dm fundamentals –class 5 goals & standards of care 2017health disparities related to:...

Diabetes Ed Services© All rights reserved 1998 ‐ 2017 www.DiabetesEd.net

DM Fundamentals – Class 5 Goals & Standards of Care 2017

Beverly Thomassian, RN, MPH, BC‐ADM, CDEPresident, Diabetes Education Services

Standards of Care ‐ Topics Review the 15 Standards of Care with a focus on updated standards

Keeping it Patient Centered

National goals and getting to target

Prevention and lifestyle interventions

CDE® Coach App – Download Success

101 Test Questions for $9.99Standards of Care Meds PocketCards


Goals and Care Delivery Systems 33‐49% of pts do not meet targets for A1c, BP or lipids

14% meet targets for A1c, BP, lipids and non smoking status

Substantial system level improvements are needed

Delivery system is fragmented, lacks clinical info capabilities, duplicates services and is poor

Why Should Zip Code Determine Life Expectancy?

California Endowment – look up your zip code at www.measureofamerica.org

1. Promoting Health ‐ Reducing Disparities in Populations

Start with patient centered communication. Incorporate pt preferences, literacy, life experiences

Treatment decisions timely, based on evidence and tailored to individual pt.

Align care with Chronic Care Model to ensure proactive practice and informed, activated patient.

Provide team‐based care, community involvement, decision support tools.


Health Disparities‐ Tailor Treatment Consider individualized care and create environmental structures to support people with: Food insecurity

Cognitive dysfunction

Mental illness (2‐3 x’s higher rates of diabetes in schizophrenia, bipolar)

HIV (meds can cause pancreatic dysfunction)

Health disparities related to: Ethnicity, culture, sex, socioeconomic status

2. Classification and Diagnosis ‐ Natural

History of Diabetes

Normal

FBG <100

Random <140

A1c <5.7%

Prediabetes

FBG 100-125

Random 140 - 199

A1c ~ 5.7- 6.4%

50% working pancreas

Diabetes

FBG 126 +

Random 200 +

A1c 6.5% or +

20% working pancreas

Development of type 2 diabetes happens over years or decades

Yes! NO

Updated Characterization of DM Primarily a beta cell disease Destruction of a beta cell

Autoimmune or chemical induced

Dysfunction of the beta cell Unable to compensate for higher levels of glucose


2. Screening for Hyperglycemia

Pre Diabetes & Type 2‐ Screening Guidelines

Start screening at age 45 or for anyone who is overweight (BMI 25, Asians BMI 23 ) with one or > additional risk factor:

First‐degree relative w/ diabetes

Member of a high‐risk ethnic population

Habitual physical inactivity

PreDiabetes

History of heart disease

Diabetes 2 ‐ Who is at Risk?(ADA Clinical Practice Guidelines)

Risk factors cont’d

HTN ‐ BP > 140/90

HDL < 35 or triglycerides > 250

baby >9 lb

History Gestational Diabetes

Polycystic ovary syndrome (PCOS)

Other conditions assoc w/ insulin resistance:

Severe obesity, acanthosis nigricans(AN)


Screening for Type 2 25% of all people with diabetes are undiagnosed 50% of all Asian and Hispanic Americans are undiagnosed Most people with prediabetes are undiagnosed.

The duration of glycemic burden is a strong predictor of adverse outcomes.

Use Validated Diabetes Risk Test (ADA) to identify those at risk and promote behavior change action for individuals and their communities.

Dentists have an excellent opportunity to find patients with undetected diabetes, since up to 30% of patients over the age of 30 seen in general dental practices have dysglycemia.

Test Criteria T2 Kids & Adolescents Overweight plus any two: Family history type 2 in 1st or 2nd degree relative

Race/ethnicity

Signs of insulin resistance or conditions associated with insulin resistance

Maternal history of diabetes or GDM

Start testing at 10 yrs or onset of puberty Recheck every 3 years or if symptoms

A1c preferred screening method


3. Comprehensive Medical Evaluation, Assessment of Comorbidities

It is necessary to take into account all aspects of a patient’s life circumstance

A team approach is important to integrate medical eval, patient engagement and lifestyle changes.

3. Keep it Patient Centered “it is clear that optimal diabetes management requires an organized, systematic approach and the involvement of a coordinated team of dedicated health professionals, working in an environment where patient centered care is a high priority”.

Coordinate care as patients transition through different stages of life.

Pt Centered Collaborative Care Use communication style that: Uses active listening

Elicits patients preferences and beliefs

Assess literacy, numeracy and barriers to care

Optimize Patient health outcomes

Health related quality of life


3. Foundations of Care and Comprehensive Medical Evaluation

Medical Evaluation1. Classify diabetes2. Detect diabetes

complications3. Review previous treatment

and risk factor control4. Assist in formulating a

management plan5. Provide a basis for

continuing care

3. Initial Eval – Looking for Comorbidities

Type 1 ‐ Autoimmune diseases

Other conditions that may appear Type 1 /2 Depression and anxiety

Obstructive sleep apnea

Fatty liver disease

Cancer

Fractures

Cognitive impairment

Low Testosterone in Men

Periodontal disease

Hearing Impairment

4. LifeStyle Management Education – Setting Up Successful Diabetes Ed Program – Level 2

Nutrition

Physical Activity Nutrition and Exercise Course –Level 1

Smoking Cessation

Psychosocial Care

Immunization


4. Lifestyle Management Patients with prediabetes Refer to behavioral counseling /DSME program to: Focus on intensive diet and physical activity

Weight loss target of 7%

Increase physical activity to 150 minutes a week

Follow‐up counseling critical for success

Consider Metformin for type 2 prevention if A1c 5.7‐6.4

Especially with BMI >35 and hx of GDM

Monitor annually and screen and mitigate modifiable CV risk factors

Physical Activity Children with diabetes – 60 mins / day

Adults – 150 min/wk moderate intensity over 3 days a week.

Don’t miss > 2 consecutive days w/out exercise

Get up every 30 mins ‐ Reduce sedentary time

T1 and T2 – resistance training 2 ‐3 xs a week

Flexibility and balance training 2‐3 xs a week (Yoga and Tai Chi)

Best Shake For People with Diabetes

From Debbie Nagata’s slide collection


Emphasize eating a variety of nutrient dense foods in appropriate portions to: Attain individualized B/P, BG and lipid goals

Attain and maintain body wt goals

Delay and/or prevent complications

Address individual nutrition needs based on personal and cultural preferences, access to food,

willingness and barriers

Maintain pleasure of eating by providing positive messages about food Limit food choices only when backed by science

Provide practical tools for day‐to‐day planning

4. Goals of Medical Nutrition Therapy – ADAPromote and support healthful eating patterns

Medical Nutrition Therapy Individualize MNT for all people with Type 1 and Type 2 Diabetes

For those on flexible insulin program, provide education on carb counting, fat and protein gm estimations

For those on fixed insulin program, focus on consistent carb intake considering timing and amount to improve BG control and reduce risk of hypo

Diabetes Nutrition Therapy Emphasize on portion control and health food choices for: For type 2 not on insulin

Pts with limited health literacy or numeracy

Elderly prone to hypoglycemia

Diabetes Nutrition Therapy benefits Cost savings

Improved outcomes – reduces A1c 1‐2%

Should be reimbursed by insurance


4. Sodium, Fat and Fiber Sodium – Try and keep less than 2,300 mg a day

Vitamin and mineral supplements not recommended ‐lack of evidence.

Fat ‐ same as recommended for general population Less than 10% saturated fat,

Limit trans fats

Less than 300 mg cholesterol daily

Mediterranean Diet looks like good option

Fiber 25 ‐38 gms a day

4. E‐ Cigarettes Not supported as an alternative to smoking or to facilitate smoking cessation.

Encourage all patients not to use cigarettes, other tobacco products, e‐cigs

Provide counseling

The uptake of e-cigarettes, which use battery-powered cartridges to produce a nicotine-laced vapor (and often contain other bad stuff)

Psychosocial Care Provide to all pts with diabetes

Integrate with a collaborative, ptcentered approach.

Routinely screen for depression, diabetes distress, anxiety, disordered eating and cognitive capacities

Evaluate adults over 65 years for cognitive impairment and depression


DiabetesEd.Net Website We have posted Clinical Practice Guidelines here

Resources >> Articles >> Practice Guidelines

5. Prevention of Diabetes Medicare will start funding approved Diabetes Prevention Programs 2018

Who would be Eligible?


CDC Diabetes Prevention Program

Standard Group ‐ 29% developed DM

Lifestyle Results ‐ 14% developed DM

58% (71% for 60yrs +) Risk reduction

30 mins daily activity

5‐7% of body wt loss

Metformin 850 BID ‐ 22% developed DM

31% risk reduction (less effective with elderly and thinner pt’s)

Weight loss and Prevention

For every 2.2 pounds of weight loss, risk of type 2 diabetes was reduced by 13%.

Have Pre‐Diabetes? Steps to Prevent Type 2

Lose 7% of body weight Healthy eating, high fiber, low fat, avoid sugar sweetened beverages, reduce total caloric intake

Exercise 150 minutes a week

Consider Metformin Therapy for Women with history of GDM

Patients with BMI of 35 or greater

Under the age of 60

Follow‐up and group education

Annual monitoring and tx of CVD risk factors


DSM Education & Support All people with diabetes and pre diabetes should receive DSME at diagnosis and as needed Pt centered, respectful, responsive to individual pt preferences, needs, values

Address psychosocial issues and emotional well being

Effective self‐management results in cost savings, improved outcomes, health status and quality of life.

Should be monitored as part of care

5. Use Technology to Prevent Diabetes Recent studies support content delivery through virtual small groups, internet social networks, cell phones and mobile devices. Validated studies that these approaches can: Support wt loss

Reduce A1c (prediabetes)

The CDC Diabetes Prevention Program is incorporating these tools into their program content

6. Glucose Goals Individualize Targets – ADA

Pre‐Prandial BG 80‐ 130rather than 70–130 mg/dL, to better reflect new data comparing actual average glucose

levels with A1C targets.

1‐2 hr post prandial < than 180*for nonpregnant adults


6. A1c Glycemic Targets Adult non pregnant A1c goals A1c < 7% ‐ a reasonable goal for adults.

A1c < 6.5% ‐ may be appropriate for those without significant risk of hypoglycemia or other adverse effects of treatment.

A1c < 8% ‐ may be appropriate for patients with history of hypoglycemia, limited life expectancy, or those with longstanding diabetes and vascular complications.

6. A1c and Estimated Avg Glucose (eAG)

A1c (%) eAG5 976 1267 1548 1839 21210 24011 26912 298

eAG = 28.7 x A1c‐46.7 ~ 29 pts per 1%Translating the A1c Assay Into Estimated Average Glucose Values – ADAG Study

Diabetes Care: 31, #8, August 2008

Order teaching tool kit free at diabetes.org


6. Pediatric Glycemic Targets A1c goal <7.5 % for all ages; however individualization is still encouraged.

A lower goal, <7% if can be achieved w/out excessive hypoglycemia

Blood glucose goals Before meals: 90‐130

Bedtime/overnight: 90‐ 150

Significant Hypoglycemia BG < 54mg/dl is defined as serious clinically significant hypoglycemia,whether that level is associated with symptoms or not.

ALL pts with BG levels less than 54 mg/dl:

Need Glucagon Emergency Kit Should notify their provider and health team

of this significant hypoglycemia, so changes can be immediately made to their medication and treatment plan.

BG <70mg/dl still considered the hypoglycemic threshold. Pts should follow the 15/15 rule and contact their provider to make any needed changes treatment plan.

7. Obesity Management for Treatment of Type 2 Diabetes

This section updates (metabolic) bariatric surgery recommendations.

At each pt encounter, calculate BMI and document in medical record


Weight Loss is Important – Type 2 Strong evidence that in overwt/obese pts, a 5% initial body wt loss: Delays progression from Pre‐diabetes to Diabetes

Improves glycemic control

Improve triglycerides

Reduces need for medications

Optimal goal – Sustained weight loss of 7%

How to Achieve Weight Loss? Diet, physical activity and behavioral therapy (80% diet, 20% exercise)

Interventions should be high intensity (16+ sessions in 6 months)

Goal: 500 ‐700 kcal/day energy deficit (3,500 kcals = 1 pound)

What is 500 kcals? 4 slices bacon, a Big Mac, bagel w/ cream cheese, 4 oz’s tortilla chips, 3 sodas, 9 Oreo cookies, blueberry muffin

5 apples, 5 bananas, 5 eggs, 3 cups of beans, 1 cup almonds

Long Term Weight Loss is the Goal Comprehensive wt loss maintenance program prescription: Provide monthly contact

Encourage ongoing body weight monitoring (weekly)

Continued consumption of reduced calorie diet

Participation in high levels of physical activity: 200 – 300 minutes a week

40‐ 50 minutes, 5 times a week


Metabolic (Bariatric) Surgery ‐2017 Consider for adults with; BMI 40 + (37.5 for Asian Americans, AA) regardless of BG control

BMI 35 – 39.9 (32.5 ‐37.4 for AA) when hyperglycemia is inadequately controlled despite lifestyle an optimal therapy

BMI 30‐34.9 (27.5 ‐32.4 for AA) if hyperglycemia is inadequately controlled despite optimal medical control by either oral or injectable medications.

Metabolic surgery should be performed at high volume center with an experienced team

Need life long support and monitoring

Provide comprehensive mental health assessment prior to surgery and mental health support on an ongoing basis.

Metabolic Surgery Benefits Increases gut hormone availability More likely to cause remission* with recently diagnosed diabetes (more beta cell mass) 30 ‐ 63% remission over 1‐5 years 35 – 50% redeveloped diabetes

Avg remission time 8.3 years

Most pts who undergo surgery maintain substantial improvement of BG control from baseline for ~5 yrs

Trials demonstrate metabolic surgery achieves superior BG control and reduction of CV risk factors in obese pts with type 2 compared to lifestyle/medical intervention

Improvements in micro and macro disease and cancer have been observed.

Procedure may reduce long term mortality*remission = BG levels normal without meds

Section 8‐ Pharmacologic Approaches to Glycemic Treatment Insulin Cost ‐ This section was updated to include the increasing cost of Insulin ‐ see chart which reviews the average wholesale price per 1000 units of insulin and options for lower cost insulin therapy.

Includes insulin therapy strategies for type 1 / type 2

Metformin & B12 ‐ For patients on long term metformin therapy, the ADA recommends periodic B12 measurement and supplementation as needed.

CV Disease ‐ For patients with cardiovascular disease, consider using empagliflozin or liraglutide to reduce the risk of cardiovascular events.


ADA Step Wise Approach to Hyperglycemia 2017 Start lifestyle coaching and metformin therapy Metformin is effective, safe, affordable, lowers CV Risk If A1c target not achieved after 3 mos, start 2nd med/ins If A1c target not achieved after 3 mos, add 3rd agent If A1c target not achieved after 3 mos, add basal insulin If A1c target not achieved after 3 mos, keep metformin, consider adding bolus insulin, or switching to GLP‐1 RA + Basal, or premixed insulin

A1c ≥ 9% consider initiating dual therapy or insulin if A1c ≥ 10% consider initiating combo insulin therapy


EMPA‐REG OUTCOME®: Summary Empagliflozin, as used in this trial, for 3 years in 1,000 patients with type 2 diabetes at high CV risk:

Empagliflozin reduced hospitalization for heart failure 35%

Empagliflozin reduced CV death by 38%

Empagliflozin improved survival by reducing all‐cause mortality by 32%

8. Insulin Management for Type 2

8. Pharmacologic Approaches to Glycemic Management

Join our Meds for Type 2 (Part 1) in Level 1 Series

Join our Meds Management for Type 2 (Part 2) in Level 2 Series

Join Insulin Pattern Management (Part 1) in Level 1 Series

Insulin Pattern Mgmt Gone Crazy (Part 2) in Level 2 Series


New PocketCards – 2 Styles

ABC’s of Diabetes

A1C

Blood Pressure

Cholesterol

9. Cardiovascular Disease and Risk Management

Cardiovascular disease is the leading cause of mortality and morbidity in diabetes

Largest contributor to direct and indirect costs

Controlling cardiovascular risk improves outcomes

Large benefits are seen when multiple risk factors are addressed globally


9. BP Goal

BP < 140 / 90 Some pts may benefit from B/P 130/80 (younger and achieved with undue tx burden)

Studies indicate that the previous B/P target of 140/80 didn’t improve outcomes enough to balance the risk of side effects such as orthostatic hypotension and polypharmacy.

9. Hypertension Guidelines Screening – Check BP at each visit.

If either • systolic 140 or >

diastolic 90 or > repeat on separate day.

Hypertension = Repeat systolic or diastolic above or equal to these levels

When taking B/P

• Pt sit still for 5 min’s

• Feet on floor,

• Arm supported at heart level

• Right size cuff

9. Blood Pressure Treatment First Line B/P Drugs Any of the 4 classes of BP meds can be used to tx hypertension (without albuminuria).

This includes ACE Inhibitors, ARBs, thiazide‐like diuretics or calcium channel blockers.

Multiple Drug Therapy often required

For best effect, administer at least one at bedtime


Antiplatelet Agents Consider aspirin therapy (71‐162 mg/day) As a primary prevention strategy for T1 or T2 at increase CV risk (10 yr risk >10%)

In pts who can’t tolerate, use Plavix, (clopidogrel) Combo therapy of aspirin + clopidogrel is reasonable for a year after MI

Includes most men or women w DM age ≥ 50 years, with at least 1 additional risk factor: Family history of premature ASCVD Hypertension Smoking Dylipidemia Albuminuria

9. Coronary Heart Disease In pts with known CVD, use: Aspirin

Statin

B/P Med Consider ACE Inhibitor to reduce risk of CV event

In pts with prior MI, Beta Blockers should be continued at least 2 years after the event

Don’t use Actos or Avandia in pts with CHF

In pts with stable CHF, Metformin can be used in renal function normal and stable

A 78 yr old man, smokes ppd A1c was 8.1% (down from 10.4%)

B/P 136/76 AM BG 100, 2 hr pp 190

Chol – TG 54, HDL 46, LDL 98

Meds: Insulin – 16 units Lantus at HS

Benazepril 20 mg

Metropolol 50mg

Warfarin 5mg

Actos 15 mg

What class of meds is this patient on?Any special instructions?Any med missing?


ABCs of Diabetes

A1c less than 7% (avg 3 month BG) Pre‐meal BG 80‐130 Post meal BG <180

Blood Pressure < 140/90Cholesterol Eval if statin therapy indicated

Mr. Jones ‐ What are Your Recommendations for Self‐Care?

Patient Profile62 yr old with newly dx type 2.

History of previous MI.Meds: Lasix, synthroid

Labs: A1c 9.3%

HDL 37 mg/dl

LDL 156 mg/dl

Triglyceride 260mg/dl

Proteinuria ‐ neg

B/P 142/92

Self‐Care Skills

Walks dog around block 3 x’s a week

Bowls every Friday

Widowed, so usually eats out

10. Microvascular Complications "Every time you see your doctor, take off your shoes and socks and show your feet!"

For patients with loss of protective sensation, foot deformities, or a history of foot ulcers

Comprehensive foot eval each year to identify risk & promote prevention


10. Microvascular Complications Nephropathy – Diabetic Kidney Disease Optimize glucose and B/P Control to protect

kidneys

Screen for Albumin‐Creat ratio and GFR Type 2 at dx then yearly

Type 1 with diabetes for 5 years, then yearly

Treat hypertension with ACE or ARB and intensify as needed

Consider referral to specialist when management is difficult and kidney disease is advanced

Not recommended to limit dietary protein intake below 0.8 g/kg/day (doesn’t improve outcomes)

See Level 2 Course, Microvascular Complications

10. Microvascular Complications Eye Disease Optimize glucose and B/P Control to protect

eyes

Screen with initial dilated and comprehensive eye exam by ophthalmologist or optometrist Type 2 at diagnosis, then every one to 2 years

Type 1 within 5 years of dx, then every 1‐2 years

Can use high quality fundus photography as screening tool‐ Initial exam should be done in person

Promptly refer pts with macular edema, severe non‐proliferative disease trained specialist

Treatment includes laser therapy (retinopathy) and Antivascular and Endothelial Growth Factor for Macular Edema

10. Microvascular Complications Nerve Disease Tight glycemic control

Medication recommendations updated

Screen all patients for nerve disease using simple tests, such as a monofilament Type 2 at diagnosis, then annually

Type 1 diabetes 5 years, then annually

Assess and treat patients to reduce pain and symptoms to improve quality of life.


11. Older Adults 26% of people over 65 have diabetes (expected to rise)

Asses the medical, functional, mental and social geriatric domains for diabetes.

Provide individualized care Determine targets and therapeutic approaches

Over age 65, high risk for depression

Provide nursing home staff with education

See Level 2 Course, Older Adults and Diabetes

Older Adults (≥65 years) with diabetes Annual screening for early detection of mild cognitive impairment or dementia

High priority population for depression screening and treatment

Avoid hypoglycemia in this high risk group Prevent hypo by adjusting glycemic targets and adjusting pharmacologic interventions

12. Children and Adolescents Start preconception counseling at puberty for all girls of childbearing potential – decreases risk of malformations associated with

unplanned pregnancies and poor metabolic control,

Type 1 or Type 2 Diabetes? Many children are overweight with new

hyperglycemia. 6% of children with new type 2 present in DKA. Type 2 in kids is different than type 2 in adults,

including more rapid decline in beta cell function and accelerated development of diabetes complications.

Evaluate autoantibodies and do a careful history to determine the correct diagnosis and provide early and appropriate treatment.

See Level 2 Course - Kids and Diabetes for full detail


13. Gestational DM ~ 7% of all Pregnancies

GDM prevalence increased by ∼10–100% during the past 20 yrs

Native Americans, Asians, Hispanics, African‐American women at highest risk

Immediately after pregnancy, 5% to 10% of GDM diagnosed with type 2 diabetes

Within 5 years, 50% chance of developing DM in next 5 years.

13. Meds used in Pregnancy Insulin is the preferred med to be used in pregnancy Glyburide and Metformin cross the placenta

Long term studies needed

14. Diabetes Care in Hospital, Nursing Home and Skilled Nursing Facility

Get A1c on all patient with DM/hyperglycemia

Start discharge planning on admission

Avoid sole use of sliding scale insulin during hospital stay ‐ Basal bolus preferred treatment

Have hypoglycemia protocol

Clearly identify type of diabetes on admission

Inpatient glucose goals: Start insulin if BG >180

Goal BG 140‐ 180 (some pts may benefit from 110‐140)

New Parenteral/Enteral Feeding Chart


Parenteral/Enteral Feeding Chart

15. Diabetes Advocacy People living with diabetes should not face discrimination

We need to all be a part of advocating for the best care and the rights of people living with diabetes.

DiabetesEd.net > Resources


Thank You Please email us with anyquestions.

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dm fundamentals –class 5 goals & standards of care 2017health disparities related to:...

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