Diabetes Risk Management Quiz

Section 1: Improving Care and Promoting Health in Populations

• A multifaceted approach encompassing patient-level, system-level, and policy-level interventions is crucial for enhancing population health in the context of diabetes.
• Patient-Level: Minimize therapeutic inertia in diagnosis and treatment. Align with evidence-based treatment guidelines. Address social determinants of health. Foster shared decision-making that considers individual preferences, prognoses, comorbidities, and financial factors.
• System-Level: Foster a quality-oriented culture to improve safety, timeliness, effectiveness, equity, and person-centeredness through system-based approaches. Leverage patient registries and electronic health records for quality enhancement in diabetes care. Use collaborative, multidisciplinary health care teams for diabetes care delivery. Incorporate telehealth alongside in-person visits to expand access to quality diabetes care. Ensure access to diabetes self-management education and support, using both professional and community-based resources. Evaluate socioeconomic and linguistic barriers to diabetes management and care, and facilitate referrals to local community resources when needed.
• Policy-Level: Ensure access to health insurance with adequate coverage for all aspects of diabetes management, including medications, supplies/equipment, technology, and medical care. Ensure access to health care professionals with expertise in diabetes management.

Section 2: Diagnosis and Classification of Diabetes

• There is insufficient evidence to support the use of continuous glucose monitoring for screening or diagnosing prediabetes or diabetes.
• In the absence of unequivocal hyperglycemia (e.g., hyperglycemic crisis), diagnosis of type 2 diabetes requires confirmatory testing.
• Classification of diabetes type is not always straightforward at presentation, and misdiagnosis is common.
• Diagnostic criteria and tests for different types of diabetes (A1C, fasting plasma glucose, 2-hour glucose tolerance test) are included.

Section 3: Prevention or Delay of Diabetes and Associated Comorbidities

• Screening for prediabetes and type 2 diabetes should be performed in asymptomatic adults with an informal assessment of risk factors or a validated risk calculator.
• Informal risk factor assessment includes factors like age, history of prediabetes, history of GDM, overweight/obesity (BMI ≥25/23 in Asians, respective), first-degree relative with diabetes, high-risk race/ethnicity, history of cardiovascular disease, hypertension, polycystic ovary syndrome, HDL cholesterol <35 mg/dL, triglycerides >250 mg/dL, physical inactivity, or other conditions associated with insulin resistance.
• Screening criteria for prediabetes and type 2 diabetes in children and adolescents include overweight (BMI ≥85th percentile) or obesity (BMI ≥95th percentile) and one or more risk factors.
• Screening should be repeated at least annually for those with prediabetes; or every 3 years (annually for those with prediabetes) if results are normal, or sooner with symptoms or changes in risk.

Section 4: Comprehensive Medical Evaluation and Assessment of Comorbidities

• People with type 1 diabetes should be screened soon after diagnosis and periodically thereafter for autoimmune thyroid disease, celiac disease, autoimmune liver disease, collagen vascular diseases, pernicious anemia, primary adrenal insufficiency, and/or myasthenia gravis.
• People with type 1 or type 2 diabetes have a higher fracture risk than those without diabetes.
• Optimizing bone health in people with diabetes includes screening older adults (>65 years of age) and high-risk young adults with Dual-energy X-ray absorptiometry every 2-3 years. Nutritional counseling (calcium and vitamin D, aerobic and weight-bearing physical activity, fall precautions) and pharmacotherapy (glucose-lowering medications safe for bone health) are also recommended where appropriate.

Section 5: Facilitating Positive Health Behaviors and Well-Being to Improve Health Outcomes

• Building positive health behaviors and maintaining psychological well-being is critical for effective diabetes management.
• Essential tasks include referral for diabetes self-management education and support (DSMES), medical nutrition therapy (MNT), counseling on routine physical activity, and support cessation of tobacco and products.
• Psychosocial care is essential for all people with diabetes; this often includes screening, interventions, and referral to behavioral health professionals or other trained healthcare professionals. Includes assessing life circumstances, and social and family support resources.

Section 6: Glycemic Goals and Hypoglycemia

• A1C, continuous glucose monitoring (CGM), and glucose management indicator (GMI) are key tools for assessing glycemic status.
• Glycemic goals are individualized based on characteristics of the person with diabetes, like age and disease duration. Also factors like comorbidities, preferences and resources/support.
• Common general guidelines include an A1C goal less than 7.0% (<53 mmol/mol) in many non-pregnant adults without significant hypoglycemia.

Section 7: Diabetes Technology

• Technology available includes insulin pumps, connected insulin pens, continuous glucose monitors (CGM), and automated insulin delivery (AID) systems; diabetes self-management support software.
• Diabetes devices should be offered to people with diabetes, with individualized type(s) and selection of devices based on needs, preferences, and skills.

Section 8: Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes

• Weight management is crucial for people with type 2 diabetes and overweight or obesity, as it delays progression, improves glycemia, reduces cardiovascular risks, and reduces other obesity-related health risks.
• Person-centered treatment options for overweight and obesity in type 2 diabetes generally include intensive behavioral counseling, obesity pharmacotherapy, and/or metabolic surgery. The appropriate choice is based on individual BMI, and other relevant factors assessed individually.

Section 9: Pharmacologic Approaches to Glycemic Treatment

• Strategies, to address barrier to treatment and empower patients to optimize diabetes care via individualization of care and use of appropriate glucose lowering medications.
• When to initiate injectable therapies (GLP-1 agonists or dual GIP/GLP-1 receptor agonists) in type 2 diabetes in relation to factors such as A1C, glucose, and/or ketosis.

Section 10: Cardiovascular Disease and Risk Management

• Atherosclerosis is the primary cause of morbidity and mortality in individuals with diabetes.
• Recommendations for treating hypertension in nonpregnant people with diabetes include lifestyle management, and initiating one or two medications based on blood pressure and albuminuria (albuminuria is a protein in urine).
• Screening and treatment for asymptomatic cardiovascular disease based on patient risk. This includes coronary artery disease, heart failure and peripheral artery disease.

Section 11: Chronic Kidney Disease and Risk Management

• Screening for chronic kidney disease (CKD) in people with type 1 or type 2 diabetes includes annually assessing urine albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR).
• Monitoring and classifying CKD is based on cause, GFR and/or albuminuria values.

Section 12: Retinopathy, Neuropathy, and Foot Care

• Optimizing the management of glycemia, blood pressure, and lipids can reduce or slow the progression of microvascular complications of diabetes.
• Routine eye exams, with dilated comprehensive eye exam or retinal photography for people with type 1 or type 2 diabetes are recommended (specific frequencies based on individual factors/complications/treatments).
• Screening for neuropathy (at diagnosis and annually thereafter for type 1 and 2 diabetes), treatment with various medications and/or behavioral interventions; as well as foot care (daily inspection, appropriate footwear).

Section 13: Older Adults

• Individualization of treatment goals and medication plans is critical for older adults with diabetes, considering factors like health status, comorbidities, and functional capabilities, and risks.
• Treatment plans for older adults should be designed with consideration for the individual's capacity for managing medications and/or complex regimens; or use simpler regimens with an emphasis on preventing serious side effects (i.e., hypoglycemia), and avoiding polypharmacy.

Section 14: Children and Adolescents

• Address diabetes self-management education and support of youth.
• Screening and diagnosis (type 2) in youth and adolescents, as well as comprehensive treatment and monitoring.

Section 15: Management of Diabetes in Pregnancy

• Preconception and preconception counseling with family planning.
• Glycemic goals in pregnancy: Optimize glucose levels; ideally A1c <6% , or goal can be <7% .
• Recommendations for management of gestational diabetes mellitus (GDM); and post-partum care.

Section 16: Diabetes Care in the Hospital

• Carefully managing people with diabetes during hospitalization is important to prevent hyperglycemia, hypoglycemia, or extreme glucose variability.
• Instituting specific care standards and protocols for managing blood glucose levels.
• Transitioning from hospital care to outpatient care; ensuring appropriate care continuity, including arranging follow-up visits.