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Reference Articles

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Patient Education

Family Doctor.org (AAFP) - a variety of diabetes topics, written in a introductory style

ADA/ACC Diabetes Toolkit - a bit more detailed, English/Spanish, includes sample glucose logs and food/exercise tracker

ADA Online Patient Risk Assessment Quiz - Could you have diabetes and not know it?

Link for Life - ADA Online Diabetes Interactive Patient Education

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Online Cases

AAFP Diabetes CME - online one hour video and slides, post-test for members with CME credit

MDFMR Self-test Case

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Definitions

Please see Diagnosis and Classification of Diabetes & Standards of Medical Care in Diabetes - Diabetes Care 1/07 for more details.

Note that the Hemoglobin A1c is not recommended as a diagnostic test for diabetes.

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Screening

Please see Standards of Medical Care in Diabetes - Diabetes Care 1/07 for more details.

Consider also checking a screening fasting lipid profile if patient meets criteria below for diabetes screening.

Standard of care in our area is to screen all pregnant women for GDM at 28 weeks. Women at high risk for GDM should be screened as early as possible in pregnancy with1 hour GTT, and if negative, should have repeat screening at 28 weeks.

There is some debate about the utility of universal screening for GDM, well reviewed in the Diabetes Care article above. The USPSTF does not support universal screening for GDM at this time. For more information, please see AHRQ Summary of USPSTF Systematic Evidence Review (2003) and AFP EBM Case.

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Lifestyle Changes

• Every patient with diabetes or impaired glucose tolerance should receive medical nutrition therapy with a dietician.
• Monitoring, but not eliminating, carbohydrates in the diet is beneficial in acheiving glycemic control. Knowledge of the glycemic index of foods may provide additional benefit.
• Structured education, such as at the Diabetes and Nutrition Center, has been shown to lead to weight loss and improved glycemic control.

• The ADA recommends 150 minutes per week (almost 3 hours) of moderate intensity exercise AND resistance training for all muscle groups 3 x/week.
• Exercise has been shown to improve glycemic control, even in the absence of weight loss.
• In previously sedentary diabetics with a 10 year cardiovascular risk of > 10%, an exercise stress test should be performed prior to initiating an exercise regimen.
• Patients with diabetic retinopathy should avoid jarring activites such as weight-lifting, boxing, and even jogging depending on the severity of disease.
• See table for suggested exercise for patients with diabetic peripheral neuropathy.

ADA Nutrition, Recipes, and Online Shopping Guides

ADA Exercise Counseling, "Club Ped" and Weight Loss Support

Cochrane Review - Exercise for type 2 diabetes

Cochrane Review - Long-term non-pharmacological weight loss interventions for adults with type 2 diabetes mellitus

Please see Standards of Medical Care in Diabetes & Physical Activity and Exercise in Diabetes & Nutrition Principles and Recommendations for more details.

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Basic Medications

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Goals of Therapy

Goals of care include not only good glycemic control, but also control of blood pressure and lipids.

Screening for complications is reviewed below.

Glycemic Control		The Evidence...
Goals	Hemoglobin A1c < 7.0, as close to 6.0 as possible - limited by hypoglycemia
Frequency	q 3 months if uncontrolled, q 6 months if at goal
At the residency...	tracking q 6 month levels as a quality goal
Dyslipidemia		The Evidence
Goals	Without overt cardiovascular disease – LDL <100 (if over the age of 40, initiate statin therapy to achieve LDL reduction of 30-40% baseline) With overt cardiovascular disease- all patients should be treated with statins to achieve LDL reduction of 30-40% baseline (LDL <70 is an option using a higher-dose statin) Other goals- triglycerides <150; HDL >40 (in women, >50)
Frequency	screen at least annually, more often if needed to achieve goals
At the residency...	tracking LDL done within one year as a quality goal
Blood Pressure		The Evidence
Goals	systolic BP <130mmHg and diastolic BP <80mmHg
Frequency	every visit
At the residency...	checking at least once yearly is being tracked as a quality parameter

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The Office Visit

A routine follow-up visit for a patient with diabetes has several goals, including monitoring and working towards improved glycemic control, screening for and managing complications of diabetes, and addressing any psychosocial issues that are relevant to the patient's illness.

HPI / ROS

Physical Exam - focus on areas of potential complications

• Weight and BP every visit
• Retinal exam (non-dilated)
• CV / Pulm
• Extremities - peripheral pulses, skin (breakdown, fungal infection), nail disease and general condition, monofilament exam

Assessment and Plan

• Assess glycemic control, blood pressure and lipids with respect to goals of therapy
• Assess presence of any end-organ complications
• Order labs as needed to help make these assessments
• Consider using a flow sheet or EMR diabetes flow to help keep organized
• Consider education around a variety of topics: diet, exercise, med compliance, target blood sugars, smoking cessation, pathophysiology of diabetes or medications, side effects of medications, complications of uncontrolled diabetes, etc.
• Follow up is generally every three months, sooner if poor control

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Quality Indicators

MaineHealth Management Coalition - FMI Quality Indicators Online