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Salud bucal y diabetes gestacional en el Centro Provincial de Atención al Diabético Translated title: Oral health and gestational diabetes at Provincial Diabetes Care Center
research-article
Author(s):
Zenobia de la Caridad Trujillo Saínz ,
Carlos Manuel Paz Paula ,
Yurien Hernández Acosta ,
Daimy Henriquez Trujillo
Publication date (Print and electronic):
August 2019
Publisher:
Editorial Ciencias Médicas
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Abstract
RESUMEN Introducción: la gestación incrementa la susceptibilidad de problemas periodontales asociados a los niveles de hormonas sexuales femeninas que favorecen la inflamación. Las gestantes presentan xerostomía por poliuria y afectaciones de la membrana basal de las células de glándulas salivales, que agravan el crecimiento bacteriano y a la disminución de las propiedades defensivas de la saliva y del periodonto. Objetivo: describir problemas de salud bucal en gestantes con diabetes gestacional atendidas en consulta del Centro Provincial de Atención al Diabético. Métodos: estudio transversal retrospectivo, en consulta externa del periodo enero de 2017 a diciembre de 2018, integrado por un total de 114 embarazadas. Se les efectuó examen bucal, con diagnóstico, orientación y remisión al segundo nivel de atención médica y periodontal. Resultados: se encontraron diferencias según el color de la piel: el 33,5 % de las pacientes de la raza blanca tenía menos de 25 años y presentaban una incidencia del 58,6 % con gingivitis y 55,1 % con periodontitis, el 44,4 % eran de la raza negra y tenían más de 25 años; 33,3 % presentaban gingivitis y 58,3 %, periodontitis. En orden decreciente: caries, gingivitis, edentulismo, retracción gingival y xerostomía. Conclusiones: la terapia periodontal constituye una necesidad de los protocolos de tratamiento antes de la semana 25 de gestación y un medio para mejorar la salud bucal y sistémica de las gestantes. Evaluar las afecciones periodontales como un problema asociado a factores bucales y riesgos sistémicos propios del fenómeno endocrino metabólico y de la fisiología del embarazo.
Translated abstract
ABSTRACT Introduction: gestation increases the susceptibility to periodontal problems associated with levels of female sex hormones that favor inflammation. Pregnant women present xerostomia due to polyuria and affect the basal membrane of the salivary gland cells, which aggravate the bacterial growth and the decrease of the defensive properties of the saliva and the periodontium. Objective: to describe oral health problems in pregnant women with gestational diabetes attended in the outpatient clinic of the Provincial Center for Diabetic Care. Methods: retrospective, cross-sectional study, in the outpatient clinic from January 2017 to December 2018, made up of a total of 114 pregnant women. They underwent an oral examination, with diagnosis, orientation and referral to the second level of medical and periodontal care. Results: differences were found according to skin color: 33.5% of white patients were under 25 years old and had an incidence of 58.6% with gingivitis and 55.1% with periodontitis, 44.4% were black and older than 25 years old; 33.3% had gingivitis and 58.3% periodontitis. In decreasing order: caries, gingivitis, edentulism, gingival retraction and xerostomy. Conclusions: periodontal therapy is a need for treatment protocols before the 25th week of gestation and a means to improve the oral and systemic health of pregnant women. To evaluate periodontal affections as a problem associated with oral factors and systemic risks typical of the metabolic endocrine phenomenon and pregnancy physiology.
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The Immune Response to Prevotella Bacteria in Chronic Inflammatory Disease.
Jeppe Larsen (2017)
The microbiota plays a central role in human health and disease by shaping immune development, immune responses, metabolism, and protecting from invading pathogens. Technical advances that allow comprehensive characterization of microbial communities by genetic sequencing have sparked the hunt for disease modulating bacteria. Emerging studies in humans have linked increased abundance of Prevotella species at mucosal sites to localized and systemic disease, including periodontitis, bacterial vaginosis, rheumatoid arthritis, metabolic disorders, and low-grade systemic inflammation. Intriguingly, Prevotella abundance is reduced within the lung microbiota of asthma and COPD. Increased Prevotella abundance is associated with augmented Th17-mediated mucosal inflammation, which is in line with the marked capacity of Prevotella in driving Th17 immune responses in vitro. Studies indicate, that Prevotella predominantly activate TLR2 leading to production of Th17-polarizing cytokines by antigen presenting cells, including IL-23 and IL-1. Furthermore, Prevotella stimulate epithelial cells to produce IL-8, IL-6 and CCL20, which can promote mucosal Th17 immune responses and neutrophil recruitment. Prevotella-mediated mucosal inflammation leads to systemic dissemination of inflammatory mediators, bacteria, and bacterial products, which in turn may affect systemic disease outcomes. Studies in mice support a causal role of Prevotella as colonization experiments promote clinical and inflammatory features of human disease. When compared to strict commensal bacteria, Prevotella exhibit increased inflammatory properties as demonstrated by augmented release of inflammatory mediators from immune cells and various stromal cells. These findings indicate that some Prevotella strains may be clinically important pathobionts that can participate in human disease by promoting chronic inflammation. This article is protected by copyright. All rights reserved.
- Record: found
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Standards of Medical Care in Diabetes—2016 Abridged for Primary Care Providers
The American Diabetes Association’s (ADA’s) Standards of Medical Care in Diabetes is updated and published annually in a supplement to the January issue of Diabetes Care. Formerly called Clinical Practice Recommendations, the Standards includes the most current evidence-based recommendations for diagnosing and treating adults and children with all forms of diabetes. ADA’s grading system uses A, B, C, or E to show the evidence level that supports each recommendation. A—Clear evidence from well-conducted, generalizable randomized controlled trials that are adequately powered B—Supportive evidence from well-conducted cohort studies C—Supportive evidence from poorly controlled or uncontrolled studies E—Expert consensus or clinical experience This is an abridged version of the current Standards containing the evidence-based recommendations most pertinent to primary care. The tables and figures have been renumbered from the original document to match this version. The complete 2016 Standards of Care document, including all supporting references, is available at professional.diabetes.org/standards. STRATEGIES FOR IMPROVING CARE Recommendations A patient-centered communication style that incorporates patient preferences, assesses literacy and numeracy, and addresses cultural barriers to care should be used. B Care should be aligned with components of the Chronic Care Model (CCM) to ensure productive interactions between a prepared, proactive practice team and an informed, activated patient. A When feasible, care systems should support team-based care, community involvement, patient registries, and decision support tools to meet patient needs. B Diabetes Care Concepts Patient-centeredness. Patients with diabetes are at a greatly increased risk of cardiovascular disease (CVD). A patient-centered approach should include a comprehensive plan to reduce cardiovascular risk by addressing blood pressure and lipid control, smoking prevention and cessation, weight management, physical activity, and healthy lifestyle choices. Diabetes across the life span. The incidence of type 2 diabetes is increasing in children and young adults. Patients with type 1 diabetes or type 2 diabetes are living well into older age. Coordination must improve between clinical teams as patients transition through different stages of life. Care Delivery Systems Chronic Care Model The CCM has been shown to be an effective framework for improving the quality of diabetes care. Collaborative, multidisciplinary teams are best equipped to provide care for people with chronic conditions such as diabetes. The CCM also facilitates patients’ self-management. Key Objectives Optimize provider and team behavior. The care team should prioritize timely and appropriate intensification of lifestyle and/or pharmacological therapy for patients who have not achieved beneficial levels of glucose, blood pressure, or lipid control. Support patient behavior change. High-quality diabetes self-management education (DSME) has been shown to improve patient self-management, satisfaction, and glucose control. Change the care system. Optimal diabetes management requires an organized, systematic approach and involves a coordinated team of dedicated health care professionals. When Treatment Goals Are Not Met Several strategies have been shown to improve patient outcomes. Providers should focus on treatment intensification, which has been associated with improvement in A1C, hypertension, and hyperlipidemia. Patient adherence should be addressed. Barriers may include patient factors (e.g., remembering to obtain or take medications, fears, depression, and health beliefs), medication factors (e.g., complexity, multiple daily dosing, cost, and side effects), and system factors (e.g., inadequate follow-up and support). Simplifying a complex treatment regimen may improve adherence. Tailoring Treatment to Vulnerable Populations Ethnic/Cultural/Sex/Socioeconomic Differences and Disparities Ethnic, cultural, religious, and sex differences and socioeconomic status may affect diabetes prevalence and outcomes. Diabetes management requires individualized, patient-centered, and culturally appropriate strategies. Strong social support leads to improved clinical outcomes, reduced psychosocial symptomatology, and adoption of healthier lifestyles. Structured interventions that are tailored to ethnic populations and integrate culture, language, religion, and literacy skills have a positive impact on patient outcomes. Food Insecurity Recommendations Providers should carefully evaluate hyperglycemia and hypoglycemia in the context of food insecurity (FI) and propose solutions accordingly. A Providers 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. A FI is the unreliable availability of nutritious food and the inability to consistently obtain food without resorting to socially unacceptable practices. Hyperglycemia and hypoglycemia are more common in those with diabetes and FI. Cognitive Dysfunction Recommendations In individuals with poor cognitive function or severe hypoglycemia, glycemic therapy should be tailored to avoid significant hypoglycemia. C In individuals with diabetes at high cardiovascular risk, the cardiovascular benefits of statin therapy outweigh the risk of cognitive dysfunction. A If a second-generation antipsychotic medication is prescribed, changes in weight, glycemic control, and cholesterol levels should be carefully monitored and the treatment regimen reassessed. C Dementia is the most severe form of cognitive dysfunction. In those with type 2 diabetes, both degree and duration of hyperglycemia are related to dementia. More rapid cognitive decline is associated with increased A1C and longer duration of diabetes. In type 2 diabetes, severe hypoglycemia is associated with reduced cognitive function, and those with poor cognitive function have more severe hypoglycemia. Data do not support an adverse effect of statins on cognition. Mental Illness The prevalence of type 2 diabetes is two to three times higher in people with schizophrenia, bipolar disorder, or schizoaffective disorder than in the general population. Diabetes medications are effective regardless of mental health status. Treatments for depression are effective in patients with diabetes, and treating depression may improve short-term glycemic control. Awareness of an individual’s medication profile, especially if the individual takes psychotropic medications, is key to effective management. CLASSIFICATION AND DIAGNOSIS OF DIABETES Diabetes can be classified into the following general categories: Type 1 diabetes (due to β-cell destruction, usually leading to absolute insulin deficiency) Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes) Specific types of diabetes due to other causes such as monogenic diabetes syndromes (e.g., neonatal diabetes or maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (e.g., cystic fibrosis), or drug- or chemical-induced diabetes (e.g., as in the treatment of HIV/AIDS or after organ transplantation) Diagnostic Tests for Diabetes Diabetes may be diagnosed based on plasma glucose criteria—either the fasting plasma glucose (FPG) or the 2-h plasma glucose value after a 75-g oral glucose tolerance test (OGTT)—or A1C criteria (Table 1). The same tests are used to screen for and diagnose diabetes and to detect individuals with prediabetes (Table 2). TABLE 1. Criteria for the Diagnosis of Diabetes FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.* OR 2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.* OR A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.* OR In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L).** * In the absence of unequivocal hyperglycemia, results should be confirmed by repeat testing. ** Only diagnostic in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis. TABLE 2. Criteria for Testing for Diabetes or Prediabetes in Asymptomatic Adults 1. Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and have additional risk factors: Physical inactivity First-degree relative with diabetes High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) Women who delivered a baby weighing >9 lb or were diagnosed with GDM Hypertension (≥140/90 mmHg or on therapy for hypertension) HDL cholesterol level 250 mg/dL (2.82 mmol/L) Women with polycystic ovary syndrome A1C ≥5.7% (39 mmol/mol), IGT, or IFG on previous testing Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) History of CVD 2. For all patients, testing should begin at age 45 years. 3. If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results (e.g., those with prediabetes should be tested yearly) and risk status. IFG, impaired fasting glucose; IGT, impaired glucose tolerance. Type 2 Diabetes and Prediabetes Recommendations Testing 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. B For all patients, testing should begin at age 45 years. B If tests are normal, repeat testing carried out at a minimum of 3-year intervals is reasonable. C In patients with prediabetes or diabetes, identify and, if appropriate, treat other CVD risk factors. B Screen women with GDM for persistent diabetes at 6–12 weeks postpartum using the OGTT and clinically appropriate nonpregnancy diagnostic criteria. E Testing to detect prediabetes and 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. E The modified recommendations of the ADA consensus report “Type 2 Diabetes in Children and Adolescents” are summarized in Table 3. TABLE 3. Testing for Type 2 Diabetes or Prediabetes in Asymptomatic Children* Criteria Overweight (BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% of ideal for height) Plus any two of the following risk factors: Family history of type 2 diabetes in first- or second-degree relative Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age birth weight) Maternal history of diabetes or GDM during the child’s gestation Age of initiation: age 10 years or at onset of puberty, if puberty occurs at a younger age Frequency: every 3 years * People aged ≤18 years. FOUNDATIONS OF CARE AND COMPREHENSIVE MEDICAL EVALUATION Foundations of Care It is necessary to take into account all aspects of a patient’s life circumstances. A team approach to care and a comprehensive clinical assessment should incorporate behavioral, dietary, lifestyle, and pharmaceutical intervention to manage this chronic condition (Table 4). Using the CCM may help improve the quality of diabetes care. TABLE 4. Components of the Comprehensive Diabetes Medical Evaluation Medical history • Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory finding) • Eating patterns, nutritional status, weight history, and physical activity habits; nutrition education and behavioral support history and needs • Presence of common comorbidities, psychosocial problems, and dental disease • Screen for depression using PHQ-2 (PHQ-9 if PHQ-2 positive) or EPDS • Screen for DD using DDS or PAID-1 • History of smoking, alcohol consumption, and substance use • Diabetes education, self-management, and support history and needs • Review of previous treatment regimens and response to therapy (A1C records) • Results of glucose monitoring and patient’s use of data • DKA frequency, severity, and cause • Hypoglycemia episodes, awareness, and frequency and causes • History of increased blood pressure, increased lipids, and tobacco use • Microvascular complications: retinopathy, nephropathy, and neuropathy (sensory, including history of foot lesions; autonomic, including sexual dysfunction and gastroparesis) • Macrovascular complications: coronary heart disease, cerebrovascular disease, and peripheral arterial disease Physical examination • Height, weight, and BMI; growth and pubertal development in children and adolescents •Blood pressure determination, including orthostatic measurements when indicated •Fundoscopic examination •Thyroid palpation •Skin examination (e.g., for acanthosis nigricans, insulin injection, or infusion set insertion sites) •Comprehensive foot examination ○ Inspection ○ Palpation of dorsalis pedis and posterior tibial pulses ○ Presence/absence of patellar and Achilles reflexes ○ Determination of proprioception, vibration, and monofilament sensation Laboratory evaluation •A1C, if results not available within the past 3 months •If not performed/available within the past year ○ Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides, as needed ○ Liver function tests ○ Spot urinary albumin–to–creatinine ratio ○ Serum creatinine and estimated glomerular filtration rate ○ Thyroid-stimulating hormone in patients with type 1 diabetes or dyslipidemia or women aged >50 years DD, diabetes distress; DDS, Diabetes Distress Scale; DKA, diabetic ketoacidosis; EPDS, Edinburgh Postnatal Depression Scale; PAID, Problem Areas in Diabetes; PHQ, Patient Health Questionnaire. Diabetes Self-Management Education and Support Recommendations In accordance with the National Standards for Diabetes Self-Management Education and Support, all people with diabetes should participate in DSME to facilitate the knowledge, skills, and abilities necessary for diabetes self-care and diabetes self-management support (DSMS) to assist with implementing and sustaining skills and behaviors needed for ongoing self-management, both at diagnosis and as needed thereafter. B Effective self-management, improved clinical outcomes, health status, and quality of life are key outcomes of DSME/S and should be measured and monitored as part of care. C DSME/S should be patient-centered, respectful, and responsive to individual patient preferences, needs, and values, which should guide clinical decisions. A DSME/S programs should have the necessary elements in their curricula that are needed to prevent the onset of diabetes. DSME/S programs should therefore tailor their content specifically when prevention of diabetes is the desired goal. B Because DSME/S can result in cost savings and improved outcomes B, they should be adequately reimbursed by third-party payers. E There are four critical time points for DSME/S delivery: at diagnosis; annually for assessment of education, nutrition, and emotional needs; when new complicating factors arise that influence self-management; and when transitions in care occur. Medical Nutrition Therapy There is no one-size-fits-all eating pattern for individuals with diabetes. There are basic guidelines that can support the team in engaging the patient in more healthful eating patterns (Table 5). TABLE 5. Nutrition Therapy Recommendations Topic Recommendations Evidence rating Effectiveness of nutrition therapy An individualized MNT program, preferably provided by a registered dietitian, is recommended for all people with type 1 or type 2 diabetes. A For 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 counting or estimation to determine mealtime insulin dosing can improve glycemic control. A For 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. B A 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. C 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. E B, A, E Energy balance Modest weight loss achievable by the combination of lifestyle modification and the reduction of energy 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. A Eating patterns and macronutrient distribution As 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. E Carbohydrate 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. B People 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. A B, A Protein In 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. B Dietary fat Whereas 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. B 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. A B, A Micronutrients and herbal supplements There is no clear evidence that dietary supplementation 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. C Alcohol Adults 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). C Alcohol 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. B Sodium As 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. B The goals of medical nutrition therapy (MNT) are to promote and support healthful eating patterns, emphasizing a variety of nutrient-dense foods in appropriate portion sizes to achieve/maintain body weight goals; attain glycemic, lipid, and blood pressure goals; and delay/prevent complications of diabetes. MNT addresses individual nutrition needs based on personal and cultural preferences, health literacy, and access to healthful foods. It maintains the pleasure of eating by providing nonjudgmental messages about food choices and offers practical tools for developing healthy patterns. All individuals should be encouraged to replace refined carbohydrates and added sugars with whole grains, legumes, vegetables, and fruit. Individuals who take mealtime insulin should be offered intensive education on coupling insulin administration with carbohydrate intake. Weight loss is discussed in more detail below. Physical Activity Recommendations Children with diabetes or prediabetes should be encouraged to engage in at least 60 min of physical activity each day. B Adults with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (50–70% maximum heart rate), spread over at least 3 days/week with no more than 2 consecutive days without exercise. A All individuals, including those with diabetes, should be encouraged to reduce sedentary time, particularly by breaking up extended amounts of time (>90 min) spent sitting. B In the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week. A Physical activity is a general term that includes all movement that increases energy use and is an important part of the diabetes management plan. Exercise is a more specific form of physical activity that is structured and designed to improve physical fitness. There is no routine pre-exercise testing recommended. However, providers should assess patients for conditions that might contraindicate certain types of exercise or predispose to injury and customize the exercise regimen to the individual’s needs. Smoking Cessation: Tobacco and e-Cigarettes Recommendations Advise all patients not to use cigarettes, other tobacco products, or e-cigarettes. A Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care. B Immunizations Recommendations Provide routine vaccinations for children and adults with diabetes as for the general population according to age-related recommendations. C Administer hepatitis B vaccine to unvaccinated adults with diabetes who are aged 19–59 years. C Consider administering hepatitis B vaccine to unvaccinated adults with diabetes who are aged ≥60 years. C Psychosocial Issues Recommendations The patient’s psychological and social situation should be addressed in the medical management of diabetes. B Psychosocial screening and follow-up may include, but are not limited to, attitudes about the illness, expectations for medical management and outcomes, affect/mood, general and diabetes-related quality of life, resources (financial, social, and emotional), and psychiatric history. E Routinely screen for psychosocial problems such as depression, diabetes-related distress, anxiety, eating disorders, and cognitive impairment. B Older adults (aged ≥65 years of age) with diabetes should be considered for evaluation of cognitive function, depression screening, and treatment. B Patients with comorbid diabetes and depression should receive a stepwise collaborative care approach for the management of depression. A Key opportunities for screening occur at multiple times during the management of diabetes: when medical status changes (e.g., at the end of the honeymoon period), when the need for intensified treatment is evident, and when complications are discovered. Optimizing the patient-provider relationship as a foundation may increase the likelihood of the patient accepting referral for other services. Comprehensive Medical Evaluation Recommendations A complete medical evaluation should be performed at the initial visit to: Confirm the diagnosis and classify diabetes. B Detect diabetes complications and potential comorbid conditions. E Review previous treatment and risk factor control in patients with established diabetes. E Begin patient engagement in the formulation of a care management plan. B Develop a plan for continuing care. B PREVENTION OR DELAY OF TYPE 2 DIABETES Recommendations 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 loss of 7% of body weight and should increase their moderate physical activity (such as brisk walking) to at least 150 min/week. A Metformin therapy for prevention of type 2 diabetes should be considered in those with prediabetes, especially in those with a BMI >35 kg/m2, those aged 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. B Pharmacotherapy Recommendations When choosing glucose-lowering medications for overweight or obese patients with type 2 diabetes, consider their effect on weight. E Whenever possible, minimize medications for comorbid conditions that are associated with weight gain. E Weight loss medications may be effective as adjuncts to diet, physical activity, and behavioral counseling for selected patients with type 2 diabetes and a BMI ≥27 kg/m2. Potential benefits must be weighed against the potential risks of the medications. A If a patient’s response to weight loss medications is 35 kg/m2 and type 2 diabetes, especially if diabetes or associated comorbidities are difficult to control with lifestyle and pharmacological therapy. B Patients with type 2 diabetes who have undergone bariatric surgery need lifelong lifestyle support and annual medical monitoring, at a minimum. B Although small trials have shown a glycemic benefit of bariatric surgery in patients with type 2 diabetes and a BMI of 30–35 kg/m2, there is currently insufficient evidence to generally recommend surgery for patients with a BMI ≤35 kg/m2. E Younger age, shorter duration of type 2 diabetes, lower A1C, higher serum insulin levels, and nonuse of insulin have all been associated with higher diabetes remission rates after bariatric surgery. APPROACHES TO GLYCEMIC TREATMENT Pharmacological Therapy for Type 1 Diabetes Recommendations 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 therapy. A Consider educating individuals with type 1 diabetes on matching prandial insulin doses to carbohydrate intake, premeal blood glucose levels, and anticipated physical activity. E Most individuals with type 1 diabetes should use insulin analogs to reduce hypoglycemia risk. A For patients with frequent nocturnal hypoglycemia and/or hypoglycemia unawareness, a sensor-augmented pump with a low glucose threshold feature may be considered. Pharmacological Therapy for Type 2 Diabetes Recommendations Metformin, if not contraindicated and if tolerated, is the preferred initial pharmacological agent for type 2 diabetes. A Consider initiating insulin therapy (with or without additional agents) in patients with newly diagnosed type 2 diabetes who are symptomatic and/or have markedly elevated blood glucose levels or A1C. E If noninsulin monotherapy at the 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. A A 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. E For patients with type 2 diabetes who are not achieving glycemic goals, insulin therapy should not be delayed. B Figure 2 emphasizes drugs commonly used in the United States and/or Europe. FIGURE 2. Antihyperglycemic therapy in type 2 diabetes: general recommendations. The order in the chart was determined by historical availability and the route of administration, with injectables to the right; it is not meant to denote any specific preference. Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed, with the usual transition moving vertically from top to bottom (although horizontal movement within therapy stages is also possible, depending on the circumstances). DPP-4-i, DPP-4 inhibitor; fxs, fractures; GI, gastrointestinal; GLP-1-RA, GLP-1 receptor agonist; GU, genitourinary; HF, heart failure; Hypo, hypoglycemia; SGLT2-i, SGLT2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione. *See ref. 17 in the full SOC document for description of efficacy categorization. †Consider starting at this stage when A1C is ≥9% (75 mmol/mol). ‡Consider starting at this stage when blood glucose is ≥300–350 mg/dL (16.7–19.4 mmol/L) and/or A1C is ≥10–12% (86–108 mmol/mol), especially if symptomatic or catabolic features are present, in which case basal insulin + mealtime insulin is the preferred initial regimen. §Usually a basal insulin (NPH, glargine, detemir, degludec). Adapted with permission from Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2015;38:140–149. A comprehensive list of the properties of available glucose-lowering agents in the United States and Europe that may guide individualized treatment choices in patients with type 2 diabetes is available in the complete 2016 Standards. Many patients with type 2 diabetes eventually require and benefit from insulin therapy. The progressive nature of type 2 diabetes and its therapies should be regularly and objectively explained to patients. Providers should avoid using insulin as a threat or describing it as a failure or punishment. Equipping patients with an algorithm for self-titration of insulin doses based on SMBG results improves glycemic control in patients with type 2 diabetes who are initiating insulin. CARDIOVASCULAR DISEASE AND RISK MANAGEMENT Atherosclerotic CVD (ASCVD)—defined as acute coronary syndromes, a history of myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease (PAD) presumed to be of atherosclerotic origin—is the leading cause of morbidity and mortality for individuals with diabetes and is the largest contributor to the direct and indirect costs of diabetes. In all patients with diabetes, cardiovascular risk factors should be systematically assessed at least annually. These risk factors include dyslipidemia, hypertension, smoking, a family history of premature coronary disease, and the presence of albuminuria. Numerous studies have shown the efficacy of controlling individual cardiovascular risk factors in preventing or slowing ASCVD in people with diabetes. Large benefits are seen when multiple risk factors are addressed simultaneously. There is evidence that measures of 10-year coronary heart disease risk among U.S. adults with diabetes have improved significantly over the past decade, and ASCVD morbidity and mortality have decreased. Blood Pressure Control Recommendations People with diabetes and hypertension should be treated to a systolic blood pressure (SBP) of 120/80 mmHg should be advised on lifestyle changes to reduce blood pressure. B 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. A In older adults, pharmacological therapy to achieve treatment goals of 50 mg/dL (1.3 mmol/L) in patients who cannot tolerate high-dose statins Moderate plus ezetimibe >75 years None Moderate ASCVD risk factors Moderate or high ASCVD High ACS and LDL cholesterol >50 mg/dL (1.3 mmol/L) in patients who cannot tolerate high-dose statins Moderate plus ezetimibe * In addition to lifestyle therapy. ** ASCVD risk factors include LDL cholesterol ≥100 mg/dL (2.6 mmol/L), high blood pressure, smoking, overweight and obesity, and family history of premature ASCVD. ACS, acute coronary syndrome. TABLE 8. High- and Moderate-Intensity Statin Therapy* High-intensity statin therapy Moderate-intensity statin therapy Lowers LDL cholesterol by ≥50% Lowers LDL cholesterol by 30% to 10%). This includes most men and women with diabetes who are ≥50 years of age who have at least one additional major risk factor (i.e., family history of premature ASCVD, hypertension, smoking, dyslipidemia, or albuminuria) and are not at increased risk of bleeding. C Aspirin should not be recommended for ASCVD prevention for adults with diabetes at low ASCVD risk (10-year ASCVD risk 10 years). Patients with high-risk foot conditions (e.g., history of ulcer or amputation, deformity, loss of protective sensation, or PAD) should be educated about their risk factors and appropriate management. The selection of appropriate footwear and footwear behaviors at home should also be discussed. This may include well-fitted walking shoes or athletic shoes that cushion the feet and redistribute pressure. People with bony deformities or more advanced disease may require custom-fitted shoes. OLDER ADULTS Recommendations Older adults (≥65 years of age) who are functional and cognitively intact and have significant life expectancy may receive diabetes care with goals similar to those developed for younger adults. E Consider 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. E Glycemic 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. E Hypoglycemia should be avoided in older adults with diabetes. It should be screened for and managed by adjusting glycemic targets and pharmacological interventions. B Patients 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. E Other 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 a life expectancy at least equal to the time frame of primary or secondary prevention trials. E When 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. E Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment. E Screening for geriatric syndromes may be appropriate in older adults experiencing limitations in their basic and instrumental activities of daily living because such limitations may affect diabetes self-management. E Older adults with diabetes should be considered a high-priority population for depression screening and treatment. B Consider diabetes education for the staff of long-term care facilities to improve the management of older adults with diabetes. E Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life. E Older individuals have a higher risk of premature death, coexisting illnesses, depression, and geriatric syndromes, including neurocognitive impairment. Refer to the ADA consensus report “Diabetes in Older Adults” for details. Treatment Goals The care of older adults with diabetes is complicated by their clinical and functional heterogeneity. Providers caring for older adults with diabetes must take this heterogeneity into consideration when setting and prioritizing treatment goals (Table 10). TABLE 10. Framework for Considering Treatment Goals for Glycemia, Blood Pressure, and Dyslipidemia in Older Adults With Diabetes Patient characteristics/health status Rationale Reasonable A1C goal‡ Fasting or preprandial glucose Bedtime glucose Blood pressure (mmHg) Lipids mg/dL mmol/L mg/dL mmol/L Healthy (few coexisting chronic illnesses, intact cognitive and functional status) Longer remaining life expectancy 250 mg/dL [13.9 mmol/L]). For patients in the LTC setting, special attention should be given to nutritional considerations, end of life care, and diabetes management in those with advanced disease. Acknowledging the limited benefit of intensive glycemic control in people with advanced disease can guide A1C goals and determine the use or withdrawal of medications. CHILDREN AND ADOLESCENTS See page 5 for screening and diagnostic testing information. The following recommendations were developed for children and adolescents with type 1 diabetes. However, the guidelines are the same for children and adolescents with type 2 diabetes, with the addition of blood pressure measurement, a fasting lipid panel, assessment for albumin excretion, and dilated eye examination at the time of type 2 diabetes diagnosis. Glycemic Control Recommendations An A1C goal of 140 mg/dL (7.8 mmol/L) Hypoglycemia : <70 mg/dL (3.9 mmol/L) Severe hypoglycemia : <40 mg/dL (2.2 mmol/L) Admission A1C value ≥6.5% (48 mmol/mol) suggests preexisting diabetes Moderate Versus Tight Glycemic Control Data have shown increased rates of severe hypoglycemia and mortality in tightly versus moderately controlled cohorts in critically ill patients. This evidence established new standards as noted above. Patients with a history of successful tight glycemic control in the outpatient setting who are clinically stable may be maintained with a glucose target <140 mg/dL. Conversely, higher glucose ranges may be acceptable in other appropriate patients. Antihyperglycemic Agents in Hospitalized Patients In most instances in the hospital setting, insulin is the preferred treatment for glycemic control. Insulin therapy IV insulin protocols should be used for critically ill patients. Basal-bolus regimens that include correction doses and account for oral intake may be used for many noncritical-care patients. Scheduled subcutaneous (SQ) insulin injections should align with meals and bedtime or be given every 4–6 hours if no meals are taken or if continuous enteral/parenteral therapy is being used. SQ insulin should be administered 1–2 hours before IV insulin is discontinued. Converting to basal insulin at 60–80% of the daily infusion dose has been shown to be effective. Standards for Special Situations Refer to the full Standards for guidance on enteral/parenteral feedings, diabetic ketoacidosis and hyperosmolar hyperglycemic state, and glucocorticoid therapy. Perioperative Care On the morning of surgery or a procedure, hold any oral hypoglycemic agents; give half of the patient’s NPH insulin dose or full doses of long-acting analog or pump basal insulin. Monitor blood glucose every 4–6 hours while a patient is NPO, and dose with short-acting insulin as needed with a target of 80–180 mg/dL (4.4–10.0 mmol/L). Treating and Preventing Hypoglycemia Standardized nurse-driven protocols should be used for hypoglycemia avoidance and treatment. Consider iatrogenic or patient factors that may result in hypoglycemia. Self-Management in the Hospital Diabetes self-management in the hospital may be appropriate for select youth and adult patients who successfully conduct comprehensive self-management of diabetes at home, have the cognitive and physical skills needed to successfully self-administer insulin, and perform SMBG. Medical Nutrition Therapy in the Hospital The goals of MNT are to optimize glycemic control, provide adequate calories to meet metabolic demands, and address personal food preferences. The term “ADA diet” is no longer used. A registered dietitian can serve as an inpatient team member. Transition From the Acute Care Setting Tailor a structured discharge plan beginning at admission and update as patient needs change. It is important that patients be provided with appropriate durable medical equipment, medications, supplies, and prescriptions, along with appropriate education at the time of discharge. An outpatient follow-up visit within 1 month of discharge is advised for all patients having hyperglycemia in the hospital. Continuing contact may also be needed. Clear communication with outpatient providers either directly or via structured hospital discharge summaries facilitates safe transitions to outpatient care. If oral medications are held in the hospital, there should be protocols for resuming them 1–2 days before discharge. DIABETES ADVOCACY Advocacy Position Statements For a list of ADA advocacy position statements, including “Diabetes and Driving” and “Diabetes and Employment,” refer to Section 14 (“Diabetes Advocacy”) of the complete 2016 Standards.
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Screening for gestational diabetes mellitus: U.S. Preventive Services Task Force recommendation statement.
, V Moyer (2014)
Update of the 2008 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for gestational diabetes mellitus (GDM). The USPSTF reviewed the evidence on the accuracy of screening tests for GDM, the benefits and harms of screening before and after 24 weeks of gestation, and the benefits and harms of treatment in the mother and infant. This recommendation applies to pregnant women who have not been previously diagnosed with type 1 or 2 diabetes mellitus. The USPSTF recommends screening for GDM in asymptomatic pregnant women after 24 weeks of gestation. (B recommendation)The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for GDM in asymptomatic pregnant women before 24 weeks of gestation. (I statement).
Author and article information
Journal
Journal ID (publisher-id): rpr
Title:
Revista de Ciencias Médicas de Pinar del Río
Abbreviated Title:
Rev Ciencias Médicas
Publisher:
Editorial Ciencias Médicas
(Pinar del Río, , Cuba
)
ISSN
(Electronic):
1561-3194
Publication date
(Print and electronic):
August
2019
Volume: 23
Issue: 4
Pages: 513-522
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Article
Publisher ID: S1561-31942019000400513 Publisher ID: S1561-3194(19)02300400513SO-VID: ecb16241-8059-4164-9d95-4b588c8cd8fd
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
History
Date
received
: 26
February
2019
Date
accepted
: 20
May
2019
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Tables: 0,
Equations: 0,
References: 14,
Pages: 10
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SciELO Cuba
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ARTÍCULOS ORIGINALES
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