in child and adolescent diabetes is strongly recommended to begin specialists who have expertise in managing children and adolescents with diabetes. …
BASIC GUIDELINES for DIABETES CARE
PHYSICAL AND EMOTIONAL ASSESSMENT
Blood Pressure, Weight - Every visit Blood pressure target goal 130/80 mmHg For children: Add height, normal BMI body mass index for age, plot on 2001 CDC growth charts wwwcdcgov/growthcharts; BP 90th percentile age standard Foot Exam for adults - Thorough visual inspection every diabetes care visit; pedal pulses, neurological exam yearly Dilated Eye Exam by trained expert - Type 1: Five years post diagnosis, then every year Type 2: Shortly after diagnosis, then every year Note: Internal quality assurance data may be used to support less frequent testing Depression - Probe for emotional/physical factors linked to depression yearly; treat aggressively with counseling, medication, and/or referral Dental - Exams at least twice yearly; Prophylaxis two to four times a year A1C HbA1c - Quarterly, if treatment changes or if not meeting goals; One-two times/year if stable Target goal 70 or 1 above lab norms For children: Modify as necessary to prevent significant hypoglycemia
LAB EXAM
Microalbuminuria Albumin/Creatinine Ratio - Type 1: Begin with puberty once the duration of diabetes is more than five years unless
proteinuria has been documented Type 2: Begin at diagnosis, then every year unless proteinuria has been documented Blood Lipids for adults - On initial visit, then yearly for adults Target goals mg/dL: cholesterol, triglycerides 150; LDL100; HDL40 for men; HDL50 for women
SELF-MANAGEMENT TRAINING
Management Principles and Complications - Initially and yearly: Assess knowledge of diabetes, medications, self-monitoring, acute/chronic complications, and problem-solving skills Ongoing: Screen for problems with and barriers to self-care; assist patient to identify achievable self-care goals For children: As appropriate for developmental stage Self-Glucose Monitoring - Type 1: Typically test four times a day Type 2 and others: As needed to meet treatment goals Medical Nutrition Therapy by trained expert - Initially: Assess needs/condition, assist patient in setting nutrition goals Ongoing: Assess progress toward goals, identify problem areas Physical Activity - Initially and ongoing: Assess and prescribe physical activity based on patients needs/condition Weight Management - Initially and ongoing: Must be individualized for patient Preconception, Pregnancy, and Postpartum Counseling
and Management - Consult with high-risk, multidisciplinary perinatal/neonatal programs, and providers where available eg, California Diabetes and Pregnancy Program Sweet Success For adolescents: Age appropriate counseling advisable, beginning with puberty Aspirin Therapy - 81-325 mg/day or 325 mg every other day in adults as primary and secondary prevention of cardiovascular disease unless contraindicated Smoking Cessation - Screen, advise, assess readiness to quit, and assist at every diabetes care visit, adjusting the frequency as appropriate to the patients response Refer to California Smokers Helpline 1-800-NO-BUTTS Immunizations - Influenza and pneumococcal, per CDC recommendations
INTERVENTIONS
These guidelines are generally consistent with American Diabetes Association Clinical Practice Recommendations 2005 Page 1 of 2 This product is part of the Basic Guidelines for Diabetes Care Packet and may be reproduced with the citation: Developed by the Diabetes Coalition of California and the California Diabetes Program, 2005-06 For further information: wwwcaldiabetesorg or 916 552-9888
EXPLANATORY NOTES
BASIC GUIDELINES for DIABETES CARE
1 These Guidelines are intended for use
by primary care professionals 2 These Guidelines are meant to be basic guidelines, not enforceable standards 3 Internal quality assurance data may be used to support less frequent testing 4 One or more of the following criteria were used for inclusion of an item in these Guidelines: Published evidence demonstrated either the efficacy or the effectiveness of the item Published studies on cost-identification, cost-effectiveness, or cost-benefit analysis of the item demonstrated favorable economic results A preponderance of expert opinion held that the item is considered to be essential to the care of persons with diabetes
5 It is assumed that the following are routinely occurring in the medical setting: A history and physical appropriate for a person with diabetes are performed Visits are sufficiently frequent to meet the patients needs and treatment goals Abnormal physical or laboratory findings result in appropriate and individualized interventions Expert multi-disciplinary health professionals provide self-management training For children/adolescents and their families, training from a diabetes team or team member with experience in child and adolescent diabetes is
strongly recommended to begin at diagnosis Physicians should consult current references for normal values and for appropriate treatment goal values, both for children and adults Specialists should be consulted when patients are unable to achieve treatment goals in a reasonable time frame, when complications arise, or whenever the primary care physician deems it appropriate Under similar circumstances, children/adolescents should be referred to specialists who have expertise in managing children and adolescents with diabetes
6 Additional comments on specific items included in these Guidelines: Psychosocial Assessment Assess barriers to self-care: common environmental obstacles, cultural issues, beliefs and feelings about diabetes, disorders of eating and mood, life stresses, and substance use A1C HbA1c / Self-Glucose Monitoring Certification by the National Glycohemoglobin Standardization Program as traceable to the DCCT reference ensures portability of A1C results Verify that the laboratory is certified in this method A1C target goals should be achieved gradually over time Target goals should be less stringent for children, the elderly, and other fragile patients Clinicians
have found that making the patient aware of his/her A1C values and their significance helps motivate the patient toward improved glycemic control This principle also applies to self-glucose monitoring Target goals should be individualized for each patient Microalbuminuria Screening is not needed if proteinuria has been documented See Screening and Initial Management of Diabetic Microalbuminuria and Nephropathy algorithm Blood Lipids Abnormal blood lipids are often under-treated An active, progressive treatment and monitoring plan should be instituted Dental Physicians are urged to recommend dental care as a part of basic diabetes care Children / Adolescents For specific diabetes care recommendations, see references Aspirin ASA-Women with diabetes are high risk for cardiovascular disease and therefore 81mg daily is indicated Doses ASA 81mg daily have increased bleeding risk and no proven additional benefits 7 A list of general and specific references is included in the Basic Guidelines for Diabetes Care Packet
Page 2 of 2 This product is part of the Basic Guidelines for Diabetes Care Packet and may be reproduced with the citation: Developed by the Diabetes Coalition of
California and the California Diabetes Program, 2005-06 For further information: wwwcaldiabetesorg or 916 552-9888
