Diabetes: Updates on ADA Guidelines

January 2013

Objectives

• State the standards of diabetic care put forth by the American Diabetes Association

• Discuss the co-morbidities of diabetes, the standards of care that influence their management and strategies to achieve the goals of care

• Discuss ways correctional institutions can improve compliance with the recommendations for diabetic care in correctional institutions

Diabetes Facts

• Diabetes affects 25.8 million people in the United States – 18.8 million diagnosed

– 7 million undiagnosed

• Diabetes is the leading cause of kidney failure, non-traumatic lower limb amputations, and new cases of blindness among adults in the United States

• Diabetes is a major cause of heart disease and stroke

• Diabetes is the seventh leading cause of death in the United States

Source: CDC Fact Sheet, 2011

Diabetes Facts

• Every 1% drop in A1c blood test results can decrease the risk of microvascular complications of diabetes by 40%

• Blood pressure control reduces the risk of cardiovascular disease (heart disease or stroke) among people with diabetes by 33% to 50%, and the risk of microvascular complications by 33%.

• In general, for every 10 mmHg reduction in systolic blood pressure, the risk for any complications related to diabetes is reduced by 12%.

• Reducing diastolic blood pressure from 90 mmHg to 80 mmHg in people with diabetes reduces the risk of major cardiovascular events by 50%.

Source: CDC Fact Sheet, 2011

Diabetes Facts

• Improved control of LDL cholesterol can reduce cardiovascular complications by 20% to 50%.

• Detecting and treating diabetic eye disease can reduce development of severe vision loss by an estimated 50% to 60%.

• Comprehensive foot care programs – risk assessment, foot care education and preventive therapy, treatment of foot problems and referral to specialists can reduce amputation rates by 45% to 85%.

• Detecting and treating early diabetic kidney disease by lowering blood pressure can reduce the decline in kidney function by 30% to 70%. ACEIs and ARBs are more effective than other antihypertensive medications in reducing the decline in kidney function

Source: CDC Fact Sheet, 2011

Magnitude of Complications

Diabetic Retinopathy

Leading cause of blindness

in working age adults

Diabetic Nephropathy

Leading cause of end-stage renal disease

Stroke

Cardiovascular Disease

2-fold to 4-fold increase in cardiovascular mortality and stroke

Diabetic Neuropathy

Leading cause of nontraumatic lower extremity amputations National Diabetes Information Clearinghouse. At:

http://www.niddk.nih.gov/health/diabetes/pubs/dmstats/dmstats.htm

Guidelines 2013

Diabetes Disease Management

Intake Medical Assessment

• Complete medical history and intake physical exam by licensed health professional in a timely manner

• Insulin-dependent diabetics should have capillary blood glucose (CBG) within 1 to 2 hours of arrival

• Medications and medical nutrition therapy (MNT) continued without interruption

Screening for Diabetes

• Evaluate for diabetes risk factors at intake physical and as appropriate thereafter

– BMI ≥ 25 with history of hypertension or hyperlipidemia

– BMI ≥ 25 and additional risk factors or age > 45 with or without risk factors

• If pregnant, risk assessment for gestational diabetes mellitus (GDM) at first pre-natal visit

– Re-screen at 24-28 weeks

Criteria for Testing for Diabetes

• Adults who are overweight (BMI ≥ 25) and have additional risk factors: – Physical inactivity – First-degree relative with diabetes – High-risk race/ethnicity – Women who delivered a baby weighing > 9 lb or were diagnosed with

GDM – Hypertension on therapy for hypertension – HDL cholesterol < 35 mg/dl and/or triglyceride > 250 mg/dl – Women with polycystic ovarian syndrome (PCOS) – A1c > 5.7% on previous testing – History of cardiovascular disease – Other clinical conditions associated with insulin resistance

• If results are normal, repeat testing at three-year intervals or more frequently depending on initial results and risk status

Criteria for Diagnosis of Diabetes

• A1c ≥ 6.5%

OR

• Fasting plasma glucose (FPG) ≥ 126 mg/dl (7.0 mmol/l) – no caloric intake for at least 8 hours

OR

• Two-hour plasma glucose ≥ 200 mg/dl (11.1 mmol/l) during an oral glucose tolerance test (OGTT)

OR

• A random plasma glucose ≥ 200 mg/dl (11.1 mmol/l)

Goals of Treatment - Glucose

• A1c < 7.0%

• Pre-prandial CBG 70 – 130 mg/dl

• Peak postprandial CBG < 180 mg/dl

• Less stringent A1c goals may be appropriate for patients with – History of severe hypoglycemia, limited life expectancy,

advanced microvascular or macrovascular complications, extensive co-morbid conditions

– Those with longstanding diabetes in whom general goal is difficult to attain despite education, glucose monitoring and effective doses of multiple glucose lowering agents including insulin

Correlation of A1c with Estimated Average Glucose

Mean plasma glucose

A1C (%) mg/dl mmol/l

6 126 7.0

7 154 8.6

8 183 10.2

9 212 11.8

10 240 13.4

11 269 14.9

12 298 16.5

ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S18. Table 9.

Components of Management

• Blood sugar control • Patient education • Nutrition counseling • Medication • Physical activity • Foot care • Retinopathy • Nephropathy • Cardiac • Lipid Management • Smoking cessation • Vaccines • Transfer and discharge

Blood Sugar Control

• Goal is A1c < 7.0%

• Chronic care clinic for management

– Every 3 – 6 months if A1c consistently < 7.0%

– Every 2 – 3 months if A1c is 7.0% - 9.0%

– Every month if A1c > 9.0% until better control is achieved

• Achieving good control requires:

– Patient education and motivation

– Effective combination of medications

– Appropriate diet and compliance

– Daily blood glucose monitoring

Patient Education

• Nutrition including commissary choices

• Medication

• Empowerment for self-management

– Choice

– Control

– Consequences

• Peer groups

Nutritional Counseling

• Individuals who have diabetes or pre-diabetes should receive individualized medical nutrition therapy

• Include counseling regarding the “better” choices from items available in the commissary

• Use commissary purchase list as an additional opportunity for education and counseling

• Encourage weight loss if BMI ≥ 25

• Education regarding portion control

• Think about implementing a heart healthy diet for ALL inmates – benefits everyone and reduces need for special medical diets

Medication

• Formularies should provide access to usual and customary oral medications and insulins to treat diabetes and related conditions

• Patients should have access to medications at dosing frequencies that are consistent with their treatment plan and direction

• Correctional institutions and police lock-ups should implement policies and procedures to diminish the risk of hypo- and hyperglycemia during off-site travel

Physical Activity

• Exercise 150 minutes/week of moderate intensity aerobic activity

• Almost everyone can walk

• If there isn’t sufficient place to walk on the grounds, consider setting aside gym time for walking around the court or running laps

• Exercise does not mean everyone has to work out in the weight room

• In absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance training three times per week

Foot care

• Instruct the patient with diabetes to examine his/her feet daily and report to medical at the first sign of breakdown

• Examine the patient’s feet at every encounter

• Annual comprehensive foot exam to include inspection, assessment of pulses, testing for loss of protective sensation (monofilament, pinprick, etc.)

• Multidisciplinary approach at the first sign of foot ulcer and for those with high-risk feet

Monofilament Testing

Upper panel

• To perform the 10-g monofilament test, place the device perpendicular to the skin, with pressure applied until the monofilament buckles

• Hold in place for 1 second and then release

Lower panel

• The monofilament test should be performed at the highlighted sites while the patient’s eyes are closed

Boulton AJM, et al. Diabetes Care. 2008;31:1679-1685

Retinopathy

• Initial dilated retinal and comprehensive eye exam by an ophthalmologist or optometrist shortly after diagnosis

• Subsequent examinations annually

• High quality fundus photographs can detect most clinically significant diabetic retinopathy. Interpretation should be performed by a trained eye care provider. This is not a substitute for a comprehensive eye exam.

• Eye exam in the first trimester with close follow up throughout pregnancy and for one year postpartum

Nephropathy

• Annual test to assess urine albumin excretion in type 1 diabetic patients with diabetes duration of 5 years

• Annual test to assess urine albumin excretion in all type 2 diabetic patients starting at diagnosis

• Serum Creatinine at least annually in all adults with diabetes regardless of the degree of urine albumin excretion

• GFR at least annually to stage level of chronic kidney disease

• If micro- or macroalbuminuria, treat with ACE or ARB (contraindicated in pregnancy)

• Reduction of protein intake if patient has CKD

Stages of Chronic Kidney Disease

Stage

Description

GFR (ml/min per 1.73 m2 body surface area)

1 Kidney damage* with normal or increased GFR

≥90

2 Kidney damage* with mildly decreased GFR

60–89

3 Moderately decreased GFR 30–59

4 Severely decreased GFR 15–29

5 Kidney failure <15 or dialysis

*Kidney damage defined as abnormalities on pathologic, urine, blood, or imaging tests

ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S34. Table 14.

Cardiovascular Disease

• BP at every encounter – goal is < 130/80

• If not at goal: – Lifestyle therapy for maximum of 3 months if systolic 130 –

139 or diastolic 80 – 89 • Weight loss if overweight

• Dietary Approaches to Stop Hypertension (DASH) diet

• Increased physical activity

• Moderation of alcohol intake

– If systolic ≥ 140 or diastolic ≥ 90 at diagnosis or follow up, begin pharmacologic therapy in addition to lifestyle therapy – ACE or ARB and diuretic (thiazide if GFR ≥ 30 and loop if GFR < 30) • Monitor kidney function and serum potassium levels

Antiplatelet Agents

• Consider aspirin therapy (75 to 162 mg/day) as a primary prevention strategy in those with type 1 and type 2 diabetes at increased cardiovascular risk (10-yr risk > 10%) – Includes men > 50 years or women > 60 years with at least one

additional major risk factor (family history of CVD, HTN, smoking, dyslipidemia, albuminuria)

– ASA not recommended for those at low cardiovascular risk

• Use aspirin as a secondary prevention strategy in patients with diabetes and history of CVD

• For patients with CVD and documented ASA allergy, clopidogrel (75 mg/day) should be used

• Combination therapy with ASA and clopidogrel is reasonable for up to one year after an acute coronary syndrome

Lipid Management

• Fasting lipid profile at least annually

• Goal is LDL-C < 100 mg/dl

• Goal for those with CVD is < 70 mg/dl

• If goal is not met on maximum drug therapy, reduction of 30% - 40% from baseline is an alternative goal

• Lifestyle therapy for all diabetic patients

• Statin therapy should be added to lifestyle therapy, regardless of lipid levels, for diabetic patients: – With overt CVD

– Without CVD who are over the age of 40 and have one or more other CVD risk factor

• Statin therapy is contraindicated in pregnancy

Smoking Cessation

• Advise all patients not to smoke

• Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care

Immunizations

• Provide an influenza vaccine annually to all diabetic patients ≥ 6 months of age

• Administer pneumococcal polysaccharide vaccine to all diabetic patients ≥ 2 years

• One-time revaccination recommended for those > 64 years previously immunized at < 65 years if administered ≥ 5 years ago

• Other indications for repeat vaccination: – Nephrotic syndrome

– Chronic renal disease

– Immunocompromised states

Housing

New recommendation in 2012:

– If feasible, consider housing inmates with diabetes in the same housing unit

• Makes it easier to time meals around medications

• Makes it easier to have emergency treatment materials in a central housing location

• Improves patient self-management

• Offers more opportunities for peer support

Transfer and Discharge

• For all inter-institutional transfers, complete a medical transfer summary to be transferred with the patient

• Diabetes supplies and medication should accompany the patient during transfer

• Begin discharge planning with adequate lead time to ensure continuity of care and facilitate entry into community diabetes care

The Role of Culture

Prison versus Correctional

• Prisonization involves the formation of an informal inmate code and develops from the individual characteristics of inmates and from institutional features of the prison.

• Correctionalization involves all aspects of prison culture (inmates) and more … It includes the actions and behaviors of the staff as well.

Gillespie, W. (2006), Prisonization: Individual and Institutional Factors Affecting Inmate Conduct. Criminal Justice. LFB Scholarly Publishing, LLC

Cultural Competency Continuum for Successful Diabetes Program in Corrections

Cultural destructiveness

Cultural incapacity

Cultural blindness

Cultural pre-competence

Basic cultural competence

Advanced cultural competence

Training Paradigms

• Corrections – Security over all else

– Care, custody and control

– Law enforcement

– Relationship

– Certifications and Standards

– Adversarial role

– Learning is often scenario-based

• Health Services – Health and life over all

– Improvement for society

– Advocate role

– Certifications and Standards

– Learning through scientific method, evidence-based practice, statistics

Correctional Culture Plays a Role

• What are some words that describe the correctional culture?

• What would medical staff say?

• What would correctional staff say?

• What would inmates say?

How Do We Bridge the Gap?

• Staff and inmates can become hardened to the environment

• Attitude is Everything

• Development of corrections-specific education & trainings

Best Practice for Adherence Within the Walls: Correctionalize All Education

Diet-Commissary, Medications,

Release, Exercise, Realities, Group

Education, Resources

Inmate-Patient

Correctional Staff

Health Services

Diabetic Emergencies

Diabetes Emergencies

• People experiencing diabetes emergencies may:

– Appear intoxicated

– Appear under the influence of drugs

– Appear uncooperative

• When in doubt, ask the person or his/her companions if the person has diabetes and check for medical identification bracelet, necklace, or card

Warning Signs that Require Action

Hypoglycemia

• Sweating

• Shakiness

• Anxiety

• Confusion

• Difficulty speaking

• Uncooperative behavior

• Paleness

• Irritability

• Dizziness

• Inability to swallow

• Seizure

• Loss of consciousness

Hyperglycemia

• Flushed skin

• Labored breathing

• Confusion

• Cramps

• Very weak

• Sweet breath

• Nausea

• Loss of consciousness

Emergency Treatment

Hypoglycemia

• Give ½ can sugared (non-diet) soda – unless the person cannot swallow

• Obtain immediate assistance from a qualified health care professional

• Continue to give sugar source every 15 minutes until blood sugar > 70

• If unconscious, give Glucagon or D50 IV

Hyperglycemia

• Give access to water

• Give access to bathroom

• Give access to medication

• Obtain immediate assistance from a qualified health care professional

• Give regular NOT LONG-ACTING insulin

How to Ensure Safety of Patients with Diabetes

• Identification – Promptly identify patients with diabetes and ensure that this information

accompanies the patient to all facilities while he/she is in custody

• Location – Patients with diabetes should only be held where there is immediate access to

health care professionals who are able to manage their care and respond to diabetes emergencies

• Access to diabetes medication and food – Patients with diabetes must continue their medication without interruption and

must always have access to food. In addition, it is important to coordinate meals and medication to maintain blood glucose levels in a safe range

• Sugar – If a patient with diabetes requests a source of sugar, immediately provide that

person with a sugared soft drink, juice, or another fast-acting source of sugar, followed by bread or crackers

• Emergencies – If a patient with diabetes requests medical care or exhibits symptoms of diabetic

illness, immediately obtain assistance from a qualified health care professional. Know the fastest way to obtain medical help in the case of an emergency that cannot be handled by on-site personnel

Summary and Key Points

• People with diabetes should receive care that meets national standards. Being incarcerated does not change these standards.

• Patients must have access to medication and nutrition needed to manage their diabetes.

• In patients who do not meet treatment targets, medical and behavioral plans should be adjusted by health care professionals in collaboration with the custody staff.

• It is critical for correctional institutions to identify particularly high-risk patients in need of more intensive evaluation and therapy, including pregnant women, patients with advanced complications, a history of repeated severe hypoglycemia, or recurrent DKA.

• A comprehensive, multidisciplinary approach to the care of people with diabetes can be an effective mechanism to improve overall health and delay or prevent the acute and chronic complications of this disease.

References

• Diabetes Management in Correctional Institutions. Agency for Healthcare Research and Quality. Available online at http://guideline.gov

• Standards of medical care in diabetes. VI. Prevention and management of diabetes complications. Agency for Healthcare Research and Quality. Available online at http://guideline.gov

• American Diabetes Association. Standards of medical care in diabetes – 2011. Diabetes Care 2011;34(suppl 1):S11-12. Available online at http://care.diabetesjournals.org/content/34/Supplement_1

• National Diabetes Fact Sheet, 2011. National Center for Chronic Disease Prevention and Health Promotion. Division of Diabetes Translation. Available online at http://www.cdc.gov

Contact Information

• Sr. Mary Jane Bookstaver:

– MaryJane.Bookstaver@CorizonHealth.com

• Jessica Lee:

– Jessica.Lee@CorizonHealth.com