Professional Documents
Culture Documents
___________________________________________________________________________________Table of Contents
TABLE OF CONTENTS
INTRODUCTION.................................................................................................................................................................... 1
CHAPTER 1: DIAGNOSIS OF DIABETES ............................................................................................................................ 3
Introduction ....................................................................................................................................................................... 3
Learning Objectives .......................................................................................................................................................... 3
Diagnosis in Symptomatic Patients ................................................................................................................................... 5
Diagnostic Tests for Diabetes ........................................................................................................................................... 6
Measurement of A1C .................................................................................................................................................... 6
Casual (or random) Plasma Glucose ............................................................................................................................ 9
Measurement of Fasting Plasma Glucose .................................................................................................................. 10
Measurement of OGTT ............................................................................................................................................... 10
Confirmation of Test Results ....................................................................................................................................... 11
Edwards Case: Follow-up Visit................................................................................................................................... 11
Screening in Asymptomatic Adults.................................................................................................................................. 11
Diagnostic Criteria for Diabetes....................................................................................................................................... 14
Summary......................................................................................................................................................................... 15
SELF-ASSESSMENT QUESTIONS .................................................................................................................................... 17
Self-Assessment QuestionsAnswers........................................................................................................................... 20
CHAPTER 2: COMPREHENSIVE MANAGEMENT OF DIABETES .................................................................................... 21
Introduction ..................................................................................................................................................................... 21
Learning Objectives ........................................................................................................................................................ 21
Comprehensive Diabetes Evaluation .............................................................................................................................. 23
Healthcare Professionals ................................................................................................................................................ 24
Ongoing Evaluation......................................................................................................................................................... 27
The ABCs of Diabetes................................................................................................................................................. 27
A1C Testing ................................................................................................................................................................ 28
Self-Monitored Blood Glucose..................................................................................................................................... 28
Blood Pressure and Cholesterol Monitoring................................................................................................................ 29
Smoking Cessation......................................................................................................................................................29
Monitoring for Microvascular Complications ................................................................................................................30
Summary of Ongoing Monitoring .................................................................................................................................30
Summary .........................................................................................................................................................................31
SELF-ASSESSMENT QUESTIONS.....................................................................................................................................33
Self-Assessment QuestionsAnswers ...........................................................................................................................34
MODULE SUMMARY...........................................................................................................................................................35
GLOSSARY..........................................................................................................................................................................39
REFERENCES .....................................................................................................................................................................41
_______________________________________________________________________________________ Introduction
INTRODUCTION
Diabetes is a chronic illness that requires continual medical care and educated patient
participation and support to prevent acute complications and to reduce the risk of longterm complications. Diabetes care is complex and requires that many issues, beyond
glycemic control, be addressed. Achieving and maintaining recommended blood glucose,
blood pressure, and cholesterol levels has been shown to reduce the complications
associated with diabetes. These three treatment areas are collectively referred to as the
ABCs of diabetes (A = A1C; B = blood pressure; C = cholesterol).
Module 2: The Diagnosis of Type 2 Diabetes provides you with a background on how
type 2 diabetes is diagnosed and introduces the healthcare professionals who work with
the patient to treat the disease. Throughout the module, case studies are used to describe
the perspectives of healthcare professionals and patients, and the challenges they face.
The initial event leading to the diagnosis of type 2 diabetes varies from patient to patient.
Some patients visit their physicians because they have symptoms. Others who are
asymptomatic may be diagnosed with type 2 diabetes when they visit their physicians for
other reasons, such as routine checkups or incidental illness While the presence of
certain symptoms may cause a physician to suspect a patient has diabetes, diagnostic
tests are required to confirm the diagnosis in all patients.
Type 2 diabetes is a serious and potentially devastating disease; care of the patient with
type 2 diabetes involves many clinical issues and often many comorbidities. Guidelines
have been developed by a number of organizations, including the following, based on
expert consensus and clinical practice to assist healthcare professionals and standardize
the care delivered:
American Diabetes Association (ADA), which publishes a variety of clinical materials,
including yearly updates to its diagnostic criteria and standards of care
American Association of Clinical Endocrinologists (AACE), which publishes a variety
of clinical materials, including diagnostic criteria and standards of care
This module discusses the diagnosis and treatment of type 2 diabetes. Specific topics
in this module include the following:
Chapter 1 describes how type 2 diabetes is diagnosed, using 2 patient case studies
Chapter 2 discusses who treats diabetes and how healthcare professionals work
with patients to manage type 2 diabetes to meet treatment goals
Throughout the text, medical terms are defined in the margin. The module concludes
with a summary, a glossary, and a bibliography.
morbidity (mawr-BID-i-tee):
sickness or disease
mortality (mawr-TAL-i-tee):
death rate
LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
1. Define the tests used to diagnose diabetes: A1C, fasting plasma glucose test,
oral glucose tolerance test, and casual plasma glucose test.
2. List the recommendations for screening in asymptomatic patients.
3. List the criteria for the diagnosis of diabetes.
4. Discuss risk factors for development of diabetes.
polyuria (pol-ee-YOOR-ee-uh):
excessive urination
polydipsia (pol-ee-DIP-see-uh):
excessive thirst
polyphagia (pol-ee-FEY-jee-uh):
excessive eating
hyperglycemia
(hahy-per-glahy-SEE-mee-uh):
abnormally high blood glucose levels
Fasting plasma glucose (FPG): measured when the patient has not eaten for at least
8 hours
Oral glucose tolerance test (OGTT): measures the patients glucose level 2 hours
after the patient drinks a solution that contains a high glucose concentration
Measurement of A1C
A1C has been used for many years for monitoring blood glucose control in patients with
diabetes. Because the A1C test has several advantages over tests used to diagnose
diabetes, including convenience and worldwide standardization, it is now the preferred
test for diagnosis of diabetes. Data have shown that glycemic threshold levels (the values
at which diabetes is diagnosed) correlate well between the A1C, FPG, and 2-hour OGTT.
glycosylation
(glayh-KOS-uhl-ay-shun):
the chemical linkage of sugar
molecules to proteins
Hemoglobin (hemo = blood, globin = protein) is a protein found within red blood cells that
carries oxygen from the lungs to all body cells. The major type of hemoglobin is called
hemoglobin A, and some molecules of hemoglobin A can link with sugars, including
glucose. This linking is called glycosylation (glyco = glucose, sylation = linking), and the
combination of hemoglobin A and glucose produces glycosylated hemoglobin A, termed
A1C. While all red blood cells contain some glucose, patients with diabetes have too
much glucose in their blood. This extra glucose attaches (glycosylates) to molecules of
hemoglobin. Figure 1 illustrates how A1C is formed.
The more glucose in a patients blood, the more glycosylated hemoglobin, or A1C, is
created in the red blood cells over the life span of the cells (approximately 120 days)
(see Figure 2). Since the reaction that causes the formation of A1C is irreversible, a single
A1C measurement provides an average of A1C content in red blood cells of all ages in a
given individual and can be used as a surrogate marker of the average blood glucose
levels over the previous 8 to12 weeks.
While A1C values are reported as the percentage of hemoglobin that is glycated, daily
monitoring of blood glucose is reported as either mg/dL or mmol/L. A1C values can be
correlated to glucose values (estimated average glucose), as shown in the following table.
6%
7%
8%
9%
10%
11%
12%
* Estimates based on average daily adjusted glucose (ADAG) data of ~2700 glucose
measurements over 3 months per A1C measurement in 507 adults with type 1 diabetes,
type 2diabetes, and no diabetes. Correlation between A1C and average glucose: 0.92. for
A calculator converting A1C results into estimated average glucose, in either mg/dL or mmol/L,
is available at http://professional.diabetes.org/eAG.
A1C testing has several advantages over FPG and OGTT testing, including that A1C:
Is more convenient, since neither fasting nor the requirements of an OGTT are
necessary
Data show good correlation between A1C, FPG, and 2-hour OGTT
Worldwide standardized testing (less chance for error)
Is less affected by day-to-day changes caused by stress or illness
Disadvantages to the use of A1C include that it is more costly than an FPG and it may
not be widely available in some regions of the world. Additionally, the A1C assay is less
sensitive for the diagnosis of diabetes compared with FPG. Assuming universal screening
of individuals who have not been diagnosed with diabetes, A1C would identify one-third
fewer individuals with diabetes compared with FPG. However, because A1C is more
convenient and practical to use, the loss in sensitivity may be offset by more widespread
screening, potentially leading to an increase in diagnoses. Some of the advantages to the
use of A1C to diagnose diabetes are summarized in Table 2.
Table 2. Selected Advantages to the Use of A1C for the Diagnosis of Diabetes
Advantages to Using A1C to Diagnose Diabetes
Lets take a closer look at the other tests that can be used to diagnose diabetes.
These tests provide direct measurements of the glucose in the blood.
preprandial (pree-PRAN-dee-uhl):
before a meal
postprandial
(pohst-PRAN-dee-uhl): after a meal
Results of a casual plasma glucose are classified as abnormal when they are 200 mg/dL
(11.1 mmol/L). A casual plasma glucose test is diagnostic of diabetes if glucose levels
are 200 mg/dL (11.1 mmol/L) and the patient has classic symptoms of hyperglycemia
or hyperglycemic crisis.
Impaired fasting glucose (IFG): blood glucose levels that are higher than normal
but not high enough for a diagnosis of diabetes; patients with impaired fasting glucose
are sometimes referred to as having prediabetes because they have a high risk of
developing type 2 diabetes in the future. Prediabetes is considered to be a risk factor
for diabetes (and cardiovascular disease) and should not be considered a diagnosis
in its own right.
Diagnostic of diabetes
Measurement of OGTT
An OGTT measures the patients glucose level after he/she has fasted for at least 8 hours
and 2 hours after the patient drinks a solution that contains a high glucose concentration.
An OGTT is commonly used to screen for gestational diabetes mellitus in pregnant
women. Similar to the FPG, the results of the OGTT tests can be classified as:
Normal (indicating no diabetes)
impaired glucose tolerance (IGT):
glucose levels measured during an
oral glucose tolerance test that are
higher than normal but not high
enough for a diagnosis of diabetes;
defined as glucose 140 mg/dL to
199 mg/dL (7.8 mmol/L to 11 mmol/L)
Impaired glucose tolerance (IGT): blood glucose levels that are higher than normal
but not high enough for a diagnosis of diabetes; patients with impaired glucose
tolerance are sometimes referred to as having prediabetes because they have a high
risk of developing type 2 diabetes in the future. is considered to be a risk factor for
diabetes (and cardiovascular disease) and should not be considered a diagnosis in
its own right.
Diagnostic of diabetes
10
11
Maria is a 45-year-old Hispanic woman. She sees her GP, Dr. Wilkins, sporadically.
In previous years, Dr. Wilkins has advised Maria that she should exercise more
frequently and try to eat healthier foods. During Marias checkup this year, Dr. Wilkins
sees that Maria has gained weight and now weighs 68.6 kg (154 lb) at 5 feet 4 inches
tall. He calculates Marias body mass index (BMI)* as 26 kg/m2, which indicates that
she is overweight. Marias blood pressure, which was measured at 141/89 mm Hg,
is elevated. Dr. Wilkins begins to tally Marias risk factorsher father died of a heart
attack when he was 58, she is physically inactive, overweight, a member of a high-risk
ethnic group, and she has had elevated blood pressure on several occasions.
Dr. Wilkins informs Maria that he is concerned about these factors, and he tells
her that he wants to test for diabetes. He sends her to the lab to have blood drawn
for an A1C and asks her to return for a follow-up visit the next week.
* While some guidelines discuss calculating BMI, keep in mind that many physicians are
comfortable simply using the patients weight as an indication of obesity.
12
Both the AACE and the ADA guidelines recommend screening for diabetes in certain
high-risk adult patient populations (see Table 3 for the ADA guidelines). The ADA also
recommends screening for type 2 diabetes in asymptomatic children aged 10 or older who
are overweight and have 2 additional risk factors. Additional risk factors for children
include: family history of diabetes, race/ethnicity, signs of insulin resistance or presence
of a condition associated with insulin resistance, and maternal history of diabetes or
gestational diabetes during the childs gestation.
Testing should be considered in all adults who are overweight (BMI 25 kg/m2*)
and who have one or more additional risk factors:
Physical inactivity
First-degree relative with diabetes
High-risk race/ethnicity (e.g., African American, Latino, Native American,
Asian American, Pacific Islander)
Women who delivered a baby weighing >9 lb or who were diagnosed
with gestational diabetes
Hypertension (blood pressure 140/90 mm Hg or on therapy for
hypertension)
High-density lipoprotein cholesterol (HDL-C) level <35 mg/dL
(0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)
Women with polycystic ovary syndrome (PCOS) with BMI 30 kg/m2
A1C between 5.7% and 6.4%, IGT, or IFG on previous testing
Other clinical conditions associated with insulin resistance (e.g., severe
obesity, acanthosis nigricans)
History of cardiovascular disease (CVD)
In the absence of the above criteria, testing for diabetes should begin at age
45 years
If results are normal, testing should be repeated at least at 3-year intervals,
with consideration of more-frequent testing depending on initial results
(e.g., those with prediabetes should be tested yearly) and risk status
hypertension
(hahy-per-TEN-shuhn):
elevated blood pressure
high-density lipoprotein
cholesterol (HDL-C) (lip-oh-PROHteen kuh-LES-tuh-rohl): good
cholesterol; transports excess
cholesterol to the liver for elimination
triglycerides
(trahy-GLIS-uh-rahydz):
lipid molecules containing 3 fatty
acids bound to glycerol; the
primary fat in the diet and the primary
molecule used for fuel storage
polycystic ovary syndrome
(POL-ee-sis-tik): a health problem
that can affect a womans menstrual
cycle, fertility, hormones, insulin
production, heart, blood vessels, and
appearance; may be characterized
by high levels of male hormones
(androgens), abnormal menstrual
cycle, and small cysts in ovaries
13
Diabetes
Diabetes
5.7% to 6.4%
Diabetes
6.5%
* The risk of developing diabetes in patients is continuous, extending below the lower limit
of the range for identified prediabetes and becoming disproportionately greater at the higher
end of the range.
Prediabetes is considered to be a risk factor for diabetes (and cardiovascular disease)
and should not be considered a diagnosis in its own right.
Unless there is unequivocal hyperglycemia, a second test should be performed to confirm
a diagnosis of diabetes.
14
SUMMARY
The following table summarizes the information presented in this chapter on the diagnosis of diabetes.
Diagnosis of Diabetes
Diagnosis in Symptomatic Patients
Some patients with diabetes are diagnosed by their physicians only after they develop symptoms of the disease
(e.g., polyuria, polydipsia, polyphagia)
At diagnosis, patients with diabetes may already be experiencing some of the long-term complications of diabetes
long-term complications of diabetes include macrovascular disease (e.g., coronary artery disease) and
microvascular disease (e.g., retinopathy)
When symptomatic patients enter a physicians office, the physician will perform a complete medical examination,
including a medical history and physical examination; the patient will also undergo laboratory tests that can
diagnose diabetes
Laboratory tests are required to confirm a diagnosis of diabetes. Tests that are used to confirm the diagnosis
of diabetes include:
A1C: measured regardless of fasting status
; provides an estimate of the patients glucose levels over the preceding 2 to 3 months
Casual plasma glucose: glucose is measured regardless of whether the patient has eaten or is fasting
Fasting plasma glucose: glucose is measured when the patient has not eaten for at last 8 hours
OGGT: glucose is measured in a patient who has fasted for at least 8 hours and 2 hours after the patient
drinks a solution containing a high glucose concentration
Unless the patient has clear symptoms (e.g., hyperglycemic crisis) a second laboratory test should be conducted
to confirm a diagnosis of diabetes
Some patients may be diagnosed when they are asymptomatic (e.g., during screening of a high-risk patient, or
incidentally when the patient visits the doctor for treatment of another ailment)
The ADA recommends screening for diabetes in certain high-risk populations, including individuals who are
overweight and have one or more additional risk factors. Additional risks factors include: lead a sedentary lifestyle;
have a family history of diabetes; individuals of certain race/ethnicity; individuals with hypertension, dyslipidemia,
prediabetes (i.e., A1C between 5.7% and 6.4%, IGT, or IFG on previous testing), PCOS with BMI 30 mg/kg2, or
another condition associated with insulin resistance; and women who have a history of gestational diabetes or have
delivered a baby weighing >9 lb
(cont.)
15
16
A1C: levels 6.5% are considered diagnostic of diabetes; patients with levels between 5.7% and 6.4% are at high
risk for development of diabetes
Casual plasma glucose: levels 200 mg/dL (11.1 mmol/L) are considered diagnostic of diabetes in a patient with
classic symptoms of hyperglycemia or hyperglycemic crisis
Fasting plasma glucose: levels 126 mg/dL (7 mmol/L) are considered diagnostic of diabetes; patients with levels
100 mg/dL to 125 mg/dL (5.6 mmol/L to 6.9 mmol/L) are considered to have IFG
OGGT: levels 200 mg/dL (11.1 mmol/L) are considered diagnostic of diabetes; patients with levels 140 mg/dL
to 199 mg/dL (7.8 mmol/L to 11.0 mmol/L) are considered to have IGT
Individuals with A1C between 5.7% and 6.4%, IFG, or IGT may be referred to as having prediabetes because they
have a very high risk for development of diabetes in the future; however, prediabetes is considered to be a risk
factor for diabetes (and cardiovascular disease) and should not be considered a diagnosis in its own right
___________________________________________________________________________Self-Assessment Questions
SELF-ASSESSMENT QUESTIONS
There may be more than one correct answer to each question.
1. Symptoms that may lead a physician to suspect diabetes include:
_____ A. polyphagia.
_____ B. polymeria.
_____ C. polyuria.
_____ D. polydipsia.
2. A(n) _____________ test is taken without regard to the timing and content of the last meal.
_____ A. postprandial glucose
_____ B. oral glucose tolerance
_____ C. casual plasma glucose
_____ D. fasting plasma glucose
3. Match each test with its description.
A. A1C _____
17
4. When evaluating an FPG test, the range consistent with impaired fasting glucose is:
_____ A. 80 to 90 mg/dL (4.4 to 5.0 mmol/L).
_____ B. 100 to 125 mg/dL (5.6 to 6.9 mmol/L).
_____ C. 140 to 199 mg/dL (7.8 to 11.0 mmol/L).
_____ D. 200 mg/dL (11.1 mmol/L).
5. What is the A1C value that is diagnostic of diabetes?
______________________________________________________________________________________________
18
___________________________________________________________________________Self-Assessment Questions
19
SELF-ASSESSMENT QUESTIONSANSWERS
1. A, C, D
2. C
3. A2; B4; C3; D1
4. B
5. 6.5%
20
LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
1. Describe the components of a comprehensive diabetes examination.
2. List the healthcare professionals involved in the care of patients with type 2 diabetes
and describe their roles.
3. Summarize the ABCs of diabetes.
4. State the normal ranges and goals for patients with type 2 diabetes for A1C, blood
pressure, and lipids.
5. Define self-monitored blood glucose.
6. State key results from studies that emphasize the importance of glucose, blood
pressure, and lipid control.
7. Describe research that supports additional treatment considerations regarding
early diagnosis of diabetes and treatment of nephropathy.
21
22
Patients history of diabetes (e.g., age of onset, characteristics of onset, diabetes education,
review of previous treatments and response to therapy)
Lifestyle characteristics (e.g., eating habits, physical activity)
Current treatment of diabetes (e.g., current medications, meal plan, physical activity patterns,
and readiness for behavior change)
Results of glucose monitoring and patients use of data
History of diabetic ketoacidosis, including severity and cause
Hypoglycemic episodes, including patient awareness and the frequency and cause of
severe episodes
History of diabetes-related complications (micro- and macrovascular)
Physical Examination
Height, weight, body mass index
Blood pressure test, including orthostatic measurements when indicated
Thyroid palpation
Skin examination (for acanthosis nigricans and insulin injection sites)
Annual comprehensive foot examination (i.e., visual inspection, palpitation of dorsalis pedis
and posterior tibial pulses, testing of patellar and Achilles reflexes, and evaluation of
proprioception, vibration, and monofilament sensation)
Visual inspection of the patients feet at every routine office visit
Laboratory Evaluation
Eye care professional for annual dilated eye exam (funduscopic examination)
Family planning for women of reproductive age
Registered dietitian for medical nutrition therapy
Diabetes self-management education
Dentist for comprehensive periodontal examination (evaluation for dental disease)
Mental health professional, if needed
Podiatrist
23
HEALTHCARE PROFESSIONALS
Both the ADA and AACE recommend that patients receive medical treatment from
a coordinated, multidisciplinary medical team. The following case study illustrates this
team of healthcare professionals. In some cases, primary care physicians, such as
general practitioners (GPs), family practitioners (FPs), and internists, provide the bulk of
routine care for patients with diabetes, including performing eye exams and foot exams.
Edna: Patient With Diabetes for 15 years
Edna, a 68-year-old woman, has had type 2 diabetes for 15 years. She has had
difficulty controlling her glucose levels, especially after dinner. She knows that she
needs to eat on a regular schedule, but finds the schedule very difficult to maintain.
Edna has tried to exercise as her physician recommends, but finds that her legs
become painful upon exertion. In addition, she recently has had difficulty with her
vision, and as an avid reader, this has become a source of frustration for her.
At her visit, her GP decides that Edna should start seeing a diabetes educator again,
as she had soon after she was diagnosed 15 years ago. Her GP also refers Edna
to a vascular surgeonbecause he is worried about blood flow in her legsand an
ophthalmologistbecause he is worried about her vision.
The following table describes some of the primary care healthcare professionals who may
care for patients with diabetes.
24
Physicians
Nurse practitioners,
physicians assistants,
and/or diabetes nurse
educators
Pharmacists
Family practitioners
General practitioners
Internists
25
Cardiologists
nephropathy (nuh-FROP-uh-thee):
kidney damage that can arise
as a complication of chronic
hyperglycemia
Nephrologists
Ophthalmologists/
optometrists
Podiatrists
(chiropodists)
Registered
dietitians
Diabetes
educators/
counselor
retinopathy (ret-n-OP-uh-thee):
damage to the retina of the eye;
can lead to blindness
Mental health
specialists with a
focus on diabetes
26
ONGOING EVALUATION
After patients like Edward and Maria are diagnosed with type 2 diabetes, a lifetime of
monitoring and managing health issues begins. Type 2 diabetes is a chronic illness
that requires continual medical care and patient self-management to prevent acute
complications and to reduce the risk of long-term complications This includes:
Blood glucose monitoring: A1C and self-monitored blood glucose (SMBG); used to
determine the effectiveness of current therapy and to guide changes in medication,
diet, and other aspects of care
Blood pressure and cholesterol monitoring (cardiovascular disease [CVD] risk factors)
Screening for additional CVD risk factors (e.g., smoking, family history of premature
coronary disease, microalbuminuria or macroalbuminuria)
Monitoring for microvascular complications
Routine screening for depression
Routine screening for obstructive sleep apnea, particularly in men over 50 years of
age; consider referral to a sleep specialist for patients with suspected sleep apnea
microalbuminuria (MAHY-kroh-albyoo-muh-NYOOR-ee-uh):
the leakage of a small amount
of albumin into the urine, defined
as 20 mcg/min to 200 mcg/min
macroalbuminuria (MAK-roh-albyoo-muh-NYOOR-ee-uh):
the leakage of large amounts of
albumin into the urine; defined
as >200 mcg/min
27
A1C Testing
The standard measure used to test glucose control is the A1C test, which, as noted
previously, can provide an estimate of blood glucose control for the previous 2 to
3 months.
The A1C goal for patients with diabetes is:
hypoglycemia
(hahy-poh-glahy-SEE-mee-uh):
abnormally low concentrations of
glucose in the circulating blood
ADA: <7.0%. The ADA guidelines note that, for selected individual patients, providers
might reasonably suggest even lower A1C goals than the general goal of <7%, if this
can be achieved without significant hypoglycemia or other adverse effects of
treatment. Such patients might include those with short duration of diabetes, long life
expectancy, and no significant cardiovascular disease. Conversely, less stringent A1C
goals (e.g., <8%) may be appropriate for patients with a history of severe
hypoglycemia, limited life expectancy, advanced microvascular or macrovascular
complications, extensive comorbid conditions, and those with long-standing diabetes in
whom the general goal is difficult to attain.
AACE: 6.5%. The AACE notes that no randomized controlled trials have established
optimum glycemic targets and while some organizations recommend target A1C
goals of <6.5%, others recommend target A1C levels of <7%. All organizations have
recognized the risks of intensive treatment to achieve target glucose levels may
outweigh the benefits of tight glucose control in some patients, including those with
a history of frequent severe hypoglycemia; those with hypoglycemia unawareness;
and those with long-standing diabetes, particularly if they have significant
comorbidities or are of advanced age.
28
High-density lipoprotein
cholesterol (HDL-C)
Triglycerides
Smoking Cessation
Because of the large body of evidence linking smoking to cardiovascular disease, an
additional recommendation is that all patients should be advised not to smoke. Smoking
cessation counseling and other forms of treatment should be included as a routine
component of diabetes care.
29
Tests
Retinopathy
Nephropathy
creatinine: (kree-AT-n-in):
a waste product filtered from the
blood and excreted in the urine
glomerular filtration rate (GFR):
amount of fluid filtered from the
kidney per unit of time; used to
measure kidney function
Modification in Diet of Renal
Disease (MDRD) equation:
estimates glomerular filtration rate
adjusted for body surface area;
variables are serum creatinine, age,
gender, and race; this equation is
widely used by clinical laboratories
and research studies
Chronic Kidney Disease
Epidemiology Collaboration (CKD
EPI) equation: estimates glomerular
filtration rate based on the level of
serum creatinine, age, sex, and race;
is as accurate as the MDRD equation
in patients with GFR <60 mL/min/
1.73 m2 and more accurate than
the MDRD equation in patients
with GFR >60 mL/min/1.73 m2
neuropathy (nyoo-ROP-uh-thee):
nerve damage, primarily peripheral
neuropathy (in which the nerves in
the extremities are affected); loss
of sensation may occur, which may
result in serious infection, gangrene,
and the need for amputation
30
Neuropathy
SUMMARY
The following table summarizes the information presented in this chapter on the management of diabetes.
Management of Diabetes
Healthcare professionals
Primary care professionals who may treat the patient with diabetes include family practitioners, general
practitioners, internists, nurse practitioners, physician assistants, and diabetes nurse educators
Pharmacists are experts on the pharmacologic management of diabetes; they may provide medication
information, instruction, or health advice
Specialists who may treat patients with diabetes include endocrinologists, cardiologists, nephrologists,
optometrists/ophthalmologists, podiatrists, registered dietitians, diabetes educators/counselors, and mental
health specialists
ABCs of diabetes
Ongoing evaluation
A1C: High percentages of A1C in the blood indicate suboptimal glucose control in patients with diabetes
Testing a patients blood for the A1C level provides a record of blood glucose control for the previous 2 to
3 months
Recommendations for A1C goals in patients with diabetes are:
ADA: <7%. For selected individual patients, even lower A1C goals may be reasonable if this can be
achieved without significant hypoglycemia or other adverse effects of treatment; conversely, less stringent
A1C goals may be appropriate for other patients, including those with a history of severe hypoglycemia or
those in whom the general goal is difficult to attain
AACE: 6.5%. Notes that randomized controlled studies have not determined an optimum blood glucose
level, and some organizations recommend A1C levels <6.5% while others, such as the ADA, recommend
levels <7%
Self-monitored blood glucose (SMBG): Patients test a drop of blood in a glucose meter that provides an
automated glucose level reading; SMBG provides real-time feedback to patients regarding glucose levels
(cont.)
31
32
SELF-ASSESSMENT QUESTIONS
There may be more than one correct answer to each question.
1. A(n) __________ is a physician specializing in diseases such as diabetes and thyroid disease.
_____ A. nephrologist
_____ B. podiatrist
_____ C. endocrinologist
_____ D. ophthalmologist
2. The hemoglobin A1C test is used to measure:
_____ A. plasma glucose levels.
_____ B. complications of diabetes.
_____ C. blood glucose control over time.
_____ D. insulin levels over time.
3. Advantages of SMBG testing include that it:
_____ A. provides real-time information regarding glucose levels.
_____ B. is normally performed by a general practitioner.
_____ C. predicts risk of cardiovascular complications.
_____ D. allows patients to participate in their own care.
4. Which of the following statements about A1C is (are) true?
_____ A. The AACE notes that no randomized controlled trials have established optimum A1C targets.
_____ B. The ADA recommends a target A1C for patients with diabetes of 5% to 6%.
_____ C. The ADA acknowledges that the A1C target may vary for individual patients.
33
SELF-ASSESSMENT QUESTIONSANSWERS
1. C
2. C
3. A, D
4. A, C
34
___________________________________________________________________________________Module Summary
MODULE SUMMARY
1) Some patients who are diagnosed with type 2 diabetes initially present to their
physicians because they have symptoms. Symptoms that can lead a physician
to suspect diabetes include:
Polyuria
Polydipsia
Polyphagia
An A1C test to assess the average glucose over the previous 2 to 3 months
Casual or random test, taken without regard to the time of the last meal
and not fasting
Fasting plasma glucose (FPG), taken >8 hours after the last meal
Oral glucose tolerance test (OGTT), taken >8 hours after the last meal
and 2 hours after drinking a standardized solution that is high in glucose
Unless a patient has clear symptoms, a second diagnostic test should be taken
to confirm a diagnosis of diabetes.
Some patients with diabetes remain asymptomatic for many years. For this reason,
in many patients, their diabetes is detected when they visit their physicians for other
reasons. Therefore, some organizations recommend routine diabetes screening,
especially in patients identified as high-risk based on:
Age
Race
Overweight or obese
Sedentary lifestyle
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Any of the 4 blood glucose tests may provide a diagnosis of diabetes. The levels
that are consistent with a diagnosis of diabetes for each of these tests are:
A1C: 6.5%
Pharmacists
Endocrinologists
Cardiologists
Nephrologists
Ophthalmologists
Podiatrists
Registered dietitians
Patients with type 2 diabetes require continual monitoring of A1C and blood
glucose, as well as monitoring for complications of diabetes.
In particular, ongoing evaluation is important to help patients achieve and maintain
their ABC goals, because achieving and maintaining the recommended goals has
been shown to prevent or delay diabetes-related complications. The ABCs of
diabetes are: A = A1C (generally recommended goal <7%)
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___________________________________________________________________________________Module Summary
Retinopathy: visual acuity test and dilated eye exam of the retina should be
taken at diagnosis and then annually
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__________________________________________________________________________________________Glossary
GLOSSARY
body mass index (BMI): calculated value used to describe an individuals weight relative to height; calculated using
the following formula: BMI = kg/m2
Chronic Kidney Disease Epidemiology Collaboration (CKD EPI) equation: estimates glomerular filtration rate
based on the level of serum creatinine, age, sex, and race; is as accurate as the MDRD equation in patients with
GFR <60 mL/min/1.73 m2 and more accurate than the MDRD equation in patients with GFR >60 mL/min/1.73 m2
creatinine (kree-AT-n-in): a waste product filtered from the blood and excreted in the urine
fasting plasma glucose (FPG): test of blood glucose levels; measured when the patient has not eaten for at least 8 hours
glomerular filtration rate (GFR): amount of fluid filtered from the kidney per unit of time; used to measure kidney function
glycosylated hemoglobin (A1C) (glahy-KOS-uhl-ahyt-ed HEE-muh-gloh-bin): the amount of hemoglobin within
red blood cells with glucose attached; provides an estimate of blood sugar control for the previous 2 to 3 months
glycosylation (glayh-KOS-uhl-ay-shun): the chemical linkage of sugar molecules to proteins
high-density lipoprotein cholesterol (HDL-C) (lip-oh-PROH-teen kuh-LES-tuh-rohl): good cholesterol; transports
excess cholesterol to the liver for elimination
hyperglycemia (hahy-per-glahy-SEE-mee-uh): abnormally high blood glucose levels
hypertension: elevated blood pressure
hypoglycemia (hahy-poh-glahy-SEE-mee-uh): abnormally low concentrations of glucose in the circulating blood
impaired fasting glucose (IFG): fasting glucose levels higher than normal but not high enough for a diagnosis of
diabetes; defined as glucose 100 mg/dL to 125 mg/dL (5.6 mmol/L to 6.9 mmol/L)
impaired glucose tolerance (IGT): glucose levels measured during an oral glucose tolerance test that are higher than
normal but not high enough for a diagnosis of diabetes; defined as glucose 140 mg/dL to 199 mg/dL (7.8 mmol/L to
11 mmol/L)
insulin (IN-suh-lin): hormone secreted by the beta-cells of the pancreas that is the key regulator of the metabolism of
glucose and processes necessary for metabolism of fats, carbohydrates, and proteins; opposes the action of glucagon
lipid (LIP-id): fat; found almost exclusively in foods of animal origin and continuously synthesized in the body
low-density lipoprotein cholesterol (LDL-C) (lip-oh-PROH-teen kuh-LES-tuh-rohl): bad cholesterol; transports most
cholesterol in the blood; when present in high amounts, deposits cholesterol in the walls of arteries, forming lipid plaques
macroalbuminuria (MAK-roh-al-byoo-muh-NYOOR-ee-uh): the leakage of large amounts of albumin into the urine;
defined as >200 mcg/min
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microalbuminuria (MAHY-kroh-al-byoo-muh-NYOOR-ee-uh): the leakage of a small amount of albumin into the urine,
defined as 20 mcg/min to 200 mcg/min
Modification in Diet of Renal Disease (MDRD) equation: estimates glomerular filtration rate adjusted for body
surface area; variables are serum creatinine, age, gender, and race; this equation is widely used by clinical laboratories
and research studies
morbidity (mawr-BID-i-tee): sickness or disease
mortality (mawr-TAL-i-tee): death rate
nephropathy (nuh-FROP-uh-thee): kidney damage that can arise as a complication of chronic hyperglycemia
neuropathy (nyoo-ROP-uh-thee): nerve damage, primarily peripheral neuropathy (in which the peripheral nerves in the
extremities are affected); can result in loss of sensation, which may result in serious infection, gangrene, and the need for
amputation
oral glucose tolerance test (OGTT): measures the 2-hour postload glucose (PG) value; patient is tested 2 hours after
ingesting 75 g of glucose
polycystic ovary syndrome (POL-ee-sis-tik): a health problem that can affect a womans menstrual cycle, fertility,
hormones, insulin production, heart, blood vessels, and appearance; may be characterized by high levels of male
hormones (androgens), abnormal menstrual cycle, and small cysts in ovaries
polydipsia (pol-ee-DIP-see-uh): excessive thirst
polyphagia (pol-ee-FEY-jee-uh): excessive eating
polyuria (pol-ee-YOOR-ee-uh): excessive urination
postprandial (pohst-PRAN-dee-uhl): after a meal
preprandial (pree-PRAN-dee-uhl): before a meal
retinopathy (ret-n-OP-uh-thee): damage to the retina of the eye; can lead to blindness
triglyceride (trahy-GLIS-uh-rahydz): lipid molecules containing 3 fatty acids bound to glycerol; the primary fat in the diet
and the primary molecule used for fuel storage
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________________________________________________________________________________________References
REFERENCES
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