10 Principles for Diabetes Management
Identify Undiagnosed Patients
Detection of prediabetes and diabetes is essential in preventing or delaying the development of cardiovascular disease (CVD) and micro- and macrovascular disease risks.<sup>1</sup> Clinicians should aim to screen asymptomatic adults aged older than 45 years, as well as adults who are overweight, obese, or have 1 or more additional risk factor (eg, family history of diabetes, high cholesterol, atherosclerotic cardiovascular disease, etc). Adults who are members of a high-risk population, including African Americans, Hispanics, American Indians, Asian Americans, Pacific Islanders, or Alaska Natives, should also be screened regularly.<sup>1</sup> Women with a history of gestational diabetes are also at an elevated risk of developing type 2 diabetes, and should be screened postpartum, and then on a yearly basis.<sup>1</sup>
Led by the National Institutes of Health (NIH), the Diabetes Prevention Program (DPP)<sup>2</sup> found that participants in the lifestyle intervention study were able to achieve a 58% reduction in diabetes incidence over 3 years.<sup>2</sup> A second study, the Study to Prevent Non-Insulin-Dependent Diabetes Mellitus3 determined that treatment with acarabose reduced type 2 diabetes incidence by 25%.<sup>3</sup> These studies, along with many others, show that prediabetes does not always progress to type 2 diabetes. Appropriate lifestyle interventions, including dietary changes and increased physical activity, can prevent this progression. Patients may benefit from referral to a registered dietitian (RD) or a certified diabetes educator (CDE), or enrollment in a CDC-recognized National Diabetes Prevention Program.<sup>4</sup>
Provide Self-Management Education and Support
Patients at risk for or with diabetes may benefit from diabetes self-management education (DSME) or support. DSME utilizes a patient’s knowledge, skill, and ability to encourage self-care. DSME also encourages “active collaboration” between patients and their health care team to improve outcomes and quality of life.<sup>1</sup> The NDEP defines self-management as “an active, ongoing process that changes as the person’s needs, priorities, and situations change.”<sup>1</sup> Self-management helps patients understand the risks and benefits of various treatment options, incorporate physical activity and healthy eating into their daily lifestyle, and perform self-monitoring and interpretation of blood pressure and blood glucose readings when necessary.<sup>5,6</sup> Comprehensive DSME should be provided by clinicians at the time of diagnosis, and after on an as-needed basis.<sup>1</sup>
Offer Nutrition Therapy
Individualized nutrition therapy can help patients with prediabetes or type 2 diabetes hit target levels of blood glucose, blood pressure, and lipids, as well as achieve weight loss goals. Medical nutrition therapy (MNT) can be provided by an RD or a registered dietitian nutritionist (RDN),<sup>1</sup> and should include a nutrition assessment, a nutrition diagnosis, individualized nutrition interventions, and nutrition monitoring, in conjunction with continued follow-up to support lifestyle changes and evaluate outcomes.<sup>1</sup> Setting weight loss goals in overweight or obese patients is another effective way to minimize risks and complications associated with prediabetes and type 2 diabetes.<sup>1</sup> Counseling surrounding calorie consumption, portion sizes, and nutrition literacy can help patients reach their weight loss goals. The Centers for Medicare and Medicaid Services (CMS) may cover both behavioral therapy and nutrition counseling for obesity when provided by a qualified primary care practitioner.<sup>1</sup>
Encourage Regular Physical Activity
Among the components of lifestyle interventions examined in the DPP study,<sup>2</sup> participants with prediabetes who engaged in regular physical activity achieved a mean 7% weight loss at 1 year.<sup>2</sup> At least 150 minutes a week of moderate-intensity physical activity can improve insulin sensitivity, glycemic control, lipids, and blood pressure, as well as reduce the risk for cardiovascular disease. When providing physical activity education, clinicians should take into account a patient’s limitations—for example, advising those with limited mobility to engage in aquatic or chair exercise. While all types of moderate and vigorous aerobic activities can be beneficial, clinicians should also encourage patients to participate in muscle and strength training exercises, such as push-ups, sit-ups, or heavy gardening.<sup>1</sup> All patients should be evaluated for contraindications to exercise before beginning a fitness regimen.<sup>1</sup>
Control Blood Glucose
Controlling blood glucose levels is key in preventing or delaying the development of diabetes complications. In a 10-year observational follow-up study<sup>7</sup> of the United Kingdom Prospective Diabetes Study),<sup>8</sup> researchers found that rates of reduced diabetes complications persisted for at least a decade after a period of intensive glycemic control (average HbA1c of 7%, compared with 7.9% in standard treatment. As with all diabetes interventions, treatment targets for glucose control should be individualized based on each patient’s presentation. Comorobid conditions, known CVD, and advanced microvascular complications should be taken into account. Hypoglycemia is the leading factor that limits glycemic management in patients with type 1 and insulin treated type 2 diabetes.<sup>1</sup> Hypoglycemia prevention is critical in those treated with insulin or sulfonylureas.<sup>1</sup>
Manage Hypertension and Dyslipidemia
Clinicians caring for patients with diabetes should be especially mindful of hypertension and dyslipidemia in their patients, which are risk factors for CVD. Paying attention to these risk factors are especially important in patients with type 1 diabetes due to their high risk for CVD. Several studies<sup>9-13</sup> have examined the evidence for blood pressure control in patients with diabetes, and found significant reductions in a patient’s risks for major macro- and microvascular events and death from CVD. Additionally, patients with type 2 diabetes may benefit from statin therapy, which can reduce CVD events in this patient population.<sup>1</sup> Lifestyle modifications targeted towards lowering LDL cholesterol levels can reduce CVD risks, especially in patients aged 45 to 75.<sup>1</sup>
Screen for Nephropathy, Neuropathy, and Retinopathy
Renal health is especially important in patients with diabetes. Clinicians should regularly screen markers associated with the development of nephropathy, neuropathy, and retinopathy, which are linked to end-stage renal disease (ESRD), blindness, and CVD. Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) can be used to lower systolic blood pressure<sup>1</sup> and prevent the onset of diabetic nephropathy. Targeted blood glucose control can reduce the risk or slow the progression of diabetic neuropathy, including chronic semsorimotor distal symmetric polyneuropathy (DPN). Retinopathy can be managed through the optimized control of blood glucose, blood pressure, and lipids; patients with any level of macular edema, proliferative diabetic retinopathy, or severe nonproliferative diabetic retinopathy should be referred to an eye care professional with experience managing retinal disease.<sup>1</sup>
Diabetes Management in Special Populations
Special considerations for managing diabetes in special populations—children, older adults, for example, or those in high-risk racial and ethnic groups—should be made. Children with diabetes require specialized self-management support and regular assessments for depression.<sup>1</sup> For older adults, diabetes management should take into account coexisting chronic conditions and the patient’s cognitive status; this patient population may also require specialized medication prescribing practices and regularly monitored therapy.<sup>1</sup> For members of at-risk racial or ethnic groups, patient-centered, culturally competent care allows clinicians to create the most effective diabetes management plan.
Benefits of Providing Patient-Centered Diabetes Care
As medical treatments have evolved, methods of patient care have also changed. Today, patient-centered care is key to managing diabetes. Shared decision-making, care coordination, and the use of a multidisciplinary care team are all methods that clinicians can use to enhance the patient experience. Health literacy among patients is also key to successful diabetes management<sup>1</sup>—data from the Agency for Healthcare Research and Quality (AHRQ)14 show that patients without adequate health literacy often experience poorer health outcomes, as well as higher health care costs. Therefore, health literacy is essential in allowing patients to successfully participate in their own care.<sup>1</sup>
Although diabetes is incredibly common in the United States,1 many gaps exist in diabetes management. In an effort to identify these gaps, as well as mitigate the $245 billion financial burden1 associated with the condition, the National Diabetes Education Program (NDEP) has provided 10 "guiding principles" of diabetes care, focused on the prevention and management of diabetes in adult populations.1
Compiled by Lauren Biscaldi
- National Diabetes Education Program (NDEP). Guiding principles for the care of people with or at risk for diabetes. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) website. Published September 2014. Accessed November 16, 2016.
- Knowler WC, Barrett-Connor E, Fowler SE, for the Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403. doi:10.1056/NEJMoa012512.
- Chaisson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laasko M; for the STOP-NIDDM Trail Research Group. Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomized trial. Lancet. 2002;359(9323):2072-2077. doi:10.1016/S0140-6736(02)08905-5.
- Centers for Disease Control and Prevention. National Diabetes Prevention Program. http://www.cdc.gov/diabetes/prevention/index.html. Accessed November 18, 2016.
- Haas L, Maryniuk M, Beck J, et al, on behalf of the 2012 Standards Revision Task Force. National standards for diabetes self-management and education and support. Diabetes Care. 2004;37 Suppl 1:S144-153. doi:10.2337/dc14-S144.
- Boucher JL, Evert A, Daly A, et al, for the American Dietetics Association. American Dietetic Association revised standards of practice and standards of professional performance for registered dietitians (generalist, specialty, and advanced) in diabetes care. J Am Diet Assoc. 2011;111(1):156-166.e1-27. doi:10.1016/jada.2010.10.053.
- UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837-853. doi:10.1016/S0140-6736(98)07019-6.
- Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359(15):1577-1589. doi:10.1056/NEJMoa0806470.
- UK Prospective Diabetes Study (UKPDS) Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabtes: UKPDS 38. BMJ. 1998;317:703. doi:10.1136/bmj.317.7160.703.
- Hansson L, Zanchetti A, Carruthers SG, et al; for the HOT Study Group. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial. Lancet. 1998;351(9118):1755-1762. doi:10.1016/S0140-6736(98)04311-6.
- Cushman WC, Evans GW, Byington RP, et al, for the ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362(17):1575-1585. doi:10.1056/NEJMoa1001286.
- Kostis JB, Wilson AC, Freudenberger RS, Cosgrove NM, Pressel SL, Davis BR; for the SHEP Collaborative Research Group. Long-term effect of diuretic-based therapy on fatal outcomes in subjects with isolated systolic hypertension with and without diabetes. Am J Cardiol. 2005;95(1):29-35. doi:10.1016/j.amjcard.2004.08.059.
- Patel A, et al; for the ADVANCE Collaborative Group. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomized controlled trial. Lancet. 2007;370(9590):829-840. doi:10.1016/S0140-6736(07)61303-8.
- Berkman N, DeWalt D, Pignone M, et al. Literacy and Health outcomes. Evidence Report/Technology Assessment No. 87. AHRQ Publication No. 04-E007-2. Rockville, MD: Agency for Healthcare Research and Quality. Published January 2004. Accessed November 2016.