What We Want to Achieve Through Systems Changes

Clinical Management

Evidence-based decision-making and patient-centered care have been covered in previous sections. These concepts are essential to providing improved clinical care for patients with diabetes. Current clinical guidelines for diabetes management are evidence-based and reflect the most recent scientific findings.

The American Diabetes Association provides Clinical Practice Recommendations that are updated in January each year. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided.  

The ADA standards cover classification and diagnosis of diabetes, screening for diabetes, detection and diagnosis of gestational diabetes mellitus, prevention/delay of type 2 diabetes, diabetes care, prevention and management of diabetes complications, diabetes care in specific populations, hypoglycemia and employment/licensure, third-party reimbursement for diabetes care, self-management education, and supplies, and strategies for improving diabetes care. The topic on diabetes care in specific settings includes:

• Diabetes care in the hospital
• Diabetes care in the school and day care setting
• Diabetes care at diabetes camps
• Diabetes care at correctional institutions
• Emergency and disaster preparedness.

It is important that the clinical guidelines used in practice are the most up-to-date available. Getting recommended treatment translated into day-to-day procedures at the clinical level is still an obstacle for many providers and prevents patient care from reaching its potential.

To help your practice stay current, NDEP provides:

1. Diabetes Numbers at-a-Glance Reference Card
   Use this handy pocket guide for a quick listing of ADA recommendations for diagnosing pre-diabetes and diabetes and for managing your patients with diabetes. Updated yearly.
2. Working Together to Manage Diabetes: Diabetes Medications Supplement - This reference booklet provides a profile of medications for controlling glycemia, high blood cholesterol and blood pressure.
3. Glomerular Filtration Rate Calculators
   Use these GFR calculators to estimate kidney function for adults and children.
4. Guiding Principles for Diabetes Care
   Learn more about the essential components of quality diabetes care for people with diabetes and pre-diabetes, their families, health care providers, and insurers.
5. Other resources for health care professionals

Other resources include slide presentations, guides to help prevent diabetes, mplement team care, and improve foot care, and office posters.

The Diabetes Control and Complications Trial (DCCT)1 has had a significant impact on clinical practice. This large clinical trial examined intensive versus standard therapy for people with type I diabetes. The DCCT trial used a multi-disciplinary team and intensive proactive care, frequent patient follow-up, counseling, and ongoing patient education. Intensively treated patients achieved an A1C value of 7.2% compared to 8.9% for patients conventionally treated patients.

The DCCT found that intensive treatment reduced the risk for microvascular complications for eye disease by 76%, kidney disease by 65% and nerve damage by 64%. The follow-on study, the Epidemiology of Diabetes Interventions and Complications (EDIC)2, continues to demonstrate longterm benefits of intensive therapy in preventing disease complications. Results have shown that intensive therapy also had dramatic long-term benefits in preventing large blood vessel damage that can lead to heart attacks and strokes (macrovascular complications), which is the leading cause of death in people with diabetes.

The United Kingdom Prospective Diabetes Study (UKPDS) showed that the risk factors for coronary heart disease in type 2 diabetes were, in order of importance, increased LDL cholesterol, decreased HDL cholesterol, hypertension, hyperglycemia, and smoking.3 Dyslipidemia also contributes to the risk of renal disease.  Two studies using the statin class of drugs have shown that rigorous lipid reduction therapy can reduce the risk of coronary heart disease in patients with diabetes.4, 5

Hypertension accelerates the rate of progression of diabetic renal disease.  Control of blood pressure as well as glucose retards this progression.6 Lowering blood pressure in a subset of the UKPDS subjects to a mean of 144/82 mm Hg reduced the risk for stroke, diabetes-related deaths, heart failure, microvascular disease, and retinopathy up to 56 percent.7 Other studies support the importance of blood pressure control, as well as the benefits of specific agents.8, 9 ACE inhibitors provide effective first-line drug therapy for hypertension because these agents have been shown to prevent or delay diabetes-associated renal and cardiovascular disease.6

Clinical Management Resources
The following resources are available to help providers implement state-of-the-art diabetes management practices. Please note: Some links on this page take you outside the Better Diabetes Care website. The NDEP does not endorse or otherwise guarantee the accuracy of links that take you out of this website.

1. National Diabetes Education Program - This program is a joint partnership among the National Institutes of Health, the Centers for Disease Control and Prevention and over 200 organizations. The website offers a variety of education tools to help physicians and patients manage daily care. www.ndep.nih.gov
    
2. Working Together to Manage Diabetes: A Guide for Pharmacists, Podiatrists, Optometrists, and Dental Professionals - This interdisciplinary primer focuses on diabetes-related conditions affecting the foot, eye, and mouth, as well as medication management. The primer promotes a team approach to comprehensive diabetes care and provides simple care recommendations to providers for making cross-disciplinary treatment referrals. The medication supplement is available separately. A color poster also is available for exam or waiting rooms to help educate patients about controlling "the ABCs of Diabetes", and take actions to collaborate with their eye, foot, dental and pharmacy professionals to control diabetes. www.ndep.nih.gov/resources/health.htm
    
3. Business and Managed Care Diabetes and Health Resource Kit - The National Diabetes Education Program in collaboration with several partners developed this online business and managed care diabetes and health resource. The kit will help businesses and managed care companies to assess the impact of diabetes in the workplace. It also provides easy-to-understand information for employers to help their employees manage their diabetes and take steps toward reducing the risk for diabetes-related complications such as heart disease.
    
   Employees with diabetes or those who have friends and family members with diabetes can also use this resource as it provides more than 20 fact sheets on diabetes-related health issues.
    
   Diabetesatwork.org will be especially helpful for:
   • Large employers
   • Small business owners
   • Human resource and wellness professionals
   • Occupational health professionals
   • EAP representatives
   • Diabetes educators
   • Managed care wellness and benefit professionals
      
   The site contains assessment tools, a planning guide, choosing a health plan, lesson plans, fact sheets and resources. www.diabetesatwork.org
   

Clinical Research

1. Translating Research into Action for Diabetes (TRIAD) - A national study that aims to improve the quality of care for patients with diabetes. www.triadstudy.org
    
2. ACCORD - Actions to Control Cardiovascular Risk in Diabetes
   Sponsored by NHLBI and co-funded by NIDDK. Results are due in 2009.
   The three strategies being tested in ACCORD include:
    
   (1) Blood glucose - ACCORD will determine whether lowering blood glucose to a level closer to normal than called for in current guidelines reduces CVD risk.
    
   (2) Blood pressure - ACCORD will determine whether lowering blood pressure to normal (systolic pressure less than 120 mm Hg) will better reduce CVD risk, as compared to a usually-targeted level in current clinical practice (i.e., below the definition of hypertension; systolic pressure less than 140 mm Hg).
    
   (3) Lipids - This part of the study will look at the effects of lowering LDL cholesterol and blood triglycerides and increasing HDL cholesterol compared to an intervention that only lowers LDL cholesterol, all in the context of good blood glucose control. A fibrate drug will be used to lower triglycerides and increase HDL cholesterol, and a statin drug will be used to lower LDL cholesterol.
    
3. TRIAD – Translating Research into Action for Diabetes
   This multi-center cohort study of diabetes care in managed care settings began in 1999 with funding from CDC and NIH. It involves six translation research centers across the country serving hundreds of thousands of people with diabetes. TRIAD objectives were to describe factors related to the quality of care and to identify and evaluate disease management strategies by health plans or provider groups that enhance or impede the quality of diabetes care and health status of persons with diabetes.
    
4. Key TRIAD findings include:
    
   • Disease management is strongly associated with processes of care but not risk factor control.
   • Among for-profit plans, group/network model provider groups have higher quality scores than IPA models.
   • Greater out-of-pocket costs (through co-pays, non-coverage) associated with lower rates of retinal exams, health education, and self-monitoring of blood glucose.
   • Quality of care, A1C and LDL cholesterol control were substantially better in the VA system than in TRIAD centers. Blood pressure and patient satisfaction did not differ.
   • Processes of care differ little by race/ethnicity but non-white patients have higher A1C levels and African-Americans have higher systolic blood pressure levels than whites.
   • Women with diabetes are less likely than men to be on aspirin, to be advised to take aspirin, to have LDL cholesterol tested and to be on statins.
   • Young diabetic patients (25-44 years) with less than high school education are much more likely to smoke (50% vs. 11% for college grads.
      

Complementary and Alternative Medical Therapies for Diabetes

nccam.nih.gov/health/diabetes.htm

The National Center for Complementary and Alternative Medicine, part of the National Institutes of Health, defines complementary and alternative medicine as a "group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine." Complementary medicine is used with conventional therapy, whereas alternative medicine is used instead of conventional medicine.

Some people with diabetes use complementary or alternative therapies to treat diabetes. Although some of these therapies may be effective, others can be ineffective or even harmful. Patients who use complementary and alternative medicine need to let their health care professionals know.

Some complementary and alternative medicine therapies are discussed below. 

• Acupuncture
   
  • Acupuncture is a procedure in which a practitioner inserts needles into designated points on the skin. Some scientists believe that acupuncture triggers the release of the body's natural painkillers. Acupuncture has been shown to offer relief from chronic pain. People with neuropathy, the painful nerve damage of diabetes, sometimes use acupuncture.
     
• Biofeedback
   
  • Biofeedback is a technique that helps a person become more aware of and learn to deal with the body's response to pain. This alternative therapy emphasizes relaxation and stress-reduction techniques. Guided imagery is a relaxation technique that some professionals who use biofeedback do. With guided imagery, a person thinks of peaceful mental images, such as ocean waves. A person may also include the images of controlling or curing a chronic disease, such as diabetes. People using this technique believe their condition can be eased with these positive images.
     
• Chromium
   
  • The benefit of added chromium for diabetes has been studied and debated for several years. Several studies report that chromium supplementation may improve diabetes control. Chromium is needed to make glucose tolerance factor, which helps insulin improve its action. Because of insufficient information on the use of chromium to treat diabetes, no recommendations for supplementation yet exist.
     
• Ginseng
   
  • Several types of plants are referred to as ginseng but most studies of ginseng and diabetes have used American ginseng. Those studies have shown some glucose-lowering effects in fasting and post-prandial (after meal) blood glucose levels as well as in A1C levels (average blood glucose levels over a 3-month period). However, larger and more long-term studies are needed before general recommendations for use of ginseng can be made. Researchers also have determined that the amount of glucose-lowering compound in ginseng plants varies widely.
     
• Magnesium
   
  • Although the relationship between magnesium and diabetes has been studied for decades, it is not yet fully understood. Studies suggest that a deficiency in magnesium may worsen blood glucose control in type 2 diabetes. Scientists believe that a deficiency of magnesium interrupts insulin secretion in the pancreas and increases insulin resistance in the body's tissues. Evidence suggests that a deficiency of magnesium may contribute to certain diabetes complications. A recent analysis showed that people with higher dietary intakes of magnesium (through consumption of whole grains, nuts, and green leafy vegetables) had a decreased risk of type 2 diabetes.
     
• Vanadium
   
  • Vanadium is a compound found in tiny amounts in plants and animals. Early studies showed that vanadium normalized blood glucose levels in animals with type 1 and type 2 diabetes. A recent study found that when people with diabetes were given vanadium, they developed a modest increase in insulin sensitivity and were able to decrease their insulin requirements. Currently researchers want to understand how vanadium works in the body, discover potential side effects, and establish safe dosages.
     
• Resources
   
  • To learn more about alternative therapies for diabetes treatment, contact the National Center for Complementary and Alternative Medicine Clearinghouse at 1–888–644–6226 or check their website at nccam.nih.gov. You can find NCCAM's information on diabetes by looking under diabetes at nccam.nih.gov/health/bydisease.htm.
  • The National Diabetes Information Clearinghouse database provides titles, abstracts, and availability information for health information and health education resources. Click here to view the results of the automatic search on Complementary Medicine.
    If you wish to perform your own search of the database, you may access and search the NIDDK Reference Collection database online.

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