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Prevalence of non-communicable disease among displaced Rohingya in southern Bangladesh: a first look at a persecuted ethnic minority from Myanmar
research-article
Author(s):
Jason T Tsichlis ,
Ipsita Hamid Trisha ,
Ghazal Aghagoli ,
Meerjady Sabrina Flora ,
M Ruhul Abid
Publication date (Electronic):
01 November 2023
Journal:
International Health
Publisher:
Oxford University Press
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There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.
Abstract
Background
In Cox's Bazar, Bangladesh, 860 356 Rohingya living in refugee camps have experienced decades of persecution. Little is known about disease burden in this population.
Methods
A retrospective review of deidentified electronic health records (EHR) of 51 270 Rohingya attending two primary health clinics in Kutupalong and Balukahli from October 2017 to October 2019 was performed. A novel EHR system named NIROG was used for patients' medical records'.
Results
Females comprised 53.8% of patients. The median age of females was 25 y and for males it was 19 y. Prevalence of adult hypertension and diabetes was 14.1% and 11.0%, respectively. Also, 16.6% of children aged <5 y had moderate or severe acute malnutrition, while 36.6% were at risk of malnutrition. Body mass index (BMI) analysis showed that 34.4% of adults were underweight. Females were more likely to be hypertensive, diabetic, overweight/obese and malnourished. BMI had a statistically significant positive correlation with fasting blood glucose levels and systolic blood pressure.
Conclusions
The use of a portable EHR system was highly effective at providing longitudinal care in a humanitarian setting. Significant proportions of the adult population appear to have hypertension or diabetes, pointing to a critical need for management of chronic non-communicable diseases (NCDs). The findings of the current study will help stakeholders to plan effective prevention and management of NCDs among displaced Rohingya and other displaced populations.
Related collections
Most cited references30
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WHO Child Growth Standards based on length/height, weight and age
Mercedes de Onis (2006)
To describe the methods used to construct the WHO Child Growth Standards based on length/height, weight and age, and to present resulting growth charts.
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An algorithm for tuberculosis screening and diagnosis in people with HIV.
M Heilig, Van Hoang, Theerawit Tasaneeyapan … (2010)
Tuberculosis screening is recommended for people with human immunodeficiency virus (HIV) infection to facilitate early diagnosis and safe initiation of antiretroviral therapy and isoniazid preventive therapy. No internationally accepted, evidence-based guideline addresses the optimal means of conducting such screening, although screening for chronic cough is common. We consecutively enrolled people with HIV infection from eight outpatient clinics in Cambodia, Thailand, and Vietnam. For each patient, three samples of sputum and one each of urine, stool, blood, and lymph-node aspirate (for patients with lymphadenopathy) were obtained for mycobacterial culture. We compared the characteristics of patients who received a diagnosis of tuberculosis (on the basis of having one or more specimens that were culture-positive) with those of patients who did not have tuberculosis to derive an algorithm for screening and diagnosis. Tuberculosis was diagnosed in 267 (15%) of 1748 patients (median CD4+ T-lymphocyte count, 242 per cubic millimeter; interquartile range, 82 to 396). The presence of a cough for 2 or 3 weeks or more during the preceding 4 weeks had a sensitivity of 22 to 33% for detecting tuberculosis. The presence of cough of any duration, fever of any duration, or night sweats lasting 3 or more weeks in the preceding 4 weeks was 93% sensitive and 36% specific for tuberculosis. In the 1199 patients with any of these symptoms, a combination of two negative sputum smears, a normal chest radiograph, and a CD4+ cell count of 350 or more per cubic millimeter helped to rule out a diagnosis of tuberculosis, whereas a positive diagnosis could be made only for the 113 patients (9%) with one or more positive sputum smears; mycobacterial culture was required for most other patients. In persons with HIV infection, screening for tuberculosis should include asking questions about a combination of symptoms rather than only about chronic cough. It is likely that antiretroviral therapy and isoniazid preventive therapy can be started safely in people whose screening for all three symptoms is negative, whereas diagnosis in most others will require mycobacterial culture. 2010 Massachusetts Medical Society
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Standards of Medical Care in Diabetes—2017 Abridged for Primary Care Providers
(2017)
The American Diabetes Association’s (ADA’s) Standards of Medical Care in Diabetes is updated and published annually in a supplement to the January issue of Diabetes Care. The ADA’s Professional Practice Committee, comprised of physicians, diabetes educators, registered dietitians, and public health experts, develops the Standards. Formerly called Clinical Practice Recommendations, the Standards includes the most current evidence-based recommendations for diagnosing and treating adults and children with all forms of diabetes. ADA’s grading system uses A, B, C, or E to show the evidence level that supports each recommendation. A—Clear evidence from well-conducted, generalizable randomized controlled trials that are adequately powered B—Supportive evidence from well-conducted cohort studies C—Supportive evidence from poorly controlled or uncontrolled studies E—Expert consensus or clinical experience This is an abridged version of the current Standards containing the evidence-based recommendations most pertinent to primary care. The tables and figures have been renumbered from the original document to match this version. The complete 2017 Standards of Care document, including all supporting references, is available at professional.diabetes.org/standards. PROMOTING HEALTH AND REDUCING DISPARITIES IN POPULATIONS Recommendations Treatment plans should align with the Chronic Care Model, emphasizing productive interactions between a prepared proactive practice team and an informed activated patient. A When feasible, care systems should support team-based care, community involvement, patient registries, and decision support tools to meet patient needs. B Diabetes and Population Health Clinical practice guidelines are key to improving population health; however, for optimal outcomes, diabetes care must be individualized for each patient. Thus, efforts to improve population health will require a combination of systems-level and patient-level approaches. With such an integrated approach in mind, the ADA highlights the importance of patient-centered care, defined as care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. Care Delivery Systems Despite the many advances in diabetes care, 33–49% of patients still do not meet targets for glycemic, blood pressure, or cholesterol control, and only 14% meet targets for all three measures while also avoiding smoking. Certain segments of the population, such as young adults and patients with complex comorbidities, financial or other social hardships, and/or limited English proficiency, face particular challenges to care. Even after adjusting for these factors, the persistent variability in the quality of diabetes care across providers and practice settings indicates that substantial system-level improvements are still needed. Chronic Care Model Numerous interventions to improve adherence to the recommended standards have been implemented. However, a major barrier to optimal care is a delivery system that is often fragmented, lacks clinical information capabilities, duplicates services, and is poorly designed for the coordinated delivery of chronic care. The Chronic Care Model (CCM) takes these factors into consideration and is an effective framework for improving the quality of diabetes care. Six Core Elements The CCM includes six core elements to optimize the care of patients with chronic disease: Delivery system design (moving from a reactive to a proactive care delivery system where planned visits are coordinated through a team-based approach) Self-management support Decision support (basing care on evidence-based, effective care guidelines) Clinical information systems (using registries that can provide patient-specific and population-based support to the care team) Community resources and policies (identifying or developing resources to support healthy lifestyles) Health systems (to create a quality-oriented culture) Redefining the roles of the health care delivery team and empowering patient self-management are funda-mental to the successful implementation of the CCM. Collaborative, multidisciplinary teams are best suited to provide care for people with chronic conditions such as diabetes and to facilitate patients’ self-management. Strategies for System-Level Improvement Optimal diabetes management requires an organized, systematic approach and the involvement of a coordinated team of dedicated health care professionals working in an environment where patient-centered, high-quality care is a priority. Three objectives to achieve this include: Optimizing provider and team behavior Supporting patient self-manage-ment Changing the care system Tailoring Treatment to Reduce Disparities Social determinants of health can be defined as the economic, environmental, political, and social conditions in which people live and are responsible for a major part of health inequality worldwide. Given the tremendous burden that obesity, unhealthy eating, physical inactivity, and smoking place on the health of patients with diabetes, efforts are needed to address and change the societal determinants of these problems. Recommendations Providers should assess social context, including potential food insecurity, housing stability, and financial barriers, and apply that information to treatment decisions. A Patients should be referred to local community resources when available. B Patients should be provided with self-management support from lay health coaches, navigators, or community health workers when available. A CLASSIFICATION AND DIAGNOSIS OF DIABETES Diabetes can be classified into the following general categories: Type 1 diabetes (due to autoimmune β-cell destruction, usually leading to absolute insulin deficiency) Type 2 diabetes (due to a progressive loss of β-cell insulin secretion frequently on the background of insulin resistance) Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes prior to gestation) Other specific types, including monogenic forms of diabetes Diagnostic Tests for Diabetes Diabetes may be diagnosed based on plasma glucose criteria—either the fasting plasma glucose (FPG) or the 2-h plasma glucose value after a 75-g oral glucose tolerance test (OGTT) —or A1C (Table 1). TABLE 1. Criteria for the Diagnosis of Diabetes FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.* OR 2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.* OR A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is NGSP certified and standardized to the Diabetes Control and Complications Trial assay.* OR In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L). * In the absence of unequivocal hyperglycemia, results should be confirmed by repeat testing. The same tests are used to screen for and diagnose diabetes and to detect individuals with prediabetes (Table 2). Prediabetes is defined as FPG of 100–125 mg/dL (5.6–6.9 mmol/L); 2-h OGTT of 140–199 mg/dL (7.8–11.0 mmol/L); or A1C of 5.7–6.4% (39–47 mmol/mol). TABLE 2. Criteria for Testing for Diabetes or Prediabetes in Asymptomatic Adults Testing should be considered in overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) adults who have one or more of the following risk factors: A1C ≥5.7% (39 mmol/mol), impaired glucose tolerance, or impaired fasting glucose on previous testing First-degree relative with diabetes High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) Women who were diagnosed with GDM History of CVD Hypertension (≥140/90 mmHg or on therapy for hypertension) HDL cholesterol level 250 mg/dL (2.82 mmol/L) Women with polycystic ovary syndrome Physical inactivity Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) For all patients, testing should begin at age 45 years. If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results (e.g., those with prediabetes should be tested yearly) and risk status. Type 2 Diabetes and Prediabetes Recommendations Screening to assess prediabetes and risk for future diabetes with an informal assessment of risk factors or validated tools should be considered in asymptomatic adults. B To test for prediabetes, FPG, OGTT, and A1C are equally appropriate. B Testing for prediabetes and type 2 diabetes should be considered in children and adolescents who are overweight or obese and who have two or more additional risk factors for diabetes. E The American Diabetes Association Risk Test is an additional option for screening. COMPREHENSIVE MEDICAL EVALUATION AND ASSESSMENT OF COMORBIDITIES The comprehensive medical evaluation includes the initial and ongoing evaluations, assessment of complications, management of comorbid conditions, and engagement of the patient throughout the process. People with diabetes should receive health care from a team that may include physicians, nurse practitioners, physician assistants, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, and mental health professionals. Individuals with diabetes must assume an active role in their care. The patient, family, physician, and health care team should formulate the management plan, which includes lifestyle management. Lifestyle management and psychosocial care are the cornerstones of diabetes management. Patients should be referred for diabetes self-management education (DSME), diabetes self-management support (DSMS), medical nutrition therapy (MNT), and psychosocial/emotional health concerns if indicated. Additional referrals should be arranged as necessary (Table 3). Patients should receive recommended preventive care services (e.g., immunizations and cancer screening); smoking cessation counseling; and ophthalmological, dental, and podiatric referrals. Clinicians should ensure that individuals with diabetes are appropriately screened for complications and comorbidities. TABLE 3. Referrals for Initial Care Management Eye care professional for annual dilated eye exam Family planning for women of reproductive age Registered dietitian for MNT DSME and DSMS Dentist for comprehensive dental and periodontal examination Mental health professional, if indicated Comprehensive Medical Evaluation The components of the comprehensive diabetes medical evaluation are listed in Table 4. TABLE 4. Components of the Comprehensive Diabetes Medical Evaluation* Medical history Age and characteristics of onset of diabetes (e.g., diabetic ketoacidosis [DKA], asymptomatic laboratory finding) Eating patterns, nutritional status, weight history, sleep behaviors (pattern and duration), and physical activity habits; nutrition education and behavioral support history and needs Complementary and alternative medicine use Presence of common comorbidities and dental disease Screen for depression, anxiety, and disordered eating using validated and appropriate measures** Screen for diabetes distress using validated and appropriate measures** Screen for psychosocial problems and other barriers to diabetes self-management such as limited financial, logistical, and support resources History of tobacco use, alcohol consumption, and substance use DSME and DSMS history and needs Review of previous treatment regimens and response to therapy (A1C records) Assess medication-taking behaviors and barriers to medication adherence Results of glucose monitoring and patient’s use of data DKA frequency, severity, and cause Hypoglycemia episodes, awareness, frequency, and causes History of increased blood pressure and abnormal lipids Microvascular complications: retinopathy, nephropathy, and neuropathy (sensory, including history of foot lesions; autonomic, including sexual dysfunction and gastroparesis) Macrovascular complications: coronary heart disease, cerebrovascular disease, and peripheral arterial disease For women with child-bearing capacity, review contraception and preconception planning Physical examination Height, weight, and BMI; growth and pubertal development in children and adolescents Blood pressure determination, including orthostatic measurements when indicated Fundoscopic examination Thyroid palpation Skin examination (e.g., for acanthosis nigricans and insulin injection or infusion set insertion sites) Comprehensive foot examination: ○ Inspection ○ Palpation of dorsalis pedis and posterior tibial pulses ○ Presence/absence of patellar and Achilles reflexes ○ Determination of proprioception, vibration, and monofilament sensation Laboratory evaluation A1C, if results not available within the past 3 months If not performed/available within the past year: ○ Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides, as needed ○ Liver function tests ○ Spot urinary albumin–to–creatinine ratio ○ Serum creatinine and eGFR ○ Thyroid-stimulating hormone in patients with type 1 diabetes * The comprehensive medical evaluation should all ideally be done on the initial visit, but if time is limited different components can be done as appropriate on follow-up visits. ** Refer to the ADA position statement “Psychochsocial Care for People With Diabetes” for additional details on diabetes-specific screening measures. Recommendations A complete medical evaluation should be performed at the initial visit to Confirm the diagnosis and classify diabetes. B Detect diabetes complications and potential comorbid conditions. E Review previous treatment and risk factor control in patients with established diabetes. E Begin patient engagement in the formulation of a care management plan. B Develop a plan for continuing care. B Immunization Recommendations Provide routine vaccinations for children and adults with diabetes according to age-related recommendations. C Annual vaccination against influenza is recommended for all people with diabetes ≥6 months of age. C Vaccination against pneumonia is recommended for all people with diabetes who are 2–64 years of age with pneumococcal polysaccharide vaccine (PPSV23). At age ≥65 years, administer the pneumococcal conjugate vaccine (PCV13) at least 1 year after vaccination with PPSV23, followed by another dose of vaccine PPSV23 at least 1 year after PCV13 and at least 5 years after the last dose of PPSV23. C Administer three-dose series of hepatitis B vaccine to unvaccinated adults with diabetes who are aged 19–59 years. C Consider administering three-dose series of hepatitis B vaccine to unvaccinated adults with diabetes who are ≥60 years of age. C Comorbidities Besides assessing diabetes-related complications, clinicians and their patients need to be aware of common comorbidities that affect people with diabetes and may complicate management. Autoimmune Diseases Recommendations Consider screening patients with type 1 diabetes for autoimmune thyroid disease and celiac disease soon after diagnosis. E Cancer Diabetes is associated with increased risk of cancers of the liver, pancreas, endometrium, colon/rectum, breast, and bladder. The association may result from shared risk factors between diabetes and cancer (older age, obesity, and physical inactivity) or diabetes-related factors such as underlying disease physiology or diabetes treatments, although evidence for these links is scarce. Patients with diabetes should be encouraged to undergo recommended age- and sex-appropriate cancer screenings and to reduce their modifiable cancer risk factors (obesity, physical inactivity, and smoking). Cognitive Impairment/Dementia Diabetes is associated with a significantly increased risk and rate of cognitive decline and an increased risk of dementia. In a 15-year prospective study of community-dwelling people >60 years of age, the presence of diabetes at baseline significantly increased the age- and sex-adjusted incidence of all-cause dementia, Alzheimer’s disease, and vascular dementia compared with rates in those with normal glucose tolerance. Fatty Liver Disease Elevations of hepatic transaminase concentrations are associated with higher BMI, waist circumference, and triglyceride levels and lower HDL cholesterol levels. In a prospective analysis, diabetes was significantly associated with incident nonalcoholic chronic liver disease and with hepatocellular carcinoma. Interventions that improve metabolic abnormalities in patients with diabetes (weight loss, glycemic control, and treatment with specific drugs for hyperglycemia or dyslipidemia) are also beneficial for fatty liver disease. Fractures Age-specific hip fracture risk is significantly increased in people with both type 1 (relative risk 6.3) and type 2 (relative risk 1.7) diabetes in both sexes. 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. Hearing Impairment Hearing impairment, both in high-frequency and low- to mid-frequency ranges, is more common in people with diabetes than in those without, perhaps due to neuropathy and/or vascular disease. Low Testosterone in Men Mean levels of testosterone are lower in men with diabetes compared with age-matched men without diabetes, but obesity is a major confounder. Treatment in asymptomatic men is controversial. The evidence that testosterone replacement affects outcomes is mixed, and recent guidelines do not recommend testing or treating men without symptoms. Obstructive Sleep Apnea Age-adjusted rates of obstructive sleep apnea, a risk factor for cardiovascular disease (CVD), are significantly higher (4- to 10-fold) with obesity, and especially with central obesity. The prevalence of obstructive sleep apnea in the population with type 2 diabetes may be as high as 23%, and the prevalence of any sleep disordered breathing may be as high as 58%. Periodontal Disease Periodontal disease is more severe and may be more prevalent in people with diabetes than in those without. Current evidence suggests that periodontal disease adversely affects diabetes outcomes, although evidence for treatment benefits on diabetes control remains unclear. Psychosocial Disorders Prevalence of clinically significant psychopathology in people with diabetes ranges across diagnostic categories, and some diagnoses are considerably more common in people with diabetes than for those without the disease. Symptoms, both clinical and subclinical, that interfere with a person’s ability to carry out diabetes self-management must be addressed. Diabetes distress is very common and distinct from a psychological disorder. Anxiety Disorders Recommendations Consider screening for anxiety in people exhibiting anxiety or worries regarding diabetes complications, insulin injections or infusion, taking medications, and/or hypoglycemia that interfere with self-management behaviors and those who express fear, dread, or irrational thoughts and/or show anxiety symptoms such as avoidance behaviors, excessive repetitive behaviors, or social withdrawal. Refer for treatment if anxiety is present. B People with hypoglycemic unawareness, which can co-occur with fear of hypoglycemia, should be treated using Blood Glucose Awareness Training (or another similar evidence-based intervention) to help re-establish awareness of hypoglycemia and reduce fear of hyperglycemia. A Depression Recommendations Providers should consider annual screening of all patients with diabetes, especially those with a self-reported history of depression, for depressive symptoms with age-appropriate depression screening measures, recognizing that further evaluation will be necessary for individuals who have a positive screen. B Beginning at diagnosis of complications or when there are significant changes in medical status, consider assessment for depression. B Referrals for treatment of depression should be made to mental health providers with experience using cognitive behavioral therapy, interpersonal therapy, or other evidence-based treatment approaches in conjunction with collaborative care with the patient’s diabetes treatment team. A Disordered Eating Behavior Recommendations Providers should consider reevaluating the treatment regimen of people with diabetes who present with symptoms of disordered eating behavior, an eating disorder, or disrupted patterns of eating. B Consider screening for disordered or disrupted eating using validated screening measures when hyperglycemia and weight loss are unexplained based on self-reported behaviors related to medication dosing, meal plan, and physical activity. In addition, a review of the medical regimen is recommended to identify potential treatment-related effects on hunger/caloric intake. B Serious Mental Illness Recommendations Annually screen people who are prescribed atypical antipsychotic medications for prediabetes or diabetes. B Incorporate monitoring of diabetes self-care activities into treatment goals in people with diabetes and serious mental illness. B LIFESTYLE MANAGEMENT Lifestyle management is a fundamental aspect of diabetes care and includes DSME and DSMS, nutrition, physical activity, smoking cessation, and psychosocial care. DSME and DSMS Recommendations In accordance with the national standards for DSME and DSMS, all people with diabetes should participate in DSME to facilitate the knowledge, skills, and ability necessary for diabetes self-care and in DSMS to assist with implementing and sustaining skills and behaviors needed for ongoing self-management, both at diagnosis and as needed thereafter. B Effective self-management and improved clinical outcomes, health status, and quality of life are key goals of DSME and DSMS that should be measured and monitored as part of routine care. C DSME and DSMS should be patient-centered, respectful, and responsive to individual patient preferences, needs, and values and should help guide clinical decisions. A DSME and DSMS programs have the necessary elements in their curricula to delay or prevent the development of type 2 diabetes. DSME and DSMS programs should therefore be able to tailor their content when prevention of diabetes is the desired goal. B Because DSME and DSMS can improve outcomes and reduce costs B, DSME and DSMS should be adequately reimbursed by third-party payers. E The overall objectives of DSME and DSMS are to support informed decision-making, self-care behaviors, problem-solving, and active collaboration with the health care team to improve clinical outcomes, health status, and quality of life in a cost-effective manner. Four critical time points have been defined when the need for DSME and DSMS should be evaluated by the medical care provider and/or multidisciplinary team, with referrals made as needed: At diagnosis Annually for assessment of education, nutrition, and emotional needs When new complicating factors (health conditions, physical limitations, emotional factors, or basic living needs) arise that influence self-management When transitions in care occur Nutrition Therapy For many individuals with diabetes, the most challenging part of the treatment plan is determining what to eat and following a food plan. There is not a one-size-fits-all eating pattern for individuals with diabetes. The Mediterranean diet, Dietary Approaches to Stop Hypertension (DASH) diet, and plant-based diets are all examples of healthful eating patterns. See Table 5 for specific nutrition recommendations. TABLE 5. MNT Recommendations Topic Recommendations Evidence Rating Effectiveness of nutrition therapy • An individualized MNT program, preferably provided by a registered dietitian, is recommended for all people with type 1 or type 2 diabetes. A • For people with type 1 diabetes and those with type 2 diabetes who are prescribed a flexible insulin therapy program, education on how to use carbohydrate counting and, in some cases, fat and protein gram estimation to determine mealtime insulin dosing can improve glycemic control. A • For individuals whose daily insulin dosing is fixed, having a consistent pattern of carbohydrate intake with respect to time and amount can result in improved glycemic control and a reduced risk of hypoglycemia. B • A simple and effective approach to glycemia and weight management emphasizing portion control and healthy food choices may be more helpful for those with type 2 diabetes who are not taking insulin, who have limited health literacy or numeracy, or who are elderly and prone to hypoglycemia. B • Because diabetes nutrition therapy can result in cost savings B and improved outcomes (e.g., A1C reduction) A, MNT should be adequately reimbursed by insurance and other payers. E B, A, E Energy balance • Modest weight loss achievable by the combination of reduction of caloric intake and lifestyle modification benefits overweight or obese adults with type 2 diabetes and also those with prediabetes. Intervention programs to facilitate this process are recommended. A Eating patterns and macronutrient distribution • Because there is no single ideal dietary distribution of calories among carbohydrates, fats, and proteins for people with diabetes, macronutrient distribution should be individualized while keeping total caloric and metabolic goals in mind. E • A variety of eating patterns are acceptable for the management of type 2 diabetes and prediabetes including the Mediterranean diet, DASH, and plant-based diets. B • Carbohydrate intake from whole grains, vegetables, fruits, legumes, and dairy products, with an emphasis on foods higher in fiber and lower in glycemic load, should be advised over other sources, especially those containing sugars. B • People with diabetes and those at risk should avoid sugar-sweetened beverages to control weight and reduce their risk for CVD and fatty liver disease B and should minimize their consumption of foods with added sugar that have the capacity to displace healthier, more nutrient-dense food choices. A B, A Protein • In individuals with type 2 diabetes, ingested protein appears to increase insulin response without increasing plasma glucose concentrations. Therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia. B Dietary fat • Whereas data on the ideal total dietary fat content for people with diabetes are inconclusive, an eating plan emphasizing elements of a Mediterranean-style diet rich in monounsaturated fats may improve glucose metabolism and lower CVD risk and can be an effective alternative to a diet low in total fat but relatively high in carbohydrates. B • Eating foods rich in long-chain ω-3 fatty acids, such as fatty fish (EPA and DHA) and nuts and seeds (ALA) is recommended to prevent or treat CVD B; however, evidence does not support a beneficial role for ω-3 dietary supplements. A B, A Micronutrients and herbal supplements • There is no clear evidence that dietary supplementation with vitamins, minerals, herbs, or spices can improve outcomes in people with diabetes who do not have underlying deficiencies, and there may be safety concerns regarding the long-term use of antioxidant supplements such as vitamins E and C and carotene. C Alcohol • Adults with diabetes who drink alcohol should do so in moderation (no more than one drink per day for adult women and no more than two drinks per day for adult men). C • Alcohol consumption may place people with diabetes at increased risk for hypoglycemia, especially if they are taking insulin or insulin secretagogues. Education and awareness regarding the recognition and management of delayed hypoglycemia are warranted. B Sodium • As for the general population, people with diabetes should limit sodium consumption to 5% weight loss should be prescribed for overweight and obese patients with type 2 diabetes ready to achieve weight loss. A Such interventions should be high intensity (≥16 sessions in 6 months) and focus on diet, physical activity, and behavioral strategies to achieve a 500–750 kcal/day energy deficit. A Diets should be individualized; eating patterns that provide the same caloric restriction but differ in protein, carbohydrate, and fat content are equally effective in achieving weight loss. A For patients who achieve short-term weight loss goals, long-term (≥1-year) comprehensive weight maintenance programs should be prescribed. Such programs should provide at least monthly contact and encourage ongoing monitoring of body weight (weekly or more frequently), continued consumption of a reduced-calorie diet, and participation in high levels of physical activity (200–300 min/week). A To achieve weight loss of >5%, short-term (3-month) high-intensity lifestyle interventions that use very-low-calorie diets (≤800 kcal/day) or total meal replacements may be prescribed for carefully selected patients by trained practitioners in medical care settings with close medical monitoring. To maintain weight loss, such programs must incorporate long-term comprehensive weight maintenance counseling. B Pharmacotherapy Recommendations When choosing glucose-lowering medications for overweight or obese patients with type 2 diabetes, consider their effect on weight. E Whenever possible, minimize the medications for comorbid conditions that are associated with weight gain. E Weight loss medications may be effective as adjuncts to diet, physical activity, and behavioral counseling for selected patients with type 2 diabetes and a BMI ≥27 kg/m2. Potential benefits must be weighed against the potential risks of the medications. A If a patient’s response to weight loss medications is 140/90 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of pharmacologic therapy to achieve blood pressure goals. A Patients with confirmed office-based blood pressure >160/100 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs to reduce CVD events in patients with diabetes. A An ACE inhibitor or an angiotensin receptor blocker (ARB) at the maximum tolerated dose indicated for blood pressure treatment is the recomended first-line treatment for hyperytension in patients with diabetes and urine albumin–to–creatinine ratio (UACR) ≥300 mg/g creatinine A or UACR 30–299 mg/g creatinine. B If one class is not tolerated, the other should be substituted. B For patients treated with an ACE inhibitor, ARB, or diuretic, serum creatinine/estimated glomerular filtration rate (eGFR) and serum potassium levels should be monitored. B For patients with blood pressure >120/80 mmHg, lifestyle intervention consists of weight loss, if overweight or obese; a DASH-style dietary pattern, including reduced sodium and increased potassium intake; moderation of alcohol intake; and increased physical activity. B Lipid Management Recommendations In adults not taking statins, it is reasonable to obtain a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every 5 years thereafter, or more frequently if indicated. E Obtain a lipid profile at initiation of statin therapy and periodically thereafter because it may help to monitor the response to therapy and inform adherence. E Lifestyle modification focusing on weight loss (if indicated); reduction of saturated fat, trans fat, and cholesterol intake; increase in omega-3 fatty acids, viscous fiber, and plant stanols/sterols intake; and increase in physical activity should be recommended to improve the lipid profile in patients with diabetes. A Intensify lifestyle therapy and optimize glycemic control for patients with elevated triglyceride levels (≥150 mg/dL [1.7 mmol/L]) and/or low HDL cholesterol ( 75 None Moderate ASCVD risk factors Moderate or high ASCVD High ACS and LDL cholesterol ≥50 mg/dL (1.3 mmol/L) or in patients with a history of ASCVD who cannot tolerate high-dose statins Moderate plus ezetimibe * In addition to lifestyle therapy. ** ASCVD risk factors include LDL cholesterol ≥100 mg/dL (2.6 mmol/L), high blood pressure, smoking, chronic kidney disease, albuminuria, and family history of premature ASCVD. TABLE 8. High- and Moderate-Intensity Statin Therapy* High-Intensity Statin Therapy (Lowers LDL cholesterol by ≥50%) Moderate-Intensity Statin Therapy (Lowers LDL cholesterol by 30 to 30 mL/min but should be avoided in unstable or hospitalized patients with congestive heart failure. B MICROVASCULAR COMPLICATIONS AND FOOT CARE 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 microvascular complications. Diabetic Kidney Disease Recommendations At least once a year, assess urinary albumin (e.g., spot UACR) and eGFR in patients with type 1 diabetes with a duration of ≥5 years, in all patients with type 2 diabetes, and in all patients with comorbid hypertension. B Optimize glucose control to reduce the risk or slow the progression of diabetic kidney disease. A Optimize blood pressure control to reduce the risk or slow the progression of diabetic kidney disease. A In nonpregnant patients with diabetes and hypertension, either an ACE inhibitor or an ARB is recommended for those with modestly elevated UACR (30–299 mg/g creatinine) B and is strongly recommended for those with UACR >300 mg/g creatinine and/or eGFR 8.5% (69 mmol/mol) are not recommended because they may expose patients to more frequent higher glucose values and the acute risks from glycosuria, dehydration, hyperglycemic hyperosmolar syndrome, and poor wound healing. Older adults with diabetes are likely to benefit from control of other cardiovascular risk factors. Evidence is strong for treatment of hypertension. There is less evidence for lipid-lowering and aspirin therapy, although the benefits of these interventions are likely to apply to older adults whose life expectancies equal or exceed the time frames of clinical prevention trials. Pharmacologic Therapy Special care is required in prescribing and monitoring pharmacologic therapy in older adults. Factors include hypoglycemia, cost, and coexisting conditions (e.g., renal status). The patient’s living situation must be considered because it may affect diabetes management and support. Treatment in Skilled Nursing Facilities and Nursing Homes Management of diabetes is unique in the long-term care (LTC) setting (i.e., nursing homes and skilled nursing facilities). Individualization of health care is important for all patients. However, practical guidance is needed for both medical providers and LTC staff and caregivers. Older adults with diabetes in LTC are especially vulnerable to hypoglycemia because of their disproportionately higher number of complications and comorbidities. Alert strategies should be in place for hypoglycemia (blood glucose ≤70 mg/dL [3.9 mmol/L]) and hyperglycemia (blood glucose >250 mg/dL [13.9 mmol/L]). For patients in the LTC setting, special attention should be given to nutritional considerations, end-of-life care, and changes in diabetes management with respect to advanced disease. Acknowledging the limited benefit of intensive glycemic control in people with advanced disease can guide A1C goals and determine the use or withdrawal of medications. For more information, see ADA’s position statement “Management of Diabetes in Long-Term Care and Skilled Nursing Facilities.” CHILDREN AND ADOLESCENTS Children and adolescents with diabetes have unique aspects of care such as changes in insulin sensitivity related to physical growth and sexual maturation, ability to provide self-care, supervision in the child care and school environment, and neurological vulnerability to hypoglycemia and hyperglycemia (in young children), as well as possible adverse neurocognitive effects of diabetic ketoacidosis (DKA). Attention to family dynamics, developmental stages, and physiological differences related to sexual maturity are all essential in developing and implementing an optimal diabetes regimen. Support Services Recommendations Youth with type 1 diabetes and parents/caregivers (for patients 160 mg/dL (4.1 mmol/L) or LDL cholesterol >130 mg/dL (3.4 mmol/L) and one or more CVD risk factors, initiated after reproductive counseling and implementation of effective birth control due to the potential teratogenic effects of statins. E The goal of therapy is an LDL cholesterol value 140 mg/dL (7.8 mmol/L) Hypoglycemia: <54 mg/dL (3.0 mmol/L) or severe cognitive impairment. (See the section on Hypoglycemia [p. 14] for additional details on the new criteria.) A glucose value ≤70 mg/dL (3.9 mmol/L) may be used as an alert value and as a threshold for further titration of insulin regimens. Antihyperglycemic Agents in Hospitalized Patients In most instances in the hospital setting, insulin is the preferred treatment for glycemic control, but in certain circumstances, a previous home regimen may be continued. Insulin Therapy IV insulin protocols should be used for critically ill patients. Basal-bolus regimens that include correction doses and account for oral intake may be used for many noncritical-care patients. Scheduled subcutaneous insulin injections should align with meals and bedtime or be given every 4–6 hours if no meals are taken or if continuous enteral/parenteral therapy is being used. Subcutaneous insulin should be administered 1–2 hours before IV insulin is discontinued. Converting to basal insulin at 60–80% of the daily infusion dose has been shown to be effective. Premixed insulins are not routinely recommended for hospital use. Standards for Special Situations Refer to the full 2017 Standards of Care for guidance on enteral/parenteral feedings, DKA and hyperosmolar hyperglycemic state, and glucocorticoid therapy. Perioperative Care On the morning of surgery or a procedure, hold any oral hypoglycemic agents; give half of the patient’s NPH insulin dose or 60–80% doses of long-acting analog or pump basal insulin. Monitor blood glucose every 4–6 hours while a patient is taking nothing by mouth and dose with short-acting insulin as needed with a target of 80–180 mg/dL (4.4–10.0 mmol/L). MNT in the Hospital The goals of MNT are to optimize glycemic control, provide adequate calories to meet metabolic demands, and address personal food preferences. The term “ADA diet” is no longer used. A registered dietitian can serve as an inpatient team member. Transition From the Acute Care Setting Tailor a structured discharge plan beginning at admission and update as patient needs change. It is important that patients be provided with appropriate durable medical equipment, medications, supplies, and prescriptions, along with appropriate education at the time of discharge. Psychosocial factors should be considered, including social determinants of care. An outpatient follow-up visit within 1 month of discharge is advised for all patients having hyperglycemia in the hospital. Continuing contact may also be needed. Clear communication with outpatient providers either directly or via structured hospital discharge summaries facilitates safe transitions to outpatient care. If oral medications are held in the hospital, there should be protocols for resuming them 1–2 days before discharge. Factors to prevent readmissions need to be considered. See the section above on older adults with diabetes regarding long-term care and skilled nursing facilities. DIABETES ADVOCACY Advocacy Position Statements For a list of ADA advocacy position statements, including “Diabetes and Driving” and “Diabetes and Employment,” refer to Section 15 (“Diabetes Advocacy”) of the complete 2017 Standards.
Author and article information
Contributors
Jason T Tsichlis
Ipsita Hamid Trisha
Ghazal Aghagoli
Meerjady Sabrina Flora
M Ruhul Abid:
ORCID: https://orcid.org/0000-0003-2981-2638
Journal
Journal ID (nlm-ta): Int Health
Journal ID (iso-abbrev): Int Health
Journal ID (publisher-id): inthealth
Title:
International Health
Publisher:
Oxford University Press
ISSN
(Print):
1876-3413
ISSN
(Electronic):
1876-3405
Publication date Collection:
July
2024
Publication date
(Electronic):
01
November
2023
Publication date PMC-release: 01
November
2023
Volume: 16
Issue: 4
Pages: 409-415
Affiliations
Author notes
Corresponding author: Tel: 401-444-6527; E-mail:
Ruhul_Abid@
123456brown.edu
Present address: Department of Pediatrics, University of California, San Francisco
School of Medicine, San Francisco, CA, USA
Present address: Department of Neurology, University of Arizona, University of Arizona
College of Medicine, Tucson, AZ, USA
Present address: Director, Institute of Epidemiology Disease Control And Research,
Dhaka, Bangladesh
Author information
M Ruhul Abid
https://orcid.org/0000-0003-2981-2638
Article
Publisher ID: ihad106DOI: 10.1093/inthealth/ihad106
PMC ID: 11218878
PubMed ID: 37930814
SO-VID: 82d1e0dd-fe4e-4d20-8a59-d8967017b82d
Copyright © © The Author(s) 2023. Published by Oxford University Press on behalf of Royal Society
of Tropical Medicine and Hygiene.
License:
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
History
Date
received
: 21
February
2023
Date
revision received
: 31
July
2023
Date
accepted
: 23
October
2023
Page count
Pages: 7
Categories
Subject:
Original Article
Subject:
AcademicSubjects/MED00390
ScienceOpen disciplines: Medicine
Data availability:
ScienceOpen disciplines: Medicine