DM Fundamentals Class 5 Goals & Standards of Care Standards of Care Topics. CDE Coach App Download Success

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1 DM Fundamentals Class 5 Goals & Standards of Care 2017 Beverly Thomassian, RN, MPH, BC ADM, CDE President, 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 $9.99 Standards of Care Meds PocketCards Diabetes Ed Services All rights reserved Page 1

2 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 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. Diabetes Ed Services All rights reserved Page 2

3 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 Yes! NO Normal FBG <100 Random <140 A1c <5.7% Prediabetes FBG Random A1c ~ % 50% working pancreas Diabetes FBG Random A1c 6.5% or + 20% working pancreas Development of type 2 diabetes happens over years or decades 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 Diabetes Ed Services All rights reserved Page 3

4 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) Diabetes Ed Services All rights reserved Page 4

5 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 1 st or 2 nd 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 Diabetes Ed Services All rights reserved Page 5

6 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 Diabetes Ed Services All rights reserved Page 6

7 3. Foundations of Care and Comprehensive Medical Evaluation Medical Evaluation 1. Classify diabetes 2. Detect diabetes complications 3. Review previous treatment and risk factor control 4. Assist in formulating a management plan 5. 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 Diabetes Ed Services All rights reserved Page 7

8 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 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 Diabetes Ed Services All rights reserved Page 8

9 4. Goals of Medical Nutrition Therapy ADA Promote and support healthful eating patterns 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 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 Diabetes Ed Services All rights reserved Page 9

10 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 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, pt centered approach. Routinely screen for depression, diabetes distress, anxiety, disordered eating and cognitive capacities Evaluate adults over 65 years for cognitive impairment and depression Diabetes Ed Services All rights reserved Page 10

11 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? Diabetes Ed Services All rights reserved Page 11

12 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 Diabetes Ed Services All rights reserved Page 12

13 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 rather than 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 Diabetes Ed Services All rights reserved Page 13

14 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 (%) eag Order teaching tool kit free at diabetes.org 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 Diabetes Ed Services All rights reserved Page 14

15 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: Bedtime/overnight: 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 Diabetes Ed Services All rights reserved Page 15

16 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: 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: minutes a week minutes, 5 times a week Diabetes Ed Services All rights reserved Page 16

17 Metabolic (Bariatric) Surgery 2017 Consider for adults with; BMI 40 + (37.5 for Asian Americans, AA) regardless of BG control BMI ( for AA) when hyperglycemia is inadequately controlled despite lifestyle an optimal therapy BMI ( 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. Diabetes Ed Services All rights reserved Page 17

18 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 2 nd med/ins If A1c target not achieved after 3 mos, add 3 rd 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 Diabetes Ed Services All rights reserved Page 18

19 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 allcause 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 Diabetes Ed Services All rights reserved Page 19

20 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 Diabetes Ed Services All rights reserved Page 20

21 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 Diabetes Ed Services All rights reserved Page 21

22 Antiplatelet Agents Consider aspirin therapy ( 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? Diabetes Ed Services All rights reserved Page 22

23 ABCs of Diabetes A1c less than 7% (avg 3 month BG) Pre meal BG Post meal BG <180 Blood Pressure < 140/90 Cholesterol Eval if statin therapy indicated Mr. Jones What are Your Recommendations for Self Care? Patient Profile 62 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 Diabetes Ed Services All rights reserved Page 23

24 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. Diabetes Ed Services All rights reserved Page 24

25 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 See Level 2 Course - Kids hyperglycemia. and Diabetes for full detail 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. Diabetes Ed Services All rights reserved Page 25

26 13. Gestational DM ~ 7% of all Pregnancies GDM prevalence increased by % 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 (some pts may benefit from ) New Parenteral/Enteral Feeding Chart Diabetes Ed Services All rights reserved Page 26

27 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 Diabetes Ed Services All rights reserved Page 27

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