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Standards of Medical Care in Diabetes: 2018

Criteria guiding the medical community for screening patients for diabetes can vary based on the professional group making the recommendations.  For example, the screening guidelines by the United States Preventive Service Task Force (2015) is less stringent that the screening guidelines by the American Diabetes Association (2018).

The 2015 screening guidelines from the United States Preventive Service Task Force (USPSTF) recommend patients be screened for diabetes if they are between 40 and 70 years old and are overweight or obese. But a recent study published in Public Library of Science (PLOS)  found many patients outside those age and weight ranges develop diabetes, especially racial and ethnic minorities.  This study suggests that the USPSTF widely accepted screening guidelines miss identifying many patients with diabetes and prediabetes.

The American Diabetes Association (ADA) recommends testing all adults beginning at age 45 years, regardless of weight, and all adults without symptoms of diabetes at any age if they are overweight or obese and have one or more additional risk factors for diabetes.  This screening recommendation was revised by the ADA for the purpose of clarifying the relationship between age, BMI, and risk for type 2 diabetes and prediabetes.

1. Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and have 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 were diagnosed with GDM

  • Hypertension (≥140/90 mmHg or on therapy for hypertension)

  • HDL cholesterol 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

  • A1C ≥5.7% (39 mmol/mol), IGT, or IFG on previous testing

  • Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)

  • History of CVD

2. For all patients, testing should begin at age 45 years.
3. If results are normal, testing should be repeated at a minimum of 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.
References:
American Diabetes Association. (2018). Standards of Medical Care in Diabetes-2018 Abridged for Primary Care Providers. Clinical diabetes: a publication of the American Diabetes Association, 34(1), 3.
O’Brien, M. J., Lee, J. Y., Carnethon, M. R., Ackermann, R. T., Vargas, M. C., Hamilton, A., … & Buchanan, D. R. (2016). Detecting Dysglycemia Using the 2015 United States Preventive Services Task Force Screening Criteria: A Cohort Analysis of Community Health Center Patients. PLoS Med, 13(7), e1002074.  Retrieved from http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002074

 

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Are you at risk for type 2 diabetes?

When I speak with a person who has just been diagnosed with diabetes I hear a very similar theme.  Some things I hear are “I don’t know what I did to make this happen,” “I must have been eating too much sugar,” “I didn’t know this would happen to me,” “My grandmother had diabetes and lost her legs.  I am scared this will happen to me.”

Type 2 diabetes is rarely a sudden onset.  Most people have been at risk for or had type 2 diabetes for months to years and were unaware.  If you would like to find out your risk for type 2 diabetes, take the “are you at risk” test at the American Diabetes Association website.

According to the Centers for Disease Control (CDC) nearly 90 percent of people with prediabetes are not aware they have it.  If current trends continue it is suggested that 15 to 30 percent of people with prediabetes will develop type 2 diabetes within five years (CDC, 2016).

Okay, that is the bad news.  So what is the good news?  The good news is that research shows prediabetes often can be reversed through lifestyle changes.  Prediabetes does not have to progress to diabetes.  Being aware of whether or not you have prediabetes would be important in order to monitor your health for progression to type 2 diabetes.

Ask your doctor for testing to determine if you have prediabetes if you find you are at risk for type 2 diabetes using the “are you at risk” test (ADA, 2016).  If your hemoglobin A1c (3 month blood sugar average test) is 5.7%-6.4%, you have prediabetes.

If you have prediabetes you can put measures in place to lower your risk for type 2 diabetes by 58% by losing 7% of your body weight (that would be 15 pounds if you weigh 200 pounds) and/or exercising moderately (such as brisk walking) 30 minutes a day, five days a week.  Set an achievable goal for weight loss and/or exercise and reset your goal after rewarding yourself for achieving your first goal!

Technology in Diabetes Care

The world of diabetes management is constantly changing. Technology continues to improve by leaps and bounds. While the world waits for the true artificial pancreas, learn more about how to use current technology for diabetes self-management.

Continuous Glucose Monitoring (CGM)

Recently two CGM systems—Dexcom’s G5 Mobile and Abbott’s FreeStyle Libre—are covered as durable medical equipment under Medicare Part B for beneficiaries with type 1 or type 2 diabetes who take multiple daily insulin doses and who make frequent adjustments to those doses.

Links to articles on insulin pump therapy and CGM:

Long-Term Insulin Pump Therapy Decreases Mortality in Type 1 Diabetes

Continuous Glucose Monitors: In Real Time

Insulin Pumps: Closer to a Pancreas