Prevention, Management and Diagnosis of Diabetes in Primary Care Dra. Rosa Castro Avila, MHSA Executive Director NeoMed Center, Inc.

Objectives Introduces the Chronic Care Model approaches to improve the quality of Diabetes care. To know social determinants of health that contributes in worldwide’ s health inequality. To refresh or update prevention, management, treatment and diagnosis of Diabetes in Primary care.

Chronic Care Model 33-49 % of diabetic patients do not meets targets for glycemic control. Numerous interventions to improve adherence to the recommended standards have been implemented. A major barriers are fragmentation of the system, lacks clinical information capabilities, duplicates services, and poorly designed for the coordinated delivery of chronic care. The Chronic Care model (CCM) considerate all of the barriers and is an effective framework for improving the quality of Diabetes care.

Chronic Care Model The CCM includes six core elements to optimize the care of patients with chronic disease: Reactive to pro active care (Planned visits-team base approach) Self-management support Evidence-based care and effective care guidelines Clinical Information system (registries, patient specific and population-based support to the care team. Community resources and policies (support healthy lifestyles) Quality-oriented culture

Patient centered approach Optimal diabetes management requires an organized, systemic approach and the involvement of a coordinated team. Dedicated health care professionals working in an environment where patient centered, high quality care is a priority.

Social Determinants of Health Economic (financial barriers) Enviromental Political Social (ex. Housing, potential food insecurity) Worldwide’s health inequality due to the conditions above.

Diabetes Classification Type 1 diabetes (autoinmune B-cell destruction, absolute insulin deficiency) Type 2 diabetes (due to a progressive loss of B-cell insulin secretion frequently on the back- ground on insulin resistance) Gestational Diabetes Mellitus (GDM) (diabetes diagnosed is the 2nd or 3rd triemester of pregnacy) No present before the pregnancy

Diagnostic Test for Diabetes Based on plasma glucose criteria: Fasting blood glucose (FPG) 2-h plasma glucose value after 75-g oral glucose tolerance test (OGTT) A1c (HgbA1c)

Diagnostic Test for Diabetes Testing should be repeated at minimum of 3-years for normal results and yearly for pre diabetes and for high risk status. Testing for pre diabetes and diabetes type 2 should be considered in: Adults, Children and adolescents with: BMI>/= 25 kg/m2 (overweight or obese) two or more additional risk factors for diabetes (Table 2)

Prediabetes is define as.. FPG- 100-125 mg/dl (5.6 mmol/L-6.9 mmol/L 2-hr OGTT- 140-199 mg/dl (7.8-11.0 mmol/L) A1c (HgbA1c)- 5.7-6.4% (39-47mmol/L)

Prevention or Delay of Diabetes Type 2 Annual monitoring in pre diabetic. Intensive behavioral lifestyle intervention (Goal: loss 7% of initial body weight and increase physical activity-walking 150 mn/week) Metformin therapy for prevention type 2 diabetes for: Prediabetic patient with BMI >35 kg/m2 <60 years patients Women with Gestational Diabetes Mellitus Patients with continuous > A1c despite lifestyle intervention.

Diabetes is define as.. FPG >126 mg/dl (>7.0 mmol/L) (No caloric intake for at least 8 hr) 2-hr OGTT >200mg/dl (>12.0 mmol/L) A1c (HgbA1c) > 6.5% (>48mmol/L) Random plasma glucose > 200 mg/dL for patient with symptoms of hyperglicemia or hyperglicemia crisis.

A Diagnosis of Diabetes was made and what’s next? Complete medical evaluation (Table 4) Medical History Physical examination Laboratory evaluation

A Diagnosis of Diabetes was made and what’s next? Detect diabetes complications and potential comorbid conditions. (Clinicians and patient should be aware of common complications) Begin patient engagement in the formulation of a care management plan. Develop a plan for continuing care. Referrals as necessary (Table 3) Preventive care services recommendations (immunizations and cancer screening).

A Diagnosis of Diabetes was made and what’s next? Lifestyle management is a fundamental aspect of diabetes care and includes: Diabetes self-management education (DSME) (at diagnosis, annually, with new complications) Diabetes self-management support (DSMS) (at diagnosis, annually, with new complications) Nutrition for Medical nutrition therapy (MNT) Physical activity Smoking cessation Psychosocial care (screening for cognitive impairment and depression in older adults of >65)

A Diagnosis of Diabetes was made and what’s next? Pharmacologic Therapy: Diabetes Type 1: Multiple injection therapy (MDI) prandial and basal insulin Continuous subcutanous infusion (insulin pump)

Diabetes Type 2: (patient-centered approach) Metformin is the preferred initial therapy, if not contraindicated and if tolerated. Dual therapy or triple therapy should be considered for patient who are not achieving glycemic goal after three month in monotherapy at maximun dose. Insulin with or without additional agents in newly diagnose patient who are symptomatic and have A1C> 10%, blood glucose level >300 md/dL and for patient not achieving glycemic goals.

HgB A1c Goals *A1c goal in Pediatric all age-groups <7.5% mg/dL *A1c goal in pregnant women <6.5% mg/dL

Diabetes Complications Intensive diabetes management with the goal achieving has been shown in large prospective, randomized studies to delay the onset and progression of microvascular complications. The most common complications seen in Diabetic patients are: Nephropathy (At least once a year assess urinary albumin and eGFR in Type 1 diabetic, Type 2 and with patient with comorbid hypertension.) Refer to a Nephrologist when eGFR<30ml/min/1.73m2

Retinopathy (Eye iniatial dilated within 5 year after the onset of diabetes type 1) (On diabetes type 2 initial assess at the time of diagnosis then annually if there no evidence of retinopathy after several years then exam every 2 years) Neuropathy (Assess for peripheral neuropathy at the diagnosis of type 2 diabetes and 5 years after the diagnoses of type 1 diabetes and annually thereafter) Foot ulcers (Inspection on every visit)

Diabetes in Special Populations Children Pregnancy Older *Will Require in some cases therapy adjustment, the establishment of individualize goals and special care.

Conclusion The management of a Diabetic patient is a big challenge at the primary care level. It’s important to stablished a patient-centered approach and a chronic care model to guarantee the best results in our patient’s life. The complications due to uncontrolled diabetes will be latent and the key of action to delay them will be to reach the glycemic control. Developing a care team that include the patient, family, other health professionals and specialist will gave us the opportunity to provide the quality of care that any diabetic patient deserves.

References American Diabetes Association; Standards of Medical Care in Diabetes-2017, Volume 40; supplement 1, January 2017 Standards of Medical Care in Diabetes-2017, Abridged for Primary Care Providers. Clinical Diabetes Paper in Press, Published online December 15, 2017 www.americandiabetesassociation.org

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