Diabetes

OVERVIEW

Genetic syndromes sometimes associated with diabetes (American Diabetes Association):

Down syndrome
Klinefelter syndrome
Turner syndrome
Prader-Willi syndrome
Myotonic dystrophy
Wolfram syndrome
Mitochondrial DNA disorders (i.e. MELAS, Kearns-Sayre)
Bardet-Biedl syndrome
Cystic fibrosis
Hemochromatosis

Other important risk factors for diabetes:

Type 1 diabetes

Genetic predisposition
Unknown environmental factors

Type 2 diabetes

Obesity
Central adiposity
Physical inactivity
Taking atypical antipsychotic medication (especially clozapine or olanzapine)
Genetic predisposition
Hispanic, African American, Native American, or Pacific Islander ancestry
Previous gestational diabetes

Special considerations for individuals with developmental disabilities

Diagnosis/treatment

Patients with speech and language deficits may have difficulty verbalizing their symptoms. Some behaviors that may have diabetes as an underlying condition include:

high activity level, rocking, and head-banging
change of consciousness

For more information, see the Developmental Disabilities Digest on nonverbal patients.

Diabetes self-management education

Individuals with developmental disabilities and their families and/or caregivers should be provided with appropriate, adaptive diabetes self-management education that is equivalent to that received by people without developmental disabilities.

To aid in the development of appropriate adaptive diabetes self-management education strategies, assess:

The patient’s desire to be independent in self-care
The patient’s age, mobility, visual acuity, hearing, manual dexterity, alertness, attention span, and ability to concentrate
The effect of the disability on the patient’s ability to perceive diabetes education and perform common diabetes self-management tasks
The patient’s non-disabled senses and abilities that could be used to convey information and skills

Develop individualized education plans for patients that incorporate strategies for maximizing the use of non-disabled senses and abilities for diabetes self-management

Examples of adaptive strategies:

Audiotape instead of print materials for blind or dyslexic individuals
Using gestures, facial expressions, objects, pictures, symbols, electronic communication boards, and computers to work with patients who use limited verbal communication
One-handed insulin measurement and administration methods for individuals with one-sided limitations in manual dexterity
Adaptive exercise programs for individuals with limited mobility (The National Center on Physical Activity and Disability)
Simplified meal planning systems for individuals with cognitive limitations

Practice Resources

California Diabetes Program: Diabetes Information Resource Center

DIRC is an easy-to-use portal to help organizations exchange information and tools to support their work to prevent or control diabetes. It includes an event calendar, forum, resources, and contact information for organizations working to prevent or control diabetes.

http://www.caldiabetes.org/dirc.cfm

Diabetes Action Network of the National Federation of the Blind: Diabetes Resources

Compilation of companies and organizations that offer products and/or information to help diabetics (especially blind diabetics) self-manage their diabetes.

http://www.nfb.org/diabres.htm

GENERAL INFORMATION ON DIABETES

Description

Diabetes mellitus is caused by defects in insulin secretion or action that lead to hyperglycemia. Chronic hyperglycemia can cause severe damage to the eyes, kidneys, nerves, heart, and other organs.

The American Diabetes Association divides diabetes into four clinical classes:

Type 1 diabetes

Characterized by autoimmune destruction of β -cells in the pancreas and absolute insulin deficiency
5-10% of diabetes cases

Type 2 diabetes

characterized by insulin resistance and progressive insulin secretory defect
90-95% of diabetes cases

Gestational diabetes

glucose intolerance with onset or first recognition during pregnancy
occurs in about 4% of U.S. pregnancies

Diabetes due to other causes

Genetic defects in ¦Â-cell function or insulin action
Diseases of the exocrine pancreas
Endocrinopathies
Drug or chemical induced
Infections

Signs and symptoms

Polyuria
Polydipsia
Weight loss (sometimes with polyphagia)
Blurred vision
Growth impairment
Susceptibility to infection

Possible complications

Acute

Hyperglycemia with ketoacidosis
Nonketotic hyperosmolar syndrome

Long-term

Retinopathy leading to vision loss
Nephropathy leading to renal failure
Peripheral neuropathy leading to foot ulcers, amputations, and neuropathic joints
Automonic neuropathy leading to gastrointestinal, genitourinary, and cardiovascular symptoms and sexual dysfunction
Increased incidence of atherosclerotic cardiovascular, peripheral arterial, and cerebrovascular disease

MEDICAL MANAGEMENT CONSIDERATIONS

Diagnostic procedures

There are three ways to diagnose diabetes*:

Symptoms of diabetes (polydypsia, polyuria, and unexplained weight loss) are present and plasma glucose concentration is ≥200 mg/dl (11.1 mmol/l) at any time of the day without regard to time since last meal

Plasma glucose ≥ 126 mg/dl (7.0 mmol/l) after no caloric intake for at least 8 hours (fasting plasma glucose)**

2-hour postload glucose ≥ 200 mg/dl (11.1 mmol/l) during an oral glucose tolerance test (OGTT)

* In the absence of unequivocal hyperglycemia, the diagnosis should be confirmed on a subsequent day with a different method. Hemoglobin A1c should not be used to diagnose diabetes.

** For children and non-pregnant adults, fasting plasma glucose is the preferred test to diagnose diabetes.

Note: The American Diabetes Association has also defined criteria for pre-diabetes (impaired glucose tolerance and/or impaired fasting glucose). Pre-diabetic patients are considered to be at high risk for developing diabetes. A patient is considered pre-diabetic if they have:

Impaired fasting glucose (IFG): fasting plasma glucose 100-125 mg/dl (5.6-6.9 mmol/l)

Impaired glucose tolerance (IGT): 2-hour postload glucose 140-199 mg/dl (7.8-11.1 mmol/l) during an oral glucose tolerance test (OGTT)

Medical nutrition therapy leading to a 5-10% loss of body weight and regular physical activity have demonstrated a significant ability to prevent or delay the onset of diabetes in people with IGT. Some pharmacological agents (i.e. biguanide metformin, ¦Á-glucosidase inhibitor acarbose and lipase inhibitor orlistat) also show promise, but there is insufficient evidence for their use as an adjunct or substitute for lifestyle changes in the prevention of diabetes.

National Diabetes Education Program. Diabetes Numbers At-a-Glance Reference Card.

A quick reference card with American Diabetes Association recommendations for diagnosing pre-diabetes and diabetes and for managing patients with diabetes.

http://ndep.nih.gov/diabetes/pubs/NumAtGlance_Eng.pdf

Screening for diabetes

Consider screening for diabetes in:

Individuals ≥45 years old, especially those with a BMI ≥25

Individuals <45 years old with a BMI ≥25 who have at least one additional risk factor for diabetes:

Habitual physical inactivity
First-degree relative with diabetes
Member of a high-risk ethnic population (African American, Latino, Native America, Asian American, Pacific Islander)
Have given birth to a baby weighing >9 lbs or have been diagnosed with GDM
Hypertension (≥ 140/90 mmHg)
HDL cholesterol <35 mg/dl (0.90 mmol/l) and/or triglyceride level >250 mg/dl (2.82 mmol/l)
History of vascular disease
Polycystic ovary syndrome (PCOS)
Pre-diabetes (monitor for the development of diabetes every 1-2 years)
High risk children beginning at age 10
If screening tests are negative, repeat screening at 3-year intervals.

Ongoing management

At each regular diabetes visit:

Measure weight and blood pressure.
Inspect feet.
Review self-monitoring blood glucose (SMBG) record.
Review/adjust medications.
Recommend regular use of aspirin for CVD prevention.
Review self-management skills, dietary needs, and physical activity.
Consider referral for medical nutrition therapy, diabetes self-management education, and psychosocial assessment.
Counsel on smoking cessation and alcohol use.

Twice a year:

Obtain hemoglobin A1c (A1C) in patients meeting treatment goals with stable glycemia (quarterly if not).
Refer for dental exam.

Annually:

Obtain fasting lipid profile (every 2 years if normal).
Obtain serum creatinine and urinalysis for protein, microalbumin, and albumin-to-creatinine ratio.
Refer for dilated eye exam (if normal, an eye care specialist may advise an exam every 2§¢3 years).
Perform comprehensive foot exam.
Administer influenza vaccination.
Review need for other preventive services.
Recommend regular use of aspirin for cardiovascular disease prevention.

Lifetime:

Administer pneumococcal vaccination (repeat if over 64 or immunocompromised and last vaccination was more than 5 years ago).

American Diabetes Association (ADA) treatment goals for diabetes

Hemoglobin A1c (A1C): <7%
Preprandial plasma glucose: 90-130 mg/dl
Peak postprandial plasma glucose (~1-2 hour after the start of a meal): <180 mg/dl
Blood pressure (mmHG): <80/<130
LDL cholesterol: <100 mg/dl
HDL cholesterol: Men >40 mg/dl; Women >50 mg/dl
Triglycerides <150 mg/dl

ADA recommendations for individualizing treatment goals

A1C goal

A1C goals closer to a normal A1C (<6%) may reduce complications, but may cause an increased risk of hypoglycemia
Close to normal (<6%) for women planning to conceive
Less stringent A1c goal for people with severe or frequent hypoglycemia

Blood pressure goal

Lower goal for people with nephropathy

Medications

Practice Resource

National Diabetes Education Program. Working Together to Manage Diabetes: Diabetes Medications Supplement.

A concise summary of important information related to the medications used to treat diabetes, high cholesterol and high blood pressure.

http://ndep.nih.gov/diabetes/pubs/Drug_tables_supplement.pdf

Patient education

Referral to a certified diabetes educator can assist patients in achieving their treatment goals. Find a certified diabetes educator (CDE) in your area.
Monitoring total carbohydrate through exchanges or carbohydrate counting is a key strategy in obtaining glycemic control.
For patients with any degree of chronic kidney disease (CKD), protein intake should be limited to the recommended dietary allowance (RDA) of 0.8 g/kg.
Minimize intake of saturated fat (<7% of total calories) and trans fat.
Overweight or obese individuals with type 2 diabetes or pre-diabetes should lose weight by reducing energy intake and increasing physical activity. Weight loss diets should supply a minimum of 1000-1200 kcal/day for women and 1200-1600 kcal/day for men. Physical activity should be increased gradually to a minimum of 150 minutes per week.

REFERENCES

Peer-reviewed Journal Articles/Academies

American Diabetes Association. Position Statement: Standards of Medical Care in Diabetes §¢ 2006. Diabetes Care. 2006;29 (Supp. 1): S4-S42.

American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2006;29 (Supp. 1): S43-S48.

Coonrod BA. Overcoming Physical Barriers to Diabetes Self-Care: Reframing Disability as an Opportunity for Ingenuity. Diabetes Spectrum. 2001; 14(1): 28-32.

Proietto J. Diabetes and antipsychotic drugs. Aust Prescr. 2004;27: 118-9.

http://www.australianprescriber.com/upload/pdf/articles/470.pdf

Lean MEJ, Pajonk FG. Patients on Atypical Antipsychotic Drugs: Another high-risk group for type 2 diabetes. Diabetes Care. 2003; 26:1597-1605.

http://care.diabetesjournals.org/cgi/reprint/26/5/1597?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=antipsychotic&searchid=1136577640273_5450&FIRSTINDEX=0&sortspec=relevance&journalcode=diacare

Special Interest Groups/Other Publications

American Association of Diabetes Educators. Diabetes Education for People with Disabilities. August 2002. http://www.diabeteseducator.org/pdf/DiabEducDisab.pdf

American Diabetes Association

www.diabetes.org

American Association of Diabetes Educators

www.diabeteseducator.org

National Diabetes Education Program

http://ndep.nih.gov

Making Systems Change for Better Diabetes Care

http://betterdiabetescare.nih.gov

National Diabetes Information Clearinghouse

www.niddk.nih.gov

Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Diabetes Public Health Resource

www.cdc.gov/diabetes (English)

http://www.cdc.gov/spanish/enfermedades/diabetes.htm (Spanish)

International Diabetes Federation

http://www.idf.org/home/

ADVISORY COMMITTEE

Mary Ann Lewis, Dr.P.H., R.N., F.A.A.N.

Theodore A. Kastner, M.D., M.S.

Sam Yang, M.D.

Larry Yin, M.D., M.S.P.H., F.A.A.P.

PUBLICATION INFORMATION

Funded by a grant from the California Department of Developmental Services

For more information, contact:

Center for Health Improvement

1330 21st Street, Suite 100

Sacramento, CA 95814

(916) 901-9645

This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.