabetes and serious mental illness. BAmerican Diabetes Association Standards of Medical Care in Diabetes. Comprehensive MedicalEvaluation and Assessment of Comorbidities. Diabetes Care 2017; 40 (Suppl. 1): S25-S32
4.LifestyleManagement
Recommendations: Diabetes Self-Management Education & Support All people with diabetes should participate in DSME andDSMS both at diagnosis and as needed thereafter. B Effective self-management, improved clinical outcomes,health status, and quality-of-life are key outcomes ofDSME and DSMS and should be measured andmonitored as part of care. C DSME/S should be patient-centered, respectful, andresponsive to individual patient preferences, needs, andvalues that should guide clinical decisions. AAmerican Diabetes Association Standards of Medical Care in Diabetes.Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43
Recommendations: Diabetes Self-Management Education & Support (2) DSME/S programs have the necessary elements intheir curricula to delay or prevent the developmentof type 2 diabetes; DSME/S programs should beable to tailor their content when prevention ofdiabetes is the desired goal. B Because DSME and DSMS can improve outcomesand reduce costs B, DSME and DSMS should beadequately reimbursed by third-party payers. EAmerican Diabetes Association Standards of Medical Care in Diabetes.Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43
DSME / DSMS DeliveryFour critical time points for DSME/S delivery:1. At diagnosis2. Annually for assessment of education, nutrition,and emotional needs3. When new complicating factors arise thatinfluence self-management; and4. When transitions in care occurAmerican Diabetes Association Standards of Medical Care in Diabetes.Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43
Goals of Nutrition Therapy1. Promote & support healthful eating patterns,emphasizing a variety of nutrient-dense foods inappropriate portion sizes, to improve health and to:– Achieve and maintain body weight goals– Attain individualized glycemic, blood pressure, and lipid goals– Delay or prevent complications of diabetes2. Address nutrition needs based on personal & culturalpreferences, health literacy & numeracy, access tohealthful foods, willingness and ability to makebehavioral changes & barriers to change.American Diabetes Association Standards of Medical Care in Diabetes.Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43
Goals of Nutrition Therapy (2)3. To maintain the pleasure of eating by providing nonjudgmental messages about food choices.4. Provide practical tools for developing healthful eatingpatterns rather than focusing on individualmacronutrients, micro-nutrients, or single foods.American Diabetes Association Standards of Medical Care in Diabetes.Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43
Recommendations: NutritionEffectiveness of Nutrition Therapy: An individualized MNT program is recommended for allpeople with type 1 and type 2 diabetes. A For people with T1D or T2D on a flexible insulinprogram, education on carb counting and, in somecases, fat and protein gram estimation can improveglycemic control. A For people whose daily insulin dosing is fixed, aconsistent pattern of carb intake can result in improvedglycemic control and a reduced risk of hypoglycemia. BAmerican Diabetes Association Standards of Medical Care in Diabetes.Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43
Recommendations: Nutrition (2)Effectiveness of Nutrition Therapy (2): Emphasizing healthy food choices and portion controlmay be more helpful for those with type 2 diabetes whoare not taking insulin, who have limited health literacy ornumeracy, and who are elderly and prone to hypoglycemia. B Because diabetes nutrition therapy can result in cost savingsB and improved outcomes (e.g., A1C reduction) A, MNTshould be adequately reimbursed by insurance and otherpayers. EAmerican Diabetes Association Standards of Medical Care in Diabetes.Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43
Recommendations: Nutrition (3)Energy Balance: Modest weight loss achievable by the combinationof lifestyle modification and the reduction of calorieintake benefits overweight or obese adults withtype 2 diabetes and also those with prediabetes.Intervention programs to facilitate this processare recommended. AAmerican Diabetes Association Standards of Medical Care in Diabetes.Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43
Recommendations: Nutrition (4)Eating patterns & macronutrient distribution: Macronutrient distribution should be individualizedwhile keeping total calorie and metabolic goals inmind. E Carbohydrate intake from whole grai
minimum of 3-year intervals is reasonable. C Recommendations: Testing for Type 2 Diabetes American Diabetes Association Standards of Medical Care in Diabetes. Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
4 Current Drivers of Home-Based Medical Care Models 5 The Opportunity 6 The Spectrum of Home-Based Medical Care Models Table 1. Longitudinal Home-Based Medical Care Models Table 2. Episodic Home-Based Medical Care Models The Bottom Line 12 Case Studies 15 Looking Ahead: An Integrated Home- and Community-Based Health Care Ecosystem 16 Endnotes .
STANDARDS OF MEDICAL CARE IN DIABETES 2016 . Armand Krikorian, MD, FACE . . Classification and diagnosis of diabetes. Diabetes Care . 2016; 39 (Suppl. 1): S13-S22 . minimum of 3 -year intervals is reasonable. C . American Diabetes Association Standards of Medical Care in Diabetes.
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