Lower blood pressure levels may be associated with impaired fetal growth. As with glucose measurements, the continuum of risk is curvilinear, so that as A1C rises, the risk of diabetes rises disproportionately (15). The ETDRS also verified the benefits of panretinal photocoagulation for high-risk PDR and in older-onset patients with severe NPDR or less-than-high-risk PDR. In women in the DPP with a history of GDM, metformin and intensive lifestyle modification led to an equivalent 50% reduction in the risk of diabetes (55). Abbott, E. Anderson, L. Consistent carbohydrate intake with respect to time and amount can result in improved glycemic control for individuals using fixed daily insulin doses (142,143). Microvascular complications were not examined. It should be noted that the World Health Organization (WHO) and a number of other diabetes organizations define the cutoff for IFG at 110 mg/dL (6.1 mmol/L). S. Horton,* K. ompanies. Nelson, G. L. Lyman, D. McPherson, M. Moreover, screening with a 50-g GLT does not require fasting and is therefore easier to accomplish for many women. The greatest predictor of A1C lowering for all age-groups was frequency of sensor use, which was lower in younger age-groups. Type 1 diabetes is associated with osteoporosis, but in type 2 diabetes an increased risk of hip fracture is seen despite higher bone mineral density (BMD) (405). Amputation and foot ulceration, consequences of diabetic neuropathy and/or PAD, are common and major causes of morbidity and disability in people with diabetes. Follow-up of all three large studies of lifestyle intervention has shown sustained reduction in the rate of conversion to type 2 diabetes, with 43% reduction at 20 years in the Da Qing study (47), 43% reduction at 7 years in the Finnish Diabetes Prevention Study (DPS) (48), and 34% reduction at 10 years in the U. In addition to competing causes of mortality in older adults, the immune response to the vaccine declines with age (314). Women using medications such as statins or ACE inhibitors need ongoing family planning counseling. Type 2 diabetes mellitus, formerly called non-insulin-dependent diabetes mellitus, is a serious, costly disease affecting approximately 8 percent of adults in the United States.1 Treatment prevents some of its devastating complications2,3 but does not usually restore normoglycemia or eliminate all the adverse consequences. In a large multiethnic cohort study, for an equivalent incidence rate of diabetes conferred by a BMI of 30 kg/m2 in whites, the BMI cutoff value was 24 kg/m2 in South Asians, 25 kg/m2 in Chinese, and 26 kg/m2 in African Americans (21). Intensive diabetes management with the goal of achieving near-normoglycemia has been shown in large prospective randomized studies to delay the onset and progression of increased urinary albumin excretion in patients with type 1 (335,336) and type 2 (83,84,88,89) diabetes. The study was designed to answer the following primary questions: Does a lifestyle intervention or treatment with metformin, a biguanide antihyperglycemic agent, prevent or delay the onset of diabetes? The Antithrombotic Trialists' (ATT) collaborators published an individual patient-level meta-analysis of the six large trials of aspirin for primary prevention in the general population. O. Brown,† J. Jinagouda,† B. Clinicians should note that the numbers in the table are now different, as they are based on ∼2,800 readings per A1C in the ADAG trial. Much of the work documenting the impact of smoking on health did not separately discuss results on subsets of individuals with diabetes, but suggests that the identified risks are at least equivalent to those found in the general population. Clifford, R. Poulos, L. Ronan, M. A systematic review and meta-analysis showed that psychosocial interventions modestly but significantly improved A1C (standardized mean difference −0.29%) and mental health outcomes. Results of SMBG can be useful in preventing hypoglycemia and adjusting medications (particularly prandial insulin doses), medical nutrition therapy (MNT), and physical activity. Complications of kidney disease correlate with level of kidney function. Hughte, L. E.
Anti diabetes drug 58
R. Sherman, C. In an analysis of one of the initial studies suggesting that statins are linked to risk of diabetes, the cardiovascular event rate reduction with statins outweighed the risk of incident diabetes even for patients at highest risk for diabetes (361). Saudek (chair); Outcomes Classification - R. Absolute stroke event rates were low; the number needed to treat to prevent one stroke over the course of 5 years with intensive blood pressure management is 89. L. Bradley,† T. Laser photocoagulation surgery in both trials was beneficial in reducing the risk of further visual loss, but generally not beneficial in reversing already diminished acuity. Unless they have severe hypertriglyceridemia at risk for pancreatitis, for most diabetic patients the first priority of dyslipidemia therapy is to lower LDL cholesterol to <100 mg/dL (2.60 mmol/L) (371). Given the substantially increased risk of hypoglycemia in type 1 diabetes trials, and now seen in recent type 2 diabetes trials, the risks of lower glycemic targets may outweigh the potential benefits on microvascular complications on a population level. For other drugs, issues of cost, side effects, and lack of persistence of effect in some studies (54) require consideration. Oral Hypoglycemic Agents (OHA) were prescribed for 86% (171) of cohorts while insulin and OHA was prescribed in 14% (29). Harroun; Quality of Well Being Reading Unit (University of California, San Diego) - T. Additionally, an RCT in patients with known CVD found no CVD benefit of insulin regimens targeting postprandial glucose compared with those targeting preprandial glucose (102). Some have posited that glycation rates differ by race (with, for example, African Americans having higher rates of glycation), but this is controversial. Calizar, L. M. Safe and effective vaccines are available that can greatly reduce the risk of serious complications from these diseases (244,245). ★ Reverse Diabetes Today Book ★: : The 3 Step Trick that Reverses Diabetes Permanently in As Little as 11 Days.[ REVERSE DIABETES TODAY BOOK ] The.. Several studies suggested that ACE inhibitors may be superior to dihydropyridine calcium channel blockers in reducing cardiovascular events (333-335). Conversely, in a substudy of the ACCORD trial, cognitive impairment at baseline or decline in cognitive function during the trial was significantly associated with subsequent episodes of severe hypoglycemia (225). Companies! Jacobsen, L. Lowering blood pressure has been shown to decrease the progression of retinopathy (255), although tight targets (systolic <120 mmHg) do not impart additional benefit (90). Post hoc analysis of achieved blood pressure in several hypertension treatment trials have suggested no benefit of lower achieved SBP. Generally, people with type 1 diabetes present with acute symptoms of diabetes and markedly elevated blood glucose levels, and some cases are diagnosed with life-threatening ketoacidosis. A. Jay, R. S. Longer-term outcome studies are currently underway. Young; University of California, San Diego - J. M. Mobley, L. It is a well-established marker of increased CVD risk (404-406). Devlin, T. Franklin, O. Therefore, while aspirin resistance appears higher in the diabetic patients when measured by a variety of ex vivo and in vitro methods (platelet aggregometry, measurement of thromboxane B2), these observations alone are insufficient to empirically recommend higher doses of aspirin be used in the diabetic patient at this time. A recent RCT of 448 participants with type 2 diabetes and hypertension demonstrated reduced cardiovascular events and mortality with median follow-up of 5.4 years if at least one antihypertensive medication was given at bedtime (345). Overall, meta-analyses suggest that compared with SMBG, CGM use is associated with A1C lowering by ∼0.26% (73). Levina, T. Michel, D. There is also evidence for diabetes remission following bariatric surgery in persons with type 2 diabetes who are less severely obese. Notably, sex differences in aspirin's effects have not been observed in studies of secondary prevention (311). It is expected that the balance between adult supervision and self-care should be defined and that it will evolve with physical, psychological, and emotional maturity. G. Saab; The University of Texas Health Science Center - S. There remains strong consensus that establishing a uniform approach to diagnosing GDM will have extensive benefits for patients, caregivers, and policymakers. Measurement of a spot urine for albumin alone (whether by immunoassay or by using a dipstick test specific for albuminuria) without simultaneously measuring urine creatinine is less expensive but susceptible to false-negative and -positive determinations as a result of variation in urine concentration due to hydration and other factors. In a large randomized controlled trial (RCT) in Europe, general practice patients between the ages of 40-69 years were screened for diabetes and then randomly assigned by practice to routine care of diabetes or intensive treatment of multiple risk factors. Nonpharmacological therapy is reasonable in diabetic individuals with mildly elevated blood pressure (SBP >120 mmHg or DBP >80 mmHg). The Kumamoto Study (82) and UK Prospective Diabetes Study (UKPDS) (83,84) confirmed that intensive glycemic control was associated with significantly decreased rates of microvascular and neuropathic complications in patients with type 2 diabetes. Approximately one-fourth of the U. Multiple clinical trials demonstrated significant effects of pharmacological (primarily statin) therapy on CVD outcomes in subjects with CHD and for primary CVD prevention (279,280). The A1C has several advantages to the FPG and OGTT, including greater convenience (since fasting is not required), evidence to suggest greater preanalytical stability, and less day-to-day perturbations during periods of stress and illness. A.1.a, a few studies have suggested that severe hypoglycemia in very young children is associated with mild impairments in cognitive function. Because some cases of GDM may represent pre-existing undiagnosed type 2 diabetes, women with a history of GDM should be screened for diabetes 6-12 weeks postpartum, using nonpregnant OGTT criteria. Culyba, M. Frazier, R. Although there are no well-controlled studies of diet and exercise in the treatment of elevated blood pressure or hypertension in individuals with diabetes, the DASH study in nondiabetic individuals has shown antihypertensive effects similar to pharmacological monotherapy. These risk factors include dyslipidemia, hypertension, smoking, a positive family history of premature coronary disease, and the presence of albuminuria. MNT is an integral component of diabetes prevention, management, and self-management education. E. Kahn, J. V. A systematic review of 34,000 patients showed that metformin is as safe as other glucose-lowering treatments in patients with diabetes and CHF, even in those with reduced left ventricular ejection fraction or concomitant chronic kidney disease (CKD); however, metformin should be avoided in hospitalized patients (403). This increase in mortality in the intensive glycemic control arm was seen in all prespecified patient subgroups. E. Kitabchi,* M. Heard, C. Johnson, D. Testing should be considered in adults of any age with BMI ≥25 kg/m2 and one or more of the known risk factors for diabetes. The primary outcome of ACCORD (nonfatal MI, nonfatal stroke, or cardiovascular death) was nonsignificantly lower in the intensive glycemic control group due to a reduction in nonfatal MI, both when the glycemic control comparison was halted and all participants transitioned to the standard glycemic control intervention (91), and at completion of the planned follow-up (95). The evidence for benefits from lower systolic blood pressure targets is, however, limited. For most patients with diabetes, the first priority of dyslipidemia therapy (unless severe hypertriglyceridemia with risk of pancreatitis is the immediate issue) is to lower LDL cholesterol to a target goal of <100 mg/dL (2.60 mmol/L) (300). The ACCORD trial examined whether a lower SBP of <120 mmHg provides greater cardiovascular protection than an SBP level of 130-140 mmHg in patients with type 2 diabetes at high risk for CVD (326). Studies show that people with diabetes on average eat about 45% of their calories from carbohydrate, ∼36-40% of calories from fat, and ∼16-18% from protein (158-160). Evidence from the DCCT/EDIC trial, which involved younger adults and adolescents with type 1 diabetes, suggested no association of frequency of severe hypoglycemia with cognitive decline (226). Low levels of HDL cholesterol, often associated with elevated triglyceride levels, are the most prevalent pattern of dyslipidemia in persons with type 2 diabetes. Comprehensive group diabetes education programs including nutrition therapy or individualized education sessions have reported A1C decreases of 0.3-1% for type 1 diabetes (117-120) and 0.5-2% for type 2 diabetes (85,121-137). As described in the Section V.b.2, severe hypoglycemia was associated with mortality in participants in both the standard and intensive glycemia arms of the ACCORD trial, but the relationships with achieved A1C and treatment intensity were not straightforward. It must be emphasized that clinical evidence and expert recommendations alone cannot improve patients' lives, but must be effectively translated into clinical management. An A1C range of 6.0-6.5% had a 5-year risk of developing diabetes between 25-50%, and a relative risk (RR) 20 times higher compared with an A1C of 5.0% (15). Hyperglycemia defines diabetes, and glycemic control is fundamental to the management of diabetes. Other triggers for referral may include difficult management issues (anemia, secondary hyperparathyroidism, metabolic bone disease, or electrolyte disturbance) or advanced kidney disease. Certainly, providers should be vigilant in preventing severe hypoglycemia in patients with advanced disease and should not aggressively attempt to achieve near-normal A1C levels in patients in whom such a target cannot be safely and reasonably easily achieved. W. Lipkin, M. Aspirin use in patients under the age of 21 years is contraindicated due to the associated risk of Reye syndrome. Hypoglycemia is the leading limiting factor in the glycemic management of type 1 and insulin-treated type 2 diabetes (223). After 5.3 years of follow-up, CVD risk factors were modestly but significantly improved with intensive treatment. For at-risk patients, it is reasonable to consider standard primary or secondary prevention strategies (reduce risk factors for falls, ensure adequate calcium and vitamin D intake, avoid use of medications that lower BMD, such as glucocorticoids), and to consider pharmacotherapy for high-risk patients. Some patients with stable glycemia well within target may do well with testing only twice per year, while unstable or highly intensively managed patients (e.g, pregnant type 1 diabetic women) may be tested more frequently than every 3 months. Intensive medical therapy that would be indicated anyway for diabetic patients at high risk for CVD seems to provide equal outcomes to invasive revascularization (322,323). There are excellent reviews available that guide the initiation and management of insulin therapy to achieve desired glycemic goals (107,109,110). H. O'Leary,* L. The benefit of intensive glycemic control in this type 1 diabetic cohort has recently been shown to persist for several decades (93). Just as there is less than 100% concordance between the FPG and 2-h PG tests, there is no perfect concordance between A1C and either glucose-based test. DSME enables patients (including youth) to optimize metabolic control, prevent and manage complications, and maximize quality of life, in a cost-effective manner (208,210). Metformin therefore might reasonably be recommended for very high-risk individuals (those with a history of GDM, the very obese, and/or those with more severe or progressive hyperglycemia). Low-dose (75-162 mg/day) aspirin use for primary prevention is reasonable for adults with diabetes and no previous history of vascular disease who are at increased CVD risk (10-year risk of CVD events over 10%) and who are not at increased risk for bleeding. Santiago,† S. However, it is not recommended to reduce CVD events in overweight or obese adults with type 2 diabetes (155). Aldrich, and W. As is the case for individuals found to have IFG and IGT, individuals with an A1C of 5.7-6.4% should be informed of their increased risk for diabetes as well as CVD and counseled about effective strategies to lower their risks (see Section IV). However, there is insufficient evidence that such combination therapy for LDL cholesterol lowering provides a significant increment in CVD risk reduction over statin therapy alone. Boyle, M. R. These tests infer the presence of coronary atherosclerosis by measuring the amount of calcium in coronary arteries and, in some circumstances, by direct visualization of luminal stenoses. The standard lifestyle recommendations for the medication groups were provided in the form of written information and in an annual 20-to-30-minute individual session that emphasized the importance of a healthy lifestyle.
Serum creatinine should be used to estimate GFR and to stage the level of CKD, if present. Murphy, C. Pepe, and J. Patients at increased CHD risk should receive aspirin and a statin, and ACE inhibitor or ARB therapy if hypertensive, unless there are contraindications to a particular drug class. F. Polak; CT-Scan Reading Unit (University of Colorado) - E. Adjusting for BMI moderately, but not completely, attenuated this association (52). Individuals in the highest versus lowest quantile of SSB intake had a 26% greater risk of developing diabetes (133). Depression affects about 20-25% of people with diabetes (268) and increases the risk for MI and post-MI (269) and all-cause mortality (270). Bissett, E. Cagliero, S. Clinical judgment should be used for those at intermediate risk (younger patients with one or more risk factors, or older patients with no risk factors; those with 10-year CVD risk of 5-10%) until further research is available. G. Marrero,* M. The ultimate balance of benefit, cost, and risks of such an approach in asymptomatic patients remains controversial, particularly in the modern setting of aggressive CVD risk factor control. G. Smith, L. Free tutorials.
This definition facilitated a uniform strategy for detection and classification of GDM, but its limitations were recognized for many years. Overall, meta-analyses suggest that compared with SMBG, CGM lowers A1C by ∼0.26% (70). Newer noninvasive CAD screening methods, such as computed tomography (CT) and CT angiography have gained in popularity. Clinical judgment should be used for those at intermediate risk (younger patients with one or more risk factors or older patients with no risk factors; those with 10-year CVD risk of 5-10%) until further research is available. Conversely, the mortality findings in ACCORD and subgroup analyses of the VADT suggest that the potential risks of intensive glycemic control may outweigh its benefits in some patients. C. Vicknair, D.
There is little evidence to support any specific dose, but using the lowest possible dosage may help reduce side effects (316). The diagnosis required confirmation by a second test, usually within six weeks, according to the same criteria. If blood pressure is refractory despite confirmed adherence to optimal doses of at least three antihypertensive agents of different classifications, one of which should be a diuretic, clinicians should consider an evaluation for secondary forms of hypertension. Treatment effects did not differ significantly according either to sex or to race or ethnic group (Table 2). Adames, E. Blanco, L. In a large multiethnic cohort study, for an equivalent incidence rate of diabetes conferred by a BMI of 30 kg/m2 in non-Hispanic whites, the BMI cutoff value was 24 kg/m2 in South Asians, 25 kg/m2 in Chinese, and 26 kg/m2 in African Americans (21). The efficacy of interventions for primary prevention of type 2 diabetes (23-29) has primarily been demonstrated among individuals with IGT, not for individuals with isolated IFG or for individuals with specific A1C levels. Although most studies of MDI versus pump therapy have been small and of short duration, a systematic review and meta-analysis concluded that there were no systematic differences in A1C or rates of severe hypoglycemia in children and adults between the two forms of intensive insulin therapy (70). M. Clark, K. In the DCCT, there was a trend toward lower risk of CVD events with intensive control, and in 9-year post-DCCT follow-up of the EDIC cohort participants previously randomized to the intensive arm had a significant 57% reduction in the risk of nonfatal myocardial infarction (MI), stroke, or CVD death compared with those previously in the standard arm (92). Mohideen, S. Consider referral to a physician experienced in the care of kidney disease when there is uncertainty about the etiology of kidney disease (heavy proteinuria, active urine sediment, absence of retinopathy, rapid decline in GFR, resistant hypertension). The confidence interval was wider for those with diabetes because of their smaller number. While the current prescribing strategy achieved glycemic control in about one third of patients, majority are still not meeting the recommended blood glucose targets due to poor adherence with prescribed drug regimen, and poor knowledge and practice of successful self-management. Patients with diabetes and high-risk foot conditions should be educated regarding their risk factors and appropriate management. Non-Insulin Therapies for Diabetes: GLP-1 Agonists, DPP4 Inhibitors and SGLT2 Inhibitors, 2016 - 2026 - CBS 58 Unless there is a clear clinical diagnosis (e.g, a patient in a hyperglycemic crisis or classic symptoms of hyperglycemia and a random plasma glucose ≥200 mg/dL), it is preferable that the same test be repeated for confirmation, since there will be a greater likelihood of concurrence. Background Type 2 diabetes affects approximately 8 percent of adults in the United States. Some risk factors - elevated plasma glucose concentrations in the fasting In-person exams are still necessary when the photos are unacceptable and for follow-up of abnormalities detected. Patients with persistent albuminuria (30-299 mg/24 h) who progress to more significant levels (≥300 mg/24 h are likely to progress to ESRD (411,412). Pills for diabetes type 2/4 dressing your truth Callus can be debrided with a scalpel by a foot care specialist or other health professional with experience and training in foot care. In adults with CVD risk greater than 1% per year, the number of CVD events prevented will be similar to or greater than the number of episodes of bleeding induced, although these complications do not have equal effects on long-term health (314). Cohort studies attempting to match subjects suggest that the procedure may reduce longer-term mortality rates (237). A. Schinleber; Massachusetts General Hospital - D. Eligible participants were randomly assigned to one of three interventions: standard lifestyle recommendations plus metformin (Glucophage) at a dose of 850 mg twice daily, standard lifestyle recommendations plus placebo twice daily, or an intensive program of lifestyle modification. Glycemic control can also beneficially modify plasma lipid levels, particularly in patients with very high triglycerides and poor glycemic control. A variety of eating patterns have been shown to be effective in managing diabetes, including Mediterranean-style (144,146,169), Dietary Approaches to Stop Hypertension (DASH)-style (161), plant-based (vegan or vegetarian) (129), lower-fat (145), and lower-carbohydrate patterns (144,163).
Although individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. The screening of asymptomatic patients remains controversial. The position statement reaffirms metformin as the preferred initial agent, barring contraindication or intolerance, either in addition to lifestyle counseling and support for weight loss and exercise, or when lifestyle efforts alone have not achieved or maintained glycemic goals. The number needed to treat to prevent one stroke over the course of 5 years with intensive blood pressure management was 89. Stimpson, C. There was a statistically significant 35% relative reduction in stroke, but the absolute risk reduction was only 1% (330). An association of severe hypoglycemia with mortality was also found in the ADVANCE trial (227), but its association with other outcomes such as pulmonary and skin disorders raises the question of whether severe hypoglycemia is a marker for a sicker patient, rather than a cause of mortality. Although there are few rigorous studies, a database study of almost 27,000 children and adolescents with type 1 diabetes showed that, after adjustment for multiple confounders, increased daily frequency of SMBG was significantly associated with lower A1C (−0.2% per additional test per day, leveling off at five tests per day) and with fewer acute complications (57). The A1C may also serve as a check on the accuracy of the patient's meter (or the patient's reported SMBG results) and the adequacy of the SMBG testing schedule. There are opportunities for the clinician to assess psychosocial status in a timely and efficient manner so that referral for appropriate services can be accomplished. J. Orchard, A. Accordingly, the overall effectiveness, especially the cost-effectiveness, of such an indiscriminate screening strategy is now questioned. Rates of adverse events, hospitalization, and mortality were similar in the three groups, except that the rate of gastrointestinal symptoms was highest in the metformin group and the rate of musculoskeletal symptoms was highest in the lifestyle-intervention group. M. Giles, D. J. Zachwieja; University of Chicago - D. H. Morris, L. Temprosa, and F. Click here! Bariatric surgery is costly in the short term and has associated risks. J. Stewart, D. A full review of the evidence regarding nutrition in preventing and controlling diabetes and its complications and additional nutrition-related recommendations can be found in the ADA position statement Nutrition Recommendations and Interventions for Diabetes (114), which is being updated as of 2013. These results have led to careful reconsideration of the diagnostic criteria for GDM. Average fat intake, which was 34.1 percent of total calories at base line, decreased by 0.8±0.2 percent in the placebo and metformin groups and by 6.6±0.2 percent in the lifestyle-intervention group (P<0.001). For most complications, there was no threshold for risk. In a smaller RCT of 129 adults and children with baseline A1C <7.0%, outcomes combining A1C and hypoglycemia favored the group utilizing CGM, suggesting that CGM is also beneficial for individuals with type 1 diabetes who have already achieved excellent control (67). These patients may benefit additionally from diabetes screening when on statin therapy. Among the oral antidiabetic agents, metformin and acarbose are classified as category B (no evidence of risk in humans) and all others as category C. The ACCORD study participants had either known CVD or two or more major cardiovascular risk factors and were randomized to intensive glycemic control (goal A1C <6%) or standard glycemic control (goal A1C 7-8%). In a systematic review of 44,203 individuals from 16 cohort studies with a follow-up interval averaging 5.6 years (range 2.8-12 years), those with an A1C between 5.5 and 6.0% had a substantially increased risk of diabetes (5-year incidences from 9 to 25%). Brancati, J. Particularly for insulin-treated patients, SMBG and, for some patients, CGM to detect incipient hypoglycemia and assess adequacy of treatment are a key component of safe therapy. All three of these trials were conducted in participants with more long-standing diabetes (mean duration 8-11 years) and either known CVD or multiple cardiovascular risk factors. C. Steinke, and B. For more details on pharmacotherapy for hyperglycemia in type 2 diabetes, including a table of information about currently approved classes of medications for treating hyperglycemia in type 2 diabetes, readers are referred to the ADA-EASD position statement (111). For decades, the diagnosis of diabetes was based on plasma glucose criteria, either the fasting plasma glucose (FPG) or the 2-h value in the 75-g oral glucose tolerance test (OGTT) (5). If the blood pressure is confirmed to be ≥140 mmHg systolic and/or ≥80 mmHg diastolic, pharmacological therapy should be initiated along with nonpharmacological therapy (252). Gonzalez, A. E. Lawton,† R. Abnormal risk factors should be treated as described elsewhere in these guidelines. Ideally, the care of a child or adolescent with type 1 diabetes should be provided by a multidisciplinary team of specialists trained in the care of children with pediatric diabetes. Beltran, K. Caenepeel-Mills, S. Testaverde,† D.
Because age is a major risk factor for diabetes, testing of those without other risk factors should begin no later than age 45 years. R. Rubin (chair); Screening and Eligibility - R. Finally, a recent randomized observational trial demonstrated no clinical benefit to routine screening of asymptomatic patients with type 2 diabetes and normal ECGs (325). While clear benefit exists for ACE inhibitor and ARB therapy in patients with nephropathy or hypertension, the benefits in patients with CVD in the absence of these conditions are less clear, especially when LDL cholesterol is concomitantly controlled (392,393). Conversely, patients with increasing albumin levels, declining GFR, increasing blood pressure, retinopathy, macrovascular disease, elevated lipids and/or uric acid concentrations, or a family history of CKD are more likely to experience a progression of diabetic kidney disease (410). ADA recognized that the anticipated increase in the incidence of GDM diagnosed by these criteria would have significant impact on the costs, medical infrastructure capacity, and potential for increased medicalization of pregnancies previously categorized as normal, but recommended these diagnostic criteria changes in the context of worrisome worldwide increases in obesity and diabetes rates with the intent of optimizing gestational outcomes for women and their babies. An association of self-reported severe hypoglycemia with 5-year mortality has also been reported in clinical practice (294). Cheatham, S. Czech, C. DeSandre, G. M. Nathan,* C. H. Herman (chair); Interventions - S. Because of variability in urinary albumin excretion, two of three specimens collected within a 3- to 6-month period should be abnormal before considering a patient to have developed increased urinary albumin excretion or had a progression in albuminuria. In many studies, it is often difficult to discern the independent effect of fiber compared with that of glycemic index on glycemic control and other outcomes. Horne, D. Leos, J. Benefits of! Glycemic goals for children are provided in Section VIII. The use of retinal photography with remote reading by experts has great potential in areas where qualified eye care professionals are not available and may also enhance efficiency and reduce costs when the expertise of ophthalmologists can be utilized for more complex examinations and for therapy (378). F. Arakaki,* R. Mau, K. Mikami, P. Examinations should be performed by an ophthalmologist or optometrist who is knowledgeable and experienced in diagnosing the presence of diabetic retinopathy and is aware of its management. The acute glycemic response correlates better with the glucose content than with the carbohydrate content of the food. Other measures of chronic glycemia such as fructosamine are available, but their linkage to average glucose and their prognostic significance are not as clear as is the case for A1C. Two large trials, the Diabetic Retinopathy Study (DRS) in patients with PDR and the Early Treatment Diabetic Retinopathy Study (ETDRS) in patients with macular edema, provide the strongest support for the therapeutic benefits of photocoagulation surgery. Santiago (deceased), and J. Education helps people with diabetes initiate effective self-management and cope with diabetes when they are first diagnosed. Mullen, A. Noel, T. As is the case with the glucose measures, several prospective studies that used A1C to predict the progression to diabetes demonstrated a strong, continuous association between A1C and subsequent diabetes. A recent RCT of 448 participants with type 2 diabetes and hypertension demonstrated reduced cardiovascular events and mortality with median follow-up of 5.4 years if at least one antihypertensive medication was given at bedtime (277). Joseph,† F. L. Major congenital malformations remain the leading cause of mortality and serious morbidity in infants of mothers with type 1 and type 2 diabetes.
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