Friday, January 18, 2008

Diabetes is Hazardous to Your Health

Practice Guidelines Issued for Screening, Diagnosing, and Treating Diabetes

December 28, 2007 — The American Diabetes Association (ADA) has issued practice guidelines for screening, diagnostic, and therapeutic interventions that are known or believed to improve health outcomes of patients with diabetes. An executive summary published in the January issue of Diabetes Care provides a detailed description of each of the ADA practice recommendations, a grading system developed by the ADA that uses A, B, C, or E to indicate the level of evidence supporting each recommendation, and suggested targets for most patients with diabetes…

Some of the specific recommendations are as follows:

• To diagnose diabetes in children and nonpregnant adults, fasting plasma glucose (FPG) is the preferred test, and use of A1C levels to diagnose diabetes is not currently recommended (E).

• Screening for prediabetes and type 2 diabetes in asymptomatic people should be considered in adults who are overweight or obese (body mass index [BMI] ≥25 kg/m2) with at least 1 more additional risk factor. Otherwise, testing should begin at age 45 years (B), and if results are normal, testing should be repeated at least at 3-year intervals (E).

• Either an FPG test or 2-hour oral glucose tolerance test (OGTT; 75-g glucose load), or both, is appropriate (B) to test for prediabetes or diabetes, and an OGTT may be considered in patients with impaired fasting glucose (IFG) to better define the risk of diabetes (E).

• Individuals found to have prediabetes should be evaluated and treated, if appropriate, for other cardiovascular risk factors (B).

• To prevent or delay onset of diabetes, patients with impaired glucose tolerance (IGT; A) or IFG (E) should be advised to lose 5% to 10% of body weight and to increase physical activity to at least 150 minutes per week of moderate activity such as walking. Follow-up counseling seems to improve the likelihood of success (B). Because of the potential cost savings associated with diabetes prevention, third-party payors should cover counseling (E).

• Metformin therapy should also be considered in patients who are at very high risk for diabetes, based on combined IFG and IGT plus other risk factors, and who are obese and younger than 60 years of age (E).

• Individuals with prediabetes should be monitored every year for the development of diabetes. (E).

• Because lowering A1C levels to an average of about 7% has been shown to reduce microvascular and neuropathic complications of diabetes and, possibly, macrovascular disease, the target A1c goal for nonpregnant adults is generally less than 7% (A).

• For selected individual patients, the A1C goal is as close to normal (<>

• For children, patients with a history of severe hypoglycemia, those with limited life expectancies, individuals with comorbid conditions, and those with long duration of diabetes and minimal or stable microvascular complications, less stringent A1C goals may be appropriate (E).

• Individuals with prediabetes or diabetes should receive individualized MNT as needed to achieve treatment goals, ideally by a registered dietitian who is knowledgeable about diabetes MNT (B). This should be covered by insurance and other payors (E).

• Specific components of MNT should include management of energy balance, overweight, and obesity with diet, physical activity, and behavior modification (B); primary prevention of diabetes among individuals at high risk of developing type 2 diabetes (A); promoting fiber and whole-grain intake meeting US Department of Agriculture recommendations (B); controlling dietary fat intake by limiting saturated fat intake to less than 7% of total calories (A) and minimizing trans fat intake (E); and managing carbohydrate intake.

• Monitoring carbohydrate intake is a key strategy in achieving glycemic control, whether by carbohydrate counting, exchanges, or experience-based estimation (A). For patients with diabetes, glycemic index and glycemic load use may modestly improve glycemic control vs that observed when considering only total carbohydrate (B).

• DSME should be offered to patients with diabetes at the time of diagnosis and as needed thereafter (B), with the goal of changing self-management behavior (E) and addressing psychosocial issues (C). Third-party payors should reimburse for DSME (E).

• People with diabetes should perform at least 150 minutes per week of moderate-intensity aerobic physical activity (50% - 70% of maximum heart rate; [A]), and unless there are contraindications, those with type 2 diabetes should perform resistance training 3 times per week (A).

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