Diabetes: Updates on ADA Guidelines

January 2013
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, non-
traumatic 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
Diabetic
Retinopathy
Leading cause
of blindness
in working age
adults

Diabetic
Nephropathy
Leading cause of
end-stage renal disease

Stroke
Cardiovascular
Disease
2-fold to 4-fold
increase in
cardiovascular
mortality
and stroke

Diabetic
Neuropathy
Leading cause of nontraumatic
lower extremity amputations

National Diabetes Information Clearinghouse. At:
http://www.niddk.nih.gov/health/diabetes/pubs/dmstats/dmstats.htm
Guidelines 2013
Diabetes Disease Management

Intake Medical Assessment

• 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


Screening for Diabetes

• 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 pre-
natal 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%
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 (%) mg/dl mmol/l
6 126 7.0
7 154 8.6
8 183 10.2
9 212 11.8
10 240 13.4
11 269 14.9
12 298 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 isn’t 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 patient’s 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
patient’s 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



Stage



Description
GFR (ml/min per
1.73 m
2
body
surface area)
1 Kidney damage
*
with normal or
increased GFR
≥90
2 Kidney damage
*
with mildly decreased
GFR
60–89
3 Moderately decreased GFR 30–59
4 Severely decreased GFR 15–29
5 Kidney failure <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
Housing
New recommendation in 2012:
– If feasible, consider housing inmates with diabetes
in the same housing unit
• Makes it easier to time meals around
medications
• Makes it easier to have emergency treatment
materials in a central housing location
• Improves patient self-management
• Offers more opportunities for peer support
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
The Role of Culture
Prison versus Correctional
• Prisonization involves the formation of an informal
inmate code and develops from the individual
characteristics of inmates and from institutional
features of the prison.
• Correctionalization involves all aspects of prison
culture (inmates) and more … It includes the actions
and behaviors of the staff as well.
Gillespie, W. (2006), Prisonization: Individual and Institutional Factors
Affecting Inmate Conduct. Criminal Justice. LFB Scholarly Publishing, LLC
Cultural Competency Continuum for Successful
Diabetes Program in Corrections

Cultural destructiveness
Cultural incapacity
Cultural blindness
Cultural pre-competence
Basic cultural competence
Advanced cultural competence

Training Paradigms
• Corrections
– Security over all else
– Care, custody and
control
– Law enforcement
– Relationship
– Certifications and
Standards
– Adversarial role
– Learning is often
scenario-based
• Health Services
– Health and life over all
– Improvement for society
– Advocate role
– Certifications and
Standards
– Learning through
scientific method,
evidence-based practice,
statistics

Correctional Culture Plays a Role
• What are some words that describe the correctional
culture?
• What would medical staff say?
• What would correctional staff say?
• What would inmates say?

How Do We Bridge the Gap?
• Staff and inmates can become hardened to the
environment
• Attitude is Everything
• Development of corrections-specific education &
trainings

Best Practice for Adherence Within the Walls:
Correctionalize All Education
Diet-Commissary,
Medications,
Release, Exercise,
Realities, Group
Education,
Resources
Inmate-
Patient
Correctional
Staff
Health
Services
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 ½ can sugared (non-
diet) 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 D
50
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 LONG-
ACTING 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 high-
risk 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

• Jessica Lee:
– Jessica.Lee@CorizonHealth.com