Diabetes Prevention and Screening.doc.doc

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Diabetes Prevention and Screening.doc.doc

  1. 1. Oklahoma State Department of Health 01-2008 – Revised PHN GUIDELINE: DIABETES MELLITUS PREVENTION AND SCREENING (CHILD/ADOLESCENT/ADULT) I. DEFINITION: A. Diabetes Mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Type 2 diabetes, the most prevalent form of the disease, is often asymptomatic in its early stages and can remain undiagnosed for many years. Diabetes Mellitus is a common, serious systemic disorder of energy metabolism. The classification and diagnostic criteria are: Classification Type 1 Type 1 diabetes mellitus: Immune mediated and Idiopathic. Refers to forms of diabetes that are primarily related to β-cell destruction and keto-acidosis prone. Type 2 Type 2 diabetes mellitus: Most prevalent form of diabetes that results from insulin resistance with associated insulin secretory defect. IGT/IFG Impaired glucose tolerance/impaired fasting glucose “Pre- Diabetes” - intermediate stage between normal glucose metabolism and diabetes. Equal prevalence to type 2 diabetes. Insulin resistance with compensating hyper-insulinemia, obesity, and hyperlipidemia. B. Criteria for the diagnosis of type 2 diabetes mellitus for children, adolescents or adults is listed below. Because of the acute onset of symptoms and rapid clinical decompensation, most cases of type 1 diabetes are detected soon after symptoms develop. 1. Symptoms of diabetes plus random plasma glucose concentration ≥ 200 mg/dl (11.1 mmol/l). Random is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss. OR 2. Fasting plasma glucose (FPG) ≥ 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 hours. OR 3. Two hour plasma glucose (2-h PG) ≥ 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by WHO (2) using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water. 4. Definitions of glucose intolerance: a. FPG < 100 mg/dl (5.6mmol/l) = normal fasting glucose b. FPG ≥ 100 mg/dl (6.1 mmol/l) and < 126 mg/dl (7.0 mmol/l) = impaired fasting glucose c. FPG ≥ 126 mg/dl (7.0 mmol/l) = provisional diagnosis of diabetes (the diagnosis must be confirmed with a repeat test on a different day). 5. Changing the diagnostic cutpoint for the FPG to 126 mg/dl (7.0 mmol/l) is based on the belief that the cutpoints for the FPG and 2-h PG should diagnose similar Diabetes Mellitus Screening - 1
  2. 2. Oklahoma State Department of Health 01-2008 – Revised conditions, given the equivalence of the FPG and the 2-h PG in their associations with vascular complications and their discrimination between two components of a bimodal frequency distribution. HbA1c measurement is not currently recommended for diagnosis of diabetes. 6. The revised criteria are for diagnosis and are not treatment criteria or goals of therapy. See diabetes management guidelines. C. Blood glucose screening is a detection method to identify individuals at risk of disease and individuals with abnormal levels who have not been previously evaluated or diagnosed. Undiagnosed Type 2 diabetes is common in Oklahoma and as many as 30% with the disease are currently undiagnosed. There is epidemiological evidence that retinopathy, neuropathy and nephropathy can begin to develop at least 7 years before the clinical diagnosis of Type 2 diabetes is made. Criteria for testing for diabetes in asymptomatic, undiagnosed individuals have now been recommended: 1. Testing for diabetes should be considered in all individuals who are at high risk. 2. Pre-diabetes and diabetes risk factors are: a. Age 45 years or older and overweight b. Obese, adults (BMI ≥ 25 KG/M2; for Asian Americans BMI > 23; and,Pacific Islanders BMI > 26) c. Obese, children and youth (greater than 85th percentile of BMI for age and sex) d. Have a first degree relative with diabetes e. Are members of a high-risk ethnic population, e.g., African-American, Hispanic-American, Native American, Asian-American, Pacific Islander. f. Have delivered a baby weighing > 9 lbs or have been diagnosed with Gestational Diabetes g. High Blood Pressure (≥ 140/90) h. Have a HDL cholesterol level ≤ 40 mg/dl for men and < 50 mg/dl for women and/or a triglyceride level > 250 mg/dl. i. Have clinical manifestations of acanthosis nigrican j. Adolescent girls or women with polycystic ovarian syndrome or amenorrhea II. ETIOLOGY: A. Etiology: The causes of diabetes are multifactorial. The cause of Type I diabetes is related to an autoimmune destruction of the beta cells of the pancreas. This process causes the person to become insulin deficient: an inability to utilize carbohydrates, resulting in an increased blood glucose concentration, and a propensity to develop keto-acidosis. Type 2 diabetes involves both insulin resistance and insulin deficiency that also leads to an inability to utilize carbohydrates and hyperglyemia, but is relatively resistant to ketosis development. B. Epidemiology: 1. Type 2 diabetes is the most common type and is seen in 8% of the adult Oklahoma population with another 4% who have the disease and who are undiagnosed. An even greater number of people (some 8 to 10%) have impaired glucose tolerance and/or impaired fasting glucose, now called pre-diabetes. In Oklahoma some 320,000 people have Type 2 diabetes. Known risk factors associated with Type 2 diabetes are obesity, both in children, adolescents, and adults, ethnicity, and signs of insulin resistance including acanthosis nigrican and polycystic ovary disease. Diabetes Mellitus Screening - 2
  3. 3. Oklahoma State Department of Health 01-2008 – Revised 2. Type 1 diabetes is seen in 1 in 600 children and adolescents under 19 years of age. In Oklahoma, the estimated number of children and adolescents with Type 1 diabetes is 1600. Type 1 diabetes is seen in some 5000 Oklahomans. The peak age for developing Type 1 diabetes is adolescents from 11-14 years who are of normal weight. The disease is most frequently diagnosed in the fall and winter months and frequently following a viral infection or other type of environmental stress. III. CLINICAL FEATURES: A. Signs and Symptoms: 1. Subjective a. Polyuria b. Polydipsia c. Polyphagia d. Weakness e. Fatigue f. Visual disturbances g. Headache h. Abdominal pain, nausea, and/or vomiting i. Irritability j. Chronic vaginal yeast infections k. Dehydration l. Amenorrhea in adolescent or young adult females 2. Objective a. Blood glucose levels over 200 mg/dl at 2 hours postprandial or doing a standard OGTT at 2 hours, or fasting at 126 mg/dl or more. b. Rapid weight loss c. Flushed or pale skin d. Poor skin turgor e. Ketonuria f. Fruity smelling breath g. Altered level of consciousness, rapid breathing h. “Acanthosis Nigrican”, a darkened skin (pigmentation) around the neck that indicates insulin resistance and high risk to Type 2 diabetes presently or in the future. B. Complications: 1. The incidence and severity of complications are directly correlated to controlling blood glucose levels at near normal ranges. Other factors include genetics, age, and blood pressure. Diabetes Mellitus attacks the blood vessels and nerves, with principal targets of complications to the kidney, heart and circulatory system, peripheral nerves and eyes. 2. Complications included are ketoacidosis, hypoglycemia, retinopathy, neuropathy, amputations, blindness, kidney failure, heart attacks and nephropathy. IV. MANAGEMENT PLAN: A. See PHN ORDER: DIABETES MELLITUS SCREENING – CHILD/ADOLESCENT/ADULT B. Follow blood glucose screening procedure and attached algorithm. Individuals with Diabetes Mellitus Screening - 3
  4. 4. Oklahoma State Department of Health 01-2008 – Revised abnormal levels should be rescreened with either fasting or postprandial testing before referral. (See rescreening algorithm) C. Client Education: 1. To reduce the incidence of Diabetes Mellitus, clients should be counseled in the following areas. a. Assess dietary intake and counsel if there is a need to reduce protein, fat, high sugar content foods, and/or calories. Persons with a BMI of ≥ 25KG/M2 should be counseled to lose 5-10% of their weight by reducing total calories and fat consumption. Have the person establish the goal, have them document consumption by utilizing a food diary, and have them account to you or someone they want to be accountable to over a six-month period. b. Exercise by performing moderate exercise of 30 minutes daily, a total of 210 minutes per week. c. Stress management d. Avoidance of tobacco and alcohol 2. Adolescents or young adults should be counseled to seek medical care immediately if after an acute viral infection, signs of illness as polydipsia, polyuria, and polyphagia and abrupt weight loss occurs. 3. To assist the person who has risk factors, for diabetes or who has a positive screen, counseling with the “Small Steps, Big Rewards, Your Game Plan” is a useful tool. This evidence-based program provides a three-booklet package with information about risk for developing diabetes and how to implement a program to prevent or delay the onset of the disease, including how to set goals, track their progress, implement a walking program, find additional resources, and monitor and record their food and drink intake and physical activity with the use of a tracker and fat and calorie counter. The site is: www.ndep.nih.gov/diabetes/control/control.htm. D. Consultation/Referral: Referral to physician, emergency room, or University Center should be written on ODH Form No. 399. Clients may be referred to the health department nutritionist for diet consultation. If indicated, referral should also be made for stress management consultation. E. Follow-up: 1. See attached algorithm. 2. Determine tracking priority utilizing professional judgment. F. Mass Screen: The following information is to be used in addition to the PHN ORDER: DIABETES MELLITUS SCREENING - CHILD/ADOLESCENT/ADULT and screening algorithm when screening clients in a mass screen setting. 1. If participating in a mass-screening event, utilize the Group Screening Record (ODH Form No.398) 2. Each client should complete a Consent for Service (ODH No. 303C) Form. Diabetes Mellitus Screening - 4
  5. 5. Oklahoma State Department of Health 01-2008 – Revised 3. If results are abnormal, open a limited visit record and utilize the Referral Form (ODH No. 399). REFERENCES: American Diabetes Association, Position Statement: Diagnosis and Classification of Diabetes Mellitus, Diabetes Care, 30:S42-S47, 2007. Chronic Disease Service, OSHD, Type 2 Diabetes Among Oklahoma Children and Adolescents: An Emerging Epidemic, Summer 2000, volume 1, number 3. National Institute of Health, National Institute of Diabetes, Digestive and Kidney Disorders, “Small Steps Big Rewards,” 2006. The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Follow-up report on the diagnosis of diabetes mellitus, Diabetes Care, 26:3160-3167, 2003. The Diabetes Prevention Program (DPP) Research Group, The Diabetes Prevention Program (DPP) Description of Lifestyle Intervention, Diabetes Care, Dec, 25 (12) 2165-2171, 2002. Tuomilehto J., Lindstrom J., Eriksson JG, et al. “Prevention of Type 2 Diabetes Mellitus by Changes in Lifestyle Among Subjects with Impaired Glucose Tolerance.” N Engl J Med, 2002:41 pp 1343-50. Agency for HealthCare Research and Quality, “The Guide to Clinical Preventive Services, Recommendations of the U.S. Preventive Health Services Task Force, Screening for Type 2 Diabetes in Adults”, 2006, pp. 144-147. Diabetes Mellitus Screening - 5
  6. 6. Oklahoma State Department of Health 01-2008 – Revised Diabetes Mellitus Screening - 6
  7. 7. Oklahoma State Department of Health 01-2008 – Revised PHN ORDER: DIABETES MELLITUS PREVENTION AND SCREENING (CHILD/ADOLESCENT/ADULT) I. LABORATORY STUDIES: A. Screen blood glucose levels. If child, adolescent or adult is not fasting or at two hour postprandial at the time of screening and has a screening value greater than 160 mg/dl, and appears acutely ill, refer to private physician, emergency room or University Center immediately. If individual has a blood glucose level of over 200 mg/dl, check for ketonuria, if test available. Ketonuria of 1+ or more or nausea and vomiting indicate a need for immediate referral. B. To obtain 75 gm solution: 1. Rotate 100 gm glucose emulsion gently to make sure concentrate is evenly dis- tributed, 2. Measure out amount to provide approximately 75 gm dose, 3. After client drinks the glucose solution, obtain a 2-hour postprandial blood sample. This test may be administered utilizing capillary whole blood and a blood glucose monitor. C. The client should be referred to private physician if the blood glucose level is equal to or greater than 160 mg/dl. Diabetes Mellitus Screening - 7
  8. 8. Oklahoma State Department of Health 01-2008 – Revised DIABETES SCREENING SUMMARY Initial Screening: Is client obese? (child or adolescent > 85th No Do not screen percentile BMI for age or sex or adult at BMI >25%), Ages 20-44 with multiple risk factors? > 45 years of age? Mass-Screening participant? Is the client fasting 8 hours but not more than 16? 400 mg or more? EMERGENCY - Refer for Immediate care. No Yes Between 200 mg and 400 mg? No Fasting blood Refer to physician immediately. glucose less than 126 mg? Yes Between 126 mg and 200 mg? Refer for recheck on another day. Ask client to come in after 8 hour fast. Advise client to be rescreened annually If client appears acutely ill, refer immediately. Is client one to two hours postprandial? 400 mg or more? EMERGENCY - Refer for immediate care. Yes Between 240 mg and 400 mg? No Refer to physician immediately Postprandial blood glucose less than 160 mg? Between 160 mg and 240 mg? Refer for recheck on another day. Ask client to come in after 8 hour fast. Yes Advise client to be If client appears acutely ill, rescreened annually refer immediately Diabetes Mellitus Screening - 8
  9. 9. Oklahoma State Department of Health 01-2008 – Revised RECHECK SCREENING SUMMARY Client FASTING blood sugar is: Advise client to be Less than 100 mg? Yes rescreened annually No Refer to physician Yes More than 126 mg? for further evaluation No Perform postprandial Between 100 mg and Yes Capillary screening with 75 gm 126 mg? glucose drink If person acutely ill. 2 hour postprandial Refer Immediately to No glucose less than 160 mg? physician Yes Advise client to be rescreened annually. 2 hour postprandial glucose more than 160 mg? Yes Refer to physician for further evaluation. Diabetes Mellitus Screening - 9
  10. 10. Oklahoma State Department of Health 01-2008 – Revised Diabetes Mellitus Screening - 10

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