Diabetes & Glandular Disease Clinic and Research Of San Antonio

( updated for 2006 )

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What You Should Expect From Your Doctors
Copyright ©  American Diabetes Association

When you have diabetes, it is important that you get quality medical care.  Now that it is clear that high glucose levels play a role in many complications, your doctor's skill is more vital than ever.  Good care helps you live a full life with as few complications as possible.

But what is good care?  The American Diabetes Association provides standards of medical care for people with diabetes.  These guidelines give doctors the most up-to-date information on caring for their patients with diabetes.  Also, the guidelines let you, the person with diabetes, know what to expect from your doctor.  They give you a way to check if your doctor is doing a good job.

The Team Approach

Because diabetes is a complicated disease, you should be receiving your diabetes care from a team recommended by your doctor.  Your doctor alone cannot be an expert in every area.  For this reason, your diabetes care team may include nurses, a dietitian, and a behavioral health specialist.  Depending on what complications you may have, your doctor may send you to other specialists as well, such as a foot specialist or eye doctor.

The Goal

Exceedingly high levels of glucose in the blood are features of all forms of diabetes.  The main goal of diabetes treatment is to bring glucose levels down to normal as safely as possible.  Suggested goals are 90 - 130 milligrams per deciliter (mg/dl) before meals, less than 180 mg/dl 1-2 hours after meals, and 100 - 140 mg/dl at bedtime.  Your doctor may set different targets for you depending on other factors such as how often you have low blood glucose reactions.  Most aspects of your treatment plan - measuring your glucose levels, taking diabetes pills or insulin shots, exercising, losing weight, eating a planned diet - are aimed at helping you achieve your target glucose level.

High glucose levels can affect many parts of the body.  They can lead  to eye, nerve, and kidney diseases.  High glucose levels also make it easier to get infections.  They can blur your vision or make you feel tired or thirsty.  People with diabetes are also more likely to develop other health problems, including high blood pressure, high cholesterol and fat levels, and heart disease.

As you can see, keeping your glucose levels under control is vital to your future health and happiness.  Monitoring your blood pressure and cholesterol and fat levels is also important.  Your doctor and/or treatment team can advise you on ways to reach this goal.  They should spend a lot of time teaching you about diabetes and how to make diabetes care part of your life.

The First Visit

Your first visit to a doctor who will treat your diabetes should consist of four parts:

1.  The doctor should take a medical history (ask questions about your life, complications, and previous diabetes treatment plan)

2.  The doctor should give you a complete physical examination. 

3. The doctor should run tests on your blood and urine to examine your blood glucose level, your glycohemoglobin level (a measure of average blood glucose levels over the past 2 - 3 months), your cholesterol and fat levels, and your urine protein level.  Your age, complications, and symptoms dictate which other laboratory tests your doctor does.

4.  Your health-care team should work with you to make a plan for managing your diabetes.

This checklist will help you ensure that your health-care team is thorough at your first visit. They should:

• measure your height and weight
• measure your blood pressure
• examine your eyes, ask you about any possible sight problems, and refer you to an eye doctor
• examine your mouth and ask about your dental health
• feel your neck to check your thyroid gland and do tests if necessary
• feel your abdomen to check your liver and other organs
• take your pulse
• examine your hands and fingers
• listen to your heart and lungs through a stethoscope
• examine your bare feet to check the sensation and pulses
• check your skin - especially the places where you inject insulin
• test your reflexes
• take blood and urine samples for tests
• ask how and when you were diagnosed with diabetes
• ask for results of laboratory tests you had in the past
• ask about your eating habits and weight history
• ask about your current diabetes treatment plan
• ask how often and how hard you exercise
• ask about times you've had ketoacidosis (ketones in the urine) and low blood glucose reactions
• ask about infections you've had
• ask what complications you've had and what treatments you've received for them
• ask about alcohol and/or controlled substance use
• ask what medications you are taking
• ask about factors that make you more likely to get heart disease, such as smoking, high blood pressure, poor eating and exercise habits, high cholesterol levels, and family history
• ask what other medical problems you've had
• ask who else in your family has diabetes
• ask about problems you may have had while pregnant

Putting together a diabetes care plan is an important part of your first visit.  Your care plan is unique and solely for you.  To work well, the plan must be adapted to your own life.  For example, the plan must be based around your work or school schedule, how active you are, what and when you like to eat, your cultural background, and other medical problems you have.

You need to be involved in devising your diabetes care plan. Otherwise, its unlikely that the plan will fit into your life or that you will understand  what you need to do.

Is your diabetes care plan complete? If so, it should include:

• a list of goals (both short term and long term)
• a list of the medicines that you will use to control your diabetes
• advice from a certified dietitian
• a list of changes you need to make in your life - such as getting more exercise or quitting smoking
• teaching sessions for you and your family on how and when to measure your blood glucose levels and urine ketones, and how to treat low blood glucose reactions
• a plan for seeing an eye doctor
• a plan for seeing a foot doctor
• a plan for seeing other specialists
• instructions on when to come back to your doctor and when you should call
• a birth-control and pre-pregnancy plan
• a plan for caring for your teeth and seeing the dentist
• a plan for seeing a diabetes educator if diabetes education was not provided by your doctor or his/her staff

Future Visits

How often you should return to your diabetes doctor depends on many factors.  If you take insulin for your diabetes or if you're having trouble controlling your glucose levels, you should see your doctor at least 4 times a year.  Otherwise, you should see your doctor 2 - 4 times a year.  You may need to visit your doctor more often if you have complications or if you are starting a new medication or insulin program.  Your doctor will advise you about when to return.  He or she should also tell you other times to call or come in for a visit.  For example, your doctor may want you to call if you've had nausea or vomiting or if you've had a fever for more than a day.  You will need to contact your doctor every week or even every day if you are making big changes in your diabetes care plan.

When you return, expect the doctor and other members of your health care team to give you a physical examination, take a medical history, run laboratory tests, and fine-tune your treatment program.  These later visits are not as in-depth as your first visit, although you should get a complete physical examination once a year.  Also, your doctor may order new tests, do other examinations, or refer you to a specialist depending on test results and your needs.

This checklist will help you make sure your health care team does a good job at your follow-up visits.  They should:

• ask about times you've had high or low blood glucose levels
• ask to see your blood glucose records
• ask what adjustments you've made to your diabetes care plan
• ask what problems you've had during your diabetes care plan
• ask about symptoms that might indicate you are getting a diabetes complication
• ask what other illnesses you had since your last visit
• ask what medicines you are taking now
• ask if your life has changed in any way
• measure your weight and blood pressure
• examine your eyes
• examine your feet
• draw blood for glycohemoglobin and cholesterol tests
• take a urine sample to look for protein and infection
• review your treatment plan to measure your progress in meeting goals and discuss any problems you may have

Children and Teenagers

Standards of care for children are somewhat different.  Children whose diabetes is not treated properly  are more likely to experience slow growth and maturity.  The doctor should measure height at every visit, not just the first.  The doctor should also check the progress of sexual maturation.  The types of laboratory tests the doctor requests depends on the age of the child, how long the child has had diabetes, and family history.

The diabetes care plan must take children's needs into account.  Children need enough nourishment to grow properly.  It's important to prevent low blood glucose reactions, which can easily happen to children when they are too young to know the warning signs of a reaction.  The dietitian may recommend more snacks and different foods to help with these special needs.  Also, children tend to get ill more frequently than adults.  Parents need instructions about treating them and when to call the doctor.

Treatment plans need to be adapted for teens as well.  The busy lives of many teenagers can make it hard for them to stick to their diabetes meal plan.  For these reasons, children and their parents should meet with a dietitian each year to review their meal plans and discuss any concerns.

 

Summary of Revisions for the 2006 Standards of Medical Care in Diabetes

 

Item                                         2005                                       2006

Dietary Protein Restriction	Restrict to .8 gm/kg in presence of nephropathy	Restrict to .8gm/kg in those with any degree of chronic renal disease
Saturated Fat	Listed separately, not included in Medical Standards	Now included in medical standards. Rec. should be <7% of total calories
Trans Fat	Listed separately, not included in Medical Standards	Now included in medical standards. Rec. “should be minimized”.
Drug Therapy and Surgery for Obesity	Not addressed	“May be appropriate in selected patients”
Nonnutritive Sweeteners	Listed separately, not included in Medical Standards	Now included in medical standards. All currently approved sweeteners are safe for use for people with DM
Alcohol	Listed separately, not included in Medical Standards	Now included in medical standards. Rec. 1 drink/day for women or less, 2 for men.
Antioxidants	Not addressed	Routine supplementation not advised because of lack of efficacy and safety concerns.
Chromium	Not addressed	Not recommended. Benefit in people with DM not conclusively demonstrated.
Diabetes Education	Not addressed	Rec. at diag. and then as needed. Should address psychosocial issues. Should be reimbursed by 3rd party payors.
Physical Activity	Build up to 30-45 min. moderate aerobic activity 3-5 days/week. 1 hr moderate or 30 min vigorous activity each day may be needed for wt. loss.	150 min. /week of moderate or 90 min/week of vigorous activity 3 days week. Don’t go more than 2 consecutive days w/o exercise. Rec. resistance training 3 X week for type 2’s
Nephropathy	Annual microalbumin screening.	Rec. annual microalbumin screening plus annual serum creatinine for the estimation of GFR in all adults with DM.
Neuropathy	Not listed as a separate section	New section added. Rec. all people with DM be screened for Distal symmetric polyneuropathy (DPN) @ diag. then annually. Screen for autonomic neuropathy @ diag. of type 2 and 5 yrs after diag. of type 1. Inspect insensate feet at 3-6 mo. intervals and refer as needed.
Glycemic Goals	A1C < or = to 7.0%. Consider more stringent goals (<6.0) in specific individuals and in pregnancy	A1C < or = to 7.0% for pts.  in general. A1C as close to normal as possible (<6%) for the individual patient w/o significant hypoglycemia. Use “point of care” A1 C testing. (Have result avail. at time of visit).

 

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