Internet delivered diabetes self-management education: a ...



Standards of Medical Care in Diabetes—2017Evidence TableRecommendationReason for Change2016 references that support recommendation (list citation #)New Evidence for 2017 (hyperlinked reference title/s)Strategies for improving CareA patient-centered communication style usingthat active listening to elicit incorporates patient preferences and, assesses literacy, and numeracy, and addresses cultural barriers to care should be usedshould be incorporated into treatment strategies to optimize health outcomes and health-related quality of life. BNow provides recommendation on a skill that can help providers get the information from patients that they need to inform treatment.Do we want to say anything about goal setting here? (reference 10) and also could just say overcoming barriers (since literacy/numeracy covered later)13, 14-17, 55 HYPERLINK "" decisions should be timely, and based on evidence-based guidelines, and made in collaboration with patients based on that are tailored to individual patient preferences, prognoses, and comorbidities. BShould include mention of collaboration/shared decision making6, 10, 12 (timely), 18-20, 34 should be aligned with components of the Chronic Care Model to ensure productive interactions between a prepared proactive practice team and an informed activated patient. A7,8 (CCM)29, 30 (activated patients)New review article (2015) in Journal of Evaluation in Clinical Practice (IF 1.05), but current references are in higher tier journal and conclusions are similar7- Preventing Chronic Disease (IF 2.17)8- Health Affairs (IF 5.23)Providers should consider the burden of treatment and patient levels of confidence/self-efficacy for management behaviors as treatment recommendations are made. EWhen feasible, care systems should support team-based care, community involvement, patient registries, and decision support tools to meet patient needs. BCommunity involvement language could stay here or move to new section6,7, 9-11, 21, 22Providers should assess social context, including potential food insecurity, housing stability, and financial barriers (to treatment adherence?) and apply to treatment decisions.AProposed heading: Social Determinants of HealthThis broadens the recommendation to incorporate other important aspects of SDH but still names food insecurity/homelessnessAdd information to text about what “appropriate resources” means6, 14-17, 59 should evaluate hyperglycemia and hypoglycemia in the context of food insecurity and propose solutions accordingly. A59Providers should recognize that homelessness, poor literacy, and poor numeracy often occur with food insecurity, and appropriate resources should be made available for patients with diabetes. AReferral to existing local community resources should be made when available BProposed heading: Community supportIncreasing evidence that integration of care management efforts that extend to the community warrants inclusion of support and community as a distinct bullet6, 7, 31Have ordered an article- need to review in its entiretyProvision of support for self-management from lay health coaches, navigators, or community health workers should be made available when feasible ASee above49, 50, 51, 52, 54Intensive glucose control is not advised for the improvement of poor cognitive function in hyperglycemic individuals with type 2 diabetes. Treatment should be tailored to avoid significant hypoglycemia B63In individuals with poor cognitive function or severe hypoglycemia, glycemic therapy should be tailored to avoid significant hypoglycemia. CThis bullet seems a bit redundanthypoglycemia language63In individuals with diabetes at high cardiovascular risk, the cardiovascular benefits of statin therapy outweigh the risk of cognitive dysfunction. ADiscuss how statins don’t affect cognitive function negatively in text68If a second-generation antipsychotic medication is prescribed for adolescents or adults, with or without diabetes, changes in weight, blood glucose levelsglycemic control, and cholesterol levels should be carefully monitored and the treatment regimen should be reassessed. CNew data regarding elevated risk for adolescents73 pPatients with HIV should be testedscreened for diabetes and prediabetes with a fasting glucose level every 6-12 months as well as before starting antiretroviral therapy and 3 months after starting or changing it. If initial screening results are normal, checking fasting glucose each year is advised. If prediabetes is detected, continue to measure levels every 3–6 months to monitor for progression to diabetes. EChanged to be more consistent with stated guidelinesIs this supposed to be a fasting glucose level specifically, and not any other glucose measure?Screening versus testing75 (2002)76 (2006Clinical Infectious Disease (2015) and Diagnosis of DiabetesTesting Screening to assess risk for future diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and in all adults. Testing is suggested in those who have one one or more additional risk factors for diabetes. BDr. Herman would like to lead a discussion among the PPC about possible revision.Table 2.2 editDescribe process in text, differentiation between screening for risk factors and testing for diabetesExcept for GDM—create separate bullet point for follow-up with GDMRefer to ADA risk text?Add commentary in text regarding ethnicity—ie lean, * in table, African americans. Add data, reference about how it’s mostly family history.10,11For Discussion:Wang B, Zhuang R, Luo X, et al. Prevalence of metabolically healthy obese and metabolically obese but normal weight in adults worldwide: A meta-analysis. Horm Metab Res 2015;47:839-845Lotta LA, Abbasi A, Sharp SJ, et al. Definitions of metabolic health and risk of future type 2 diabetes in body mass index categories: a systematic review and network meta-analysis. Diabetes Care 2015;38(11):2177-2187Lee SH, Yang HK, Ha HS, et al. Changes in metabolic health status over time and risk of developing type 2 diabetes: A prospective cohort study. Medicine (Baltimore) 2015;94(40):e1705.For all patients, testing should begin at age 45 years. BNo Change Recommended10,11,24If tests are normal, repeat testing carried out at a minimum of 3-year intervals is reasonable. CNo Change Recommended10,11,32To test for prediabetes, fasting plasma glucose, 2-h plasma glucose after 75-g oral glucose tolerance test, and A1C are equally appropriate. BNo Change RecommendedMake change to recommendation and narrative in response to recent FDA advisory panel meeting on POC A1C testing?10-15For Discussion (Dr. Ratner):MedPage Today StoryIn patients with prediabetes, identify and, if appropriate, treat other cardiovascular disease risk factors. BNo Change Recommended10,11Testing to detect prediabetes should be considered in children and adolescents who are overweight or obese and who have two or more additional risk factors for diabetes. ENo Change Recommended16,33-36Possible addition?Type 2 diabetes in children and adolescents. American Diabetes Association. Diabetes Care 2000;23(3):381-389Blood glucose rather than A1C should be used to diagnose acute onset of type 1 diabetes in individuals with symptoms of hyperglycemia. ENo Change Recommended2Inform the relatives of patients with type 1 diabetes of the opportunity to be tested for type 1 diabetes risk, but only in the setting of a clinical research study. ENo Change RecommendedNo references currently cited in 2016 standards (supported by narrative and reference to )Add GAD or antibody panel recommendation to catch adult-onset type 1 diabetesAdd short paragraph in type 2 diabetes section, describing LADA without saying LADATesting to detect type 2 diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and who have one or more additional risk factors for diabetes. BDr. Herman would like to lead a discussion among the PPC about possible revision.Added a subsection on “Screening in Dental Clinics” for consideration21,25-27For Discussion:Wang B, Zhuang R, Luo X, et al. Prevalence of metabolically healthy obese and metabolically obese but normal weight in adults worldwide: A meta-analysis. Horm Metab Res 2015;47:839-845Lotta LA, Abbasi A, Sharp SJ, et al. Definitions of metabolic health and risk of future type 2 diabetes in body mass index categories: a systematic review and network meta-analysis. Diabetes Care 2015;38(11):2177-2187Lee SH, Yang HK, Ha HS, et al. Changes in metabolic health status over time and risk of developing type 2 diabetes: A prospective cohort study. Medicine (Baltimore) 2015;94(40):e1705.Dental Clinic Screening References:Lalla E, Kunzel C, Burkett S, et al. Identification of unrecognized diabetes and pre-diabetes in a dental setting. J Dent Res 2011;90(7):855-860Lalla E, Cheng B, Kunzel C, et al. Dental findings and identification of undiagnosed hyperglycemia. J Dent Res 2013;92(10):888-892Herman WH, Taylor GW, Jacobson JJ, et al. Screening for prediabetes and type 2 diabetes in dental offices. J Public Health Dent 2015;75(3):175-182For all patientspeople, testing should begin at age 45 years. BNo Change Recommended10,11,24If tests are normal, repeat testing carried out at a minimum of 3-year intervals is reasonable. CNo Change Recommended10,11,32To test for type 2 diabetes, fasting plasma glucose, 2-h plasma glucose after 75-g oral glucose tolerance test, and A1C are equally appropriate. BNo Change Recommended10-15In patients with diabetes, identify and, if appropriate, treat other cardiovascular disease risk factors. BNo Change Recommended22,23Testing to detect type 2 diabetes should be considered in children and adolescents who are overweight or obese and who have two or more additional risk factors for diabetes. ENo Change Recommended16,33-36Possible addition?Type 2 diabetes in children and adolescents. American Diabetes Association. Diabetes Care 2000;23(3):381-389Test for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, using standard diagnostic criteria. BNo Change Recommended37,38,Test for gestational diabetes mellitus at 24–28 weeks of gestation in pregnant women not previously known to have diabetes. AQuestion for Discussion:Maintain current recommendations per Table 2.5, or should this be changed to recommend one-step strategy only? If the two-step strategy stays in the table, should it be simplified to include either reference 55 or 56 only (for simplification)?39,40-47Donovan L, Hartling L, Muise M, Guthrie A, Vandermeer B, Dryden DM. Screening tests for gestational diabetes: a systematic review for the U.S. Preventive Services Task Force. Annals of Internal medicine 2013: 159: 1-8.Khalafallah A, Phuah E, Al-Barazan AM, Nikakis I, Radford A, Clarkson W, Trevett C, Brain T, Gebski V, Corbould A. Glycosylated haemoglobin for screening and diagnosis of gestational diabetes mellitus. BMJ Open 2016 Apr 4; 6(4): e011059Harper LM, Mele L, Landon MB, et al. Carpenter-Coustan Compared With National Diabetes Data Group Criteria for Diagnosing Gestational Diabetes. Obstet Gynecol 2016; 127:893.Werner EF, Pettker CM, Zuckerwise L et al. Screening for gestational diabetes mellitus: are the criteria proposed by the International Association of the Diabetes in Pregnancy Study Groups cost-effective? Diabetes Care 2012; 35: 529-535.Yjmei W, Huixia Y, Weiwei Z, Hongyun Y, Haixia L, Jie Y, Cuiklin Z. International Association of Diabetes and pregnancy Study Group criteria is suitable for gestational diabetes mellitus diagnosis: further evidence from China. Chinese medical Journal 2014; 127: 3553-3556.Feldman RK, Tieu RS, Yasumara L. Gestational diabetes screening: the IADPSG compared with the Carpentar-Coustan screening. Obstet Gynecol 2016; 127: 10-17.Mayo K, Melamed N, Vandenberghe H, Berger H. The impact of adoption of the International Association of Diabetes in Pregnancy Study Group criteria for the screening and diagnosis of gestational diabetes. Am J Obstet Gynecol 2015: 212: 224e1-9.McIntyre HD, Sacks DA, Barbour LA, Feig D, Catalano PM, Damm P, McElduff A. HYPERLINK "" Issues with the diagnosis and classification of hyperglycemia in early pregnancy. Diabetes Care 2016;39: 53-54Screen Test women with gestational diabetes mellitus for persistent diabetes at 64–12 weeks postpartum, using the oral glucose tolerance test and clinically appropriate non-pregnancy diagnostic criteria. EPer Dr. Coustan: “This comes from the chapter on management in pregnancy. The recommendation for doing the post partum OGTT at 6-12 weeks post partum is, to my knowledge, unencumbered by data. Rather it is informed by custom. In fact, most obstetricians see their patients at 6 weeks post partum. We recommend scheduling the test just before the post partum checkup so that the results can be discussed with the patient, and if the patient did not attend the test it can be rescheduled. I’ll try to craft some verbiage into the narrative in the treatment chapter about this.”Reference added to narrative:McIntyre HD, Sacks DA, Barbour LA, Feig D, Catalano PM, Damm P, McElduff A. HYPERLINK "" Issues with the diagnosis and classification of hyperglycemia in early pregnancy. Diabetes Care 1026;39: 53-54Women with a history of gestational diabetes mellitus should have lifelong screening for the development of diabetes or prediabetes at least every 3 years. BNo Change RecommendedNot specifically discussed in this section – Readers referred to “Management of Diabetes in Pregnancy” sectionWomen with a history of gestational diabetes mellitus found to have prediabetes should receive intensive lifestyle interventions or metformin to prevent diabetes. AMinor wording change.Not specifically discussed in this section – Readers referred to “Management of Diabetes in Pregnancy” sectionAll children diagnosed with diabetes in the first 6 months of life should have immediate genetic testing for neonatal diabetes. ABMinor wording change and evidence level changed to “A.” 48,49Maturity-onset diabetes of the young should be considered in individuals who have mild stable fasting hyperglycemia and multiple family members with diabetes not characteristic of type 1 or type 2 diabetes. EDelete per edits to following recommendations.Because a diagnosis of maturity-onset diabetes of the young may impact therapy and lead to identification of other affected family members, consider referring individuals with diabetes not typicalChildren and adults who have diabetes not characteristic of type 1 or type 2 diabetes and that occursring in successive generations (suggestive of an autosomal dominant pattern of inheritance) to a specialist for further evaluationshould have genetic testing for maturity-onset diabetes of the young (MODY). AERevised and evidence level changed to “A.”48,49In both instances, consultation with a center specializing in diabetes genetics is recommended to understand the significance of these mutations and how best to approach further evaluation, treatment and genetic counseling. ENew suggested Recommendation.N/A – New RecommendationAnnual screening for cystic fibrosis–related diabetes with oral glucose tolerance test should begin by age 10 years in all patients with cystic fibrosis who do not have cystic fibrosis–related diabetes. BNo Change Recommended. 54A1C as a screening test for cystic fibrosis–related diabetes is not recommended. BNo Change Recommended.54Patients with cystic fibrosis–related diabetes should be treated with insulin to attain individualized glycemic goals. ANo Change Recommended.53, 54In patients with cystic fibrosis and impaired glucose tolerance without confirmed diabetes, prandial insulin therapy should be considered to maintain weight. BRecommendation recommended to be removed by outside expert reviewer (Dr. Toni Moran). Per Dr. Moran: “I wasn't involved in that recommendation and don't agree with it, there are no good studies, just some small uncontrolled case series and an Australian paper with problematic baseline data.? So no new studies, and if you prefer to keep it in that is fine but it is not B level evidence.”54Beginning 5 years after the diagnosis of cystic fibrosis–related diabetes, annual monitoring for complications of diabetes is recommended. ENo Change Recommended.54Patients should be screened post-transplantation for hyperglycemia, with a formal diagnosis of PTDM being best made once a patient is stable on an immunosuppressive regimen and in the absence of an acute infection. ENew recommendation with addition of PTDM subsection. Recommendations and narrative reviewed by invited outside expert (Dr. Mark Molitch)No evidence to preferred treatment.NODAT versus PTDM—mean the same thing. Changed nomenclature to capture undiagnosed diabetes that was caught after transplant.Immunosuppressive regimen trumps everythingN/A – New SubsectionSharif A, Hecking M, de Vries AP, et al. Proceedings from an international consensus meeting on posttransplantation diabetes mellitus: recommendations and future directions. Am J Transplant 2014;14(9):1992-2000The OGTT is the preferred test to make a diagnosis of PTDM. BNew recommendation with addition of PTDM subsection. Recommendations and narrative reviewed by invited outside expert (Dr. Mark Molitch)N/A – New SubsectionSharif A, Hecking M, de Vries AP, et al. Proceedings from an international consensus meeting on posttransplantation diabetes mellitus: recommendations and future directions. Am J Transplant 2014;14(9):1992-2000Hecking M, Werzowa J, Haidinger M, et al. New-onset diabetes after transplantation: Development, prevention, and treatment. Nephrol Dial Transplant 2013;28:550-566Hecking M, Kainz A, Werzowa J, et al. Glucose metabolism after renal transplantation. Diabetes Care 2013;36:2763-2771Sharif A, Moore RH, Baboolal K. The use of oral glucose tolerance tests to risk stratify for new-onset diabetes after transplantation: An underdiagnosed phenomenon. Transplantation 2006;82:1667-1672Valderhaug TG, Jenssen T, Hartmann A, et al. Fasting plasma glucose and glycosylated hemoglobin in the screening for diabetes mellitus after renal transplantation. Transplantation 2009;88:429-434Immunosuppressive regimens shown to provide the best outcomes for patient and graft survival should be used, irrespective of PTDM risk. ENew recommendation with addition of PTDM subsection. Recommendations and narrative reviewed by invited outside expert (Dr. Mark Molitch)N/A – New SubsectionSharif A, Hecking M, de Vries AP, et al. Proceedings from an international consensus meeting on posttransplantation diabetes mellitus: recommendations and future directions. Am J Transplant 2014;14(9):1992-2000Comprehensive Medical Evaluation and Comorbidities AssessmentProvide routine vaccinations for patients with diabetes as for the general population according to age-related recommendations. CNo changeAdminister hepatitis B vaccine to unvaccinated adults with diabetes who are aged 19–59 years. CNo changeConsider administering hepatitis B vaccine to unvaccinated adults with diabetes who are aged 60 years. CNo changeThe following psychosocial factors should be assessed at the initial visit, monitored at periodic intervals, and when there is a patient specific indication for need of behavioral services such as a change in disease, treatment or life circumstances: symptoms of diabetes distress, depression, anxiety and disordered eating; and cognitive capacities. BPerformance of self-management behaviors as well as psychosocial factors impacting the person’s self-management should be monitored at every visit, including but not limited to diabetes distress/burdens and the impact of diabetes on health related quality of life. EScreen all patients with pre-diabetes, diabetes and/or a self-reported history of depression for depressive symptoms annually as well as when patients are experiencing a worsening of disease status or intensification of treatment with age-appropriate depression screening measures, recognizing that further evaluation will be necessary for positive screens B. (B, E)Positive screens for depressive symptoms should be followed by formal clinical diagnostic assessment. .BPatients who meet clinical diagnostic criteria for depression should be evaluated for antidepressant medications and/or psychotherapy.A Maybe removedPersons with diabetes who clinically present with symptoms of disordered eating behavior, an eating disorder, or disrupted patterns of eating should be referred for re-evaluation of their treatment regimen and if symptoms indicate, to a behavioral health provider for assessment of eating and weight-related cognitions.BIf disordered eating behavior is suspected, assess for intentional omission of insulin or oral medication to intentionally cause weight loss. If identified, refer to a behavioral health provider for evaluation and intervention.BPersons with diabetes who express fear, dread or irrational thoughts and/or show anxiety symptoms, as well as those exhibiting anxiety or excessive worries regarding diabetes complications, insulin injections or infusion, taking medications and/or hypoglycemia that interfere with adherence to medical treatment should be screened for anxiety B (B, D, E)Alicia: Combine with belowPositive screens for anxiety or fear of hypoglycemia should be referred to a behavioral health provider formal clinical diagnostic assessment.EPatients who meet clinical diagnostic criteria for anxiety disorders or fear of hypoglycemia should be referred for further evaluation for treatment with an anxiolytic medication and/or to a behavioral health provider. AIf a serious mental illness is suspected in a person with diabetes, immediate referral for diagnosis and treatment should be implemented to support diabetes self-care behaviors. BCoordinated management of diabetes, pre-diabetes and SMI is recommended to achieve diabetes treatment targets. EA complete medical evaluation should be performed at the initial visit to:Confirm the diagnosis and classify the type of diabetes. BDetect diabetes complications and potential comorbid conditions. ENo changeAssess for the presence of additional autoimmune conditions soon after the diagnosis and if symptoms or signs develop in patients with type 1 diabetes. ECopied from children and adolescentsReview previous treatment and risk factor control in patients with established diabetes. ENo changeBegin patient engagement in the formulation of a care management plan. BNo changeDevelop a plan for continuing care. BNo changeLifestyle ManagementIn accordance with the national standards for diabetes self-management education (DSME) and support (DSMS), all people with diabetes should participate in DSME to facilitate the knowledge, skills, and ability necessary for diabetes self-care and in DSMS to assist with implementing and sustaining skills and behaviors needed for ongoing self-management, both at diagnosis and as needed thereafter. BOK(note – undergoing revision starting in Sept; for publication next year.4, 5, 6, 7Somewhere in the text we should acknowledge the emerging evidence that internet based diabetes education may be helpful:Diabetes Technol Ther. 2015 Jan;17(1):55-63. doi: 10.1089/dia.2014.0155.Internet delivered diabetes self-management education: a review.Pereira K1, Phillips B, Johnson C, Vorderstrasse A.And by Sepah et al (including Anne Peters) on 2 yr online DM prevention program. Effective self-management, improved clinical outcomes, health status, and quality of life are key outcomes of DSME and DSMS and should be measured and monitored as part of care. C4, 6, 9, 10, 11, 12, 10, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23DSME and DSMS should be patient centered, respectful, and responsive to individual patient preferences, needs, and values, which should guide clinical decisions. A20, 21, 22, 23, 12, 26,Diabet Med. 2016 Mar 21. doi: 10.1111/dme.13120. [Epub ahead of print]Reasons why patients referred to diabetes education programmes choose not to attend: a systematic review.Horigan G1, Davies M2, Findlay-White F3, Chaney D3, Coates V1. and DSMS programs should have the necessary elements in their curricula that are needed to prevent the onset of diabetes. DSME and DSMS programs should therefore tailor their content specifically when prevention of diabetes is the desired goal. BOk – or this could be part of the “prevention” section. It may be misplaced here. Because DSME and DSMS can result in cost savings and improved outcomes B, DSME and DSMS should be adequately reimbursed by third-party payers. EThe section on reimbursement only references #4 – but I think should include 16, 17. Self-management behaviors including medication adherence should be assessed directly and regularly. A1c is not a reliable indicator of difficulties with diabetes self-management. BPsychosocial positon statementProviders should be aware that diabetes self-management behaviors require a foundation of diabetes education, skill building, emotional support and access to care resources.BConsider deleting?People with diabetes who are demonstrating difficulty with self-management behaviors should be referred for assessment of health literacy and numeracy. B Delete, redundant with abovePersons of all ages who demonstrate difficulty performing routine self-management tasks should be treated using targeted behavioral interventions to support diabetes self-care.EPeople with diabetes should be monitored for diabetes distress routinely and especially when treatment targets are not met for: regiment adherence or glycemic control; and/or the onset of diabetes complication BPeople with diabetes distress should be referred for diabetes education to identify and address areas of diabetes self-care that are most relevant to the patient and most problematic for diabetes outcomes. Those whose self-care remains impaired after tailored diabetes education should be referred to a behavioral health provider for evaluation and treatment. EInvolvement of caregivers and family members in identifying, preventing and/or resolving psychosocial problems should be assessed, solicited and supported. EStandardized/validated tools and methods should be used for psychosocial monitoring, assessment and intervention whenever possible. Psychosocial assessment and intervention materials should be appropriate for the age and cognitive capacity of the person with diabetes.EPsychosocial problems should be addressed upon identification. If an intervention cannot be initiated during the visit when the problem is identified, a follow-up visit or referral to a qualified behavioral health care provider should be scheduled during that visit. E An individualized MNT program, preferably provided by a registered dietitian, is recommended for all people with type 1 or type 2 diabetes. Aok34, 35Add 2015 EAL citations for T1 and T2 people with type 1 diabetes or those with type 2 diabetes who are prescribed a flexible insulin therapy program, education on how to use carbohydrate and in some cases fat and protein counting or estimation to determine mealtime insulin dosing can improve glycemic control. AFor type 1, insulin dosing should also take into account fat content of the meal. (especially larger quantiries – over 40 gm)Reexamine to determine if fat/protein should be included in recommendation or in the text37Diabetes Care. 2016 Jul 7. pii: dc152855. [Epub ahead of print]Optimized Mealtime Insulin Dosing for Fat and Protein in Type 1 Diabetes: Application of a Model-Based Approach to Derive Insulin Doses for Open-Loop Diabetes Management.Bell KJ1, Toschi E2, Steil GM3, Wolpert HA4. individuals whose daily insulin dosing is fixed, having a consistent pattern of carbohydrate intake with respect to time and amount can result in improved glycemic control and a reduced risk of hypoglycemia. BA simple and effective approach to glycemia and weight management emphasizing healthy food choices and portion control may be more helpful for those with type 2 diabetes who are not taking insulin, who have limited health literacy or numeracy, and who are elderly and prone to hypoglycemia. C39Add reference on effectiveness of plate method: Bowen et al. Pt Educ and Counseling - 2016 HYPERLINK "" ? Because diabetes nutrition therapy can result in cost savings B and improved outcomes (e.g., A1C reduction) A, MNT should be adequately reimbursed by insurance and other payers. EModest weight loss achievable by the combination of lifestyle modification and the reduction of energy calorie intake benefits overweight or obese adults with type 2 diabetes and also those at risk for diabetes. Interventional programs to facilitate this process are recommended. AUpdate ref #50 to be 2015 Circulation reference HYPERLINK "" there is no single ideal dietary distribution of calories among carbohydrates, fats, and proteins for people with diabetes, macronutrient distribution should be individualized while keeping total calorie and metabolic goals in mind. E47,48,49,50Add – Ajala - 2013 HYPERLINK "" variety of eating patterns are acceptable for the management of diabetes and prediabetes, including Mediterranean, DASH and plant-based diets; Not “pattern” --meal composition insteadIncorporate into text and/or recommendation aboveShould say something more about “patterns”such as plant based; Mediterranean…. HYPERLINK "" Dietary GuidelinesDiet quality index paper: HYPERLINK "" paper from Canada on plant based diets: HYPERLINK "" (14)60613-9/abstractCarbohydrate intake from whole grains, vegetables, fruits, legumes, and dairy products, with an emphasis on foods higher in fiber and lower in glycemic load, should be advised over other sources, especially those containing sugars. B53-56People with diabetes and those at risk should avoid sugar-sweetened beverages in order to control weight and reduce their risk for CVD and fatty liver B and should minimize the consumption of sucrose-containing foods that have the capacity to displace healthier, more nutrient-dense food choices. A56Newer rferences to support” HYPERLINK "" from Frank Hu: individuals with type 2 diabetes, ingested protein appears to increase insulin response without increasing plasma glucose concentrations. Therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia. B53 ? - 61Whereas data on the ideal total dietary fat content for people with diabetes are inconclusive, an eating plan emphasizing elements of a Mediterranean-style diet rich in monounsaturated fats may improve glucose metabolism and lower CVD risk and can be an effective alternative to a diet low in total fat but relatively high in carbohydrates. B65-73Omit word “mono” HYPERLINK "" HYPERLINK "" \o "Annals of internal medicine." Ann Intern Med. 2016 Jul 19. doi: 10.7326/M16-0361. [Epub ahead of print]Effects on Health Outcomes of a Mediterranean Diet With No Restriction on Fat Intake: A Systematic Review and Meta-analysis. HYPERLINK "" Bloomfield HE, HYPERLINK "" Koeller E, HYPERLINK "" Greer N, HYPERLINK "" MacDonald R, HYPERLINK "" Kane R, HYPERLINK "" Wilt TJ.Eating foods rich in long-chain omega-3 fatty acids, such as fatty fish (EPA and DHA) and nuts and seeds (ALA), is recommended to prevent or treat CVD B; however, evidence does not support a beneficial role for omega-3 dietary supplements. AImportance of replacing sat fat and trans fats with unsaturated fatsWang D et al. JAMA Internal Medicine July 5 2016Association of Specific Dietary Fats With Total and Cause-Specific Mortality HYPERLINK "" article from Erika: HYPERLINK "" is no clear evidence that dietary supplementation in people with diabetes who don’t have underlying deficiences with vitamins, minerals, herbs, or spices can improve diabetes, and there may be safety concerns regarding the long-term use of antioxidant supplements such as vitamins E and C and carotene. CAcknowledge vitamin D in textNote: While low Mg intake is linked with increased risk of T2DM, if the indivual consumes a varied diet rich in plant based Mg sources (whole grains, nuts, leafy greens)- this risk is reduced.I find nothing compelling for T1DM re: Mg supplementationThis study concluded: further study is needed to determine if supplementation is warranted.” Lin CC et al. Clin Nutr 2016 Aug:35(4):880-4 doi: 10.1016/j.clnu.2015.05.022. Epub 2015 Jun 9 Magnesium, Zinc and chromium levels in children, adol and young adults with T1DMPossible addition of B12 /metformin? "Long-term use of metformin may be associated with biochemical B12 deficiency, and routine measurement of vitamin B12 levels in metformin-treated patients should be considered.”Comments fromMozaffarian D (Circulation Jan 12, 2016):“Ca and Mg supplements cannot yet be recommended for general CVD prevention”“VitD supplementation – not warrented as means to improve cardiometabolic heatlh”J Clin Endocrinol Metab. 2014 Oct;99(10):3551-60. doi: 10.1210/jc.2014-2136. Epub 2014 Jul 25.Clinical review: Effect of vitamin D3 supplementation on improving glucose homeostasis and preventing diabetes: a systematic review and meta-analysis.Seida JC1, Mitri J, Colmers IN, Majumdar SR, Davidson MB, Edwards AL, Hanley DA, Pittas AG, Tjosvold L, Johnson JA.“No effect of D3 supplementation on glucose homeostasis or diabetes prevention”Risk of Type 2 DM is lower in US Adults taking Chromium containing supplements. McIver DJ et al. Am Society for Nutrition. Oct 7 2015.Magnesium – reducing risk for T2DM: 2011 article in D.Care - of NNSs has the potential to reduce overall calorie and carbohydrate intake if substituted for caloric sweeteners without compensation by intake of additional calories from other food sources and are safe to use in moderation. From 2013 paper. Added section in yellow. Check nutrition recommendation for evidence levelBUse 2012 paper published in DCare HYPERLINK "" to be used: HYPERLINK "" with diabetes who drink alcohol should do so in moderation (no more than one drink per day for adult women and no more than two drinks per day for adult men). CAlcohol consumption may place people with diabetes at increased risk for delayed hypoglycemia, especially if taking insulin or insulin secretagogues. Education and awareness regarding the recognition and management of delayed hypoglycemia are warranted. BAs for the general population, people with diabetes should limit sodium consumption to <2,300 mg/day, although further restriction may be indicated for those with both diabetes and hypertension. BChildren with diabetes or prediabetes should be encouraged to engage in at least 60 min of physical activity each day. BAdults with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (50–70% of maximum heart rate), spread over at least 3 days/week with no more than 2 consecutive days without exercise. AAll individuals, including those with diabetes, should be encouraged to reduce sedentary time, particularly by breaking up extended amounts of time (>90 min) spent sitting. BIn the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week. AAll adults, and particularly those with type 2 diabetes, should decrease the amount of time spent in daily sedentary behavior.BThis implies that everyone spends too much time sedentaryDempsey PC, Owen N, Biddle SJ, Dunstan DW: Managing sedentary behavior to reduce the risk of diabetes and cardiovascular disease. Curr Diab Rep 2014;14:522 A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS, Alter DA: Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: A systematic review and meta-analysis. Ann Intern Med 2015;162:123-132 JY, Grunseit AC, Chey T, Stamatakis E, Brown WJ, Matthews CE, Bauman AE, van der Ploeg HP: Daily sitting time and all-cause mortality: A meta-analysis. PLoS One 2013;8:e80000 EG, Edwardson CL, Achana FA, Davies MJ, Gorely T, Gray LJ, Khunti K, Yates T, Biddle SJ: Sedentary time in adults and the association with diabetes, cardiovascular disease and death: Systematic review and meta-analysis. Diabetologia 2012;55:2895-2905 C, Park H, Richardson A, Park C, Collins EG, Mermelstein R, Riesche L, Quinn L: Association between daily time spent in sedentary behavior and duration of hyperglycemia in type 2 diabetes. Biol Res Nurs 2016; 18(2):160-6 sitting should be interrupted with bouts of light activity every 30 min for blood glucose benefits, at least in adults with type 2 diabetes. CDempsey PC, Owen N, Biddle SJ, Dunstan DW: Managing sedentary behavior to reduce the risk of diabetes and cardiovascular disease. Curr Diab Rep 2014;14:522 A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS, Alter DA: Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: A systematic review and meta-analysis. Ann Intern Med 2015;162:123-132 JY, Grunseit AC, Chey T, Stamatakis E, Brown WJ, Matthews CE, Bauman AE, van der Ploeg HP: Daily sitting time and all-cause mortality: A meta-analysis. PLoS One 2013;8:e80000 EG, Edwardson CL, Achana FA, Davies MJ, Gorely T, Gray LJ, Khunti K, Yates T, Biddle SJ: Sedentary time in adults and the association with diabetes, cardiovascular disease and death: Systematic review and meta-analysis. Diabetologia 2012;55:2895-2905 C, Park H, Richardson A, Park C, Collins EG, Mermelstein R, Riesche L, Quinn L: Association between daily time spent in sedentary behavior and duration of hyperglycemia in type 2 diabetes. Biol Res Nurs 2016; 18(2):160-6 JP, Mellor DD, Morris M, Joseph F: Standing-based office work shows encouraging signs of attenuating post-prandial glycaemic excursion. Occup Environ Med 2014;71:109-111 J, Davies MJ, Bodicoat DH, Edwardson CL, Gill JM, Stensel DJ, Tolfrey K, Dunstan DW, Khunti K, Yates T: Breaking up prolonged sitting with standing or walking attenuates the postprandial metabolic response in postmenopausal women: A randomized acute study. Diabetes Care 2016;39:130-138 AA, Kingwell BA, Sethi P, Hammond L, Owen N, Dunstan DW: Alternating bouts of sitting and standing attenuate postprandial glucose responses. Med Sci Sports Exerc 2014;46:2053-2061 DW, Kingwell BA, Larsen R, Healy GN, Cerin E, Hamilton MT, Shaw JE, Bertovic DA, Zimmet PZ, Salmon J, Owen N: Breaking up prolonged sitting reduces postprandial glucose and insulin responses. Diabetes Care 2012;35:976-983 RN, Kingwell BA, Robinson C, Hammond L, Cerin E, Shaw JE, Healy GN, Hamilton MT, Owen N, Dunstan DW: Breaking up of prolonged sitting over three days sustains, but does not enhance, lowering of postprandial plasma glucose and insulin in overweight and obese adults. Clin Sci (Lond) 2015;129:117-127 Dijk JW, Venema M, van Mechelen W, Stehouwer CD, Hartgens F, van Loon LJ: Effect of moderate-intensity exercise versus activities of daily living on 24-hour blood glucose homeostasis in male patients with type 2 diabetes. Diabetes Care 2013;36:3448-3453 PC, Larsen RN, Sethi P, Sacre JW, Straznicky NE, Cohen ND, Cerin E, Lambert GW, Owen N, Kingwell BA, Dunstan DW: Benefits for type 2 diabetes of interrupting prolonged sitting with brief bouts of light walking or simple resistance activities. Diabetes Care 2016;39(6):964-72 exercise, or at least not allowing more than two days to elapse between exercise sessions, is recommended to enhance insulin action in people with type 2 diabetes. BMagkos F, Tsekouras Y, Kavouras SA, Mittendorfer B, Sidossis LS: Improved insulin sensitivity after a single bout of exercise is curvilinearly related to exercise energy expenditure. Clin Sci (Lond) 2008;114:59-64 JB, Little JP, Punthakee Z, Tarnopolsky MA, Riddell MC, Gibala MJ: Acute high-intensity interval exercise reduces the postprandial glucose response and prevalence of hyperglycaemia in patients with type 2 diabetes. Diabetes Obes Metab 2012;14:575-577 SA, Everett AC, Hinko A, Horowitz JF: A single session of low-intensity exercise is sufficient to enhance insulin sensitivity into the next day in obese adults. Diabetes Care 2013;36:2516-2522 lifestyle interventions that include at least 150 min/week of physical activity and dietary changes resulting in weight loss of 5?7% are recommended to prevent or delay the onset of type 2 diabetes in high-risk and prediabetic populations. A Erika: Belongs in prevention section? Use of “prediabetic”?Chen L, Pei JH, Kuang J, Chen HM, Chen Z, Li ZW, Yang HZ: Effect of lifestyle intervention in patients with type 2 diabetes: A meta-analysis. Metabolism 2015;64:338-347 X, Zhang X, Guo J, Roberts CK, McKenzie S, Wu WC, Liu S, Song Y: Effects of exercise training on cardiorespiratory fitness and biomarkers of cardiometabolic health: A systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc 2015;4 ES, Dryden DM, Vandermeer B, Ha C, Korownyk C: Lifestyle interventions for patients with and at risk for type 2 diabetes: A systematic review and meta-analysis. Ann Intern Med 2013;159:543-551 JE, Hay J, Abou-Setta AM, Marks SD, McGavock J: A systematic review and meta-analysis of exercise interventions in adults with type 1 diabetes. Diabetes Res Clin Pract 2014;106:393-400 and adults with type 1 diabetes can benefit from being physically active, and activity should be recommended to all. BYardley JE, Hay J, Abou-Setta AM, Marks SD, McGavock J: A systematic review and meta-analysis of exercise interventions in adults with type 1 diabetes. Diabetes Res Clin Pract 2014;106:393-400 glucose responses to physical activity in all with type 1 diabetes are highly variable based on activity type/timing and require different adjustments. BYardley JE, Hay J, Abou-Setta AM, Marks SD, McGavock J: A systematic review and meta-analysis of exercise interventions in adults with type 1 diabetes. Diabetes Res Clin Pract 2014;106:393-400 adults with type 1 (C) and type 2 (B) diabetes should engage in 150 min or more of moderate-to-vigorous intensity activity weekly, spread over at least 3 days/week, with no more than 2 consecutive days without activity. Shorter durations (minimum 75 minutes/week) of vigorous-intensity or interval training may be sufficient for younger and more physically fit individuals. Type 2: Many prior refs (not included in PS, but can use 2010 PS on T2D as ref: )Jelleyman C, Yates T, O'Donovan G, Gray LJ, King JA, Khunti K, Davies MJ: The effects of high-intensity interval training on glucose regulation and insulin resistance: A meta-analysis. Obes Rev 2015;16:942-961 1:Tonoli C, Heyman E, Roelands B, Buyse L, Cheung SS, Berthoin S, Meeusen R: Effects of different types of acute and chronic (training) exercise on glycaemic control in type 1 diabetes mellitus: A meta-analysis. Sports Med 2012;42:1059-1080 and adolescents with type 1 or type 2 diabetes should engage in 60 min/day or more of moderate or vigorous intensity aerobic activity, with vigorous, muscle-strengthening, and bone-strengthening activities included at least three days/week. CInclude in children/adolescent section?Physical Activity Guidelines Advisory Committee: Physical activity guidelines advisory committee report, 2008. Washington, DC, U.S.Department of Health and Human Services, 2008, p. 683 with type 1 (C) and type 2 (B)diabetes should engage in 2?3 sessions/week of resistance exercise on non-consecutive days. Type 2: Willey KA, Singh MA: Battling insulin resistance in elderly obese people with type 2 diabetes: Bring on the heavy weights. Diabetes Care 2003;26:1580-1588 1:Physical Activity Guidelines Advisory Committee: Physical activity guidelines advisory committee report, 2008. Washington, DC, U.S.Department of Health and Human Services, 2008, p. 683 training and balance training are recommended 2?3 times/week for older adults with diabetes. Yoga and tai chi may be included based on individual preferences to increase flexibility, muscular strength, and balance. CInclude in older adults section?Herriott MT, Colberg SR, Parson HK, Nunnold T, Vinik AI: Effects of 8 weeks of flexibility and resistance training in older adults with type 2 diabetes. Diabetes Care 2004;27:2988-2989 S, Colberg SR, Mariano M, Parson HK, Vinik AI: Balance training reduces falls risk in older individuals with type 2 diabetes. Diabetes Care 2010;33:748-750 KE, Selfe TK: Yoga for adults with type 2 diabetes: A systematic review of controlled trials. J Diabetes Res 2016;2016:6979370 S, Song R: Effects of tai chi exercise on glucose control, neuropathy scores, balance, and quality of life in patients with type 2 diabetes and neuropathy. J Altern Complement Med 2012;18:1172-1178 with pre-existing diabetes of any type should be advised to engage in regular physical activity prior to and during pregnancy. CMove to pregnancy section?Gynecology ACoOa: Acog committee opinion no. 650: Physical activity and exercise during pregnancy and the postpartum period. Obstet Gynecol 2015;126:e135-142 G, Garcia-Hermoso A, Poyatos-Leon R, Alvarez-Bueno C, Sanchez-Lopez M, Martinez-Vizcaino V: Effectiveness of physical activity interventions on preventing gestational diabetes mellitus and excessive maternal weight gain: A meta-analysis. Bjog 2015;122:1167-1174 LM, Nobles C, Ertel KA, Chasan-Taber L, Whitcomb BW: Physical activity interventions in pregnancy and risk of gestational diabetes mellitus: A systematic review and meta-analysis. Obstet Gynecol 2015;125:576-582 a program of physical activity can be safe for all individuals, a detailed assessment of risk should be conducted to minimize adverse events related to hypoglycemia or exacerbating complications. Evidence level??Refer to new position statementAdvise all patients not to use cigarettes, other tobacco products, or e-cigarettes. A97 – 104Add new articles to this group – showing smoking is a greater risk than obesity for MI. HYPERLINK "" article 2013 – supports the benefits of smoking cessation in spite of wt gain. And new one: 2016(16)30049-8/abstractInclude smoking cessation counseling and other forms of treatment as a routine component of diabetes care. BSleep consultant for next year.Prevention or Delay of Type 2 DiabetesNothing in prior Standards of Care (new item)//Note from Erika: Needs to be rewritten as recommendation//Should this be here or in chapter 2 (noted above as comment about adding ADA risk test above)Move this above.Delete here, reference above.Validated risk factor screening tools may be useful to identify persons at risk for Prediabetes and Diabetes?(C)(Poltavskiy E et al. Diabetes Res Clin Pract (2016))Bang H et al. Ann Intern Med. 2009 Dec 1;151(11):775-83. doi: 10.7326/0003-4819-151-11-200912010-00005.Herman WH et al.?Diabetes?Care. 1995 Mar;18(3):382-7.Siu AL; U S Preventive Services Task Force.Ann Intern Med. 2015 Dec 1;163(11):861-8. doi: 10.7326/M15-2345. Epub 2015 Oct 27Screening for Abnormal Blood Glucose and Type 2 Diabetes Mellitus: U.S. Preventive Services Task Force Recommendation Statement.?[Ann Intern Med. 2015].Patients with prediabetes should be referred to an intensive diet and physical activity behavioral counseling program adhering to the tenets of the Diabetes Prevention Program (DPP) targeting a loss of 7% of body weight and should increase their moderate-intensity physical activity (such as brisk walking) to at least 150 min/week. AGood new ref:Ackermann RT et al.?Am J Public Health. 2015 Nov;105(11):2328-34. doi: 10.2105/AJPH.2015.302641. Epub 2015 Sep 17.Eating patterns and foods associated with diabetes prevention should be encouraged including Mediterranean, Plant based, DASH, and high quality diets including whole grains, diary, nuts, and green leafy vegetables. EVIDENCE LEVEL? HYPERLINK "" \o "PLoS medicine." PLoS Med. 2016 Jun 14;13(6):e1002039. doi: 10.1371/journal.pmed.1002039. eCollection 2016.Plant-Based Dietary Patterns and Incidence of Type 2 Diabetes in US Men and Women: Results from Three Prospective Cohort Studies. HYPERLINK "" Satija A1 HYPERLINK "" HYPERLINK "" \o "Circulation." Circulation. 2016 Jan 12;133(2):187-225. doi: 10.1161/CIRCULATIONAHA.115.018585.Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review. HYPERLINK "" Mozaffarian D1. HYPERLINK "" HYPERLINK "" SH et al. Prevention and Mangement of type 2 diabetse: dietary components and nutritional strategies. Lancet Vol 383 June 7 2014Follow-up counseling and maintenance programs should be offered for long-term success in preventing diabetes. BReplace old references with newer, more comprehensive onesreplace (8) with Li G?et al.?Lancet Diabetes Endocrinol.?2014 Jun;2(6):474-80. doi: 10.1016/S2213-8587(14)70057-9. Epub 2014 Apr 3.Replace (9) with Lindstr?m J?et al. ?HYPERLINK ""Diabetologia.?2013 Feb;56(2):284-93. doi: 10.1007/s00125-012-2752-5. Epub 2012 Oct 24.Replace 13 withAckermann?RT et al.?Chronic Illn.?2011 Dec;7(4):279-90. doi: 10.1177/1742395311407532. Epub 2011 Aug 12Based on the cost-effectiveness of diabetes prevention, such programs should increasingly be covered by third-party payers. BMay cite CMS announcement and analysis on which it was based for DPP, and use Medicare's intensive behavioral therapy for obesity: an exploratory cost-effectiveness analysis.?HYPERLINK ""Hoerger TJ?et al.?Am J ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? Prev?Med.?2015 Apr;48(4):419-25. doi: 10.1016/j.amepre.2014.11.008. Epub 2015 Feb 20.As an alternative to lifestyle therapy, mMetformin is recommended to therapy for prevention of type 2 diabetes should be considered in those with prediabetes, especially in those with if BMI 35 kg/m2, age isthose aged 60 years, or inand women with prior gestational diabetes mellitus. A Monitoring of Vitamin B12 levels should be considered for those in whom metformin is prescribed C/E.Check the language here—is metformin only recommended for these populations? What about metformin for people who don’t meet these criteriaAdd a caveat to metformin B12 rec? (only in those with symptoms of neuropathy, etc.)Package insert says to monitor?Lifestyle and Metformin Ameliorate Insulin Sensitivity Independently of the Genetic Burden of Established Insulin ? ? ? ? ? ? ? ? Resistance Variants in?Diabetes?Prevention Program Participants.? ? ? ? ? ? Hivert MF et al?Diabetes. 2016 Feb;65(2):520-6. doi: 10.2337/db15-0950. Epub 2015 Nov 2.? ? ? ? ? ?Long-term Metformin Use and Vitamin B12 Deficiency in the?Diabetes?Prevention Program Outcomes Study.? ? ? ? ? ?Aroda VR et al?Diabetes?Prevention Program Research Group.?J Clin Endocrinol Metab. 2016 Apr;101(4):1754-61. doi: 10.1210/jc.2015- ? ? ? ? ? ? ? ? 3754. Epub 2016 Feb 22.Association of Biochemical B12?Deficiency With Metformin Therapy and Vitamin B12?Supplements. Reinstatler L et al?Diabetes Care?2012 Feb;?35(2):?327-333.At least annual monitoring for the development of diabetes in those with prediabetes is suggested. EScreening for and treatment of modifiable risk factors for cardiovascular disease is suggested. BH. Feldman still working on pulling articles.Diabetes self-management education and support programs are appropriate venues for people with prediabetes to receive education and support to develop and maintain behaviors that can prevent or delay the onset of diabetes. BTechnology-assisted tools including Internet-based social networks, distance learning, DVD-based content, and mobile applications can be useful in preventing diabetes and/or enhancing the effectiveness of existing programs. elements of effective lifestyle modification to prevent diabetes. BInclude reference to Omada health’s research cited above in Education section – HYPERLINK "" by Sepah et al (including Anne Peters) on 2 yr online DM prevention program.Will find more. The studies are pilot in nature, but are emerging. Several online/mobile versions of DPP, for example, are now listed on the CDC’s DPRP site. CMS will potentially reimburse for the use of these, as long as engagement can be documented and weight loss goals are achievable.Assessment of Glycemic ControlWhen prescribed as part of a broader educational context, self-monitoring of blood glucose (SMBG) results may help to guide treatment decisions and/or self-management for patients using less frequent insulin injections B or non-insulin therapies. ENo Change Recommended.1-14When prescribing SMBG, ensure that patients receive ongoing instruction and regular evaluation of SMBG technique, SMBG results, and their ability to use SMBG data to adjust therapy. ENo Change Recommended.No references currently cited in 2016 standards (supported by narrative)Most patients on intensive insulin regimens (multiple-dose insulin or insulin pump therapy) should consider SMBG prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving. BNo ChangeWhen used properly, continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens is a useful tool to lower A1C in selected adults (aged 25 years) with type 1 diabetes. ANo Change Recommended.15, 20Although the evidence for A1C lowering is less strong in children, teens, and younger adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing use of the device. BNo Change Recommended.16-20,23CGM may be a supplemental tool to SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes. CNo Change Recommended.Need to add/modify a recommendation if the FDA approves non-ancillary use of Dexcom G5?Add information to text?20-22For Discussion (Dr. Ratner?):Endocrine Today ArticleGiven variable adherence to CGM, assess individual readiness for continuing CGM use prior to prescribing. ENo Change Recommended.16,24When prescribing CGM, robust diabetes education, training, and support are required for optimal CGM implementation and ongoing use. ENo Change Recommended.16,24People who have been successfully using CGM should have continued access after they turn 65 years of age. ENo Change Recommended.No references currently cited in 2016 standards (supported by narrative)Herman WH, Ilag LL, Johnson SL, et al. A clinical trial of continuous subcutaneous insulin infusion versus multiple daily injections in older adults with type 2 diabetes. Diabetes Care 2005;28:1568–1573Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). ENo Change Recommended.No references currently cited in 2016 standards (supported by narrative)Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals. ENo Change Recommended.No references currently cited in 2016 standards (supported by narrative)Point-of-care testing for A1C provides the opportunity for more timely treatment changes. ENo Change Currently Recommended.Need to modify if POC A1C testing granted as diagnostic by FDA?No references currently cited in 2016 standards.Added a sentence to make note of POC testing within this subsection.A reasonable A1C goal for many nonpregnant adults is <7% (53 mmol/mol). ANo Change Recommended.32-37, 53Providers might reasonably suggest more stringent A1C goals (such as <6.5% [48 mmol/mol]) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease. CNo Change Recommended.34-37; Supported by narrativeLess stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin. BNo Change Recommended.38-53Individuals at risk for hypoglycemia should be asked about symptomatic and asymptomatic hypoglycemia at each encounter. CNo Change Recommended.Not explicitly mentioned in the narrative within this section.Hypoglycemia recommendations to be reviewed when ADA/EASD joint position statement availableGlucose (15–20 g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. Fifteen minutes after treatment, if SMBG shows continued hypoglycemia, the treatment should be repeated. Once SMBG returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. ENo Change Recommended.No references currently cited in 2016 standards (supported by narrative)Added sentence in narrative to make note of consuming a meal or snack per the recommendation.Hypoglycemia recommendations to be reviewed when ADA/EASD joint position statement availableGlucagon should be prescribed for all individuals at increased risk of severe hypoglycemia, defined as hypoglycemia requiring assistance, and caregivers, school personnel, or family members of these individuals should be instructed in its administration. Glucagon administration is not limited to health care professionals. ENo Change Recommended.Change to align with hypo statementNo references currently cited in 2016 standards (supported by narrative)Hypoglycemia recommendations to be reviewed when ADA/EASD joint position statement availableHypoglycemia unawareness or one or more episodes of severe hypoglycemia should trigger re-evaluation of the treatment regimen. ENo Change Recommended.Align with hypo (remove severe)62; Supported by narrativeHypoglycemia recommendations to be reviewed when ADA/EASD joint position statement availableInsulin-treated patients with hypoglycemia unawareness or an episode of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes. ANo Change Recommended.62Hypoglycemia recommendations to be reviewed when ADA/EASD joint position statement availableOngoing assessment of cognitive function is suggested with increased vigilance for hypoglycemia by the clinician, patient, and caregivers if low cognition or declining cognition is found. BNo Change Recommended.56,57Hypoglycemia recommendations to be reviewed when ADA/EASD joint position statement availableObesity Managment for the Treatment of Type 2 DiabetesAt each patient encounter, BMI should be calculated and documented in the medical record. BNo Change Recommended.12Diet, physical activity, and behavioral therapy designed to achieve 5% weight loss should be prescribed for overweight and obese patients with type 2 diabetes ready to achieve weight loss. ANo Change Recommended.13-16Steven et al. Very-low-calorie diet and 6 months of weight stability in type 2 diabetes: Pathophysiologic changes in responders and nonresponders. Diabetes Care March 21, 2016. Epub Ahead of Print.Such interventions should be high intensity (16 sessions in 6 months) and focus on diet, physical activity, and behavioral strategies to achieve a 500–750 kcal/day energy deficit. ANo Change Recommended.Franz article 2015 JAND HYPERLINK "" that provide the same caloric restriction but differ in protein, carbohydrate, and fat content are equally effective in achieving weight loss. ANo Change Recommended.13-16For patients who achieve short-term weight loss goals, long-term (1-year) comprehensive weight maintenance programs should be prescribed. Such programs should provide at least monthly contact and encourage ongoing monitoring of body weight (weekly or more frequently), continued consumption of a reduced calorie diet, and participation in high levels of physical activity (200–300 min/week). ANo Change Recommended.18To achieve weight loss of >5%, short-term (3-month) high-intensity lifestyle interventions that use very low-calorie diets (800 kcal/day) and total meal replacements may be prescribed for carefully selected patients by trained practitioners in medical care settings with close medical monitoring. To maintain weight loss, such programs must incorporate long-term comprehensive weight maintenance counseling. BNo Change Recommended.Text should address meal replacement outcomes19-20Meal replacement article:Shows high quality of diets in T2 DM consuming meal replacementsRaynor H et al. JAND. 2015; 115:731-When choosing glucose-lowering medications for overweight or obese patients with type 2 diabetes, consider their effect on weight. ENo Change Recommended.No references currently cited in 2016 standards (supported by narrative)Whenever possible, minimize the medications for comorbid conditions that are associated with weight gain. ENo Change Recommended.No references currently cited in 2016 standards (supported by narrative)Weight loss medications may be effective as adjuncts to diet, physical activity, and behavioral counseling for selected patients with type 2 diabetes and BMI 27 kg/m2. Potential benefits must be weighed against the potential risks of the medications. ANo Change Recommended.21-23If a patient’s response to weight loss medications is <5% after 3 months or if there are any safety or tolerability issues at any time, the medication should be discontinued and alternative medications or treatment approaches should be considered. ANo Change Recommended.21-23Bariatric or metabolic surgery may be considered for adults with BMI >35 kg/m2 and type 2 diabetes, especially if diabetes or associated comorbidities are difficult to control with lifestyle and pharmacological therapy. Bshould be recommended to treat type 2 diabetes in appropriate surgical candidates with BMI ≥40 kg/m2 (BMI ≥37.5 kg/m2 in Asian Americans), regardless of the level of glycemic control or complexity of glucose-lowering regimens, and in patients with BMI 35.0-39.9 kg/m2 (32.5-37.4 kg/m2 in Asian Americans) when hyperglycemia is inadequately controlled despite lifestyle and optimal medical therapy. ARevised per Rubino 2016.Change bariatric to metabolic—address in text why we are doing that.Rubino et al. Metabolic Surgery in the treatment algorithm for type 2 diabetes: A joint statement by international diabetes organizations. Diabetes Care 2016;39:861-877Metabolic surgery should be considered for patients with T2DM and BMI 30.0-34.9 kg/m2 (27.5-32.4 kg/m2 in Asian Americans) if hyperglycemia is inadequately controlled despite optimal treatment with oral and/or injectable medications (including insulin). BNew Suggested Recommendation8,9,38,39Rubino et al. Metabolic Surgery in the treatment algorithm for type 2 diabetes: A joint statement by international diabetes organizations. Diabetes Care 2016;39:861-877Metabolic surgery should be performed in high-volume centeres with multidisciplinary teams that understand and are experienced in the management of diabetes and gastrointestinal surgery. CNew Suggested RecommendationRubino et al. Metabolic Surgery in the treatment algorithm for type 2 diabetes: A joint statement by international diabetes organizations. Diabetes Care 2016;39:861-877Patients with type 2 diabetes who have undergone bariatric surgery need lifelong lifestyleLong-term support and annual medical monitoring, at a minimum of micronutrient and nutritional status must be provided to patients after surgery, according to guidelines for postoperative management of bariatric/metabolic surgery by national and international professional societies. CBRevised per Rubino 2016.Rubino et al. Metabolic Surgery in the treatment algorithm for type 2 diabetes: A joint statement by international diabetes organizations. Diabetes Care 2016;39:861-877Persons presenting for metabolic surgery, should receive a comprehensive mental health assessment that includes health related quality of life and eating cognitions and behaviors by a professional familiar weight loss interventions and post-bariatric surgery behavioral requirements. BIf psychopathology is evident, particularly suicidal ideation and/or significant depression, postponement of surgery should be considered so that patient suffering can be addressed before adding the burden of recovery and lifestyle/psychosocial adjustment. EPersons who undergo bariatric surgery should be assessed for need of ongoing mental health services to help them adjust to medical and psychosocial changes post-surgery.C Although small trials have shown a glycemic benefit of bariatric surgery in patients with type 2 diabetes and BMI 30–35 kg/m2, there is currently insufficient evidence to generally recommend surgery in patients with BMI ≤35 kg/m2. ERecommend to delete recommendation per changes to above recommendations.Pharmacologic Approaches To Glycemic TreatmentInclude advocacy recommendation about access to medications that are best for an individual patient (model on CGM recommendation) Run anything by Bob, Shareen,***Most people with type 1 diabetes should be treated with multiple-dose insulin injections (three to four injections per day of basal and prandial insulin) or continuous subcutaneous insulin infusion. ANo Change Recommended.Recommended change to current reference #12 (delete current reference #12 and replace with Bode et al.) and narrative related to inhaled prandial insulin in T1DM. 2-6,8,9Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) Study Research Group. Mortality in Type 1 diabetes in the DCCT/EDIC versus the general population. Diabetes Care 2016;39(8):1378-1383 Bode, BW, McGill JB, Lorber DL, et al. Inhaled technosphere insulin compared with injected prandial insulin in type 1 diabetes: A randomized 24-week trial. Diabetes Care 2015;38:2266-2273Consider educating individuals with type 1 diabetes on matching prandial insulin dose to carbohydrate intake, premeal blood glucose, and anticipated activity. ENo Change Recommended.No references currently cited in 2016 standards (supported by narrative)Most individuals with type 1 diabetes should use insulin analogs to reduce hypoglycemia risk. ANo Change Recommended.Individuals who have been successfully using continuous subcutaneous insulin infusion should have continued access after they turn 65 years of age. ENo Change Recommended.30 (Not specifically discussed in the narrative within the T1DM section)Added text for consideration regarding this expert opinion recommendation such that it was mentioned in the narrative in the T1DM section.Metformin, if not contraindicated and if tolerated, is the preferred initial pharmacological agent for type 2 diabetes. ANo Change Recommended.17,18Aroda VR, Edelstein SL, Goldberg RB, et al. Long-term metformin use and vitamin B12 deficiency in the Diabetes Prevention Program Outcomes Study. J Clin Endocrinol Metab 2016;101:1754-1761US Food and Drug Administration (FDA) MedWatch for Metformin-containing Drugs: Revised Warnings for Certain Patients with Reduced Kidney Function. Website Link.Long-term use of metformin may be associated with biochemical B12 deficiency, and routine measurement of vitamin B12 levels in metformin-treated patients should be considered B HYPERLINK "" Long-term Metformin Use and Vitamin B12 Deficiency in the Diabetes Prevention Program Outcomes StudyConsider initiating insulin therapy (with or without additional agents) in patients with newly diagnosed type 2 diabetes and markedly symptomatic and/or elevated blood glucose levels or A1C. ENo Change Recommended.17If noninsulin monotherapy at maximum tolerated dose does not achieve or maintain the A1C target over 3 months, then add a second oral agent, a glucagon-like peptide 1 receptor agonist, or basal insulin. ANo Change Recommended.Added text to narrative and reference in Table 1 related to EMPA-REG OUTCOME and LEADER results.Added IRIS study to Table 1.Created draft tables for pricing on: 1) non-insulin agents; and 2) insulin products (separate attachments).Add footnote to make clear that price to consumers may vary17, 27Giugliano, D, Chiodini P, Maiorino MI, et al. Intensification of insulin therapy with basal-bolus or premixed insulin regimens in type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. Endocrine 2016;51:417-428 Zinman B, Wanner C, Lachin JM, et al.; EMPA-REG OUTCOME Investigators. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med 2015;373:2117-2128Marso SP, Daniels GH, Brown-Frandsen K, et al.; LEADER Investigators. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2016;375(4):311-322Kernan WN, Viscoli CM, Furie KL, et al. Pioglitazone after ischemic stroke or transient ischemic attack. N Engl J Med 2016;374:1321-1331A patient-centered approach should be used to guide the choice of pharmacological agents. Considerations include efficacy, cost, potential side effects, weight, comorbidities, hypoglycemia risk, and patient preferences. ENo Change Recommended.For discussion: Should CV benefit be added to recommendation and Figure 7.1 per recent CVOT results (EMPA-REG, LEADER, etc.)?Add section on biosimilars to text.17,20,22,23,24Palmer SC, Mavridis D, Nicolucci A, et al. Comparison of clinical outcomes and adverse events associated with glucose-lowering drugs in patients with type 2 diabetes: A meta-analysis. JAMA 2016;316(3):313-324For patients with type 2 diabetes who are not achieving glycemic goals, insulin therapy should not be delayed. BNo Change Recommended.17Cardiovascular Disease and Risk ManagementBlood pressure should be measured at every routine visit. Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day. BNo changePeople Most patients with diabetes and hypertension should be treated to a systolic blood pressure goal of <140 mmHg and a diastolic blood pressure goals of <90 mmHg. AAcknowledge options for individualization belowLower systolic targets, such as <125-130 mmHg, may be appropriate for certain individuals with diabetes who have diastolic blood pressures consistently above 60 mmHg, high, such as younger patients, those with albuminuria, and/or those with hypertension and one or more additional atherosclerotic cardiovascular disease risk factors, atherosclerotic cardiovascular risk, or more than 300 mg/day of albuminuria, if they can be achieved without undue treatment burden. CAdd stroke information, Is 60 mmHg right? Too low? Delete callout of 60 mmHg—add to text, subsumed by undue treatment burden, or add “including undue lowering of diastolic.”Make sure this is consistent with recommendation in the DKD sectionIndividuals with diabetes should be treated to a diastolic blood pressure goal of <90 mmHg. AMerged with aboveLower diastolic targets, such as <80 mmHg, may be appropriate for certain individuals with diabetes, such as younger patients, those with albuminuria, and/or those with hypertension and one or more additional atherosclerotic cardiovascular disease risk factors, if they can be achieved without undue treatment burden. BCLevel of evidence downgraded, consistent with SBP individualization. Much debate about whether both should be B or C among HTN group.Lifestyle therapy for pPatients with blood pressure >120/80 mmHg consists of weight loss, if overweight or obese; a Dietary Approaches to Stop Hypertension (DASH)-style dietary pattern including reducing sodium and increasing potassium intake as long as the eGFR is above 45 ml/min/ 1.73m2; moderation of alcohol intake; and increased physical activityshould be advised on lifestyle changes to reduce blood pressure. BMerged with subsequent lifestyle recMove this below the next bullet?Patients with confirmed office-based blood pressure >140/90 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely subsequent titration of pharmacological therapy to achieve blood pressure goals. ANo changeIn older adults, pharmacological therapy to achieve treatment goals of < 130/70 mmHg is not recommended; treating to systolic blood pressure <130 mmHg has not been shown to improve cardiovascular outcomes and treating to diastolic blood pressure <70 mmHg has been associated with higher mortality. CTo text in context of individualizationLifestyle therapy for elevated blood pressure consists of weight loss, if overweight or obese; a Dietary Approaches to Stop Hypertension (DASH)-style dietary pattern including reducing sodium and increasing potassium intake; moderation of alcohol intake; and increased physical activity. BMerged with abovePharmacological therapy for patients with diabetes and hypertension should comprise a regimen that includes either an ACE inhibitor or an angiotensin receptor blocker but not both. B If one class is not tolerated, the other should be substituted. CInitial drug therapy for those with a blood pressure >140/90 mmHg should be with a drug class demonstrated to reduce CVD events in patients with diabetes (ACE inhibitors or ARBs or thiazide-like diuretics or dihydropyridine calcium channel blockers) or, if confirmed office blood pressures >160/100 mmHg, with a single pill combination of drugs demonstrated to reduce CVD events in patients with diabetes. AAcknowledge new evidence that ACEI or ARB not necessarily superior in absence of DKDAdd this back in?: If one class is not tolerated, the other should be substituted. CInclude information here about—in the absence of kidney disease—or something?Highlight role of thiazides/calcium channel blockers in African Americans?Cherrington working with JNC writing group—put this past them to see if they are consistent.Reword to (Rita)ACE and ARB should be used in those with albuminuria, and may be used in othersThen other classes may be used in those without kidney disease.Keep single pill discussion out of it—too specific for StandardsPatients with urinary albumin excretion ?>300 mg/day should be treated with either an ACE inhibitor or an ARB as part of their antihypertensive regiment. (A)Added based on clear trials evidence* Need to synch with microvascular rec?Multiple-drug therapy (including a thiazide diuretic and ACE inhibitor/angiotensin receptor blocker, at maximal doses) is generally required to achieve blood pressure targets. BTo textIf ACE inhibitors, angiotensin receptor blockers, or diuretics are used, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored. EBIncreased level of evidenceTrials demonstrating AKI and hyperkalemia with intensive BP control, associations of AKI and hyperkalemia with adverse outcomesPatients with resistant hypertension who have failed conventional drug therapy with three agents, including a diuretic, and/or with a significant renal disease should be referred to a physician experienced in the care of patients with hypertension certified hypertension specialist or someone with experience with resistant hypertension. EConsider adding vs in hypertension position statement onlyStay in statement, don’t include in StandardsPatients with resistant hypertension who have failed conventional drug therapy with three agents should be considered for mineral corticocoid receptor antagonist therapy BNew data on effectiveness of spironolactone for BP control and finerenone for albuminuria reductionStay in statement, not in StandardsIn pregnant patients with diabetes and chronic hypertension, blood pressure targets of 120–160/80–105110–129/65–79 mmHg are suggested in the interest of optimizing long-term maternal health and minimizing impaired fetal growth. EConsistent with ACOG guidelines, concerns regarding fetal perfusion at low BPsDon Coustan comment?In adults not taking statins, it is reasonable to obtain a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every 5 years thereafter, or more frequently if indicated. EObtain a lipid profile at initiation of statin therapy and periodically thereafter as it may help to monitor the response to therapy and inform adherence. ELifestyle modification focusing on weight loss (if indicated); the reduction of saturated fat, trans fat, and dietary cholesterol intake; increase of omega-3 fatty acids, viscous fiber, and plant stanols/sterols intake; and increased physical activity should be recommended to improve the lipid profile in patients with diabetes. AIs cholesterol recommendation still true? cite studies on lack of evidence for dietary supplementsIntensify lifestyle therapy and optimize glycemic control for patients with elevated triglyceride levels (150 mg/dL [1.7 mmol/L]) and/or low HDL cholesterol (<40 mg/dL [1.0 mmol/L] for men, <50 mg/dL [1.3 mmol/L] for women). CFor patients with fasting triglyceride levels 500 mg/dL (5.7 mmol/L), evaluate for secondary causes of hypertriglyceridemia and consider medical therapy to reduce the risk of pancreatitis. CFor patients of all ages with diabetes and atherosclerotic cardiovascular disease, high-intensity statin therapy should be added to lifestyle therapy. AFor patients with diabetes aged <40 years with additional atherosclerotic cardiovascular disease risk factors, consider using moderate-intensity or high-intensity statin and lifestyle therapy. CFor patients with diabetes aged 40–75 years without additional atherosclerotic cardiovascular disease risk factors, consider using moderate-intensity statin and life-style therapy. AFor patients with diabetes aged 40–75 years with additional atherosclerotic cardiovascular disease risk factors, consider using high-intensity statin and lifestyle therapy. BFor patients with diabetes aged >75 years without additional atherosclerotic cardiovascular disease risk factors, consider using moderate-intensity statin therapy and lifestyle therapy. BFor patients with diabetes aged >75 years with additional atherosclerotic cardiovascular disease risk factors, consider using moderate-intensity or high-intensity statin therapy and lifestyle therapy. BIn clinical practice, providers may need to adjust intensity of statin therapy based on individual patient response to medication (e.g., side effects, tolerability, LDL cholesterol levels). EThe addition of ezetimibe to moderate-intensity statin therapy has been shown to provide additional cardiovascular benefit compared with to moderate-intensity statin therapy alone and may be considered for patients with a recent acute coronary syndrome with LDL cholesterol 50 mg/dL (1.3 mmol/L) or for those patients who cannot tolerate high-intensity statin therapy. ARefer to comment to SOC 2016Combination therapy (statin/fibrate) has not been shown to improve atherosclerotic cardiovascular disease outcomes and is generally not recommended. A However, therapy with statin and fenofibrate may be considered for men with both triglyceride level 204 mg/dL (2.3 mmol/L) and HDL cholesterol level ≤34 mg/dL (0.9 mmol/L). BCombination therapy (statin/niacin) has not been shown to provide additional cardiovascular benefit above statin therapy alone and may increase the risk of stroke and is not generally recommended. AStatin therapy is contraindicated in pregnancy. BConsider aspirin therapy (75–162 mg/day) as a primary prevention strategy in those with type 1 or type 2 diabetes who are at increased cardiovascular risk (10-year risk >10%). This includes most men or women with diabetes aged 50 years who have at least one additional major riskfactor (family history of premature atherosclerotic cardiovascular disease, hypertension, smoking, dyslipidemia, or albuminuria) and are not at increased risk of bleeding. CThe risk calculators have not been as well validated in diabetes and we don’t emphasize them in the rest of the SOC. HYPERLINK "" \t "_blank" Low-Dose Aspirin in the Primary Prevention of Cardiovascular Disease:?Shared Decision Making in Clinical Practice??Samia?Mora,?MD, MHS; Jeffrey M.?Ames,?BS, MEng; JoAnn E.?Manson,?MD, DrPHJAMA. Published online June 20, 2016. doi:10.1001/jama.2016.8362In Vivo Platelet Activation and?Aspirin?Responsiveness in Type 1?Diabetes.Zaccardi F, Rizzi A, Petrucci G, Ciaffardini F, Tanese L, Pagliaccia F, Cavalca V, Ciminello A, Habib A, Squellerio I, Rizzo P, Tremoli E, Rocca B, Pitocco D, Patrono C.Diabetes. 2016 Feb;65(2):503-9. doi: 10.2337/db15-0936. Epub 2015 Oct 15.PMID: 26470782 HYPERLINK "" Value of Coronary Computed Tomography Angiography in Tailoring?Aspirin?Therapy for Primary Prevention of Atherosclerotic Events in Patients at High Risk With?Diabetes?Mellitus.Dimitriu-Leen AC, Scholte AJ, van Rosendael AR, van den Hoogen IJ, Kharagjitsingh AV, Wolterbeek R, Knuuti J, Kroft LJ, Delgado V, Jukema JW, de Graaf MA, Bax JJ.Am J Cardiol. 2016 Mar 15;117(6):887-93. doi: 10.1016/j.amjcard.2015.12.023. Epub 2015 Dec 30.Aspirin should not be recommended for atherosclerotic cardiovascular disease prevention for adults with diabetes at low atherosclerotic cardiovascular disease risk (10- year atherosclerotic cardiovascular disease risk <5%), such as in men or women with diabetes aged <50 years with no major additional atherosclerotic cardiovascular disease risk factors, as the potential adverse effects from bleeding likely offset the potential benefits. CThe risk calculators have not been as well validated in diabetes and we don’t emphasize them in the rest of the SOC.In patients with diabetes <50 years of age with multiple other risk factors (e.g., 10-year risk 5–10%), clinical judgment is required. EThe risk calculators have not been as well validated in diabetes and we don’t emphasize them in the rest of the SOC.Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes and a history of atherosclerotic cardiovascular disease. ANo changeFor patients with atherosclerotic cardiovascular disease and documented aspirin allergy, clopidogrel (75 mg/day) should be used. BNo changeDual antiplatelet therapy is reasonable for up to a year after an acute coronary syndrome and may have benefits beyond this period. BIn patients with?diabetes?with prior MI (1-3 years prior), adding ticagrelor to?aspirin?significantly reduces the risk?of?recurrent ischemic events, including cardiovascular and coronary heart disease death HYPERLINK "" Reduction in Ischemic Events With Ticagrelor in?Diabetic?Patients With Prior Myocardial Infarction in PEGASUS-TIMI 54.Bhatt DL, Bonaca MP, Bansilal S, Angiolillo DJ, Cohen M, Storey RF, Im K, Murphy SA, Held P, Braunwald E, Sabatine MS, Steg PG.J Am Coll Cardiol. 2016 Jun 14;67(23):2732-40. doi: 10.1016/j.jacc.2016.03.529. Epub 2016 Apr 1.In asymptomatic patients, routine screening for coronary artery disease is not recommended as it does not improve outcomes as long as atherosclerotic cardiovascular disease risk factors are treated. AConsider investigations for coronary artery disease in the presence of any of the following: atypical cardiac symptoms (e.g., unexplained dyspnea, chest discomfort); signs or symptoms of associated vascular disease including carotid bruits, transient ischemic attack, stroke, claudication, or peripheral arterial disease; or electrocardiogram abnormalities (e.g., Q waves). EIn patients with known atherosclerotic cardiovascular disease, use aspirin and statin therapy (if not contraindicated) A and consider ACE inhibitor therapy C to reduce the risk of cardiovascular events.In patients with prior myocardial infarction, -blockers should be continued for at least 2 years after the event. BIn patients with symptomatic heart failure, thiazolidinedione treatment should not be used. A? positive statement about empaliflozinEmpagliflozin and liraglutide may be considered as particularly effective in people with CVD to minimize further vascular and renal events.AShould we include a positive statement about empagliflozin? In text—highlight the status of data on diabetes meds overall, things may change as new trial data becomes availableBill will draft recommendation and text for the group to decide.See this article? HYPERLINK "" Eli Lilly & Co and Boehringer Ingelheim should be allowed to claim that their diabetes drug Jardiance cuts the risk of cardiovascular death, an advisory panel to the U.S. Food and Drug Administration concluded on Tuesday.The FDA is not obliged to follow the advice of its advisory committees but typically does so.Jardiance, also known as empagliflozin, was approved in 2014 to help lower blood sugar in patients with type 2 diabetes. The companies are seeking approval to claim that it also cuts the risk of death from heart attacks and strokes.The panelists voted 12-11 to allow the claim that it cuts the risk of cardiovascular death. The panel voted unanimously that it does not add to the risk of cardiovascular problems.In patients with type 2 diabetes with stable congestive heart failure, metformin may be used if renal function is normal but should be avoided in unstable or hospitalized patients with congestive heart failure. BMirovascular Complications and Foot CareAt least once a year, assess urinary albumin (e.g., spot urinary albumin–to– creatinine ratio) and estimated glomerular filtration rate in patients with type 1 diabetes with duration of 5 years, in all patients with type 2 diabetes, and in all patients with comorbid hypertension. BNo changeOptimize glucose control to reduce the risk or slow the progression of diabetic kidney disease. ANo changeSeveral to addOptimize blood pressure control (<140/90 mmHg or lower) to reduce the risk or slow the progression of diabetic kidney disease. ANo change anticipatedAcknowledge individualizationAwait HTN statement, include metaanalyses, SPRINT, ADVANCEFor people with nondialysis-dependent diabetic kidney disease, dietary protein intake should be 0.8 g/kg body weight per day (the recommended daily allowance). For patients on dialysis, higher levels of dietary protein intake should be considered. ABThere are no new data here, but NKF and KDIGO consider this lower-grade evidence, and I personally consider it a level B at bestEither an ACE inhibitor or an angiotensin receptor blocker is recommended for the treatment of nonpregnant patients with diabetes, hypertension, and modestly elevated urinary albumin excretion (30–299 mg/day) B and is strongly recommended for those with urinary albumin excretion 300 mg/day and/or estimated glomerular filtration rate <60 mL/min/1.73 m2. ASpecify for hypertension* Need to synch with hypertension rec?Match hypertension statement to match thisAdd new metaanalysesPeriodically monitor serum creatinine and potassium levels for the development of increased creatinine or changes in potassium when ACE inhibitors, angiotensin receptor blockers, or diuretics are used. EBNo changeUpdgrade level of evidence as in hypertension guidelineContinued monitoring of urinary albumin–to–creatinine ratio in patients with albuminuria treated with an ACE inhibitor or an angiotensin receptor blocker is reasonable to assess the response to treatment and progression of diabetic kidney disease. ENo changeAdd to text: if you are treating with and ACE or ARB for DKD, use maximum dose, if tolerated.An ACE inhibitor or an angiotensin receptor blocker is not recommended for the primary prevention of diabetic kidney disease in patients with diabetes who have normal blood pressure, normal urinary albumin–to–creatinine ratio (<30 mg/g), and normal estimated glomerular filtration rate. BDelete? Take out rec and put in text? Keep in When estimated glomerular filtration rate is <60 mL/min/1.73 m2, evaluate and manage potential complications of chronic kidney disease. EPatients should be referred for evaluation for renal replacement treatment if they have estimated glomerular filtration rate <30 mL/min/1.73 m2. APromptly refer to a physician experienced in the care of kidney disease for uncertainty about the etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease. BOptimize glycemic control to reduce the risk or slow the progression of diabetic retinopathy. ANo change HYPERLINK "" Effects of Prior Intensive Insulin Therapy and Risk Factors on Patient-Reported Visual Function Outcomes in the?Diabetes?Control and Complications Trial/Epidemiology of?Diabetes?Interventions and Complications (DCCT/EDIC) Cohort.Writing Team for the DCCT/EDIC Research Group, Gubitosi-Klug RA, Sun W, Cleary PA, Braffett BH, Aiello LP, Das A, Tamborlane W, Klein R.Add DCCT:The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus. N Engl J Med. 1993;329(14):977–86. Optimize blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic retinopathy. ANo change HYPERLINK "" Comparative effectiveness of angiotensin-converting-enzyme inhibitors and angiotensin II receptor blockers in patients with type 2?diabetes?and?retinopathy.Shih CJ, Chen HT, Kuo SC, Li SY, Lai PH, Chen SC, Ou SM, Chen YT.CMAJ. 2016 May 17;188(8):E148-57. doi: 10.1503/cmaj.150771. Epub 2016 Mar 21.Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. BPatients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis. BIf there is no evidence of retinopathy for one or more annual eye exams, then exams every 2 years may be considered. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations for patients with type 1 or type 2 diabetes should be repeated at least annually by an ophthalmologist or optometrist. If retinopathy is progressing or sight-threatening, then examinations will be required more frequently. BWhile retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam, which should be performed at least initially and at intervals thereafter as recommended by an eye care professional. ENo change HYPERLINK "" Evaluation of Automated Teleretinal Screening Program for?Diabetic?Retinopathy.Walton OB 4th, Garoon RB, Weng CY, Gross J, Young AK, Camero KA, Jin H, Carvounis PE, Coffee RE, Chu YI.JAMA Ophthalmol. 2016 Feb;134(2):204-9. doi: 10.1001/jamaophthalmol.2015.5083.Dilated eEye examinations should occur before pregnancy or in the first trimester, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy. BPromptly refer patients with any level of macular edema, severe nonproliferative diabetic retinopathy (a precursor of proliferative diabetic retinopathy), or any proliferative diabetic retinopathy to an ophthalmologist who is knowledgeable and experienced in the management and treatment of diabetic retinopathy. ALaser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with high-risk proliferative diabetic retinopathy and, in some cases, severe nonproliferative diabetic retinopathy. ANo change HYPERLINK "" Panretinal Photocoagulation vs Intravitreous Ranibizumab for Proliferative?Diabetic?Retinopathy: A Randomized Clinical Trial.Writing Committee for the?Diabetic?Retinopathy?Clinical Research Network, Gross JG, Glassman AR, Jampol LM, Inusah S, Aiello LP, Antoszyk AN, Baker CW, Berger BB, Bressler NM, Browning D, Elman MJ, Ferris FL 3rd, Friedman SM, Marcus DM, Melia M, Stockdale CR, Sun JK, Beck RW.JAMA. 2015 Nov 24;314(20):2137-46. doi: 10.1001/jama.2015.15217Intravitreal injections of antivascular endothelial growth factor are indicated for center-involved diabetic macular edema, which occurs beneath the foveal center and may threaten reading vision. AThe presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of retinal hemorrhage. AAll patients should be assessed for diabetic peripheral neuropathy starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes and at least annually thereafter. BAssessment for distal symmetric polyneuropathy should include a careful history and assessment of either temperature or pinprick sensation (small fiber function) and vibration sensation using a 128-Hz tuning fork (large fiber function).? All patients should have annual 10-gm monofilament testing to assess for feet at risk for ulceration and amputation (see section on foot care, below).Assessment should include a careful history and 10-g monofilament testing and at least one of the following tests: pinprick, temperature, or vibration sensation. BAssessment should include a careful history, and a combination of at least two of the following tests: vibration, pinprick, or temperature sensation or 10-g monofilament testing. B-neuropathy position statement suggestionThis should happen for all patients at all exams –rework language to clarify60. Freeman R, Baron R, Bouhassira D, Cabrera J, Emir B: Sensory profiles of patients with neuropathic pain based on the neuropathic pain symptoms and signs. Pain 2014;155:367-376Symptoms and signs of autonomic neuropathy should be assessed in patients with microvascular and neuropathic complications. EAll patients should be assessed for CAN starting 10 years after diagnosis or in the presence of other forms of diabetic neuropathy and/or other diabetic complications. B--Wording from the position statement – but PPC subgroup prefers not to change this recommendationAdd specific recommendations in text for how to assess?PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TcGFsbG9uZTwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+

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ADDIN EN.CITE.DATA (13; 153-157; 161; 167; 169) from neuro statementConsider gastroparesis in people with diabetic neuropathy, retinopathy, and/or nephropathy by assessing for symptoms of unexpected glycemic variability, early satiety, bloating, nausea, and vomiting, after excluding other causes for these symptoms. CNeuropathy position statement--In text, add that it can often be asymptomaticDiabetic kidney disease instead of nephropathy?Include mention of glycemic variabilityAdditional wordsmithingNeuro statement references 178, 183, 185, 191Optimize glucose control to prevent or delay the development of neuropathy in patients with type 1 diabetes A and to prevent or slow the progression of neuropathy in patients with type 2 diabetes. B21. Ismail-Beigi F, et al.: Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial. Lancet 2010;376:419-43025. Ang L, et. al: Glucose control and diabetic neuropathy: lessons from recent large clinical trials. Curr Diab Rep 2014;14:52826. Pop-Busui R, et al.: Impact of glycemic control strategies on the progression of diabetic peripheral neuropathy in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Cohort. Diabetes Care 2013;36:3208-3215Lifestyle interventions are effective forrecommended for the prevention of DSPN prevention in patients with pre-diabetes/metabolic syndrome. BChange to a level C? Check for RCT.Change language to be recommendedMove to prevention section—in text, not as recommendation32. Carnethon MR, Prineas RJ, Temprosa M, Zhang ZM, Uwaifo G, Molitch ME: The association among autonomic nervous system function, incident diabetes, and intervention arm in the diabetes prevention program. Diabetes Care 2006;29:914-91933. Smith AG, Russell J, Feldman EL, Goldstein J, Peltier A, Smith S, Hamwi J, Pollari D, Bixby B, Howard J, Singleton JR: Lifestyle intervention for pre-diabetic neuropathy. Diabetes Care 2006;29:1294-1299Assess and treat patients to reduce pain related to diabetic peripheral neuropathy B and symptoms of autonomic neuropathy and to improve quality of life. EConsider using either pregabalin or duloxetine as theare recommended as the initial approach in the symptomatic treatment for neuropathic pain in diabetes. ANeuropathy position statementStrengthen language—these are first line therapies that are recommended.Neuro statement references 15, 86, 88, 89, 91-96, 98-101Gabapentin may be also used as an effective initial approach taking into account patients’ socio-economic status, comorbidities, and potential drug interactions. Although not FDA-approved, amitriptyline is also effective for neuropathic pain in diabetes, but should be used with caution given the higher risk of serious side effects. B.Neuropathy position statementNeither are FDA approved—needs to be moved to textBroaden amitriptyline to include all tricyclicsNeuro statement references 15, 86, 96, 106, 110Given the high risks of addiction and other complications, the use of opioids including tapentadol or tramadol is generally not recommended for treating the pain associated with DSPN. E.Neuropathy position statementNeuro statement reference 15Perform a comprehensive foot evaluation at least annuallyeach year to identify risk factors for ulcers and amputations. BFrom the statementWe recommend that patients with diabetes undergo annual interval foot inspections by physicians (MD, DO, DPM) or advanced practice providers with training in foot care (Grade 1C).1)Normal foot: annually2)Peripheral neuropathy: semiannual3)Neuropathy with PAD or deformity: quarterly4) Previous ulcer or amputation: monthly or quarterlyThe management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine HYPERLINK "(15)X0005-X" February 2016Volume 63, Issue 2, Supplement, Pages?3S–21S(15)02025-X/abstractObtain a prior history of ulceration, amputation, Charcot foot, angioplasty or vascular surgery, cigarette smoking, retinopathy, and renal disease and assess current symptoms of neuropathy (pain, burning, numbness) and peripheral vascular disease (leg fatigue, claudication). BThe examination should include inspection of the skin, assessment of foot deformities, neurological assessment including Semmes-Weinstein 10-g monofilament testing and pinprick or vibration testing or assessment of ankle reflexes, and vascular assessment including pulses in the legs and feet. BModify to be consistent with any changes in neuropathy sectionPatients with a history of ulcers or amputations, foot deformities, insensate feet, and peripheral arterial disease are at substantially increased risk for ulcers and amputations and should have their feet examined at every visit. CPatients with symptoms of claudication or decreased or absent pedal pulses should be referred for ankle-brachial index and for further vascular assessment as appropriate. CFrom the foot care statement:We suggest that patients with diabetes have ABI measurements performed when they reach 50?years of age (Grade 2C).They reference our ADA statement:American Diabetes Association.?Peripheral arterial disease in people with diabetes.Diabetes Care.?2003;?26:?3333–3341A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet (e.g., dialysis patients and those with Charcot foot, prior ulcers, or amputation). BShould we define multidisciplinary? Why are these examples singled out?Refer patients who smoke or who have histories of prior lower-extremity complications, loss of protective sensation, structural abnormalities, or peripheral arterial disease to foot care specialists for ongoing preventive care and lifelong surveillance. CProvide general foot self-care education to all patients with diabetes. BUse specialized therapeutic footwear in high-risk patients with diabetes including those with severe neuropathy, foot deformities, or history of amputation. B Should we add a recommendation about use of specialized foot wear?From the foot care statement:a.We suggest against the routine use of specialized therapeutic footwear in average-risk diabetic patients (Grade 2C).b.We recommend using custom therapeutic footwear in high-risk diabetic patients, including those with significant neuropathy, foot deformities, or previous amputation (Grade 1B).Recommended footwear should include a broad and square toe box, laces with three or four eyes per side, padded tongue, quality lightweight materials, and sufficient size to accommodate a cushioned insole. HYPERLINK "javascript:void(0);" 31?In-shoe orthotic inlays are effective in preventing ulceration as assessed by a Cochrane review. HYPERLINK "javascript:void(0);" 32?In one study of 117 patients, custom footwear was successful in reducing peak pressure points in patients at high risk of DFU, but hard outcomes of ulceration were not reported. HYPERLINK "javascript:void(0);" 33?However, a recent large randomized controlled trial (RCT) in 298 high-risk patients with custom orthoses and foot care compared with routine care found a 48% reduction in incident ulcers at 5?years (P?< .0001). HYPERLINK "javascript:void(0);" 34Int J Low Extrem Wounds. 2012 Mar;11(1):59-64. doi: 10.1177/1534734612438729. Epub 2012 Feb 15.Custom-made orthesis and shoes in a structured follow-up program reduces the incidence of neuropathic ulcers in high-risk diabetic foot patients.Rizzo L1, Tedeschi A, Fallani E, Coppelli A, Vallini V, Iacopi E, Piaggesi A. HYPERLINK "" management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine HYPERLINK "(15)X0005-X" February 2016Volume 63, Issue 2, Supplement, Pages?3S–21S(15)02025-X/abstractOlder AdultsAnnual screening for cognitive impairment is indicated for adults age 65 years or older for early detection of mild cognitive impairment or dementia BNew from psychosocial position statement This is a more specific version of a recommendation we already have—annual may be a bit much. Need to check against references—is annual really necessary?Persons who screen positive for cognitive impairments should receive diagnostic assessment as appropriate including referral to a behavioral health provider for formal cognitive/neuropsychological evaluation. BNew from psychosocial position statement Move to textOlder adults with diabetes should be assessed for disease treatment and self-management knowledge, health literacy and numeracy at the onset of treatment. Self-management knowledge and skills should be re-assessed when regimen changes are made or an individual’s functional abilities diminish.ENew from psychosocial position statementShift to textDeclining or impaired ability to perform diabetes self-care behaviors may be an indication for referral of older adults with diabetes for cognitive and physical functional screening using age normed evaluation tools. ENew from psychosocial position statementShift to textSocial and instrumental support networks (e.g. adult children, caretakers) who provide instrumental or emotional support for older adults with diabetes should be included in diabetes management discussions and shared decision-making.ENew from psychosocial position statementShift to textConsider the assessment of medical, functional, mental, and social geriatric domains for diabetes management in older adults to provide a framework to determine targets and therapeutic approaches. ECitation #3 (Chapter 10) for geriatric syndromes may be appropriate in older adults experiencing limitations in their basic and instrumental activities of daily living, as they may affect diabetes self-management. EAdditional relevant evidenceCitation #3 (Chapter 10) N, Karter AJ, Liu JY, et al. Correlates of quality of life in older adults with diabetes: the Diabetes & Aging Study. Diabetes Care 2011;34:1749–1753 adults (65 years of age) with diabetes should be considered a high-priority population for depression screening and treatment. BCitation # 2 (Chapter 10) should be avoided in older adults with diabetes. It should be screened for and managed by adjusting glycemic targets and pharmacological interventions. BCitation #3 (Chapter 10) adults who are functional and cognitively intact and have significant life expectancy may receive diabetes care with goals similar to those developed for younger adults. EAdditional relevant referenceCitation #3 (Chapter 10) C, Cigolle CT, Boyd C, et al.Clinical complexity in middle-aged and older adults with diabetes: the Health and Retirement Study. Med Care 2010; 48:327–334 goals for some older adults might reasonably be relaxed, using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients. EAdditional relevant referenceCitation #3 (Chapter 10) C, Cigolle CT, Boyd C, et al.Clinical complexity in middle-aged and older adults with diabetes: the Health and Retirement Study. Med Care 2010; 48:327–334 for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment. ECitation #3 (Chapter 10) cardiovascular risk factors should be treated in older adults with consideration of the time frame of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and lipid-lowering and aspirin therapy may benefit those with life expectancy at least equal to the time frame of primary or secondary prevention trials. EAdditional relevant referenceCitation #3 (Chapter 10) C, Cigolle CT, Boyd C, et al.Clinical complexity in middle-aged and older adults with diabetes: the Health and Retirement Study. Med Care 2010; 48:327–334 palliative care is needed in older adults with diabetes, strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate. Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. EUpdating referenceMunshi M, Florez H, Huang ES et al. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care. 2016;39(2):308-18 diabetes education for the staff of long-term care facilities to improve the management of older adults with diabetes. EUpdating referenceMunshi M, Florez H, Huang ES et al. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care. 2016;39(2):308-18 with diabetes residing in long-term care facilities need careful assessment to establish a glycemic goal and to make appropriate choices of glucose-lowering agents based on their clinical and functional status. EUpdating referenceMunshi M, Florez H, Huang ES et al. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care. 2016;39(2):308-18 comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life. EUpdating referenceMunshi M, Florez H, Huang ES et al. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care. 2016;39(2):308-18 and AdolescentsProviders should monitor youth and their parents about social adjustment (peer relationships) and school performance to determine whether further evaluation is needed. B,ENew from psychosocial statement Youth with diabetes should be clinically assessed for generic and diabetes-related distress as early as development indicates, generally at 7-8 years of age. More detailed questioning should begin by the age at which children can provide assent to receiving care, usually age 12. Practitioners should include children in consenting processes as early as cognitive development indicates understanding of health consequences of behavior.A,ENew from psychosocial statement Alicia: Adolescents should have time by themselves with their care provider(s) starting at age 12 yrs. ENew from psychosocial statement Why 12?Providers should begin to discuss care transition to an adolescent medicine/transition clinic/adult provider no later than one year prior to starting the transfer, but preferably during early adolescence (~ age 14). E New from psychosocial statement Support from parents/caretakers should be monitored in emerging adults with diabetes. Instrumental support (e.g., ordering supplies) and optimizing collaborative decision making among caregivers should be encouraged. A, EYouth and families who are demonstrating difficulty with self-care behaviors, repeated hospitalizations for DKA or significant distress should be referred to a behavioral health provider for assessment and treatment.ENew from psychosocial statement Girls who have reached childbearing age should be given preconception counseling as part of routine management. AMales at the time of puberty should be counseled regarding adoption of a healthy lifestyle to reduce risk for sexual dysfunction. EYouth with type 1 diabetes and parents/caregivers (for patients aged <18 years) should receive culturally sensitive and developmentally appropriate individualized diabetes self-management education and support according to national standards at diagnosis and routinely thereafter. BCitation #6 (Chapter 11) diagnosis and during routine follow-up care, assess psychosocial issues and family stresses that could impact adherence to diabetes management and provide appropriate referrals to trained mental health professionals, preferably experi enced in childhood diabetes. EAdditional evidence: Pediatric Diabetes Consortium T1D and T2D registries: Symptoms of depression were identified in 13% of T1D and 22% of T2D participants Add comment: “Depressive symptoms are more frequent than diagnosed depression in youth with T1D or T2D and underscore the need for regular depression screening and appropriate referral for youth with diabetes.”Citation #7 (Chapter 11) #8 (Chapter 11) #9 (Chapter 11) #10 (Chapter 11) #11 (Chapter 11) #12 (Chapter 11) #13 (Chapter 11) J, Cheng P, Ruedy KJDepressive Symptoms in Youth With Type 1 or Type 2 Diabetes: Results of the Pediatric Diabetes Consortium Screening Assessment of Depression in Diabetes Study. Diabetes Care. 2015; 38(12):2341-3. developmentally appropriate family involvement in diabetes management tasks for children and adolescents, recognizing that premature transfer of diabetes care to the child can result in nonadherence and deterioration in glycemic control. BN/ACitation #15 (Chapter 11) #16 (Chapter 11) #17 (Chapter 11) mental health professionals as integral members of the pediatric diabetes multidisciplinary team. EN/ACitation #14 (Chapter 11) A1C goal of <7.5% (58 mmol/mol) is recommended across all pediatric age-groups. ECitation #20Blasetti: Meta-analysis confirms that recurrent severe hypoglycemia has a selective negative effect on the children's cognitive functions. Caution with small sample sizes, the different definitions of severe hypoglycemia, and variety of neuropsychological tests used.Data from T1D Exchange:Children with excellent glycemic control tend to exhibit markedly different diabetes self-management techniques than those with poor control. Old Citation #18 (Chapter 11)Diabetes Care. 2013 May;36(5):1384-95. doi: 10.2337/dc12-2480. Epub 2013 Apr 15. Omit this citation.Citation # 19 (Chapter 11) # 21 (Chapter 11) #22 (Chapter 11) #23 (Chapter 11) #24 (Chapter 11) #25 (Chapter 11) #26 (Chapter 11) #27 (Chapter 11) #1 (Chapter 11) Citation #18? (Chapter 11)Campbell MS, Schatz DA, Chen V, et al. A contrast between children and adolescents with excellent and poor control: the T1D Exchange clinic registry experience. Pediatr Diabetes. 2014; 15(2):110-7. doi: 10.1111/pedi.12067. for the presence of additional autoimmune conditions soon after the diagnosis and if symptoms develop. EWhere should these green highlighted recs go? They are not limited to children but should be expanded to include any person with type 1 diabetes (child or adult)For now, we have duplicated this first rec into the new comprehensive medical management sectionCitation #28 (Chapter 11) #29 (Chapter 11) #30 (Chapter 11) #31 (Chapter 11) #32 (Chapter 11) testing children individuals with type 1 diabetes for antithyroid peroxidase and antithyroglobulin antibodies soon after the diagnosis. ESee aboveMeasure thyroid-stimulating hormone concentrations soon after the diagnosis of type 1 diabetes and after glucose control has been established. If normal, consider rechecking every 1–2 years or sooner if the patient develops symptoms suggestive of thyroid dysfunction, thyromegaly, an abnormal growth rate, or an unexplained glycemic variation. ESee aboveConsider screening children individuals with type 1 diabetes for celiac disease by measuring either tissue transglutaminase or deamidated gliadin antibodies, with documentation of normal total serum IgA levels, soon after the diagnosis of diabetes. EAdditional reference - proposal to upgrade recommendation to C. Meta-analysis/ systematic review of studies with at least 100 individuals with type 1 diabetes screened for coeliac disease: More than one in twenty patients with type 1 diabetes have biopsy-verified coeliac disease. Citation #33 (Chapter 11) #34 (Chapter 11) #35 (Chapter 11) #36 (Chapter 11) #37 (Chapter 11) #38 (Chapter 11) P1, Sundstr?m J, Ludvigsson JF. Systematic review with meta-analysis: associations between coeliac disease and type 1 diabetes.Aliment Pharmacol Ther. 2014 Nov;40(10):1123-32. screening in individualschildren who have a first-degree relative with celiac disease, growth failure, weight loss, failure to gain weight, diarrhea, flatulence, abdominal pain, or signs of malabsorption or in children with frequent unexplained hypoglycemia or deterioration in glycemic control. ESee above—should this be “individuals” stillChildren Individuals with biopsy-confirmed celiac disease should be placed on a gluten-free diet and have a consultation with a dietitian experienced in managing both diabetes and celiac disease. BSee aboveBlood pressure should be measured at each routine visit. Children found to have high-normal blood pressure (systolic blood pressure or diastolic blood pressure 90th percentile for age, sex, and height) or hypertension (systolic blood pressure or diastolic blood pressure 95th percentile for age, sex, and height) should have blood pressure confirmed on 3 separate days. BCitation # 39 (Chapter 11) treatment of high-normal blood pressure (systolic blood pressure or diastolic blood pressure consistently 90th percentile for age, sex, and height) includes dietary modification and increased exercise, if appropriate, aimed at weight control. If target blood pressure is not reached with 3–6 months of initiating lifestyle intervention, pharmacological treatment should be considered. EIn addition to lifestyle modification, pharmacological treatment of hypertension (systolic blood pressure or diastolic blood pressure consistently 95th percentile for age, sex, and height) should be considered as soon as hypertension is confirmed. EACE inhibitors or angiotensin recep tor blockers should be considered forthe initial pharmacological treatment of hypertension, following reproductive counseling due to the potential teratogenic effects of both drug classes. EThe goal of treatment is blood pressure consistently <90th percentile for age, sex, and height. EObtain a fasting lipid profile in children 10 years of age soon after the diagnosis (after glucose control has been established). ECitation #40 (Chapter 11) #41 (Chapter 11) #42 (Chapter 11) #43 (Chapter 11) #44 (Chapter 11) #45 (Chapter 11) lipids are abnormal, annual monitoring is reasonable. If LDL cholesterol values are within the accepted risk level (<100 mg/dL [2.6 mmol/L]), a lipid profile repeated every 3–5 years is reasonable. ECheck with alignment with nutrition section-adultsInitial therapy should consist of optimizing glucose control and medical nutrition therapy using a Step 2 American Heart Association diet to decrease the amount of saturated fat in the diet. BCitation #46 (Chapter 11) #47 (Chapter 11) #48 (Chapter 11) #49 (Chapter 11) #50 (Chapter 11) #51 (Chapter 11) #52 (Chapter 11) the age of 10 years, addition of a statin is suggested in patients who, despite medical nutrition therapy and lifestyle changes, continue to have LDL cholesterol >160 mg/dL (4.1 mmol/L) or LDL cholesterol >130 mg/dL (3.4 mmol/L) and one or more cardiovascular disease risk factors. ECitation #53 (Chapter 11) #55 (Chapter 11) goal of therapy is an LDL cholesterol value <100 mg/dL (2.6 mmol/L). EElicit a smoking history at initial and follow-up diabetes visits and discourage smoking in youth who do not smoke and encourage smoking cessation in those who do smoke. BCitation #56 (Chapter 11) screening for albuminuria with a random spot urine sample for albumin–to–creatinine ratio should be considered once the child has had diabetes for 5 years. BCitation #57 (Chapter 11) glomerular filtration rate at initial evaluation and then based on age, diabetes duration, and treatment. ECitation #58 (Chapter 11) with an ACE inhibitor, titrated to normalization of albumin excretion, should be considered when elevated urinary albumin–to–creatinine ratio (>30 mg/g) is documented with at least two of three urine samples. These should be obtained over a 6-month interval following efforts to improve glycemic control and normalize blood pressure. B COnly small studies (no RCT).Consider changing recommendation to C (or E)Citation #59 (Chapter 11) initial dilated and comprehensive eye examination is recommended at age 10 years or after puberty has started, whichever is earlier, once the youth has had diabetes for 3–5 years. BCitation #60 (Chapter 11) the initial examination, annual routine follow-up is generally recommended. Less frequent examinations, every 2 years, may be acceptable on the advice of an eye care professional. EConsider an annual comprehensive foot exam for the child at the start of puberty or at age 10 years, whichever is earlier, once the youth has had type 1 diabetes for 5 years. ECitation #60 (Chapter 11) care providers and families should begin to prepare youth in early to mid-adolescence and, at the latest, at least 1 year before the transition to adult health care. EBlend this with earlier psychosocial statementCitation #70 (Chapter 11) #71 (Chapter 11) #72 (Chapter 11) # 73(Chapter 11) # (Chapter 11) pediatricians and adult health care providers should assist in providing support and links to resources for the teen and emerging adult. BManagement of Diabetes in PregnancyProvide preconception counseling that addresses the importance of glycemic control as close to normal as is safely possible, ideally A1C <6.5% (48 mmol/mol), to reduce the risk of congenital anomalies. BN/ACitations #3, 4, 5, 6, 10 (Chapter 12) planning should be discussed and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant. AWomen with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. Dilated eEye examinations should occur before pregnancy or in the first trimester and then be monitored every trimester and for 1 year postpartum as indicated by degree of retinopathy. BCitation #26 (Chapter 12) change is an essential component of management of gestational diabetes mellitus and may suffice for treatment for many women. Medications should be added if needed to achieve glycemic targets. ATwo RCTs that are not new, but provide the evidence that lifestyle changes suffice to treat GDM in the majority of cases.Citation #16 (Chapter 12) CA, et al. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. NEJM 2005;352:2477-86 Landon MB, Spong CY, Thom E et al. A Multicenter, Randomized Trial of Treatment for Mild Gestational Diabetes. NEJM 361:1339-48, 2009 is the preferred medication for treating hyperglycemia in gestational diabetes as it does not cross the placenta to a measurable extent. Metformin and glyburide may be used but both cross the placenta to the fetus, with metformin likely to a greater extent than glyburide. Glyburide may have a higher rate of neonatal hypoglycemia and macrosomia than insulin or metformin. Other agents have not been adequately studied. All oral agents lack long-term safety data. APreferred medications in gestational diabetes mellitus are insulin and metformin; glyburide may be used but may have a higher rate of neonatal hypoglycemia and macrosomia than insulin or metformin. Other agents have not been adequately studied. Most oral agents cross the placenta, and all lack long-term safety data. AClarify that insulin is treatment of choice.This proposed modification is based on Concentration of metformin on the fetal side of the placenta to levels similar to or twice those in the maternal circulation.Glyburide levels in cord blood have been shown to be approximately 70% of simultaneous maternal level.Condense, add some to text, add treatment failures to text (half of metformin treated end up on insulin)Check on FDA category for insulin changeCitation #23 (Chapter 12) this systematic review suggested that metformin has a more favorable short term outcome profile than glibenclamide, but metformin appears to be concentrated on the fetal side of the placenta, it may be better (prudent) to be non-directive about the choice between the two when patients decline to take insulin injections.Vanky E, Zahlsen K, Spigset O, Carlsen SM: Placental passage of metformin in women with polycystic ovary syndrome. Fertility Sterility 2005;83:1575-1578 B, Norris R, Xiao X, Hague W. Population pharmacokinetics of metformin in late pregnancy. Ther Drug Monit 2006; 28: 67-72. Hebert MF et al: Are we optimizing gestational diabetes treatment with glyburide? Clinical Pharmacology & Therapeutics 85:607-614, 2009 teratogenic medications (ACE inhibitors, statins, etc.) should be avoided in sexually active women of childbearing age who are not using reliable contraception. BCitations about statin, ACE-inhibitors and ARBs use in pregnancyTaguchi N, Rubin ET, Hosokawa A, Choi J, Ying AY, Moretti ME, et al. Prenatal exposure to HMG-CoA reductase inhibitors: effects on fetal and neonatal outcomes. Reprod Toxicol 2008;26:175–7. BT, Hernandez-Diaz S, Fischer MA et al. Statins and congenital malformations: cohort study. BMJ. 2015 Mar 17;350:h1035 J, Koren G. The fetal safety of statins: a systematic review and meta-analysis. J Obstet Gynaecol Can. 2014; 36(6):506-9. M1, Tschumi S, Bucher BS, et al. Pregnancy outcome following exposure to angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists: a systematic review. Hypertension. 2012; 60(2): 444-50. PMID: 22753220, preprandial, and postprandial self-monitoring of blood glucose are recommended in both gestational diabetes mellitus and preexisting type 2 diabetes not on multiple daily injections. In addition, preprandial monitoring of blood glucose is also recommended for pregestational preexisting type 1 diabetes and for those on multiple daily injections in pregnancy to achieve glycemic control. BWhile preprandial glucose monitoring is standard in nonpregnant individuals with type 1 or type 2 diabetes, available data do not support its use in pregnancy (with regard to improving pregnancy outcomes) and most caregivers involved in the field do not ask their patients to monitor blood sugars preprandially. This would be even more true with gestational diabetes.Say preprandial is fine in text—necessary for carb countingRCT of preprandial vs postprandial glucose testing in GDM:De Veciana M, Major CA, Morgan MA et al. Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy. NEJM 1995; 333: 1237-41. analysis from DIEP observational study showing that postprandial glucose values are more predictive of fetal macrosomia than fasting values:Jovanovic-Peterson L, Peterson CM, Reed GF, et al. Maternal postprandial glucose levels and infant birth weight: the Diabetes in Early Pregnancy Study. The National Institute of Child Health and Human Development--Diabetes in Early Pregnancy Study. Am J Obstet Gynecol. 1991; 164:103-11. PMID: 1986596 to increased red blood cell turnover, A1C is lower in normal pregnancy than in normal nonpregnant women. The A1C target in pregnancy is 6–6.5% (42–48 mmol/mol); <6% (42 mmol/mol) may be optimal if this can be achieved without significant hypoglycemia, but the target may be relaxed to <7% (53 mmol/mol) if necessary to prevent hypoglycemia. BN/AThere is an additional reference with a larger sample size (445 non diabetic pregnant women) who were tested at between 15 and 36 weeks and compared to 384 non-pregnant controls. It provides standards for various gestational intervals.Citations #3, #4 #12 (Chapter 12) #12 is a study of 100 pregnant women without diabetes and supports the assertion that A1c is lower in early and later pregnancy than in the non-pregnant state. Mosca A, Paleari R, Dalfra MG, DiCianni G et al. Reference intervals for hemoglobin A1c in pregnant women: data from an Italian multicenter study. Clinical Chemistry 2006; 52(6): 1138-1143. Care in the HospitalConsider performing an A1C on all patients with diabetes or hyperglycemia admitted to the hospital if not performed in the prior 3 months. CNew evidence that supports use of A1C But still a C recommendationPasquel FJ, Gomez-Huelgas R, Anzola L et al. Predictive Value of Admission Hemoglobin A1c on Inpatient Glycemic Control and Response to Insulin Therapy in Medicine and Surgery Patients With Type 2 Diabetes. Diabetes Care 2015 Dec; 38(12): e202-e203 GE, Reyes D, Smiley D, et al. Hospital Discharge AlgorithmBased on Admission HbA1c for the Management of Patients With Type 2 Diabetes. Diabetes Care. 2014; 37: 2934-9 therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold 180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients A and noncritically ill patients. CN/A (removing non critical ill patients C)Citation #2 (Chapter 13) stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) may be appropriate for selected critically ill patients, as long as this can be achieved without significant hypoglycemia. CCitation #2 (Chapter 13) insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose. ECitation #2 (Chapter 13) of two advisors is that this prior consensus was best in absence of data.Change letter to EundoCitation #2 (Chapter 13) GE, Hellman R, Korytkowski MT, et al. Management of Hyperglycemia in HospitalizedPatients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 97: 16–38, 2012 basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and correction components is the preferred treatment for patients with good nutritional intake. ACitations # 10, 13 ( Chapter 13) sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged. ACitations #2, 11 (Chapter 13) hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. ECitation #2 (Chapter 13) treatment regimen should be reviewed and changed if necessary to prevent further hypoglycemia when a blood glucose value is <70 mg/dL (3.9 mmol/L). CChange this to <50 or 55 depending on where hypoglycemia position statement ends upCitation #28 (Chapter 13) should be a structured discharge plan tailored to the individual patient. BAdd more details about avoiding readmissionsCitation #33 (Chapter 13) ................
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