Diabetes: Updates on ADA Guidelines

January 2012

Objectives
State the standards of diabetic care put forth by the
American Diabetes Association
Discuss the co-morbidities of diabetes, the standards
of care that influence their management and
strategies to achieve the goals of care
Discuss ways correctional institutions can improve
compliance with the recommendations for diabetic
care in correctional institutions

Diabetes Facts
Diabetes affects 25.8 million people in the United
States
18.8 million diagnosed
7 million undiagnosed

Diabetes is the leading cause of kidney failure, nontraumatic lower limb amputations, and new cases of
blindness among adults in the United States
Diabetes is a major cause of heart disease and stroke
Diabetes is the seventh leading cause of death in the
United States
Source: CDC Fact Sheet, 2011

Diabetes Facts
Every 1% drop in A1c blood test results can decrease
the risk of microvascular complications of diabetes
by 40%
Blood pressure control reduces the risk of
cardiovascular disease (heart disease or stroke)
among people with diabetes by 33% to 50%, and the
risk of microvascular complications by 33%.
In general, for every 10 mmHg reduction in systolic
blood pressure, the risk for any complications related
to diabetes is reduced by 12%.
Reducing diastolic blood pressure from 90 mmHg to
80 mmHg in people with diabetes reduces the risk of
major cardiovascular events by 50%.
Source: CDC Fact Sheet, 2011

Diabetes Facts
Improved control of LDL cholesterol can reduce
cardiovascular complications by 20% to 50%.
Detecting and treating diabetic eye disease can reduce
development of severe vision loss by an estimated 50%
to 60%.
Comprehensive foot care programs risk assessment,
foot care education and preventive therapy, treatment of
foot problems and referral to specialists can reduce
amputation rates by 45% to 85%.
Detecting and treating early diabetic kidney disease by
lowering blood pressure can reduce the decline in kidney
function by 30% to 70%. ACEIs and ARBs are more
effective than other antihypertensive medications in
reducing the decline in kidney function
Source: CDC Fact Sheet, 2011

Magnitude of Complications
Leading cause
of blindness
in working age
adults

Diabetic
Retinopathy

Stroke

Diabetic
Nephropathy

Leading cause of
end-stage renal disease

National Diabetes Information Clearinghouse. At:

http://www.niddk.nih.gov/health/diabetes/pubs/dmstats/dmstats.htm

2-fold to 4-fold
increase in
cardiovascular
mortality
and stroke

Cardiovascular
Disease
Diabetic
Neuropathy
Leading cause of nontraumatic
lower extremity amputations

Guidelines 2011

Diabetes Disease Management

Intake Medical Assessment

Screening for Diabetes

Complete medical history

and intake physical exam by
licensed health professional
in a timely manner
Insulin-dependent diabetics
should have capillary blood
glucose (CBG) within 1 to 2
hours of arrival
Medications and medical
nutrition therapy (MNT)
continued without
interruption

Evaluate for diabetes risk

factors at intake physical and
as appropriate thereafter
BMI 25 with history of
hypertension or hyperlipidemia
BMI 25 and additional risk
factors or age > 45 with or
without risk factors

If pregnant, risk assessment

for gestational diabetes
mellitus (GDM) at first prenatal visit
Re-screen at 24-28 weeks

Criteria for Testing for Diabetes

Adults who are overweight (BMI 25) and have additional risk
factors:

Physical inactivity
First-degree relative with diabetes
High-risk race/ethnicity
Women who delivered a baby weighing > 9 lb or were diagnosed with
GDM
Hypertension on therapy for hypertension
HDL cholesterol < 35 mg/dl and/or triglyceride > 250 mg/dl
Women with polycystic ovarian syndrome (PCOS)
A1c > 5.7% on previous testing
History of cardiovascular disease
Other clinical conditions associated with insulin resistance

If results are normal, repeat testing at three-year intervals or

more frequently depending on initial results and risk status

Criteria for Diagnosis of Diabetes

A1c 6.5% - NEW!
OR
Fasting plasma glucose (FPG) 126 mg/dl (7.0
mmol/l) no caloric intake for at least 8 hours
OR
Two-hour plasma glucose 200 mg/dl (11.1 mmol/l)
during an oral glucose tolerance test (OGTT)
OR
A random plasma glucose 200 mg/dl (11.1 mmol/l)

Goals of Treatment - Glucose

A1c
< 7.0%
Pre-prandial CBG
70 130 mg/dl
Peak postprandial CBG < 180 mg/dl

Less stringent A1c goals may be appropriate for patients

with
History of severe hypoglycemia, limited life expectancy,
advanced microvascular or macrovascular complications,
extensive co-morbid conditions
Those with longstanding diabetes in whom general goal is
difficult to attain despite education, glucose monitoring and
effective doses of multiple glucose lowering agents including
insulin

Correlation of A1c with Estimated Average Glucose

Mean plasma glucose
A1C (%)
6
7

mg/dl
126
154

mmol/l
7.0
8.6

8
9
10
11
12

183
212
240
269
298

10.2
11.8
13.4
14.9
16.5

ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S18. Table 9.

Components of Management

Blood sugar control

Patient education
Nutrition counseling
Medication
Physical activity
Foot care
Retinopathy
Nephropathy
Cardiac
Lipid Management
Smoking cessation
Vaccines
Transfer and discharge

Blood Sugar Control

Goal is A1c < 7.0%
Chronic care clinic for management
Every 3 6 months if A1c consistently < 7.0%
Every 2 3 months if A1c is 7.0% - 9.0%
Every month if A1c > 9.0% until better control is achieved

Achieving good control requires:

Patient education and motivation

Effective combination of medications
Appropriate diet and compliance
Daily blood glucose monitoring

Patient Education
Nutrition including commissary choices
Medication
Empowerment for self-management
Choice
Control
Consequences

Peer groups

Nutritional Counseling
Individuals who have diabetes or pre-diabetes should
receive individualized medical nutrition therapy
Include counseling regarding the better choices
from items available in the commissary
Use commissary purchase list as an additional
opportunity for education and counseling
Encourage weight loss if BMI 25
Education regarding portion control
Think about implementing a heart healthy diet for
ALL inmates benefits everyone and reduces need
for special medical diets

Medication
Formularies should provide access to usual and
customary oral medications and insulins to treat
diabetes and related conditions
Patients should have access to medications at dosing
frequencies that are consistent with their treatment
plan and direction
Correctional institutions and police lock-ups should
implement policies and procedures to diminish the
risk of hypo- and hyperglycemia during off-site travel

Physical Activity
Exercise 150 minutes/week of moderate intensity
aerobic activity
Almost everyone can walk
If there isnt sufficient place to walk on the grounds,
consider setting aside gym time for walking around
the court or running laps
Exercise does not mean everyone has to work out in
the weight room
In absence of contraindications, people with type 2
diabetes should be encouraged to perform resistance
training three times per week

Foot care
Instruct the patient with diabetes to examine his/her
feet daily and report to medical at the first sign of
breakdown
Examine the patients feet at every encounter
Annual comprehensive foot exam to include
inspection, assessment of pulses, testing for loss of
protective sensation (monofilament, pinprick, etc.)
Multidisciplinary approach at the first sign of foot
ulcer and for those with high-risk feet

Monofilament Testing
Upper panel
To perform the 10-g
monofilament test, place the
device perpendicular to the
skin, with pressure applied
until the monofilament
buckles
Hold in place for 1 second
and then release
Lower panel
The monofilament test
should be performed at the
highlighted sites while the
patients eyes are closed

Boulton AJM, et al. Diabetes Care.

2008;31:1679-1685

Retinopathy
Initial dilated retinal and comprehensive eye exam by
an ophthalmologist or optometrist shortly after
diagnosis
Subsequent examinations annually
High quality fundus photographs can detect most
clinically significant diabetic retinopathy.
Interpretation should be performed by a trained eye
care provider. This is not a substitute for a
comprehensive eye exam.
Eye exam in the first trimester with close follow up
throughout pregnancy and for one year postpartum

Nephropathy
Annual test to assess urine albumin excretion in type 1
diabetic patients with diabetes duration of 5 years
Annual test to assess urine albumin excretion in all type 2
diabetic patients starting at diagnosis
Serum Creatinine at least annually in all adults with
diabetes regardless of the degree of urine albumin
excretion
GFR at least annually to stage level of chronic kidney
disease
If micro- or macroalbuminuria, treat with ACE or ARB
(contraindicated in pregnancy)
Reduction of protein intake if patient has CKD

Stages of Chronic Kidney Disease

GFR (ml/min per
1.73 m2 body
surface area)
Stage

Description

Kidney damage* with normal or

increased GFR

Kidney damage* with mildly decreased

GFR

6089

Moderately decreased GFR

3059

Severely decreased GFR

1529

Kidney failure

90

<15 or dialysis

*Kidney damage defined as abnormalities on pathologic, urine, blood, or imaging tests

ADA. VI. Prevention, Management of Complications.
Diabetes Care 2011;34(suppl 1):S34. Table 14.

Cardiovascular Disease
BP at every encounter goal is < 130/80
If not at goal:
Lifestyle therapy for maximum of 3 months if systolic 130
139 or diastolic 80 89

Weight loss if overweight

Dietary Approaches to Stop Hypertension (DASH) diet
Increased physical activity
Moderation of alcohol intake

If systolic 140 or diastolic 90 at diagnosis or follow up,

begin pharmacologic therapy in addition to lifestyle
therapy ACE or ARB and diuretic (thiazide if GFR 30 and
loop if GFR < 30)
Monitor kidney function and serum potassium levels

Antiplatelet Agents
Consider aspirin therapy (75 to 162 mg/day) as a primary
prevention strategy in those with type 1 and type 2 diabetes
at increased cardiovascular risk (10-yr risk > 10%)
Includes men > 50 years or women > 60 years with at least one
additional major risk factor (family history of CVD, HTN, smoking,
dyslipidemia, albuminuria)
ASA not recommended for those at low cardiovascular risk

Use aspirin as a secondary prevention strategy in patients

with diabetes and history of CVD
For patients with CVD and documented ASA allergy,
clopidogrel (75 mg/day) should be used
Combination therapy with ASA and clopidogrel is reasonable
for up to one year after an acute coronary syndrome

Lipid Management

Fasting lipid profile at least annually

Goal is LDL-C < 100 mg/dl
Goal for those with CVD is < 70 mg/dl
If goal is not met on maximum drug therapy, reduction of
30% - 40% from baseline is an alternative goal
Lifestyle therapy for all diabetic patients
Statin therapy should be added to lifestyle therapy,
regardless of lipid levels, for diabetic patients:
With overt CVD
Without CVD who are over the age of 40 and have one or more
other CVD risk factor

Statin therapy is contraindicated in pregnancy

Smoking Cessation
Advise all patients not to smoke
Include smoking cessation counseling and other
forms of treatment as a routine component of
diabetes care

Immunizations
Provide an influenza vaccine annually to all diabetic
patients 6 months of age
Administer pneumococcal polysaccharide vaccine to
all diabetic patients 2 years
One-time revaccination recommended for those > 64
years previously immunized at < 65 years if
administered 5 years ago
Other indications for repeat vaccination:
Nephrotic syndrome
Chronic renal disease
Immunocompromised states

Transfer and Discharge

For all inter-institutional transfers, complete a
medical transfer summary to be transferred with the
patient
Diabetes supplies and medication should accompany
the patient during transfer
Begin discharge planning with adequate lead time to
ensure continuity of care and facilitate entry into
community diabetes care

Diabetic Emergencies

Diabetes Emergencies
People experiencing diabetes emergencies may:
Appear intoxicated
Appear under the influence of drugs
Appear uncooperative

When in doubt, ask the person or his/her

companions if the person has diabetes and check for
medical identification bracelet, necklace, or card

Warning Signs that Require Action

Hypoglycemia

Sweating
Shakiness
Anxiety
Confusion
Difficulty speaking
Uncooperative behavior
Paleness
Irritability
Dizziness
Inability to swallow
Seizure
Loss of consciousness

Hyperglycemia
Flushed skin
Labored breathing
Confusion
Cramps
Very weak
Sweet breath
Nausea
Loss of consciousness

Emergency Treatment
Hypoglycemia
Give can sugared (nondiet) soda unless the
person cannot swallow
Obtain immediate
assistance from a qualified
health care professional
Continue to give sugar
source every 15 minutes
until blood sugar > 70
If unconscious, give
Glucagon or D50 IV

Hyperglycemia
Give access to water
Give access to bathroom
Give access to medication
Obtain immediate
assistance from a qualified
health care professional
Give regular NOT LONGACTING insulin

How to Ensure Safety of Patients with Diabetes

Identification
Promptly identify patients with diabetes and ensure that this information
accompanies the patient to all facilities while he/she is in custody

Location
Patients with diabetes should only be held where there is immediate access to
health care professionals who are able to manage their care and respond to
diabetes emergencies

Access to diabetes medication and food

Patients with diabetes must continue their medication without interruption and
must always have access to food. In addition, it is important to coordinate meals
and medication to maintain blood glucose levels in a safe range

Sugar
If a patient with diabetes requests a source of sugar, immediately provide that
person with a sugared soft drink, juice, or another fast-acting source of sugar,
followed by bread or crackers

Emergencies
If a patient with diabetes requests medical care or exhibits symptoms of diabetic
illness, immediately obtain assistance from a qualified health care professional.
Know the fastest way to obtain medical help in the case of an emergency that
cannot be handled by on-site personnel

Summary and Key Points

People with diabetes should receive care that meets national
standards. Being incarcerated does not change these standards.
Patients must have access to medication and nutrition needed to
manage their diabetes.
In patients who do not meet treatment targets, medical and
behavioral plans should be adjusted by health care professionals in
collaboration with the custody staff.
It is critical for correctional institutions to identify particularly highrisk patients in need of more intensive evaluation and therapy,
including pregnant women, patients with advanced complications, a
history of repeated severe hypoglycemia, or recurrent DKA.
A comprehensive, multidisciplinary approach to the care of people
with diabetes can be an effective mechanism to improve overall
health and delay or prevent the acute and chronic complications of
this disease.

References
Diabetes Management in Correctional Institutions. Agency for
Healthcare Research and Quality. Available online at
http://guideline.gov
Standards of medical care in diabetes. VI. Prevention and
management of diabetes complications. Agency for
Healthcare Research and Quality. Available online at
http://guideline.gov
American Diabetes Association. Standards of medical care in
diabetes 2011. Diabetes Care 2011;34(suppl 1):S11-12.
Available online at
http://care.diabetesjournals.org/content/34/Supplement_1
National Diabetes Fact Sheet, 2011. National Center for
Chronic Disease Prevention and Health Promotion. Division of
Diabetes Translation. Available online at http://www.cdc.gov

Contact Information
Sr. Mary Jane Bookstaver:
MaryJane.Bookstaver@CorizonHealth.com