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#1 Absolute Best Way To Lower Blood Sugar Fpr Disclosures. Please read the Disclaimer at the end of this page. Ac goals for diabetes management natural history of most patients manaegment type 2 diabftes is Ac goals for diabetes management blood glucose concentrations to foe gradually Guarana Powder for Sale time, and rising Defense against harmful microorganisms gor usually the indication for therapy intensification. Treatments for hyperglycemia that fails to respond to initial monotherapy or fpr medication use in type 2 diabetes are reviewed here. Options for initial therapy and other therapeutic issues in diabetes management, such as the frequency of monitoring and evaluation for microvascular and macrovascular complications, are discussed separately. See "Initial management of hyperglycemia in adults with type 2 diabetes mellitus" and "Overview of general medical care in nonpregnant adults with diabetes mellitus". Related Pathway s : Diabetes: Initiation and titration of insulin therapy in non-pregnant adults with type 2 DM and Diabetes: Initial therapy for non-pregnant adults with type 2 DM and Diabetes: Medication selection for non-pregnant adults with type 2 DM and persistent hyperglycemia despite monotherapy.Managemebt Disclosures. Please read the Disclaimer at the end of gosls page. All of these treatments msnagement goals need gals be doabetes based Macronutrients and blood sugar control individual factors, such as age, life expectancy, and comorbidities.
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DIABETES EDUCATION — Patients voals newly doabetes diabetes should participate in a managemenf diabetes self-management education program, which duabetes individualized instruction on nutrition, physical activity, optimizing metabolic control, and preventing complications.
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See 'Diet' below and "Medical nutrition therapy for type 2 diabetes mellitus". Weight management — For patients with type 2 diabetes, body weight management should be considered as a therapeutic target in addition to glycemia.
Patients should receive counseling regarding changes in diet and physical activity to achieve weight loss or to prevent weight gain. Weight loss improves glycemia through mitigation of insulin resistance and impaired beta cell function, two major metabolic perturbations evident in type 2 diabetes [ 12,13 ].
For patients who have difficulty achieving weight loss, weight maintenance rather than gain is an alternative goal. Strategies for weight management include lifestyle change, pharmacologic therapy, and metabolic surgery. Lifestyle change includes diet and physical activity, as well as behaviors that facilitate these changes, and is an essential component of any weight management plan.
We emphasize lifestyle change as our initial approach to body weight reduction and reserve pharmacotherapy and metabolic surgery for patients who do not achieve targeted weight loss with lifestyle change alone. We tailor our specific recommendations to patients' goals and preferences and encourage "intensive" lifestyle modification, where available, for highly motivated patients.
Diet — Diagnosis of type 2 diabetes is often a powerful motivator for lifestyle change. Dietary modification is a highly effective strategy for weight loss and for management of glycemia and hypertension in patients who are willing to commit to it, with metabolic benefit likely outlasting the effect of weight loss per se.
The improvement in glycemia is related both to the degree of caloric restriction and weight reduction [ 12,14,15 ]. Body weight loss of 5 to 10 percent may also improve nonalcoholic steatohepatitis, sleep apnea, and other comorbidities of type 2 diabetes [ 16 ].
Consumption of sugar-sweetened beverages, including natural fruit juice, should be specifically queried and strongly discouraged in order to manage glycemia, weight, and reduce risk for CVD and fatty liver [ 17 ].
See "Medical nutrition therapy for type 2 diabetes mellitus", section on 'Designing a nutrition care plan' and "Management of nonalcoholic fatty liver disease in adults", section on 'Initial lifestyle interventions'.
In a two-year analysis of the DiRECT trial, only 11 percent of intervention participants had weight loss of 15 kg or more compared with 24 percent in the one-year analysis [ 18 ].
However, 36 percent of participants maintained diabetes remission, compared with 3 percent of control patients. Several studies have evaluated the long-term efficacy of diet alone or with exercise in patients with newly diagnosed type 2 diabetes see "Medical nutrition therapy for type 2 diabetes mellitus".
In the United Kingdom Prospective Diabetes Study UKPDSfor example, all patients were given a low-calorie, low-fat, high complex carbohydrate diet [ 21 ]. Furthermore, the mean glucose value was substantially higher with diet alone than with diet plus an oral hypoglycemic drug or insulin.
The likelihood of a successful glycemic response to diet is determined in large part by the initial fasting blood glucose. Pharmacologic therapy — Pharmacotherapy targeted solely for weight management is effective in patients with type 2 diabetes.
Although metformin is usually started for the management of hyperglycemia, it is also frequently an effective medication to promote modest weight loss. When additional body weight reduction is a primary goal of therapy, we choose medications that promote weight loss and lower glucose.
Glucagon-like peptide 1 GLP-1 receptor and dual GLP-1 and glucose-dependent insulinotropic polypeptide GIP agonist therapies promote weight loss and help prevent weight gain due to other glucose-lowering pharmacotherapies.
We add these medications sequentially to metformin if additional glucose lowering or weight loss is a treatment goal. See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus" and "Obesity in adults: Drug therapy".
Surgical therapy — Weight loss surgery in patients with obesity and type 2 diabetes results in the largest degree of sustained weight loss and, in parallel, improvements in blood glucose management and the most frequent sustained remissions of diabetes. Weight loss surgery is an option to treat poorly managed type 2 diabetes when other modalities have failed.
This topic is reviewed in detail separately. See "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Bariatric metabolic surgery'. Exercise — Regular exercise is beneficial in type 2 diabetes, independent of weight loss. It leads to improved glycemic management due to increased responsiveness to insulin; it can also delay the progression of impaired glucose tolerance to overt diabetes [ 22,23 ].
These beneficial effects are directly due to exercise, but concurrent weight reduction plays a contributory role. In one study, however, only 50 percent of patients with type 2 diabetes were able to maintain a regular exercise regimen [ 24 ]. See "Exercise guidance in adults with diabetes mellitus".
Shorter-duration, intensive exercise may be appropriate for physically fit individuals [ 25 ]. Resistance training may be particularly important for individuals with type 2 diabetes who do not have overweight or obesity, in whom relative sarcopenia may contribute to diabetes pathophysiology [ 26 ].
Intensive lifestyle modification — In patients with established type 2 diabetes, intensive behavioral modification interventions focusing on weight reduction and increasing activity levels are successful in reducing weight and improving glycemic management while, at the same time, reducing the need for glucose-lowering and other medications [ 15,18, ].
The intensive intervention included caloric restriction maximum 30 percent calories from fat, minimum 15 percent protein, and the remainder from carbohydrates, in the form of liquid meal replacements, frozen food entrees, or structured meal plansmoderate-intensity physical activity goal minutes weeklyand weekly group or individual sessions with registered dietitians, behavioral psychologists, and exercise specialists.
The primary outcome was a composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, and hospitalization for angina. Although the anticipated follow-up period was After a median follow-up of 9.
The improvement in weight and glycemia did not reduce the occurrence of cardiovascular events. Possible reasons for this finding include the lower-than-expected rates of cardiovascular events in both groups, improved overall cardiovascular risk factor treatment with medical therapy antihypertensives, statins in the standard diabetes education arm, enrollment of a relatively healthy patient population, gradual weight loss in the control group such that the differential weight loss between the two groups was only 2.
A sustained weight loss of greater than that achieved in the trial may be required to reduce the risk of CVD. In an observational post hoc analysis of the Look AHEAD trial, weight loss of 10 percent or greater in the first year was associated with a reduction in the primary outcome 1.
However, this post hoc analysis is problematic. Moreover, the degree of weight loss is difficult to achieve and maintain through lifestyle intervention alone. Weight loss, weight loss maintenance, and exercise remain important components of diabetes management due to overall health benefits. The following summarizes several other major observations from the Look AHEAD trial [ 27,31, ]:.
The difference was attenuated but remained significant throughout the trial 6 versus 3. Changes in waist circumference and physical fitness were also significantly better in the intervention group throughout the study.
By study end, mean A1C was significantly lower in the intervention group 7. Psychological interventions — Patients with type 2 diabetes often experience significant stress, a condition often called diabetes distress, related to the many self-care responsibilities required for glycemic management lifestyle modifications, medication, and blood glucose monitoring [BGM] [ 42 ].
Concurrent depression similarly may interfere with self-care. See "Overview of general medical care in nonpregnant adults with diabetes mellitus", section on 'Comorbid conditions'.
Psychotherapy reduces psychological distress and improves glycemic management in some [ 43,44 ], but not all [ 45 ], studies. In a meta-analysis of 12 trials of patients with type 2 diabetes randomly assigned to psychological intervention or usual care, mean A1C was lower in the intervention group pooled mean difference Measures of psychological distress were also significantly lower in the intervention group, but there were no differences in weight management.
Pregnancy planning — All women of childbearing age with diabetes should be counseled about the potential effects of diabetes and commonly used medications on maternal and fetal outcomes and the potential impact of pregnancy on their diabetes management and any existing complications.
See "Pregestational preexisting diabetes: Preconception counseling, evaluation, and management". When to start — Early institution of treatment for diabetes, at a time when the A1C is not substantially elevated, is associated with improved glycemic management over time and decreased long-term complications [ 46 ].
Pharmacologic therapy should be initiated along with consultation for lifestyle modification focusing on dietary and other lifestyle contributors to hyperglycemia. Weight loss and weight loss maintenance underpins all effective type 2 diabetes therapy, and lifestyle change reduces the risk of weight gain associated with sulfonylureas and insulin.
However, for those patients who have clear and modifiable contributors to hyperglycemia and who are motivated to change them eg, commitment to reduce consumption of sugar-sweetened beveragesa three-month trial of lifestyle modification prior to initiation of pharmacologic therapy is warranted.
Choice of initial therapy — Our suggestions are based upon clinical trial evidence and clinical experience in achieving glycemic targets and minimizing adverse effects table 1with the recognition that there is a paucity of high-quality, head-to-head drug comparison trials and long-duration trials or ones with important clinical endpoints, such as effects on complications.
The long-term benefits and risks of using one approach over another are unknown. In selecting initial therapy, we consider patient presentation eg, presence or absence of symptoms of hyperglycemia, comorbidities, baseline A1C levelindividualized treatment goals and preferences, the glucose-lowering efficacy of individual drugs, and their adverse effect profile, tolerability, and cost [ 47 ].
We prefer initiating a single agent typically metformin and then sequentially adding additional glucose-lowering agents as needed, rather than starting with combination therapy [ 48 ]. Related Pathway s : Diabetes: Initial therapy for non-pregnant adults with type 2 DM.
: Ac goals for diabetes management| Diabetes Canada | Clinical Practice Guidelines | Diabbetes Ac goals for diabetes management of incretin-based therapy in manaement patients with type 2 diabetes. There dizbetes little to Importance of BMI evidence fir any Nutrition for golfers benefit diabetse intervening to achieve a target Managsment in these populations; there Grape Infused Cocktails plenty of evidence for harm. Diabetes Care Providers in the Hospital. Pulmonary Arterial Hypertension. Glucose-lowering medication in type 2 diabetes: Overall approach Glycemic control in type 2 diabetes A1C over time in type 2 diabetes Combination insulin and oral hypoglycemic therapy Combination injectable therapy for type 2 diabetes mellitus. Rizzo MR,Marfella R, Barbieri M, et al. Insulin use in long term care settings for patients with type 2 diabetes mellitus: A systematic review of the literature. |
| Get Active! | Diabetes | CDC | There is very little role for measuring A1C in these patients. Patients should be warned and educated about the signs of hypoglycemia and hypoglycemia unawareness. The acute risks of hyperglycemia as experienced in this stage center mainly on the risk of a hyperosmolar hyperglycemic state and associated complications, such as osmotic diuresis, recurrent infection, and poor wound healing. As patients move into this phase, the importance of glycemic control is less apparent and preventing hypoglycemia is of greater significance. Patient and caregiver education regarding the telltale signs of dehydration and hypoglycemia and an appropriate plan of action is of vital importance. The risk of renal or hepatic failure becomes more evident at this stage, and insulin or other glucose-lowering medication dosages may need to be reduced in both patients with type 1 diabetes and patients with type 2 diabetes. Most practitioners in this case would simply withdraw all oral hypoglycemic agents and stop insulin in most patients with type 2 diabetes. Ford-Dunn et al. At this point, care is focused on patient comfort and preparatory bereavement counseling for caretakers and patients, where appropriate. Patients admitted to LTC facilities are not seen daily by a practitioner. Because of this reality, successful diabetes care needs to include a dedicated interprofessional team. Patients admitted to LTC facilities are typically seen by a medical provider at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. In practice, patients are seen within the first week of admission and also when medically necessary although this may be several days after an event or change of condition. This system means that patients may have uncontrolled blood glucose levels or wide excursions without the practitioner being notified. Adjustments to treatment regimens can be made by telephone, fax, or order entry into electronic health records. Standing orders for glucose monitoring and practitioner notification that are approved by the facility and the practitioner at the time of admission may be useful. Table 6 delineates the practical recommendations for the LTC staff in management of specific situations in patients with diabetes. It is more important to address persistently abnormal trends in blood glucose values rather than attempting to adjust the treatment regimen in response to a few isolated abnormal values. Pandya and Patel 54 have described the challenges in managing diabetes in postacute and LTC settings. The challenges specific to patients include altered pharmacokinetics and pharmacodynamics of medications, increased risk of hypoglycemia, unpredictable meal consumption, comorbidities such as cognitive dysfunction and depression, psychological resistance to insulin, impaired vision and dexterity, and greater potential for adverse effects and drug interactions. Institutional-level challenges include staff turnover and lack of familiarity with patients, restrictive diet orders, inadequate review of glucose logs and trends, lack of facility-specific diabetes treatment algorithms for blood glucose levels and provider notifications, and, often, lack of administrative buy-in to promote the roles of the medical director, the director of nursing, and the consultant pharmacist. Challenges specific to staff and practitioners include multiple changing treatment approaches, lack of team communication, excessive reliance on SSI, inappropriate dosing or timing of insulin, knowledge deficits, lack of comfort with new insulin and injectable agents, failure of timely stepwise advance in therapy, failure to individualize care, and therapeutic nihilism. It requires a dedicated interprofessional team composed of registered nurses, certified nursing assistants, diabetes educators, dietitians, food service managers, consultant pharmacists, physical therapists, social workers, and practitioners to manage older patients with diabetes in LTC facilities. In order to assess and improve facility-wide management of diabetes directed by multiple practitioners, the facility leadership e. These could include sharing data with managerial staff, providing staff education, and planning a performance improvement project. In general, the facility medical leadership and nursing administration have the opportunity to develop and implement patient care policies that can facilitate optimal management of the older patient with diabetes and to coordinate efforts with the multidisciplinary team. Nursing leadership training programs for nurses working in LTC facilities that include skills in diabetes management can also help to improve quality of care offered to patients in these facilities 55 , F-tags can be given at an annual state licensing survey or in response to a complaint survey at any time of the year. LTC facilities that are noncompliant may be subject to financial penalties. Consequently, ensuring a high level of care for patients with diabetes in LTC facilities is also necessary for compliance with federal regulations. Diabetes is a common, morbid, and costly disease in older adults. This population is heterogeneous and presents unique challenges pertaining to diabetes management. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities. This understanding requires knowledge of the patient population as well as the functioning of the facilities. Once the challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life. The authors acknowledge Dr. Jane L. Chiang's invaluable editorial contribution throughout the development of this position statement. is supported in part through the following grants: Midcareer Investigator Award in Patient-Oriented Research K24 DK , the Chicago Center for Diabetes Translation Research P30 DK , and a project grant R01 HS is supported in part by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases KDK is supported by the Health Resources and Services Administration HRSA of the U. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS, or the U. Duality of Interest. is a consultant for Sanofi and Novo Nordisk. was an advisory group member for AstraZeneca as part of a 1-day meeting. No other potential conflicts of interest relevant to this article were reported. The position statement was reviewed and approved by the Professional Practice Committee in November and approved by the Executive Committee of the Board of Directors in November Sign In or Create an Account. Search Dropdown Menu. header search search input Search input auto suggest. filter your search All Content All Journals Diabetes Care. Advanced Search. User Tools Dropdown. Sign In. Skip Nav Destination Close navigation menu Article navigation. Volume 39, Issue 2. Previous Article Next Article. General Approach to Care. Goals and Strategies. Diabetes Management During Transitions of Care. Diabetes Management in Patients at End of Life Including Issues for Palliative Care and Hospice Patients. Integration of Diabetes Management Into LTC Facilities. Article Information. Article Navigation. Position Statement January 11 Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association Medha N. Munshi ; Medha N. Corresponding author: Medha N. Munshi, mmunshi bidmc. This Site. Google Scholar. Hermes Florez ; Hermes Florez. Elbert S. Huang ; Elbert S. Rita R. Kalyani ; Rita R. Maria Mupanomunda ; Maria Mupanomunda. Naushira Pandya ; Naushira Pandya. Lauderdale, FL. Carrie S. Swift ; Carrie S. Tracey H. Taveira ; Tracey H. Linda B. Haas Linda B. Diabetes Care ;39 2 — Get Permissions. toolbar search Search Dropdown Menu. toolbar search search input Search input auto suggest. E Diabetes management in LTC patients residents requires different approaches because of unique challenges faced by this population and the workings of LTC facilities. Table 1 Characteristics of older adults and their diabetes management based on living situation. Community-dwelling patients. Assisted living facilities. Hospitalized inpatients. Skilled nursing facility. Nursing facility long-term. View Large. B Simplified treatment regimens are preferred and better tolerated. E Sole use of SSI should be avoided. C Liberal diet plans have been associated with improvement in food and beverage intake in this population. Table 2 Framework for considering diabetes management goals. Special considerations. Fasting and premeal blood glucose targets. Glucose monitoring. Table 3 Commonly found comorbidities in LTC and strategies to improve diabetes care. Clinical presentation that may interfere with diabetes management. Possible strategies to manage diabetes. ADL, activities of daily living such as bathing, toileting, eating, dressing, transferring. Table 4 Advantages, disadvantages, and caveats in using glucose-lowering agents in LTC population. Caveats in LTC population. Table 5 Strategies to replace SSI in LTC. Current regimen. Suggested steps. Also, if you are experiencing a lot of hypoglycemia or have hypoglycemic unawareness your provider may suggest you target higher blood sugar levels. In contrast, pregnant women or women thinking about getting pregnant will have lower blood glucose targets. Self assessment quizzes are available for topics covered in this website. To find out how much you have learned about Monitoring Your Diabetes , take our self assessment quiz when you have completed this section. The quiz is multiple choice. Please choose the single best answer to each question. At the end of the quiz, your score will display. All rights reserved. University of California, San Francisco About UCSF Search UCSF UCSF Medical Center. Lifestyle changes are very effective, and the side effects of eating more healthfully and staying more active are positive ones. Every person with type 2 diabetes is an individual. No single goal is right for everyone, and each patient should have a say in how to manage their blood sugars and manage risk. That means an informed discussion, and thoughtful consideration to the number. Hemoglobin A1c targets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus: A guidance statement update from the American College of Physicians. Annals of Internal Medicine , March An overview of the management of diabetes in non-pregnant adults. MGH Primary Care Office Insite, updated June Management of persistent hyperglycemia in type 2 diabetes mellitus. UpToDate, updated April Monique Tello, MD, MPH , Contributor. 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| Normal ranges for blood sugar | Advanced Search. Information on medication changes, pending tests and studies, and follow-up needs must be accurately and promptly communicated to outpatient physicians. Rare Blood. However, if lifestyle intervention has not produced a significant reduction in symptoms of hyperglycemia or in glucose values after one or two weeks, then the sulfonylurea should be added. On the other hand, monitoring is often conducted when it is not required. |
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