Standards of Care for People with Diabetes

2/7/98

Developed from information provided by the
Diabetes Treatment Centers of America

Charles Booras M.D.

by Charles H. Booras, MD

When you have diabetes, it is important that you get good medical care. It's now crystal clear that high glucose levels play a role in many complications, thus your doctor's skill is more vital than ever. Good care helps you live a full life and have as few complications as possible.

But what is good care? The American Diabetes Association writes standards of medical care for people with diabetes. These guidelines give doctors the most up-to-date information on caring for their patients with diabetes.

The Team Approach

You should be receiving your diabetes care from a team put together by your doctor. Diabetes is complicated. Your doctor alone cannot be an expert in every area.

For this reason, your diabetes care team probably includes an eye doctor, nurses, and a dietitian. Depending on what complications you have, your doctor may send you to other specialists, such as a Podiatrist (foot doctor), Nephrologist (kidney doctor), Ophthalmologist (eye doctor) and Cardiologist (heart doctor).

The Goal

Too-high level of glucose ("sugar") in the blood is the main feature of all forms of diabetes. The main goal of diabetes treatment is to bring glucose levels down as close to normal as is safely possible.

How far down? Suggested goals are less than 140 milligrams per deciliter (mg/dl) before meals and under 160 mg/dl at bedtime. Most aspects of your treatment plan -- measuring your glucose levels, taking diabetes pills or insulin shots, exercising, losing weight, eating a planned diet -- are aimed at helping you achieve your target glucose level. The best test for diabetes control is the "Glyco-hemoglobin" or "Hemoglobin A1c" (see table below).

Your target A1c is below 7.0.

High glucose levels can affect many parts of the body. They can lead to diabetic eye disease, nerve disease, and kidney disease. High glucose levels also make it easier to get infections. They can blur your vision or make you feel tired or thirsty all the time. People with diabetes also are more likely to get other health problems, including high blood pressure, high cholesterol levels, and heart disease.

As you can see, keeping your glucose levels under control is vital to your future health and happiness. Your doctor can advise you on ways to reach this goal. But much rests on your shoulders. For this reason, your treatment team should spend a lot of time teaching you about diabetes and how to make diabetes care part of your life. To work well, the plan must be adapted to your own life. For example, it needs to take into account your work or school schedule, how active you are, what and when you like to eat, your cultural background, and what other medical problems you have.

You need to be involved in devising your diabetes care plan. Otherwise, it's unlikely that the plan will fit into your life or that you will understand what you need to do. Your doctor will advise you about when to return for follow-up visits. These later visits are to fine-tune your treatment program and are not as in-depth as your first visit, although you should get a complete physical exam once a year.


The following table summarizes the comprehensive approach now being taken to better manage people with diabetes. Attention to each and every one of these parameters will lessen the risk of developing complications in the future.

Test

Description

Goal

Diabetic Education Ideally, every single person with diabetes should go through a course of comprehensive diabetic education with a certified diabetic educator (CDE) and a dietician. Education truly is the "drug of choice" for treating this disease. Most insurances cover this type of educational program. Hands-on instruction on the technique of home blood sugar monitoring is invaluable.

For every diabetic at any time after the diagnosis has been made.

Hemo-
globin A1c
This test measures your average glucose value over the past 2-3 months and is currently the best test of diabetic control. Frequency: 2-4 times a year

Below
7.0

Foot Inspection Inspect your feet daily and have the doctor inspect them at each visit. Remove shoes and socks at each doctor visit.  
Yearly
Foot Exam
Using a painless monofilament probe that delivers a calibrated 10 grams of pressure. Loss of feeling in the feet is a sign of nerve damage and a risk factor for amputation.  
Dilated
Retina
Exam
To find changes in the eyes that could lead to blindness if left untreated. A specialist trained to look for diabetic eye disease should do this exam YEARLY.  
Fasting
Lipid Panel
People with diabetes have heart attacks at a higher rate and at an earlier age than people without diabetes. This test should be done at least once a year LDL < 130.
HDL > 35.
TG's < 200.
Blood
Pressure
Diabetes and high blood pressure can lead to serious complications such as heart attacks, strokes, or kidney disease. High blood pressure also worsens diabetic eye disease.

Below 130/85

Micro-
albumin
Microscopic amounts of protein in the urine can be an early warning sign of kidney damage. If found early, kidney disease can usually be successfully treated with medication. This test should be performed yearly.


Below 30

Serum
Creatinine
This is a blood test to monitor kidney function. If normal, this test should be performed at least yearly.

Below 1.5

Yearly
Flu
Vaccine
If a person with diabetes catches "the flu" (Influenza), they will likely become much sicker than a person without diabetes. A yearly flu vaccination can help you avoid the "influenza blues".

Between

October 15 - November 15.

Pneumonia
Vaccine
Pneumonia can be more serious for people with diabetes. This vaccine can lessen your chances of becoming seriously ill if you develop pneumococcal (a type of bacteria) pneumonia. Given when diabetes is diagnosed (if below age 65), and again at age 65.  
Aspirin
Therapy
Aspirin has been shown to reduce the incidence of heart attack, stroke and even colon cancer. This dose is 1/4 of an adult aspirin (325 mg.). Some companies (like Bayer) already make an 81 mg. tablet.

81 mg. a day.

Periodic
Health
Exam
A periodic health exam should be carried out yearly. At this time other topics of preventive medicine, like smoking cessation, nutritional supplements, and exercise will be reviewed and discussed.

Yearly

Exercise Stress
Testing
Heart disease is the number one cause of death in people with diabetes (who often have no warning symptoms). An exercise stress test (a "Treadmill" exam) should be considered for all men over age 40 and all women over age 50. The test may be indicated at an earlier age for those with multiple other risk factors or diabetes of over 10 years duration.  


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