Following is
from
the section entitled
"Treatment"
from the document "Diabetes: A National
Plan for Action", written in December 2004.
The Importance of Diabetes Treatment and Management
If left untreated or undertreated, diabetes can cause severe complications that can damage
many vital organs in the body and lead to premature death.(70) Possible complications from
diabetes can include heart disease, blindness, lower extremity amputations, kidney failure, dental
disease, and increased susceptibility to infections. Estimates suggest that in many states, half of
all people with diabetes do not receive recommended preventive care services that are known to
reduce the risk of diabetes complications.(71)
The good news is that the complications from diabetes can often be prevented or delayed
with quality medical care and by adopting healthy behaviors to manage diabetes. For example,
the Diabetes Control and Complications Trial (DCCT) demonstrated that careful control of blood
glucose levels resulted in delaying the onset and slowing the progression of retinopathy (eye
disease), nephropathy (kidney disease), and neuropathy (nerve disorders) for people with type 1
diabetes.(72) Other studies such as the U.K. Prospective Diabetes Study (UKPDS)(73) have shown
similar dramatic reductions in complications with control of blood glucose for people with type 2
diabetes. Empowering people with diabetes with knowledge and resources to proactively manage
their disease and prevent or control diabetes complications is an important step in successful
disease management. Friends and family members, health care professionals, schools,
employers, health insurance providers, community organizations, the public media, and
government agencies can all help persons with diabetes to live healthy and productive lives. This
section suggests action steps to improve diabetes management and decrease risks for diabetes
complications.
Action Steps for Treatment
Individuals
The possible complications from diabetes can be extremely serious. There is strong
evidence from clinical trials that many of these complications may be delayed or prevented by
carefully controlling blood glucose levels, blood pressure, and LDL cholesterol levels.(74) To help
manage diabetes, individuals should discuss, create, and follow a diabetes management plan with
a health care provider and set goals for a treatment plan. The following are some specific
suggestions to consider:
- Ask health care providers about the ABCs of diabetes. "A" is HbA1c, a measure of
average blood glucose; "B" is blood pressure; and "C" is LDL-cholesterol. Patients
should determine what their levels are, what they should be, and what steps they can
take to reach those goals.(75)
- Work with health care providers to establish and maintain individualized target blood
glucose levels. Ask how often and when to measure blood glucose levels. Individuals
should keep a record of blood glucose readings to show their health care provider so
they can better regulate their blood glucose.
- Be aware of the symptoms for hypoglycemia (low blood sugar) and hyperglycemia
(high blood sugar). Individuals who experience these symptoms, should adjust their
treatment plan and seek medical advice on how to maintain healthy blood glucose
levels. Table 3 presents symptoms of hypoglycemia and hyperglycemia.
Table 3. Symptoms of Hypoglycemia and Hyperglycemia
Symptoms of hypoglycemia
- Feel weak, confused, irritable, hungry, or tired
- Sweat a lot or get a headache
- Feel shaky
Symptoms of hyperglycemia
- Feel very thirsty and tired
- Have blurry vision
- Have to go to the bathroom often
- Nausea
SOURCE: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Your guide to diabetes—type 1 and
type 2. Available at: http://diabetes.niddk.nih.gov/dm/pubs/type1and2/lowglucose.htm.
Hypoglycemia is a low blood sugar. Hyperglycemia is a high blood sugar.
Follow a meal plan developed with a health care provider. This can be an important
step for maintaining desirable blood glucose levels and avoiding complications.
Work with a health care provider to develop an appropriate exercise program and
follow this plan. Appropriate exercise can be important for people with diabetes
because it can help insulin work better to lower blood glucose levels and improve
cardiovascular health.
Follow a health care provider's recommendations for how and when to take diabetes
medications. Discuss with a health care provider if medications do not seem to be
working properly.
Individuals should ask their primary care provider about a dilated eye exam at least
once a year as people with diabetes are at higher risk for vision problems and
blindness. Early detection and treatment of diabetic eye disease can prevent or delay
vision loss.
Request regular blood pressure checks at every medical visit and cholesterol checks at
least once per year because people with diabetes are at higher risk for heart disease
and stroke. Lowering blood pressure and cholesterol can reduce the risk of heart
attack and stroke, the major cause of death in people with diabetes.
Individuals, who smoke cigarettes, should seek help from a health care provider to
quit smoking to further reduce their risk for heart disease.
Brush teeth regularly and visit a dentist at least once every six months because people
with diabetes are at higher risk for gum disease.
Check feet for sores and calluses every day, wear shoes that fit properly, and get a
comprehensive foot exam at least once per year with a health care professional since
people with diabetes are at a higher risk for foot problems that can be caused by
neuropathy (nerve damage) or poor blood flow to the feet.
Ask for a urine test by a health professional at least once a year to monitor the level of
protein in urine, a measure of kidney function.
If planning a pregnancy, consult a health care provider to make a care plan that
focuses on good blood glucose control before and during the pregnancy.
Maintain records of daily self-management activities and medical visits. The checklist
in Table 4 can help individuals and healthcare providers keep track of diabetes care.
Other materials for managing diabetes can be found at
http://www.ndep.nih.gov/diabetes/control/control.htm or by calling 1-800-860-8747.
Ask a health care provider about new medicines and medical devices, such as blood
glucose meters and insulin pens and pumps that could help manage diabetes.
Seek the help of qualified health care professionals—such as a primary care provider,
an endocrinologist, a certified diabetes educator or a registered dietician—to help
with diabetes management.
Seek help and encouragement through a diabetes support group.
Continue to obtain information on diabetes. The National Diabetes Education
Program (http://www.ndep.nih.gov/ or 1-800-438-5383) and organizations such as the
American Diabetes Association (http://www.diabetes.org/home.jsp or 1-800-
DIABETES), the American Association of Diabetes Educators and the Juvenile
Diabetes Research Foundation International (http://www.jdrf.org/ or 1-800-533-
CURE) can be excellent resources to help in learning more about caring for diabetes.
Get information about clinical trials in progress that may identify new and more
effective medicines and treatment regimens to treat diabetes (Available at:
http://www.clinicaltrials.gov).
Talk about diabetes with family and friends to make them aware of ways they can
help with diabetes management.
Table 4. Diabetes Care Checklist
Daily diabetes care activities
- Exercise
- Follow meal plan
- Take diabetes medicine
- Check blood glucose as recommended by a health care provider
- Check feet for sores that are not healing properly
- Brush teeth and floss
At doctor visits
- Get feet checked
- Check blood pressure
At least twice per year
- Get an HbA1c test
- Get a dental check-up and have teeth cleaned by a dental professional
At least once per year
- Get a dilated eye exam
- Get a complete foot exam—checking circulation and for changes in foot shape
- Get a urine test for kidney function
- Get a flu shot
- Get blood lipid levels (cholesterol) checked
SOURCE: National Diabetes Education Program. (2001). 7 principles for controlling your diabetes for life. NIH Publication No.
99-4343L. Available at: http://www.ndep.nih.gov/diabetes/pubs/7Principles_Eng.pdf.
Families and Friends
People with diabetes need their family members and friends to help them manage their
disease and keep track of their diabetes care. Here are some things families and friends can do to
support people with diabetes:
- Plan walks or other activities with friends and family with diabetes to help them get
regular exercise. Help them follow the advice of their health care provider about ways
to exercise safely.
- Prepare healthy meals that fit into meal plans for people with diabetes and prediabetes.
- Offer to help friends or family members check their feet for sores or calluses.
- Provide transportation to the heath care provider's office so that friends or family
members do not miss important medical visits.
- Become aware of the signs and symptoms of hypoglycemia and hyperglycemia and
how to appropriately treat them.
- If friends or family members do not understand English, help translate patient
education materials into a language he/she knows or help identify resources that are
language appropriate.
- Provide assistance to a friend or family member with diabetes that is sick with a cold,
the flu, or another type of infection or illness. Being sick can raise blood glucose and
may make it difficult to eat properly or monitor blood glucose as needed.
- If a child in your family has been diagnosed with diabetes, work closely with health
care providers to develop a care plan that addresses diabetes and fits in with the
child's schedule. Revisit the plan on an ongoing basis to make sure that changes in
the child's condition or lifestyle are considered. Seek advice from health care
providers about ways to teach children to be proactive in taking care of their diabetes.
Schools
Because diabetes must be managed on a daily basis, school staff (teachers, nurses,
principals, and office staff) can play an important role in helping students manage their diabetes.
Specific action steps for schools to take to help students manage diabetes include:
- Provide training for school staff that work with students with diabetes. This training
should include basic information about diabetes and the student's needs, how to
recognize medical emergencies, and steps to take in the event of an emergency.
- Work with children with diabetes and their parents or caregivers to follow the
personalized diabetes care plan devised by the family and the health care team. The
National Diabetes Education Program has compiled a comprehensive booklet called
"Helping the Student with Diabetes Succeed: A Guide for School Personnel," which
can be can be found at
http://www.ndep.nih.gov/diabetes/pubs/Youth_NDEPSchoolGuide.pdf or by calling
1-800-860-8747.
Table 5. Examples of Items to Include in Flow Chart for Patients with Diabetes
Each visit
- Weight check
- Blood pressure check
- Foot exam
- Diabetes education and self-management
Twice per year
- HbA1c test (quarterly if not within recommended range)
- Dental exam
Annual
- Lipid profile
- Dilated eye exam
- Physical exam for detecting nerve damage
- Serum creatinine and urinalysis for protein, microalbumin to creatinine ratio to detect kidney
disease
Vaccines
- Influenza (annual)
- Pneumoccal (usually only once, repeat if over age 64 or immunocompromised and the last vaccice
was longer than 5 years ago)
SOURCE: National Diabetes Education Program (NDEP). Guiding principles for diabetes care: for health care providers. HHS
Publication No. 99-4343. Available at: http://www.ndep.nih.gov/diabetes/pubs/GuidPrin_HC_Eng.pdf. Accessed August 24,
2004.
Health Care Providers
Primary care providers, such as family physicians, internists, physicians' assistants, and nurse
practitioners, play an important role in providing routine high-quality diabetes care as well as
referrals to other practitioners for specialty care. As new research and drugs become available
and practice guidelines for diabetes evolve, it is critical for health care providers to stay abreast
of standards of care and new evidence-based treatments and devices to support diabetes
management. Important information for providers about diabetes care can be found at
http://www.ndep.nih.gov/resources/health.htm, http://www.betterdiabetescare.org,
http://care.diabetesjournals.org/content/vol28/suppl_1/. Possible action steps for the primary
care provider include:
- Help patients control blood glucose levels. The DCCT and the UKPDS demonstrated
that intensive therapy in blood glucose management is effective in delaying the onset
of complications and slowing the progression of diabetes.76
- Educate patients on the "ABCs of Diabetes"77 (HbA1c, blood pressure, and
cholesterol) to lower overall risks for heart disease. Goal ranges are HbA1c of less
than 7 percent, blood pressure of less than 130/80, and cholesterol (LDL) of less than
100 mg/dl.78
- Develop flowcharts that ensure patients with diabetes receive preventive and
diagnostic services. Table 5 contains examples of care practices to include in flow
charts for patients with diabetes.79
- Advise women with diabetes considering pregnancy about the risks that diabetes
poses for pregnancy and the importance of good blood glucose control before and
during pregnancy.
- Incorporate information management systems, such as patient registries, to track
patient health status and receipt of preventive care services and provide information
about the patient's status to the entire care team.
- Use office prompts (e.g., posters asking patients to remove their shoes and socks prior
to the exam) to facilitate care.
- Work with patients and their families to develop comprehensive care plans that
include lifestyle changes and medical services needed to control blood glucose, blood
pressure, and LDL cholesterol and prevent and manage complications from diabetes.
Care plans should include the following: a meal plan, an exercise program to help
patients maintain a healthy weight and good cardiovascular health, diabetes education
to guide self-management, and a schedule to ensure that patients receive preventive
and diagnostic care services, such as HbA1C tests, dilated eye exams, and foot exams
in a timely manner.
- Prescribe medications (angiotensin converting enzyme inhibitors or angiotensin
receptor blockers) that can slow progression of diabetic kidney disease in patients
found to have hypertension and/or elevated urinary microalbumin.
- Ask if patients with diabetes smoke, and help those who smoke to stop smoking.
- Help educate patients' family members and friends about ways they can help loved
ones with diabetes to manage the condition.
- Refer patients with diabetes to various health care specialists and educators as
appropriate.
- Refer people with diabetes to community resources that can help them manage their
diabetes.
- Facilitate community support groups for people with diabetes and their friends and
family to help educate them about the health problems that can be caused by diabetes
and the ways they can manage the disease and live healthy and productive lives.
- Talk with community leaders about diabetes and the importance of supporting people
with diabetes.
- Translate patient materials into other languages for people in the community when
feasible.
- Participate in clinical trials to evaluate new technologies for treating diabetes.
- Become involved in research studies to determine effective approaches for educating
and treating patients with diabetes in various populations, such as children, elderly
persons, and members of specific racial/ethnic groups.
70) CDC, National Diabetes Fact Sheet, op.cit.
71) Centers for Disease Control and Prevention (CDC). Levels of Diabetes-related preventive-care practices-United
States, 1997-1999. MMWR Morbidity Mortality Weekly Report 2000; 49(42), 954-958.
72) The Diabetes Control and Complications Trial Research Group, op.cit; and Diabetes Complications, National
Diabetes Information Clearing House. Available at http://diabetes.niddk.nih.gov/complications/. Accessed on
September 7, 2004.
73) Turner, RC, op.cit.
74) The Diabetes Control and Complications Trial Research Group, op.cit; and Turner, RC, opt.cit
75) The ABCs of Diabetes refers to knowing the patient's blood glucose level through the HbA1c test and making
sure blood pressure and cholesterol are at recommended levels. Information on "Knowing your ABCs" can be
found at: http://www.ndep.nih.gov/diabetes/control/4Steps.htm#Step2.
76) The Diabetes Control and Complications Trial Research Group, op.cit; and Turner, RC, op.cit.
77) The ABCs of Diabetes, op.cit.
78) National Diabetes Education Program (NDEP). Guiding principles for diabetes care: For health care providers.
HHS Publication No. 99-4343. Available at: http://www.ndep.nih.gov/diabetes/pubs/GuidPrin_HC_Eng.pdf.
79) ibid.
From the NDEP
Dec2004
http://aspe.hhs.gov/health/NDAP/NDAP04.pdf
[PDF file]
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