This is the 2^nd installment of my Practical Diabetes Care blog in which I review the basic principles of the organization of diabetes care in the office setting. As well, I discuss beginning of the diabetes assessment: screening and diagnosis. For more detail, refer to my book: Practical diabetes Care for the Health Care Professional.

 ORGANIZATION OF DIABETES CARE:

Diabetes is primarily self-managed. People with diabetes must commit themselves to a daily balance of lifestyle choices with respect to food intake and physical activity, in association with frequent monitoring of blood glucose and the use of medications (i.e. antihyperglycemic agents, insulin or both). The concept of the Diabetes Health Care (DHC) team, where the person with diabetes is at the center surrounded by a core of health care professionals, is well-recognized as providing the most successful long-term care for diabetes. There have also been increasing technological advances in office practice organization that make this system more efficient. However, it is recognized that living well with diabetes can be stressful and this is where an expanded DHC team can provide the necessary emotional and psychological support as well.

Shared Care

Successful diabetes management occurs when the DHC team shares the care with the primary care provider. It cannot be overstated that the central team member is the person with diabetes, followed closely by their primary support network of family and friends.

Importantly, research has demonstrated that people with Type 1 (T1) diabetes have better outcomes working within a shared care model with a DHC team that includes an endocrinologist and certified diabetes educators (CDEs). This is related to the level of complexity that can often arise in the management of T1 diabetes. Advanced DHC teams, i.e. those that include CDEs, can provide additional support with respect to managing complex diabetes medication regimens, continuous glucose monitoring systems, insulin pumps, diabetes-specific problem-solving and individualized case management. They can also help those with diabetes cope with the day-to-day stress of juggling nutritional intake, physical activity and medication regimens.

People with Type 2 (T2) diabetes with complex management requirements (e.g. secondary to diabetes-related complications) may also benefit from interaction with a DHC team that includes CDEs.

For those with less complex T2 diabetes, the DHC team may look different, with a primary care provider – rather than an endocrinologist – and the involvement of community-based diabetes educators. Many local health care jurisdictions have community-based diabetes education resource centres that provide patient education and counselling regarding nutrition, physical activity, self monitoring of blood glucose and insulin administration. When necessary, the DHC team can expand to include other health care providers and community service professionals and providers.

Endocrinologists/diabetes specialists may take on roles beyond the customary consultant role; indeed, they may act as mentors, educators and facilitators of shared-care/case-management approaches with a primary care provider. The traditional role of the specialist consultant is evolving as team-based care in many clinical areas is becoming more common.

Reminder and Recall Systems

Clinical organizational practices that have been shown to improve the care of people with diabetes include reminder and recall systems for the physician, the DHC team and the person with diabetes. These systems render the regular monitoring of diabetes and its complications an automatic function. Depending on the individual clinic situation, reminder and recall systems are increasingly centralized through an electronic medical record (EMR). Depending on the function of an EMR, ongoing flow sheets of key laboratory results can be generated, allowing the DHC team to review changing values over time, e.g. glycated hemoglobin (A1C). Abnormal lab results can be flagged and even linked to evidence-based clinical practice guidelines that provide management recommendations. Such systems can facilitate individual diabetes case management and specific problem-solving by DHC team members.

Diabetes in the Office

Diabetes care comprises a significant amount of routine office practice for the primary care provider. As with all chronic conditions, diabetes takes time. As well, recognizing the complications associated with diabetes, it is no longer enough to simply review blood glucose levels with patients. A complete assessment of people with diabetes must also include a review of diabetes medications and other medication regimens, glycemic control, nutritional intake, physical activity and a discussion about stress and its detrimental effect on blood glucose control. Also, importantly, an assessment for any possible long-term micro- and macrovascular complications must be completed. All these components play a role in successful diabetes management.

Screening & Diagnosis

It is not recommended that screening for T1 diabetes be conducted routinely. Although there is an increased genetic risk in families with T1 diabetes, regular screening of non-affected family members is not advised. Awareness of presenting symptoms is helpful to recognize possible T1 diabetes early in its onset.

As T2 diabetes may be asymptomatic, there may be significant lag time between true onset and diagnosis of the condition. Accordingly, recognition of the potential risk factors and active screening for T2 diabetes is key.

Diagnosis of Diabetes

Table 1. Diagnostic criteria for diabetes

2h PG, 2 hour plasma glucose; A1C, glycated hemoglobin; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; PG, plasma glucose

Diagnosis of Prediabetes

Prediabetes defines an earlier stage of glucose intolerance, identified as either impaired glucose tolerance (IGT) or impaired fasting glucose (IFG). A1C values of 6.0–6.4% are also diagnostic indicators for prediabetes.

Table 2. Diagnosis of prediabetes

2h PG, 2 hour plasma glucose; A1C, glycated hemoglobin; FPG, fasting plasma glucose; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; OGTT, oral glucose tolerance test

Diagnosis of Metabolic Syndrome of Insulin Resistance

Metabolic syndrome of insulin resistance (i.e. metabolic syndrome) refers to a constellation of conditions that confer a high risk of CVD in an individual. These conditions include prediabetes, diabetes, hypertension, dyslipidemia and abdominal obesity, most of which can be modified.

Table 3. Clinical characteristics for diagnosing metabolic syndrome

BP, blood pressure; FPG, fasting plasma glucose; HDL-C, high-density lipoprotein cholesterol; TG, triglycerides

Implications for metabolic syndrome are as follows:

• Recognition
• Insulin resistance as the key characteristic; therefore, the need to screen for prediabetes/T2 diabetes
• Multi-pronged management approach for the modifiable components

Future blogs will review that basic assessment of a person with diabetes, nonpharmacologic & pharmacologic management of diabetes and its complications.

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