The evidence grading system (A through C, E) is defined at the end of the "Major Recommendations" field.
Intake Medical Assessment
See figure 1 in the original guideline document for the essential components of the initial history and physical examination.
- Patients with a diagnosis of diabetes should have a complete medical history and undergo an intake physical examination by a licensed health professional in a timely manner. (E)
- Insulin-treated patients should have a capillary blood glucose (CBG) determination within 1 to 2 hours of arrival. (E)
- Medications and medical nutrition therapy (MNT) should be continued without interruption upon entry into the correctional environment. (E)
Screening for Diabetes
Consistent with the American Diabetes Association (ADA) Standards of Care, patients should be evaluated for diabetes risk factors at the intake physical and at appropriate times thereafter. Those who are at high risk should be considered for blood glucose screening. If pregnant, a risk assessment for gestational diabetes mellitus (GDM) should be undertaken at the first prenatal visit. Patients with clinical characteristics consistent with a high risk for GDM should undergo glucose testing as soon as possible. High-risk women not found to have GDM at the initial screening and average-risk women should be tested between 24 and 28 weeks of gestation. For more detailed information on screening for both type 2 and GDM, see the National Guideline Clearinghouse (NGC) summaries of the ADA guidelines Testing for Prediabetes and Diabetes in Asymptomatic Patients, and Detection and Diagnosis of Gestational Diabetes Mellitus (GDM).
Management Plan
Summary of Recommendations for Glycemic, Blood Pressure, and Lipid Control for Adults with Diabetes
- Glycated hemoglobin (A1C): <7.0%*
- Blood Pressure: <130/80 mmHg
- Lipids
- Low-density lipoprotein (LDL) cholesterol: <100 mg/dL (<2.6 mmol/L)**
*Referenced to a nondiabetic range of 4.0% to 6.0% using a Diabetes Control and Complications Trial (DCCT)-based assay.
**In individuals with overt cardiovascular disease (CVD), a lower LDL cholesterol goal of <70 mg/dL (1.8 mmol/L), using a high dose of a statin, is an option.
Urgent and Emergency Issues
- Train correctional staff in the recognition, treatment, and appropriate referral for hypo- and hyperglycemia. (E)
- Train appropriate staff to administer glucagon. (E)
- Train staff to recognize symptoms and signs of serious metabolic decompensation, and immediately refer the patient for appropriate medical care. (E)
- Institutions should implement a policy requiring staff to notify a physician of all CBG results outside of a specified range, as determined by the treating physician (e.g., <50 or >350 mg/dL). (E)
- Identify patients with type 1 diabetes who are at high risk for diabetic ketoacidosis (DKA). (E)
Medication
- Formularies should provide access to usual and customary oral medications and insulins to treat diabetes and related conditions. (E)
- Patients should have access to medication at dosing frequencies that are consistent with their treatment plan and medical direction. (E)
- Correctional institutions and police lock-ups should implement policies and procedures to diminish the risk of hypo- and hyperglycemia during off-site travel (e.g., court appearances). (E)
Routine Screening for and Management of Diabetes Complications
All patients with a diagnosis of diabetes should receive routine screening for diabetes-related complications, as detailed in the ADA's Standards of Care (See the NGC summary of the ADA guideline, Prevention and Management of Diabetes Complications). Interval chronic disease clinics for persons with diabetes provide an efficient mechanism to monitor patients for complications of diabetes. In this way, appropriate referrals to consultant specialists, such as optometrists/ophthalmologists, nephrologists, and cardiologists, can be made on an as needed basis and interval laboratory testing can be done.
The following complications should be considered.
- Foot care: Recommendations for foot care for patients with diabetes and no history of an open foot lesion are described in the ADA Standards of Care. A comprehensive foot examination is recommended annually for all patients with diabetes to identify risk factors predictive of ulcers and amputations. Persons with an insensate foot, an open foot lesion, or a history of such a lesion should be referred for evaluation by an appropriate licensed health professional (e.g., podiatrist or vascular surgeon). Special shoes should be provided as recommended by licensed health professionals to aid healing of foot lesions and to prevent development of new lesions.
- Retinopathy: Annual retinal examinations by a licensed eye care professional should be performed for all patients with diabetes, as recommended in the ADA Standards of Care. Visual changes that cannot be accounted for by acute changes in glycemic control require prompt evaluation by an eye care professional.
- Nephropathy: An annual spot urine test for determination of microalbumin-to-creatinine ratio should be performed. The use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers is recommended for all patients with albuminuria. Blood pressure should be controlled to <130/80 mmHg.
- Cardiac: People with type 2 diabetes are at a particularly high risk of coronary artery disease. Cardiovascular disease risk factor management is of demonstrated benefit in reducing this complication in patients with diabetes. Blood pressure should be measured at every routine diabetes visit. In adult patients, test for lipid disorders at least annually and as needed to achieve goals with treatment. Use aspirin therapy (75 to 162 mg/day) in all adult patients with diabetes and cardiovascular risk factors or known macrovascular disease. Current national standards for adults with diabetes call for treatment of lipids to goals of LDL <100, high-density lipoprotein (HDL) >40, triglycerides <150 mg/dL, and blood pressure to a level of <130/80 mmHg.
Monitoring/Tests of Glycemia
- In the correctional setting, policies and procedures need to be developed and implemented to enable CBG monitoring to occur at the frequency necessitated by the individual patient's glycemic control and diabetes regimen. (E)
- A1C should be checked every 3 to 6 months. (E)
Self-Management Education
Major Components of Diabetes Self-Management Education
Survival Skills
- Hypo-/hyperglycemia
- Sick day management
- Medication
- Monitoring
- Foot care
Daily Management Issues
- Disease process
- Nutritional management
- Physical activity
- Medications
- Monitoring
- Acute complications
- Risk reduction
- Goal setting/problem solving
- Psychosocial adjustment
- Preconception care/pregnancy/gestational diabetes management
Staff Education
- Include diabetes in correctional staff education programs. (E)
Alcohol and Drugs
Patients with diabetes who are withdrawing from drugs and alcohol need special consideration. This issue particularly affects initial police custody and jails. At an intake facility, proper initial identification and assessment of these patients are critical. The presence of diabetes may complicate detoxification. Patients in need of complicated detoxifications should be referred to a facility equipped to deal with high-risk detoxification. Patients with diabetes should be educated in the risks involved with smoking cessation should be provided as practical.
Transfer and Discharge
- For all interinstitutional transfers, complete a medical transfer summary to be transferred with the patient. (E)
- Diabetes supplies and medication should accompany the patient during transfer. (E)
- Begin discharge planning with adequate lead time to insure continuity of care and facilitate entry into community diabetes care. (E)
Sharing of Medical Information and Records
Practical considerations may prohibit obtaining medical records from providers who treated the patient before arrest. Intake facilities should implement policies that 1) define the circumstances under which prior medical records are obtained (e.g., for patients who have an extensive history of treatment for complications); 2) identify person(s) responsible for contacting the prior provider; and 3) establish procedures for tracking requests.
Facilities that use outside medical providers should implement policies and procedures for ensuring that key information (e.g., test results, diagnoses, physicians' orders, appointment dates) is received from the provider and incorporated into the patient's medical chart after each outside appointment. The procedure should include, at a minimum, a means to highlight when key information has not been received and designation of a person responsible for contacting the outside provider for this information.
All medical charts should contain CBG test results in a specified, readily accessible section and should be reviewed on a regular basis.
Children and Adolescents with Diabetes
Nutrition and Activity
Growing children and adolescents have greater caloric/nutritional needs than adults. The provision of an adequate amount of calories and nutrients for adolescents is critical to maintaining good nutritional status. Physical activity should be provided at the same time each day. If increased physical activity occurs, additional CBG monitoring is necessary and additional carbohydrate snacks may be required.
Medical Management and Follow-Up
Children and adolescents who are incarcerated for extended periods should have follow-up visits at least every 3 months with individuals who are experienced in the care of children and adolescents with diabetes. Thyroid function tests and fasting lipid and microalbumin measurements should be performed according to recognized standards for children and adolescents in order to monitor for autoimmune thyroid disease and complications and comorbidities of diabetes.
Children and adolescents with diabetes exhibiting unusual behavior should have their CBG checked at that time. Because children and adolescents are reported to have higher rates of nocturnal hypoglycemia, consideration should be given regarding the use of episodic overnight blood glucose monitoring in these patients. In particular, this should be considered in children and adolescents who have recently had their overnight insulin dose changed.
Pregnancy
Pregnancy in a woman with diabetes is by definition a high-risk pregnancy. Every effort should be made to ensure that treatment of the pregnant woman with diabetes meets accepted standards. It should be noted that glycemic standards are more stringent, the details of dietary management are more complex and exacting, insulin is the only antidiabetic agent approved for use in pregnancy, and a number of medications used in the management of diabetic comorbidities are known to be teratogenic and must be discontinued in the setting of pregnancy.
Summary and Key Points
People with diabetes should receive care that meets national standards. Being incarcerated does not change these standards. Patients must have access to medication and nutrition needed to manage their disease. In patients who do not meet treatment targets, medical and behavioral plans should be adjusted by health care professionals in collaboration with the prison staff. It is critical for correctional institutions to identify particularly high-risk patients in need of more intensive evaluation and therapy, including pregnant women, patients with advanced complications, a history of repeated severe hypoglycemia, or recurrent DKA.
A comprehensive, multidisciplinary approach to the care of people with diabetes can be an effective mechanism to improve overall health and delay or prevent the acute and chronic complications of this disease.
Definitions:
American Diabetes Association's Evidence Grading System for Clinical Practice Recommendations
A
Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered, including:
- Evidence from a well-conducted multicenter trial
- Evidence from a meta-analysis that incorporated quality ratings in the analysis
- Compelling non-experimental evidence (i.e., "all or none" rule developed by the Center for Evidence Based Medicine at Oxford*)
Supportive evidence from well-conducted randomized controlled trials that are adequately powered including:
- Evidence from a well-conducted trial at one or more institutions
- Evidence from a meta-analysis that incorporated quality ratings in the analysis
*
Either all patients died before therapy and at least some survived with therapy, or some patients died without therapy and none died with therapy. Example: use of insulin in the treatment of diabetic ketoacidosis.
B
Supportive evidence from well-conducted cohort studies:
- Evidence from a well-conducted prospective cohort study or registry
- Evidence from a well-conducted prospective cohort study
- Evidence from a well-conducted meta-analysis of cohort studies
Supportive evidence from a well-conducted case-control study
C
Supportive evidence from poorly controlled or uncontrolled studies, including:
- Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that could invalidate the results
- Evidence from observational studies with high potential for bias (such as case series with comparison with historical controls)
- Evidence from case series or case reports
Conflicting evidence with the weight of evidence supporting the recommendation
E
Expert consensus or clinical experience
