2008 Clinical Practice Guidelines - Canadian Diabetes Association

More documents

Recommendations

Info

2008 CLINICAL PRACTICE GUIDELINES S188 (21) in Aboriginal children with ≥1 additional risk factor(s) (e.g. obesity, family history of type 2 diabetes, exposure to diabetes in utero, acanthosis nigricans, polycystic ovary syndrome [PCOS], hypertension, dyslipidemia and use of antipsychotic medications/atypical neuroleptics).An oral glucose tolerance test (OGTT) should be done annually in children who are very obese (BMI ≥99.5 percentile) (see “Type 2 Diabetes in Children and Adolescents,” p. S162). Those individuals with normal results but with diabetes risk factors (in addition to Aboriginal heritage) should receive post-test counselling on promotion of healthy lifestyles for diabetes prevention.Annual OGTT testing in individuals with prediabetes (IFG and/or IGT) or PCOS should be encouraged, as 20 to 50% of high-risk individuals with IFG may have a 2-hour plasma glucose ≥11.1 mmol/L (22). PRIMARY PREVENTION Efforts to prevent diabetes should focus on all diabetes risk factors, including pregravid obesity to reduce GDM, macrosomia and diabetes risk in offspring; promotion of breastfeeding; and prevention of childhood, adolescent and adult obesity. Primary prevention of diabetes requires collaboration between community leaders, healthcare professionals and funding agencies. Several initiatives with communityresearcher partnerships are ongoing, and include programs to mobilize entire communities, promote environmental changes and prevent GDM (23-27).These partnerships share the common values of incorporating traditions and local culture to promote empowerment, increased physical activity, balanced eating and healthy body weights. Such programs reinforce to individuals and families that they have some control over their risk for diabetes.This can impact positively on the approach to self-care and to the philosophy around family or community activities, all of which affect family members who already have the disease or are at risk for diabetes. However, there remains a lack of published evidence that these interventions result in a reduction in the incidence of diabetes in the target communities (27). Prevention of childhood obesity through moderate interventions starting in infancy has been shown to be effective (28). In Zuni First Nations children, an educational component targeting decreased consumption of sugared beverages, knowledge of diabetes risk factors and a youth-oriented fitness centre significantly decreased insulin resistance (29). These types of interventions aimed at decreasing childhood obesity, as well as efforts to promote breast-feeding in the first year of life (30), may help to reduce the risk for diabetes.As well, strategies aimed at the prevention of maternal obesity prior to first conception or subsequent pregnancy may be important tools to decrease the incidence of GDM and type 2 diabetes in pregnancy, thereby potentially decreasing the incidence of diabetes in subsequent generations of Aboriginal Canadians (5,18,26). MANAGEMENT Treatment of diabetes in Aboriginal peoples should follow current clinical practice guidelines, with Aboriginal-specific community diabetes management programs developed and delivered in partnership with the target communities, reflecting a population health approach. Ideally, multidisciplinary teams should include community members with local knowledge and expertise. Diabetes education programs should consider various learning styles, incorporate local traditions and culture, promote traditional activities and foods (provided they are safe, acceptable and accessible) and, ideally, be taught in the language of the individual. In Aboriginal communities, much of the responsibility for diabetes care falls to community health representatives (local lay healthcare providers), who are often already overburdened.These individuals are able to provide better care when they have appropriate additional training and can focus on diabetes. A number of communities have provided comprehensive diabetes training to local lay people, who can then combine their knowledge of diabetes with sensitivity to the culture and issues in their community. Weight loss associated with a temporary return to a traditional hunter-gatherer lifestyle was shown to significantly improve glycemic control among adult male volunteers in an Australian Aboriginal community (31). A number of recent American studies have demonstrated that carbohydraterestricted diets, which resemble traditional Aboriginal diets, have a salutary effect on diabetes and metabolic syndrome (32-37). A focus on dietary change to a more carbohydraterestricted diet may be warranted in both the prevention and treatment of diabetes in Aboriginal populations. Comprehensive management of diabetes in small remote communities remains difficult, due to discontinuities in staffing, lack of work-practice support and individuals’ acceptance of services (38). In some communities, mobile teams of nurses, technicians and in some cases physicians assess and treat community members with diagnosed diabetes (39). Use of a nurse-directed hypertension treatment protocol has been shown to be effective in Aboriginal peoples in Northern Canada (40). Use of a nurse case manager in large urban centres (caring for a mean of 365 Aboriginal patients) was shown to be somewhat more effective than usual care when assessing diabetes care on multiple parameters, and may be an effective strategy for remote and poorly serviced communities (41). Retinal photography has been shown to be another effective strategy for screening for diabetic retinopathy in remote communities (42). Due to the heterogeneous settings of different high-risk groups, each community or region must determine the most costeffective strategy to provide comprehensive diabetes care to best suit their reality. In the United States, federally funded on-reserve programs include diabetes registries, use of flow charts, annual chart audits with continuous quality assurance, full-time
dedicated diabetes clinical staff (e.g. nurses) and funding for community initiatives. These programs have conclusively demonstrated improvements in conventional diabetes measures (e.g. decreased glycated hemoglobin, improved lipid profiles, reductions in blood pressure) (43).A similar national program should be established in Canada for on- and offreserve Aboriginal communities. RECOMMENDATIONS 1. Starting in early childhood,Aboriginal people should be routinely assessed for modifiable risk factors of diabetes (e.g. obesity, elevated WC, lack of physical activity, unhealthy eating habits), IFG or IGT in order to identify higher-risk individuals who would benefit from diabetes prevention strategies [Grade D, Consensus]. 2. Screening for diabetes in Aboriginal children and adults should follow guidelines for high-risk populations (i.e. earlier and at more frequent intervals depending on presence of additional risk factors) [Grade D, Consensus]. 3. Culturally appropriate primary prevention programs for children and adults should be initiated in and by Aboriginal communities to increase awareness of diabetes, increase physical activity, improve eating habits and achieve healthy body weights, and to promote an environment supportive of a healthy lifestyle [Grade D, Consensus]. 4. Management of prediabetes and diabetes in Aboriginal people should follow the same clinical practice guidelines as those for the general population with recognition of, respect for and sensitivity to the unique language, cultural and geographic issues as they relate to diabetes care and education in Aboriginal communities across Canada [Grade D, Consensus]. 5.Aboriginal peoples in Canada should have access in their communities to a diabetes management program that would include the hiring of diabetes healthcare professionals, the establishment of diabetes registries, and ongoing quality assurance programs [Grade D, Consensus]. OTHER RELEVANT GUIDELINES Screening for Type 1 and Type 2 Diabetes, p. S14 Prevention of Diabetes, p. S17 Management of Obesity in Diabetes, p. S77 Type 2 Diabetes in Children and Adolescents, p. S162 RELATED WEBSITES Aboriginal Diabetes Initiative, First Nations and Inuit Health Branch.Available at: http://www.hc-sc.gc.ca/fnihb/cp/adi/ index.htm. Accessed September 1, 2008. National Aboriginal Diabetes Association. Available at: http://www.nada.ca. Accessed September 1, 2008. REFERENCES 1. Green C, Blanchard J, Young TK, et al. The epidemiology of diabetes in the Manitoba-registered First Nation population: current patterns and comparative trends. Diabetes Care. 2003; 26:1993-1998. 2. Harris SB, Gittelsohn J, Hanley A, et al. The prevalence of NIDDM and associated risk factors in Native Canadians. Diabetes Care. 1997;20:185-187. 3. Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al.Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective. J Pediatr. 2000;136:664-672. 4. Dyck R, Klomp H, Tan LK, et al. A comparison of rates, risk factors, and outcomes of gestational diabetes between aboriginal and non-aboriginal women in the Saskatoon health district. Diabetes Care. 2002;25:487-493. 5. Brennand EA, Dannenbaum D, Willows ND. Pregnancy outcomes of First Nation women in relation to pregravid weight and pregnancy weight gain. J Obstet Gynaecol Can. 2005;27: 936-944. 6. Pollex RL, Hanley JG, Zinman B, et al. Synergism between mutant HNF1A and the metabolic syndrome in Oji Cree Type 2 diabetes. Diabet Med. 2005;22;1510-1515. 7. Hanley AJ, Harris SB, Mamakeesick M, et al. Complications of type 2 diabetes among Aboriginal Canadians: prevalence and associated risk factors. Diabetes Care. 2005;28:2054-2057. 8. Diabetes in Canada. 2nd ed. Ottawa, ON: Centre for Chronic Disease Prevention and Control, Population and Public Health Branch, Health Canada; 2002. 9. Dowse G, Zimmet P. The thrifty genotype in non-insulin dependent diabetes. BMJ. 1993;306:532-533. 10. Hegele RA, Cao H, Harris SB, et al. The hepatocyte nuclear factor-1alpha G319S. A private mutation in Oji-Cree associated with type 2 diabetes. Diabetes Care. 1999;22:524. 11. Valencia ME,Weil EJ, Nelson RG, et al. Impact of lifestyle on prevalence of kidney disease in Pima Indians in Mexico and the United States. Kidney Int Suppl. 2005:97:S141-S144. 12. Hanley AJ, Harris SB, Gittelsohn J, et al. Overweight among children and adolescents in a Native Canadian community: prevalence and associated factors. Am J Clin Nutr. 2000;71: 693-700. 13. Young TK. Obesity among Aboriginal peoples in North America: epidemiological patterns, risk factors and metabolic consequences. In:Angel A,Anderson H, Bouchard C, et al, eds. Progress in Obesity Research. London, UK: John Libby; 1996:337- 342. 14. Wang Z, Hoy WE. Body size measurements as predictors of type 2 diabetes in Aboriginal people. Int J Obes Relat Metab Disord. 2004;28:1580-1584. 15. Hanson RL, Imperatore G, Bennett PH, et al. Components of the “metabolic syndrome” and incidence of type 2 diabetes. Diabetes. 2002;51:3120-3127. 16. Resnick HE, Jones K, Ruotolo G, et al. Insulin resistance, the metabolic syndrome, and risk of incident cardiovascular disease in nondiabetic American Indians: the Strong Heart Study. Diabetes Care. 2003;26:861-867. S189 DIABETES IN SPECIAL POPULATIONS
Page 1:
Canadian Publication Mail Agreement
Page 4 and 5:
2008 CLINICAL PRACTICE GUIDELINES i
Page 6 and 7:
2008 CLINICAL PRACTICE GUIDELINES i
Page 8 and 9:
2008 CLINICAL PRACTICE GUIDELINES v
Page 10 and 11:
2008 CLINICAL PRACTICE GUIDELINES v
Page 12:
2008 CLINICAL PRACTICE GUIDELINES x
Page 16 and 17:
2008 CLINICAL PRACTICE GUIDELINES S
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153: 2008 CLINICAL PRACTICE GUIDELINES S
show all

2008 Clinical Practice Guidelines - Canadian Diabetes Association

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?