On January 31, 2005, the American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE) met in Washington, D.C. to discuss management of outpatient diabetes mellitus (DM). Out of this meeting came key recommendations, and a new national guideline was instituted on February 21, 2005, to manage patients with type 2 diabetes mellitus (DM2). 1 The guideline is available at http://www.guideline. gov, and a personal digital assistant (PDA) application of the guideline can be downloaded for free as well.
The guideline consists of four algorithms, including management of DM2, glycemic control, blood pressure control, and ongoing management. The clinical guideline covers both patients who are diagnosed as having DM2 and those having "prediabetes," which is either impaired fasting glucose or impaired glucose tolerance. Identification and management of this second group is important because early identification and intervention may keep these patients from developing DM2 and cardiovascular disease. It is also suggested in the guideline to screen for depression, since the prevalence of depression in the diabetic population is twice as common as in the general population. In diabetics with complications, at least one-half of patients are clinically depressed.
Diabetes mellitus is a growing problem in the United States; over 20 million Americans are affected and there has been a 41% increase in the prevalence of DM over the past decade. Also, DM2 is now being seen at an earlier age with a 70% increase in adults 30 to 39 years of age. It is estimated that one-third of Americans with DM are undiagnosed and approximately 41 million Americans have impaired fasting glucose (IFG) or impaired glucose tolerance (IGT), "prediabetes," which if left untreated will eventually develop into DM. 1 The complications of uncontrolled diabetes in 2002 cost over $132 million in the United States alone.
Cardiovascular Disease and DM
Interventions with patients who demonstrate IFG/IGT or prediabetes to lower glucose values into the normal range are imperative to help prevent cardiovascular disease associated with DM. Cardiovascular disease develops years before the onset of full-blown DM. In two studies, the Diabetes Prevention Program and the Diabetes Intervention Study, a 58% reduction through lifestyle changes was demonstrated with halting of progression of IFG/IGT to DM2. Lifestyle changes include, but are not limited to, nutrition, exercise, weight management, behavioral support, and avoidance of smoking. Glycemic control has shown a reduction in atherosclerosis development as evidenced by a reduction in carotid intima-media thickness, which is a marker for atherosclerosis. Regular follow-up with reassessment of risk factors in IFG/IGT patients should be carried out a minimum of every 1 to 3 years.
Treatment
Pharmacological agents have also been shown to halt the progression of IFG/IGT to DM. Specific agents studied have included metformin (Glucophage), acarbose (Precose), and orlistat (Xenical). Each of these agents is different in action and yet all help to control the progression of IFG/IGT. Troglitazone was withdrawn from the market in 2000 due to hepatic concerns, but other agents in its class, thiazolidinediones, are available. Food and Drug Administration approval for prevention of DM2 has only been granted to orlistat at this time. However, the American Diabetes Association does not recommend the use of medications in prediabetes because research has shown that lifestyle modification is more effective.
The ACE/AACE agreed that measurement of hemoglobin A1c was the most important measure of glycemic control in DM patients. Studies have also shown that the postprandial readings are more closely associated with cardiovascular disease than fasting blood sugar. It has been hypothesized that postprandial "spikes" lead to oxidative stress, which negatively affects endothelial function. Currently, the guidelines suggest achieving an A1C level of < 6.5%, a fasting blood sugar of < 110 mg/dL, and a 2-hour postprandial blood sugar of < 140 mg/dL. 2 Note that the new national guidelines left 7.0% as the A1C target. However, it is generally accepted that the tighter the control and the closer the A1C to normal (< 6%), the lower the complication rate in diabetics. 2
In order to quickly achieve these levels of glycemic control, some suggest that earlier use of insulin should be considered. Using basal insulin combined with oral agents will achieve glycemic control more quickly, thereby halting the systemic effects of high blood sugar in patients with DM2. Insulin must be individually tailored to each patient to avoid hypoglycemia episodes, however, this is not as common of a problem in patients with DM2 as it is in patients with DM1, whose only regimen will be with insulins. Patients who may need insulin initially for stabilization may include those that are pregnant, have increased sugar levels because of surgery, infection, or steroid use, have fasting glucose measurements above 300 mg/dL or random levels greater than 350 mg/dL, hyperosmolar (glucose > 600 mg/dL, osmolality > 330 mOsm/L), nonketotic condition, and inpatient diabetics who are unstable for any reason.
Educating for Self-Management
The consensus group noted that diabetes is essentially a self-managed disease. If diabetics are to adequately self-manage, then education is paramount. Education should begin with self-monitoring of blood sugars, since the information derived from self-testing helps diabetics determine if blood sugar is too high, too low, or within parameters. A self-management program also includes nutrition, exercise, foot care, and awareness of community and national resources.
Education should stem from a multidisciplinary team, including the healthcare provider, diabetic educator, nutritionist, and other specialists deemed necessary. Diabetes is a life-long problem, so education should be ongoing. In order for diabetics to self-manage, they also need help formulating an action plan for when they are ill, when they eat out, when blood sugars are out of range, etc. The group identified that the one major obstacle to helping diabetics learn self-management is the lack of a supportive healthcare system, and stated that care is often more fragmented than streamlined. The committee noted diabetic education programs that have been successful, such as the International Diabetes Center in Minneapolis, Minn. They also stated that the National Diabetes Education Program has an online center to help health-care professionals better educate their diabetic patients (http://www.betterdiabetescare.nih.gov). Use of a chronic care model to implement a diabetes program is also recommended.A chronic care model includes decision support, clinical information systems, self-management education, and delivery system redesign.
Along with helping the patient become more proficient at self-management, the provider also needs to be more proficient at diabetes care. If recommendations include looking at the diabetic's feet at each office visit, measuring microalbumin annually, and obtaining an A1c quarterly, then flow charts or reminders to follow these recommendations will help the patient achieve tighter control of their diabetes and recognize complications or other problems as early as possible.
There are some discrepancies between the consensus group and the newly published national guidelines (see Table: "2005 Diabetes Management Recommendations"). However, keep in mind that the common goal of all groups is to have glucose control as close to normal values as possible, avoiding hypoglycemic episodes and deleterious adverse reactions of medications used to achieve lower glucose values.
These diabetic experts have challenged nurse practitioners (NPs) to learn as much as possible about diabetes identification and management so that we can give patients the tools and resources necessary for self-management. The focus should begin with identifying those at risk for the development of diabetes-"prediabetics"-and then begin their intensive education and lifestyle strategies. Support for these patients is a big part of their treatment, and it is up to NPs to make sure there is adequate support from the medical community and the general community, which may also help prediabetic patients from developing diabetes.
If you have a PDA, download the national guidelines so that they are easy to find and refer to when you are seeing prediabetic and diabetic patients. The use of flow charts should also be initiated so that suggestions for diabetic care are close at hand, reminding both the patient and the provider when certain laboratories, education, or other follow-up is necessary. If you do not have your own flow sheet, using the guidelines to devise one or locating a sample on the Web can help.
Diabetes Web Sites
American Association of Clinical Endocrinologistshttp://www.aace.com
AACE Power of Preventionhttp://www.powerofprevention.com
American Association of Diabetes Educatorshttp://www.diabeteseducator.org
American Diabetes Associationhttp://www.diabetes.org
Council for the Advancement of Diabetes Research and Educationhttp://www.cadre-diabetes.org
National Diabetes Education Programhttp://www.ndep.nih.gov
National Institute of Diabetes and Digestive and Kidney Diseaseshttp://www.niddk.nih.gov
National Guideline Clearinghousehttp://www.guideline.gov
International Diabetes Federationhttp://www.idf.org
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