2024 ADA Recommendations for Diabetes Care (Abridged) PDF

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. This approach may include the following key elements. Patient-Level...

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. This approach may include the following key elements. Patient-Level System-Level Policy-Level Minimize therapeutic Foster a quality-oriented culture to improve safety, Ensure access to Downloaded from http://diabetesjournals.org/clinical/article-pdf/42/2/182/756287/diaclincd24a001.pdf by guest on 13 December 2024 inertia in diagnosis and timeliness, effectiveness, equity, and person- health insurance with treatment. centeredness through system-based approaches. adequate coverage for all aspects of diabetes Align with evidence- Leverage patient registries and electronic health management, including based treatment records for quality enhancement in diabetes care. medications, supplies/ guidelines. Use collaborative, multidisciplinary health care equipment, technology, Address social teams for diabetes care delivery. and medical care. determinants of health. Incorporate telehealth alongside in-person visits to Ensure access to health Foster shared expand access to quality diabetes care. care professionals with decision-making that expertise in diabetes Ensure access to diabetes self-management considers individual management. education and support, using both professional and preferences, prognoses, community-based resources. comorbidities, and financial factors. Evaluate socioeconomic and linguistic barriers to diabetes management and care, and facilitate referrals to local community resources when needed. Suggested citation: American Diabetes Association Primary Care Advisory Group. 1. Improving care and promoting health in populations: Standards of Care in Diabetes—2024 abridged for primary care professionals. Clin Diabetes 2024;42:182 (doi: 10.2337/cd24-a001). ©2024 by the American Diabetes Association. 182 DIABETESJOURNAL.ORG/CLINICAL Section 2: Diagnosis and Classification of Diabetes Diagnostic Tests for Diabetes A1C Fasting plasma glucose Prediabetes: Prediabetes: 5.7–6.4% (39–47 mmol/ 100–125 mg/dL mol) (5.6–6.9 mmol/L) Downloaded from http://diabetesjournals.org/clinical/article-pdf/42/2/183/756119/diaclincd24a002.pdf by guest on 13 December 2024 Diabetes: Diabetes: ≥6.5% (≥48 mmol/mol) ≥126 mg/dL (≥7.0 mmol/L) 2-hour glucose Diagnostic criteria Random glucose value during a value with classic 75-g oral glucose hyperglycemia tolerance test symptoms/ hyperglycemic crisis Prediabetes: 140–199 mg/dL (7.8–11.0 mmol/L) Diabetes: ≥200 mg/dL (≥11.1 mmol/L) Diabetes: ≥200 mg/dL (≥11.1 mmol/L) 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, which can be a different test on the same day or the same test on a different day. Marked discordance between A1C and repeated blood glucose measurements should raise the possibility of a problem or interference with either test. Classification Classification of diabetes type is not always straightforward at presentation, and misdiagnosis is common. Type 2 diabetes (non-autoimmune Type 1 diabetes (idiopathic or progressive loss of adequate β-cell autoimmune β-cell destruction) insulin secretion frequently on the background of insulin resistance and metabolic syndrome) Gestational diabetes mellitus (GDM; detected at 24–28 weeks Diabetes from other causes (e.g., of gestation in individuals monogenic diabetes syndromes, without previously identified diseases of the exocrine pancreas, diabetes or high-risk glucose and drug- or chemical-induced metabolism) diabetes) Suggested citation: American Diabetes Association Primary Care Advisory Group. 2. Diagnosis and classification of diabetes: Standards of Care in Diabetes—2024 abridged for primary care professionals. Clin Diabetes 2024;42:183–185 (doi: 10.2337/cd24-a002). ©2024 by the American Diabetes Association. 183 DIABETESJOURNALS.ORG/CLINICAL ABRIDGED STANDARDS OF CARE 2024 Section 2: Diagnosis and Classification of Diabetes Screening Criteria for Prediabetes and Type 2 Diabetes: 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 for Prediabetes and Type 2 Diabetes Everyone ≥35 History of years of age prediabetes People with HIV, exposure Downloaded from http://diabetesjournals.org/clinical/article-pdf/42/2/183/756119/diaclincd24a002.pdf by guest on 13 December 2024 People with to high-risk medicines, or a prior GDM history of pancreatitis. Adults (≥18 years of age) with overweight or obesity (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian American individuals) who have one or more of the following risk factors: ʜʜ First-degree relative with diabetes ʜʜ High-risk race/ethnicity ʜʜ History of cardiovascular disease ʜʜ Hypertension (≥130/80 mmHg or on therapy for hypertension) ʜʜ Polycystic ovary syndrome ʜʜ HDL cholestorol 2.8 mmol/L) ʜʜ Physical inactivity ʜʜ Other clinical conditions associated with insulin resistance Clinical Notes ӳӳ If results are normal, repeat screening at least every 3 years (annually for those with prediabetes), or sooner with symptoms or changes in risk. ӳӳ Risk-based screening for prediabetes or type 2 diabetes should be considered after the onset of puberty or after 10 years of age, whichever occurs earlier, in children and adolescents with overweight (BMI ≥85th percentile) or obesity (BMI ≥95th percentile) who have one or more risk factors for diabetes. VOLUME 42, NUMBER 2, SPRING 2024 184  AMERICAN DIABETES ASSOCIATION Additional Screening Guidelines Condition Clinical Tips Best Test An altered relationship A mismatch between A1C and glycemia could be caused Fasting plasma between A1C and glycemia by some hemoglobin variants, pregnancy (second and third glucose trimesters and the postpartum period), glucose-6-phosphate dehydrogenase deficiency, HIV, hemodialysis, recent blood loss or transfusion, anemia, or erythropoietin therapy. People with HIV should be screened for diabetes and prediabetes before and 3–6 months after starting or changing antiretroviral therapy, and annually if initial results are normal. Acute pancreatitis Screen for diabetes 3-6 months after an episode of acute Any standard test pancreatitis and annually thereafter. for diagnosing diabetes Downloaded from http://diabetesjournals.org/clinical/article-pdf/42/2/183/756119/diaclincd24a002.pdf by guest on 13 December 2024 Cystic fibrosis Annual screening should begin by the age of 10 years in all Oral glucose people with cystic fibrosis not previously diagnosed with tolerance test cystic fibrosis-related diabetes Posttransplantation status Screen for hyperglycemia after organ transplantation. Oral glucose Posttransplantation diabetes mellitus should be diagnosed tolerance test when the individual is stable on immunosuppressive therapy and free of acute infections. Possible monogenic Suspect monogenic diabetes in people diagnosed with Any standard test diabetes diabetes in the first 6 months of life and in children and for diagnosing young adults with atypical characteristics of type 1 or type diabetes plus 2 diabetes, who often have a family history of diabetes appropriate genetic in successive generations (suggestive of an autosomal testing dominant pattern of inheritance). Therapy with certain Consider screening people for prediabetes or diabetes if Any standard test medications they are on certain medications known to increase diabetes test for diagnosing risk, such as glucocorticoids, statins, thiazide diuretics, diabetes some HIV medications, and second-generation antipsychotic medications. 185 DIABETESJOURNALS.ORG/CLINICAL Section 3: Prevention or Delay of Diabetes and Associated Comorbidities Screening for Type 2 Diabetes Downloaded from http://diabetesjournals.org/clinical/article-pdf/42/2/186/756109/diaclincd24a003.pdf by guest on 13 December 2024 1. Why Screen? 2. How to Screen 3. When to Screen Lab testing is safe and cost- Conduct an informal assessment Monitor people with prediabetes effective. of risk factors. at least annually. Screening presents an opportunity –or– In those without prediabetes to address cardiovascular risk who have normal results, repeat Use an assessment tool such as factors (e.g., hypertension and screening at least every 3 years. the ADA risk test. dyslipidemia). Screen after the onset of puberty Consider diagnostic testing based or after the age of 10 years in on assessment results. children and adolescents with overweight (BMI ≥85th percentile) or obesity (BMI ≥95th percentile) who have at least one risk factor. Symptoms suggestive of diabetes or changes in risk Diet and Physical Activity Recommendations for Adults at Risk for Type 2 Diabetes Follow a Healthy Eating Pattern Get Regular Physical Activity Emphasize whole grains, legumes, nuts, fruits, and ≥150 min/week of moderate-intensity physical vegetables and minimize refined and processed activity, such as brisk walking foods May include resistance or strength training A variety of healthy eating patterns include: Break up prolonged sedentary time » Mediterranean-style » Low-carbohydrate » Vegetarian or plant-based » DASH (Dietary Approaches to Stop Hypertension) Suggested citation: American Diabetes Association Primary Care Advisory Group. 3. Prevention or delay of diabetes and associated comorbidities: Standards of Care in Diabetes—2024 abridged for primary care professionals. Clin Diabetes 2024;42:186–188 (doi: 10.2337/cd24-a003). ©2024 by the American Diabetes Association. 186 DIABETESJOURNALS.ORG/CLINICAL  AMERICAN DIABETES ASSOCIATION Where to Refer қ What is the Diabetes Prevention Program? Refer adults with overweight or The Diabetes Prevention Program (DPP) study demonstrated obesity who are at high risk for that intensive lifestyle intervention could reduce the risk of type type 2 diabetes to a recognized 2 diabetes by 58% over 3 years. The two major goals of the DPP diabetes prevention lifestyle intensive lifestyle intervention were to achieve and maintain change program ≥7% weight loss and ≥150 min of moderate-intensity physical (cdc.gov/diabetes/ prevention/ activity, such as brisk walking, per week. find-a-program.html). Technology-assisted programs using smartphones, web apps, and telehealth platforms can effectively deliver the DPP lifestyle change program, overcoming barriers, especially for low-income and rural individuals. Downloaded from http://diabetesjournals.org/clinical/article-pdf/42/2/186/756109/diaclincd24a003.pdf by guest on 13 December 2024 Person-Centered Care Goals for Individuals at Risk of Type 2 Diabetes It is important to weight the individualized risks and benefits of interventions. Facilitate weight management in Minimize progression of Reduce cardiovascular risk. those with overweight/obesity. hyperglycemia. Consider more intensive approaches for individuals at high risk of progression to diabetes. BMI ≥35 kg/m² Higher glucose levels History of gestational (e.g., fasting plasma glucose diabetes mellitus 110–125 mg/dL [6.1–6.9 mmol/L], 2–h post-challenge glucose 173–199 mg/dL [9.6–11 mmol/L], and A1C ≥6.0% [42 mmol/mol]) VOLUME 42, NUMBER 2, SPRING 2024 187 ABRIDGED STANDARDS OF CARE 2024 Section 3: Prevention or Delay of Diabetes and Associated Comorbidities қ What medications can be prescribed to adults to prevent type 2 diabetes? The U.S. Food and Drug Administration has not approved any drugs for diabetes prevention. Metformin has the strongest evidence base for diabetes prevention. қ Who should be considered for metformin therapy to prevent type 2 diabetes? Adults aged 25–59 years with a BMI ≥35 kg/m2 Individuals with higher fasting plasma glucose (e.g., ≥110 mg/dL [≥ 6 mmol/L]) Those with higher A1C (e.g., ≥6.0% [≥42 mmol/mol]) Individuals with a history of gestational diabetes mellitus Downloaded from http://diabetesjournals.org/clinical/article-pdf/42/2/186/756109/diaclincd24a003.pdf by guest on 13 December 2024 қ What parameters should be monitoring in people on metformin therapy? Vitamin B12 should be measured periodically, especially in those with anemia or peripheral neuropathy. қ Screening for type 1 diabetes? 1. Screen using autoantibodies 2. In people with preclinical type 1 diabetes, monitor for disease progression using A1C approximately every 6 months and 75-g oral glucose tolerance test (i.e., fasting and 2-h plasma glucose) annually; modify frequency of monitoring based on individual risk assessment based on age, number and type of autoantibodies, and glycemic metrics. Ҝ Medication to delay the onset of type 1 diabetes Teplizumab-mzwv infusion to delay the onset of symptomatic type 1 diabetes should be considered in selected individuals who are ≥8 years of age and have stage 2 type 1 diabetes. Staging of type 1 diabetes Stage 1 Stage 2 Stage 3 Characteristics Autoimmunity Autoimmunity Autoimmunity Normoglycemia Dysglycemia Overt hyperglycemia Presymptomatic Presymptomatic Symptomatic Diagnostic criteria Multiple islet Islet autoantibodies (usually multiple) Autoantibodies may autoantibodies Dysglycemia: IFG and/or IGT become absent No IGT or IFG FPG 100–125 mg/dl (5.6–6.9 mmol/L) Diabetes by standard 2-h PG 140–199 mg/dl (7.8–11.0 mmol/L) criteria A1C 5.7–6.4% (39–47 mmol/mol) or ≥10% increase in A1C Adapted from Skyler JS, Bakris GL, Bonifacio E, et al. Differentiation of diabetes by pathophysiology, natural history, and prognosis. Diabetes 2017;66:241–255.. FPG, fasting plasma glucose; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; 2-h PG, 2-h plasma glucose. Alternative additional stage 2 diagnostic criteria of 30-, 60-, or 90-min plasma glucose on oral glucose tolerance test ≥200 mg/dL (≥11.1 mmol/L) and confirmatory testing in those aged ≥ 18 years have been used in clinical trials. Herold KC, Bundy BN, Long SA, et al.; Type 1 Diabetes TrialNet Study Group. An anti-CD3 antibody, teplizumab, in relatives at risk for type 1 diabetes. N Engl JMed 2019;381:603–613. қ Does statin therapy increase the risk of developing type 2 diabetes? Statin therapy may slightly elevate type 2 diabetes risk in high-risk individuals. In primary and secondary prevention of cardiovascular disease, statin benefits outweigh diabetes risk. Discontinuing statins based on concerns about increased diabetes risk is not advised. қ Does pioglitazone have a role in secondary cardiovascular prevention in people at risk for type 2 diabetes? Pioglitazone could reduce stroke and myocardial infarction risks in people with a history of stroke and evidence of insulin resistance or prediabetes. However, the benefit must be weighed against potential weight gain, edema, and increased fracture risk. Lower doses may lessen these adverse effects. 188 DIABETESJOURNALS.ORG/CLINICAL Section 4: Comprehensive Medical Evaluation and Assessment of Comorbidities Diabetes treatment goals aim to prevent or delay complications and optimize quality of life. These goals should be developed collaboratively with people with diabetes to honor their preferences and values. Comprehensive diabetes care should be provided by an interprofessional team which may include but is not limited to diabetes care and education specialists, primary care and subspecialty clinicians, nurses, registered dietitian nutritionists, exercise specialists, pharmacists, dentists, podiatrists, behavioral health professionals, and community partners such as community health workers and community paramedics. Ongoing treatment necessitates regular follow-up and the active engagement of people with diabetes and their care partners. Comprehensive medical evaluations (described in the table below) and the provision of all recommended Downloaded from http://diabetesjournals.org/clinical/article-pdf/42/2/189/756155/diaclincd24a004.pdf by guest on 13 December 2024 vaccinations (cdc.gov/vaccines) are essential components of ongoing diabetes care. Assessment of Comorbidities қ What autoimmune conditions should people with type 1 diabetes be screened for? People with type 1 diabetes should be screened soon after diagnosis and periodically thereafter for: Қ Autoimmune thyroid disease Қ Other autoimmune conditions, if suggestive signs and symptoms are present Autoimmune Conditions Associated With Type 1 Diabetes Collagen Autoimmune Celiac disease vascular liver disease diseases Autoimmune Pernicious Primary adrenal Myasthenia thyroid disease anemia insufficiency gravis қ How does diabetes affect bone health? Қ People with type 1 or type 2 diabetes have a higher fracture risk than those without diabetes. Қ This risk escalates with longer diabetes duration and poor glycemic control. Қ People with type 2 diabetes on thiazolidinediones, insulin, or a sulfonylurea have an even higher fracture risk. Optimizing Bone Health in People With Diabetes Nutrition and Screening Pharmacotherapy Activity Қ In older adults Counsel on: Қ Choose glucose-lowering medications (>65 years of age) Қ Calcium and vitamin with safe profiles for bone health and and high-risk young D low hypoglycemia risk to prevent falls. adults Қ Aerobic and weight- Қ Consider antiresorptive and osteo- Қ Dual-energy X-ray bearing physical anabolic agents for those with a absorptiometry activity T-score ≤−2.0 or previous fragility every 2–3 years Қ Fall precautions fractures. Suggested citation: American Diabetes Association Primary Care Advisory Group. 4. Comprehensive medical evaluation and assessment of comorbidities: Standards of Care in Diabetes—2024 abridged for primary care professionals. Clin Diabetes 2024;42:189–192 (doi: 10.2337/cd24-a004). ©2024 by the American Diabetes Association. VOLUME 42, NUMBER 2, SPRING 2024 189 ABRIDGED STANDARDS OF CARE 2024 Section 4: Comprehensive Medical Evaluation and Assessment of Comorbidities қ Are people with diabetes at increased risk for cancer? Қ Diabetes is associated with increased risk of cancers of the liver, pancreas, endometrium, colon/rectum, breast, and bladder. Nevertheless, cancer screening recommendations are the same for people with diabetes as for those without diabetes. қ How prevalent is nonalcoholic fatty liver disease (NAFLD)? Who should be screened for it and how? High-Risk Prevalence Screening Goals Screening Tool Individuals Downloaded from http://diabetesjournals.org/clinical/article-pdf/42/2/189/756155/diaclincd24a004.pdf by guest on 13 December 2024 Approximately To identify People with Calculate the 70% of people individuals at risk central obesity and fibrosis-4 (FIB-4) with type 2 for complications cardiometabolic index score, which diabetes have from nonalcoholic risks or insulin is based on a NAFLD. steatohepatitis resistance person's age, ALT (NASH), such Individuals >50 and AST levels, and as cirrhosis and years of age platelet count hepatocellular Those with Screen with the carcinoma persistent FIB-4 index even if To prevent death liver enzymes are high plasma from liver disease normal aminotransferase levels (AST/ALT A FIB-4 index >30 units/L for >6 calculation tool is months) available online at Proposed Algorithm for Risk Stratification in Individuals mdcalc.com/calc/22 with NAFLD or NASH. 00/fibrosis-4-fib-4-i ndex-liver-fibrosis Noninvasive testing for fibrosis (FIB-4) Management Қ Weight loss with intensive lifestyle therapy and/or metabolic surgery, as Low risk Indeterminate risk High risk appropriate, is recommended. Қ Pioglitazone and glucagon-like peptide 1 receptor agonists are the preferred agents for treatment Repeat in 2–3 years Vibration-controlled transient elastography of hyperglycemia in adults with or ELF blood test type 2 diabetes and NASH, unless decompensated cirrhosis is present. Қ People with type 2 diabetes and decompensated cirrhosis Low risk High risk from NASH should be treated with insulin. Adapted from Kanwal F, Қ Statin therapy is safe in the Shubrook JH, Younossi setting of NAFLD. Use with caution Z, et al. Preparing for the Refer to a and close monitoring in people with NASH epidemic: a call Repeat in 2–3 years gastroenterologist or decompensated cirrhosis. to action. Diabetes Care hepatologist 2021;44:2162–2172. ELF, enhanced liver fibrosis. 190 DIABETESJOURNALS.ORG/CLINICAL  AMERICAN DIABETES ASSOCIATION Components of the Comprehensive Diabetes Medical Evaluation at Initial, Follow-Up, and Annual Visits Every Annual Initial Visit Follow-Up Visit Visit DIABETES HISTORY Characteristics at onset (e.g., age, symptoms) CIRCLE-CHECK Review of previous treatment plans and response CIRCLE-CHECK Assess frequency/cause/severity of past hospitalizations CIRCLE-CHECK FAMILY HISTORY Family history of diabetes in a first-degree relative CIRCLE-CHECK Family history of autoimmune disorder CIRCLE-CHECK PERSONAL HISTORY OF COMPLICATIONS AND COMMON COMORBIDITIES Downloaded from http://diabetesjournals.org/clinical/article-pdf/42/2/189/756155/diaclincd24a004.pdf by guest on 13 December 2024 Common comorbidities (e.g., obesity, OSA, NAFLD) CIRCLE-CHECK PAST MEDICAL High blood pressure or abnormal lipids CIRCLE-CHECK CIRCLE-CHECK AND FAMILY Macrovascular and microvascular complications CIRCLE-CHECK CIRCLE-CHECK HISTORY Hypoglycemia: awareness/frequency/causes/timing of episodes CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK Presence of hemoglobinopathies or anemias CIRCLE-CHECK CIRCLE-CHECK Last dental visit CIRCLE-CHECK CIRCLE-CHECK Last dilated eye exam CIRCLE-CHECK Visits to specialists CIRCLE-CHECK Disability assessment and use of assistive devices (e.g., physical, CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK cognitive, vision and auditory, history of fractures, podiatry) Personal history of autoimmune disease CIRCLE-CHECK INTERVAL HISTORY Changes in medical/family history since last visit CIRCLE-CHECK CIRCLE-CHECK Eating patterns and weight history CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK Assess familiarity with carbohydrate counting (e.g., type 1 diabetes, type 2 CIRCLE-CHECK CIRCLE-CHECK BEHAVIORAL diabetes treated with intensive insulin therapy) FACTORS Physical activity and sleep behaviors, screen for obstructive sleep apnea CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK Tobacco, alcohol, and substance use CIRCLE-CHECK CIRCLE-CHECK Current medication plan CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK Medication-taking behavior, including rationing of medications and/or CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK MEDICATIONS medical equipment AND VACCINATIONS Medication intolerance or side effects CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK Complementary and alternative medicine use CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK Vaccination history and needs CIRCLE-CHECK CIRCLE-CHECK Assess use of health apps, online education, patient portals, etc. CIRCLE-CHECK CIRCLE-CHECK TECHNOLOGY Glucose monitoring (meter/CGM): results and data use CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK USE Review insulin pump settings and use, connected pen and glucose data CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK VOLUME 42, NUMBER 2, SPRING 2024 191 ABRIDGED STANDARDS OF CARE 2024 Section 4: Comprehensive Medical Evaluation and Assessment of Comorbidities Every Annual Initial Visit Follow-Up Visit Visit SOCIAL NETWORK Identify existing social supports CIRCLE-CHECK CIRCLE-CHECK Identify surrogate decision maker, advanced care plan CIRCLE-CHECK CIRCLE-CHECK SOCIAL LIFE ASSESSMENT Identify social determinants of health (e.g., food security, housing stability & homelessness, transportation access, financial security, community CIRCLE-CHECK CIRCLE-CHECK safety) Assess daily routine and environment, including school/work schedules and CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK ability to engage in diabetes self-management Height, weight, and BMI; growth/pubertal development in children and CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK adolescents Blood pressure determination CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK Orthostatic blood pressure measures (when indicated) CIRCLE-CHECK Downloaded from http://diabetesjournals.org/clinical/article-pdf/42/2/189/756155/diaclincd24a004.pdf by guest on 13 December 2024 Fundoscopic examination (refer to eye specialist) CIRCLE-CHECK CIRCLE-CHECK Thyroid palpation CIRCLE-CHECK CIRCLE-CHECK Skin examination (e.g., acanthosis nigricans, insulin injection or insertion CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK sites, lipodystrophy) Comprehensive foot examination CIRCLE-CHECK CIRCLE-CHECK PHYSICAL EXAMINATION » Visual inspection (e.g., skin integrity, callous formation, foot deformity CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK or ulcer, toenails) ** » Screen for PAD (pedal pulses—refer for ABI if diminished) CIRCLE-CHECK CIRCLE-CHECK » Determination of temperature, vibration or pinprick sensation, and 10-g CIRCLE-CHECK CIRCLE-CHECK monofilament exam Screen for depression, anxiety, diabetes distress, fear of hypoglycemia, CIRCLE-CHECK CIRCLE-CHECK and disordered eating Consider assessment for cognitive performance* CIRCLE-CHECK CIRCLE-CHECK Consider assessment for functional performance* CIRCLE-CHECK CIRCLE-CHECK Consider assessment for bone pain CIRCLE-CHECK CIRCLE-CHECK A1C, if the results are not available within the past 3 months CIRCLE-CHECK CIRCLE-CHECK CIRCLE-CHECK If not performed/available within the past year CIRCLE-CHECK CIRCLE-CHECK » Lipid profile, including total, LDL, and HDL cholesterol and triglycerides# CIRCLE-CHECK CIRCLE-CHECK^ » Liver function tests# CIRCLE-CHECK CIRCLE-CHECK » Spot urinary albumin-to-creatinine ratio CIRCLE-CHECK CIRCLE-CHECK LABORATORY » Serum creatinine and estimated glomerular filtration rate + CIRCLE-CHECK CIRCLE-CHECK EVALUATION » Thyroid-stimulating hormone in people with type 1 diabetes # CIRCLE-CHECK CIRCLE-CHECK » Vitamin B12 if on metformin CIRCLE-CHECK CIRCLE-CHECK » Complete Blood Count (CBC) with platelets CIRCLE-CHECK CIRCLE-CHECK » Serum potassium levels in people with diabetes on ACE inhibitors, CIRCLE-CHECK CIRCLE-CHECK ARBs, or diuretics+ » Calcium, vitamin D, phosphorus for appropriate patients CIRCLE-CHECK CIRCLE-CHECK ABI, ankle-brachial pressure index; ARBs, angiotensin receptor blockers; CGM, continuous glucose monitors; MDI, multiple daily injections; NAFLD, nonalcoholic fatty liver disease; OSA, obstructive sleep apnea; PAD, peripheral arterial disease. *At 65 years of age or older. +May be needed more frequently in people with diabetes with known chronic kidney disease or with changes in medications that affect kidney function and serum potassium #May also need to be checked after initiation or dose changes of medications that affect these laboratory values (i.e., diabetes medications, blood pressure medications, cholesterol medications, or thyroid medications). ^In people without dyslipidemia and not on cholesterol-lowering therapy, testing may be less frequent. **Should be performed at every visit in people with diabetes with sensory loss, previous foot ulcers, or amputations. 192 DIABETESJOURNALS.ORG/CLINICAL Section 5: Facilitating Positive Health Behaviors and Well-Being to Improve Health Outcomes Building positive health behaviors and maintaining psychological well-being are foundational for achieving diabetes management goals and maximizing quality of life. Essential tasks to help people with diabetes achieve their health goals: Refer for diabetes self-management education and Counsel on and support cessation of tobacco support (DSMES) products and vaping Refer for medical nutrition therapy (MNT) Counsel on health behaviors Downloaded from http://diabetesjournals.org/clinical/article-pdf/42/2/193/758585/diaclincd24a005.pdf by guest on 13 December 2024 Support and refer to behavior health professionals for Counsel on routine physical activity psychosocial care DSMES Is Critical Advantages Ensures informed decision-making People Who Benefit Promotes self-care behaviors Facilitates problem-solving All people with diabetes Improved collaboration with the health care team Imparts knowledge and self-care skills Incorporates needs, goals, and life experiences Appropriate Settings Group or individual visits Times to Refer In-person, telehealth, or digital Annually platforms At diagnosis When not meeting treatment goals When complicating factors develop Proven Outcomes When transitions in life and care occur Improved diabetes knowledge, self-care, and quality of life Lower A1C and self-reported Essential Components weight reductions Provide culturally appropriate content Reduced all-cause mortality risk, Be responsive to individual preferences, needs, and values acute care and hospital services Use positive, strength-based language that puts people first. utilization, and lower health care Consider social determinants of health with a focus on health equity. costs Increased use of primary care and preventive services Positive coping behavior Psychosocial Care for All People With Diabetes: Considerations and Recommendations Screening Interventions ✓ Clinically significant mental health diagnoses are considerably more ✓ Interventions should be collaborative, prevalent in people with diabetes than in those without. person-centered, and culturally informed. ✓ Clinicians should implement psychosocial screening protocols, ✓ Refer to behavioral health professionals including for diabetes distress. or other trained health care professionals, ✓ People with diabetes, caregivers, and family members should be ideally with experience in diabetes. screened at least annually or when changes in disease, treatment, ✓ Consider individuals’ treatment or life circumstances occur. burden, confidence and self-efficacy in ✓ Address both clinical and subclinical psychological symptoms, management, and social and family support. which can affect the ability to carry out self-management, short- term glycemic stability, as well as mortality risk. Resources are available to help health care professionals support behavioral and mental health in people with diabetes. Find them at https://professional.diabetes.org/meetings/behavioral-health-toolkit. Suggested citation: American Diabetes Association Primary Care Advisory Group. 5. Facilitating positive health behaviors and well-being to improve health outcomes: Standards of Care in Diabetes—2024 abridged for primary care professionals. Clin Diabetes 2024;42:193–195 (doi: 10.2337/cd24-a005). ©2024 by the American Diabetes Association. VOLUME 42, NUMBER 2, SPRING 2024 193 ABRIDGED STANDARDS OF CARE 2024 Section 5: Facilitating Positive Health Behaviors and Well-Being to Improve Health Outcomes Diabetes Distress The ongoing demands of diabetes self-care and the possibility or reality of disease progression are directly linked to reported diabetes distress. High levels of distress: ҧ Significantly affect medication-taking behavior ҧ Are linked to higher A1C, lower self-efficacy, and less-optimal eating and exercise behavior MNT There is a no one-size-fits-all eating pattern. Successful MNT programs are: Screen for: Downloaded from http://diabetesjournals.org/clinical/article-pdf/42/2/193/758585/diaclincd24a005.pdf by guest on 13 December 2024 Flexible, realistic, and sustainable Disordered eating Provided by a registered dietitian nutritionist Food insecurity Offered to all people with type 1 or type 2 diabetes, History of dieting prediabetes, and gestational diabetes mellitus Key Nutrition Principles: Include Minimize Nonstarchy Meat vegetables Sugar-sweetened Whole grains beverages Nuts/seeds Sweets Low-fat dairy Refined grains products Ultra-processed Whole fruits foods Legumes Data do not support a specific distribution of macronutrients. People with diabetes may choose from a variety of healthy eating patterns to fit their needs and preferences. Support positive health behavior through: Motivational interviewing Problem-solving STOP Cigarettes Encouragement of health behavior self- Patient activation monitoring, with or without clinician feedback E-cigarettes/vapes All tobacco products Goal-setting and Identification of social support resources action-planning With counseling and/or pharmacologic treatment 194 DIABETESJOURNALS.ORG/CLINICAL  AMERICAN DIABETES ASSOCIATION Importance of 24-Hour Physical Behaviors for Type 2 Diabetes SITTING/BREAKING UP PROLONGED SITTING SWEATING (MODERATE-TO-VIGOROUS ACTIVITY) Limit sitting. Breaking up prolonged sitting (every 30 min) with Encourage ≥150 min/week of moderate-intensity physical short regular bouts of slow walking/simple resistance exercises activity (i.e., uses large muscle groups, rhythmic in nature) can improve glucose metabolism. OR ≥75 min/week vigorous-intensity activity spread over ≥3 days/week, with no more than 2 consecutive days of inactivity. Supplement with two to three resistance, flexibility, and/or balance SITTING/ sessions. BREAKING UP As little as 30 min/week of moderate- PROLONGED intensity physical activity improves SITTING metabolic profiles. STEPPING An increase of only 500 steps/day is associated with SWEATING 2-9% decreased risk PHYSICAL FUNCTION/ of cardiovascular FRAILTY/SARCOPENIA PHYSICAL morbidity and all- FUNCTION The frailty phenotype cause mortality. in type 2 diabetes Downloaded from http://diabetesjournals.org/clinical/article-pdf/42/2/193/758585/diaclincd24a005.pdf by guest on 13 December 2024 STRENGTHENING A 5-to 6-min brisk- is unique, often intensity walk per encompassing obesity day equates to ~4 alongside physical years' greater life frailty, at an earlier expectancy. age. The ability STEPPING of people with type 2 diabetes to undertake simple functional exercises 24 HOURS in middle age is similar to that in those over a SLEEP decade older. Aim for consistent, uninterrupted sleep, even on weekends. Quantity - Long (>8 h) and SLEEP CHRONOTYPE short (