Measuring Providers’ Adherence to the American Diabetes Association Screening Recommendation for Prevention of Diabetic Nephropathy

Purpose: The purpose of this study was to evaluate provider adherence to the ADA’s recommendation for an annual screening urinary albumin excretion level to check for the presence of microalbuminuria. A secondary objective was to assess for adequate treatment (i.e. ACE inhibitor or ARB prescription) in those patients with microalbuminuria present. Methods: A retrospective chart review was conducted on 60 randomly selected patients seen within a primary care practice in an urban university setting between January 1st, 2014 and December 31st, 2014. Inclusion criteria included age ≥ 18 years and an active diagnosis of type 2 DM as evidenced by ICD codes 250.00-250.93. Data collected included age, gender, ethnicity, marital status, insurance type, BMI, tobacco use status, presence or absence of a urinary albumin excretion level collected within the specified timeframe, and presence or absence of an active ACE inhibitor/ARB prescription. A database of 972 qualifying patients was provided by the university’s Division of Biomedical Informatics and 60 patients were randomly sampled from this database utilizing a random number generator. Results: The retrospective chart review demonstrated that only 1 out of the 60 charts reviewed had received screening for microalbuminuria within the previous calendar year, as recommended by the national guidelines. Conclusion: Increasing urinary albumin excretion rate screening is essential in early recognition and management of renal complications in patients with type 2 DM. Current rates in many practice settings appear to be suboptimal and there exists an opportunity for quality improvement and identifying strategies for improving screening rates

Prediabetes, Implementation of ADA Practice Guidelines and Provider Perspective

AbstractPrediabetes occurs before the development of diabetes in some people. Practitioners who educate people about prediabetes are not consistently using the latest evidence-based practice guidelines. The purpose of this mixed-method study was to fill a gap in the literature by providing evidence of the provider practices, attitudes and barriers when implementing American Diabetes Association (ADA) practice guidelines for the prediabetic patient. The Theory of Planned Behavior applies to evidence-based practice and the implementation of evidence-based practice guidelines. Research questions for this study focused on determining rate of compliance with ADA clinical practice guidelines from health care professionals to include providers in Florida. The quantitative sample was a convenience sample of licensed health care providers in Florida (n=436) who have patients with prediabetes and (n=410) reported responses for screening and treatment preferences for prediabetes. The sample for the qualitative portion of the study were providers (n=5) who participated in interviews after questionnaire completion. Descriptive and inferential statistics that relate to usage of the ADA standards of care were analyzed. A one sample proportion test with confidence interval for screening was not significant at the \u3c.05 level. Interview data were analyzed for themes using hand and auto coding. Self-reported attitudes (3/5) were more favorable than not favorable regarding the preventive treatment of patients with diabetes. Qualitative findings indicate attitudes or barriers may play a role in screening for prediabetes. Potential social change implications include care improvements related to adequate provider resources and support for preventive care for the prediabetic patient potentially reducing risks, complications and costs associated with developing type 2 diabetes mellitus

primary prevention of cardiovascular disease and type 2 diabetes in patients at metabolic risk an endocrine society clinical practice guideline

Objective: The objective was to develop clinical practice guidelines for the primary prevention of cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) in patients at metabolic risk. Conclusions: Healthcare providers should incorporate into their practice concrete measures to reduce the risk of developing CVD and T2DM. These include the regular screening and identification of patients at metabolic risk (at higher risk for both CVD and T2DM) with measurement of blood pressure, waist circumference, fasting lipid profile, and fasting glucose. All patients identified as having metabolic risk should undergo 10-yr global risk assessment for either CVD or coronary heart disease. This scoring will determine the targets of therapy for reduction of apolipoprotein B-containing lipoproteins. Careful attention should be given to the treatment of elevated blood pressure to the targets outlined in this guideline. The prothrombotic state associated with metabolic risk should be treated with lifestyle modification measures and in appropriate individuals with low-dose aspirin prophylaxis. Patients with prediabetes (impaired glucose tolerance or impaired fasting glucose) should be screened at 1- to 2-yr intervals for the development of diabetes with either measurement of fasting plasma glucose or a 2-h oral glucose tolerance test. For the prevention of CVD and T2DM, we recommend that priority be given to lifestyle management.Thisincludesantiatherogenicdietarymodification,aprogramofincreasedphysicalactivity, andweightreduction.Effortstopromotelifestylemodificationshouldbeconsideredanimportant component of the medical management of patients to reduce the risk of both CVD and T2DM. (J Clin Endocrinol Metab 93: 3671–3689, 2008

Diabetes Care in Venezuela

Background: The incidence of type 2 diabetes (T2D) and its economic burden have increased in Venezuela, posing difficult challenges in a country already in great turmoil. Objectives: The aim of this study was to review the prevalence, causes, prevention, management, health policies, and challenges for successful management of diabetes and its complications in Venezuela. Methods: A comprehensive literature review spanning 1960 to 2015 was performed. Literature not indexed also was reviewed. The weighted prevalence of diabetes and prediabetes was estimated from published regional and subnational population-based studies. Diabetes care strategies were analyzed. Findings: In Venezuela, the weighted prevalence of diabetes was 7.7% and prediabetes was 11.2%. Diabetes was the fifth leading cause of death (7.1%) in 2012 with the mortality rate increasing 7% per year from 1990 to 2012. In 2012, cardiovascular disease and diabetes together were the leading cause of disability-adjusted life years.T2D drivers are genetic, epigenetic, and lifestyle, including unhealthy dietary patterns and physical inactivity. Obesity, insulin resistance, and metabolic syndrome are present at lower cutoffs for body mass index, homeostatic model assessment, and visceral or ectopic fat, respectively. Institutional programs for early detection and/or prevention of T2D have not been established. Most patients with diabetes (∼87%) are cared for in public facilities in a fragmented health system. Local clinical practice guidelines are available, but implementation is suboptimal and supporting information is limited. Conclusions: Strategies to improve diabetes care in Venezuela include enhancing resources, reducing costs, improving education, implementing screening (using Latin America Finnish Diabetes Risk Score), promoting diabetes care units, avoiding insulin levels as diagnostic tool, correct use of oral glucose tolerance testing and metformin as first-line T2D treatment, and reducing health system fragmentation. Use of the Venezuelan adaptation of the transcultural Diabetes Nutrition Algorithm for lifestyle recommendations and the Latin American Diabetes Association guidelines for pharmacologic interventions can assist primary care physicians in diabetes management

Type 2 diabetes mellitus (T2DM) onset and remission .

Background: Type 2 diabetes mellitus (T2DM) is a progressive disease condition. As the disease progresses the function of beta (β) cells (cells which regulate insulin) decline, thereby increasing the circulating blood glucose levels. If left unmanaged the disease progresses from onset to development of T2DM related complications and eventually death. When managed, in certain individuals, T2DM onset can be prevented and/or slowed down and in certain T2DM individuals, remission is observed. There are some known modifiable risk factors such as diet and physical activities that are associated with the speed and direction of progression, but much is still unknown. In order to develop effective intervention and management programs, it is first important to understand the factors that predict speed and direction of T2DM progression. Purpose: This dissertation evaluated T2DM disease progression with three key objectives: a) evaluate factors that predict T2DM onset; b) evaluate rate of T2DM “remission” and, c) evaluate factors that predict T2DM “remission” in Medicare patients 65 years and older who did not undergo bariatric surgery. Methods: A retrospective cohort analysis of a Medicare Advantage health plan was conducted using administrative data. An individual was identified as T2DM if they had: ≥ 2 medical claims for T2DM coded 250.xx excluding type 1 diabetes; or ≥ 2 pharmacy claims related to T2DM; or ≥ 2 combined medical claims, pharmacy claims for T2DM in 12 months. A T2DM individual was in “remission” if they had no T2DM related claims for more than 12 months continuously. This is different from the standard American Diabetes Association definition of remission which includes HbA1c values and hence is represented in quotation (as “remission”). 89,390 individuals were evaluated for T2DM onset and 10,059 T2DM individuals were evaluated for T2DM “remission” over a period of 8 years from 2008 to 2015. Cox proportional hazards was used to identify significant variables associated with T2DM onset and “remission.” Results: The factors that were significantly associated with T2DM onset were: male gender; non-white ethnicity (African American, Hispanics); statin use; hypertension; hyperlipidemia; heart failure; ulcer of lower limbs; atherosclerosis; other retinopathy; angina pectoris; blindness and low vision; absence of other chronic ischemic heart disease (IHD) (pConclusions:In line with previously published studies, the study presented here also found that hyperlipidemia, hypertension, gender and race are significantly associated with T2DM onset. In addition to these known factors, this study identified additional factors associated with T2DM onset such as: statin use; hypertension; hyperlipidemia; heart failure; ulcer of lower limbs; atherosclerosis; other retinopathy; angina pectoris; blindness and low vision and absence of other chronic ischemic heart disease. This study found that in Medicare T2DM patients 65 years and older “remission” does occur without bariatric surgery. This study verified known factors such as absence of dyslipidemia and race to be associated with T2DM “remission.” In addition to these known factors this study found that no statin use; low diabetes complications severity index score (DCSI); no hypertension; no neuropathy; no retinopathy; presence of other chronic ischemic heart disease (IHD) and female gender were significantly associated with T2DM “remission.” These findings could be used for the development of T2DM related disease intervention and management programs. The DCSI score of T2DM individuals could be used to help stratify them based on T2DM severity for design and individualized, targeted outreach. Lastly, in this study hypertension, hyperlipidemia, statins use were associated with T2DM onset and T2DM “remission.” Since these factors are also associated with metabolic disease, their mutual relation needs to be evaluated further, upon availability of laboratory and physician notes data. Metabolic disease is a known predictor for T2DM onset and future studies might find that metabolic disease might also be a predictor for T2DM “remission.

Glycemic Index of Foods, Adiposity and Metabolic Syndrome Risk in Emirati Young Adults

This dissertation is concerned with determining the prevalence of metabolic syndrome (MetS) in Emirati females aged 17–25 years and its relation to overweight and obesity. It also aims to determine the glycemic index (GI) and glycemic load (GL) values for traditional Emirati foods that have not been tested yet. In a cross-sectional study design, anthropometric measurements, blood pressure and biochemical measurements were collected from a total of 555 Emirati female college students and the prevalence of MetS was concluded. Furthermore, at least fifteen healthy subjects participated in the measurement of GI and GL values for each of the twenty-three Emirati test foods. This study showed a high prevalence of MetS among college female young adults aged 17–25 years (6.8%). Of the 555 participants enrolled, 23.1% were overweight and 10.4% were classified as obese. MetS was significantly associated with obesity, waisthip ratio, glycated hemoglobin and high sensitivity C-reactive protein. The current study also provides a comprehensive food composition table including proximate data, minerals, vitamins, lipids, and sugars contents, along with GI and GL values of twentythree locally consumed foods in the UAE which could be utilized in offering better dietary recommendations for the Emirati population. The results advocate the need for MetS identification and immediate intervention programs to improve the future health of this youthful group

Exploring Factors Influencing Health Promoting Behaviors Among Latino Immigrants

Latinos immigrants may experience stress during acculturation to the U. S., which can influence their ability to engage in health-promoting behaviors, such as dietary intake and physical activity. Dietary intake and physical activity influence the prevention or development of pre-diabetes/Type 2 Diabetes (T2DM). The immigrant’s ability to perform health-promoting behaviors can also be influenced by their perceptions of self-efficacy to engage in health-promoting behaviors. Limited information is available in the literature on effective strategies for decreasing stress during the acculturation process of Latino immigrants, while also increasing self-efficacy on health-promoting behaviors. The purpose of this study was to explore the associations between stress, acculturation, self-efficacy and the health-promoting behaviors of Latino adults. An adapted theoretical model based on the Health Promotion Model by Pender will guide this study. Participants were adults (N = 195), 18 years or older, who were Latino immigrants. Participants completed 4 surveys with all questions in both Spanish and English, exploring perceptions of self-efficacy, exercise behavior, acculturation, and stress. Participants also completed pre-diabetes and demographic questionnaires. 61% of the respondents reported having at least one family member with T2DM. Having a family member with T2DM did not influence physical activity of the participants. Examination of physical activity levels by gender suggested that Latino men reported engaging in significantly more vigorous physical activity when compared to Latino women (p = 0.017). There were significant correlations between walking behaviors and vigorous physical activity (χ2 (137) = .380, p = .05). Significant correlations were also found between walking and moderate physical activity (χ2 (137) = .278, p = .01). Among Latinos without prediabetes/T2DM, self-efficacy level and stress predicted physical activity. Among Latinos with pre-diabetes/T2DM, only age predicted physical activity. When the sample was stratified by pre-diabetes/T2DM status, self-efficacy remained a significant predictor of physical activity among Latinos without pre-diabetes/T2DM. However, among Latinos with pre-diabetes/T2DM, gender was the only significant predictor of physical activity, and age no longer predicted physical activity. Assessing self-efficacy level may help recognize Latinos at risk for chronic illnesses, such as type 2 diabetes. Stress level can impact health-promoting behaviors among Latino immigrants and assessing stress is important for nurses to consider during interactions with Latinos in order to support health-promoting behaviors and lower risk for T2DM