Prediabetes

Diagnosis

In prediabetes, blood glucose levels are elevated but not enough to qualify as type 2 diabetes. Prediabetes is defined by a fasting plasma glucose level of 100–125 mg/dL, two-hour plasma glucose during a 75 g oral glucose tolerance test of 140–99 mg/dL, or A1c of 5.7–6.4%.²¹

Prediabetes is associated with other medical conditions, including obesity, dyslipidemia and hypertension. People with A1c levels in the prediabetes range have a substantially elevated risk of developing type 2 diabetes, with the risk rising at higher blood glucose levels.²²

The ADA recommends that asymptomatic adults with risk factors should be considered for prediabetes and type 2 diabetes screenings.²¹ Screening for prediabetes may be repeated every one to three years, with frequency determined by the degree of risk.

Sidebar 2 Type 1 Diabetes and LADA

Some adult patients with type 1 diabetes or latent autoimmune diabetes in adults (LADA) may present with symptoms or be flagged in testing for prediabetes and type 2 diabetes. Adult patients with type 1 diabetes may not present with classic symptoms of childhood diabetes. Adults suspected to have prediabetes or type 2 diabetes but who are of normal weight or underweight should be further tested for type 1 diabetes or LADA. If there is a suspicion of type 1 diabetes or LADA, the clinician should check the patient’s plasma glucose, C-peptide levels, and/or the presence of glutamic acid decarboxylase (GAD) antibodies or anti-islet antibodies. At minimum, the patient should be started on insulin and referred to an endocrinologist urgently if testing for type 1 diabetes or LADA is positive.21 Type 2 Diabetes Usually appears slowly Occurs more frequently in adults than in children Commonly features insulin obesity and clinical signs of insulin resistance, such as acanthosis nigricans Typically runs in families; a first-degree relative may also have type 2 diabetes Might be effectively managed with oral medication long-term Type 1 Diabetes Usually appears rapidly Features presence of GAD antibodies, islet cell antibodies or other autoimmune markers Less frequently has a family history Requires insulin from the onset Does not improve with oral agents LADA Usually appears slowly Occurs in adults age 30 or older Features presence of GAD antibodies about 90% of the time Often occurs in younger patients who may be overweight but not obese Often occurs in people with a family history of autoimmune disease May initially respond to oral therapies but eventually requires insulin

 

Prediabetes Management Overview

People with prediabetes should be tested each year for diabetes,²¹ and more importantly, they should be offered a full range of diabetes prevention tools, including lifestyle and medical management. An intensive behavioral/lifestyle program, such as the National Diabetes Prevention Program, may reduce the incidence of type 2 diabetes by 58% over three years in people with prediabetes.²³ Another effective program is the National Institute of Diabetes and Digestive and Kidney Diseases Your Game Plan to Prevent Type 2 Diabetes.²⁴ Additional resources can be found in Section V (page 32). Lifestyle management to prevent the onset of diabetes can also improve related conditions, including dyslipidemia, hypertension and inflammation.²¹

Lifestyle Management for Prediabetes

Lifestyle management encompasses strategies for becoming physically active, adopting a healthy eating plan and, if necessary, losing weight. Patients should also be encouraged to develop executive functioning skills, including:

• Goal-setting
• Planning for menus and exercise times
• Tracking progress
• Collaborating with their healthcare teams
• Asking questions and proactively obtaining support²⁴

Weight Loss for Diabetes Prevention

People at risk of developing type 2 diabetes who are overweight or obese benefit from participation in structured behavioral weight-loss therapy, including a reduced-calorie meal plan and regular physical activity.

Overweight patients should be counseled to lose at minimum 7% of body weight, based on findings from the National Diabetes Prevention Program.²⁵ Calorie restriction for gradual weight loss of no more than 1–2 pounds per week is believed most sustainable. Patients who need to lose weight should ideally be referred to a registered dietitian nutritionist (RDN) for individualized counseling and meal planning. Until they can meet with an RDN, patients may be counseled to reduce caloric intake by 500–1,000 calories per day, depending on their body weight.²⁵

Because weight loss can be challenging, patients who need to lose weight should also be offered a range of therapeutic options for weight loss, including pharmacotherapy and referral for weight-loss surgery, if appropriate.

Nutrition and exercise recommendations are applicable for people with type 2 diabetes as well as prediabetes.

Smoking Cessation

Smoking is a major risk factor for development of type 2 diabetes, and individuals with prediabetes who smoke should be referred to a smoking cessation program. Stopping smoking may be associated with a short-term increased risk of developing diabetes,²⁶ so care team members should coordinate closely to help patients work through the dual challenge of eliminating tobacco use and reducing caloric and carbohydrate intake.

Individualization and Behavioral Assistance

Losing weight and starting or increasing exercise can also be challenging for patients, even with the goal of avoiding type 2 diabetes. Numerous competencies and socioeconomic factors impact diet and activity levels. Patients may prefer to eat healthy diets that fit well with their religious or cultural backgrounds, or to exercise in ways that suit their environment, budget and personal preference. Education and support for self-management of prediabetes can help people individualize and maintain healthy eating and behavior patterns and, in so doing, delay or prevent the development of type 2 diabetes.²⁷

Support for lifestyle changes may be provided by an RDN, a diabetes educator, an exercise coach or other care team member.

Prediabetes Medical Management

Metformin therapy to prevent type 2 diabetes should be considered when:

• Combined impaired fasting glucose and impaired glucose tolerance are present
• A1c is greater than 6.1% and does not decline with six months of lifestyle change
• Patient has a BMI ≥ 35 (kg/m²)²²
• Patient is younger than age 60
• Has a history of gestational diabetes mellitus

Patient preference should be considered when prescribing metformin for prediabetes.

Type 2 Diabetes Mellitus Identification and Lifestyle Management

Screening and Diagnosis

The ADA, the American Academy of Family Physicians and numerous other associations recommend population screening for type 2 diabetes.^28,29 Early identification of type 2 diabetes can delay or prevent diabetes complications and improve diabetes-related comorbidities. For detailed information on screening and diagnosis of type 2 diabetes.

Lifestyle Management for Type 2 Diabetes

Lifestyle management for patients with type 2 diabetes is a complex process involving medical nutrition therapy (MNT), physical activity and smoking cessation, as well as the psychosocial supports and wellness education that enable sustained behavioral change. Healthy eating, regular exercise and weight loss can help people with type 2 diabetes keep their blood glucose at lower levels, avoid comorbidities and delay the need to escalate medication regimens. Routine visits with clinicians or other members of the healthcare team between visits can help ensure patients are achieving their goals and help them get back on track when they need extra assistance.

Nutrition

Every patient diagnosed with type 2 diabetes should be referred for MNT upon diagnosis. Each patient should collaborate with clinicians and other members of the healthcare team to create an eating plan that he or she will be able to maintain long-term.²⁸

In-depth nutrition planning to support specific health and/or medical goals, MNT is administered in a disease-specific fashion and is most effective when overseen by a registered dietitian nutritionist.³⁰ MNT aims at improving body weight; helping patients meet blood pressure, cholesterol and glycemic goals; and delaying or preventing diabetes complications or comorbidities.²⁸  MNT is covered by Medicare for patients diagnosed with type 2 diabetes.

There are many structured, low-calorie meal plans that can help patients meet medical-nutritional goals. Among these, the Mediterranean eating plan is particularly effective; however, a variety of factors—ranging from other health complications to the patient’s tastes, culture and circumstances—all impact what meal plan will be most effective and sustainable. With any meal plan, emphasis should be on eating minimally processed, nutrient-dense foods, such as vegetables, fruits, nuts and whole grains, as well as selecting lean protein sources, including fish, beans and other legumes.

 

People with diabetes, like the general population, should limit alcohol consumption to a maximum of one drink per day for women, two for men. Excessive alcohol intake may lead to hyperglycemia.³¹ Drinking alcohol in excess may also lead to hypoglycemia due to impaired gluconeogenesis.

Exercise

Combined with nutrition education, exercise can help those with prediabetes and type 2 diabetes lose weight, maintain weight loss, and postpone or avoid diabetes complications.³⁴ People with suspected health conditions such as cardiovascular or kidney disease should receive medical clearance before initiating an exercise program or increasing the intensity of their current regimen.

In encouraging patients to begin or intensify their exercise routine, clinicians and specialists should consider the person’s³⁵:

• Current activity level (amount, duration, type)
• Health status, including possible cardiovascular, metabolic or kidney disease
• Goals for amount, duration and type of physical activity

Encourage:

• Activity personalization. Patients who take medications that can cause hypoglycemia (see Sidebar 4, page 26) may experience activity-induced hypoglycemia. Conversely, catecholamine release during exercise can cause worsening of blood sugars if patients begin exercise while significantly hyperglycemic. Personalized plans for testing blood sugar and adjusting medication or carbohydrate intake around exercise may be needed.
• Aerobic exercise. The ADA recommends adults with type 2 diabetes engage in at least 150 minutes of moderate-intensity exercise each week, an amount that may be increased in duration or intensity as patient exercise capacity increases. Exercise sessions should be spread out so that no more than one day passes without exercise.²⁸ Many options do not require equipment or training. For instance, walking at a quick pace, jogging, swimming or water walking, lawn sports, and heavy gardening can all raise heart rate to the moderate-intensity range.
• Strength training. In addition to aerobic exercise, those with type 2 diabetes should be encouraged to engage in strength or resistance training two to three times a week, allowing at least one rest day between sessions.²⁸ Strength training can take place in a gym under the supervision of a personal trainer, but basic exercises relying on body weight—such as squats, sit-ups and push-ups—can be performed at home after minimal instruction.
• Flexibility and balance. Flexibility and balance training are also important. Older adults, in particular, should regularly perform exercises to improve their balance.²⁸ Flexibility and balance exercises, such as yoga or tai chi, are often taught in community settings.

Discourage:

Sedentary behavior. Regardless of exercise frequency or intensity, people should avoid sitting for prolonged intervals during the day. Those with type 2 diabetes have been shown to improve glucose control when they interrupt periods of sitting every 30 minutes to walk or engage in other light activities.³⁶

Sidebar 3 Exercise and Peripheral Neuropathy

Patients with peripheral neuropathy may hesitate to exercise due to poor balance and concerns about falling. However, motor deficits and sensory symptoms associated with peripheral neuropathy may be improved by balance training,37 and exercise may reduce neuropathy-related numbness and pain.38 Endurance exercises are also effective at delaying effects of peripheral neuropathy.38 Physical and occupational therapy can help patients at risk of falling develop strength, balance, sensory motor perception and situational awareness so they can exercise safely.39 Patients with peripheral neuropathy should wear appropriate footgear at all times and inspect their feet daily: Those with open foot sores or injuries should select non-weight-bearing exercises28 and consult their clinician about appropriate exercises to avoid negatively impacting the wound or injury.

 

Psychosocial Support

Lifestyle management for people with diabetes should include conversations about the resources and support available to them, their goals and expectations for their disease, and their emotional well-being. Quality of life and ability to manage their disease should be assessed for each patient, while patients older than 65 should also be screened for depression and cognitive impairment that may affect their disease management.²⁸ Vanderbilt Health Affiliated Network recommends the Problem Areas in Diabetes-5 (PAID-5) tool to screen for diabetes-related distress.

Clinicians and the diabetes care team should maintain regular, supportive contact with patients and work collaboratively with behavioral health specialists to optimize patient ability to manage diabetes for a good quality of life. In some cases, patients should be referred to a mental health provider for further support. Indications for referral include²⁸:

• Self-care concerns that persist after patient education, including:
  • Cognitive impairment
  • Inadequate support for young, elderly or disabled patients
• Mental illness
• Diagnosis of depression or anxiety
• Disordered eating, including eating disorder or manipulating medications to provoke weight loss
• Multiple episodes of diabetic ketoacidosis, hospitalizations, etc.
• Other significant distress

The Patient Visit

No one model of a patient visit can take all circumstances into account. A patient with type 2 diabetes may need extensive instruction and several referrals in the initial visit after diagnosis, whereas he or she may need more routine care in a maintenance visit in which all goals are being met. Patients with type 2 diabetes may present for care due to their condition in a variety of settings:

• Initial visit (new patient or new diagnosis)
• Maintenance visit
• Urgent care visit (to urgent care center or symptom-based visit to regular clinician)
• Emergency room visit
• Conception or pregnancy counseling
• Telemedicine or e-consult, where services are available
• To reduce unnecessary visits to the emergency room, we recommend teaching patients self-management and sick-day skills, including when to contact their clinicians for help and when more urgent levels of care are warranted. Provide patients with the My Emergency Plan of Care patient brochure.

Type 2 Diabetes Mellitus Medical Management

Guiding Philosophy

Vanderbilt Health Affiliated Network aims to help people with type 2 diabetes attain the best possible blood glucose control given their health and abilities, while relying on the smallest number of effective prescriptions to achieve personalized glycemic control goals. While prescribing directives can be given in the form of a chart or algorithm, each patient’s disease trajectory and personal story—including abilities, environment, preferences and response to treatment—help inform treatment decisions.

Individualized Goal Setting and Monitoring

Individualized goal setting for glycemic control should take into account each patient’s preference, health status and ability to undertake treatment responsibilities and expenses.⁴⁰ The ADA recommends an A1c goal of less than 7% for many nonpregnant adults. Goals may be modified for numerous individual circumstances (see Table 3, below).²⁸ A1c should be monitored by in-office tests at least twice a year for patients meeting this goal and quarterly for patients not meeting the goal.²⁸

 

Prescribing Guidelines

The primary goal of medication for type 2 diabetes is helping patients achieve glycemic control when lifestyle modifications alone do not achieve the desired change. Secondary goals include reducing cardiovascular risk, enhancing weight loss if needed, avoiding weight gain, avoiding polypharmacy and reducing costs. Metformin is prescribed first, with choice of second- and third-line agents to be determined by patient comorbidities, needs and goals . Deprescribing of ineffective medications is also an important part of medication management.

Deprescribing: Values, Goals, Approaches

Deprescribing is an important component of avoiding polypharmacy. It includes discontinuing medications, finding alternative medications when side effects arise, and tapering medications.⁴¹ Deprescribing should be undertaken with an eye toward patient safety. In addition to avoiding polypharmacy, deprescribing may be undertaken:

• To address recurrent hypoglycemia²⁸
• When patients have impaired renal function⁴¹
• When older patients have lost physical or cognitive ability to maintain a complex medication regimen²⁸
• When patients have limited life expectancy⁴¹
• In response to troublesome or harmful side effects⁴¹

Other possible reasons for deprescribing include patient preferences in balancing glycemic control with treatment burden and cost.⁴¹

Deprescribing and Prescribing

As new hyperglycemic agents are added to combat glycemic load, it is appropriate to deprescribe other agents that are ineffective or redundant, or have adverse interactions with new agents. Algorithm 2 (page 14) includes points at which medications should be discontinued as new options are introduced.

Deprescribing and Older Patients

Deprescribing should always be considered for older patients, with the hyperglycemic agent time lapse between when the medication is administered to when it begins working weighed against possible liabilities, especially hypoglycemia.

Dose Reduction and Monitoring

Deprescribing should be undertaken gradually, incorporating in-office monitoring and home blood sugar testing. After a medication is reduced or discontinued, monitor patients daily for one to two weeks for:

• Evidence of hyperglycemia, including increased thirst, urination or tiredness; or measured hyperglycemia on home testing
• Evidence of hypoglycemia
• Evidence that adverse effects of reduced or discontinued medication are being ameliorated

(Changes in A1c will be delayed relative to other signs.)

If patients display ongoing hypoglycemia, consider further reducing dose or deprescribing another medication. If patients demonstrate hyperglycemia, consider restoring the previous dose or trying another medication.⁴¹

Insulin Dosing

Starting Insulin

If the patient’s A1c target is not met within approximately three months of triple therapy, patient should be moved to basal insulin. Metformin therapy should be maintained. Consider deprescribing secondary and tertiary oral agents or non-insulin injectables unless there is clear evidence of efficacy. In following Algorithm 3 (page 24), the clinician should also consider renal function and risk of hypoglycemia.

Following the chronic care model, the ADA recommends supplementary care to lifestyle and medication therapies for patients in difficult circumstances. These include case management, educational resources and coordinated management by a care team consisting of a clinician, nurses, registered dietitian nutritionist, diabetes educator, pharmacist, social worker and others.²⁸ Patients experiencing social context challenges should be referred to local community resources, such as social workers, food pantries, churches and adult protective services. They may also draw on nonmedical health coaches and health system navigators when available.

Since patients may not discuss their individual circumstances or larger social context unprompted, clinicians should systematically use validated tools to identify areas of concern with each patient.²⁸ Educational materials should be available in patients’ preferred language, and if possible, multilingual diabetes educators or translators should be utilized.

Remote consultations via telemedicine or e-consultation between care providers may allow clinicians to answer questions or provide support and guidance when the patient does not have easy access to a clinic.²⁸ Such interventions have proven effective at helping patients in rural areas maintain glycemic control.⁴⁴

Cost Management

It is appropriate to take cost of medical therapies into account when prescribing,²⁸ in consultation with the patient. Depending on the patient’s insurance status and other factors, medication costs will differ from patient to patient. As patients move between jobs, become eligible for Medicare or go through other life changes, the cost for the same medication for the same patient may also change. An ongoing conversation about affordability of antihyperglycemics and other medications is always warranted. Response to a medication compliance survey, such as the ARMS-7, may provide a starting point to talk about costs.

Sidebar 4 Antihyperglycemics With Hypoglycemia Risk41

Insulin, especially regular and intermediate-acting Sulfonylureas Meglitinides Other drug interactions may contribute to hypoglycemia

 

Working With an Endocrinologist

While a primary care clinician can diagnose and treat most cases of type 2 diabetes successfully in collaboration with his or her chronic care team, certain clinical situations may warrant the involvement of an endocrinologist. Clinicians should consider referring patients to an endocrinologist when:

• LADA or type 1 diabetes is suspected.
• Hyperglycemia persists despite medication dose increase and/or addition of second- and third-line antihyperglycemics to metformin.⁴¹
• Patient experiences relapse after successful disease management.
• Patient blood sugar is extremely labile.⁴⁵
• Hypoglycemia persists despite deprescribing.⁴¹
• Patients are receiving dialysis and having difficulty with glycemic control.⁴¹
• Patients have steroid-induced hyperglycemia that is difficult to manage.⁴¹
• Primary care clinician desires to start an injectable therapy but does not have the resources to provide appropriate education in the office.
• Patient may benefit from an insulin pump.⁴⁵ , for comments on insulin pumps and continuous glucose monitors in type 2 diabetes.

In addition, patients who are not responding to medication instructions and/or diabetes education may be referred to an endocrinologist to help them recognize the severity of their health situation⁴⁵ and to hear a second perspective on management. For example, patients who frequently require an entire office visit focused on their diabetes may warrant referral to an endocrinologist. In general, if patients have not responded to medication therapy, including additional antihyperglycemics, within 12 to 18 months after diagnosis, referral should be considered.⁴⁵

Once an endocrinologist has made recommendations and prescriptions, the primary care clinician can generally carry on his or her recommended treatment plan, consulting occasionally as needed. Particularly when patients have achieved their personalized glycemic control goals and are stable, endocrinologists should consider returning the patient to ongoing management by the primary care clinician. The primary care clinician and endocrinologist may elect to co-manage some patients, such as those with multiple diabetes-related hospitalizations or repeated loss of glycemic control. Continued endocrinologist care is appropriate for patients on insulin pumps or u500 insulin and for patients with multiple injection therapy who continue to require regular dose adjustments to maintain control.

Patients sometimes relapse to poor control after initial improvement following consultation with an endocrinologist or other intervention. We recommend first assessing for adherence to the previously successful diet and medications. The ARMS-7 tool may help uncover nonadherence, and barriers such as medication costs can be explored. If resuming the previously successful regimen does not return the patient to goal control, reconsultation is appropriate.

Where available, e-consultation may be appropriate for focused questions related to diabetes care, particularly for questions the clinician would consider asking as a “curbside” or to assist with co-management of a patient known to both providers. For example, if a patient has transitioned back to sole management by primary care but develops hypoglycemia, the primary care provider may consider an e-consultation from the endocrinologist to advise on medication adjustments. Clinicians caring for patients in rural areas in particular may find e-consultation with an endocrinologist useful in managing patients who would be challenged to travel to specialist visits.

PeriProcedural Management

People with diabetes are at risk for hyperglycemia and hypoglycemia during hospital stays. Both conditions are associated with poor hospital outcomes. The ADA recommends that hospital care for patients with diabetes should have the goal of preventing complications and readmission while minimizing length of stay.²⁸

Hospital management includes:

• All patients admitted with hyperglycemia should have an A1c test performed if they have not had one in the past three months.²⁸
  • If new or unmanaged cases of diabetes are diagnosed, patients should learn self-care measures and receive initial medication orders in the hospital,²⁸ along with referral for follow-up care.
• For persistent hyperglycemia, insulin therapy should be administered with a goal of glucose ranging from 140–180 mg/dL for most patients
  • For patients who are not eating, the preferred approach is basal insulin or basal plus correction insulin.
  • For patients who are eating, the preferred regimen is basal, mealtime and correction doses.²⁸
• A trained diabetes specialist or care team should be available for consultation.²⁸
• Glucose should be monitored before meals or every four to six hours for patients who are not eating. Patients on intravenous insulin should be monitored every half hour to two hours.²⁸
• Patients should also be monitored for hypoglycemia and treatment regimens altered when glucose levels of less than 70 mg/dL occur.²⁸
• To prevent hypoglycemia, medical and nutritional management should be integrated.²⁸
• Discharge planning should include²⁸:
  • A tailored care plan
  • Referrals to the diabetes educator, primary care clinician or endocrinologist, with appointments scheduled before discharge
  • Patient education about the condition, monitoring, self-care and any new medications
  • Medication reconciliation
  • Full patient records provided to primary care clinician and to next location of care (skilled
    nursing, etc.)
  • Provision of sufficient medications and supplies (testing supplies, syringes, pen needles, etc.) until patient can meet with an outpatient clinician

Day of Surgery

Before surgery, patients at risk for ischemic heart disease, autonomic neuropathy and/or renal failure should undergo a risk assessment. For periprocedural care for the patient with diabetes, the ADA recommends²⁸:

• Withholding metformin the day surgery is scheduled
• Withholding other antihyperglycemic agents except for 60–80% of long-acting analog or pump basal insulin
• Blood glucose goal of between 80–180 mg/dL during the perioperative period
• Monitoring of blood glucose four to six hours or more frequently during procedure; dose with rapid-acting insulin if needed

Transitions of Care

Transitions of care locations, especially transitions following acute hospital stays, provide opportunities for clinicians to review patient health status, prescriptions and abilities to ensure ongoing optimal care. Structured planning at discharge, tailored to meet individual patient needs, may leave patients with a clearer understanding of their health status, new medication regimen and any additional changes they need for their lifestyle or self-care practices.

Gaps in Care Transitions

Hospital admissions can be an opportunity to recognize and address poor glycemic control. However, one retrospective cohort study found that clinical inertia was present in 32% of admissions with A1c > 8%: These patients had no change made in therapy at discharge, no follow-up within 30 days, and no reassessment of A1c within 60 days.⁴⁶

When adjustments are made at hospital discharge, timely communication to the outpatient provider is critical. If primary care clinicians do not receive information about medication adjustments made during their patients’ hospital visits, patients may be left to decide between at least two conflicting medication regimens after discharge from acute care stays.

Medication Following Care Transition

Measuring A1c at admission may help determine appropriate medication levels at discharge. In one study, the following medication adjustments  were effective at managing A1c levels at 12 weeks post-discharge.⁴⁷

Principles for Structured Discharge Management

In preparing structured discharge education and follow-up care for each patient, clinicians should take the following factors into account:

• Total health status. Consider the effects of other illnesses and medications on blood glucose levels. For example, infections and steroids may raise glucose and require more intense treatment temporarily. Changes in renal function may affect the metabolism of insulin and other medications.
• Medication continuity. Any patient going home on a new insulin should be instructed in its safe use. All relevant supplies, including pen or syringe and testing tools, should be prescribed, along with the insulin checklist. Patients should leave the hospital with sufficient medication and supplies to last until they can access more, e.g., fill a prescription at a pharmacy.
• Patient and caregiver abilities. Consider patient capacity to take medications and monitor blood glucose levels. Patient capacity may have changed due to acute care stay. Review any changes in health status and medication with the patient and his or her caregivers.
• Follow-up visit. At minimum, schedule a follow-up visit with the primary care clinician, endocrinologist or diabetes educator within one month of discharge. However, if antihyperglycemic medications have changed or glycemic control is not optimal, schedule the follow-up appointment within one to two weeks after discharge. Also schedule the follow-up appointment within one to two weeks if health status is expected to change further—for instance, if the patient is overcoming an infection, going on dialysis or having non-antihyperglycemic medication changes.

Transitions also provide an opportunity to renew patient education about self-training and support. Patients may find themselves in settings with different food selections (for instance, they are staying at a family member’s home or a long-term care facility) and need to review healthy food choices for that setting. A change in physical abilities may require review of injection techniques. Additionally, family caregivers may need diabetes education if they are providing more patient care. Consider scheduling an appointment with a diabetes educator if patient abilities or living situation have changed following a care transition.

Prevention and Management of Atherosclerotic Cardiovascular Disease

Patients with type 2 diabetes have increased risk for atherosclerotic cardiovascular disease (ASCVD). In fact, ASCVD is the most frequent cause of death for people with type 2 diabetes.²⁸ The vectors of risk are twofold: diabetes often coexists with hypertension and high cholesterol, which are risk factors for ASCVD, and diabetes is in itself a risk factor for the condition. However, aggressively controlling ASCVD risk factors may help prevent or delay the condition in people with diabetes.

Clinicians can help diabetes patients manage their risk of ASCVD by:

• Using a validated risk calculator, such as the American College of Cardiology’s ASCVD Risk Estimator Plus, to help people gauge and understand the severity of their risk.⁴⁸
• Measure blood pressure at each appointment.
• Set treatment goals for patients to manage their risk of ASCVD, including managing blood glucose, keeping blood pressure below 130/80 mmHg and managing cholesterol levels with statins.²⁸ Most patients with diabetes have a goal of 140/90 mmHg, but those with higher cardiovascular disease risk should aim for 130/80 mmHg.

The lifestyle management guidance found in Section III equally applies to patients with heightened risk of ASCVD. In addition, these patients should be encouraged to reduce sodium intake to less than 2,300 mg/day, increase potassium intake and increase physical activity.²⁸

Patients with risk, history or symptoms of ASCVD also warrant medical management.

All persons with type 2 diabetes age 45–75 should be considered for statin therapy unless there is a contraindication, such as pregnancy or the ability to become pregnant (i.e. female and not on a reliable contraceptive). Statin use in type 2 diabetes is not dependent on lipid levels alone.

Other Related Conditions

Patients with type 2 diabetes are also more likely than the general population to experience kidney disease, retinopathy, neuropathy and foot problems. Clinicians should routinely monitor for these conditions and refer patients to specialists when indicated.

Patient Education

Excellent patient self-management education and support have the potential to improve patient outcomes, including feelings of well-being, efficacy at self-managing the condition and glucose control.²⁸ A patient education baseline for people with type 2 diabetes includes:

• Helping patients understand the clinical aspect of their condition
• Helping patients understand how to take medications correctly and why it is essential. Nearly 25% of uncontrolled blood glucose issues, high blood pressure and high cholesterol are associated with medication adherence problems.⁴⁹
• Identifying lifestyle changes needed to improve disease management
• Teaching patients how to set goals and solve problems to operationalize medical understanding gained through diabetes education

Best Practices in Patient Education

To achieve an excellent understanding and optimal management of their diabetes, patients should receive education and reinforcement from a number of sources. Clinicians, registered dietitian nutritionists, certified diabetes educators and community organizations are all sources for information and reinforcement for diabetes patients.

Education and diabetes management coaching should be provided regularly, with office visits supplemented by community resources, if available. Numerous, efficient, diverse moments of education are supported over infrequent, lengthy or single-mode communication. The American Academy of Family Physicians suggests a high-touch model of patient contact, with weekly phone calls by a nurse manager and monthly calls by a clinician to support medication adherence and weight loss.⁵⁰

At critical transitions, a patient’s need for education and support should be evaluated, and new self-management skills training added when necessary. The ADA recommends an evaluation of patient educational needs²⁸:

• At initial diagnosis
• When new or complicating factors like health conditions, physical limitations, emotional factors or basic living needs arise that affect the patient’s ability to self-manage
• At transitions between care settings
• At least annually barring these events

When possible, education should be provided in the patient’s native language, if preferred, and an easy-to-navigate format. Multiple approaches are especially effective; patients should be encouraged to participate in face-to-face and technology-driven interactions, as well as educational meetings with support groups and classes.²⁸

Sidebar 5 Insulin Pumps and Continuous Glucose Monitoring (CGM)

Insulin Pumps It is rare for patients with type 2 diabetes to have a strong indication for insulin pump therapy. Patients should be referred to an endocrinologist when pump therapy is under consideration. CGM While many patients find CGM technology appealing, there is not yet evidence to suggest that patients who are not adherent to blood sugar testing as recommended will be more adherent to proper use of CGM. To use CGM effectively, patients need to be trained in the use of the technology and pattern recognition. Additionally, a clinician who is prescribing the technology should be prepared to use the data to enhance patient care. The clinician should include ways to review data in the course of a visit and be comfortable with making recommendations based on patterns. Clinicians may meet this need by having trained personnel, such as a certified diabetes educator (CDE), on the care team. While insurance criteria for approval may vary and include additional requirements, CGM may be appropriate for patients meeting the following criteria: Using two or more injections of insulin daily Testing blood sugar four times per day (or, if physically unable to perform tests, demonstrate an interest in testing this frequently) Meeting at least one of the following conditions: Frequent hypoglycemia or hypoglycemia unawareness Suboptimal control with fluctuating glucose levels Patient instructed and trained to adjust insulin dose based on data output Training in use of CGM by an experienced CDE or clinician A number of CGMs are available. Some CGM products provide a continuous display on a dedicated device or a patient’s smartphone or insulin pump while others require action by the patient to scan the device. Some CGM products include alarm features. The clinician should have a good understanding of CGM product capabilities before prescribing. Among currently available products, the Abbott Freestyle Libre system is less costly than the Dexcom system and should probably be favored for that reason, unless there is a need for alarm features. After an initial one- to three-month trial, consider the discontinuation of the CGM device prescription if the patient does not routinely adhere to the recommended scanning frequency.

 

Type 2 Diabetes Resources

Vanderbilt Health Affiliated Networks

My Insulin Pen Guide
My Insulin Guide
These pamphlets cover where and how to inject insulin, as well as when to call a clinician about concerns or emergencies related to insulin and blood glucose.

My Emergency Plan
This pamphlet covers planning ahead for being sick and unable to eat or take medications to control diabetes. When to call a diabetes care team member and 911 are also included.

Taking Control of My Diabetes
This pamphlet covers ideas for setting and achieving healthy goals and provides a log to note weight, blood pressure, medication adherence, lab results, and annual screenings and pneumonia vaccinations recommended for people with diabetes.

PRIDE Interactive Teaching Materials
The PRIDE toolkit consists of a series of interactive diabetes education modules in English and Spanish. They are designed to help patients with low literacy and numeracy understand and manage their diabetes. Modules are illustrated with simple pictures and diagrams. The modules are arranged sequentially and intended to supplement conversations between patients and clinicians. PRIDE is available through the Vanderbilt University Medical Center online portal. Note: PRIDE tools are meant to be used by clinicians with patients.⁵¹

Other Approved Materials
National organizations, including the ADA, the American College of Cardiology/American Heart Association and the U.S. Department of Health and Human Services publish useful patient educational materials. Among our recommended resources are:

American Association of Diabetes Educators
The American Association of Diabetes Educators website provides patient-facing materials, including self-care documents about eating, exercising, monitoring, taking medications and problem-solving. The website is also geared to be used concurrently with face-to-face diabetes education.

Caregiver.org
The website of the Family Caregiver Alliance, this site contains numerous educational materials for family caregivers, covering matters from estate planning to taking medication.

ChooseMyPlate.gov
Containing regularly updated dietary guidelines for Americans, this website uses the now-famous “four-sectioned plate” to succinctly illustrate nutrient balance and portion size. It also contains tip sheets, many in the form of printable infographics.

Diabetes.org
The website of the ADA, this site contains a wide range of information conveyed in basic language, including a risk calculator, explanations of the disease, food and exercise advice, and materials tailored for specific age and cultural groups. There are also numerous how-to guides.

EatRight.org
The website of the Academy of Nutrition and Dietetics, this online destination provides a wealth of food-related information and instruction, including recipes, shopping, budgeting and reading food labels.

National Diabetes Prevention Program
The National Diabetes Prevention Program (DPP) is an evidence-based prevention program for people at risk for diabetes. This CDC program site contains a mix of patient- and clinician-facing materials. Of interest are a risk calculator and links to guide the patient to participate in the National DPP either online or via local resources, often through YMCAs. Several levels of clicks are required to get to actionable information, so a CDE or clinician may need to walk non-computer-savvy patients through the site.

SilverSneakers
A health and fitness program for adults 65 and older, SilverSneakers may be covered by Medicare Advantage. The website allows people to check their eligibility, locate classes or participate in exercise sessions via online instruction; however, the online instruction is paywalled.

Tennessee Disability Pathfinder
This online, statewide database of social services includes low-income medical clinics, recreational programs and other resources for disabled persons.

Your Game Plan to Prevent Type 2 Diabetes
A patient-facing site of the National Institute of Diabetes and Digestive and Kidney Disorders, this online resource contains information about goal-setting, diet, exercise and more.

The following resources may be useful for patients with cost barriers to care:

Applying for TennCare
Healthcare.gov
1-800-318-2596
Any Department of Health and Human Services office in Tennessee can help people apply for and select a plan.

Appendices

Appendix A

Population Screening for Type 2 Diabetes

Because of the growing prevalence and cost burden of type 2 diabetes, the American Diabetes Association recommends population screening rather than case-by-case testing of symptomatic patients.¹² While the recommendations in this care path guide may be tailored to meet individual patient needs, the overarching demand is for a systemic approach to identify type 2 diabetes and for consistent, responsive care delivery systems ready to proactively identify and promptly begin care for each patient in a coordinated, team-based fashion. We follow the Chronic Care Model identified by the ADA as a proven, system-based framework for delivering high-quality diabetes care.⁵² The ADA provides more guidance on the appropriate patient population that should be screened, but this is outside the scope of this specific care path.

Appendix B

Gestational Diabetes

Diabetes during pregnancy can result from existing type 1 or type 2 disease, or may first occur during pregnancy, in which case it is known as gestational diabetes (GDM). Any form of diabetes during pregnancy increases the risk of maternal and/or fetal death, miscarriage, birth defects, large fetal size, preeclampsia, neonatal hyperglycemia, and neonatal hyperbilirubinemia. Women who experience gestational diabetes are subsequently at greater risk for type 2 diabetes.²⁸

All pregnant women without an existing diagnosis of diabetes should be tested for gestational diabetes at 24–28 weeks of gestation, using GDM-specific parameters for guidelines. Treatment for gestational diabetes includes blood glucose monitoring, with a goal of achieving fasting blood glucose of less than 95 mg/dL, one-hour postprandial blood glucose less than 140 mg/dL or two-hour postprandial blood glucose of less than 120 mg/dL, as well as A1c levels of less than 6%.²¹ Lifestyle changes should be recommended as treatment for women with gestational diabetes. Insulin may be prescribed to manage glucose levels; however, metformin should not be prescribed to pregnant women.

Patients with existing prediabetes or type 2 diabetes who may become pregnant should be routinely counseled about the dangers of uncontrolled diabetes during pregnancy and the importance of self-care and tight glycemic control should they become pregnant. Family planning education is also important for these patients.²¹ Pregnant women with diabetes of any type should be managed by experienced providers, and management of GDM and pre-existing diabetes in pregnancy is outside the scope of this care path guide.

Preconception and Pregnancy Blood Glucose Goals

Preconception (intending or attempting to conceive)	Aim for tight control of < 6.5% to reduce risk of preeclampsia and fetal abnormalities28
Pregnancy	Goal should be < 6%, but may be relaxed to 7% if hypoglycemia occurs28 Pregnant patients with diabetes of any type should be managed by clinicians experienced in this area

Appendix C

Special Considerations in Prescribing and Dosing

Patients with A1c Between 8.5 and 10

A1c levels between 8.5% and 10% indicate that diabetes is not well controlled. This can put patients at risk for microvascular complications and premature mortality.²⁸ For these patients, the ADA recommends early introduction of insulin²⁸ . Additionally, we recommend aiming to achieve control with a smaller number of drugs and choosing those more likely to be effective in this stage. Using a smaller number of effective drugs, and discontinuing those not providing benefit when the entire regimen is viewed as a whole, is cost effective, reduces polypharmacy and conceivably increases may increase patient satisfaction.

Frail and Vulnerable Patients

Diabetes is a risk factor for frailty,²⁸ and frail patients may have difficulty with blood glucose monitoring and medication management. Additionally, these patients may be at risk for hypoglycemia and benefit from less stringent goals.

Other patients, while more physically robust, may have other areas of vulnerability, such as a lack of medication access, barriers to keeping refrigerated medications, difficulty manipulating medication containers or syringes, and/or cognitive disabilities or dementia. It is important to take patient circumstances into account when prescribing type 2 diabetes medications. Circumstances or social context includes such factors as regular access to a healthful diet, access to stable housing and reliable transportation, and language and financial barriers to care.

Social determinants of health with direct impact on glycemic control.

Appendix D

Foot Care

Patients with type 2 diabetes often experience foot problems, ranging from peripheral neuropathy, peripheral vascular disease and poor wound healing. Since patients may lack sensation and proprioceptive sense, foot care should focus on avoiding injuries that could lead to ulcers or other long-term wounds. Patients should be encouraged to have their feet examined regularly by their clinician and should also inspect their own feet daily, as well as observe good foot safety and hygiene measures.

Foot exams include:

• Checking for problems, such as cuts, ulcers, open or slow healing wounds, redness or swelling
• Assessing for neuropathy (burning, pain, numbness)
• Assessing for vascular disease (claudication or fatigue in the legs)
• Inspecting the skin
• Assessing for deformities
• Screening for neurological issues, including microfilament test and another measure, such as pinprick test
• Additionally, the clinician should take a history of foot problems and related conditions or complicating factors, including angioplasty or vascular surgery, amputation, Charcot foot, prior ulcers, renal disease, retinopathy and smoking. Instruct patient about how to maintain and monitor foot health.

Foot maintenance and protection for patients

• Do not use feet to check for hot pavement, bathwater, etc.
• Avoid going barefoot.
• Do not cut off corns or calluses—file carefully if needed.
• Cut nails straight across rather than crescents.
• Wear soft, deep shoes with sufficient width.
• Wear specially designed diabetic footwear if ulcers or deformities are present.
• Check feet daily for cuts, ulcers, open or slow-healing wounds, redness and/or swelling. Wear white socks to help identify foot bleeding or drainage. Inspect underside of foot with handheld mirror placed on the floor if a direct view is inaccessible.

Insurance may cover routine nail care for patients with neuropathy or peripheral vascular disease. Patients with open ulcers or wounds should be urgently referred to a podiatrist or other appropriate specialist.

Appendix E

Care Team Roles

The chronic care model is a patient-centric approach to healthcare, acknowledging the patient will need ongoing care. The chronic care model has proven effective at managing patients with diabetes.⁵² A team-based approach helps ensure patients with diabetes receive treatment, monitoring, disease management education, reassurance, referrals, resources and support. While not every care team will have all the members listed below, each member of the team should have a clearly defined function, while all members should coordinate to enable and sustain patient self-management.²⁸

• Primary care clinician. Clinicians diagnose the condition and prescribe medication and other treatment. They are also the primary point of contact to help with patient goal-setting and delegate to the other team members to ensure those goals are met. The clinician investigates new clinical issues that arise and provides modified treatment plans.⁵³
• Registered nurse. Nurses help with monitoring blood sugar and other important metrics. They follow up with patients about medications and progress toward goals. They also coordinate care between the primary care clinician and the rest of the team.⁵³
• Medical assistant. Medical assistants schedule appointments, follow up on missed appointments and make routine referrals. They take patient vitals and record data.⁵³
• Registered dietitian nutritionist. RDNs work with each patient to complete a medical nutrition therapy (MNT) plan. They help the patient with behavioral management strategies to achieve nutritional and weight-loss goals.²⁸ Patients are advised to visit an RDN once upon diagnosis of type 2 diabetes, approximately bimonthly for six months following and annually thereafter.⁵⁴ The services of an RDN for people diagnosed with diabetes are covered by Medicare Parts A and B.⁵⁵ MNT is covered at no cost, while 10 hours of diabetes self-management education over the course of one year are covered at 20% of Medicare approved amount; Part B deductible applies.
• Certified diabetes educator. CDEs provide patients with detailed information about the disease and treatment goals. They answer questions and spend time with patients, going over glucose readings, identifying pattern recognition and helping patients create personal eating and medication schedules. The CDE’s role also includes aspects of a health navigator by putting patients in touch with services that can be beneficial in the healthcare network and across the community. CDEs increase patient comfort levels in managing and living with type 2 diabetes. Utilization of CDEs in a care team may reduce patient A1c levels by 0.2–0.8%.⁵⁶ Typically, patients are referred to a CDE at first diagnosis and again at certain thresholds, such as when their A1c levels pass 8%. If the patient’s insurance will cover two visits on the same day, it may be helpful to see the CDE the same day as the clinician in order to reinforce information.⁵⁷
• Endocrinologist. Endocrinologists provide diagnosis and treatment plans for patients suspected of having latent autoimmune diabetes or type 1 diabetes. For patients with type 2 diabetes, the endocrinologist helps resolve challenging clinical situations and consults with the primary care clinician about medication prescribing, dosing and deprescribing. Some type 2 patients, particularly those on multiple-dose insulin therapy and those with other medical or lifestyle concerns that create lability in diabetes control, may need to be co-managed by endocrinologists over the long term. However, we recommend that stable, well-controlled patients primarily managed by non-insulin medications be regularly reassessed for potential return to primary care. Indications for referral to an endocrinologist are listed in Section IV .
• Pharmacist. Pharmacists help provide patient education about treatment options, specifically medications, and reinforce proper understanding of the prescribed treatment. This typically involves an assessment of the plan to ensure proper indication, effectiveness, safety and accessibility of the prescribed medicine(s). The pharmacist can also assist in teaching patients how to use medical devices (i.e. glucometers) and medication in general (i.e. insulin or other injectables).
• Community experts. While not part of the formal medical care team, community resources may be cultivated as regular partners in patient care and well-being. Among these, individuals—such as fitness coaches and social workers—and organizations—such as YMCA, SilverSneakers groups and Overeaters Anonymous—may provide additional support and fellowship for the patient.

Appendix F

Caregiver Support

When patients are especially frail, family members or other caregivers may, in essence, take on many of the patient roles—listening to and understanding information, making sure clinician instructions are followed, and monitoring patient progress. This can be burdensome for caregivers. However, since families undertake a lion’s share of chronic care—providing 80% of the long-term care delivered in the U.S.⁵⁸—it is important to include caregivers as part of the care delivery team, keeping them informed and also ensuring their own health is not compromised in the caregiving process.

Clinicians can include family caregivers in the process by:

• Providing them with the same scheduling, medication and educational information patients receive, including the pathophysiology of type 2 diabetes
• Providing instruction about best practices for helping the patient avoid disease complications (medication adherence, home foot inspections, etc.)
• Helping them understand the symptoms that may warrant scheduling a clinician’s appointment or visiting the emergency room
• Helping them understand how to identify low blood sugar in patients who may be unaware of it through timing of blood glucose testing and interpretion of the results
• Assisting them in creating a plan to enhance diabetes management of their loved one
• Guiding them to community caregiving resources
• With permission, collaborating with the caregiver’s primary care clinician to ensure caregiving stresses are recognized and managed
• To increase positive results, caregivers of the elderly can be directed to local supportive services, such as Tennessee Area Agencies on Aging/Disability.⁵⁹ The Family Caregiver Alliance has detailed information and educational materials for caregivers in a variety of circumstances.⁵⁸ Of particular importance is information about:
• Medical visits: How caregivers can talk with physicians about patient medications
• Locating community resources to help with caregiving
• Advanced illness: DNR and end-of-life planning

References & Contributors

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Vanderbilt Health Affiliated Network Contributors

Michelle Griffith, MD, Assistant Professor, Vanderbilt University Medical Center Diabetes/Endocrinology

Tiffanie Marksbury, DNP, ANP, CDE, Assistant in Medicine, NP Amb, Vanderbilt University Medical Center Diabetes/Endocrinology

Lauren Shaw, RN, BSN, CDE, Patient Care Coordinator, Disease Management Team

Christopher Terry, PharmD, CDE, Clinical Pharmacist, Vanderbilt Health Affiliated Network Medication Management

Howard Baum, MD, Assoc Professor, Vanderbilt University Medical Center Diabetes/Endo

Rosette Chakkalakal, MD, MHS, Assistant Professor, Vanderbilt University Medical Center Internal Medicine

Jessica Herron PA, CDE, Jackson Clinic, Vanderbilt Health Affiliated Network

Brad Vander Veen, MD, Premier Medical Group, Vanderbilt Health Affiliated Network

Mike Modic, MD, Sr. Vice President, Vanderbilt Health Affiliated Network

Esther Smith, Admin Director, Vanderbilt Health Affiliated Network Strategic Ops

Megan Pacella, Content Manager, Vanderbilt Health Affiliated Network B2B Marketing

Karen Stone, Director, Vanderbilt Health Affiliated Network B2B Marketing

Matthew Resnick, Assoc Professor, Vanderbilt University Medical Center Urology

Megan Pruce, Vice President, Strategic Marketing, Vanderbilt Health Affiliated Network

Claude Pirtle, MD, Clinical Fellow, Vanderbilt University Medical Center Biomedical Informatics

Justin Bachmann, MD, MPH, Assistant Professor, Vanderbilt University Medical Center Cardiovascular

Andrew O. Smith, Sr. Project Manager, Population Health, Vanderbilt Health Affiliated Network

Russell Brothers, Principal Analytics Cslt, Enterprise Analytics, Vanderbilt Health Affiliated Network

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