GUIDING PRINCIPLES FOR DIABETES CARE FOR HEALTH CARE PROVIDERS

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GUIDING PRINCIPLES FOR DIABETES CARE FOR HEALTH CARE PROVIDERS

www.ndep.nih.gov

The National Diabetes Education Program (NDEP) has developed these Guiding Principles for Diabetes Care to help the health care team manage the disease effectively. The principles outline seven essential components of quality diabetes care that form the basis of NDEP's public and professional awareness programs. Payers of health care, managed care organizations, and large employers can use them to establish diabetes care principles, to assess quality, and to assure quality diabetes care and treatment service options in health plans. The NDEP believes that people with diabetes and their families should actively participate with their health care team to plan and implement their care. While these principles serve as a guide for discussing diabetes management, each person with diabetes and his or her health care team determine the specific management plan.



Introduction

Principle 1: Identify People with Pre-Diabetes and Undiagnosed Diabetes

Principle 2: Provide Ongoing, Patient-Centered Care

Principle 3: Offer Diabetes Education

Principle 4: Treat Diabetes Comprehensively

Principle 5: Monitor Blood Glucose Control using the A1C Test

Principle 6: Prevent Long-term Diabetes Problems

Principle 7: Identify and Treat Long-term Diabetes Problems

Resources


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Introduction
The goal of the National Diabetes Education Program (NDEP) is to reduce the morbidity and mortality caused by diabetes and its complications through programs that increase awareness of the seriousness of the disease and the value of its treatment and prevention. These Guiding Principles for Diabetes Care for health care providers are evidence-based and describe the essential components of quality diabetes care.

People with diabetes and their health care team need to have ongoing discussions about what care is best for each individual and why. Many health care providers make up the team to care for people with diabetes, including physicians, diabetes educators, nurses, dietitians, pharmacists, social and mental health workers, eye specialists, foot specialists, and dentists.

Ongoing, comprehensive diabetes care can prevent or control diabetes-related macrovascular complications (heart disease, stroke, and circulatory problems) and microvascular complications (blindness, amputations, and end-stage renal disease). With proper education and self-care, people with diabetes should expect to lead long, active, and productive lives.

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Principle 1: Identify People with Pre-Diabetes and Undiagnosed Diabetes
To improve health outcomes, it is essential to identify people at high risk for diabetes as well as those who are undiagnosed, and treat them appropriately. More than 18 million Americans have diabetes; 5.2 million of whom have undiagnosed type 2 diabetes. More than 40 percent of U.S. adults ages 40-74¡ªor 41 million people¡ªcurrently have pre-diabetes, placing them at increased risk for cardiovascular disease and type 2 diabetes.

DEFINITIONS Impaired Fasting Glucose Fasting plasma glucose (FPG) 100¨C125 mg/dl after an overnight fast
Impaired Glucose Tolerance 2-hr post 75g glucose challenge 140¨C199 mg/dl
Diabetes Random plasma glucose>200 mg/dl with symptoms (polyuria, polydypsia, and unexplained weight loss) or FPG>126 mg/dl or 2-hr plasma glucose>200 mg/dl post 75g glucose challenge
Pre-diabetes is the term that has been adopted to describe those states that occur when a person¡¯s blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. People with pre-diabetes have impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) and are at increased risk for type 2 diabetes.

Although the 2-hour 75g glucose challenge is more sensitive than a FPG value for diagnosing pre-diabetes or diabetes, use of the test is not always practical. If only a FPG is used, however, some diagnoses will be missed. The diagnosing health care provider should use clinical judgment to decide which test to use. A diagnosis of diabetes should be confirmed on another day.

RISK FACTORS FOR PRE-DIABETES AND DIABETES INCLUDE:

Age: 45 and older
Overweight: body mass index ¡Ý25 kg/m2 (¡Ý23 if Asian American or ¡Ý26 if Pacific Islander)
In addition to age and weight, these factors increase risk:

Ethnicity: African American, American Indian, Asian American, Hispanic and Latino American, or Pacific Islander heritage
Family history: have a first-degree relative with diabetes
History of gestational diabetes or gave birth to a baby weighing > 9 lbs
Hypertension: blood pressure >140/90
Abnormal lipid levels: HDL cholesterol level <40mg/dl for men and <50mg/dl for women; triglyceride level >250 mg/dl
IGT or IFG on previous testing
Polycystic ovary syndrome or acanthosis nigricans History of vascular disease
Inactive lifestyle: exercises less than three times a week
Testing is strongly recommended when a person is age 45 or older and overweight. Consider testing when a person is:

45 or older or
younger than 45, overweight, with one or more risk factors.
If results are normal, consider testing at 3-year intervals.

Early identification of pre-diabetes and diabetes may reduce or prevent the development of long-term complications before the person has been diagnosed. The diagnosis of pre-diabetes and diabetes should be clear, based on accepted guidelines for FPG or IGT values.

Terms such as ¡°a touch of diabetes¡± or ¡°sugar¡¯s a little high¡± are confusing and should not be used. People with diabetes should know what type of diabetes they have.

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Principle 2: Provide Ongoing, Patient-Centered Care
People with diabetes need to be part of a health care delivery system that provides high quality, patient-centered care on an ongoing basis. This approach ensures that timely changes in their treatment are made to achieve optimal control of the disease.

People with diabetes need ongoing care in a patient centered, supportive, and positive environment, without barriers to obtaining care. The health care team should include a provider responsible for ongoing care and skilled in its delivery, with access to other physician specialists and health care professionals.

Certain high risk groups¡ªethnic populations, children, pregnant women, and the elderly¡ªhave special needs that should be addressed. People with diabetes also need support from their family, friends, and co-workers. Financial resources are needed for ongoing education, durable equipment,supplies, medications, and insulin. Discrimination against employment, licensing, and obtaining insurance should be avoided.

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Principle 3: Offer Diabetes Education
People with diabetes and their family members need accurate information and education for diabetes self-care.

Health care providers are responsible for offering diabetes education that addresses the medical and emotional needs of the individual patient. Education enables people with diabetes to participate more actively in their treatment and in prevention of complications.

Diabetes education is a continuous process. It should begin with the essential elements of self-care and include instruction on following the prescribed medical regimen. Over time, the instruction should become a dialogue that defines and addresses the ongoing needs of the individual and his or her family.

People with pre-diabetes and diabetes need opportunities to acquire the knowledge and skills that enable and empower them to perform effective self-care. Certified diabetes educators and dietitians can help provide these services. It is important to enlist family members and others who provide support to help the patient achieve a greater measure of self-care and quality of life.

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Principle 4: Treat Diabetes Comprehensively
A1C, blood pressure, and cholesterol, the ¡°ABCs of diabetes,¡± should be kept as near to normal as is safely possible. The target values should be based on an overall assessment of the person¡¯s health.

A primary goal of diabetes treatment is the control of hyperglycemia by a variety of methods. It is well known that over many years hyperglycemia causes long-term complications of diabetes. The risk of eye disease (retinopathy), kidney disease (nephropathy) and nerve damage (neuropathy) is strongly linked with high blood glucose levels.

Target ABC Value A1C <7 percent
Blood Pressure <130/80
Cholesterol (LDL) <100 mg/dl
Scientific evidence shows that controlling blood glucose, blood pressure, and cholesterol¡ªthe ¡°ABCs of diabetes¡±¡ªcan lower the risk for cardiovascular disease (hardening of the arteries, heart attack, stroke, and circulatory problems).

All people with diabetes should follow a healthy food and physical activity plan. In type 1 diabetes, insulin is always required, combined with a welldefined treatment plan. In some people with type 2 diabetes, following a healthy food and exercise plan initially achieves diabetes control, but most will eventually require the addition of oral medications and/or insulin.

The exact methods of treatment¡ªdiet, exercise, oral antidiabetic agents and/or insulin¡ªshould be tailored to individual needs. People with diabetes should participate in the decision making process, with options, goals, and targets clearly stated.

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Principle 5: Monitor Blood Glucose Control using the A1C Test
A1C and blood glucose should be measured on a routine basis using current, reliable methods.

A1C is the principal method for monitoring glucose control. The NDEP and it partners have adopted the simple name ¡°A1C¡± when referring to the hemoglobin A1c test. It is a standardized blood test that indicates the average blood glucose over the previous 8 to 12 weeks. Since most long-term complications of diabetes are related to A1C, measuring it should be a regular part of assessing diabetes care. People with diabetes should know their own A1C and whether they are reaching their target.

The absence of symptoms of high blood glucose is an unreliable guide for judging glucose control since symptoms do not occur until blood glucose reaches high levels. Diabetes is often called a ¡°silent disease¡± because it can cause serious complications without having serious symptoms.

Routine self-monitoring of blood glucose is a successful approach in self-management of diabetes because it provides a picture of the immediate blood glucose level. Individual circumstances will define how often self-monitoring is used, the specific approach, and the methods of recording and reporting results. People with diabetes need access to self-management tools, including blood glucose meters and strips.

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Principle 6: Prevent Long-term Diabetes Problems
Comprehensive care can significantly lower risk for long-term diabetes problems.

For those with pre-diabetes, modest weight loss (5 to 7 percent) through regular physical activity and a low fat, low calorie diet can prevent or delay the onset of diabetes. Preventing or delaying the onset of diabetes also is likely to prevent or delay the onset of diabetes complications.

For those with diabetes, controlling blood glucose is one important way to prevent complications. For every 1 percent lowering of the A1C toward normal, there is up to a 37 percent reduction in risk for microvascular complications in people with type 1 and type 2 diabetes.

To reduce the risk of cardiovascular disease, other important risk factors must be controlled¡ª hypertension, abnormal blood fats (especially high LDL-cholesterol, high total cholesterol, and low HDL-cholesterol), and smoking. Routine measurement and management of these risk factors are essential for good diabetes care. In people with diabetes, the cardiovascular benefits of blood pressure and lipid control are equal to or greater than the benefits to people without diabetes.

For both types of diabetes, preventing long-term complications is enhanced by practicing the following healthy self-care behaviors:

Eating healthy foods
Controlling portion sizes
Getting daily physical activity
Taking prescribed medications (including aspirin)
Performing foot care
Making routine visits to health care providers for foot, dental, and eye care
Stopping smoking
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Principle 7: Identify and Treat Long-term Diabetes Problems
People with diabetes should have regular exams to help find and treat diabetes problems. All diabetes problems have effective treatments.

Routine checking for long-term complications can help detect problems at a time when they can be treated and managed successfully. The physical examination and laboratory tests that identify early complications include:

At each diabetes visit:

Blood pressure
Weight check
Foot check
Annually:

Lipid profile (every 2 years in normal)
Dilated eye examination by a competent professional for detecting retinal and other eye complications (if normal, an eye care specialist may advise an exam every 2 to 3 years)
A physical examination for detecting nerve damage
Comprehensive foot exam to identify high risk feet (by checking circulation, loss of feeling, sores, or changes in shape)
Serum creatinine and urinalysis for protein, microalbumin, albumin-to-creatinine ratio to detect kidney disease
Twice each year:

A1C (quarterly if patient is not meeting goals)
Dental exams to prevent gum disease and loss of teeth Vaccinations:
Influenza (annually)
Pneumoccal (usually only once, repeat if over 64 or immunocompromised and last vaccination was more than 5 years ago)
Diabetes complications usually can be prevented or delayed if found and treated at an early stage. Progression of cardiovascular disease leading to heart attack and stroke can be slowed or prevented by rigorous management of blood pressure and lipids. Diabetic kidney disease can be slowed or prevented by controlling blood pressure and blood glucose. Severe eye disease can be successfully treated by laser therapy. Circulatory complications in the legs, heart, or brain may be improved by treatment, including vascular surgery. These examples show the importance of treating long-term complications at any stage of diabetes.


About NDEP
The National Diabetes Education Program is a federally funded program sponsored by the U.S. Department of Health and Human Services' National Institutes of Health and the Centers for Disease Control and Prevention and includes over 200 partners at the federal, state, and local levels, working together to reduce the morbidity and mortality associated with diabetes

Contact Us
By Phone
Office of Communications and Public Liaison, NIDDK, NIH 301-49...

By Mail
National Diabetes Education Program
One Diabetes Way
Bethesda, MD 20814-9692

By Email
ndep@mail.nih.gov

To Order Materials
Call 1-888-693-NDEP (6337) to order diabetes education materials for consumers and health care providers.